Thinking about HPSP/USUHS? READ THIS.

[deuist]

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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.

Why can't I denigrate both?

 

[AvoidMilitaryMedicine]

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.

First off, congrats on the acceptance -- I suspect that your clinical training in years 3 and 4 and GME will be at a significant disadvantage (loss of senior physicians, lack of sub-specialists, lack of access to very sick patient population), GME has and does supplement milmed shortfalls with civilian training, but no one really knows where it's going.

What I can tell you with absolute certainty is that I've been in for 10+ years and somehow, everything non-medically related that comes with wearing the uniform, whether its something simple as taking your own vacation time, to pointless trainings, deployments/PCS, living situation has gotten exponentially more difficult and cumbersome -- despite the fact that I've gotten more knowledgeable, gained more rank and arguably, have become more resilient. Clinically, every year it seems, we are asked to do more and more with less everything.

If you want to be a military officer, great. If you want to be a military physician, also great -- we need people. BUT, consider joining after you complete residency -- there will always be a need, and you can always do it then. If you sign up now, in my opinion, you will be condemning yourself to 10-15 years of indentured servitude in a system that often displays an astonishing level of stupidity when it comes to doing even the most menial of tasks. We can only delay gratification for so long before we hit our breaking point.

I know the money is nice, but in the big picture, for approx. 95% of specialties, it is NOT worth it.

If you have an acceptance at any other medical school, go there -- forget HPSP and USU. Remember, if you want to join later (via FAP or some other program), you always can.

 

[mslall]

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

I’d disagree with the statement that ‘.milmed’ has done a marginal job in training. I’d take my residency experience and go head to head with any residency experience in the country. And not just in board pass rate. I’d take one of my R2s or R3s in almost any clinical situation over an equivalent year group at any of 3 civilian programs in my area.

https://www.americanjournalofsurgery.com/article/S0002-9610(18)30524-5/fulltext

I think the residents that are currently in training will be just fine because things just don’t change that quickly. I have no idea how things will play out for current students or those considering .milmed.

 

[DrMetal]

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.)
.

I think we make a little too much of the clinical deficiencies (which are certainly true) of GMOs. We've been using IDCs and medics in operational components for > 230 years. At the very least, a GMO is equivalent to that. You need certain qualities to be a good GMO:

- smart enough to recognize that somebody is too sick (if 4 years of med school + 1 year of training doesn't get you that, in a patient population that's generally healthy (the operational community)....then damn the whole system), and

- humility (to ask for help.....this is where GMOs really get in trouble). I would bet money that most GMOs get in trouble because they don't ask for help (too arrogant, shy, or stubborn to do so), not because they lack the knowledge to diagnose MEN. And this lack of humility is a personality flaw that (likely) no amount of training can correct.

Better reasons to get rid of the GMO system: interrupted training is no bueno, much better to let your physicians train straight through, for the sake of their education. Also, allowing doctors to pay their time back as a GMO I think is a waste of payback, from the military's standpoint. If I paid for you education, I'd much rather have you pay me back as a BC/BE'd physician in your specialty.

 

[HighPriest]

I'm of mixed feelings here, because on one hand GMOs definitely have serious clinical deficiencies. On the other hand, the question is whether or not they have -enough- training to do the job that they have. And I don't think that's a static measure for 230 years. It may have been enough then, but it isn't necessarily enough now because standards of care raise as medical knowledge increases.

We used to have family docs doing appendectomies and tonsillectomies, but for the most part they don't anymore. They're actually better trained than they used to be because they're residency trained now, but they actually do less. But they have a greater wealth of knowledge. So, just because it was ok before doesn't mean that it is now.

I think DrMetal is on point there. I think the issue that concerns me most is not having enough knowledge to actually know when you're missing something. 75 years ago, that GP doing a tonsillectomy in BG Wyoming wasn't expected to necessarily realize that there was a small cancer in the tonsil. More importantly, the treatment options were limited even if he did. Today he'd be sued into oblivion and probably have his license revoked.

Obviously GMOs arent' doing tonsils (at least I hope not), but it's part having the humility to ask for help and part having the knowledge to know when you need to do that. That problem is RAMPANT in the NP and PA community out there in the urgent care centers. They don't know what they're actually looking at most of the time. I question how much better a GMO does with that regards. BUT, FWIW, I saw way more BS from NPs than I EVER did from GMOs.

