Residency Question

[breakmon]

NOTE: I have read a lot of the major threads that people say to read in this section of the forum. I'm only posting a topic because I felt like the answer wasn't clearly written out anywhere. Please don't bash me.

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I'm thinking about doing the Air Force HPSP. My grandpa served in that branch for 20 years, and my dad served for 4. I guess you could say it's kind of a legacy.

Anyway, I'm just concerned about whether or not the Air Force would provide the best quality of training? Does anyone have any opinions regarding which branch of the military would be best in that regard?

Also, I from browsing through these forums I got the impression that the military could pull you out of your residency after just one year, which essentially means you still haven't received the proper training that you need as a doctor. Is that true? I don't want to do join the military if it means that I'll be delaying my residency for 4 years after I've graduated medical school. Also, I wouldn't really feel comfortable practicing on patients if I haven't completed my residency.

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[sonofva]

NOTE: I have read a lot of the major threads that people say to read in this section of the forum. I'm only posting a topic because I felt like the answer wasn't clearly written out anywhere. Please don't bash me.

___________________________________________________________________________________________________________

I'm thinking about doing the Air Force HPSP. My grandpa served in that branch for 20 years, and my dad served for 4. I guess you could say it's kind of a legacy.

Anyway, I'm just concerned about whether or not the Air Force would provide the best quality of training? Does anyone have any opinions regarding which branch of the military would be best in that regard?

Also, I from browsing through these forums I got the impression that the military could pull you out of your residency after just one year, which essentially means you still haven't received the proper training that you need as a doctor. Is that true? I don't want to do join the military if it means that I'll be delaying my residency for 4 years after I've graduated medical school. Also, I wouldn't really feel comfortable practicing on patients if I haven't completed my residency.

What stage of training are you in plz?

 

[BigNavyPedsGuy]

Everything you are concerned about is a distinct possibility. If you're willing for that to happen, then don't join. The training depends on which specialty, but you likely won't know which specialty Neil half way through your third year of medical school.

 

[Doctor Bob]

Anyway, I'm just concerned about whether or not the Air Force would provide the best quality of training? Does anyone have any opinions regarding which branch of the military would be best in that regard?

There is no clear answer on this in previous threads as there is no clear answer. Everyone has their own opinions and they are all equally valid. Join the branch in which you want to serve. They all have distinct personalities.

Also, I from browsing through these forums I got the impression that the military could pull you out of your residency after just one year, which essentially means you still haven't received the proper training that you need as a doctor. Is that true?

If you match into a 1yr internship right out of med school; if you do not then match into a residency (for a variety of reasons) then you'll be put out into the field as a general medical officer. The degree of pathology you will see in that billet will be amply handled by your one year of training. If you come across something you're unfamiliar with, then you pass it off to the specialists. However, if you go into a formal residency, they won't yank you out after being in for just a year.

I don't want to do join the military if it means that I'll be delaying my residency for 4 years after I've graduated medical school. Also, I wouldn't really feel comfortable practicing on patients if I haven't completed my residency.

It is a possibility that you won't do a full formal residency until after your 4 year commitment. That is a risk in military medicine.

 

[BigNavyPedsGuy]

If you match into a 1yr internship right out of med school; if you do not then match into a residency (for a variety of reasons) then you'll be put out into the field as a general medical officer. The degree of pathology you will see in that billet will be amply handled by your one year of training. If you come across something you're unfamiliar with, then you pass it off to the specialists. However, if you go into a formal residency, they won't yank you out after being in for just a year.

Having been a GMO myself and now working with a good number of Flight Surgeons, I have to give a warning of caution. If one only has an internship under his/her belt then they often don't know what they don't know. One year of psyche or ortho internship does not prepare someone much to be a primary care doctor/first responder potentially thousands of miles from any help. There's a reason this isn't standard of care anymore.

Sorry to hijack the thread, but to brush off GMOs because they "won't see much pathology anyway" is an over-simplification and part of the problem.

 

[TxsMed14]

It is a possibility that you won't do a full formal residency until after your 4 year commitment. That is a risk in military medicine.

Poor training is a serious issue for the patients. but that aside, why is that a bad thing? Taking a few years of to GMO gives you more points to get a better residency or fellowship position, pays back active duty, and seems like with more general experience under your belt, you would get more out of residency training.

I would opt to do this anyway for those reasons. Is there an advantage to jumping straight into your specialty, if you end up with the same or better training either way?

