Is medicine really different inside and out?

[AR2233]

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I have read over and over many complaining about the bureaucracy of the army, and the lower pays for everybody except pcp. But is it really different? i mean, if you do USU, you owe your life to Uncle Sam. If you take loans, you owe wallstreet. in the military you have a higher ranking nurse telling you how to do your job (not that i mind, some nurses know way more than young doctors). in the civilian world, you have the investors and the hospital boards and the HMO owning your ass.

so, my point is: is it really that different on that matter? deployments aside of course

 

[bustbones26]

I have read over and over many complaining about the bureaucracy of the army, and the lower pays for everybody except pcp. But is it really different? i mean, if you do USU, you owe your life to Uncle Sam. If you take loans, you owe wallstreet. in the military you have a higher ranking nurse telling you how to do your job (not that i mind, some nurses know way more than young doctors). in the civilian world, you have the investors and the hospital boards and the HMO owning your ass.

so, my point is: is it really that different on that matter? deployments aside of course

1. About 100 to 150K extra in pay as a civilian
2. Not having to deploy as a general medical officer after completing residency in a subspeciality
3. Actually seeing patients and keeing your skills sharp.

There is a difference between owing loans and owing uncle sam. You have more autonomy and choices in regards to your career. If you do USU, your obligation is 7 years baseline. If you do a lengthy residency or fellowship training, you can expect to extend that obligation way beyond 7 years. Additionally, you may not be awarded fellowship or even the residency of your choice for that matter in the military, even if you are qualified.

Yes, as a civilian there are also layers of beareaucracy: hospital administrators, insurances, competitors, etc. These are aggravations that doctors have dealt with for years and LOVE to complain about because frankly, if they did not complain, they'd have nothing to talk about in the physician lounge at lunch. There are EXTRA layers of bureacracy at a military hospital that I just cannot describe and my explanation would be lengthy. My civilian hospitals are very concerned that I meet my credientials: keep my license and CME up to date, etc.

 

[orbitsurgMD]

You can quit a civilian job you do not like. In private practice, you can fire and replace employees who do not do their jobs. You can move to another place when you want if you want. You do not have to ask permission to take your vacation. You can decide all by yourself whether you want to attend a particular course or not. You can decide all by yourself when or if you will do a fellowship. You can wear whatever clothing you like and not crappy plastic uniform clothing. No one will make you attend pointless and time-wasteful training on stupid topics and policies. You will get better pay.

So yes, things are better in many ways on the outside. Much better. For professionals, military quality of life has seen a big slide downward. The military does not appreciate the value of professionals and in many ways is openly contemptuous of them, at many levels.

 

[HomeSkool]

I'll post more of my thoughts in a bit, but let me start by saying this: one of the attendings from my residency program just got out of the military and tripled his salary. TRIPLED.

 

[DoctorDoom]

I have read over and over many complaining about the bureaucracy of the army, and the lower pays for everybody except pcp. But is it really different? i mean, if you do USU, you owe your life to Uncle Sam. If you take loans, you owe wallstreet. in the military you have a higher ranking nurse telling you how to do your job (not that i mind, some nurses know way more than young doctors). in the civilian world, you have the investors and the hospital boards and the HMO owning your ass.

so, my point is: is it really that different on that matter? deployments aside of course

It's amazing how little you seem to know about the business of medicine, which is a real shame considering you are planning to spend your life in this sector of the economy. That ignorance is only rivaled by your clearly not having any idea what working for Uncle Sam truly entails, even in garrison with milmed.

But trust me, having been on both sides, it is even more different than you can imagine.

 

[pgg]

in the military you have a higher ranking nurse telling you how to do your job

No, they don't.

(not that i mind, some nurses know way more than young doctors).

No, they don't.

And yes you would, if they did.



Here's the root of the cultural difference between civilian and military medicine:

1) In the civilian world, doctors are income creators for hospitals. They bring the patients, diagnose the patients, treat the patients, do the procedures. We print money.

2) In the military world, doctors are an expense. A grudgingly tolerated expense at that. Every dollar the military spends on health care is a dollar that can't be spent on guns, ammo, aircraft, deployments, and warfighters. We cost money.

Everything else flows from that inescapable reality.

And I'm not saying it's wrong. The military is not a jobs program - it exists to kill people, break things, and violently impose our nation's will on uncooperative foreigners. Military doctors are a cog in a machine that is mostly non-medical.

 

[pgg]

in the military you have a higher ranking nurse telling you how to do your job

To clarify my earlier sarcastic response to this -

Yes, in the military, senior nurses often have a role in creating hospital policy. Some of those policies may impact the environment in which you practice medicine.

But nurses, regardless of seniority, don't tell you how to treat patients. They don't tell obstetricians "c-section rates are up 4% this month so you can't take that patient to the OR" and they don't tell pediatricians "that kid's asthma isn't bad enough to warrant that medicine so use this one instead" and they don't tell anesthesiologists "stop using LMAs because they cost more than endotracheal tubes" and they don't tell radiologists "that gray blur on the mammogram isn't gray enough to warrant a biopsy" ...

