Heads may roll

[IgD]

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Looks like Army medicine is about to get its house cleaned:
http://www.military.com/news/article/heads-may-roll-in-dod-fort-hood-probe.html?ESRC=topstories.RSS

WASHINGTON -- Military officials investigating failures in the wake of the Fort Hood shootings may recommend that individuals be held accountable for failing to perform their duties.

Such a move would be notable for a military grappling with how to prevent another tragedy when the perpetrator is one of its own, as in the case of alleged Fort Hood shooter Army Maj. Nidal Malik Hasan. Such disciplinary action could create a new expectation that all service members must learn to be more vigilant.

The two retired military officials leading the Pentagon's review of the shootings visited Fort Hood Tuesday and vowed to identify "programs, policies or procedural weaknesses" within the Defense Department that may have allowed the shooting to happen. The investigators emphasized that they were not looking to pin the blame on someone.

But if the review finds that individuals were derelict in their duty, those individuals could be recommended for disciplinary action, according to another military official. "It's pretty clear that one of the expectations is to do just that," said the official, who asked to remain anonymous because of the sensitivity of the issue.

 

[notdeadyet]

Did anyone not see this coming? Any predictions on the highest rank whose going to get handed his head? O-5?

 

[DrMetal]

Did anyone not see this coming? Any predictions on the highest rank whose going to get handed his head? O-5?

I say they should start with the psych res PD at Walter Reed (what, an O-4, O-5?). How can you let someone get away with so many dings, never disciplining him, allowing him to graduate, then even placing him in a fellowship?! He should've been failed out of the program, given the boot, and force to payback both his USUHS and ROTC commitment. Yeah, I know the Army is in need of psychs, but I'd rather have the need and the shortfalls, than nutjobs like Hasan walking around.

 

[IgD]

I think it is a complicated situation.

Here are some thoughts I have:

1. Were Hasan's academic credentials appropriate for USUHS?
2. If he did struggle academically at USUHS, why was he allowed to graduate and why was he allowed to go straight into a residency without a GMO tour?
3. With the terrible evaluation he got from his program director, why was he allowed to graduate residency?
4. Why was his residency program director a MAJ? In my experience usually a program director is a LTCOL/COL with a lot of experience dealing with impaired physicians.
5. Why was he permitted to go straight into a fellowship without a utilization tour?
6. What was his performance like during fellowship? Why was he allowed to graduate?
7. With apparently a long track record of problems, why was he allowed to PCS to a smaller command?
8. On top of all that, why was he penciled in for a deployment?

I think there are a lot of individuals involved who could be potential targets:

• Senior official at USUHS
• Residency program director
• Fellowship program director
• Psychiatry specialty leader and Detailer who probably collaborated on his orders/disposition
• Senior department head at FT HOOD who facilitated the deployment

 

[DrMetal]

• Senior official at USUHS
• Residency program director
• Fellowship program director
• Psychiatry specialty leader and Detailer who probably worked hand-in-hand
• Senior department head at FT HOOD who facilitated the deployment

One thing that's been unclear throughout this whole story is exactly how bad of a student (or how much of a headcase) was Hasan in medical school. Was he a really awful student, just allowed to skirt by? I don't think so. USUHS doesn't hesitate to kick out really troubled students (for either academic reasons, or other violations, like DUIs etc). They give em the boot all the time. So my guess is that Hassan was an average student with the occasional D or F, was put a probation, but got thru the system eventually.

So I think it'd be hard to pin this on USUHS. His recent PD and fellowship director were much closer to and observant of him. For crying out loud, they discussed his eccentricities and potential to hurt patients! If the conversation about someone ever gets to that level, I'd think that some action would be taken.

I feel like it's even moot discussing this, I don't think the tragedy could've been avoided in any case. The guy was determined.

Again, the only conclusion I can come to: Everybody arm yourself! At least then we can take out these crazies, end result being only 2-3 dead instead of 13. If those civilian cops hadn't been there to take him out, death toll might've been ~30, 40, who knows.

 

[IgD]

One thing that's been unclear throughout this whole story is exactly how bad of a student (or how much of a headcase) was Hasan in medical school. Was he a really awful student, just allowed to skirt by?

Need to validate this but I read a report that it took him 6 years to graduate from a 4 year program.

 

[AirmanCatalyst]

I'm not sure about the firings, but I wouldn't be surprised if they decided to bug us some more with CBTs which just get clicked to the page so that we can get back to work.

 

[AF M4]

Need to validate this but I read a report that it took him 6 years to graduate from a 4 year program.

Interesting.

However, if your goal is to prevent further incidents like this tragedy, I question the idea of going after academically deficient physicians. Any reason why an A+ student couldn't go nuts in a similar fashion?

And given the various recruitment issues plaguing milmed...well, quite frankly, if we got rid of every doc with a below-average academic record, we'd be booting out more than half our current active duty and contractor physicians. Side product of treating the med side like crap for a decade.

Now, all those reports about crazy jihadist lectures during grand rounds - definitely a problem.

Anyway, just wanted to highlight the difference between someone struggling academically and someone who is outright nuts.

 

[bustbones26]

Interesting.

However, if your goal is to prevent further incidents like this tragedy, I question the idea of going after academically deficient physicians. Any reason why an A+ student couldn't go nuts in a similar fashion?

And given the various recruitment issues plaguing milmed...well, quite frankly, if we got rid of every doc with a below-average academic record, we'd be booting out more than half our current active duty and contractor physicians. Side product of treating the med side like crap for a decade.

Now, all those reports about crazy jihadist lectures during grand rounds - definitely a problem.

Anyway, just wanted to highlight the difference between someone struggling academically and someone who is outright nuts.

The root of the problem is not the fact that he was academically challenged. The problem is, his academic challenges were either overlooked or mishandled. I have seen this in my own residency program.

