Is anyone else like me???

[Informer]

After reading some recent posts, I have to say something

I joined HPSP not for the money, I joined because it's something I've always wanted to do, it's been my calling for many years. It was natural for me to accept the scholarship because I was going to join the military after medical school anyways! After going to OTS and doing a few rotations, I LOVE this stuff. I love the saluting, organization, chain of command lifestyle the military has.

I WANT to become a flight surgeon, I WANT to be deployed with our troops, I WANT to travel every 3 years, I WANT to help our troops defend this nation, I WANT to spend 20+ years and I couldn't care less that I'd make 20K less than an FP nor would I care if a nurse that outranks me has a BIGGER office nor would I care if my life weren't as comfortable as my civilian counterparts.

But everytime I read these forums, i feel like 90% of posters absolutely hate military medicine and joined for the wrong reasons. It makes me worried that 90% of my future colleagues seemed to join the military only to help pay for med school. I've been seeing a lot of "I wanna do my time and get out," "is there anyways to leave early?" "Having less docs in the military would be great! can I get out of my contract?" "How can nurses have better quarters than doctors?!" All i've been hearing are from people who can't wait to get out or from those who want to defer their active duty time as long as possible.

So what you scored in the 99th percentile on your boards, so what if you can get into a Harvard residency with ease, I couldn't care less, and to be honest, most troops wouldn't care either. They don't care how much you know UNTIL THEY KNOW HOW MUCH YOU CARE!!!

I just want to hear from the other 10%. I know you exist. Please let me know that there is SOMEBODY else out there who is as gung-ho and semper fidelis as me, who joined not because of money issues, but because they're just so damn patriotic as I am

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[Homunculus]

you aren't alone. two of my good friends from medical school are doing FP at Bragg-- both of them are so f*cking into operational medicine they're borderline crazy seriously though, they went to the flight surgeon's course for an elective, and want to be "at the tip of the spear" with the infantry.

after being at walter reed for a couple of months now, i've become even more supportive of our cause. you see these kids (literally kids) with their wives and parents getting wheeled around with legs, arms, hands, feet, or eye missing. they put everything on the line, and if they don't deserve the best medical care we have to offer, who does? they need to know that if something happens to them, they have the greatest chance of any fighting man in history to survive their wounds. and for the most part i think it's true. there's something to be said for being behind these guys-- it has to give them, i hope, some kind of peace of mind.

believe it or not, i've talked with several soldiers that would *prefer* to be over there than back at their permanent station. they don't pay taxes, get extra pay, and don't put up with a lot of the BS that is involved in day to day training and working on a base.

--your friendly neighborhood hu-ah caveman

 

[Mirror Form]

after being at walter reed for a couple of months now, i've become even more supportive of our cause. you see these kids (literally kids) with their wives and parents getting wheeled around with legs, arms, hands, feet, or eye missing. they put everything on the line, and if they don't deserve the best medical care we have to offer, who does? they need to know that if something happens to them, they have the greatest chance of any fighting man in history to survive their wounds. and for the most part i think it's true. there's something to be said for being behind these guys-- it has to give them, i hope, some kind of peace of mind.

Well said, those are some powerful words! I should put something like that into my personal statement.

 

[exia80]

yea u guys sound like my essay....

 

[militarymd]

Being gung-ho and patriotic and wanting to do all that military stuff doesn't mean you are going to give the troops the care that they deserve.

Read my threads, and pay attention....the underlying theme of my threads are that because of the military crap, the physicians are not able to deliver that best care possible.

Just because you are a doctor, just because you're gung-ho, and just because you are on the front line doesn't mean the troops are getting good care. Good medical care exists because a system exists to allow the physicians to do their jobs.....the military does not have that.

 

[Rudy]

Well said MMD.

And by the way, Informer, many of us that are sharing our concerns about some of the serious problems facing military medicine are actually very patriotic. It is, in fact, that patriotism and love of country that drives part of my disappointment with the current military medical system that we have. Please do not confuse ojective and honest observations about the challenges facing military medicine today with a "lack of patriotism".

