Thinking about HPSP/USUHS? READ THIS.

[Ziehl-Neelsen]

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Uhhh, you guys going on about Heme/Onc being a bucket 2 specialty do realize that these physicians are board certified in medical hematology right?

I'm sure the bucket 2 designation doesn't come from their ability to prescribe a neoadjuvant chemo regimen for triple negative breast cancer but from the fact that they are board certified in the diagnosis and treatment of hemostatic and thrombophilic disorders.

 

[HighPriest]

Uhhh, you guys going on about Heme/Onc being a bucket 2 specialty do realize that these physicians are board certified in medical hematology right?

I'm sure the bucket 2 designation doesn't come from their ability to prescribe a neoadjuvant chemo regimen for triple negative breast cancer but from the fact that they are board certified in the diagnosis and treatment of hemostatic and thrombophilic disorders.

Sure. But if the theory is that you're trying to narrow care down to medically necessary personnel, wouldn't a hemostatic disorder (aside from those caused by resuscitation) be an extreme rarity? Having not specifically checked the regs, I would think having hemophilia would be a no-go for AD.

I mean, I can also treat facial fractures. But there's OMFS, so when it comes to deploy-ability I'm just not necessary.

 

[Gastrapathy]

Seriously, the argument is heme? There is absolutely no need for operational heme beyond what is routinely managed by an ICU doc or trauma surgeon.

 

[Ziehl-Neelsen]

Having not specifically checked the regs, I would think having hemophilia would be a no-go for AD.

It is a disqualifying condition. That said, mild/moderate hemophiliacs without a family history do slip through MEPS and make it on active duty from time to time. One such patient was caught at one of the hospitals where you were an attending.

wouldn't a hemostatic disorder (aside from those caused by resuscitation) be an extreme rarity?

Hemostatic disorders caused by resuscitation along with the occasional acquired hemostatic or thrombotic disorders are the exact reason that I think big Army thinks it might be a good idea to have a hematologist in theater stationed at the big CSH.

Seriously, the argument is heme? There is absolutely no need for operational heme beyond what is routinely managed by an ICU doc or trauma surgeon.

I disagree. There are 2 ACGME accredited training programs that have formal requirements for instruction in blood banking and transfusion medicine. Those 2 training programs are clinical pathology and medical hematology. If you're gonna run a blood bank and transfuse people down range, it's probably a good idea to have access to the medical specialties that have formal training in this area of medicine and are qualified to serve as consultants/medical directors.

 

[BlackFrancis33]

From my understanding, part of the reason heme/onc is bucket 2 is due to expertise in managing the cytopenias that would occur in the case of a nuclear disaster. However unlikely that scenario may be, I don't think it requires that much thought to understand how that type of expertise could be important if that were to happen on a large scale.

 

[Gastrapathy]

If you want to reach that deep, you can make an argument about every specialty. That’s precisely my point.

 

[HighPriest]

It is a disqualifying condition. That said, mild/moderate hemophiliacs without a family history do slip through MEPS and make it on active duty from time to time. One such patient was caught at one of the hospitals where you were an attending.


Hemostatic disorders caused by resuscitation along with the occasional acquired hemostatic or thrombotic disorders are the exact reason that I think big Army thinks it might be a good idea to have a hematologist in theater stationed at the big CSH.


I disagree. There are 2 ACGME accredited training programs that have formal requirements for instruction in blood banking and transfusion medicine. Those 2 training programs are clinical pathology and medical hematology. If you're gonna run a blood bank and transfuse people down range, it's probably a good idea to have access to the medical specialties that have formal training in this area of medicine and are qualified to serve as consultants/medical directors.

Yeah, but, if they skip through then med board them.

Or you can lay a hematologist’s salary for 20 years to accommodate someone who is a major risk while deployed.

And you need pathologists if you have surgeons. So just use pathologists to manage your blood banks.

And I can’t recall ever being on a trauma code on general surgery where we consulted hematology. Granted, my experience was limited to my time on those services, but they seemed to have a handle on it.

 

[HighPriest]

If you want to reach that deep, you can make an argument about every specialty. That’s precisely my point.

Agree here. The demo for oropharyngeal cancer is much younger than it used to be. Active duty guys who never smoked are at risk, especially senior officers and NCOs. So if we’re going down that rabbit hole, you need your rad onc guys back.

 

[AvoidMilitaryMedicine]

This is all over the different Facebook Med Corps groups... tough times ahead, well worth the read

https://www.usnews.com/news/nationa...at1bfjN-vRq1IIYssAker3oroDdjD9DU34NhAibwzaFYQ

--
To keep control of their medical personnel, Edwards says, the Army had begun transferring many from the medical command to line units commanded by officers who know nothing about medicine and everything about leading troops into battle.

"It was so backwards to me," she says. "It would be up to the commander to figure out how (medical personnel) would maintain their skills. Obviously, the doctors and nurses were very upset about this."

--
"My (superior) wants us all to say we're general surgeons or trauma surgeons," the highly specialized military surgeon says. "The fear is that otherwise we'll wind up doing sick-call physicals for the next several years."

