E-mail from Immediate Past President, Soc. of Medical Consultants to the Armed Forces

[MedicalCorpse]

---

Members don't see this ad.

First, my e-mail to him:

Memorandum For: Major General Scotti 20 Aug 2006

From: Robert C. Jones, M.D., ex-LtCol, USAF, MC

Subject: The "Astonishing" Murder of U.S. Military Medicine

I just finished reading your May 2006 SMCAF Newsletter. I would like to know how the distinguished members of the SMCAF plan to register their "astonishment"at the brutal murder of U.S. Military Medicine which is taking place at this moment, and which has been at least ten years in the making.

I left the USAF in July 05 after 19 years on active duty service to my country. I resigned my Regular Commission as a LtCol senior anesthesiologist, and walked away from all retirement pay and benefits, as a direct result of the tragic problems with military medicine which are now, finally, "astonishing" you.

Here are a few items for your consideration, Sir:

Item: Military GME at Wilford Hall and elsewhere was slashed in 1997

Item: Since 1997, the AF Objective Medical Group (and OMG II) made nurses, pharmacists, and housekeepers co-equal to physicians in the Medical Group org chart structure.

Item: In 1999, the policy of the USAF SG was to encourage independent (mal)practice of CRNAs, without appropriate anesthesiologist supervision (as is required by Federal Medicare law and the vast majority of states).

Item: My specialty, anesthesiology (AFSC 45A3) was 50% or less manned from 2000 until I left the USAF as a senior LtCol in 2005. No hope was in sight for improving this critical shortage of "wartime critical" specialist physicians.

Item: The military, across the board, is increasingly relying on non-physician "providers", rather than board-certified M.D.s. PAs and NPs stay in to make rank, while M.D.s flee to the civilian world.

Item: MTFs across the country and around the world have been shuttered, forcing retirees to drive hundreds of miles for care they had been promised during their active duty years.

Item: MTFs that haven't been shuttered are being "force shaped" into uselessness; witness my experience at Andrews, where we went from 10 anesthesiologists in 2000 to 2 functional, clinical docs in 2001. We went from approximately 8 ICU beds to zero now. At one point in 2005, we had zero intensivists covering the ICU; interns and FP residents were forced to act as attendings, to the permanent detriment of several patients.

Item: Physicians are being punished for pointing out the "Emperor's New Clothes". Non-clinician commanders installed under the OMG (and the other services' equivalents) are handing out Letters of Reprimand to physicians like myself who stand up to insist upon evidence-based referral of our sickest patients from devolved ex-"Medical Centers" (like Andrews) to hospitals with appropriate, higher levels of care (such as Walter Reed or civilian hospitals). Why? Money. The military wants to avoid spending the money on treating patients correctly "downtown", so they force attending physicians to bow to political pressures to (mal)practice on critically-ill patients in the absence (due to "force shaping") of adequate system-wide infrastructure. Just because a hospital has a vascular surgeon on staff, does not mean that the hospital as a system has the capability to meet standard of care for high risk/low volume surgical interventions (like AAAs, CEAs, and Fem-pops, for example). In addition to adequate ancillary support staff (e.g., blood bank, lab, radiology) and equipment; nursing, technician, anesthesia, and, yes, surgeon experience all must meet standard of care for good outcomes to result. No one in command is willing to stand up and say, "My hospital has now met mission failure criteria for the following functions; please shut us down now, in the interest of patient safety." This just does NOT look good on one's OPR.

Item: Physician retention beyond ADSC dates, especially among surgeons and anesthesiologists, remains in the single digit range. Nothing has been done to make specialty bonus pay commensurate with civilian pay; nothing has been done to increase basic physician bonus pay (a lousy $15K, before taxes) since I joined the Medical Corps in 1990 straight out of USUHS.

