Am I understanding the new Navy "OMO"?

[Bill Evans]

Hello everyone, so I've been trying to understand the new OMO system the Navy is transitioning to. Some things didn't click right so I'm just trying to check if I'm understanding it correctly:

So basically starting this year, with BUMED dropping instructions on applying to OMO in 2021, graduating medical students will either take
1. GMO route if no residency is matched.
2. OMO route after residency, if matched --> Meaning, finish residency and serve as a Flight Surgeon, Undersea MO, Surface MO, or Fleet Marine MO.

*Assuming that the current GMO system is fully replaced by OMO. It seems like the transition would be gradual.
( Sources referred from: Navy Medicine > Medical Corps > Operational Medical Officer and https://mccareer.files.wordpress.com/2021/06/bumedinst-1520.42b-11-jun-2021.pdf )

If this is correct, I'm confused because... are people basically entering minimum of 2 years of "rebranded GMO" when they are freshly out of residency? So I believe this brings up a new version of skill atrophy concern especially when someone is not FM or IM?

I (as a HPSP student) was once thinking of taking the Navy route to return 4 years of obligation as a GMO Flight Surgeon and then apply civilian residency but it seems like it's not an option to spend 4 years as a flight surgeon before starting residency since FS is now an 'OMO' not GMO. I'm not even sure why there would be a restriction for taking OMOs only after residency when their task would virtually be the same as current GMO's. Or will OMOs actually practice within their own specialty now?

Another example: Let's say someone went to Walter Reed for Orthopedics with a whopping 6-yr residency. Now there is 4+6 years of ADSO. At least 2 years would be burnt as an OMO, and then extra 8 years somewhere else with constant deployment / relocation. (I've been searching on this forum and noticed that someone is already on 7th deployment after completing ortho residency.)

Are there any errors in the statements I made above?
Thanks!

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[SirGecko]

I think you basically seem to understand it. Someone correct me if I'm wrong but I'm not sure if the timing of OMO tours after residency has been definitely answered. Every time I see people trying to get an answer on that it seems to be something along the lines of "OMO is one way to get operational experience. There will be other ways and we will make sure you also have the ability to practice in your specialty." Or basically saying that there will be some people that go directly to an OMO tour and others that do not.

The reality of what will happen... probably actually unclear. They say you will be able to still practice in your specialty but don't have a strict definition of how often qualifies. How much may actually wind up somewhat depending on individual motivation, the actual billet, etc. As for timing I don't think that doing utilization tours in your primary specialty followed by an OMO tour will be sustainable unless the actually billet numbers for OMO jobs change. The timing doesn't seem to work out for most HPSP people as you will have a lot that want to do their four years and get out trying to extend at their initial duty station rather than going through additional training to sign on to more years for something outside their specialty. Now if the actual percentage of time in your primary specialty is higher, maybe this will be more attractive? I don't know but I think it is likely that they will wind up needing to send people directly to OMO tours post residency against their will. (the army and air force already do this to an extent)

 

[Bill Evans]

@SirGecko Thank you! Ok so I'm not completely off from whatever's published on the surface... I guess we will need to wait and see how the new system actually plays out! I've been poking the Navy Medical Corps website and actually had a chance to talk to one of directors, and even she admitted that they can't say how it will work out and we may need to wait a few years to see how it actually changes and improves the current system.

Personally it still sounds like the expanded GMO (with surface MO and fleet marine as extra options). It always feels like the military medicine has been trying to cut down the expenses, especially with specialities, and just flat out everyone into generalist while outsourcing civilian side for any specialty care so this movement kind of seemed counterintuitive for me. Unless they are actually trying hard to make the military medicine attractive even for those who seek specialty.

 

[pgg]

Another example: Let's say someone went to Walter Reed for Orthopedics with a whopping 6-yr residency. Now there is 4+6 years of ADSO. At least 2 years would be burnt as an OMO, and then extra 8 years somewhere else with constant deployment / relocation. (I've been searching on this forum and noticed that someone is already on 7th deployment after completing ortho residency.)

No

Residency payback is effectively concurrent with medical school (HPSP or USUHS) payback. Technically speaking I think HPSP is paid off while in residency while incurring the residency obligation. And, intern year is a "dead" year, counting for neither payback nor an ADSO.

Also, 6 years for ortho? I though ortho was intern + 4 = 5. Does Walter Reed throw in a mandatory research year or something?

Anyway. This hypothetical ortho grad, after 1 year of internship and 5 of residency, would owe 5 years, not the 10 you noted in your post.

 

[Bill Evans]

No

Residency payback is effectively concurrent with medical school (HPSP or USUHS) payback. Technically speaking I think HPSP is paid off while in residency while incurring the residency obligation. And, intern year is a "dead" year, counting for neither payback nor an ADSO.

Also, 6 years for ortho? I though ortho was intern + 4 = 5. Does Walter Reed throw in a mandatory research year or something?

Anyway. This hypothetical ortho grad, after 1 year of internship and 5 of residency, would owe 5 years, not the 10 you noted in your post.

