Improving Military Medicine

[jhrugger]

There are clearly some aspects of military medicine that need improvement. My intent in starting this thread is to consolidate people's views regarding specific problems and specific (at least in theory) solutions. I have not been in military medicine (I am actually just going to be beginning medical school next fall), but I am considering a career, at least for a short time, in the Army Medical Corps. I talked with a health care recruiter and obtained HPSP documentation, but I did not submit the HPSP primarily due to what I learned from this forum... so first off, thank you! I realize signing an HPSP contract would have been a mistake for me.

Problem: understaffing
Solution: more incentives for prospective corps members. maybe a higher salary? maybe improving the work experience for physicians by delegating a significant amount of paperwork to others so physicians can concern themselves primarily with caregiving?

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[Mirror Form]

Here's an idea, the Army Medical Center that I work at would be a great place to build a hospital.

 

[USAFdoc]

There are clearly some aspects of military medicine that need improvement. My intent in starting this thread is to consolidate people's views regarding specific problems and specific (at least in theory) solutions. I have not been in military medicine (I am actually just going to be beginning medical school next fall), but I am considering a career, at least for a short time, in the Army Medical Corps. I talked with a health care recruiter and obtained HPSP documentation, but I did not submit the HPSP primarily due to what I learned from this forum... so first off, thank you! I realize signing an HPSP contract would have been a mistake for me.

Problem: understaffing
Solution: more incentives for prospective corps members. maybe a higher salary? maybe improving the work experience for physicians by delegating a significant amount of paperwork to others so physicians can concern themselves primarily with caregiving?

the problem/cause of understaffing is not because there are not enough docs that could fill the billet; it is because the SG PURPOSELY has determined that he will underman the clinics; whether this is because it saves money, or makes it look as if the USAF can do more with less that the other services, that I do not know. For example, at one time we were short several docs due to deployment and separation...we arranged for civilian hires to fill those slots, the SG said we either had to enroll another 3000 patients if we kept those civ docs, or we had to let them go. Our commander made what turned out to be the worst choice...he kept the civ docs, enrolled another 3000 patients,then because the clinic was so bad, the civ docs quit, leaving the mil docs holding onto another 3000 pts in an already overloaded clinic.

some solutions: the physicians must be given some amount of authority within the clinic. Also,a reasonable plan for ensuring minimum staffing and retention must be in place. As it is, the business side of the clinic completely dominates the picture.

 

[militarymd]

Get rid of military medicine.

The military needs to contract for its care. State what the mission goals are, and let people bid to fulfill the contract.

This gets rid of all the losers who are looking for rank by leaving clinical medicine.

 

[deegs]

Get rid of military medicine.

The military needs to contract for its care. State what the mission goals are, and let people bid to fulfill the contract.

This gets rid of all the losers who are looking for rank by leaving clinical medicine.

I wouldn't say this is the absolute answer, although it is a step in the right direction. I used to work in government contracting , and the contractor that wins the low bid can be something that crawled out from under a log. before the government turns over medical care to these potential weasels, it needs to overhaul the way it does contracting........

 

[R-Me-Doc]

Get rid of military medicine.

The military needs to contract for its care. State what the mission goals are, and let people bid to fulfill the contract.

This gets rid of all the losers who are looking for rank by leaving clinical medicine.

The military needs to get out of the business of caring for dependents and retirees. Military medicine should focus on care for soldiers, developing a relatively small, rapidly deployable force to do "battlefield care" and just few stateside "centers of excellence" for caring for evac patients. Specialty focus needs to be on surgeons, internal med and psych, i.e, specialties needed in combat environments, not arcane stuff like radiation oncology and pediatric cardiology . . . that stuff can be farmed out to the civilian sector on contract.

Dependents and retirees can be put into a CHAMPUS-like system that allows them to get care from civilian docs on the economy (and, yes, TRICARE needs to start paying it's network docs a) sufficiently and b) on time, then maybe they would actually have a reasonable civilian network.

The operational needs of a military-focused medical corps (trauma/acute care-focused, deployable) are completely at odds with the needs of a dependent-retiree focused system (stable, primary and specialty care based). As recent events have demonstrated, YOU CAN'T HAVE IT BOTH WAYS, unless you can throw enormous amounts of money and manpower into the system (which clearly is not going to happen).

