Military Health Service "healthy debates"

[Galo]

Well, I never held out much hope for a new forum from the civilian side of the miltiary to get anywhere. As you will see if you care to follow the link, the discussion as to accession and retention problems for physicians has been puny. I posted a comment over 3 days ago asking the Assistant Secretary of Defence for Health Affairs, a Dr. Casscells, if these comments had not been heard by leadership before?? They were soundly noted on every climate assesment survey given to me and my colleagues, to only be summarily spinned to say that things were OK. I also posted a link to this site, and to www.medicalcorpse.com, but I guess that was too much disclosure of what prospective med students are reading now. So after 3 days of patiently waiting, I posted this just a little while ago:

Over 3 days ago I posted my thoughts on the poor quantity of discussion on this site, and posed the question to Dr. Casscells whether or not the little that has been discussed here is new information or not? I feel in every climate survey that was filled out by me and my colleagues, these problems were brought out over and over with no seeming change. Whenever someone asked for out opinion, it was usually someone who really had no power to change anything. SO I am wondering what it will take to change? How far down does recruitment and retention need to get before someone really understands what is happening. The USAF will have a projected 37 general surgeons by 2009, and these projections were set forth by USAF consultant to the surgeon general in March 03.


I also placed a link to a site where much more discussion occurs, though very negative, and what may certainly be considered "bashing", its what many prospective students are understanding as the reality of military medicine. I know the military leadership of the AF knows about the site, and I wondered if Dr. Casscells knew about it, and if not what he thought about it:

http://forums.studentdoctor.net/forumdisplay.php?f=72

I'm not sure why my post was not placed here, no email, no discussion nothing. So I thought I would try it again and see if truly health discussion is something that is wanted. Choosing to ignore the problems will not make them go away. As is evident by the decreased accessions and horrible retention of physicians, something has to be done. I hope this one gets discussion going.

I am trying to repost the presentation from 2003 from the General Surgery consultant to the Surgeon General, but I can't seem to use it as an attachment here. One of the forum members had hosted it and placed a link to it, but that link is now dead. If anyone wants to host it, or has any idea where I can post it, let me know.

SO, what do you all think about this "healthy debate"???


http://www.health.mil/Debates/Debate.aspx?ID=9&a=1

---

Members don't see this ad.

 

[ieatpizza]

I found this particular post on that site to be a novel way to retain physicians interested in academic medicine:

I recently collected data regarding retention of army physicians. I found that of 721 physicians leaving active duty, between 23-27.5 were leaving for positions in academic medicine. This is out of 339 reporting, so this sets a floor of nearly 4% going into academic medicine, with the actual number potentially as high as 8%. This subgroup is very important for a number of reasons: 1) They are already trained. As opposed to trying to get someone to come in as an HPSP student, they are probably $2-300k less expensive. 2) They represent the "cream of the crop". Not all physicians are capable of getting a job in academic medicine. This 4-8% represents some of the best researchers and teachers in our system. 3) They are not leaving primarily because of money. While this may oversimplify, in general academic salaries and O-6 doctor salaries are comparable. This suggests that other, non-monetary factors like supporting their research, hiring ancillary staff, or protection from deployment to do research might be enough to keep them in the army. 4) They have a ripple effect on those around them. This has been studied in the civilian academic setting. Star performers have a beneficial effect on their institution that extends beyond the papers and grants that they themselves write. 5) We are going to pay 50% of their base pay anyway. Most of the moves to academic medicine were retiring O-6s. Here is where the retirement system really bites us in the butt. Right when, in a civilian academic setting, a senior physician/scientist is hitting their stride, we offer them half of their base pay to go away. This is crazy. What I recommend: 1) Offer grants for research, say $100k to $250k (i.e. what we would pay to recruit and train a HPSP student) as unrestricted research grants to the top 5 applicants yearly who are willing to stay after becoming retirement-eligible. 2) Offer the money that they would get in retirement as actual salary (again, we will be paying this money if they leave, might as well use it to get them to stay). 3) During this 2 years, they will not be deployed unless they volunteer. 4) Finally, collect data on all of the physicians who have received the "A" proficiency designator. My hunch is that many (I'm betting over 10%) are leaving the military for civilian academic positions.​

Any thoughts on this? I especially like the idea of supplementing the retirement-eligible officer's income with the retirement money if he stays, in addition to grant money for research. It seems this would be beneficial to the military since they would retain experienced, top-notch physicians (grants would be rewarded on a competitive basis) who would provide some stability in terms of GME. Or would this just create research physicians with no real interest in clinical training and teaching?

 

[IgD]

SO, what do you all think about this "healthy debate"???

I think the reason your comments weren't posted is because they might have been perceived as a personal attack. I think you have some valuable and important points that should be heard. It would be a shame if they weren't posted because of a misperception. Is there a way you could phrase your thoughts in such a way that would be viewed as more positive or constructive?

 

[elderjack21]

SO, what do you all think about this "healthy debate"???


http://www.health.mil/Debates/Debate.aspx?ID=9&a=1

Healthy debates are great, but you know "the Man " (or to be PC, in some cases, “Woman”) kind of sets the tone for what "Healthy" is and generally restricts the level of dissonance.

This was an interesting post there:

Bill at 2008-04-03 12:04:07 wrote:

“Quote
MAJ, MC, USA I echo your concerns about the enormous amount of money that is being spent on physician recruitment by the military services. A good estimate for the overall cost of a 4 year HPSP scholarship on average is 250 to 300,000! That amount is probably a lot more when the actual recruiting costs are factored in (recruiting officers, advertising, etc...). Times that amount by 350 (yearly recruitment efforts by the Army) and we are looking at 105,000,000 dollars spent each year to convince medical students to sign up for the Army. Instead, cut the recruitment budget by half and spend the other half on retention bonuses for the docs in uniform. A much greater effort needs to be directed towards keeping the best trained staff docs on duty! Economic incentives will most definitely improve retention!”

