Military Medicine: Fire. Aim. Ready.

[MedicalCorpse]

Military Medicine: Fire. Aim. Ready.

TL;DR: The Pentagon is finishing tomorrow a six-month review of how to reverse course and bring dependents and retirees back to the military health system (MHS). Of course, they plan to start moving physicians and other "providers" to implement this plan no later than the next day.

Here's the List of Military Clinics That Will No Longer Serve Retirees, Families

Since 2017, the Department of Health Affairs (DHA) which now runs what used to be military "health care" under the Department of Defense (no longer "military medicine" since physicians were demoted to "providers" in the 1990s) has been implementing their carefully thought-out Slash Treatment/Undermine Physicians/Infuriate Dependents (S.T.U.P.I.D) Plan to restrict care at military treatment facilities (MTFs) to active duty only.

155,000 Military Health System Patients to Be Pushed to Civilian Care Starting This Year

Surprisingly, they got pushback from whiny, intelligent people, so they revised the plan to exclude 29 sites that were allowed to continue to see dependents and retirees to maintain the clinical skills of "providers" if they wanted to. Or not, whatever.

In Reversal, Defense Department Now Wants to Bring Tricare Beneficiaries Back to Military Health System

Then, in December 2023, the M0rons In Charge (MIC) of "military health care" gathered around a huge wooden table at the Pentagon with ancient coffee stains and eructated the following wisdom:

"Oops, this isn't working. People are getting burned out from having inadequate staff, infrastructure, and morale to do their jobs. They are also losing clinical skills from no longer providing health care to actual sick and/or pregnant people and their kids. Because of these problems, mistakes are being made by the stressed and undereducated 'clinicians' we have left that can injure or kill the few active duty troops we are still malpracticing on. Our retention rate of smart 'providers' who have finished their active duty service commitment (ADSC) is about zero.

We need to hire good doctors to help us out, but no competent civilian physician wants to work at our sad facilities for bad pay under the command of snooty nurses with shiny things on their shoulders, and, even more sadly, unlike our active duty docs, we can't force them to.

We have a great idea. Instead of chasing away dependents and retirees from our now-downsized clinics the size of cardboard refrigerator boxes, we need to increase the number of military dependents and retirees we are seeing. We should also pay civilian 'providers' more money to work at our trashy military dumps built in the 1950s, because we have been too ignorant and shortsighted to train and retain enough uniformed providers to succeed at our mission without expensive non-military medical help since around 2000.

Owing to our brains that bacteria would be ashamed of, instead of planning wisely and funding our workforce correctly over the past 30-odd years, we forced out the competent doctors and other 'clinicians' and downsized or demolished major military hospitals. We use that money for cushy fact-finding trips every February to warm places with beaches or shiny convention centers in Colorado. There, we can sip umbrella drinks or après-ski while we bemoan the decomposing state of what used to be the healthy body of military medicine. In retrospect, oops squared."

Military Health System Stabilization: Rebuilding Health Care Access is ‘Critical to the Wellbeing of our Patients’

So, for the past six months, the same idiots who came up with the S.T.U.P.I.D Plan have been racking their primitive cnidarian nerve nets to figure out how to reverse their gutting of military health care. Now they intend to make a 180 degree turn to re-attract military dependents and retirees who they had intentionally forced out to the civilian world over the past seven years. Instead of admitting that no one at any level can plan their way out of a wet paper bag because they are dumb, they call this public admission of failure "stabilization". The deadline for this "comprehensive review" is tomorrow, 30 June 2024.

Naturally, they plan to start moving people no later than the next day, 1 July 2024, to implement this 20:15 vision. DHA only requires 24 hours to analyze the information in this "review" in order to make excellent decisions regarding where to move the few remaining active duty health professionals; how to attract civilian "providers" with better pay and working conditions; and how to restore the trust of all the dismayed humans who were excreted from the Military Health System like the noisome waste products DHA treats them as. That's some AI-level brilliance right there.

I for one have deep and abiding faith that the MIC will get it right this time after three decades of soiling the bed when it comes to planning and implementing anything that promotes the provision of competent, compassionate, prompt, local, and free health care to our active duty military members, their dependents, and our honored retirees. Don't you?

PS I guess my invitation to their fancy conference on the future of military medicine got lost in the mail:

“Rebuild, Reattract, Restore”: Military Health System Leaders Convene to Forge a New Way Forward

PPS I had to write the first word of MIC that way because the system censored it when written correctly. Go figure.

PPPS I have no connection to military.com. Please feel free to DuckDuckGo other links to equivalent content and post them below. Thanks.

Final postscript: for those who don't know me and my former web site, I gave 16 suggestions to on how to fix military medicine (especially anesthesiology, since that's my specialty) back in 2006 and kept them online for almost a decade:

Rob's Opinion Editorials submitted for publication

Of course, the MIC then, as now, only listen to their inbred clique of ring-knockers that get promoted for continuing to breathe without making waves until they reach O-6 or above, at which time they undergo their customary frontal lobotomies so as not to stick out from the crowd of "leaders", so my suggestions were tossed into the circular file reserved for all good ideas.

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[DrMetal]

It's the wrong way to go (trying to bring back dependents and retirees). These patients can be complex and challenging; the DoD is not in a position to do complex medical care. Nor does it really wish to do complex medical care, any more than it wishes to build fighter jets (a task left to Northrup Grumman, a civilian company).

We in the MC can't seem to wrap our heads around this fact.

Not only should we keep dependents/retirees in the civilian space, we should probably defer our most active duty care to the civilian world as well. Shut down the MTFs. Turn most of us into reservists. Get rid of military GME.

That's the only real honest way forward.

 

[Correlate Clinically]

For about 5 min I held out some hope they actually meant it when DHA and the services seemed to admit that sending everyone off base was a bad idea and we should bring patients back to the MTF.

But the AF is also talking about removing more MC authorizations from the MTFs and putting them into the new combat wings as flight docs, the Navy is critically manned or worse in many areas, and while I know less about the Army the few Army USU classmates I still hear from say similar things. DHA has no money to hire GS, assuming they could find enough physicians to take the GS jobs in the first place. I'm not filled with hope that this is going to go anywhere.

