Changes to Military Medicine/DHA

[DaniellaDavis]

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Hello, I've been doing a lot of research about how the Army, Navy, and Air Force are consolidating their healthcare professionals under the DHA, and that the transition should be complete in several years. So basically, all healthcare professionals in the military will be a separate branch (?) What I'm wondering is what this means for current/future medical officers. Say you're a Lieutenant/doctor in the Navy or an Army Captain/nurse. Once you are moved to work under the DHA, are you separated from your service, and become a civilian doctor/nurse who provides care to current members of the military? What happens to your classification (Army, Navy, AF) and your rank/benefits?

 

[Matthew9Thirtyfive]

Hello, I've been doing a lot of research about how the Army, Navy, and Air Force are consolidating their healthcare professionals under the DHA, and that the transition should be complete in several years. So basically, all healthcare professionals in the military will be a separate branch (?) What I'm wondering is what this means for current/future medical officers. Say you're a Lieutenant/doctor in the Navy or an Army Captain/nurse. Once you are moved to work under the DHA, are you separated from your service, and become a civilian doctor/nurse who provides care to current members of the military? What happens to your classification (Army, Navy, AF) and your rank/benefits?

I don’t think anyone knows what it is going to look like yet, but we are not being separated to work under DHA as far as I know. DHA is taking over the MTFs and the like, but we will still be Navy/Army/AF docs.

 

[DaniellaDavis]

I don’t think anyone knows what it is going to look like yet, but we are not being separated to work under DHA as far as I know. DHA is taking over the MTFs and the like, but we will still be Navy/Army/AF docs.

Thanks for the response! I just want to say I LOVE your signature (go Taylor Swift xD)

 

[right500]

The idea is to have civilians take over many of the current positions filled by uniformed personnel. Hypothetically the MTFs will be entirely civilian staffed and DHA has already made them civilian-run (almost). That means some AOCs will shrink, others will shift focus, and everyone will focus on being a soldier/sailor/airmen with a special set of skills. Think surgeon in a CSH/FH rather than GP at a MTF. My source is the new Surgeon General of the Army via the Pharmacy Consultant but things change rapidly. I suspect (note: personal conjecture/opinion) many junior and prospective direct commission officers will leave the service after their ADSO, or never join, and go to the DHA as civilians.

 

[DaniellaDavis]

The idea is to have civilians take over many of the current positions filled by uniformed personnel. Hypothetically the MTFs will be entirely civilian staffed and DHA has already made them civilian-run (almost). That means some AOCs will shrink, others will shift focus, and everyone will focus on being a soldier/sailor/airmen with a special set of skills. Think surgeon in a CSH/FH rather than GP at a MTF. My source is the new Surgeon General of the Army via the Pharmacy Consultant but things change rapidly. I suspect (note: personal conjecture/opinion) many junior and prospective direct commission officers will leave the service after their ADSO, or never join, and go to the DHA as civilians.

Thank you for your response. So if I am currently commissioned as a 2LT in the Army, and will enter as an Army CPT/doctor, I will likely be working in a field hospital or combat support hospital, and be "lent" to the DHA to work in MTFs as needed? If someone is currently an Army Captain, they will stay in the Army but just have the assignments changed a bit?

 

[HighPriest]

Thank you for your response. So if I am currently commissioned as a 2LT in the Army, and will enter as an Army CPT/doctor, I will likely be working in a field hospital or combat support hospital, and be "lent" to the DHA to work in MTFs as needed? If someone is currently an Army Captain, they will stay in the Army but just have the assignments changed a bit?

You won’t be working in a tent unless you’re deployed. I have never heard anything about all former military hospitals, now DHA being completely staffed by civilians, and that certainly isn’t how it’s working in the few places where changes have been implemented. they have to have somewhere to place surgeons and physicians when they aren’t down range, and it certainly isn’t going to be a tent on Fort Hood. They’d have exactly zero applicants. They’re dumb. They’re not THAT dumb. The question that does remain is whether or not they’ll have military surgeons working at civilian centers, and that is TBD and frankly speculative.

 

[right500]

Thank you for your response. So if I am currently commissioned as a 2LT in the Army, and will enter as an Army CPT/doctor, I will likely be working in a field hospital or combat support hospital, and be "lent" to the DHA to work in MTFs as needed? If someone is currently an Army Captain, they will stay in the Army but just have the assignments changed a bit?

That is what is coming down from above right now. You have heard or will hear "Everything is in the air" or something similar a lot. Physicians will probably have a more similar early career path to their present than other professions because you do residencies and fellowships. Personally, my career progression is unclear because the senior positions available today are being replaced with DHA civilians. There aren't enough CSH sites for our current personnel. I think soldiers will still staff the harder to fill MTFs like at Irwin and Polk.

