Army General Surgery Payback timeline

[pgg]

They are

I hope you're right. I guess it's possible there's a whole bunch of efficient, directed, fruitful activity going on behind closed doors and an Oprah-style big reveal is coming. I'm at the point where I won't believe it until I have a shift scheduled. And maybe not even until the first shift is over.

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[DoctorDoom]

I wonder if Uncle Sam and the DHA are finding ways to integrate surgical readiness with increased cooperation with large trauma hospitals stateside (having .mil surgeons hone their craft as normal surgeons, and deploy when needed as a med-corps officer (who happens to be a surgeon)

They are

It's not clear to me why there's so much difficulty in moving forward. LAC+USC has had the Naval Trauma Training Center for years, with 2 Navy O-5's as Attendings and military residents and fellows (I was a senior resident) with a dedicated Trauma team. A similar arrangement exists with Ryder. In terms of non-trauma General Surgery, multiple locations have agreements with their local VA's, providing patient acuity and volume. Yet the MC Leadership seems focused on gaining Trauma Center accreditation for MEDCENs. Seems to be taking the hard road instead of the easier, and existing, solution.

 

[DoctorDoom]

.. I stumble upon this article regarding general surgery case volume...

Half of the authors were my junior residents. I'm old...

I still stay in touch with a couple of them, and they are miserable. But none of the reasons they are miserable in Army GenSurg are surprises; issues of low case volume and frequent deployments with almost no operative time at all was a concern back near the start of the war in 2005. Sadly, some of the papers they cite have authors who were part of the problem, and only waited to write papers for JACS on their way out the door.

Even worse, mil surgeon's sentiments are eerily similar to the sentiments a lot of us had since at least before 2010.

 

[Cooperd0g]

It's not clear to me why there's so much difficulty in moving forward. LAC+USC has had the Naval Trauma Training Center for years, with 2 Navy O-5's as Attendings and military residents and fellows (I was a senior resident) with a dedicated Trauma team. A similar arrangement exists with Ryder. In terms of non-trauma General Surgery, multiple locations have agreements with their local VA's, providing patient acuity and volume. Yet the MC Leadership seems focused on gaining Trauma Center accreditation for MEDCENs. Seems to be taking the hard road instead of the easier, and existing, solution.

I think the issue has more to do with the fact that these things have to be set up with individual hospitals and there is probably a lot of red tape for each instance. Now try and set that up dozens and dozens of places. And it is probably one or two people trying to coordinate it all.

 

[DoctorDoom]

I think the issue has more to do with the fact that these things have to be set up with individual hospitals and there is probably a lot of red tape for each instance. Now try and set that up dozens and dozens of places. And it is probably one or two people trying to coordinate it all.

Certainly, but how could it possibly be any worse than dealing with every Trauma Center AND every state government trying to get accreditation? In the face of staffing reduction? It would seem to be much worse with the current approach, as opposed to following and already existent private agreement that doesn't need local government permission, for lack of a better term.

 

[pgg]

It's not clear to me why there's so much difficulty in moving forward. LAC+USC has had the Naval Trauma Training Center for years, with 2 Navy O-5's as Attendings and military residents and fellows (I was a senior resident) with a dedicated Trauma team. A similar arrangement exists with Ryder. In terms of non-trauma General Surgery, multiple locations have agreements with their local VA's, providing patient acuity and volume. Yet the MC Leadership seems focused on gaining Trauma Center accreditation for MEDCENs. Seems to be taking the hard road instead of the easier, and existing, solution.

As an anesthesiologist, a few years back I went to NTTC for 3 weeks as part of pre-deployment trauma refresher training. I went with 3 other anesthesiologists, a couple of surgeons, some nurses. Some ER corpsmen too. Can't remember if we had surgical techs with us or not for that trip. Maybe?

They didn't let us work in the OR. They let us observe in the ER. Their residents did all the procedures, in the slowly-gaining-competence way trainees do procedures, while we as experienced attendings looked on, occasionally stepping in to teach them. We couldn't follow the (very rare) trauma case that went straight to the OR. Yay? Outside of a pretty good lecture series (put on by Navy personnel) and a couple of cadaver labs, it was a terrible experience. Utterly worthless from a clinical perspective.

So if NTTC is the gold standard we're aiming for ... sigh.