From what I can tell, there is no substance or resourcing. It's just talk about expanding access and bringing back acuity. There's not actually anyone available to take care of those patients, even if they are convinced to call for an appointment at the MTF.

 

[MedicalCorpse]

It's the wrong way to go (trying to bring back dependents and retirees). These patients can be complex and challenging; the DoD is not in a position to do complex medical care. Nor does it really wish to do complex medical care, any more than it wishes to build fighter jets (a task left to Northrup Grumman, a civilian company).

In the year 2024, I agree with you, except for the reserves part (see below).

When I left the USAF in 2005, I felt that we still had time to correct the course of the ship before we hit the iceberg.

Not any more.

I predict this latest 180 degree pivot by DoD/DHA will prove to be an unmitigated disaster of yet another underplanned, unimplementable, unfunded mandate that will just stress out the one remaining janitor seeing patients in the one room MTF of 2034.

But they will try anyway, because no one asked those of us with collective centuries of military medical experience to advise them before they went off and made yet another bad decision that will cost lives, because that's how m0rons at the top roll.

Oh well. (edited by me to prevent thread drift)

PS Have you talked to anyone with inside knowledge of the state of the reserves in 2024? When you do, you may need to rethink how a system designed in the 1960s to move wounded draftees back to CONUS could possibly attract, train, and retain competent volunteer physicians and other health care professionals who would put up with every demoralizing thing the armed forces continually stuff down the throats of highly educated humans who just want to help sick people.

People's exhibit number one: mandatory, short suspense Computer Based Training (CBT) that somehow doesn't work at home on civilian computers, even with a card reader, requiring you to travel 100 miles to your reserve squadron to complete tonight. True story.

I rest my case.

 

[narcusprince]

First, Rob nice to see your back. You opened my eyes as a young medical student. Now the padwan has become the jedi master. The reserves is a disaster far far more lost then active duty. NOSCS have a wide range command leadership. The NOSC leadership is usually run by active duty line guys who screwed up driving ships and waiting for the IG complaints to slow down to retire. I was lukewarm about active duty the reserves was far far more lost. The reserves would be nice if it was doctors running others like them. Also time is money no way the reserves can pay what I make for a weekend of work. The reserves should have quarterly mobilizations and the rest through zoom etc. All that $$& to bring folks to stupid noscs and sit in a classroom Saturday and Sunday.

 

[HQCare]

The military can blow things up but history proves it cannot run a healthcare organization. They should take the big MTFs and privatize them. I'd like to see a Sentara Naval Medical Center Portsmouth where the active duty physicians, nurses and other healthcare professionals just plug in to an already time tested and effective system.

 

[Helpful Troll]

The military can blow things up but history proves it cannot run a healthcare organization. They should take the big MTFs and privatize them. I'd like to see a Sentara Naval Medical Center Portsmouth where the active duty physicians, nurses and other healthcare professionals just plug in to an already time tested and effective system.

Be careful in this direction for privatization of MTFs. Look at the sh**show of PE in US medicine today and a related military example, the privatization of military housing. Privatization of MTFs won't improve care for service members, retirees, or dependents.

 

[DOswag]

So glad I separated last summer. DHA was destroying any inkling of morale that was even suspected of being left with those I worked with who knew I was on my way out the door. Genesis didn’t help that either though AHLTA/CHCS was a dinosaur of a system, but it was the dinosaur we all knew to unexpectedly crash on us for a couple of hours in the middle of the day.

Sounds like it’s a repeat of every other big change from the top. Lots of high up brass with little to no in the trenches medical experience patting themselves on the back for a strat or bullet to add to an opr to climb those ranks. Good idea fairies doing what they do best.

 

[armytrainingsir]

On USAjobs.com, the VA is advertising they are starting docs at a few cents over $58 per hour.

It would be insulting if it wasn’t so comical.

The level of incompetence at the federal level is simply staggering.

But decades of selective hiring to right perceived wrongs have gotten us to this point of incompetence on the federal stage and there isn’t enough intelligent influence left in DC to dial it back.

Joe and his performance the other night is an apt personification for the leadership not only of the DoD, but our country in general.

Buckle up, because the bumpy ride is just starting.

 

[pgg]

Darn. I was hoping they'd have some kind of morale- and need-assessing survey for physicians to fill out this week.

 

[afteranesthesia]

In the year 2024, I agree with you, except for the reserves part (see below).

When I left the USAF in 2005, I felt that we still had time to correct the course of the ship before we hit the iceberg.

Not any more.

I predict this latest 180 degree pivot by DoD/DHA will prove to be an unmitigated disaster of yet another underplanned, unimplementable, unfunded mandate that will just stress out the one remaining janitor seeing patients in the one room MTF of 2034.

But they will try anyway, because no one asked those of us with collective centuries of military medical experience to advise them before they went off and made yet another bad decision that will cost lives, because that's how m0rons at the top roll.

Oh well. (edited by me to prevent thread drift)

PS Have you talked to anyone with inside knowledge of the state of the reserves in 2024? When you do, you may need to rethink how a system designed in the 1960s to move wounded draftees back to CONUS could possibly attract, train, and retain competent volunteer physicians and other health care professionals who would put up with every demoralizing thing the armed forces continually stuff down the throats of highly educated humans who just want to help sick people.

People's exhibit number one: mandatory, short suspense Computer Based Training (CBT) that somehow doesn't work at home on civilian computers, even with a card reader, requiring you to travel 100 miles to your reserve squadron to complete tonight. True story.

I rest my case.

Wish I had listened to you back when I signed up. I remember your posts. Separated recently and am now more vocal as a result of that. Absolutely hated my time in the military as an anesthesiologist. I had to fight tooth and nail to stay current in my subspecialty so I could be gainfully employed after military time. If I hadn't worked so hard at this - no way would I have been able to get and then actually do a civilian job bc I would have been a %^&U anesthesiologist.

 

[MedicalCorpse]

Darn. I was hoping they'd have some kind of morale- and need-assessing survey for physicians to fill out this week.

Surveys and feedback requests, you say?