 

[FliteSurgn]

the underlying theme of my threads are that because of the military crap, the physicians are not able to deliver that best care possible.

...Good medical care exists because a system exists to allow the physicians to do their jobs.....the military does not have that.

Well said, xMMD.

As evidenced by the threads thenavysurgeon started, it's apparent that even when doctors are poised to enter duty and provide exemplary care they are allowed to twist on the vine...watching their skills (those very skills that our servicemen/women so greatly deserve) fade away.

I was one of those gung-ho guys...prior enlisted Army infantry...Soldier of the Year...Honor Guard...etc. I really thought that I would want to continue my service both to my country and to my fellow soldiers. The way military medicine is run, surgical skills are not a priority. My job is to fill a slot, it doesn't matter if I stay up-to-date on technical abilities. Not only does this do a disservice to the surgeon being wasted, but it compromises the care that those soldiers will ultimately receive. That's not fair to any of us.

Here's a good example...At an unnamed AFB, there are 2 surgeons...one is a 40ish Colonel and the other a 30ish Captain. The AFB has an outpatient surgery center, while any larger cases are performed at the local hospital. The colonel refuses to get privileges at the downtown hospital even though he's been on station for several years. The colonel also refuses to take any night or weekend call. He told the captain that he will take call M-F 8-4:30 and that is it. No one seems to be able/willing to shake some sense into this guy. On the outside, the colonel would be in the prime of his surgical career and would be a great mentor/knowledge resource for the younger surgeon. Instead, the colonel is a huge drain on the system. He's worthless except to fill his slot. No one cares that the guy will be unemployable on the outside. No one cares that the guy would actually be a liability in a deployment. How can you do anything but be discouraged?

I will say that I did enjoy my time as a flight surgeon. And even though it prolonged my ultimate goal of becoming a surgeon, I'm glad that I have those memories. Shouldn't everyone rotate to the desert once or twice?

 

[Homunculus]

Being gung-ho and patriotic and wanting to do all that military stuff doesn't mean you are going to give the troops the care that they deserve.

Read my threads, and pay attention....the underlying theme of my threads are that because of the military crap, the physicians are not able to deliver that best care possible.

Just because you are a doctor, just because you're gung-ho, and just because you are on the front line doesn't mean the troops are getting good care. Good medical care exists because a system exists to allow the physicians to do their jobs.....the military does not have that.

excellent points. and now that you're free and clear, what to you are the biggest hurdles in health care delivery to deployed soldiers? is most of it training (case volume) or is it logistics? i'm not sure about you, but to me it's pretty impressive that we can get soldiers stabilized and to a acute level care facility halfway around the world in literally a day or so.

--your friendly neighborhood inquisitive caveman

 

[militarymd]

excellent points. and now that you're free and clear, what to you are the biggest hurdles in health care delivery to deployed soldiers? is most of it training (case volume) or is it logistics? i'm not sure about you, but to me it's pretty impressive that we can get soldiers stabilized and to a acute level care facility halfway around the world in literally a day or so.

--your friendly neighborhood inquisitive caveman

What you see there at Walter Reed (kids who have come back from Iraq) is just a small fraction of military medical health care as a whole. So whether they are doing a good job at taking care of them or not is really not as important as military medicine as a whole.

Are they doing a good job? That is debatable.....I have no first hand knowledge of what is going right now, but I can tell you that during "major combat operations", there were some poorly trained surgeons operating who should not have been (O-5,O-6s who have not seen a trauma case in god knows how long).

Not to belittle your medical training, but it is pretty easy to impress new interns with smoke screen and mirrors because your knowledge of medicine is not very broad. "We saved so many lives...blah blah blah" when actually "so many lives + 15 could have been saved" if the logistics and personnel were what they should have been.

Does that make sense?

