All Branch Topic (ABT) 35 Reasons Not to Join Military Medicine

"There sighs, lamentations and loud wailings resounded through the starless air, so that at first it made me weep; strange tongues, horrible language, words of pain, tones of anger, voices loud and hoarse, and with these the sound of hands, made a tumult which is whirling through the air forever dark, as sand eddies in a whirlwind."
--Dante Alighieri, Inferno, Canto III, line 22

0) Tyrannical, Pointy-Haired Boss (PHB) commanders: Idiots in charge have lost all touch with clinical medicine, yet feel free to micromanage/punish those with more knowledge/training/skill than themselves. Note: many of these commanders will be nurses, PAs, or MSC officers with zero hours of medical school.

1) Unending deployments to remote locations: At remote, IED-filled sand traps, surgeons will be ordered to see sick call (runny noses, jock itch), while primary care docs will act as glorified techs under the watchful eye of R.N. commanders. Clinical skills of highly trained physicians will atrophy in smelly tents, a tedium uninterrupted except for rare moments of sheer terror.

2) AEF (Aerospace Expeditionary Force) is a broken promise: Abysmal management of deployments and AEF system-- 3 month AEF "buckets" increased to 4-8 month window with transitional Blue/Silver AEF groups (due to sheer poor personnel planning on USAF's part). [Update to Legacy Reason: Before 9/11, the Air Force was promising 90 day deployments to improve morale/retention. Then, when the balloon went up with the Iraq war, it was all "Oops! Due to Sheer Poor Planning, we don't have enough bodies to fulfill that promise we made to our service members, so we will just take it back." Accordingly, highly trained ophthalmology technicians were deployed to the sand as part of Army units to serve as machine gunners in the back of trucks (true story) for a year or more: "Um, you will be deployed as long as the rest of the members of your Army unit, because the Air Force generals at the Pentagon don't want to have their manhoods compared to the Army generals during rounds of golf."] Basically, in 2020, you'll be deployed for some vague time, and then they'll extend it, and then extend it again, until the day you have your bags packed to go to the airport, then they will extend it again. Lack of predictability leads to family strife, loss of morale, and minimization of retention post-deployment.

3) The Objectionable Medical Group: All animals are equal, but some are more equal than others. Starting in 1993, the "Objective" Medical group made physicians = nurses = pharmacists = housekeepers in terms of rank and command potential on the org chart. Thus, the Commanding General of Andrews AFB hospital from 2000-2003 was a nurse, who had life-or-death UCMJ authority over the physicians beneath her. Gulp. Better not annoy *any* nurse in the hospital, or you'd better pack your bags for Greenland...

4) Inappropriate subordination of anesthesiologists to surgeons: In the civilian world, anesthesiology is its own department. In the military, anesthesiologists are lumped in with all the surgeons, including surgical subspecialists. When a surgeon is the person who writes your OPR (Officer Performance Report, which determines promotion and assignments, among other things), are you going to cancel a sexy yet high-risk case and ruin your career, or are you going to endanger the patient's life, in violation of medical standards of care? Do you want to hang or get shot?

5) Inappropriate subordination of physicians to nurses, pharmacists, and other non-MC officers who are able to attain rank/position due to OMG: Corollary of 4, but worth repeating. The first time a nurse overrules your doctor's order because of the rank she wears on her shoulders, you will not a happy camper be.

6) Extremely poor long-term planning by everyone above O-5: Multiple AF Surgeons General and the Air Staff woefully miscalculated regarding needed end-strength in both medical corps and line. Entire year groups of physicians who wanted to become anesthesiologists were alienated between 1997-2001 due to perceived lack of flight surgeons/GMOs-- they were prevented from going to residency and forced into GMO/flight surgeon billets (Roadman). This dried up the pipeline of fresh, new anesthesiologists entering the Air Force. Remaining stale schmucks like myself were forced to pull every-other-night call for THREE MONTHS after 9/11 just to keep up the Ops Tempo of the Operating Rooms (surgeons might have one O.R. day per week, if they're lucky; anesthesiologists have 5-7 O.R. days/week). No one cared about the after-effects of burnout and demoralization this caused (which contributed in no small part to the disastrous career-ending reprisals against me when I spoke out as a patient safety advocate when we were forced to both perform our own stat C-section anesthetics while "covering" four CRNAs on the other side of the hospital against all anesthesia ethical standards of care because "we're short-staffed and this is the only way to keep up our ops tempo so shut up").