At one point we had one micromanaging our department's call schedule, and it sure was irritating, but that doesn't really qualify as telling us how to do our job.

I have never once had a nurse tell me what to do concerning a patient.

 

[DoctorDoom]

...2) In the military world, doctors are an expense. A grudgingly tolerated expense at that. Every dollar the military spends on health care is a dollar that can't be spent on guns, ammo, aircraft, deployments, and warfighters. We cost money.

Everything else flows from that inescapable reality.

And I'm not saying it's wrong. The military is not a jobs program - it exists to kill people, break things, and violently impose our nation's will on uncooperative foreigners. Military doctors are a cog in a machine that is mostly non-medical.

This is an excellent point regarding the "cultural" (for lack of a better word) aspect of military medicine that even many military doctors don't seem to grasp. Doctors are doing almost exactly the opposite of the military's primary function. That different purpose necessarily means that military medicine is fundamentally different from civilian medicine.

 

[Apollyon]

This is an excellent point regarding the "cultural" (for lack of a better word) aspect of military medicine that even many military doctors don't seem to grasp. Doctors are doing almost exactly the opposite of the military's primary function. That different purpose necessarily means that military medicine is fundamentally different from civilian medicine.

As "Marco" (Dave Marcozzi) told us in residency, "the staff exists to keep the war machine rolling". All the staff corps keep the line functioning. As long as you keep that at the forefront, you won't lose the ball.

 

[a1qwerty55]

I have read over and over many complaining about the bureaucracy of the army, and the lower pays for everybody except pcp. But is it really different? i mean, if you do USU, you owe your life to Uncle Sam. If you take loans, you owe wallstreet. in the military you have a higher ranking nurse telling you how to do your job (not that i mind, some nurses know way more than young doctors). in the civilian world, you have the investors and the hospital boards and the HMO owning your ass.

so, my point is: is it really that different on that matter? deployments aside of course

In the military you are a sharecropper - they own you and they make sure you know it. Find me any healthcare system which takes a fully trained doctor and asks them to do nonclinical work for three years. The Army is destroying the careers of their subspecialists by sending them to be Brigade Surgeons fresh out of fellowship. The military medical leaders are bad, I mean really bad. It is a zero sum game for them and if there is any issue which arises which might reflect poorly on them they immediately fix blame and throw the individual under the bus. The nursing leaders are even worse than the physician leaders.

Anyone who has seen my posts in the past would label me as a cheerleader. That decidedly is not the case now.

 

[jabreal00]

In the military you are a sharecropper - they own you and they make sure you know it. Find me any healthcare system which takes a fully trained doctor and asks them to do nonclinical work for three years. The Army is destroying the careers of their subspecialists by sending them to be Brigade Surgeons fresh out of fellowship. The military medical leaders are bad, I mean really bad. It is a zero sum game for them and if there is any issue which arises which might reflect poorly on them they immediately fix blame and throw the individual under the bus. The nursing leaders are even worse than the physician leaders.

Anyone who has seen my posts in the past would label me as a cheerleader. That decidedly is not the case now.

This is the death of military medicine. My subspecialty consultant alerted us that two more of us will be tasked for brigade surgeon assignment. We had two last year. I knew an anesthesiologist tasked. This bone headed move plus the new GME rule that all graduates will do a two year mandatory assignment before they can apply for fellowship is the sure death of milmed. Initially I thought it was by boneheaded policies. However, I've come to realize it's by purposeful design. I gleaned this from a shill who came from HRC to give a pep talk about the benefits of operational medicine. He flatly told me that the Army was on the cusp of getting rid of medical corp in the 90s. He said civilians could staff all CONUS or OCONUS MTFs. However, there would always be a need for operational medicine.

So the bottom line is that big Army could give a rat's @ss about the medical corp. All they care about is the operational aspect of it (Brigade, flight or battalion surgeon).

 

[Gastrapathy]

To clarify my earlier sarcastic response to this -

Yes, in the military, senior nurses often have a role in creating hospital policy. Some of those policies may impact the environment in which you practice medicine.

But nurses, regardless of seniority, don't tell you how to treat patients. They don't tell obstetricians "c-section rates are up 4% this month so you can't take that patient to the OR" and they don't tell pediatricians "that kid's asthma isn't bad enough to warrant that medicine so use this one instead" and they don't tell anesthesiologists "stop using LMAs because they cost more than endotracheal tubes" and they don't tell radiologists "that gray blur on the mammogram isn't gray enough to warrant a biopsy" ...

At one point we had one micromanaging our department's call schedule, and it sure was irritating, but that doesn't really qualify as telling us how to do our job.

I have never once had a nurse tell me what to do concerning a patient.

I never had a nurse or senior physician tell me how to practice but they affected my clinical decision-making in more subtle ways.

