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I had planned on writing this at 1 year out, but just didn't get around to it. Then Homonculus wrote his, and now I'm motivated again.
BLUF is that there were good and bad things about my time in service. I ultimately wouldn't have done it again, but at the same time I did get some things out of it that I certainly could not have experienced without the military. The thing that bothers me the most, honestly, is that I don't feel like I really contributed anything to military medicine. Sure, I worked as a doc, but as a result of my location I'm basically the unofficial ENT doc for a naval hospital now but without all of the hassle. So service for me was just wearing a uniform and dealing with a lot of other headaches. I never deployed, which is part of it I think.
I got my first choice of specialty out of med school. Second choice in training location. Glad I trained where I did, all things considered. I felt like my training was fairly good. We were utterly dependent on outside rotations, however. It would not have been possible to train up to code without them. My lifestyle was actually pretty good as a resident. I applied for fellowship, and I was qualified, but this was denied by the military. Ultimately I'm not upset about that either, and I'm happy as a "general" sub-specialist.
When I ranked my first duty station things got a bit worse. I actually got an RFO for my first choice. Orders were starting to come out, and my wife and I had leave planned to go look for a house. I was on vacation when I got a condolence text from one of the docs at said station indicating that she was sorry to hear I wasn't going there after all. That was the first I had heard of it. My consultant had pulled the orders, and rerouted my to the taint of America. Ostensibly this was because the assistant to the surgeon general had demanded that he send someone there. That ultimately ended up being half-true. This was an MTF that was on the chopping block for downgrade to a superclinic. They had been fighting this tooth and nail for literal years. The guy who was there had managed to actually be busy, and so the hospital command had requested that they actually grow the department. Now, I say he was busy and he was, but with the most basic bread-and-butter stuff you can imagine. Nothing remotely complex. Not enough to maintain a skillset - not even close. Plus, he wasn't sending anything to the community (unless it simply couldn't be supported). So I don't know why they thought they needed extra boots. I have to assume that they were either not paying attention at all, or that they were but they didn't care because this would make them look busy and make them a harder target to knock down. I later found out that someone else was actually slated to go there, but he knew the consultant on a more personal level than I did. So he was sent to a very cush billet (that wasn't even available when I ranked) and I was sent to BFE. He and I had the same amount of seniority, mind you. So the idea that "someone had to go" was true, but the idea that it had to be me was entirely political. Without going in to too much detail, that consultant had a chip on his shoulder for essentially anyone connected with our residency, and he took every opportunity available to show it.
So that was disappointing. When I got there, I was actually very busy. Not at first, because as I said we really didn't need two people. Ultimately I ended up being one of the most productive ENTs in the DoD. They actually gave me an award for that. Which is great. But it was all very, very basic stuff. I didn't do a neck dissection in 2 years. I think I did one parotid. Despite having some ludicrous number of births on post every year, I don't think I saw a single pediatric neck mass (which is either a statistical anomaly, or they were finding their way out to the network without my approval). I absolutely had to moonlight to keep my skills up, and even that was hard.
The command there was unbelievable hostile. I recall having the hospital commander actually come to pull me out of the OR to do a UA. I had 13 UAs in 9 months. They would call at 0300 and tell you to show up at 0600, and unlike any other MTF I had ever worked at you had to stay until you went - even if you had patients waiting. So when I had to take a case to the OR from the ER, I chose to help the patient rather than show up and pee in a cup for the millionth time, and the top dog in the facility came in to yell at me. She actually told me at first to leave the OR and to to the UA, which I refused. I had a patient sleeping. I was actually operating when she told me this.
They were always extremely worried that they were going to be shut down. This caused undue pressure in many cases. I'm sure it caused due pressure in others. For me, it was never a boon. I had a 12 year old girl with a cholesteatoma extending into her middle cranial fossa. I sent her to the "local" (2.5 hours away) children's hospital for treatment because she needed a neurosurgeon and an ICU. The next day, DCCS was in my office. Without asking me any details, he told me that if I wasn't going to do ear cases, maybe they would revoke my credentials to do ears. Keep in mind that I sent about 1 patient/month to the network, saw 25/day, and did ear cases regularly. He just got it up in his panties that he didn't like this case. So he threatened me. In a way that would show up on my record essentially forever (have you ever had your credentials suspended or revoked...) Ultimately I was able to talk him off the ledge, but the fact is I should never have had to do so in the first place. And this guy was a surgeon (OBGYN). They actually DID pull the credentials of two other providers for similar issues, so it wasn't an idle threat. Just terrorism.
