Declining Case Load

briannarenee316 said:

From the many threads that I have read here, there seems to be a trend of saying that there are declining case loads in military medicine, for example surgeons not having enough cases to keep them busy/up to par and having to scrub in at civilian hospitals just to stay current.

I was just wondering if this is indeed accurate, and if so why this is the case?

Also it seems that if this is the case, why is the military so desperate for more physicians?

Thanks for your insights!

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You need to do some extensive reading of the stickies. If you click on the link I am placing, and go to post # 6, there is a direct link to the reasons direct from the horses mouth. Its a trainwreck lecture given by the general surgery consultant to the surgeon general. Its very specific about why there is a direct decline in case load. In a nutshell, for surgeons, it started with tricare, coupled by the decline in support, loss of clinical skills, administrative lack of undertanding/care, ops tempo, pay, etc. When you go to the link, save it to your computer so you can read the narrative at the bottom of the slides, it is imperative to fully understanding the lecture.

Good luck, and keep reading!!!!!!!!!!!!

Galo said:

You need to do some extensive reading of the stickies. If you click on the link I am placing, and go to post # 6, there is a direct link to the reasons direct from the horses mouth. Its a trainwreck lecture given by the general surgery consultant to the surgeon general. Its very specific about why there is a direct decline in case load. In a nutshell, for surgeons, it started with tricare, coupled by the decline in support, loss of clinical skills, administrative lack of undertanding/care, ops tempo, pay, etc. When you go to the link, save it to your computer so you can read the narrative at the bottom of the slides, it is imperative to fully understanding the lecture.

Good luck, and keep reading!!!!!!!!!!!!

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can you repost the link?

briannarenee316 said:

From the many threads that I have read here, there seems to be a trend of saying that there are declining case loads in military medicine, for example surgeons not having enough cases to keep them busy/up to par....
Also it seems that if this is the case, why is the military so desperate for more physicians?

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The main reason I am hesitant to/won't join (as a surgeon).

Remember that a large unit needs to have key staff on standby should the occasional need arise for their services. Posted many times in this forum are anectdotes of dedicated surgeons who lose skills for lack of caseload. I can't imagine finishing residency then immediately being placed into a position where I won't operate.

The options for a new surgeon are to go into private practice and immediately start doing dozens of cases per month with partners around to help as needed or going into the military and doing less than a dozen cases with little/no immediate help from collegues.

Also posted here are anectdotes of local commanders who work against established military policy aimed at enabling surgeons to maintain their skills by scrubbing cases off-base.

And I'm supposed to get a warm and fuzzy over this and sign up? Accepting pay that is 25% of the private sector and putting up with military BS are issues I could theoretically deal with. Willingly signing up and throwing away my training is absolutely crazy. Why would anyone do this.

dry dre said:

The main reason I am hesitant to/won't join (as a surgeon).

Remember that a large unit needs to have key staff on standby should the occasional need arise for their services. Posted many times in this forum are anectdotes of dedicated surgeons who lose skills for lack of caseload. I can't imagine finishing residency then immediately being placed into a position where I won't operate.

The options for a new surgeon are to go into private practice and immediately start doing dozens of cases per month with partners around to help as needed or going into the military and doing less than a dozen cases with little/no immediate help from collegues.

Also posted here are anectdotes of local commanders who work against established military policy aimed at enabling surgeons to maintain their skills by scrubbing cases off-base.

And I'm supposed to get a warm and fuzzy over this and sign up? Accepting pay that is 25% of the private sector and putting up with military BS are issues I could theoretically deal with. Willingly signing up and throwing away my training is absolutely crazy. Why would anyone do this.

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This is it in a nutshell. You forgot to add deployment tempo where you will deploy for a total of approx 4-5 months every other year, and essentially be doing nothing. I often sight my friends experience of having done 8-10 cases over a total of 10 months cumulative time of beind deployed. This includes down time in getting ready, and then time to ramp back up when you get back. For a surgeon, its a 100% loosing proposition.

I had tried to post that link before, but the attachment is too large, and it would not let me. If you go the the thread linked above, and go to post #6, there is a direct link to it there. Just save it to your computer so you can read the whole lecture.

Could you please explain why this is the case (the declining case load)?

I've tried to logically work this out. People in the armed forces will invariably need some sort of surgery like the general public. They will get in the occasional car crash, have some sort of cancer, clogged arteries, etc. and will need some sort of surgical procedure to remedy their situation. Why then, if the military has less surgeons than on the outside, would there be less case load? There are many active and retired personnel that need medical asst.

KalicoKat said:

Could you please explain why this is the case (the declining case load)?

I've tried to logically work this out. People in the armed forces will invariably need some sort of surgery like the general public. They will get in the occasional car crash, have some sort of cancer, clogged arteries, etc. and will need some sort of surgical procedure to remedy their situation. Why then, if the military has less surgeons than on the outside, would there be less case load? There are many active and retired personnel that need medical asst.