That is a lot of money being spent on recruiting. There seems to be some resentment out there that people signing up for today’s HPSP are getting that 20k, rather than offering it to physicians who are near the end of their contracts. That doesn’t seem like much to me at all. And fast forward 7 years from now, post medical school and post residency, I don’t think another 20k would be even close to enough to keep most docs in.

 

[Galo]

Well, it looks like they finally put it up, but I submitted it on tuesday night before I left town, last night when I started this thread it was not there, and now at 6 PM, its there, but it looks like it was inserted just prior to another post. Anyways, here's what my original post was:

Its clear from the little traffic on this site, that no major discussion is occuring. Unfortunately it seems that when it comes to try and improving military medicine there is more often than not, no ear to hear, no leader to lead. I would pose the question to Dr. Casscells: In what state does the leadership see military medicine in right now?? What steps are being done to change it?? Are some of the issues posted here new to you or those in charge?? As there has been little discussion here, let me suggest the only site I know that has unabatted discussion. Although I am sure diehards will consider alot of it bashing, I think it has made great leaps in giving knowledge to potential applicants, the problems that they could face in military medicine today, and for a long time to come. I know that some AF officers know and monitor the site, so I would not be surprised if you know it, and would also be interested in your comments on it: http://forums.studentdoctor.net/forumdisplay.php?f=72 Another would be: http://www.medicalcorpse.com/index.html Though the last one is not for the weak hearted. It has been my unfortunate active duty experience that when it comes time to seek opinions, and engage discussion, it usually falls on deaf ears, or the person seeking them really has no power to do anything about them at all. I am not much more hopeful on the outside, but I am committed because I think our fighting force deserves better than they are getting. Dr. Casscells, I do hope you can make some kind of comment on where we go from here.

SO, is it that negative?? I mean how do you project the severity of the problem as not negative?? I think part of the problem is that the leadership is so POOR that they really do not get it, or they just cant do anything about it. I mean common!! You can't tell me that they think they have shinola instead of SH&T. Once again, it seems it will continue to be ignored.

ANYONE able to post Peyton's lecture for me??

 

[TX_NFS]

ANYONE able to post Peyton's lecture for me??

Have you looked at using http://www.yousendit.com/ yet? On that main page I think you can upload a file with just your email and a destination email, but once the file gets uploaded it is accessible by anyone via a URL. The file stays up for seven days, but I'm not sure of the restrictions of bandwidth or downloads per day. A related (or possibly same) service they have is a free "lite" account you can sign up for with the same restrictions.

 

[BomberDoc]

Holy s#it, Batman. I'm absolutely shocked that the military would allow a comment on their site that references both this forum and medicalcorpse.com.

 

[Galo]

OK, here it is, available for the next 14 days.

Be sure to look at the bottom of the slides for the narrative. Also note that the projections that have been made for active duty surgeons are now much worse. The actual number expected by 2009 is less than 40, and I got that from an active duty surgeon with access to that information.

If someone can figure out how to make this a sticky?? Or place it on the forum permanently, I think it would be good.

Caveman, is this possible, allowable??

Here it is:

http://www.yousendit.com/transfer.php?action=download&ufid=5DE67EDA3D5EAFC0

 

[Galo]

Ok,

I just posted this:

Dr. Casscells, thank you for placing my post. The following is a link to a briefing given by the general surgeon consultant to the surgeon general in 2003. Feel free to check with the AF staff, as the predictions in that lecture have now not only come true, but are projected to be much lower. How or who do you hold accountable for such a lapse in judgement?? One of the major problems I see is that there is NO accountability to any of these problems. One general leaves, another comes in, the problems get worse or stay the same. Your comments on the briefing?? http://www.yousendit.com/transfer.php?action=download&ufid=5DE67EDA3D5EAFC0

 

[The White Coat Investor]

Very interesting Galo. I imagine an EM presentation would be similar. I found this discussion of seeking direct accessions and FAP candidates particularly enlightening:

"

.Thus, a number of problems are colliding. For the last 5 GME selection boards, we have had only 15-19 qualified applicants for general surgery. One third of our surgeons have more than 4 years in practice but they are leaving and not being replaced. I saw a list the other day that there are many reserve openings for general surgeons as well. Although the recruiters are out beating the bushes for direct accessions and for financial assistance program applicants, this is not a panacea. During my 6 months as consultant, I have evaluated 4 surgery residents for the FAP program. Two were US born but had to go to the islands for medical school, one is an osteopath at the bottom of his class and one has had two felony arrests. Of the two general surgeons, they have 9 and 10 malpractice claims respectively, one of which had his privileges limited and closed his practice months ago.".​

 

[BomberDoc]

OK, here it is, available for the next 14 days.

http://www.yousendit.com/transfer.php?action=download&ufid=5DE67EDA3D5EAFC0

Just got around to looking at the surgery PPT slides. Although it isn't surprising to see the numbers of active duty General Surgeons falling, it is somewhat surprising that nobody in management seems to notice or even care. Apoptosis, indeed.

 

[BOHICA-FIGMO]

Just got around to looking at the surgery PPT slides. Although it isn't surprising to see the numbers of active duty General Surgeons falling, it is somewhat surprising that nobody in management seems to notice or even care. Apoptosis, indeed.

I just wonder how in touch this guy is. At one point in his notes he says, "General surgery has become far less attractive in the civilian world as indicated by the last several civilian matches." What color is the sky in his world? Surgery may not be as lucrative in the civilian world as it once was, but categorical surgery spots are among the most competitive in the match--right up there with diagnostic radiology and ortho.

 

[elderjack21]

Nice brief. One of the biggest problems highlighted was that there weren't enough cases for the number of surgeons. Now that there aren't that many surgeons, should the caseload be much higher? Or does it not work that way?