 

[DrMetal]

I would vote with my hands/feet to abolish the GMO system. I have no kinship to it, despite having done it for 3 years (in a busy sea-tempo environment).

I firmly believe that you have enough training after medical school and pgy-1 to identify a sick patient that you shouldn't touch and instead you should ask for help with. You may have no idea what's going on with him/her, how to diagnose or treat, but at the least you should know to ask for help (this is what every IDC/medic does too, in the non-gmo platforms).

Otherwise what are we to do....get rid of all GMOs/IDCs/Medics , replace them all with BC/BE'd physicians? (every submarine will have an FP, every special warfare unit will have an emergency physician stashed with them?). Sign me up.

 

[colbgw02]

Do GMOs or IDCs ever treat beneficiaries?

 

[HighPriest]

I don't think it's an either-or scenario. And like I said, I think fully trained NPs are less qualified than most GMOs. But there's a difference between having a medic stopping bleeding in a field and having one diagnose and treat a chronic medical issue. I don't expect them to do the latter. I don't think it's reasonable to put them in a position to do it. I feel the same way about GMOs. It all depends upon what we're asking them to do. (and I've never been a GMO, so I'm fairly ignorant in that respect). The idea should be that a soldier/sailor/what-have-you is cleared for duty either in deployment or on a sub or whatever and a GMO is really there in case something unexpected happens while they're out there. If they're used to manage chronic medical issues for a soldier, that's probably not reasonable - primarily because the standard of care is higher now than it was when the whole GMO idea came to be. And if we're only asking them to hand out motrin and make a call as to when someone needs to go back to garrison, then we really ought to replace them with PAs anyway.

 

[pgg]

I think we make a little too much of the clinical deficiencies (which are certainly true) of GMOs. We've been using IDCs and medics in operational components for > 230 years. At the very least, a GMO is equivalent to that.

Your points are well taken, but a great deal more is expected of a GMO than an IDC.

The line commanders know what an IDC is. But they think they're getting a fully trained doctor when it's a GMO. More importantly, so do the patients, and they are in a somewhat more precarious position (age, rank, position).

The very titles "battalion surgeon" and "flight surgeon" imply something that isn't true.

My opinion is that all GMO billets should be replaced with board eligible or board certified physicians from an appropriate primary care specialty. I understand there are cost reasons why this would be hard, and that there are arguments that the pre-screened and generally fit AD patient population is adequately served by GMOs. I think we should do it anyway.

 

[Matthew9Thirtyfive]

Do GMOs or IDCs ever treat beneficiaries?

Ours never did. Our squadron GMOs had a weekly women’s health clinic, a day where they saw sep/retirement/commissioning physicals, sick call days, and an admin day. Our IDCs just acted as the chief of the medical department on the ship, doing admin, seeing Sailors, and dealing with the triad.

 

[pgg]

Do GMOs or IDCs ever treat beneficiaries?

I did, back in the day, when I was a Marine GMO. It wasn't part of my normal sick call duties, but I was expected to see family members as part of the politics/service nature of the position. I don't think that's the norm now, but I'm not sure.

 

[DrMetal]

Do GMOs or IDCs ever treat beneficiaries?

Absolutely not, nor should they (and this is where an arrogant or un-cautious GMO might get in trouble). Beneficiaries have their own PCM, that's who they should go to.

Your points are well taken, but a great deal more is expected of a GMO than an IDC.

Perhaps, in the sense that a GMO is an officer (might be more educated, pay more attention to details, more professional). But most line commanders also understand that their organic medical is very limited out in the field or at sea (and that's mostly because of a lack of resources, not a lack in medical knowledge of any caretaker). Thus they're never hesitant to medevac when the time comes.

The very titles "battalion surgeon" and "flight surgeon" imply something that isn't true.

I whole-heatedly agree that we should get rid of these terms. They sound ridiculous and are antiquated.

Y
My opinion is that all GMO billets should be replaced with board eligible or board certified physicians from an appropriate primary care specialty.

I think this was attempted at some point....and sure as hell, there was a backlash from the BC/BEd physicians.

But still, this could happen. The surgeon general of the Navy could come up with a plan to replace all GMOs, present said plan to the CNO over lunch (or 9-holes of golf), and it could be done with. The line commanders might miss their GMOs, but they wouldn't miss them that much (I think we also make too much about how much the line loves us). They love us in so much as that we don't get them in any hot water, akin to their JAG. The typical line officer wouldn't have that much heartache over losing a GMO, or having him replaced by a PA.