 

[Doctor Bob]

Poor training is a serious issue for the patients. but that aside, why is that a bad thing? Taking a few years of to GMO gives you more points to get a better residency or fellowship position, pays back active duty, and seems like with more general experience under your belt, you would get more out of residency training.

I would opt to do this anyway for those reasons. Is there an advantage to jumping straight into your specialty, if you end up with the same or better training either way?

If you had to retake step I right now how well would you do? If you're like most people you'd probably do pretty poorly even though that information is less than 4 years old in your head.

After being out of school for 4 years, doing mostly administrative work and well-patient checks, it becomes very difficult to return to a learning environment because there is a knowledge atrophy that occurs as time goes on when you're doing something else.

Residency assumes you come in with a baseline amount of knowledge and builds from there. Being on staff at a military academic site I can tell which people are recently out of med school and which are coming in from operational tours; the latter group is much harder to spin up.

And you're pretty much obligated to stay in the military at that point. A civilian program will rank you lower because of the gap time since medical school/internship; only the military will give you higher standing because of the gap time.

 

[deuist]

I don't want to do join the military if it means that I'll be delaying my residency for 4 years after I've graduated medical school. Also, I wouldn't really feel comfortable practicing on patients if I haven't completed my residency.

I think that you've already made your decision up then.

 

[pgg]

Is there an advantage to jumping straight into your specialty, if you end up with the same or better training either way?

Well, you won't need to spend 2 or 3 years of unsupervised practice in primary care, usually with backup but not always, despite being a glorified intern who's ineligible for medical licensing in many states.

Someone'll be along shortly to say there's nothing wrong with a guy two weeks out of an OB internship taking on the battalion surgeon position for 1000 Marines imminently bound for a FOB on the Pakistani border of Afghanistan. My opinion on this has evolved over time. Fortunately, it usually works out OK, but regardless of the good memories and professional development, a GMO tour is a delay in training that carries risk.

 

[notdeadyet]

Is there an advantage to jumping straight into your specialty, if you end up with the same or better training either way?

Where do you get this impression?

 

[TxsMed14]

Where do you get this impression?

I.e. you complete the same residency program in end, if you plan to stick with the military, right?

Im a non-trad med applicant and was an EMT for five years. Always found life is what you make of it; if you go into residency with more life experience, you'll get more out of it. Anyway, i guess I don't look down on GMO work having been an EMT, and it sounds like i wouldnt have much control over where mil puts me regardless. Personally, I'd rather do everything I could to make myself competitive for residency or fellowship.

I also didnt realize you had to re-take step II. In that case, maybe it's better to do a tour after residency, and before fellowship training?

I'm still in my app cycle for 2014 matriculation, so this is by no means a valid opinion. Just curious/asking questions to learn more about the experience.

 

[StarboardMD]

Being an EMT is in no way comparable to being a GMO. As an EMT, you are close to a higher echelon of medical care, and your job is merely to keep the patient alive until you get there. As a GMO, you can and probably will be in a situation where there is no higher echelon of care available for a significant amount of time, and you will have to manage the acute patient with only your own dreadfully inadequate amount of training. It is a terrible position to be in, and I thank God every single night that I have not lost any of my soldiers yet on my tour, but I still have over a month left in country and I cannot wait until I can sleep at night knowing that there is a hospital nearby that can manage my soldiers so very much better than I can. God forbid that someone should suffer or die because of my ignorance (lack of experience and training) and I have to live with that the rest of my life.

 

[pgg]

Anyway, i guess I don't look down on GMO work having been an EMT

This is a misunderstanding of what GMOs are and what GMOs do. GMOs are independently practicing doctors who may or may not have a great deal of responsibility given to them from time to time. Perhaps inappropriately so, depending on one's opinion and many factors, but that's not the GMO's fault and no reason to look down on them.

I also didnt realize you had to re-take step II.

The only reason to re-take Step II would be if you failed it. GMO or no GMO tour, you'll take Step III during your PGY-1/intern year, and then get yourself a medical license. And then you're done with the Steps forever, hallelujah and amen.

 

[orbitsurgMD]

. . . Everyone has their own opinions and they are all equally valid. . . . .

If you match into a 1yr internship right out of med school; if you do not then match into a residency (for a variety of reasons) then you'll be put out into the field as a general medical officer. The degree of pathology you will see in that billet will be amply handled by your one year of training. . . . . .

That is simply not true, and I am calling you out on this. The degree of pathology that the GMO may be asked to see is not within the control of the GMO and may without notice greatly exceed the capabilities and experience of an otherwise well-trained first-year resident. And it is a fact, not merely an opinion among "equally valid" opinions that the same GMOs may be required to work in emergency room settings without any backup at all, including laboratory, radiology and specialty support, conditions that would be unacceptable and unimaginable in a civilian practice organization.

