Military Medicine....persistently broken and not getting better

[Galo]

So I had to look up the last time I posted here: April 2014

I guess I got tired of banging my head against the wall. I have received numerous emails throughout the years from people actually doing some research, and I feel at least they received more information than most. At least they can either do more research, ask questions, or go in with different expectations.

As a surgeon one of the many, (probably one of the most important ones) issues was the fraud waste and abuse of our skills. There are so many places where the problem starts in training where as a surgeon especially in military alone programs, (almost exclusively), you are exposed to very little of the population you are going to have to take care of. The only partial saving grace is military programs where you can train part time in a civilian institution. The problem then continues with many so called hospitals are no more than glorified surgery centers where you can do the most basic of surgeries, have no access to specialists, certainly no trauma, and you end up being a surgeon in name with a severe case of skill atrophy. Although that affects surgeons and their patients in a most severe manner, its even worse when we are involved in crazy wars and a military surgeon who has NO EXPERIENCE with trauma is suddenly thrust into a situation where you have a multiply injured patient who needs immediate and acute expert care. When is the last time an active duty guy took care of a destroyed liver, bowel, spleen, from a high velocity round?

What had been the military's answer? Well in various forms it has involved sending active duty surgeons to large city academic institutions to practice trauma for a month at a time. SO picture an F-16 pilot who flies Cessna's for 11 months of the year and flies an actual F-16 one month of the year, as a backseater....You get the picture.

SO these band-aids for trauma currency continue to be failures. They were kicked out of Ben Taub in Houston, they went to Shock Trauma at Baltimore where you function as a second year resident for a month doing blood draws, histories, and being a second or third assistant to their chief residents and trauma fellows. A total waste of time.

So as a fellow of the American College of Surgeons I participate in some of the information forums...much like this one. I was surprised to see one from Military Surgeons and it gets very little traffic. But in the last few days I saw this:

I recently attended the TCAA Lobby Day where we asked for support of legislation to address the problem of trauma experience in military surgeons. It has passed the House UNANIMOUSLY and is gathering steam in the senate. Here is the TCAA statement.
TCAA 2018 Advocacy Institute & Lobby Day
On March 12th and 13th, representatives of trauma centers and national advocacy organizations from across the nation came to Washington, DC to participate in TCAA's annual Lobby Day & Trauma Advocacy Institute.

Organized by TCAA's staff and board of directors, participants attended a federal policy briefing and advocacy-training program presented by Winning Strategies Washington. The advocates then spread out over Capitol Hill for meetings with Members of the U.S. House and Senate to raise awareness about the specialized care provided only by trauma centers and to lobby in favor of several key legislative priorities.

The advocates thanked Members of the House for recently approving the MISSION ZERO Act (H.R. 880), bipartisan legislation to fund the integration of military medical personnel at civilian trauma centers, and urged Senators to co-sponsor and approve the Senate MISSION ZERO Act (S. 1022). They also urged Congress to modernize and renew trauma related grant programs based on the current and future federal funding needs for state and regional trauma systems and centers.

TCAA thanks the many participants of this year's advocacy event for the time and energy they devoted to educating legislators and for helping to move forward trauma care policy during such a critical period in Washington. We also extend a warm thank you to our advocacy partners for attending and to the Society of Trauma Nurses for sponsoring the annual lobby day lunch.

House Unanimously Approves Military-Civilian Trauma Care Legislation

On February 26, the U.S. House of Representatives unanimously approved the MISSION ACT (H.R. 880). TCAA is extremely proud of the grassroots effort it spearheaded to educate lawmakers about the importance of the federal funding that H.R. 880 will provide to train and incorporate military trauma care providers into civilian trauma centers.

Our advocacy efforts are now focused on the advancement of MISSION ZERO in the Senate where the bill (S. 1022) is sponsored by Sen. Johnny Isakson (R-GA). TCAA joined 13 other members of the Trauma Coalition to Sen. Isakson and other sponsors of S. 1022 expressing the trauma community's support and urging swift action in the Senate to make MISSION ZERO law this year.

I hope this is helpful.


And so the effort continues. Like I've said many times. There are great people in the military. There are great physicians. The problem is there is many more HORRIBLE FLAWED people who relish power and their own misguided self agenda's. As there is multiple layers of bureaucracy that will continue to hinder the advancement of military medicine to come even close to civilian practice. Its just too messed up a system to ever become efficient....specifically when it comes to sub specialties where you need an independent self thinking and acting asset, not a robot soldier who follows orders, and in the military that is what you are, no matter your specialty.

To those who are concerned becoming a part of this debacle, especially in areas where sub specialization is mandatory....think twice and do your research before becoming a part of it. As I always say, and learned. You must commit to being a military officer first and a doctor second. Don't let the carrot of money lead to you a potential decade of not what you though it was going to be.

I guess I do hope that I am wrong and active duty military surgeons really do get to rotate at civilian trauma centers, (though not all surgeons would want to or even like trauma). But based on history, I have my doubts.

My offer to receive emails and offer short advice remains. Those wishing can find my email in the multitude of posts that I have made.

Good luck

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[Galo]

Here's the note that started that thread. I am not sure I can post the entire article it references in the body of the note. I'm not sure its necessary. You can see that the author is expressing the CURRENT and continuing problems that cripple surgeons. Mind you the ARMY is the biggest service. The Navy and Air Force are smaller and frequently have much smaller bases that still suck up surgeons as resources to check a box weather or not that surgeon is going to be used effectively. Anyways here's the note:

Those of you who are on active duty in the U.S. Army are well aware of the severe challenges we are (rather silently) facing.