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In one word, TRICARE.

This has essentially removed the ability for us to see people of age where the diseases that need surgery exists. That's just one word. Lack of support, lack of ancillary personell, deployments, etc.

Once again!! Go to the link I posted and read the powerpoint presentation to the surgeon general.

Many other reasons have been covered extensively. You need to read the pro/con posts, avoid military medicien, the decline of military medicine. ITs all there.

Am I missing something? Where would one find the link?

The options for a new surgeon are to go into private practice and immediately start doing dozens of cases per month with partners around to help as needed or going into the military and doing less than a dozen cases with little/no immediate help from collegues.

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This really depends on where you're located. If you are stationed at one of the main teaching hospitals you will get your fair share of cases/month (granted it still may not be as many as a well established civy surgeon).

Once again!! Go to the link I posted and read the powerpoint presentation to the surgeon general.

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Could you "once again" post the link!!

rotatores

I was doing SRP duty when OIF started. Huge backlog of surgical cases from NG and reserves stuck on med hold when the call up started.

One that stands out in my mind was a 55 y/o female NG member with a fibroid uterus so large, she couldn't get her pistol belt to snap closed. They did the surgery, then sat on her for months for the convo/post-op period.

Given what is stated here, we should have, in retrospect, sent all this stuff on over to theater and done the surgery there. At least these types of pts would have been doing something instead of just coming in once a day to sign in and collecting a check at the mobilization site. Since they're just wanting to say they have "x" number of troops deployed anyway, that would have been better than nothing.

Galo said:

This is it in a nutshell. You forgot to add deployment tempo where you will deploy for a total of approx 4-5 months every other year, and essentially be doing nothing. I often sight my friends experience of having done 8-10 cases over a total of 10 months cumulative time of beind deployed. This includes down time in getting ready, and then time to ramp back up when you get back. For a surgeon, its a 100% loosing proposition.

I had tried to post that link before, but the attachment is too large, and it would not let me. If you go the the thread linked above, and go to post #6, there is a direct link to it there. Just save it to your computer so you can read the whole lecture.

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Let me try to summarize the problems with surgical case volume, although it is multifactorial and complex. I have personally experienced this decline in both a general and vascular surgery practice within the Air Force. Here are some of the issues I see.

1. Tricare reorganization has forced most of the over-65 population out of the MTF’s. Most big cases in general surgery and its subspecialties come from this population. In vascular surgery, nearly ALL of the patients needing major arterial reconstruction come from this group. Without patients over 65, you are left with appendectomy and cholecystectomy as your entire case load.

2. Downsizing of MTF’s has resulted in loss of support for major cases. You can’t do major General/Vascular/CT surgery in a vacuum. It takes support from radiology, heme/onc, cardiology, etc. Its impossible do a Whipple procedure at a 10-bed “hospital” that is a glorified clinic. There are now about 600 inpatient beds in the ENTIRE Air Force healthcare system. That’s about the same size as a SINGLE large community hospital on the civilian side. With the decline in inpatient capacity, the critical mass for support of major surgery has evaporated, and with the BRAC it will be completely gone within the AF (ie no Wilford Hall).

3. Ancillary support has been cut to the bone or eliminated. Two years ago, I had six (yes, SIX!!!) staff in my clinic supporting a single vascular surgeon. Now I have zero. I simply can’t see a large enough volume of patients in my clinic to generate a lot of cases. No technicians to do vascular ultrasound, no secretary to schedule appointments, no PA to do wound care, and no technicians to take vitals and move patients in and out of rooms means minimal clinic volume and minimal operative case load.

4. Frequent deployments with very few cases. Although there are notable exceptions (the CSH in Baghdad and the AFTH at Balad), most deployments are 4-6 months of minimal case load. I spent 4 months in Oman in 2003 and did zero cases. Add to that 2-4 weeks of ramp-down and ramp-up time on either end of the deployment and you have got a lot of dead time. And even the cases that do get done during deployment are often resuscitation/damage control prior to movement to the next echelon of care. This has minimal relevance to typical general surgery practice.

5. The ongoing primary care fiasco. Primary care providers are often overwhelmed or inexperienced (i.e. unsupervised PA’s, GMO’s) and many referrals to surgery are for clearly non-surgical problems. Wading through a tremendous number of non-operative consults means less appointments for truly surgical cases. On the civilian side, a high percentage of surgical consults result in operative intervention, while in the military it is rare to see patients in surgery clinic who actually need surgery.

So you can see that while the services may “desperately need” surgeons, what they really need are bodies with general surgical training to fill the ever-growing list of deployment slots. The services (at least the Air Force) have no plans at all to support something as resource-intensive as a busy general or vascular surgery practice.

1. Tricare reorganization has forced most of the over-65 population out of the MTF’s. Most big cases in general surgery and its subspecialties come from this population. In vascular surgery, nearly ALL of the patients needing major arterial reconstruction come from this group. Without patients over 65, you are left with appendectomy and cholecystectomy as your entire case load.
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Where then do people over 65 get treated? What was the motivation for this decision? Money?

