DM: We started looking at this approximately two years ago. The impetus for it was basically 9/11, and during the time that we were actively drawing together the subject matter that would become the core competencies for disaster medicine we had the Florida hurricanes in 2004, and then Katrina, Rita, and Wilma in 2005. Along with the situation in the Middle East and Iraq, it became ever more clear to us that we were on the right track – that the United States was entering a time in its history when there were going to be more and more disasters, both natural and manmade. It was also clear to us that our ability to respond as a profession to both terrorism and natural disasters was sub-optimal. Part of the reason for that is that doctors exist in multiple specialties and think of a specialty as a container. In dire circumstances, the containers don’t communicate well, one to the other. Emergency managers, who have been board certified in this country for several years now, became very frustrated with the medical profession because, in a time of a disaster, instead of everyone communicating and trying to take care of things with one command structure, the docs were all pigeon-holed into their own little containers and it became very hard to get anything done. So, the Board of Disaster Medicine is committed, not only to excellence in education in disasters, but also to breaking down communication barriers that are so fundamentally opposed to good disaster management.

DM: We looked at all of the specialties in medicine, and it turns out that just about all of them can play a fundamental role in disasters if they would talk to one another. We got a consensus group together of specialists from all over the United States and over a period of two years distilled down the core competencies for someone to be board certified in disaster medicine. It became rapidly clear to all of us that one of the essential core competencies of a disaster medical board certification is that the doctor must be well-versed in incident command and know how to work under its aegis, much like fire departments, police departments and emergency operation centers throughout the United States in time of disaster. Otherwise, they were going to remain in containers that didn’t talk to one another.

DM: As of May 1^st we’ll be accepting applications for the initial written certification in the fall of 2006. However, it is a two-step process. Assuming you pass the written exam, which further assumes you meet all the candidacy requirements that are now published on the ABPS website, then approximately one year later you will be admitted to an oral exam which will include disaster simulation and probably some tabletop disaster exercises, as well. If you pass both parts, then and only then would you be considered disaster board certified.

DM: All specialties, but the primary care specialties are the ones that have the least other candidacy requirements added on top of them. We felt strongly that any doctor of any specialty who wanted to get involved in disasters and wanted to get him or herself up to speed with incident command, Basic Disaster Life Support (BDLS) and Advanced Disaster Life Support (ADLS) training could be admitted to the exam. The primary care specialties, being the ones that are clinically most likely to have dealt with situations like a disaster or could at least stretch themselves to work in a disaster – they would be admitted with fewer other candidacy requirements than, say, a doctor in radiology or radiation oncology, who doesn’t practice patient care in the sense of clinical medicine day-to-day.

DM: They vary by specialty, but basically you have to be residency trained and board certified. You would then have to either have done disaster medical assistance team training through FEMA, or have done both ADLS and BDLS through the American Medical Association – those are training courses in disaster life support. If you’re not one of the primary care specialties, you would also have to either have HAZMAT instructor status, national disaster life support instructor status, or a couple of other things. The requirements are more stringent for non-primary care specialties. For instance, suppose you are a radiation oncologist and you do wonderful things for people with cancer, but 9/11 changed you and you really want to be able to respond to a disaster, should one occur. Well, because you don’t practice primary care medicine – stitching up lacerations, setting bones and all that stuff – you would need to avail yourself of some upgrading of your skills. You would have to read quite a bit of the literature to augment what you don’t normally do day-to-day, and we will have a fairly extensive bibliography of things that docs can read to get themselves up to speed. Then, you would need either to become Disaster Medical Assistance Team (DMAT) trained, which you can do through FEMA, or you would have to have done ADLS and BDLS through the American Medical Association. There are 52 DMATs in the U.S.; they exist through the Department of Homeland Security and under it, through FEMA. They are the groups of doctors, nurses, respiratory therapists, paramedics, etc. who deploy when there are federal disasters declared. In addition, you must either be a HAZMAT instructor or a National Disaster Life Support (NDLS) instructor – which is the instructor course that one has to do to teach BDLS and ADLS. On top of that, you would either have to do 50 CME hours in disaster medicine, or 25 hours of CME in disaster medicine plus 50 hours in either field work in a disaster or have published in peer-reviewed journals or given lectures at conferences on disaster medicine. All of the prerequisites are described on our website: www.abpsga.org.