Here are a few blasts from the past that have aged pretty well, if I must say so myself...now in .pdf format
for your convenience.

I also updated the Editorials page to make it more readable and fix most of the dead links.

https://www.medicalcorpse.com/Grievances-redacted.pdf
https://www.medicalcorpse.com/OPDformRCJfinal.pdf
https://www.medicalcorpse.com/USUsurvey.pdf
https://www.medicalcorpse.com/ClimateComments.pdf

Narcusprince: Thanks for your kind comments. Regarding face to face meetings in the reserves: the entire military is still stuck in a 2019 pre-COVID mindset. The higher ups are hopelessly addicted to stuffing 100 people into a cramped classroom with blackboards and sharing spit droplets to give out boring, unclassified information that could easily go into an e-mail or telepresence session. My theory is that they all get dopamine rushes and pleasant bloodflow redirections from forcing people to sit down and listen to the bovine solid waste emanating from their mouths. The M0rons In Charge get extra jolts and turgidity from forcing people to stand up (not sit) cheek to jowl with that coughing LT at an inconvenient venue after duty hours on a Friday. It's also true that they are too dumb to figure out how to use Zoom, so Powerpoint Rangers still rule.

When the next pandemic comes, mark my words: military Commander's calls and face to face unit meetings will constitute superspreader events that smart people should try to avoid using whatever excuse necessary.

 

[armytrainingsir]

Darn. I was hoping they'd have some kind of morale- and need-assessing survey for physicians to fill out this week.

I know I feel so much more optimistic after I fill them out!
😂😂😂

 

[MedicalCorpse]

Wish I had listened to you back when I signed up. I remember your posts. Separated recently and am now more vocal as a result of that. Absolutely hated my time in the military as an anesthesiologist. I had to fight tooth and nail to stay current in my subspecialty so I could be gainfully employed after military time. If I hadn't worked so hard at this - no way would I have been able to get and then actually do a civilian job bc I would have been a %^&U anesthesiologist.

When we went from 10+ anesthesiologists to two worker bees plus an O-6 pain doc after 9/11 due to rats leaving the sinking ship, we begged our Flight Commander and Consultant to the Surgeon General for Anesthesiology to share call duties with us. She said she couldn't take call because she didn't know how to use sevo or roc or any of the other "new" drugs that had been out for ten years because she only did itty bitty pain injections on the 50 days per year (or less) that she actually worked.

I seriously doubt she could have intubated an active duty airman with a Mallampati 0 airway, let alone the fluffy parturients for stat C-sections we got down in the basement of Malcolm Grow.

So my colleague and I were forced to take every other night call for three months in a row while dealing with the mental, emotional, and physical fallout of 9/11...because we were cursed with enough competence to function as anesthesiologists, unlike her.

As you can see, I am still traumatized by the injustice of it all.

I left out the rest of the story, which many of you know already...I wrote it all out and deleted it three times.

However, when I did leave the USAF after 15 years toward retirement, I was able to start work the next day at a local community hospital where I practiced for the next 12 years, so there is that.

 

[afteranesthesia]

When we went from 10+ anesthesiologists to two worker bees plus an O-6 pain doc after 9/11 due to rats leaving the sinking ship, we begged our Flight Commander and Consultant to the Surgeon General for Anesthesiology to share call duties with us. She said she couldn't take call because she didn't know how to use sevo or roc or any of the other "new" drugs that had been out for ten years because she only did itty bitty pain injections on the 50 days per year (or less) that she actually worked.

I seriously doubt she could have intubated an active duty airman with a Mallampati 0 airway, let alone the fluffy parturients for stat C-sections we got down in the basement of Malcolm Grow.

So my colleague and I were forced to take every other night call for three months in a row while dealing with the mental, emotional, and physical fallout of 9/11...because we were cursed with enough competence to function as anesthesiologists, unlike her.

As you can see, I am still traumatized by the injustice of it all.

I left out the rest of the story, which many of you know already...I wrote it all out and deleted it three times.

However, when I did leave the USAF after 15 years toward retirement, I was able to start work the next day at a local community hospital where I practiced for the next 12 years, so there is that.

Totally agree. I'm cardiac, and I had to break rules, work tons of extra shifts and do anything and everything to moonlight to keep up an adequate case load. So glad I did all that bc I have a civilian job I love that includes cardiac. Reading some of your documents - mentions you resigned your commission. I have one year in IRR - can I resign my commission immediately after? What are the steps of that?

 

[MedicalCorpse]

Reading some of your documents - mentions you resigned your commission. I have one year in IRR - can I resign my commission immediately after? What are the steps of that?

Dude, back in my day, there was a piece of paper you got during outprocessing after completion of your ADSC. I just checked "resign commission" and added it to the stack of other papers that some airman in Personnel took care of.

Nowadays, with the awesome power of search engines, this is what I found (for Air Force...ymmv):

https://www.arpc.afrc.af.mil/News/A...2/understanding-the-individual-ready-reserve/

"Officers are a little bit different. Upon the completion of an officer’s initial eight year MSO, members are automatically shifted into the Non-Obligated Non-Participating Ready Reserve Personnel Section (NNRPS) for an additional two-year commitment however, members have the ability to opt out of this by resigning their commission. Officers wishing to resign their commission can start this process by contacting the ARPC Separations section via myPers."

Note: myPers didn't exist when I left, so, you may want to ask someone with more recent knowledge.

Update: Of course, the official Air Force Reserve web site is giving out incorrect information. Evidently, myPers was shut down last year:

So Long, myPers: Airmen and Guardians Have Until April 30 to Retrieve Records

"The website will no longer be accessible to Airmen and Guardians starting April 30, and the old features used in myPers are being migrated to the websites my Force Support Squadron (myFSS) and MyVector."

This would be funny if it weren't so sad.

 

[DOswag]

When we went from 10+ anesthesiologists to two worker bees plus an O-6 pain doc after 9/11 due to rats leaving the sinking ship, we begged our Flight Commander and Consultant to the Surgeon General for Anesthesiology to share call duties with us. She said she couldn't take call because she didn't know how to use sevo or roc or any of the other "new" drugs that had been out for ten years because she only did itty bitty pain injections on the 50 days per year (or less) that she actually worked.

