and for part 2 of these insightful LETTERS to the EDITOR. And I want to say, I am NOT AGAINST anyone joining military medicine. Those who do, are doing a great service for our country and our troops. What I am hoping to do, is let you know what you may be getting into.
Letters To The Editor (Part II) -
Physician Departures:
Let The Dialogue Begin!
I found Dr. Koenig's article to be insightful and pertinent to the problem of physician retention in the USPHS as well as military. I especially identified with the comment that "things are wrong and being ignored." I think that people with some "real world" experience who occasionally wander into the system are undervalued and their potential contributions ignored.
I think that the morale in the Corps is very low. My wife and I, both board certified specialists, volunteered to work with the IHS and were commissioned five years ago, after several years of successful private practice, and not feeling quite ready to retire. We are now planning to leave the system, instead of renewing four-year contracts. We enjoy caring for Native Americans and even the challenge of working in challenging hospital settings and do not find the lower remuneration to be a problem. We do appreciate the freedom from the burdens of private practice and practicing with a team of other physicians.
Our primary reasons for leaving are the frustrations of having no control over an administrative bureaucracy that does not recognize or is incapable of fixing relatively straightforward problems. When decisions are made that negatively impact the image of our hospital, with little input from physicians, and when the hospital regularly runs out of money at mid year for equipment and medications, while the billing department flounders in inefficiency, it directly impacts how we are able to serve our patients. On a local level, our services are welcomed and valued, but on a regional or national level, we feel like we are treated like high school students, in view of the systems for monitoring our performance and evaluating our past experience and potential contribution.
Thank you for beginning the discussion of this important topic. If we are to retain physicians in government service, we must start a dialogue to understand why new physicians as well as more mature ones, decide to move on rather than feel like they have an important role in the system.
PAUL SCHREIBER, M.D.
Most Senior Physicians
Focus On Themselves
I'm a retired Air Force physician assistant (PA). I read with interest your article in U.S. MEDICINE on physician retention. You state that "The vast majority of senior military physicians are superb mentors, role models and champions of their younger colleagues." I couldn't possibly disagree more. Seven PAs and one physician "leader," a grossly overweight lieutenant colonel board-certified in internal medicine, staffed the primary care clinic at Scott AFB Ill. He saw active duty only. Meanwhile, I would be in the office with an 80-year-old who was taking 15 different medications. See anything wrong with this picture? The higher "leadership" in the hospital knew all about this, and did nothing.
At Brooks AFB Texas, I had to work for a 63-year-old lieutenant colonel physician. After 14 years in the Public Health Service, this individual came into the Air Force because the PHS wanted her to move out of Texas, and she didn't want to go. Not exactly a poster child for "Service above Self," wouldn't you agree?
She did not understand the Air Force corporate culture or the promotion dynamic, didn't know how to write an officer performance report or a promotion recommendation form, and didn't want to know about any of the above. Her sole interest was punching the time clock until she could retire. In short, she was a disservice to everyone who had to be supervised by her. Not willing to go on for pages, I will simply say that the described individuals are the rule in military medicine, not the exception. The Air Force Medical Service (AFMS) is infected with these types. I refuse to believe that the Army and Navy differ significantly in their physician make-up. Indeed, as a former Navy corpsman, my insight extends to that service as well.
These individuals were my "superb…role models?" I don't think so. The only thing the vast majority of AFMS "leaders" can represent is how not to be a role model.
The problem is leadership. Medical/nursing/dental schools are technical schools. No one learns anything about leadership or management in these technical schools. That fact is, all too often, all too painfully obvious. Those in military medicine leadership positions tend to be in way over their heads. Almost always, they have too much arrogance to admit it. That's a bad combination. Defining terms, arrogance is when you don't know what you're doing, and have nothing to say, but insist on your point of view. Indeed, this definition accurately describes most of the AFMS senior individuals. The reason they're in leadership positions is that they're the only ones left. Anyone who is not a strict careerist took one look at what was going on and got out a long time ago.
