Do you see military medicine improving?

Discussion in 'Military Medicine' started by Randomstudent66, Feb 10, 2018.

  1. HighPriest

    HighPriest insert "clever" statement

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    I’m not an orthopedic surgeon, but I did always feel like I was helping people who needed it. Taking care of soldiers and their families is the best part of milmed. My only gripe was how difficult it often was to make that happen to the extent I would have liked. But when it did, it was very satisfying.
     
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  3. militaryPHYS

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    Speaking strictly about Navy ortho here. Also, I like sports and I am headed to sports fellowship so my views are biased. Long story short, Yes. The military is made up of predominantly young and healthy "athletes" who hurt themselves one way or another. There is usually never a shortage of ortho cases. That being said it is predominantly SPORTS heavy (meniscus work, ACLs, shoulder scopes, etc.) as well as basic trauma (ankle fractures, forearms, hand/finger fractures, etc). Joints are only done stateside and mainly at the bigger MTF's. Real ortho trauma is few and far between at the MTF's.

    Best part about ortho is that there is a lot of instant gratification and ability to "help" someone. Bone broke - Me fix. ACL torn, I reconstruct. These are the reasons I pursued it (military friendly and instant gratification).

    Yes. Treating young Marines/Sailors is a great thing in my opinion. There are some repeat offenders just looking for their ticket out of the military, but you learn to deal with it and do whats best for them and the military.

    Currently I average 2 clinic days a week and 2 ORs a week. The 5th day is either admin, an extra clinic or extra OR depending on what is going on. My clinics are usually around 5-8 patients per each half-day section. Not all of the OR cases are my primary, but we tag-team a lot of them to help each other out and keep our hands scrubbed rather than see more clinic or more admin time. Right now it is enough to stay busy and proficient (in sports, basic trauma and hand) but not feel overworked.
     
    #52 militaryPHYS, Feb 13, 2018
    Last edited: Feb 13, 2018
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  4. Homunculus

    Homunculus SDN Caveman Administrator
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    i thought i felt a disturbance outside my cave.

    interesting discussion, and too much for me to comment on since i've joined a little late in the game. to answer the OP's question, it depends on the specialty but no, i don't see things getting better. at least in the army, and at least any time soon. hence me leaving this summer.

    yes, there are a few happy people. most have accepted their fate and drank the kool aid. some have managed to get within shouting distance of their retirement and are just coasting to the finish line and seem okay with things. but the average staff physician is more disenchanted than before. you can tell because people go into the "do my work and go home" worker bee mode. the genesis debacle hasn't helped. and neither has "everyone has to go work some shifts over at the SRP site." or the pay shenanigans last summer/fall. and no, things aren't like this in the civilian world because my wife works there. they have nurses, support staff, and though they may expect more they actually have a vested interest in helping you be efficient. and they pay you on time.

    i'll save my manifesto for a later time, but i desperately wanted some reasons to stay but couldn't really come up with any beyond liking my colleagues and getting paid pretty well for the piddly amount of work i'm able to produce in the inefficient system i'm stuck in. at some point you reach a saturation point and beyond that you'll know it's time to go.

    as far as this being a biased resource-- there is already selection bias built into the .mil. those who stay are tolerant of the system, so of course they will say how great their GMO, deployment, admin, or operational time was. this forum is user generated, and as admin/moderators we don't have a vested interest one way or the other. it's nice though to google military medicine and see us as a resource.

    --your friendly neighborhood hammering his manifesto into a stone tablet caveman
     
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  5. militaryPHYS

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    Definitely my bad. I was doing so well for a while there but then there were back to back new threads on Sunday that I felt were a result of so much lamenting.

    I fell from the wagon. I think I'm back on now.

    The system is not built for retention and I'm sure the further residency fades in the rearview the more you wish they'd throw you a bone to make you stick around longer. But alas, not the case and we all know that. Is that to say though that it wasn't worth the preceding 10, 12, 15 years prior to the saturation point? I think that is the question premeds should be asking. But alas, then we'd be back to PURELY subjective responses. :poke: I'm sure you all have discussed this in the recent past anyway.
     
