The end of military GME is just a matter of time

Very intersting read

1) From that final bullet point, it seemed to say that a resident would only be deployed if civilian accrediting organizations were willing to consider this continuous training, which I am pretty confident will never happen (and if it does, I'm all for it). I don't think that they were suggesting that residents should be removed from residency do deployed, and then reinerted to pick up where they left off 6 months later.

2) The bullet point that said that "no study" supports the theory that completion of a GME results in better medical care was disturbing. Does anyone know of such a study, by the way?

3) This just seems like the kind of thing that's not going to survive the election.

"Admit that the rhetoric of needing GME to maintain the force structure as it relates to quality, recruitment, retention and cost effectiveness may not be true."

Gasp...

There's a very easy solution to this and it's cheap. Eliminate all GME in the military. Eliminate all MTF care for anyone except active duty personnel anf farm everything else out to Tricare. Re-enact the Barry plan and draft Docs into military following residency, or vastly expand FAP.

I'm not saying it would be the best idea (nor something that I would support), but it would be cheap.

It is interesting to read the "study" or try to read it -- I think my dog can write better than that. I think they're ignoring the elephant in the room -- what is the value of military GME? I also think it's amusing that the author drinks the GME Kool-aid that high inservice exam scores are an indication of quality of program.


Ed

This so-called "study" is really just a statement of current opinion about GME from some of the big decision-makers in military medicine. It has a little window dressing to make it look data-driven and serves to codify what has been obvious for years--GME is viewed as completely expendable by the command and will not be supported in the future.

Although I must say that ridiculous suggestions like deploying residents for six months are so fanciful that it calls into question the legitimacy of the entire publication. Seriously, where would you send them? Combat, with it's accompanying casualties, is inherently unpredictable in time, intensity and location. I've been on deployments where I did absolutely nothing for months and others which were so casualty-heavy that there was really no time to teach, and no place for an un-trained surgeon. Sure, there are currently locations in Iraq with a steady, predictable flow of casualties (like the one I'm in now) but what about a year from now when we may be exiting the country or no longer accepting Iraqi civilian truama? Will we be fighting in Iran, or will conflict die down with a new administration and foreign policy? Who can know?

It's absurd to think that you could plan a MAJOR portion of a residency program around the assumption that there will be fixed war-zone locations with constant casualty flow and an appropriate teaching environment. The RRC would laugh at the idea. Have the study's authors ever been deployed or run a residency program recently?

I wish that someone would just step up to the plate and make a decision about GME--either support it, close it, or drastically reorganize it. This slow downward spiral is terrible for the residents and is the worst possible situation.

Is there any way to validate the authenticity of the document?

Here is my favorite part...

The TRICARE system, with its choices, lack of nonavailability statements, and its freedoms to seek local care – have limited the ability of the military to create Centers of Excellence

LOL it has to be fake.

IgD said:

LOL it has to be fake.

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http://usminstitute.org/
it's posted on this site, which on quick glance seems legit.
http://www.usminstitute.org/pdf/NDIAStudyonGME.pdf

So GME may be eliminated and HPSP with it? How would this affect those get into HPSP in 2010? They still have to put in their time, but then what?

Currently if you like military med you can stay on and pursue a career, with GME eliminated would that mean that military physicians will be let go?

Or is this a case of HPSP going away but the military still having its own docs?

Or are we about to see civilian contracters take over and run the damned thing like an HMO?

That would really suck for people like my two younger sisters, who are thinking about careers in medicine but almost certainly won't be able to afford the med school tuition.

With tuition costs climbing faster than inflation and no end in sight, it is likely that they will be forced to take out crazy amounts of loans to become doctors, especially if HPSP is gone.

What's next close USUHS?

Triage is so efficient today that wounded soldiers are out of theater in 24 hours, and can be in civilian US hospitals in 72. The cold-war model that the AMEDD is currently built on (large overseas MEDCENS where patients receive staged definitive care) is thus obsolete.

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I think it's important to recognize the difference between 'obsolete' and 'not relevant to the war that we're currently fighting'. You don't think that reason for the rapid, efficient evacuation of wounded soldiers, and the resultant lower use of that Cold War model, is that we are fighting an enemy that is not particularly good at destroying our aircraft? What happens when we fight another enemy that is being provided with truely modern anti-aircraft weapons by China, Russia, or one of the richer Arab countries? Or what if (I hope this doesn't happen in my lifetime) we actually engage another major world power like China or India? We watch as the patients die getting evacuated (or die waiting weeks in transit), say oops, and then painful go about the process of rebuilding the military medical system.

That would really suck for people like my two younger sisters, who are thinking about careers in medicine but almost certainly won't be able to afford the med school tuition.

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I wouldn't worry about this. No one can 'afford' medical school tuition, almost everyone takes out private loans for almost the full cost of tuition and living expenses. That's true even at incredibly expensive private schools like the one I attend, even for the kids that got no scholarships and virtually no financial aid.

I suspect that the military would not have too much trouble contracting civilian surgeons and medicine docs (for big $$$$) to perform stabilization surgery and basic medical care for one short tour (say 4 months). There are, after all, plenty of patriotic docs who would jump at the chance to provide care to wounded soldiers, as long as it didn't mean that they themselves had to wear the uniform. Besides, the civilian contractor model of doing things in the military has taken on a life of it's own in the last decade, and I don't see why the military won't try to extend this philosophy to medical care. Imagine locum tenens in Iraq!

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The above would have been heresy just a few years ago, and I would never have believed it would happen. But on my current deployment, I met an army reservist who was quite far along in the planning stages of setting up a corporation in partnership with a big-name defense contractor to do just that--privatize some of the war-time medical care.

