Here's the posts - beware as it is overall very negative (and long)!
from usmedicine.com
February 2001
Letters To The Editor -
Military Physicians Leave For A Plethora Of Reasons I have been reading several of the articles in your publication concerning military physician retention. I have recent experience with military medicine and find
much of what has been written very accurate.
I do wish to add some things:
During my four year stint in the military I did not witness one single physician with the rank of O-4 or below remain in the military beyond their initial obligation for HPSP or USUHS. Thus, from what I have
seen, military physician retention at the rank of O-4 and below is zero. This goes for all specialties across the board.
The only physicians I have seen stay are those in ranks of O-5 and above who seem "stuck" in the system for whatever reason. But, they are certainly in the
minority and are mostly in administrative non-clinical jobs.
This all combines to produce a practicing military medical corps that is consistently youthful and relatively inexperienced.
Why this severe military physician retention problem? Obviously, the military is not a good place to practice medicine. Here are some contributing factors:
Low Pay and Difficult Working Conditions. Why continue to work for the federal government, [which] is consistently demanding more and more from physicians,
when one can go to the private sector and still work as hard but be much better compensated for it? This is true for all specialties and is a "no-brainer."
Inadequate Retirement Plan. The retirement plan is not a good deal for physicians. This is because it is based upon "base pay" only, and is not based upon the total income.
Too much Managed Care. The military now seems to have a love affair with managed care, and has forced it upon its physicians. Unless one shares this passion for managed care, practicing medicine in the military,
especially as a "PCM," is demanding, difficult and frustrating. This is mainly because one does not have the autonomy
to limit the amount of HMO patients in his or her practice. Military medicine (in the MTF) is now 100 per cent HMO. One primary care physician who recently left the
military described the experience as "hellish" because of this. This leads to the next reason.
Lack of Autonomy. All physicians place a high degree of value upon this, whether they are willing to admit it or not. Most, if not all, physicians are strong-willed, independent people or they would not
have the "right stuff" to get into and through the rigors of medical school and residency. (If the military allowed them a residency—which is a whole other problem.)
Military physicians, simply because of the
organization they are in, have less autonomy than any others. Granted, this is given up when one chooses to "sign on the dotted line" and accept money from the government for medical education. But as soon as
freedom can be regained, most take advantage of the opportunity. However just because one "belongs" to the military does not mean that there needs to be as much micromanagement of military medical practice that there now seems to be. This micromanagement is a direct result of total "managed care."
Loss of Traditional, "Old-Fashioned" Medical Values. Military medicine now seems to be concerned more with numbers such as "metrics" and "productivity." Whatever
happened to the patient? The patient seems to have become lost in all this. In
fact, the patient no longer exists at all; this is evidenced by the fact that the patient has become a "customer." Pardon me, but a "customer" is someone who buys a
hamburger from McDonald's. A "patient" is someone who seeks the help of a physician. But wait, the physician has been lost also, the physician no longer exists either but is now a "provider." So, we have "customers" "accessing" "providers." This doesn't sound like medicine at all. Sounds more like business doesn't it?
So, there we have it folks, military medicine is now all about business. What is business all about? MONEY. So, what is military medicine all about now? MONEY.
Yes, private practice is about earning money also, but it is not the prime focus. Believe it or not, most physicians I know did go to medical school because they wanted to help people. People are what is most important in their lives, not making money. On the other hand, the prime focus of military healthcare as a whole now seems to be centered around money. What does this have to do with physician retention? Practicing medicine in such an overly cost-conscious environment is often very difficult and frustrating because of the limitations that are imposed in an
effort to preserve that which is valued the most: money. What limitations? Limited pharmacy formularies, strict referral criteria, and the many other limitations
imposed by managed care.
Career Progression Leads Out of Clinical Medicine. In the military, achieving higher rank (and thus higher pay), almost certainly means leaving the practice of medicine for a "desk job." This is a good thing for
physicians who don't want to practice medicine anymore, for whatever reason. But for most who want to continue the full time practice of medicine AND experience career progression, there is only one direction to go: out.