I seriously doubt she could have intubated an active duty airman with a Mallampati 0 airway, let alone the fluffy parturients for stat C-sections we got down in the basement of Malcolm Grow.

So my colleague and I were forced to take every other night call for three months in a row while dealing with the mental, emotional, and physical fallout of 9/11...because we were cursed with enough competence to function as anesthesiologists, unlike her.

As you can see, I am still traumatized by the injustice of it all.

I left out the rest of the story, which many of you know already...I wrote it all out and deleted it three times.

However, when I did leave the USAF after 15 years toward retirement, I was able to start work the next day at a local community hospital where I practiced for the next 12 years, so there is that.

I’m a psychiatrist and was in residency through a combined mil/civ residency which was great because I got good training for all the severe mental illness we saw on the civ side to use none of it while I was active duty seeing 4-5 healthy patients per day who have adjustment disorder because their desk job sucks and they’re burned out from the military. (Truthfully I did see PTSD from some patients who saw some bad sh$t from deployments but a lot of patients were just miserable from their jobs). If we did actually have a patient that was truly psychotic or manic (pretty rare) they were typically stabilized in an inpatient setting and then we got to do the paperwork and babysit them as an outpatient to get them med boarded or sent back to CONUS to finish the med board (was stationed PACAF for a little while).

I bolded that sentence because I was in residency when I learned that those docs that stay in and gun for climbing ranks and admin positions only have to do about 2 weeks worth of seeing patients in the clinic in a year to “keep up clinical skills and with advances in medicine” in order to maintain whatever minimal standard the Air Force had set. Was blown away at how minimal and flippant it seemed and my eyes started to open to what the higher ups are there for which is bureaucratic bs and politics. Couldn’t get out fast enough. I see enough patients now on the civ side in a day and a half to meet that standard if we’re just counting patient encounters. My job is way less stressful now without the headache of pointless meetings everyday, paperwork, admin handcuffing me and telling me to do more while piling up mandatory cbt’s, more meetings, limited staffing, bogus new regulations of how we had to see patients, documentation requirements, profiles, the list goes on and on. I’m getting paid so much more, better schedule and I actually don’t dread going to work everyday. I’m amazed at those people that can withstand the ever crumbling work environment of milmed for 20+ years.

 

[afteranesthesia]

I’m a psychiatrist and was in residency through a combined mil/civ residency which was great because I got good training for all the severe mental illness we saw on the civ side to use none of it while I was active duty seeing 4-5 healthy patients per day who have adjustment disorder because their desk job sucks and they’re burned out from the military. (Truthfully I did see PTSD from some patients who saw some bad sh$t from deployments but a lot of patients were just miserable from their jobs). If we did actually have a patient that was truly psychotic or manic (pretty rare) they were typically stabilized in an inpatient setting and then we got to do the paperwork and babysit them as an outpatient to get them med boarded or sent back to CONUS to finish the med board (was stationed PACAF for a little while).

I bolded that sentence because I was in residency when I learned that those docs that stay in and gun for climbing ranks and admin positions only have to do about 2 weeks worth of seeing patients in the clinic in a year to “keep up clinical skills and with advances in medicine” in order to maintain whatever minimal standard the Air Force had set. Was blown away at how minimal and flippant it seemed and my eyes started to open to what the higher ups are there for which is bureaucratic bs and politics. Couldn’t get out fast enough. I see enough patients now on the civ side in a day and a half to meet that standard if we’re just counting patient encounters. My job is way less stressful now without the headache of pointless meetings everyday, paperwork, admin handcuffing me and telling me to do more while piling up mandatory cbt’s, more meetings, limited staffing, bogus new regulations of how we had to see patients, documentation requirements, profiles, the list goes on and on. I’m getting paid so much more, better schedule and I actually don’t dread going to work everyday. I’m amazed at those people that can withstand the ever crumbling work environment of milmed for 20+ years.

totally agree. I'm now a CT anesthesiologist doing pretty much everything in a doc only job in PP, and it's absolutely unbelievable how many more cases I do and how much better clinically I am even than when I moonlighted all the time when active duty. I'm just a better doc working the way I do now, and my schedule is still very liveable, and I make about 3-4 X as much as I did active duty. Sad.

I honestly post now to hopefully deter people from signing up. I hope I can influence people to never ever sign up for the military.

 

[pgg]

Totally agree. I'm cardiac, and I had to break rules, work tons of extra shifts and do anything and everything to moonlight to keep up an adequate case load. So glad I did all that bc I have a civilian job I love that includes cardiac. Reading some of your documents - mentions you resigned your commission. I have one year in IRR - can I resign my commission immediately after? What are the steps of that?

Also a cardiac anesthesiologist. Finished fellowship in June 2017, went back to the MTF, which promptly closed its cardiac surgery program later that same year.

The next few years before I retired were a struggle to maintain bare minimum case numbers via moonlighting.

I was fortunate enough to have competent and agreeable department and director leadership, and a CO who was willing to waive the hour restrictions and mandatory rest period for off duty employment. They also permitted me to do some TAD time at a VA hospital, but it was 90 minutes away, had low volume, and an overabundance of staff.

The last 18 months or so I was on active duty I burned all of my accrued leave specifically to fly to another city to do cardiac anesthesia locums. It worked out to about a week per month. Despite spending 3x as many days at the MTF, I did about 2x as many cases outside it. MTF volume was that low, and the number of nonclinical days at the MTF was that high. I got out with enough cases to be credentialable at my post Navy job thanks to grinding away off duty. But man, it was a grind.

My first year of full time private practice I only took 5 weeks of vacation. My partners thought I was nuts, since we could opt for up to 12. (Vacation is unpaid.) Still, after a few years of spending every off-duty moment moonlighting, actually having 5 weeks of vacation was a bizarre luxury. This year I took 8 weeks off and I hardly know what to do with all that time.

 

[narcusprince]

5 weeks that must have been tough. I cant believe we only had 30 days of leave annually. My current gig I get 91 days of vacation. Those days were rough…..