One thing that nobody has yet mentioned, you can't place a resident on probation without formal counseling and a remediation plan. If the resident does not meet the conditions of the remediation plan, then they can be placed onto probation. Remediation is not a permanent blemish on your record (probation is). My guess, and its only a speculation, he was placed on a lax remediation program that he apparently med the conditions stipulated, taken off the remediation program, and never on a formal probation.

His academic difficulties are one thing, and you are correct, other academically challenged physicians should certainly not be equated as nut jobs, which leads me to my next question. Despite his academics, I find it hard to believe that his leaders denied ever noting any peculiar behaviors or disregarding him as a threat.

Lastly, if he was PFC Hasan, his butt would have been chaptered out a long time ago. I am not sure why the army goes lax when it comes to doctors?

 

[bustbones26]

Interesting.

However, if your goal is to prevent further incidents like this tragedy, I question the idea of going after academically deficient physicians. Any reason why an A+ student couldn't go nuts in a similar fashion?

And given the various recruitment issues plaguing milmed...well, quite frankly, if we got rid of every doc with a below-average academic record, we'd be booting out more than half our current active duty and contractor physicians. Side product of treating the med side like crap for a decade.

Now, all those reports about crazy jihadist lectures during grand rounds - definitely a problem.

Anyway, just wanted to highlight the difference between someone struggling academically and someone who is outright nuts.

The root of the problem is not the fact that he was academically challenged. The problem is, his academic challenges were either overlooked or mishandled. I have seen this in my own residency program.

One thing that nobody has yet mentioned, you can't place a resident on probation without formal counseling and a remediation plan. If the resident does not meet the conditions of the remediation plan, then they can be placed onto probation. Remediation is not a permanent blemish on your record (probation is). My guess, and its only a speculation, he was placed on a lax remediation program that he apparently met the conditions stipulated, taken off the remediation program, and was never on a formal probation (which would be a black eye on your record).

His academic difficulties are one thing, and you are correct, other academically challenged physicians should certainly should not be equated as nut jobs, which leads me to my next question. Despite his academics, I find it hard to believe that his leaders denied ever noting any peculiar behaviors or disregarding him as a threat. I suppose by human nature, we don't want to imagine that a person is mentally ill enough to go out and shoot people like sitting ducks, but, if he was PFC Hasan, his butt would have been chaptered out a long time ago. I am not sure why the army goes lax when it comes to doctors?

 

[IgD]

And given the various recruitment issues plaguing milmed...well, quite frankly, if we got rid of every doc with a below-average academic record, we'd be booting out more than half our current active duty and contractor physicians. Side product of treating the med side like crap for a decade.

Military medicine might have to address some of the problems impacting recruiting and retention that are described on this site and elsewhere!

 

[IgD]

Lastly, if he was PFC Hasan, his butt would have been chaptered out a long time ago. I am not sure why the army goes lax when it comes to doctors?

No matter how you look at it, that is the question everyone is asking. I think it is broader than just being a PFC. I suspect if this guy was a junior Naval officer on a ship or serving with Marines he would have been released for cause. I think one of the reasons you see a lot of outrage is because the senior military officers who are looking at this have come to the same conclusion.

 

[Perrotfish]

No matter how you look at it, that is the question everyone is asking. I think it is broader than just being a PFC. I suspect if this guy was a junior Naval officer on a ship or serving with Marines he would have been released for cause. I think one of the reasons you see a lot of outrage is because the senior military officers who are looking at this have come to the same conclusion.

I'm sorry, I'm just not seeing the clear cut clues that should have told everyone he was insane. So far the craziest thing I've seen that he did was one time where he gave a wierd grand rounds lecture. Also, of course, he was isolated, had political opinions that people disagreed with, and was a little pushy about his religion. Would you really have fired a guy based on that? Particularly someone that had served for over a decade?

Now maybe it will come out during the course of the investigation that Maj Hasan made some more direct threats to his colleagues, but unless that happens I think people are giving themselves way too much credit to say that they would have have noticed all of these warning signs if they had been there.

 

[IgD]

I'm sorry, I'm just not seeing the clear cut clues that should have told everyone he was insane...

I don't think that is the issue. I think the issue is more did Hasan meet academic, professional and military standards? I read he skipped a call night and didn't show up for a shelf exam. That is pretty concerning...

 

[Perrotfish]

I don't think that is the issue. I think the issue is more did Hasan meet academic, professional and military standards? I read he skipped a call night and didn't show up for a shelf exam. That is pretty concerning...

I don't see what his not meeting standards has to do with anything. The point of this investigation is that we're questioning whether anything could have been done to prevent the shooting. Mediocrity is not a warning sign.

 

[R-Me-Doc]

I don't see what his not meeting standards has to do with anything. The point of this investigation is that we're questioning whether anything could have been done to prevent the shooting. Mediocrity is not a warning sign.

What could have been done to prevent the shooting was to have bounced him out of the military (and possibly medicine in general) before he ever even got to Ft Hood.

Not responding to calls and skipping exams is not "mediocrity," it's highly aberrant behavior that suggests some real underlying problems. In the military I suspect it could also be construed as "dereliction of duty."

I think the burden of blame here is on his residency/fellowship program (or possibly med school) for not weeding him out earlier if there was indeed substandard performance and/or unprofessional behavior. I'm also glad I'm not in the hospital chain of command at Ft Hood who signed off on his credentialling papers . . .

That being said, it's not easy to do that for a variety of reasons, in both the military and civilian worlds. Med schools and residency programs will generally bend over backwards to try to "remediate" people. Part of this is because they probably genuinely feel that "a mind is a terrible thing to waste" and if you were smart enough to get in to begin with, you must have some upside potential. Part of it is not wanting to admit you made a mistake admitting the person to begin with. Part of it, frankly, is fear of lawsuits. And part of it is just that nobody wants to tell a student/resident "sorry, your lifelong dream of being a doctor is over." It's even more difficult and complicated once someone is done with residency and actually practicing. I've been involved in a couple of reviews of "questionable providers" and unless there's some flat out felonious behavior involved, it's really a rather painful process for everyone.

