Corps Chief to SLs: we don't need you

[Gastrapathy]

So...heard a rumor that a bunch of Navy specialties have been told they are getting the axe. The GI SL apparently passed on that the new end strength will be 4 GIs. Similar news for other specialties.

Troops on the ground, what say you??? Is this real?

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[IlDestriero]

Probably for the best.


--
Il Destriero

 

[Perrotfish]

I've heard nothing about it, but its in line with what Congress told us to do.

I honestly have mixed feelings about this decision, if its true. I personally hope that, if we reduce the number of military subspecialists that are permanently tied to our residency programs and replace them with contractors, we might counter balance that by firing the generalist contractors and creating teaching positions for military generalists who can actually rotate between residency programs, small commands, and the fleet.

 

[militaryPHYS]

All part of the restructuring based off of NDAA 2017. I heard the specialties are being “tiered”. Tier 1 (essential military specialties like trauma, primary care, mental health) aren’t going to see changes. Tier 2 and 3 May be getting “phased out” and will be seen in community. I haven’t seen anything official for the tiers and/or phase out plan yet, but seems to be moving in that direction. Heard ENT fellowships are impossible now as well as pediatric sub specialties.

 

[Perrotfish]

All part of the restructuring based off of NDAA 2017. I heard the specialties are being “tiered”. Tier 1 (essential military specialties like trauma, primary care, mental health) aren’t going to see changes. Tier 2 and 3 May be getting “phased out” and will be seen in community. I haven’t seen anything official for the tiers and/or phase out plan yet, but seems to be moving in that direction. Heard ENT fellowships are impossible now as well as pediatric sub specialties.

It would be nice if they would actually talk to us about the new grand plan. Does the end of Peds subspecialists mean the end of Pediatric residency programs in the military? Or more military generalist positions in the residency programs? Or is it just going to be status quo except that our residents will now be trained entirely by contractors? Or is this all just made up?

What about the existing specialists? Do they stick around until retirement? Or do they actually get forced out into general practice again? Will small commands have anyone to call for subspecialty concerns?

A rule of the military seems.to be that the number of emails about an issue I get is inversely related to the impact that issue has on my career and patients. Issues like my broken pay or massive changes to my career path get communicated almost entirely through the rumor mill, possibly supplemented by one cryptic email from a civilian contractor 7 months after the issue arises. DMHRSI due this week? I get daily reminders.

 

[DD214_DOC]

So...heard a rumor that a bunch of Navy specialties have been told they are getting the axe. The GI SL apparently passed on that the new end strength will be 4 GIs. Similar news for other specialties.

Troops on the ground, what say you??? Is this real?

This would be in line with what I have heard recently. It seems things are changing in a very big way. Within the last year, my unique peds subspecialty-specific MOS ceased to exist. I have also been told there are no plans to fill my position with another active duty when I leave. Unfortunately, there aren't any civilians either.

 

[Gastrapathy]

@militaryPHYS yet you're still recommending milmed to the pups? Kinda seems important that most specialties are going away.

 

[Perrotfish]

@militaryPHYS yet you're still recommending milmed to the pups? Kinda seems important that most specialties are going away.

To be fair, this is yet another problem with a military career, not with the initial 4 year obligation through HPSP.

 

[teacherman84]

To be fair, this is yet another problem with a military career, not with the initial 4 year obligation through HPSP.

Unless the specialty you want to train in is one of the ones going away.

On a related note, I thought OB was on the list of things going away eventually as well, but the AF is now opening a new OB residency...granted it's joined with a civilian program. But I thought the move a going toward getting out of the baby business.

 

[Perrotfish]

I though that all the residencies we're staying, and only fellowships are going.

If we start getting rid of residency training programs that's a whole new level of bad for milimed.

 

[Gastrapathy]

Fellowship is the reason people are willing to do IM. They get a utilization tour before fellowship.

 

[jabreal00]

Honestly there's no need for most active duty specialties and sub-specialties and this comes from someone who did fellowship in the military (GI). Primary care (IM, FP, PA/NP), general surgery, ortho, ER are some I can think of that would still be essential to active military medicine. Basically if one can deploy and practice in their given specialty then they are useful to the military. When I deployed as I was basically a GMO even though I was residency trained. Most of other specialties can be farmed out to either civilian contractors working at CONUS DOD facilities or civilian hospitals. I don't see Milmed at its current state being sustainable.