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  6. Gastrapathy

    Gastrapathy no longer apathetic
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    Leaving at 15+ years is not about the money. It’s a bad choice financially for high paid specialties. It’s about being deeply unhappy.
     
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  7. militaryPHYS

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    PLEASE PLEASE provide specifics on specialty, obligation served, service, etc. because again, this is not the case across the board and would help interested premeds.

    Even with sacrificing benefits and pension, if we are talking about high paid specialties then financially it can make sense if they've hit their military saturation point. Most surgical specialties or primary care subspecialties can expect a 2x to 3x pay increase to justify sacrificing pension/benefits if truly unhappy on active duty.

    For example, Navy ortho is usually about a 3x pay increase since at 15 years they are likely to have already done fellowship, too. So if they are already financially independent or close to it at their 15 year mark and expect a 3x pay increase they can still work for a few years at that income to save/invest enough to offset the sacrifice of their 50% base pay pension.
     
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  8. narcusprince

    narcusprince Rough Rider

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    Why dont we just lose all anonymity. Lets start with name rank residency current duty station and last 4 and dodid number. :)
     
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  9. Gastrapathy

    Gastrapathy no longer apathetic
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    Do it yourself. Value a 20 year O5 pension plus 5 years of .mil comp and see what you need to earn to cover that. Don’t forget the taxman.

    I quit at 13. I’m also in a highly paid specialty and I made a spreadsheet where I could play with rates of return, pension value (longevity), etc. All but the rosiest predictions had it as a (solid)net loser to quit. A few years later, I have no regrets.

    Ortho is also the most extreme example given the pay gap. Very few people make 3x their post tax total comp.

    If you can’t come up with a long list of these people off the top of your head, is hard to believe you are who you say.
     
    #58 Gastrapathy, Feb 14, 2018
    Last edited: Feb 14, 2018
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  10. Perrotfish

    Perrotfish Has an MD in Horribleness
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    It makes financial sense for pretty much no one. Even ignoring the value of Tricare for life, the value of an 04 pension at 20 (worst case scenario for a physician) is about 1.4 million. That's what you would need to spend to buy an annuity at the same age that pays the same amount. That's not 1.4 million you need to EARN, though, because that would 1.4 million after tax dollars. Best case scenario (no income tax) you need to actually earn 2 million dollars.

    For it to make sense to get out at 15 years you would need a 400K/year pay raise from your transition to the civilian sector to break even. You would need to get that insane raise AND work the same number of hours as a senior medical officer (which is impossible) to truly break even. That's, again, excluding the value of Tricare for life, lifetime commissary benefits and base access, and of course non monetary value of the various honors that go with being a retired member of the military rather than just a former member of the military (you can participate in friends' retirements, continue to wear your uniform on special occasions, etc). It is HORRIFIC if anyone is getting out at 15. Its a sign of a deeply broken organization.
     
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  11. colbgw02

    colbgw02 Delightfully Tacky

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    Let me add my weight behind this, because Gastrapthy and Perrotfish are dead-on-balls accurate. I left at 9 years and, in a relatively well-compensated specialty, my pay more than doubled immediately. That will triple relatively quickly, and it still didn't make sense financially for me to walk away from the pension. The financial value of the pension is tremendous. Anyone voluntarily walking away at 15+ years is doing so because they simply can't stand it any longer.
     
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  12. narcusprince

    narcusprince Rough Rider

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  13. Gastrapathy

    Gastrapathy no longer apathetic
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    I’m 100% for that policy.
     
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  14. militaryPHYS

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    Discussing service, specialty and obligation incurred vs. served keeps as much anonymity as you want while providing hard facts for premeds considering something similar

    You are preaching to the choir since I do understand the value of pension/benefits (website). I just redid all of the numbers and such related to BRS, etc. Remember also that I am talking Orthopedics here. Specifically sub-specialized ortho. I have run numbers for spine guys, joints guys, etc. where there are plenty of scenarios to justify getting out to earn 500k/600k+ to make up for the lost pension.