Still, having said all of this, nothing has happened over the last 10 years! (possibly over the last 20). Why?

 

[colbgw02]

Thanks, guys. The reason I ask is that it's pretty clear that military medicine has embraced, both implicitly and explicitly, civilian medical standards in non-austere environments, e.g. USUHS, residency, and hospital accreditation, licensure, board certification, promotion criteria, sentinel event reviews, etc.

Well, the civilian standard of care is that a physician needs to be BC/BE to practice independently, at least regularly, and it's been that way for some time now. They're talking out of both sides of their mouths when they adhere to the standards, but then forget them whenever it's convenient. And I'm not talking about on a sub, FOB, or some other austere environment, obviously.

I was never a GMO, but I would be scared to death to treat a beneficiary because I'm going to get held to the standard of care of BC/BE physician. At least with active duty personnel, there's some protection because of Feres.

 

[Cavalry]

I think we are all waiting for a little more elaboration from @Cavalry.

Wouldn't that be irony, though, or direct? That is, if the cavalry comes over the hill to save the day?

Well I'll do my best,

So for efficiency system-wide, there are things like drug prescription and distribution that is very efficient compared to civilian counterparts and our patients never see a co-pay for prescriptions at MTFs - "After comparing the cost of prescriptions filled at military pharmacies with those filled at private sector pharmacies, we estimate that the overall cost of dispensing direct care prescriptions would have been 42 percent higher had the prescriptions been dispensed at a mix of retail and home delivery pharmacies." (2016, Insitute for Defense Analyses, Comparing the Costs of Military Treatment Facilities with Private Sector Care, Lurie). The DoD's MTFs outpace the VA on pretty much every quality metric (not saying that's the highest bar by any means, though MTFs are often confused with the VA) and we can get appointments for pts in many subspecialty clinics, particularly in the Army, better than many of our civilian counterparts. "Soldiers, retirees and family members reported very high overall satisfaction – 93 percent – with their experience at Army medical treatment facilities...other two big metrics are ease of access to Army providers, which was rated 83 percent positive, the highest in the military health services, and overall experience with Army pharmacies, which was rated 78 percent positive." Survey indicates higher satisfaction with military medical facilities | Health.mil.
For overall costs - "2016 Kaiser Permanente collected $64.6 billion to care for its 11.3 million members. The Department of Defense’s FY2017 budget for military health is $48.8 billion to care for its 9.4 million beneficiaries... Military health spending grew too, but recently it has increased at a far slower pace than civilian health spending." (https://www.healthaffairs.org/do/10.1377/hblog20170427.059833/full/)
Furthermore, "Critics assert that the military health system does not perform enough complex surgical procedures in peacetime to maintain provider skills. The volume-quality relationship is strong, but it is not absolute. High-quality training and strict adherence to procedures—an approach first championed by military aviation—can largely compensate for smaller case volumes. In 2014, the military health system compared its performance to three of our nation’s top health care systems—Geisinger, Intermountain Healthcare, and Kaiser Permanente—and found that it did better in some areas, worse in others, and generally as well overall." (https://www.healthaffairs.org/do/10.1377/hblog20170427.059833/full/)
A recent American College of Surgeons assessment of surgical outcomes, based on national data, identified several military health system hospitals as top performers. Another study found that the military health system does not have the racial disparities in care commonly seen in civilian hospitals. A recently published analysis of more than 10,000 military health system beneficiaries with carotid artery stenosis (a condition that can lead to stroke) found that patients treated by military doctors got fewer procedures but had better outcomes than beneficiaries treated by private, fee-for-service doctors." (https://www.healthaffairs.org/do/10.1377/hblog20170427.059833/full/)
Our hospitals often outperform civilian centers nationally and rank well above the national average in Well Child Visits in the first 15 months, Child Strep Tests, Child Common Cold, Breast Cancer Screenings, Cervical Cancer Screenings, Colon Cancer Screenings, Diabetes A1c Testing, Diabetes A1C Control <8, Low Back Pain management, Admission for Mental Health Follow Up within 7 days, and Admission for Mental Health Follow Up within 30 days. All are national metrics using HEDIS measures in national surveys (See HEIDIS attachment, for national percentile scores, anything above 50% is above the national median).

