Overturning the VA rule re: CRNA independent practice is just the beginning

[MedicalCorpse]

(Also posted to American Society of Anesthesiologists [ASA] open forum. Everyone should immediately go to the Safe VA Care web site: American Society of Anesthesiologists and send a message to the VA during this limited comment window.)

As a U.S. veteran who resigned my regular commission after 19 years of total active duty service (11 as an anesthesiologist after eight years of training within the military system; 15 years toward retirement due to DOPMA changes in USUHS rules which took effect the year I started), I wholeheartedly commend the ASA for speaking out against the proposed VA rule that would neutralize the role of anesthesiologists in the anesthesia care team, and thereby endanger patient safety.

How do I know it would endanger patient safety? I was the "Medical Director of Anesthesia" under the command of a CRNA anesthesia element leader when the civil war between anesthesiologists and CRNAs broke out at Travis AFB, CA in October, 1998. This was the direct result of the Air Force's decision in 1993 to make all command billets corps neutral under the infamous “Objective Medical Group”.

Simply put, this policy sea change meant that nurses could now command physicians, CRNAs could command anesthesiologists, and optometrists could command ophthalmologists. More importantly, it authorized CRNAs to practice completely independently for the first time, in violation of the decades-old collaborative Anesthesia Care Team model with anesthesiologist leadership.

The result was nothing short of disastrous. The Air Force went from staffing 4-5 anesthesiologists per day to cover 8 operating rooms, pediatric sedation for MRI/CT/GI, other radiology procedures, and a busy OB suite, to one. The Air Force Instruction was changed so that it was left up to the CRNA to decide if she felt like "consulting" her consultant anesthesiologist about any case perioperatively, regardless of ASA physical status. Because of sheer poor planning and failure to retain or recruit anesthesiologists, as well as escalating deployments overseas, there was now often only one anesthesiologist available at Travis after 2001 as a consultant...often at home post-call, rather than in house.

This situation resulted in the deaths or brain damage of several young active duty members when no physician anesthesiologist was available to rescue them from airway disasters, etc. Because of the Feres doctrine, active duty were prevented from suing the government for malpractice, so the money saved by hiring CRNAs instead of expensive anesthesiologists continues to be a fine selling point for zeroing out the end strength of anesthesiologists on active military duty.

This tragic situation continues to this day in every branch of the U.S. armed services. Anesthesiologists are not only incorrectly subordinated to surgeons on the org charts; they can also be subordinated to CRNAs or just plain nurses or medical service corps officers with zero anesthesia training. Anyone who speaks out against this system as a patient safety advocate is subject to the full weight of military reprimands and career-killing negative officer evaluations. Speaking truth to power is a recipe for career suicide in the U.S. military, which expects "Ma'am, yes Ma'am" rather than a scientific discussion of rational anesthesia care team policy. Thus, the retention rate of mid-grade anesthesiologists after their mandatory service period concludes approaches zero.

Here's a fun fact: the current Surgeon General of the Air Force is a nurse (mainly because 99% of physicians run away when their educational payback is finished). They evidently could not find one physician with enough brass on her shoulders to fill that role in the year 2020…or did not care to try.

I hope that, after the ASA leadership lends its political and financial support to overturning the proposed VA rule, it carefully consider the tragic circumstances faced by our millions of active duty, retirees, and dependents at Military Treatment Facilities worldwide which have ditched anesthesiologists and the Anesthesia Care Team in favor of CRNAs acting completely independently. Just as we veterans deserve to have an anesthesiologist involved in our perioperative care, so also do our active duty troops, their dependents, and honored retirees.

--
Rob Jones, M.D.
Ex-LtCol, USAF, MC
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, CA
OEF Anesthesiologist, 39th EMEDS, Incirlik AB, Turkey (2002)
Harvard '85 (ROTC Det. 365); USUHS '90; WHMC Anesthesiology '94

(MedicalCorpse.com is still on hiatus. That may change in the near future.)

(Returning after 8 or so years away. I appreciate the folks who asked for me to return a while back. Beware of what you ask for, it is written, because you might get it.)

---

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[Apollyon]

Dude - welcome back! Nearly 14 years since your last post, great to see you again!

 

[MedicalCorpse]

Dude - welcome back! Nearly 14 years since your last post, great to see you again!

Thanks. Fifteen years in the civilian world has given me some perspective on my fifteen years as a military physician.

I do not regret one word that I wrote back then, when everything was still fresh in my mind (and heart).

I got tired of being called names, including "unpatriotic" and worse, by people on SDN who had not walked one mile in my shoes, let alone 15 years. At some point I decided that, to be a better father and husband, I needed to take a break from SDN and refocus on my family, so that the bitter emotions stirred up by some wouldn't bleed into my improved civilian life.

This latest round of proposed VA rules to enable complete independent practice of CRNAs without any physician anesthesiologist oversight has gotten my attention for several reasons.

First, the American Society of Anesthesiologists is going full tilt to overturn this decision in 2020, whereas they ignored the plight of active duty anesthesiologists (and their poor patients) in all three branches from 1993 on. Somehow, now that money is involved, it all becomes important to them. I personally spoke to many people high up in the ASA from the late 1990s onward; there was a resounding response of "crickets" regarding CRNA independent practice and corps neutral command policies in the military because, well, it didn't affect them or their bottom line.

Second, as a veteran, I do not forget those who are still "in the trenches" supporting and defending our Constitution every day on active duty. They and their families and our honored military retirees deserve the best possible perioperative care. I have always believed that means the anesthesiologist-led Anesthesia Care Team model I had grown up with in military medicine since starting residency in 1991.

Third, where does this stop? If cheaper CRNAs are given the right to practice 100% independently in all 50 states in the civilian world, where does that leave us anesthesiologists? We will be relegated to the dustbin of history, as Trotsky said, along with those physicians who specialized in bloodletting or noxious humour counter-irritation back in the day. Pretty soon we will see PA trauma surgeons, NP neurosurgeons, and RN psychiatrists with full prescribing ability, and the day of the physician will be over.

After all, money talks and training walks, in this coming age of the non-physician "health care provider" who learned everything by watching TV reruns and online videos.

Hope everyone here stays safe and healthy during this coming "Dark Winter"...and, no, I am not about to politicize the pandemic.

Peace,

Rob

 

[absolutdokta]

It’s 2am, I just spent the last hour pouring over your posts from 2006 haha. I couldn’t stop reading and reeeeeeeally hope you resurrect your website....I’m genuinely interested in its contents. I’m 7 months out from completing my ADSO, only did my four years of payback before getting out so I definitely haven’t experienced the level of frustration you did. However, I have had days where banging the wall with my head was all I could do. But....I digress from your OP and that’s not my intent. Thanks for sharing your knowledge and experience!

 

[MedicalCorpse]

It’s 2am, I just spent the last hour pouring over your posts from 2006 haha. I couldn’t stop reading and reeeeeeeally hope you resurrect your website....I’m genuinely interested in its contents. I’m 7 months out from completing my ADSO, only did my four years of payback before getting out so I definitely haven’t experienced the level of frustration you did. However, I have had days where banging the wall with my head was all I could do. But....I digress from your OP and that’s not my intent. Thanks for sharing your knowledge and experience!

Thank you very much. And thank you for your continuing service to our nation.

Once again, the U.S. military demonstrates how little it cares about retention. It boggles the mind that after 10, 12, or 19 years of real life experience, the short-sighted pencil pushers at DoD would rather hire a cheap non-physician "provider" to replace a seasoned physician like yourself. Those physicians who do stay past their ETS share two key characteristics: 1) member of service academy old boys' network destined for O-6 and beyond and 2) completely incapable of functioning in the civilian world after years of allowing their clinical skills to be eclipsed by their desk-flying e-mail-fu and superhuman ability to say "mandatory fun run" without falling on the ground laughing.

Or as one very chill reservist CRNA with a billion years in uniform told me: "There are three kinds of anesthesiologists in the Air Force. In training, in payback, and incompetent."

But I digress...

Not sure if/when I will put MedicalCorpse.com back online. I did share 75% of the best "gouge" (to use Navy terms) in my SDN posts from 2006 onward. Oh, and, in case anyone asks, I did not start my web site until after I had left the USAF and resigned my commission (some had speculated that the government came down on me. They tried and failed years before that.).

Best wishes,

Rob

 

[DrMetal]

Thank you very much. And thank you for your continuing service to our nation.

Not quite sure why you're posting this here, as opposed to some other more general forum in SDN.