I suspect that, for the reasons above, he was allowed to progress through residency and fellowship. One of the other posters asked "why was he assigned to a smaller command and pencilled in for deployment." Well, that's probably a case of the Army trying to get him out of sight and out of mind -- send him somewhere out of the way, and then out of the country for a while, and by the time he's back either he'll be straightened out or he'll be someone else's problem.

X-RMD

 

[AF M4]

What could have been done to prevent the shooting was to have bounced him out of the military (and possibly medicine in general) before he ever even got to Ft Hood.

Not responding to calls and skipping exams is not "mediocrity," it's highly aberrant behavior that suggests some real underlying problems. In the military I suspect it could also be construed as "dereliction of duty."

I think the burden of blame here is on his residency/fellowship program (or possibly med school) for not weeding him out earlier if there was indeed substandard performance and/or unprofessional behavior. I'm also glad I'm not in the hospital chain of command at Ft Hood who signed off on his credentialling papers . . .

X-RMD

Exactly. Saying that you're only a cog in a faulty system that specializes in passing the buck is not good enough. You were still the med school administrator who graduated him, you were still the residency program director who recognized that he had problems that were serious enough to boot him from the program, and you were still the hospital coordinator who credentialled him to the staff despite receiving a letter from the PD which basically said "This guy sucks to the point where I wanted to boot him from my residency, but it looked like too much work and I was too chicken to do it. Sorry, but he's your problem now."

Yes, the system is certainly a problem but so are the people enabling it. IgD, I heartily agree with your points. I particularly hope that they make some fixes to the system, so people like those listed above aren't constantly forced into such compromising positions. My fear is that the powers that be will instead simply go after the requisite pound of flesh from the O-4/O-5/O-6's involved in the shooter's career progression, then turtle until the whole mess blows over. Then back to business as usual.

 

[orbitsurgMD]

Looks like Army medicine is about to get its house cleaned:
http://www.military.com/news/article/heads-may-roll-in-dod-fort-hood-probe.html?ESRC=topstories.RSS

WASHINGTON -- Military officials investigating failures in the wake of the Fort Hood shootings may recommend that individuals be held accountable for failing to perform their duties.

Such a move would be notable for a military grappling with how to prevent another tragedy when the perpetrator is one of its own, as in the case of alleged Fort Hood shooter Army Maj. Nidal Malik Hasan. Such disciplinary action could create a new expectation that all service members must learn to be more vigilant.

The two retired military officials leading the Pentagon's review of the shootings visited Fort Hood Tuesday and vowed to identify "programs, policies or procedural weaknesses" within the Defense Department that may have allowed the shooting to happen. The investigators emphasized that they were not looking to pin the blame on someone.

But if the review finds that individuals were derelict in their duty, those individuals could be recommended for disciplinary action, according to another military official. "It's pretty clear that one of the expectations is to do just that," said the official, who asked to remain anonymous because of the sensitivity of the issue.

Gutting the psychiatry department would be the wrong thing to do. At their ranks, some of the PDs and department heads aren't all that senior. And when it comes to giving someone the boot, you really need an iron clad case, one that will stand up to the due process, which any formal adverse action would have to do.

Being academically weak as a medical student is not an indicator of being criminally dangerous. Giving a crappy and strange grand rounds presentation is not grounds for expulsion from a residency, a fellowship or anything else. And so far, no one has reported that Hasan ever did or said anything threatening to anyone. Yes, he had harsh and unfamiliar religious beliefs, but that too does not make him all that unique; the services are shot through with people with harsh and strange religious beliefs but, because they call themselves "christian," they get a pass.

The investigation almost presumes the knowledge that something existed before this rare and violent event that would have reliably predicted the outcome and was the kind of knowledge upon which some kind of preventative action might have been taken had it come to the attention of someone with the authority to expel Dr. Hasan before he ever got to Ft. Hood.

I have no doubt the Army will try to hang "responsibility" on someone. They might start with the senior Army line, active duty and retired general officers, who along with their sister services have starved the medical corps and have created a culture where cost-cutting and short-term thinking have systematically undermined the capacity to attract and retain better and more competitive candidates to their respective medical corps, as they once routinely were able to do. Chipping away at quality training opportunities, closing medical centers, removing whole populations of eligible patients under the shell-game called Tricare have ultimately eroded the ability to attract students who once accepted HPSP scolarships from the nation's best schools but who appear no longer interested in doing so, from a time well before our recent period of expeditionary warfighting.

I have no doubt that the professors at USUHS and WRAMC would have preferred a stronger candidate for a degree and a residency certificate than Hasan was, but it seems they did not have much choice in the matter nor did they very likely have a suitable and available alternate. When you aren't a McLean Hospital or UCSF, you sometimes have to settle for people who wouldn't be your first choice, especially in psychiatry.

I also wonder how he was allowed to go straight through without either a GMO tour or a utilization tour in general psychiatry. They must have a tremendous need for residency graduates. The fellowship before a utilization tour is still more of a puzzle. Perhaps they needed someone to take the somewhat unique and unconventional billet or perhaps that by accepting Hasan who might have been willing to stay, they were able to delay the problem of detailing out a questionable practitioner and keep him under an umbrella of observation he might not otherwise have had at a more remote duty station (during which Dr. Hasan demonstrated a continuing pattern of substandard behaviors.)

An investigation that punishes the department heads but doesn't look at the larger, pervasive and pernicious trends in military medicine that inevitably lead to having to accept more substandard candidates than better quality civilian programs would generally find acceptable will deliberately fall short of any useful conclusion. With the short time allowance for a conclusion to this investigation, I wonder whether such an outcome has been assured.

 

[IgD]

The investigation almost presumes the knowledge that something existed before this rare and violent event that would have reliably predicted the outcome and was the kind of knowledge upon which some kind of preventative action might have been taken had it come to the attention of someone with the authority to expel Dr. Hasan before he ever got to Ft. Hood.