-- Comments from the FB MC group (names/identifying information removed)

Good luck to USU on recruiting - or even retaining the students who accepted a spot for 2019. I wonder how many will jump ship?

with what’s described I expect HPSP and USUHS enrollments to drop precipitously in short order. But by that point all those responsible for this will have been retired, sitting on various corporate boards, talking about how they brought efficiency to the bloated MHS...

i think about this often. I had a great experience at USU and my time as ---/--- GI until about the last 18 months. I’m at the end of my career with all these changes. I can’t imagine being a med student currently or part of the incoming classes.

 

[Mace1370]

This is all over the different Facebook Med Corps groups... tough times ahead, well worth the read

https://www.usnews.com/news/nationa...at1bfjN-vRq1IIYssAker3oroDdjD9DU34NhAibwzaFYQ

--
To keep control of their medical personnel, Edwards says, the Army had begun transferring many from the medical command to line units commanded by officers who know nothing about medicine and everything about leading troops into battle.

"It was so backwards to me," she says. "It would be up to the commander to figure out how (medical personnel) would maintain their skills. Obviously, the doctors and nurses were very upset about this."

--
"My (superior) wants us all to say we're general surgeons or trauma surgeons," the highly specialized military surgeon says. "The fear is that otherwise we'll wind up doing sick-call physicals for the next several years."

-- Comments from the FB MC group (names/identifying information removed)

Good luck to USU on recruiting - or even retaining the students who accepted a spot for 2019. I wonder how many will jump ship?

with what’s described I expect HPSP and USUHS enrollments to drop precipitously in short order. But by that point all those responsible for this will have been retired, sitting on various corporate boards, talking about how they brought efficiency to the bloated MHS...

i think about this often. I had a great experience at USU and my time as ---/--- GI until about the last 18 months. I’m at the end of my career with all these changes. I can’t imagine being a med student currently or part of the incoming classes.

I'm at a MTF with a GME program and rotating medical students. There is a palpable air of despair that was not there prior to these changes.

 

[AvoidMilitaryMedicine]

I'm at a MTF with a GME program and rotating medical students. There is a palpable air of despair that was not there prior to these changes.

It's unfortunate because I think this will be the literal end of GME and military medicine...

This post on the FB group encapsulated it pretty well:

The natural history of this disease process is the literal death of army medicine. DHA has its responsibility to deliver health care to beneficiaries (our families) while we deploy for 9 months, and go pitch tents with our MTOE units. DHA has the $$ now, and we will be replaced. When we cannot get the patient reps to acomplish the new ICTLs, we will go out to the civilian centers. So why not just make us all reservists now, or send us to civilian hospitals and make this a clean kill. Our we can make this process languish and suffer.

---

The morale amongst the junior med corps staff is very low. I've advocated to our consultant to pitch the idea of:

- Convert all AD docs to reservists who get called up only to drill and deploy.
- Embed small AD teams with nurse case managers at local hospitals near posts to manage (and prioritize) complex AD care needs
- Close down MTFs and expand Tricare (to treat dependents).
- Expand PA/NP scholarships to recruit and assign PA/NPs as battalion/division surgeons and at sick-call

The massive cost savings from closing down MTFs, farming out AD physician staff, using mid-levels to take care of day-to-day unit level medical care and admin with nurse case managers to coordinate care would have been, in my opinion, a win for win everyone because it'd save money, improve readiness, and allow providers to retain and develop their skills with the best of civilian/military medicine.

Ah well, too little too late to put out this dumpster fire.

 

[militaryPHYS]

This is all over the different Facebook Med Corps groups... tough times ahead, well worth the read

https://www.usnews.com/news/nationa...at1bfjN-vRq1IIYssAker3oroDdjD9DU34NhAibwzaFYQ

--
To keep control of their medical personnel, Edwards says, the Army had begun transferring many from the medical command to line units commanded by officers who know nothing about medicine and everything about leading troops into battle.

"It was so backwards to me," she says. "It would be up to the commander to figure out how (medical personnel) would maintain their skills. Obviously, the doctors and nurses were very upset about this."

--
"My (superior) wants us all to say we're general surgeons or trauma surgeons," the highly specialized military surgeon says. "The fear is that otherwise we'll wind up doing sick-call physicals for the next several years."

-- Comments from the FB MC group (names/identifying information removed)

Good luck to USU on recruiting - or even retaining the students who accepted a spot for 2019. I wonder how many will jump ship?

with what’s described I expect HPSP and USUHS enrollments to drop precipitously in short order. But by that point all those responsible for this will have been retired, sitting on various corporate boards, talking about how they brought efficiency to the bloated MHS...

i think about this often. I had a great experience at USU and my time as ---/--- GI until about the last 18 months. I’m at the end of my career with all these changes. I can’t imagine being a med student currently or part of the incoming classes.

Holy cow. That article is all over the place. I agree there is doom and gloom but we all have to keep an objective head on us.

The reason there is reorganization and cuts are because of the very things about MilMed that they mention. The goal (as I see it) is to consolidate everything to allow those that remain to be an active duty care and war fighting medical force. It is also to increase the ability of surgeons to maintain their skills via integration with the civilian world. Of course there are going to be cuts. Of course GME is going to decrease significantly if not all together. Of course our beneficiaries (CONUS care of non-active duty) will be pushed out to the civilian world. It is going to be chaos until the dust settles.

