“The simple answer is no”

[Gastrapathy]

POM20 – Joel Schofer's Career Planning Blog

Posts about POM20 written by Joel Schofer, MD, MBA, CPE

mccareer.org

Some interesting tidbits in this interview. You gotta love this guy. He picks the questions and chose one he could answer with “nope”.

It sounds like the POM20 cuts are back on the table. I hadn’t heard the word divestiture before.

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[narcusprince]

I thought he was a terminal Captain?

 

[Gastrapathy]

The video was from CAPT Schofer’s boss

 

[DoctorWhere]

Rear Admiral James Hancock

 

[MCCareer.org]

POM20 – Joel Schofer's Career Planning Blog

Posts about POM20 written by Joel Schofer, MD, MBA, CPE

mccareer.org

Some interesting tidbits in this interview. You gotta love this guy. He picks the questions and chose one he could answer with “nope”.

It sounds like the POM20 cuts are back on the table. I hadn’t heard the word divestiture before.

The questions were submitted via social media. We didn't pick them.

The original billet cuts were referred to as the "POM20 divestitures." Now we're on POM23 and the divestitures are still on pause. They were never "off the table" but Congress keeps hitting the pause button with the annual National Defense Authorization Acts (NDAAs).

 

[Gastrapathy]

Folks should watch the video. The questions may well have been submitted but he picked which ones to answer and they were prepared remarks.

 

[militaryPHYS]

Folks should watch the video. The questions may well have been submitted but he picked which ones to answer and they were prepared remarks.

You were expecting something else from a planned video release?

Honestly I found it reassuring that the information we all get through different sources of media are consistent with what the RADML would answer. Lot's of unknowns based on budgets and Congress and the Chief should be the one to openly acknowledge such facts, what he is doing to mitigate it's impact on our clinical medicine careers and what we should expect moving forward. Keep them coming

 

[Gastrapathy]

Yeah I would have expected more. If you’re going to take on a question as a leader with such serious implications for your doctors, you should do better than that.

 

[MCCareer.org]

Folks should watch the video. The questions may well have been submitted but he picked which ones to answer and they were prepared remarks.

We answered every question submitted. I think there were 4 total. We left none unanswered.

 

[Gastrapathy]

I stand corrected. I’m surprised you didn’t have 100 questions from which to choose.

 

[xpert787]

When he makes that distinction between clinical specialty and 'operational specialty' and says you might be a radiologist but work as a flight surgeon.... Is that really the direction they are moving in? and if so who in the heck would want to do that?

 

[MCCareer.org]

When he makes that distinction between clinical specialty and 'operational specialty' and says you might be a radiologist but work as a flight surgeon.... Is that really the direction they are moving in? and if so who in the heck would want to do that?

It wouldn't be everyone, but many people would have a clinical specialty (radiology) and an operational specialty (flight surgery) and the ability to alternate between the two. Who would want to do that? People who like the military.

 

[ProwlerturnGas]

I am a specialist and have operational privileges as well. I now have to keep case logs to keep my operational credentials. I’ve never had to do this in my career.

 

[SirGecko]

When he makes that distinction between clinical specialty and 'operational specialty' and says you might be a radiologist but work as a flight surgeon.... Is that really the direction they are moving in? and if so who in the heck would want to do that?

Really the question of having an "operational specialty" its not that much of a change as people already do this. You go do a UMO or flight tour between intern year and residency? That's your "operational specialty".

The difference going forward I think is how much they might be asking people to rotate back to a flight or dive or GMO billet as historically its been less common than it seems it will be going forward. Also I am curious how recruitment for flight and dive positions will fare with the transition to sending more people straight through to residency. (obviously that will be one of the driving forces making more board certified doctors go back out for operational billets because if the interns aren't being sent out someone will be)

 

[xpert787]

It wouldn't be everyone, but many people would have a clinical specialty (radiology) and an operational specialty (flight surgery) and the ability to alternate between the two. Who would want to do that? People who like the military.

Really the question of having an "operational specialty" its not that much of a change as people already do this. You go do a UMO or flight tour between intern year and residency? That's your "operational specialty".

The difference going forward I think is how much they might be asking people to rotate back to a flight or dive or GMO billet as historically its been less common than it seems it will be going forward. Also I am curious how recruitment for flight and dive positions will fare with the transition to sending more people straight through to residency. (obviously that will be one of the driving forces making more board certified doctors go back out for operational billets because if the interns aren't being sent out someone will be)

Well hopefully they have some plan in place to retrain the people they impose this on, unless it's for very brief periods there is going to be significant skill atrophy.