RMD 0-7-26

 

[island doc]

The military needs to get out of the business of caring for dependents and retirees. Military medicine should focus on care for soldiers, developing a relatively small, rapidly deployable force to do "battlefield care" and just few stateside "centers of excellence" for caring for evac patients. Specialty focus needs to be on surgeons, internal med and psych, i.e, specialties needed in combat environments, not arcane stuff like radiation oncology and pediatric cardiology . . . that stuff can be farmed out to the civilian sector on contract.

Dependents and retirees can be put into a CHAMPUS-like system that allows them to get care from civilian docs on the economy (and, yes, TRICARE needs to start paying it's network docs a) sufficiently and b) on time, then maybe they would actually have a reasonable civilian network.

The operational needs of a military-focused medical corps (trauma/acute care-focused, deployable) are completely at odds with the needs of a dependent-retiree focused system (stable, primary and specialty care based). As recent events have demonstrated, YOU CAN'T HAVE IT BOTH WAYS, unless you can throw enormous amounts of money and manpower into the system (which clearly is not going to happen).

RMD 0-7-26

Your ideas are brilliant and make perfect sense, unfortunately because they make so much sense, they probably will not be implemented. No seriously, they probably will not be implemented because of politics. MTF delivered healthcare to dependents and retirees is a political "third rail" for the Washington politicians who cater to special interest groups, such as military families and retirees.

 

[r90t]

Who fights to prevent a military base from closing? #1 local economics, #2 retirees that have settled near a base for continued care and use of the base's financial incentives.

BTW, be nice to the rad oncs, we're the one's that get out ASAP! In reality, the military doesn't need us for operational matters. We are familiar with radiation/tissue effects for CBR purposes, but a HP or MP can fill in this slot as well.
The financial costs are much less to keep us on staff if we are going to continue to treat retirees, than to outsource (150K vs 400+K/year). Benefits, pension, etc...does not eat up 250K to make it affordable to replace us(same with radiology). We can also bill for a variety of professional and treatment fees, making us a profit generator. One Navy MTF had a prostate ca contract with the local VA and was reimbursed accordingly.

 

[USAFdoc]

Who fights to prevent a military base from closing? #1 local economics, #2 retirees that have settled near a base for continued care and use of the base's financial incentives.

BTW, be nice to the rad oncs, we're the one's that get out ASAP! In reality, the military doesn't need us for operational matters. We are familiar with radiation/tissue effects for CBR purposes, but a HP or MP can fill in this slot as well.
The financial costs are much less to keep us on staff if we are going to continue to treat retirees, than to outsource (150K vs 400+K/year). Benefits, pension, etc...does not eat up 250K to make it affordable to replace us(same with radiology). We can also bill for a variety of professional and treatment fees, making us a profit generator. One Navy MTF had a prostate ca contract with the local VA and was reimbursed accordingly.

Military medicine has always had it's "limitations"; lack of continuity, relatively inexperienced docs, and the combo of military and "civilian-type" duties.
One of the biggest reasons for the current downslide in military medicine is the combination of making military medicine more complex, more duties, less people, and perhaps most importantly, micromanaging.

Military medicine is like this: you the doc are in this car, only you are not the one driving, in fact, the car is being remote control driven from Wash DC.
Now at first, things are ok, in fact, you may like the fact that you are not driving because you can concentate on the scenery (patient care). Also, the road you are driving on is the Great Salt Flats in Nevada; no traffic, plenty of room in case Wash DC steers you off course a bit, no worry about crashing or hitting somebody.

Now imagine you are in the same car, still remote controlled from Wash DC. Only now you are in downtown NYC!!! There are people everywhere, traffic sucks, and that occassional off course steering is now causing near misses, some not so near misses, fender benders etc.

As the doc in this car, either give me the wheel, or it's time for me to get out of the car.

Military Primary care patient effective panel sizes have gone up 200-400% since 2000, there are more collateral duties, and the docs have absolutely no say on "how the car is being driven." We have full responsibility, and zero authority, and it is no wonder that docs are trading in their military "car lease" for a new civilian "ride" as soon as the lease (DOS) is up.

 

[jhrugger]

Military medicine has always had it's "limitations"; lack of continuity, relatively inexperienced docs, and the combo of military and "civilian-type" duties.
One of the biggest reasons for the current downslide in military medicine is the combination of making military medicine more complex, more duties, less people, and perhaps most importantly, micromanaging.