The main problems with current rollout is the 1) lack of communication and direct statements of intent 2) failure to properly overhaul tricare prior to doing all this. Improved reimbursement and universal acceptance policies should have been addressed first in order to maintain proper and easy care for our loved ones out in town. 3) lack of communication and direct statements of intent.

I also don't fully understand the PROFIS and return to platform based assignments that is going on. Seems contradictory to their intent (keeping doctors proficient and job-focussed)....but I think time will show that eventually we will be returned to being primarily at what few MTF's remain.

 

[Trefoil]

It's unfortunate because I think this will be the literal end of GME and military medicine...

This post on the FB group encapsulated it pretty well:

The natural history of this disease process is the literal death of army medicine. DHA has its responsibility to deliver health care to beneficiaries (our families) while we deploy for 9 months, and go pitch tents with our MTOE units. DHA has the $$ now, and we will be replaced. When we cannot get the patient reps to acomplish the new ICTLs, we will go out to the civilian centers. So why not just make us all reservists now, or send us to civilian hospitals and make this a clean kill. Our we can make this process languish and suffer.

---

The morale amongst the junior med corps staff is very low. I've advocated to our consultant to pitch the idea of:

- Convert all AD docs to reservists who get called up only to drill and deploy.
- Embed small AD teams with nurse case managers at local hospitals near posts to manage (and prioritize) complex AD care needs
- Close down MTFs and expand Tricare (to treat dependents).
- Expand PA/NP scholarships to recruit and assign PA/NPs as battalion/division surgeons and at sick-call

The massive cost savings from closing down MTFs, farming out AD physician staff, using mid-levels to take care of day-to-day unit level medical care and admin with nurse case managers to coordinate care would have been, in my opinion, a win for win everyone because it'd save money, improve readiness, and allow providers to retain and develop their skills with the best of civilian/military medicine.

Ah well, too little too late to put out this dumpster fire.

Actually, the idea of farming us out to civilian hospitals was listed as a possibility in the article. I’ve seen that particular set up in action before, and I think it made a lot of sense. A civilian hospital signs a contract with the military. The military supplies the civilian hospital with their personnel for some specified time (I think 1-2 years). The personnel then works at the civilian hospital with their normal military pay for that period of time. The contract allows you to be deployable, and you are still active duty. This method was already in use to maintain the skill sets of Air Force ER docs.

This makes the most sense to me. Instead of saturating the workforce in large MTF’s, they can get their money back and keep us ready to deploy with these civilian contract jobs. This may only apply to bucket one specialties as it looks like they came up with some waste basket type categories for everything they don’t need to deploy.

 

[eqkc]

This is all over the different Facebook Med Corps groups... tough times ahead, well worth the read

https://www.usnews.com/news/nationa...at1bfjN-vRq1IIYssAker3oroDdjD9DU34NhAibwzaFYQ

--
To keep control of their medical personnel, Edwards says, the Army had begun transferring many from the medical command to line units commanded by officers who know nothing about medicine and everything about leading troops into battle.

"It was so backwards to me," she says. "It would be up to the commander to figure out how (medical personnel) would maintain their skills. Obviously, the doctors and nurses were very upset about this."

--
"My (superior) wants us all to say we're general surgeons or trauma surgeons," the highly specialized military surgeon says. "The fear is that otherwise we'll wind up doing sick-call physicals for the next several years."

-- Comments from the FB MC group (names/identifying information removed)

Good luck to USU on recruiting - or even retaining the students who accepted a spot for 2019. I wonder how many will jump ship?

with what’s described I expect HPSP and USUHS enrollments to drop precipitously in short order. But by that point all those responsible for this will have been retired, sitting on various corporate boards, talking about how they brought efficiency to the bloated MHS...

i think about this often. I had a great experience at USU and my time as ---/--- GI until about the last 18 months. I’m at the end of my career with all these changes. I can’t imagine being a med student currently or part of the incoming classes.

I'm only aware of an Army fb group... Are there others? (I'm Navy)

 

[teacherman84]

Actually, the idea of farming us out to civilian hospitals was listed as a possibility in the article. I’ve seen that particular set up in action before, and I think it made a lot of sense. A civilian hospital signs a contract with the military. The military supplies the civilian hospital with their personnel for some specified time (I think 1-2 years). The personnel then works at the civilian hospital with their normal military pay for that period of time. The contract allows you to be deployable, and you are still active duty. This method was already in use to maintain the skill sets of Air Force ER docs.

This makes the most sense to me. Instead of saturating the workforce in large MTF’s, they can get their money back and keep us ready to deploy with these civilian contract jobs. This may only apply to bucket one specialties as it looks like they came up with some waste basket type categories for everything they don’t need to deploy.

I dont know all the details but I know this happens for multiple specialties at Nellis AFB.
They have general surgeons, ER docs, ortho, pulm/CC, nurses, resp techs and medics who work downtown in the level 1 trauma center. The GS and ED guys do it as part of the joint GME they have with the civilian programs.

 

[militaryPHYS]

I'm hoping we will have something similar everywhere, for all services. Air Force always gets to do the best stuff with the most money... Lucky

 

[Gastrapathy]

A lot of the discussion about integrating with the civilian sector doesn't reflect the reality of the economics. Universal acceptance policies, for example, are the requirement that I, as an individual physician, pay a tax to the government for the privilege of going to work. Its amazing how republicans can become socialists when it is in their interest. The rotating physicians that can contract "with a hospital" will inevitably be used against local physician groups in negotiations. We really don't want a bunch of part-time docs diluting the labor pool but not being able to be counted on for call, etc. You can expect that, if that concept expands, there will be major resistance and resentment.