 

[Homunculus]

Does that make sense?

sorta.

what i'm trying to figure out is if the primary job of the military medical corps-- delivering health care to soldiers to decrease mortality and morbidity(whether preventative or acutely)-- is being carried out well.

i realize military medicine as a whole is not efficient-- i'm specifically addressing deployed medical assets and their function. so it *is* the kids coming back from Iraq that i'm wondering about. and the ones i've spoken with, without fail, are impressed and have nothing but good things to say about not only the quality of care they received but the speed and efficiency with which they received it.

were you ever deployed? what has your experience been with "tip of the spear" medical delivery? i guess that's what i'm really wondering about-- what things are like when it really matters the most. you state that more lives could be saved if things were "like they should have been"-- what is that exactly?

and one more thing-- unlike the navy interns, we army interns never got the motivational "so many lives" thing. the navy folks did, but that's because the majority of them are going to be farmed out to GMO billets.

--your friendly neighborhood "easy to impress" caveman

 

[bobbyseal]

I think I would have to agree with milmd's opinions. I honestly joined HPSP to serve my country, but I wanted to do it on my own terms. I felt that as a physician, I could provide excellent health care to the troops and their families. All the while I would be serving my country.

At times I get discouraged because I feel like military medicine has become adequate at best. The surgical residents get their best training at outside hospitals, and the chief residents log maybe 900-1100 cases by the time they graduate. I think most good programs get 2000 cases for their chiefs. Sure, they pass the boards just fine because they have lots of time to study.

However, it's ridiculous how low tech the or's have become. The laparascopic surgery equipment is state of the art 1996. In fact, they stopped allowing people to use endobags to take specimens, and instead you have to use a latex glove. WTF is up with that? A rubber glove to hold a specimen. It's ******ed and cheap.

Boo to military medicine for restricting our ability to provide care.

 

[militarymd]

sorta.

what i'm trying to figure out is if the primary job of the military medical corps-- delivering health care to soldiers to decrease mortality and morbidity(whether preventative or acutely)-- is being carried out well.

i realize military medicine as a whole is not efficient-- i'm specifically addressing deployed medical assets and their function. so it *is* the kids coming back from Iraq that i'm wondering about. and the ones i've spoken with, without fail, are impressed and have nothing but good things to say about not only the quality of care they received but the speed and efficiency with which they received it.

were you ever deployed? what has your experience been with "tip of the spear" medical delivery? i guess that's what i'm really wondering about-- what things are like when it really matters the most. you state that more lives could be saved if things were "like they should have been"-- what is that exactly?

and one more thing-- unlike the navy interns, we army interns never got the motivational "so many lives" thing. the navy folks did, but that's because the majority of them are going to be farmed out to GMO billets.

--your friendly neighborhood "easy to impress" caveman

I'm going to respond to you in parts.

First thing that needs to be addressed is "how is quality of care judged"?

Consumers of healthcare are very poor judges of the quality of care they received. Consumers tend to value....waiting time, friendliness of staff, quality of reading material in the waiting area, cleanliness of office, appearance of physician, whether the physician is "nice" or not, and in the case of a very young soldier.....the "rank" of the officer who spent the time to "do their job"....to treat them.

So, that fact that these wounded soldiers are impressed with their care means ABSOLUTELY nothing in terms of the quality of their medical care.

The next question is..."how do you judge the quality of care?"

This question is much more difficult to answer. In academic centers, in specific situations, criteria can be used to evaluate quality of care. Here are some examples:

-Total blood loss per case for each surgeon for the same type of cases....e.g. total colectomy.

-Incidence of peri-operative MI for each anesthesiologist for the same type of cases in similiarly ill patients.

- Incidence of post-operative wound infections after surgery...

- etc. etc.

The military's view on quality of care is this....maximum number of patients taken care of with the least number of dollars....Is this good care.

I know people will say that insurance companies and HMOs do the same thing, however, there is a significant difference. Civilian medicine has benchmarks that can be followed....because outcomes will be compared to academic centers....