For those of you who many not be as familiar, we are serving frequent "combat" deployments, currently spending about 30% of our careers deployed. During those deployments, we are averaging one trauma case or patient encounter per month. While this is great news for all the servicemembers not getting injured, it is widely acknowledged that this is not an adequate workload to maintain surgical skills.

Additionally, when we return, many of my peers provide essential but low-volume skills at smaller hospitals to military beneficiaries, and do not routinely provide trauma care at all.

Our outgoing General Surgery Consultant COL Mary Edwards, along with several of her senior colleagues, have (again) nicely summarized these issues, this time from an ethical perspective, in an upcoming JACS issue.

(The "in-press" article is available at the website http://www.journalacs.org/article/S1072-7515(18)30174-1/fulltext )

The article discusses how our military responsibilities (including frequent yet quiet deployments) conflicts with our medical obligation to provide quality surgical care.

I encourage all of you to read and share it widely, I believe we need to discuss these issues openly and freely in order to fix them.

v/r

Rich Lesperance
MAJ, MC

 

[militaryPHYS]

I've read through the basics of H.R.880 but still confused on how it will be implemented. Are these military surgeons just moonlighting there on a regular basis or does this time at the trauma centers take the place of their duties/responsibilities at their local MTF? Will they be taking away cases from the civilian surgeons at these trauma centers? Are they compensated as a moonlighting physician?

I also think I missed your ultimate conclusion. Do you think that these new efforts to improve a deficiency in military medicine are useless and won't improve our military general surgeon's trauma abilities? Are we just to give up?

 

[HighPriest]

They work at civilian trauma centers, but they don’t get paid and they can only look at cases from the corner, through an old toilet paper tube. Also, they have to take leave, and they have to do online wilderness survival training before they go, plus complete a 97 page agreement packet every week that they’re there. We won’t have our surgeons benefitting from this situation, that’s basically a form of bribery.

 

[alpinism]

I've read through the basics of H.R.880 but still confused on how it will be implemented. Are these military surgeons just moonlighting there on a regular basis or does this time at the trauma centers take the place of their duties/responsibilities at their local MTF? Will they be taking away cases from the civilian surgeons at these trauma centers? Are they compensated as a moonlighting physician?

I also think I missed your ultimate conclusion. Do you think that these new efforts to improve a deficiency in military medicine are useless and won't improve our military general surgeon's trauma abilities? Are we just to give up?

Considering how little trauma most civilian hospitals see nowadays (with a few exceptions) there's no way in hell civilian surgeons are going to just give up their 1 case per week to visiting military surgeons when they barely have enough numbers to stay competent themselves. Most likely they'll spend their time assisting with general surgery cases and doing scutwork (functioning as a resident) instead of gaining any meaningful experience.

 

[Perrotfish]

Considering how little trauma most civilian hospitals see nowadays (with a few exceptions) there's no way in hell civilian surgeons are going to just give up their 1 case per week to visiting military surgeons when they barely have enough numbers to stay competent themselves. Most likely they'll spend their time assisting with general surgery cases and doing scutwork (functioning as a resident) instead of gaining any meaningful experience.

So what's the solution? Send them abroad for TAD months with doctors without borders, so they get regular exposure to warzone trauma? Join busy non trauma services and hope that the experience carries over? More sims? Give up and say that this is the best we can do?

 

[BlackFrancis33]

For one, provide financial incentive to be a military general surgeon. Significantly increase and change the specialty pay structure, but make the increased bay based on being deployable and meeting standards for deployed trauma surgery (I don't pretend to know what this standard would be). I'm not a surgeon, but I readily admit that serving 30% of your career deployed is a huge difference compared to most of us. 'Station' the active duty surgeons at civilian hospitals but pay their salaries, BAH, malpractice etc. Civilian hospitals would take them on for sure in that situation. I would guess that smaller midwestern cities probably have more trauma than most MEDCENs and likely have a hard time recruiting quality general surgeons. I'm thinking places like El Paso, Oklahoma City, Omaha etc. DHA would possibly even have some negotiating power in those situations. You would save on BAH in some of those non-coastal locations too. Training more general surgeons, part of the current plan, could make the current problems worse, right? Spreading around cases in already low volume MEDCENs and MEDDACs among even more surgeons will further degrade readiness. These ideas aren't new, or original, and have many holes that require filling. This would be a huge departure from how things are done, but don't tell me it couldn't be done.

 

[alpinism]

So what's the solution? Send them abroad for TAD months with doctors without borders, so they get regular exposure to warzone trauma? Join busy non trauma services and hope that the experience carries over? More sims? Give up and say that this is the best we can do?

The only real practical solution at this point would be to set up exchange programs with understaffed foreign hospitals that see a good deal of trauma.

Places like Mexico, Honduras, and Colombia, etc.. come to mind.

 

[HighPriest]

We just need to start wars with more formidable countries. That’s a sure-fire way to generate cases.

 

[Galo]

All the suggestions above have been suggested. Every surgeon in the military that gave a damn about their job or skills has had those thoughts. A few of us have struggled with commanders who sometimes are totally clueless about taking additional time to keep trauma skills up to date by being in rotation with large city trauma centers, or even just the ability to do more than local outpatient surgeries. Some of us have paid for those attempts with lots of anguish and just total disbelief. For example I had a friend who went to article 32 hearing for "moonlighting" at the local hospital. I myself was the focus of a OSI investigation because I was taking trauma call, (UNPAID), and someone felt there was fraud. I had to hold up sale of my house and be away from my family while that crap went away into nothing. So a few of us who try to do something positive seem to get in trouble for it. There is no uniformity or single purpose of keeping trauma, let alone general skills by commanders who can be great but cant do anything, or commanders (including nurses), who could give a crap about anything other than how they perceive the rules.