This problem---of midlevel providers, encroaching on physicians in medicine . . . whether it be CRNAs displacing anesthesiologists, or NPs/PA displacing physician PCMs, hospitalists---is much broader than mil med. In fact, the problem is way more rampant in the civilian world. CA just passed a law allowing NPs to work independently. I have several anes friends who can't find work in their home towns because their target hospitals are only hiring CRNAs. And the CRNA model paved this path for several other specialties, starting some 20 years ago.

And yet, much of this is our (us physician's fault). We're introverts, we don't assemble, we don't watch out for ourselves. We insist on making our professional lives as difficult as possible (excess CME, MOC) . . .we're expensive to pay, to insure, we're a liability. And then we're shock/surprised when the healthcare system finds a way to circumnavigate around us.

 

[grotto]

Physicians created this problem and we need to manage it. Demand physician leadership!
The last DMS at Portsmouth was a nurse! Unbelievable and unacceptable.

 

[MedicalCorpse]

Not quite sure why you're posting this here, as opposed to some other more general forum in SDN.

This problem---of midlevel providers, encroaching on physicians in medicine . . . whether it be CRNAs displacing anesthesiologists, or NPs/PA displacing physician PCMs, hospitalists---is much broader than mil med.

Hi,

Well, I don't have experience practicing in states with zero requirement for CRNA oversight...yet. I guess
I should make up my own pseudo-election map with different colors for "anesthesiologist oversight"
vs. "independent practice" and put it on my wall.

We can only speak of our personal experiences in this short life. My personal experience with this subject matter still
affects me greatly 22 plus years after it began.

I happened to be practicing at ground zero when this issue of independent practice blew up like an
extinction level event asteroid in the U.S. Air Force and other services in the late 1990s.

My Air Force career certainly went the way of the dinosaurs, given that I refused to move to Keesler just before Katrina to be commanded by a CRNA. I would have been terminally pissed for the next five years for reasons you can imagine,
so I am hoping that things turned out for the better this way.

Ironically, since I grew up in the military medical system since starting USU in 1986, I totally drank the
artificially sweetened pseudo-fruit beverage about working as hard as possible to make sure that
our Air Force CRNAs were trained to the highest level of competence.

I was initially so idealistic that, when my colleague Dave told me that "we were cutting our own throats"
teaching CRNAs (given that Travis was a major CRNA training site in the USAF), I told him to go stuff it,
because, in case of war or national emergency, we needed our CRNAs to be the best trained possible to care for our
wounded troops. This was when I anticipated staying in for 20+ years, and did not prioritize what might happen in
the civilian world in 2010 and beyond.

I even have a piece of paper from UC Davis stating that I was given an academic position of "Assistant Professor of Nurse Anesthesia" or some such in recognition of the six years I spent as Director of Education trying to make sure that our Anesthesia Care Teams were practicing the safest, most scientific care possible.

I have since abjectly apologized to Dave (years ago) and admitted that, in the long term, he was correct.

I guess I never imagined that my entire medical specialty could be legislated into extinction by
bureaucrats who get paid off of by rich national lobbying organizations to claim that physicians
are the same as nurses, and that cheaper care is always better care. I had personally witnessed what
a bad idea 100% independent practice is, starting with the first USAF Sentinel Event reported to JCAHO.

I suppose all of us have been remiss in not speaking out more forcefully in defense of our medical art.

The reason I posted here first is because my impression is that physicians who have never been in the
military neither know nor care about what is going on in that mysterious black box of military "health care".
Any mention of UCMJ, AFI, USUHS, "DoD's transfer of MTFs to DHA", or other military acronyms reliably
resulted in the MEGO syndrome on their part (as in "my eyes glazed over").

I have been out of the loop since I resigned my commission and punched out in 2005. I was hoping that
y'all with more proximate milmed experience might rally 'round and second my proposal, or tell me it
was hopeless and to stop tilting at windmills in my usual fashion.

Or, in the infamous words of the then AF Surgeon General to his Consultant for Anesthesiology, when the chief anesthesiologist in the USAF warned in 2000 of the impending catastrophic shortage of anesthesiologists due to the closure of the only Air Force training program (Wilford Hall) plus the shunting of interns into GMO/FS slots plus the zero percent retention of mid-grade physicians: "Sit down, shut up, and color" (personal communication to me from Col (Dr.) N. at the time).

A subset of people here can always be counted on to label me as unpatriotic for speaking out to improve the
system. They are usually the ones who have >10 years prior service, a recruiting billet, and <1 year as an
attending military physician. They had 600 HALO jumps into incoming photon torpedoes, and I had zero, so
I needed to shut up. That got old ca. 2007, and might again.

I guess I can always drive for food delivery services...until AI advances enough to take that away as well.

Peace,

Rob

 

[armytrainingsir]

What?
Independent nurse practice in government?
Nurses calling the shots in .gov healthcare?



MG Nancy Adams was, IIRC, the first nurse to command a MEDCEN (Tripler). That was in 98 or so. And how did that go? TAMC achieved a perfect JCAHO score. Hard to argue with such 'success', esp to non medical folks. Tripler was literally a perfect hospital. Just imagine how much had to be diverted away from patient care to achieve that milestone? No telling. But hey, sacrifices have to be made, right?

But that doesn't matter. What matters is nurses brought perfection to military medicine, something physicians never could. And add in to that, of course, the never ending propaganda about how much more nurses 'care'. Physicians? We have let society paint us as only caring about is money.

Heck, Trump appointed a nurse as acting Surgeon General in 2017.

So, here we are, and undoing decades of RN control is going to be close to impossible, esp in the .gov arena.

 

[DrMetal]

You guys are kinda missing the bigger picture.

This problem of nurses (or PAs, or non-physicians) encroaching on our leadership positions, or encroaching clinically (CRNAs assuming the role of anes, NPs/PAs as PCMs, now we even have certified nurse 'radiologists') . . . . this all started in the civilian world (and is ongoing with a fervor). The civilian world is way ahead in this game, and lack of physician involvement/leadership is squarely to blame.

The military is just following suit. In fact, dare I say it, but mil med may be the last bastion where a physician might actually care and assume a leadership role to try to reverse this (I don't they will, nor will such a reversal come . . . this ship has already sailed).

The physician is a dying profession. It doesn't make economic sense; and yes, economics matters, in capitalistic free-market way of life. (which I love by the way, it allows me to get a cheap cell phone . . . but in the same way, it's killing my profession).

 

[Mace1370]

You guys are kinda missing the bigger picture.

This problem of nurses (or PAs, or non-physicians) encroaching on our leadership positions, or encroaching clinically (CRNAs assuming the role of anes, NPs/PAs as PCMs, now we even have certified nurse 'radiologists') . . . . this all started in the civilian world (and is ongoing with a fervor). The civilian world is way ahead in this game, and lack of physician involvement/leadership is squarely to blame.

The military is just following suit. In fact, dare I say it, but mil med may be the last bastion where a physician might actually care and assume a leadership role to try to reverse this (I don't they will, nor will such a reversal come . . . this ship has already sailed).

The physician is a dying profession. It doesn't make economic sense; and yes, economics matters, in capitalistic free-market way of life. (which I love by the way, it allows me to get a cheap cell phone . . . but in the same way, it's killing my profession).

The cost of physician care is a drop in the bucket compared to how much we spend on healthcare. This has nothing to do with cost savings/economics/capitalism, and everything to do with powerful lobbying groups paying off politicians who more and more control the healthcare industry.

 

[armytrainingsir]

The civilian world is way ahead in this game, and lack of physician involvement/leadership is squarely to blame.

Physicians are to blame, BUT, what doc wants the job? Physicians in admin roles are almost always vilified as sell outs by their colleagues. Perhaps they are, which is a prerequisite of the position? What CEO would willingly invite an adversary to the c-suite? Not to mention the pay cut most docs would take for years to start climbing the civilian world career progression. Self interests, esp financial, always trump group interests.

I would disagree that the .civ world is way ahead. Civilian medicine still has to think about $$ and the medical staff provides the bulk of that income, so they at least get some lip service. I think the .military is ahead in non-MD influential leaders. There has always been tons of senior officers in everything but the Medical Corps, searching for some 'leadership' job for the ol OER for the fight for the next promotion. Docs, not so much. Being a good doc will get you to 05 without doing anything else. (06 in the good old days) The .mil likes to see a progression of leadership roles, so the RN with a couple of commands under her belt will always win over the 05 doc with nothing but clinical experience. Most .mil docs bitch about being sent out to be a battalion or division surgeon, but then wonder why the army doesn't care about their opinion. Big army sees them as whiny docs not wanting to do army stuff vs the gung-ho NC officer.