Part of the problem is that I'm sensing that DHA and the new powers perceive the skill maintenance problem to be almost entirely trauma-centric. And that makes a little bit of sense - we're the military, trauma is a core part of our business. But that's not the skill maintenance exposure I need as an anesthesiologist.

As an anesthesiologist, trauma is easy. Almost trivially so. An anesthesiologist can do zero trauma for years and be back up to speed almost immediately when working trauma again. It's procedural, formulaic, and it's always the same. Resuscitation, blood products, tube goes in, ventilator goes on, more resuscitation.

After my worthless clinical experience at NTTC, I went straight to the Kandahar Role 3, and golly, on day one, multiple amputee from an IED blast, my first actual trauma case since some forgettable MVA in residency. And it went fine. 98%+ of casualties that reach a Role 3 survive.

I don't need DHA to send me TAD to a civilian hospital to do trauma. I need them to send me TAD to a civilian hospital to cardiac cases involving bypass, echocardiography in the OR, ECMO, thoracic surgery, major abdominal surgery, high volume ortho that benefits from regional techniques. Anything BUT trauma.

 

[DrMetal]

We couldn't follow the (very rare) trauma case that went straight to the OR. Yay? Outside of a pretty good lecture series (put on by Navy personnel) and a couple of cadaver labs, it was a terrible experience. Utterly worthless from a clinical perspective.

So if NTTC is the gold standard we're aiming for ... sigh.

Just as I suspected, I'm glad I never went.

It's quite a farce that the military is good at trauma surgery....we're really not. Our active duty surgeons don't have the skills (unless they moonlight like a jack rabbit), and our hospitals (ICUs, nursing, ORs, corpsmen, etc) can't support it.

Yes we've had moments of brilliance in war time.

If we ever have a large scale war again (ie Vietnam, Korea), we will undoubtedly look to the civilian world to find our best trauma surgeons, to deploy (make them a 'reservist', throw a uniform on them, and get them in the fight). It would be nice to build a good reserve force of such surgeons (I think it already exists?). We don't need these guys to be on active duty full time, and thus we don't really need a robust active duty trauma program. Again, we just don't have the patient load, the capacity or the personnel to make it happen....lets be honest. Working the reserve component would be a better option, in my opinion.

 

[pgg]

Just as I suspected, I'm glad I never went.

It's quite a farce that the military is good at trauma surgery....we're really not. Our active duty surgeons don't have the skills (unless they moonlight like a jack rabbit), and our hospitals (ICUs, nursing, ORs, corpsmen, etc) can't support it.

Yes we've had moments of brilliance in war time.

If we ever have a large scale war again (ie Vietnam, Korea), we will undoubtedly look to the civilian world to find our best trauma surgeons, to deploy (make them a 'reservist', throw a uniform on them, and get them in the fight). It would be nice to build a good reserve force of such surgeons (I think it already exists?). We don't need these guys to be on active duty full time, and thus we don't really need a robust active duty trauma program. Again, we just don't have the patient load, the capacity or the personnel to make it happen....lets be honest. Working the reserve component would be a better option, in my opinion.

NTTC is a nice solution for the two trauma surgeons that get PCS'd to that duty station. I bet the rotating residents get a good experience too. Those are good things and the Navy deserves credit for them.

Making some MTFs trauma centers is perhaps a part of the solution too, if it brings cases in. This seems to be working OK at Lejeune. I hope it does at Portsmouth too.

There's even been at least one effort to get active duty teams into foreign hospitals, though there were some problems with the iteration I was part of. I don't believe those problems can be overcome, but perhaps they'll figure it out.


But even if all of these trauma-related endeavors work, there'll still be ongoing gaps outside their laser focus on trauma. Case load in many surgical specialties at many MTFs is inadequate for skill maintenance, let alone development over the course of a career. I'm just hoping to see some DHA-led, large scale, multi-specialty (to include RNs and techs) agreements to get us out to these facilities where we can work.

Here's the main reason why I'm concerned they won't be able to make it work. Every time the hospital ship goes out, we close 1/3 of our operating rooms for lack of ancillary staff to run them. If we don't have the staff to meet operational needs (obviously priority #1) and keep the MTFs running at their full capacity (priority #2), how are we going to be able to send people TAD for 3 or 6 months out of the year (priority #not1or2)? There's a math problem here and I can't make the numbers work in my head.