 

[HighPriest]

Not only are there not enough CSH, but it would be literally impossible to practice as a surgeon if you spent 100% of your time in a CSH. And no member of Congress is going to support the idea of doing a routine appendectomy in CONUS in a CSH when there’s a perfectly good real hospital nearby. If this were even remotely true, what you would have is a whole caste of completely inept military surgeons with everything that needed attention anywhere near a real hospital going to said hospital, and only real honest-to-god emergencies being treated by the military medical officers, who now have no idea whatsoever what they’re doing. Perhaps some of this applies to pharmacy somehow, but I don’t buy it for MD/DOs. They may as well just go completely reserve right now. They don’t even treat everything at a CSH in a deployed situation. Many, many things are stabilized and transported to Germany or stateside. Or a boat, presumably.

 

[right500]

Not only are there not enough CSH, but it would be literally impossible to practice as a surgeon if you spent 100% of your time in a CSH. And no member of Congress is going to support the idea of doing a routine appendectomy in CONUS in a CSH when there’s a perfectly good real hospital nearby. If this were even remotely true, what you would have is a whole caste of completely inept military surgeons with everything that needed attention anywhere near a real hospital going to said hospital, and only real honest-to-god emergencies being treated by the military medical officers, who now have no idea whatsoever what they’re doing. Perhaps some of this applies to pharmacy somehow, but I don’t buy it for MD/DOs. They may as well just go completely reserve right now. They don’t even treat everything at a CSH in a deployed situation. Many, many things are stabilized and transported to Germany or stateside. Or a boat, presumably.

I agree with you and I doubt the Medical Corps will be affected by changes as much as the others in AMEDD. If some of the change ideas floating down were implemented it would be a scandal very quickly. It would be bizarre for the CSH at JBLM to hoard surgeons for example. Some specialties have no role there anyway and would skill atrophy into oblivion. Congress might just talk and propose various plans and never make any of the proposed changes before something catches their attention and distracts them.

 

[backrow]

The idea is to have civilians take over many of the current positions filled by uniformed personnel. Hypothetically the MTFs will be entirely civilian staffed and DHA has already made them civilian-run (almost). That means some AOCs will shrink, others will shift focus, and everyone will focus on being a soldier/sailor/airmen with a special set of skills. Think surgeon in a CSH/FH rather than GP at a MTF. My source is the new Surgeon General of the Army via the Pharmacy Consultant but things change rapidly. I suspect (note: personal conjecture/opinion) many junior and prospective direct commission officers will leave the service after their ADSO, or never join, and go to the DHA as civilians.

For the Navy there are bits in here that are accurate to the current understanding, but a lot that is not how it is being implemented.

For Navy commands the MTFs are being “virtually” split in two is the best way I can describe it. They are now two commands, but with the same Commander who now wears two hats: one to the Hospital and one to this new entity called the Navy Medical Readiness & Training Command (NMRTC).

All active duty now technically belong to this NMRTC and not the hospital. The NMRTC “loans” the member to the hospital for the portion of time they are not needed for readiness and training. So, say the Navy says they need you for 30% of the time to be ready to fight the next fight. You would then work for the MTF for the other 70% providing the “benefit” of medical care to the enrolled patients.

Now, the rub that I don’t think has been fully vetted for the Navy is that with a single Commander responsible for both there is always the “opportunity” to rob Peter to pay Paul. What mission wins for the CO? Who provides their budget? Who signs the FitRep? I think those are actually two different groups (Chain of command for FitRep and DHA for budget) so we are going to see competing interests hit against each other.

The sell was that active duty would be more operationally focused, would become slimmer, and civilians would backfill those clinical positions at the MTF that were vacated due to this increased offset for readiness and training.

I have heard zero input that the goal is to turn command of the MTFs to civilians and at least at my MTF all directors and above are active duty. I would say Dept Head and above, but there’s probably like one clinic off somewhere random with a civilian DH.

So what does all that mean? If you are joining today plan on spending more time doing operational “things” than folks did in the past. You will be tied to an operational platform and when that platform deploys you will too. When you are home you will spend part of your time ensuring you are ready to deploy on that platform, but the majority of your time will likely still be at the MTF (save for GMO and operational billets such as Senior Medical Officer on a ship or Battalion Surgeon for an Army Battalion).


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[didja]

Implementing lowest common denominator/ simplified logistics and appointment management is another key component of the DHA. They want to be able to measure productivity and find the best practices. To achieve that, they want to standardize appointment templates so that comparisons can be made between services, clinics and MTFs without as many variables.