After interacting with many reservists on multiple deployments, it is obvious to me that there is tremendous enthusiasm for "helping out the troops," as long as it is a short tour and doesn't destroy their life and practice. Frankly, most reservists are more enthusiastic than the average active-duty doc, who is beaten down with multiple deployments, administrative BS, AHLTA, etc. I think you would have a flood of volunteers to do 4 months in Iraq or Kuwait for $500,000. Especially since they could avoid most of the other BS that goes along with the military.

I think it's a virtual certainty that we will see some degree of civilian contract medical care in the war zone. Just how much remains to be seen.

Heh, I've still got 3 years of active duty to go, followed by IRR.

But I imagine if I heard at the end of my tour that they were asking for docs to do a few months in the desert for 500K, I imagine that I could put off residency for a bit for that kind of money.

Actually, I'd probably run it up for a few months more, invest it all and then forego residency to live off the interest and possibly get some sort of chill job consulting someplace.

And as a brief aside to adamg, ya, your sisters will most likely have to take out huge loans to go to medical school in the future, but do not let that be the motivating factor for going into the military. I know the numbers are intimidating, but compare them to post-residency salaries. One of my ER doc friends told me that when he graduated residency he simply busted his ass for five months straight doing shifts at the three hospitals in my home town, and by the end of that stretch he had paid off 200K in loans, bought a new car and made a down payment on his house. Then he took a couple of months off and reveled in his financial security while perfecting his home brewery.

Mmm, beer.

Tired said:

I think everyone is putting a little too much stock in a single position paper published by some unknown officer.

Peruse the professional military journals some time. They are filled with similar papers on all aspect of military practice, many of which suggest dramatic alterations in structure and practice. And like most scientific papers, they are ignored and relegated to obscure publications and websites.

By no means should anyone take a paper like this as indicative of command policy or intent. This was likely some classroom assignment at one of the Officer leadership courses.

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"John S. Parker, MD, FCCP, FACS, Major General MC, USA (Ret.) was the study chair and reported to Julie Susman, Director of the Health Affairs Division."

I think everyone is putting a little too much stock in a single position paper published by some unknown officer.

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Clearly this particular paper by itself is not particularly important and does not set policy. However, it is quite reflective of current command thinking regarding GME. It isn't news to anyone involved with GME that when it comes to budgeting and reorganization in military medicine, maintaining GME is not a priority in any way, shape or form. People just pay lip service to it.

It is impossible to overstate the degree of pessimism surrounding GME among program directors in most surgical and many non-surgical specialties. It doesn't really filter down to junior resident level, but there is constant e-mail traffic and recurring high-level meetings regarding "How to salvage GME in the current environment."

(deleted)

GME isn't going away,

In case you wondered how relevant this author is, check out his bio: I don't know him but would have big reservations about him.

He hasn't been clinically engaged in a very very long time (I mean he was a general when Fitzsimmons was still around. He works for one of the biggest bilkers of the U.S. taxpayers around.. SAIC. There clearly is an agenda. Nothing like going from Ft. Detrick (material command) to a military contractor. Bio from SAIC follows:

John S. Parker, MD

MD, FACS, FCCP, Major General, USA (ret)
Chief Medical Officer, Health Solutions, SAIC

Dr. John S. Parker has been with the Enterprise and Health Solutions Sector of SAIC since 2002 and leads the company’s efforts supporting the national homeland defense initiatives in the areas of chemical and biological defense, public health and biosurveillance. Dr. Parker is a member of the Homeland Security Coordinating Committee.

Dr. Parker joined SAIC after 37 years of service with the United States Army. Most recently, as Commanding General, U.S. Army Medical Research and Materiel Command and Fort Detrick, Dr. Parker was responsible for the Army’s medical research, product development, technology assessment and rapid prototyping, medical logistics management and health facility planning, and medical information management and technology. Dr. Parker served as the Special Assistant Secretary of Defense (HA) for Medical, Chemical and Biological Defense; Deputy for Medical Systems, Office of the Assistant Secretary for Acquisition Logistics and Technology; Head of Contracting Activity; the Army’s Medical Materiel Developer; and Principal Proponent for Medical Advanced Technology in the Army.

Dr. Parker’s prior key assignments included tenure as Assistant Chief, Thoracic and Cardiovascular Surgery, Walter Reed Army Medical Center; Chief, Thoracic Surgery, Landstuhl Army Regional Medical Center; Division Surgeon, 8th Infantry Division (MECH); Surgical Consultant, 7th MEDCOM and EUCOM; Surgical Consultant to The Surgeon General; Commander, United States Army MEDDAC, Fort Carson; Chief, Medical Corps Branch, PERSCOM; Commanding General, Fitzsimons Army Medical Center and Installation; Commanding General, Central Health Services Support Area and DOD Lead Agent for TRICARE Region 8; Assistant Surgeon General for Force Projection, Deputy Chief of Staff for Operations, Health Policy and Services, USAMEDCOM and Chief of the U.S. Army Medical Corps.

Dr. Parker received a doctorate in Medicine from Georgetown University of Medicine in 1974 and a bachelor’s degree in Biology, Philosophy and Journalism from Washington and Jefferson College in 1963. He is a diplomat of the American Board of Surgery and the American Board of Thoracic Surgery, a fellow of the American College of Surgeons and the American College of Chest Physicians, and a member of the American College of Physician Executives, the American Telemedicine Association, and the American Medical Association.

mitchconnie said:

After interacting with many reservists on multiple deployments, it is obvious to me that there is tremendous enthusiasm for "helping out the troops," as long as it is a short tour and doesn't destroy their life and practice.

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The problem will be with the "and practice" part. How would it ever be possible for any busy surgeon to take 4 months off of their practice and go to Iraq? We'd definitley be hiring from the bottom of the barrell.