Is there really the will (and money, and legal ability given near-constant federal hiring freezes) to permanently hire civilians to pre-backfill those MTF positions? From what I've glimpsed of the hiring process, even in those cases where a position, need, and money have coalesced ... well ... let's just say that hope springs eternal, but eternity is a long time..

 

[DrMetal]

NTTC is a nice solution for the two trauma surgeons that get PCS'd to that duty station. I bet the rotating residents get a good experience too. Those are good things and the Navy deserves credit for them.

Making some MTFs trauma centers is perhaps a part of the solution too, if it brings cases in. This seems to be working OK at Lejeune. I hope it does at Portsmouth too.

Lejune isn't a level 1, right? Only MTF Level 1 I know of is BAMC.

It doesn't make any sense, for all the points that you just pointed out. This is better done in the civilian world, might as well keep it there.

I can't imagine NMCP ever being a Level 1. I don't think the ICU could support it.

 

[pgg]

Lejune isn't a level 1, right? Only MTF Level 1 I know of is BAMC.

It doesn't make any sense, for all the points that you just pointed out. This is better done in the civilian world, might as well keep it there.

I can't imagine NMCP ever being a Level 1. I don't think the ICU could support it.

Lejeune was a 3, last I looked. I did see one note that there was potential to grow into a 2.

I think the ambition for Portsmouth is to be a level 2, but I'm not aware enough of the process to comment intelligently on how NMCP will get there.

As long as our hospitals are open, anything to bring volume to them is helpful.


Getting out to the civilian world is harder than it seems. It all comes down to money. Civilian hospitals are typically happy with accepting visiting surgeons, especially if they bring patients (even Tricare), because of the $$$ they get for the facility fee and all of the ancillary and inpatient billing. Anesthesia is another story - no private group or management company with an exclusive anesthesia contract will tolerate some random military guy coming in to take away their billable hours. Anesthesia is always the elephant in the room when these ERSAs and partnerships are discussed with civilian hospitals. At different hospitals, I've been laughed away, politely shut down, kindly told we weren't good enough to work there, and one group even had the audacity to say they'd let us do cases for free for them if the Navy could put together an attractive six-figure financial package to compensate them for their loss.

I'm just a worker bee now, no longer a DSS, so I'm not part of these discussions any more. But I know how they go. The best I've come up with in 10 years of effort is one MOU with a VA hospital 90 minutes away. And they don't have the volume to give me cases to do solo ... because their guys need cases too.

There may be some potential for an agreement where the military personnel go work, still get paid by the military, and the hospital or associated groups are allowed to bill for the care they provide. I've heard this discussed but I'm not sure how it would pass double-dipping legal review for patients with government insurance, outside of a training status. (Obviously FTOS fellows get paid by the government and Tricare/etc patients they care for still get billed by the institution. But attending level care may be different.)

I think we'll see people who are traditionally hospital employees (nurses, RTs, etc) getting hours at civilian hospitals long before anesthesiologists.

The enlisted side has a whole 'nother set of issues. The civilian world doesn't recognize a "Corpsman" as anything. A Corpsman can't walk into a civilian hospital and do the same work he was doing at the MTF. Some of our Corpsmen have civilian credentials and certifications (EMT, surgical tech, etc) but many do not. Getting them into a hospital to do useful work is a different sort of hurdle.

DHA has its work cut out for it ...

 

[backrow]

As usual PGG has some sage advice here and hits many of the issues with some of the proposed “solutions”. There are so many layers to this that it is nearly impossible to unpack: surgeons, corpsmen, surg techs, nurses, anesthesiologists, CRNAs, non-surgical physicians, SRNAs, residents, etc etc. Each piece requires significant work just to set “something” up that may be useful only to then open another Pandora’s box.

Let’s just take making a hospital a trauma center: ok, who pays for the non-insured? Folks say that’s easy, just send bills. But the answer requires Service Secretary input. And which Service is going to give up money that could be spent on the Nth generation Tie Fighter? Oh....DHA?? And where do they get their money?

Ok, so let’s send our surgeons to a trauma hospital...ok, but what happens when that requires TAD and all the sudden there’s no budget or a Continuing Resolution that ends all TAD? Oops! I also don’t think this is viable from a personnel standpoint. I don’t know about y’all, but if I had to go shoreside TAD for 3-6 months every year or two with deployments in between my family life and welfare would be significantly affected.