Aha okay, that clears out a lot of other confusions I had actually. Thank you so much! So just to confirm if I understand it correctly, PGY-1 (intern) is considered neutral to ADSO (no payback nor accrued), and PGY-2 and beyond payback and accrue at the same time, right?

1. So for example, if a typical HPSP student with 4 years of ADSO goes through a 5-yr residency, PGY2-5 basically pays off HPSP's 4 yr AND adds extra 4 yr of ADSO so when the person finishes the residency, there is 4 yr of ADSO left, making the entire residency look "dead/neutral" for the obligation, right? I guess this is the same for any residencies 5 yr or shorter.

2. But for 6 year residency, PGY-6 adds another year but there is no more HPSP obligation to pay off, so it will simply add another year, which is why the hypothetical ortho grad will owe 5 yr after residency like you explained it to me.

3. And for any fellowship, if pursued, will add another ADSO. (2 yr fellowship in either civ or mil will add 2 yr of ADSO, so returning to civilian will be delayed by 4 years.)

And for the Walter Reed - yeah! It seems like WR's surgical specialties (GS, ortho) have an extra year for research after PGY3. Didn't seem like other big facilities in San Diego or San Antonio follow this, so this seems to be unique to WR. I referred to this page: Walter Reed Orthopaedics

 

[pawprint]

I agree with above that it’s pretty unclear when board certified doctors will be utilized as OMO’s. Right now we have a shortage of doctors in the operational world (FS/GMO/UMO) because residency trained doctors aren’t volunteering to go do an OMO tour at the rate needed. For the future this means people are going to be volun-told to do this, and the only timing that you could make someone do an OMO tour is right out of residency or else they will complete their Hpsp payback and the military won’t really have any leverage to make someone go be an OMO once their payback is complete (unless it’s someone who wants to do 20 years).

Flight surgeon billets are especially concerning because you can’t be forced to become a flight surgeon. Flight school has a lot of physical standards you have to meet, and getting into an aircraft is all voluntary. You could make OMO’s become AME’s (Aeromedical Examiners, basically flight surgeons who don’t fly), however, AME’s cannot do some of the required things you NEED flight surgeons for, such as mishap investigation response and some required squadron council meetings. I also don’t know why a board certified doc would pick flight surgery over a surface ship billet, it’s a longer commitment away from your specialty (3 years for flight vs 2 years for surface ship…this is because flight school takes a year and then you fill your 2 year billet afterwards).

Will be interesting to see how this plays out.

 

[sarturo]

I agree with above that it’s pretty unclear when board certified doctors will be utilized as OMO’s. Right now we have a shortage of doctors in the operational world (FS/GMO/UMO) because residency trained doctors aren’t volunteering to go do an OMO tour at the rate needed. For the future this means people are going to be volun-told to do this, and the only timing that you could make someone do an OMO tour is right out of residency or else they will complete their Hpsp payback and the military won’t really have any leverage to make someone go be an OMO once their payback is complete (unless it’s someone who wants to do 20 years).

Flight surgeon billets are especially concerning because you can’t be forced to become a flight surgeon. Flight school has a lot of physical standards you have to meet, and getting into an aircraft is all voluntary. You could make OMO’s become AME’s (Aeromedical Examiners, basically flight surgeons who don’t fly), however, AME’s cannot do some of the required things you NEED flight surgeons for, such as mishap investigation response and some required squadron council meetings. I also don’t know why a board certified doc would pick flight surgery over a surface ship billet, it’s a longer commitment away from your specialty (3 years for flight vs 2 years for surface ship…this is because flight school takes a year and then you fill your 2 year billet afterwards).

Will be interesting to see how this plays out.

So do we know if this means it is still possible to try to do FS after intern year?

 

[pawprint]

So do we know if this means it is still possible to try to do FS after intern year?

I’m sure it will still be an option for those who do a TY year.

But for everyone else, they will be in straight-through residency spots with no application between pgy-1 and pgy-2, so I imagine those folks would have to be a special circumstance for why they would leave mid-residency.

 

[backrow]

I’m sure it will still be an option for those who do a TY year.

But for everyone else, they will be in straight-through residency spots with no application between pgy-1 and pgy-2, so I imagine those folks would have to be a special circumstance for why they would leave mid-residency.

If you had a straight through spot you would have to resign from residency to do flight surgery (or any OMO) after intern year. Depending on the specialty there would likely not be a spot for you to return to training. I would not recommend taking that chance.

 

[j4pac]

From the way this reads…it’s much more likely to affect residency complete military physicians than those trying to do 4 year GMO and GTFO

 

[backrow]

From the way this reads…it’s much more likely to affect residency complete military physicians than those trying to do 4 year GMO and GTFO

One of the issues is that people will likely need to make this decision earlier (ie as a Med student) instead of in the past when they could do intern year, go out to the fleet and decide when it was time to reapply for GME. Now since a majority will be straight through contracts there won’t really be that off-ramp.

Ultimately though you are correct that in say 3-5 years the OMO will be more pertinent to residency graduates. The specialty leaders have been working on this for at least a couple years now, so I’d recommend anyone (Navy) who wants the scoop for their specialty to reach out to their specialty leader.

