# Command Conflicts in the CFHS?



## Snakedoc (10 Oct 2008)

Being an outsider to the CFHS, I am not too familiar with how things work within the branch.  I did a search and wasn't able to come up with the answers I was looking for.  Something I'm curious about is whether there are ever command conflicts when providing care to patients in the CFHS within the medical team.

What I'm trying to compare the health setting to is with that on a ship.  On a ship, the Captain is always in command of the ship and it doesn't matter if there is someone higher ranking such as an admiral onboard, the Captain always has command of the ship itself (such as its movements, what happens onboard etc.).  Similarily, the Officer of the Watch (OOW) on a ship can be the lowest ranking officer onboard (ie a SLt), but as the OOW, they are the highest 'ranking' (via position) onboard other than the Captain him/herself and is able to give orders to different departments etc. run by people higher ranking than him/her. These relationships are very specifically laid out in various orders and instructions the Navy has.

What I'm wondering is if there is something similar that occurs on the CFHS side of things.  Does the MO always have 'command' over the trauma team or the care of a patient for example?  What if a NO who's a Major disagrees with a treatment option a Captain (army) MO is giving?  Is this command conflict avoided via specific orders or instructions given by the CFHS?  Or is the MO expected to just follow the order and get on with it?  Often these issues can be solved by scope of practice for each profession but with overlapping scopes, if the NO is a nurse practitioner and the order falls within the nurse practitioner scope of practice and the MO scope of practice...who has 'right of way?' Rank or profession/position as a MO?

To further complicate things, with some of the talk of having PA's become commissioned officers (something I believe the U.S. curently has), if a PA and MO disagree on patient treatment but the treatment lies within both profession's scope of practice and training (more likely to occur for the PA's than NO), and the PA is higher ranking than the MO...how would this conflict be resolved?

Have any of you encountered similar problems in your line of work?


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## Blackadder1916 (10 Oct 2008)

Obviously your search did not extend to QUEEN’S REGULATIONS AND ORDERS FOR THE CANADIAN FORCES.

http://www.admfincs.forces.gc.ca/qr_o/vol1/ch003_e.asp#3.33


> 3.33 – COMMAND IN THE CANADIAN FORCES MEDICAL SERVICE
> 
> No officer who is not a medical officer shall exercise command over a medical officer in respect of his treatment of a patient.


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## ModlrMike (10 Oct 2008)

What a great question! The answer is difficult at best. Basically, we work more as a team. If you wanted a strict hierarchy, then the following *might* apply:

Specialist
MO
NP/GDNO/PA
Med Tech

The reality is much more complex. Usually we all defer to the MO, regardless of rank. However, it is also a question of where you fit on the team. I have been the Trauma Team Leader, with both officers and NCOs "subordinate" to me... in that role. It's extremely difficult to compare the atmosphere on a ship, with the ER, in that context, as there is a lot of give and take by everybody in order to maximize the probability that the patient will have a positive outcome. After all, it's not about us and our egos.

WRT to your question regarding MO/PA, the answer is we would defer to the MO, regardless of rank.

Of course, when it comes to command issues, then rank trumps trade.


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## Armymedic (10 Oct 2008)

ModlrMike said:
			
		

> What a great question! The answer is difficult at best. Basically, we work more as a team. If you wanted a strict hierarchy, then the following *might* apply:
> 
> Specialist
> MO
> ...



Actually because of the medical model for training of PAa and thier role in the extension of MOs, the hierarchy in the example above would be:

MO,
PA,
Nurse (of any type)

Also as a Sgt Med Tech I have been in charge of a patient (under MO supervison of course) where I was directing care, and therefor Nursing officers were following my "orders". But that would be an exception, rather than the rule.

When patient care is the issue, it is professional rank vs. military rank.


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## Staff Weenie (10 Oct 2008)

Great answer Mike.

The situation can become even more convoluted on very rare occasions - most particularly in the Res F, where there are more than a few Med Techs who are licensed Nurses, and there was at one point at least 2x civilian Doctors who were Cpl Med Tech. 