I had an MSC officer in the command suite flat out tell us (CC: all providers) to withhold certain information from a visiting senatorial committee, and to flat out lie if asked certain questions directly. This had to do with trying to make the hospital look better, and hopefully garner support to keep it from being downgraded. I actually saved that e-mail just in case, because there was no way I was going to do that. And this wasn't some kind of subjective thing she was asking me to punt on.
This was a 12 bed hospital. It was staffed typically by one internist. Usually a civilian who had absolutely no desire to be there, but sometimes a uniformed doc from the clinics. The census was usually 1-2 patients, usually ortho, usually healthy. The hospital commander at one point decided that they needed to expand those services. Again, this was primarily to prevent closure (prove worth). But I wasn't against the concept in principle. The problem was her idea was to make one room an "e-ICU." See, we had a ventilator that the hospital had bought about 10 years ago. So she would buy a telemedicine suite and pay a stipend to the local university pulmonologist who could just stream in when needed. This would then let us manage ICU patients on a vent. No plans to hire or billet an actual critical care specialist. The primary doc would be this 75 year old, work-opposed internist. She actually got $800,000 from the DoD to make this happen. As far as I know it never did, thank God. She asked me directly what additional services I could provide the hospital if this was in place, and I told her none. For starters: e-ICUs have been tested in situations where a community hospital already has an ICU already staffed by at least internists with experience in the ICU and nursing staff with ICU experience who just don't have a CC specialist. The idea is that the telemedicine box can be used in a pinch, or to help decide if the patient needs to be transported to a higher level of care. You can't just buy a view screen on a cart and start handling vent patients. Secondly, the internists had no desire AT ALL to do this. So yes, they would be "primary," but ultimately they're just going to call me for any problem they have. it was insane and dangerously negligent to even consider.
They actually had been awarded $400,000,000 to build a brand new hospital two years before the DoD then decided to turn them in to a superclinic. But because the hammer never actually fell, they build the new facility. It was supposed to be completed before I ever got there, and by the time I left THE ARMY it was still empty. I think they're in it now. I was told that at one point they had to delay moving in because the building had set vacant for so long that it developed a serious mold problem and had to be remodeled in certain areas.
They required a peer review for every single tonsil bleed that I had. They considered it a potentially compensable event (PCE). Meaning that I had to write a report and have it reviewed by an outside ENT every time it happened. In case you aren't aware, posttonsil bleeds occur in anywhere between 5-13% of all tonsillectomy patients (which is why they are often the bane of ENT call). My rate was 2.3% when I left. At one point I had another ENT reviewer ask me why in the hell he keeps getting these...
I had codes called on TWO kids in the OR, both during emergence from anesthesia. One was an ear tube, the other was an ear tube and adenoid (short anesthesia, completely healthy kids). In both cases it was ultimately determined that the CRNA over-sedated and then wasn't prepared to deal with the consequences (bradycardia in both). That had never happened to me before, and hasn't happened since - not even once. I realize that it CAN, but it happened TWICE in 1 year at the same facility.
Leave was regularly denied if it was felt that it would result in less clinic time. I was the only doc my last 1.5 years, so ALL leave would effect clinic time. Yet I was pulled out of clinic for field training every year, and we had regular, sporadic but weekly meetings during clinic time that were mandatory.
The list does go on. Believe it or not this is truncated.
During this time the military had decided not to support CME of any kind. So that was all out-of-pocket.
In any case, ultimately our consultant changed. The new consultant asked me if I thought ENT was needed where I was (up inside Satan's @$$hole), and I told him I was very busy, but it was very difficult to maintain my skills. He ended up PCSing me after 2 years. I went to a much larger facility. There were still issues, but certainly far fewer. The biggest one was that our facility couldn't admit pediatric patients - at all. Which was insane because the pediatricians actually wanted to provide inpatient services, and we wanted to admit them too, but (and I kid you not) the nurses didn't want to learn PALs, and their command supported them. So we didn't admit kids. Period. Its insane. Skill rot was still an issue at the second post, but much less of one. We had a VA who allowed their patients to be seen, and we had ERSAs with local hospitals, and those things together provided for at least a modicum of complex cases....just not peds cases...