@pgg I agree that the article was all over the place. The terminology of a "field surgeon" was lost on the author, as usual. But these articles are entirely the fault of the leadership because they are unable or unwilling to get out an accurate message.

 

[militaryPHYS]

A lot of the discussion about integrating with the civilian sector doesn't reflect the reality of the economics. Universal acceptance policies, for example, are the requirement that I, as an individual physician, pay a tax to the government for the privilege of going to work. Its amazing how republicans can become socialists when it is in their interest. The rotating physicians that can contract "with a hospital" will inevitably be used against local physician groups in negotiations. We really don't want a bunch of part-time docs diluting the labor pool but not being able to be counted on for call, etc. You can expect that, if that concept expands, there will be major resistance and resentment.

@pgg I agree that the article was all over the place. The terminology of a "field surgeon" was lost on the author, as usual. But these articles are entirely the fault of the leadership because they are unable or unwilling to get out an accurate message.

But this day and age aren't most civilian docs at these large civilian hospital-groups salaried when it comes to covering trauma call or ICU call? Some places are different and still provide incentive based payments or contracts to private groups, but the large systems (i.e. kaiser and similar) are salary and continue their private-ish practice separate from the call stuff. Therefore adding more to the pool improves lifestyle....but decreases volume. Thankfully there is usually enough to go around at the large Level I centers.

 

[Gastrapathy]

Depends on the region and the laws about the corporate practice of medicine. There are rival trauma groups in my town and the hospitals play them off each other. “Free” shifts from another player could be very disruptive. EM groups are often competing over contracts (sometimes with large CMGs) and you could imagine that the large CMG would be the one contracted with the .mil. Could easily be enough to change the dynamic.

Decreasing call might improve “lifestyle” but volume still = money in most practices.

I’m not sure what you mean that KP practices separate from call.

 

[militaryPHYS]

The small amount of exposure to the civilian sector I have involved KP. They had their elective practice separate from the agreed upon call requirement at "x" hospital. For the ortho guys (non-trauma) I was talking to they didn't care about the call shifts. It was basically like having to do alcohol awareness...didn't effect their end of year pay and was just an added headache they were required to perform. But again, each hospital and/or center is going to be different. Each specialty is going to be different. I just don't know enough about the civilian sector yet. I understand for many groups and specialties it would change things considerably.

 

[DD214_DOC]

This reassignment to MTOE but, "with duty at xMTF", was hopefully vetted through DHA. It functionally sounds like a reservist situation, except we're the reservist for the MTOE and will be, "called up", for deployments, FTX, and whatever else the MTOE commander fancies. I cannot imagine DHA will tolerate the incredible disruption to patient care, dragging down of sacred metrics, and personnel that may still count towards MTF staffing caps and all that -- assuming this will still apply.

I believe there's a possibility DHA will simply say GTFO of our hospital, replace us with GS or contractors, and condemn docs to solely what the MTOE can find for them to do.

 

[stevejohnson543215321]

Question on Navy 2018 GME match. For general surgery, the full time in service residency selection goals include 5 spots for incumbent interns and 2 spots for remaining FTIS from either incumbent interns or GMOs. There are suppose to be a total of 30 total spots for general surgery across Bethesda, Portsmouth, and San Diego though. Does this mean they only filled a fraction of general surgery for this year? Is this what everyone has been talking about here about big military significantly decreasing availability of residency opportunities?

 

[mr11]

As someone who's staring down the barrel of a 5 year residency for a bucket 2 specialty this all makes me very uneasy. Does anyone know if they're obligated to train me all 5 years in the specialty I matched to? Is there any precedent for eliminating a GME program with residents still in the pipeline?

 

[teacherman84]

As someone who's staring down the barrel of a 5 year residency for a bucket 2 specialty this all makes me very uneasy. Does anyone know if they're obligated to train me all 5 years in the specialty I matched to? Is there any precedent for eliminating a GME program with residents still in the pipeline?

Navy closed 2 FM residencies around 2014ish (Pensacola and Bremerton I believe). I think residents were given the option of finishing without junior residents or going GMO...but not 100 percent sure how it played out.

 

[militaryPHYS]

Question on Navy 2018 GME match. For general surgery, the full time in service residency selection goals include 5 spots for incumbent interns and 2 spots for remaining FTIS from either incumbent interns or GMOs. There are suppose to be a total of 30 total spots for general surgery across Bethesda, Portsmouth, and San Diego though. Does this mean they only filled a fraction of general surgery for this year? Is this what everyone has been talking about here about big military significantly decreasing availability of residency opportunities?

I believe the incumbent intern, Remaining FTIS and FTIS fellowship numbers on Enclosure 4 are utilized to determine FTIS and FTOS numbers related to deferments and such. BUT, if we have someone with more experience interpreting Enclosure 4, please chime in on this. Either way the 10 number for Gen Surg has been consistent on enclosure 4 BUMEDNOTE 1524 since 2015 so I don't think it is reflecting any of the current policy changes.