 

[Perrotfish]

Fellowship is the reason people are willing to do IM. They get a utilization tour before fellowship.

I think if you took away the fellowships IM would still fill, and they would just treat their entire HPSP obligation as their utilization tour prior to a civilian fellowship. We would get twice as much 'military' time out of each IM resident for the same price.

 

[militaryPHYS]

@militaryPHYS yet you're still recommending milmed to the pups? Kinda seems important that most specialties are going away.

Of course I still recommend it to those who understand the limitations and can live with it. I didn't know I wanted to do ortho when I signed up for USUHS, nor was I thinking about any residency at the time.... I just wanted to be a doctor, serve my country and have a stable income. I think if ortho wasn't an option I would have found myself being happy with something else (only specialties I definitely didn't want to do was psych and OB). Most people don't decide on their residency of choice until their clinical years and your choice depends a lot on the hospitals you are rotating at. So anyway, if their heart is set on something specific before med school even starts and the military can't guarantee that then the military is not for them

It goes with my initial point this whole time. You have to be willing to sacrifice some freedom of choice for yourself to gain the income, benefits and debt-free life.

 

[militaryPHYS]

By the way. Via the grapevine:

ENT 52 --> 28
Optho 45 --> 26
Peds 159 --> 61
OB 114 --> 50
Surg 163 --> 257
Ortho and Family stay stable
Psych to drop slightly

 

[Cooperd0g]

I assume this is all related to the SG push to focus on operational medicine?

 

[Perrotfish]

By the way. Via the grapevine:

ENT 52 --> 28
Optho 45 --> 26
Peds 159 --> 61
OB 114 --> 50
Surg 163 --> 257
Ortho and Family stay stable
Psych to drop slightly

That's a very specific grapevine

If this is true I guess the MC will just get smaller overall?

 

[Perrotfish]

I assume this is all related to the SG push to focus on operational medicine?

This comes from higher than the SG. Congress

 

[IlDestriero]

By the way. Via the grapevine:

ENT 52 --> 28
Optho 45 --> 26
Peds 159 --> 61
OB 114 --> 50
Surg 163 --> 257
Ortho and Family stay stable
Psych to drop slightly

The general surgeons already don’t work very hard. I guess they’ll have time to moonlight!


--
Il Destriero

 

[Perrotfish]

Looks like MC total strength to remain the same...adjustments coming to specialties and sub-specialties

I agree with most of the changes, even if it does kill my specialty.

What is your source for this stuff? I haven't heard anything.

 

[Gastrapathy]

This is just medmacre? They've ignored those recs for years.

 

[militaryPHYS]

Medical Corps Chief website. All unclassified. Need a CAC to access. I'd provide the link but I'm still not cool enough yet on SDN

 

[militaryPHYS]

This is just medmacre? They've ignored those recs for years.

I think with NDAA 2017 and restructuring they are looking at it now?? not sure

 

[DondeEstaElBano]

MedMACRE rearing it’s head. In the MSC, pharmacy and optometry are losing a significant number of billets. They’re being converted to Lab Officers, PAs, and HCAs. If your specialty has few operational support and OCONUS billets, the CONUS billets are likely going to be cut.

From what I understand total end strength is not decreasing, just billet distribution.

 

[Gastrapathy]

So how will DHA provide the care? They think they will hire civilian sub specialists? Maybe in DC, Tacoma, San Diego and Oahu.

 

[Perrotfish]

So how will DHA provide the care? They think they will hire civilian sub specialists? Maybe in DC, Tacoma, San Diego and Oahu.

That's where they all are, though. Half of my specialty is made up of active duty subspecialists in the big 3 who will never leave the big 3 unless they decide to put in an XO/CO in packet. We have more than a dozen docs in neonatology alone. We could cut the numbers for Peds in half and not lose any coverage for the small hospitals.