 

[armytrainingsir]

I don't know how the AF is, but one thing i have seen is how the army CRNAs have aggressively pursued deployments while the few AD anesthesiologists I know were pretty unhappy their moonlighting gig was gonna be disrupted for 5 or 6 months. It should not be a surprise to anyone that the adoption of the combat anesthesia role has won the CRNAs serious street cred from big army. Senior army leaders, as former combat guys, think if the CRNAs are good enough in the middle of Bumblefrackistan, they certainly can handle a modern hospital setting.

As I alluded to above, gotta play army if you expect army types to listen to your opinion. Being a great doc in garrison won't get you all that far these days.

 

[DrMetal]

The cost of physician care is a drop in the bucket compared to how much we spend on healthcare.

It's not a drop in the bucket if you multiply it by large numbers. Many drops makes a full bucket. And other expenses in health care are often deemed to be necessary. As expensive it is to run a cath lab, every hospital will bite that cost. But, they won't pay for a cardiologist to round in the CCU every day if they can get a cheaper NP to do the same. True story.

This has nothing to do with cost savings/economics/capitalism,

Of course it does, cmon. And in a sick way, we have to be ok with it. You can't love capitalism and free market enterprise when it yields you what you want (a cheap car), but then hate it when it smacks your profession around.

and everything to do with powerful lobbying groups paying off politicians who more and more control the healthcare industry.

Well, that is quite true as well. NPs/PAs have great lobbying groups, unions, whatever you call them. Physicians have what, the AMA? What a joke. And our respective specialty academies are mediocre at best.

 

[MedicalCorpse]

But that doesn't matter. What matters is nurses brought perfection to military medicine, something physicians never could. And add in to that, of course, the never ending propaganda about how much more nurses 'care'. Physicians? We have let society paint us as only caring about is money.
...
So, here we are, and undoing decades of RN control is going to be close to impossible, esp in the .gov arena.

And thus, we see once more the limitation of the text medium for communication among us primates.

"Nurses brought perfection" is to "military medicine" as "guillotine" is to "head". I am 99% sure you are going for irony, but it's kind of subtle for this medium. Perhaps over brewskis where we could see your eyes rolling toward your occipital lobe your point would be better understood.

Any of us who have been through JCAHO just once realizes that their prime directive is to destroy clinical patient care and maximize patient risk in the name of arbitrary rules pulled out of someone's nether region with zero scientific data behind (sic) it.

Here are a few examples from my 30 years as a physician, both in and out of the military:

1) Circa 1997, JCAHO visited David Grant Medical Center (DGMC) and determined that we should not have a satellite blood refrigerator outside the room where we routinely did AAAs, hepatic lobectomies, and other major blood-letting cases. Their reasoning: "Because." Accordingly, from then on, we had to send someone out of the OR on weekends or after hours to run to the other side of the hospital to the blood bank, hoping that the most-expendable newbie wouldn't get lost in the bowels of the major medical center before the patient bled to death on the table in room 2.

2) Circa 1998, JCAHO determined that we at DGMC were using too many restraints on intubated patients (usually veterans from the new "Joint" VA-AF hospital project that went kaboom a few years later...but that's another story). They exhorted us to "empower" our patients by minimizing restraints. Accordingly, JCAHO mandated a ten page list of escalating "non-restraint" orders that surgeons had to sign, and nurses had to follow, in order to convince intubated patients in the middle of delirium tremens not to yank the plastic thing out of their throat (including fresh trachs). "Sir, don't do that." "Seriously, leave it alone." "If you don't leave it alone, I'll be forced to sing you an approved gender-neutral lullaby...", etc. As any reasonable person would guess, many of our patients subsequently "empowered" themselves into the next life by yanking out their breathing tubes in the middle of the night, while the clueless ICU interns and residents were unable to reintubate them, given that the sole in-house CRNA was usually busy all night in the OR or OB suite.

3) Circa 2010, JCAHO visited my civilian hospital and determined that PACU RNs could no longer use their nursing judgment to give 25 mcg of fentanyl first, then 1 mg of morphine or 0.2 mg of dilaudid, then 25 mcg of fentanyl. Nooooo. They had to act like robots and give up the max of analgesic 1, then the max of analgesic 2, then the max of anti-emetic 1, then the max of anti-emetic 2. The scientific reason given was, again, "Because." This royally angered our highly trained PACU nurses, many of whom had been at our hospital for 20 years or more in both the ICU and PACU settings.

4) A hilarious one just came across the American Society of Anesthesiologists discussion forum (ASA logon required, I believe):
"We have been informed by the hospital system infection control department by a written policy we should change the unused anesthesia circuit:

1) every time a different patient has been in the room such as a MAC GE case, cataract case or a case under regional.
2) every 24 hours in an empty room.

This is in preparation for an upcoming Joint Commission Inspection..."

JCAHO = the Department of Increasing Your Costs For No Good Reason Without Scientific Data Department (a fully-funded subsidiary of the Department of Redundancy Department).

I welcome y'all to add to my list of JCAHO-ho-ho fiascos you've experienced.

As far as your argument "So, here we are, and undoing decades of RN control is going to be close to impossible, esp in the .gov arena," I would like to point out a few historical examples where this fatalism proved incorrect due to the unyielding and implacable resistance of good people to bad government, societal, or corporate policies:

1) The Divine Right of Kings in Europe vs. the Magna Carta and the later English Revolution
2) Warsaw Pact vs. NATO
3) The Berlin Wall vs. NATO and the will of the German people for reunification
4) Slavery in the U.S. vs. Abraham Lincoln, the Union military, and the hard work of abolitionists of all skin colors
5) Jim Crow vs. Rosa Parks, Brown vs. Board of Education, the Civil Rights act of 1964 and the Voting Rights act of 1965 (not to say that this battle has been won by any means, but that many ignorant people asserted that separate bathrooms and classrooms had been part of their racist cultural "heritage" for so long that the customs would be "impossible" to overturn).
6) Japan's 214 year long Exclusionary Policy (鎖国政策) closing the country to most foreigners vs. Commodore Matthew Perry's gunships
7) The beverage TAB vs. tastebuds (after 60 years...finally).

I could go on, but you see the point. A war is only lost when the losers give up. Some causes are worth fighting for over
many generations. Call me idealistic (big surprise), but I refuse to believe that your average American, in or out of uniform, would rather have his/her/their life in the hands of a nurse, nurse practitioner, CRNA, physician assistant, assistant to the physician's assistant, assistant to the assistant of a physician's assistant vs. a board-certified physician.

Time will tell if we anesthesiologists have the guts to fight this good fight or go the way of the dodo.

P.S. Everyone should immediately go to the Safe VA Care web site: American Society of Anesthesiologists and send a message to the VA during this limited comment window. Ideally everyone should encourage all of their colleagues, family, etc. to do the same (as one of the people on the ASA forum says, the 1+5 plus rule: yourself plus 5 or more others).

Peace.

 

[MedicalCorpse]

You guys are kinda missing the bigger picture.

The military is just following suit. In fact, dare I say it, but mil med may be the last bastion where a physician might actually care and assume a leadership role to try to reverse this (I don't they will, nor will such a reversal come . . . this ship has already sailed).

The physician is a dying profession. It doesn't make economic sense; and yes, economics matters, in capitalistic free-market way of life. (which I love by the way, it allows me to get a cheap cell phone . . . but in the same way, it's killing my profession).

So we just give up?

Peace.

 

[MedicalCorpse]

The cost of physician care is a drop in the bucket compared to how much we spend on healthcare. This has nothing to do with cost savings/economics/capitalism, and everything to do with powerful lobbying groups paying off politicians who more and more control the healthcare industry.

Note that overseas care of our military and dependents is being taken over by civilian International SOS company:

Government

Governments, military and international organisations' forces and personnel abroad are often exposed to threats and dangers that private citizens only rarely come across. We provide specialised and innovative services for the different type of governmental organisations. These are designed to...

www.internationalsos.com

International SOS Wins $960M Contract to Support DHA's Overseas Military Health Care Program - GovCon Wire

Looking for the latest GovCon News? Check out our story: International SOS Wins $960M Contract to Support DHA's Overseas Military Health Care Program. Click to read more!

www.govconwire.com

" International SOS Wins $960M Contract to Support DHA’s Overseas Military Health Care Program

International SOS' government services unit has won a potential eight-year, $960.4M contract to supplement the Defense Health Agency's efforts to deliver care services at overseas and remote military treatment facilities.

The company will provide supplementary health care for eligible beneficiaries under the TRICARE Overseas Program through Aug. 31, 2028, the Department of Defense said Monday.

DHA awarded the single-award, indefinite-delivery/indefinite-quantity contract after a full and open competition."