    Even for lower paying specialty colleagues, if the provider wants to get out, is already at or close to FI and will reach his safe withdrawal number (25x annual expenses or more) by the time he is ready to stop practicing, it can work. If they are smart with their savings rate and life inflation then it can make even more sense. I'm not saying the numbers are equal so don't freak out...just pointing out scenarios that can work and help justify giving up the pension. If they aren't there with their investments/retirement and realize that financially it would make sense for them to stay in to get the pension then it is up to their misery level to decide. When given the option, yes, most want to get out because of more freedom to live where they want, more effective/efficient practices, financial opportunities, etc. BUT, (anecdotal alert) surprisingly, for whatever reason, I have rarely encountered anyone who is miserable enough to intentionally deter people from investigating military medicine. Sure, they want to get out for reasons just listed, but they don't regret their years served or education being paid. Maybe its a navy thing?

    I understand everybody's points though... Financially it didn't make sense to get out but you did anyway because you were so miserable. Totally fine and I would default to family and overall happiness any day just the same. Unfortunately there is no guarantee the next generation will be more or less miserable because there are so many variables and everyone is unique. Only way we can give people an idea of if they might be happy or not is to provide specifics on service, specialty, years served, obligated years, potential salary and practice as objective data points. Then subjectively the deal breaking points of stay vs. go for that person.
     
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  15. Randomstudent66

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    Wow, that seems like it would financially benefit the military alot. Perhaps they would use some of the money on military medicine and training programs? Or is this not very likely?
     
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  17. TheEarDoc

    TheEarDoc Audiologist

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    I couldn't help but laugh at this story. Many are facing retention issues and running skeleton crews to exhaustion (Navy especially) and now they are talking about kicking people out who are non-deployable. So let's see you get a profile and cannot deploy. So you are forced out. Well fine now I claim a med board do it for my issue. Med boards take forever so someone could go in, be non-deployable after the first year and finish their 4 out before even making it through the med board.

    I have a feeling lots of exceptions to this rule will occur. Probably some nice murky language like "at the discretion of btn command" or some sort.
     
  18. TheEarDoc

    TheEarDoc Audiologist

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    Yes and no.

    Yes because you would get rid of a lot of folks who cannot be deployed to do their jobs. The problem will be the backlog of med board claims so these folks will be still collecting a military check, be non-deployable, probably on restricted duty or no duty at all (depending on their issue), for more than a year until their med boarding is done. Then they will move over to the VA and collect a large compensation check for their issues. So it's going to cost a lot out of the DOD budget and the VA budget with this policy.

    Then you have to figure if we are kicking more people out then we have less to deploy so we will have to pull more reservists and guardsmen and active duty folks to overseas deployments. See what that will do for retention.
     
  19. Medic741

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    This was kind of a paradigm shifting perspective. Well said
     
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  20. Randomstudent66

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    Just found this article on atrophy here's a extract since I can't post a link for some reason:

    Military medical officials have responded in recent years, sometimes citing costs, by downsizing some hospitals to health centers, shuttering their obstetrical centers and surgical facilities and sending patients to local civilian facilities.

    They have also encouraged medical commands to forge agreements with nearby civilian trauma centers and Department of Veterans Affairs hospitals to allow military physicians to practice there. That effort is being expanded, according to the Army Medical Command.

    Since Edwards’ article was published, progress had been made, Edwards and Nessen said.

    “There is a definite level of awareness that operative volumes are critically important for surgeon readiness and that this needs to be quantified and evaluated prior to deployment,” they wrote in their email to Stars and Stripes. “There is no question that the military surgical community, working with our military and civilian surgical leaders, is taking this issue very seriously
    .”

    From what you practicing physicians see, is it true that the leadership is working towards fixing this issue and trying to prevent atrophy. Do you think they will succeed in atleast reducing it?
     
  21. pgg

    pgg Laugh at me, will they?
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    I would answer that with a qualified yes. But there's a long way to go yet.

    The basic problem we're working through right now is that there doesn't seem to be any top-down, enterprise level leadership to establish these relationships with civilian or VA facilities. In every case I have observed and been a part of, these arrangements (when they occur) have very much been driven by individual commands or individual physicians. There's good and bad to this delegation of responsibility to individual physicians, but it's mostly bad, because it results in absolutely monumental duplications of effort and wasted man-hours.