Also a second question, with so few cases, what do you actually end up doing for most of the work day, while in the U.S., and also when abroad?


I've heard of military physicians moonlighting on the weekends at local civ hospitals. Are you familiar/have you participated in this? If so, do many general and specialized surgeons participate to keep up their skills?

I actually have read the powerpoint presentation. In some points, I think perhaps because I'm not too familiar yet with the operations, it was a bit confusing.

Do you know if there has been any actions on the suggestions that were made in the powerpoint?

KalicoKat said:

I actually have read the powerpoint presentation. In some points, I think perhaps because I'm not too familiar yet with the operations, it was a bit confusing.

Do you know if there has been any actions on the suggestions that were made in the powerpoint?

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It went in one ear and out the other. The constant change over of leadership does not allow for critical problems to be taken care of because usually its just one of many critical problems, and each surgeon general has a different agenda, and a different boss. Its practically impossible for them to make policy change, when they have no ability, money, and personel to effectively do so.

Mitchconnie's post is excellent, and right on the money. This is the reality of most surgeons in the AF, and likely very similar in the Army and Navy.

G

Croooz said:

Am I missing something? Where would one find the link?

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http://forums.studentdoctor.net/showthread.php?t=254552

Sorry, I thought I posted this recently. It must have been another thread, or I just did not do it.

Once you get to that thread, go to post #6, and the link is there. Save the document to your computer, and then you will be able to see the whole presentation, including the text which is imperative.

KalicoKat said:

1. Tricare reorganization has forced most of the over-65 population out of the MTF’s. Most big cases in general surgery and its subspecialties come from this population. In vascular surgery, nearly ALL of the patients needing major arterial reconstruction come from this group. Without patients over 65, you are left with appendectomy and cholecystectomy as your entire case load.
-------

Where then do people over 65 get treated? What was the motivation for this decision? Money?

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Yes, 100% a money issue. The patients get refered out to the network where a local surgeon will end up doing a case and get equal or less money than medicare. Many surgeons are dropping out of that network because the compensation is so poor. A real thanks to people who served in the military heh?

KalicoKat said:

Also a second question, with so few cases, what do you actually end up doing for most of the work day, while in the U.S., and also when abroad?


I've heard of military physicians moonlighting on the weekends at local civ hospitals. Are you familiar/have you participated in this? If so, do many general and specialized surgeons participate to keep up their skills?

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This is also highly variable, and totally dependent on the ability of the hospital commander to be able to use his/her brain, and often involve lawyers that will usually see a conflict of interest, and not allow it. From personal experience, I ended up under investigation for doing this type of moonlighting for 3 years, and a buddy of mine ended up getting an article 15, and was almost court martialed for moonlighting. SO its most of the times, not an option, and even if it is, its usually not the case load that would even come close to catching you up. Lots of commanders will actually make you take personal leave in order to do this. Its a joke!

That was the straw that broke the camels back for me in getting out.

Why should I stay in the service for 20 years and get no better access to care than I would have received under Medicare (assuming it's still there in 27 years)

My wife and daughter was dropped by their civ Tricare PCP while I was in Korea. That was the wake up call right there.

Galo said:

Yes, 100% a money issue. The patients get refered out to the network where a local surgeon will end up doing a case and get equal or less money than medicare. Many surgeons are dropping out of that network because the compensation is so poor. A real thanks to people who served in the military heh?

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2. Downsizing of MTF’s has resulted in loss of support for major cases. You can’t do major General/Vascular/CT surgery in a vacuum. It takes support from radiology, heme/onc, cardiology, etc. Its impossible do a Whipple procedure at a 10-bed “hospital” that is a glorified clinic.

3. Ancillary support has been cut to the bone or eliminated. Two years ago, I had six (yes, SIX!!!) staff in my clinic supporting a single vascular surgeon.

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Sounds like you were at Malcolm Grow....

Thank you to these gentlemen for posting accurate, useful information that will hopefully help many prospective medical students understand the dire realities facing military (especially Air Force) medicine.

If you want to see firsthand the reality of lack of cases, go to San Antonio and walk around in Wilford Hall Medical Center (aka the Flagship of AF Medicine). What you will see is a huge hospital with 9 floors that used to hold 1000 inpatient beds in the 1990s, but now maintains less than 150. These previous patient rooms are now used as admin offices, nurse lounges, and other bureaucratic fluff. It is actually quite sad to see what has happened to a once strong medical center.

As a result, many residencies are struggling to survive and are having to send out residents for months at a time to go to other cities for their training. The most recent is the ENT residency is requiring their residents to go to Houston because there are not enough head and neck cancer cases to meet GME requirements. The residents are angry and frustrated because it is extremely residency is hard enough without having to leave family and friends and go to an unfamiliar city with unfamiliar staff and hospital surroundings to try to learn the basic skills needed to become competent.