For some, that means they'll need to see more patients. For others (like myself), that means that rather than my outstanding productivity and ability to appropriately manage my patients, instead I'll join the morass of inefficiency that characterizes military medicine. Many of my patients will likely be leaked off base and will feel abandoned and betrayed by the system that they have entrusted their well-being to. Frankly, I don't see the DHA gaining efficiency back after dumbing things down but we'll seen.

 

[HighPriest]

For the Navy there are bits in here that are accurate to the current understanding, but a lot that is not how it is being implemented.

For Navy commands the MTFs are being “virtually” split in two is the best way I can describe it. They are now two commands, but with the same Commander who now wears two hats: one to the Hospital and one to this new entity called the Navy Medical Readiness & Training Command (NMRTC).

All active duty now technically belong to this NMRTC and not the hospital. The NMRTC “loans” the member to the hospital for the portion of time they are not needed for readiness and training. So, say the Navy says they need you for 30% of the time to be ready to fight the next fight. You would then work for the MTF for the other 70% providing the “benefit” of medical care to the enrolled patients.

Now, the rub that I don’t think has been fully vetted for the Navy is that with a single Commander responsible for both there is always the “opportunity” to rob Peter to pay Paul. What mission wins for the CO? Who provides their budget? Who signs the FitRep? I think those are actually two different groups (Chain of command for FitRep and DHA for budget) so we are going to see competing interests hit against each other.

The sell was that active duty would be more operationally focused, would become slimmer, and civilians would backfill those clinical positions at the MTF that were vacated due to this increased offset for readiness and training.

I have heard zero input that the goal is to turn command of the MTFs to civilians and at least at my MTF all directors and above are active duty. I would say Dept Head and above, but there’s probably like one clinic off somewhere random with a civilian DH.

So what does all that mean? If you are joining today plan on spending more time doing operational “things” than folks did in the past. You will be tied to an operational platform and when that platform deploys you will too. When you are home you will spend part of your time ensuring you are ready to deploy on that platform, but the majority of your time will likely still be at the MTF (save for GMO and operational billets such as Senior Medical Officer on a ship or Battalion Surgeon for an Army Battalion).


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Right. This is more or less similar to what they Army has told people they want to do. And they have done it to a limited degree at a few places to me understanding. Difference is they haven’t split the hospital or created a new position. They’ve just plopped medical officers under a line chain of command.

 

[TheEarDoc]

I foresee it as just more joint operations where your commander might be the same branch, a different branch, or some civilian. I see more operational work vs. sitting at the MTF working in a clinic (which is fine by me since I joined the reserves for something different than my everyday civilian gig, but for full time folks with a specialty it could be concerning). My other concern is having folks running things who aren't used to how the military and military med functions. I can see the potential for a lot of misinformation to patients (ie. active duty soldiers/sailors/airmen) by civilians who have no clue how things work in the military world.

I have been in a short time too, but I first hand have already seen the difference in a civilian worker handling something I need done vs. uniformed personnel. I pretty much knew when a civilian was handling something I needed done it was either not going to get done or be extremely delayed, and I personally often times would seek out the uniformed personnel instead and speak with them. Something about taking care of someone else in uniform I think driving someone to actually do their job!

So in short I don't think anyone is going to lose their branch identity, rank structure, etc., but you might end up working under someone who is not even in uniform.

Too early to tell.

 

[Neogenesis]

And no member of Congress is going to support the idea of doing a routine appendectomy in CONUS in a CSH when there’s a perfectly good real hospital nearby.

I would beg to differ. I have personally seen elective procedures done CONUS in a CSH set up in a parking lot of a military hospital that had perfectly good ORs within it’s walls.

 

[HighPriest]

I would beg to differ. I have personally seen elective procedures done CONUS in a CSH set up in a parking lot of a military hospital that had perfectly good ORs within it’s walls.

That’s some classic proof by example fallacy.

And that is the same as making this routine because? Don’t confuse sneaking a one-off through with changing the state of the system.
If they decided to make this the way thing are as a standard, I would write my congressman in protest, let alone anyone not familiar with the military system.
Once the military decides to sacrifice standard of care entirely, and without good reason, you may as well pack it in.

 

[pgg]

I would beg to differ. I have personally seen elective procedures done CONUS in a CSH set up in a parking lot of a military hospital that had perfectly good ORs within it’s walls.

If I saw that happen, I would report every physician involved to the state medical board. Absolutely indefensible.

 

[Gastrapathy]

@pgg Bremerton circa 2008ish. They used to have a field support hospital (I can’t remember the exact title) and did the same thing. The story from that episode that I recall is that the CO showed up after everything had been put up and didn’t like the orientation of the hospital. So it was taken down and rotated 90 degrees.