"Some senior physicians successfully navigate a career in military medicine by ‘playing it safe?' " Negative repeat negative! Try almost all instead of some. When all the people of integrity walk out, all you have left are don't-rock-the-boat types who have one interest—the furtherance of their own careers.
There are two kinds of people in military medicine. In the decided minority, we have those who believe that we must do what is right. In the vast majority, there are those who believe that the end justifies the means. In case there's any doubt, that "end" would be their next promotion. That's the mainspring of every decision these people make. Rather chilling to think of these individuals supervising people, say, in a wartime situation, isn't it?
As to those in the minority, I'm happy to say that I met one just yesterday. He is a young, bright specialist physician with a lot of common sense, a level head on his shoulders and a brilliant future ahead of him. He separates from the military in two weeks to go to a civilian residency, and is extremely happy about it. Can't say that I blame him.
CHIP SEIDERER
Patient Care Must Be Made
Military's Top Priority
I just finished reading [Dr. Harold Koenig's] article entitled "Physician Retention Within The Military," and I would like to share my comments and experiences with you concerning this issue. First, after reading your article, I felt as if you were speaking about me. I am a GMO in the USAF who entered into the military through an HPSP scholarship. I took this scholarship not only for the obvious financial benefits but also because of an underlying sense of proud patriotism. My father, uncles, and both grandfathers all served in the United States armed forces in one capacity or another. So, I entered into the USAF with expectations of serving my country proudly as my elders have done.
However, I have become quite discouraged during the past three years of active-duty service. After finishing a general surgery internship, I was sent to Kunsan, ROK, for a year as a GMO. Then I was sent to Los Angeles Air Force Base, where I have completed the second of my four-year active duty service commitment. I would like to relate to you my experiences with respect to Professional Development, Leadership, and Working Conditions.
Professional Development:
As stated above I am a GMO. My initial plans were to enter into a urology residency after medical school; however, the USAF did not need very many urologists my year, so I was sent to a general surgery internship. I had very little primary care training in medical school and virtually none in internship. Yet I was sent to Korea for a year to be one of four physicians in a remote primary care clinic.
I was lucky, because the other three docs were family practitioners who took me under their wings and taught me a lot. I call the type of medicine that GMOs practice "trial by fire" medicine. We are thrown into staff positions with very little training, and we are expected to function like fully residency trained physicians. So, all that we can do to survive and not hurt anyone is to learn quickly on-the-job.
I have indeed run into several situations where I was and am being held to a higher standard than that to which I have been trained. The most negligent is the fact that I am required to work a single-physician Saturday clinic once a month where half the patients are children. I have absolutely no training in pediatrics, and I related this fact to my supervisors. The other physicians in the clinic were very concerned about this issue, but because of a "manning shortage" I was told by my nurse commander that I had to do this anyway—even in spite of my concerns about my lack of training.
Leadership
I feel that there is a total void in the area of medical leadership. In medical school and internship, we were always around older physicians who could be called mentors. These physicians were full of experience and insight. They helped us develop into competent young physicians. They helped us choose our paths into residency and beyond.
There is very little mentorship within the Medical Corps. I am very worried about my future after the military: how competitive am I for a residency? Which residency should I pursue? etc. But there are no elder, wiser docs with whom to talk. My colleagues are straight out of residency. They are as young as I am. How are we to succeed professionally without the proper guidance?
Furthermore, I feel that you missed a very important aspect of leadership. We physicians are in a very tough situation with regards to choosing a career in military medicine. If we stay on active duty, then inevitably we will become administrators and not clinicians. Right now, this occurs by the time that one pins on Major. My SGH at Kunsan was a Major just two years out of his FP residency. He saw almost no patients during the whole year. How sad is that?
Most physicians that I know went into medicine because they liked to see patients—not because of a desire to push a pencil. But this becomes a much more sinister problem. Since most physicians have shied away from the "admin" roles, there are many essential leadership positions that have become available. These positions are now filled by nurses, which leads to a fundamental management problem. How can a career nurse understand the day-to-day frustrations not to mention the career goals of a physician when he/she has never been in that scenario?