I have since left. Things are 1,000,000x better. I make 3-4x what I did in the military. I see more patients, but it actually feels like I'm doing less work because i have SUPPORT. If I ask someone to do something (like an MA) they do it. They don't get pissy. They don't argue. They don't disappear for 45 minutes. In fact, I think I had a little PTSD when I first got out because I was in the habit of just doing absolutely everything on my own (from taking vitals to rooming patients) because for the 9 years I was in the military you just couldn't trust that anyone would do it. I mean, they would. Clearly patients got admitted and roomed. But it was so slow and so inefficient and came with so many strings attached, you couldn't trust it. I don't even consider it anymore. My credentialing office does legwork. They just call me to sign things. I don't do online training. At all. The OR WANTS you to do cases. It's mind boggling. I call and they're happy to get the business. No one gives me $#!t for making them stay past 3pm. if I ask someone in my office to do something, no one ever tells me that it isn't in their job description. They don't just NOT do it and wait for me to ask them again. They don't get their union rep involved. If they don't know how to do something, they take the initiative to find out. (I certainly had enlisted soldiers who would do these things, but very few GS employees) I can go on vacation any time. I only have to tell them I'm going. No paperwork, no SERE training to go to (*&king Japan - I just go. I don't even think about moonlighting. I see a huge breadth of cases, and it ultimately boils down to what I want to do. People treat you with respect. The general gestalt is that they actually want to do what it takes to keep you working.
I met a lot of great people in the military. I don't regret that at all. I'm still very good friends with a lot of them. That is quite literally the only reason I would even hesitate to say that I wouldn't do HPSP again. Of course, had I not done it, I have to assume I would have met great people somewhere else. But maybe not as many. There are a lot of good people in the service. I loved treating soldiers. It was a privilege and an honor to do it. Again, the issue is that I'm treating service members now. I just don't have all of the baggage. I'm sure there's more I could post. Happy to expand or elaborate if needed.
BLUF is that there were good and bad things about my time in service. I ultimately wouldn't have done it again, but at the same time I did get some things out of it that I certainly could not have experienced without the military. The thing that bothers me the most, honestly, is that I don't feel like I really contributed anything to military medicine. Sure, I worked as a doc, but as a result of my location I'm basically the unofficial ENT doc for a naval hospital now but without all of the hassle. So service for me was just wearing a uniform and dealing with a lot of other headaches. I never deployed, which is part of it I think.
I got my first choice of specialty out of med school. Second choice in training location. Glad I trained where I did, all things considered. I felt like my training was fairly good. We were utterly dependent on outside rotations, however. It would not have been possible to train up to code without them. My lifestyle was actually pretty good as a resident. I applied for fellowship, and I was qualified, but this was denied by the military. Ultimately I'm not upset about that either, and I'm happy as a "general" sub-specialist.
When I ranked my first duty station things got a bit worse. I actually got an RFO for my first choice. Orders were starting to come out, and my wife and I had leave planned to go look for a house. I was on vacation when I got a condolence text from one of the docs at said station indicating that she was sorry to hear I wasn't going there after all. That was the first I had heard of it. My consultant had pulled the orders, and rerouted my to the taint of America. Ostensibly this was because the assistant to the surgeon general had demanded that he send someone there. That ultimately ended up being half-true. This was an MTF that was on the chopping block for downgrade to a superclinic. They had been fighting this tooth and nail for literal years. The guy who was there had managed to actually be busy, and so the hospital command had requested that they actually grow the department. Now, I say he was busy and he was, but with the most basic bread-and-butter stuff you can imagine. Nothing remotely complex. Not enough to maintain a skillset - not even close. Plus, he wasn't sending anything to the community (unless it simply couldn't be supported). So I don't know why they thought they needed extra boots. I have to assume that they were either not paying attention at all, or that they were but they didn't care because this would make them look busy and make them a harder target to knock down. I later found out that someone else was actually slated to go there, but he knew the consultant on a more personal level than I did. So he was sent to a very cush billet (that wasn't even available when I ranked) and I was sent to BFE. He and I had the same amount of seniority, mind you. So the idea that "someone had to go" was true, but the idea that it had to be me was entirely political. Without going in to too much detail, that consultant had a chip on his shoulder for essentially anyone connected with our residency, and he took every opportunity available to show it.