I don't think its an issue of predicting he was dangerous, I think the issue was that some of the information published suggested he should have been released for cause at perhaps multiple points in his career. If this is true, the tragedy would have been prevented.

...They might start with the senior Army line, active duty and retired general officers, who along with their sister services have starved the medical corps and have created a culture where cost-cutting and short-term thinking have systematically undermined the capacity to attract and retain better and more competitive candidates to their respective medical corps, as they once routinely were able to do. Chipping away at quality training opportunities, closing medical centers, removing whole populations of eligible patients under the shell-game called Tricare have ultimately eroded the ability to attract students who once accepted HPSP scolarships from the nation's best schools but who appear no longer interested in doing so, from a time well before our recent period of expeditionary warfighting.

That's a great paragraph right there. I think it captures a lot of the debate on the DoD blog website. I think it is likely that the FORT HOOD incident is related to the recruiting and retention problems in military medicine. The end result of all the cuts is that it is costing the DoD more and more in the long run in more ways than just money.

I have no doubt that the professors at USUHS and WRAMC would have preferred a stronger candidate for a degree and a residency certificate than Hasan was, but it seems they did not have much choice in the matter nor did they very likely have a suitable and available alternate...

My residency program had to release a resident. It wasn't an easy thing to do but it was the right thing to do and consistent with good leadership. I think the big question is why didn't this happen and was there a leadership failure.

I also wonder how he was allowed to go straight through without either a GMO tour or a utilization tour in general psychiatry. They must have a tremendous need for residency graduates. The fellowship before a utilization tour is still more of a puzzle...

It's certainly not equitable that Navy and Air Force physicians are being pulled to take Army deployments while Army physicians are not being required to do GMO or utilization tours.

An investigation that punishes the department heads but doesn't look at the larger, pervasive and pernicious trends in military medicine that inevitably lead to having to accept more substandard candidates than better quality civilian programs would generally find acceptable will deliberately fall short of any useful conclusion. With the short time allowance for a conclusion to this investigation, I wonder whether such an outcome has been assured.

Like I said before, as terrible as this situation is I think its a great opportunity for military medicine to look at itself in the mirror and address some of the systemic problems. I hope this opportunity isn't lost...

 

[bustbones26]

We are beating at a dead horse! We only know bits and pieces of the story and can only speculate the truth.

Many come here and say, "hey wait, its not fair to compare all academically challenged individuals to him". Let me point out that there is a difference between being academically challenged and being unprofessional! If you are prone to failing test, courses, etc. your leaders will go the extra mile to help you if you ask for help and remain professional about it. Possible co-morbid mental illness or not, skipping out on call and just being a lazy piece of crap on top of having academic issues should just not be tolerated, period!

Here is the major problem, Hasan is not in a club by himself as there are plenty of medical students, interns, residents, fellows, etc. that are unprofessional, lazy, and also plenty that have mental illnesses or warning signs of mental illness. Everybody here can think of "somebody" they know right now! The bottom line, even though working with that "somebody" annoys you, you'd never imagine that they'd go out and kill people. Unfortunately, it happens.


This was not the first time in history that a person performed a mass shooting and as history tends to repeat itself, it likely is not the last. In all cases, everybody knew the shooter had "quirks" but still never imagined that they would have taken it that far.

My anger with this case is how we doctors are lax and turn a blind eye. Let us forget about this fort hood shooting for a moment, let's pretend for a moment that it never happened, his antics otherwise would never had been tolerated if he was some enlisted guy with a menial MOS. Where else in the military can you be an O3 or above and even get promoted and yet, not get deployed (in some cases, yes it happens), be unprofessional, and just be a lazy piece of crap, other than the medical corps?

 

[orbitsurgMD]

We are beating at a dead horse! We only know bits and pieces of the story and can only speculate the truth.

. . . Where else in the military can you be an O3 or above and even get promoted and yet, not get deployed (in some cases, yes it happens), be unprofessional, and just be a lazy piece of crap, other than the medical corps?

[Bolds mine]

I dunno, Dental Corps, Nurse Corps, Medical Service Corps, QMs, Chaplains corps, JAG corps?
Probably all of them.

 

[IgD]

Here is the major problem, Hasan is not in a club by himself as there are plenty of medical students, interns, residents, fellows, etc. that are unprofessional, lazy, and also plenty that have mental illnesses or warning signs of mental illness. Everybody here can think of "somebody" they know right now!

I don't think that is true at all. I never heard of anyone who skipped a shelf exam before. I have only heard of one resident who skipped a call night and he was expeditiously terminated.

 

[pgg]

[Bolds mine]

I dunno, Dental Corps, Nurse Corps, Medical Service Corps, QMs, Chaplains corps, JAG corps?
Probably all of them.

Don't forget the line ...

At one point my USMC infantry battalion's "legal platoon" was approaching company size.

 

[Galo]

Not to be the downer, but have'nt we been down this road before. Everytime some disaster or near disaster happens in military medicine and it gets publicized, (the decrepid conditions where soldiers were staying in rat infested buildings, whistleblower psychologist shows how hospital commander denied psych eval to soldiers with problems in order to look better than other hospitals, the Pulitzer price winning expose of military medicine: http://www.pulitzer.org/works/1998-National-Reporting, and now the Ft Hood killings), we get all our hopes up, (not that there is anything wrong with that), that military medicine is finally going to be reformed.

I for one am not holding my breath. The sacrificial lamb will be brought out, whether in public or behind the scenes, his head will be handed to him/her, maybe after allowing them to retire with full benefits, and the cancer of military medicine will continue to grow and metastacize till the next disaster comes along. It really sad, but I do not see the paradigm shift needed coming out of this sad event.

Does the fact this happened in the army now make it as bad as the AF? Just kidding, no need for onslaught, the AF still the worst.