 

[j4pac]

One of the issues is that people will likely need to make this decision earlier (ie as a Med student) instead of in the past when they could do intern year, go out to the fleet and decide when it was time to reapply for GME. Now since a majority will be straight through contracts there won’t really be that off-ramp.

Ultimately though you are correct that in say 3-5 years the OMO will be more pertinent to residency graduates. The specialty leaders have been working on this for at least a couple years now, so I’d recommend anyone (Navy) who wants the scoop for their specialty to reach out to their specialty leader.

You and I have been doing this a while. We both know this fear of GMO dissolving has existed for decades. Here we are…still tons of Navy GMO spots and GTFO strategy is still in play. Getting rid of GMO would be stupid…as it’s really the only thing that actually works in milmed.

I’m not sure I’d counsel anyone different based on new developments. If someone would hate making a career in the military, then they should probably not go HPSP. But that’s nothing new.

 

[backrow]

You and I have been doing this a while. We both know this fear of GMO dissolving has existed for decades. Here we are…still tons of Navy GMO spots and GTFO strategy is still in play. Getting rid of GMO would be stupid…as it’s really the only thing that actually works in milmed. .

Oh, I agree GMO isn’t completely going away; however, there is definitely a plan in place and action already taken to be more in line with what we see in the Army & Air Force. This years GMESB note will likely be telling.

Some specialties have already had to discuss how they will fill certain numbers of OMO billets and others have been told where OMO billets will be that they will be expected to fill from their residency-trained staff.

Where this is difficult is in the flight surgery and UMO-world. You can’t force someone to do that training; however, they are getting ahead of that issue by having aeromedical and undersea “medical examiners” which are folks who do the classroom work but not the flight/dive training.

With all that being said there is a new Medical Corps Chief inbound, so things could change yet again.

 

[DrMetal]

How has this aged? As someone interested primarily in a Navy TY -> FS -> Get out track for HPSP, it sounds like I won’t have any problems doing just that?

No, you shouldn't have any problem at all in doing that.

One thing has remained constant over the decades: The Navy has never forced someone to do a residency (PGY2+). Many have ended up with their second choice (the wannabe neurosurgeon who ends up doing FM), but still, it was a choice.

As such, if you don't accept a PGY2+ spot (or if you don't even apply), you will GMO your way out (maybe as a FS, maybe something else).

The only monkey wrench is, if states start to require more than PGY1 for licensure, then the Navy will have to change. But even then, it's doubtful the Navy will force someone to do a residency that they don't want to do. What's more likely is the Navy will just make some cockamamie policy that allows for post-PGY1 non-licensed MOs to practice under someone else's license. Or, everyone will just have to get a license from the one of the few states that allow for PGY1 licensure [there are still plenty, none of this is really in play right now].

 

[DrMetal]

Awesome, this is very reassuring. Thank you!

Well, don't be too reassured. You still have some thinking to do. Fast forward to 10 years from now, when you're getting out, you're 36-yo and still haven't completed a residency. Still happy? [you certainly might be, it's all been done before . . .but just give it some deep thought and make sure it's what you want, or at least, what you might be ok with]

 

[DMBandFan86]

The military is typically 1-5% cool and the rest of it isn’t. But that’s how they market to you; that it’s all exciting and fun and fast paced.

Are you going to be in your mid 30s when you get done and have to start residency? That just sounds terrible from the pay cut alone. But the years you loose on establishing a practice, savings for pension, costs to family or kids are a lot higher than you realize. Your non military colleagues will be years ahead from that standpoint.

But like Dr. Metal said, it’s been done many times before and if that’s what you want then go for it.

 

[pgg]

That's not an unreasonable plan.

The happiest military doctors tend to be the ones who wanted to be in the military because of some of the military stuff, and were flexible about timelines.

I'm glad I did my GMO time with the Marines, and later I spent about 8 years on the Navy rifle team, which was a lot of fun.

However - just bear in the back of your mind that what you think you want now, might be different from what you want after 4 years of medical school and an internship year. It may be less fun to walk away from medicine for a 3-4 year break than you think, after devoting five difficult years of your life to learn the trade.

Also. Some consideration should be given to whether or not you really want to be part of GMO-land at all - it is, objectively speaking, a system somewhere between quaint archaic novelty and the outright dangerous/inappropriate practice of medicine. More and more states won't even license a physician with a single year of GME, and for all the military's reassurance about "a healthy patient population" and support from other (fully trained) physicians ... there's just no denying that GMOs are really just glorified interns that would never be allowed to practice independently anywhere else in the USA.

(Even though many states will license a physician with just 1 year of GME, that doesn't mean any facility will credential that physician to practice independently, or that any insurance company will pay that physician.)

Most of us here are extremely critical of the ongoing use of GMOs. Medicine itself, and the standards of practice, are different now than they were decades ago. Independent GMOs were probably OK in the 1970s and 80s when it wasn't unheard of for an intern to graduate and set up a practice in the community. GMO work was often sketchy when I did it (2003-2006) and I feel fortunate to have finished my tour without hurting anyone. It's really hard to defend the practice now in 2023 - and honestly, virtually the only people doing so these days are the official spokespeople for the system that somehow still relies on them.