So that was disappointing. When I got there, I was actually very busy. Not at first, because as I said we really didn't need two people. Ultimately I ended up being one of the most productive ENTs in the DoD. They actually gave me an award for that. Which is great. But it was all very, very basic stuff. I didn't do a neck dissection in 2 years. I think I did one parotid. Despite having some ludicrous number of births on post every year, I don't think I saw a single pediatric neck mass (which is either a statistical anomaly, or they were finding their way out to the network without my approval). I absolutely had to moonlight to keep my skills up, and even that was hard.
The command there was unbelievable hostile. I recall having the hospital commander actually come to pull me out of the OR to do a UA. I had 13 UAs in 9 months. They would call at 0300 and tell you to show up at 0600, and unlike any other MTF I had ever worked at you had to stay until you went - even if you had patients waiting. So when I had to take a case to the OR from the ER, I chose to help the patient rather than show up and pee in a cup for the millionth time, and the top dog in the facility came in to yell at me. She actually told me at first to leave the OR and to to the UA, which I refused. I had a patient sleeping. I was actually operating when she told me this.
They were always extremely worried that they were going to be shut down. This caused undue pressure in many cases. I'm sure it caused due pressure in others. For me, it was never a boon. I had a 12 year old girl with a cholesteatoma extending into her middle cranial fossa. I sent her to the "local" (2.5 hours away) children's hospital for treatment because she needed a neurosurgeon and an ICU. The next day, DCCS was in my office. Without asking me any details, he told me that if I wasn't going to do ear cases, maybe they would revoke my credentials to do ears. Keep in mind that I sent about 1 patient/month to the network, saw 25/day, and did ear cases regularly. He just got it up in his panties that he didn't like this case. So he threatened me. In a way that would show up on my record essentially forever (have you ever had your credentials suspended or revoked...) Ultimately I was able to talk him off the ledge, but the fact is I should never have had to do so in the first place. And this guy was a surgeon (OBGYN). They actually DID pull the credentials of two other providers for similar issues, so it wasn't an idle threat. Just terrorism.
I had an MSC officer in the command suite flat out tell us (CC: all providers) to withhold certain information from a visiting senatorial committee, and to flat out lie if asked certain questions directly. This had to do with trying to make the hospital look better, and hopefully garner support to keep it from being downgraded. I actually saved that e-mail just in case, because there was no way I was going to do that. And this wasn't some kind of subjective thing she was asking me to punt on.
This was a 12 bed hospital. It was staffed typically by one internist. Usually a civilian who had absolutely no desire to be there, but sometimes a uniformed doc from the clinics. The census was usually 1-2 patients, usually ortho, usually healthy. The hospital commander at one point decided that they needed to expand those services. Again, this was primarily to prevent closure (prove worth). But I wasn't against the concept in principle. The problem was her idea was to make one room an "e-ICU." See, we had a ventilator that the hospital had bought about 10 years ago. So she would buy a telemedicine suite and pay a stipend to the local university pulmonologist who could just stream in when needed. This would then let us manage ICU patients on a vent. No plans to hire or billet an actual critical care specialist. The primary doc would be this 75 year old, work-opposed internist. She actually got $800,000 from the DoD to make this happen. As far as I know it never did, thank God. She asked me directly what additional services I could provide the hospital if this was in place, and I told her none. For starters: e-ICUs have been tested in situations where a community hospital already has an ICU already staffed by at least internists with experience in the ICU and nursing staff with ICU experience who just don't have a CC specialist. The idea is that the telemedicine box can be used in a pinch, or to help decide if the patient needs to be transported to a higher level of care. You can't just buy a view screen on a cart and start handling vent patients. Secondly, the internists had no desire AT ALL to do this. So yes, they would be "primary," but ultimately they're just going to call me for any problem they have. it was insane and dangerously negligent to even consider.
