Who are our commanding officers?

[ProudMD]

Once we (military physicians) finish our residency training and report for duty as attending, who typically serve as our commanding officers? Will they mostly be senior military physicians or line officers?

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[BigNavyPedsGuy]

They won't be line officers. They'll be either physicians, nurses or medical admin folks. Most likely an O-6 - unless you're at a big training site.

 

[colbgw02]

In the Army, at least, you will have parallel chains of command. I have a series of physician bosses who are in charge of my daily schedule, write my OERs, etc., and then I have company and troop commanders. The latter make sure that everyone gets a flu shot, takes the APFT, etc. They also generally annoy the hell out of every physician that they track with their mind-boggling levels of bureaucracy.

 

[TurtleDO2012]

Every nurse and spouse of a LTC and above hahaha.

 

[ProudMD]

In the Army, at least, you will have parallel chains of command. I have a series of physician bosses who are in charge of my daily schedule, write my OERs, etc., and then I have company and troop commanders. The latter make sure that everyone gets a flu shot, takes the APFT, etc. They also generally annoy the hell out of every physician that they track with their mind-boggling levels of bureaucracy.

Thanks for the response.

As a followup question, which chain of command approves our annual special pays? According to my knowledge, both ASP and ISP need to be approved by our commanding officers on a yearly basis. Will physician bosses approve these, or will company/troop commanders approve these?

Also, in general, which chain of command is in charge of our promotions/assignment placements?

 

[colbgw02]

Thanks for the response.

Also, which chain of command approves our annual special pays? According to my knowledge, both ASP and ISP need to be approved by our commanding officers on a yearly basis. Will physician bosses approve these, or will company/troop commanders approve these?

Without checking, I think these contracts had the hospital commander's signature block on them, which would make him the approving authority.

Special pays is something that I've never really seen anyone try to muck with. For me, someone from the S1 shop start sending out mass emails in April (MASP) and August (ISP) with designated times and places to show up with an unrestricted medical license. The whole process as been pretty seamless, at least for me, especially considering I've even gotten paid on time. Assuming you are appropriately privileged and in good standing, I would think it would be the same for you.

 

[ProudMD]

Without checking, I think these contracts had the hospital commander's signature block on them, which would make him the approving authority.

Special pays is something that I've never really seen anyone try to muck with. For me, someone from the S1 shop start sending out mass emails in April (MASP) and August (ISP) with designated times and places to show up with an unrestricted medical license. The whole process as been pretty seamless, at least for me, especially considering I've even gotten paid on time. Assuming you are appropriately privileged and in good standing, I would think it would be the same for you.

Thanks. Are hospital commanders line officers or physicians/nurses?

 

[colbgw02]

Also, in general, which chain of command is in charge of our promotions/assignment placements?

Neither, really. The final approval authority for Army MC is the OTSG, but the assignments are actually created at Human Resources Command (HRC). There will be someone at HRC assigned to your AOC who will work closely with your field's consultant to plug all holes. The consultant can hold considerable sway, but - as the name indicates - they are still an advisor, strictly speaking.

 

[colbgw02]

Thanks. Are hospital commanders line officers or physicians/nurses?

All of the above, if you include MSC as a line officer. You won't have an infantry officer as a CO, if that's what you mean. Although, now that I think about it, I'm not entirely sure I've ever seen an MSC officer as a hospital CO. I'm sure it's happened; I just haven't been under one. That's a little surprising considering I've seen 8 different hospital COs in 9 years, to include several physicians, a CRNA, a dentist, a nurse, and a PA (or maybe it was PT?).

Edited to clarify: You won't have an infantry CO if you are assigned to an MTF/TD&A unit. If you are in the MTOE world, then it will depend on the unit type.