We don't bother with playing the preauthorization insurance game, if the patient needs a CT, or an X-ray, or an MRI, it's ordered and it gets done - no insurance company involved. I'm not saying that every hospital support system is as efficient as that of the private sector, and I will be the first to admit that it often isn't. But EDs in MTFs rarely get backed up the way all our civilian ones stateside often do, and surgery tires to refuse taking patients when we call from the ED (unlike my last job when we always got flak. Yes, there is a lower case volume at MTFs around the country, but our programs are actually quite good. Our first-year gen surg interns in MTFs often perform between 40 and 70 cases as primary surgeon or first assistant, unlike many civilian gen surg programs (see SurgeryBrochure2018 attachment) AND many such programs are ranked amongst the top of civilian gen surgical programs across the nation in peer-reviewed research papers (see American Journal of Surgery Article) - (For you, my dear deuist)

Also, what top 10 list are you referring to? If military residency programs were considered so competitive, every civilian out there would be throwing themselves at the Department of Defense to join its GME.

There are lots of things that we can do to improve our hospitals and the military health system overall. Some of the articles I cited above as well as this jama article Transforming TRICARE and the Military Health System and this white paper (http://www.businessofgovernment.org... to Improve Military Hospital Performance.pdf) likely include the most credible go-tos, including shuttering some very low-volume MTFs of the total 50-something Military Hospitals across the US (Comparing Military Hospitals). However, there are also well-founded calls for expansion of the most successful MTFs, and those serve as the bedrock that will continue to provide strong graduate medical education in the military.

I look forward to your critique 🙂

 

[Cavalry]

@Cavalry Please educate us on these "best funded, most efficiently run hospitals" and the metrics you believe demonstrate those claims.

Please educate us on these top-ten residency programs and the metrics you believe demonstrate those claims.

This is the latest paper I'd seen (2018) using American Board of Surgery examination performance, 2 of the military's 8 total gen surg programs were rated top 10, another 2 in the top 25, and all were in the top half of programs.

 

[militaryPHYS]

How come there is no "mic drop" Emoji?

Unfortunately, despite these papers, there are some who will continue to discredit the reports or any progress we make while continuing to generalize their negative experience on everything and everyone. Such is life I guess.

Thank you for taking the time to compile this information in one place.

 

[d2305]

The only dependents I saw as an IDC was on a tiger cruise. Working in FP as a PA, I saw dependents exclusively.

 

[Gastrapathy]

Yup, test scores. Thought so. Unfortunately, that’s not how anyone else would rate a residency.

The HEDIS numbers have always been fake because they only count the people they choose to care for. If they do the mammo, they count it, if they don’t, they say the patient was disengaged and drop from the denominator. The real population data is much worse because there is no tracking of disengaged patients and their screening rates are ~20%. But the MTF doesn’t own those patients even though they live in the town. It’s a good game.

There are CT surgeons on that residency brochure. Can’t be teaching much CT surgery since they were shut down for lack of volume and outcomes. Also, lots of very inexperienced attendings (half within 3 years of finishing training). That’s the norm as everyone quits but not a good thing for a residency.

You can pick the mic back up now.

A top 10 program has experienced internationally recognized faculty, a national reputation that attracts complex cases, research, volume, etc. it’s just silly to claim that any military program is more than an above average community program. It shows the incredible tunnel vision that occurs within milmed that someone would try to make the argument.

 

[militaryPHYS]

☝️See?

 

[Gastrapathy]

Yup. Just because you posted first doesn't make me wrong.

Which military program is better than Penn, Southwestern, Duke, BWH, Wash U, Columbia, Stanford or Mayo Rochester (the 7-10th ranked programs on Doximity and US News) and which of those programs would you move off the list?

 

[militaryPHYS]

You can choose to decide who is best based on popularity, status symbols and sub-sub specialties all you want. There are many ways to judge a skinned cat. The point is that MilMed programs are doing great things and are being recognized as solid programs. Nobody is claiming they are best of the best across all possible metrics, but you also can’t say that MilMed programs are not good.

I’ve seen James Andrews do an ACL. I’d choose my education and mentors again every day of the week.

 

[Gastrapathy]

Way to move the bar. They used to be average community programs. They were never top 10. Now they are being decimated. You think closing CT is no big deal?

 

[militaryPHYS]

Way to move the bar. They used to be average community programs. They were never top 10. Now they are being decimated. You think closing CT is no big deal?