Anyway. Life ought to be more than checking the boxes in a stepwise logical fashion to get from point A to point B. Go in as an informed person, with eyes open, and enjoy the ride if that's what you want to do.

 

[pgg]

This is a good ethical point you bring up about GMOs even being ready to practice medicine. From my count, it seems that there’s already about 20 states that require at least 2 years of training (for MD) before getting a medical license. So that does limit the number of GMO/FS opportunities I will be open to with this track.

It's not really a limit. Practice in the military (or at federal facilities like the VA or federal prison system) requires a license in any state, not necessarily the one the person is working in.

Lots of GMOs just get a license in the cheapest state, because it doesn't really matter. Maybe it's worth getting licensed in a state you expect to later practice in, or expect to do residency in.

I got a NC license for my GMO tour, and still have it active all these years later. Have even done locums work in that state as recently as 2022.

What percentage of cases do you think an intern-trained GMO would see that you think would be beyond their capabilities?

Well that's the thing, everything is routine until it isn't.

And would 5% be too much?

1%? If you've got 1000 Marines in your unit, that's 10 guys. Don't those 10 guys deserve good care?

Most GMO clinic work is routine minor stuff, knee pain, coughs and colds, paperwork for basic physicals so someone can drive an ammo truck or work in food prep, etc.

But then you're mid deployment in Afghanistan and the 22 year old Marine who has fatigue and weight loss (like every other one of the 1000 Marines who's carrying a 60 pound pack and body armor and a rifle up and down the mountains at altitude) comes in ... looking pale and just a bit off after he was seen for the same thing three weeks ago. Maybe this time the GMO is lucky to be 100 yards away from a Role 2 surgical team and decides to walk the Marine over for a second opinion. And 2 hours later the Marine is packing for a flight home because he's got subtle but palpable supraclavicular lymph nodes and a CBC shows a hemoglobin of 6 and 95% lymphocytes, and a week later he's getting his first round of chemotherapy. (In an alternate universe the GMO missed it and the Marine dropped dead a month later at some godforsaken FOB with a nice view of Pakistan.)

Or maybe the 21 year old Marine who saw a little bit of blood when he threw up after drinking was just hitting the ibuprofen a little hard and had a bit of NSAID gastritis, or maybe he had an esophageal adenocarcinoma.

Or maybe the GMO is deployed and some locals being an injured kid to him. Maybe the girl got too close to the trash pile her ******* uncle was lighting with some gasoline and has a bunch of 2nd and 3rd degree burns, and maybe the medevac request is denied because she wasn't injured by coalition forces, and maybe the GMO is stuck doing wound care every other day for a couple weeks using intramuscular ketamine for sedation before she gets septic and medevac is finally approved because now she's on the edge of death.

If you didn't guess, these things happened to me.

And those are the times that I knew I wasn't up to the task, and got lucky. But lesser or incompletely trained people can lack the experience and knowledge to know when they need help. I still wonder if or how many times I missed something that a fully trained doctor wouldn't have missed.

I totally understand if many in the community feel the difference in level of patient safety between a GMO and OMO is a big gap, especially since you guys are able to see things now in hindsight. Also, from the perspective of being fully trained, it doesn’t quite make sense to me that all specialities would make for a better GMO. Your duties in operational medicine generally require you to be a generalist. So yes, your specialty training will make you more competent in handling cases in your specialty, it doesn’t necessarily improve your ability to handle cases in other areas unless your specialty is say general IM, FM, EM.

This isn't really correct. I'm a subspecialized cardiac anesthesiologist now but the breadth of my medical knowledge and experience in ascertaining if a patient is "sick or not sick" is far better than it was when I was a GMO. I'm also better acquainted with the edges of my knowledge and the gray areas.

I sure don't know less than I did as a newly graduated intern. There's no world in which any GMO is better qualified than any residency-trained physician.

Residency isn't just time to narrow focus and learn one specialty in depth, it's a time to learn judgment and proper consultation with others with the safety net of being a supervised trainee.

It seems weird to use words like maturity when talking about grown-up adult doctors with medical licenses, but there's a maturity to how one approaches ambiguity, assesses risk, and makes decisions, that is specifically trained and cultivated in residency. Regardless of the specialty.

Yes, FM is probably the specialty most directly suited to GMO work, but your average ophthalmologist or pathologist or gynecologic oncologist is always going to be a step up from an intern/GMO.

If GMO’s are being transitioned away from, that means that more fully-trained doctors are taking their place. Perhaps that does mean there is more support in place for GMOs to defer when things are out of their wheelhouse? Also despite their lack of training, I also just don’t see GMOs going away anytime soon unless Big Navy is willing to foot the bill to incentivize more fully-trained OMOs. You can tell me if you see that happening anytime soon…

Oh I totally agree. But bear in mind that when I interviewed at USUHS in the late 90s they told me GMOs would be mostly gone before I got to the fleet. So. Hold your breath for the changes if you like.