Military medicine as such is going to SUCK and not make significant changes despite the hard work of dedicated military and civilian advocates. Below is another post on the American College of Surgeons. I wont bother posting the ones that say, look we're trying and things are going to change.......I call BS on that, and would not hold my breath.

The unfortunate victims here are not only the patients but the surgeons who signed up to help out their country, and are now shackled against doing their job and developing a hatred for the archaic, glacial good old soldier network that the military is, and will likely always be. So most military docs come in, do their time, and leave disgusted.

Here is the post:

I'm reminded of a conversation that took place in Kuwait in December 2004. When pressed about the lack of armor of vehicle and other shortages, then Secretary of Defense Donald Rumsfeld responded, "You go to war with the army you have, not the army you might want or wish to have at a later time."

This is where we are today – working with what we have and wishing for something better. For those surgeons currently on active duty there isn't anything we can do now that will change their clinical experiences – the wheels of change in the military are far too slow for that. Of course we knew that when we started asking for changes nearly 20 years ago. But then the wars in Afghanistan and Iraq came along and delayed the almost inevitable erosion of military surgery. Now we are back to where we were in 1996 – although perhaps we are in a better position now then we were then.

As Dr. Hannon points out, the language in the NDAA and the development of the MHSSPACS are two positive steps forward. In addition, the trauma advances, research, and publications that have come out of our wartime experiences over the past 15 years ensure that future military surgeons and leaders will have this information. And finally, all three services are shouting the same message – something that wasn't happening a decade ago.

I think it's important to recall our history because what we face today as military surgeons is neither new nor unforeseen. The question is "Will we do better than last time?" And as for Dr Edward's question about the moral dilemma faced by military surgeons I offer the words of SPC Thomas Wilson who asked Secretary Rumsfeld about the lack of resources. Commenting later to a New York Times reporter, SPC Wilson said, "I'm a soldier and I'll do this on a bicycle if I have to, but we need help."

 

[pgg]

I feel like this isn't limited to just military medicine but the peace-time (relative) military as a whole. Even in combat arms the quality soldier has dropped as the amount of deployments have been reduced.

I don't know about that. Peacetime doesn't afford a lot of opportunities for soldiers to get combat experience. There's no substitute for time on a two way range.

The last 15 years, we've probably had the best cohort of soldiers since Vietnam.

 

[HighPriest]

Regardless, it's apples and oranges. Don't get me wrong, I appreciate the importance of well trained soldiers. History is very clear about the effectiveness of veteran armies. However, veteran physicians are also more valuable, so that's a wash. What matters is: I can train up an infantryman in what? 9-12 weeks? Whereas it takes a minimum of 9 years to train a GMO physician. Plus, let's be honest, the pool of possible riflemen is a bit larger than the pool of possible doctors. So while it is unarguably important to have a trained soldier, you really have more to lose by not keeping your physicians trained up.

 

[Galo]

To add logs to the fire:

https://www.usnews.com/news/nationa...military-surgeons-skills-preparedness-for-war

 

[HighPriest]

It’s logs on a fire in a burning house at this point.

 

[John1513]

Galo... HighPriest...

Please share some insight on “chain of command?”

Have you found an effective way to communicate major concerns to the Triad without setting off a ‘hornets’ nest?

Galo’s story about baseless OSI investigation certainly is scary.

I have noticed that in Milmed, non-physicians have their “office politics game” down solid. Physicians, often sacrificing so much time to be trained, usually have a steep learning curve for this adulting that is “office politics.”

Could it be possible that Milmed will improve with the new DHA take over?

 

[John1513]

To add logs to the fire:

https://www.usnews.com/news/nationa...military-surgeons-skills-preparedness-for-war

Gee, everything that has been said on SDN for over 10 years. Could it be... could it be finally that things will change? Those in charge certainly can’t ignore US News.

Just look at how the admin types scurry around, furrowed brows and clip board in hand —- when there is one negative ICE comment. Task force, pronto!

Logs indeed! But, at tipping point, we may just be!

 

[HighPriest]

Galo... HighPriest...

Please share some insight on “chain of command?”

Have you found an effective way to communicate major concerns to the Triad without setting off a ‘hornets’ nest?

Galo’s story about baseless OSI investigation certainly is scary.

I have noticed that in Milmed, non-physicians have their “office politics game” down solid. Physicians, often sacrificing so much time to be trained, usually have a steep learning curve for this adulting that is “office politics.”

Could it be possible that Milmed will improve with the new DHA take over?
.

That is a large font.

I never felt like I kicked a hornets nest. I just felt like I was ignored most of the time, and that the only way to actually get things done was to ask for forgiveness rather than for permission.

 

[HighPriest]

Those in charge certainly can’t ignore US News.

Sure they can.

 

[Chonal Atresia]

To add logs to the fire:

https://www.usnews.com/news/nationa...military-surgeons-skills-preparedness-for-war

 

[Chonal Atresia]

Scott was my chief resident when I was an intern.

He loved the army, general surgery and teaching. He is a great surgeon as evidence by his current position at the Cleveland Clinic.

He left the army with 18 years in - no reserves. Military medicine just plain sucks. We should be screaming from the hilltops preventing med students from making our same mistakes.

 

[Gastrapathy]

Ive heard that the CT surgeons at NMCSD are refusing to operate. Anyone confirm?