In my opinion, the clinics should be managed by folks trained in hospital administration not in medicine or nursing. We doctors should be consultants to our managers. In my current clinic, the nurses are more concerned about the "numbers" rather than patient care. We doctors try to make suggestions that would best benefit our patients, but these are often very unpopular with our commanders because they may sacrifice a "good" metric.
My question: who are we serving if we are not working on behalf of our patients? This is absolutely ludicrous.
Working Conditions
I sometimes feel like I am working in a 3rd world country, even though my office is in the middle of a major metropolitan area. We have supply problems all of the time. At one point, we had no table paper, gyn speculums, or tongue depressors—in addition to the fact that we are required to see 25 patients per day with minimal support staff. Civilian doctors see many more patients a day than we do, but they have 4-5 exam rooms, plenty of ancillary staff, and they dictate their notes. How are we supposed to compete with this?
How are we supposed to give good care to our patients in a 15-minute time slot when we spend half the time finding out why the patient is here because there is no chart and the other half of the appointment is spent writing?
If the Unites States military is the least bit concerned about retention, then they certainly are not showing it very much. I would like to say that I am in complete agreement with your assessment. If more of today's leaders would listen to the messages that are being sent by today's military physicians, then I believe both physician and patient would be much happier. And this in turn would lead to more physicians making a career out of the military.
Physicians are a very committed bunch. We toil through medical school and residency in spite of our family and other personal commitments. When we come onto active duty, why can't we be treated with the respect that we deserve? We are our patients' advocates.
Until some kind of paradigm shift is made so that the patients as well as the doctors who treat them are regarded as priority-one, I believe that the military will certainly "hemorrhage" doctors.
AN AIR FORCE PHYSICIAN
Silence By Senior Officers
Leads To Physician Loss
Dr. Harold Koenig's editorial on physician retention certainly touched a variety of necessary changes to combat the physician exodus from the military. But [the situation] is not an "ooze" as he describes, but rather multi-system organ failure from a serious volume loss due to massive hemorrhaging of talent from our military's medical corps.
Many of us joined the military not merely for the financial incentives of medical student debt relief, but for reasons of patriotism and giving back to our country our medical talents to our fellow military active-duty and retired personnel and their families. It was during this advocacy for our active-duty personnel while a destroyer squadron physician with the USS AMERICA battlegroup during the Bosnia conflict in 1995-1996, that I found my greatest pride in our military. It was there on the ships that I met the greatest sailors you could ever ask for. It was also there I learned that the only member of the crew required to set sail was the Independent Duty Corpsman (IDC)— not the CO, XO or any other member of the crew. It was the senior enlisted corpsman (IDC) that was required at all times to be onboard while underway.
I realized then, as I understand now, that the medical oversight on our Navy ships is imperative and must not be compromised. For it is the IDC who checks the water, food and any other inoculum (vaccines, TB skin tests, etc.) or other health related issue, and is solely responsible to protect his/her fellow sailors and Marines. If we lose his/her oversight function, our country stands close to the edge of a military medical casualty resulting in needless morbidity and mortality.
This is what I believe is happening with the Anthrax Vaccination Immunization Program (AVIP). Shortly before I decided to resign my commission and leave the Navy, I heard from many of my old IDC friends from their SURFLANT deployments. I was appalled by what they told me. They were instructed to "look the other way" regarding any health reactions to this vaccine. Further, they were instructed to squelch anyone wishing to file a VAERS form (FDA/CDC required adverse reaction form).
The IDC's role as supreme medical safety advocate for his fellow shipmates was being threatened by a Naval community headstrong in "making this vaccination program work." Interestingly, I heard the same thing about TriCare, months earlier from our Navy Surgeon General. This was alarming and I could no longer remain in an organization that literally threw away its medical responsibility "to do no harm." Where were my fellow medical corps officers? I spoke out publicly on this issue in the Navy/Army/Air Force and Marine Times and was summarily tossed in the career trashcan. I was even passed over for lieutenant commander; for a physician it is a relatively rare event, and one I remain extremely proud of.