More GMO supervision and consult resources while in the US are great but don't lose sight of the fact that all that help will mean precisely **** all if you get deployed and end up being the guy in some remote place. It can be lonely out there. Medical evacuations are a big deal. There is always pressure to just handle it yourself.

Just food for thought, I don't claim to have all the answers and there are absolutely obstacles to ending the GMO phenomenon.

 

[Gastrapathy]

I made a couple mistakes when I was a GMO. Still bothers me.

 

[pgg]

I made a couple mistakes when I was a GMO. Still bothers me.

The stuff I dwell on most is related to mental health. A few weeks of outpatient psych as a med student and intern didn't really qualify me to do bulk counseling/screening or treat/refer a battalion of Marines on their way home from a deployment that saw 8 deaths and 68 combat CASEVACs. I wobble between worrying that someone didn't get the care they should've, and being pissed at the Navy for dumping that task on GMOs.

 

[SirGecko]

Another point to consider as well is that it isn't just deploying. You could be tasked to be the only doctor in a clinic for the state for 3000 patients with only an independent duty corpsman and a nurse practitioner for support. There are ways to get help but you have to know you don’t know something. The things you don’t know you don’t know are the reason practicing with suboptimal training can be dangerous.

 

[epidural man]

Another point to consider as well is that it isn't just deploying. You could be tasked to be the only doctor in a clinic for the state for 3000 patients with only an independent duty corpsman and a nurse practitioner for support. There are ways to get help but you have to know you don’t know something. The things you don’t know you don’t know are the reason practicing with suboptimal training can be dangerous.

I was a GMO on a carrier (full component 5,500 people) and was constantly seeing stuff that was clearly over my head.

Like @pgg, at first I was pissed at the Navy for putting me in that situation. The first year, I spent so much time reading, it was crazy. I felt much more comfortable the second year and so was less mad - but had resigned myself to say - "well, it isn't my fault if I screw this up. That rests 100% on the Navy's shoulders. "

That first year, my SMO never really completed a real residency. I knew I was screwed when that first week, he brought an EKG to me and asked me to interpret.

 

[DrMetal]

I was a GMO on a carrier (full component 5,500 people) and was constantly seeing stuff that was clearly over my head.

Like what? How so? If it's over your head, you ask for help (help = send to ER, or med advice, or medevac). Job of a GMO isn't that hard. You basically triage, make a first attempt at diagnosis/treatment, monitor, then ask for help. You should be able to make initial decisions like that and judge sick vs not sick (considering we employ IDCs to do the same).

That first year, my SMO never really completed a real residency. I knew I was screwed when that first week, he brought an EKG to me and asked me to interpret.

Now this is the true travesty. But it's our own fault: the Navy allows and permits doctors to do non-sense residencies (non-sense = those specialties that have very little civilian analogues). If it were my Navy MC, every physician (especially in the operational setting) would be trained in either IM/FM/GS/Pes/Obgyn/Anes/Rads etc.

 

[pgg]

Like what? How so? If it's over your head, you ask for help (help = send to ER, or med advice, or medevac). Job of a GMO isn't that hard. You basically triage, make a first attempt at diagnosis/treatment, monitor, then ask for help. You should be able to make initial decisions like that and judge sick vs not sick (considering we employ IDCs to do the same).

When I was a GMO for an infantry battalion at Lejeune, there was a sports medicine clinic staffed by some family med and ortho docs from the hospital.

If I saw a Marine with an ortho complaint that I didn't have a good answer or plan for, or didn't improve with some light duty, I referred them to sports medicine.

They routinely gave me a hard time for "dumping musculoskeletal sick call" on them. Inappropriate consults. I ignored the emails and kept doing it, but there was pressure to not bother the real docs across the base.

Either I was an inadequate doctor who couldn't handle basic ortho (in which case referring ortho to someone competent was the right answer) or I was an adequate doctor who knew his limits (in which case referring ortho to someone competent was the right answer).

I was writing medical boards to get Marines discharged.

I did some very minor procedures in my BAS. Epidermal inclusion cysts, lipomas. I had a Marine with a lipoma that bothered him when he wore a pack or body armor. It wasn't huge, and I'm sure I could've cut the thing out without the Marine exsanguinating in my BAS, but I didn't feel comfortable doing it. I sent him to gen surg and he gave me crap for not doing it myself.

I take your point about IDCs being asked to mostly do the same job. The difference I experienced is that an IDC would never be given a hard time for consulting a doctor. GMOs were expected to just handle it. (And if an IDC makes a mistake, there's the "just an IDC" explanation built in.)

The notable exception was division psychiatry - they were awesome. Always helpful. Any time I referred a Marine, they were on it. Any time I needed some kind of backup to convince my CO that a Marine needed to not deploy with us, they were on it.

There was no peer review. Not a single chart of mine was ever reviewed by anyone, ever, the entire three years I was there.

Granted, this was ca. 2003-2005. I hope the atmosphere has changed since then. I hear there are more BC/BE people at the regimental level now, and peer review is more formalized, so maybe it's better.