 

[Gastrapathy]

It’s never been about trauma for me. That was always a red herring. Trauma surgery can be relearned by any busy surgeon pretty fast in a high volume wartime setting. It’s the day to day procedures. I would have been scared to have half our surgeons take out my GB let alone do something hard. In my current practice, it’s just not that way.

 

[Atlas Shrugged]

NMCSD ORs were closed for some time due to issues with sterilization. There were weeks of surgery residents organizing transfer to other facilities and very little surgery going on. I overheard that they “maybe” had one exlap set “just in case”.

I would no be surprised if it was still and ongoing problem. Absolutely embarrassing.


Sent from my iPhone using SDN mobile

 

[pgg]

Ive heard that the CT surgeons at NMCSD are refusing to operate. Anyone confirm?

I have heard via various channels that NMCSD is not currently doing cardiac surgery, and there may be some arrangement for them to take those cases to the VA and/or UCSD. I don't know what prompted that.

At NMCP, the contract for perfusion services and CT surgeon backup expired in December and was not renewed. There had been broad dissatisfaction with some aspects of that contract for many years. Presently the plan is to hire a perfusionist(s) and CT PA. That hasn't been completed yet; in the meantime the surgeons are operating at a nearby civilian hospital.

I think Bethesda is business as usual.

 

[pgg]

It’s never been about trauma for me. That was always a red herring. Trauma surgery can be relearned by any busy surgeon pretty fast in a high volume wartime setting.

I've always felt the same way about trauma.

Nobody, even at the busy knife and gun clubs, is doing the kind of blast and high velocity GSW injuries typical of a deployed surgeon.

As an anesthesiologist, I'd done essentially zero trauma in the 4 years prior to my last deployment. They gave all of us (physicians, nurses, techs) a 3 week refresher course at USC, that was about 80% didactic. It was fine. We all stepped into the R3 in Kandahar pretty easily. The outcome numbers were excellent.

 

[John1513]

Navy Surgeon General Opening Remarks To Senate Appropriations Committee – Defense – Navy Medicine


When the SG spoke to Senate, I thought to myself that maybe he reads SDN.

Is this hopeful or just strategic lip service?

 

[HighPriest]

Navy Surgeon General Opening Remarks To Senate Appropriations Committee – Defense – Navy Medicine


When the SG spoke to Senate, I thought to myself that maybe he reads SDN.

Is this hopeful or just strategic lip service?

I don't actually see anything hopeful in his statement. I didn't read the written statement. But the gist of his statement seems to be "we're doing a good job, don't worry. Camp Lejeune is trying to be a level III trauma center, which is really going to help train our docs because it means they'll have an ER now and they'll be able to defer trauma cases to level II and I centers....also I'm not exactly sure what the different levels of trauma centers are, or what kind of experience we're missing..."

In fact, just skimming his written statement, "word class care" just means having an expensive EMR, using telemedicine to make up for your lack of skilled professionals, and reorganizing the leadership algorithm to make it look like you're shaking things up. I don't really see anything that mentions how terrible military medicine is as skill maintenance. Other than that he mentions one agreement with a civilian trauma center without mentioning whether that's made a difference in any meaningful way.

 

[HighPriest]

I've always felt the same way about trauma.

Nobody, even at the busy knife and gun clubs, is doing the kind of blast and high velocity GSW injuries typical of a deployed surgeon.

As an anesthesiologist, I'd done essentially zero trauma in the 4 years prior to my last deployment. They gave all of us (physicians, nurses, techs) a 3 week refresher course at USC, that was about 80% didactic. It was fine. We all stepped into the R3 in Kandahar pretty easily. The outcome numbers were excellent.

I don't agree at all with the idea that trauma surgery can be relearned with a refresher course. I certainly wouldn't try to put together a complicated LeForte III with an NOE component, no matter how many refresher courses I took. I could do a neck exploration, but only because I'm doing a lot of head and neck cases right now. When I was in Kansas, I did zero. Multiply that by about four years, and I wouldn't feel comfortable there either.

I could certainly do it with a gun to my head. I know the anatomy. But it's not just about sticking things together again in a generally appeal-able position. Either you know how to do it well, or you're doing a disservice to the patient. That may be very different when you're talking about a GSW to the leg or abdomen. I honestly wouldn't know. That's why, if I had facial trauma, I'd go to the county hospital where they're putting together smashed faces all the time. I wouldn't do it where I live, even though I think the surgeons here are very competent and know how to read a textbook.

I agree, to an extent, that there's a difference between civilian trauma and battlefield trauma. But there's a difference between taking a trauma surgeon who does a lot of trauma and asking him to do some super trauma versus taking a surgeon who does zero trauma and putting him in the same position.

If we're talking stabilize and mobilize, then sure, a refresher course is probably fine. And I do get that in many cases that's what is happening - stabilize the guy and send him back for definitive repair. But these guys are still going to military facilities for this definitive repair. So when they get there, it'd be nice to have someone who knows what the hell they're doing waiting for them.

I can tell you from experience that where I trained, we did trauma, but none of the staff really felt that comfortable with it. The head and neck oncologist could get through a trauma case if he had to, but we were only a level II, so the real bad stuff when to the county anyway. The facial plastics guy felt ok about it. But none of them were even close to as good at dealing with it as the guys downtown. Period. And the more complicated the trauma got, the less comfortable they felt with it. And these were guys who had spent years at a major MEDCEN, and a "military trauma facility."

Again, it's not even about how badly milmed does. It's about how much better they COULD do if they just put a little effort into it. I mean, what are we here for?