When we start to see the numbers on Enclosure 3 drop precipitously...thats when we'll have an idea of where we are headed.

 

[Cooperd0g]

Navy closed 2 FM residencies around 2014ish (Pensacola and Bremerton I believe). I think residents were given the option of finishing without junior residents or going GMO...but not 100 percent sure how it played out.

Those completing internship at the closing of the FM programs were offered deferment to a civilian program or GMO. PGY2 stayed on as PGY3 with no interns or PGY2 beneath them.

Also, when the Occ med year left RAM with the Army, the residents who were accepted to the combined program were allowed to leave when complete with the Aerospace component or stay for an unaccredited Occ med year. All new residents were only for Aerospace.

So yeah, it could happen ... hopefully it doesn’t.

 

[orbitsurgMD]

This entire scheme seems to be the worst-considered and most incompetently-planned concept: so we can get some "warfighters," let's gut our medical services, destroy our training hospitals and have no explainable way of providing medical services to active duty and their families except the vague "hire it out in town" idea. Yeah, that'll work on the Tricare plan. I suspect that what will result in many places will be a corporate entity--some version of Booz-Allen or Halliburton opening clinics staffed by "techs," PAs and NPs with the bare-bones-minimum number of specialists on poorly-paid closed-panel contracts and all-too-predictable turnover those enterprises have. It will run not like the VA but more like the federal prison health service. The active duty "warfighters" should have something better, but that isn't what they're going to get. And how exactly will the remaining "hospitals" satisfy the ACGME requirements to run training programs for these highly-desired "bucket 1" specialties the magical-thinking medical corps leaders think they are going to produce? (Hint: they can't and won't) The GME department will become a medical SATO office, shipping trainees wherever a qualified program will take them.

A far better approach would be for USUHS to operate as the umbrella training organization for a collection of tertiary all-service hospitals (including PHS) around the country in locations close to operational commands. Close integration with the V.A. and nearby universities would be desirable. If they are going to cut, start with the fat and bloated nurse corps and medical service corps. No more clipboard nurses. If you want to do clipboard duty, you become a twig. The military hospitals should be allowed to bill Tricare. If they want to use AD physicians or hire contractors, they have to justify the choice. The hospitals should be in major population centers where the resources exist for crossover to VA and university centers: San Diego, Oakland, Seattle, Atlanta, St. Louis, Denver, Chicago, Washington, Virginia Beach, Tampa, San Antonio. In many of those locations, there already exist military hospitals that could be repurposed.

Of course, none of that works if your real purpose is to take billets and you don't really care what kind of medical service you have left.

 

[HighPriest]

They're going to have trouble getting care for all of the dependents on Tricare out in the community for sure. I've been rolling that around in my head, and ultimately I can only see a couple of solutions:
There are -a few- practices that see Tricare. No many. But hospital-employed docs will still see them. So that's an option, if they're available. They definitely aren't in many locations (like Kansas, for example).

They could completely revamp the VA system and increase it's budget to allow dependents to go under Tricare. But that's such an enormous, unpredictable, inefficient solution that I can't see it happening. You'd literally be better off just trashing Tricare and the VA and just building a new system from the ground up.

The third option is that they contract with large hospital corps like Kaiser. They're based entirely upon seeing low-payers and ensuring that they don't lose money based upon how they manage them. But, there aren't Kaisers everywhere....currently...I could see that changing if they suddenly picked up 10,000 new patients in BFE. Feed the Tricare dependents to the HMOs. It's exactly the MIC Eisenhower warned you about.

 

[Matthew9Thirtyfive]

There are -a few- practices that see Tricare. No many.

I think I was spoiled living in San Diego. There were tons of docs who took Tricare. We never had any trouble finding primary care or specialists who would take it. But that's San Diego. I'm assuming it's different in the rest of the country.

 

[HighPriest]

I think I was spoiled living in San Diego. There were tons of docs who took Tricare. We never had any trouble finding primary care or specialists who would take it. But that's San Diego. I'm assuming it's different in the rest of the country.

It is not that way in many other areas of the country.

 

[notdeadyet]

It is not that way in many other areas of the country.

Agreed. The only way you can run a practice taking Tricare is if you make it up with volume.

It’s akin to Medicaid (poor reimbursement for the overhead required): Kaiser and such agencies can do it and so can places where this is all they do. The Tricare equivalent is going to be in military retirement hubs like San Diego. But good luck with Tricare in a lot of the country.

 

[militaryPHYS]

Four military treatment facilities earn prestigious surgical quality awards | Health.mil

 

[Detective SnowBucket]

So, I got into this thread into the first place because I'm currently pursuing HPSP through the Navy. I recently brought this up the last time I met with my recruiter and his point is yet to have been shot down.

When I said the Navy will be cutting a ton of billets, he said the Navy intends to cut people (rather than specialties) that can't deploy and fill those spots with younger HPSP students. Thoughts?

 

[AvoidMilitaryMedicine]

So, I got into this thread into the first place because I'm currently pursuing HPSP through the Navy. I recently brought this up the last time I met with my recruiter and his point is yet to have been shot down.

When I said the Navy will be cutting a ton of billets, he said the Navy intends to cut people (rather than specialties) that can't deploy and fill those spots with younger HPSP students. Thoughts?

