“The simple answer is no”

[militaryPHYS]

Changes in action:

Internal Medicine physician had orders to new duty station in Med Battalion billet. Orders got pulled. Billet will now be filled with either FP or ER doc. Apparently no more "non-operational" physician will have option to be placed in to Med Battalion billets.

Stay operationally or exec med relevant people!

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[SirGecko]

Changes in action:

Internal Medicine physician had orders to new duty station in Med Battalion billet. Orders got pulled. Billet will now be filled with either FP or ER doc. Apparently no more "non-operational" physician will have option to be placed in to Med Battalion billets.

Stay operationally or exec med relevant people!

I'm a little confused about what you are saying. Are you saying they pulled the IM doctor's orders because they didn't think IM was qualified to be in a Med Battalion billet? Like FP and ER are somehow intrinsically "operational" but not IM?

 

[militaryPHYS]

I'm a little confused about what you are saying. Are you saying they pulled the IM doctor's orders because they didn't think IM was qualified to be in a Med Battalion billet? Like FP and ER are somehow intrinsically "operational" but not IM?

FP and ER have always been likely to maintain current strength. IM was a bit of an unknown given their primary care capabilities. I think this is showing IM will likely be going the way of OB/GYN and peds as it relates to divestitures.

 

[Brouillet2017]

Changes in action:

Internal Medicine physician had orders to new duty station in Med Battalion billet. Orders got pulled. Billet will now be filled with either FP or ER doc. Apparently no more "non-operational" physician will have option to be placed in to Med Battalion billets.

Stay operationally or exec med relevant people!

So what happens to said IM physician now?

 

[orbitsurgMD]

"Divestiture" of a major core medical discipline within the military medical system should be treated with alarm. At any respectable teaching hospital, the core academic disciplines are internal medicine, surgery, pediatrics, OB and psychiatry. Those departments anchor everything else, neurology, the surgery subspecialties, all the medicine and peds subspecialties, rads, path , anesthesia, PM&R, even derm. Indulging in the illusion that a medical system can do without a cadre representing a core discipline is professionally irresponsible. Maybe it is about time the military system is treated just like any civilian system instead of with apparent (and undeserved) deference. Fail to meet ACGME standards, you are on probation. No exceptions.

 

[militaryPHYS]

So what happens to said IM physician now?

Stay at current MTF or go flight/dive to open up PCS opportunities.

I’m most worried about those coming out of residency. Sounds like options very limited.

 

[Brouillet2017]

Stay at current MTF or go flight/dive to open up PCS opportunities.

I’m most worried about those coming out of residency. Sounds like options very limited.

As someone going into residency soon, that is quite worrisome. Mostly due to the uncertainty of it.

 

[Gastrapathy]

Well FP feels like they are being drawn down at the expense of IM so these anecdotes all just illustrate how poor the communication is from the top. When people aren’t given information, they make **** up to connect the dots.

 

[backrow]

Changes in action:

Internal Medicine physician had orders to new duty station in Med Battalion billet. Orders got pulled. Billet will now be filled with either FP or ER doc. Apparently no more "non-operational" physician will have option to be placed in to Med Battalion billets.

Stay operationally or exec med relevant people!

Do you have any further clarity on the reasoning or is it speculation? Was this a slated/milestone billet as that would also make a difference in what this actually means.

In previous discussions with the IM specialty leader IM is one of the specialties that was definitely planned on being used in operational type billets, so me thinks there is more to this story.

I would think the dwindling numbers of general internists at MTFs would have much more to do with the orders change than what you are suggesting.

 

[militaryPHYS]

Per report: Navy was planning to buy back flight surgery hospitalist billets from USMC for OMO spots but apparently that got shot down after orders were already written.