The military will always practice in unusual environments for which there is no benchmark to compare to....only what the individual physician feels is good care.....so the nickel and diming will lead to poor quality of care.

 

[militarymd]

I'm going to respond to you in parts.

First thing that needs to be addressed is "how is quality of care judged"?

Consumers of healthcare are very poor judges of the quality of care they received. Consumers tend to value....waiting time, friendliness of staff, quality of reading material in the waiting area, cleanliness of office, appearance of physician, whether the physician is "nice" or not, and in the case of a very young soldier.....the "rank" of the officer who spent the time to "do their job"....to treat them.

So, that fact that these wounded soldiers are impressed with their care means ABSOLUTELY nothing in terms of the quality of their medical care.

The next question is..."how do you judge the quality of care?"

This question is much more difficult to answer. In academic centers, in specific situations, criteria can be used to evaluate quality of care. Here are some examples:

-Total blood loss per case for each surgeon for the same type of cases....e.g. total colectomy.

-Incidence of peri-operative MI for each anesthesiologist for the same type of cases in similiarly ill patients.

- Incidence of post-operative wound infections after surgery...

- etc. etc.

The military's view on quality of care is this....maximum number of patients taken care of with the least number of dollars....Is this good care.

I know people will say that insurance companies and HMOs do the same thing, however, there is a significant difference. Civilian medicine has benchmarks that can be followed....because outcomes will be compared to academic centers....

The military will always practice in unusual environments for which there is no benchmark to compare to....only what the individual physician feels is good care.....so the nickel and diming will lead to poor quality of care.

Example of quality of care for Peds would be:

Incidence of ER visits for asthma exacerbation in the clinic patients.

 

[militarymd]

I was deployed last year during "major combat operations". Us Navy folks went in with the Marines....so first in, first out.

We had a variety of platforms....from small Shock Trauma platoons(I'm not sure what they are called) which consisted of speciaty trained docs (intensivists, cardiologists, pulmonologists, EM, etc.) and GMOs and EMTs who moved with the ground forces to the big white ship with the red cross on it which is supposed to be a 1000 bed trauma hospital.

I was deployed to a LHD as a surgical team. The idea is that we can receive casualty, perform "life-limb saving stabilizing surgery" before medevacing them to definitive care. Great idea, but What a joke in implementation. The team had experienced anesthesiologists/intensivist...me and my partners, some good CRNAs, and a couple of good surgeons (but with limited experience in trauma)....and support staff with absolutely no experience in taking care of sick patients....The ship had no consumables that is needed to take care of sick patients (IV, fluids, blood, laboratory, etc.) We could have taken care of maybe one sick patient before we exhausted our supplies...fortunately we received zero casualities. So we wasted 3 months on float doing nothing and not capable of doing much...while patients back home had to wait longer for their surgeries.

I was also sent to the Comfort because they were short staffed on intensivists....The Comfort had supplies, but then there were some pretty bad surgeons (O-5,O-6) there....I won't say more about that.

The devil docs...well you saw them on CNN...and I work with them personally state side....Exceptional physicians....guess where they are headed when their time is up???? because of the disgust they had with the military administration.

 

[militarymd]

Now, let me tell you about the Shock Trauma Platoons....or whatever they are called.

This platform exemplifies the pointiest point of the spear, and what a lot of you med Studs out there romanticize as "Operational Medicine".

They're out with the troops, riding in the Humvees, and carrying sidearms....and they are iwithout question in harm's way. A cardiologist friend of mine actually took fire.

Let's examine this platform.....a lot of highly trained physicians in an environment for which they are not trained. I also spent sometime in Kuwait while awaiting re-deployment, and got to talk to a gung-ho colleague of mine who was all into this Shock Trauma Platoon concept.

The following treatment modalities are what is available to these teams:
IVF, Abx, morphine, pressure dressing, splints, chest tube, radio to call for help.

