Projected changes to Military Medicine

[YayPudding]

Good evening all,

I'm enjoying my final 2 months of medical school before embarking on a 6 year general surgery residency. Curious if some of the old and not-so-old timers could impart upon my peers and myself what their feeling are on the future of military medicine, particularly surgery and the Army side of things? Even within the past few years I feel DHA and MHS has completely altered what I thought the AMEDD would be like. I was considering given the duration of my training and obligation of staying in until retirement, and I understand I have no rush for this decision, but curious what those within the ranks feel about the state of military medicine.

Thanks and cheers 🍻

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[pgg]

Nobody really knows, but most of us are concerned about it.

You didn't say if you were going to be training at a military program or if you were going to be civilian deferred for residency. Residency training for general surgery, being a "war critical" specialty, will probably enjoy relative priority when it comes to various realignment or rightsizing plans. One issue that is starting to become a problem is that the associated de-emphasis on "non war critical" specialties will unavoidably damage those physicians and their practices. Superficially, this seems OK as long as you're not one of them, but you can't really run a solid general surgery residency program at a hospital that doesn't have all those other specialties around (and thriving). To an extent this is and will be alleviated by sending residents out to non-military hospitals for portions of their training.

Practice for individuals after training looks uncertain. Military hospitals have experienced a more-or-less uninterrupted trend of deferring sick/old patients to civilian care for (IMO) dubious cost and philosophical reasons. Most active duty general surgeons have quite poor case volume and complexity compared to civilian counterparts. An exception there might be orthopedic surgery - they are fairly busy, at least with the bread & butter cases. Much of this will be very location dependent.

One way to mitigate the skill maintenance issue is to put active military physicians at civilian hopsitals. There has been discussion about establishing partnerships with civilian hospitals for the last 20+ years, with little actual movement. The leadership appears to be a little bit more serious about that now. Time will tell. Part of the problem is that military physicians are generally saddled with significant non-medical collateral duties that demand their time (and presence) at military hospitals. While the correct answer might be to park military doctors at a civilian hospital full time for a 3 year tour, and periodically pull them for deployments and operational work ... that seems to be unworkable. A lucky few might get that opportunity, but someone has to clock in at the MTF because the Powerpoints aren't going to compose and present themselves.

In any case, there's not much for you to do now, except be the best resident you can be. Six years is a long, long time and you'd be hard pressed to find someone who can credibly tell you what's going to happen next year.

 

[YayPudding]

Nobody really knows, but most of us are concerned about it.

You didn't say if you were going to be training at a military program or if you were going to be civilian deferred for residency. Residency training for general surgery, being a "war critical" specialty, will probably enjoy relative priority when it comes to various realignment or rightsizing plans. One issue that is starting to become a problem is that the associated de-emphasis on "non war critical" specialties will unavoidably damage those physicians and their practices. Superficially, this seems OK as long as you're not one of them, but you can't really run a solid general surgery residency program at a hospital that doesn't have all those other specialties around (and thriving). To an extent this is and will be alleviated by sending residents out to non-military hospitals for portions of their training.

Practice for individuals after training looks uncertain. Military hospitals have experienced a more-or-less uninterrupted trend of deferring sick/old patients to civilian care for (IMO) dubious cost and philosophical reasons. Most active duty general surgeons have quite poor case volume and complexity compared to civilian counterparts. An exception there might be orthopedic surgery - they are fairly busy, at least with the bread & butter cases. Much of this will be very location dependent.

One way to mitigate the skill maintenance issue is to put active military physicians at civilian hopsitals. There has been discussion about establishing partnerships with civilian hospitals for the last 20+ years, with little actual movement. The leadership appears to be a little bit more serious about that now. Time will tell. Part of the problem is that military physicians are generally saddled with significant non-medical collateral duties that demand their time (and presence) at military hospitals. While the correct answer might be to park military doctors at a civilian hospital full time for a 3 year tour, and periodically pull them for deployments and operational work ... that seems to be unworkable. A lucky few might get that opportunity, but someone has to clock in at the MTF because the Powerpoints aren't going to compose and present themselves.

In any case, there's not much for you to do now, except be the best resident you can be. Six years is a long, long time and you'd be hard pressed to find someone who can credibly tell you what's going to happen next year.

I will be undertaking residency at a military program, and you have indeed hit on some points that I have encountered along the way. I think my timeline and the ongoing flux we're seeing precludes a lot of crystal ball gazing but I appreciate your perspective, sir or ma'am

 

[DrMetal]

Nobody really knows,

Ya know, we always say this . . . but I'm gonna go out on a limb and say I know exactly what's going on.

The military (and I especially see it in the Navy) is trying to leave the business of complex health care. The DoD doesn't want to manage chronic conditions, would rather farm it out, as evidenced by the massive deferral of dependents and retirees to our local civilian networks. This has been ongoing for the last 20 years---it's been done slowly, so that it doesn't look like we're civilianizing the MHS, though that's exactly what we're doing. Maybe somewhat accelerated now via DHA.

You wont be affected as a medical student, you won't be affected much as a resident (b/c programs have to get your experience, either inside or outside of your program) . . . but you might be bored to death as an attending. (There's no obligation on the part of the DoD to keep you gainfully employed at an attending. Be prepared to moonlight.