No anesthesia services available in your clinic...come on up to the OR. Of course, that will waste half a day so do I really need to go? Maybe I should just sedate the patient and take my chances. Moderate sedation nurse watch bill...we can't support that. Just take all your weekend cases to the OR where you'll compete with the surgeons for times. You'll be the one sitting around waiting, not them.

The constant lack of resources did wear me down. Its gradual and you don't necessarily notice it at the time but I think its real. They may not have told you to stop using LMAs but they definitely limited my supplies of certain devices (SEMS, etc) and forced me to compromise. I know our surgeons faced similar compromises on a regular basis and, as I think back, I remember an anesthesiologist complaining about the dearth of fiberoptic scopes at one point because the service contract had been cancelled and they were all broken.

No one has ever told me how to do my job. If I had a bad outcome because I compromised to get something done within our system, you can bet I would have been the only one to blame.

Leadership in the .mil is always focused on the short term. The half-life of a flag officer is 2-3 years.

The .mil always owns you. At first you are obligated and then you are stuck until retirement. I would not have the fortitude to get out at 18 years. Depending on the specialty, I think most folks are still better off staying if they are in at the 12-14 year mark.

 

[DoctorDoom]

As "Marco" (Dave Marcozzi) told us in residency, "the staff exists to keep the war machine rolling". All the staff corps keep the line functioning. As long as you keep that at the forefront, you won't lose the ball.

Indeed, but this is easy to forget for those who are never in a TO&E assignment and only in TDA settings. And some just refuse to understand this fundamental fact. Look at all the complaints about TOE/operational assignments, and the lack of support to the MC officers who do go to those units, as well as lack of proper Corps administration of that function. However, it's not entirely TDA providers at fault, as they are being ask to treat dependents and retirees, their primary function having nothing to do with warfighters or "conserving fighting strength" at all. We have a chimeric system that heavily slants away from warfighter focus.

 

[DoctorDoom]

I never had a nurse or senior physician tell me how to practice but they affected my clinical decision-making in more subtle ways.

That's been my experience as well. Having to explain my clinical decisions to a higher ranking nurse because of their ignorance, constantly having to justify labs/equipment/support, it's gotten real old.

 

[DoctorDoom]

The Army is destroying the careers of their subspecialists by sending them to be Brigade Surgeons fresh out of fellowship.

This is the death of military medicine... He said civilians could staff all CONUS or OCONUS MTFs. However, there would always be a need for operational medicine.
So the bottom line is that big Army could give a rat's @ss about the medical corp. All they care about is the operational aspect of it (Brigade, flight or battalion surgeon).

I'm not sure that the new focus on Brigade Surgeon assignments means the death of milmed; it may be one cause through destroying morale, because it absolutely hurts the new fellows and sub-subspecialists to be sent right after training, which makes everyone else unhappy too, but it's only one tour, and usually the timing isn't at the worst times, ie. right after fellowship or right after residency. I think that some of us are being a little melodramatic, although it is absolutely a crappy situation.

What these assignments are REALLY effective at is cutting down the number of sub-specialists whose fellowship training is not supported by milmed (why train transplant surgeons in the Army, for example) through attrition. It's not fair to train a pediatric hem-onc person and then make them do operational jobs, but if they aren't using their fellowship training, and you want to shift the focus to operational medicine and primary care, this kind of assignment is a good way to get them to ETS. That's what I suspect is the true goal here, rather than the MC being interested only in operational medicine. All evidence points to the contrary. Even these assignments now are treating operational medicine as a way to check the box for higher level commands in the future for those who stay in.

While I do think there needs to be more support and emphasis on operational assignments (which is arguably the entire purpose of milmed), the way this shift is being implemented is pretty poorly executed and is obviously having unintended effects. Again I lay the problem at the foot of MC leadership. I think people would be ok with doing operational assignments if they weren't just out of residency or fellowship, if the ROAD senior officers would also be required to take their turn, and if it seemed like HRC was able to assign them to the appropriate operational assignment and then get them back to the right MTF assignment. My replacement as Brigade Surgeon arrived on station about 4 years after he finished residency, did the job, and then instead of being sent back to his prior MEDCEN so that he could go to fellowship or become Associate PD for the residency, they sent him to a MEDDAC. His family had to move, all after he had been promised he would be sent back to his original MEDCEN. He's getting out right now, 2 years later, and I can't blame him. I'm in a similar situation.

I bet I know the HRC shill you speak of: MSC officer, one each, who claimed to understand what it's like to go through residency. 🙄 It's probably the same guy who patronized me with the "Army isn't for everyone" line when I asked about these issues at Brigade Surgeon Course. I responded that being an "Army type" person does not include being able to tolerate either his incompetence or his condescension. The same asshat was also the one who assigned me to a slot that was already filled.

It's the unbelievably poor leadership you mentioned, a1qwerty55, that will be the death of MC. I think the death knell has already sounded.

