Low patient-population subspecialties

You raised two issues in your post that require different thinking.

One question regards adequacy of learning opportunities for residents and fellows to be exposed to enough depth and breadth of cases while training. This issue has been discussed at great length here and is, in my opinion, the greatest problem with military graduate medical education.

The second question addressed the adequacy of care for patients. Certainly this is a good issue for discussion. Regarding Peds Heme-Onc, I had great experiences with this as an Army pediatrician. Peds Heme-Onc is a tough example, however, because treatment is based on national protocols. Thus, a child will get the exact same treatment at Hopkins as at Walter Reed. Of course, the people make the institution, so quality of nursing staff makes a difference, as does the quality of the house staff. I think that our chemo kids got much more TLC at Madigan then they would have up the road at Seattle Children's. Of course with other specialties, especially those involving great technical skill there's a strong argument to go to Big University Hospital.

Ed

edmadison said:

You raised two issues in your post that require different thinking.

One question regards adequacy of learning opportunities for residents and fellows to be exposed to enough depth and breadth of cases while training. This issue has been discussed at great length here and is, in my opinion, the greatest problem with military graduate medical education.

The second question addressed the adequacy of care for patients. Certainly this is a good issue for discussion. Regarding Peds Heme-Onc, I had great experiences with this as an Army pediatrician. Peds Heme-Onc is a tough example, however, because treatment is based on national protocols. Thus, a child will get the exact same treatment at Hopkins as at Walter Reed. Of course, the people make the institution, so quality of nursing staff makes a difference, as does the quality of the house staff. I think that our chemo kids got much more TLC at Madigan then they would have up the road at Seattle Children's. Of course with other specialties, especially those involving great technical skill there's a strong argument to go to Big University Hospital.

Ed

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ed, per ususal, is spot on with this. but since i trained at the WRAMC peds program recently, and know the heme-onc dept fairly well, i'll adress a few points a little deeper.

mac61 said:

1) How effective is a training program with (relatively) low numbers of complicated cases? I don't know the numbers, but how many cases of pediatric gliobastoma, for example, are seen at WRAMC compared to the surrounding hospitals..

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the training the fellows receive at WRAMC is pretty broad, and due to being in proximity to DC Children's, the NIH, and JHU, they get exposed to most cutting edge treatments and protocols as well. it's really no different than having trainign at a mid-major heme-onc fellowship anywhere else-- except due to its location you can integrate outrotations and research easier. as ed mentioned, most pediatric cancers are treated cookbook style-- once properly categorized, patients fall into ACOG protocols-- there may be some wiggle room from one to the next given a patients age or complicating factors, but the standard of care with oncology is the most "standard" i have seen in any subspecialty.

mac61 said:

2) Does TRICARE force patients to be treated at a MEDCEN even when larger institutions are available? For instance, if a soldier is located at Fort Drum, will TRICARE allow the pt to be treated at say, Boston Children's, or are they mandated to transfer care to WRAMC? If larger institutions are available I think it is reasonable to ask how many servicemembers would choose WRAMC over a nationally recognized institution, and this can only further limit the patient load for WRAMC..

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WRAMC is the facility Ft. Drum patients would go to-- the northeast region, europe, and everything else in that half of the world, lol. For more "common" issues, like leukemia, I most kids (as far as i know) are sent to the nearest appropriate location. We did not see all ALL patients in the northeast region at WRAMC-- many went to their local hospitals for treatment. Similarly, in the region I am in, kids are sent to the nearest appropriate children's hospital, not the region's MEDCEN. The second part of your question is a bit more loaded. The truth of the matter, as ed mentioned, is that once servicemembers are presented with treatment options 99% of the time they will choose to stay with WRAMC (if they are in WRAMC catchment area or are referred there) because chemo regimens and such are so standardized the only difference is the level of care and personal touches that a smaller program can provide. For instance-- patients have fellows pager numbers 24/7 at WRAMC-- i doubt civilians institutions have that level of access. Similarly, at WRAMC patients become known on a first name basis with the residents and staff, and other subspecialties (peds ID, endo, pulm, etc) who may need to be consulted on PHO kids are just a walk down the hall away. In my 3 years there, i saw more patients go from civilian to miltiary than vice versa, and the times when they did go from military to civilian is was often due to surgical (neurosurg in particular) issues or for NIH studies that required patients be taken care of there to be able to enroll in their study.

mac61 said:

3) With the tax on ancillary services (social services, mental health, temporary housing) being focused on OIF/OEF, are adequate services available for families treated at WRAMC?.

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unqualified yes. there are pediatric case managers there that know patients and families by name who will do anything for their patients. most families live or are compassionately reassigned to teh area, so housing normally isn't an issue. and when it is they normall will get a spot at the fisher house or at civilian lodging.

mac61 said:

4) What happens when the military decides to stop offering a low patient population subspecialty? Do the ped-onc docs with commitment remaing go back to being gen pediatricians? What does this do for thier post-service job potential? .

