I will never forget the most unbelievable patient encounter I have ever had anywhere. I was working alone as an AF GMO in the ER in the early morning hours one day when a young mother brought in her two young previously healthy children and signed them in as patients. Upon triage where there vital signs were normal, the chief complaint was that the children needed a medical check. Given the fact that we were bound by EMTALA/AF Policy to see anyone for anything anytime, we obliged. With bleary eyes and a tired brain, I entered the exam room and asked this young mother what problems her children were having and her answer was NONE!! Incredibly, she went on to tell me that their family was leaving to go on vacation later that day and she just wanted them "checked out" to make sure that they would not get sick while on vacation!!! Nothing like that has even happened to me since, and I am convinced that such a thing would only happen within the context of MTF medical practice where everything is scott free. Furthermore this "free" environment, fosters a lack of gratitude on the part of patients. In my current civilian position, I am continuously receiving written and verbal expressions of gratitude and appreciation from patients, it is obvious that they value and appreciate the care they receive, but as I look back on my military medical experience all I seem to recall patients doing was constantly belly aching and complaining about this, that or whatever. I'll never forget the vice-commander of the medical group telling me once that patient complaints there were just a part of doing business!! For an organization that is so money oriented, I just cannot understand why service fees have not been instituted in MTF's.
You have a very good point about what totally fee-free healthcare fosters. That said, you've been living a very sheltered life. The military patients I've worked with so far have been infintiely better and nicer then all the frickin IV drug using medicaid patients I had to put up with in med school. Even the non iv using medicaid patients were terrible. It wasn't that uncommon for those obnoxious patients to call for an ambulance to drive them to the peds urgent care center b/c "it's cheaper then the bus." Then they'd say their kids had asthma to get seen quickly. Come to find out they just had a cold and also needed to get some gym papers signed.
I am currently doing my peds rotation at a inner city hospital so I feel your pain. At this hospital we call it a TAXILANCE.
My most unusual patient was a food service person with a 14x10x10 cm level 3 neck node that didn't want treatment because it would interfere with his job. I don't think I would want somebody with that necrotic mass serving my lunch.
Fee free healthcare is fee free healthcare, regardless of the setting, be it the MTF or a Community Healthcare Center (medicaid). Believe me, I too have seen firsthand the problems with medicaid (in my previous civilian positions, none of that here of course). Bottom line, both MTF healthcare and medicaid are similarly abused (by patients), though my above story takes the cake. Major medicaid reform is underway in many states to implement strict medicaid HMO's, in an effort to save the billions that are being spent/wasted. So, medicaid recipients look out...."Tricare Prime" type of arrangements are coming to a clinic near you. Whether or not it saves the taxpayers money or ends up costs them more due to increased bureaucracy remains to be seen. Speaking of "Tricare Prime", I cannot help but wonder if this was a Clinton Administration initiative implemented during that time, because Hillary failed at "reforming" healthcare nationwide, therefore they turned their attention to the military system which they did have control over. Any thoughts?
Nobody knows more about what is, and what is not working, better than the doctor. The doctor is the best advocate for the patient, certainly the best for the physician. Any system that removed all authority from the physician is doomed in todays health care world. The military healthcare system is the prime example of that kind of system.
Look, you need to see the big picture. As long as the doctor is not paying for the patient's care, he is not going to have full authority. Maybe I misunderstood what you are trying to say here, but as much as I would love to be in full charge of what gets done, it's unrealistic to think so. And I would also point out that it is rather parochial to think that only doctors "know what works". Is an infantry private the only person who knows how the army works? WHat about the guy who works the counter at Mickie Ds - is he the only one who knows how the restaurant works? I agree with your points (previously made) that too much decision making power has been taken away from the doctors. But I'm hoping it's just (understandable) hyperbole on your part when you make statements like that.
Of course I am not saying docs need FULL authority. I am saying that when docs have zero, or near zero authority,you will have that problem. The rather unique position that military medicine has is that the physician also lacks the power that the civilian has;that to leave when things cross a threshhold of ridiculousness. Believe me,if the civilian HMOs,under the current cost cutting frenzy,had their civ docs locked in to iron clad 4 year options, you might see some of the same things (until word got out, and then that HMO would either go under in 4 years,or be forced to change). And as docs,we are more than "counter people"at Mc Donalds. As the doc,we do know if the referral system is working, if we have the right supplies,support staff, etc to get the job done. We are the "rate limiting step" in the medical care reaction. Is it fair to work us hard? ABSOLUTELY. Is it fair to man a system at 20%? To have near high schoolers as our support staff? To be unable tooffer pts appointments because staffing is so low? and many other things from prev threads? And again, who license,whose responsibility is the care for these patients.....it is ours.
The training program that I am at has 2 training areas. One is a large county hospital serving as a primary hospital for, what seems, all of Central America. Care is covered my medi-cal. People complain about having to get approval by the county to get q 3 month MRIs to follow their post op surgical resections that cost upwards of 50K+ with no out of pocket expense. The ER is a primary care faucility as well as a major trauma center, because non-paying customers abuse it for any ache an pain. Our department have a 30-40% no show rate for consult appts and CT imaging slots. We double book with the expectation that people won't show up for appts. You would think someone with cancer would be prompt at making their appointments. Wrong. Across the street at a major cancer center, people will emergently page you at Sunday 2 am, because their arm hurts for 2 weeks. You invest lots of time and money into an oral cancer patient, only to have your patient come back smelling like booze and tobacco. Same stuff that you deal with in the active duty and dependent population. Private practice with cash paying customers does not apply to the above!!!! I am referring to no fee service. The difference between the two abusing groups: the military population is a deployable AD or is the dependent of an active duty soldier/sailor/marine/coastie. The young enlisted spouses have never had to worry about what to do for medical because this is their first time away from their parent's house 2000 miles away, now with no family support group. They misuse the system because they often don't know better. There are abuses of military medicine and our resources. I will not deny that, but if you remember who you are supporting, it makes it easier. One of my pts was a SEAL who stepped on a bad guy before he was wounded in Afganistan, and he was joking about it while recovering on our ward. He also wanted to get back to his friends as fast as possible. I'll treat his kid with an otitis media in the ER on a late sunday night without complaining.
I have two words for you: Sick Call. IN my experience, (which is about 18 months in the operational Army), this is abused even more than our ER. I have seen patients that show up for stuff that does not need to be seen at all. Sometimes, an injury/illness is faked to get out of PT. So many providers have gone to having sick call after PT to lessen the shamming. We as Dr. can't ignore the patient- we have to move the shammers out fst and return them to duty ASAP so we can spend more time with our real sick, injured patients that need our help.
tons of things to hate so little time...before you know it you'll be out...and thank goodness for that...otherwise, I'd kill myself