The above treatments are meant for paramedics/EMTs to administer.....not fully trained "cardiologists, intensivists, etc."

OK, so you're a gung-ho Internist, and want to get in on this BS....that's fine, but here is the problem.......The line commanders (poor judges of quality of medical care) thinks that because they have fully trained physicians and not paramedics/EMTs, think they have higher medical capabilities than they really have.......and subsequently are more willing to put their troops in positions where they may be injured more....How do I know this????? I was told by the line commanders "How much safer they feel that these Docs are around?????!!!!"

The line commanders think they have better care, but they don't.....That is similar to giving them non-bullet proof vests, and telling them that they are bullet proof.

I wonder how many marines got shot because their Captain ordered them to take certain positions because the Captain thinks that the presence of a ER specialist elevates the standards of medical care?

 

[MoosePilot]

I wonder how many marines got shot because their Captain ordered them to take certain positions because the Captain thinks that the presence of a ER specialist elevates the standards of medical care?

Put yourself in the place of the Captain. He's not likely to change his tactical battle plan based on the presence of a doc. That's only likely to be a problem at higher levels of command, which are more geographically distant from the actual furball.

 

[militarymd]

Put yourself in the place of the Captain. He's not likely to change his tactical battle plan based on the presence of a doc. That's only likely to be a problem at higher levels of command, which are more geographically distant from the actual furball.

The actual rank was Lt Colonel. That person said he felt so much more comfortable using his troops in firefights because of the presence of trained physicians......you decide what that means.....I take it to mean....I have a bullet proof vest now....while in actuality...it is not bullet proof at all.

 

[Mirror Form]

OK, so you're a gung-ho Internist, and want to get in on this BS....that's fine, but here is the problem.......The line commanders (poor judges of quality of medical care) thinks that because they have fully trained physicians and not paramedics/EMTs, think they have higher medical capabilities than they really have.......and subsequently are more willing to put their troops in positions where they may be injured more....How do I know this????? I was told by the line commanders "How much safer they feel that these Docs are around?????!!!!"

The line commanders think they have better care, but they don't.....That is similar to giving them non-bullet proof vests, and telling them that they are bullet proof.

I wonder how many marines got shot because their Captain ordered them to take certain positions because the Captain thinks that the presence of a ER specialist elevates the standards of medical care?

Interesting point. You're probably right about some commanders thinking they're safer w/ docs around, although I hope it's just the minority. But just to play the devil's advocate, how do you know that the higher ups don't want docs on the front line to do exactly what you did. That is, you're purpose for being there might have actually been to make the troops feel better and raise moral. It's also good politics to tell the media and senators that there are docs right up there with the front line.

 

[militarymd]

Interesting point. You're probably right about some commanders thinking they're safer w/ docs around, although I hope it's just the minority. But just to play the devil's advocate, how do you know that the higher ups don't want docs on the front line to do exactly what you did. That is, you're purpose for being there might have actually been to make the troops feel better and raise moral. It's also good politics to tell the media and senators that there are docs right up there with the front line.

If what you say is true, then I rest my case about how the military mis-utilize limited medical resources.

 

[Mirror Form]

If what you say is true, then I rest my case about how the military mis-utilize limited medical resources.

How is raising the morale of troops before a battle a misuse? If it makes the soldiers fight better, then I'd say it's a superb use from the military's stand point. Obviously it would be a waste for a doctor to be stuck on the front lines their whole career. But if it was only for one deployment, it would be okay.

Don't get me wrong, I'm not trying to say we should have docs on the front line instead of EMT's. Basically I'm just trying to somehow rationalize the military's apparent stupidity.

 

[T.A.M]

Interesting point. You're probably right about some commanders thinking they're safer w/ docs around, although I hope it's just the minority. But just to play the devil's advocate, how do you know that the higher ups don't want docs on the front line to do exactly what you did. That is, you're purpose for being there might have actually been to make the troops feel better and raise moral. It's also good politics to tell the media and senators that there are docs right up there with the front line.