Again, I think it would be better if they kept the specialty a little larger than they're planning, and made the generalist/hospitalist positions at the big 3 active duty, but I agree with the Navy that there is no point to keeping people who don't either deploy or rotate to small haspitals.

 

[Gastrapathy]

I don't have a problem with the changes. Just the lack of an articulated plan.

 

[BlackFrancis33]

It may be obvious but be careful with that we only need GS, ER, Ortho argument. The inconvenient truth is that you need Peds sub-specialists to train ER doctors (for example). If a kid comes in with status epilepticus you better have Peds Neurologists on call at your MTF. I use that example as Peds Neuro was put on Tier 3. Obviously, this is only in the MTFs offering the full spectrum of care and involved in GME. The idea that you can hire sub-specialists, even in DC, Tacoma, San Diego is not aligned with reality. I heard a story of a Peds Neuro position at a nice location for almost double the average salary that has gone unfilled with no applications. If you don't train sub-specialists, you won't have them at the MTFs. The key is to properly align the needs of the military and put people where they are needed. Ft bliss needs a peds cardiologist, oh look the Air Force has an extra one...

 

[j4pac]

This is going to be devastating for recruitment. I was the prototypical Navy HPSP applicant. I wanted to serve more than get the money...and I planned on being career military. But this would have scared even myself away from HPSP. Even if you think you want to go primary care/gen surg...very few applicants are going to be willing to shut the door on non primary care/gen surg and fellowship before med school even begins. They may need to open the door to foreign/Caribbean applicants.

 

[backrow]

I don't have a problem with the changes. Just the lack of an articulated plan.

Oh, there's a plan, it's just we haven't been informed fully of what it is. I believe the specialty leaders are well aware of what the plan is and have been involved for quite a while on this.

The numbers quoted above are similar to what I have heard from those in a place to know. I have also been told that nobody is going to be released from service prior to them wanting to leave, but instead these goals will be met through attrition. My reading of the tea leaves(and I have no direct insight here) is:

The Services (Army, Navy, Air Force) have been tasked with the operational mission. The DHA has been tasked with "everybody else." This is causing the Services to say, "well...then we don't need all these doctors in the (Insert Service Here), because we only need to take care of the operational forces." The DHA is getting left holding the bag with a mandate, but no doctors to fulfill that mandate. My guess is the Services will hemorrhage doctors in the "non-critical" areas and the DHA will be picking up those jobs through civilian conversions. Where I see the issue is in the coming years where the Services are downsizing, but the money isn't there to hire the civilians. We could be really lean for a few years in some specialties.

In regards to GME, I think you will see the Services remain in GME; however, at a likely reduced level. If you only need 61 pediatricians then you aren't going to train as many as you are now. That means consolidation of programs. You probably don't need 3 programs if you only need a smaller number of trainees. You will then see a consolidation of the active duty specialists at the GME locations with civilianized cadre at the other centers that still need to maintain subspecialized care, such as NICU, etc. This isn't necessarily a bad thing for the patients. They may see an increase in the continuity of their care. A significant issue though will be, as noted above, hiring the civilian specialists. Some of these bases aren't in the most desirable locations, and even in those that are you can't necessarily pay them what would bring in top notch doctors. This may be offset some by active duty retirements deciding to stay on as civilians.

One way they will continue to attract students is by guaranteeing future GME training. There are currently less spots in GME nationwide than there are American graduates. This is only going to get worse in the next 5-10 years with the continued expansion of medical schools, especially the for-profit sector. The military will be able to come in and say, "look, here, take this scholarship and we will guarantee you some form of GME training." That will be a big draw for some, unfortunately it will be a draw to the lower tier student.

Okay, this turned into longer than I meant it to already...but if you aren't aware of what the "plan" is then I recommend you reach out to your specialty leader (I recommend waiting a week or so as the GMESB is this week and they may be a bit busy).

 

[usma05]

Wherever these numbers came from, were there any anesthesia numbers? Or are the we just giving pts whiskey and a bullet to bite in the future?