Item: The ongoing "Long War" against anyone arbitrarily deemed an enemy of the State, combined with the brutal fiasco which is Iraq, has resulted in physicians being subjected to back to back deployments over years, in complete violation of the promises given to us when the Aerospace Expeditionary Force was rolled out in 1999. We had been promised 90 day deployments q 15 months...then 120 (day) deployments...then 6 months...then, well, whenever the "Needs of the Air Force" determined...thus gutting clinics at Andrews, Wilford Hall, Wright Pat, Travis, and elsewhere, resulting in no capability to provide garrison care to the family members left behind (and our retirees).

Item: TRICARE is a decade-old, multi-billion dollar disaster of epic proportions. It is simply a means of infusing cash into government contract corporations, which then turn around and provide generous consulting jobs to Generals who retire to exclusive golf course communities, far from the madding din of TRICARE beneficiaries screaming for care while on terminal phone-menu hold for hours.

Item: Day-to-day patient care at MTFs in CONUS is being turned over pell-mell to contract physicians. Many of these contractors are ex-military docs who decided to turn in their oak leaves and eagles in order to get paid three times as much, without any involuntary call, annoying computer-based training, or opportunities for IED-filled desert vacations. With very few exceptions, in my personal experience, the contractors DoD has scraped from the bottom of the civilian barrel are among the laziest and least competent physicians I have ever met...else, why would they subject themselves to the mind-numbing bureaucratic hoops DoD makes them jump through on a daily basis? The few good ones eventually get fed up when MAJCOMs screw up the dollars yet again, thus zeroing out money available for contractors. But wait, it's O.K.: We'll just make the remaining junior active duty docs pull every other night call for THREE MONTHS in a row to compensate (as I had to do after 9/11, as a result of Sheer Poor Planning at the highest levels of military medicine).

Item: As a result of the above, the medical care given to our valiant warfighters, their families, and our honored retirees is devolving at an "astonishing" rate, and nothing...nothing...effective is being done to advertise this fact to the American public, or to reverse these brain dead policies which RIGHT NOW are endangering the lives of real patients at home and around the world.

I have been working on writing two books on this subject since I left the military; it's the only therapy for my anger and grief at the death of both my career and military medicine the VA will authorize (I have been waiting a year now for the VA to make a determination on my Compensation and Pension). Until they are published, I invite you to read the information on the companion website I have written:

Military Medical Corpse: The Premeditated Murder of U.S. Military Medicine
http://www.medicalcorpse.com

As a patriotic American citizen, I urge you and your group to use all of your combined connections, influence, and moral suasion to do something...anything...to undo the near-fatal damage which has been inflicted on military medicine over the past decade, and which now appears to be heading toward the final coup de grace.

Sincerely,

Robert C. Jones, M.D.
Ex-LtCol, USAF, MC
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, MD
Harvard '85, USUHS '90, WHMC anesthesiology '94
[email protected]
http://www.medicalcorpse.com


Nemo Me Impune Lacessit.

 

[MedicalCorpse]

First, my e-mail to him:

Memorandum For: Major General Scotti 20 Aug 2006

Now, his response, which he asked me to hold in confidence until his term as President of the SMCAF expired on 23 October:

21 Aug 06

The time and care evidenced in your memorandum is appreciated. I spent some time on your web site with particular interest in the excerpts from your forthcoming book. I also took the liberty of sharing your memo with the Society's leadership.

My president's letter in the May newsletter used the term "astonished" in reference to the FY2007 plan given the current operation tempo. SMCAF has been fully informed over the past several years by the leadership of the services and by the ASD (HA) of the reductions in active duty physician positions, increasing use of physician assistants and nurse clinicians, the disruptions caused by the contracting process and the increasing use of the civilian health care system for care that was once the province of the military health care system. The past two years have accelerated the need for repetitive deployments with the expected impact on continuity of care and retention. The number of physicians such as yourself that have left active duty within a few years of retirement eligibility is higher than anyone can remember, the major cause being the increased recalls of retired physicians who are eligible for such involuntary recall for life. Recruitment is down significantly: the HPSP program did not fill this past year.