...in no small part due to revolving door warriors like this, who gut military medicine (as MSC officers) while on active duty in favor of contractors, and then become Senior Vice Presidents in said corporations after retirement:

"It is a true honor and privilege to serve our nation's military overseas, ensuring access to high-quality health care services no matter where their work or travels take them."
COL (Ret.) Rafael E. De Jesus, SVP Military Services, International SOS Government Services

I am 99% sure that, in order to save money, International SOS will continue the military's policy to scrape the bottom of the barrel to care for the tip of the spear of our nation's troops overseas...

 

[MedicalCorpse]

Most .mil docs bitch about being sent out to be a battalion or division surgeon, but then wonder why the army doesn't care about their opinion. Big army sees them as whiny docs not wanting to do army stuff vs the gung-ho NC officer.

As a former Air Force officer who did not attend the Air Force Academy, I was often amused and/or astonished at how every single freaking aspect of medicine had to be dumbed down to a flying analogy for higher-ups to understand.

Example:
1) My functionally-illiterate, former flyer, USAFA-graduate, surgeon Squadron Commander telling me that surgeons were in the "left seat" in the OR, while anesthesiologists were in the "right seat", so anesthesiologists needed to shut the bleep up in and out of the OR and do what the surgeon says 100% of the time. My attempts to convince him that the practice of medicine was not EXACTLY the same as the practice of flying chunks of metal through the air fell on deaf ears.

2) When my fanatically evangelical, Opus Dei new hospital commander insisted that he was going to bring everyone under his command closer to Jesus, regardless of their actual faith or lack of same, he promulgated the "Four Tie-Downs" in order to include "Spiritual Wellness" as one of the mandatory items that supervisors were going to be required to discuss with their subordinates during annual performance reviews:

This is because, of course, planes require four (not three or seven) tie downs, so humans need exactly four also. QED.
When I asked him how my supervisor was going to know enough about my religions (plural) to bring me closer to either the Goddess or Anuttara-samyak-sambodhi, or how atheists or other non-Christians could be brought closer to Jesus, he told me that "Everyone worshipped God, just with a different name" and then ordered me to be a member of his new "Spiritual Life Committee" (a long story for another time).

3) Every time I was forced to write the OPRs of my colleagues in order to enable my lazy flight commanders to play more Solitaire on duty, I was strongly encouraged to emphasize how much money my colleagues saved the Air Force and/or how important their non-medical, "operational" deployments or CMRTs were vs. saving the lives of sick humans in the operating room. To me it always seemed as ludicrous as telling an Air Force pilot: "OK, you shot down 19 bad guys in a dogfight, but how many people did you successfully code this year, hmmm?"

Short of upgrading the brains of line commanders to realize that their docs will not have as many confirmed kills on their records as their SOF troops or tactical flyers will have (nor should they), and that "Military Command Title That I Recognize" may be LESS important in judging the worth of a physician than "Academic Appointment to Major Medical School" or "Teacher of the Year Award from USUHS", just to give a few examples, what hope is there for docs nowadays to get that magic O-6 rank where people finally start listening to him/her/them?

Peace.

 

[MedicalCorpse]

It should not be a surprise to anyone that the adoption of the combat anesthesia role has won the CRNAs serious street cred from big army. Senior army leaders, as former combat guys, think if the CRNAs are good enough in the middle of Bumblefrackistan, they certainly can handle a modern hospital setting.

As I alluded to above, gotta play army if you expect army types to listen to your opinion. Being a great doc in garrison won't get you all that far these days.

Not to mention that CRNAs I knew who got deployed overseas usually managed to get their pictures taken
with M-4s they were issued when they volunteered for guard duty, given that nurses and other non-physicians are allowed under the Geneva Convention to go all Rambo and shoot bad guys outside of the very narrow limitations that physicians operate under per international LOAC (only able to defend their patients, not even themselves, if their MEDDAC is overrun by hostiles).

Physicians are also guided by rules, including the Hippocratic Oath, which prevent (or should prevent) them from engaging in war crimes such as forced feeding of prisoners, psychological torture, poisoning of terrorists with anesthesia drugs placed onto pizzas ordered by command to disable simulated bad guys during a war game (true story from Andrews AFB), etc.

I do not want to see our troops treated by undertrained CRNAs or other Independent Providers of Extremely Competent
Anesthesia Care (IPECAC)...so I don't claim to have all the answers. I just know that zeroing out the end strength of
all physicians except surgeons (who, so far, have managed to hang on to the trauma surgeon title vs. the trauma PA or NP) in the U.S. military is not a good idea for our troops, dependents, or retirees...

 

[armytrainingsir]

And thus, we see once more the limitation of the text medium for communication among us primates.

"Nurses brought perfection" is to "military medicine" as "guillotine" is to "head". I am 99% sure you are going for irony, but it's kind of subtle for this medium. Perhaps over brewskis where we could see your eyes rolling toward your occipital lobe your point would be better understood.

Haha, yes it is a poor medium.
It was most certainly irony.

 

[armytrainingsir]

Note that overseas care of our military and dependents is being taken over by civilian International SOS company:

..........

I am 99% sure that, in order to save money, International SOS will continue the military's policy to scrape the bottom of the barrel to care for the tip of the spear of our nation's troops overseas...

More accurate than you know!
From International SOS website, one of the qualifications for a part time primary care doc in Asia with US credentials

"Requirements:
'The ability to effectively balance medical needs with commercial considerations"

Part-Time US Certified Doctor

Part-Time US Certified Doctor

careers.internationalsos.com

 

[MedicalCorpse]

=======================================================================

More accurate than you know!
"Requirements:
'The ability to effectively balance medical needs with commercial considerations"

=======================================================================

Internal Corporate Document
Not for Public Release

Onboarding of New Health Care Provider Recruits​

Module 9: Balancing Medical Needs with Commercial Considerations

I As a member of our team, you will be called upon to make difficult decisions regarding the transportation and care of ill or injured Customers around the world. Note that the word "patient" is discouraged throughout the Corporation, as you will see below.

Based on your previous training as a health care provider, you may be fooled into following old ways of thinking, such as:

II "Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood..."

In the 2020s and beyond, you and the Customer belong to the Corporation. The Corporation is Mother; the Corporation is Father. Anything you do in the course of your employment will be judged based on its monetary and intangible benefit to the Corporation, not your Customer, yourself, or anyone else. If lying to a dying Customer gooses the Corporation's stock price upward by 1%, then telling the truth is literally stealing from your parents. See test at end of this module.

III "Whatever, in the course of my practice, I may see or hear (even when not invited), whatever I may happen to obtain knowledge of, if it be not proper to repeat it, I will keep sacred and secret within my own breast."

In your previous life as a health care professional, you may have been brainwashed into believing in the antiquated notions of "provider-Customer confidentiality" or "protected health information". These were codified by the ancient United States HIPAA law, about which you have taken dozens of computer-based tests over the past 20 years written by illiterate high school graduates in order to insult your intelligence.

The Corporation reminds you that you are not in Kansas anymore. We are acting independently beyond the borders of the U.S., and any really civilized country, so anything and everything goes. Every scrap of information you gain from your Customers that may either enrich the Corporation or increase its stock price (or both) is expected to be recorded using the encryption technology provided to you and forwarded to Headquarters for analysis and exploitation to the fullest extent. See the test at the end.

IV Price List for your Convenience

The following is a general guideline as to how much of the Corporation's resources you will be expected to expend based on the following medical conditions. As noted above, you are expected to balance medical needs of your Customer with the key Corporate considerations of maintaining stock price, reducing payment for care, and optimizing the number of yachts and, it follows logically, paramours that the members of the Corporation Board possess.

0. Maximum (including all of the below): $35,000 (any more than that will be docked from your pay)
1. One limb or eye = $25,000 (inform Customer that pirate patches are considered to be "cool" nowadays)
2. Genital(s) or ovary(ies) = $20,000 (damage likely due to Darwin Award behavior, esp. with males)
3. Surgical Abdomen = $15,000 (be sure to call ahead to base to arrange for the cheapest local witch provider-surgeon)
4. ARDS/SIRS (non-COVID) = $12,000 (breathing is overrated)
5. ACS/Cardiac disease = $10,000 (they are probably too old to bother spending money on anyway)
6. CVA/TIA/stroke = $8,000 (they won't remember the quality of their care in any case)
7. Confirmed SarsCov-2 Infection (symptomatic) = $5,000 (these Customers will live or die regardless of treatment, and pose an infection threat to our aircrew, who constitute expensive Assets of the Corporation that are harder to replace than you.)
8. Imaging-confirmed Xenomorph infestation: $0.00 (expectant; use of lethal force authorized)
9. Broken limbs: $0.00 (that's what stick splints and bandana slings were made for)

Remember that the Corporation maintains several hidden lairs around the world to protect you in case of the likely event of malpractice complaints against your professional license. If they can't serve you papers, you can fly with us forever! Please read the small print of your contract regarding the Corporation's rights if you are unfortunately served with malpractice papers while overseas or on leave in the U.S., including your consent to immediate lead-based termination from employment.