 

[pgg]

those docs that stay in and gun for climbing ranks and admin positions only have to do about 2 weeks worth of seeing patients in the clinic in a year to “keep up clinical skills and with advances in medicine” in order to maintain whatever minimal standard the Air Force had set.

Let's be honest - most of those guys aren't really concerned with keeping up clinical skills. They only pop into the clinic or the OR a day or two per month so that they can remain technically eligible for their specialty bonus pay. And maybe so they can look in the mirror and convince themselves they're still doctors, sort of.

They're the same guys who conjured the concept of "KSAs" (knowledge skills and abilities? don't recall if that's the correct translation) as a yardstick for converting online CME time and simulator time to some metric that they think will make up for lack of actual patient contact time.

 

[narcusprince]

I will say this. In the military I did encounter some very good leadership, some terrible, some excellent in the beginning but challenging in the end. I was always impressed by senior leaders who were clinically strong. The relationships I made in the military prepared me for understanding leadership skills at any hospital setting. It wasn’t all bad or all good. Sure I could have more money but some the experiences were priceless.

 

[pgg]

5 weeks that must have been tough. I cant believe we only had 30 days of leave annually. My current gig I get 91 days of vacation. Those days were rough…..

Another funny (not "haha" funny) thing about the military was the command-to-command variation in how leave was charged.

You could have a reasonable person running the leave approval process, who permitted you to combine leave and liberty, and take 5 days M-F and be off for the bookend weekends, and stretch those 5 days into 9. If that command had a generous liberty radius, you could travel 100s of miles on those extra days, and be within the regs. So the 30 days of annual leave could be stretched into ~6 weeks of time off.

Or you could have a belligerent rule Nazi who interpreted the rules in the most unfavorable way, and if you wanted to take M-F off, you also had to include the bookending liberty days. So a week off would cost you 8 days, and that 30 days of annual leave would barely hit 4 weeks.

Likewise, approval of funded or no-cost TAD requests was extremely variable from place to place. If you had a command with a reasonable DSS and CO you could get CME or other travel OK'd. No-cost TAD is effectively paid vacation time. As you probably remember, they allowed me no-cost TAD orders a couple times per year to go off with the Navy rifle and pistol team.

I will say this. In the military I did encounter some very good leadership, some terrible, some excellent in the beginning but challenging in the end. I was always impressed by senior leaders who were clinically strong. The relationships I made in the military prepared me for understanding leadership skills at any hospital setting. It wasn’t all bad or all good. Sure I could have more money but some the experiences were priceless.

So much about being a doctor in the military depends on the luck of where you get stationed and who's in charge when you're there.

I honestly felt pretty fortunate those last years at Portsmouth. The biggest kick in the 'nads that place gave me was closing the cardiac surgery program right after I finished fellowship, but I can't lay that at the feet of the local leadership. We had excellent people in that department. A good DH and DSS, and a couple of COs who didn't go out of their way to torture us.

I had a good experience, overall, in the Navy. Private practice is great - more money, more cases, far less administrative bull****. But it's not all good news. It's a business and there will always be an economic shadow looming in the background. Times are good now but some old-timers remember how the 90s were for our specialty. The military paid poorly but there was never even a shred of uncertainty about what we'd get paid or when or if.

 

[narcusprince]

Pgg, one extraordinarily positive effort was the navys response to covid. We had plenty of masks ppe and steady stream of income. Its funny I didn’t catch covid until I left the military. Their was zero certainty about my family and myself safety. This was truly a great response.

 

[comp1]

There are no VA jobs for physicians (or heck NPs) that pay the equivalent of just $58 an hour. I get that the whole base pay plus locality pay is confusing, but it's not THAT bad.

 

[Gastrapathy]

Everyone in charge in the military now grew up after they started the slow death spiral. There isn't even any institutional memory of the 1990s when there were real centers of excellence providing outstanding care. It's been more than a decade since the death of AFIP. Everyone is a low-volume doctor now and whatever fake metrics they want to trot out finally can't hide the truth. These are dangerous places to get surgery or need any kind of complex care for the actually sick. There are more administrators now than there were back then and an ever-shrinking organization for them to micromanage. This latest effort is like chest compressions for a hospice patient.

I would close every CONUS MTF. Enroll AD and families in a TFL type insurance. MSC officers and enlisted would embed with units to coordinate care for AD and ensure that fitness for duty is evaluated appropriately. OCONUS hospitals would be staffed by contractors and GS doctors. Instead of HPSP, I would offer loan repayment and enough cash to make it worth it for the right specialty mix for reservist doctors to exist (still so much cheaper than all the infinite admin types and buildings) for deployments only. One military medical branch. 3 month deployments. Mil med would be surgeons, anesthesiologists, ICU/hospitalists, derm, psych and maybe I'm forgetting someone. Everyone has to have a day job where they actually doctor.

 

[pgg]

Everyone in charge in the military now grew up after they started the slow death spiral. There isn't even any institutional memory of the 1990s when there were real centers of excellence providing outstanding care.

Institutional memory. Hoo boy. Rant inbound -


The two primary justifications for a nation having a standing army are readiness and institutional knowledge. Readiness because an army can't rapidly take a bunch of conscripts or volunteers away from their day jobs making cheese or giving haircuts and turn them into professional soldiers. You need soldiers sitting around doing soldier things all the time, so they're ready to be soldiers instantly. Institutional knowledge is critical because mid-rank leadership and experience is critical to not getting people killed when things jump off. You don't have to look any further than Russia's experience in Ukraine to see what you get when you have an inexperienced or absent or unempowered NCO corps. (Also: bad doctrine, bad equipment, bad senior leadership, bad planning.)

These ideas have been applied to the alleged need for a standing medical corps, as well. But there aren't really any plausible readiness reasons - because reserve or conscripted or volunteer doctors are doctors in their civilian life too. A reserve medical corps can absolutely meet the deployed operational needs of our military. (This is completely unlike a mortarman who obviously isn't a mortarman in his civilian life.) But so, so much ink has been spilled on the claim that there is medical institutional knowledge that implies a need for a large and continuously active duty cohort of doctors thinking about and practicing "military" medicine all the time. Else they might somehow "forget" 🙄 about things like tourniquets or the golden hour or 1:1:1 transfusion or damage control surgery or triage. And indeed some hard-earned knowledge was lost between WWII and Korea and Vietnam. But that's just not the case today given the way medicine is learned, taught, and practiced.