It is a possibility that you won't do a full formal residency until after your 4 year commitment. That is a risk in military medicine.

[bolds mine]

The risk isn't merely of the frustration and annoyance in the interruption to training, but is also a risk of damage to your career due to inappropriate tasking (never mind risk to patients, another thread entirely.) The military is all too happy to wield all the usual powers of any healthcare organization in the way of QA, peer review and privileging actions, powers all civilian clinics and hospitals have. What makes them different is their recklessness in using undertrained physicians as they do and their utter moral depravity in then policing those same practitioners with those same measures when they know that they hazard both the doctors and the patients by the practice of withholding full training.

 

[Doctor Bob]

That is simply not true, and I am calling you out on this. The degree of pathology that the GMO may be asked to see is not within the control of the GMO and may without notice greatly exceed the capabilities and experience of an otherwise well-trained first-year resident.

Oh snap.
Did I just get served?

I can only speak to my experience.
So I'm an ER guy at a role III hospital; our base is crawling with flight docs who run their own clinics around base. We get a steady stream of patients from role II's (also staffed by ER docs with a plethora of flight docs) as well. The GMOs bring in people all the time to be evaluated by either myself or a colleage because they aren't sure what's wrong (or how to treat it). They have a good idea of their limit and as such their guys aren't in jeopardy. There have been no patients that have come through where the consensus was "this person suffered an adverse event as a result of being seen by a GMO who didn't know what they were doing".

Are there flight docs a little farther afield without the immediate support of a residency trained physician? Yes. But that's where you get to the question of "is a poorly trained doc better than no doc". Some would say yes, some would say no. I'm of the opinion that so long as the doc knows their limitations and they don't try to do any more than a well trained IDMT, then sure they do just fine (and that has been my experience when I get patients from a role I setting).

And it is a fact, not merely an opinion among "equally valid" opinions that the same GMOs may be required to work in emergency room settings without any backup at all, including laboratory, radiology and specialty support, conditions that would be unacceptable and unimaginable in a civilian practice organization.

Err... "That is simply not true, and I am calling you out on this". Two of the civilian ERs that I first worked at as moonlighting staff were also staffed by guys who had done one year of training then got a license (one had failed out of residency halfway through 2nd year, so he was a little more trained than the others). These were rural hospitals and they took what they could get (they were ecstatic when I offered to moonlight there... a fully trained ER doc? I had my pick of schedules because they didn't want to chase me off). These guys had minimal training, limited support, and they did the best they could. Same as GMOs in the military. So those conditions are acceptable and imaginable and very real in the civilian world.

With aaalllll that being said, yes, I would prefer that all docs in the military (and civilian world) be fully residency trained and overall that would be better for patient care. But if wishes were fishes....

 

[orbitsurgMD]

Oh snap.
Did I just get served?

I can only speak to my experience.
So I'm an ER guy at a role III hospital; our base is crawling with flight docs who run their own clinics around base. We get a steady stream of patients from role II's (also staffed by ER docs with a plethora of flight docs) as well. The GMOs bring in people all the time to be evaluated by either myself or a colleage because they aren't sure what's wrong (or how to treat it). They have a good idea of their limit and as such their guys aren't in jeopardy. There have been no patients that have come through where the consensus was "this person suffered an adverse event as a result of being seen by a GMO who didn't know what they were doing".

Are there flight docs a little farther afield without the immediate support of a residency trained physician? Yes. But that's where you get to the question of "is a poorly trained doc better than no doc". Some would say yes, some would say no. I'm of the opinion that so long as the doc knows their limitations and they don't try to do any more than a well trained IDMT, then sure they do just fine (and that has been my experience when I get patients from a role I setting).



Err... "That is simply not true, and I am calling you out on this". Two of the civilian ERs that I first worked at as moonlighting staff were also staffed by guys who had done one year of training then got a license (one had failed out of residency halfway through 2nd year, so he was a little more trained than the others). These were rural hospitals and they took what they could get (they were ecstatic when I offered to moonlight there... a fully trained ER doc? I had my pick of schedules because they didn't want to chase me off). These guys had minimal training, limited support, and they did the best they could. Same as GMOs in the military. So those conditions are acceptable and imaginable and very real in the civilian world.

With aaalllll that being said, yes, I would prefer that all docs in the military (and civilian world) be fully residency trained and overall that would be better for patient care. But if wishes were fishes....