ERSAs are reasonable if you have patients to take, but if you don’t have the providers in clinic (ie POM20 or just undermanned) then you aren’t going to generate cases to take.

Overall my biggest complaint about all this right now is the lack of realistic and frank discussion. A discussion on “we understand your issues and here’s what we are trying to do and the hurdles we are running into” would be a good start. It would be at least a half day meeting so it will never happen.



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[HighPriest]

I always had the impression that the Army just couldn't figure out why it's medical box was making noise. I mean, it's just a tool, right? Why can't it just be quiet and do medicine? Like if your TV remote suddenly started complaining about interference from the microwave. My opinion is that nothing will change until something horrific enough happens to force it. We start losing the joint commission rubber stamp? Maybe. Outcomes drop off to such a level that it can no longer be ignored? Maybe. We have a war with increased medical casualties? That would do it. I don't want that to be the case, but for whatever reason the larger military feels like it's medical corps is the only tool in its arsenal that basically never needs updating or attention. Not from any meaningful level of command. They ought to make it mandatory that all senators get their medical care in the Tricare system. That would do it.

 

[DrMetal]

As usual PGG has some sage advice here and hits many of the issues with some of the proposed “solutions”. There are so many layers to this that it is nearly impossible to unpack: surgeons, corpsmen, surg techs, nurses, anesthesiologists, CRNAs, non-surgical physicians, SRNAs, residents, etc etc. Each piece requires significant work just to set “something” up that may be useful only to then open another Pandora’s box.

Not to mention the 5 years it would take to set it all up, assuming it goes smoothly. Who the hell is around for 5 years??? we all rotate q 2 years, sometimes even sooner.

The hurdles are just too high. Leave trauma surgery and medicine to the civilian world. That's really the right answer.

 

[HighPriest]

I think this is exactly the reason nothing has changed. It's really a baby/bathwater scenario. I don't think there are any good patches that are going to fix the problems that people are bringing up. It really has to be a systematic change, which i think they're hoping DHA will be. But, i think all of the concerns here are very real. The other option is to just have a cadre of reservist trauma surgeons that you rotate in-and-out. You would have to make that cadre large enough that you wouldn't destroy careers by constantly deploying the same people. It's also not ideal, but at least they would be operating when stateside.

 

[militaryPHYS]

Locally we are dealing with similar issue on smaller scale. USMC has bought medical assets who sit idle doing admin work without any specific plan of action for skill maintenance. The top leadership began complicating the process by discussing TAD or one-to-one swaps to get their people to the hospital for sustainment while we provide hospital people back to the unit to backfill their admin. Not necessary for the majority of persons who need skill training. They just need an agreed upon # of days per week to be on the call team or work schedule. Anyone of us could sacrifice a day a week and likely still get our work done. A rad tech or lab tech stuck in the S3 shop of a USMC unit definitely can.

Some NEC's/specialties/jobs would require 100% time at the hospital for a block of time which might necessitate TAD or other complicated processes. But that doesn't mean we are scrapping the whole thing for a problem with the minority. We are working on local MOU's to take care of the low-hanging fruit. We are assessing the logistics and gathering the data needed to possibly propose broad, generalized policy for any medical assets in the region who need skill sustainment. We are optimizing the check-in/credentialing process to be able to do it within one day to make sustainability of this happen.



For AD physicians needing civilian hospital exposure it is obviously a bit more complex as discussed by all. A new system will have to be established with local hospitals/systems which are primarily salary based. The Kaiser Permanente's, etc. Yes licenses/credentialing/etc. will be a problem, but once the system is established and optimized it should be self sufficient.

We will likely be seeing the closing of the small MTF's easily covered by the local civilian system (Lemoore, etc). Any remaining MilMed assets will only have so many hospitals to be placed at since we will all be working together under one big DHA umbrella. Think only the large academic centers. At these centers we establish new local policy with the large civilian healthcare system. Everyone being assigned to that region will know what will happen.

i.e. I know if I am getting stationed in the San Diego area as an orthopedic surgeon that I will be rolled in to a Monday/Tuesday call pool within the Kaiser system then fulfilling my role to Tricare/beneficiaries Wednesday to Friday at either Pendleton or Balboa. If I am a pediatrician then I would be covering the ward Monday/Tuesday at Kaiser then seeing outpatient Tricare clinic or covering the ward at Pendleton or Balboa WED-FRI. If we are getting stationed in Virginia area then we know what civilian healthcare system we will be rolled in to (Wellspan, Bon Secours, etc) in a similar manner.