As a point of fact, recruiters know almost nothing about the realities of the medical corps and know absolutely nothing about the **** storm on the horizon. They will spin "alternative facts," to get you to sign on the dotted line because you are not their priority, their quota is.

All 3 services will be significantly reducing their ability to sustain and support GME -- but in my opinion, the Navy has always been pretty awful at GME because it's regularly forced highly qualified people into GMO land for years allowing them to languish as glorified mid-levels until a spot (may) become available in their chosen specialty -- which in my opinion is a complete waste of resources.

The Pentagon has recently issued a 'deploy or get out,' directive, but there are plenty of Army docs who are on "dead man's profiles," who will never get medically boarded despite never being able to deploy because they will be waived from the 'deploy or get out,' policy -- rather, provided they can pass ht/wt and their fitness test, they will be allowed to stay in and promote.

I've read that over 80% of docs get out as soon as their first ADSO contract is up (my residency class has been 100%), so this will leave 3 types of docs in the higher echelons of the medical corps:

1) The incompetent... either through a general lack of competence and/or severe skill degradation (e.g., highly specialized surgeons, etc.) who realize that they won't "make it," on the outside because they can't handle the patient volumes, the rigor and/or have just become institutionalized over the years and decide to stay in for 20 years for a 6-figure salary and retirement.

2) The incapable... medically unfit physicians who can continue to promote and advance in the military despite not deploying and/or not maintaining rigorous clinical skills.

3) The lifers... the service academy + USUHS grads... the bravest of the brave... who decide that they are too far gone to come back now and decide to stick it out for a "few more years," to make it to retirement.

 

[Matthew9Thirtyfive]

As a point of fact, recruiters know almost nothing about the realities of the medical corps and know absolutely nothing about the **** storm on the horizon. They will spin "alternative facts," to get you to sign on the dotted line because you are not their priority, their quota is.

While I disagree that you can foresee what is going to happen, this is definitely true. Recruiters, at least in the Navy, are enlisted folks who have a tangential knowledge of what being a physician in the military is like, and no one has any idea what is going to happen with the changes coming. They will say what they need to say to get you in. That's their job. The good ones won't lie, but they are still going to spin things the right way. They need to fill their quotas.

 

[militaryPHYS]

When I said the Navy will be cutting a ton of billets, he said the Navy intends to cut people (rather than specialties) that can't deploy and fill those spots with younger HPSP students. Thoughts?

This isn't entirely true. The military as a whole is working towards getting the non-performers out and keeping the performers in but MilMed itself has many cuts/consolidation/restructuring coming its way. Nobody knows specifics yet.

As a point of fact, recruiters know almost nothing about the realities of the medical corps and absolutely nothing about the **** storm on the horizon. They will spin "alternative facts," to get you to sign on the dotted line because you are not their priority, their quota is.

All 3 services will be significantly reducing their ability to sustain and support GME -- but in my opinion, the Navy has always been pretty awful at GME because it's regularly forced highly qualified people into GMO land for years allowing them to languish as glorified mid-levels until a spot (may) become available in their chosen specialty -- which in my opinion is a complete waste of resources.

The Pentagon has recently issued a 'deploy or get out,' directive, but there are plenty of Army docs who are on "dead man's profiles," who will never get medically boarded despite never being able to deploy because they will be waived from the 'deploy or get out,' policy -- rather, provided they can pass ht/wt and their fitness test, they will be allowed to stay in and promote.

I've read that over 80% of docs get out as soon as their first ADSO contract is up (my residency class has been 100%), so this will leave 3 types of docs in the higher echelons of the medical corps:

1) The incompetent... either through a general lack of competence and/or severe skill degradation (e.g., highly specialized surgeons, etc.) who realize that they won't "make it," on the outside because they can't handle the patient volumes, the rigor and/or have just become institutionalized over the years and decide to stay in for 20 years for a 6-figure salary and retirement.

2) The incapable... medically unfit physicians who can continue to promote and advance in the military despite not deploying and/or not maintaining rigorous clinical skills.

3) The lifers... the service academy + USUHS grads... the bravest of the brave... who decide that they are too far gone to come back now and decide to stick it out for a "few more years," to make it to retirement.

First of all. GMO land (or unit-level medical coverage) is a required part of military medicine and should be expected (not feared) when you sign up. People are unhappy because recruiters or disgruntled MilMed docs inaccurately try to compare/contrast MilMed to the Civilian world. MilMed is NOT civilian medicine while wearing a uniform for a few years. It is a very distinct pathway for a medical career that you better understand before you get involved. If you don't like the idea of a GMO tour or possible delay in your education then DO NOT sign up.

Second. Of course most get out after their service obligation. This has always been the case. I am sure it will increase in the next few years. Your numbered list of MilMed docs who remain is not only ignorant, near-sighted and wrong but it is insulting to the good ones who became invaluable mentors, clinicians and academics to us in training.

It is very easy to dissuade a premed from joining military medicine. You do not have to resort to discrediting your fellow MilMed physicians; current, future or former.

 

[AvoidMilitaryMedicine]

This isn't entirely true. The military as a whole is working towards getting the non-performers out and keeping the performers in but MilMed itself has many cuts/consolidation/restructuring coming its way. Nobody knows specifics yet.