    Recent personal example - I'm a fellowship trained subspecialist at a large MTF that recently stopped providing a subset of that subspecialty care. I can still practice a limited subset of the subspecialty, and there's value in having me here as part of the residency program faculty, but its far from ideal in terms of maintaining the full spectrum of my skill set, much less advancing it.

    So, my options for continuing to practice in my subspecialty are

    1) Moonlighting. This requires expending personal leave, finding a place to work, getting credentialed, obtaining a license in that state, securing liability insurance, obtaining permission from my command, and filling out monthly audit paperwork so they track it all. This hassle is admittedly offset by the fact that large sums of money are then paid to me. This is a good option for physicians who have vacation time to burn, who practice in specialties conducive to shift work, and who want to work extra hours.

    2) Getting temporary duty orders to another military hospital where that subspecialty is needed. Typically, when it comes to subspecialty care, other military hospitals also have low volume, and they have their own people just like you who are looking for more work.

    3) Working at a VA hospital. Sounds perfect, actually - they're federal hospitals where any state license is good, liability insurance is covered by the federal tort claims act (it's the physician's military place of duty for the day), and oh by the way Congress has been explicitly telling the military and the VA to cooperate and share personnel and other resources for more than 30 years now. Easy answer, right?


    The VA option sounds ideal for skill maintenance. But it's not a straightforward solution -

    It took me about six months to get credentialed at one. I actually needed to miss a day of work at my Navy hospital to go to the VA hospital for a pre-employment physical and another day so I could go and swear the oath of office in person. Fingerprinting and background checks. It's just utterly bizarre that an active duty physician with a secret or better security clearance would need to do this.

    In my case, the VA hospital is almost two hours away from my current duty station. If I spend a day or a week there, I'll need a hotel. TAD funding is going to have to come from my department's budget.

    There was no existing memorandum of understanding between this VA hospital and my Navy hospital. One had to be conjured from scratch and approved by both institutions. Who wrote it? The VA's lawyers? The Navy's lawyers? No. I did. I took a MOU that our residency program uses when our residents do outside rotations, and rewrote the parts describing supervised practice and evaluations so that they reflected the intent of this whole endeavor. I'm not going there to be someone's student or scut monkey; I'm a fully credentialed, licensed, multiply-boarded subspecialist physician and I expect to practice as one.

    In theory, the military and the VA could plan for regularly scheduled, predictable blocks of time where the military physician is at the VA facility. The VA could open up more clinic time, or operating room time, and improve their patients' access to care. A greater volume of work could be done. But what actually happens is the VA does the same fixed volume of work, and merely takes advantage of the intermittent, sorta unpredictable presence of an extra body from the military. There's no efficiency gain here, no added value to taxpayers, no reduction in VA patients' wait times. Sharing of staff and resources between the military and the VA could be something wonderful and efficient, but it's not - because it's still so uncommon, inconsistent, and individually driven.


    If the enterprise was really "taking this issue seriously" there would be nationwide, tri-service, cooperative infrastructure and agreements in place between the DOD and the VA. If travel was required, it would be paid for by DHA, not the individual physician's department's operating funds. Military physicians would coordinate their daily place of duty with their department's scheduler and the VA's scheduler and that would be the end of it.

    What we have are arrangements that are very much local/individual one-off phenomena. I expect that in time, these circumstances will improve. Efforts are being made. We have a ways to go yet.
     
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  22. HighPriest

    HighPriest insert "clever" statement

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    In the Army, at least as of last July, the answer is no. It gets a ton of lip service, but not much actual traction. I think pgg hit on all of the points as to why, but I don’t necessarily agree that a vague appreciation that there’s a problem represents an effort to address the problem. It’s like acknowledging that your roof is leaking, and printing out leaflets that roof leaks are a major problem, but not being willing to even put a bucket under the drip. Of course, you let everyone know that there are buckets out there, all they need to do is go get them. At your own expense. And btw, no one will carve out time for you to go to Home Depot.