They actually had been awarded $400,000,000 to build a brand new hospital two years before the DoD then decided to turn them in to a superclinic. But because the hammer never actually fell, they build the new facility. It was supposed to be completed before I ever got there, and by the time I left THE ARMY it was still empty. I think they're in it now. I was told that at one point they had to delay moving in because the building had set vacant for so long that it developed a serious mold problem and had to be remodeled in certain areas.
They required a peer review for every single tonsil bleed that I had. They considered it a potentially compensable event (PCE). Meaning that I had to write a report and have it reviewed by an outside ENT every time it happened. In case you aren't aware, posttonsil bleeds occur in anywhere between 5-13% of all tonsillectomy patients (which is why they are often the bane of ENT call). My rate was 2.3% when I left. At one point I had another ENT reviewer ask me why in the hell he keeps getting these...
I had codes called on TWO kids in the OR, both during emergence from anesthesia. One was an ear tube, the other was an ear tube and adenoid (short anesthesia, completely healthy kids). In both cases it was ultimately determined that the CRNA over-sedated and then wasn't prepared to deal with the consequences (bradycardia in both). That had never happened to me before, and hasn't happened since - not even once. I realize that it CAN, but it happened TWICE in 1 year at the same facility.
Leave was regularly denied if it was felt that it would result in less clinic time. I was the only doc my last 1.5 years, so ALL leave would effect clinic time. Yet I was pulled out of clinic for field training every year, and we had regular, sporadic but weekly meetings during clinic time that were mandatory.
The list does go on. Believe it or not this is truncated.
During this time the military had decided not to support CME of any kind. So that was all out-of-pocket.
In any case, ultimately our consultant changed. The new consultant asked me if I thought ENT was needed where I was (up inside Satan's @$$hole), and I told him I was very busy, but it was very difficult to maintain my skills. He ended up PCSing me after 2 years. I went to a much larger facility. There were still issues, but certainly far fewer. The biggest one was that our facility couldn't admit pediatric patients - at all. Which was insane because the pediatricians actually wanted to provide inpatient services, and we wanted to admit them too, but (and I kid you not) the nurses didn't want to learn PALs, and their command supported them. So we didn't admit kids. Period. Its insane. Skill rot was still an issue at the second post, but much less of one. We had a VA who allowed their patients to be seen, and we had ERSAs with local hospitals, and those things together provided for at least a modicum of complex cases....just not peds cases...
I have since left. Things are 1,000,000x better. I make 3-4x what I did in the military. I see more patients, but it actually feels like I'm doing less work because i have SUPPORT. If I ask someone to do something (like an MA) they do it. They don't get pissy. They don't argue. They don't disappear for 45 minutes. In fact, I think I had a little PTSD when I first got out because I was in the habit of just doing absolutely everything on my own (from taking vitals to rooming patients) because for the 9 years I was in the military you just couldn't trust that anyone would do it. I mean, they would. Clearly patients got admitted and roomed. But it was so slow and so inefficient and came with so many strings attached, you couldn't trust it. I don't even consider it anymore. My credentialing office does legwork. They just call me to sign things. I don't do online training. At all. The OR WANTS you to do cases. It's mind boggling. I call and they're happy to get the business. No one gives me $#!t for making them stay past 3pm. if I ask someone in my office to do something, no one ever tells me that it isn't in their job description. They don't just NOT do it and wait for me to ask them again. They don't get their union rep involved. If they don't know how to do something, they take the initiative to find out. (I certainly had enlisted soldiers who would do these things, but very few GS employees) I can go on vacation any time. I only have to tell them I'm going. No paperwork, no SERE training to go to (*&king Japan - I just go. I don't even think about moonlighting. I see a huge breadth of cases, and it ultimately boils down to what I want to do. People treat you with respect. The general gestalt is that they actually want to do what it takes to keep you working.
I met a lot of great people in the military. I don't regret that at all. I'm still very good friends with a lot of them. That is quite literally the only reason I would even hesitate to say that I wouldn't do HPSP again. Of course, had I not done it, I have to assume I would have met great people somewhere else. But maybe not as many. There are a lot of good people in the service. I loved treating soldiers. It was a privilege and an honor to do it. Again, the issue is that I'm treating service members now. I just don't have all of the baggage. I'm sure there's more I could post. Happy to expand or elaborate if needed.
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