 

[narcusprince]

Really the question of having an "operational specialty" its not that much of a change as people already do this. You go do a UMO or flight tour between intern year and residency? That's your "operational specialty".

The difference going forward I think is how much they might be asking people to rotate back to a flight or dive or GMO billet as historically its been less common than it seems it will be going forward. Also I am curious how recruitment for flight and dive positions will fare with the transition to sending more people straight through to residency. (obviously that will be one of the driving forces making more board certified doctors go back out for operational billets because if the interns aren't being sent out someone will be)

Certain specialities will always align operational with MTF mission. My understanding would be for those specialities that are not necessary to the mtf for example peds/heme onc or endo that they then have a operational component. My question for big Navy would be are you ok deferring a board certified endocrinologist to flight surgery for training to create a deployable asset?
Will DHA allow a smaller provider pool to create these deployable assets?

 

[MCCareer.org]

Certain specialities will always align operational with MTF mission. My understanding would be for those specialities that are not necessary to the mtf for example peds/heme onc or endo that they then have a operational component. My question for big Navy would be are you ok deferring a board certified endocrinologist to flight surgery for training to create a deployable asset?
Will DHA allow a smaller provider pool to create these deployable assets?

The answer to your first question is that we are willing to consider it. The answer to your 2nd question is that DHA doesn't control the active duty personnel, the services/military departments (MILDEPs) do.

 

[MCCareer.org]

Well hopefully they have some plan in place to retrain the people they impose this on, unless it's for very brief periods there is going to be significant skill atrophy.

The various operational specialties have training and refreshers.

 

[Gastrapathy]

This is an interesting program and I have to admit it’s pretty clever. To get rid of GMOs, you need BC docs in operational roles. These roles are nearly entirely within the standard primary care scope of practice with a few very narrow easily trained extra duties. You can’t claim that a radiologist is qualified to be a primary care physician. You’ve cut retention bonuses for FP dramatically. So, to fill the spots, create new “operational specialties”.

 

[militaryPHYS]

I'm not sure why people are still questioning the direction MilMed is heading. It seems quite clear. It will be more streamlined and operational for the active duty force. Therefore, if you came in before this shift and ended up in a less operationally relevant specialty you will have to adopt a more operational-focused purpose (i.e. flight, dive, exec med) otherwise staying in won't make much sense. My personal thoughts are that if you don't want to do that then get out when your commitment is up. If you have a lot of time left then focus on finding a billet that allows for moonlighting and good transition to civilian world. Sometimes that won't be possible.

Those coming in must understand that they will have to be operationally relevant. If there is a concern about finding your calling or purpose in an operationally relevant way then it is probably best to stay a civilian and pay off your loans quickly after residency/fellowship.

How all of this will effect MilMed GME and skill sustainment seems to be the last piece of the puzzle. Will the number of personnel in "non-operationally" relevant specialties (but essential for milmed GME programs) be reduced to minimum required to maintain active duty GME programs? For staff needing skill sustainment it seems that KSA's are hoping to help guide our understanding of which specialties maintain proficiency with their active duty practice alone vs. someone who cannot. Is this correct? Those who are not staying proficient from AD practice alone will get first dibs on TAD's and partnerships or are civilian integration/partnerships going to be the norm for everyone? Hoping @MCCareer.org can help us understand this a bit better.

 

[MCCareer.org]

I'm not sure why people are still questioning the direction MilMed is heading. It seems quite clear. It will be more streamlined and operational for the active duty force. Therefore, if you came in before this shift and ended up in a less operationally relevant specialty you will have to adopt a more operational-focused purpose (i.e. flight, dive, exec med) otherwise staying in won't make much sense. My personal thoughts are that if you don't want to do that then get out when your commitment is up. If you have a lot of time left then focus on finding a billet that allows for moonlighting and good transition to civilian world. Sometimes that won't be possible.

Those coming in must understand that they will have to be operationally relevant. If there is a concern about finding your calling or purpose in an operationally relevant way then it is probably best to stay a civilian and pay off your loans quickly after residency/fellowship.

How all of this will effect MilMed GME and skill sustainment seems to be the last piece of the puzzle. Will the number of personnel in "non-operationally" relevant specialties (but essential for milmed GME programs) be reduced to minimum required to maintain active duty GME programs? For staff needing skill sustainment it seems that KSA's are hoping to help guide our understanding of which specialties maintain proficiency with their active duty practice alone vs. someone who cannot. Is this correct? Those who are not staying proficient from AD practice alone will get first dibs on TAD's and partnerships or are civilian integration/partnerships going to be the norm for everyone? Hoping @MCCareer.org can help us understand this a bit better.