 

[orbitsurgMD]

I have to believe the ACGME and its constituent accrediting specialty member organizations bend over backwards for military medical training programs, doing whatever possible to avoid placing any program on probation, in ways they would be far less likely to do for a civilian program. A military *resident* is very unlikely to have his or her training program tainted by probationary status. Nobody much cares in the larger community if some urban hospital's civilian program gets put on probation (aside from the usual insider and specialty clucking and gossiping) but it becomes a completely different political and news cycle event for this to happen to a military hospital program. Military centers will shrink programs or combine with other service programs all in the effort to maintain accreditation and to avoid negative events like a probation. I know that the ACGME has tried to normalize probationary status because of the negative consequences to recruitment (at one point, things like an open chairmanship or PD position was enough to win a probation) but it still has a stigmatizing effect.

 

[militaryPHYS]

Ya know, we always say this . . . but I'm gonna go out on a limb and say I know exactly what's going on.

The military (and I especially see it in the Navy) is trying to leave the business of complex health care. The DoD doesn't want to manage chronic conditions, would rather farm it out, as evidenced by the massive deferral of dependents and retirees to our local civilian networks. This has been ongoing for the last 20 years---it's been done slowly, so that it doesn't look like we're civilianizing the MHS, though that's exactly what we're doing. Maybe somewhat accelerated now via DHA.

You wont be affected as a medical student, you won't be affected much as a resident (b/c programs have to get your experience, either inside or outside of your program) . . . but you might be bored to death as an attending. (There's no obligation on the part of the DoD to keep you gainfully employed at an attending. Be prepared to moonlight.

Agree with this plus everything @pgg said . I still have hope that the civilian partnerships (for attendings) is lagging behind the downward curve of case and complexity we have been seeing for years. DHA/MHS will have to make it happen or we will be left with a wartime critical medical force who all lost their mojo after residency.

I agree that ortho does stay busy with bread and butter (sports, some basic hand and very basic trauma)…not stuff that you see down range.

 

[DrMetal]

I still have hope that the civilian partnerships (for attendings)

The medical corps should be (predominantly) a reserve force. In any other sect of the military, if an occupation had to rely on civilian partnerships, they would just 'reservize' that community.

 

[pgg]

Agree with this plus everything @pgg said . I still have hope that the civilian partnerships (for attendings) is lagging behind the downward curve of case and complexity we have been seeing for years. DHA/MHS will have to make it happen or we will be left with a wartime critical medical force who all lost their mojo after residency.

I agree that ortho does stay busy with bread and butter (sports, some basic hand and very basic trauma)…not stuff that you see down range.

In fairness, nobody anywhere sees the stuff we do down range.

The gunniest and knifiest knife & gun club at the innermost inner city trauma center isn't seeing blast injuries and high velocity GSWs. It's all MVAs and handguns and stabbings and falls and ODs.

I think good surgeons and good anesthesiologists and good intensivists can step right into the kind of crazy triple-amputee IED casualties with bits of gravel embedded in every square inch of skin, who arrive cold, with 3 tourniquets, and a fentanyl lollipop taped to their thumb. And provide excellent care with some minimal ATLS and JTS guideline refresher time. Because this was basically the case with all of us at the Kandahar Role 3. None of us had been doing trauma prior to arrival. The truth is trauma can be difficult and unforgiving, but it's pretty simple, formulaic, and procedural. So if you've got good physicians, everything is OK. Everything in theater is damage control surgery, resuscitation, and transport.

So my opinion (and like everything I write here, it's just my opinion ) is that our civilian partnership efforts should be focused on ensuring everyone has a case load that is complex, varied, and large ... and NOT necessarily trauma-centric. I think trauma-focused partnerships like NTTC, and perhaps this new thing at Penn, are a little misdirected. I'd rather see our people busy, with sick and old and otherwise difficult patients that challenge them to stay current, to grow, to get better.

As an anesthesiologist, I'm obviously best qualified to comment on what's good for my specialty - and it's not trauma. It's big abdominal whacks, big vascular cases, hearts, thoracic stuff, neurosurgery, livers, complicated OB, peds ... maybe ortho but mainly because that's what requires the best regional skills. Trauma is easy, easy, easy. Perhaps I'm overstepping to suggest that it's the same for surgeons, but I don't think so.

I fear trauma-focused partnerships will miss the point, and miss better opportunities.

 

[TheTruckGuy]

I wonder if patient satisfaction scores would go up with civilian contractors replacing most of the active duty physician force. You know, real doctors instead of us fake ones that just went to a medical MOS school. Then the critical war time specialties could be a reserve force and stay up to date with critical skills at high complex patient volume civilian hospitals.

 

[pgg]

I wonder if patient satisfaction scores would go up with civilian contractors replacing most of the active duty physician force. You know, real doctors instead of us fake ones that just went to a medical MOS school.

You're a fake doctor? This is a weird post.

 

[TheTruckGuy]

You're a fake doctor? This is a weird post.

A little tongue in cheek. The number of junior enlisted, and even some junior officers, that think Navy doctors aren't actual credentialed MDs/DOs is astounding. When they need a specialist they all want a referral off base. It was great for them during COVID when the MTF wasn't seeing patients and everyone was getting sent off base, but that set a bad precedent. Now they're all throwing a fit that they can't get seen out in town.

 

[DrMetal]

The number of junior enlisted, and even some junior officers,

Most of them aren't that sick and don't require that much subspecialty care.

Where this really hurts is when you're the PCP of a 62-yo retiree, who has bad PMR/chronic GCA, and your local MTF rheum clinic is refusing to see him because they've gone "active duty only", [sarcasm/] because yes, we have a lot of active duty members with complex rheum issues [/sarcasm]. Then your patient has to wait 4 months for an appointment out in town. Fine, I can manage him until then, but then what the hell is the point of the referral?

What sucks even more is when he, the 62-yo retiree, states something like "I served 30 years in this Navy, why am I not allowed to see the rheum clinic at my local MTF?" and then you, as the PCP, have to come up with some fake excuse.