Some of the changes make sense: the closure of very small hospitals with less than enough inpatient workload to preclude quality care; avoiding duplication of high cost technologies in military treatment facilities (MTFs) geographically near each other; using nearby civilian facilities for services where the volume in the MTF is small, e.g. neonatology. Many are not fiscally responsible but are driven by limitations in active duty strength and civilian employment caps. The civilian leadership of DOD and the services appointed by the current administration favor outsourcing and privatization. The military leadership has allocated personnel positions to perform the current and expected missions thus special forces increase and dependent health care in the direct health care system decreases. Additionally, there have been errors in estimates of demand not dissimilar to the proclaimed glut of physicians, now being reversed. All this has placed stress on the clinical leadership at MTFs. The measurable quality of care by outcome criteria has not suffered, but the quality of life for patients and providers alike has. Moreover, the military health care system and the individuals serving therein cannot sustain the unpredictability.

The Society has worked with the civilian leadership of DOD and the services with some effect, but sorry to say, more in blunting the process rather than reversing it. We also meet monthly with the Military Coalition (TMC), an umbrella organization for 34 military associated non-profit associations from the American Legion to the Gold Star Wives. The TMC has a strong lobbying presence in Washington, and they are speaking up. While we will continue, my own belief is that great progress will not be made under this administration. I believe that working through the political process is the best option. An informed electorate is essential; your work is directed at that end.

It is essential to address physician issues, but not sufficient. Patients, commanders, other health care disciplines and support services have important issues as well. Physicians cannot work alone. While there are non-physician health care providers that behave in ways that do not result in the optimal care for the patient, the overwhelming majority want what you want.

I hope I have seriously responded to your memorandum. Please continue to work positively to a common objective.

Mike Scottti

Some of this
Michael J. Scotti, Jr., MD
(contact info redacted)

 

[IgD]

Please continue to work positively to a common objective.

Interesting choice of words.

 

[MedicalCorpse]

Interesting choice of words.

This is a pathetic and shameful mode of ad hominem debate: pick one word out of 580 to respond to out of context, rather than addressing the totality of the General's message in context.

1/580 = 0.001724, or almost (not quite) 2/10ths of 1% of the General's e-mail.

I am positive that the following excerpts are far more relevant to the future of military medicine than whether I, Rob Jones, M.D., am being "positive" or "negative" in my ongoing attempt to create a grass-roots movement to reform U.S. Military Medicine before one more warfighter dies needlessly due to a broken system:

"The past two years have accelerated the need for repetitive deployments with the expected impact on continuity of care and retention. The number of physicians such as yourself that have left active duty within a few years of retirement eligibility is higher than anyone can remember, the major cause being the increased recalls of retired physicians who are eligible for such involuntary recall for life. Recruitment is down significantly: the HPSP program did not fill this past year."

"Many are not fiscally responsible but are driven by limitations in active duty strength and civilian employment caps. The civilian leadership of DOD and the services appointed by the current administration favor outsourcing and privatization."

"...there have been errors in estimates of demand not dissimilar to the proclaimed glut of physicians, now being reversed. All this has placed stress on the clinical leadership at MTFs. The measurable quality of care by outcome criteria has not suffered, but the quality of life for patients and providers alike has. Moreover, the military health care system and the individuals serving therein cannot sustain the unpredictability."

"While we will continue, my own belief is that great progress will not be made under this administration. I believe that working through the political process is the best option. An informed electorate is essential; your work is directed at that end."


Care to respond to the above remarks, which constitute a full 38.2% of the content of General Scotti's letter?

Did you (and the rest of the forum) know that involuntary recalls of physicians to active duty after retirement is considered by the leadership of military medicine to be "the major cause" of lack of retention of experienced military docs who have 15+ years toward retirement?

Do you agree that Congressionally-mandated limitations in active duty end strength and civilian employment unncecessarily hamper the military's ability to respond flexibly to dynamic threats by hiring and/or retaining more personnel? Should these caps not be modified upward, or eliminated altogether?

Has privatization of military "health care" made the average troop and her family healthier and happier, or the converse?