Lets not confuse the discussion. We are currently talking about residency programs which typically consists of well established partnerships and MOU’s with civilian high volume centers to cover gaps in MilMed sub-specialty care. Once you graduate and become staff those partnerships often go away and you lack a good avenue for skill sustainment in areas MilMed doesn’t see...just like your average community hospital. This is what changes are trying to address: be more lethal while also ensuring across the board skill sustainment.

CT should be closed if we don’t have the volume. Why maintain something not applicable to wartime just to say we can do it when we can send those patients, residents and staff to the high volume center next door?

 

[Gastrapathy]

Think what you are saying. These amazing programs have to shop their residents to other places to cover for their inadequacies. A top 10 program doesn't need to find other places to teach their residents for them. This is what average community programs do. Its the right choice given the situation but it's not the same as working in your own center.

The reason the ACGME takes such a dim view on out rotations (and limits them) is that deficient residents are always given a social pass. Its only a home program that will actually assess in a meaningful way. Out rotations appreciate the free labor and are not invested. MOUs don't fix that. How can a residency even determine competence for procedures that they aren't capable of performing?

 

[colbgw02]

You can choose to decide who is best based on popularity, status symbols and sub-sub specialties all you want. There are many ways to judge a skinned cat. The point is that MilMed programs are doing great things and are being recognized as solid programs. Nobody is claiming they are best of the best across all possible metrics, but you also can’t say that MilMed programs are not good.

I’ve seen James Andrews do an ACL. I’d choose my education and mentors again every day of the week.

I'm stealing this.

Also, Andrews' genius definitely isn't surgical technique. It's marketing.

 

[militaryPHYS]

I'm stealing this.

Also, Andrews' genius definitely isn't surgical technique. It's marketing.

True. Also his personability and availability to his patients is second to none

 

[Chonal Atresia]

How come there is no "mic drop" Emoji?

Unfortunately, despite these papers, there are some who will continue to discredit the reports or any progress we make while continuing to generalize their negative experience on everything and everyone. Such is life I guess.

Thank you for taking the time to compile this information in one place.

How come there is no "mic drop" Emoji?

Unfortunately, despite these papers, there are some who will continue to discredit the reports or any progress we make while continuing to generalize their negative experience on everything and everyone. Such is life I guess.

Thank you for taking the time to compile this information in one place.

The reason why military residency programs tend to score well on in-service exams is because their case volume is less than most civilian programs and they have more time to study. A generalization? Yes, but one that I think holds true for most programs.

Case volumes (for surgeons of all types) are much lower than almost all civilian programs. My partner did a civilian residency and can blow through neck dissections in under 2 hours with confidence. It takes me close to twice that long and I usually ask him to assist. The difference - he probably did 4-5x more of these procedure in residencies than me.

Now I can only speak for military ENT programs but I think they prepare you well to be a generalist, and that’s OK. As has been said before, residency programs in the military are comparable to middle of the road civilian programs. If you want to subspecialize or go the academic route, it’s a bad move to join the military as a physician.

I think the bigger issue is the case volume and skill atrophy after residency. militaryPHYS has said in the past that he has 6-8 scheduled patients per clinic! My orthopedic counterparts average 25-30/clinic. If it was you son/daughter/spouse needing surgery, would you rather have someone performing said procedure 100 times/year or 10 times/year? No offense to militaryPHYS, but it is human nature not to work as hard/be as productive when there is no financial incentive to do so. Throw in lack of support staff and other specialists (as proposed with “buckets”) to help you take care of these patients and it’s a problem that is only going to get worse.

 

[militaryPHYS]

The reason why military residency programs tend to score well on in-service exams is because their case volume is less than most civilian programs and they have more time to study. A generalization? Yes, but one that I think holds true for most programs.

Case volumes (for surgeons of all types) are much lower than almost all civilian programs. My partner did a civilian residency and can blow through neck dissections in under 2 hours with confidence. It takes me close to twice that long and I usually ask him to assist. The difference - he probably did 4-5x more of these procedure in residencies than me.

Now I can only speak for military ENT programs but I think they prepare you well to be a generalist, and that’s OK. As has been said before, residency programs in the military are comparable to middle of the road civilian programs. If you want to subspecialize or go the academic route, it’s a bad move to join the military as a physician.