 

[Perrotfish]

Again, it's not even about how badly milmed does. It's about how much better they COULD do if they just put a little effort into it. I mean, what are we here for?

As others have said, it seems like of all the problems discussed on this board, this is one of the hardest to fix. Trauma in general is in short supply in the US, and what there is usually is already saturated with trainees. Do we pay attending trauma surgeons to push our guys to the head of the line for surgery? If so then where do the civilian residents get their trauma experience? Do we send physicians to wars that we aren't otherwise involved in just to keep their trauma knowledge current? If so how do we protect them, prevent mission creep, and minimize the political fallout? Do we move to a mostly reservist model for trauma surgery, or have our surgeons staff level one trauma centers full time for free? If so how much does it cost, and who manages civilian trauma centers when we have a war?

There are a lot of problems with military medicine that I think could be solved with a little effort and some common sense, but those problems are mostly in the small hospital system. That's the other thing we're here for, and I think that we could easily be doing that job a lot better without even pouring a lot of money into it. Maintaining wartime trauma surgery skills in a military that's not seeing a lot of wartime trauma, on the other hand, is not a problem that I think anyone has a great solution to.

 

[HighPriest]

totally. we should just keep doing what we're doing and not try doing anything differently because it's hard.

I can't comment on general surgery. I can comment on facial and head-and-neck trauma. There's so much of it locally that the county hospital has a hard time keeping surgeons on staff to take care of it. They burn out faster than they can hire them. Seems like an opportunity in there somewhere.

When I was moonlighting in certain areas (not major metro areas), I'd get 1-4 trauma calls every single night. And unless the local docs are being paid by the hospital, no one wants facial trauma. Or, at least, very few people want it. The call sucks, the patients are rarely insured, the reimbursement is terrible, and if you have a broken jaw there's an 80% chance you're an @$$hole.

There was a practice that tried to recruit me where the hospital their local group $1200/night just to cover trauma call (not including general call, just trauma). They would get 2-3 calls every single night. Now, some of those were just broken noses, but a lot of them were big smash ups. The local group was having trouble hiring. Partially because its location, but also partially because no one wants to do that kind of trauma call. And this wasn't a big town.

Should you station a military doc there for that? Probably not. Could a military doc come in and bang out a bunch of trauma cases in a day that had been lined up for him so that the local docs don't have to make hours and hours of time in their day to do cases that aren't worth their time? Maybe. Maybe not. But it seems like these are all possible opportunities.

The other issue is, as stated before in the forum, it is ok to train with cases that are -similar- to trauma cases in many circumstances. As I said, I could get through a penetrating neck case because I know the goals and the indications and I do a lot of head and neck. That doesn’t really apply to bony facial trauma, but if I did orthagnathic or craniofacial surgery, it would help. So trying to get similar cases can be a help as well. Any of those options are better than expecting a training course to prepare you for a major surgery that you haven’t done since residency, and even then only a few times.

 

[militaryPHYS]

Scott was my chief resident when I was an intern.

He loved the army, general surgery and teaching. He is a great surgeon as evidence by his current position at the Cleveland Clinic.

When did he get out? What is he doing now in terms of relation to milmed? i.e. What's his skin in the game currently?

Do you see his article from 2015? https://www.usnews.com/news/articles/2015/05/18/risks-are-high-at-low-volume-hospitals. This is basically what they are discussing in the current article, just focussing on military "community hospitals". The point is valid that if you're at a hospital that doesn't do enough of a procedure to maintain your skills then it needs to be referred to a larger institution.

 

[HighPriest]

But this also includes larger MEDCENs, depending upon the procedure. There are cardiac surgeons at MEDCENs who do basically no cardiac surgery, but every now-and-then they try to build a practice back up. Even with head-and-neck oncology, we'd have some years where we a reasonable amount (never a ton) and we'd have other years where we didn't do enough to support a residency (or a surgical skillset). So what's the answer? Stop doing it? Then you also need to stop training residents. we had away rotations, but doing 3 months of oncology at an outside facility, one time, during your residency isn't enough to become proficient, no matter how many cases you do.

So, the problem is worse in small MTFs, but it's present everyone in the military. It's just somewhat better at MEDCENs.

 

[militaryPHYS]

To be honest, I've been pleasantly surprised with how well our OCONUS transfer systems work to transfer complex or advanced cases to the nearest MTF (tripler/SD). Now, whether or not the receiving providers are the right people for the job is the ultimate question, but I personally verify who they are going to and know them either personally or professionally via my partners.

Dare I say...hopefully with the new push for civilian integration....having available OR's at civilian centers close to our large MEDCENs who will have multiple sub-specialized civilian providers also available will allow a better system to perform these complex cases with the assistance of hands who may have performed the procedure hundreds/thousands of times. (this is one way I see this new stuff being advantageous....if it works).

 

[Zulu451]

Time and time again every major obstacle that comes up in our system boils down to the fact that the military needs to get out of the business of CONUS medicine. Time to make us all reservists and watch it all burn to the ground. Keep some price of freedom hospitals open where you rotate through but that’s about it.

 

[deuist]

Time and time again every major obstacle that comes up in our system boils down to the fact that the military needs to get out of the business of CONUS medicine. Time to make us all reservists and watch it all burn to the ground. Keep some price of freedom hospitals open where you rotate through but that’s about it.

That has been a suggestion for decades. The problem is that no one in a higher levels of authority will ever sign off on it. No colonel or general wants a bullet point to say, "The hospital were shut down under my command."

 

[HighPriest]

That has been a suggestion for decades. The problem is that no one in a higher levels of authority will ever sign off on it. No colonel or general once a bullet point to say, "The hospital were shut down under my command."