 

[AF M4]

Not to be the downer, but have'nt we been down this road before. Everytime some disaster or near disaster happens in military medicine and it gets publicized, (the decrepid conditions where soldiers were staying in rat infested buildings, whistleblower psychologist shows how hospital commander denied psych eval to soldiers with problems in order to look better than other hospitals, the Pulitzer price winning expose of military medicine: http://www.pulitzer.org/works/1998-National-Reporting, and now the Ft Hood killings), we get all our hopes up, (not that there is anything wrong with that), that military medicine is finally going to be reformed.

I for one am not holding my breath. The sacrificial lamb will be brought out, whether in public or behind the scenes, his head will be handed to him/her, maybe after allowing them to retire with full benefits, and the cancer of military medicine will continue to grow and metastacize till the next disaster comes along. It really sad, but I do not see the paradigm shift needed coming out of this sad event.

Does the fact this happened in the army now make it as bad as the AF? Just kidding, no need for onslaught, the AF still the worst.

Unfortunately, gotta agree. Read through some of the 1998 piece, and note how we've discussed many of those problems on this thread in regards to Ft. Hood (i.e., poor physicians passed through the .mil), as well as how we've also encountered many of these problems that are still present and thriving in today's milmed.

Long story short, there are waaay too many people in high-ranking places in the current system who are too invested in "the way things are" to make anything more than the most superficial changes. Bring forth the scapegoats, so that we may sacrifice them upon the altar of bureaucracy so as to appease the gods of the fourth estate.

 

[a1qwerty55]

Not to be the downer, but have'nt we been down this road before. Everytime some disaster or near disaster happens in military medicine and it gets publicized, (the decrepid conditions where soldiers were staying in rat infested buildings, whistleblower psychologist shows how hospital commander denied psych eval to soldiers with problems in order to look better than other hospitals, the Pulitzer price winning expose of military medicine: http://www.pulitzer.org/works/1998-National-Reporting, and now the Ft Hood killings), we get all our hopes up, (not that there is anything wrong with that), that military medicine is finally going to be reformed.

I for one am not holding my breath. The sacrificial lamb will be brought out, whether in public or behind the scenes, his head will be handed to him/her, maybe after allowing them to retire with full benefits, and the cancer of military medicine will continue to grow and metastacize till the next disaster comes along. It really sad, but I do not see the paradigm shift needed coming out of this sad event.

Does the fact this happened in the army now make it as bad as the AF? Just kidding, no need for onslaught, the AF still the worst.

The Ft Hood incident has zero to do with military medicine and to trying to somehow link the two is insulting. Is Virginia Tech a crappy institution b/c the shooter came from there? - by the way they also had another mass killer and a grad student decapitate a girlfriend in the cafeteria - perhaps we should judge VT on that? Hopefully not. Nuts are nuts, often go into psych and are hard to predict.

Must we rehash this? -

The Dayton paper pointed out some legitimate issues with physician licensing - this was corrected.

Having been involved in the adverse credentialling/priviledging actions process in both the military and civilian setting I can report that the military has far more stringent standards (In anticipation of some pithy comments, no,, I wasn't the one getting depriviledged).

It is common practice for a backroom meeting to happen between a hospital leadership and a incompetent physician with the result being that the doc politely resigns and moves to malpractice elsewhere - this is common knowledge in the civilian world. The fear of litigation keeps many hospitals and medical boards from sanctioning physicians. You may not know that if a military provider has his/her privileges held, they cannot leave the military until the issue is cleared, either they are repriviledged after an investigation or not. This is Congressionally mandated to keep the military from dumping problem docs on the civilian sector. - I

With regards to "decrepit" conditions at WRAMC - let's remember the soldiers were offered alternate lodging before it ever became an issue and declined. The rooms involved were a few and not reflective of the entire building and WRAMC was barred from fixing them as Congress cut off funding for repairs since WRAMC was being closed. It made for a great story but the truth was far less exciting. Also there was no issue with the medical care the soldiers received - the story was more about the follow up process/case manager process failing - much money has been thrown at that issue and is largely resolved. If a soldier falls through the cracks with the current WTB system - they are actively trying to do so.

I looked into the claims by a disgruntled civilian "whistleblower" in the story that a hospital commander in MO pressured staff to pencil whip psych evals - this was to my knowledge investigated and found to be without merit - I have not first hand knowledge on this one.

Don't try to spin the events in Ft Hood to support your world view. It isn't fair, nor professional.

 

[Galo]

The Ft Hood incident has zero to do with military medicine and to trying to somehow link the two is insulting. Is Virginia Tech a crappy institution b/c the shooter came from there? - by the way they also had another mass killer and a grad student decapitate a girlfriend in the cafeteria - perhaps we should judge VT on that? Hopefully not. Nuts are nuts, often go into psych and are hard to predict.

Must we rehash this? -

The Dayton paper pointed out some legitimate issues with physician licensing - this was corrected.

Having been involved in the adverse credentialling/priviledging actions process in both the military and civilian setting I can report that the military has far more stringent standards (In anticipation of some pithy comments, no,, I wasn't the one getting depriviledged).

It is common practice for a backroom meeting to happen between a hospital leadership and a incompetent physician with the result being that the doc politely resigns and moves to malpractice elsewhere - this is common knowledge in the civilian world. The fear of litigation keeps many hospitals and medical boards from sanctioning physicians. You may not know that if a military provider has his/her privileges held, they cannot leave the military until the issue is cleared, either they are repriviledged after an investigation or not. This is Congressionally mandated to keep the military from dumping problem docs on the civilian sector. - I

With regards to "decrepit" conditions at WRAMC - let's remember the soldiers were offered alternate lodging before it ever became an issue and declined. The rooms involved were a few and not reflective of the entire building and WRAMC was barred from fixing them as Congress cut off funding for repairs since WRAMC was being closed. It made for a great story but the truth was far less exciting. Also there was no issue with the medical care the soldiers received - the story was more about the follow up process/case manager process failing - much money has been thrown at that issue and is largely resolved. If a soldier falls through the cracks with the current WTB system - they are actively trying to do so.

