Improving Life for Air Force Docs

[spiveydog]

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I have been a frequent visitor to this forum but this is my first post. I am an AD AF doc who shares many of the woes so well documented on this site. You guys help my sanity since I know that others share my pain...

As some of you in the AF may may know, there was a summit meeting of sorts in Virginia last month. Basically it was a bunch of Hospital Commanders and selected "providers of PCO". One of my colleagues (Family Physician) made the trip. The topic: "How can we get our doctors to stay?" Apparently, the "higher ups" are finally concerned about the quickening pace of physicians getting out. Concerned enough that they schduled a week in Virginia to apparently pick the brains of physicians and to discuss potential solutions to issues and problems. My colleague claims that my Hospital Commander was "very interested" in hearing how we can "fix things". Last week I rec'd an e-mail requesting my presence at a meeting with the other "PCO Providers" and the Hospital Commander. Apparently he wants to discuss possible "solutions to problems we are having/how can we help make this a place you'd want to stay and continue to work in".

I am happy since this is the FIRST time ANYONE in the Air Force has ever asked my opinion on how to manage any problem in my clinic. However, I am completely overwhelmed on how to approach this issue. On one hand, we all know the issues facing our profession in the military are MUCH bigger than what he can fix after an hour meeting. But, this is a real opportunity to actually be heard and (cross my fingers) get something constructive done. So my question to the group is this: How would (or have ) YOU handled this situation/opportunity? Do you concentrate on simple and seemingly fixable issues or do you try to convince him to fix bigger issues that might have more "ripple effect"? Either way, I am not optimistic that anything big will be done that will change my patients or my life very much. Unfortunately, my time in the Air Force Medical system has taught me to be pessimistic about changes for the good.

So, what would you recommend? I would be interested in hearing what issues people of this forum would bring to the table...part of me wants to list 30 big issues that piss me off/don't make sense/know won't get fixed vs. the other part of me who want to tackle smaller, more mundane (ie won't feel as good saying to my Commander), more fixable problems:

Big Problem (less likely to change)
1. Commanders are most interested in Money and Metrics and when they will be promoted and when they will next PCS rather than helping THEIR clinics run more efficiently, safely, and with high morale.

Smaller (maybe we can make some headway)
1. balancing out the provider patient mix--make sure providers have a similar empanelments as far as age, chronicity etc (some of our providers see all the sick people, others have none)

I am curious how the people of the forum would tackle this problem (? opportunity) if in the same sitiuation. I am honestly unsure how to approach the meeting (we were told to come with issues in hand) to get the most positive results. Opinions?

 

[The White Coat Investor]

I am honestly unsure how to approach the meeting (we were told to come with issues in hand) to get the most positive results. Opinions?

First off, welcome to the Forum. It is always nice to see someone new post. I would concentrate on the issues posted in the thread on the reasons why people aren't taking the scholarship. Although there are a few differences, for the most part, people don't take the scholarship for the same reasons they don't reenlist. The things that would have to change for me to be willing to stay after my commitment are (in no particular order):

1) Allow me to practice my specialty as it is practiced in the civilian world. For me, that means putting me in a higher acuity facility than the one I'm in (Emergency doc working in an urgent care.) For others, such as the surgeons, it means taking steps to ensure a higher case load. Our skills are languishing in the military medical system. I'm sure every specialty has a similar tale of woe. Some have noted that their equipment is ****ty. There is nothing more frustrating, I'm sure, than trying to do a delicate procedure with the wrong tool. I mean, come on, no one skimps on an F-22's weapon system. Why can't the ophthalmologist have the best operating microscope on the planet? You want those pilots to be able to see or not?

2) Get rid of the current "medical special pay system." Just pay us the standard officer pay/BAH/BAS and then incentivize the remainder of our pay. If I see more patients, get higher ratings from patients, have better outcomes etc I want to be paid more than a colleague who lets the waiting room fill and treats patients poorly. Since we're all on salary the incentive is to work as little as possible, and that doesn't help the struggling system.

3) Along the same lines, we've got to align our pay more with the civilian world. If the average FP makes $130K, he'll consider staying longer for $120K/year than an ophthalmologist who would make $300K on the outside. The difference between their pay in the military however is only $13K. I mean, come on, what kind of a message are we sending? "We don't want you to stay in." That's what I'm hearing.