Touch to answer many of those questions definitively. Congress, DHA, the MILDEPs, and the service SGs continue to maneuver. We are definitely acting to shore up GME faculty, even for those non-operationally focused. For example, we need Rad Onc to provide cancer care and get complicated cases for many other specialties, so we are trying to preserve that in uniform until it is proven that DHA can/will hire what we don't have or don't need to be in uniform.

How the DHA and MILDEPs will navigate obtaining KSAs for those specialties that can't meet them in MTFs is also up in the air. The only thing I can definitively say is that it is being worked. Anything more solid than that would be a guess/prediction. It is, as they say, a wicked problem.

 

[militaryPHYS]

Touch to answer many of those questions definitively. Congress, DHA, the MILDEPs, and the service SGs continue to maneuver. We are definitely acting to shore up GME faculty, even for those non-operationally focused. For example, we need Rad Onc to provide cancer care and get complicated cases for many other specialties, so we are trying to preserve that in uniform until it is proven that DHA can/will hire what we don't have or don't need to be in uniform.

How the DHA and MILDEPs will navigate obtaining KSAs for those specialties that can't meet them in MTFs is also up in the air. The only thing I can definitively say is that it is being worked. Anything more solid than that would be a guess/prediction. It is, as they say, a wicked problem.

The transparency is much appreciated.

How do we as "boots on the ground" physicians help contribute to the overall discussion and direction? As you know, we often see that many of the people helping to drive decision making at the top have been removed from the pre-HPSP and 4-10 year post-HPSP or USUHS world for quite a while. Even our specialty leaders can't always understand the real impact these decisions have on the average MilMed physician in all specialties/sub-specialties.

 

[DocSurgeon]

-Work full time as civilian physician and participate in the reserves without burning your vacation: no problem!
-Work full time as military physician and request to moonlight without burning leave: you’re double dipping!

 

[MCCareer.org]

The transparency is much appreciated.

How do we as "boots on the ground" physicians help contribute to the overall discussion and direction? As you know, we often see that many of the people helping to drive decision making at the top have been removed from the pre-HPSP and 4-10 year post-HPSP or USUHS world for quite a while. Even our specialty leaders can't always understand the real impact these decisions have on the average MilMed physician in all specialties/sub-specialties.

Hard to incorporate 4,000 opinions. I'd say talk to your Specialty Leader is the easiest answer.

 

[MCCareer.org]

-Work full time as civilian physician and participate in the reserves without burning your vacation: no problem!
-Work full time as military physician and request to moonlight without burning leave: you’re double dipping!

Well, that is the way it works, as you have pointed out. Nothing anyone can do about that.

 

[flightdoc09]

The transparency is much appreciated.

How do we as "boots on the ground" physicians help contribute to the overall discussion and direction? As you know, we often see that many of the people helping to drive decision making at the top have been removed from the pre-HPSP and 4-10 year post-HPSP or USUHS world for quite a while. Even our specialty leaders can't always understand the real impact these decisions have on the average MilMed physician in all specialties/sub-specialties.

Agreed. I think you're probably talking more about career progression and training. But speaking from an operational provider perspective, I could write pages of examples about this. Good ideas that are just out of touch with reality of what it's like right now. In a siloed environment with adequate support it would be awesome. But just dumping more and more on the same number, or fewer, docs and corpsmen just isn't working. Not all is BUMED either. Some of it is Congressionally mandated (like the PHA and DHRAs), and some of it comes from the line community.

I think if some of the higher ups went back to see what it's like being a junior GMO/FS they'd be quite surprised at how bad everything is. It'll be interesting to see how the new OMOs deal with the admin burden and games of trying to keep up with all the different instructions.

 

[Chonal Atresia]

Well, that is the way it works, as you have pointed out. Nothing anyone can do about that.

This is not the type of statement that inspires active duty physicians to strive for excellence (i.e. suck it up because we have you by the b$&@! and nothing can be done about it anyway).

While this may be the current guideline, why not start knocking on doors of the policy-makers to get it changed?

Poor leadership. You can challenge bad policy or keep drinking the kool-aid and decimate recruiting/retention (or maybe that is the goal)....at least until the next big conflict leaves military medicine screwed.

 

[SirGecko]

I’m not sure I understand the moonlighting issue. You can moonlight when on a liberty status and not burn leave right? Is the issue that some specialties need to travel to do locums or have to do several days at a time?

 

[TheTruckGuy]

I’m not sure I understand the moonlighting issue. You can moonlight when on a liberty status and not burn leave right? Is the issue that some specialties need to travel to do locums or have to do several days at a time?