Bottom line: the military needs to shutdown GME and outsource all residency training.

The things I have posted are true based on personal experience, and I can confirm that the things that Galo and Mitchconnie have posted are true also. The problem is that so many here on this forum are so early in their training that they do not fully understand the implications of these realities of military medicine. The military hooks people when they are young and medically naive and poor, and then binds them to an irreversible contract for many years (especially if you were unfortunate enough to attend USUHS as I did). Even current USUHS students, frequent posters and purveyors of info on this site, have not yet experienced the day-to-day dysfunction of military medicine, because USUHS does a good song-and-dance out in the National Capital Area bubble. Outside of the NCA, things are much different though.

I remember when the med students from USUHS used to rotate over at Malcolm Grow. The shock on their faces when they saw how FUBAR Air Force medical operations really was....well it was the typical "What the hell have I gotten myself into?!" type of expression. I felt sorry for them, but did my best to try to make life easy for them. Well, at least those who actually put forth an effort to be at least polite to me.

I was an army PA both AD and reserve, part of the "primary care fiasco" as you describe it. Let me tell you about the "supervision" I was getting just before I resigned...

A lot, and I mean A LOT, of those inappropriate consults you get, were written at gun point. They are done at the direct order of spineless,chickens**t hospital MSC officers, too many damned nurses with with too much rank playing "patient advocate" , limp wristed MC docs that are just trying to create as little turmoil as possible. I mean hell, if they called BS, they might find themselves deployed.

After 25 years in this business both civilian HMO, and military, I know how to be a gatekeeper. I even have some notion as to "pimp proof" a case before I call you guys. They're not interested in all that. These admin types want as little conflict as possible through out their soft 9-4 pm day as possible. Giving dependents, malingering GI's, EO what ever they want is the agenda, actual surgery has nothing to do with it.

I'm sure you must also realize some cases are simply CYA to check the box are part of a bureaucratic maze that is required to MEB out some broke-dick (and I'm not talking about combat related injuries) that has been retired on active duty for a decade or more. Be glad you got that case. It means somebody like me took the time to finally DO something and risk pissing people off and get rid of that dead weight.




5. The ongoing primary care fiasco. Primary care providers are often overwhelmed or inexperienced (i.e. unsupervised PA’s, GMO’s) and many referrals to surgery are for clearly non-surgical problems. Wading through a tremendous number of non-operative consults means less appointments for truly surgical cases. On the civilian side, a high percentage of surgical consults result in operative intervention, while in the military it is rare to see patients in surgery clinic who actually need surgery.
So you can see that while the services may “desperately need” surgeons, what they really need are bodies with general surgical training to fill the ever-growing list of deployment slots. The services (at least the Air Force) have no plans at all to support something as resource-intensive as a busy general or vascular surgery practice.[/QUOTE]

Does it really look like there will not ever be change to this system?

At some point it seems to me like things must....

Is there any hopeful progress in any sectors that you have seen that may warrant a hope for the future?

The hope for the military is that more naive kids sign up.

The real hope is that those naive kids stay and work to make change. What eventually happens is the lure of being the CO or earning that star begins to corrupt their original goal of affecting change. Absolute power and all that....

Hopefully there is some good to come of this war and military medical care is addressed. The problem with this is that it would be to point out how some of the wounded vets can't afford treatment because their provider won't accept tricare.

I guess if all civilian providers refused tricare then that might be a start?

Galo, what kind of surgeons were your friends that only did 8-10 cases in 10 months? Were they general surgeons or sub-specialists? If sub-specialists, what kinds? Is the case load really this low for all surgical departments?....all three military services????

Galo said:

This is it in a nutshell. You forgot to add deployment tempo where you will deploy for a total of approx 4-5 months every other year, and essentially be doing nothing. I often sight my friends experience of having done 8-10 cases over a total of 10 months cumulative time of beind deployed. This includes down time in getting ready, and then time to ramp back up when you get back. For a surgeon, its a 100% loosing proposition.

I had tried to post that link before, but the attachment is too large, and it would not let me. If you go the the thread linked above, and go to post #6, there is a direct link to it there. Just save it to your computer so you can read the whole lecture.

Click to expand...

RugbyFool said:

Galo, what kind of surgeons were your friends that only did 8-10 cases in 10 months? Were they general surgeons or sub-specialists? If sub-specialists, what kinds? Is the case load really this low for all surgical departments?....all three military services????

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Like I said, but perhaps not in specifics, general surgeon deployed to Jordan for 4 months, and then to Balad Iraq for 4 months.

Mitchconnie, a current active duty general/vascular surgeon, had a very similar experience, as has every AF surgeon, except the ones that took over the army hospital, in the last 6 months. The army is busier, but its mostly vascular, and ortho. I suspect the Navy is in much the same shape as the AF, but have no firsthand knowledge of it.

Croooz said:

The hope for the military is that more naive kids sign up.