What's kind of funny, is that I think I'd be a terrible GMO today. I haven't examined a knee in forever. I'm so far removed from any kind of primary care that I'd probably refer a whole lot more than newly graduated interns.

 

[Gastrapathy]

Yeah if we referred to Derm, they wouldn’t see the patient unless you, the GMO, accompanied them. So you could “learn” aka be harassed about wasting their time. It’s an impossible situation and totally unfair to blame the GMO who’s beset on all sides.

 

[epidural man]

Like what? How so? If it's over your head, you ask for help (help = send to ER, or med advice, or medevac). Job of a GMO isn't that hard. You basically triage, make a first attempt at diagnosis/treatment, monitor, then ask for help. You should be able to make initial decisions like that and judge sick vs not sick (considering we employ IDCs to do the same).



Now this is the true travesty. But it's our own fault: the Navy allows and permits doctors to do non-sense residencies (non-sense = those specialties that have very little civilian analogues). If it were my Navy MC, every physician (especially in the operational setting) would be trained in either IM/FM/GS/Pes/Obgyn/Anes/Rads etc.

I don't remember specifics to tell you the truth.

I just always had this feeling of being in over my head that first year.

I do remember one time - which actually is a great story about how physical exam CAN mean something -

We were out to sea. There was always a handful of sailors walking around the ship that every time a medical emergency was called, I would think "oh...this is probably one of those guys finally having that stroke or MI".

Anyway, one of those guys comes walking in one day and he looked like crap....short of breath, red in the face, struggling to exist on this planet. I said - let's get him hooked up to the monitors, get vitals,...I probably ordered some labs and a chest x-ray. On the tele, he was throwing PVC's all over the place, his Sats on RA were low (if I recall), and he was complaining of chest pain. Oh boy...I know what this is! So I do my exam which was normal except the irregular heart rate. I get the chest x-ray to be complete, but this guy is clearly having an MI.

Anyway, his x-ray comes back and he has a huge right lower lobe socked-in pneumonia. I am like "how the crap did I hear clear lungs on the exam? That can't be right."

So I go back and listen - and he CLEARLY had no lung sounds on the right side. I couldn't believe I missed it. But at the time I listened, I had already made my mind up that this was cardiac.

Parenthetically, this guy did NOT improve with IV antibiotics in the ICU. He eventually got shipped off and needed decortication surgery.

 

[DrMetal]

When I was a GMO for an infantry battalion at Lejeune, there was a sports medicine clinic staffed by some family med and ortho docs from the hospital.

If I saw a Marine with an ortho complaint that I didn't have a good answer or plan for, or didn't improve with some light duty, I referred them to sports medicine.

They routinely gave me a hard time for "dumping musculoskeletal sick call" on them. Inappropriate consults. I ignored the emails and kept doing it, but there was pressure to not bother the real docs across the base.

You did the right things. I must've had >200 consults. No one should ever give a GMO crap for a consult.

 

[DrMetal]

Anyway, his x-ray comes back and he has a huge right lower lobe socked-in pneumonia. I am like "how the crap did I hear clear lungs on the exam? That can't be right."

If it's any consolation to you, most attendings would've missed it too. We're all terrible at the physical exam, b/c society for the most part has deemed it unnecessary and not objective enough to base decisions on. It's good that you got the cxr. I teach all my IDCs and junior MOs to get ancillary objective data (vitals, labs, rads) whenever possible. Do a good physical exam . . .but if your ancillary data contradicts your exam, chances are the former is correct.

 

[Onefellswoop87]

You did the right things. I must've had >200 consults. No one should ever give a GMO crap for a consult.

Ortho (and other surgeons) at Tripler took my consult with no issues but then wouldn’t help with any administrative post-op case cause they wrote “profiles” and we do “light/limited duty.” That was annoying
But Navy derm at Pearl Harbor kicked back a few of mine. I had one where I tried all I thought was reasonable, sent a consult, they denied saying “get a biopsy” then we’ll see him. Seemed reasonable as having them biopsy would just delay. I did a punch biopsy, then they rejected the biopsy cause I surely have the answer now, so I just need to treat it. *facepalm* I knew as an intern that derm doesn’t come to the hospital, I hoped that derm would allow the patient to drive to them

 

[flightdoc09]

Ortho (and other surgeons) at Tripler took my consult with no issues but then wouldn’t help with any administrative post-op case cause they wrote “profiles” and we do “light/limited duty.” That was annoying
But Navy derm at Pearl Harbor kicked back a few of mine. I had one where I tried all I thought was reasonable, sent a consult, they denied saying “get a biopsy” then we’ll see him. Seemed reasonable as having them biopsy would just delay. I did a punch biopsy, then they rejected the biopsy cause I surely have the answer now, so I just need to treat it. *facepalm* I knew as an intern that derm doesn’t come to the hospital, I hoped that derm would allow the patient to drive to them

Referral guidelines to MTF specialties is definitely frustrating. Civilian providers wouldn't mind doing the biopsy because they can just bill for it. That being said, it is reasonable to and sometimes necessary to have the PCP do the ground work so the specialist can just do their job and address the issue. Like I know general surgery wants a bunch of hormones ordered before they'll see someone for gynecomastia removal. Someone has a testicular mass, you should probably get the ultrasound before you send to urology.