Saw this first hand at my first duty station - had been on the chopping block since BRAC. Really should have been shut down. Poor care, poor facilities, no one wanted to be there so no one was there mentally anyway. Two commanders, both did absolutely everything they could to keep the place open even though the civilian sector could have supported the base. And I mean everything - dangerous things - doing everything short of frankly ordering providers to take care of patients that shouldn't have been taken care of locally just so that we weren't sending anything off post. I actually saved an e-mail (in case of rain) where one of the nurse-officers in the command suite straight up told us to withhold information from a senator visiting the site, even if asked directly. I'm not talking about her saying "this is above your paygrade, so pass the question up to us." It was something along the lines of "it would put a fork in us if they found out "x", so do not let them have that information."

 

[Perrotfish]

Time and time again every major obstacle that comes up in our system boils down to the fact that the military needs to get out of the business of CONUS medicine. Time to make us all reservists and watch it all burn to the ground. Keep some price of freedom hospitals open where you rotate through but that’s about it.

This is a devil is in the details suggestion. Who provides healthcare in Guam and Leemore? Contractors? Have you seen the kind of civilian doctors we get out there? How do you attract reservist docs? Yes other countries do that, but they pay their civilian doctors was less and also fight way fewer wars. Just how much would you need to pay a US Ortho to be ready to leave his 600K/year net income practice and be ready to deploy to Syria on a moment's notice.? Who makes the policies for the medical corps? Do we hand it over to the full time MSC guys, and let the reservist docors walk into the kind if clinical environment that would create?

 

[HighPriest]

I love these circular arguments. No one is saying (so far as I can tell) that the military shouldn't employ doctors. They just shouldn't run hospitals. You don't need an orthopedic surgeon in Guam. Maybe you need a family doc, sure. Or a GMO. You keep a stable of physicians. You keep them on the government's dime, and you put them in civilian hospitals, and you pull them when you need them to backfill. Hell, they -already- do that. They pull sub-specialists from MEDCENs to backfill in these hole-in-the-wall places.

The argument is that the military shouldn't run hospitals. Or at least, not so many hospitals. I can see keeping major centers like NCC/WR or BAMC open or even Tripler just due to it's location. But you staff them with a number of physicians proportional to the amount of pathology they have to offer. Not 9 ENTs in a clinic that really needs 3. Military hospitals provider poorer care (demonstrated in studies), have poorer outcomes (demonstrated in studies), and are ludicrously expensive to run, they don't support skillsets, they contribute to burnout more than anything else in the military. They're just boxes where the military stores doctors until they're rotten.

By the way, the people making policy for the medical corps are already freaking *****s. And I've seen the quality of civilian contractors we get at military MEDCENS. There are exceptions to the rule, but frankly they're not going to be splitting the atom any time soon.

Just how much would you need to pay a US Ortho to be ready to leave his 600K/year net income practice and be ready to deploy to Syria on a moment's notice.?

I dunno, how much do they pay reservist Ortho guys to do just that?

 

[Perrotfish]

I dunno, how much do they pay reservist Ortho guys to do just that?

My point was I don't think there are many Ortho guys/gals that have taken them up on the reserves, and the ones they did find were mostly at least halfway through a military career. I don't think we could find nearly enough reservists to meet our needs if we got rid of the AD military docs. US medicine just isn't structed in a way that's friendly towards reserve physicians, particularly surgeons.

 

[HighPriest]

My point was I don't think there are many Ortho guys/gals that have taken them up on the reserves, and the ones they did find were mostly at least halfway through a military career. I don't think we could find nearly enough reservists to meet our needs if we got rid of the AD military docs. US medicine just isn't structed in a way that's friendly towards reserve physicians, particularly surgeons.

I understand what you're saying here. But, again, we shouldn't get rid of AD physicians. We should get rid of (most) DoD-run hospitals.

 

[Perrotfish]

Of course the other issue with an reservist model, or a model with AD docs at busy civilian hospitals, is that the military now pays for healthcare twice. The hospital at Guam isn't just a place to store doctors when their skills rot, it's a desperate attempt to recapture some of the insane cost of running the medical corps. The mitary had been streched very thin for a very long time, and the idea that we are going to pay a trauma surgeon to operate on civilians at tertiary civilian medical centers while paying a civilian surgeon to operate on the Marines who wreck their cars wod be a hard sell even if our medical outcomes we're truely bad. And they're not. They're not Hopkins, but they're not worse than the community standard either.

 

[Perrotfish]

I understand what you're saying here. But, again, we shouldn't get rid of AD physicians. We should get rid of (most) DoD-run hospitals.

I've heard this suggestions before, but besides the cost issue I mentioned above, why in the world would anyone be an AD physicians if there weren't DOD hospitals?. To the extent that anyone likes mitary medicine, they like the patient population, the insurance, the low work volume, the sense of community, and (yes) the cachet of being an officer.

Without hospitals what are the options? A never ending operational tour? Most people can't deal with more than two or three of those in a career without losing their ****. A civilian hospital? So now you have civilian productivity goals, insurance problems, and patients but a military salary and the threat if deployment? A reservist model? Again, what groups in the US want to hire someone who might deploy at any moment? I just don't see how this works better than the system we have now.

 

[John1513]

Cheeky case in point -

On National Doctors’ day, did you guys see any fanfare, desktop wallpapers, emails in the military? (None, nada, zilch)

Now, how about for National Nurses’ week? ( all week, PAO announcements, different desktop screensavers, posters, morning Tweets etc)

Yup.