 

[pgg]

I'm curious how they presented the idea to the patients.

 

[Gastrapathy]

Yeah in hindsight that’s clearly the bigger issue but at the time, all people cared about was the rotation.

 

[Neogenesis]

That’s some classic proof by example fallacy.

And that is the same as making this routine because? Don’t confuse sneaking a one-off through with changing the state of the system.
If they decided to make this the way thing are as a standard, I would write my congressman in protest, let alone anyone not familiar with the military system.
Once the military decides to sacrifice standard of care entirely, and without good reason, you may as well pack it in.

I was not implying that it was routine. However, I am saying that it has been approved and done to complete routine, elective surgeries in the US. And when the good idea fairy comes a knocking and there is even the smallest amount of precedent to be found it’s amazing what can get approved.

While in residency at BAMC circa 2011-2012, 4 ISO ORs were set up in the parking lot and routine surgeries were performed there to help with surgical load during the OR renovations

Winn ACH, Ft Stewart GA circa 2014-2015. A CSH surgical team was set up in the parking lot (ISO OR, tent pre-op/PACU) to help off set surgical backload. When I questioned the safety and legality of that setup, we were assured by patient safety and facilities that the setup met all OSHA and Joint Commission requirements that the main ORs were held to. I found that hard to believe when I toured the facility and the tent kept flapping in the wind while grass kept blowing through it on the surgical side of the red line. I made it known that the CSH would have to be self sustaining and that the anesthesia department would not be involved in providing care for those cases. The powers that be couldn’t understand why we would be concerned. After all, they were only talking about doing the “easy” quick cases in there, like pediatric T&As [emoji2361]. Myself and the ENTs put the brakes on that ridiculous idea. But they did perform a fair number of procedures (mostly ortho stuff) out there over several months.

 

[HighPriest]

I was not implying that it was routine. However, I am saying that it has been approved and done to complete routine, elective surgeries in the US. And when the good idea fairy comes a knocking and there is even the smallest amount of precedent to be found it’s amazing what can get approved.

While in residency at BAMC circa 2011-2012, 4 ISO ORs were set up in the parking lot and routine surgeries were performed there to help with surgical load during the OR renovations

Winn ACH, Ft Stewart GA circa 2014-2015. A CSH surgical team was set up in the parking lot (ISO OR, tent pre-op/PACU) to help off set surgical backload. When I questioned the safety and legality of that setup, we were assured by patient safety and facilities that the setup met all OSHA and Joint Commission requirements that the main ORs were held to. I found that hard to believe when I toured the facility and the tent kept flapping in the wind while grass kept blowing through it on the surgical side of the red line. I made it known that the CSH would have to be self sustaining and that the anesthesia department would not be involved in providing care for those cases. The powers that be couldn’t understand why we would be concerned. After all, they were only talking about doing the “easy” quick cases in there, like pediatric T&As [emoji2361]. Myself and the ENTs put the brakes on that ridiculous idea. But they did perform a fair number of procedures (mostly ortho stuff) out there over several months.

I see where you’re coming from. In any case, I cannot imagine if they tried to make this the standard that it wouldn’t get shut down. If you told me you were going to put a pin in my leg in a tent, I’d lawyer up.
Wash Post would have a front page article about what is being done to our soldiers to save a buck.

 

[pgg]

@Neogenesis what do you mean by "ISO OR"?

What I'm picturing is the typical role 2 surgical suite in a tent, a FRSS, CSH, etc. I'm deployed right now and we've got a 4 tent FRSS/STP stacked up on pallets and in quadcons ready to move, and it's pretty great for being mobile and usable in a forward area under austere conditions. Sterility is an oft-unattainable luxury in trauma, anyway. But to put that up in the parking lot of a CONUS hospital in peacetime and actually do elective surgery in it? W in the actual F!?

 

[Neogenesis]

@Neogenesis what do you mean by "ISO OR"?

What I'm picturing is the typical role 2 surgical suite in a tent, a FRSS, CSH, etc. I'm deployed right now and we've got a 4 tent FRSS/STP stacked up on pallets and in quadcons ready to move, and it's pretty great for being mobile and usable in a forward area under austere conditions. Sterility is an oft-unattainable luxury in trauma, anyway. But to put that up in the parking lot of a CONUS hospital in peacetime and actually do elective surgery in it? W in the actual F!?

The hard sided metal ORs like these

And the preop/PACU was the tent set up like these

 

[pgg]

That's not quite as egregious. I still wouldn't do it, though.