I would hope (and also hope you would agree) that the lowest-quality, most desperate-for-support civilian hospitals in the country are not the standard-setters for the military medical system. You seem to be suggesting that since there are such examples in the civilian world that it is OK for the military to staff its facilities the same way. The fact is that you will not get any clinical appointment at most community hospitals without at least being board-eligible, except in the military.

"If wishes were fishes" is not an excuse for dereliction of reasonable training and staffing standards. The Navy and other services were instructed over a decade ago by Congress to discontinue the practice but they have willfully ignored that instruction.

 

[Doctor Bob]

I would hope (and also hope you would agree) that the lowest-quality, most desperate-for-support civilian hospitals in the country are not the standard-setters for the military medical system.

Standard setters? No. Minimal acceptable standards maybe... and to some extent I think that's what we're talking about; what is the minimum acceptable level of training.

You seem to be suggesting that since there are such examples in the civilian world that it is OK for the military to staff its facilities the same way.

It is acceptable when there is no other option.

The fact is that you will not get any clinical appointment at most community hospitals without at least being board-eligible, except in the military.

I wish this were true. At most big urban centers it certainly is and as time goes on it's filtering out to the less populated areas. But even at my primary residency training site, a level 1 trauma center, level 3 NICU, tertiary referral center, 700 bed hospital, heart and stroke center of excellence, ECMO certified center, St. Jude affiliate, children's hospital, etc, etc, etc.... docs could still get privileges with just an internship year. There were other restrictions the hospital put on them such as requiring them to have a BC consultant on all of their inpatient cases but that's sort of what we do here also. The GMOs can see the patients in clinic by themselves, but in the hospital it gets elevated to a BC/BE doc.

"If wishes were fishes" is not an excuse for dereliction of reasonable training and staffing standards. The Navy and other services were instructed over a decade ago by Congress to discontinue the practice but they have willfully ignored that instruction.

No.. it's not an excuse. But I figure there are other forces in play besides just willfully ignoring directions. There must be some other constraint preventing the change. I'm just a cog so I have no understanding of the greater machinations.

 

[Gastrapathy]

No.. it's not an excuse. But I figure there are other forces in play besides just willfully ignoring directions. There must be some other constraint preventing the change. I'm just a cog so I have no understanding of the greater machinations.

Wow, I've never seen anyone call themselves a cog in the machine. Strange world. The constraints are that our 3 year max flag officers are never focused on the greater good at the expense their next fitrep. Our leadership is so short-sighted that the hard decision never gets made. They create a system where we need GMOs and then throw up their hands.

I get the feeling you never experienced GMO life or saw just how compromised they can be. Overnight shifts alone in the ED at Guam? Check. Solo provider not just to one ship but to several operating more than a day from the big deck? Check (this was two GMOs but one had been a psych intern). The examples are endless.

Here's another thread where I try to explain what I mean to another cog (starting about post 35): http://forums.studentdoctor.net/showthread.php?t=985046

In short, we need to incentivize primary care enough to persuade people to do it. This would cost money. Instead, they choose to save the money and force future radiologists, pathologist, psychiatrists and surgeons with one year of incorrectly focused GME to experiment on their patients. Its not ethical. But, our ethics are under attack from a variety of sources. Anyone put an NG tube in a detainee recently? Your medical board might want to know about it.

 

[BigNavyPedsGuy]

In short, we need to incentivize primary care enough to persuade people to do it. This would cost money. Instead, they choose to save the money and force future radiologists, pathologist, psychiatrists and surgeons with one year of incorrectly focused GME to experiment on their patients. Its not ethical. But, our ethics are under attack from a variety of sources. Anyone put an NG tube in a detainee recently? Your medical board might want to know about it.

You mean it's not normal for a peds intern who has done about 5 total pelvic exams to show up to a ship and be the "well woman coordinator" for 120+ women? You mean that's not adequate training? But I found the cervix in most of them, so I'm good, right?

 

[Mirror Form]

Poor training is a serious issue for the patients. but that aside, why is that a bad thing?

Please write that quote down and read it again once you've finished training and had some time to practice independently as a physician. Right now you don't really understand the responsibility that comes with being a doctor.

Do you really think it's no big deal if your lack of training causes you to harm a patient? Do you really think that you won't have any liability to worry about b/c you're wearing a uniform?

 

[Gastrapathy]

But hanging around with pilots hoping you'll play homoerotic volleyball is more important than quality healthcare.