I think what you're saying is correct. Additionally, I think what RDML Hancock is saying is that you're being paid to be at the MTF, to do X amount of work for Y number of days. They can't pay you to do that work and then allow you to, in a way, play hooky (no cost TAD) to go moonlight somewhere.

It kinda makes sense. Like you wouldn't allow a sailor to go get paid at a mechanic's shop in town when he's supposed to be fixing engines on base. If he wants to make some extra money he can do that on his own time (leave or liberty). Even if it means it'll make him better at his Navy job, I can see the legal/ethical issue. On the other hand I bet many of us could make more money doing locums work than our base pay - what if the Navy hit pause on our paycheck and let us go PTAD wherever?

I really don't think the Navy can realistically hope to give us the real opportunities to maintain our skillset. It just isn't going to happen in our patient population, no matter where we are. The volume may be there, but the acuity and pathology won't be. TAD could work, but I doubt MTFs are willing to give up docs for weeks at a time every year. I think it'll happen a few times here and there and it'll be used as an example of "see, we help you maintain your skills," but it won't be sustained at any meaningful level.

 

[DocSurgeon]

I’m not sure I understand the moonlighting issue. You can moonlight when on a liberty status and not burn leave right? Is the issue that some specialties need to travel to do locums or have to do several days at a time?

Sure if you can find something in town nights or weekends only. If you need to go out of town you need to take leave since you're out of the "local area" (definitions vary by branch and base). So instead of burning leave to cover a weekend one state over let's do a reverse reserves. 1 weekend a month, 2 weeks a year PTDY and active in civilian hospitals moonlighting. Guaranteed that 90% of mil docs could pull that off with zero impact on AD, dependent and retiree care and no increased cost to the govt. Increase volume, increase case complexity, increase compensation to better compete with civilian jobs.
Everyone wins*

*It'll never happen.

 

[MCCareer.org]

I’m not sure I understand the moonlighting issue. You can moonlight when on a liberty status and not burn leave right? Is the issue that some specialties need to travel to do locums or have to do several days at a time?

Most commands allow you to moonlight when on liberty and within a 2 hour drive of your command. If you need to go outside of that radius, you must take leave. People are asking for no-cost TAD to moonlight, but that is not an option because when you are TAD you are acting on behalf of the government, even if it is permissive/no-cost. You can't get paid while on TAD by anyone other than the government, and you can't practice for anyone other than the government. You'd be exposing the government to liability and find yourself in legal trouble as well.

 

[Gastrapathy]

The answers from leadership here and on the video are why I started the thread. It just makes me sad to read and should really give everyone pause.

The inability to practice in the specialty in which you've trained is a major problem for military physicians. Dedicating yourself to this profession requires a great personal cost and the skills we develop are easily lost. The services have become far less interested in providing complex care over the past decade and this problem is worse than ever. Yet, it cannot be more clear that this is viewed by leadership as a "you problem" and they aren't interested in innovating to fix it. That would be hard and they have decided not to do hard. Programs like career intermission exist in the line community. If the military medical leadership was united and decided it was worth caring about this, they could solve it. It would take money, time and effort. It would be difficult. Instead, as they said, "the simple answer is no" and military physicians sit around doing 2 cases a month at major MTFs with residents crowding around. They can't even be bothered to ensure that the current limited moonlighting opportunities exist at all commands.

Remember when the Navy wanted to be a Top 50 employer?

A Top 50 employer wouldn't tell their employees that the only way to remain competent is to work on your off hours. The distinction between leave and liberty is completely irrelevant. This is a fulltime job (not in productivity but in hours). The only way for many physicians to stay remotely competent (not excellent mind you, just competent) is to spend the off time that they should be using to recharge, be a parent and maintain resiliency to work somewhere else. There is so much burnout in the military physicians I speak with. Think how disconnected they must be for this video to have answered all the submitted questions. With "4000 opinions", there should be lots of questions but clearly they have given up asking because they recognize futility.

The bottom line is that Navy Medicine has quite literally thrown up its hands. For anyone in military medicine or thinking about joining, just remember that they aren't going to make sure you have the work to be good at your job and they aren't willing to try.

Lets look at the Stanford Wellness Model for physicians. There are four domains:
1. Culture of wellness
2. Efficiency of practice
3. Personal resiliency
4. Professional fulfillment

Not a great list for the current state of military medicine, is it?

But, hey, they've created new "operational specialties" so that everyone can dabble in primary care regardless of their residency training. Every Marine is a rifleman, so why not.