Sadly, it is the relative silence by our senior medical leaders which I find so disturbing. Not only junior medical officers are watching this silence in disbelief, but junior corpsmen are equally disturbed by our medical officers' lack of health advocacy for our men and women in uniform. I applaud Dr. Koenig's attempt at bringing to light a variety of important issues as to what is causing the exodus of talented personnel from its ranks. But besides money, promotion, working conditions, expectations, and adventure is the profound lack of medical leadership on a variety of issues, including TriCare, AVIP, defective chemical suits, heat exhaustion from improper hydration during fitness runs, documented harassment of various kinds leading to deaths of soldiers, airmen, Marines and sailors within a number of military bases throughout the world, including suicides far in excess of societal norms.
Until our medical corps of our services begin to take a moral, ethical and legal responsibility for the health and safety of our military, both active and retired, will we ever come close to turning the tide of an impending demise of what was a great heritage—military medicine.
CRAIG MICHAEL UHL, MD
Monarch Beach, California
Existing Problems Affect
Medical Officer Retention
I must say, you have impeccable timing with your recent article entitled "Physician Retention Within the Military."
In my e-mail inbox I have, among others, four e-mail messages. The first message, from my previous department head, says he submitted me for a Navy Commendation Medal for my work in a previous position under him. He submitted it before I changed positions; however, an MSC lost the award package. When the DH found out, he resubmitted it, but because it was past the CO's deadline for awards (the deadline being three months after a position change), it was not approved by the CO. "Sorry."
The second message mentions the two awards this branch clinic won in February 2000—both of the only two DoD/TriCare awards given to an Army/Navy/AF outpatient clinic, one for customer satisfaction, one for access to care. Each award came with $15,000 for the clinic to use for "morale building purchases."
Clinic staff decided on a new staff lounge, paintings for the clinic and exercise equipment. We have been waiting to buy all this since February 2000. However, the CO says the hospital is still low on funds and she has higher priorities for the money at the main hospital (medical equipment, pharmaceuticals, etc.) so we will not be able to buy anything with it until after October 1, "Hopefully then."
The third message is from my OIC saying that my request for my one and only medical conference for the year (the American Association of Family Physicians Convention in Dallas, Texas, in September 2000) has been disapproved due to lack of funds. The CO "suggests reading some medical journals and submitting the cards for CME." It's not the same thing.
Then the fourth message, sent to the fleet by the new CNO, contained the following paragraph:
"We prize leadership as the foundation for mission success in our profession. I expect every Navy leader to uphold the highest standards of leadership—that's a given. As shipmates and colleagues in service, we are bound by a voluntary covenant to our country and to each other, up and down the chain of command. As part of that covenant, leaders promise respect, clear direction, meaningful work and the tools and training to do that work, recognition for a job well done, and opportunity for personal and professional growth. The measure of any leader is the extent to which he or she fulfills that promise."
When there is such an obvious disconnect between the levels of the senior chain of command, is it really surprising that there is dissatisfaction among those of us on the front lines seeing the patients? And people ask me why I, as a commander, am getting out next year instead of retiring. (Actually, more of the reason I am getting out is to be able to take care of my elderly in-laws in upstate NY. They live near Fort Drum, and I asked the detailer if he could arrange for me to finish my time at the Army Family Practice clinic there, maybe switching places with an Army doctor—which, as a USUHS grad, does not seem unreasonable to me, especially given Fort Drum is in the snow belt and the Navy has some nice locations—but the detailer said his job is to "Find Navy people for Navy billets.")
After a previous e-mail conversation we had, I put down on paper some thoughts about how I feel Navy medicine could be improved to meet the current needs of the Navy as well as the needs of the Navy medical personnel. I had intended to submit it as an article for publication…but my COC discouraged me from doing so. I found it fascinating that your article was so similar to a portion of the article that I wrote, our coming from such different perspectives.
Following is an excerpt from mine.
Medical Staff Satisfaction: On a day-to-day basis, I would say most nurses, physicians, corps staff, and Medical Service Corps officers are generally happy doing what they are doing. They are satisfied with their lifestyles, opportunities to travel, call schedules, and access to entertainment in the area of the base. The general inclination of a professional is to make the best of their situation and try not to dwell on the problems, especially those over which they have no control. Nevertheless, problems exist and they affect overall satisfaction of the medical staff with the Navy. Difficulties with physician retention are one sign of this.