7) Zero emphasis on retention: Nothing is done to make life as a physician in the military easier. You get no respect, little pay, long hours, and minimal opportunity for leadership. Embittered and demoralized staff docs leave after 4 years post-residency, just when they are hitting the prime of their skills, leaving behind the largest two cohorts of M.D.s: intelligent but inexperienced folks right out of residency, and pencil-pushing dinosaurs who haven't touched a patient (appropriately, at least) in years. This reminds me of the hospital Vice Commander surgeon who would only come to the O.R. to scrub in on breast reductions, so he could spend 5 minutes massaging the patient's mammaries while she was under general anesthesia, before the real plastic surgeon did the case in a professional manner...

8) Stop-Loss and IRR Call-ups: The inevitable result of the Sheer Poor Planning and Lack of Retention documented above.

9) AF emphasis on non-physician medical care (PAs, NPs, Nurse Midwives, etc.). This is subtly different from the OMG issue. You, your family, and your patients are more likely to see non-physicians operating with inadequate physician supervision when they present for care at MTFs. The resulting malpractice will injure and demoralize you, your family, and your poor patients.

10) Lack of appropriate chain of command designation in absence of Flight Commander creates authority vacuum: There are three kinds of bosses in the military a) Absentee Landlords/Landladies, who never show up for work, but spend all of their time on fictitious "TDYs" while watching TV at home with their twins or building their McMansions; b) Tyrant PHBs, who micromanage more competent subordinates with utter brutality, and c) Clueless GOBs (Good Old' Boys) who made rank because of their Air Force Academy and/or Aggie Flight Surgeon street cred. When your boss is an Absentee Landlady, the Tyrant above her will continually scream for immediate action on worthless paperwork that only she can sign. If she passively refused to set up a hierarchy in her absence, it will lead to confusion and stress: Should the LtCol Nurse sign the doctor's OPR, or should the next senior Doc, or what about Mr. Rob, the housekeeper...

11) Misusing anesthesiologists as IV start service: nursing staff, techs, ward clerks feel "empowered" to consult anesthesia service to start IVs, because they are completely incompetent to do anything except chart vital signs on the computer and update their social media statuses on their phones. Interns and residents become completely incapable of starting IVs (a critical ACLS skill) due to their addiction to anesthesia doing their jobs for them at 0300. In the outside world for 15 years, I was never (not once) called to the ward to start an IV, because they knew I would CHARGE MONEY for the CONSULT, and nobody wanted to pay that. The solution is to have the military train a cohort of "rapid response" nurses/techs to respond to things like patient decompensation on the ward or lack of IV access. That, of course, would require money and planning, which is harder for the system than abusing board-certified physicians in the middle of their call night.

12) No (Competent) Pediatric Care: Andrews AFB Adult Ward was magically designated pediatric ward after I complained that kids were being recovered on an adult ward sans peds nursing, peds equipment, or inpatient pediatricians. This is a result of both downsizing (closing pediatric ward and sending pediatricians to staff only outpatient clinic) and inadequate training of staff. Every SINGLE peds patient requires anesthesia to start/restart IV. An active duty CRNAs son got sick; his wife (medical tech) had to stay with kid 24/7 because ward nurses were "uncomfortable" caring for kids and didn't even know how to take kids' temperatures, let alone draw blood. All the nurses have to say is that they are "uncomfortable" in order to draft specialist physicians to do their jobs. Of course, the nursing chain of command will support them 100% in the "interest of patient care" vs. getting butter bar nurses adequate training to do their jobs competently.

13) Polyester uniform pants: Being told not to wear BDUs in time of war due to arbitrary decision of people at HQ AMC for propaganda purposes ("The War Is Over, See, We're In Blues Now") is uncomfortable and demoralizing. This is just one of many examples of seemingly-minor "crazy makers" that drive physicians out of the military. BDUs are 1,000x more comfortable to wear all day than polyester, but some General at the Pentagon wasn't saluted from 30 feet away because the rank was subdued rather than shiny, so the rest of the Air Force has to suffer so he can avoid using his ED meds by getting dopamine hits from groveling underlings.

14) Keeping up with the Army Syndrome: 1.5 Mile run --> psycho ergometry --> 1.5 mile run + pushups + sit-ups. Too many overweight NCOs and Senior Officers were keeling over dead on the tracks during annual 1.5 mile runs. Thus, in the 1990s, the AF spent literally millions of dollars implementing "psycho ergometry": stationary bike testing, which measures your ability to relax rather than cardiac conditioning (I passed every time by hypnotizing myself into a relaxed state, thus preventing excessive tachycardia). When our Army colleagues started making jokes about the "Chair Force", the Chief of Staff unilaterally implemented increased PT requirements in order to make him look more manly in the Pentagon bathroom. Line officers and enlisted folks shut down their offices to train during duty hours. You will notice this fact when you try to go to finance or MPF on your limited time off duty before they close at 1500, only to find their offices closed for "Unit PT". Guess when you, as a doc, will have to do your PT training: on your own time, or after hours (see #18 below).