 

[wingbowlchamp3]

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.

i've been out almost 4 years so i don't think i can be accused of brown nosing when i say...

your communication was always very much appreciated on the blog. at times you were the only communication i got from outside of my bubble in japan about how to manage my career. diving in here takes some courage and should also be appreciated.

if navy leadership took time to be human and say something simple like "we get it"...i think there would be significantly more trust. the leadership i'm used to is sitting next to an admiral for 4 hours at a japanese baseball game during his visit to your command where he also gave you a letter of appreciation...and then he clearly doesn't remember who you are the next year. i know they meet a lot of people...but it firmed up my notion that their visits are just for show.

the lack of questions speaks to the lack of faith anything will be done or even considered. i never even knew where to ask questions. if i directed them beyond my chain of command when i had the rate opportunity to do it...i got a slap on the wrist from my leadership.

it's surprising to hear the changes to primary care. we're the best suited for military medicine so it doesn't make sense that there seems to be less incentive to stay in. it seems like things are a crossroads where they're trying to put the military back into military medicine...but unsure how to provide a full scope of care including adequately trained specialists that will always be needed in some form. making any effort to reach out and listen to the boots on the ground would be the first step.

 

[SirGecko]

Per report: Navy was planning to buy back flight surgery hospitalist billets from USMC for OMO spots but apparently that got shot down after orders were already written.

Maybe it’s just my ignorance but I’m still confused about what you are saying. Flight surgery hospitalist? Like you work part time as a flight surgeon and part time as a hospitalist?

Also does OMO in this context stand for operational medicine officer? Are you saying the marine corps stopped them from converting a flight surgery billet to an operational medicine officer billet? I guess I’m not sure what medicine vs family or em has to do with that since the operational medicine thing isn’t specialty specific per messaging from the navy. (Like the example they gave of a radiologist having the operational specialty of flight surgeon)

Also is medicine not considered primary care? I guess I don’t understand how family medicine or ER is primary care but internal medicine isn’t.

 

[militaryPHYS]

Maybe it’s just my ignorance but I’m still confused about what you are saying. Flight surgery hospitalist? Like you work part time as a flight surgeon and part time as a hospitalist?

Also does OMO in this context stand for operational medicine officer? Are you saying the marine corps stopped them from converting a flight surgery billet to an operational medicine officer billet? I guess I’m not sure what medicine vs family or em has to do with that since the operational medicine thing isn’t specialty specific per messaging from the navy. (Like the example they gave of a radiologist having the operational specialty of flight surgeon)

Also is medicine not considered primary care? I guess I don’t understand how family medicine or ER is primary care but internal medicine isn’t.

I don’t have all the details as I’m a bit disconnected this year. @MCCareer.org likely has more details.

 

[flightdoc09]

Maybe it’s just my ignorance but I’m still confused about what you are saying. Flight surgery hospitalist? Like you work part time as a flight surgeon and part time as a hospitalist?

Also does OMO in this context stand for operational medicine officer? Are you saying the marine corps stopped them from converting a flight surgery billet to an operational medicine officer billet? I guess I’m not sure what medicine vs family or em has to do with that since the operational medicine thing isn’t specialty specific per messaging from the navy. (Like the example they gave of a radiologist having the operational specialty of flight surgeon)

Also is medicine not considered primary care? I guess I don’t understand how family medicine or ER is primary care but internal medicine isn’t.

My understanding is that OMOs will be board certified GMOs. As such, an internist may be partly owned by their operational billet, and partly owned by the hospital. On greenside, the hospital has virtually no ownership of a GMO/FS, and it's possible the hospital wanted ownership with an understanding they'd be loaned out to the greenside command? I've heard rumors of OMOs in some highly specialized fields that will work part time as a flight surgeon and part time at the local MTF.

But the post you quoted confused me as well.

the lack of questions speaks to the lack of faith anything will be done or even considered. i never even knew where to ask questions. if i directed them beyond my chain of command when i had the rate opportunity to do it...i got a slap on the wrist from my leadership.