I looked into the claims by a disgruntled civilian "whistleblower" in the story that a hospital commander in MO pressured staff to pencil whip psych evals - this was to my knowledge investigated and found to be without merit - I have not first hand knowledge on this one.

Don't try to spin the events in Ft Hood to support your world view. It isn't fair, nor professional.

At least for once you left the insults out. Congrats, and thank you for being "professional".

I think it would be ironic not to point out that your whole "world view" of military medicine, and its non failings, are just why I have no hope that it will not change. The clip that someone placed from animal house is just perfectly dean on you. So the media has blown everything out of proportion, and everything is OK???

I think I'll let others jump in on this as its just too ovbious that your are way off, and totally biased in protecting an institution that is damaged beyond repair, but not to those who run it and defend it.

Just one point. I never said that the issue was with Ft. Hood, so your parallels to VT are pointless. This guy was a nut, and military medicine and its infrastructure failed to recognize it despite what many say now were obvious warning signs. I hardly think many of the problmes from the 98 articles have been "fixed". And anyone in the military knows how investigations of high ranking officers always seem to find no merit. Oh that was two points. Tired, bedtime.

 

[Galo]

The Ft Hood incident has zero to do with military medicine and to trying to somehow link the two is insulting. Is Virginia Tech a crappy institution b/c the shooter came from there? - by the way they also had another mass killer and a grad student decapitate a girlfriend in the cafeteria - perhaps we should judge VT on that? Hopefully not. Nuts are nuts, often go into psych and are hard to predict.

Must we rehash this? -

The Dayton paper pointed out some legitimate issues with physician licensing - this was corrected.

Having been involved in the adverse credentialling/priviledging actions process in both the military and civilian setting I can report that the military has far more stringent standards (In anticipation of some pithy comments, no,, I wasn't the one getting depriviledged).

It is common practice for a backroom meeting to happen between a hospital leadership and a incompetent physician with the result being that the doc politely resigns and moves to malpractice elsewhere - this is common knowledge in the civilian world. The fear of litigation keeps many hospitals and medical boards from sanctioning physicians. You may not know that if a military provider has his/her privileges held, they cannot leave the military until the issue is cleared, either they are repriviledged after an investigation or not. This is Congressionally mandated to keep the military from dumping problem docs on the civilian sector. - I

With regards to "decrepit" conditions at WRAMC - let's remember the soldiers were offered alternate lodging before it ever became an issue and declined. The rooms involved were a few and not reflective of the entire building and WRAMC was barred from fixing them as Congress cut off funding for repairs since WRAMC was being closed. It made for a great story but the truth was far less exciting. Also there was no issue with the medical care the soldiers received - the story was more about the follow up process/case manager process failing - much money has been thrown at that issue and is largely resolved. If a soldier falls through the cracks with the current WTB system - they are actively trying to do so.

I looked into the claims by a disgruntled civilian "whistleblower" in the story that a hospital commander in MO pressured staff to pencil whip psych evals - this was to my knowledge investigated and found to be without merit - I have not first hand knowledge on this one.

Don't try to spin the events in Ft Hood to support your world view. It isn't fair, nor professional.

At least for once you left the insults out. Congrats, and thank you for being "professional".

I think it would be ironic not to point out that your whole "world view" of military medicine, and its non failings, are just why I have no hope that it will not change. The clip that someone placed from animal house is just perfectly dead on you. So the media has blown everything out of proportion, and everything is OK???

I think I'll let others jump in on this as its just too ovbious that your are way off, and totally biased in protecting an institution that is damaged beyond repair, but not to those who run it and defend it.

Just one point. I never said that the issue was with Ft. Hood, so your parallels to VT are pointless. This guy was a nut, and military medicine and its infrastructure failed to recognize it despite what many say now were obvious warning signs. I hardly think many of the problmes from the 98 articles have been "fixed". And anyone in the military knows how investigations of high ranking officers always seem to find no merit. Oh that was two points. Tired, bedtime.

 

[IgD]

The Ft Hood incident has zero to do with military medicine and to trying to somehow link the two is insulting.

I sincerely hope you are right but after reading up on the situation I've concluded otherwise.

Don't try to spin the events in Ft Hood to support your world view. It isn't fair, nor professional.

Once could argue that is what you are trying to do as well. I really want to see a thorough investigation is conducted. We will see what happens.

 

[a1qwerty55]

I sincerely hope you are right but after reading up on the situation I've concluded otherwise.



Once could argue that is what you are trying to do as well. I really want to see a thorough investigation is conducted. We will see what happens.

Do you honestly think a civilian residency would not have let the guy graduate?

As a psychiatrist you are probably the last person to push to have someone seperated - in other words never work as a physician again, because of personality quirks, or even alcoholism. I've never a met a psychiatrist who wasn't willing to give a patient 20 chances to prove them wrong.

Here's the investigation - he kinda sucked as a student but met the standards - therefore he was graduated.


Residency - missed call once maybe blew off some pages - he said she said (my pager battery was dead, I didn't get the pager etc. etc. No one is getting booted from a residency for that.

May have had a substance abuse problem (alcohol) - he and like 30% of physicians - probably enrolled in impaired provider program, did some rehab, was monitored for a period and didn't relapse, released off program appropriately.

Fellowship - an Islamophilic lecture - "I was just trying to present the perspective of those crazy islamists", case closed.

There isn't going to be some grassy knoll here - the guy is a nut, and as stated earlier, nutty guys do nutty things, especially angry, nutty, celibate, conflicted (maybe gay) muslim guys.

- The screw up was FBI not tipping off the military that the guy was a pen pal of an Al Qaeda mullah.

 

[BigNavyPedsGuy]

- The screw up was FBI not tipping off the military that the guy was a pen pal of an Al Qaeda mullah.

I heard an interesting observation on NPR. Likely the military was alerted by the FBI, but the only thing that was reviewed was his service record, which we all know tell very little about us. His training file at the GME office was probably never reviewed.

It's plausible that the FBI told the military, but the military didn't tell itself. But you're right, somewhere in that game of telephone, the ball was dropped.