    When you hear a senior military official say that something is being handled, that could mean anything from a $2 billion budget to everyone half-heartedly agreeing that something ought to be done at a weekly meeting.

    I promise you that transgendered service training gets a larger budget and more attention than skill atrophy.
     
    #70 HighPriest, Feb 17, 2018
    Last edited: Feb 17, 2018
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  23. j4pac

    j4pac PM&R resident

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    Hopefully you stick around...you present your side of the argument very well.
     
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  24. Perrotfish

    Perrotfish Has an MD in Horribleness
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    I wonder to what extent our outcomes reflect our actual competence. It seems like (and I could be very wrong, perspectives are appreciated) our current model for caring for battlefield injuries involves some initial stabilization followed by almost immediate air evacuation to a tertiary care center . In that model it seems.like physicians are not the weak link because they are barely in the chain.

    It seems like our current model of care is dependent on both a volume of casualties that are low enough that they never overwhelm our air support, and an enemy that can't shoot down helicopters.
    If we ever had a war against a.more comperable enemy I wonder.if our medical corps would really be up to the job of prolonged stabilization of those.patients at a lower level of care.
     
  25. usma05

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    It's interesting that you bring this up, cause I've heard a fair amount about this at work at my MTF, going on humanitarian missions elsewhere, and other places. They are anticipating a coming conflict (ill leave you to guess where ;) ) where we won't have air superiority meaning prolonged times between limited windows of evacuation. As a low level minion I'm not privy to all their plans, but the buzzword I've heard flag officers throw around is multidomain battlefield. In the anesthesia world, I've been told by others to be prepared to be pushed forward and have to deal with casualties for an extended perioperative phase until evacuation could come. Practically, I dealt somewhat with it as a member of a GHOST-T (like) team in RC-South in 2015 where we had a few "camping trips" outside the Golden Hour with an austere setup that thankfully had limited use. Since then, going on MEDRETEs the focus has shifted in last 2.5 years to now where we are told to fall in onto host country's equipment and meds and make do with what we got (we are techincally forbidden from bringing our own durable medical equipment). A lot of situations that is workable, but its unnerving when your host country can't meet basic ASA guidelines for monitoring particularly with peds pts. I do think the problem of limited timeframe evacuations and prolonged far forward perioperative phases is going to initially present a big problem, I just hope pushing these providers forward that will be met with a robust supply chain and a sufficient MTOE to do their job right. Count me in as sceptical yet hopeful.
     
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  26. militaryPHYS

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    Great points by pgg and High Priest. Despite this being a central topic currently (centralization of DHA, efficiency, civilianization and triservice), we are still at the very beginnings of any sort of implementation. Nothing major has changed per se (yet) but I am still skeptically optimistic it will come given the push of ndaa2017 and the continued forward momentum to date. Trouble is, anything could derail progress...new conflict, new priorities, red shiny balls or squirrels, etc.

    Who knows whether the recent interest in skill atrophy is related to ndaa2017 or for other things related to what Perrotfish and USMA05 lead with above... o_O
     
  27. dr zaius

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    This is a very accurate metaphor.

    The buckets they put under the leak here are "simulations," which I'm pretty sure any decent surgeon will tell you is not a substitute for actually operating. Another solution to general surgeons not receiving adequate trauma volume was requiring a multiple choice test prior to deployment. The buckets they put down are basically colanders.
     
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  28. militaryPHYS

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  29. HighPriest

    HighPriest insert "clever" statement

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    No. Unfortunately it will probably ultimately end up much more like milmed, as a single payer system. But it’s 1,000x better now, so I’ll ride that train until the end of the line.
     
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  30. Perrotfish

    Perrotfish Has an MD in Horribleness
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    I think I could actually like a true single payer system. I know some people who work in Canada, or for that matter for Kaiser, and they think its great. A lot of the problems with milimed arise from he fact that rather than embracing the fact that we are a socialized, single payer system we for some reason import every inefficiency associated with our corporatized civilian medical system. I lose hours per day writing H&Ps/ROSs/Physical exams that at in no way pertinent to my patients and exist only for billing and lawyers. We track customer service metrics (every patient complaint needs to be evaluated by the CO!). We still track RVUs that reward the amount of care we provide, rather than the quality of that care. Those of us who see dependents are still subject to our nation's insane system for civil liability. Despite the fact that we do not send anyone a bill, every small MTF employs billers and coders to make sure our charts are billed correctly. We gleefully embrace every corporate fad and buzzword regardless of how little value they add.