 

[Cooperd0g]

It may be obvious but be careful with that we only need GS, ER, Ortho argument. The inconvenient truth is that you need Peds sub-specialists to train ER doctors (for example). If a kid comes in with status epilepticus you better have Peds Neurologists on call at your MTF. I use that example as Peds Neuro was put on Tier 3. Obviously, this is only in the MTFs offering the full spectrum of care and involved in GME. The idea that you can hire sub-specialists, even in DC, Tacoma, San Diego is not aligned with reality. I heard a story of a Peds Neuro position at a nice location for almost double the average salary that has gone unfilled with no applications. If you don't train sub-specialists, you won't have them at the MTFs. The key is to properly align the needs of the military and put people where they are needed. Ft bliss needs a peds cardiologist, oh look the Air Force has an extra one...

You need those specialists at the hospitals that have residencies. They don’t have to be active duty physicians. Civilian hospitals don’t all train their own, they have to hire people too.

 

[pgg]

Wherever these numbers came from, were there any anesthesia numbers? Or are the we just giving pts whiskey and a bullet to bite in the future?

Disclaimer - I have no direct knowledge of where the anesthesia numbers are going.

However, IIRC, if they implement the MEDMACRE plan, then total Navy anesthesia billets will increase. The whole point of that plan was to realign the medical corps head counts to something that resembles what a warfighting force needs. So, gains for surgery and anesthesia and EM and the like, losses for others. However, since Navy anesthesia has been "overmanned" for a while, the effect was expected to bring our authorized numbers up to the numbers we actually already have. I would guess the Army situation is about the same.

I don't know what that means for subspecialist anesthesiologists. On the Navy side, a couple years ago the billets were realigned to allow for a few more subspecialists, and the 2016 GMESB actually selected 4 for cardiac and I think one or two more for peds (?). For cardiac anesthesia, this was after a multi year drought of almost zero selects. One in 2015, zero in 2014, zero in 2013, maybe one in 2011 or 2012? I think there are zero projected for this year's board. We have two FTIS pain slots every year, and I can't imagine those will be cut. Unlike FTOS where you can open and close the faucet at will, when you've got an inservice program, you need to keep it going every year if you want to keep ACGME off your back.

 

[SPQR]

The big 3's are being run like glorified family practice hospitals, this is why I left the Navy to become subspecialist.

 

[BlackFrancis33]

You need those specialists at the hospitals that have residencies. They don’t have to be active duty physicians. Civilian hospitals don’t all train their own, they have to hire people too.

I agree they don't have to be active duty and can be physicians, but can you hire those sub-specialists at MTFs? Or can you hire quality sub-specialists to work at DOD-affiliated hospitals in the numbers needed to maintain GME programs? Those are big what if type questions.

 

[Cooperd0g]

I agree they don't have to be active duty and can be physicians, but can you hire those sub-specialists at MTFs? Or can you hire quality sub-specialists to work at DOD-affiliated hospitals in the numbers needed to maintain GME programs? Those are big what if type questions.

Only speaking In regards to the Navy, GME programs are essentially at San Diego, Portsmouth, and Washington DC. Those are all large enough population centers with other civilian GME programs in the area as well. I see no reason the Navy couldn’t hire the necessary people. The two Family Med programs are at smaller hospitals and they are similar to civilian community hospital programs that also won’t have uber levels of subspecialty support.

 

[Gastrapathy]

Portsmouth tried to hire a civilian GI for 2 years and then gave up.

 

[grotto]

There are a ton of civilian GI at WR. Specialists don’t make good money in the DC area due to oversaturation so the GS salary is competitive. Probably more competitive compensation on the civilian side in Hampton roads area. And it is a huge pain to hire GS.

 

[Perrotfish]

I agree they don't have to be active duty and can be physicians, but can you hire those sub-specialists at MTFs? Or can you hire quality sub-specialists to work at DOD-affiliated hospitals in the numbers needed to maintain GME programs? Those are big what if type questions.

It might actually improve the big MTFs to have to hire and retain civilian physicians in large numbers. Fixing the problems with the support staff and culture might suddenly be more of a top priority if the command knows that their programs will shut down if things don't get better.

 

[Gastrapathy]

I was shocked at the D.C. PP market. I can't understand why anyone would choose it.

 

[pgg]

I was shocked at the D.C. PP market. I can't understand why anyone would choose it.