4) Exempt the docs from some of the irritating things such as computer based training and replace them with real CME. I could have used a half day course on how to use CHCS (or at least a half hour), but instead I spent hours learning not to pick up prostitutes because it involves human trafficking. My CME this year is taking my board exams. Not exactly educational, if you get my drift. Likewise, if we're passing our PT tests, exempt us from PT. I mean, if you want a good medical care system perhaps you could open the clinics one more morning a week...such as when we're doing PT.

5) Make deployments short (3-4 months), predictable and fair. The Air Force has made great strides in this compared to the other services. Most of us are willing to go, but six months is a long time.

6) Get out of the residency training game. Most HPSP students would prefer to be able to defer and do a civilian residency. Almost all of them can match in their chosen specialty. The military doesn't seem to be very good at forecasting their future specialty needs anyway. Why not let the med students pick what they want to do? What a novel concept. So what if we don't get enough generalists. I think we would be better off giving people training in their specialty and if we get too many of something, force them to have a 1 afternoon a week primary care clinic. I suspect an anesthesiologist or an opthalmologist is probably about as well equipped to run a primary care clinic as a GMO. They have both had the same 1 year internship.

The military residencies suck as a general rule because they are seeing low acuity patients, not getting enough cases, and do not have stable faculty. They brag about their inservice exam scores because that is the only thing they do well. Residency isn't about studying for a test, it is about seeing patients and making hard decisions.

7) Make sure hospital commanders and medical group commanders are physicians. Enough said. Don't have non-physicians supervising physicians.

8) Base retirement on our full pay, not just on our base pay. 50% of the average of their pay for the last 3 years of their career is what the other members of the military get. The docs, nope, they get about 25% (because the medical special pays don't count.) Along those same lines, when is the TSP going to match military members contributions like it does for federal employees? Another beef, give everyone credit toward retirement for residency. Why does someone who chooses an inferior military residency get to count his training years toward retirement whereas one who was deferred does not?

9) The nursing staff has similar recruiting problems. My job is 3 times harder with inexperienced nursing staff and I'm sure that applies to most other specialties. Surround me with good staff and you'll be surprised what I can do.

10) Match up medical students with practicing active duty docs early in their HPSP career so they can get some guidance. I never felt more alone than as an HPSP student. I didn't know what unit I belonged to, who to call with questions, what to expect, how to get my money, how the match worked etc.

11) Honesty in recruiting. Nearly everyone on this site has noted that he was lied to by his recruiter. If the system were better, the recruiters wouldn't have to lie. If the system were better, you could send docs out to talk to pre-med groups at colleges across the country. But they don't dare do that, because they know what the docs would tell the students.

The military provides some unique opportunities. The opportunity to serve our country is wonderful. The opportunity to be deployed and see unique pathology cannot be found elsewhere. I suspect many trauma surgeons in this country would go to Iraq as contractors for a 3 month stint if they didn't have to put up with the rest of the BS joining the military requires. The military has the potential to be a wonderful way for a debt-averse, patriotic person to go to medical school. But we have to ensure that it doesn't hurt that person's professional career and that it is a good deal financially to even think about recruiting more docs and getting more to stay. Treat em right from the beginning and you'll have a better chance. I knew I wouldn't stay in the military after my commitment before I ever applied for the military match.

Many on this forum won't agree with some of this, and who knows, in a few years maybe I won't either.

 

[MedicalCorpse]

So my question to the group is this: How would (or have ) YOU handled this situation/opportunity? Do you concentrate on simple and seemingly fixable issues or do you try to convince him to fix bigger issues that might have more "ripple effect"?

In my opinion, aim for the bleachers. I would bring both hard copies and PowerPoint slides on disk for presentation to the muckety mucks with detailed issues/grievances from your flight level all the way past MAJCOM to Air Force level. The worst they can say is "No". You have already demonstrated that you are too intelligent to consider making the USAF your career. Thus, try to help those who will follow after you.