80% of the foundation of this justification for a large active duty medical corps is based on this 50-70 year old idea that you can't take a surgeon, anesthesiologist, intensivist, or EM doc out of a busy civilian practice and have them perform at a high level with combat casualties. And we know this is wrong (obviously wrong!) because for 20 years in Afghanistan and Iraq we saw reservists float in and out for deployments, and not only did they do just fine, but they did superb work. The other 20% is an uninformed and poorly advised gaggle of line commanders that think they need "their" doc embedded with them through workups, deployment, and redeployment ... rinse and repeat with "their" doc. This is, of course, bull****.


The irony here is that the actual institutional memory of AFIP-level excellence is fading or gone, but the myth of institutional memory with regard to combat casualty care is alive and well and is a big piece of why our military remains committed to an obsolete model that becomes more harmful to readiness and competence every year.

That medical corps flag officers aren't shouting the above at the top of their lungs at line commanders and Congress is reason #9 why they should all be relieved.

 

[HighPriest]

Of course the obvious alternative is to have civilian mortarmen. Checkmate.

 

[HighPriest]

I’m thinking, like, land clearing and maybe rodent exterminator vis-a-vis casdyshack.

 

[armytrainingsir]

There are no VA jobs for physicians (or heck NPs) that pay the equivalent of just $58 an hour. I get that the whole base pay plus locality pay is confusing, but it's not THAT bad.

haha. While I agree, the main point is the incompetence in how they advertise the job.

 

[TheEarDoc]

haha. While I agree, the main point is the incompetence in how they advertise the job.

Don't forget how long it takes to hire someone through any federal process.

When someone puts in notice it takes usually 3-6 months to beg for approval of the position to be re-authorized to be filled. Then you spend a month gathering applicants. Half the good ones get kicked out because HR is awful at their job. Then you end up with small pool of applicants, and you pray there are at least 2-3 good ones to choose from. Then you interview. Then you select. Then 3-6 months later you might actually get the person you hired, pending they haven't already gotten sick of the waiting game and haven't accepted a better paid position elsewhere.

 

[usma05]

YMMV, but my two years of experience in USAR relative to my 13 years in AD doesn't instill faith in a purely reserves model functionally working. I do think institutional knowledge is necessary, and if a big war kicks off and we have casualties actual survive and casevac still be a thing we still need functioning MEDCENs (notably LRMC, BAMC, and WRNMMC but im sure others too) as I don't see the civilian system absorbing combat casualty care (cause we're pretty full consistently too).

My AD experience wasn't all rainbows and lollipops but I do feel it was valuable and I do think I was lucky enough to work at places that were functional while there. I have no comparison to the 90s, but the height of the War on Terror we were doing some good things with what we had and I definitely thing it provided me a strong skillset which I translated to a niche job in an top academic center that is almost purely clinical and has significant volume. Have seen both sides of the same coin, I think the civilian side is better but I think a lot of this conversation is overstating the bad w/ military medical care and the good w/ civilian care.

I also think it'd be a huge mistake to be purely Reserves based for the medical Corps and rely on AD MSC to make planning/decision making capacity for medical logistics.

 

[MedicalCorpse]

Institutional memory. Hoo boy. Rant inbound -

... our military remains committed to an obsolete model that becomes more harmful to readiness and competence every year.

That medical corps flag officers aren't shouting the above at the top of their lungs at line commanders and Congress is reason #9 why they should all be relieved.

A couple of thoughts:

The reason why I called the DHA's idea to restrict all MTFs to active duty only stupid is because no one with any intelligence is going to sign up for the following voluntarily:

Military Physician Job description in 2030 (under S.T.U.P.I.D. Plan):

1) Spend your entire career caring exclusively for young, healthy people who don't take drugs because they have to pee in cups randomly and can't be too overweight or severely out of shape or they get fired! No kids, no elderly, no pregnant people, no problem!

2) Typical garrison medical challenges faced 2030:

--Sniffles

--Rashes

--STDs

--Transitioning issues

--Malingering

--Fugue states from excessive computer based training

--Adjustment disorder with F*** It mood

--Sprains and fractures whenever there is an outbreak of softball

3) Typical deployed medical issues faced 2030:

-- massive trauma from high explosive artillery rounds, bullets, IEDs, and non-I EDs.

-- nurses, techs, and housekeepers telling you how to practice medicine in tents from the 1950s

-- nasty infectious diseases no one has heard of, because the bad guys just cooked them up yesterday

-- nanotech infections that chew up humans at the atomic level and thus make the disfiguring disease from Game of Thrones (grayscale) seem like a really good time in comparison.

-- Hospital infrastructure left over from the 20th century if you are lucky...or leaky tents.

-- Untreated combat stress cases that make the trenches of WWI look like rave venues.

-- (if things get really bad) The twitching, vomiting aftermath of apocalyptic nuclear, chemical, and directed energy weapons which we have spent zero minutes teaching you how to diagnose, let alone treat.

4) Service specific deployed medical challenges 2030:

--Navy: Drowning. Lots of drowning. Unwanted physical contact on ships and subs between and among all 19 official genders.

--Army: Finding enough parts to fill a plastic bag for DNA identification after the shells hit. Unwanted physical contact.

--Air Force: Notifying next of kin when the manned tin cans the USAF insists on fielding don't come back from their latest sortie against much smarter drones. Unwanted physical contact.

--Space Force: Unwanted online contact. "Hey, is that a hyperson..." Static.

--Public Health Corps: Convincing people to get vaccinated against CoBirdAnthOlaPox-29...again. Unwanted physical contact among all four of them.

--Marine Corps: Just kidding! We are still not dumb enough to let marines become physicians.

5) Anticipate finishing your 4-30 year career in uniform with no marketable skills whatsoever!