 

[IgD]

Do you honestly think a civilian residency would not have let the guy graduate?

I think that's the big question. The program director's evaluation that was published on CNN was pretty concerning. I suspect he should have at least been put on probation. If that would have happened and he would have taken another unauthorized absence he probably would have been terminated. On top of all that though, what is the reasoning in letting this guy do a prestigious fellowship and putting him in an operational environment? There seems like a number of questionable leadership decisions made in this situation.

 

[orbitsurgMD]

I think that's the big question. The program director's evaluation that was published on CNN was pretty concerning. I suspect he should have at least been put on probation. If that would have happened and he would have taken another unauthorized absence he probably would have been terminated. On top of all that though, what is the reasoning in letting this guy do a prestigious fellowship and putting him in an operational environment? There seems like a number of questionable leadership decisions made in this situation.

From what I read, nothing he did would have got him much more than a warning from most PDs. Missing a page will not get you fired. If you are a strange, lazy bum, you will probably go to probation faster for missing call duties than you might if you were otherwise hardworking and responsible.

Given the quality of the paging apparatus I was forced to use when I worked at military facilities, I am surprised more pages aren't missed.

 

[IgD]

So we can all be on the same page, please see attached for the memo from Hasan's program director. What would have happened if a junior officer or NCO would have exhibited that kind of behavior?

 

[orbitsurgMD]

So we can all be on the same page, please see attached for the memo from Hasan's program director. What would have happened if a junior officer or NCO would have exhibited that kind of behavior?

Seems like someone who really didn't want to be a psychiatrist in the first place.

 

[a1qwerty55]

So we can all be on the same page, please see attached for the memo from Hasan's program director. What would have happened if a junior officer or NCO would have exhibited that kind of behavior?

Actually not a lot in today's military. I had a LT when I was deployed lose his firearm, later pull it on another soldier in jest, get essentially nothing more than a bad talking to. OER's in the Army for O-3 and below now are no longer are competitive, in other words, you aren't ranked against your peers. Promotions are purely time based not performance based. The standard is lower anywhere you look - be it Army, Navy, AF, WalMart etc.

The problem as Dr Moran alluded to is that these problem children usually don't screw up when they are under the microscope and under probation.
Since they "pass" their period of remediation or supervision, you can't boot them. He telegraphed pretty clearly this guy was a disaster.

I've always felt that when it comes to the profession of medicine, we (military and civilian) don't set the bar very high. Medical schools have excessively high graduation rates and board certification which in the past was a quality marker is now just a minimum standard. I mean what is the value of "board certification" if 80% of the first time takers pass and half of them don't even speak the language proficiently?

It's American culture in general - everyone has to succeed or the instructor is at fault, everyone is a "star". I mean, Airborne wings used to mean something, now you have 400 graduating out of a class of 500 and the "runs" are brisk walks as they position the bloated females in the class in front of the formation to be the pace setters.

 

[a1qwerty55]

duplicate post ugh!

 

[a1qwerty55]

triplicate post ugh!!

 

[BigNavyPedsGuy]

So we can all be on the same page, please see attached for the memo from Hasan's program director. What would have happened if a junior officer or NCO would have exhibited that kind of behavior?

And this jackass gets a fellowship??

We had a pretty terrible resident that lawyered up and ended up graduating with almost an entirely different set of standards than everyone else.

 

[ieatpizza]

And this jackass gets a fellowship??

We had a pretty terrible resident that lawyered up and ended up graduating with almost an entirely different set of standards than everyone else.

BTW, I don't think the Preventive Psychiatry program is a particularly "prestigious" fellowship as previously mentioned or particularly desirable/highly sought after.

 

[Ziehl-Neelsen]

BTW, I don't think the Preventive Psychiatry program is a particularly "prestigious" fellowship as previously mentioned or particularly desirable/highly sought after.

It is not a prestegoius fellowship. Everyone in the department knew he was a poor physician and had personality issues, but obviously nobody thought he had the capacity to do as he did.

There were multiple discussions within the Psych program as to whether or not to graduate him. He was given a fellowship where he could be observed in DC and would have as little individual contact with patients as possible. And to cap it all off, when the incident happened at Fort Hood, he was the
2nd ranking Psychiatrist on the base, but he was not the assistant chieh of psych. That position went to another graduate of Walter Reed who is a CPT.

Psych separates a lot of their physicians from the military due to a variety of psych issues (we all did psych rotations in med school and know what psych docs can be like). Plus, they have a deployment tempo comparable to surgeons. There is a severe shortage of psychiatrists in the Army, and the competent ones who are staring a 4th deployment in the face are getting out in droves. Leadership is doing all it can to keep these competent docs, and I'm sure that this played no small part in keeping Hasan around and allowing him to deploy.

Hindsight is 20/20. Hasan had multiple personality clashes with many individuals, but he was not like the guy in Pittsburgh posting his hatred of women on the internet and excoriatintg himself "for not having the courage to do it." In a world where there are no other considerations besides ensuring that soldiers are threated by good and competent docs Hasan would have been gone after his 2nd year at USUHS. But as y'all know, we don't live in that world.

 

[IgD]

Interesting...

http://www.usuhs.mil/psy/psyfellowship.html

Preventive/Disaster Psychiatry- MPH Fellowship (Brochure)

National Capital Consortium

Description

This two year program is designed to provide military psychiatrists with expertise on preparing for and responding to mass casualty events, designing population-oriented behavioral health prevention and intervention programs, and performing behavioral health epidemiology. Graduates will use their strong quantitative and analytical skills in biostatistics and epidemiology to identify and measure organizational health needs, population surveillance, and to investigate the impact of biological, environmental and behavioral factors on organizational health.

...

Eligibility

* Board certification in general psychiatry
* At least 1 utilization tour as a military psychiatrist

The bottom of the page says "Last update: 06/19/09".

My understanding was Hasan was neither board certified nor had a utilization tour...