Promotion Dependent upon Unnecessary Non-Applicable Professional Military Education. In the military, physicians cannot be promoted beyond the rank of O-4
without "Professional Military Education." This "PME" is not geared toward medical officers in any way shape or form, but rather is totally oriented toward line
officers. For a physician who wants to become a line officer, this is probably a necessary thing, but how many of those are there? Furthermore, I doubt we will ever see a medical officer in command of a line organization.
Little or No Professional Development. The military continues to deny medical school graduates the opportunity to obtain a seamless medical education from medical school through residency before entering
practice. The military has come under congressional heat for this and deserves every bit of it. Hopefully, Congress
will keep the pressure on to put an end to this archaic practice. No need is so great as to justify this. All too often, these unfortunate physicians must serve out their entire time with incomplete medical
training, because the military then refuses to provide them with the additional education they need and ask for, or they are so disillusioned and disappointed with their military medical experience (after what has
happened to them) that they just want to get it behind them. This goes for GMOs and GMO-flight surgeons. Speaking of GMO-flight surgeons, isn't it baffling that its pilots—among the military's most valuable
human assets—are being cared for by its least trained physicians? Go figure.
This list is by no means exhaustive. I could go on and on, but I think most would agree that I have hit the big ones. Will anything be done to correct all this and thus the
physician retention problems? It's anybody's guess. But, I wouldn't hold my breath.
—NAME WITHELD
I have a different attitude! I enjoyed my military time, had some great experiences and feel like I learned a great deal. I only left so I could complete my training. Yes it was a pain not being able to go straight through, but during the last 5 years there
was huge cuts in GME. I don't blame anyone and would gladly return after my training is complete.
regards
In the early eighties I went through medical school on a U.S. Army HPSP scholarship. Upon graduation, I was informed that I could not perform my internship in a civilian program but was required to accept a military internship. I reluctantly applied and was accepted at the Army's supposedly "premier" program in my specialty only to find it was in disarray, lacking in quality instructors, and staffed by inadequate and poorly trained ancillary staff. Needless to say, I was very disappointed and discouraged. I elected not to enter military residency after internship and became a GMO (General Medical Officer) for several years to fulfill my obligation. In addition, we were required to put up with all the military bull**** while passing through one of the most stressful periods of our lives. Upon completing my military obligation, I entered a university residency to complete my training (I changed specialties and had to complete a second
internship).
I would not recommend anyone accept an Army HPSP scholarship unless they really and absolutely know what they were getting into. Do not believe for a minute that they will give you a deferment to train in a civilian program when you graduate from medical
school. Look very closely at the quality of the residency program you might enter. Finally, make absolutely sure you are military material before signing up.
I doubt that all military training programs are as poor as the one I was required to enter. Over the years (and while in the Army) I have worked with many military trained physicians and found most to be of
high caliber and expertise. However, very few of them have much good to say about the military. I believe that most (though certainly not all) quality physicians leave the military after their obligation not only because of the relatively low pay but also
because of the excessive bureaucratic intrusion and poor quality of care. Imagine the worst Kaiser system with a bad paint job.
I would certainly not advise any indentured medical student to defy the military lest he or she find themselves in some deep ****. There is no such thing as military justice.
I was naive enough to listen to the Army Medical Center's rhetoric about the quality of their program. I must add once again that not all Army GME programs were as disorganized and lacking in the qualities that make for good training.
I also want to add that my years as a General Medical Officer (GMO) were not particularly challenging but neither was it stressful. It gave me four years to
think aout what I wanted to do with the rest of my life.
I spent the time being a Dad to my two kids and also going to graduate school. So I spent the time well. In retrospect I would never had taken an HPSP scholarship. Who knows...things could have turned out
worse. I am not bitter about my military sevice but I would not do it again or nor recommend it to anyone.
Response - Anon_bc471b on 05/30/01 02:02 PM
Military medicine has changed dramatically in the 6 years I have been in it. I have 1 year left on my obligation, and will definitely separate when my time
is up. I did a military residency and think I was very well trained, but it seems the military is putting less time, energy, and money into GME. I am very concerned about the direction I see residency training
in the military going. The military seems to be more concerned about implementing the new PCO clinic concept and keeping track of all it's so called ways of tracking productivity, that it's lost sight of both
good patient care and keeping it's own providers somewhat happy. I don't know of anyone I work with at my institution that will stay in beyond their committment. I also know of someone who is getting out
as an 0-5 with 14 years in because he realized the extra $40K a year in retirement is not worth spending 6 more years on active duty making at least that much less than he will make in his civilian practice, as
well as having to move his family every 3-4 years. Overall, things have worked out well for me and I am not bitter, but I wouldn't necessarily recommend HPSP to incoming medical students anymore either.