What is the general policy on moonlighting? Where I was stationed at (army), residents couldn't moonlight, but staff did all the time. Is this something that commanders at respective hospitals can set policy on? (as in restrict you to not moonlight?)


Has this changed since 2003: "We talked about the negative impact of deployments on currency. Note that those surgeons who deployed for OEF and had the opportunity to actually provide surgical care to our forces, found the calling for which they joined the AF. Recently, I have surgeons call and ask "how can I get to the war?" I have not had a single surgeon ask "how can I get out of the war?" We just want to be current and we want to have the very best skill when those skills need to be brought to bear."?

 

[Galo]

I just wonder how in touch this guy is. At one point in his notes he says, "General surgery has become far less attractive in the civilian world as indicated by the last several civilian matches." What color is the sky in his world? Surgery may not be as lucrative in the civilian world as it once was, but categorical surgery spots are among the most competitive in the match--right up there with diagnostic radiology and ortho.

This guy was very in touch!! Although very much a company man, he did an oustanding job with this report not only in gathering the data, but in putting it in a straightforward manner that a third grader could read. Also, general surgery in the civilian world has slowed down severely, many programs did not fill in the last couple of years, and the pool of candidates despite the mandatory 80 hr workweek has decreased both in number and in quality, and no where near as competitive as ortho or diagnosic/interventional rads.

In the next 10 years there is going to be a very large defecit of general surgeons in the civilian community. In the military, its going to be much sooner.

 

[Mirror Form]

This guy was very in touch!! Although very much a company man, he did an oustanding job with this report not only in gathering the data, but in putting it in a straightforward manner that a third grader could read. Also, general surgery in the civilian world has slowed down severely, many programs did not fill in the last couple of years, and the pool of candidates despite the mandatory 80 hr workweek has decreased both in number and in quality, and no where near as competitive as ortho or diagnosic/interventional rads.

Gen surg went through quite a down period, but that does seem to have reveresed somewhat w/ the 80 hr work week. My graduating class a few years ago had tons of strong applicants gunning for competitive gen surg slots.

In the next 10 years there is going to be a very large defecit of general surgeons in the civilian community. In the military, its going to be much sooner.

That scenario is extremely unlikely. This is because many people go into gen surg with the intention of doing a fellowship later. If the market for gen surg ever improved, there would be tons of people ready and available who would just stay gen surg instead of doing fellowships. So it's one of those fields like IM, where there'll never be a significant shortage.

 

[Galo]

Gen surg went through quite a down period, but that does seem to have reveresed somewhat w/ the 80 hr work week. My graduating class a few years ago had tons of strong applicants gunning for competitive gen surg slots.

anecdotal at best, not nationwide representative.

That scenario is extremely unlikely. This is because many people go into gen surg with the intention of doing a fellowship later. If the market for gen surg ever improved, there would be tons of people ready and available who would just stay gen surg instead of doing fellowships. So it's one of those fields like IM, where there'll never be a significant shortage.

The following is an article from Journal of American Surgery:

During the past 25 years, there has been much debate about general surgical workforce supply and demand. In the late 1970s and early 1980s, concern was raised by the Study on Surgical Services for the United States and the Graduate Medical Education National Advisory Council that there would be a gross oversupply of total physicians and surgeons by the years 1990 and 2000.

In a 1990 report sponsored by the Council on Graduate Medical Education, reevaluation of the workforce data showed no surplus at that time and instead predicted a deficit of surgeons by 2010. Studies by other investigators in the mid-1990s supported these conclusions. Furthermore, a new workforce model published in 2002 predicted a significant overall deficit of physicians by 2020. The discrepancies in the projected and the actual data have been explained by a variety of factors including an aging population with increased surgical needs, an increasing number of outpatient surgical procedures, subspecialization within the field of general surgery, and decreasing interest in the field by United States medical students.

Although it is difficult to compare data among studies, and there are many confounding factors in the data, review of the workforce data does support a future deficit of surgeons, a prediction that warrants further investigation.


This kind of debate is not really as important as the fact mil med sucks and getting worse, but if you look at the literature, there is a shortage of general surgeons coming whether you want to believe it or not.

 

[Mirror Form]

This kind of debate is not really as important as the fact mil med sucks and getting worse,

agreed.

but if you look at the literature, there is a shortage of general surgeons coming whether you want to believe it or not.

No doubt that as the boomers close in on their 70's, there will be a shortage of all types of surgeons (and actually of all doctors in general). Because gen surg residencies are a pre-req for many fellowships, it will likely suffer less of a shortage.

If the job market is that great, physicians will just take job offers as general surgeons instead of going on to do a fellowship. The worst shortages will probably be in the less lucrative (comparitively speaking) surgery fellowships like thoracic surg, where they won't be able to recruit enough surgeons into their fellowships b/c the surgeons will be able to make just as much w/o a fellowship.

 

[Galo]

This was my last post on the "healthy debate" since it was scheduled to close today:

Its unfortunate that this forum will come to a close tomorrow. Its evident from the few posts that the criticism all seem to be in line..........poor leadership, poor support, poor pay, poor working conditions, and a poor ability to practice medicine. I realize nothing will be solved in this forum, and it may be presumptious of me to expect Dr. Casscells to begin to explain, or even excuse the conditions of military medicine as I have asked. Unfortunately I have few answers. It seems writting congress does nothing, being in the military and raising these questions only makes you a target for retribution, the general public seems could care less, I'm not sure how else to effect or even if I can contribute to make a change. The only way I can help, is to educate prospective physicians of how bad the military medicine has become, and that hopefully by not joining, the leadership will finally get a clue. I invite anyone reading this to keep further discussion going on the only other forum I know for this: http://forums.studentdoctor.net/forumdisplay.php?=72


This was the responce I found today:

We are extending this debate to April 23 - Please continue to submit your valuable comments and suggestions and keep the debate going.