There's no moonlighting, no TAD, just a new way in which we practice as military physicians. We aren't just another billet so we can't try to imagine a new system incorporating old military habit/policy on any other billet. We need simplicity, standardization and sustainment. That's what I preach locally here and it is what we are working on even if it is way outside the box. The box has thankfully been opened up by US News and other such outlets so lets capitalize on it while it is there. Easier said than done.

Most anesthesia is provided through private groups contracted in which makes it difficult. Sucks for them. But I wouldn't stop working out easy incorporation of the low hanging fruit that are already in need in the civilian world (general surgeons, ortho surgeons, Internists, ED providers, pediatricians, etc.) just because it doesn't work for anesthesiologists. They will be part of the more difficult process just like the NEC's that will require dedicated TAD.

None of the above (aside from what I said about our local stuff) is based on anything concrete coming from DoD. But this would be the first step before all active duty physicians are transitioned in to a reservist system while all Military healthcare is farmed out to these same civilian healthcare systems we will initially be integrated in to. In my opinion.

 

[Helpful Troll]

Locally we are dealing with similar issue on smaller scale. USMC has bought medical assets who sit idle doing admin work without any specific plan of action for skill maintenance. The top leadership began complicating the process by discussing TAD or one-to-one swaps to get their people to the hospital for sustainment while we provide hospital people back to the unit to backfill their admin. Not necessary for the majority of persons who need skill training. They just need an agreed upon # of days per week to be on the call team or work schedule. Anyone of us could sacrifice a day a week and likely still get our work done. A rad tech or lab tech stuck in the S3 shop of a USMC unit definitely can.

Some NEC's/specialties/jobs would require 100% time at the hospital for a block of time which might necessitate TAD or other complicated processes. But that doesn't mean we are scrapping the whole thing for a problem with the minority. We are working on local MOU's to take care of the low-hanging fruit. We are assessing the logistics and gathering the data needed to possibly propose broad, generalized policy for any medical assets in the region who need skill sustainment. We are optimizing the check-in/credentialing process to be able to do it within one day to make sustainability of this happen.



For AD physicians needing civilian hospital exposure it is obviously a bit more complex as discussed by all. A new system will have to be established with local hospitals/systems which are primarily salary based. The Kaiser Permanente's, etc. Yes licenses/credentialing/etc. will be a problem, but once the system is established and optimized it should be self sufficient.

We will likely be seeing the closing of the small MTF's easily covered by the local civilian system (Lemoore, etc). Any remaining MilMed assets will only have so many hospitals to be placed at since we will all be working together under one big DHA umbrella. Think only the large academic centers. At these centers we establish new local policy with the large civilian healthcare system. Everyone being assigned to that region will know what will happen.

i.e. I know if I am getting stationed in the San Diego area as an orthopedic surgeon that I will be rolled in to a Monday/Tuesday call pool within the Kaiser system then fulfilling my role to Tricare/beneficiaries Wednesday to Friday at either Pendleton or Balboa. If I am a pediatrician then I would be covering the ward Monday/Tuesday at Kaiser then seeing outpatient Tricare clinic or covering the ward at Pendleton or Balboa WED-FRI. If we are getting stationed in Virginia area then we know what civilian healthcare system we will be rolled in to (Wellspan, Bon Secours, etc) in a similar manner.

There's no moonlighting, no TAD, just a new way in which we practice as military physicians. We aren't just another billet so we can't try to imagine a new system incorporating old military habit/policy on any other billet. We need simplicity, standardization and sustainment. That's what I preach locally here and it is what we are working on even if it is way outside the box. The box has thankfully been opened up by US News and other such outlets so lets capitalize on it while it is there. Easier said than done.

Most anesthesia is provided through private groups contracted in which makes it difficult. Sucks for them. But I wouldn't stop working out easy incorporation of the low hanging fruit that are already in need in the civilian world (general surgeons, ortho surgeons, Internists, ED providers, pediatricians, etc.) just because it doesn't work for anesthesiologists. They will be part of the more difficult process just like the NEC's that will require dedicated TAD.