15) New bright Blue BDUs after I have spent hundreds of $$ getting green ones: [Legacy Complaint, but uniforms change way too often to justify the jobs of the dweebs in the DAUCFNGR [Department of Arbitrary Uniform Changes For No Good Reason]). As officers, you have to buy your own uniforms rather than have them issued to you (for the most part). Just when you get your uniforms broken in, lusers whose only job is to change uniforms constantly will change them (example: cheap plastic name tags on Service Dress Uniform --> No name tags for a few years--> Mandatory $15.00 polished metal name tags--> ? tomorrow).

16) Woeful lack of experience on wards: constant shuffling of officers and NCOs as soon as they get good at one job due to antiquated assignment system prevents maintenance of "cadre" of seasoned nurses and techs. Nurses FOB (Fresh off the Boat) expected to recover patients after thoracic surgery. One 2Lt looked at the sternal dressing after CME and asked me if that's where the a-line had been placed. "Ya, right into the aorta...we get very accurate readings that way," I replied.

17) No meetings during patient care hours: Part of what I call the SARS: Stupid @ssed Rules Syndrome. Other SARS include non-use of military telephones to call home to tell your family you will be two hours late because the charting computer crashed AND you can't use your cell phone in the hospital (Catch 22.5); restriction of Occupational Badges to keep nurses happy (i.e., senior and chief physician badges used to be based on residency training; now based on longevity alone); and requirement to wear your uniform to work on weekends/holidays UNLESS you are a surgeon or internist, because they just ignore the SARS anyway with impunity.

18) Mandatory "Fun Runs" with squadron commander after hours or on training days instead of getting home an hour or two early to see one's family

(to be continued...hit character limit...too much character gets you in trouble in the military...)

Lasciate ogni speranza, voi ch'entrate.
Translation: Abandon all hope, you who enter here (speaking of USAFMC).
--Dante Alighieri, Inferno, Canto III, line 9

--
Rob Jones, M.D.
Ex-LtCol, USAF, MC
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, CA
OEF Anesthesiologist, 39th EMEDS, Incirlik AB, Turkey (2002)
Harvard '85 (ROTC Det. 365); USUHS '90; WHMC Anesthesiology '94
webmaster_AT_medicalcorpse_d0t_com
On Hiatus
Nemo Me Impune Lacessit

(continued; see post above for the first set of reasons)

19) Lack of military discipline/customs/courtesies in young officers and enlisted: I walked all around the Walter Reed Post in Dec 04, and had more than 10 enlisted Army types fail to salute me as a LtCol...and I am NOT counting the "no salute" area right outside the hospital, where arrogant enlisted folks smoke where they're not supposed to. Airman yelled out on OB deck: "The anesthesia dude is here!" "Ahem, that would be LtCol Dr. anesthesia dude to you, dude," I replied. He wasn't fazed a bit; he just laughed off his rude insubordination.

20) No incentive to finish O.R.s early: no extra pay for overtime; clinics take priority for surgeons due to political pressures. "Emergency" fracture cases, etc., forced to wait until 1630, when the ONE ortho surgeon who is not deployed has finished holding the hands and de-ruffling the feathers of General's wives in the clinic. This ensures you will be doing major hip fracture cases after hours when every other consultant in the hospital is at home and drinking margaritas when your patient starts to have severe ST changes on the monitor indicative of an impending MI...

21) No doctors' parking lots: lots of reserved parking for NCOs, clipboard-carrying nurses and non-clinical bureaucratic functionaries. One of the best parts of starting Day 1 at my civilian hospital was finally being able to park in the Doctors' Parking Lot after 15 years of fighting for a parking spot close enough to let me get to the OR in time. 1/3 of parking lot is taken up by construction or landscaping contractors 24/7.

22) Department of Beneath My Dignity Department: Medical officers/enlisted ordered to pick up trash around base for visiting bigwigs--> a private air show to which we were not invited (canceled by Hurricane Isabel). Psychiatrists were ordered to give up Saturday to come in to the records section of "Gold Team" primary care clinic to sort charts that the incompetent regular folks couldn't handle. Hospital personnel, including LtCol oral surgeon, ordered to close clinics to go pick up sticks and leaves from the hospital grounds after Hurricane Isabel (evidently not in the civilian groundskeepers' taxpayer-funded contracts, so hospital providers used as free labor chain gang).