This concludes Module 9. After you have finished the Post-Test (below), please click on the "Next Module" button to start Module 10: "How to live with yourself when you kill Customers due to your personal incompetence, with special emphasis on the surprising benefits of substance abuse."

POST-TEST:

1) You have just been consulted regarding a 28-year-old contractor in Outer Cornholia who suffered several bites from a snake species known for 100% fatality without appropriate treatment. You should ideally:

A Tell the Customer to start sucking out the venom, or enlist an attractive colleague to do so.
B Tell the Customer to walk it off, as snake bites constitute "flesh wounds" according to Monty Python(TM) rules.
C Tell the Customer to wait 48 hours and call back again if they are still able to breathe.
D Tell the Customer you are immediately dispatching an aircraft with anti-venom on board.

2) You happen to hear a wounded patient moan out in pain under the influence of sedatives with details of private information of interest to the Corporation, such as patents, business plans, military secrets, and/or the naughty personal lives of social media "influencers". You are expected to:

A Immediately forget everything you heard in the interest of maintaining Customer privacy.
B Check the medical condition of the Customer to see if they need more analgesics.
C Advise others on your team of the importance of protecting private information.
D Record all babbling on your cell phone and submit to HQ for analysis and financial exploitation.

3) You are consulted regarding a 34-year-old contractor who just fell 50 feet from a tree and can no longer feel anything below the chest. Your best response is:

A Have you tried walking it off?
B Call back tomorrow if you feel any pain below your chest area.
C Good grief, man! It's 0300 here! Call back during normal business hours.
D I am immediately dispatching air evac to your site with a neurosurgical team.

Scoring:
Question 1: 10 points for either A, B, or C; zero for D
Question 2: Zero points for anything but D
Question 3: 10 points for A, B, or C. If you answered D, dock your own pay $35,000 USD.

(note: the above document is for parody and commentary purposes only, and is not real...as far as you know)

 

[DrMetal]

So we just give up?

Peace.

Yeah, maybe. I've been giving serious consideration to just bailing on clinical medicine and going back into research. It seems like no matter what we do as physicians, the cards are always stacked against us. I thought it would be better in the civilian world (I'm still active duty, but moonlight often), but that doesn't look to be the case.

Are you still practicing? What's your civilian work environment like, many CRNAs?

 

[MedicalCorpse]

Yeah, maybe. I've been giving serious consideration to just bailing on clinical medicine and going back into research. It seems like no matter what we do as physicians, the cards are always stacked against us. I thought it would be better in the civilian world (I'm still active duty, but moonlight often), but that doesn't look to be the case.

Are you still practicing? What's your civilian work environment like, many CRNAs?

(long story deleted)

Worked with CRNAs for 12 years after leaving the miltary in anesthesia care team model.

Almost all of them liked me...can't please everyone.

National company took over after small anesthesia group members got old and quit.

That lasted for 4 months of every-other-night call when I was promised 1 in 5.

Trying to make solo locum tenens business work despite COVID-19.

Like the magic 8-ball, "Cannot predict now".

Peace,

 

[militaryPHYS]

(long story deleted)

Worked with CRNAs for 12 years after leaving the miltary in anesthesia care team model.

Almost all of them liked me...can't please everyone.

National company took over after small anesthesia group members got old and quit.

That lasted for 4 months of every-other-night call when I was promised 1 in 5.

Trying to make solo locum tenens business work despite COVID-19.

Like the magic 8-ball, "Cannot predict now".

Peace,

So was the grass greener?

Physicians in admin roles are almost always vilified as sell outs by their colleagues.

This is a great point. We complain when nurses get the admin roles and make small changes over time which eventually upset us...but few MDs or DOs wanted to take that admin role because we were too proud to give up part of our clinical practice. We see things like this coming but fail to act to prevent it. Now it's too late and it's everyone else's fault.



Welcome back. It will be good to rehash all of the same issues again and again

 

[HighPriest]

The Divine Right of Kings in Europe vs. the Magna Carta and the later English Revolution

As long as the Stuarts don’t end up in charge of the hospital systems again...

 

[MedicalCorpse]

So was the grass greener?

The 12 years I worked for a small private practice group were like heaven compared to my final seven years in the military.

Then a large AMC took over, and things went south quickly.

I was managing to build my locum tenens business until COVID hit.

Everything was looking up.

Now everything is in limbo.

Being unemployed is still better than taking orders from a housekeeper with rank on her shoulders.

And no one has asked me to commit a war crime since 2004, so there's that.

And I have enjoyed running water, air conditioning, and sand-free accomodations this whole time.

If you want to rehash issues, we can just use the "search" function for old posts and save ourselves the typing.

Peace,

P.S. Funny you mention the Stuarts, HighPriest...

Nemo me impune lacessit.

 

[militaryPHYS]

A lot has changed. Some things haven't. I wouldn't assume all experiences and memories still have a direct correlation to someone serving today. Take sexism for example. Thankfully it isn't tolerated in the service anymore and I personally find it disgusting.

 

[MedicalCorpse]

A lot has changed. Some things haven't. I wouldn't assume all experiences and memories still have a direct correlation to someone serving today. Take sexism for example. Thankfully it isn't tolerated in the service anymore and I personally find it disgusting.

I still remember to this day being shocked when a senior LtCol CRNA started crying uncontrollably when asked by the Anti-Suicide-Day discussion leader functionary to comment on her experiences commanding female Air Force personnel downrange. She had had to deal with so many cases of sexual assault by our people against our people, almost none of which resulted in any action against the perpetrator(s). I am so glad to hear that sexism is a thing of the past in today's military.

 

[HighPriest]

Nemo me impune lacessit.

And yet Charles I could never wrap his head around that being a two way street up to the point where they took it off his shoulders. That’s an ironic-@$$ed motto.

That’s also the unofficial motto of, like, every girl I ever dated so the Stuarts ain’t special.

 

[HighPriest]

I still remember to this day being shocked when a senior LtCol CRNA started crying uncontrollably when asked by the Anti-Suicide-Day discussion leader functionary to comment on her experiences commanding female Air Force personnel downrange. She had had to deal with so many cases of sexual assault by our people against our people, almost none of which resulted in any action against the perpetrator(s). I am so glad to hear that sexism is a thing of the past in today's military.

That last article is already 2 days old. Things have changed since then, man. Let it go.

 

[pgg]

This is a great point. We complain when nurses get the admin roles and make small changes over time which eventually upset us...but few MDs or DOs wanted to take that admin role because we were too proud to give up part of our clinical practice. We see things like this coming but fail to act to prevent it. Now it's too late and it's everyone else's fault.

If you think the reason physicians decline admin roles because they're too "proud" you're looking at the issue through a narrow lens.

Once upon a time I was passed over for O5, so I sought and interviewed and won the DSS position. For nearly a year I did 90% nonclinical work. It got me promoted. Beyond that, it wasn't a totally wasted year; I was still able to moonlight a bunch, and I learned some things about how hospitals work. One of the things I learned was that those jobs aren't worth it.

This year I was passed over for O6 - but that was by design. I opted out. I did a FTOS fellowship year a few years ago knowing that it'd be a big hole in my observed fitreps and would probably sink my O6 odds. (My specialty leader explicitly told me when I applied to the GMESB that if I did the fellowship then I would only do clinical work for at least a full tour and not be allowed to take orders to places or jobs that would get me promoted to O6 - he meant this as a warning, but I accepted it as a perk.) Upon returning from fellowship, I turned down repeated invitations to apply for leadership positions in the department, the residency program, the directorate. I was senior enough and well-liked enough that I could have had them. Instead, I opted out in very clear terms - I told my dept chairs to give me P fitreps and save the MPs and EPs for people looking to earn a little silver eagle. (Their reactions indicated that this was not a common request. )

Why do good physicians and good officers decline admin roles?

I'll tell you, because I am those things, and I've been there, in those admin roles. I've learned that the ship really can't be steered, or even nudged, and that the best any of us can do is make our little corner of the Navy a little better for immediate colleagues and patients. It's possible to do that as a clinician.

More to the point, it's enough.

I can't begin to tell you how wonderful it's been to embrace a terminal rank of O5. You can take away that last lever of pressure they have ("you won't promote") if you genuinely don't want it or need the reward that is held out. I've known physicians who took it personally when they didn't get the EP or MP, as if forced distribution of ranking on a fitness report designed for line officers doing tactical things means anything about their abilities as physicians.