Problem areas/Ways to improve:
1) Staffing: See comments under "efficiency," above. Doctors enjoy training corpsmen, medical students, interns and residents. Corpsmen want to be trained, they want to see patients-they do not want to spend all of their waking hours taking vital signs.
2) Becoming administrative to advance: It is a generally accepted fact that most staff corps officers will not make captain unless they are in a department head or other administrative position. On the other hand, the civilian world is looking for doctors who are clinically great physicians, who see patients quickly, who practice cost-effective medicine, who have a wealth of clinical experience, and who are warm, friendly, and caring.
The Navy needs to put an emphasis on retaining physicians who meet those same qualities. They are not well-reflected in the current fitness report. Paradigm shift: Great doctors should be recognized and advanced regardless of how much "admin" they do. Maybe patients should be able to have some say in this.
3) Work hours: Many clinics are now open weekends and evening hours with no increase in staffing.
4) Access to recent technology: Even just three years ago I was at a facility that had 39 physicians and about 10 medical students sharing one computer. The computer situation is gradually improving as Y2K concerns forced most clinics and hospitals to replace their outdated computers, but there are still entire clinics in which no physician has a computer, there are physician department heads without computers, and there are physicians with old computers or computers that lack Internet access.
We need computers, but we need even to go beyond simply the acquisition of computers and start using the technology in a useful and time-saving way:
a) Upgrade to multimedia computers with Internet access, CHCS (Composite Health Care System—the medical net), word processing, voice recognition, and e-mail capability for each physician. With voice recognition, the provider can dictate patient records directly into the computer, avoiding need for a transcriptionist.
b) Establish an e-mail listserve for each specialty. I am the list-serve manager for the Navy's Family Practice List-serve, which is an e-mail group of 174 physicians, whose purpose is to share educational materials, billet opportunities, and other information relevant to all Navy FPs. The other specialties should also have listserves. (For information contact me at
[email protected].)
c) Navy-sponsored access to medical references available via the Internet. Some great sites with on-line up-to-date medical journals are costly for individuals, as are journal prescriptions.
d) Computerized medical records: Longtime promised, but slow in the coming. Once they are here, we will need access to digital cameras to put a picture of that "difficult to describe" rash into the record, or to document how that mole looks now to compare to any future changes, or to e-mail to a dermatologist for help with diagnosis. We will also need access to digital video to document procedures done via scopes, such as flexible sigmoidoscopy.
5) Respect: The erosion of respect for physicians as professionals in the civilian world (evidenced by frivolous lawsuits, HMOs dictating how to treat patients, decreasing physician "perks" at most hospitals, etc.) has made it into the military. Though respect between military personnel is an integral part of military culture, in certain subtle ways there is a decided lack of respect for physicians as professionals. Some physicians have an exam table in their office because other clinic personnel do not want to share an office in order to give the provider a separate exam room.
I have heard senior staff members seriously state, "What does a doctor need a computer for?" At one hospital recently an administrator spontaneously moved the physicians' call room four floors up without asking the physicians—because he wanted a larger office with a window. At another clinic, the physicians have to search for a parking space 200 yards from the clinic and walk by 15 parking spaces reserved for enlisted and civilian staff—since only one physician has a reserved parking space.
6) Compensation: The recent increase in base pay and the coming "adjustment" for middle-grade officers are certainly welcome. Increasing the bonuses, too, may get some short-term gains in retention, but the issue is actually more involved.
a) Pay discrepancy: When Navy physician pay is compared to civilian physician pay, it seems the maximum possible military pay (captain with no military obligation signing up for 4 years) is used and compared to average civilian pay for the specialty (including physicians newly out of training)—this is not a fair comparison.