The real hope is that those naive kids stay and work to make change. What eventually happens is the lure of being the CO or earning that star begins to corrupt their original goal of affecting change. Absolute power and all that....

Hopefully there is some good to come of this war and military medical care is addressed. The problem with this is that it would be to point out how some of the wounded vets can't afford treatment because their provider won't accept tricare.

I guess if all civilian providers refused tricare then that might be a start?

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I just read Crooz's post from the past and IT IS AS WELL PUT AS POSSIBLE.

One of the most interesting things I got out of college was during a political science course...I read one historian (wish I could remember who) who said that people's relationship with any political institution occurs in four stages:

Idealism - one first encounters/enters the system full of enthusiasm and bright ideas to make things better. Young congressman, young HPSPer, etc.

Pragmatism - after a significant amount of time/experience in the system, the person realizes that most of their initial ideas are either extremely difficult or impossible to accomplish because of various obstacles within the system. The person adjusts their goals and now tries to accomplish what parts of their initial ideas seem feasible.

Ambition - after the person has invested a significant amount of time and effort into the system, his viewpoint begins to shift from promoting those ideals he initially entered the system with to promoting his own interests and career. He has now learned the system well and therefore becomes resistant to change, because his hard-earned knowledge of the system is what will allow his advancement. Ironically, he may even become one of the obstacles to change that the current idealists entering the system are encountering.

Corruption - the final stage, and this does not necessarily happen to everyone. It occurs when the person's viewpoint shifts completely to his own interests and he begins to exploit the system for purposes that the system was never intended for. The congressman takes bribes for certain legislation, a president hands out pardons to criminal cronies, etc.

Anyway, I thought that was an interesting perspective on the way bureaucracies work, and how things get the way they do.

AF M4 said:

One of the most interesting things I got out of college was during a political science course...I read one historian (wish I could remember who) who said that people's relationship with any political institution occurs in four stages:

Idealism - one first encounters/enters the system full of enthusiasm and bright ideas to make things better. Young congressman, young HPSPer, etc.

Pragmatism - after a significant amount of time/experience in the system, the person realizes that most of their initial ideas are either extremely difficult or impossible to accomplish because of various obstacles within the system. The person adjusts their goals and now tries to accomplish what parts of their initial ideas seem feasible.

Ambition - after the person has invested a significant amount of time and effort into the system, his viewpoint begins to shift from promoting those ideals he initially entered the system with to promoting his own interests and career. He has now learned the system well and therefore becomes resistant to change, because his hard-earned knowledge of the system is what will allow his advancement. Ironically, he may even become one of the obstacles to change that the current idealists entering the system are encountering.

Corruption - the final stage, and this does not necessarily happen to everyone. It occurs when the person's viewpoint shifts completely to his own interests and he begins to exploit the system for purposes that the system was never intended for. The congressman takes bribes for certain legislation, a president hands out pardons to criminal cronies, etc.

Anyway, I thought that was an interesting perspective on the way bureaucracies work, and how things get the way they do.

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Hope to always be a Pragmatist.

NavyFP said:

Hope to always be a Pragmatist.

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Your terminal rank will likely be CDR then.

Cause you have to go over to the dark side of ambition to make CAPT.

Personally, I have barely made it into pragmatism, thats why I am getting out as soon as possible.

i want out

i want out said:

Your terminal rank will likely be CDR then.

Cause you have to go over to the dark side of ambition to make CAPT.

Personally, I have barely made it into pragmatism, thats why I am getting out as soon as possible.

i want out

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I can live with that.

As I've posted in other threads, my average was 5 "cases" per week over the last couple of years...and 4 of those 5 cases were colonoscopies or EGDs. So, I averaged ONE operative case per week and that included things like breast biopsies and hemorrhoids. Not exactly the kind of practice one envisions as they finish residency. I did about 30 gallbladders in 2 years...I know civilian colleagues that do more than that per month.

As for "military combat readiness" training, I was well-prepared for any trauma coming out of civilian residency. After 2 years of doing colonoscopies, I was much less "ready" to manage anything trauma related. Number of laparotomies performed in last 2 years=less than 10, number of emergency laparotomies=1, number of ICU patients=ZERO, number of inpatients staying longer than overnight recovering from surgery=less than 10. What a waste.

On a brighter note, my commitment is up, my resignation has been accepted and I have officially separated from this brain drain. I start civilian practice next week.

FliteSurgn said:

As I've posted in other threads, my average was 5 "cases" per week over the last couple of years...and 4 of those 5 cases were colonoscopies or EGDs. So, I averaged ONE operative case per week and that included things like breast biopsies and hemorrhoids. Not exactly the kind of practice one envisions as they finish residency. I did about 30 gallbladders in 2 years...I know civilian colleagues that do more than that per month.