 

[jabreal00]

I'm not sure that the new focus on Brigade Surgeon assignments means the death of milmed; it may be one cause through destroying morale, because it absolutely hurts the new fellows and sub-subspecialists to be sent right after training, which makes everyone else unhappy too, but it's only one tour, and usually the timing isn't at the worst times, ie. right after fellowship or right after residency. I think that some of us are being a little melodramatic, although it is absolutely a crappy situation.

What these assignments are REALLY effective at is cutting down the number of sub-specialists whose fellowship training is not supported by milmed (why train transplant surgeons in the Army, for example) through attrition. It's not fair to train a pediatric hem-onc person and then make them do operational jobs, but if they aren't using their fellowship training, and you want to shift the focus to operational medicine and primary care, this kind of assignment is a good way to get them to ETS. That's what I suspect is the true goal here, rather than the MC being interested only in operational medicine. All evidence points to the contrary. Even these assignments now are treating operational medicine as a way to check the box for higher level commands in the future for those who stay in.

While I do think there needs to be more support and emphasis on operational assignments (which is arguably the entire purpose of milmed), the way this shift is being implemented is pretty poorly executed and is obviously having unintended effects. Again I lay the problem at the foot of MC leadership. I think people would be ok with doing operational assignments if they weren't just out of residency or fellowship, if the ROAD senior officers would also be required to take their turn, and if it seemed like HRC was able to assign them to the appropriate operational assignment and then get them back to the right MTF assignment. My replacement as Brigade Surgeon arrived on station about 4 years after he finished residency, did the job, and then instead of being sent back to his prior MEDCEN so that he could go to fellowship or become Associate PD for the residency, they sent him to a MEDDAC. His family had to move, all after he had been promised he would be sent back to his original MEDCEN. He's getting out right now, 2 years later, and I can't blame him. I'm in a similar situation.

I bet I know the HRC shill you speak of: MSC officer, one each, who claimed to understand what it's like to go through residency. 🙄 It's probably the same guy who patronized me with the "Army isn't for everyone" line when I asked about these issues at Brigade Surgeon Course. I responded that being an "Army type" person does not include being able to tolerate either his incompetence or his condescension. The same asshat was also the one who assigned me to a slot that was already filled.

It's the unbelievably poor leadership you mentioned, a1qwerty55, that will be the death of MC. I think the death knell has already sounded.

In my sub-specialty we are being tasked for two year tours. That's two years of very few to no procedures. That definitely kills moral. Plus, there is a shortage of my specialty due to people getting out but we still are tasked with filling two slots. Secondly, residents no longer can continue to fellowship straight out or after one year as a staff. Everyone must spend two years before applying. People will catch wind of this and less people will enter the medicine through HPSP. This will only exacerbate the need to fill a brigade surgeon with a pathologist, dermatologist, radiologist or medicine sub-specialist. It's not good times if someone is thinking of making a career, in my opinion.

Sure I get that the emphasis in the military is on operational medicine. However, it was always more of a voluntary thing in the past. Someone wanted bullets on their OER for promotion, getting a plumb assignment, or fellowship. I was and will always be fine with the deployment aspect of it because that is what I signed up for. I didn't envision pushing papers and writing MEBs for two years out of my professional life with the specter of more administrative boondoggle as one gets higher up in rank.

 

[DoctorDoom]

In my sub-specialty we are being tasked for two year tours. That's two years of very few to no procedures. That definitely kills moral. Plus, there is a shortage of my specialty due to people getting out but we still are tasked with filling two slots. Secondly, residents no longer can continue to fellowship straight out or after one year as a staff. Everyone must spend two years before applying. People will catch wind of this and less people will enter the medicine through HPSP. This will only exacerbate the need to fill a brigade surgeon with a pathologist, dermatologist, radiologist or medicine sub-specialist. It's not good times if someone is thinking of making a career, in my opinion.

Sure I get that the emphasis in the military is on operational medicine. However, it was always more of a voluntary thing in the past. Someone wanted bullets on their OER for promotion, getting a plumb assignment, or fellowship. I was and will always be fine with the deployment aspect of it because that is what I signed up for. I didn't envision pushing papers and writing MEBs for two years out of my professional life with the specter of more administrative boondoggle as one gets higher up in rank.

All tours are 2 years for Brigade Surgeon, by the way, unless you go to Korea, so no one specialty is specifically being tasked for 2 years while others aren't, we all suffer equally in that sense. As a general surgeon, believe me I get the lack of procedures. The improper tasking and lack of adjustment for specialty (sending a Thoracic radiologist to a Brigade that is not MTOE'd for a Brigade PA or a MEDO is just tossing that guy to the wolves) is definitely a huge problem.

I'm not sure how much it will decrease HPSP applications, because ultimately going straight through to fellowship in the past was nice, but Uncle Sugar never cared what would be preferable to us. I think the Army is relying on people coming into HPSP and other direct accession paths, but in primary care specialties. They are having no problems filling those slots. Of course, the problem is that a new grad is not the same as a physician that has 5 years of independent practice under their belt, something that MEDCOM doesn't seem to understand. 1 =/= 1 in this situation.