The guy in Fight Club says, The things you own end up owning you. In the military, I think it's The rank you want ends up owning you. I can't count how many people I've seen grow angry and bitter and frustrated and burnt out trying to check boxes to get promoted to a rank that really doesn't mean anything more than a tiny pay raise and some different-colored flair to wear.

I can tell you truthfully, I like being in the Navy. I like my job (though I wish the case load was better). I like everyone in my dept. My local leadership is superb. I have time to moonlight and do good cases (though covid has put a temporary hitch in that). Deploying to the Kandahar Role 3 was one of the highlights of my professional career and life. Serving with Marines has been a joy (mostly). I've got ~1.5 years left until I can retire and there's a lot that I'll miss. Serving in "admin roles" isn't among them, and pride's got nothing to do with it.

There's a lot I love about this institution and am proud to be part of. But institutions can't love you back, and giving them things that harm you in the hopes that the institution will change or remember you when you're gone is dumb. There's a wall full of old name tags in our dept that people leave when they go. Dozens of people. I knew most of them. I miss a lot of them. The Navy doesn't care that they're gone.

I'd advise anyone to think carefully about what they want from their military service, and then take it. Or don't. But don't let anyone make you feel guilty or otherwise inadequate because your service didn't serve their purpose well enough.

 

[DrMetal]

I've learned that the ship really can't be steered, or even nudged, and that the best any of us can do is make our little corner of the Navy a little better for immediate colleagues and patients. It's possible to do that as a clinician.

as if forced distribution of ranking on a fitness report designed for line officers doing tactical things means anything about their abilities as physicians.

Such true statements. It's hard to lead in an organization that defies change. And our promotion system is ridiculous.

But who has a problem with non-physicians assuming leadership roles?! I don't. If a nurse, an HCA, an MBA, hell even the janitor wants to take on the leadership role, go for it. Just do a frickin good job and listen to your clinicians!

What I'm really concerned about---and again, I think this is way more rampant in the civilian world---is that doctors are now getting pushed out of even their clinical roles.

If I consult 3 services (cardiology, nephrology, and the intensivist for a procedure), 2 of the 3 (sometimes 3 of the 3) calling me back are NPs/PAs.

 

[Matthew9Thirtyfive]

I'd advise anyone to think carefully about what they want from their military service, and then take it. Or don't. But don't let anyone make you feel guilty or otherwise inadequate because your service didn't serve their purpose well enough.

Amen. I did this my whole enlisted career and plan to do it my whole commissioned career.

 

[MedicalCorpse]

That last article is already 2 days old. Things have changed since then, man. Let it go.

Kudos. I got so sick of that in 2006... "Everything changed after 30 June 2005, so come on back now, y'hear?"

What with milmed being taken over by DHA and all the other changes...I guess I should just enjoy my memories from
1981 until 1998, when I first experienced the downhill plunge of "military medicine" vis a vis "military health care run by people with half of your training but more rank than you so shut up about this patient safety nonsense."

Oh, and the ever-increasing sprint toward 100% outsourcing of military "health care" in order to enrich generals who enjoy the revolving door from "streamlining business processes" to Senior Vice President positions on the boards of the very corporations that are making money by NOT providing timely and competent health care to our troops, their families, and retirees...I should forget about that too, and remember when the U.S. military actually trained and or/hired enough physicians to provide actual medical care in the military...sometime in the mid-1990s, I guess...

I guess there's a reason that "algia" is part of "nostalgia"...

 

[MedicalCorpse]

I can't begin to tell you how wonderful it's been to embrace a terminal rank of O5. You can take away that last lever of pressure they have ("you won't promote") if you genuinely don't want it or need the reward that is held out. I've known physicians who took it personally when they didn't get the EP or MP, as if forced distribution of ranking on a fitness report designed for line officers doing tactical things means anything about their abilities as physicians.

The guy in Fight Club says, The things you own end up owning you. In the military, I think it's The rank you want ends up owning you. I can't count how many people I've seen grow angry and bitter and frustrated and burnt out trying to check boxes to get promoted to a rank that really doesn't mean anything more than a tiny pay raise and some different-colored flair to wear.

Lol at flair! Excellent "Office Space" reference. When my rusty surgeon ex-Squadron Commander gave me my second LOR for attempting to act as a perioperative physician, rather than as someone who needs to sit down and shut up and pass gas, I went to the IG for retaliation because he explicitly threatened my promotion. I wasn't the pitiful money or prestige (which is nothing compared to O-6, where Generals start to look at you as somewhat less of a peon) . I guess it was just pride. I felt that I had done my duty since starting ROTC in 1981, and I shouldn't be denied promotion because this surgeon, in his own words to me, had sworn that he would never allow anesthesia to cancel cases if he ever got in a position of power (he had PTSD from being shot down in residency by a powerful anesthesiologist, according to his personal communication to me shortly after 9/11).

Well, I did get promoted, and am still proud to be ex-LtCol, but I learned a hard lesson. When the USAF and other services incentivize the Core Value of "Shutting up and Kissing Butt" in order for physicians to get promoted beyond O-4, it really is not worth it to join the "Liar's Club" of O-6s and above, to quote Anonymous in his book Imperial Hubris. It is especially not worth it to sacrifice your own self-esteem and honor as a physician on the altar of coasting to retirement by keeping your head down and not making waves, regardless of clear and present dangers to patient safety created by the broken system.

There's a lot I love about this institution and am proud to be part of. But institutions can't love you back, and giving them things that harm you in the hopes that the institution will change or remember you when you're gone is dumb. There's a wall full of old name tags in our dept that people leave when they go. Dozens of people. I knew most of them. I miss a lot of them. The Navy doesn't care that they're gone.

This is so true. In retrospect, 15 years after I resigned my commission and punched out, I realize that a lot of my PTSD from the death of my military career is due to the total lack of caring by the USAF when all of my smart colleagues (and me) left without one attempt to retain them in the service. It's as though you spend your formative years working for recognition and respect from your father, only to have him leave you and your siblings to rot while he moves to another state to avoid paying child support (for example). It boggles the mind how much institutional knowledge is (bleeped) away by the military every day when experienced young O-4s and O-5s at the peak of their vitality and skill walk away from the military without one attempt to change their minds.

All I asked for in 2005 was for the military to give me a PCA to USU from Andrews (cost to taxpayers: $0.00) and allow me to teach a few days a week, and then work at NHB or Andrews the other days as needed. Nope. No can do. You are going to Keesler to be commanded by an O-5 CRNA with DOR on you, so she will be in command of you. Oh, and Sir, (bleep) you very much. Not one attempt by anyone to keep this "troublemaker" in the military...but also no attempt to keep my "non-troublemaker" colleagues in uniform either. In retrospect, just for fun, someone should have filed a Fraud, Waste, and Abuse charge against all the military services for their abysmal mismanagement of mid-grade physician retention.
==============================================================
From: (Chief anesthesiologist at the Air Force's largest hospital) LtCol 59 MSGS/MCOA
To: (senior USAF anesthesiologists, including myself)
Subject: RE: MSP/ISP (physician pay bonuses)
Date: Tue, 29 Jul 2003 14:59:33

Dear (Chief anesthesiologist in the Air Force),

Thank you for the information, disappointing as it is. I look
forward to continuing to sign on, hire, and shake hands daily with less
qualified civilians, making 2-3 times what I do, while they watch a near
constant parade of military anesthesiologists getting deployed and leaving
the service. I now know that those in power in Washington do not care, and
only want to hasten the exodus of military anesthesiologists from the
service.

(redacted)

(redacted), Lt Col, USAF, MC
Flight Commander and Chairman
Department of Anesthesiology, Wilford Hall Med Cen
(redacted)
=============================================================

So glad you have "wonderful" local leadership. I know you realize how lucky you are to be in such a rare position.
Best of luck for the rest of your career, and, as always, thank you for your service defending our nation.

 

[pgg]

I do recognize I've been fortunate in my military career. It's been a mixture of luck, my decisions, my expectations, and my hopes, in some proportion that is at least a little muddy. I've picked some fights, even won a few, but also have chosen not to die on certain hills.

I have always had the impression that the Air Force had a much more shark-jumped and/or toxic environment to practice in than the Navy.

The kind of absurdities I hear about from that quarter, ranging from non-physicians trying to dictate medical decisions, to being subjected to E4-led vehicle inspections prior to getting leave approved, getting recalled from leave for random UAs … I just haven't ever seen that at any Navy hospital. And it appears you were cursed with the worst end of the institutional bell curve in your career, even for the Air Force.