 

[pgg]

Here's another thread where I try to explain what I mean to another cog (starting about post 35): http://forums.studentdoctor.net/showthread.php?t=985046

I just re-browsed that thread. The OP's willful not-getting-it-itis made my head hurt all over again.

Anyone put an NG tube in a detainee recently? Your medical board might want to know about it.

Just a few days ago this subject came up with some other physicians who are deployed with me. Good people, good friends, excellent physicians I'd trust to take care of me. Conversation quickly went elsewhere, but they didn't seem to have any real concerns or reservations over the practice, which surprised me. I guess it's possible they just haven't thought about it very much because they've never been asked to do it. I've been meaning to re-open that conversation but the opportunity hasn't really come up.

 

[d2305]

I considered it an accomplishment when I got my sailors seen by the squadron medical officer (GMO), when I was an IDC. Most of them were excellent. You think that a GMO is an accident waiting to happen, an IDC only has 10 months didactic training and 2 months clinical. More than half of the classroom training was administrative programs. I was lucky that no one died due to my negligence. Ignorance is bliss.

 

[Doctor Bob]

Wow, I've never seen anyone call themselves a cog in the machine. Strange world.

I was going to go with sprocket, or geegaw, but cog took fewer letters, and what with the sequester and all I'm trying to conserve resources.
I do the best I can within the system I'm in. But at this point I can either roll with the machine or get rolled over.

Here's another thread where I try to explain what I mean to another cog (starting about post 35): http://forums.studentdoctor.net/showthread.php?t=985046

One of the recurrent issues and complaints about GMOs is "they're undertrained and they don't know what they don't know". Which I agree with. But. I see similar problems with board certified docs here, and in the civilian world. GS docs that can't diagnose a hernia (happened here twice), endocrinologists tasked as ICU docs, FM docs who send -everything- from their clinic to the ED (and that's a problem in the civilian world also).

When it functions right, the flight docs are a front-line triage deflecting the walking well (which is a tremendous number when your patient population is young and healthy).

I dunno, I'm not qualified to speak about the entire state of military medicine; all I can say is the flight docs around here have done a decent job. And I haven't had any messes to clean up, or M&Ms to attend.

 

[StarboardMD]

When it functions right, the flight docs are a front-line triage deflecting the walking well (which is a tremendous number when your patient population is young and healthy).

If all we did was garrison medicine, then yes, GMOs could certainly have a valuable place in military medicine. But that's not all we do. The concern is for the GMO who is isolated and forced to take on the care of a critical patient whose needs are well beyond the training and skill set of the GMO.

I have no problem playing triage nurse when there's an ER down the road, but when I'm the only doc around and the frequent sand storms make both air and ground travel impossible, that's when I believe my patients' lives are literally in danger due to my single intern year of (largely surgical) training. Sure, I'm better than nothing, but is this really the best that the military can do for its soldiers?

 

[Doctor Bob]

Sure, I'm better than nothing, but is this really the best that the military can do for its soldiers?

... yes.

To have all BE/BC docs there would need to be either a dramatic increase in the number of active duty residency training slots (we don't really have the volume or acuity to do that); increase the number of deferral slots available each year (possibly a solution, but only if you can change the demographics of what people want to ultimately do); increase the compensation packages for doctors (not likely to happen in an era of reduced spending); or decrease the number of people who can seek care through the military (this would get my vote, but still not going to happen).

A piece of data, germane to this conversation and which I don't have, is how many of the people who go the GMO route ultimately wanted to do FM/IM but were unable to get a spot. And how many wanted to do some other field? If most want to do FM/IM then yes, figuring out how to shunt them into full training would be best. But if they all want to do something else, then by letting them do whatever training they want still leaves us with a care gap because having a rheumatologist as the sole doc out in the middle of nowhere is about as useful as having a GMO as the sole doc out in the middle of nowhere.

 

[BigNavyPedsGuy]

That argument is the same stupid argument used to justify substandard care all over the military "well, it's not standard of care but I don't have a better idea without spending more money...."

Stupid, dangerous argument.

 

[Doctor Bob]

That argument is the same stupid argument used to justify substandard care all over the military "well, it's not standard of care but I don't have a better idea without spending more money...."

Stupid, dangerous argument.

What is your solution?

See.. I'm not saying the situation as it currently stands is the ideal... But within the constraints the system has I don't see a great solution.
So my choices become: complain and rail against the current situation, but be powerless to do anything about it; or accept it and move on with my life doing the best job I can do with what I have, realizing the system is so much larger than what a peon like me can reasonably affect.

I choose the latter.