None of the above (aside from what I said about our local stuff) is based on anything concrete coming from DoD. But this would be the first step before all active duty physicians are transitioned in to a reservist system while all Military healthcare is farmed out to these same civilian healthcare systems we will initially be integrated in to. In my opinion.

Who's paying the malpractice insurance when working at Kaiser, Wellspan, or Bon Secours and when you leave?

 

[militaryPHYS]

Who's paying the malpractice insurance when working at Kaiser, Wellspan, or Bon Secours and when you leave?

Great question. Don't know. Might not be up to us to decide but not a reason to wait on taking steps towards something.

 

[backrow]

Who's paying the malpractice insurance when working at Kaiser, Wellspan, or Bon Secours and when you leave?

Since you are still employed and directed to do so by the US Government your malpractice coverage is the same as at an MTF. This is similar to when folks do FTOS fellowships.

The only difference is, I believe, you are potentially at a higher risk of a claim being filed and I’m not sure how they would adjudicate reporting to the national practitioner databank


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[Helpful Troll]

Since you are still employed and directed to do so by the US Government your malpractice coverage is the same as at an MTF. This is similar to when folks do FTOS fellowships.

The only difference is, I believe, you are potentially at a higher risk of a claim being filed and I’m not sure how they would adjudicate reporting to the national practitioner databank


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Backrow - I'm not sure it would be the same as at an MTF with a 'closed/limited' patient base. Will the patients know their physician doesn't have personal malpractice insurance or deep pockets to cover a claim?

Doesn't working in civilian hospitals in other than a trainee capacity (resident/fellow) with a patient base not associated with the military introduce a different risk of malpractice claims to the physician? If the risk of a claim is 'on' the military physician and can't be effectively transferred to the US Government I'm not sure it's a financially sound decision to accept this risk. At least with paid moonlighting, the military physician has malpractice insurance and is compensated for the risk.

It's just something to consider.

 

[notdeadyet]

For AD physicians needing civilian hospital exposure it is obviously a bit more complex as discussed by all. A new system will have to be established with local hospitals/systems which are primarily salary based. The Kaiser Permanente's, etc. Yes licenses/credentialing/etc. will be a problem, but once the system is established and optimized it should be self sufficient.

We will likely be seeing the closing of the small MTF's easily covered by the local civilian system (Lemoore, etc). Any remaining MilMed assets will only have so many hospitals to be placed at since we will all be working together under one big DHA umbrella. Think only the large academic centers. At these centers we establish new local policy with the large civilian healthcare system. Everyone being assigned to that region will know what will happen.

I think you may be greatly overestimating the civilian medical community's desire to assume a new huge patient population with very different expectations than the civilian population for the pleasure of being reimbursed by an insurance system that no one likes to take.

Using your Lemoore example, Lemoore NAS has about 7K military and 10K dependents. They will now be serviced entirely by, what, Adventist in Hanford? A system already struggling to provide care to a bunch of folks around the central valley? Adventist would now be responsible for this new population, which is highly expecting drop-in services and fitness-for-duty evaluations, both of which a community hospital is not set up to provide. And this new staffing will e taken care of by a bunch of part-time employees who see working in this community hospital as a "necessary evil," and not motivated for providing the care to the (heavily bilingual) underserved population that is my community's bread and butter? And staff who can (and will) be frequently pulled at a moment's notice without any reasonable promises of backfill?

The military always seems to assume they can slide into civilian medical care and residency training much more easily than is in any way realistic. And many civilian practices and hospitals would be wisely very reluctant to enter this kind or arrangement.

 

[militaryPHYS]

I don't advocate for closing hospitals...I am simply running with what the hearsay is coming down the wire. IF DoD will be closing smaller MTF's such as Lemoore then the civilian system will have to expand to adapt to it. Whether or not it is feasible, right, etc. isn't up to us to decide.

Although, from a specialist standpoint the community already absorbs a large portion of these patients anyway. Where else are they going when their 1 of 1 doc is on Leave or access to care is too far out? Primary care is the real problem which I believe you were eluding to. If that is your question then I imagine in the short term the "clinics" would stay functional...or at the very least the unit level medical officers will handle the active duty folk primary care stuff while dependents get absorbed in to the civilian system. This would likely be temporary while the local civilian system expands to absorb new population. Then all you are left with will be unit level primary care.