    If I could provide Canadian healthcare, and could just write a short two sentence blurb on everyone to remind me what I did and why rather than our exhaustive notes, that alone might be enough to keep me in military healthcare.
     
    #78 Perrotfish, Feb 19, 2018
    Last edited: Feb 19, 2018
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  31. HighPriest

    HighPriest insert "clever" statement

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    I don’t disagree with you.

    What I will say is that I simply haven’t had to deal with any of the situations mentioned in militaryPHYS’s post. In fact, I had to defend myself to Tricare more as a physician in milmed than I do to insurers now (mostly with regards to doing cases off post when there was no OR time on post, or getting an NDR approved by pharmacy). Granted, I’m a subspecialist, so maybe that’s a part of it. But, we have a ton of Medicare/Medicaid.

    My fear with any single payer system would simply be that it would end up like, well, milmed. And I 100% agree with you regarding milmed trying to act like it’s not single payer when it essentially is. Which results in everything you mentioned. In fact, I’m sure I’ve made that same point in the past here on SDN. It could be better if it would just lose that pretense of needing to act like the private system.
     
  32. militaryPHYS

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    Any Canadians on here? I am sure that they have to code/bill just the same as us in the USA and even in milmed. (in fact I googled and will paste an interesting PDF below - I find the opening paragraph applicable to this discussion).

    Billing/coding is how work is tracked, even if you services are "free" to the patients. Nobody can just not do it, even in the most socialized of healthcare systems. The government needs widgets to justify their budgets. Sure, coding means much less in milmed since this is socialized medicine, but it still relates to funding, billeting, etc. for us. Same with H&P's,ROS's,etc. Every single physician in the US has to do the same reporting/coding/etc. because of the increased regulation on healthcare this century. Maybe a bit more of a headache for us in milmed, but manageable.

    I had a mentor in residency (military residency) who told me something close to "When you work for "the system" the system always seems stupid. It will end up screwing you at some point so you might as well code properly to CYA in case the system comes for you." Therefore I always cover my @ss to show electronically the work I provide, but I also like to have a second measure of objective data for the reporting/regulation God's to ensure the department is best represented up the chain. Not saying it is right that we have to do this, but also saying it is not limited to Milmed. This is universal BS paperwork all physicians have to deal with in one form or another. Maybe a civilian practice pays people to do everything for you, but this is also not universal.

    Actionable tip: I use the "add note" feature in AHLTA for every single encounter. I have a folder full of word document templates that have prepopulated ROS, med rec statements, physical exams, etc. etc for my high yield encounters (ankle fracture, pediatric elbow, degen knee, meniscus tear w/ mechanical symptoms, etc.). Then all I have to do is fill in pertinents, copy and paste, then code/dispo. Every splint/cast/reduction procedure codes are saved in AHLTA and takes two seconds to click. It reads 10x better than "check box AHLTA" and takes a quarter of the time.

    https://www.cma.ca/Assets/assets-library/document/en/practice-management-and-wellness/2015-Chapter3_Medical_billing-e.pdf
     
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  33. narcusprince

    narcusprince Rough Rider

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    I think that your perspective on the civilian sector is specialty specific. In anesthesia the civilian world is 5,000 times better then the navy. Given the militarys as$ backwards policy that gives equivalence between anesthesiologist and crnas. I will never recommend this organization to anyone interested in anesthesia. Yes my patient load is less and yes I love the patients. I feel I have to work 1000% times harder in the military due to system failures and people’s preconceived thought that MD=CRNA and if you add on the racially tense environment the military stress load is much greater. You go to medical school and complete residency to learn and have the ability to do said x y procedure but as an experienced physician you learn when to say no. I also feel the Navy in particular you have a loss of autonomy in defining workflow systems. Instead you have endless SOPs usually nursing generated used to define the system for you(albeit you dont know your bucking the system until a nurse defines it). Giving the autonomy back to the physicians would aid retention. Hell in the end I think they want us as miserable as possible so we do not stick around for 20 years.
     