I may not have made this clear in my post, but I think the point of these assignments is part of a larger goal of decreasing derm, path, rads, and sub-specialists, the people that can be replaced by civilians or simply be referred out to the economy, as that HRC guy noted. So while that will change milmed, it matches the mission. But it does screw the people who are already in.

The "voluntary" nature of Brigade Surgeon assignment in the past was really the problem, I think, at least according to the senior leadership. It wasn't even really voluntary, especially at battalion levels; mostly it was just ignored at brigade level, and it was mostly used to make up some kind of deficiency on the CV (eg. MAJ who wanted to make LTC who hadn't done any residency.)

By ignoring force requirements and leaving those slots unfilled (four years ago the fill rate was 35%), we had a dearth of senior officers qualified to fill even higher admin/command posts, like command/theater/army surgeon slots, and ultimately the GO officer positions (that's how we we ended up with a Nurse ASG, and all those MSC/Nurse hospital commanders, which is also not a good situation.) Which gave us a glut of senior O-6's that couldn't do admin and didn't see patients (look at the rank distribution of MC.) It lead to an idea of a career path and expectation of responsibilities at higher rank that, like yours, did not match Army needs. And when what we envision and what we want doesn't match what the line says it needs, or what the MC Corps Chief wants to do to change the dominance of non-MC senior officers in charge of MC functions, guess who wins?

I tend to be one of those who thinks the change in emphasis is not bad per se, but I also think the way the new emphasis is being put in place is really poorly done. Making people who don't want to progress beyond LTC or don't want to do anything but practice clinical medicine go to these assignments is not ideal, especially since the people who apply to fellowship aren't the people who want to make general and become ASG. Still, we can't have it both ways. If we don't want nurses and MSC guys in charge of us, we can't also refuse non-clinical assignments forever. This adjustment will be very painful, and decimate MC as we knew and know it.

 

[a1qwerty55]

When I joined the MC it was still possible to be both a clinician and a leader (granted not a Division Surgeon) but a hospital Commander or DCCS. I remember the Chief of Departments being the best of the best (clinical experts and good leaders), I remember working for CG's who still got clinical medicine. That is no longer the case. As the bureaucracy of medicine has exploded, those with desires to remain clinical relevant were marginalized. It just wasn't possible to keep on top of the burgeoning requirements, policies etc and see patients. The clinically inept and those with narcisistic traits which motivated them to seek titles gladly stepped into the void. The Nurse and MS Corps officers also loved the new opportunites when Command jobs became branch immaterial.

The net effect is that the shat floated to the top. I was lucky in my time in the military that I hit the sweet spot when there was money and an understanding that quality mattered. I also worked for good leaders and was able to expand my skills and build a practice. The current environment is one of complete stagnation. We are only pulling back with regards to clinical activities and capability. This results in substantard care, poor morale and a system which will implode.

 

[BigNavyPedsGuy]

... The current environment is one of complete stagnation. We are only pulling back with regards to clinical activities and capability. This results in substantard care, poor morale and a system which will implode.

Amen

 

[NavyFP]

The current environment is one of complete stagnation. We are only pulling back with regards to clinical activities and capability. This results in substantard care, poor morale and a system which will implode.

Anyone remember the late 70s.........

 

[a1qwerty55]

Anyone remember the late 70s.........

Yes, you mean when we had a ineffective Democratic President and were coming out of a long unpopular war? Sounds familiar.

 

[BigNavyPedsGuy]

Yes, you mean when we had a ineffective Democratic President and were coming out of a long unpopular war? Sounds familiar.

You're seriously choosing today to get political? Really?

 

[a1qwerty55]

You're seriously choosing today to get political? Really?

Just pointing out the parallels... there are a few... sorry if this somehow got your panties in a wad.

 

[notdeadyet]

Just pointing out the parallels... there are a few...

Meh, a lot more differences than parallels. I don't remember the shutdown in the 90's occurring due to a party unhappy with a law they passed 3 years prior and whose constitutionality was upheld by the Supreme Court, all in the setting of a fragile economy in recovery. Cut-your-nose-to-spite-your-face fringe partisan politics at its ugliest.

 

[bricktamland]

Meh, a lot more differences than parallels. I don't remember the shutdown in the 90's occurring due to a party unhappy with a law they passed 3 years prior and whose constitutionality was upheld by the Supreme Court, all in the setting of a fragile economy in recovery. Cut-your-nose-to-spite-your-face fringe partisan politics at its ugliest.

Well put. This unwavering obsession with tearing down the ACA by a certain faction of Congress is getting old. Move on, already. Do something constructive for once. Is the law perfect? Far from it, but they've failed like 500 times to repeal the law, why not just accept it and try to work with it, make it better, and maybe some compromises could be made. They're like a bunch of children throwing a tantrum and ruining things for everybody until they get their way.