--In 2030, 100% of our civilian population has a BMI > 50, is on 3 ADHD meds (including amphetamines), and has already failed every GLP-1 agonist we have, so they will aspirate and die from terminal gastroparesis if they are put to sleep to fix anything serious. Heroin, carfentanil, and country music are all 100% legal. The average citizen's idea of exercise is getting off the couch to get their sixth daily delivery of yummy ultraprocessed "food" from MicroTesApplMart-Plus. If you try to use your military medical skills on this population, you will kill them dead from Powerpoint poisoning, acronym ague, and e-mail-induced dysentery, because that's all you can remember how to do after so many years spent not practicing actual medicine.

6) Your career support system 2030:

--Brain dead senior docs who haven't touched a patient (appropriately, at least) in 20 years

--Haughty nurses with date of rank on you who will micromanage you into an early grave

--Nurse practitioners, PAs, nurse midwives, optometrists, and every other non-physician you can think of who know they know more than you do, and have the shiny accessories on their shoulders to prove it.

--Techs who have been "cross-trained" from non-medical stuff to ophthalmology and/or anesthesia because what's the worst that could happen?

--The Feres Doctrine: We still have it, and it still covers your...malpractice.

--Vodka. It leaves less odor on your breath, so you can consult it while on duty easier.

--AI expert system to double-check your clinical impressions: approved, but not funded until 2060, by which time we will be working for them, if we do our best and diligently earn our oxygen from our silicon masters.

7) Conclusion:

--Remember, the worse you do your job of saving lives, the fewer annoying and expensive retirees and veterans we have living under our bridges begging for things like water! It's win-win!

---

Proposal: Shut down active duty military "health care" and replace it with reservists:

The problem is that the reserves are not capable of absorbing so many humans into their early 1950s system, because they will quickly run out of carbon paper for their mission-critical TDY forms to fill out by hand in triplicate using #2 pencils by yesterday's suspense, because all computer systems are still down due to hacking by one pimply-faced teen in Outer Slobovia who did it for the lulz, since they spent all the cybersecurity funds on updated stationery with new logos. They will also only be able to pay physicians and other professionals in recycled slogans and tired buzzwords rather than money, seeing as our government sent all that money overseas, or used it to build shiny new floating, flying or rolling drone targets (FFRDTs) we used to call "ships, planes, and tanks" back three wars ago.

---

Institutional knowledge:

I distinctly remember being told in my Military Contingency Medicine course at USU circa 1988 by a gray-haired physician who probably joined in the 1960s that tourniquets are contraindicated to stop bleeding, because the doctors in Vietnam thought they caused excessive nerve damage. We were instructed to use direct compression only until the patient got to an echelon that had surgeons capable of using hemostats, etc. Of course, we have new "institutional knowledge" now based on our careful double-blind studies in the desert circa 2003. This includes making sure the red cross that makes medics invulnerable is clearly visible in all light spectra from infrared to ultraviolet for the convenience of our enemies, who will surely drop tasty, exotic food rations to feed us when we begin to starve from bad logistics because [Geneva Conventions], rather than kamikaze quadcopters laden with even more hungry hunter-killer nanobots.

 

[MedicalCorpse]

haha. While I agree, the main point is the incompetence in how they advertise the job.

Sadly, this is nothing new.

I archived how they were recruiting for anesthesiologists the year after I punched out as a LtCol after 19 years TAFMS (15 toward retirement because of DOPMA and USU...thanks, government). I mean, who wouldn't want to use ether in the O.R. in 2006?

Yes, I want to join the USAF to Use Ether!

 

[HQCare]

I don't know about all that but there is nothing like the stress of serving in military medicine. The organization is dysfunctional, chaotic and they keep pulling the rug out from under you. Gotta be some way to get it to a better place...

 

[Correlate Clinically]

The problem with civilianizing any more AD positions or actual healthcare delivery is that positions are insanely hard to create and even if you create them, for most specialties the pay is too low to attract anyone good. It doesn't help that DHA is broke.

The AF makes the mess worse by relying heavily on contractors instead of GS. There are issues with GS, don't get me wrong. But the CTR positions also pay poorly (all go through staffing companies as well), have no benefits, and are often unstable (lost your UFR at the last minute, oops). The few long term CTRs I've seen have all been retired military, because they have a pension and medical to offset the cruddy contract and they happen to want to stay at their last duty location.

I'm highly skeptical we could hire enough civilians to take care of the AD force, let alone dependents. Dependents could be kicked to Tricare in some areas, but there are a lot of bases in healthcare deserts or just plain in the middle of nowhere. There's also OCONUS.

Maybe a better mix of reserve and AD would help. AD focused where needed with large reserve "surge" capacity, resulting in an overall small AD MC.

I don't have a ton of hope anyone is really planning ahead. Until it breaks so bad it's a PR problem, there's not much motivation to fix things.

 

[MedicalCorpse]

I don't have a ton of hope anyone is really planning ahead. Until it breaks so bad it's a PR problem, there's not much motivation to fix things.

Catch 23: It can't become a PR problem if active duty physicians (and others) are scared to go public with details of all of the avoidable Sentinel Events they witness on a daily basis, because they fear retaliation, and rightly so. Being fined thousands of USD for releasing protected "Quality Assurance Information" is one thing. Being sent UNaccompanied (without your family) to a very bad assignment for several years in retribution is much worse. This is not to mention the military career-ending LORs, referral OPRs (now "Performance Statements") and other non-judicial punishments they could suffer at the hands of purple-faced commanders who just want their underlings to sit down, shut up, and color until the commander can retire.

I don't know the answer. As I've said before, the institutional inertia of the military/Pentagon/DHA will continue down its spiral path into the sewer plumbing until the next war demonstrates the complete mission incapability of what's left of the military medical system they have intentionally torn down, underfunded, and outsourced for the past 30 years or more.

P.S. Happy Independence Day, USA! Just in time for July 4th, Medicalcorpse.com is coming back online...slowly...expect many broken/non-functional links until I can fix ten years of offline bit rot.

 

[Correlate Clinically]

To be fair to the powers that be, whatever and whoever they are: "military medical" isn't broken because commanders still mostly get what they need. Or what they think they need. From a military, top down perspective, physician complaints don't matter because we still deploy able bodies, people who need bullets and warheads get them, and historically we did a pretty good job with expeditionary care.