 

[ProudMD]

All of the above, if you include MSC as a line officer. You won't have an infantry officer as a CO, if that's what you mean. Although, now that I think about it, I'm not entirely sure I've ever seen an MSC officer as a hospital CO. I'm sure it's happened; I just haven't been under one. That's a little surprising considering I've seen 8 different hospital COs in 9 years, to include several physicians, a CRNA, a dentist, a nurse, and a PA (or maybe it was PT?).

Edited to clarify: You won't have an infantry CO if you are assigned to an MTF/TD&A unit. If you are in the MTOE world, then it will depend on the unit type.

Please excuse my ignorance, but what does this mean?

 

[colbgw02]

Please excuse my ignorance, but what does this mean?

MTOE = modified table of organization and equipment. In broad strokes, an MTOE (pronounced 'emtoe') unit is defined as an operational unit, so think infantry battalion. In contradistinction, a TDA (table of distribution and allowances) unit is a non-operational unit, like a hospital.

 

[deuist]

Edited to clarify: You won't have an infantry CO if you are assigned to an MTF/TD&A unit. If you are in the MTOE world, then it will depend on the unit type.

The same could happen to flight surgeons who are assigned to flying squadrons. Your boss might be a pilot. In general, however, expect that your commander will have some kind of healthcare training or experience.

 

[Doctor Bob]

Although, now that I think about it, I'm not entirely sure I've ever seen an MSC officer as a hospital CO. I'm sure it's happened; I just haven't been under one. That's a little surprising considering I've seen 8 different hospital COs in 9 years, to include several physicians, a CRNA, a dentist, a nurse, and a PA (or maybe it was PT?).

Wasn't the last CO at BAMC an MSC? From his certification blurb: he is "board certified in healthcare management and a Fellow in the American College of Healthcare Executives". He was a nurse in a past life though...

The guy running the place now is a surgeon.

 

[colbgw02]

Wasn't the last CO at BAMC an MSC? From his certification blurb: he is "board certified in healthcare management and a Fellow in the American College of Healthcare Executives". He was a nurse in a past life though...

The guy running the place now is a surgeon.

I was always a little unsure about that guy's résumé. It seems like I had been told he was either a PA or PT, but also spent time as an MSC officer as well as flying helicopters (not sure if as avaiation corps or warrant).

 

[jabreal00]

Every nurse and spouse of a LTC and above hahaha.

Or any douche-bag LTC and above battalion commander who is a demanding patient of yours and wants to be waited on hand and foot because you are a lowly 04.

 

[TurtleDO2012]

Former guy at BAMC was a nurse first then branch transfer to aviation and became a pilot. There for some time. Eventually did the military Baylor program for their masters in health administration and slid back into the hospital admin route.

Next demanding patient just tell them they need a rectal exam.

 

[jabreal00]

Next demanding patient just tell them they need a rectal exam.

With my line of work that is often is part of my initial assessment! These are the types who demand more

 

[HighPriest]

Just echoing:

My chain of command is as follows:

My techs, NCOs, MSAs -> ME -> Department of Surgery Chief (currently a civilian surgeon, formerly not a physician) -> DCCS (a physician who rarely practices) -> Hospital Commander (A nurse)
But wait, there's more!
That's the hospital's command structure, but you're also part of a regular military company. The chain of command is hazier there, but it is basically:

Me -> A bunch of civilians and maybe the company's first sergeant -> the company commander (a captain, MSC officer).

For your day-to-day work, the company has little involvement, and your chain is the hospital command. For all of your Army related training and requirements, the Company is your go to. They're calling you at 0300 for UAs, making sure you're present for PT, scheduling you for field training, AWT, and the M-9 range without asking you, that sort of thing.

Some stuff gets sign off from both sides. When I ask for leave, the DOS chief signs it, then it goes to the Company where the Company CO (a man two-grades lower than the DOS chief) signs off on it. MASP/ISP, etc. starts in the Company, and then ends up on the Hospital Commander's desk for final approval. ODE is the same way.

It is extremely convoluted and ridiculous, and it is a product of milmed being crammed into the same general format that every other military unit is assigned, while not being anything like any other military unit.