First of all. GMO land (or unit-level medical coverage) is a required part of military medicine and should be expected (not feared) when you sign up. People are unhappy because recruiters or disgruntled MilMed docs inaccurately try to compare/contrast MilMed to the Civilian world. MilMed is NOT civilian medicine while wearing a uniform for a few years. It is a very distinct pathway for a medical career that you better understand before you get involved. If you don't like the idea of a GMO tour or possible delay in your education then DO NOT sign up.

Second. Of course most get out after their service obligation. This has always been the case. I am sure it will increase in the next few years. Your numbered list of MilMed docs who remain is not only ignorant, near-sighted and wrong but it is insulting to the good ones who became invaluable mentors, clinicians and academics to us in training.

It is very easy to dissuade a premed from joining military medicine. You do not have to resort to discrediting your fellow MilMed physicians; current, future or former.

I know I probably sounded like an a-hole... and for what it's worth, I wasn't try to take cheapshots at the docs I am serving with --- the numbered items were a compilation of both my direct observations and the observations of my peers, I've even had multiple military surgeons tell me directly that they feel like they wouldn't make it on the outside due to skill degradation and radiology colleagues who've told me that they can't keep pace with civilian volumes. No offense intended, but I stand by what I think are readily observable trends in milmed.

 

[militaryPHYS]

I know I probably sounded like an a-hole... and for what it's worth, I wasn't try to take cheapshots at the docs I am serving with --- the numbered items were a compilation of both my direct observations and the observations of my peers, I've even had multiple military surgeons tell me directly that they feel like they wouldn't make it on the outside due to skill degradation and radiology colleagues who've told me that they can't keep pace with civilian volumes. No offense intended, but I stand by what I think are readily observable trends in milmed.

Right. And the changes being made to MilMed (while yes, not the best rollout so far) are intended to fix these problems. Nobody knows what will come of this but people have been complaining about MilMed and asking for change for 20+ years. It is an inefficient, wasteful beast that breads mediocrity. Now that they are changing things to improve volume, increase civilian integration, etc. we still complain about the same stuff which caused the changes.

For me, the easy answer when premeds ask is that there are too many unknowns right now. Don't sign up unless you are 100% committed to being a military officer first, physician second. I try to stick to objective data and not just my observations since my echo-chamber is actually pretty happy (Navy Ortho) and I realize that isn't representative of MilMed as a whole.

 

[HighPriest]

So, I got into this thread into the first place because I'm currently pursuing HPSP through the Navy. I recently brought this up the last time I met with my recruiter and his point is yet to have been shot down.

When I said the Navy will be cutting a ton of billets, he said the Navy intends to cut people (rather than specialties) that can't deploy and fill those spots with younger HPSP students. Thoughts?

So he's saying the Navy has 5,000 medical personal who are just physically unfit to deploy? Is that the card he's playing?

Thats...absolutely ridiculous. You couldn't even being to justify the extent of the changes that have been proposed with the argument that the docs that they have are just too old and unfit. The average age is - what? - like 40? 38? And you're talking about a field where the youngest people are at least 30 after college, med school, and residency.

They're talking about limiting or cutting specialties. No just washing out the glass and refilling it.

They're cutting people. Then, they're not replacing many of those people. I think it's far to premature to say who or how many, but nothing points to what your recruiter is saying being accurate.

 

[Gastrapathy]

The changes have nothing to do with quality or any other lofty goal. This is returning bodies to the line regardless of the consequences. The rest is propaganda

 

[orbitsurgMD]

Agreed. The only way you can run a practice taking Tricare is if you make it up with volume.

It’s akin to Medicaid (poor reimbursement for the overhead required): Kaiser and such agencies can do it and so can places where this is all they do. The Tricare equivalent is going to be in military retirement hubs like San Diego. But good luck with Tricare in a lot of the country.

Most of the places that do volumes of that work are federally-subsidized clinics. This plan is going to blow up in their faces.

 

[militaryPHYS]

Most of the places that do volumes of that work are federally-subsidized clinics. This plan is going to blow up in their faces.

How do the federal subsidies to clinics work? A group says "yes I will accept Medicaid or Tricare" and then the government gives them a tax write-off to help augment whatever tiny reimbursement the programs pay out?

Not addressing the poor reimbursement and overall low acceptance rates of Tricare FIRST before making these changes is the biggest snafu so far.

 

[deuist]

First of all. GMO land (or unit-level medical coverage) is a required part of military medicine and should be expected (not feared) when you sign up.

First of all, recruiters do not typically worn applicants of what GMO/flight surgery truly involves. I'm not sure why you think every medical student considering the military should "expect" a GMO tour. Second, we are doing a real disservice to our war fighters by giving them incompletely trained doctors in the form of GMOs. If anything, we can make the first utilization tour of family physicians and emergency physicians as unit medical officers. However, a one-year surgical internship is wholly inappropriate for independent practice. Many state medical boards and all civilian hospitals and insurance companies would agree with me.

 

[runner12345]

As an accepted USUHS applicant set to begin school this fall, I have some concerns after reading this thread. At the end of the day, I am completely fine with embracing the "officer first" mentality and currently have no preference on specialty; I want to serve in the military and feel the best way for me to do this would be as a physician.