Who is responsible for the "errors in estimates" made by the leadership of U.S. military medicine: the leaders, or the followers? Where is the accountability in the system, when Surgeons General can retire to golf courses after destroying a formerly functional system without replacing it with one that ensures quality care our Active Duty, retirees, and their families deserve?

When the General says that the "military health care system and the individuals serving therein cannot sustain the unpredictability", does that mean that the key to reversal of this tragic state of affairs is for Rob Jones, M.D., to display a positive attitude, or are there more profound, systemic, global problems that should be addressed first, before reform of my "negativity" is considered?

Tag. You're it.

Your ex-polyester-clad Pollyanna,

--
R

 

[Galo]

Hope I'm not flamed for pointing out the ovious and continuing lack of understanding, and ignorance by this resident who has never revealed much about himself. You are trying to muddy waters that are crystal clear. You need to let go of whatever hope and anchor you are holding onto, and open your eyes. Seems every intelligent well thought out discussion/post is certain to have a stupid, childish, or malignant follow up from you. Grow up!

 

[resxn]

That which I find most interesting is it appears General Scotti is aware of the issue as are those with whom he has contact. Similarly it is not that my hospital commander is unaware of the issues in the med group.

What seems to be the fundamental issue is that either those who are informed and at rank to do something can't or won't.

The "can't" answer is the one that would provide me somewhat more comfort albeit minimal. The "won't" answer just gets me so angry I want to, per Spanglish, "light my hair on fire and pound my head in with a hammer."

Whenever I see a letter like this or hear an 0-6 or 0-7 and up speak, they choose so carefully their words, I can't tell to which group the speaker belongs.

The frightening thing to me is, the longer I stay in the more I think it's a combination of the two within the same leaders. They may want to but they feel they "can't" and they "won't." The mentality of get me through to my 20 and then I'm gone is a powerful motivation on the line side.

 

[MedicalCorpse]

The frightening thing to me is, the longer I stay in the more I think it's a combination of the two within the same leaders. They may want to but they feel they "can't" and they "won't." The mentality of get me through to my 20 and then I'm gone is a powerful motivation on the line side.

Not only the line side. Almost every single physician I knew with between 15 and 19 years of service was a sheep. They were all ROAD scholars who kept their heads down, forwarded e-mails, and accepted the malpractice being forced upon them by their superiors in the system. Not one of them stood up to say: "Ma'am, with respect, I cannot do this. It violates standard of care."

Instead, they pass the buck to their subordinate fall guys/girls, while they high-tail it out of town for one of their 20 TDYs per year.

Example: forcing anesthesiologists to do PICC lines sans training and sans C-arm guidance (as per manufacturer's guidelines in the PICC kit's instructions)

Example: forcing anesthesiologists to give CRNAs morning, lunch, and afternoon breaks while SIMULTANEOUSLY staffing multiple other CRNAs in other operating rooms (in complete violation of standards of care, but rationalized as necessary because "how else will the CRNAs get breaks" if we don't put patients at risk because their anesthesiologist is tied up personally passing gas, and unable to respond to their intraoperative emergency as they expected [and deserved]).

Example: You get the point. Any medical officer who stands up with integrity to oppose the party line being sprayed upon him/her like diarrhea by Generals who have lost all touch with clinical medicine is committing career suicide in today's Air Force. All the O-6s want is that shiny brass ring...which will turn a sickly green when they are involuntarily recalled to active duty when we invade Iran...

--
R

 

[IgD]

Not only the line side. Almost every single physician I knew with between 15 and 19 years of service was a sheep. They were all ROAD scholars who kept their heads down, forwarded e-mails, and accepted the malpractice being forced upon them by their superiors in the system. Not one of them stood up to say: "Ma'am, with respect, I cannot do this. It violates standard of care."

The more you post, the more you sound like T.O. from the NFL. T.O. is a good receiver but in the end his antics hurt the team more than whatever good he can contribute. I think its important to be a team player!

 

[IgD]

Tag. You're it.