Often times, when I need something signed or when I have a question that cannot be answered via e-mail, I have to cancel at least a half day of clinic so that I can go back-and-forth between the company and the hospital to get signatures in person - because my time is considered the least important of all. For example: credentialing, MASP, ISP, ODE-related issues.

 

[Monty Python]

Former guy at BAMC was a nurse first then branch transfer to aviation and became a pilot. There for some time. Eventually did the military Baylor program for their masters in health administration and slid back into the hospital admin route.

.

COL Kyle Campbell, now retired, is the VP and Chief Operating Officer at Scripps Medical Foundation in San Diego. While I only knew him superficially, he seemed very sharp. And yes, he was RN, then pilot, then healthcare admin. Very interesting resume':

https://www.linkedin.com/pub/kyle-d-campbell-fache/12/664/a49

If you read his resume' you'll notice one thing which irritates me: how the military shuffles leaders essentially q2years. While that cycle gets rid of toxic/ineffective leaders from a given site rather quickly, it also causes you to lose good ones before they can implement real and needed change at their current location. With Joint Commission's new focus on High Reliability Organizations, I hope the MHS rethinks the tenure of their hospital leaders. Constant q2yr turnover goes against the principles of implementing genuine and effective leadership.

 

[ProudMD]

Just echoing:

My chain of command is as follows:

My techs, NCOs, MSAs -> ME -> Department of Surgery Chief (currently a civilian surgeon, formerly not a physician) -> DCCS (a physician who rarely practices) -> Hospital Commander (A nurse)
But wait, there's more!
That's the hospital's command structure, but you're also part of a regular military company. The chain of command is hazier there, but it is basically:

Me -> A bunch of civilians and maybe the company's first sergeant -> the company commander (a captain, MSC officer).

For your day-to-day work, the company has little involvement, and your chain is the hospital command. For all of your Army related training and requirements, the Company is your go to. They're calling you at 0300 for UAs, making sure you're present for PT, scheduling you for field training, AWT, and the M-9 range without asking you, that sort of thing.

Some stuff gets sign off from both sides. When I ask for leave, the DOS chief signs it, then it goes to the Company where the Company CO (a man two-grades lower than the DOS chief) signs off on it. MASP/ISP, etc. starts in the Company, and then ends up on the Hospital Commander's desk for final approval. ODE is the same way.

It is extremely convoluted and ridiculous, and it is a product of milmed being crammed into the same general format that every other military unit is assigned, while not being anything like any other military unit.

Often times, when I need something signed or when I have a question that cannot be answered via e-mail, I have to cancel at least a half day of clinic so that I can go back-and-forth between the company and the hospital to get signatures in person - because my time is considered the least important of all. For example: credentialing, MASP, ISP, ODE-related issues.

@HighPriest

Wait...

You are at least a Captain (O-3) when you begin your career as an army physician. How can you be subordinate to ANOTHER Army Captain (O-3)? And when you get promoted to O-4 and above, are you still under the command of a COMPANY COMMANDER - as in, are you still part of a COMPANY unit when you become a Major? Can you elaborate more on this? Do line officers have authority over all medical officers?

 

[BigNavyPedsGuy]

@HighPriest

Wait...

You are at least a Captain (O-3) when you begin your career as an army physician. How can you be subordinate to ANOTHER Army Captain (O-3)? And when you get promoted to O-4 and above, are you still under the command of a COMPANY COMMANDER - as in, are you still part of a COMPANY unit when you become a Major? Can you elaborate more on this? Do line officers have authority over all medical officers?

So, there's rank authority and positional authority. I was a Dept Head as an O-4. I had to approve the leave requests/schedule of one of my O-6 partners. Not every person who outranks you is your CO? If you are at the hospital as an O-3 resident and one of your patients is an O-5 tank driver, they don't command you. You say "sir/Maam" etc, but they can't order you around. It does get tricky sometimes.

