“Never ascribe to malice that which can be adequately explained by incompetence” -Napoleon Bonaparte
Responding to the medical challenges posed by natural or manmade disasters requires a complex set of knowledge, skills, and attitudes. As it now exists, though, the nation’s healthcare system does very little to cultivate these desirable qualities in U.S. healthcare professionals. Moreover, Hurricane Katrina and other notable recent failures in disaster medical response have brought legal, political, and media scrutiny that more often than not blamed healthcare practitioners for lacking desirable competencies that are presumed, but not taught. If the United States is truly serious, therefore, about improving the medical capabilities needed in times of disaster, the concept of disaster medical competence must first be defined, and then developed.
To meet that ambitious goal one starts with a basic question – namely, how is medical competency developed? In the normal education of medical and allied specialties such as nursing, training in medical competencies is commonly divided into three categories: knowledge, skills, and attitudes. Knowledge acquisition and mastery is largely the task of professional medical schools, and competence is measured by professional board examinations – which are developed, monitored, and controlled in almost all cases by state medical boards. To ensure not only that there are enough competent medical practitioners, but also that those practitioners who are licensed are truly competent, the United States Medical Licensing Examination will fail anywhere from 10 percent to 50 percent of those who attempt the test.
Skill acquisition is largely taught through practical training – in settings (hospitals, primarily) in which the novice practitioner is trained by a more senior and experienced supervisor. Generally, the novice must successfully complete a certain number of required procedures in a satisfactory and supervised manner prior to the determination, by qualified supervisors, of the novice’s competence. Physicians in training are often held back, or dismissed, should they fail to progress to a certain degree of competence. For physicians, training residencies may last 3-6 years after medical school, after which another specialty-board examination is required – failure rates on the latter commonly run anywhere from 5 percent to 30 percent.
Attitudinal training, a more nebulous concept, refers to development of the judgment needed to guide the professional on the proper time and place to apply his or her medical knowledge and skills. Understanding the complex social, emotional, and ethical needs that must be met through the use of acquired knowledge and developed skills represents the “art” of medicine. Attitudinal training is largely the responsibility of the role model who is emulated by the trainee. During medical school and training residencies, young doctors are constantly evaluated on these three competencies in training programs that continue for several years, and in some instances a decade or more. The young doctors also must pass periodic and extremely difficult examinations – and, should they fail to pass just one of those examinations, they risk completely failing their planned careers.
Difficulties in Developing Medical Competency
To develop the specialized skills needed to cope with the massive medical challenges posed by mass-casualty incidents – e.g., natural disasters, epidemics, hazardous materials events, and even combat situations – the nation’s medical practitioners (doctors, nurses, paramedics, and other healthcare professionals) must acquire the additional knowledge, skills, and attitudes needed to complement their previous medical competencies. Unfortunately, there are currently very few medical schools, residencies, or allied schools of the health professions that actually teach what might be described as “disaster medical competence” in an organized and productive manner.
There seem to be two principal reasons for this apparent lack of professional interest on the part of the medical schools and those who run them. First, the nature of most disasters is that they are low-frequency/high-intensity events. This means that disaster response may or may not occur, even once, during an individual practitioner’s career – and, if it does, the skills needed may be unique to the particular event and not broadly applicable to the general practice of medicine.
The second reason is that the forefront of medical knowledge is constantly expanding – but for various practical reasons the professional training provided by most U.S. medical schools (usually four years minimum for an M.D. degree, followed by a minimum one-year apprenticeship) cannot be compressed into a shorter period of time, and also cannot easily be extended. This unavoidable time squeeze creates a strong pressure to create and follow an economical curriculum that is focused primarily on the main practice of the specialty, with little if any time and/or attention paid to such “frill” courses as disaster medical response. The result of these combined time and economic pressures is that most U.S. medical professionals currently have rather significant gaps in the comprehensive (and still growing) set of knowledge, skills, and attitudes needed to respond to a disaster.
Unexplored, Unfunded, and Undone (Unfortunately)
In addition to the lack of individual competence in disaster response, competence at the health-system level of the overall U.S. medical system is largely unexplored except for the scheduling of a few carefully planned and tightly choreographed disaster drills. Here it should be emphasized that, although a health system per se is composed of individuals, that system must respond as a complex team to meet the logistical, safety, medical care, and financial challenges that a disaster may present. It is largely for that reason that a comprehensive “systems design” perspective for private medical-system disaster-response is at present both unfunded and undone.
In that context, it also is worth noting that, although many health systems do have competent and trained disaster-response professionals who do their very best, a system-level response is limited, as elsewhere in life, by the least competent members of the team. In the complex world of natural disasters, rapid climate changes, and random acts of terrorism, an incompetent medical system will therefore cost lives – and perhaps in large numbers.
Despite the difficulties noted above, disaster training is being conducted through an impressive, and growing, number of private, state, and federal programs focused on a variety of different disaster-related medical problems. These programs generally run from one day (or even one half-day) to as much as several days in duration, and are designed to accommodate a rather wide range of students. An impressively broad array of disaster-related training programs also is available. However, a casual analysis of a representative sampling of these programs identifies what seems to be a rather common problem – namely, “competence assessment.” The blunt fact is that most current U.S. disaster medical education programs lack either: (a) minimum standards of competence; or (b) a legitimate validation method of those core competencies; or (c) both. Not incidentally, the goal of the training strategies designed for most of those programs is to achieve a somewhat imprecisely defined “Awareness level.”
Needed: A Higher Level of Unawareness?
By not establishing and validating core competencies for different medical professions, it is possible for subsequent teams to be led, and plans to be developed and approved, by individuals who have indeed been “trained” – but remain incompetent nonetheless. To put this concept into perspective one might consider for a moment the discomforting possibility of boarding an airplane piloted by an “awareness-level” pilot, or raising a family in a building designed by an awareness-level architect, or having an operation performed by an awareness-level surgeon. All of these, and many others that might be considered, would be unacceptable choices. Nonetheless, disaster medical response currently depends on planning and teams led by awareness-level practitioners with unmeasured skills.
From an educational design perspective, the lack of competence validation blinds the training program’s ability to assess instructors, training strategies, and instructional techniques. Without competency measurement, any training program is as good as any other one. By not measuring competence in meaningful ways, curriculum instruction cannot progress beyond current levels.
Another concern is that the current panoply of disaster medical curricula is largely defined by the members of so-called “expert” panels. However, although expert panels can help, to some degree at least, to define a place to start, they also can easily create fixed understandings that have “blind spots.” A particularly conspicuous example of a specific blind spot that had lethal consequences was the question of whether anthrax could be transmitted by mail – the anthrax deaths that followed shortly after the 9/11 terrorist attacks proved that the answer was “Yes.”
In short, it should be remembered that medical knowledge is a constantly growing entity and is always being reshaped both by research and by new ideas. For that reason, the disaster medicine curriculum probably must make the difficult transition into a “sub-specialty” status for it to remain both relevant and updated.
Finally, without the continuing engagement of professional societies and board-certification organizations, existing training efforts may be wasted. “How?,” “Who?,” and “To what level of competency?” are questions that must be answered by the medical professions themselves. Specialty-specific knowledge, skills, and attitudes must be integrated into existing health-profession education, residency training, fellowship training, and research programming. By taking the long view and creating a viable new career path for professionals with validated competency, disaster plans, teams, and response capabilities all can be improved and elevated to a high national standard. Then, actual competency will eventually – over some impossible-to-define period of time – replace awareness-level incompetence and expert-panel limitations.
Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.