As for "military combat readiness" training, I was well-prepared for any trauma coming out of civilian residency. After 2 years of doing colonoscopies, I was much less "ready" to manage anything trauma related. Number of laparotomies performed in last 2 years=less than 10, number of emergency laparotomies=1, number of ICU patients=ZERO, number of inpatients staying longer than overnight recovering from surgery=less than 10. What a waste.


On a brighter note, my commitment is up, my resignation has been accepted and I have officially separated from this brain drain. I start civilian practice next week.

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Congrats!! sent you a PM

The next year will be amazing compared to the crap you just went through. It will be interesting for others to see you posts as you enter normal life. Did you get to do an out interview with anybody??

My exit was so sudden that even though I had written volumes, it would not have mattered what I wrote, it was just going to be pitched in the trash. Every physician that I have talked to that gets out tells them in no uncertain terms the reasons they left are much of what we post here, but it never seems to make any difference. You'd think that someone would be paying particular attention to what all these physicians are saying about their time in the military. But that would only make too much sence.

I wish you the best.

Galo

Galo said:

Congrats!! sent you a PM

The next year will be amazing compared to the crap you just went through. It will be interesting for others to see you posts as you enter normal life. Did you get to do an out interview with anybody??

My exit was so sudden that even though I had written volumes, it would not have mattered what I wrote, it was just going to be pitched in the trash. Every physician that I have talked to that gets out tells them in no uncertain terms the reasons they left are much of what we post here, but it never seems to make any difference. You'd think that someone would be paying particular attention to what all these physicians are saying about their time in the military. But that would only make too much sence.

I wish you the best.

Galo

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I was told that I should rewrite the first draft of my resignation, because some things "they just don't want to hear".

Chain of command didn't come right out and say that they wouldn't route my letter unless I changed it, but they did insinuate that.

At this point, I just want out, and getting my resignation through the chain is higher on my priority's than telling the complete truth.

i want out

i want out said:

I was told that I should rewrite the first draft of my resignation, because some things "they just don't want to hear".

Chain of command didn't come right out and say that they wouldn't route my letter unless I changed it, but they did insinuate that.

At this point, I just want out, and getting my resignation through the chain is higher on my priority's than telling the complete truth.

i want out

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I'm not sure they have a choice. They do not have to endorse it, but if they do not, the next person up wont. Its is highly unlikely that it will work, but surely its your right to do it. How much time do you own??

Galo said:

I'm not sure they have a choice. They do not have to endorse it, but if they do not, the next person up wont. Its is highly unlikely that it will work, but surely its your right to do it. How much time do you own??

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I am aware that each step has the ability not to endorse my resignation, thats why I am more interested in getting it through than complete truth.

I only have another 10 months on my contract, so they should accept it.

i want out

i want out said:

I am aware that each step has the ability not to endorse my resignation, thats why I am more interested in getting it through than complete truth.

I only have another 10 months on my contract, so they should accept it.

i want out

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They can't keep you by refusing your resignation unless you are regular Navy, not reserve. Unless you have extended by accepting minimum orders somewhere they moved you, or there is a stop-loss, you are finished at your EAOS.

If you write controversial things in the body of the letter, those through whom it passes may signal their disagreement (to their superiors) by not endorsing, and they may suggest that you change this or that in the letter, but the lack of endorsement doesn't prevent you from leaving. It might slow them down, which is why a letter giving just the reason that you are leaving for professional training or some such neutral statement might get the stamp and move faster.

If you are using the letter to really tell them why you don't want to stay, save that for a different piece of correspondence.

orbitsurgMD said:

They can't keep you by refusing your resignation unless you are regular Navy, not reserve. Unless you have extended by accepting minimum orders somewhere they moved you, or there is a stop-loss, you are finished at your EAOS.

If you write controversial things in the body of the letter, those through whom it passes may signal their disagreement (to their superiors) by not endorsing, and they may suggest that you change this or that in the letter, but the lack of endorsement doesn't prevent you from leaving. It might slow them down, which is why a letter giving just the reason that you are leaving for professional training or some such neutral statement might get the stamp and move faster.

If you are using the letter to really tell them why you don't want to stay, save that for a differrent piece of correspondence.

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Everybody that was a 2105 last March was automaticly augmented by default to 2100. So the USNR versus USN distinction is no longer available for those of us that are on active duty.

i want out

i want out said:

Everybody that was a 2105 last March was automaticly augmented by default to 2100. So the USNR versus USN distinction is no longer available for those of us that are on active duty.

i want out

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Are you therefore vested by being 2100? Do they have to cut you a check for your retirement contribution if you leave, or does that apply only if they RIF or separate you against your will?

orbitsurgMD said:

Are you therefore vested by being 2100? Do they have to cut you a check for your retirement contribution if you leave, or does that apply only if they RIF or separate you against your will?

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I have no idea about being vested or retirement contribution's.

i want out

Croooz said:

Am I missing something? Where would one find the link?

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http://www.medicalcorpse.com/Apoptosis lecture.ppt

For best results, right click on link above, and "save target as" or
"save link as" to your desktop, then open in Powerpoint.