In general, if you are stationed at a hospital, your boss is medical. If you're a GMO/Flight surgeon/battalion surgeon, your boss is a line officer.

 

[ProudMD]

So, there's rank authority and positional authority. I was a Dept Head as an O-4. I had to approve the leave requests/schedule of one of my O-6 partners. Not every person who outranks you is your CO? If you are at the hospital as an O-3 resident and one of your patients is an O-5 tank driver, they don't command you. You say "sir/Maam" etc, but they can't order you around. It does get tricky sometimes.

In general, if you are stationed at a hospital, your boss is medical. If you're a GMO/Flight surgeon/battalion surgeon, your boss is a line officer.

That's definitely an interesting power/relational dynamic.

 

[Pannu86]

So let me get this straight, if you have a RN who is also taking care of your patient but who out ranks you, can she give you a direct order? What about you giving her/him medical orders as you are an MD, would you have to be all respectful and courteous? What about in an emergent situation like a code, how do you order techs or RNs who may out rank you? Do you still render salutes to such RNs or techs in ceremonies or outdoors when routine saluting is warranted? Pardon my ignorance please.

 

[colbgw02]

So let me get this straight, if you have a RN who is also taking care of your patient but who out ranks you, can she give you a direct order? What about you giving her/him medical orders as you are an MD, would you have to be all respectful and courteous? What about in an emergent situation like a code, how do you order techs or RNs who may out rank you? Do you still render salutes to such RNs or techs in ceremonies or outdoors when routine saluting is warranted? Pardon my ignorance please.

The RN won't try to pull rank in order to get the physician to change management. Or, more accurately, he/she will do it once. Then the **** hits the fan and, assuming the doc was in the right, the nurse loses.

You should honor all military customs to all ranks, including those below you. As staff, I've had to salute residents. Remember, respect the rank, not the man.

 

[Pannu86]

All RNs, lab services, pharmacy techs are your eyes and ears.

 

[ProudMD]

The RN won't try to pull rank in order to get the physician to change management. Or, more accurately, he/she will do it once. Then the **** hits the fan and, assuming the doc was in the right, the nurse loses.

You should honor all military customs to all ranks, including those below you. As staff, I've had to salute residents. Remember, respect the rank, not the man.

How is this possible? More specifically, how can a military resident (O-3) be higher ranked than an attending (O-3 at minimum, often O-4 or higher)?

 

[colbgw02]

How is this possible? More specifically, how can a military resident (O-3) be higher ranked than an attending (O-3 at minimum, often O-4 or higher)?

Not all residents are O-3s, obviously.

 

[colbgw02]

It happened to me as an intern. With a nurse manager of a ward. I was polite, explained why it needed to be done the way I wrote, and everything worked out fine.

It's worth noting, I think, that nurses have a responsibility to monitor our practice, to ensure that aren't making a mistake or doing something dangerous. They aren't automatons who have to blindly execute everything we write on an order sheet. And I'm glad for that. While I've had run-ins with nurses just like everyone else, I have had more times where they caught mistakes for me before something bad happened.

Absolutely. I was just trying to point out that, in my experience, nurses or any non-physician providers in the military generally don't feel emboldened to challenge physicians because of their rank. They may be emboldened because they're either right to do so or it's in their nature to be confrontational, but the former definitely isn't unique to milmed and the latter - if it's even more common in MTFs - is only circuitiously related to being in uniform.

 

[ProudMD]

Not all residents are O-3s, obviously.

Is it common for people to delay residency for so long after graduating medical school that by the time they get to residency they are already O-4s (or even higher) in rank?

 

[colbgw02]

Is it common for people to delay residency for so long after graduating medical school that by the time they get to residency they are already O-4s (or even higher) in rank?

This is phrased as if the people had a choice.

The frequency of this will depend a lot on the branch and specialty. I work in a specialty where we have a relatively high-percentage of former GMOs and people completing second residencies.

