Working as a ship's doctor

A life on the ocean wave? Shafiq Shafi tends the sick on passenger liners-and it isn't always a cruise

If you enjoy your work as a general practitioner, but dream of world travel on a payroll, becoming a ship's doctor might just be what you're looking for. It is one of the less common career avenues considered by doctors, very little has been written about it, and the doctors that do go out to sea have little or no contact with any particular group of doctors when on dry land. The result is that most doctors know little of the speciality.

In this currently changing political climate of general practice, many of the doctors who would have proceeded onto becoming principals after their training are looking for alternatives and are less willing to commit themselves to any long term practice partnerships.

Becoming a doctor at sea for a year or more will enrich your knowledge of the world and its people. This is probably the opposite end of the spectrum to working for a voluntary services organization yet there are some fundamental principles which are similar.

The cruise ship industry is slowly expanding to reach a wider population. The number and size of ships built is increasing every year and increasingly cruises are being marketed to younger people and those with families, not just the wealthy or retired.

Who can apply?

General practice training is essential. Basic training during the vocational training scheme should have included an accident and emergency post and experience in an intensive care unit. You should have the Advanced Cardiac Life Support certificate, and, if the ship is serves American passengers, have been on an Advanced Trauma Life Support course for medicolegal reasons.

The ideal ships doctor a broad base of knowledge in as many fields as possible: experience in other specialties such as general medicine, care of the elderly, or psychiatry will be a bonus to you. I have found that the job stretches my knowledge and skills to a maximum and I have had to go back and read topics on various specialities I studied during my training both during my undergraduate and postgraduate days. There are both male and female ship's doctors, though men predominate, probably for family reasons.

As well as the clinical requirements, a certain personality is required to work on board. Ideally, you should be sociable and a good communicator. You will meet a broad range of people, from some of the very well off passengers to one of the possibly 20 or more nationalities of crew members, some of whom can just about put a sentence together in English. They are all used to a different type of health care from their doctor and will behave differently according to their cultural model of the sick role. Contracts are at least four months long although they can be as long as eight months with usually a two month unpaid break in between. Some companies will take on a locum ship doctor for a few weeks but these positions are rare. With such long periods away from home, you will find yourself asking òwhat are you doing?ó when you have a partner or loved ones at home. Being independent and single or having a very understanding partner is essential. Most ships' doctors are either single or have never wholeheartedly committed themselves to a serious relationship.

Uniform requirements

Most companies have an officer's uniform and you will be expected to wear it if you want to be anywhere near passenger areas. If the idea of changing back into your old school uniform does not appeal to you, it is unlikely that being a ship's doctor will be your cup of tea. There is a certain degree of naval hierarchy in these jobs which takes a while getting used to but you should soon accept it as the norm.

The bread-and-butter of your job is to run a morning and evening clinic every day of the week. On ships with two doctors (2300 people), situations vary. In some companies, the work is split equally between the doctors, who both see crew and passengers. On others, the senior doctor will see the passengers during the day and the assistant doctor will look after the crew. After 8pm, the assistant will be on call and see both passengers and crew until 8am. On single doctor ships (about 1100 people), the doctor will run clinics for both crew and passengers twice a day.

All passengers are seen on a private basis: there is no NHS on board. Some British passengers find this a little bit of a shock, especially retired people who have got used to free health care throughout their lives. The Americans, on the other hand, willingly hand over their credit card as they find the costs on board a bargain compared to what they are used to paying. Because this is private practice, a more understanding attitude to their symptoms is required, no matter how trivial they seem, for they are paying for your professional time. Unfortunately, this also applies to out of hours calls - when a cabin visit is requested in the middle of the night, it has to be done. Trying to advise the passenger that it is not an urgent problem usually just wastes time - it's quicker just to take the elevator and see them - and at least there's no driving to make a house call.