23) The Ninth Circle of Hail: Friday, 1630 "standup" Hail and Farewells every month with new Andrews Wing Commander dude in order to increase liquor sales at soon-to-be-closed Andrews Officers' Club (insultingly combined with enlisted "Fox Den" club circa 2004).

24) Special Pay Blues: have to download info from internet (rather than having form sent to you through distro as in prior to 1996); late decisions regarding medical special pay (often after 1 October).

25) Interest free loans from active duty docs to U.S. Treasury through willful late payment of physician bonuses (thanks to D.M.): Quote from E-mail: "The FY04 MC Officer Medical Special Pays plan has NOT been approved and released yet, according to the Medical Special Pays web page (http://afas.afpc.randolph.af.mil/medical/Special_Pays). Until the plan is approved and released, MC officers cannot apply for special pays that begin in FY04 (1 Oct 03 and later) as HQ AFPC/DPAMF1 will not accept applications for FY04 special pays submitted on the currently-available FY03 contracts. Physicians who desire to sign a contract for a medical special pay (MSP, ISP, or ASP) that begins in FY04 must be patient and wait for the FY04 contracts to be released."

26) Denied AFIT funding to American Society of Anesthesiologists Meeting, Oct 04, because nurses and others had scarfed up all the dollars by signing up for Continuing Nosepicking Education meetings, which, of course, took priority over whatever stinking doctors needed.

27) Extremely incompetent interns and residents: no history, no physical exam, no CXR on obese smoker preop for mastectomy with rip-roaring URI; intern at Travis wrote "No significant PMH" on H&P, because he was too lazy to request VA chart. Patient (who actually had known end-stage liver failure) ended up in ICU on ventilator due to this intern's criminal incompetence. Intern later went back and hand-corrected his dictated narrative summary to cover-up his malpractice. Nothing was ever done to this dust-for-brains fool. He'll probably make General soon. Another quote from this *****: "I sent him to see anesthesia (preop) completely un-worked up, but I did the best I could." There is no way to fire people in the military: they just get promoted for continuing to breathe.

28) USAF now wants to keep up with HMOs by tracking costs of drugs/medical care (unfunded mandate); poor inpatient records personnel tasked with doing this job (instead of AF hiring actual experts or paying for bubble sheet system in use at civilian hospitals since the 1980s). Hiliarious thing is that nothing is done with all of this data, because budgets are still pulled out of the lower regions of lawmakers at the last minute every year. See: making doctors fill out time sheets.

29) Computer Based Training (CBT): we used to be able to get a few days off per year to sit in air conditioned lecture halls for Annual Recurrent Training (Geneva Convention, gas masks, etc.); now you have to do it on your own time on the computer, THEN fax the computer printout to Medical Readiness because the AF has ten different CBT systems, not ONE of which talks to any other, and NONE of which can be accessed online by the bean counters who harass M.D.s to complete mindless, repetitive, short-notice/no notice mandatory training.

30) Only lobotomized *****s can make O-6: prior promise of 3 co-equal tracks to make rank (clinical, research, command) that was promised to me in huge lecture halls at USUHS and Wilford Hall broken by USAF command as part of OMG. There is zero respect for skilled clinicians; only command billets look good to the NON-PHYSICIANS who "rack and stack" physicians' military records for promotions (i.e., pilots don't understand "Residency Director" or "Clinical Research Chief" thangs; only "Flight Commander", "Squadron Commander", etc.).

31) Ongoing BRAC base closures combined with shortage of AD anesthesiologists has resulted in Consultant pulling anesthesiologists back to major medical centers with ICUs = severe loss of flexibility in assignments (do you want Travis or Keesler or Lackland or Wright Pat? MGMC is becoming essentially a superclinic according to the MAPPG-06). Probability of landing in the "Deliverance" Zone Bunghole of the Universe now 1:4 for anesthesiologists (take one extremely wet guess).