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i'm not sure why you keep jumping to the "low patient population subspecialty" thing. most chemo is outpatient, and on some days the heme/onc service (inaptient chemo, neutropenic fevers, etc) outnumbers the general peds service on the inpatient ward. you should be careful when drawing these kinds of conclusions witout having any data. having peds heme-onc in house saves the military money, so i don't think they are getting rid of them anytime soon. no heme-onc trained physician i know of has been forced to do general peds, unless they choose to.

mac61 said:

I think that this argument can be used for several specific specialties, and then moved down the proverbial slippery slope to everything outside of primary care for active duty servicemembers.

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the problem is cost. it is cheaper to treat in house with your own facilities and staff than to refer to a civilian center.

mac61 said:

Have there been moves to eliminate specialties offered by MTFs/MEDCENS? Are any on the block right now?.

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not that i'm aware of. tehy know approx how many they need, and will approve training for that many, but none are being phased out.

mac61 said:

Ah yes, for the record and transparency, my family considered treatment at the WRAMC ped-onc clinic and decided to seek treatment at Johns Hopkins for no reason other than a personality conflict with a member of the non-physician staff. We have however met several families treated at WRAMC who have raised concerns, some of which I addressed above.

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that's unfortunate. i think you would have appreciated the amount of care given at WRAMC. and whomever you have met with similar concerns, you should take them to the heme-onc department so they can be addressed.

as much as i dislike the military system and what it has become and what its leaders have done to it, i feel pediatric subspecialty care, and pediatric care in general, is very good at WRAMC/NNMC. i rotated through DC Children's and other pediatric hospitals, and while it isn't a mecca of pediatric academia, it's definitely a good mix of access, knowledge, and people wanting to make a difference in spite of "the system". god forbid i ever have to deal with one of my own kids having cancer, but if they did i would go there in a heartbeat without hesitation-- and that's about the biggest stamp of approval i can give.

--your friendly neighborhood getting typing cramps caveman

Thanks, Caveman and Ed. This has all been very informative. It seems that most of the concerns that I hear about are in training and caseload for surgery, but I see here that this is not the case for peds hem-onc. What about other subspecialties in internal medicine and pediatrics? I am curious about their breadth of training and caseload, especially in the Army programs. Thanks in advance.

Why is it that you think that WRAMC is the only Med Center that has a Peds Heme/Onc service. Last I checked the OTHER Med Center on the east coast with an active PH/O service was actually busier than WRAMC.

http://www-nmcp.mar.med.navy.mil/Pediatrics/Residency%20program brochure2007.pdf
(Page 2)

🙄

mac61 said:

Thanks caveman I was actually hoping you'd catch this. I truly appreciate your input.

I think that the clarification of the training of fellows is worth discussing, and this little bit of insight is very valuable. I think, as ed argued, that some of the central points of concern in military medicine are case load maintenance and quality of training. I thought that focusing on "small populations" (i.e. care that, guessed by swag, effects <5% of the population) would examplify these issues.

Thanks again for the input, I hope the conversation continues without devolution (no offense caveman).

I do however feel like I need to make a couple of things more clear, for no reason other than clarity.

1) I have no problems, at all, with the ped heme/onc service at WRAMC. Not only would I love to train there, but would have been happy to have my son treated there if not for a singular personality conflict. I have (or had since they retired) good relationships with two senior physicians in the clinic, and have no ill feelings toward any member of the team, save one. THIS THREAD WAS NOT STARTED TO "BASH" MILITARY MEDICINE, AND WAS DEFINITELY NOT INTENDED TO INSULT THE PEDIATRIC HEME/ONC SERVICE AT WRAMC.

2) I used ped heme/onc as an example ONLY because this is the discussion that my wife and I were having last week. NONE OF MY QUESTIONS, ASSUMPTIONS, OR ASSERTIONS ARE BASED ON ANY EVIDENCE. I HAVE NO KNOWLEGE OF THE SIZE OF PATIENT POPULATIONS, TRAINING BREADTH/DEPTH FOR SPECIALTIES, COST OF TRAINING, OR COST OF REFERAL. I was simply starting a conversation that stemmed from a private conversation and comments made by several SMs who are disgruntled about military medicine.

3) I am a member of the naive prior service medical student crowd, therefore still not mad at the world but not so naive to think that military medicine is perfect.

Thanks again for the conversation.

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no offense taken. 🙂

1) i didn't think you were bashing it

2) all training programs have to put out graduates who can pass boards, and must be accredited. most non-procedure driven specialties that don't rely on volume can rely on strong didactics or out-rotations to make up for gaps in their own program.

3) the reality is definitely somewhere between the two extremes.

mac61 said:

I'll go ahead and put this in the "Learn something everyday" book. Once again proves that whole "assumption proverb." Can't believe we haven't heard about our Navy bretheren to the south.

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lol. we sure knew of NMCP. NMCP was the only place we could transfer some of our complicated/high maintenance/life draining patients. they sent us their fair share of headaches as well, though, so it all probably evened out. . .

--your friendly neighborhood turfing caveman