However, getting back to topic. . . . Having started moonlighting at a private practice recently, one big difference I've noticed is how invested people are when they truly own something. It's much more motivating to work hard and try to improve the practice when you own it and you immediately benefit from that. On the contrary, when you work in the military, the practice owns you.

 

[a1qwerty55]

Again, 1970's my friend - Obama looks a lot like Carter with his disjointed and feeble foreign policy resulting in a loss of US credibility in the world, US taxpayer tired of a 10+ year war (that would be Vietnam for those of you still not tracking), a military who's capability was steadily degraded in an attempt to fund social programs. Oh yes, military healthcare stunk as well. Are you seeing parallels yet?

 

[bricktamland]

I would argue that US foreign policy and credibility went down the toilet when the Bush administration started two ill-conceived and unecessary wars based on feeble (at best) intelligence. Trillions of dollars wasted on "nation building" in countries that would like to see the US burned to the ground. If you want to talk about the atrocious squadering of tax payer dollars, look no farther than Iraq and Afganistan.

On the other hand, I think Obama has done a commendable job with foreign policy. The capture of OBL was a tremendous success. Also the Obama administration has thus far handled Libya and Syria without committing any troops to the ground. For the first time in ages, we are having some encouraging dialogue with Iran.

In regards to healthcare, the ACA makes a lot of sense: guaranteed insurance, no lifetime caps, no rejections for pre-existing conditions, and ability to keep kids up to 26 on the family plan. Plus, early reports show that the costs of premiums are coming in lower than what was expected. It's not perfect though. I worry about negative effects on small business. However, it's those sorts of things I wish Congress could work together on to improve, instead of this all or nothing approach.

 

[EsTxDr]

I would argue that US foreign policy and credibility went down the toilet when the Bush administration started two ill-conceived and unecessary wars based on feeble (at best) intelligence. Trillions of dollars wasted on "nation building" in countries that would like to see the US burned to the ground. If you want to talk about the atrocious squadering of tax payer dollars, look no farther than Iraq and Afganistan.

On the other hand, I think Obama has done a commendable job with foreign policy. The capture of OBL was a tremendous success. Also the Obama administration has thus far handled Libya and Syria without committing any troops to the ground. For the first time in ages, we are having some encouraging dialogue with Iran.

In regards to healthcare, the ACA makes a lot of sense: guaranteed insurance, no lifetime caps, no rejections for pre-existing conditions, and ability to keep kids up to 26 on the family plan. Plus, early reports show that the costs of premiums are coming in lower than what was expected. It's not perfect though. I worry about negative effects on small business. However, it's those sorts of things I wish Congress could work together on to improve, instead of this all or nothing approach.

We should just stick to the topic here.

 

[a1qwerty55]

We should just stick to the topic here.

Agree. Is medicine really different inside versus outside the military?

Why yes it is. I'm not aware of any civilian system which slashing services and compromising care. The point is that the military healthcare system is in a free fall and like it or not, it is cyclical and politically driven.

 

[idq1i]

Agree. Is medicine really different inside versus outside the military?

Why yes it is. I'm not aware of any civilian system which slashing services and compromising care. The point is that the military healthcare system is in a free fall and like it or not, it is cyclical and politically driven.

Let's see:
The person in charge is a nurse.
Everyone is a "provider." No distinction between MD or an LPN.
Incompetent providers hide behind their rank, and drop their professional titles
NPs and PAs and CRNAs practice essentially without oversight.
PT/OT/DCs are allowed to order studies and essentially practice like physicians.
Physicians are "gently encouraged" to extend their practice to beyond their training and comfort levels.
CME and TDY are canceled.
Your promotion/advancement relies on longevity, powerpoint skills, meeting attendance record, military education and not your medical skills.
Lack of caseload to allow subspecialists to keep up skills, and yet moonlighting a is strongly discouraged, and sometimes banned.
Your NCO barely speaks English - that's perfect because it's representative of diversity.
Forced vaccination, sometimes experimental.
Forced medical case with barely competent providers.
Incompetent civilians that YOU CAN NEVER FIRE (more of a federal thing, and not just DoD)

You know how we all hate the DMV? Milmed is just like a big, huge DMV on steroids and a large slush fund.

Just a very short list...

 

[met19]

Let's see:
The person in charge is a nurse.
Everyone is a "provider." No distinction between MD or an LPN.
Incompetent providers hide behind their rank, and drop their professional titles
NPs and PAs and CRNAs practice essentially without oversight.
PT/OT/DCs are allowed to order studies and essentially practice like physicians.
Physicians are "gently encouraged" to extend their practice to beyond their training and comfort levels.
CME and TDY are canceled.
Your promotion/advancement relies on longevity, powerpoint skills, meeting attendance record, military education and not your medical skills.
Lack of caseload to allow subspecialists to keep up skills, and yet moonlighting a is strongly discouraged, and sometimes banned.
Your NCO barely speaks English - that's perfect because it's representative of diversity.
Forced vaccination, sometimes experimental.
Forced medical case with barely competent providers.
Incompetent civilians that YOU CAN NEVER FIRE (more of a federal thing, and not just DoD)

You know how we all hate the DMV? Milmed is just like a big, huge DMV on steroids and a large slush fund.