'round these parts, a surgeon who tried to pull rank to overrule an anesthesiologist who postponed a case would be given a firm no with a polite explanation, and if he persisted his dept chair or the DSS would be made aware of the inappropriate behavior. (Plus or minus some mild intradepartmental mockery behind his back.) I've honestly seen more prima donna surgeons play the "I'm important I bring in $$$ here" to try to force cases in the civilian world than in the Navy.

Anesthesiologists in particular are often not the most assertive bunch of people, and an awful lot of anesthesia departments throughout the USA are led by doormats. I once quit a moonlighting job at a civilian surgicenter after four days because of how dangerous the place was because the spineless anesthesiologist in charge OK'd every ridiculous thing every surgeon wanted to do. I haven't found a tendency to roll over and give in to unreasonable clinical demands to be worse in the Navy, quite the contrary actually.

This is so true. In retrospect, 15 years after I resigned my commission and punched out, I realize that a lot of my PTSD from the death of my military career is due to the total lack of caring by the USAF when all of my smart colleagues (and me) left without one attempt to retain them in the service. It's as though you spend your formative years working for recognition and respect from your father, only to have him leave you and your siblings to rot while he moves to another state to avoid paying child support (for example). It boggles the mind how much institutional knowledge is (bleeped) away by the military every day when experienced young O-4s and O-5s at the peak of their vitality and skill walk away from the military without one attempt to change their minds.

The "institutions can't love you back" bit was not something I coined specifically about the military. It's a reference to an excellent article called "Understanding Academic Medical Centers: Simone’s Maxims" and well worth a read: Understanding Academic Medical Centers: Simone’s Maxims

My FTOS fellowship was at a renowned civilian institution. You think the military views junior physicians as disposable? Oh man, you ain't seen nothin' ...

 

[Chonal Atresia]

I do recognize I've been fortunate in my military career. It's been a mixture of luck, my decisions, my expectations, and my hopes, in some proportion that is at least a little muddy. I've picked some fights, even won a few, but also have chosen not to die on certain hills.

I have always had the impression that the Air Force had a much more shark-jumped and/or toxic environment to practice in than the Navy.

The kind of absurdities I hear about from that quarter, ranging from non-physicians trying to dictate medical decisions, to being subjected to E4-led vehicle inspections prior to getting leave approved, getting recalled from leave for random UAs … I just haven't ever seen that at any Navy hospital. And it appears you were cursed with the worst end of the institutional bell curve in your career, even for the Air Force.

'round these parts, a surgeon who tried to pull rank to overrule an anesthesiologist who postponed a case would be given a firm no with a polite explanation, and if he persisted his dept chair or the DSS would be made aware of the inappropriate behavior. (Plus or minus some mild intradepartmental mockery behind his back.) I've honestly seen more prima donna surgeons play the "I'm important I bring in $$$ here" to try to force cases in the civilian world than in the Navy.

Anesthesiologists in particular are often not the most assertive bunch of people, and an awful lot of anesthesia departments throughout the USA are led by doormats. I once quit a moonlighting job at a civilian surgicenter after four days because of how dangerous the place was because the spineless anesthesiologist in charge OK'd every ridiculous thing every surgeon wanted to do. I haven't found a tendency to roll over and give in to unreasonable clinical demands to be worse in the Navy, quite the contrary actually.



The "institutions can't love you back" bit was not something I coined specifically about the military. It's a reference to an excellent article called "Understanding Academic Medical Centers: Simone’s Maxims" and well worth a read: Understanding Academic Medical Centers: Simone’s Maxims

My FTOS fellowship was at a renowned civilian institution. You think the military views junior physicians as disposable? Oh man, you ain't seen nothin' ...

This is why I love private practice.

Nobody can tell me to see more (or less) patients, how to code, how much call I need to take, what type of cases I need to do, how my bonus is structured, etc.

I am fortunate to be a partner in a large multi-specialty surgical clinic which generates $75M+ per year. I will NEVER work for the government (or hospital for that matter) again.

 

[Mace1370]

This is why I love private practice.

Nobody can tell me to see more (or less) patients, how to code, how much call I need to take, what type of cases I need to do, how my bonus is structured, etc.

I am fortunate to be a partner in a large multi-specialty surgical clinic which generates $75M+ per year. I will NEVER work for the government (or hospital for that matter) again.

Just out of curiosity, where do you guys send your pathology? Do you know how that decision gets made?

 

[Chonal Atresia]

Just out of curiosity, where do you guys send your pathology? Do you know how that decision gets made?

The local pathology group gets our specimens. They rent space from the hospital.

 

[nvdoc]

Kudos. I got so sick of that in 2006... "Everything changed after 30 June 2005, so come on back now, y'hear?"

What with milmed being taken over by DHA and all the other changes...I guess I should just enjoy my memories from
1981 until 1998, when I first experienced the downhill plunge of "military medicine" vis a vis "military health care run by people with half of your training but more rank than you so shut up about this patient safety nonsense."

Oh, and the ever-increasing sprint toward 100% outsourcing of military "health care" in order to enrich generals who enjoy the revolving door from "streamlining business processes" to Senior Vice President positions on the boards of the very corporations that are making money by NOT providing timely and competent health care to our troops, their families, and retirees...I should forget about that too, and remember when the U.S. military actually trained and or/hired enough physicians to provide actual medical care in the military...sometime in the mid-1990s, I guess...

I guess there's a reason that "algia" is part of "nostalgia"...

First of all welcome back, I remember reading your posts as a wee medical student back in the day. I'm a Pulm/CC doc (reserve compo), recently returned from a "deployment" where my skillset was used to perform PAP smears and dole out anti-anxiolytics (at the height of COVID). Thought about switching over to AF res for CCATT, but have heard ? rumors about studying using ARNPs or CRNAs to potentially fill the physician role in the future. I think this is going to be more widespread with DHA as I don't see how they are going to retain an "operational physician" force going forward. Every O-4 I met overseas was getting ready to drop papers.

 

[TheGoose]

VA Establishes Path to Potentially Adopt Full Practice Authority for PAs

The Department of Veterans Affairs (VA) issued an interim final rule that could serve as a step towards authorizing PAs working at the VA to be granted full practice authority. The rule confirms the VA’s authority to establish national standards of practice.

www.aapa.org

 

[MedicalCorpse]

First of all welcome back, I remember reading your posts as a wee medical student back in the day.

(Bowing) Thank you very much. I kind of gave up on attempting to steer the sinking Titanic of milmed years ago. This whole VA CRNA independent practice thing just re-triggered my PTSD from my Air Force civil war experiences.

I'm a Pulm/CC doc (reserve compo), recently returned from a "deployment" where my skillset was used to perform PAP smears and dole out anti-anxiolytics (at the height of COVID).

This is just sad. I had heard about radiologists and pathologists being ordered to take ER call downrange during the Iraq fiasco, simply because some RN commander needed a physician warm body to fill that role, regardless of how demeaning/humiliating/dangerous it would be to both the physician and the poor patients. Just the thought of being ordered to perform PAP smears as a pulmonologist provokes thalamic rage on your behalf I thought I had left behind fifteen years ago.

The Department of Lack of Retention strikes again.

Thought about switching over to AF res for CCATT, but have heard ? rumors about studying using ARNPs or CRNAs to potentially fill the physician role in the future. I think this is going to be more widespread with DHA as I don't see how they are going to retain an "operational physician" force going forward. Every O-4 I met overseas was getting ready to drop papers.

Speaking with my friend who is currently deployed in the AF reserves in an AE role, the CCATT docs they scraped up are from beneath the bottom of the barrel. I could tell you anecdotes, but you wouldn't believe them. I am convinced that all military services are continuing the transition away from "operational physicians" to "operational providers" that started in the 1990s. Why hire a smart pulmonologist/critical care physician when you, as a nurse/MSC commander, can order around PAs, NPs, CRNAs, midwives, etc. so much easier? Also, for bonus points, less-trained humans cost less than well-trained humans...and no one will ever know the difference, because DHA is shutting down care at MTFs for everyone who doesn't fall under the Feres doctrine (those pesky dependents and retirees might sue when they are malpracticed upon, and we can't afford that!).

As far as all O-4s being about to drop papers...it just goes to show what I've been saying since 2006: How do you recognize the best and brightest in military medicine? They are the ones who already left.

Best of luck, and stay safe!

 

[DrMetal]

VA Establishes Path to Potentially Adopt Full Practice Authority for PAs

The Department of Veterans Affairs (VA) issued an interim final rule that could serve as a step towards authorizing PAs working at the VA to be granted full practice authority. The rule confirms the VA’s authority to establish national standards of practice.

www.aapa.org

What specialty did u end up in?