People will happily earn half as much to live in an area with double the cost of living and 10x the traffic.

It is known. But I don’t understand it either.

 

[Perrotfish]

I was shocked at the D.C. PP market. I can't understand why anyone would choose it.

At the last Pediatrics national conference I went to they said that DC is the single most overserved city in the nation. One Pediatrician per 500 kids. I have no idea what they do all day. The second most overserved city had about 1000 kids per doc.

 

[j4pac]

Portsmouth tried to hire a civilian GI for 2 years and then gave up.

Lol. Why would a civilian want to work as a military contractor? It doesn’t matter how much you pay them...they leave. Military personnel are the only ones who will provide some form of continuity and retention. People looking at numbers are making decisions...but they are completely out of touch. This is going to be a cluster.

 

[narcusprince]

At the last Pediatrics national conference I went to they said that DC is the single most overserved city in the nation. One Pediatrician per 500 kids. I have no idea what they do all day. The second most overserved city had about 1000 kids per doc.

I say close military hospitals with civilian markets that are saturated. Realign mtf with austere locations like Camp Lejune, Fort Polk. The army does not have many hospitals in major metro areas. In my location we do some pedis ent when most if not all surrounding hospitals send their peds to the local peds hospital.

 

[DD214_DOC]

By the way. Via the grapevine:

ENT 52 --> 28
Optho 45 --> 26
Peds 159 --> 61
OB 114 --> 50
Surg 163 --> 257
Ortho and Family stay stable
Psych to drop slightly

What are these numbers?

 

[backrow]

What are these numbers?

Number of current billets to number of future billets


Sent from my iPhone using SDN mobile

 

[coltsorbroncos]

Sorry, I'm haunting the military medicine forum since I'm considering an AF HPSP but Idon't understand a lot of this. Are these changes regarding the Navy HPSP and Navy medicine specifically?

 

[militaryPHYS]

To all:

[Beware...shameless plug alert]

Sorry for delayed response (just got back from 10 day vacation around Japan/Taiwan).

I tried to consolidate what I have available to me (Interim update as of 29OCT plus Navy Chief of Medical Corps website) in a fresh post on my blog. It also has links to a lot of useful information if you want to explore upcoming interim reports as they are available. Thought it might be useful for newcomers to this thread.

I make no money on this website. No ads. The NDAA of 2017 and the future of Military Medicine - The Military Physician

 

[coltsorbroncos]

To all:

[Beware...shameless plug alert]

Sorry for delayed response (just got back from 10 day vacation around Japan/Taiwan).

I tried to consolidate what I have available to me (Interim update as of 29OCT plus Navy Chief of Medical Corps website) in a fresh post on my blog. It also has links to a lot of useful information if you want to explore upcoming interim reports as they are available. Thought it might be useful for newcomers to this thread.

I make no money on this website. No ads. The NDAA of 2017 and the future of Military Medicine - The Military Physician

Thanks for writing the blog!

 

[coltsorbroncos]

To all:

[Beware...shameless plug alert]

Sorry for delayed response (just got back from 10 day vacation around Japan/Taiwan).

I tried to consolidate what I have available to me (Interim update as of 29OCT plus Navy Chief of Medical Corps website) in a fresh post on my blog. It also has links to a lot of useful information if you want to explore upcoming interim reports as they are available. Thought it might be useful for newcomers to this thread.

I make no money on this website. No ads. The NDAA of 2017 and the future of Military Medicine - The Military Physician

I have a few questions about information on your blog I was hoping you might be willing and able to answer. I haven't read through all of the blog so please refer me back to it if these questions have already been addressed.

1. If the NDAA 2017 changes proceed as planned with consolidation of different medical branches into the DHA, how will that affect the frequency of AF GMOs (my recruiter told me that AF doesn't have GMO, but he didn't tell me about the NDAA either)? Will they be more or less likely to be put into GMO out of AF HPSP?
2. How do GMOs affect military and civilian residency competitiveness? Is there a correlation between GMO tour length and residency competitiveness?
3. I'm assuming all MTFs will be open to all branches of service in the DHA? (i.e. a Tripler posting being open to Navy and AF too)