 

[pgg]

This is an interesting program and I have to admit it’s pretty clever. To get rid of GMOs, you need BC docs in operational roles. These roles are nearly entirely within the standard primary care scope of practice with a few very narrow easily trained extra duties. You can’t claim that a radiologist is qualified to be a primary care physician. You’ve cut retention bonuses for FP dramatically. So, to fill the spots, create new “operational specialties”.

Lots of us, you and I among them, have been calling for GMO positions to be filled with board certified or board eligible physicians for a long time. I have to say I'm happy to see the Navy moving in this direction (and straight-through residency training too). We have some issues to work on, to be blunt. I can appreciate that leadership is operating under constraints that are not of their making and I certainly don't fault them for putting on a brave face and speaking in positive tones about it all. What else would you have them do?

So I was glad to see Adm Hancock address some of those questions and I'm always glad to see Capt Shofer posting here.


What concerns me most are three things where I see either no progress or backwards progress:

1) Steps have clearly been taken that devalue certain "non war critical" specialties. As just one example, they have singled out primary care (family medicine, internal medicine, pediatrics) and eliminated their ability to take 4- and 6-year retention contracts. These are physicians who are probably most appropriate to fill these GMO-like billets (certainly they're at less risk of skill atrophy and professional damage than procedure-focused specialties) and they're getting a clear signal that their presence and retention aren't important. This is genuinely astonishing to me - at a time with renewed emphasis on operational work, the physicians most suited to that work are being told to leave.

2) GME is in dire straits. Although COVID was (hopefully) a once-in-a-lifetime event and speed bump, the stress it put on the system exposed just how fragile our training programs are, just how close to the edge they're running in good times. Our ability to offer excellent residency training to physicians, particularly "war critical" specialties that rely on sick/old/broken patients, has steadily declined over the last ~20 years as case load and complexity has shrunk. I'm presently faculty at the inservice program I graduated from 12 years ago and it is a shadow of what it once was. When I was a resident, rotations at other institutions were a valuable supplement to what I did at home. Now those rotations are core components of residents' education - and we're approaching the point (51% "away" rotations) where we won't meet ACGME requirements. Again, devaluing all of those "non war critical" specialties has consequences - we need the obstetrics and NICU and oncology and geriatric pipelines to feed the operating room with cases to train "war critical" surgeons and anesthesiologists. You can't run a quality tertiary-care hospital without them.

3) Skill maintenance and growth of attendings. So many of us are completely dependent upon moonlighting (while burning leave). ERSAs with local civilian institutions have been promised for a decade+ and haven't materialized in significant numbers. Flagship projects like the one they're standing up at Penn are neat, but as I've argued here before, PCS'ing a lucky handful of people to a non-deployable billet at civilian hospital for 3 years is NOT a solution. The solution - if we can't reclaim all the sick/old patients we've deferred - is for everyone (physician, nurse, techs, corpsmen) to spend 20% or 40% of their time working at a civilian hospital local to them. Every week. Every month. Every year. All the time. As part of the MTF's baseline staffing and planning model, not just on a hopeful "if we can support it" basis. But that's not on the table. So the problem will remain unsolved at an institutional/leadership level, which leaves it to individuals to get it done on their weekends and leave.


As much as it pains me to say it, I've come around to the point of view that we'd be better off with a medical corps that was 90% reserve. Recruit and generously pay a core group of physicians who want to be attached to flight, dive, surface ship, and green units all the time. For the reservists, 3-4 month deployments ... mobilization should be a 72-hour process of gear issue and team meeting, not a month of garbage powerpoints and scavenger hunts that everyone, and I mean everyone, knows are useless. You've been there - you know as well as I that it's wasted time. Fold every MTF into the VA system - GME would again flourish in a stable environment full of sick and old people.

 

[pgg]

People are asking for no-cost TAD to moonlight, but that is not an option because when you are TAD you are acting on behalf of the government, even if it is permissive/no-cost. You can't get paid while on TAD by anyone other than the government, and you can't practice for anyone other than the government. You'd be exposing the government to liability and find yourself in legal trouble as well.

Agreed - this is clear cut, black and white. Moonlighting for $ while on TAD orders is a hard no.

One desirable solution would be for one's "Navy place of duty" every Tuesday and Friday to be at a local civilian institution that has a MOU with the MTF. The active duty physician wouldn't get paid extra, wouldn't get charged leave. The civilian hospital benefits from free labor, the military benefits from case load and skill maintenance.

In reality though, civilians often don't want to play this game. On more than one occasion civilian groups at hospitals have turned down offers for military physicians to work there free of charge because they don't want to give up any billing. They're happy to pay us to work there (on leave) because they can bill for our services and take a cut above the hourly moonlighting wage. They're not happy to give up billable cases for some Navy guys to work in their house for free. This is a problem ... I'm sure it's solvable with the right mix of contracting and incentives, but again ... thus far in my career I've never seen any effort to solve it.