For just one example, a lieutenant commander family practitioner with 10 years out of medical school but still with military obligation (the category of physician most likely to be debating about getting out of the Navy) makes about $83K (K=$1,000), compared to about 110K for the Navy captain physician. Starting pay for a civilian FP fresh out of training is $100 to $120K, but the average pay for an experienced civilian FP is $165 to $215K. The average physician assistant in the U.S. makes about $68K. Yes, some of the pay is tax free, but there is still a sizable difference in pay, and the civilians are not moving their families every few years and putting their lives in dangerous situations.
b) Defense Officer Personnel Management Act (DOPMA): As a result of DOPMA, which went into effect in 1986, the time physicians spend in medical school as ensigns does not count toward time in service or pay. This means that a physician who spent four years as an ensign at USUHS and graduated before 1986 would start out as a "LT over 4" (for pay) and be able to retire 16 years after graduation, whereas a physician who graduated in 1987 would start out as a "LT under 2" and have to wait 20 more years to retire.
I rarely hear DOPMA discussed, but it is a significant reason that post-DOPMA graduates are opting to get out now. Post-DOPMA physicians are now finishing their three-year residencies and their seven-year obligations for USUHS and are looking at 10 more years before they can retire instead of just 6 years—they do not make as much and have to stay in longer to retire. What other Navy officer cannot retire until 24 years in?
c) Retirement pay: Physician bonuses do not count toward calculation of retirement pay, only base pay. Retirement pay for a Navy captain might be about $30K, which admittedly is good money, but is a 73 per cent drop in income, and would only be 18 per cent of their income if they get out of the Navy and make $165K.
d) Decreasing medical benefits: Navy physicians are not simply care providers, they and their families are also consumers of Navy medical care themselves and also have a vested interest in what is happening with Navy medicine from that perspective. Though the Navy medical system certainly has some positive aspects to it, the decision to no longer care for retirees for free in Navy medical facilities, the seemingly frequent comparisons by civilian physicians of TriCare compensation to Medicaid compensation, the increasing dependence of the military system on civilian care, the relatively poor dependent dental coverage, and the types of problems that chronic budget shortfalls are causing cannot help but make one wonder about the future.
7) Recognition: The previous dearth in awards given to physicians in the past is much improved in today's Navy. Awards, though, are still given primarily for administrative responsibilities, and sometimes for research participation. The civilians want doctors who are great doctors—impeccable medical expertise, well-trained, see patients quickly, efficiently and cost-effectively—not simply great administrators or great leaders or great researchers.
The Navy "fitreps" and physician peer review certainly picks out the "bad apples," but we need to go the next step and find a way to truly recognize outstanding medical care.
8) Sufficient variety of experiences to maintain skills: As the Navy silently slides toward active duty-only medical care there is an inevitable erosion of the variety of patients that all physicians need to maintain their skills. There is a limit to how long a general surgeon (or family practitioner, or psychiatrist, etc.) can stay on board an aircraft carrier and expect to remember the intricacies of operating on a trauma patient (or for an FP to deliver a baby, or psychiatrist to treat a schizophrenic).
Likewise, replacing general medical officers in active duty medical clinics with specialists like family practitioners can only work if the clinics are truly converted to family practice clinics—which means the FPs are allowed to see ALL ages, from newborns to geriatrics, are allowed to see and deliver obstetric patients, and have access to the full spectrum of family practice procedures, including flexible sigmoidoscopy, colposcopy, exercise stress tests, vasectomies, obstetric ultrasound, and endometrial biopsies.
9) Homesteading: Many physicians are moved far too frequently, especially the specialists. Consideration needs to be given to improving the degree to which physicians are able to homestead. It would be nice to be able to stay six years in the same location.
There is also a significant urge for many physicians to want to live near family, and the detailers should do what they can to make that happen. That might sometimes mean talking to Army or Air Force detailers to do a personnel switch occasionally—though I am not in favor of a "purple" Medical Corps—Washington D.C. has, after all, three tri-service hospitals now. Interservice cooperation should not be anathema.
10) Exit Interviews: All of the above are heard in exit interviews, but the most common trend seen is that the physician is not able to practice the full spectrum of medicine that he/she would like to.
CDR. GLENN THIBAULT, MC USN
http://www.usmedicine.com/article.cfm?articleID=61&issueID=16
