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Maintaining specialized skills in military med

Discussion in 'Military Medicine' started by Rudy, Apr 24, 2004.

  1. Rudy

    Rudy Member
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    Let me preface my comments by saying that as an active duty resident at a military medical center, I am happy to be serving my country and the folks that are fighting for our freedom. I am grateful for the opportunities that the military has provided me and I will serve my committment to the best of my ability. With that being said, I hope you will take my comments as someone trying to provide an honest perspective on one of the major challenges facing military medicine right now.

    As MilitaryMD has alluded to in prior posts, one major problem in military medicine that is not addressed by recruiters is the diminishing case loads and lack of opportunity to maintain specialized skills in military medicine. This is most pronounced at smaller bases away from the larger medical centers, and most severely affects specialized fields such as radiology, pathology, rad onc, surgical subs, etc. The result is that physicians in these fields that are stationed for prolonged periods of time at these bases can atrophy in their training and therefore be poorly equipped to seek a job on the civilian sector or as a teaching staff at a military medical center. Therefore, you get these O-5 and O-6 docs that are barely competent and barely working, becoming a burden to the military medicine, making $140,000 a year just hanging out and biding their time to retirement. These are the kinds of docs that many of the new graduating residents have to work with right out of residency. In my experience, most of the competent, motivated docs get out after their committment is up (we lost four great teaching staff this year), and what you are left with is the dead weight.

    Obviously, there are exceptions to this; there are some O-5 and O-6 docs who are competent and stay in military medicine because they like it. But I think this issue of low case volume is becoming a major problem for military medicine and someone has to start deciding what to do about it. To be honest, even our largest medical centers have been drastically downsized. Look the once busy Bethesda Naval Hospital (or should I say "the President's hospital") for example; it has now been reduced to a very large clinic. Wilford Hall Air Force Medical Center used to be a 1000 be hospital; now 100 beds would be pushing it. The caseload for general surgeons at Wilford Hall has been shrinking; they only do a few cases a week. Yet with Tricare, increasing numbers of patients go to civilian docs for elective surgeries, thus further reducing much needed cases for staff skill maintenance and resident teaching. All of these factors make one wonder how long military medicine can maintain GME and staff these large medical centers that were built in the post WWII years. Something needs to be done.

    I mention this on this board to give some perspective about this issue to those who may be trying to decide on whether military medicine is for them. This is an area of military medicine I knew nothing about prior to signing up. I think the bottom line is that if you love the military, join up; the deployments, lack of physician respect, remote assignments, bureaucracy garbage, etc will not phase you. If you are only doing it for financial reasons, think long and hard; $150,000 in debt can be dealt with fairly easily for most physicians. Just know that in military medicine, you may eventually get the residency of your choice, but maintaining those specialized skills during your payback years may be difficult.
     
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  3. ek6

    ek6 Senior Member
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    I'd expect to either hear:
    1) you're right, the military docs have far too light a caseload to maintain their skills
    OR
    2) it depends on the luck you get with your assignments

    That aside, I'd like to hear some more detailed replies to this post.
     
  4. mitchconnie

    mitchconnie Member
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    I agree 100% with the above post and believe it is the single most critical issue in military medicine today. The lack of opportunity to get first-rate specialty training and maintain your skills as an attending is driving people away. The bureaucracy and assignment politics have always been around, but doctors used to put up with it because they loved doing what they were trained to do. Currently, people interested in maintaining or improving clinical skills leave the services (often bitter about the experience) and those that are interested in lifestyle/operational medicine/Admin. stay. It?s true with nurses as well?witness the number of experienced nurses working the wards (zero) vs. the number of experienced ?clipboard nurses? pushing paperwork (too numerous to count).

    The military doc?s deserve better, but the people who REALLY deserve better are the guys who are out on the line getting shot at. The soldier who gets shot in the abdomen deserves better than a surgeon who did half as many cases in training as his civilian counterpart and hasn?t done a major abdominal case since he finished residency two years ago. The retired master sergeant who has his AAA fixed deserves better than to be taken care of in an ICU where the MOST experienced clinical nurse is a year out of training. The dependent wife with cholecysitis who?s husband is deployed to Iraq deserves better than to have her gallbladder taken out with equipment that is 15 years out of date.

    Putting undertrained and inexperienced surgical specialists into a war zone--or even onto a ward of sick patients--is like sending a pilot out to fly the F-16 over Iraq when he?s been doing nothing but sit behind a desk for two years. It?s like sending a marine into combat who hasn?t fired an M-16 since four years ago in basic training.

    Guys like Pat Tillman who put their lives on the line every day deserve the best health-care money can buy and we are most-assuredly not giving it to them.
     
  5. militarymd

    militarymd SDN Angel
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    Mitchconnie is 100% correct. A more important question is, how can this be corrected?

    I'm not sure what the answer is, but I know that nobody seems to care. In my time in, I have seen the physicians in the military separate themselves in the the following groups:

    1) dedicated physicians who believe in practicing state of the art medicine who become disenchanted in military medicine and leave at the earliest opportunity (I'm in this group...seems like the vast majority).