In this day and age, having access to resources like UpToDate, there's no reason you can't start the workup. And in the referral just document workup/initial treatment failure. If it gets kicked back, it's often some scheduler following an algorithm. Just call/email a physician in the clinic and make your case. Or call the on call specialist at the MTF and ask your question/for advice - they're on call for a reason. If you develop a good relationship with them, can also email.

I remember talking to the on call ortho once who was kinda rude to me on the phone when I was trying to take care of a Marine that had a broken ankle while TAD that was splinted at an outside ED and sent back home. He emailed me after seeing the Marine and apologized because he didn't realize that I had already done all the ground work for him. I got outside records, repeat imaging, and I had the LIMDU documentation teed up pending his eval.

I think a lot of GMOs in the fleet can be a bit lazy. It's very easy to just send a patient to the ER. But every 19 year old with chest pain doesn't need to go to the ER. Especially when it has been going on for months. Yet they get sent to the ER time and time again - probably by front desk staff. But it doesn't take much to do a quick exam on them. And it is never wrong to ask for help, or hand off to a higher authority. But punting should be avoided.

If a specialist at the MTF is giving a GMO a hard time about asking for help, that needs to be addressed by the regimental/group/division/wing/etc surgeon, because that is unacceptable.

 

[pawprint]

Yeah it’s ridiculous to me to hear stories of specialists having any sort of negative emotional reaction to operational GMO’s sending over a consult. I have no sympathy.

At the end of the day, It’s the job of the MTF to support the operational units (aka GMO’s). If a dermatologist is irritated about a GMO sending over a rash they don’t understand, then the dermatologist can trade places, and get out of the clinic and deploy for 6 months. I’d much rather finish my residency training, understand rashes better, and sit in clinic all day, and would gladly trade places if they want. Without me filling in my role as the GMO seeing all the nonsense, you’d be pulled out and deployed in my place.

My viewpoint: be thankful for your GMO’s, they are deploying and you aren’t. they are screening 95% of the garbage medical complaints. If they send you a nosebleed, see the nosebleed and then go home to your family at night and enjoy your 96’s. Because the GMO doesn’t always get that privilege. And if you’re upset your GMO’s don’t have enough medical knowledge, you’re right, they don’t…but that’s not their fault.

As we move away from the GMO system, the board certified folks are the ones who are going to get overwhelmed with all garbage because there won’t even be a GMO to screen in the first place.

 

[DrMetal]

As we move away from the GMO system

We're not moving away from it. Not a thing has changed, not a single GMO billet has been closed over the past 5 years, and we still have >100 PGY1s who don't go on to PGY2, who need something to do. You'll know we're moving away from it, when you see billets changing, and when you see us recruiting less at the MS level.

 

[pawprint]

We're not moving away from it. Not a thing has changed, not a single GMO billet has been closed over the past 5 years, and we still have >100 PGY1s who don't go on to PGY2, who need something to do. You'll know we're moving away from it, when you see billets changing, and when you see us recruiting less at the MS

the navy currently has a 70% gap on our current flight surgeon billets forecasted for this upcoming year. Last year it was 50%. My last duty station went from 20 flight surgeons to a current staffing of 7 in a 2 year time frame. I don’t know where the pgy-1’s went, but they certainly haven’t gone on to flight school. So yes, the gmo billets aren’t “closing”, but they are going unfilled until the navy starts sending the board certified specialists to close the gaps.

 

[backrow]

We're not moving away from it. Not a thing has changed, not a single GMO billet has been closed over the past 5 years, and we still have >100 PGY1s who don't go on to PGY2, who need something to do. You'll know we're moving away from it, when you see billets changing, and when you see us recruiting less at the MS level.

Something like 70% of Navy PGY1’s went straight through to training last year and for this coming academic year. There is absolutely a shift to continuous training occurring. The billets will never go away, who fills those billets is shifting.

That 70% number is a drastic change from 10 years ago, and even 5 years ago where the number was probably closer to 30%, or less, straight through.

 

[orbitsurgMD]

the navy currently has a 70% gap on our current flight surgeon billets forecasted for this upcoming year. Last year it was 50%. My last duty station went from 20 flight surgeons to a current staffing of 7 in a 2 year time frame. I don’t know where the pgy-1’s went, but they certainly haven’t gone on to flight school. So yes, the gmo billets aren’t “closing”, but they are going unfilled until the navy starts sending the board certified specialists to close the gaps.

Sounds like they are going to have to blow the dust off the checkbook and clean off their nibs.

 

[DrMetal]

the navy currently has a 70% gap on our current flight surgeon billets forecasted for this upcoming year. Last year it was 50%. My last duty station went from 20 flight surgeons to a current staffing of 7 in a 2 year time frame. I don’t know where the pgy-1’s went, but they certainly haven’t gone on to flight school. So yes, the gmo billets aren’t “closing”, but they are going unfilled until the navy starts sending the board certified specialists to close the gaps.