32) TRICARE: Search for this: TRICARE "try and get care" I could go on for twenty pages about how tragically broken the TRICARE system is. Suffice it to say that, due to severe downsizing/"force shaping" of MTFs around the world, your family will not get access to specialist care at any MTF in real time without inside connections. Thus, you will be thrown to the wolves of the outside, civilian medical system, where TRICARE is avoided by most physicians and hospitals like the two-day-old skunk you just ran over on your way into work. The few places that will accept TRICARE will put you face-to-face with the gum-snapping high school graduates who sit in phone banks thousands of miles away, whose sole job is to protect the government health contractor's bottom line by denying you indicated care, or by incorrectly telling you to pay for care that should be free. It took me weeks to convince TRICARE to pay $4000.00 for anesthesia care for my handicapped, autistic son. I got letter after letter from TRICARE stating that I was responsible for this payment...until the last letter, which said: "Whoops! If you paid the hospital, you'd better try to get your money back, because they weren't authorized by law to bill you in the first place." Luckily, I was willing to stand up to collections agencies by refusing to pay, because I was an older doc with a secure credit rating and a nice house. Junior 2Lts and Captains won't have that luxury: one delinquent hospital or clinic bill (incorrectly unpaid by one of TRICARE's contract agencies) could ruin your credit score for years after you leave the military.

33) Military Retirement is the last thing you want: It entails involuntary recall to active duty for life at the pleasure of the president, as well as placing military retirees subject to UCMJ punishments for activities they engage in after retirement...for life. The lady who did my hair for years divorced her husband of 30 years because he was recalled involuntarily to active duty for a third time during the Iraq war. For details of the applicable Federal law, see my post here.

34) Speaking out for Patient Safety Leads to Reprisals: See this article in the New York Times: Military Hospital Care Is Questioned; Next, Reprisals

As someone with a computer programming background since the 1970s, I developed a simple algorithm to describe how the U.S. military medical system handles any kind of complaint or concern voiced by any physician:

START IF complaint THEN tell physician to shut up END
START IF continued complaint THEN reprise against physician by [many evil ways] until problem (noise) solves itself END

"Many evil ways" include, but are not limited to: receive an assignment overseas for three years without your wife and three children UNaccompanied on a usually ACCOMPANIED tour; Letter of Reprimand for acting as if you are a board-certified physician who must follow standards of care of your specialty vs. the surgical standard of SHUT UP AND PUT THEM TO SLEEP; when you have asthma and have a profile to prevent your partaking in fun runs in freezing conditions, be made a "road guard" just so your Squadron Commander can screw with you in one more creative way; firing from position of "Medical Director of Anesthesia" because you were insisting on medical direction of anesthesia PLUS being replaced in that role by a young staff doc who was one of your JUNIOR RESIDENTS during training, because he was known to be shy and malleable.

35 Buzzwords that Nobody Follows: "Integrity last; Self before Service; Mediocrity in all we do" would be much more honest these days.
--Integrity means sometimes saying "No" when asked to do things that are wrong. Can't have that.
--Self before Service means looking out for the political side of every issue and "Watching your 6" rather than taking a stand.
--Mediocrity: It takes a lot less time (and costs less money) and most people won't notice the difference until it's too late.

I will leave it to others to wax eloquent on the takeover of U.S. military medicine by civilian functionary bureaucrats at DHA (Defense Health Agency), the reverse-PROFIS system, the boneheaded decision by DHA to shut down dependent and retiree care at many MTFs, and the ongoing apoptosis of military Graduate Medical Education.

Lasciate ogni speranza, voi ch'entrate. ​

Translation: Abandon all hope, you who enter here (speaking of USAF Medical Corpse).
--Dante Alighieri, Inferno, Canto III, line 9

You have been warned.

--
Rob Jones, M.D.
Ex-LtCol, USAF, MC
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, CA
OEF Anesthesiologist, 39th EMEDS, Incirlik AB, Turkey (2002)
Harvard '85 (ROTC Det. 365); USUHS '90; WHMC Anesthesiology '94
webmaster_AT_medicalcorpse_d0t_com
On Hiatus
Nemo Me Impune Lacessit

What next? Is the chief of anesthesiology a CRNA? Is the chief of surgery a nurse who has never done surgery? What kind of pathetic structure is this?

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Precisely. This is the crux of the problem with the "Objective Medical Group" abomination (which, in my book and on the wards, is often called the "Objectionable Medical Group"). Starting ca. 1993, but really implemented around 1997, OMG makes R.N.s = BSCs = M.D.s=Janitors in determination of fitness for command billets. Thus, because more nurses stay in to make rank in the military (more bucks, less work, far more power than the civilian world offers), more high-ranking nurses with golden clipboards are running around to take command spots, where they hold life-or-death UCMJ power over the poor M.D.s beneath them.