    2) dedicated physicians who believe in practicing state of the art medicine who remain and put up with the bs for whatever reason....thumbs up to them, but not enough of them.

    3) dedicated military officers who have also MDs in their credentials and who stay no matter what.....brainwashed enough about the military that they seem to have forgotten or never learned what state of the art medicine is.

    4) slackers who can't make it in the civilian world who stay for obvious reasons.

    There is overlap in the groups above. Certain physicians fit into more than one group.

    This somewhat diverse group of physicians is then tasked to fulfill the needs of military medicine which is fairly schizophrenic. The needs are as follows in the military's priority of importance:

    1) operational support - which, when evaluated carefully, is really mostly occupational health/preventive health/health maintenance...very little medicine as specialists think of it. What you see on TV and what is going on right now in Iraq represents a very small percentage of military medicine/operational medicine as a whole.

    2) everything else - dependents/retirees -

    This is what it ultimately boils down to. The military does not need any specialists other then the ones being used in Iraq right now....Pretty much what Rumsfeld said. Only deployable specialties are needed, but most of the time their skills are not maintained because of the nature of the need. We only get casualties occasionally.

    So how can this be fixed? I doubt that it can be. The question for individuals thinking about joining is if you will fit into the system. In order for problems to be fix, there will need to be a major overhaul which I don't see coming. You have to decide if you can fit into an environment where most physicians seem unhappy.

    For those who know it sucks, and if it sucked some more, it wouldn't bother you....more power to you!!!
     
  6. Spang

    Spang SDN Angel
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    My sentiments expressed much more eloquently than I could have expressed them.

    Though I've not yet entered the realm of military medicine I do have a lot of experience on the aviation side, where the situation was similar. Issues of equipment and training (available flight hours) and the administrative BS were not a lot different than those described re: medicine.

    I tried to placate my self by taking as much as I could in order to "compensate" myself for what I was giving. I took every side trip on med dets to see whatever Greek ruins or Roman statue was there. I took extra flight gear for my use when it was available. I took all my leave and flew Space-A as much as I could. I took special lib or basket leave when I could. I hauled home cases of wine without going through customs, when I could. I got bottles of 800 mg Motrin for free when I could. I also lived in Key West for four years, wrote my own flight schedule, supervised the civilian contract maintenance and trained all of the other station pilots. Bought a nice house there and made a lot close friends, there and other places.

    None of this equalled what I could have been making as an airline pilot, but I felt a little better about the red-a$$ing we took on a semi-regular basis. I guess I really do fall into the "sucks, and if it sucked more" category and hope I can overlap a couple of the earlier categories as well.

    Spang
     
  7. Rudy

    Rudy Member
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    The comments above are completely in line with what I am seeing and hearing from active duty docs across all specialties. And again, it has nothing to do with being "negative" or not wanting to support the troops, be patriotic, etc. The reality is that military medicine right now is struggling to support the broad, diverse specialized group of physicians that it has had since WWII. It is almost eery to see large medical centers become so underutilized as ward after ward of patient rooms become converted into more and more admin offices. In San Antonio alone, we have two large medical centers that are barely half-utilized; at BAMC you see large waiting rooms with hardly anyone sitting in the chairs. Yet, Wilford Hall is the "flagship" of Air Force medicine; the other pseudo-medical centers (or glorified clinics) in the Air Force are even slower. Again, these are things that it is hard for medical students to appreciate. Med students are too busy learning how to function on the wards, write progress notes and impress the attendings to notice that military medicine is circling the drain. That is why the perspectives of more experienced folks in this forum is invaluable.

    We are coming to a crossroads in military medicine where a decision has to be made. We need to provide first rate care for the troops in the field, but it is becoming more clear that maintaining the large, expensive complex infrastructure required to provide state of the art care to dependents and retirees is becoming extremely difficult to impossilbe. Something needs to be done, the sooner the better. But the politics and red tape involved with restructuring military medicine are staggering; and no significant changes are likely any time soon. For now, the rest of us are left to watch mil med as we know it die a painful death, and continue to spit shine our little section of the deck of the sinking Titanic.
     
  8. HeavyD

    HeavyD Member
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    How common is it to perform a 'full-time outservice' residency?

    Do those that train in civilian residencies come back to active duty more skilled?

    Is it compulsory to moon-light to keep skills up?

    I have three years left of school but am excited to serve and am willing to do what I can to work toward solutions to this reportedly jacked up system. I am hoping that ya'all will provide some methods, ideas, etc. to us who are in the 'pipe-line' (ie. name's on the dotted line already) so as we might have some tools if only to prevent the further decline of military medicine once folks like myself come on line over the next few years.
     
  9. militarymd

    militarymd SDN Angel
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    Unfortunately, I don't what the individual can do.....other than suck it up, and do your best.

    Then decide whether you want to stick it out or not.
     
  10. idq1i

    Physician 15+ Year Member

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    Have any AD docs here gotten a deferral to do a civ residency?
     
  11. edinOH

    edinOH Can I get a work excuse?
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    This is an interesting thread.