I think a lot of us at different levels just accept the status quo because, as has been mentioned earlier, we're in a large bureaucracy and change is difficult - even when it's really good. And if it isn't the bureaucracy, it's probably funding (or lack of). And if it isn't that, it's something else. Additionally, we need to get junior officers more of a direct line to decision makers. Problem solving needs to start with the people actually facing the problems, not the people that faced the problems 5-20 years ago. I think I have good ideas that reflect the reality I've faced as a flight doc the past few years, but I bet in 2-3 years things will change quite a bit. And good leaders should encourage questions and ideas from the lowest level.

 

[DrMetal]

Ahhh this thread makes me wanna drink.

 

[militaryPHYS]

Just got some more clarification.

IM community was ready to start integrating further in to operational medical officer billets (OMO) at Med Battalions. Orders were written for this to happen and then leadership at Med Battalions changed their mind.

 

[armytrainingsir]

I don’t understand how family medicine or ER is primary care but internal medicine isn’t.

My guess is IM doesn’t fire off enough unnecessary consults to be considered primary care.

 

[DrMetal]

My guess is IM doesn’t fire off enough unnecessary consults to be considered primary care.

Oh yes we do.

FM can do plenty of primary care, especially for the 18-65 yo demographic, the military being mostly the 18-45 yo demographic.

Internal Medicine is more vested in taking care of the old (>65yo), complex, several comorbid population. We take care of old sick people. This is exactly the business that the mil wants to get out of. It's too costly. They'd rather farm it out (somehow that's cheaper).

 

[flightdoc09]

My guess is IM doesn’t fire off enough unnecessary consults to be considered primary care.

Yeah, I've seen plenty of specialists (IM, gen surg, derm, ortho, etc) send of some of the dumbest consults or order MRIs for the weakest reasons and as far as I can tell they don't get any push back for it. But when little old GMO, that has far less experience, tries for a consult we get it cancelled because it doesn't meet referral guidelines, and we get an email saying "how about you send to this other specialist" or "please follow this algorithm, then if that doesn't work, then this other algorithm, and then if that doesn't work, then we'd be happy to see your patient."

Sometimes I wish we got paid by RVUs.

 

[jsat]

So, out of curiosity I know this pertains to the Navy.... but is the Army planning on doing something similar? I ask because I'm considering applying to Army HPSP in addition to the VA HPSP. If this the case I'd probably sway more towards the VA

 

[Kilgoretrout 65]

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.

This is exactly right. DOD should not be in the GME business but it would be a **** show if they were to get out. These programs are hanging by a thread right when the ACGME is piling on requirements and expectations.

 

[Kingfisher]

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.

People who don’t mind seeing their years of training, hard work, and clinical skills erode you mean?

 

[flightdoc09]

People who don’t mind seeing their years of training, hard work, and clinical skills erode you mean?

I dunno man, I wouldn't mind be a part time flight surgeon again and doing cool stuff. I loved flying.

The problem though, is that it's going to be tough to be good at your operational job. The radiologist would probably need to spend 2 days a week doing rads, and 3 days a week doing operational stuff. Those 3 days would need to be split between clinic and unit admin time. I dunno if you did a GMO tour, but even spending 50% of my week in clinic and 50% at my squadron, I was still seeing marines at my squadron for medical stuff, and doing admin work on the weekend. I had to hop back and forth between squadron meetings, force preservation councils, human factors councils, LIMDU meetings, staff meetings, etc.

I don't think the line side is going to be very happy with the relative lack of unit participation by OMOs, and I think the clinics are going to suffer with relative lack of FTEs spent in clinic. The actual GMOs are going to have to pick up the slack and they're going to get even more burned out than they are currently. I know I was extremely burned out coming back to residency. Probably still worth it to get to fly.

 

[orbitsurgMD]

I dunno man, I wouldn't mind be a part time flight surgeon again and doing cool stuff. I loved flying.