Examples:

The Squadron Commander of Surgery at Travis, is or recently was a physical therapist:

AVOID MILITARY MEDICINE if possible

The Commanding General of Malcolm Grow Medical Center from 2000-2003 was BG Barbara Brannon, R.N. (also Chief Nurse of the Air Force)

My Element Leader at Travis was a LtCol CRNA, who was, according to OMG rules, in charge of everyone in the element, including me, the "Medical Director of Anesthesia" Major Anesthesiologist.

The Commander of Travis until recently was Col. Young, a pharmacist.

The Commander of the Special Care Flight at Andrews (now probably defunct due to MAPPG-O6) when I left in 2005 was an O-5 R.N....not the O-6 M.D. intensivist, who was evidently just on the R.O.A.D. to retirement.

Read this submission to my website from an active duty surgeon, who had experienced an R.N. refusing to take the doctor's orders of a physician anesthesiologist, who was commanded by a CRNA:

http://www.medicalcorpse.com/doctorssuggestions.html

Day in and day out, the acting Flight Commander at Andrews was a most excellent CRNA LtCol (hi, CC!), who was only 10 times more competent as a leader than my Absentee Landlady O-6 anesthesiologist Flight Commander. She was actually infinity times more competent, because she showed up for work every single day when she was scheduled to do so...whereas "Col. Hurtus" showed up when she felt like it.

So, to answer your question: Is the chief of surgery a nurse who has never done surgery? Nowadays, increasingly, in all three services, the answer is a demoralized: Yes.

This needs to be fixed if military medicine is going to survive.

--
Rob Jones, M.D.
Ex-LtCol, USAF, MC
On Hiatus

bliss72 said:

This is because Clinical and Hospital Services deal directly with patient care, a doc always supercedes an RN on patient care issues but Command issues have nothing to do with that.

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This is patently false, as my own experiences related in nauseating detail on my website prove.

If you don't believe me, believe this active duty surgeon, who e-mailed me the following horror story of an O-6 nurse pulling rank to refuse to follow written doctor's orders on a patient's chart:

(web site on hiatus)

Listen, from 1981 until 1997, I had no problem being commanded by MSC officers and nurses. The Nurse O-6 who pinned major on me at Travis was excellent: took care of administrative stuff, and left clinical medicine to docs.

However: this is a personality-dependent situation. Given the OMG (and its equivalents in the other services), all it takes is one power-hungry but clueless non-physician to start using the awesome power of the UCMJ to reprimand physicians for doing their jobs (as the anesthesiologist above was threatened with an Article 15 for trying to save patients from death via respiratory depression at a deployed location).

bliss72 said:

The military has a ranking sysytem and if you are a LTC MD doesn't mean that just because you are the superior when it comes to patient care that you can blow off a COL who happens to be in Command and an RN.

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As I have always said to anyone who will listen: any Pointy Haired Idiot O-6 boss can order me to show up in full Service Dress Uniform in front of her office at 0300 and order me into the front leaning rest until the point of complete physical exhaustion...and that would not violate my integrity. I wouldn't be happy, but I wouldn't harbor this level of animus.

IF, however, said boss tells me, a board-certified consultant specialist physician, to violate accepted standards of care because HE says so, that is an illegal order in my book. No one can order me to commit malpractice on a patient. This is what the USAF paid all that money for: my medical judgment. "To interpose the threat of physical destruction between a man and his perception of reality, is to negate and paralyze his means of survival; to force him to act against his own judgment, is like forcing him to act against his own sight." --Ayn Rand, Atlas Shrugged

bliss72 said:

If I may not like the idea of a woman being in charge ( I don't mind), I still have to obey her when she outranks me. Not because I want to but because I swore to.

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Don't even set up this straw woman. I never said I had problems with a woman being in charge. I'm married; I'm used to *that*. Moreover, my religion is based on a female deity, so don't even start insinuating that anything I wrote was intended to mean that I had problems with my Commanders' gender.

bliss72 said:

We don't get to choose which orders we like and those which we don't, Bottom line. When we are in charge, we want others to listen to us, let's give the same respect that we would expect. You have to give to get. A CO being an RN is irrelevant.

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This *would* be true, IF and ONLY IF they completely set up a firewall between administrative duties and clinical ones. Tell me: if an administrator decided to make clinic visit appointments 45 seconds long in order to improve metrics of productivity, is this an administrative or clinical decision? Would the M.D.s under her have a right to object that she was giving an illegal order, since they would have to malpractice on patients to follow it?

bliss72 said:

Why as a physician one should feel that one is entitled to anything above and beyond what one is getting is beyond me.