I think the bigger issue is the case volume and skill atrophy after residency. militaryPHYS has said in the past that he has 6-8 scheduled patients per clinic! My orthopedic counterparts average 25-30/clinic. If it was you son/daughter/spouse needing surgery, would you rather have someone performing said procedure 100 times/year or 10 times/year? No offense to militaryPHYS, but it is human nature not to work as hard/be as productive when there is no financial incentive to do so. Throw in lack of support staff and other specialists (as proposed with “buckets”) to help you take care of these patients and it’s a problem that is only going to get worse.

Points well taken. Aside from specifics of my practice you know nothing about. 6-8 per half day template which also doesn’t include our acute clinic every morning or post ops. But yes, I still see less than a civilian practice. I also do less surgeries. To accommodate we have consolidated our clinic and admin time to allow more dedicated OR assist time to increase time our hands our dirty.

I laugh every time someone compares current MilMed practice to civilian. Not even worth it. Apples to oranges and no MilMed physician would argue otherwise. Hence why things are changing. But I still feel we are very proficient in what we need to do overseas (sports and general) and everything else is packed/wrapped with medevac to conus medcen.

 

[militaryPHYS]

Plus you are also using an overseas billet to compare to civilian provider. More like apples to kumquats. Docs at conus medcens to much closer volume to civilian world, albeit still lower. If they are lacking in a certain area due to military population and diseases, those areas will hopefully be fulfilled through partnerships...Hopefully

ie you can due T&A’s all day at an MTF and go do complex neck dissections at a civilian center.

 

[Chonal Atresia]

Points well taken. Aside from specifics of my practice you know nothing about. 6-8 per half day template which also doesn’t include our acute clinic every morning or post ops. But yes, I still see less than a civilian practice. I also do less surgeries. To accommodate we have consolidated our clinic and admin time to allow more dedicated OR assist time to increase time our hands our dirty.

I laugh every time someone compares current MilMed practice to civilian. Not even worth it. Apples to oranges and no MilMed physician would argue otherwise. Hence why things are changing. But I still feel we are very proficient in what we need to do overseas (sports and general) and everything else is packed/wrapped with medevac to conus medcen.

I know zero about your practice but I will make a single point:

1) “Assisting” on a case in the OR is not the same as being the primary surgeon. I know you didn’t say that outright, but your statement above implies that “getting your hands dirty” somehow compensates for lack of case volume - it does not.

If you plan to spend your entire career in the military and VA, case volume and complexity doesn’t matter because both will take any Joe-Schmo with a medical license (talking civilian GS in the military). If you want to leave at some point, these issues can become a problem. We hired a general surgeon last year out of the military to be a surgical hospitalist but because of lack of case volume/complexity his last couple years on active duty, he needed one of my partners with him on most cases for the first 6 months. Pretty embarrassing.

 

[militaryPHYS]

1) “Assisting” on a case in the OR is not the same as being the primary surgeon. I know you didn’t say that outright, but your statement above implies that “getting your hands dirty” somehow compensates for lack of case volume - it does not.

Yeah thanks. Well aware.

The point is that MilMed is MilMed. Especially overseas. You either adapt to limitations or you’re even more in the hurt locker.

Overall kind of tired discussing the same issues over and over, especially when it is back and forth with staff MilMed physicians.

 

[HighPriest]

I think you're having back-and-forth discussions because these are the problems associated with military medicine, and this is a forum dedicated to that topic. There's no doubt people continue to harp on the same issues, but those issues haven't changed in a very, very long time. And that's part of the problem, init?

The counter argument that these are issues that are intrinsic to military medicine, and so you just gotta deal with them - well, I see where you're coming from. Part of the whole deal in the military is doing your job with the Army you have. Or Navy. Whatever. And the more you resist that, the worse it is. I can't disagree with that. But, again, this is a forum dedicated to military medicine, and read by students who want to know what they're getting in to. So they need to know that case volume can be a real problem if they ever want to get out and go into practice in the "real world." And, they also need to know that if they join the military, there are going to be a lot of things that they just need to accept. But accepting them doesn't make them not an issue. It just means you're not letting it get to you. Which is the right call once you've made the decision to join.

 

[militaryPHYS]

I think you're having back-and-forth discussions because these are the problems associated with military medicine, and this is a forum dedicated to that topic. There's no doubt people continue to harp on the same issues, but those issues haven't changed in a very, very long time. And that's part of the problem, init?