 

[colbgw02]

What is your solution?

See.. I'm not saying the situation as it currently stands is the ideal... But within the constraints the system has I don't see a great solution.
So my choices become: complain and rail against the current situation, but be powerless to do anything about it; or accept it and move on with my life doing the best job I can do with what I have, realizing the system is so much larger than what a peon like me can reasonably affect.

I choose the latter.

It seems pretty clear to me that people think the system needs to be changed. Finding a solution "within the constraints the system" [sic] was never really an option.

 

[orbitsurgMD]

Expand your imagination.

You get the necessary trained doctors by hiring them. You get the ones you want by offering terms the people you want will find attractive. You get choices by paying for them. The military services have a pathetic inability to imagine that the same process that delivers state-of-the-art vessels and weapons systems also works for hiring doctors. And don't tell me that is impossible or unaffordable: the managers at every major consulting firm doing hundreds of billions of dollars worth of contract business with the DOD and other branches of the defense and intelligence departments of the federal government have provided the object lesson.

HPSP does not have to be your only source of doctors. Neither does USUHS. Believe it or not, you can actually hire doctors off the street and from universities and all sorts of places where they work. All it takes is the willingness to pay them well enough and to treat them well. Of course, that might take a little more sophisticated and professional approach to recruiting than military recruiting organizations are used to having to muster, but it can be done.

But even within your own organizations, there are mechanisms to make that possible. Want someone to take a hard-to-fill billet? Give them a bonus. Then give them a guarantee of whatever they want to follow: choice of location (and no, not the usual sh*tty detailer's Hobson's choice, but really anywhere they want) or a guaranteed service-funded fellowship of their choice with no additional service obligation, or a full-time service-funded research assignment at a major university, or an all-expenses-paid set of orders to a graduate program of the professional's choice. Want to get that Ph.D.? Here is the ticket. Want three years at HHMI to do research? Here is your ticket. Want a billet in that overmanned department in San Diego? Voila! Your reward.

Give them double time credit toward their retirement for the time they spend in operational billets.

What that takes is a breaking out of the miserable, low-rent personnel management mindset that endlessly bedevils the military. Sometimes you actually do have to spend a little more money and treat your people well to get the best from them.

 

[Doctor Bob]

Expand your imagination.

You get the necessary trained doctors by hiring them. You get the ones you want by offering terms the people you want will find attractive. You get choices by paying for them. The military services have a pathetic inability to imagine that the same process that delivers state-of-the-art vessels and weapons systems also works for hiring doctors. And don't tell me that is impossible or unaffordable: the managers at every major consulting firm doing hundreds of billions of dollars worth of contract business with the DOD and other branches of the defense and intelligence departments of the federal government have provided the object lesson.

HPSP does not have to be your only source of doctors. Neither does USUHS. Believe it or not, you can actually hire doctors off the street and from universities and all sorts of places where they work. All it takes is the willingness to pay them well enough and to treat them well. Of course, that might take a little more sophisticated and professional approach to recruiting than military recruiting organizations are used to having to muster, but it can be done.

But even within your own organizations, there are mechanisms to make that possible. Want someone to take a hard-to-fill billet? Give them a bonus. Then give them a guarantee of whatever they want to follow: choice of location (and no, not the usual sh*tty detailer's Hobson's choice, but really anywhere they want) or a guaranteed service-funded fellowship of their choice with no additional service obligation, or a full-time service-funded research assignment at a major university, or an all-expenses-paid set of orders to a graduate program of the professional's choice. Want to get that Ph.D., here is the ticket. Want three years at HHMI to do research? Here is your ticket. Want a billet in that overmanned department in San Diego. Voila! Your reward.

Give them double time credit toward their retirement for the time they spend in operational billets.

What that takes is a breaking out of the miserable, low-rent personnel management mindset that endlessly bedevils the military. Sometimes you actually do have to spend a little more money and treat your people well to get the best from them.

Spending more money is a theoretical solution.
Now make it happen.
I'm not saying there aren't ways to fix the problem; I'm saying the ways people come up with aren't going to happen.

We could also fix the problem by opening an additional 10 medical schools purely for the military, consolidate all of the medical corps into one group, assign people specialties based on the needs of the military, fully train them within a uniformed residency service, pay them twice what they would make in the civilian world, remove the bureaucratic roadblocks that make people unhappy with a career in the military, etc, etc, etc.
And this plan fixes all of the milmed problems, but it's not feasible.

Or a draft... we could completely outsource all of the stateside medical care into the civilian community, then draft physicians to work in war environments based on the needs at the time.