 

[deuist]

why in the world would anyone be an AD physicians if there weren't DOD hospitals?. To the extent that anyone likes mitary medicine, they like the patient population, the insurance, the low work volume, the sense of community, and (yes) the cachet of being an officer.

This statement is mostly false. I worked more clinical hours and saw more patients on active duty than I do as a civilian. I did it at 1/3 of the pay and had to go in on my off days to pee in a cup, learn why I shouldn't rape my colleagues, and out-run the junior enlisted during annual PT tests. The patient population was made of dependents and junior enlisted malingers who needed parents, not a physician. And I'm not sure what "community" you're referring to. All of the ED docs clock in, clock out, and go home. We're not all hanging out after work. TriCare is useful for getting healthcare paid for. There are some parents of special needs children who need it, but most docs would experience the same with civilian insurance.

 

[militaryPHYS]

This statement is mostly false. I worked more clinical hours and saw more patients on active duty than I do as a civilian. I did it at 1/3 of the pay and had to go in on my off days to pee in a cup, learn why I shouldn't rape my colleagues, and out-run the junior enlisted during annual PT tests. The patient population was made of dependents and junior enlisted malingers who needed parents, not a physician. And I'm not sure what "community" you're referring to. All of the ED docs clock in, clock out, and go home. We're not all hanging out after work. TriCare is useful for getting healthcare paid for. There are some parents of special needs children who need it, but most docs would experience the same with civilian insurance.

That statement is mostly false...FOR YOU. For me it is quite true. Everything is dependent on branch of service, MTF location and specialty. There are no absolutes. Everything you say here is completely opposite from my current situation. There are sometimes good situations in Milmed and there are happy people.

Back to original discussion. So long as we have missions in places like Guam we have to support them. It is very naïve, especially for senior members with experience, to say that we could just pack up and not support the operational mission on that island or any other overseas location as they all have a strategic purpose. To rely on "the network" there would be pure neglect as we would be allowing our members to receive substandard care. Even in Japan there is still a different standard of care out in town, especially when you move in to the realm of sub specialization. Wherever there is a strategic mission with a purpose we must have AD physicians there to support them. That means some of those physicians will have a slow, mundane practice due to low volume and acuity. That is why we have PRD's so we can rotate on to the next place. Even 2 years is certainly enough time for skill atrophy, but unfortunately one year tours aren't very advantageous for continuity or finances. Its a balance.

Everything is counter-intuitive. OCONUS and at small, rural commands the acuity and volume is lower, but the need for AD physicians to care for the members there is paramount as the local "network" can't provide the level of care we expect. CONUS and at large MTF's the AD physicians aren't really needed because we have such a strong "network" in the U.S.

Should we all be essentially civilians when we are stateside and have a rotation set up for 1 year unaccompanied tours to our CONUS billets in addition to our rotation for actual deployments?? I'm not sure I would like that more than our current situation. We would likely be away 2/3rds of the time as opposed to now being "home" 90+% of the time?? The AD physician is not going away. There will be less of us in certain specialties as we are already seeing and there will be a lot of restructuring, but we can't be without them.

 

[Perrotfish]

This statement is mostly false. I worked more clinical hours and saw more patients on active duty than I do as a civilian. I did it at 1/3 of the pay and had to go in on my off days to pee in a cup, learn why I shouldn't rape my colleagues, and out-run the junior enlisted during annual PT tests. The patient population was made of dependents and junior enlisted malingers who needed parents, not a physician. And I'm not sure what "community" you're referring to. All of the ED docs clock in, clock out, and go home. We're not all hanging out after work. TriCare is useful for getting healthcare paid for. There are some parents of special needs children who need it, but most docs would experience the same with civilian insurance.

ER doctors have light hours and no problems ordering tests everywhere. I'm talking about the 90% of us that work in some kind of clinic, and especially the 50% of us that work in primary care.

I have never filled out a pre-auth. I have never had a test turned down. I can order a same day CT or MRI from a clinic. My patients have a >80% compliance rate with my therapies and I have no more than 2 or 3 no shows per day. When I say 'go to the ER' the patient never, ever says that they can't afford it. I don't need to tailor my medication to my patient's insurance and/or the Walmart $5 mediation list. These are all things civilians in my profession deal with daily. And the patients are better than civilian patients. Both AD and their dependents are more pleasant and more compliant that the civilian patients I've seen, on average. Not perfect, and again its an average with the usual outliers, but they're better.

And, again, I'm not saying military medicine is good. What I am saying is that if you made me an AD military doc but put me in a civilian hospital to maintain my skills that seems even worse than what we have now. I would then have all the civilian problems (pre-auths, no shows, awful patients) with the same piss tests, PRTs, and crappy pay that I had at the military hospital. That seems like a definite step down, rather than a solution.

 

[HighPriest]

I've heard this suggestions before, but besides the cost issue I mentioned above, why in the world would anyone be an AD physicians if there weren't DOD hospitals?.

I feel like there’s a serious disconnect here between what is being suggested and the picture you have of that suggestion. No one joins the military because of AD hospitals. Not doctors. Not soldiers. No one.

People would join because it’s the exact same deal it is now, but better because you’re not working at some $#!tsack MEDCEN. You do HPSP. You get school paid for. In exchange, you are in the military, but you’re stationed at a civilian facility that cares for the nearby military population. You get paid less than your civilian counterparts. You do PT tests. You get UA’ed (although probably at a more rationale frequency). You see AD soldiers and dependents as a priority the hospital is happy to have you because they’re collecting facility fees, which is still less expensive for the DoD than running an insanely inefficient hospital. The hospital isn’t paying you, so productivity is less of an issue than the free service they’re receiving to begin with, but most of the guys I know would be thrilled to be able to work more at a more efficient facility where they could see more patients and keep their skill set by supplementing with locals now and then.