    I was a corpsman in the Navy for few years before medical school. For the last couple of years of my enlistment I worked at NMC San Diego (aka Balboa) in Ophthalmology. I left in December of 1997 so it has been a few years since I have been in the system, but from what I witnessed there, those docs were on the cutting edge of Ophthalmology.

    They had a busy general and subspecialty teaching service. The residency I believe took six per year. There seemed to be plenty of general anterior chamber cases as well as retina, plastics and cornea work including PRK which was the new thing back then. I'm sure Ophthalmology has advanced some since I was there but the "new" technique of "clear cornea" phaco and topical vs retrobulbar anesth. was being aggressively taught and practiced well. The equipment and technology were first-rate and the attending staff were well published and had many on-going projects. Most came either from USUHS or very well regarded civilain institutions including Stanford, Harvard, and Georgetown and received fellowship training at some of the big names in Ophtho. (Wills etc). Our clinic waiting rooms were always full and the OR schedule was full and diverse as mentioned above.

    I can't speak for the other fields of Navy medicine, but I think what I experienced there compares very favorably to what I have experienced in civilian academic medicine.

    On the other hand, I can't really speak to what the general ophthalmologist experienced once he/she graduated and was sent to Guam, Japan or even Camp Pendelton for three years.
     
  12. mitchconnie

    mitchconnie Member
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    Heavy D,

    By "full-time outservice" I assume that you mean a civilian-sponsored program where you remain on active-duty and get active-duty pay while training civilian. Very uncommon for residency--only in a few highly-specialized areas. Very common for fellowships. What is common for residency is a deferment. You basically are a civilian for residency and then come on active duty when you finish--clearly the way to go in my opinion.

    It's hard to generalize that civilian training is always better, but my feeling is that a middle-of-the-road civilian program is better than any military program. In some highly-specialized areas, the military programs are awful. In primary-care, I suspect they are not as bad.

    Moonlighting is absolutely key to maintaining your skills and maintaining contact with state-of-the-art medicine. Your first priority as a military attending should be to get a moonlighting gig set up (kind of a sad statement). It's hard, though, since moonlighting is often discouraged by the administration. Finding a good situation to moonlight is tricky too. You need someplace where you can do shift work--ER and trauma are great. Some critical-care guys I know moonlight doing weekend ICU coverage. It's difficult if you're a cardiologist, or nephrologist, or some other specialty where there really is no good place to do shift work.

    If you work at it, you really can maintain your skills, but the hospital administration does not encourage you and may even fight you. An acquaintance of mine was an orthopedic trauma specialist and spent two years trying to get approved to work one day a week FOR FREE at our local level I trauma center. He was eventually denied the privilege of maintaining his trauma skills because it might take him away from seeing non-operative DJD and sprained ankles in the clinic.

    At some of the smaller bases, I think the higher-ups are more supportive, but I've seen a lot of guy's sneaking around and bending the moonlighting rules to keep their skills current.

    In the long-run, I think the obvious solution is to do away with most military medical centers and military GME entirely, and put all the specialists on reserve status so they can maintain their skills in civilian practice. Tri-care may be the first step and PBD 712 continues the trend. In the short-term, there are way to many O-6 administrators, flag officers, and politicians around with a big stake in the current ridiculous system to let that happen. I would suggest that partnerships with nearby civilian institutions are currently the thing to work toward. I intend to keep my skills up that way, even if it means not being popular with our hospital commander. I hope you can too!
     
  13. r90t

    r90t Senior Member
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    Full Time Out Service (FTOS) is hard to get, and only for limited to programs that aren't in the military medicine training, or has indentified shortage of physicians. This is when your time in service clock is running and you are on full pay and benefits, as well as promotions.

    They have a bunch of deferred positions, where you can apply through the military match to defer to a civilian residency. They do this for high demand residencies such as ortho, opth, and other desirable programs where there is a constant bleeding of talent, or where there isn't enough positions in the military to fill the demand. Your commitment clock is not running and you accrue no time in service during residency. This is limited to HPSP'ers as our brothers and sisters at USUHS are supposed to do an AD internship.

    There is a very easy solution to the problems that we face, but it is unaccepted to the public. That would be to draft physicians as they did in past wars and tricare out as much as possible during times of peace. Then, we would have very experienced trauma, emergency med and general surgeons deployed in Iraq right now. Reserves are good sources of talent, but it will soon be an unpopular option after we deploy reserve doctors in droves, wreaking havoc on private practices. I have a reserve FP friend that was a solo practitioner that flew to No. Cal. F-Sun to see his private practice pts, in an attempt to keep his practice alive.

    There is always the plan to cut navy medicine to only the necessary people to fill operational assignments and hire contractors for all other work at military hospital positions. This has been going on since at least 1995.

    EdinOH- We probably overlapped when I was at NMCSD. Dr. Schallhorn PRK'ed me back in 97.

    I would hope that HPSP students that defer and go to civilian programs bring enough new talent in to keep the gene pool from getting to restricted.
     
  14. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD
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    I'm currently a PGY1 EM resident in a civilian residency s/p HPSP. About 50% of those who match EM in the AF match go to civilian residencies each year.
     

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