If you don't have Powerpoint installed (almost every gummint computer does, because idjits can't say "Shine your shoes" without making it a Powerpoint bullet), you can download the free Powerpoint viewer here:

http://www.microsoft.com/downloads/...27-43ab-4f24-90b7-a94784af71a4&displaylang=en

Very much worth reading...thanks again, Galo!

Peace out,

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

Did you have any difficulty in your job interviews given the difference between your case load and most civilian surgeons???? I'm sure you're a great doc, I'm just curious if the low caseload concerned any of your interviewers. Good luck with everything.

FliteSurgn said:

As I've posted in other threads, my average was 5 "cases" per week over the last couple of years...and 4 of those 5 cases were colonoscopies or EGDs. So, I averaged ONE operative case per week and that included things like breast biopsies and hemorrhoids. Not exactly the kind of practice one envisions as they finish residency. I did about 30 gallbladders in 2 years...I know civilian colleagues that do more than that per month.

As for "military combat readiness" training, I was well-prepared for any trauma coming out of civilian residency. After 2 years of doing colonoscopies, I was much less "ready" to manage anything trauma related. Number of laparotomies performed in last 2 years=less than 10, number of emergency laparotomies=1, number of ICU patients=ZERO, number of inpatients staying longer than overnight recovering from surgery=less than 10. What a waste.

On a brighter note, my commitment is up, my resignation has been accepted and I have officially separated from this brain drain. I start civilian practice next week.

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while I am in no position to disagree with the information above, if I may I want to add a couple of sentences.
I have been in the navy now exactly a year (this week).
I share many of the complains and complements all the gents above have stated.. . but in terms of cases .. I am on the lucky side.
to date I have done 110 colonscopies/EGD, and 245 operative caeses (of which 75 are what I would consider major.. ie colectomies, gastrectomies, thoractomies, nissans, ... ) (and about 30 or these are plastics ie abdominoplasties...)

again, I am on the lucky side it seems. I know a few surgeons elsewhere that dream of what I do here. So overall, it seems to be all dependent on where you are.

hope this helps
Ciao
A

aatrek said:

I share many of the complains and complements...

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Hmm...

aatrek said:

ie colectomies, gastrectomies, thoractomies, nissans, ... )

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I will now share with you a quote from my upcoming book, A Fly in the Hand: True, Uncensored Military Medical Quotes, copyright (C) 2006, R. Carlton Jones, M.D., All Rights Reserved:

"RCJ: Definition: The All New, 2006 Lap Nissen Maxima-- a guaranteed, three-surgery double round-trip to and from the ICU, when inexperienced surgeons commit what they write on the charts as "Nissans" on the persons of poor patients, with resultant esophageal strangulation, unrecognized stomach perforations, uncontrolled post-op bleeding, or other disasters that might have been prevented with adequate adult surgical supervision."

Count the round trips to figure out what happens to the patient, in the end.

Are you a board-certified thoracic surgeon? Did your thoractotomies go well? Do you think that the fact your patients survived means that you did the right thing?

Here's another copyrighted quote:

"I always tell my 5 year old, when he asks why he has to wear his bicycle helmet, when the other kids in the neighborhood don't: Just because you ride around without your helmet and haven't yet fallen and hurt your head, doesn't mean that you are doing a safe thing."
--Anesthesiologist former colleague at Travis, re: surgeons' willingness to live life on the edge, beyond their level of either training or credentialling, just because the military system lets them get away with same.

aatrek said:

(and about 30 or these are plastics ie abdominoplasties...)

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Are you board-certifed in plastic surgery? Do you feel competent to do C-sections as well? I get the impression that you are a general surgeon. Why do you feel competent to do abdominoplasties? I work with experienced plastic surgeons in the civilian world (one of whom is a retired O-6); none of them would come to your defense as an expert witness if you suffered a bad patient outcome.

This reminds me of the butcher who was the ranking general surgeon while I was deployed at Incirlik; he got in huge medicolegal trouble for committing breast reductions on young women in Turkey without formal training in plastics. When their nipples turned black and fell off, they were not happy. Sadly for him, he chose to operate on at least one dependent wife, from what I heard...he forgot the bit about the Feres doctrine only applying to active duty. D'oh!

His karma obviously ran over his dogma. Consider my words well, grasshopper.

--
R. Carlton Jones, M.D.
Ex-LtCol, USAF, MC
http://www.medicalcorpse.com

Survivor of at least 3 "Lap Nissen Maximas" at Travis, two of which led to young NCOs getting trachs; see: http://www.medicalcorpse.com/MII Travis Oct 98.ppt for details on one; read especially the section on surgeon experience and privileging, from which I quote:

"Finding #4: Privileging problems
Assumption that if a surgeon recently completed a residency program that he was competent in advanced laparoscopic procedures.
--No objective criteria

Impact:
Surgical inexperience almost certainly prolonged the case and led to greater than normal blood loss and fluid requirements. This would have compounded airway problems associated with OSA

Recommendations:
Applicants for privileges should at least have their residency case logs available to the person responsible for credentialling.
This information should be used to look at experience in types of operations rather than specific procedures."