 

[BigNavyPedsGuy]

Yeah, I agree with you 100%. I have heard anecdotal stories in the past about nurses attempting to "pull rank," but have yet to see it myself. I also haven't had any of my colleagues complain of this. I agree that the conflicts we do experience are much more garden variety physician/nurse conflicts, rather than having anything to do with military rank.

I've had this be preeeeetty close to them trying to make me change my management by using their rank. It was with the NOD (nurse of the day) when I was a senior resident. We didn't have very many beds and she was questioning whether or not I should be admitting a sick child. Then I asked her if she would rather I just discharged all of the sick patients (including HONC patients getting chemo) in the middle of the night. She backed off.

 

[BigNavyPedsGuy]

I haven't had that problem since I've been out, but I'm not at a tertiary care center. If we're full we just refer up the chain to the folks who can almost never divert (sorry guys)

 

[Pannu86]

I am at a tertiary care center and trained at another. Diversion/transfers/re-routing were/are/will happen during surges. Patients Gotta get beds somewhere period.

 

[HighPriest]

@HighPriest

Wait...

You are at least a Captain (O-3) when you begin your career as an army physician. How can you be subordinate to ANOTHER Army Captain (O-3)? And when you get promoted to O-4 and above, are you still under the command of a COMPANY COMMANDER - as in, are you still part of a COMPANY unit when you become a Major? Can you elaborate more on this? Do line officers have authority over all medical officers?

Seems like this has been answered. I outrank the Company CO, but he is still the CO. I do not envy his job.

 

[ProudMD]

Seems like this has been answered. I outrank the Company CO, but he is still the CO. I do not envy his job.

I see. So he is your "superior" officer but you are higher in rank? So who salutes who in such instances? Does military rank always take precedent?

 

[TurtleDO2012]

ProudMD who cares about these sort of irrelevant details. You'll figure it out during your respective officer summer course during med school if u happen to sign up and take the scholarship and survive medical school.

 

[ProudMD]

ProudMD who cares about these sort of irrelevant details. You'll figure it out during your respective officer summer course during med school if u happen to sign up and take the scholarship and survive medical school.

I am already committed to USUHS, and I don't think these are "irrelevant details". I am genuinely curious and want to know as much about the military aspects of a military physician as possible.

 

[colbgw02]

I think what's more important is that there are about eleventy billion details and nuances of military customs and culture. You're going to figure it out eventually, either because you'll be taught it or you'll live it, so learning about it piecemeal over the internet is of limited utility, especially if your decision to join has already been made.

 

[pgg]

That's definitely an interesting power/relational dynamic.

Once upon a time I was an anesthesiologist fresh out of residency, PCS'd to a small command for my first staff tour, and my dept head was a CRNA. It mostly worked out OK. We had some occasional conflicts more related to her my-way-or-the-highway tendency and knack for burning every bridge with every person on sight whether it'd been crossed or not, whether that person was a willing ally or not, but she never attempted to influence my care of patients. And she was quite good at many of the admin side tasks. Eventually I took over as dept head then later DSS and to be honest I often missed just being a worker bee.

 

[244913]

I am already committed to USUHS, and I don't think these are "irrelevant details". I am genuinely curious and want to know as much about the military aspects of a military physician as possible.

Stop being such a weenie. You were smart enough to get into USUHS you will figure all of this out. They teach 18 yo privates with IQ's somewhere around room temperature how to do this in a couple of weeks.

When I was commissioned I was given a copy of the Army Officer's guide, which is fairly outdated but explains every custom/courtesy in excruciating detail. I didn't learn a thing from it. I got a good handle on military custom after being immersed in an operational unit for four weeks. After 4 years, I probably could have written a book myself.

FWIW my bosses for all 4 years were helicopter pilots and for the most part I couldn't have asked for better leaders, mentors, or confidantes. I would have taken them in a heartbeat over the nurses, MSC's (who hate doctors), physical therapists and other non-entities who abound in clinics/MTF's. I always felt sorry for the guys who weren't in line units.