 

[Gastrapathy]

@pgg Totally agree with everything you wrote with one caveat. The replacement of GMOs with board certified physicians presumed they were board certified in a relevant specialty. These operational specialties sound like dressed up GMOs to me. The dramatic decrease in retention bonuses for FP seem to suggest that the Navy thinks they are overmanned so it seems like they aren’t moving in the direction we would both support.

I’m glad CAPT Schofer is posting here too and his answers undoubtedly are open and truthful. But if you are a practicing cardiac anesthesiologist trying to maintain competency, his answers didn’t help. There is no will to fix it.

 

[pgg]

@pgg Totally agree with everything you wrote with one caveat. The replacement of GMOs with board certified physicians presumed they were board certified in a relevant specialty. These operational specialties sound like dressed up GMOs to me. The dramatic decrease in retention bonuses for FP seem to suggest that the Navy thinks they are overmanned so it seems like they aren’t moving in the direction we would both support.

Agreed. I would assume that the only people who'd elect to take these FS/dive/green billets would be people in primary care.

And you bring up another point that I glossed over - I can try to divine the "why" behind the special pay decisions and retention bonuses, but I'm just guessing. Maybe the RBs changed because the left hand was looking at some powerpoint with a green "100% manned" box while the right hand was looking at filling GMO billets with BC/BE people. Maybe it's deliberate force shaping away from "war critical" specialties. Maybe the budget demanded cuts and they thought that was the least damaging way to balance it.

I’m glad CAPT Schofer is posting here too and his answers undoubtedly are open and truthful. But if you are a practicing cardiac anesthesiologist trying to maintain competency, his answers didn’t help.

I'm a year from retirement, with enough banked leave to spend a full week or two per month moonlighting from here out, and depart with a leave balance of zero. I have lots of time over the coming months already booked at a university that needs my kind of locums. I'm in great shape.

I suspect I'm posting here for the same reasons you are. Neither of us need personal help from the Navy at this point, but we still care about the institution of Navy medicine, the people in it, and above all the people dependent upon it for care here and down range.

 

[pgg]

On the other hand I bet many of us could make more money doing locums work than our base pay - what if the Navy hit pause on our paycheck and let us go PTAD wherever?

That's what a reservist is.

 

[TheTruckGuy]

As Einstein supposedly said "We cannot solve our problems with the same thinking we used to create them." I feel like we need to radically rethink everything from the ground up and be honest with ourselves. Maybe the answer is getting rid of Navy GME and everyone does FTOS. Maybe we petition Congress to do stop meddling in military medicine. Maybe we just have to let the system break before it can be rebuilt better.

 

[pgg]

As Einstein supposedly said "We cannot solve our problems with the same thinking we used to create them." I feel like we need to radically rethink everything from the ground up and be honest with ourselves. Maybe the answer is getting rid of Navy GME and everyone does FTOS. Maybe we petition Congress to do stop meddling in military medicine. Maybe we just have to let the system break before it can be rebuilt better.

The great unintended consequence of the military getting out of the GME business hinges on the fact that the military presently trains a substantial portion of ALL physicians in the USA. Last I looked, military residency programs trained a few percent (3%? 6%? don't recall) of ALL residents.

It's not a trivial number.

With the growth of medical school classes in the nation, along with the long-running freeze in federal GME funding, the supply of graduating medical students is already outpacing available GME positions. So far, the unlucky few left without a spot have been largely FMGs, IMGs, and bottom tier barely-grads of DO and MD schools.

If the military cut off its GME pipeline, a whole lot more new grads will be unable to find a residency program. Even if the government funded more spots, you can't just turn on the spigot and create new programs. For the most part, hospitals in the US that are capable of supporting residency programs already have them (or don't want them).

Bottom line, if we quit GME there wouldn't be anywhere to send those residents FTOS.

 

[DrMetal]

As much as it pains me to say it, I've come around to the point of view that we'd be better off with a medical corps that was 90% reserve. Recruit and generously pay a core group of physicians who want to be attached to flight, dive, surface ship, and green units all the time. For the reservists, 3-4 month deployments ... mobilization should be a 72-hour process of gear issue and team meeting, not a month of garbage powerpoints and scavenger hunts that everyone, and I mean everyone, knows are useless. You've been there - you know as well as I that it's wasted time. Fold every MTF into the VA system - GME would again flourish in a stable environment full of sick and old people.

This really is the best solution to the entire dilemma. And there would be no harm/foul in 'reservizing' the entire MC, that's what the reserve community exists for. In fact, the Founding Fathers intended for the military to be largely a reserve force, not the behemoth active-duty welfare state that it's become today.