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  34. narcusprince

    narcusprince Rough Rider

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    Here is a thought replace the words captain or colonel woth Dr and give all the ascribed rights the O-6’s have to physicians problem solved.
     
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  35. teacherman84

    Physician

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    This is not allowed in outpatient primary care...at least not at my MTF...and i patient notes were starting to be forced away from it as well.
    Iforget the reasoning, but one of the TSWF click-you-to-death templates had to be used in all but procedure only notes.

    We still used cut and paste from word into the AHLTA templates but it's very time consuming. When I tell coworkers this at my civilian fellowship, they all immediately stop complaining about the various troubled EMRs they came from.
     
  36. militaryPHYS

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    Likely related to the "auto-coding" that AHLTA does based on the click-to-death templates. It auto-selects how much to code for based on #of ROS, PE findings, etc. that you clicked the box for.

    Must be a MTF-specific coding thing because we haven't had any push back here...Yet. I believe, as long as you end up coding correctly in the A/P and Dispo then it does not matter. I will discuss with my coders though and get back to you.
     
  37. militaryPHYS

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    Do you think this is MTF size driven? Anecdotally (and I am not anesthesia) it seemed at one of the big three I worked at that the hierarchy was maintained by having an MD/DO oversee 2 or 3 rooms being run by CRNA's. Here at my new small and cozy MTF the physicians are amongst the large pot of gas-passers that also include CRNAs. To the naked eye they would be one in the same here. Just wondering your experience at different sized commands.

    Unfortunately the nurses have more time to have finished a masters of some sort, which helps their exec medicine pathways. In all honesty if they are smart and good at what they do then I'd rather let them run more of the executive/admin stuff and let us maintain higher FTE. BUT, then I'd be sacrificing promotions, awards and any real clout within the command. I also feel your frustration when unqualified and lesser trained individuals are given leadership roles to dictate procedure they have little first-hand experience in. The best ones I have found are personable and actively pursue advice or bounce ideas off of the physicians for input on policy changes.

    Really sad to hear that this is still an issue. I hope nothing I say makes it sound like I am discounting anything you have voiced since you are living it and dealing with it first hand. It sucks a big one that you have to deal with that $(&*. I've always felt that the increased diversity we have compared to the general population helps these issues stay very few and far between. That being said I realize my inherent human context bias and how that impacts my perspective, so my opinions are basically useless. I'm just curious how racial issues persist in a command when there is so much oversight and intolerance for that kind of thing military-wide.
     
  38. Cooperd0g

    Cooperd0g Something witty goes here.

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    You are more correct than you may even realize. Our spectacular outcomes are primarily a product of two things:

    1. TCCC along with self and buddy aid training. Most combat losses are from hemorrhage, these things have had a major impact on death from blood loss.
    2. Total air superiority. This allows for rapid and voluminous aeromedical evacuation, neither of which would be quite so available in a contested air environment.

    Having said that, a lot of what was implemented to make those things happen was because of physicians at high levels.
     
  39. mosothoamosoeu

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    I'm new to the milmed forums, but, OP, if you haven't already noticed, there are like 5-10 users on here who feel very passionately about military medicine, either for or against, and make up a VAST majority of recent posts. While I respect their views and conviction, it's still a frickin tiny sample, no matter how much anyone wants to generalize, or how convincing anyone may sound.
     
  40. HighPriest

    HighPriest insert "clever" statement

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    Absolutely true. Don't use studentdoctor network as your sole source of....well, anything. That would be dumb.
     
  41. Gastrapathy

    Gastrapathy no longer apathetic
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    So what’s your background and opinion?
     
  42. mosothoamosoeu

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    My background is that I too am interested in military medicine and have been reading a lot online and on these forums. And my opinion is that it is very difficult to develop what feels like a meaningful opinion based solely on reading a few people's anecdotes and opinions. As such, I remain feeling very torn between the benefits of HPSP and a military career, and those of becoming a civilian doctor.
     