Response - Anon_9bf7a3 on 05/30/01 04:31 PM
I have been in for 15 years and am thinking of leaving because assignments are not binding, there is insufficient professional development funding, and the emphasis is on supporting a military lifestyle of
comfort rather than on medicine. The doctors are an appendage. Our clinics are understaffed with nurses, or nurses masquerade as doctors (Fort Jackson, S.C.). The records are often missing. The best way to describe the place is this:They pay the administrative types first--the Rear-Echelon MF's--then they appoint a non-clinical
person to command doctors, then they abuse doctors. It's a Hollywood Drop. There isn't much behind the front. Doctors are leaving. Over in the Navy, the band is still playing, but the stern is in the air, because
the anesthesiologists are leaving (while nurse anesthetists are running higer liability rates in civilian life). See
www.uscova.org for the article by Colonel Hackworth (Dec, 1999, Archives,
www.Hackworth.com).
Response - Anon_bc471b on 05/30/01 05:44 PM
I have watched morale at my current hospital plummet over the past 2 years. Every department is way understaffed with providers, nurses and technicians.
We are losing 4 providers to PCS or separation this summer and getting 2 in return. The command comes to us every day asking us what we plan to do about the
number of available appointments this summer. The solution is simple - get more bodies, even if that means civilian contractors. However, their answer was
to tell us that no one can take leave or TDY until further notice. Good thinking.
Response - Anon_bc471b on 07/18/01 05:30 PM
I posted that response, and no, this is not a mecca. Idid train at one of the military " Meccas" for residency, and feel that I saw a lot during my residency, and worked with some great teachers/attendings. I feel that I am very well trained and well equipped to handle most situations I have encountered here. However, I have kept in touch
with people who are still at my former training program and hear that things are changing there as well. The ward and ICU have half the bed capacity that they had when I started my training there due to
nursing/tech shortages - this is not ideal for learning opportunities for residents to say the least. Everyone I've talked to says PCO is a disaster so far. They all agree that the bottom line is numbers only,
not quality of care, and certainly not residency training anymore. I can also tell you that morale here sucks worse than
it did 2 months ago. Almost everyone I know here is tired and pissed off. Our commander, who is not a provider, or even a nurse (Military Career Admin type) will go in and create additional appointments during lunch and after regular clinic hours because we don't have enough appointments to meet their access criteria. Well, part of the reason for this is because we lost several providers to PCS, pregnancy, and separation, and the command denied our requests for manning assist twice. Despite the new PCO system which was designed to improve access to care, we now have about 800 fewer appointments per month because the command reduced our staffing by 50% over the past year because they said we only needed X number of PCM's based on the number of patients in our local area. We are now getting record numbers of patient complaints
regarding lack of available appointments. The hospital patient rep is down here every week with complaint letters that we then have to respond to with a formal letter to our SGH. They will cancel an entire morning
of clinic for all providers for commanders calls, changes of command, "mandatory briefings," etc., and then bitch at the end of each month about our access. We spend so much time chasing our tails here it's not
funny. Luckily, I can see the light at the end of the tunnel and will be separating in 1 year. Despite my above complaining, I have been lucky - I received good residency training, received a great assignment as far
as location goes, have met some wonderful people, and have zero debt from my education. But, would I recommend to someone starting medical school that they should take an HPSP scholarship now?? I seriously
doubt it, although each individual may have different needs, tolerances for military life, etc.
Response - Anon_7a6a34 on 07/21/01 09:12 AM
bc471b - Your experience is typical. Isn't it
interesting that the air farce doesn't tell potential physician recruits about these things? Highly unethical, in my opinion. All we can do is tell potential recruits ourselves - I wish someone had taken the time to tell me. Several of the physicians
at my hospital (I use that term loosely) have already contacted the premedical advisors of their undergraduate schools. They have told them to tell these kids the truth.
There's more, but you get the idea. Opinions??