Just a very short list...

i have to agree with this- especially the CME component.

 

[bricktamland]

First, my apologies for having deviated off topic in the prior posts. I'm probably just a little sour after having my hopes dashed once again for having my ISP bonus paid in a timely manner (talking about in/out differences, I doubt that screwing with people's pay goes over well on the outside. . . . ).

The above list is spot on. The NPs function essentially autonomously, and some of the care is downright frightening (I will acknowledge there are a few decent ones, but the quality of their training is widely inconsistent).

As a radiologist, I frequently encounter orders from PT/OT/DCs for advanced imaging studies, mainly MRIs, that on the outside I don't think they would have the privilege to order. The studies coming from these folks have an exceedingly high rate of normal. Add to this an excessive number of normal MRIs ordered by GMOs, and you have the makings of wasteful medicine.

Our Ortho doc started complaining about long wait times for MRIs. I said, well, the best way to cut down on the wait times would be to reduce the number of unnecessary MRIs, which are mostly Ortho related studies, coming from the GMOs, PT/OT/DC. To achieve that, someone with decent physical exam skills and clinical knowledge would need to examine the patients instead, i.e., him! Once he put 2 and 2 together, and realized his Ortho clinic referrals would then be overflowing, he quickly dropped the issue. I don't blame him, he's one of one, and has a ton on his plate.

That sort of segues into another issue. The nature of socialized medicine (military medicine) vs medicine for profit (outside). The main difference is the incentives.

Within military medicine, there is a greater incentive to pass work on to someone else. In fact, the less actual clinical work you do, the more time you have for the activities the military actually rewards you for--the administrative work. So I would say there is actually a disincentive for productivity in the military.

On the outside, efficiency and productivity are paramount. You are rewarded for hard work. The hospital staff treats you with more respect (mainly I think because physicians generate most of the money). Your support staff and technicians are better trained, because crappy ones lose money and get fired.

Each system has its pros and cons. Socialized medicine may work well when everyone in the system is competent, caring, and scrupulous. However, that is rarely the case. I think the vast majority of military physicians are fanatastic and the problem stems mainly from the bloated bureaucracy, bad leadership, and whims of politicians. Another major problem with socialized medicine is that it breeds complacency and a lack of innovation.

On the other hand, in a system driven mainly by profit like it is on the outside, greed can become a factor. Unnecessary surgeries, drugs, hospitalizations, all for more profit. Those aren't problems characteristic of military medicine.

 

[idq1i]

As a radiologist, I frequently encounter orders from PT/OT/DCs for advanced imaging studies, mainly MRIs, that on the outside I don't think they would have the privilege to order. The studies coming from these folks have an exceedingly high rate of normal. Add to this an excessive number of normal MRIs ordered by GMOs, and you have the makings of wasteful medicine.

Wait... do we work together in the same department, in the same hospital, with the same "provider" pool????
😱

 

[Kilgoretrout 65]

Let's see:
The person in charge is a nurse.
Everyone is a "provider." No distinction between MD or an LPN.
Incompetent providers hide behind their rank, and drop their professional titles
NPs and PAs and CRNAs practice essentially without oversight.
PT/OT/DCs are allowed to order studies and essentially practice like physicians.
Physicians are "gently encouraged" to extend their practice to beyond their training and comfort levels.
CME and TDY are canceled.
Your promotion/advancement relies on longevity, powerpoint skills, meeting attendance record, military education and not your medical skills.
Lack of caseload to allow subspecialists to keep up skills, and yet moonlighting a is strongly discouraged, and sometimes banned.
Your NCO barely speaks English - that's perfect because it's representative of diversity.
Forced vaccination, sometimes experimental.
Forced medical case with barely competent providers.
Incompetent civilians that YOU CAN NEVER FIRE (more of a federal thing, and not just DoD)

You know how we all hate the DMV? Milmed is just like a big, huge DMV on steroids and a large slush fund.

Just a very short list...

Although rescinded yesterday, the Army had cancelled permissive TDY as well. Take away our funded TDY for a conference, then take away the chance to go on our own dime while not burning leave, what *****s. All of us need CME; some programs require the director to get certain specific kinds of CME. I need to tell the next inspector that my leaders don't value that kind of education.

 

[orbitsurgMD]

Although rescinded yesterday, the Army had cancelled permissive TDY as well. Take away our funded TDY for a conference, then take away the chance to go on our own dime while not burning leave, what *****s. All of us need CME; some programs require the director to get certain specific kinds of CME. I need to tell the next inspector that my leaders don't value that kind of education.