I think what he is describing in his letter is a "perfect storm" scenario for military medicine. All of the following things are happening simultaneously:

• Healthcare costs are increasing
• Prior to the war we were privatizing/civilianizing military medical care and the system was struggling to adapt to the change
• Demand for medical services is increasing
• Operational deployments are increasing because of the war
• Retention numbers are decreasing
• Recruiting numbers are decreasing

The part that struck me most was "The Society has worked with the civilian leadership of DOD and the services with some effect, but sorry to say, more in blunting the process rather than reversing it...While we will continue, my own belief is that great progress will not be made under this administration."

I think he is saying that he agrees with you that there are problems and is frustrated that they haven't been able to impact change.

Another comment he made was: "I believe that working through the political process is the best option."

At first I thought he was suggesting to engage the leadership through constructive dialog and lobbying. I'm not sure. He might be suggesting everyone call their congressman.

This statement is important too: "While there are non-physician health care providers that behave in ways that do not result in the optimal care for the patient, the overwhelming majority want what you want."

Nurse practioners and physicians assistants are here to stay. We have to include them as partners in fixing the problems. It would be a mistake to alienate them.

 

[MedicalCorpse]

(Post title quote from: http://www.appleseeds.org/workplac.htm )

The more you post, the more you sound like T.O. from the NFL. T.O. is a good receiver but in the end his antics hurt the team more than whatever good he can contribute. I think its important to be a team player!

The more you post, the more you sound like Donald Rumsfeld.

From: http://www.washingtonpost.com/wp-dyn/content/article/2006/10/26/AR2006102600832.html

"You ought to just back off, take a look at it, relax, understand that it's complicated, it's difficult," Rumsfeld said, appearing unusually combative as he sparred with reporters at the Pentagon. "Honorable people are working on these things together..."

So, the SECDEF feels that the answer to critical foreign policy quandries which are right now costing American troops their lives is for pesky people with annoying questions "to just back off." Priceless.

Well, the press is not backing off, and nor am I. Propagandistic appeal to being a "team player" nullifies any claim you may make for putting integrity and honor first. Are these our new Air Force Core Values?

1. Be a Team Player
2. No Antics
3. Integrity is Optional, if it violates Core Value #1: Be a Team Player

Let us all consider governments and political systems which have historically put being "A Team Player" above "Doing the Right Thing, Even If It Means Speaking Out Against Government Policies":

1.
2.
3.

(Think about it. Fill in the blanks)

Is being a team player more important than doing the right thing, as one sees it? Really? So, when you eventually graduate from residency and become an attending, you will be willing to let one of your patients die in order for you to look like a team player? Hypothetically, if you are essentially ordered by the O-6 Vice Commander of your hospital and the O-6 SGH to kill a three year old child who is posturing from increased ICP by giving her propofol for an MRI scan, even though the hospital does not have an MRI-compatible anesthesia machine to allow her to be cared for appropriately, even though your hospital does not have a peds neurosurgeon who can fix her, and even though she is scheduled to be life-flighted out ASAP, you would, according to your philosophy, go along with this illegal order (commission of malpractice) in order to be "A Team Player"? If the acting SGH of the hospital asks you how to put poisonous sedatives on a pizza in order to "subdue" hostage takers, would you A) Follow the Hippocratic Oath and instruct the SGH that physicians providing poisons violates all standards of biomedical ethics and the Geneva Conventions or B) Be a "Team Player" and commit a crime against humanity? You may think these are "hypotheticals"; you would be wrong. If you have read my website, you know these scenarios actually happened to Active Duty Physicians (my friend and myself, respectively).

"Men have been taught that it is a virtue to agree with others. But the creator is the man who disagrees. Men have been taught that it is a virtue to swim with the current. But the creator is the man who goes against the current. Men have been taught that it is a virtue to stand together. But the creator is the man who stands alone." --Ayn Rand (1905-82), philosopher/novelist

I am beginning to wonder whether you are trolling everyone here, or whether you are just dense. As Dogbert says: "Or?"