My purpose here isn't to be snarky and sarcastic; but I try to take a realistic approach to things. In the realm of feasible solutions there are things that are feasible yet improbable, and things that are feasible and likely.

 

[orbitsurgMD]

Spending more money is a theoretical solution.
Now make it happen.
I'm not saying there aren't ways to fix the problem; I'm saying the ways people come up with aren't going to happen.

We could also fix the problem by opening an additional 10 medical schools purely for the military, consolidate all of the medical corps into one group, assign people specialties based on the needs of the military, fully train them within a uniformed residency service, pay them twice what they would make in the civilian world, remove the bureaucratic roadblocks that make people unhappy with a career in the military, etc, etc, etc.
And this plan fixes all of the milmed problems, but it's not feasible.

Or a draft... we could completely outsource all of the stateside medical care into the civilian community, then draft physicians to work in war environments based on the needs at the time.

My purpose here isn't to be snarky and sarcastic; but I try to take a realistic approach to things. In the realm of feasible solutions there are things that are feasible yet improbable, and things that are feasible and likely.

There is one thing about your examples of "solutions" that betrays a lack of understanding of the problem. And that lack of understanding is also a problem with the so-called "leaders" of the military medical community.

None of your examples of solutions would actually motivate in any positive way the person filling that difficult to fill job that really should have a better-trained person doing it.

The military's leadership is so busy with its sticks that it wouldn't know a carrot if they were bi+ch-slapped with one.

The reply of "there's no money so we can't" just does not fly. There is money.

 

[Perrotfish]

For those who have been GMOs, do you know if you had any recorded data that would reflect the quality of care that your patients received? Time to a tertiary care center after injury, morbidity and mortality data, percentage that received adequate preventive healthcare, etc? Something that could be data mined?

It seems like the big problem is we have no comparative studies concerning the quality of care delivered by internship trained physicians vs board certified physicians vs PAs vs IDCs. Which is strange because we have comparable populations cared for by all of those models. Do you think a research project retrospectively comparing outcomes for those populations is feasible?

 

[Doctor Bob]

For those who have been GMOs, do you know if you had any recorded data that would reflect the quality of care that your patients received? Time to a tertiary care center after injury, morbidity and mortality data, percentage that received adequate preventive healthcare, etc? Something that could be data mined?

It seems like the big problem is we have no comparative studies concerning the quality of care delivered by internship trained physicians vs board certified physicians vs PAs vs IDCs. Which is strange because we have comparable populations cared for by all of those models. Do you think a research project retrospectively comparing outcomes for those populations is feasible?

That's the sort of data you'd need. But there are problems with trying to construct a research project to answer that question.
If you look at adverse outcomes on a patient (because that's what we care about), you'd then have to show that a higher trained person would have been able to do differently. And since it's a knowledge differential you'd have to show that the other provider would have known what to do (very difficult to prove).

You also don't quite have comparable populations; other folks have mentioned that there are lots of flightdocs out in the middle of nowhere while the deployment locations for the specialists are at role II and role III hospitals. You'd have a headache trying to control for confounders (is is lack of knowledge leading to increased mortality or lack of supplies, or increased transit time, or etc etc etc). The mortality rate of a flightdoc in the middle of nowehere with a point of care injury isn't comparable to my mortality rate at a role III with a point of care injury.

 

[Perrotfish]

That's the sort of data you'd need. But there are problems with trying to construct a research project to answer that question.
If you look at adverse outcomes on a patient (because that's what we care about), you'd then have to show that a higher trained person would have been able to do differently. And since it's a knowledge differential you'd have to show that the other provider would have known what to do (very difficult to prove).

You also don't quite have comparable populations; other folks have mentioned that there are lots of flightdocs out in the middle of nowhere while the deployment locations for the specialists are at role II and role III hospitals. You'd have a headache trying to control for confounders (is is lack of knowledge leading to increased mortality or lack of supplies, or increased transit time, or etc etc etc). The mortality rate of a flightdoc in the middle of nowehere with a point of care injury isn't comparable to my mortality rate at a role III with a point of care injury.

My comparative populations would be the Army battalion surgeons attached to Army infantry and Navy GMOs attached to Marine Infantry. While its not perfect, they are fairly similar populations and the Navy is using internship trained physicians while the Army is using residency trained physicians. Another option would be to compare Navy battalion surgeons to Navy FPs filling the same role after straight through training, which they sometimes do instead of going to FP specific spots (I think there would be enough data points there to make a meaningful study). Either way, it would be a study of physicians with different levels of training and no practical out of residency experience filling the same battalion surgeon roles.