The counter argument that these are issues that are intrinsic to military medicine, and so you just gotta deal with them - well, I see where you're coming from. Part of the whole deal in the military is doing your job with the Army you have. Or Navy. Whatever. And the more you resist that, the worse it is. I can't disagree with that. But, again, this is a forum dedicated to military medicine, and read by students who want to know what they're getting in to. So they need to know that case volume can be a real problem if they ever want to get out and go into practice in the "real world." And, they also need to know that if they join the military, there are going to be a lot of things that they just need to accept. But accepting them doesn't make them not an issue. It just means you're not letting it get to you. Which is the right call once you've made the decision to join.

Sure. But don’t use overseas me as an example. You want standard Navy ortho exit from MilMed? Most maintain their skills very easily. My spine guy got out and went to harbor view. One of my sports guys got out and rolled in to a high volume practice in Fairfax and became a team doc for redskins with no retrain time. The other joined a practice in Naples and had no issue with transition. My two joints guys rolled out of their high volume practice in MilMed and in to a high volume civilian practice.

If I was your gen surg buddy I would have been moonlighting more my last year or stayed in long enough to be at a location with moonlight capabilities. Otherwise don’t complain about getting out. The system is the system. Understand it and adapt. Just like low volume periods overseas or coming back to residency after a GMO tour, you gotta adapt and take ownership of your volunteer situation

 

[Gastrapathy]

The back and forth comes up when you make claims like “top ten program”. If you don’t want to discuss the quality of milmed, don’t make or support claims like that. Also, the argument that the changes coming are preplanned to address the problems of milmed is total spin. There is no plan and while the lower level PR folks might try to justify it that way, this is only about billets and money for the line.

 

[militaryPHYS]

Or it’s because it’s still just me in a sea of milmed low-volume surgical specialties.

Also I will never stop supporting the awesome progress all of the programs listed in those papers have accomplished to set themselves apart from others, both military and civilian.

 

[pgg]

those areas will hopefully be fulfilled through partnerships...Hopefully

ie you can due T&A’s all day at an MTF and go do complex neck dissections at a civilian center.

Is anyone aware of any such partnerships yet? Is DHA actively pursuing any at this time, or is this task being delegated to individual commands?

I ask because locally we have not had any success. After some direct discussion with one institution (our dept to their dept), they politely declined last week. They couldn't commit to essentially "hiring" a revolving attending staff member that they don't get to interview, screen, or choose. I can't say I really fault them. They can be extremely selective in the people they hire. Asking them to slip whoever we send into their schedule matrix is a lot to ask.

I'm beginning to think that maybe "partnerships" aren't the best answer. At its core, what we're really attempting is to turn the military health system into a locums agency:

• We have a pool of doctors that need work.
• We will cover travel and liability insurance.
• We're looking for places that have an excess of work and a shortage of doctors.

That's a locums agency.

Maybe "partnerships" aren't what we need. Maybe what we need is DHA to start renting us out. We'd have no shortage of places to go by next Thursday.

Just thinking out loud.

 

[Chonal Atresia]

Or it’s because it’s still just me in a sea of milmed low-volume surgical specialties.

Also I will never stop supporting the awesome progress all of the programs listed in those papers have accomplished to set themselves apart from others, both military and civilian.

I was almost sent sent out as a brigade surgeon (against my will ) for a 2-year non-clinical tour right before my ADSO. It took the intervention of the now USUHS-president to stop it. It may not apply to your Navy, but it sure is an issue in the Army.

Tell me how I would have moonlighted during those years? I’m sure the brigade commander would have had no problem letting me take a week off every 2-3 months to travel to ND (where I actually did moonlight for 4 years on a recurrent basis). Your argument that this general surgeon somehow “deserved it” is completely ridiculous.

And posters like me, HighPriest, Gastrapathy won’t stop telling the truth of these problems and injustices.

 

[Matthew9Thirtyfive]

Is anyone aware of any such partnerships yet?

They are doing it in Jacksonville (edit: just for full disclosure I heard about this a while ago and can’t confirm it is still happening—but it was). I’m not there so can’t comment on it more than just from what I’ve heard, but it seems to work for the surgeons involved.

 

[pgg]

Surgeons are usually easier to find homes for, especially if they bring patients that the MTF can't handle. Hospitals will work hard to get them. I've observed less success with anesthesiologists, internists, medicine subspecialists, radiologists, etc ... in fact I'm not sure that I've ever even heard of, say, a psychiatrist or intensivist working out in the community as part of an ERSA or other partnership.