Frankly, I don’t see how that doesn’t work. My understand was that the AF was already doing it. I have no idea what you’re talking about with regards to a never ending operational tour, or how that applies in any way to what I’m suggesting.
And yes, you could be deployed, just like any other military physician, or any other reservist, who currently wears a uniform.

Lots of civilian facilities would jump on this. My experience is that they would break down the door for it. And they already do hire guys who could be deployed. Theyre called reservists.

 

[HighPriest]

That statement is mostly false...FOR YOU. For me it is quite true. Everything is dependent on branch of service, MTF location and specialty. There are no absolutes. Everything you say here is completely opposite from my current situation. There are sometimes good situations in Milmed and there are happy people.

Back to original discussion. So long as we have missions in places like Guam we have to support them. It is very naïve, especially for senior members with experience, to say that we could just pack up and not support the operational mission on that island or any other overseas location as they all have a strategic purpose. To rely on "the network" there would be pure neglect as we would be allowing our members to receive substandard care. Even in Japan there is still a different standard of care out in town, especially when you move in to the realm of sub specialization. Wherever there is a strategic mission with a purpose we must have AD physicians there to support them. That means some of those physicians will have a slow, mundane practice due to low volume and acuity. That is why we have PRD's so we can rotate on to the next place. Even 2 years is certainly enough time for skill atrophy, but unfortunately one year tours aren't very advantageous for continuity or finances. Its a balance.

Everything is counter-intuitive. OCONUS and at small, rural commands the acuity and volume is lower, but the need for AD physicians to care for the members there is paramount as the local "network" can't provide the level of care we expect. CONUS and at large MTF's the AD physicians aren't really needed because we have such a strong "network" in the U.S.

Should we all be essentially civilians when we are stateside and have a rotation set up for 1 year unaccompanied tours to our CONUS billets in addition to our rotation for actual deployments?? I'm not sure I would like that more than our current situation. We would likely be away 2/3rds of the time as opposed to now being "home" 90+% of the time?? The AD physician is not going away. There will be less of us in certain specialties as we are already seeing and there will be a lot of restructuring, but we can't be without them.

Why would you be away any more frequently doing exactly what you’re doing now at a civilian facility than you are now? I’m not talking about sending guys to New York. Just to a nearby civilian facility. I can tell you for sure that short rotational tours to preserve skill sets isn’t what the Army does. They’ll plop you down in BFE for your entire ADSO and then leave you on the curb afterwards. And, as mentioned above, you don’t need to close every single facility. But they should close every military facility that is close enough to a civilian counterpart to be a redundant facility. Because no one is worse at running hospitals than the DoD. Keep rotating docs. I promise you that the hospitals won’t care so long as there’s a rotation. You’re extra FTEs that they don’t pay for and that they didn’t have before.

 

[HighPriest]

ER doctors have light hours and no problems ordering tests everywhere. I'm talking about the 90% of us that work in some kind of clinic, and especially the 50% of us that work in primary care.

I have never filled out a pre-auth. I have never had a test turned down. I can order a same day CT or MRI from a clinic. My patients have a >80% compliance rate with my therapies and I have no more than 2 or 3 no shows per day. When I say 'go to the ER' the patient never, ever says that they can't afford it. I don't need to tailor my medication to my patient's insurance and/or the Walmart $5 mediation list. These are all things civilians in my profession deal with daily. And the patients are better than civilian patients. Both AD and their dependents are more pleasant and more compliant that the civilian patients I've seen, on average. Not perfect, and again its an average with the usual outliers, but they're better.

And, again, I'm not saying military medicine is good. What I am saying is that if you made me an AD military doc but put me in a civilian hospital to maintain my skills that seems even worse than what we have now. I would then have all the civilian problems (pre-auths, no shows, awful patients) with the same piss tests, PRTs, and crappy pay that I had at the military hospital. That seems like a definite step down, rather than a solution.

Except that Tricare is still Tricare. You’re still dealing with the same insurer you are now. I’m sure that dynamic would change a little, but you’re still an AD physician seeing a Tricare patient who has Tricare. You wouldn’t have to tailor your RXs any more than you currrently do because you use a facility formulary or you fill out an NDR.
The exception would be the civilians you see.

I get it if your argument is that you actually like the military system because the patients are great (they are), or because you like not having to see a lot of patients or don’t want to work as much. To be fair, I had never even considered the possibility that someone might prefer the $#!tshow that milmed is. That’s not a criticism of you at all, its my own blind spot. But I think you’re in the minority there as evidenced by the retention rates. And that has got to be a reflection of how Navy medicine is relative to the Army.

But, fine. Have the military keep primary care clinics open and host surgeons somewhere where they can actually do their jobs. That’s also a better model. The less medicine the DoD manages in CONUS, the better it is for everyone. Even if it isn’t a complete sweep of their facilities. I certainly don’t pretend to have a perfect model, but I think any suggestion with less DoD management is a better option.

 

[HighPriest]

MEDCENs are like having an old refrigerator sitting in your yard. They’re dirty and broken down. They’re an eyesore for the neighbors. Anything you put in it will rot. Kids definitely shouldn’t go inside. And it’s a great place for rats to hold up and breed other rats. Sure, it’s technically a refrigerator. It kind of looks like one should have 20 years ago. But it doesn’t work. And you should throw it away. But you don’t, because you’re gonna fix it up one day and use it in the garage.