 

[TheTruckGuy]

not the behemoth active-duty welfare state that it's become today.

Sad, but true.

Bottom line, if we quit GME there wouldn't be anywhere to send those residents FTOS.

Fair point. Another reason to let the system break in order to rebuild it better. Because right now we're looking down the barrel of sub-par training.

 

[militaryPHYS]

There are working groups, clinical communities and Facebook groups for every topic imaginable yet no working groups composed of MilMed officers in varying levels of training to assist with this MilMed shift. I agree with @TheTruckGuy in that we have to do it differently from the ground up.

 

[narcusprince]

The great unintended consequence of the military getting out of the GME business hinges on the fact that the military presently trains a substantial portion of ALL physicians in the USA. Last I looked, military residency programs trained a few percent (3%? 6%? don't recall) of ALL residents.

It's not a trivial number.

With the growth of medical school classes in the nation, along with the long-running freeze in federal GME funding, the supply of graduating medical students is already outpacing available GME positions. So far, the unlucky few left without a spot have been largely FMGs, IMGs, and bottom tier barely-grads of DO and MD schools.

If the military cut off its GME pipeline, a whole lot more new grads will be unable to find a residency program. Even if the government funded more spots, you can't just turn on the spigot and create new programs. For the most part, hospitals in the US that are capable of supporting residency programs already have them (or don't want them).

Bottom line, if we quit GME there wouldn't be anywhere to send those residents FTOS.

What if you cut all military GME. And shifted scholarships to those selected for residency. Almost a super FAP program that incentivises military service to those already in residency. Get out of the classic hpsp pipeline.

 

[Gastrapathy]

@narcusprince the problem is no one would do it. The military has to get them young.

@pgg I don’t think the military students would fail to match civilian. They are AMGS, they bring their own funding and lots of programs aren’t fully funded by CMS. Closing the military programs would put a squeeze on spots as you say but I think it would push out IMGs and poor performing DO students first.

From the discussion above about a radiologist with an “operational specialty”, I don’t think your assumption about their plan is necessarily accurate.

My global point was that there is no will in leadership to fix this. All the suggestions that followed demonstrate that there are solutions, they just aren’t easy ones and there is no appetite for doing the hard thing for short term leaders.

 

[flightdoc09]

Really the question of having an "operational specialty" its not that much of a change as people already do this. You go do a UMO or flight tour between intern year and residency? That's your "operational specialty".

The difference going forward I think is how much they might be asking people to rotate back to a flight or dive or GMO billet as historically its been less common than it seems it will be going forward. Also I am curious how recruitment for flight and dive positions will fare with the transition to sending more people straight through to residency. (obviously that will be one of the driving forces making more board certified doctors go back out for operational billets because if the interns aren't being sent out someone will be)

If we're talking about skill atrophy as an attending working at an MTF in your specialty, can you imagine skill atrophy working as a GMO/UMO/FS? Or, what if you spend .3 FTE in clinic, .3 FTE at the nearest MTF trying to sustain your skills, and .4 FTE at your squadron, can you imagine how bad of an OMO you'd be? The clinic work load would shift to other people for seeing your unit. Your unit would hate you because you're never around. Your CO would get frustrated because, while you may have more experience and knowledge, you aren't as available as the intern trained GMO. We'd need to hire civilian contractors to pick up the load at the clinic.

Maybe this'll be a rude awakening for some of the hospital specialists that are always giving GMOs a hard time and they'll finally see how much work we have to do and how little support we get from the MTF. Or maybe it's just our clinic.

 

[orbitsurgMD]

If we're talking about skill atrophy as an attending working at an MTF in your specialty, can you imagine skill atrophy working as a GMO/UMO/FS? Or, what if you spend .3 FTE in clinic, .3 FTE at the nearest MTF trying to sustain your skills, and .4 FTE at your squadron, can you imagine how bad of an OMO you'd be? The clinic work load would shift to other people for seeing your unit. Your unit would hate you because you're never around. Your CO would get frustrated because, while you may have more experience and knowledge, you aren't as available as the intern trained GMO. We'd need to hire civilian contractors to pick up the load at the clinic.

Maybe this'll be a rude awakening for some of the hospital specialists that are always giving GMOs a hard time and they'll finally see how much work we have to do and how little support we get from the MTF. Or maybe it's just our clinic.

At one point, it was possible as a GMO needing a consult to anticipate speaking with a specialist who had been out in the fleet or with the FMF themselves and explain the situation with a patient (and you could tell pretty quickly in an exchange if they had not). That will become less common and, unfortunately lead to an even greater professional isolation of the intern-trained GMO. Just not good.