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Because I didn't go to six years of Evil Medical School to be called Mr. Evil, thank you very much. When a nurse midwife can get in my face and object to taking a request for an epidural from her, rather than the attending physician on the OB deck (who had no idea his patient was that far along, and who thanked me for telling him), there's something bass-ackwards with our system. Especially when I was a LtCol, and she was a Major...so much for your rank theory.

bliss72 said:

We still have to wait in line at the DMV don't we? Well you must look for parking like everyone else(as frustrating as that may be, believe me I AGREE with you).

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Perhaps you don't understand that parking is an epiphenomenon. Those in power are clipboard-carrying non-clinicians. Even clinic chiefs don't get parking spaces. The abominable dichotomy set up by the OMG with two separate chains of command (Medical to the SGH, and Command through the chain to the CC) is destroying military medicine.

bliss72 said:

I work in a place where we have to pay money to use the pool on a military post because the club that runs it is owned by civilians. ON A MILITARY POST!! I don't agree with it but until I can change it, that is the way of things.

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The government under every administration since 1992 seems intent on outsourcing and privatizing everything. "The way of things" argument you make was also made by people after Kristallnacht, the Great Leap Forward, 9/11. I don't buy it. Even if we can't change something that is wrong, we must speak out, even at the risk of our own lives, careers, etc.

"The Truth is Out There".

bliss72 said:

The state of military medicine is atrocious but..hear me out I am not attacking anyone, esepcially not you; if a car is broken and all the qualified mechanics complain about it but never pick up the tools to fix it, it reamins broken. If the all mechanics leave the car for someone else to fix, it will never be repaired

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I cannot improve on the demolition of your flawed analogy provided above, so I shall not try. Suffice it to say that if there were no mechanics any more, car companies would be forced to build more reliable cars in the first place.
If no one raises his/her hand to join military medicine, eventually, something will have to give...the system will *have* to be overhauled, as I have said, from stem to stern. Complacency at the highest levels due to adequate numbers (though not experience and quality) of bodies in the system has thus far prevented this bureaucratically uncomfortable but medically indicated radical surgery. The band aids must come off if the boil is to be lanced.

bliss72 said:

Thank you for serving I aspire to be what you are.

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I highly doubt that.

Peace,

--
Robert C. Jones, M.D.
Ex-LtCol, USAF, MC
On Hiatus

orbitsurgMD said:

I was posting mostly in jest. A. 138 is the UCMJ article that defines grievance proceedings against superior officers. It is a rarely-invoked process and requires substantial facts to justify, but it is a due-process pathway for complaint and redress of wrongs done by superiors. It is also a process that should not be undertaken lightly or without advice of counsel.

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I really wish the Andrews ADC had even once mentioned this route...
the Board of Correction of Military Records just seemed like a waste of perfectly good ATP, by the time I heard about it.

At this juncture, I have to hope that rusty tyrants will be subject to the Law of Return: Everything we do comes back to us thrice.

--
R

velvethead said:

I'm really curious about this, as it appears that it will be something that I may or may not have to deal with depending on what specialty I end up going into.

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You will have to deal with it at some point. If you happen to be in a specialty which provides services to other, more powerful specialties (i.e., radiology, anesthesiology, pathology), you will be even more vulnerable.

It's a cliche, but it's true: power corrupts, and absolute power corrupts absolutely. The power-hungry dolts who are attracted to Command billets like moths to a flame have absolutely no conception how incompetent they are to judge the clinical actions of physicians far more intelligent and skilled than they are. Thus, they see all opposition to their boneheaded policies which endanger patient safety as rank insubordination, rather than as concern by well-meaning healer underlings for the well-being of vulnerable, ill humans. The Commanders themselves don't give one rat's @ss for such non-metric-able ephemera, so they cannot conceptualize other physicians acting on principle, at the risks of their careers, in order to save human lives. They can only imagine, in their tunnel vision, that opposition from below is an incipient coup: a way of making them look bad so the underling can wrest power and prestige away from the Commander. Thus, they respond with thalamic rage at all attempts to improve the system, in order to improve patient care, and lash out with the irrational fury of a two year old who feels his lollipop is in danger of being snatched from his fat, greedy fingers. Luckily, two year olds can't send you to Diego Garcia or take away your bonus pay; sadly, Commanders can.

In your time on active duty in the medical corps, you will find far more competence in the ranks of O-3-->O-5 than you will in O-6 and above. It's a self-propagating disease: idiots selecting other idiots to join their exclusive, anti-integrity, anti-intellectual club of self-serving sycophants.