However, the thought of significant cuts to GME and physician billets is worrying me. If, for example, military GME was completely eliminated, what would happen to USUHS/HPSP students? Would they complete a civilian residency? Also, one of the articles mentioned transitioning military doctors to contract rather than active duty. For those of you who are currently military physicians, what do you think are the chances of this happening?

I know a lot of the talk here is speculation, and nobody knows exactly what is going to happen. However, insight by those currently part of the system would be greatly appreciated.

 

[militaryPHYS]

First of all, recruiters do not typically worn applicants of what GMO/flight surgery truly involves. I'm not sure why you think every medical student considering the military should "expect" a GMO tour

I think they should expect it because then they have considered their option fully and mentally accepted it before it happens. This helps prevent anger/frustration if you are sent out which can bread non-performing MilMed docs. If you aren't willing to accept everything that comes along with the MilMed contract then don't do it. That is my point. I have tried to find a way to hold recruiters accountable. I'm failing so far. Therefore, the best we can do is help correct their lies via this Forum.

Would you want to finish residency in a specialty and then sent to a ground unit to let your skills rot for 2 or three years? Skill atrophy is already bad in Milmed. Send specialists to unit level care and you will multiply the problem 10-fold. Army is trying to do it with the whole PROFIS thing.

We can argue whether or not internship is enough to train someone to be a GMO till the cows come home. We've done it many times before. Doubt it will change. For the purposes of sick call, PCP work and possible battlefield care, GMO's have been functioning well for decades. The only times there is a real problem is when they refuse to ask for help.

 

[militaryPHYS]

As an accepted USUHS applicant set to begin school this fall, I have some concerns after reading this thread. At the end of the day, I am completely fine with embracing the "officer first" mentality and currently have no preference on specialty; I want to serve in the military and feel the best way for me to do this would be as a physician.

However, the thought of significant cuts to GME and physician billets is worrying me. If, for example, military GME was completely eliminated, what would happen to USUHS/HPSP students? Would they complete a civilian residency? Also, one of the articles mentioned transitioning military doctors to contract rather than active duty. For those of you who are currently military physicians, what do you think are the chances of this happening?

I know a lot of the talk here is speculation, and nobody knows exactly what is going to happen. However, insight by those currently part of the system would be greatly appreciated.

Congrats on the acceptance to USUHS!

I like to think that they will be nice enough to continue to let everyone currently in the pipeline finish their training. This would be either through the remaining active duty programs that are left once the consolidation happens or through civilian deferments.

They may increase contract positions but I would think this would be for fully trained docs with no service obligation remaining.

Nobody knows for sure yet!

 

[244913]

Line CO's love having Doctors around. They love seeing them at command and staff, they want them around for emergency zpacks, to discuss immunizations and profiles, or sometimes in general just to BS b/c the "Doc" is often a convenient relief valve and you can talk with him in a way you couldn't with the XO or the 3.

The Line makes no distinction between GMO/Internist/Brain Surgeon. You're just "Doc."

.Milmed has done a marginal job of training physicians (especially subspecialty types) for some time now and this job just got a lot harder. Even worse the shuttering of hospitals only exacerbates skill atrophy once you complete a sub optimal residency and get back from your deployment where you operated once in 6 months.

The .Mil should get out of the GME business, they are doing applicants- present and future- a grave disservice.

These recent moves (still in flux) should dispel any doubt doe eyed pre meds, clipboard nurses and non deployable O6 MEDCEN potted plants may have about who "runs" MilMed...they wear stars on their sleeves not twigs.

- ex 61N

 

[armytrainingsir]

Second, we are doing a real disservice to our war fighters by giving them incompletely trained doctors in the form of GMOs. If anything, we can make the first utilization tour of family physicians and emergency physicians as unit medical officers. However, a one-year surgical internship is wholly inappropriate for independent practice. Many state medical boards and all civilian hospitals and insurance companies would agree with me.

LOL. A year of surgical internship after medical school is 'wholly inappropriate for independent practice'?
Look at the legions of less than marginally trained NPs our medical culture and political culture have granted independent practice.
I would suggest you stop denigrating the selection process and medical education of physicians and direct your vitriol to the those that think a new BSN graduate with an online NP degree( available to anyone with a student loan bankroll) is now called 'doctor' and eligible for independent practice.

 

[orbitsurgMD]

LOL. A year of surgical internship after medical school is 'wholly inappropriate for independent practice'?
Look at the legions of less than marginally trained NPs our medical culture and political culture have granted independent practice.
I would suggest you stop denigrating the selection process and medical education of physicians and direct your vitriol to the those that think a new BSN graduate with an online NP degree( available to anyone with a student loan bankroll) is now called 'doctor' and eligible for independent practice.

True, but unrelated. The idea of a one-year training experience as qualification to practice independently died in about 1938.

 

[pgg]

LOL. A year of surgical internship after medical school is 'wholly inappropriate for independent practice'?

Yes. Many of us think it is.

Many of us think independent practice by PAs and NPs and other midlevels is also wholly inappropriate. That the laws in some places permit that doesn't magically mean its OK for incompletely trained doctors to do it too.

Many of us did GMO tours after 1 year of internship and also think that was wholly inappropriate. (I didn't think so at the time, but I feel very differently now. Training and experience has changed my mind.)

Many state medical boards also clearly think it's wholly inappropriate too, as evidenced by their refusal to even license physicians with only a single year of post graduate training.