Not quite sure it means much, but now's the time if anyone thinks its worth a few minutes to put your opinion where it seems, (???????????), someone maybe looking at it, or having a good laugh, don't know which. I think even the cheerleaders should say what they feel is negative if anything. Though I doubt personal attacks and idiocy will get posted, so let it be known how you feel in a "healthy" way. Have at it!!

 

[Galo]

I recommend you all take a quick look at the "healthy forum." There has been some good ol discussion about the state of military medicine, including some from retired docs. Certainly looks like someone other than leadership is listening. What worries me is that no matter how many negative posts they get, they will summarily dismiss them as outliers, atypical docs with an "ax to grind", "trouble makers", etc etc, the usual insults we get from those who believe there is no problem, or that we should not bring them up.

 

[Galo]

I looked at this forum, and it's stupid. It's just a series of disjointed comments, none of which actually relate to each other, interpersed with questions that are clearly and obviously out of place ("How can I become a psychologist in the military?"). The formatting is difficult to read, and there is no coherent theme, despite the promising title. You seem to be the only person on the thread who is actually addressing the topic at hand.

In all honesty, I don't understand why you're wasting your time with this site.

Same reason I waste my time on this site. To try to educate and give a different option to those young umpressionable gullible college/med school graduates (much like I was), who get fed a bunch of lies by recruiters or cheerleaders about a system that is decrepid, getting worse, and that anyone really thinking of joining it, needs to think hard about the reasons why, and the potential outcomes.

You reading the same site? Looks like a number of physicians have posted what amounts to very negative experiences with some recommendations that although make perfect sence, will never be applied to the system, because of leadership, funding, military mindset issues.

Remember, its only up for 3 weeks? How long did it take this site to get to the point it is now? YEARS, so I don't expect much from it. I seriouly doubt this guy Casselles neither has the power or will to enact any change. The only comment he's made is to tell someone how to get into the system.

 

[Sgt Whizzo]

Galo,
Thanks for posting link to Healthy Debates site. Seems as if the forum has been extended again (for new input) to 4/30 as more people are finding the site and posting. Let's keep spreading the word so that the senior leaders hear from people who are at decision point or who have already decided. I have seen many talented people leave and hope that their input will make things better for the next generation. There is a lot of constructive input amongst doctors at decision point as we each wrestle with the realities of staying/going and what would have pushed us one way or the other. Input has very little effect at MTF level but may actually have potential for policy-implications via this discussion given the audience.

 

[Perrotfish]

I looked at this forum, and it's stupid. It's just a series of disjointed comments, none of which actually relate to each other, interpersed with questions that are clearly and obviously out of place ("How can I become a psychologist in the military?"). The formatting is difficult to read, and there is no coherent theme, despite the promising title. You seem to be the only person on the thread who is actually addressing the topic at hand.

Well, it is basically a brainstorming session, if you look at it that way. The ideas would have to be disjointed because they´re just that: ideas, not a coherent plan yet. Some people comment on GMOs, others on leadership, other on that computer system everyone hates, and yet others on how much they need to pay HPSP students to get more to join. Who knows, they´ll almost definitely not do most of what they need to do, but they maybe they might take at least one thing from it. Who knows, maybe at the end of the debate they´ll keep everything else but at least start phasing out that computer system everyone hates.

Galo, would you ever consider a position in military leadership if you felt you could help bring about the sort of reforms you´ve been suggesting?

 

[a1qwerty55]

I seriouly doubt this guy Casselles neither has the power or will to enact any change. The only comment he's made is to tell someone how to get into the system.

"This Guy", Dr. Cascells (nice job mispelling his name), is well respected by all who know him (Cardiologist, clinician researcher and educator), and having met him, I for one can say he totally gets it.

What do you expect him to do? Personally answer your questions, or somehow change the course of the MHS supertanker instantly?

Give the him some credit for doing what no one else has ever done - creating an open official forum, where concerns can be raised and solutions proposed. Did you ever think that by doing so officially that perhaps this might create some capital for some of the changes we would all like to see?

Do you in your narcisistic fog believe that everyone other than yourself is an idiot?

Sadly, he's only in the job till the election and then God knows what we will get.

 

[Galo]

"This Guy", Dr. Cascells (nice job mispelling his name), is well respected by all who know him (Cardiologist, clinician researcher and educator), and having met him, I for one can say he totally gets it.

What do you expect him to do? Personally answer your questions, or somehow change the course of the MHS supertanker instantly?

Give the him some credit for doing what no one else has ever done - creating an open official forum, where concerns can be raised and solutions proposed. Did you ever think that by doing so officially that perhaps this might create some capital for some of the changes we would all like to see?

Do you in your narcisistic fog believe that everyone other than yourself is an idiot?

Sadly, he's only in the job till the election and then God knows what we will get.

I wish it would have been longer till you crawled out of the pit. Once again, your comments serve no purpose here other personally insulting me. Typical of the incorrigible cheerleader who suddenly seems surprised that just now a forum for change has been enacted. Are you surprised by the amount of army docs with complaints?? You in the same army??

As always, you have your head so far up your *** that you can't see past your eyelashes. I'm sure at some point in your accession of power you have filled out a "climate survey". In case you haven't, they are usually done minimum on a yearly basis, and are compilled and given to the Chief of the Air Force, Navy, and I'm assuming Army. So I'm I surprised that someone in the company started a mechanism to hear complaints? Yes. How could the "MHS supertanker" (as you so cleverly call it, boy you're smart), have gotten this off course with no one asking a question despite all the warnings. If Dr. Casscells (happy now?) is just learning this information, he did not do his homework before taking this job.