Here are some thoughts, in case you haven't read these already; not all of these will apply to a primary care specialty (I was an Air Force anesthesiologist, obviously). These should get you started, however:

http://www.medicalcorpse.com/Grievances-redacted.doc
http://www.medicalcorpse.com/OPDformRCJ-redacted.doc
http://www.medicalcorpse.com/editorials.html (See "16 Steps")
http://forums.studentdoctor.net/showpost.php?p=4053647&postcount=1
http://forums.studentdoctor.net/showpost.php?p=4053683&postcount=2

I also heartily recommend:
http://forums.studentdoctor.net/showthread.php?t=324400
and
http://forums.studentdoctor.net/showthread.php?t=325041
and, of course, the canonically correct:
http://forums.studentdoctor.net/showthread.php?t=203316

Slice, dice, and julienne fry these bullet points and decoct them with your own ideas, then serve on a bed of "Wake Up, You Ignorant Losers!", with a side of "Or everyone else will jump ship, leaving you with a sum total of zero peons to boss around."

Hope this helps,

--
R

 

[MedicalCorpse]

The things that would have to change for me to be willing to stay after my commitment are (in no particular order):

(snip: eloquent truths)

Many on this forum won't agree with some of this, and who knows, in a few years maybe I won't either.

Sniff. That was beautiful, man.

Oh, and add: Make sure that those who have served their country for 20 years on active duty, often in war zones, are not subject to involuntary recall to active duty for the rest of their natural lives.

Remember this data point from Major General Scotti:
from: http://www.medicalcorpse.com/MG_Scotti_responds.html

"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."

Also remember the 86 year old psychologist who was recalled to active duty more than a decade after he gave up practicing in the civilian world, only to require air evac back to the states from downrange. Beyond sad...pathetic.

Why would anyone in his/her right mind retire if this meant the potential for involuntary servitude forever? See:
http://ecfr.gpoaccess.gov/cgi/t/tex...;view=text;node=32:1.1.1.4.34;idno=32;cc=ecfr

I did not know this during ROTC. I did not know this during my time at USUHS. I did not know this until doing research for my book AFTER I had resigned my Regular Commission as a LtCol.

I feel as though I ducked a bullet. Many other retirees, including the husband of the lady who cut my hair the other day, have been recalled to active duty involuntarily up to THREE TIMES since 9/11.

Verbum sat, man, verbum sat.

--
R

 

[militarymd]

ONE hour meeting????!!?@$#@%#

Why don't you try something simple AND VERY easy to fix at your level.....and see if it is fixed.....

and also ask, in the meeting, to meet again in 4 months....for follow up on the easy to fix problem.

I will bet one months salary that...the easy to fix problem won't be fixed....and there will be no 4 month follow up.

 

[Croooz]

Desperado,
Points 2 & 8 don't match up. If the pay is changed to incentive then why would it then be included in the calculation of your retirement pay? The way it is now, it would be easier for the military to calculate 50% of your overall pay. There wouldn't be a need for individual retirement pay calculations due to productivity during service. I like the incentive pay suggestion but not sure how that would work when calculating retirement. Not sure if anyone remembers how screwed up the services were before direct deposit but all docs receiving retirement pay based on their work would probably take us back to those times of printed checks, long PSD lines, and hours with DFAS on the phone. 😡

 

[DogFaceMedic]

Good Luck in presenting some ideas that stick. But, let me offer some advice from experience presenting to senior execs: Make it short, avoid the long essays, and unrealistic ideas blow the credibility of the rest of the proposals.

So, my two bits:
1. Physicians run it: those with the medical responsibility, need the authority.
2. In order to placate the support staff that want command opportunities, find them command-type equivelancy. Yes, private hospitals are run by non-physicians, but the medical staff does not work for the hospital and can leave.
3. A long shot but still a good idea is to allow junior ranking physicians to rate and command senior ranking RN's and support staff (ie, the MBAs and MPHs.)
4. This is a biggy but boring: enforce accountability of civilian staff. They have a rating system but it is not used or done improperly. If supervisors were forced to do accurate rating or they would be fired, then they would no longer, play "get along by going along."
5. And, absolutely change the "metrics" by how CDRs are measured.

I have more, but that is a start.