I served as a medical service officer (70B, for those that speak the lingo) for a few years before med school. Fortunately, the brass who commanded in my brigade had the good sense to know that docs could do the most good placed where they belong, in the battalion aid stations and brigade support areas, not on the front lines! It sounds like you found yourself under the command of someone who either did not receive or did not listen to advice on how to position his medical assets. I

 

[thenavysurgeon]

'They don't care how much you know UNTIL THEY KNOW HOW MUCH YOU CARE!!!'...from the OP...

Are you a HPSP recruiter spy? I knew they were lurking on this site!!

Anyway, some good discussion above...

...as an active duty, deployable surgeon with a lot of trauma experience...i can tell you that forward field medicine capabilties are not remarkably different than they were 50 years ago...the presence of a physician I do not think emboldens a field commander to be more aggressive with his troops. I don't think that they think in those terms. Troop Safety? I don't think that crosses their minds. I also do not believe that the average Marine has any idea what a doc in the field can and cannot do for an injured soldier. Not much really. Certainly, surgeons and anesthesiologists belong out in the desert. There are selected patients with injuries that can be converted into survivable with a damage-control operation in the field, and expeditious evac out of the desert.

Military medicine is great, in concept only. You have a pool of money. You have a group of young and able *(mostly) providers. You care for a fixed number of people in a cost-conscious way, and find a way to make it work.

But this is only the ideal.

What contaminates this utopian, collectivist concept is the absence of a phyisician-run practice in most military hospitals. The chain of responsibility is distorted by a bunch of bloated, over-promoted RNs and MSC idiots that know nothing about good medical care. There is not enough money to do the job. Surgeons that should be sewing vascular anastomoses in prep for battle surgery are doing routine colonoscopies on dependants...Review my previous posts. Military medicine is going to write itself out of the script in the next 15-20 years. An early retirement for some of you 'lifers'

TNS

 

[militarymd]

bump

 

[Informer]

Well, it's been 3 year since I originally posted this <EDIT - holy cow it's actually been 4 years!!>

I graduated, got married, had a kid, am now chief at a military residency and will become a flight surgeon right out of residency, most likely with AFSOC (met a few people who remembered me from before, offered me a slot, now the wheels are in motion)

And guess what? I still love this job . . .

 

[IgD]

Well, it's been 3 year since I originally posted this <EDIT - holy cow it's actually been 4 years!!>

I graduated, got married, had a kid, am now chief at a military residency and will become a flight surgeon right out of residency, most likely with AFSOC (met a few people who remembered me from before, offered me a slot, now the wheels are in motion)

And guess what? I still love this job . . .

You are in the birth canal about to leave the womb. Please check back from time to time and tell us how you are doing. I was optimistic and kept up the intensity for as long as I could but in the end I became burned out and frustrated. I sincerely hope you fare better and wish you the best.

 

[almostfamous]

Now, let me tell you about the Shock Trauma Platoons....or whatever they are called.

This platform exemplifies the pointiest point of the spear, and what a lot of you med Studs out there romanticize as "Operational Medicine".

They're out with the troops, riding in the Humvees, and carrying sidearms....and they are iwithout question in harm's way. A cardiologist friend of mine actually took fire.

Let's examine this platform.....a lot of highly trained physicians in an environment for which they are not trained. I also spent sometime in Kuwait while awaiting re-deployment, and got to talk to a gung-ho colleague of mine who was all into this Shock Trauma Platoon concept.

There is a shock trauma platoon currently deploying with a just-graduated OBGYN resident and an ENT as the 'general surgeons'.

 

[militarymd]

There is a shock trauma platoon currently deploying with a just-graduated OBGYN resident and an ENT as the 'general surgeons'.

no surprise there.

 

[edmadison]

And guess what? I still love this job . . .

About six months before I graduated residency was when the wheels came off for me.

Ed