I think this "new" information will likely lead to not much change, or not nearly enough to put the "MHS supertanker" back on course. Getting rid of officers like you would be a start, the civilian world is going to chew you up and spit you out. Being an A_HOLE as a civilian doc is not well tolerated. Do your self a favor, stay on the ship, swab the deck, and go down with it.

Oh, by the way, on the forum, his name is spelled both ways, note the direct line from his responce to me and others:

ward cascells at 2008-04-20 15:37:22 wrote:

So what now cheerleader?

 

[a1qwerty55]

I wish it would have been longer till you crawled out of the pit. Once again, your comments serve no purpose here other personally insulting me. Typical of the incorrigible cheerleader who suddenly seems surprised that just now a forum for change has been enacted.

As always, you have your head so far up your *** that you can't see past your eyelashes.

If Dr. Casscells (happy now?) is just learning this information, he did not do his homework before taking this job.

Getting rid of officers like you would be a start, the civilian world is going to chew you up and spit you out. Being an A_HOLE as a civilian doc is not well tolerated. Do your self a favor, stay on the ship, swab the deck, and go down with it.

Another eloquent and professional response from the troll FORMER USAF Surgeon. To those placing any stock in this guys comments, bookmark this idiotic post.

I took offense that you are too dense to figure out that you insulted the top Civilian Leader in the MHS, who actually is trying to do what he can do. The guy took the job to fix the problems. Nothing like assuming he is the problem without any information to support your assumption. Your pathology is that you always assume you are the arbiter of truth and everyone is some inferior being. If anyone doubts this take a look at this guys posts.

Are you that dull that you can't figure out that I think his forum is a good thing?

 

[Galo]

Another eloquent and professional response from the troll FORMER USAF Surgeon. To those placing any stock in this guys comments, bookmark this idiotic post.

I took offense that you are too dense to figure out that you insulted the top Civilian Leader in the MHS, who actually is trying to do what he can do. The guy took the job to fix the problems. Nothing like assuming he is the problem without any information to support your assumption. Your pathology is that you always assume you are the arbiter of truth and everyone is some inferior being. If anyone doubts this take a look at this guys posts.

Are you that dull that you can't figure out that I think his forum is a good thing?

On a recent post you said you regreted finding this forum. I wish if you did not have anything other than your vile attacks, you would just stay away. Go back an look at 95% of the crap you post, and most of it is a direct reaction to what I say. You are always the attacker. You must have some deep resentment towards me, and I don't know why, and if I speculate I will only insult you. You contribute nothing here other than making a side show of insults to derail the conversations.

Caveman, other admins, could you please review this current ACTIVE DUTY UNTOLD BRANCH OF MEDICINE TROLL's activity and BAN HIM! What purpose does it serve to just come on and insult people. I said nothing about him, and if he disagrees, he should just say so, instead of coming on with insults. Its truly a view of what type of so called professional he is, and from his conduct here, he is no professional at all.

People can judge for themselves, or just ignore your *****ic ramblings.



Back to the original issue of the thread, is that I'm frustrated, (as I'm sure are others), of these seemingly outward attempts at change. They happen when we are asked to do climate surveys, we were interviewed by HQ personell asking us what we need, we write letters to the surgeon general......point being, this is not the first time this information should have been available to these people in command, and I hope change starts, but I'm skeptical.

 

[Perrotfish]

I took offense that you are too dense to figure out that you insulted the top Civilian Leader in the MHS, who actually is trying to do what he can do. The guy took the job to fix the problems. Nothing like assuming he is the problem without any information to support your assumption. Your pathology is that you always assume you are the arbiter of truth and everyone is some inferior being. If anyone doubts this take a look at this guys posts.

Common, you were unnecessarily rude. If I read your post correctly you were responding to Galo´s comment of

I seriouly doubt this guy Casselles neither has the power or will to enact any change. The only comment he's made is to tell someone how to get into the system.

From what I read in your origional post, all you really meant to say here was something along the lines of:

"Actually I know Dr. Cascells, he´s a respected cardiologist with a good reputation and I think he´s trying to help. I think you should give him the benifit of the doubt, it takes a long time to change things in the military"

There was no reason to throw in:

Do you in your narcisistic fog believe that everyone other than yourself is an idiot?

That provokes a fight, which rather keeps your origional point from getting across.

As for

What do you expect him to do? Personally answer your questions, or somehow change the course of the MHS supertanker instantly?

You have to admit that the moderator did take the time to respond to the person who posted that they were interested in joining.

 

[a1qwerty55]

Common, you were unnecessarily rude. If I read your post correctly you were responding to Galo´s comment of

From what I read in your origional post, all you really meant to say here was something along the lines of:

"Actually I know Dr. Cascells, he´s a respected cardiologist with a good reputation and I think he´s trying to help. I think you should give him the benifit of the doubt, it takes a long time to change things in the military"

There was no reason to throw in:

That provokes a fight, which rather keeps your origional point from getting across.

As for

You have to admit that the moderator did take the time to respond to the person who posted that they were interested in joining.

I think it is very clear that to say I dislike Galo is an understatement.

It also is clear that there is a very long history on his part of reacting to all who disagree with him with slanderous rants, and pointless hyperbole. I'm his most recent target.

As far as Dr Cascells. I have met him but only briefly. I would not characterize that as knowing him. I guarantee he doesn't know me, nonetheless, a limited encounter can provide some insight into someones knowledge and motivation.

With regards to narcisism - look for traits like being hypercritical of others in positions or authority, thinking your perspective is always correct, and feeling like you are under appreciated and under recognized. The content of his posts, would suggest at least narcisistic traits. Sure it is an insult, but when you throw rocks, sometimes they come back at you.