Here's a great article I am going to include in my book for sure:
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(fair use quote)

http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2000/01/18/MN73840.DTL

Incompetent People Really Have No Clue, Studies Find
They're blind to own failings, others' skills

There are many incompetent people in the world. Dr. David A. Dunning is haunted by the fear that he might be one of them.

Dunning, a professor of psychology at Cornell, worries about this because, according to his research, most incompetent people do not know that they are incompetent.

On the contrary. People who do things badly, Dunning has found in studies conducted with a graduate student, Justin Kruger, are usually supremely confident of their abilities -- more confident, in fact, than people who do things well.

``I began to think that there were probably lots of things that I was bad at, and I didn't know it,'' Dunning said.

One reason that the ignorant also tend to be the blissfully self-assured, the researchers believe, is that the skills required for competence often are the same skills necessary to recognize competence.

The incompetent, therefore, suffer doubly, they suggested in a paper appearing in the December issue of the Journal of Personality and Social Psychology.

``Not only do they reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the ability to realize it,'' wrote Kruger, now an assistant professor at the University of Illinois, and Dunning.
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Sadly, with regard to Article 138 (or any other Article), the UCMJ is a deck stacked WAY against subordinates. Commanders have all the power; lower-ranking officers are mere peons. And don't EVEN get me started talking about the uselessness of IG complaints...

--
Rob Jones, M.D.
ex-LtCol, USAF, MC
http://www.medicalcorpse.com

delicatefade said:

How would a pathologist be more vulnerable to this kind of problem??? Seeing as they pretty much don't work with nurses at all, I don't see what the problem would be. Same for radiology. Or are nurses also the heads of their departments???

I can understand how anesthesiologists would face this, with a CRNA commander, etc...

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I might be speaking outside of my expertise on this matter; perhaps some radiologists or pathologists might chime in.

It seems to me that the RAP specialties, which are usually "hospital based" in civilian practice, don't have the sexiness of bringing patients into the hospital, which is a primary basis of the power of surgeons and procedure-oriented internists (G.I., pulmonary, interventional cardiology) in the civilian world. Radiology and Path provide services to other specialities, just as anesthesia does (outside of pain management). Thus, less power to avoid unfunded mandates for service beyond capabilities.

I will speak for anesthesiology. It's easy for a Surgeon commander to say that no case will ever be canceled for any reason. Each surgeon only has, at most, one O.R. day per one to two weeks; no big deal to stay up late one day in 14. However, anesthesia is in the O.R. or OB 7/7 days/week, without letup. The unfunded mandate doesn't hurt the surgeons one bit, while the Anesthesia flight is tasked to death (i.e., every other night call, in house from 0700-2100 or later, and home call thereafter until the next day).

Similarly, radiology can be tasked to provide X amount of support with Y amount of capability. Interestingly, at least at Andrews, Radiology was very good at sending out daily e-mails like this:

The Department of Radiology Can offer the following services today:
( ) Chest X-Rays
( ) MRI
( ) CT
( ) US
( ) Mammo
( ) Other plain films
(X) None of the above.

Better luck tomorrow; we're hitting the golf course early (1100).

Signed,

Chief of Radiology

Maybe I just need to go to bed and lucidly more tomorrow post do.

--
R

DiveMD said:

All this discussion in not only very serious…it’s scary….

BTW, Dr. Medical Corpse, I also get the same radiology messages in my current command. Golfing in Hawaii is great!!!

2 more years and counting....

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More alert now. Yes, Virginia, here's evidence that Radiology is also subject to the same "production pressure" that I experienced as one of the senior anesthesiologists in DoD:

from: http://forums.studentdoctor.net/showpost.php?p=3982002&postcount=51

Galo said:

The radiologists at Offutt (went) from 4-2 with no change in volume of films or reading expectations. One of them almost got divorced because of the stress it added for almost a year before they were able to work out a deal and sent radiology stuff out. At Wright (Pat), one of the department of (defense's) only (specialty) trained neurointerventional radiologist was deprived of his ability to practice at the univ of Cincy where he was able to do more neurointerventional in a weekend, than he did at our base in a month. They cut everybody's ability to moonlight. They hired a BOZO for 400,000/yr. He had been fired from his previous job for alleged sexual harrasment. Every radiologist in that department was unhappy. One left with 15 yrs active duty time. He felt like the life was being squeezed from him, and he had been a line officer before going to med school. All these guys were dedicated and hard working, and all hated the system that they recognized was a piece of crap. So maybe your radiologist was just doing his bare minimum and when it came time to get out he did.

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...still waiting to hear from a pathologist.

--
R. Carlton Jones, M.D.
http://www.medicalcorpse.com