 

[TheGoose]

As far as all O-4s being about to drop papers...it just goes to show what I've been saying since 2006: How do you recognize the best and brightest in military medicine? They are the ones who already left.

I'll try to find the public release info on this but the Army recently had a retention survey and I want to say that the number of O4s in surgical specialties planning to get out at earliest opportunity was 92% and even current O5s may have been nearing 60%. Ill try to hunt that down.

I still think that the folks staying in are comprised of lifers from academies/usuhs, folks who wouldn't do well outside the mil system or want admin/command, and a third group who believe in what they are doing and are excellent clinicians relying on that belief to push through the b.s. and "try" to make things better (although it often involves hitting your head against the wall)

 

[TheGoose]

What specialty did u end up in?

Surgical/surgical sub. Been here since 2007 as a premed now an attending and love the continuity from the OGs. Welcome back, medicalcorpse

 

[MedicalCorpse]

Surgical/surgical sub. Been here since 2007 as a premed now an attending and love the continuity from the OGs. Welcome back, medicalcorpse

Thanks, Goose. I looked all over the net for the survey you are referring to. The closest I could find was this:
U.S. Army Medical Corps Recruitment, Job Satisfaction, and Retention: Historical Perspectives and Current Issues ,
from which I quote:

"Measuring Army MCO longitudinal job satisfaction in a statistically valid manner is not possible because of a lack of standardized and validated tools. There is no evidence of physician surveys between 2002 and 2016... An informal survey (total responses = 1,009) was performed by the MC Deputy Corps Chief in 2016 with key findings as noted in Tables I and II.

TABLE I

Concerns That Are an Obstruction to Care

Inability to hire/fire personnel 81.7%
Electronic Health Record 69.1%
Over-emphasis on workload targets 49.2%
Poor communication 42.0%
Lack of leadership 32.2%
Toxic environment 24.7%

(MedicalCorpse commentary: when 25% of your docs report "toxic environment" as key problem, it means that 75% or more are experiencing a toxic environment, but 50% of physicians are too scared to report this, especially without adequate anonymity, in fear of immediate and brutal reprisal by their toxic chain of command.)

Current MC Job Satisfaction Concerns

Chief of Medical Corps Affairs MG Brian Lein ordered a MCO survey in April 2018. Forty-eight percent of MCOs responded (total = 2,050). The responses included over 700 pages of free text.

Key survey findings (% agreeing)

(a) 75% proud to work in Army Medicine.

(b) 64% understand downrange readiness requirements.

(c) 58% confident they are ready. (MedicalCorpse commentary: 42% of docs are not ready)

(d) 41% career goals can be achieved.

(e) 40% maintain currency in full range of AOC. (MedicalCorpse commentary: 60% of docs don't)

(f) 25% have appropriate administrative support.

(g) 18% unit is doing a good job recognizing physicians.

(h) < 20% CPT/MAJs likely to stay on past ADSO. (MC: Note: 1% is less than 20%; why is this the only metric with "<"?)

Survey trends

(a) Trends were qualitative rather than quantitative, but suggest:

(b) Satisfaction drivers worse among majors and lieutenant colonels.

(c) Satisfaction drivers worse among surgical specialties.

(d) Top incentives to improve retention and satisfaction were

(i) Salary

(ii) Administrative support

(iii) Ability to practice full scope"

The conclusions at the end of the article are interesting:

"It is vital that the current concerns in MCO recruitment, job satisfaction, and retention are fully understood in historical context and investigated. A strategic plan, specific to the Medical Corps, to address survey-identified vulnerabilities with accountable reporting is indicated. Courses of action to address issues should be developed, implemented, and communicated to Medical Corps officers. To support those courses of action, consistent data should be assembled and maintained on MCO recruiting, satisfaction, and retention.

We have identified a number of proposals that could address these concerns:

• (1) Link Medical Corps Incentive Pay (MCIP) to a predetermined percentage of a civilian benchmark (eg, MGMA) to ensure the Army remains competitive on pay.
• (2) Increase the statutory cap on MCIP and retention bonuses (RBs) to allow flexibility for critical specialties.
• (3) Allow MCO to renegotiate RBs every year, as Navy and Air Force do.
• (4) Ensure the ancillary and administrative support meets civilian practice standards.
• (5) Utilize military-civilian partnerships to minimize skill degradation from low-volume, low acuity military treatment facilities.
• (6) Implement medical Individual Critical Task Lists and hold commanders accountable to ensure the required training and experience requirements are met.
• (7) Adopt a talent management strategy that takes into account individual preferences and career development.
• (8) Increase the length of duty assignments to more than 3 years if desired by the individual MCO.
• (9) Tailor professional military education so that it prepares MCO for expected duties and responsibilities while not removing the officers from patient care for extended periods of time.
• (10) Increase recognition of good work."

So, to summarize:
1-3: More pay to bring specialists up to somewhere close to civilian pay, rather than the bonuses which are stuck in the 1980s by laws that haven't changed in 40 years. Being paid less than 50% of your civilian colleagues to practice in the military is beyond demoralizing.
4. Don't make anesthesiologists be anesthesia techs to save money. Don't make physicians fill out insulting DMHRSi time cards that are not used to get more bodies to do the job, but just keep docs in their offices after hours doing busy work. Don't allow snotty techs and nurses not to do their jobs (IV starts, etc.) just because they can call anesthesia to do their jobs for them. Don't force anesthesiologists to place PICC lines without any training at all ("I stopped doing it after my 10th failure" --fellow anesthesiologist at Andrews) just because the military can't/won't retain enough interventional radiologists or specially trained IV access nurses to do the job.
5. Keeping up surgeons' skills is a good idea. However, they should also address "low volume, high acuity" situations at MTFs where vascular surgeons insist on being able to do 2 AAAs/year or 2 thoracotomies/year while the collective skills of the entire OR team (anesthesia, techs, nurses, and the surgeons) devolve below accepted standards of civilian care.
6. Yeah, having idiotic, desk-bound commanders be responsible for the training needs of their smarter underlings is a fine idea. Oh, I have a better one: have the individual specialists determine a list every year of what they need training in, and mandating travel/CME/civilian mentoring from the bottom up, rather than the top down. Oh, wait, that makes too much sense.
7. In other words, fire every single person at Air Force Personnel Center and rehire humans who actually care about retention of military members of all types. "Sorry, sir, we can't send you to Korea, Germany, England, or Japan to fulfill your DEROS overseas requirement, because the computer says that only CRNA slots are available. How about we send you to Alaska for three years UNaccompanied on a usually accompanied tour, because the Air Force can't handle special needs EFMP kids in Alaska or anywhere overseas..."
8. I never understood this maniacal insistance on rotating humans every 3 years. Sure, I suppose you don't want your three star generals and above to homestead long enough to form a power base to foment coups, but that's the least of our worries here in the USA (I hope). I was lucky enough to spend 6 years at Travis and 5 years at Andrews, which resulted in my being able to know who people were in the hospital, where things are, and to mentor new folks rotating in and out of the revolving door of the military assignment system. Of course, if you had personal, political connections, you could stay for 10 or more years at cushy assignments, as some of my commanders managed.
9. PME is a joke for physicians. Air Command and Staff College, chapter 6: How to Call in Nuclear Strikes; Chapter 13: Logistics: the most boring set of criminally-obscure acronyms you will every read. Don't get me started on the requirement to complete Air War College via distance learning BEFORE signing up to do it in residency in order to schmooze with other O-6s who will grease your wheels to command and retirement. Oh, I have an idea: how about physician-specific PME to address CBRNE defense; mass casualty concepts, including triage; space-specific medical care for the 21st Century Space Corps; cultural/religious/national issues for overseas medical care; liaison with non-US military physicians; working with/for PAs, CRNAs, NPs, nurse midwives, and other non-physician "providers" who will almost certainly outrank you; review of parasitology/tropical/desert/mountain diseases and conditions you may face during wartime...
10. Never going to happen. Ever. With the military promotion system, crap floats to the top and gets birds and stars on its shoulders. In this context, the best physician is the one who shuts up, sits down, colors, and doesn't make waves about critical patient safety issues due to criminally poor planning by Flag Officers ten years ago. Being the best clinician in your MTF is not as important as a stupid OPR bullet statement about how much money you saved downrange by seeing sick call as a radiologist. Oh, here's an idea: get rid of the antiquated, 1940s OPR system altogether and replace it with a 21st century employee evaluation tool used by modern companies (why reinvent the wheel?).

I'm sure I missed something in my summary. Feel free to add to the list.

Cheers,