  43. Gastrapathy

    Gastrapathy no longer apathetic
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    Well...if you join, do your part. You won’t be able to say you weren’t warned.
     
  44. HighPriest

    HighPriest insert "clever" statement

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    Don't pay as much attention to the anecdotes, and pay more attention to the general themes. The fact is, and it has been stated by many people here to include myself, experiences vary greatly. You may have the best time in the world in the military. Or it could really, really suck. Just pay attention to the general reasons people say it sucks (or why they like it), and look for common themes. There are a bunch of them. You absolutely can't know what your experience will be like based upon reading this forum. But you can be prepared for the worst.
     
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  45. psychbender

    psychbender Cynical Member
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    What benefit do you see of a career in military medicine, starting now?

    Sent from my SM-G930V using SDN mobile
     
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  46. TheEarDoc

    TheEarDoc Audiologist

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    I always thought a better use of reservist and guard docs (especially highly specialized fields) would be have those folks perform 2 days of drill at a VA facility. Would be a great way to keep the relationship between VA and DOD going and a way to actually fill drill time. I know I've seen specialists (neuro for one) leave the Army base near where I was at and go 2 hours to a large VA hospital and see patients 1 day a week.
     
  47. Mace1370

    Physician

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    Look, you have to think critically about what you read here. It's absolutely true that there are members on this board that have an overwhelmingly negative view of military medicine. Their bias is absolutely something you should take into account. However, at the end of the day you cannot discount their experiences. The most important thing you need to realize before you join (if you do) is what are the possible ramifications of that decision.

    To give you another data point -- I joined military medicine when I was single. At the time, I thought to myself that I wouldn't mind if I got moved all over the country for medical school rotations (I went to USUHS). I thought it won't matter where I serve my time as I am happy living most places. The reality is that life is unpredictable. I met a partner who is far less geographically flexible than I am (both for personal reasons as well as for career reasons). The military is making things extremely difficult for us right now because of that inflexibility. You can say to yourself that this might not apply to you, but the reality is you have no idea who you will fall in love with if you are single. Put this in context that I have largely been given everything I wanted that military medicine could offer. I went to USUHS (a good medical school with solid training). I was selected for my specialty of choice at my #1 location on match day. I matched immediately after medical school without having to do a GMO tour. Furthermore, immediately after my residency training I was selected for the civilian fellowship of my choice without having to do a utilization tour. I have just been given orders to be relocated to one of the three largest Army hospitals, where I will practice my subspecialty and will not have to worry about skill rot. Furthermore, my specialty is actually in a fairly good place in the military compared to the civilian sector. This is literally one of the best scenarios that could have happened to me once I joined and the Army is still making my life difficult. That said, I am not at all sorry I joined. I wanted to serve and I knew this was a possibility when I signed up. I just want to make sure that you are aware of the possible outcomes if you sign up. It's called "service" for a reason.
     
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  48. orbitsurgMD

    orbitsurgMD Senior Member

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    If you believe that past performance is a useful predictor of future performance, then no.

    If you believe that, in general, trends regress toward the mean . . . then, yes.
     
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  49. John1513

    John1513 Staff Physician
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    Likely, this would be admin sep, as opposed to Medboard
     
  50. John1513

    John1513 Staff Physician
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    So good!!! I never understood why coders and billers scurry around in Milmed. Monopoly money! Great post!!!
     
  51. pgg

    pgg Laugh at me, will they?
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    One reason is that it's a not-unreasonable metric to track work load. If this information could be accurately measured and tabulated, it would be useful.

    The other reason is that the military provides a lot of care to non active duty people, namely working spouses and the children of the household with a non-AD parent, who may have other insurance. The law requires this outside insurance to be billed as primary. Facilities that are diligent about it can bring in a lot of money.
     
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  52. TheEarDoc

    TheEarDoc Audiologist

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    Nah I'm sure everyone and their brother would have the attitude, "You want to boot me out, then I'm gonna make you pay for it and boot me out through medboard".
     
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