Military medicine is like this: you the doc are in this car, only you are not the one driving, in fact, the car is being remote control driven from Wash DC.
Now at first, things are ok, in fact, you may like the fact that you are not driving because you can concentate on the scenery (patient care). Also, the road you are driving on is the Great Salt Flats in Nevada; no traffic, plenty of room in case Wash DC steers you off course a bit, no worry about crashing or hitting somebody.

Now imagine you are in the same car, still remote controlled from Wash DC. Only now you are in downtown NYC!!! There are people everywhere, traffic sucks, and that occassional off course steering is now causing near misses, some not so near misses, fender benders etc.

As the doc in this car, either give me the wheel, or it's time for me to get out of the car.

Military Primary care patient effective panel sizes have gone up 200-400% since 2000, there are more collateral duties, and the docs have absolutely no say on "how the car is being driven." We have full responsibility, and zero authority, and it is no wonder that docs are trading in their military "car lease" for a new civilian "ride" as soon as the lease (DOS) is up.

Are there ways that the doc can begin to assume control of the wheel? I am interested in finding out what types of measures are available for the physician with regard to fixing/streamlining/restructuring of the "system". Are there groups ("unions") of docs at military hospitals that lobby for change? If not, is it possible to form one? Perhaps my question is naive, but I am only 22 and would like to see some positive changes take place and am looking for the tools that may be available to make those changes (or at least make a start).

Any info you have about ways of enacting reform would be great to hear, because my interest in military medicine is still strong, yet waning because I am not aware of any ways that the physician can assume authority in changing things that warrant change.

Thanks for your candid replies,

jhrugger

 

[USAFGMODOC]

I am a GMO FS, but when I see something "broken" or not right, I speak up and explain why this affects patient care and/or is a bad deal for the other docs who work with me. The "man" does not like it when I buck the system, but I just make it a point to present both the problem and the solution===and not just to complain.... So far, some things have improved, but in no way is it perfect... Other docs are "afraid" of speaking out for fear of reprisal, but I am just professional about it and thus far I haven't been torched for it. Point is, if it benefits patient care/safety and improves morale, I bring it up because I want it to be better... most others don't because they are already burned out or don't care or are separating. In my 15 years in the AF, I have always done this and it has served me well, hopefully this helps you too!

 

[dpill]

So far, some things have improved, but in no way is it perfect... QUOTE]

Glad to hear someone in the med world has been able to make a some postive changes- however small. Sounds similar to my experiences in the AF (so far). Overall I think the military is a difficult place to work because it is hard to change things that are broken. My impression so far is that the med side may be even more difficult than ops, but in reality- it is probably a challenge no matter where you work in the military. You will see LOTS of things that are broken and it will seem absolutely futile if you decide to tackle every issue. I have had to learn to pick and choose my battles, but when I think it really matters- I speak up. And *sometimes* things change. Finding the right person and determining the right way is the biggest challenge. I have hit a few bumps along the way (to put it politely), but to me the effort has been worth it.

 

[jhrugger]

It sounds encouraging that individuals can effect some change. But is there actually any institutional framework or infrastructure that allows the physicians to "lobby" for change. Like committees or groups that get together to petition/recommend changes?

 

[R-Me-Doc]

Are there ways that the doc can begin to assume control of the wheel?

No. You are far, far, far in the back seat of the bus. Quite frankly, even your hospital commander's hands are largely tied by the dictates of San Antonio and DC.

Are there groups ("unions") of docs at military hospitals that lobby for change? If not, is it possible to form one? Perhaps my question is naive . . .

"Naive" doesn't even begin to describe it.

. . . my interest in military medicine is still strong, yet waning . . . .

With a little luck it'll wane to the point of nonexistence before it's too late.

That's my candid reply.

RMD 0-7-25

 

[r90t]

I've mentioned this before, but my last CO was the inverse of what you guys had to deal with.

He set a cap on the # of AD/dependents that we could handle.

When we were near the enrollment limit, he limited enrollment to E-4 and below family members. They are the one's that could least afford the copay. Everyout else was outsourced to pcm's out in town.

He did not expand patient panels when we lost a physician, but instead would continue to use civilian providers, even if only temorary.

He would listen to input and was very visible talking to the E-1 to the O-6, and every Friday he would recognize our returning OIF corpsmen has "heroes" of the command.

He took pride in our command and could be seen picking up small pieces of litter where ever he saw them.

I don't have one bad thing to say about this MC officer (my old CO) and he was a career oriented oriented officer. He is the type that I want to stay in and put a star on. With that said, for every CO like this guy, there are probably 4-5 like the one's that you have experienced with poor leadership and judgement.