Thus, I've seen some minor 'No Duff' calls where the Cpl or Pte has the highest clinical skill set and license, but not the rank. Skill set won the day for leading the team, but pers tiptoed around the rank issue. It can work as long as ego stays outside the tent...but it's not ideal.

This sort of situation had to go up to the Surg Gen to be addressed. As I haven't the easy recourse to the Directive issued, I'll not try to quote it here.

I also love the term collaborative practice - we're a team, and each member brings skills and value (except maybe us HCAs....). Respect for the other members of the team is the key to success.

When I read the title of the post though, I wondered if you meant issues with the Hybrid National HQ for CF H Svcs Gp, where we mixed CF H Svcs Gp HQ, Surg Gen, and Director General Health Services staff functions into one HQ (in essence mixing line and staff, a traditional no-no...).  CF H Svcs Gp was driven to this as we simply don't have the people to have three separate organizations.  I have my thoughts on this setup, and the relative advantages and disadvantages, but not for expression in a public forum.


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## Snakedoc (10 Oct 2008)

Blackadder1916 said:
			
		

> Obviously your search did not extend to QUEEN’S REGULATIONS AND ORDERS FOR THE CANADIAN FORCES.
> 
> http://www.admfincs.forces.gc.ca/qr_o/vol1/ch003_e.asp#3.33



Thanks for this, my search was confined to the forums at the time.

Great replies, it's interesting to see the unique working relationships of a medical team in a military environment.  In the case mentioned about a PA working with a NP in an area of shared training and scope of practice, would the PA's 'professional rank' trump that of the NP's because PA's are operating under the MO's licence and therefore their orders are essentially the MO's orders?  I can definitely see how it gets complicated with civie doc's as med tech's..but could the argument be made that they are not military MOC qualified and not classified as MO's so therefore not 'qualified' to give medical orders?  I'm trying to draw the comparison to a civilian navigator who's a LS helmsman telling MARS officers how to navigate...wouldn't fly haha, but clearly having a patient's life on the line is quite different.

The term collaborative practice definitely makes sense and I would think the general principles should apply to almost any situation in the CF.

In Prairie Dog's medical model, would it be appropriate to put other allied health professionals along the same line as the nurses such as PT's or pharmacists?


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## Armymedic (10 Oct 2008)

Physio and Pharm officers are specialists in thier own sence of the word, and while they would respect a GDMO or Specialist MO's orders, they indeed have situations where they are "in command". For instance, the Base Pharmacist is in charge of all narcotics on the base and not only responsible to the military, but also to Health Canada for thier safe keeping and all that goes on with it.


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## ModlrMike (11 Oct 2008)

Snakedoc said:
			
		

> In the case mentioned about a PA working with a NP in an area of shared training and scope of practice, would the PA's 'professional rank' trump that of the NP's because PA's are operating under the MO's licence and therefore their orders are essentially the MO's orders?



It's a bit of a legal fiction that we work under the MO's licence. The reality is that in cases of malpractice, everyone gets sued. If I act in a negligent fashion, then I'm on the hook for it, not the MO. As I said, that doesn't prevent the MO from getting sued. The MO is only really at risk if they know of, and allow questionable practise to continue, of if they are negligent in their own right.

To answer your question though, it would be determined by who was the primary care giver for the patient. It's asking for trouble to interfere with the care of somebody else's case.


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## DartmouthDave (18 Oct 2008)

Hello,

I agree with Mike's order;

Spec.
MO
NP/NO/PA
Med-A

Now, I am sure we can argue all day with examples of how one profession is better than other. The truth is, it depends on the patient.  

For example, PA may be slicker in the trauma bay due to training and clinical experience. Whereas, a NO may be better with critical care or critical care transport.  A neurosurgeon who is a specialist may defer to a GP who has more experience with L+D, for example.  Plus, I can think of numerious times a medevac team helped out a GP or a community NP with a sick ICU patinet in a small town up North.  This did not put the medevac team 'above' them...just better suited to that one specific situation.

The military health care team (or elements of it) need to stop trying to 'peg' everybody in a pecking order.  

Cheers,
David


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