The question is, for those who did a GMO tour, did enough data actually get recorded somewhere when you were in a remote location that I would have something to mine?

 

[Gastrapathy]

Of course not. The navy doesn't ask questions when they don't want the answer.

 

[BigNavyPedsGuy]

The question is, for those who did a GMO tour, did enough data actually get recorded somewhere when you were in a remote location that I would have something to mine?

No

 

[StarboardMD]

Nope. Even if AHLTA-T weren't a completely worthless program, a lot of my documentation manages to not make it out of my computer...

 

[Perrotfish]

Can you guys think of any data points that would be available to mine? Pregnancies in theater? Amputation/Mortality rate for patients evacuated to higher level of care? Incidence of medical discharge after deployment? Percent disability for the medically discharged? Do you think there would be a statistically significant difference in outcomes in any of those measures?

 

[Doctor Bob]

Can you guys think of any data points that would be available to mine? Pregnancies in theater? Amputation/Mortality rate for patients evacuated to higher level of care? Incidence of medical discharge after deployment? Percent disability for the medically discharged? Do you think there would be a statistically significant difference in outcomes in any of those measures?

Hehehe... my first thought when I read this was that you were suggesting that there might be a difference in the rates of in-theater pregnancies depending on what kind of doctor was taking care of the women.

I'd imagine that the military would be -very- interested if that was the case.

 

[bricktamland]

But hanging around with pilots hoping you'll play homoerotic volleyball is more important than quality healthcare.

That line is freaking hilarious. Totally reminds me of some flight surgeons I knew.

BTW, being a GMO is probably more frightening than one realizes at the time. You get used to seeing so many normals and sh_tbirds crying and whining their way into your clinic trying to get out of stuff, that you almost become blind to real pathology. As a GMO, I once had this frequent flyer come to the clinic for the umpteenth time, and today's complaint was ankle swelling. He was probably 22 y/o. To my surprise, there was genuine edema of the ankles bilaterally. No history of trauma, no signs of infection, no pain. He had recently returned from a transcontinental flight. I was stumped and could only come up with one working diagnosis, a DVT. I called the ER to tell them I was going to send this guy over to be worked up for a DVT. The ER doctor scoffed at me and treated me like an idiot, "nobody gets bilateral DVTs," she says. But something was bothering me about the case so I told her tough sh_t, I'm sending him anyway.

So later in the day I call the ER. The kid was admitted to the hospital. It wasn't a DVT after all. Turns out he had leukemia.

The point of this story is that GMOs will get a few bonafide cases of cancer, rare diseases, and other serious pathology. Is their training up to snuff to recognize these cases in a timely manner? IMO, hell no. I think I got lucky as a GMO and never had anything bad happen. But now as staff, I've seen a few M&M cases in the last year that occured under GMO care. I won't go into any details, but I'll say they were quite serious. I feel like the military roles the dice with both the patients and the careers of young doctors.

 

[BigNavyPedsGuy]

The point of this story is that GMOs will get a few bonafide cases of cancer, rare diseases, and other serious pathology. Is their training up to snuff to recognize these cases in a timely manner? IMO, hell no. I think I got lucky as a GMO and never had anything bad happen. But now as staff, I've seen a few M&M cases in the last year that occured under GMO care. I won't go into any details, but I'll say they were quite serious. I feel like the military roles the dice with both the patients and the careers of young doctors.

Well said. There it is.

 

[kyu1q84]

So later in the day I call the ER. The kid was admitted to the hospital. It wasn't a DVT after all. Turns out he had leukemia.

 

[pgg]

The point of this story is that GMOs will get a few bonafide cases of cancer, rare diseases, and other serious pathology. Is their training up to snuff to recognize these cases in a timely manner? IMO, hell no. I think I got lucky as a GMO and never had anything bad happen.

Agreed. I've been there.

22 year old Marine came in with a little bit of chest/abd discomfort and some hematemesis. NSAID gastritis like the last 73 cases like that? No. Esophageal adenocarcinoma.

On a deployment, all by myself within rock-chucking distance of Pakistan, another young Marine came in with URI symptoms. Blew it off with the usual cold pack. He came back 3 weeks later, not better. Still felt tired, and had lost some weight. Deployed-Marine-tired-and-fit-from-hiking-in-the-mountains syndrome like the other 1000 Marines in the battalion? No. Leukemia.

Pathology is out there, even in the 18-24 yo indestructable demographic. I still wonder about what kind of problems I missed.