--
R

 

[MedicalCorpse]

Nurse practioners and physicians assistants are here to stay. We have to include them as partners in fixing the problems. It would be a mistake to alienate them.

Physicians are not alienating them. They are alienating us by insisting on complete independence of practice WHILE SIMULTANEOUSLY making the physicians in de jure charge of them responsible for the results of inevitable errors in judgment. Everyone makes errors in judgment from time to time. The problem arises when I am made culpable for a decision in which I had no say.

I have never said that I am "Anti-PA" or "Anti-CRNA". It's in the FAQ on my website. I taught student CRNAs/Nurse Anesthesia Residents (NARs) in one of the Air Force's largest CRNA training programs (Travis) for 6 years. I spoke out vociferously against anesthesiologist colleagues who claimed that teaching CRNAs regional techniques was tantamount to "slitting our own throats", because they would compete with us in the civilian world. I was well liked by almost all the NARs, because I taught them and guided them without demeaning them or ignoring them, as some of my colleagues did. When a certain arrogant peds surgeon insisted during a Squadron meeting that he refused to allow NARs to intubate his kids ever, I stood up, as Medical Director of Anesthesia, to ask if that meant that the Dept. of Anesthesia had the right to refuse to allow M.D. residents to take part in surgical procedures on kids. His "policy" was overturned.

I have worked with CRNAs and PAs on a daily basis in my civilian practice. They uniformly appreciate working with me...the CRNAs even get depressed if I am on vacation or tasked to work elsewhere in the hospital for too long...because I give them RESPECT for being professionals, while simultaneously working WITH them to protect patient safety.

What bothers me about the military paradigm, if you can get this through your head, is this: the military refuses to pay for sufficient M.D.s to provide safe oversight and supervision of PAs, NPs, and CRNAs. Thus, the non-M.D.s are encouraged to "follow their bliss" by practicing completely independently. Meanwhile, the few remaining M.D.s are forced to sign the non-physicians' charts as if they were morally and legally responsible for taking part in the patient's plan of care...oh, wait, they ARE morally and legally responsible, but simultaneously have zero authority to alter the treatment plan of the "Independent Practitioner of Extremely Competent Anesthesia Care" (IPECAC).

The military independent practice paradigm has directly led to the death and brain damage of active duty troops.

Thus, if "alienating" military PAs, NPs, and CRNAs is the price to be paid for insisting, based on medical facts, that DoD is jeopardizing the lives of warfighters and their families by purposely refusing to hire enough M.D.s to ensure safe, appropriate physician supervision of non-physician "providers", then SO BE IT. I would rather alienate every single non-physician in the military than advocate a flawed medical treatment model which I have witnessed first hand put patients into comas and caskets.

So, to boil it down for your ease of comprehension: PAs, NPs, and CRNAs: Good. Independent practice: Bad.

The first day when you, as an attending, are brought a stack of PA or CRNA charts to sign to provide a "fig leaf" of physician oversight in order to bamboozle JCAHO, you will understand what I am saying.

--
R

 

[IgD]

Yawn...

 

[USAFdoc]

Yawn...

IgD; you have just shown yet another invaluable characteristic to make it big in USAF Leadership.😍

YAWN away Captain! (Note that people close their eyes when they yawn)

 

[Galo]

IgD; you have just shown yet another invaluable characteristic to make it big in USAF Leadership.😍

YAWN away Captain! (Note that people close their eyes when they yawn)

The one thing that he has told us is that he is in the navy. Small thanks for AF docs, but not the navy doctors he will torture, or patients he will murder when being the quarterback for the "team".

IgD, you are like the boss I had: you may not be breaking any rules, even though I think you are trolling threads to inject you poisonous views, so the clubman can't swing his club at you. However, your clear inability to recognize when you are dead wrong is typical of the military mentality that will lead you to mediocrity, and thus straight to the head of the "team." Keep playing: it seems to work for you; but stop showing your ignorance on this forum. There is not one single physician who agrees with your diatribes, so get a clue!