The services, and the Navy particularly, need to keep FM, IM and peds, in fact, they need to reinforce the training and support for those specialties because they will be essential to acquiring the numbers of mission-essential specialists in the "Bucket 1" list deemed necessary for mission contingencies. Cutting those core primary training programs will prove disastrous. It will thwart the entire effort to secure surgeons and other combat-essential physicians and badly damage readiness in ways that will ultimately be much more costly to repair.

Unfortunately no effective alternatives to the farming-out fascination were ever seriously developed, like having HHS/CMS compensate the military for taking care of retirees and other beneficiaries who would otherwise be seeking care in the civilian communities under Medcare, or doing the same for those with private insurance who were willing to go to the military for care instead of the civilian communities.

It is never cheap to operate a good hospital, and that is especially true for a teaching hospital. Why not just accept that? It is a necessary component to producing the readiness standard the services desire. The engineer's triad applies to the military as anywhere else.

"GMO" assignment of an appropriate residency-trained physician can be done in a way that is beneficial and that attracts better-quality candidates. Promotional points, bonuses (good ones), guaranteed orders for fellowship or an advanced degree program, mitigation of skill atrophy by job sharing so that during the operational tour a physician might rotate back to a MTF for a stretch of 45-60 days at a time to keep current, spotted by another operational physician doing the same.

The DHS and its predecessors have been trying to pull rabbits from hats. It just doesn't work that way.

 

[MCCareer.org]

This is not the type of statement that inspires active duty physicians to strive for excellence (i.e. suck it up because we have you by the b$&@! and nothing can be done about it anyway).

While this may be the current guideline, why not start knocking on doors of the policy-makers to get it changed?

Poor leadership. You can challenge bad policy or keep drinking the kool-aid and decimate recruiting/retention (or maybe that is the goal)....at least until the next big conflict leaves military medicine screwed

Lots of opinions on here in this string and it is really hard for me to address all of them. I will say the following:

1. We get it.
2. We are trying to address everything mentioned here.
3. At the end of the day, all we can do is the best we can. We are in a very large bureaucracy and everyone has a boss, not necessarily with agenda you'd like. It was not Navy Medicine's idea to cut billets or pay.

All I can assure those who read this is that there are people at the top who are trying to make Navy Medicine and military medicine better. Like anyone working in a bureaucracy, success is variable and we work the best we can within the constraints that are real.

 

[pgg]

Lots of opinions on here in this string and it is really hard for me to address all of them. I will say the following:

1. We get it.
2. We are trying to address everything mentioned here.
3. At the end of the day, all we can do is the best we can. We are in a very large bureaucracy and everyone has a boss, not necessarily with agenda you'd like. It was not Navy Medicine's idea to cut billets or pay.

All I can assure those who read this is that there are people at the top who are trying to make Navy Medicine and military medicine better. Like anyone working in a bureaucracy, success is variable and we work the best we can within the constraints that are real.

Thank you. I appreciate your efforts and know you're acting in good faith. I hope you're allowed to succeed.

 

[pgg]

@pgg I don’t think the military students would fail to match civilian. They are AMGS, they bring their own funding and lots of programs aren’t fully funded by CMS. Closing the military programs would put a squeeze on spots as you say but I think it would push out IMGs and poor performing DO students first.

I'm not sure that I can just dismiss as OK the notion of pushing out anyone. Even the bad side of the bell curve for physicians is still pretty good, given the alternative (increased reliance on midlevels). Decreasing the size of the physician training pipeline for the United States is not a solution.

As you note, the military might do OK ... then again it might not. There's been an unfortunate trend over the last few decades, in which we've enjoyed fewer HPSP students from top tier medical schools, and more and more from newer DO schools. Part of that is simply economic - DO schools tend to be more costly, and HPSP therefore more valuable and attractive to those students. The very DO students you acknowledge are first on the block to be outta luck may in fact be skewed toward the military scholarships.

I still think the basic problem is that civilian institutions either already have residency programs, or don't want them. I've worked at a number of hospitals that had the case load and volume to support a program, and the people working there explicitly don't want one. They're working fast, efficient, making money, loving life. Not everyone wants to be an educator.

I think the GME system in the USA is at capacity and that ending military GME would significantly impact that capacity.

 

[Gastrapathy]

@pgg this is a bit of a tangent but the number of residency slots has grown over the past few years. HCA and others have discovered the “benefit” of increasing supply in hospital employed fields in particular. The growth hasn’t kept up with the growth in medical student positions but I’m not sure that it should.