The problem though, is that it's going to be tough to be good at your operational job. The radiologist would probably need to spend 2 days a week doing rads, and 3 days a week doing operational stuff. Those 3 days would need to be split between clinic and unit admin time. I dunno if you did a GMO tour, but even spending 50% of my week in clinic and 50% at my squadron, I was still seeing marines at my squadron for medical stuff, and doing admin work on the weekend. I had to hop back and forth between squadron meetings, force preservation councils, human factors councils, LIMDU meetings, staff meetings, etc.

I don't think the line side is going to be very happy with the relative lack of unit participation by OMOs, and I think the clinics are going to suffer with relative lack of FTEs spent in clinic. The actual GMOs are going to have to pick up the slack and they're going to get even more burned out than they are currently. I know I was extremely burned out coming back to residency. Probably still worth it to get to fly.

It isn't workable--the split week example--if your specialty practice isn't local. Then there is the elephant-in-the-room of deployments. I spent one third or more of my FS time away. Tell me how that works on the ground.

I lost count of how many times I was brought in when some junior enlisted was acting out in one way or another (one guy, an oddball for certain, had been picked up by base police a couple of times dumpster diving for cans. Somehow that had to involve medical. Another nut attached to a local recruiting station was making up wild combat tales his XO knew wasn't true. I had to spend time on that. An administrative process would have discharged them in other places.) At one remote forward site I worked, medical, the deployed psychologist and the chaplain's office pretty much had round-the-clock call for all behavioral health matters for both the base and the fleet ships we hosted, including at least one carrier group, it got crazy. A carrier pulled in with five deaths aboard during its transit time from the West Coast. Their medical department was overwhelmed. A psych crisis team was deployed to the ship, but that wasn't enough. I can't see how having a split assignment with a specialist works here.

 

[flightdoc09]

It isn't workable--the split week example--if your specialty practice isn't local. Then there is the elephant-in-the-room of deployments. I spent one third or more of my FS time away. Tell me how that works on the ground.

I lost count of how many times I was brought in when some junior enlisted was acting out in one way or another (one guy, an oddball for certain, had been picked up by base police a couple of times dumpster diving for cans. Somehow that had to involve medical. Another nut attached to a local recruiting station was making up wild combat tales his XO knew wasn't true. I had to spend time on that. An administrative process would have discharged them in other places.) At one remote forward site I worked, medical, the deployed psychologist and the chaplain's office pretty much had round-the-clock call for all behavioral health matters for both the base and the fleet ships we hosted, including at least one carrier group, it got crazy. A carrier pulled in with five deaths aboard during its transit time from the West Coast. Their medical department was overwhelmed. A psych crisis team was deployed to the ship, but that wasn't enough. I can't see how having a split assignment with a specialist works here.

Exactly. I remember getting phone calls on weekends, or driving home at the end of an already long day, and having to come back to deal with a discipline or mental health case. Heck, once I was on leave, and the command knew it was local leave, and I got called in for a brig physical because they supposedly couldn't get a hold of the doc covering for me. I'm pretty sure they just didn't even try. And then coordinating care, dealing with LIMDU, initiating PEBs when service members are slipping through the cracks or their specialist doesn't know how. Like what attending radiologist/ophthalmologist/gynecologist/etc that is an O4/O5 is going to deal with that? And agreed, zero skills sustainment during a deployment for most specialties and most deployments.

But then again, the Army and Air Force have managed to do it. I don't know what it's like for them. Maybe one of them can chime in. Maybe their line commanders aren't as demanding and more respectful of their time off. Maybe they have a more robust admin support staff? I have no clue. But something is going to need to change for the OMO concept to be successful long term

 

[orbitsurgMD]

The Navy is notorious for having lots of little bases and activities fairly far away from any military MTF: VLF communications stations for subs, stations for ASW operations in very remote places:, servicing arctic and Antarctic missions and activities in the Aleutians, Gitmo, Diego Garcia, coastal Korea, east coastal Maine, remote parts of Hawaii, Guam and Japan. The Air Force also has some similar remote facilities. The Army has a deeper resource base in medical, but their bases seem more concentrated and much larger.