The medical centres are surprisingly well equipped. Most cruise liners have x ray facilities, an intensive care unit, a minilaboratory for blood biochemistry, a pharmacy, a treatment room which doubles up to be an operating theatre and several wards for the inpatients. On larger ships, you will find between 2 and 5 nurses and on single doctor ships usually 2 nurses. The nurses complement the doctor in that they are broadly trained in their profession and have a casualty or intensive care background.

No escape from paperwork

Administration, unfortunately, is one area that cannot be avoided even at sea. Note keeping is more comprehensive than normal general practice for medicolegal reasons. There is a system of paperwork for any accidents that occur that must be followed, however trivial. Other responsibilities include making sure that you have enough drugs and supplies to last through your cruise, that all the equipment is in full working order, and that you know how to use it. As the director of public health for the ship you must notify any outbreaks of disease, for example, diarrhoea and vomiting, to the captain, who will in turn notify the ports of call. The port authorities may decide not to allow anyone to disembark or, worse still, impound the vessel in that port. The ship's doctor takes on a policing role for the alcohol policy of the company, breathalysing crew members, usually after they have been involved in an unwanted incident on board.

If a decision is made to land someone to a shoreside medical facility or arrange evacuation by air, there will be a lot of paperwork to ensure the procedure runs smoothly and everyone knows what the plan of action is. The last thing an injured and confused patient wants is to be at the doorstep of a foreign hospital that knows nothing about the admission. A doctor will usually escort the seriously ill to hospital on ships with two doctors.

Other duties include performing galley rounds on a weekly basis. You are allocated a working area of the ship and you must make a note of any maintenance that may be required or any health and safety issues arising from your inspection. Finally you are in charge of the medical or stretcher party and supplied with 12-14 crew members to pick up injured patients from any part of the ship: mock accidents and emergencies are held regularly for practice.

Continuing education

Whether you are considering this career for a short or long period, you will need to know what progress and changes are being made back home on land. It is probably difficult in this kind of job to know the latest changes in general practice due to the lack of an efficient mail system. It usually takes 10 days for your journals to arrive at the designated port of arrival and if you miss them, you'll probably not receive them at all. Fortunately, there is a system set up where certain publications such as Update, The Drugs and Therapeutic Bulletin', Telemed videos and Professional Nurse (for your colleagues) are distributed. Others may be organised as required.

There is usually a comprehensive range of reference books available covering all specialties: you never know when you might have to reach for an introductory text on, say, anaesthesia. I always take my Oxford Handbook of Clinical Medicine and its sister publication summarising the clinical specialties. They are easy to use when you reach a rusty area of your knowledge, especially during a particularly rough 4am callout (that is, due to rough weather, not a late night drinking session in the crew bar). If you wish to attend a particular course it should not be too difficult, assuming that the fleet medical officer agrees it is relevant. It is in your company's interest to make sure you are adequately trained and up to date.

Working with another doctor in a relatively confined environment leads to an easier exchange of ideas, knowledge and skills. The fact that there is a no referral system encourages this - if you the middle of the Pacific Ocean for several days, the buck stops with you.

If all this appeals you'll need to find a job. Keep an eye on the classified section of the BMJ to find positions available on both British and American ships. Ship's doctors are not only required for cruise liners but also for working ships such as those laying cables at sea and for scientific expeditions (usually to the colder climates of the world). Writing directly to the personnel department of the company may be fruitful but of course they may not have a job when you apply. They will keep your details on file for future vacancies. Some of the larger GP locum agencies may also have occasional work for a few weeks as cover for some unexpected circumstance with one of their own doctors.

So, what are the benefits? The obvious ones are those of being able to travel around the world and get a taste of the countries you probably would never have visited in your life. Even though you may only have half a day or so to explore a city or port, it's enough of an experience to help you decide whether you might return for longer in the future.

In your spare time, you have access to all the facilities of the ship such as the gym, swimming pool and dining areas. Some captains insist that you socialise by hosting a passenger table and attending the pre-dinner cocktail parties but this will depend on your workload for that evening. In your role as an ambassador for the company you will be approached by passengers of all backgrounds and you will find it easy to make new friends, if you wish to do so. Who knows where new contacts, mainly from outside the medical world, may lead?