DM: Core competencies would include an all-hazards disaster approach: no matter what disaster – terrorist, natural, whatever – you apply a specific set of psycho-motor and cognitive skills to defining the disaster and responding to it. You would have to be well-versed in the incident command system, the national incident management system and the federal response plan. You would have to have knowledge of blast injuries and biochemical and radiological injuries due to terrorism, as well as basic emergency medicine in situations where you might have mass casualties – anything from concussions to broken bones to multi-system trauma, shock, and death. You have to be well-versed in how to triage in a mass casualty situation. That can be very challenging because doctors are trained in medical school to do as much good for the patient lying in front of them as they can. In a disaster, that paradigm does not work. You may have hundreds, thousands, or even tens of thousands who need your help simultaneously. The disaster paradigm is to do as much good for as many as you can, and the ones who are too badly injured – you give them comfort and let them die. That’s a hard thing for doctors to do, but that, along with incident command and learning to keep your wits about you when everyone else is losing theirs, is the fundamental set that a doc needs to be a good disaster doc.

DM: There are post residency fellowships in disaster medicine – which is one of the other alternate paths that a non-primary care specialist can take. It’s a one-year course offered at the University of Oklahoma and several other universities in the northeast. Also, any licensed physician in the U.S. can become part of the Disaster Medical Assistance Teams through FEMA. Defore you can deploy you have to do extensive training in disaster paradigms – how to respond, how to work the flight line of a C-130 – you basically get trained in military-style disaster medicine. And by the way, the military has excellent training in disaster medicine, so any doc that worked in the military would probably have already received extensive disaster training. Our board is also running an international disaster medicine conference in Vancouver, British Columbia at the end of June of this year, which will call together docs from the international community to better prepare for disasters, not just in the United States, but in Canada, Mexico and even in Europe.

DM: Exactly the latter. Our core competency curriculum doesn’t really have any one specialty as its basis. It draws from all the specialties to create this new branch of knowledge known as core competencies of disaster medicine. If there were one specialty that is most seminal, it would be emergency medicine. But that is not sufficient, nor it is the only way through. Any doc who wants to brush up on his or her primary care skills, and then wants to read on how to work in a disaster – and remember that communication is critical in that situation – would have to read a fair bit of material on his or her own, brush up on any clinical skills they may not have used in recent years, meet the other candidacy requirements, and then they can sit for the board. The more onerous part of the exam structure is the second part, where we will be using what’s called medi-simulation mannequins – they’re about $250,000 apiece and are computer-run. Every drug that you give, every operation or procedure that you do on the mannequin, the computer takes into account and changes the physiological properties of the mannequin in real-time, so that if you treat the mannequin properly it gets better, and if don’t treat it right it goes downhill and either dies or becomes horribly incapacitated. You can see that, if a doc has normally been doing radiation oncology for the last ten years, that kind of an exam would be very challenging, and that’s why we tell them if your clinical skills in emergency medicine and advanced life support are not good, you may need to do some upgrading.

DM: We only announced it in February and we already have inquiries in the hundreds. Ultimately, we would expect probably several thousand over a period of five to ten years.

DM: The practicality of it is that our country is in the middle of a war on terror and we live day-to-day with the knowledge that at any time a nuclear blast could occur, or a biological weapon could be released, or a chemical weapon could be deployed, or we could just get hit by ten more terrible hurricanes in the next five years. The bottom line of what we should have learned from Katrina and Rita and the Florida hurricanes is that our ability as a profession to respond to disasters is sub-optimal – and that’s putting it mildly. The advantage to the doc is, number one, an altruistic one to be able to better protect the homeland. But there are economic benefits to the doc, too. I can tell you that I’m getting asked to speak in a lot of venues now because, as a core competency disaster-trained doc, I’m in high demand for a lot of conferences and groups that want to hear how we can improve our homeland defense. They turn to physicians who are disaster-boarded, who are perceived to have more on the ball in how to best deal with these scenarios.