- ex 61N

 

[HighPriest]

I see. So he is your "superior" officer but you are higher in rank? So who salutes who in such instances? Does military rank always take precedent?

You salute the rank, not the man. Didn't you learn anything from Band of Brothers?

 

[HighPriest]

To piggyback on this, the culture is quite different between the different sides of the Navy. Marine Corps very different from surface fleet, and very different from an MTF. At USUHS, they'll teach you plenty. If you were HPSP, these questions are a little more important to figure out up front. In your case, I wouldn't even waste your time with pre-education. It would be like reading Robbins the summer before you start.

I was HPSP. These details still don't matter now that I'm "out here." But it's cool to ask.

What I mean to say is that there are tons of details (as mentioned) and you'll learn them as you go. Ultimately you might find them interesting and you might really adapt to military culture. Or you might not. As far as I am concerned the only important thing you can do is to be a good physician, and take good care of your patients. If you do that, feel free to learn as much or as little about pomp and circumstance as you like.

 

[d2305]

Never stick your hand out to a senior upon meeting. If he wants to shake hands, he must initiate the gesture.

 

[HighPriest]

Or do. Whatever.

 

[pgg]

FWIW my bosses for all 4 years were helicopter pilots and for the most part I couldn't have asked for better leaders, mentors, or confidantes. I would have taken them in a heartbeat over the nurses, MSC's (who hate doctors), physical therapists and other non-entities who abound in clinics/MTF's. I always felt sorry for the guys who weren't in line units.

The best CO that I ever had was a Marine LtCol. He's a general now and I hope he runs for President someday. I would go through that wall nose-first for him.

The next best CO that I ever had was Nurse Practitioner. Enough of a clinician to understand what matters and what doesn't. Let us work, gave us what we needed, stuck her neck out to support staff to do the right thing, even when Navy policy was a little hazy in those areas.

My worst CO ever was a doctor, but my suspicion is that he took a series of not-doctor billets before becoming a CO because he was not a good doctor and wasn't interested in medicine. I'm not sure where he is now, but if I ever run into him again, I will tread lightly, because I have no doubt he'd open my throat if he thought a little silver star might fall out.

They had a nurse admiral in charge of Bethesda for a while way back when I was an intern, and although she did some wacky stuff, I was too busy being an intern to really get hurt by her shenanigans.

I once had a dentist as a CO, but I was deployed during about 1/2 of his tenure. People complained about him but I thought he was OK.

On the XO side ... mostly of my XOs have been doctors I think, with one nurse midwife and a pharmacist. The pharmacist was wonderful; he went on to become a CO and deservedly so.


Long story short, I can't really say I think Corps of origin is very well correlated with quality of hospital leadership.

 

[Pannu86]

Never stick your hand out to a senior upon meeting. If he wants to shake hands, he must initiate the gesture.

Interesting! I shook hands of every 0-5 that I met during my in-processing, never realizing they must have cringed inside lol!

 

[HighPriest]

I've stuck my hand out to the same O-8 on at least 4 seperate occasions. The first time as a junior resident. So did the other residents, so did our staff docs. The sky remained intact.

 

[244913]

I've stuck my hand out to the same O-8 on at least 4 seperate occasions. The first time as a junior resident. So did the other residents, so did our staff docs. The sky remained intact.

That O8 is not a line officer and you're in a medical setting. Very different worlds. In operational units leaders will cut you some slack if you're a good Doc but you must have a much deeper understanding of customs and courtesies.

For the most part you are held to the exact same standard as any other Staff officer.

- ex 61N

 

[deuist]

Eventually I took over as dept head then later DSS and to be honest I often missed just being a worker bee.

My department chair is an O-4, as are about 10 other people in the shop. His job is definitely not enviable. Like many things in the military, his responsibility is to keep the paperwork moving and he never gets to make decisions.

 

[TurtleDO2012]

hopefully they'll have a coin ready for ya.