The system is dysfunctional from a healthcare perspective, but functional (or functional enough) from a military perspective.

It's frustrating because we could do this well and we have done it well in the past. The resources aren't there because there are other demands and, again, because it doesn't look broken.

Imagine sitting in a room with a combatant commander and telling him or her all the things that almost went wrong. Their next question is "Well, yes, but it didn't go wrong. What are the odds and what is the risk? I also need to do X, Y, Z." I may disagree with their priorities, but that's how I imagine we have stumbled into this situation over time.

Medical personnel across all 3 services are dedicated and keep finding ways to prevent awful things from happening with duct tape and chewing gum. In a MX shop you could just not fix the engine to highlight that you don't have the bodies to do the job, but that's not really an option in medicine.

 

[HighPriest]

Yeah, as I have said before: you’re just a tool for the military. If you get the job done, that’s what matters. Even if you’re the wrong tool for the job and even if you think you’re not being maintained properly. Your whole career is worth less financially than a lot of the equipment that the military considers expendable under the right circumstances. And you’re talking about an organization that will send people’s children to certain death if it means getting the job done.

if they’re willing to literally kill Tommy from Nebraska to take a pillbox, why would the future of your medical career matter? Because it’s more expensive? $#!t a patriot missile costs $4,000,000.

I’m not anti-military by any means, but the cold hearted truth is the real truth.

Until you force the hand of the DoD by embarrassing them in front of politicians who hold their leash, or until you can’t perform the duty they need performed well, nothing matters. They don’t care if MTFs are well run or efficient. If they are, great. If not: it’s just not that important in the scheme of things.

And yeah, efficiency is cheaper, but who are we kidding? When did the DoD start caring about how much money it spends overall?

 

[Baron Samedi]

Anyone willingly sticking around is like the poor souls on the Titanic who refused to board lifeboats because they thought it was safer on the ship.

 

[militaryPHYS]

So great to come back and read such uplifting words from all of you.

I was considering responding to each of your biased comments regarding 1 to 20+ year old information but it is better to just let an entire thread go without providing any counter discussion. Happy Independence Day!

Love,
a happy military physician

 

[HighPriest]

“Any opinion that isn’t mine is a biased comment.”
-one of the few happy military physicians.

 

[militaryPHYS]

Every opinion is biased 😎 especially mine

 

[pgg]

a happy military physician

You're a sports med orthopod. You're a kid in a candy store. Of course you're happy.

 

[DrMetal]

Anyone willingly sticking around is like the poor souls on the Titanic who refused to board lifeboats because they thought it was safer on the ship.

You know, riddle me this: [I'm going to pose a an honest question/scenario]

Suppose the following:

• You're active duty: Your pay (including base, BAH, bonuses) equates nicely to the your civilian counterparts, maybe even +$50-100K (think primary care general specialties, I'm not talking about neurosurgery).
• Your active duty job is easy. Maybe you're doing some monkey admin/operational job, light clinical duty, etc.
• So easy is your AD job, that you have ample time to moonlight (maybe even 'daylight'). You got a nice side-hustle going.

So why not stay in?

 

[Baron Samedi]

You know, riddle me this: [I'm going to pose a an honest question/scenario]

Suppose the following:

• You're active duty: Your pay (including base, BAH, bonuses) equates nicely to the your civilian counterparts, maybe even +$50-100K (think primary care general specialties, I'm not talking about neurosurgery).
• Your active duty job is easy. Maybe you're doing some monkey admin/operational job, light clinical duty, etc.
• So easy is your AD job, that you have ample time to moonlight (maybe even 'daylight'). You got a nice side-hustle going.

So why not stay in?

Direct primary care docs clear 300k+++ seeing like 1-6 patients a day.

Part of the reason milmed keeps people in is that it degrades any desire to "bet on yourself" and makes you believe that the only alternative is to work your butt off for peanuts in some HOPD. It makes you believe that you can't hack it as a "real doc" or entrepreneur.

 

[militaryPHYS]

And/or let’s say your lack of debt and dual income allowed you to build a portfolio that allows you to be financially independent by the time AD pension kicks in negating the need to sign full time contracts and meet RVU minimums, cover trauma call, etc.? Instead spend even more time with family, do locums, consulting or whatever you feel like before the age of 50.

Seems like an OK option

 

[Baron Samedi]

And/or let’s say your lack of debt and dual income allowed you to build a portfolio that allows you to be financially independent by the time AD pension kicks in negating the need to sign full time contracts and meet RVU minimums, cover trauma call, etc.? Instead spend even more time with family, do locums, consulting or whatever you feel like before the age of 50.

Seems like an OK option

Locums isn't a perk of military medicine. It's a bandage covering the festering wounds of skill atrophy and poor wages.

 

[DrMetal]

Direct primary care docs clear 300k+++ seeing like 1-6 patients a day.

Maybe (if in the right part of the country, with the right clientele). Try setting up a new DPC practice in a large metropolitan part of the country, where there are already many well-established primary care groups, not to mention the PE/VC firms swallowing up said groups and completely usurping all primary care. Good luck with that.

It makes you believe that you can't hack it as a "real doc" or entrepreneur.

But we're doing it! (acting as real docs and/or entrepreneurs). We're just doing as a side hustle. Why give up your W2 job?!

And/or let’s say your lack of debt and dual income allowed you to build a portfolio that allows you to be financially independent by the time AD pension kicks in negating the need to sign full time contracts and meet RVU minimums, cover trauma call, etc.? Instead spend even more time with family, do locums, consulting or whatever you feel like before the age of 50.

That's basically what I'm talking about. Now admittedly, I'm not in a high paying specialty. If I were, I'd probably bail on the Navy the way a sailor bails on a Tijuana prostitute on a Sunday morning.

 

[Baron Samedi]

But we're doing it! (asking as real docs and/or entrepreneurs). We're just doing as a side hustle. Why give up your W2 job?!

If the number 1 quoted perk of your primary job is that you can work a different job during your time off, then you should probably question the merits of your primary job.