 

[The White Coat Investor]

Desperado,
Points 2 & 8 don't match up. If the pay is changed to incentive then why would it then be included in the calculation of your retirement pay? The way it is now, it would be easier for the military to calculate 50% of your overall pay. There wouldn't be a need for individual retirement pay calculations due to productivity during service. I like the incentive pay suggestion but not sure how that would work when calculating retirement. Not sure if anyone remembers how screwed up the services were before direct deposit but all docs receiving retirement pay based on their work would probably take us back to those times of printed checks, long PSD lines, and hours with DFAS on the phone. 😡

Yea well, I suppose we'd have to sit down and hammer out the exact details. How about just fixing one or the other of the two problems?🙂

 

[resxn]

For Me:

1 - Give me staff. I can't run a clinic with one staff when the average FTE for a civilian MD in my specialty is 3.6.

2 - show me the money. At least make it reasonably competitive. When I would need over 18.5 years of commitment to make it worth staying to provide for my family because getting out with 19 months left is a better financial decision, the choice is clear when I only owe 3 years. Man that was poor English, but you know what I mean.

3 - And this can't or won't be fixed. I agree with Desperado here. Make it run like the civilian business model. Give me a budget and then let it be incentivized. Don't allow me to buy a new microscope but not deliver it. Don't tell me we can't afford a strobe when I've referred more money (than the cost of the equipment) to civilian physicians to use a strobe to evaluate a patient. Don't buy me a new camera that doesn't hook into an old tower. Get a new tower too or don't buy the stuff in the first place. Let me operate where it's best for the patient, whether on base or off.

4 - Let me practice medicine, not how to jerry-rig [sic] the system so I can bide my time until I get out.

5 - Do not make me do meaningless paperwork (don't make me write the diagnosis 6 times on 4 sheets of paper to do pre-op stuff).

6- Don't make me spray a fire extinguisher just to show the safety lady I know how to do it.

7 - Don't send fake patients to me during a MARE so I can make sure I know how to triage and take care of people--we are a freaking outpatient clinic for the love of all that is holy AND I'm a board certified physician (a patient with nice latex make-up in no way compares to being on-call for a trauma hospital for 5 years of residency).

8 - Stop paying me 4 months later than promised

9 - Don't break 30% of my household goods every time you move me

10 - Don't move me if I don't want to move. If I'm happy and there is no purpose in moving me other than I've been here for 3 years, don't do it.

11 - Don't treat me like a 19yo who wants to drink every night.

12 - Don't make me randomly pee in a cup at 5 AM just because some 19yo in the same med group got caught with meth out on the town the week before.

13 - Don't give me crap for low RVU's when you don't even count the RVU's I generate taking patients to the University Med Center to operate on them (on my biggest cases where my biggest RVU's are generated) when you can't support 40% of the surgeries I do as a specialist in the ASC of our MTF.

14 - Don't keep harping on me to check my clinic's web page for correct information. I've checked it. And those little games you play where you go in and change the information just to see if I'll notice is juvenile. I'm not going to play that game.

15 - Quit telling me how to drive and how to correctly shovel snow in the winter during commander's call. Tell me how to code better, tell me how to get a civilian contractor, tell me how to increase HCPC's documentation, tell me where I can find the most cost-effective supplies.

16 - Stop telling me that I have to take leave to go on vacation on a 3-day weekend when I wouldn't be working anyway

17 - stop taking money out of my budget if I don't spend it that quarter--I actually might like to save it to buy something useful more than Kleenex

18 - back me up when I make a decision in the patient's best interest. Don't side with someone because of their rank.

19 - Don't tell me to do something regarding medical decision making because you have higher rank. I don't honestly care if you're a general. I'm going to do what is right in my best estimation for the patient.

20 - just because you get a medication from a lower bidder, it doesn't make the medication a better option

21 - I'm an adult, let me cross the street where I want (for Galo)

22 - Don't make me wear BDU's when I round at a civilian institution. It is really unprofessional. For that matter, let me wear blues in clinic, it is more professional.

23 - give me an anesthesiologist so I can operate at the MTF on someone other than an ASA I

24 - join the 1990's, get a PACs system

25 - if an enlisted isn't perfect, let me give them a 4 without having to write up a dissertation on it

26 - respect the fact that I work harder for you for less pay than anyone else who is my civilian counterpart. At least just respect it.

Now I'm going into stuff that is probably beyond the scope of this future meeting. But please, stop thinking that you need to protect your pot of money and think how you can serve your country.

that is all.