Galo has a very simple (overly simple for a professional) understanding of the workings of government agencies. He somehow thinks that Dr Cascells can just flip a switch and increase pay, change deployments etc. My point it set Realistic Expectations. Remember that the USN, USAF, and USA Chiefs of Staff have to all agree on pay changes etc, this means that so long as buying airplanes, ships etc, take a priority to recruiting and retaining physicians, there can be no change. Maybe Dr Cascells can beat them (JCS) over the head with data, posts etc. Maybe there will be a motivation to change. Remember that the line guys already think we are OVERPAID (scary but true). Anyway you slice it, it is commendable that he opened the forum.

I'm impressed he responded with a post. It would be unreasonable and frankly unwise for him to try to react to posts, point by point.

I just hate the everything is broken, nothing can be fixed tone of every single one of Galo's posts.

To prospective or current HPSP students, current residents, GMO's. Please realize that there are good people spending lots of energy, and personal time trying to make things better. This is a fact and it does not soft peddle the problems the system has. But anyone who is an honest broker can point to postive changes even if very, painfully slow in coming.

 

[Perrotfish]

I have held off answering Galo, Dr Glass, Navy Doc and all the others who have been candid and generous with their input. It seems clear to me we need to do more to reward people based on not just the quantity but the quality of clinical care, teaching, research,and their insistence on improving the system. Such evals ought to include not just the commander but peers and patients and students. The rewards need to be multiple (dollars, assistance, recognition, advancement), etc and the docs should have some choice. I too have seen the numbers that say we are fine on recruiting and retention but i do not believe the posts here are mainly from people with personal frustrations because there are so many detailed and innovative suggestions. Also, i believe the quality of our recruits is not the best it could be. I will share all the comments with the Undersecretary for Personnel and Readiness David Chu, PhD, and our SGs, and ask my deputy Steve Jones PhD (like Dr Chu former Army) and Mike Dinneen, MD (CAPT,USN,ret) to review the posts and see if they could be used to design a quick survey so we can determine how a broad cross-section rank the priorities and proposed solutions. Meanwhile, I will keep checking back for new posts, and we will push the comments to a wider listserv. Thanks, Ward Casscells,MD

Dr. Casscells first response to the thread. Thought I would post it here.

 

[Galo]

I think it is very clear that to say I dislike Galo is an understatement.

It also is clear that there is a very long history on his part of reacting to all who disagree with him with slanderous rants, and pointless hyperbole. I'm his most recent target.

As far as Dr Cascells. I have met him but only briefly. I would not characterize that as knowing him. I guarantee he doesn't know me, nonetheless, a limited encounter can provide some insight into someones knowledge and motivation.

With regards to narcisism - look for traits like being hypercritical of others in positions or authority, thinking your perspective is always correct, and feeling like you are under appreciated and under recognized. The content of his posts, would suggest at least narcisistic traits. Sure it is an insult, but when you throw rocks, sometimes they come back at you.

Galo has a very simple (overly simple for a professional) understanding of the workings of government agencies. He somehow thinks that Dr Cascells can just flip a switch and increase pay, change deployments etc. My point it set Realistic Expectations. Remember that the USN, USAF, and USA Chiefs of Staff have to all agree on pay changes etc, this means that so long as buying airplanes, ships etc, take a priority to recruiting and retaining physicians, there can be no change. Maybe Dr Cascells can beat them (JCS) over the head with data, posts etc. Maybe there will be a motivation to change. Remember that the line guys already think we are OVERPAID (scary but true). Anyway you slice it, it is commendable that he opened the forum.

I'm impressed he responded with a post. It would be unreasonable and frankly unwise for him to try to react to posts, point by point.

I just hate the everything is broken, nothing can be fixed tone of every single one of Galo's posts.

To prospective or current HPSP students, current residents, GMO's. Please realize that there are good people spending lots of energy, and personal time trying to make things better. This is a fact and it does not soft peddle the problems the system has. But anyone who is an honest broker can point to postive changes even if very, painfully slow in coming.

Regardless of your backpeddaling, you are always the instigator of fights, you are rude, unprofessional, and I bet you are not liked at all by the people you work with, and will not be liked by the people that hire and likely fire you.

As much black and white as you assert I see things, as usual you let your vindictive insinuations dominate your thoughts. If I say things are broken what can you say that is not.

Once again, I call the administrators of this forum to BAN this ridiculous TROLL how admitedly has a problem with me, (although he's never met me).

 

[Galo]

Presuming the cheerleader will go fire some army doc he does not like, I'd like to get back on topic.

I think one of my friends who does not post on this forum for ovious reasons, (jerkoffs like A1qwerty, premeds, and med students who refuse to accept reality), could not have placed a more succint and on the point post.:

I am a former AF interventional radiologist who had been a department head and who is a friend of Galo's. Prior to medical school, I was a line officer who was a program manager for electronic warfare systems so I've briefed Generals and Undersecretaries of the AF, seen the financial side of the AF and have some rudimentary understanding of the power plays that occur. I've been in private practice for slightly less than 4 years. I have watched the site after Galo notified me of its existence and waited to decide if I would weigh in on the discussions. Can't really tell you why I'm taking my time to do this (I've had to rewrite the thing about 6 times, and it is massively truncated from its original form), but perhaps it's that I want to believe something can be done to ensure that those who put everything on the line are taken care of properly. I don't know that I really have any more to add than to what has already been posted as all of the observations are, in my opinion, critically salient, and during my AF existence, all have also been mentioned in various forums. What I can offer is about 20 + years of observation (almost 16 creditable towards retirement but left while I still had remnants of gastric mucosa) of the "system" (AF bias admittedly, but the problems expressed by the Navy and Army docs aren't too disparate from what I saw in the AF) and its evolution/devolution. As military medical care is an emotional topic for me I will try to keep this brief, but it will be difficult, as I believe you cannot and should not divorce emotion from the discussion. Dr Cascells, I know you've been in your position for about a year, have done a tour in Iraq and more than likely done more than your fair share of "homework" on this topic, but I don't know if you have the sense of perspective/frustration from someone who did their level best to change the system from within while trying to be as tolerant as humanly possible of its inadequacies but finding that being piratical always worked more effectively than being articulate. Ultimately the bucket went to the well once too often and I had no more energy to reinvent the wheel another time at another assignment with another hospital commander nor wanting to hear more physicians (or nurses) turned admin types spout management buzzwords/platitudes/tripe. As is obvious from the posts, the problem is a hydra. Always has been. Always will be, especially if we repeat the individual "fixes" of the past. Can't just cut off one head you have to kill the whole thing. Our insight means nothing if there is no will to implement change from those who control the purse strings and Dr Cascells is not given the latitude to implement essentially all of the changes placed on the posts. Without that assurance, we'll just continue to stumble along with half-fixes. That may sound naïve, but, in respectful disagreement with gas gangrene's post, the system isn't toxic, from where I'm sittin' it's now serious enough to liken to a widely metastatic malignancy. The "fix" will have to be a widespread multifaceted one (just like chemo with adjuvant therapies) and if you are not given that latitude, we will be doomed to failure. I would like to offer a couple of final inputs regarding the generation of the survey you have proposed. Many of us are exceedingly wary of surveys. Every single one that I participated in was completely toothless. Try to assure folks that positive change will come from this particular process and how/why this is different from years past. To me all of the fixes should have priority one, but realizing that likely will not be fiscally possible, at least group them somehow into the ones that might be reasonable from a fiscal perspective and have people select from groupings as well as latitude to propose others. To all of you who are in and those who remained through to collect retirement, my admiration is with you. I do truly miss taking care of the military patient population and the close interaction with my various colleagues, but could no longer tolerate the multitude of difficulties inherent to the system (As one colleague said " A ton of feathers is still a ton."). I would like to think we've thrown down a gauntlet to those who can effect change. Our visibility, due to relatively recent and often unfortunate events has likely never been greater. To Dr Cascells, I would say from what I've seen in the posts, you've been given all the critical reagents to proceed, what is needed is an appropriate catalyst to make sure all those reactions happen to get the desired product and the reaction can continue to proceed once you have gone. Thank you for considering my post.


I think alot of ex-military physicians feel this heavy disconnect after leaving the service and having tried their very best to change a system that continually blocks good efforts. Can you imagine working for a cheerleader like A1? It would be complete misery. Now imagine the head nurse A1, the squadron commander A1, the Hospital commander A1, the surgeon general A1. Any suggestion, complaint, demand becomes tantamount to career suicide, so eventually the smart ones stop beating their heads against the wall, get out, and rarely look back. Although I think the system has multifaceted problems, having ineffective leadership, metric loving, physicians like A1, non-physicians with no knowledge of leadership, poor support, poor finance, and a mentality that no or little change needs to occur, and you have this malignant growth (my friend's great description), that needs multiple treatments of different kinds that I seriously doubt the military will be willing and able to accept. So once again, I am a skeptic. Have a contrary viewpoint, plainly state it, and don't rip my head off like a petulant, unprofessional, *****ic oaf.

 

[Perrotfish]

You lob vile bombs at our coworkers and profession, then act suprised that they come back at you? If you stuck to trashing the system, you'd get far less venom directed your way. Instead you actively trash any AD physician who is not actively trying to get out of the service, portraying them as stupid, incompetent, and uncaring. What were you expecting to hear from career military docs? Honestly.

Yeah but you have to look at it from thread to thread. Responsibility for the current rudeness goes to the person who lobbed the first rude comment in this thread. That honor would go to A1, Galo was staying pretty much on topic and had not insulted anyone. So, in this thread, I would say that Galo has a right to feel offended.

As for who started this whole cycle of rudeness in the first place, I think you would have better luck sorting out the whole Palastine-Israel thing.

 

[Galo]

You lob vile bombs at our coworkers and profession, then act suprised that they come back at you? If you stuck to trashing the system, you'd get far less venom directed your way. Instead you actively trash any AD physician who is not actively trying to get out of the service, portraying them as stupid, incompetent, and uncaring. What were you expecting to hear from career military docs? Honestly.

That they're idiots. Just kidding.


Perhaps you haven't been paying attention to what's occuring in mil med. Show me where I have trashed someone for merely being on AD and not trying to get out. As usual you are following A1's lead, and you are going down a path that will not lead you to a happy place. Also show me where I have called someone (without being provoked), stupid, incompetent, and uncaring.

I have experienced those type of physicians mostly, in the military. Also, if you have not noticed, I am not the only one writting reality about the military. If you go on the MHS site you can see that its coming from all services from all different docs. You gonna call them out for thrashinig the system. Just maybe you are on the tip of realizing what you got yourself into, and are becoming defensive. As you've alluded to in the past, keep posting your experience once you become an attending. Let's see where this wonderful system takes you.

Stop making this thread about me, its about MHS. If you got an opinion on it post it.

 

[Galo]

<sigh> Yes yes, it's just one big cheerleading squad. I'm just his puppet on a string . . . for the love of God, do you see me calling you militarymd's boy toy? Seriously, there are a lot of people here who disagree with you. Most have their own reasons for it. We don't get together to get "leadership" from anyone.



I hardly think you confer with him, but it seems when he takes a personal attack, you are right there behind him. People who disagree with me need only say so, and if they have evidence to back them up, then bring it. What does not make sense is to start out the disagreement with insulting me. Show me where I have done that to you or anyone else, and I don't think pointing out that one has no experience...premed, med student, resident to some degree..... is an insult.


No, and I'm not calling you out for trashing the system. I'm lightly chiding you for suggesting that unprofessional posts should get a user banned. If that were the rule here, you'd be on your 9th or 10th account.


Perhaps you are right, but I'm so narcisistic I think its always a reaction. I need to meditate more.



You're right, and I will stop hijacking your thread.