That is inexcusable failure to support. It is either rank incompetence, dereliction or outright malfeasance, take your pick.

 

[pgg]

That is inexcusable failure to support. It is either rank incompetence, dereliction or outright malfeasance, take your pick.

Why can't it be all three?


As of today the Navy still had cancelled all previously approved no-cost TAD. The American Soc Anesthesiologists conference starts Saturday; the Uniformed Services Soc Anesthesiologists annual meeting is tomorrow.

I'm curious to see how many people show up to the USSA meeting tomorrow. Lots of us have cancelled (despite paying out of pocket in advance for the conference and travel), some of us are taking leave instead. It's absurd.

I'm still going, but there are some people I was looking forward to seeing who cut their losses and canceled.

 

[Chonal Atresia]

First, my apologies for having deviated off topic in the prior posts. I'm probably just a little sour after having my hopes dashed once again for having my ISP bonus paid in a timely manner (talking about in/out differences, I doubt that screwing with people's pay goes over well on the outside. . . . ).

The above list is spot on. The NPs function essentially autonomously, and some of the care is downright frightening (I will acknowledge there are a few decent ones, but the quality of their training is widely inconsistent).

As a radiologist, I frequently encounter orders from PT/OT/DCs for advanced imaging studies, mainly MRIs, that on the outside I don't think they would have the privilege to order. The studies coming from these folks have an exceedingly high rate of normal. Add to this an excessive number of normal MRIs ordered by GMOs, and you have the makings of wasteful medicine.

Our Ortho doc started complaining about long wait times for MRIs. I said, well, the best way to cut down on the wait times would be to reduce the number of unnecessary MRIs, which are mostly Ortho related studies, coming from the GMOs, PT/OT/DC. To achieve that, someone with decent physical exam skills and clinical knowledge would need to examine the patients instead, i.e., him! Once he put 2 and 2 together, and realized his Ortho clinic referrals would then be overflowing, he quickly dropped the issue. I don't blame him, he's one of one, and has a ton on his plate.

That sort of segues into another issue. The nature of socialized medicine (military medicine) vs medicine for profit (outside). The main difference is the incentives.

Within military medicine, there is a greater incentive to pass work on to someone else. In fact, the less actual clinical work you do, the more time you have for the activities the military actually rewards you for--the administrative work. So I would say there is actually a disincentive for productivity in the military.

On the outside, efficiency and productivity are paramount. You are rewarded for hard work. The hospital staff treats you with more respect (mainly I think because physicians generate most of the money). Your support staff and technicians are better trained, because crappy ones lose money and get fired.

Each system has its pros and cons. Socialized medicine may work well when everyone in the system is competent, caring, and scrupulous. However, that is rarely the case. I think the vast majority of military physicians are fanatastic and the problem stems mainly from the bloated bureaucracy, bad leadership, and whims of politicians. Another major problem with socialized medicine is that it breeds complacency and a lack of innovation.

On the other hand, in a system driven mainly by profit like it is on the outside, greed can become a factor. Unnecessary surgeries, drugs, hospitalizations, all for more profit. Those aren't problems characteristic of military medicine.

This post is spot on! Fortunately, I am separating in just over 6 months. I am so disenchanted with military medicine right now that I'm contemplating counseling medical students (on my own time in private practice) against taking the HPSP/USUHS routes. This is the only way to really hit them where it hurts - decimate the feeding ground and wipe out their ranks.

 

[deuist]

Glory! I finally got ASP today. It only took lots of phone calls and emails to various financial offices to accomplish. For the pre-meds and medical students who don't know what that means, I finally got my DoD-required physician pay that was supposed to be paid out 3 and 1/2 months ago. Can any of you think of a company that is so backwards that its HR department doesn't know what its employees are getting paid?

 

[idq1i]

I finally got my DoD-required physician pay that was supposed to be paid out 3 and 1/2 months ago.

HAHAHA. Beat you. 11 months and 4 escalations to get the correct base pay. 2 more months to get appropriate specialty pay,

 

[deuist]

I still haven't got the correct base pay. I've gotten a different pay check every 2 weeks. I've given up on fighting that one.

 

[pgg]

Glory! I finally got ASP today.

I unexpectedly got my MSP/ISP today.

Had to check the news to see if the government reopened when I wasn't looking ... nope. Still closed.

Maybe I better go spend it all before they notice the mistake and take it back. 🙂

 

[Kingfisher]

I unexpectedly got my MSP/ISP today.

Had to check the news to see if the government reopened when I wasn't looking ... nope. Still closed.

Maybe I better go spend it all before they notice the mistake and take it back. 🙂

I got my ISP as well!!! 😍

 

[8654Marine]

As "Marco" (Dave Marcozzi) told us in residency, "the staff exists to keep the war machine rolling". All the staff corps keep the line functioning. As long as you keep that at the forefront, you won't lose the ball.

Marco is a good dude. Was in my residency.