The closing of smaller MTF's. Coordination of Large MTF's with civilian systems. Two different beasts that will have to move forward in parallel.

 

[backrow]

Backrow - I'm not sure it would be the same as at an MTF with a 'closed/limited' patient base. Will the patients know their physician doesn't have personal malpractice insurance or deep pockets to cover a claim?

Doesn't working in civilian hospitals in other than a trainee capacity (resident/fellow) with a patient base not associated with the military introduce a different risk of malpractice claims to the physician? If the risk of a claim is 'on' the military physician and can't be effectively transferred to the US Government I'm not sure it's a financially sound decision to accept this risk. At least with paid moonlighting, the military physician has malpractice insurance and is compensated for the risk.

It's just something to consider.

The malpractice risk is still covered by the US Govt because you are still acting as an agent of the US Govt. The case would still have your name replaced with “US Government” as the defendant. (At least this is how it currently works for those staff/surgeons who spend a large chunk of time at civilian hospitals)



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[mslall]

[/B]

@militaryPHYS can discuss Navy Orthopedics (self) and Internal Medicine (wife)

I know I’m late to the party. Army general surgery. Currently in fellowship. I’m happy to answer any questions and can speak to a lot of them

The research year isn’t an army mandate by doctrine and can be cut. It would just be predicated on the program having a slot for you in the next year group (ie someone would have had to quit or be cut)

 

[DoctorDoom]

As an anesthesiologist, a few years back I went to NTTC for 3 weeks as part of pre-deployment trauma refresher training. I went with 3 other anesthesiologists, a couple of surgeons, some nurses. Some ER corpsmen too. Can't remember if we had surgical techs with us or not for that trip. Maybe?
...

So if NTTC is the gold standard we're aiming for ... sigh.

You guys did have surgical techs. And I agree, the NTTC exerience for Anesthesia... ugh. But then again, it's an entirely different specialty, and I don't think you guys needed to be there at all for pre-deployment workup.

 

[Detective SnowBucket]

While we're talking about surg payback timeline, what's the payback like for direct accession?

 

[deleted480308]

While we're talking about surg payback timeline, what's the payback like for direct accession?

Post residency? No payback, but a minimum 8yr commission iirc. Usually served as 6 active or drilling with 2irr.

 

[pgg]

While we're talking about surg payback timeline, what's the payback like for direct accession?

Depends

You always owe at least 8 years, combined time active and IRR. Absolute minimum active contract is 2 years, I think.

If you get an accession bonus, it comes with an active duty service obligation (ADSO) for the years that bonus is paid out. Typically 4 years if I'm not mistaken. However, just because (for example) a $400K accession bonus is authorized for some specialty doesn't actually mean that any of those accessions are actually funded in any given year. If you do get an accession bonus, during its payout and ADSO period you're ineligible to sign a multi-year retention contract because you're effectively already under one.

Presumably if you don't get an accession bonus, you could enter a 4 (or 6?) year retention bonus contract immediately, since you're residency trained and have no existing educational obligation, and that would be your ADSO. I've never met a person who joined without an accession bonus though, so I'm not sure.

 

[Detective SnowBucket]

Depends

You always owe at least 8 years, combined time active and IRR. Absolute minimum active contract is 2 years, I think.

If you get an accession bonus, it comes with an active duty service obligation (ADSO) for the years that bonus is paid out. Typically 4 years if I'm not mistaken. However, just because (for example) a $400K accession bonus is authorized for some specialty doesn't actually mean that any of those accessions are actually funded in any given year. If you do get an accession bonus, during its payout and ADSO period you're ineligible to sign a multi-year retention contract because you're effectively already under one.

Presumably if you don't get an accession bonus, you could enter a 4 (or 6?) year retention bonus contract immediately, since you're residency trained and have no existing educational obligation, and that would be your ADSO. I've never met a person who joined without an accession bonus though, so I'm not sure.

Thanks! That's exactly what I wanted to hear. I talked with my Navy recruiter and he said the DA bonus for ortho (just because I thought they'd have the highest bonus) was ~$360,000. I was thinking, if the ADSO is only 4 yrs, even for 2/3 of that I would take it to pay off student debt and would love to serve for 4 years.
I genuinely do want to go into the military but just can't do the 7 years for HPSP.