I just want people to learn what others are saying. Here is a decent number of physicians who never post here telling it like it is, and its an opportunity prospective applicants should be privy to. Would you have made the same decision if you access to all this information?? Say me and exusaf, and exmilmed did not exist, but you read what those docs are saying. I certainly would have chosen another route.

You don't need to answer my questions unless its burning you.

The answers in bold are mine. I've been on this forum for a long time, and I have to confess stupidity that I do not know how to answer people in the blue blocks like they do me.?

 

[DoctorPardi]

Ok guys let's keep it civil. If the thread continues to degrade into personal attacks it may be closed and warnings may be given.

 

[ieatpizza]

OMG, this thread has devolved. And that post by the Dr. Coiner (the former AF IR) was a little excessive on the metaphors.

 

[TX_NFS]

The answers in bold are mine. I've been on this forum for a long time, and I have to confess stupidity that I do not know how to answer people in the blue blocks like they do me.?

At the bottom right of every post, there are three buttons. The leftmost one is if you just want to quote one post. The smaller one in the middle allows you to flag multiple posts you want to quote... after flagging to your heart's content, you just click the main 'post reply' button (or at least I do) and it should have the associated quotes. The right most button is "quick reply", which doesn't do much I know of for quoting.

Now, if you wanted break up a post into multiple quoted sections, I don't know of any other way other than manually adding in the quote tags. Adding {QUOTE=XYZ}I'm sleep deprived{/QUOTE} but using normal [] brackets instead of {} should yield:

I'm sleep deprived

It seems that the closing /quote tag is missing for the first block of Tired's text you quoted, so that's why it didn't work. The tags should also work regardless of typing them in caps or no caps.

 

[Homunculus]

You're the milmed mod now? I thought Hom was our guy?

i still am. someone reported a post, and it gets sent to the general mod populus as well as me. i tend to be more hands off-ish with this stuff, but this thread has caught my attention. and now that it has been officially reported, even more so.

--your friendly neighborhood scrutinizing caveman

 

[Galo]

i still am. someone reported a post, and it gets sent to the general mod populus as well as me. i tend to be more hands off-ish with this stuff, but this thread has caught my attention. and now that it has been officially reported, even more so.

--your friendly neighborhood scrutinizing caveman

I know I have been equally nasty with A1, but its mostly after being insulted without provocation. His continual unprofessional behavior and personal attacks at me, bomber doc, and others continues to detract from intelligent discussions, and I see no purpose for his continued derailments. If we are ever to have a civilized discussion we need this harrasment to stop immediately.

If you go to the MHS forum that was put up, you can see that there are many unhappy physcians letting their frustrations be know. I've yet to see someone attack them for their opinions. I assume we are all working with getting our service men and women the best care possible, and that is just not happening now.

 

[Homunculus]

I know I have been equally nasty with A1, but its mostly after being insulted without provocation. His continual unprofessional behavior and personal attacks at me, bomber doc, and others continues to detract from intelligent discussions, and I see no purpose for his continued derailments. If we are ever to have a civilized discussion we need this harrasment to stop immediately.

If you go to the MHS forum that was put up, you can see that there are many unhappy physcians letting their frustrations be know. I've yet to see someone attack them for their opinions. I assume we are all working with getting our service men and women the best care possible, and that is just not happening now.

oh, c'mon. you are just as culpable as he is. remember, i'm a pediatrician-- i see this all the time. you can't poke someone repeatedly then go running to the nearest authority figure when they fight back. do you ever wonder why you are the person having most of the issues with him? most other people seem to do fine here, perhaps you need to look at your posts vs some of the other posts that don't get an emotional response and see what is different.

honestly, you and qwerty need to figure out how to co-exist without ruining threads you participate in. you both realize there is an "ignore user" feature, right?

--your friendly neighborhood brushing off his admin club caveman

 

[elderjack21]

OMG, this thread has devolved. And that post by the Dr. Coiner (the former AF IR) was a little excessive on the metaphors.

yeah, way over the top with metaphors...it was like reading a PS by a pre-med trying to show he knows some medical terms.

Anyway, this thread started out well...but has gone down the road of others here...garbage.

Too bad we all perceive reality in a different way and are not conformists, it would be so much easier if we were, but less interesting.

 

[Galo]

oh, c'mon. you are just as culpable as he is. remember, i'm a pediatrician-- i see this all the time. you can't poke someone repeatedly then go running to the nearest authority figure when they fight back. do you ever wonder why you are the person having most of the issues with him? most other people seem to do fine here, perhaps you need to look at your posts vs some of the other posts that don't get an emotional response and see what is different.

honestly, you and qwerty need to figure out how to co-exist without ruining threads you participate in. you both realize there is an "ignore user" feature, right?

--your friendly neighborhood brushing off his admin club caveman

Caveman, that's a bunch of crap. You need to look at the last few posts, and see that my poking is only as a reaction to his unprovoked insults. If you can't see that, I'll need to aks someone with more authority to look into it. Wow, this is like deja vu. Also this is the first time I have ever complained.

I'll strive for restraint.

 

[Mirror Form]

Caveman, that's a bunch of crap. You need to look at the last few posts, and see that my poking is only as a reaction to his unprovoked insults.

Please stop acting like the innocent victim. You already lost the higher ground by responding with similar vitriol. You're getting right down on A1's level and hence have no room to turn around and then complain about who "started it" first.

 

[a1qwerty55]

Please stop acting like the innocent victim. You already lost the higher ground by responding with similar vitriol. You're getting right down on A1's level and hence have no room to turn around and then complain about who "started it" first.

I must say I'm a bit offended if you think that I have ever stooped to the depths of Galo. Put our posts side by side and see which on average are more useful and less offensive. I'll admit it I really dislike the guy, but the vast majority of my posts, are brief, and factual, and with the exception of one drunken rant don't fall to his depths. I'm no angel but give me a break here.