That's rather concerning. If those billets are so important, how they can they go unfilled? Who's doing the work then, some IDC? Makes you wonder if the billets need to exist at all.

 

[pawprint]

That's rather concerning. If those billets are so important, how they can they go unfilled? Who's doing the work then, some IDC? Makes you wonder if the billets need to exist at all.

It’s a good question. At my last command, flight surgeons started double and triple covering squadrons. Which caused a lot of backup in our clinic, and we could no longer attend the marine corps “mandatory” squadron meetings. we also had to start sending corpsmen on their own on detachments, and they would call the flight doc who they were attached to (who was usually on a different deployment/detachment) if something popped up.

Totally inappropriate way to handle things with how little training corpsmen get, which is why it’s not going to be sustainable.

 

[SirGecko]

It’s a good question. At my last command, flight surgeons started double and triple covering squadrons. Which caused a lot of backup in our clinic, and we could no longer attend the marine corps “mandatory” squadron meetings. we also had to start sending corpsmen on their own on detachments, and they would call the flight doc who they were attached to (who was usually on a different deployment/detachment) if something popped up.

Totally inappropriate way to handle things with how little training corpsmen get, which is why it’s not going to be sustainable.

Ehh… I dunno. The navy’s ratio for flight surgeons to squadrons always seemed like an extravagant luxury to me. I mean if they want to pay for it fine but it’s certainly not the only way to man that requirement.

 

[flightdoc09]

That's rather concerning. If those billets are so important, how they can they go unfilled? Who's doing the work then, some IDC? Makes you wonder if the billets need to exist at all.

It’s a good question. At my last command, flight surgeons started double and triple covering squadrons. Which caused a lot of backup in our clinic, and we could no longer attend the marine corps “mandatory” squadron meetings. we also had to start sending corpsmen on their own on detachments, and they would call the flight doc who they were attached to (who was usually on a different deployment/detachment) if something popped up.

Totally inappropriate way to handle things with how little training corpsmen get, which is why it’s not going to be sustainable.

As pawprint pointed out, the same amount of work exists, and it's just being shouldered by fewer people. I was thoroughly burned out by the end of my tour. Took almost my whole first year back in residency to recover from the burnout.

I always felt the way the Navy/Marines handled billeting for flight surgeons allowed for a greater connection with the squadrons, which was a very useful thing to developing a relationship and trust with pilots and aircrew. Same with putting us through API and primary (or at least a portion of it). Could certainly trim the budget and turn us into 100% clinic and 0% squadron, without the hands on training in Pensacola. But I know some of us, including myself, joined for the opportunity to fly and do other cool things. Take that away, and you better be giving us much bigger GMO pay or something to compensate.

 

[almostforgotaboutDre]

Well my thinking is follows.
1) I actually am interested in the experience of operational medicine and the cool, fun things you can potentially do in the military. Might as well scratch that itch now while I have basically no major commitments in life. Though I’m doing more investigation into what GMO/FS do on a daily basis. I’ve been reading they do a lot of paperwork, STDs/UTI/pelvic exam non-sense, and other BS. So trying to gauge the average ratio of good to bad stuff. But overall the potential for experiences you would never have as a civ and the ability to claim service to the country both seem worth it to me.

2. I want more options for GME (both in terms of quality of training and location), so I would prefer the civ options more. Given that I want a Civ career, I think it matters more for me where I do GME.

3. No skill atrophy. Once I’m trained, I want to just practice my specialty. Not be at risk of being forced into operational medicine and losing my skills.

4. I’d rather be younger when I’m being ordered around by the military, than when I’m older and have to worry about family commitments.

5. It’s not nothing to not have the stress of having enormous debt while in medical school and after, especially if I go to one of the expensive private schools. Yes you make less on the backend with HPSP. But not by much in primary care (which is what I want to do).

1. Agree with others - 1-5% is cool, rest is complete and utter BS. Paperwork is like 75+% and it's not actually medical - it's "Health Service" related or worse - inspections. It was a constant battle during GMO time to try and keep my medical knowledge up, seek additional CME, etc.

2. I think you're right. Plus, you could do residency and then sign up if for some reason the landscape looks good, and it works for your needs. Plus, you wouldn't have had to deal with all the military match/manning BS.

3. You will 100% have skill atrophy. Surgeons and anesthetists get deployed or attached to a unit, and go literal MONTHS without operating. You will however be asked to "chip in" and do primary care work in the interest of "readiness".

4. You're not going to be young by the time the Navy is done with you, and unless you have a mil-mil situation you're still looking at deployments or PCS.

5. Even in Primary Care you will fare FAR better. DM me and I can give you several anecdotal examples of buddies of mine that have gone into primary care and are doing insanely better. Contracts, incentives, payback stuff - civilian hospitals and practices are businesses that are more nimble and respond more quickly to needs/gaps. The supply of docs is very low in the US so with willingness to move/relocate - you could make more with a few days of work than you would with a month of your military salary.