 

[Pemberley]

2) Get rid of the current "medical special pay system." Just pay us the standard officer pay/BAH/BAS and then incentivize the remainder of our pay. If I see more patients, get higher ratings from patients, have better outcomes etc I want to be paid more than a colleague who lets the waiting room fill and treats patients poorly. Since we're all on salary the incentive is to work as little as possible, and that doesn't help the struggling system.

13 - Don't give me crap for low RVU's when you don't even count the RVU's I generate taking patients to the University Med Center to operate on them (on my biggest cases where my biggest RVU's are generated) when you can't support 40% of the surgeries I do as a specialist in the ASC of our MTF.

Point of curiosity here -- and it really is just that, not trying to assert an opinion -- I hear you guys complain about RVUs all the time... if you gave the bureaucrats the opportunity to incentivize your pay based on metrics, wouldn't they just continue to choose senseless metrics?

6- Don't make me spray a fire extinguisher just to show the safety lady I know how to do it.

11 - Don't treat me like a 19yo who wants to drink every night.

12 - Don't make me randomly pee in a cup at 5 AM just because some 19yo in the same med group got caught with meth out on the town the week before.

15 - Quit telling me how to drive and how to correctly shovel snow in the winter during commander's call.

(For the OP's sake as he's new around here): I'm not claiming a medical background, just an Air Force one.

A point from the reasonably-intelligent-former-officer peanut gallery: like rexsn indicated above, commanders calls and ancillary training have gotten seriously out of hand. Appropriate for the junior enlisted? not my call. Appropriate for doctors? If so, you've hired the wrong doctors.

A point from the officer-who-wanted-to-work-hard-not-uselessly-brown-nose-for-promotion peanut gallery: make it possible for competent doctors to gain rank and pay increases at the appropriate pace while playing as few OPR-bullet-grubbing games as possible. The current promotion system is designed to disgust non-self-promoting officers into quitting.

A point from the just-now-applying-to-med-school peanut gallery: acquire fewer people through HPSP followed by jobs they don't want, and more through FAP followed by jobs they do want. The GMO tour, which is a turn-off to so many, would be attractive to indebted FP residency graduates.

 

[resxn]

Point of curiosity here -- and it really is just that, not trying to assert an opinion -- I hear you guys complain about RVUs all the time... if you gave the bureaucrats the opportunity to incentivize your pay based on metrics, wouldn't they just continue to choose senseless metrics?

I don't mind metrics when they mean something. The metrics at my institution exist solely for the purpose of telling me whether I'm meeting an esoteric goal that was created by someone who did not account for the ability of my clinic to meet it. In the real world, as a physician you are paid for what you do, not for how long you sit in a building. The same could exist at least in part in the military. Even Kaiser offers incentives for those MD's who do more than their fare share.

 

[dpill]

So, what would you recommend? I would be interested in hearing what issues people of this forum would bring to the table...part of me wants to list 30 big issues that piss me off/don't make sense/know won't get fixed vs. the other part of me who want to tackle smaller, more mundane (ie won't feel as good saying to my Commander), more fixable problems:

Big Problem (less likely to change)
1. Commanders are most interested in Money and Metrics and when they will be promoted and when they will next PCS rather than helping THEIR clinics run more efficiently, safely, and with high morale.

Smaller (maybe we can make some headway)
1. balancing out the provider patient mix--make sure providers have a similar empanelments as far as age, chronicity etc (some of our providers see all the sick people, others have none)

I am curious how the people of the forum would tackle this problem (? opportunity) if in the same sitiuation. I am honestly unsure how to approach the meeting (we were told to come with issues in hand) to get the most positive results. Opinions?

It is fine to bring up some of the smaller issues, but don't leave them with the impression that fixing the smaller stuff will be enough to keep people in. In my opinion, you definitely shouldn't pass up the opportunity to bring up the big topics- especially poor management by career seeking individuals, tricare bureaucracy, etc. The Air Force can make minor adjustments, but the bottom line is until they overhaul the way they are doing business and improve quality of life (physician and patient), people aren’t going to stay in. Your point above about money and metrics is great.