 

[IgD]

I've read what you guys had to say but I still can't defend what is in that memo. My gut instinct based on what limited information is available is the guy should have been gone.

I think there is going to be a lot of senior military leaders involved in the investigation. They would have dealt with disciplinary issues throughout their career including Article 15/Captain's mast for numerous physicians and other enlisted personnel. It will be interesting to see how they respond.

My last tour was with the Marines and they had a low threshold for throwing the book at someone. A Marine Corps lawyer told me the Marines were the smallest branch of the military but had the highest number of court martials.

 

[IgD]

One other thing, this story makes me angry and want to put my uniform and pack back on. Maybe I need to see a psychiatrist🙂

 

[a1qwerty55]

It is not a prestegoius fellowship. Everyone in the department knew he was a poor physician and had personality issues, but obviously nobody thought he had the capacity to do as he did.

There were multiple discussions within the Psych program as to whether or not to graduate him. He was given a fellowship where he could be observed in DC and would have as little individual contact with patients as possible. And to cap it all off, when the incident happened at Fort Hood, he was the
2nd ranking Psychiatrist on the base, but he was not the assistant chieh of psych. That position went to another graduate of Walter Reed who is a CPT.

Psych separates a lot of their physicians from the military due to a variety of psych issues (we all did psych rotations in med school and know what psych docs can be like). Plus, they have a deployment tempo comparable to surgeons. There is a severe shortage of psychiatrists in the Army, and the competent ones who are staring a 4th deployment in the face are getting out in droves. Leadership is doing all it can to keep these competent docs, and I'm sure that this played no small part in keeping Hasan around and allowing him to deploy.

I couldn't agree more with this post. totally on target.

 

[IgD]

Looks like we got an update on this issue:

http://www.foxnews.com/story/0,2933,582732,00.html

WASHINGTON — A Defense Department review of the shooting rampage at Fort Hood, Texas, has found the doctors overseeing Maj. Nidal Hasan's medical training repeatedly voiced concerns over his strident views on Islam and his inappropriate behavior, yet continued to give him positive performance evaluations that kept him moving through the ranks.
into question long before he reported to Fort Hood."

 

[orbitsurgMD]

Looks like we got an update on this issue:

http://www.foxnews.com/story/0,2933,582732,00.html

WASHINGTON — A Defense Department review of the shooting rampage at Fort Hood, Texas, has found the doctors overseeing Maj. Nidal Hasan's medical training repeatedly voiced concerns over his strident views on Islam and his inappropriate behavior, yet continued to give him positive performance evaluations that kept him moving through the ranks.
into question long before he reported to Fort Hood."

I can't say these conclusions are surprising, as fallacious as they probably are. This is Monday-morning quarterbacking done by blue-ribbon committee. Essentially, what they are saying (cranking in that retrospectoscope) is if someone had just kicked him out earlier, none of this would have happened (who, exactly, I would like to know, since no one person who supervised Hasan had the authority to kick him out--he did have due process rights, after all, and saying he was weird or that he gave indications of being generally unhappy and disgruntled, or gave a crappy grand rounds presentation doesn't get you to that; he probably could have fought a discharge on those grounds and won). I doubt there was a conspiracy to push Captain Hasan along the great colon of medical training; there was probably not enough wrongful or inept activity at any given point to kick him out.

There is a huge difference between having a low opinion of a colleague and having enough to derail a career, which is what this report suggests someone should have done. I really doubt it would have been possible unless the Army were willing to pull Captain Hasan aside and say "here is an honorable discharge given to you at the convenience of the government and you don't owe us a dime." Exits like that aren't usually possible and really aren't possible when the reason is that the guy getting the early out is going because he sounds and increasingly acts like a jihadist and an enemy.

This is looking like a whitewash investigation, Togo West or not. Anytime you say that the investigation report has to be done by a set, and usually early deadline, you are stage-managing, and the investigation really becomes a political and public relations tool. This was no Warren Commission Report.

Still, they will try to hang someone below flag rank. It is the military way, stupid as it is.

 

[NavyFP]

Still, they will try to hang someone below flag rank. It is the military way, stupid as it is.

As wrong as it would be, I am going to guess Scott Moran will be pegged.

There was an AP article in Stars and Stripes today and Scott was the only person specifically named.

"Early in 2007, Maj Scott Moran became director of psychiatry residency and took a much firmer line with Hasan.............Despite his earlier reservations, Moran wrote a solid reference letter for Hasan that said he was a competent doctor."

I suspect the "reference letter" was the one posted earlier that was far from a recommendation. It is presented in the article as positive. This would seem to be part of the set up for a fall guy.

 

[AF M4]

As wrong as it would be, I am going to guess Scott Moran will be pegged.

There was an AP article in Stars and Stripes today and Scott was the only person specifically named.

"Early in 2007, Maj Scott Moran became director of psychiatry residency and took a much firmer line with Hasan.............Despite his earlier reservations, Moran wrote a solid reference letter for Hasan that said he was a competent doctor."

I suspect the "reference letter" was the one posted earlier that was far from a recommendation. It is presented in the article as positive. This would seem to be part of the set up for a fall guy.

Agreed, getting your name mentioned in this kind of toxic story is the kiss of death. Hope Dr. Moran doesn't let himself be destroyed by this kind of thing; much as the committee will try to blame this on him, he can always ask what specifically he should have done differently given the information he had at the time.

Yikes, be careful who you write reference letters for.

 

[The White Coat Investor]

I say they should start with the psych res PD at Walter Reed (what, an O-4, O-5?). How can you let someone get away with so many dings, never disciplining him, allowing him to graduate, then even placing him in a fellowship?! He should've been failed out of the program, given the boot, and force to payback both his USUHS and ROTC commitment. Yeah, I know the Army is in need of psychs, but I'd rather have the need and the shortfalls, than nutjobs like Hasan walking around.

You say that like there's only one person. There was probably 2 or 3, and they probably all did a deployment while he was a resident.

Besides, isn't that the norm in Psych? They all seem a bit odd to me.