While you keep on quoting mil docs.. I will give you a hundered quotes from docs like Dr. Claude organ, Abcarian, Brit, and many many others that support my position.
but I don't have to.. Simply because I am a surgeon that I know what I am trained in and I know what I am credentialed to do.
All I ask is that you go look up (in the really world.. not the mil med world) who is doing the vast majority of plastic, hand, thoracic, and plastics surgery.. uhmmm I remember I talk by Dr. Bass about this.. you guess it .. General surgeons.. we are credentialed to do this.. The only difference is where you trained... odds are if you trained in a mil setting you will do hernias for the rest of your life..but that is not true for the rest of us.

someone keeps on lieing to these poor mil surgerons that only thoracic boarded doc do thoractomies.. SIMPLY NOT TRUE...

anyway.. gotta go..
thanks for your advice, and best of luck

A.

delicatefade said:

Did you have any difficulty in your job interviews given the difference between your case load and most civilian surgeons???? I'm sure you're a great doc, I'm just curious if the low caseload concerned any of your interviewers. Good luck with everything.

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I had several things still going in my favor. First, I'd only been in the brain-drain as a surgeon for 2 years. Second, I actively pursued every difficult case in order to keep my skills up as much as possible. Third, my partners (and even the local general surgeons) recognised me as an expert in laparoscopic surgery...therefore, they referred many patients to me or had me assist during those surgeries (like Nissen Maximas). Fourth, I had unbelievably good experience during residency that put me way ahead of most other graduating chief residents. Fifth, without trying to be cocky, my technical skills have been praised by every attending surgeon that I've ever worked with.

The area that I feel degraded the most was my (lack of) ICU care. Fortunately, my practice is associated with a very good group of intensivists that follow all of our ICU patients.

BTW, here was my first "on call" case...a 65 y/o male that doesn't speak English...h/o multiple UGI bleeds s/p unknown type of ulcer operation 30 years ago in Asia, Hep B and C, ventilated for aspiration pneumonia after endoscopy last week, and now a recurrent UGI bleed that has failed endoscopic and angiographic control, 20 units into the bleed before I get the call. At operation, I discover that he's got cirrhosis and ascites too. Nothing like a nice simple case to get back in the swing of things! He's doing ok thus far, but with a pre-op albumen of less than one and the other comorbidities, the odds are against him.

MedicalCorpse said:

Are you a board-certified thoracic surgeon? Did your thoractotomies go well? Do you think that the fact your patients survived means that you did the right thing?

Are you board-certifed in plastic surgery? Do you feel competent to do C-sections as well? I get the impression that you are a general surgeon. Why do you feel competent to do abdominoplasties? I work with experienced plastic surgeons in the civilian world (one of whom is a retired O-6); none of them would come to your defense as an expert witness if you suffered a bad patient outcome.

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Training, judgement and experience are the keys to good outcomes. I know plenty of general surgeons that perform thoracic surgery, plastics procedures, and, yes, even c-sections. And they all have great outcomes. Abdominoplasties are not a very technically difficult surgery. I've performed them many times. I still scrub them with my plastic surgery collegue to fix associated hernias. We tag-team the abdominoplasty dissection and closure (each of us do one side). Actually, I did a ton of plastics during my training. I joked with my residency director that I did more breast reconstructions during residency than I did mastectomies. Whenever a mastectomy patient of mine is having an immediate reconstruction, I help...and if they're getting bilateral reconstructions...once again, I do one side and the plastic surgeon does one side. There have been plenty of times when the plastics guy will sheepishly confess that my side looks better.

In testament to my ability, prior to me leaving active duty I had 4 of the OR personnel come to me for operations before I left. I was very proud that they chose me. They were people that saw all of the surgeons work everyday. This included 2 of the CRNAs, one OR nurse, and one scrub tech.

I completely agree with you that there are surgeons that overstep their skills, especially in advanced laparoscopy. I recommend that they send all of those cases to me! Especially the Nissen Maximas.

aatrek said:

hundered...

Simply because I am a surgeon that I know what I am trained in and I know what I am credentialed to do.

uhmmm I remember I talk by Dr. Bass about this.. you guess it .. .

someone keeps on lieing to these poor mil surgerons that only thoracic boarded doc do thoractomies

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You leave me uncharacteristically speechless.

The next iteration of these fora must include spell checking as an option.

Fere libenter homines id quod volunt credunt.

--
R
The Un-Surgeron

Oh, yeah, the title means:
"The weather is nice today, isn't it?" in Welsh Gaelic.

The military likes the OR to be done all elective cases by 330 pm or as I used to say, 1530. At Brooke Army, you couldn't start a case at 2pm that would project to end at 1600.