I am appalled by stories of higher ranking nurses and administrators overriding doctors orders for whatever reason (they personally don’t think they are necessary, they don’t want to do something because it will make the metrics look bad, etc), especially in situations where patient safety is being compromised. For whatever reason, thriving on “rank and power” seems to be much more pervasive in the medical community than on the line. On the line, the aircraft/ mission commander is responsible for making decisions about a particular mission. I never saw a squadron commander try to intervene when they shouldn't (especially one that wasn't a pilot). I am not sure why the same doesn’t apply in the medical world- shouldn’t physicians have ultimate responsibility and authority to make decisions about patient care? If you want to bring up something like mandatory PT, put it in the context that the Air Force can’t expect doctors to be happy about participating in mandatory PT just to keep the base “combat fitness” metrics up when physicians are also responsible for ever-increasing patient panels and more and more admin duties since all the admin support has been slashed (and again, patient care is suffering).

While pay incentives and small improvements are nice, they will never overcome the shortfalls of a bad system and poor quality of life. I would go to the meeting armed with a list of easier things they can fix (who knows they might try to fix some of them), but I wouldn’t pass up the chance to convey the system needs some serious work if they really hope to improve retention.

 

[g293]

While pay incentives and small improvements are nice, they will never overcome the shortfalls of a bad system and poor quality of life. I would go to the meeting armed with a list of easier things they can fix (who knows they might try to fix some of them), but I wouldn’t pass up the chance to convey the system needs some serious work if they really hope to improve retention.

Yeah, but if I was making another 150K a year, I would whistle a happier tune to all the stupid stuff. You want to pay me civilian equiv pay to do computer based training all day, fine by me. What, commanders call, fine by me. All that stuff is incredibly painful, but it's even more painful when you're making 50% of what your friends make.

I know it's small stuff, but how about some doctor's parking and a doctor's lounge with some coffee and food like a real hospital?

Also, my pet peeve is the "provider" label. I'm a physician, and no, that doesn't make me a better person than the other "providers", we still aren't all the same.

 

[The White Coat Investor]

Yeah, but if I was making another 150K a year, I would whistle a happier tune to all the stupid stuff. .

I'm glad to hear someone else mention the money as a big negative. I was starting to think I was the only one, and that everyone else was pure and noble.

 

[BomberDoc]

The highest levels of government don't want to make positive changes. They want military medicine to fail. This is how they can justify outsourcing it to the civilian economy. Somebody thinks this is going to save money. We're going to a tri-service medical corps(e) so they can get more work from fewer people. This is a downsizing in order to squeeze more people out. They don't have to fire us, the work environment is so sh*##y that most of us walk out at the earliest opportunity.

When it comes to management (there is no leadership in milmed), I don't believe any promises or hope of improvement until I see it.

 

[dpill]

.

 

[dpill]

Yeah, but if I was making another 150K a year, I would whistle a happier tune to all the stupid stuff. You want to pay me civilian equiv pay to do computer based training all day, fine by me. What, commanders call, fine by me. All that stuff is incredibly painful, but it's even more painful when you're making 50% of what your friends make.

I know it's small stuff, but how about some doctor's parking and a doctor's lounge with some coffee and food like a real hospital?

Also, my pet peeve is the "provider" label. I'm a physician, and no, that doesn't make me a better person than the other "providers", we still aren't all the same.

Agreed, the pay is a big negative when you compare military to civilian- I am just trying to emphasize the point they won't retain people without addressing the fact the entire system is broken.

 

[Ex-44E3A]

The money might take some of the sting out of the inane bullsh*t, but that's only a bandaid. It's not addressing the problem, it's just paying people to shut up.

But what the heck? The govt certainly has a long and distinguished history of throwing money at problems in an effort to make them go away. The worst they can say is "no," so go for it.

It wouldn't have been enough for me to stay, but it might be for some.

 

[former military]

Yeah, but if I was making another 150K a year, I would whistle a happier tune to all the stupid stuff. You want to pay me civilian equiv pay to do computer based training all day, fine by me. What, commanders call, fine by me. All that stuff is incredibly painful, but it's even more painful when you're making 50% of what your friends make.

I know it's small stuff, but how about some doctor's parking and a doctor's lounge with some coffee and food like a real hospital?

Also, my pet peeve is the "provider" label. I'm a physician, and no, that doesn't make me a better person than the other "providers", we still aren't all the same.

Really? You mean you didn't go to University of Evil Provider School?