In 2013/2014 I was the DSS at a small Navy hospital, and we worked out an ERSA with a nearby civilian hospital. They rolled out the red carpet for our surgeons, but no one else could go. I knew the anesthesia group partners well because I moonlighted with them all the time, and they collectively laughed out loud when I brought it up - they weren't going to give up billable units at a hospital where they had an exclusive contract, just so some Navy guys could come over and do cases for free.

I ran into the same issue where I am now last year, when our cardiac surgeons were taking some of our patients to a nearby hospital to operate. The anesthesia group wouldn't let me come with the surgeons ... but they did extend a counteroffer. If the Navy could put together "an attractive financial package" to pay them to allow us to work there, they'd consider it. The paltry sum of $400K was put on the table. I went to the VA instead (another partnership requiring a new MOU that was 100% driven by me, the individual, not my command or BUMED or DHA), and went looking for moonlighting work.

To the above I'll add the observation that all ERSAs and partnerships I've ever observed have been locally initiated projects. I hope DHA is planning to centralize this process. I just don't have the clout as a lone guy in the wilderness trying to make it happen.


Has there been any talk about including nurses? Our nurses in the ICU, cath lab, ER could use some volume and acuity.

 

[pgg]

I was almost sent sent out as a brigade surgeon (against my will ) for a 2-year non-clinical tour right before my ADSO. It took the intervention of the now USUHS-president to stop it. It may not apply to your Navy, but it sure is an issue in the Army.

In the Navy, we get our brigade surgeon equivalents (GMOs) from the intern pool. Thus far, most of the operational billets that require more senior leadership have been going to the people that want them. The risk of a Navy subspecialist getting put in a nonclinical billet isn't zero, but it's a lot lower than the Army.

Recently the Marine Corps "purchased" a bunch of medical billets, and we're starting to see some residency-trained specialists sent to USMC units. But the word there is that they'll be owned by the units and mostly loaned/TAD'd to hospitals. I'm honestly not sure what's actually happening in that area.

 

[Gastrapathy]

I’ve written about my skepticism of the success of these partnerships before. So many issues. In hospitals that employ doctors, you’ll be used to suppress salaries. For private groups, they won’t be willing to give up the volume or the quality control. And, you guys are unreliable. Programs like this start and stop with the whims of ever changing COs. Once they’ve had to cover a surprise weekend or 4, folks will decide it’s not worth it.

 

[Gastrapathy]

https://www.google.com/amp/s/abcnews.go.com/amp/Health/medical-corps-crosshairs-military-bean-counters/story?id=61591927

$50B for 9 million members is $55k per person per year.

Our national per capita spending is the highest in the world at $10k per person.

 

[militaryPHYS]

Is anyone aware of any such partnerships yet? Is DHA actively pursuing any at this time, or is this task being delegated to individual commands?

Army Medicine joins forces with civilian hospitals to sustain medical readiness | Health.mil. I think it is still local, with support from DHA. Ortho in Beaufort operates at a civilian hospital but this was set up a long time ago. Agree with your Locums argument. Ideally the hospital across the street or water could support, but that obviously won't always be the case.

I knew the anesthesia group partners well because I moonlighted with them all the time, and they collectively laughed out loud when I brought it up - they weren't going to give up billable units at a hospital where they had an exclusive contract, just so some Navy guys could come over and do cases for free.

I ran into the same issue where I am now last year, when our cardiac surgeons were taking some of our patients to a nearby hospital to operate. The anesthesia group wouldn't let me come with the surgeons ... but they did extend a counteroffer. If the Navy could put together "an attractive financial package" to pay them to allow us to work there, they'd consider it. The paltry sum of $400K was put on the table. I went to the VA instead (another partnership requiring a new MOU that was 100% driven by me, the individual, not my command or BUMED or DHA), and went looking for moonlighting work.

I honestly don't know the specifics yet. Probably locally driven and DHA supported. I am guessing any sustainable partnerships will be made with large academic centers which are all essentially salary/shift based anyway. If the money is being allocated to support such sustainable partnerships it will make the process easier as we transition.

Recently the Marine Corps "purchased" a bunch of medical billets, and we're starting to see some residency-trained specialists sent to USMC units. But the word there is that they'll be owned by the units and mostly loaned/TAD'd to hospitals. I'm honestly not sure what's actually happening in that area.

We have a Green Side ortho surgeon here. He essentially works at hospital but also has his second chain of command for train-ups and missions which complicates things sometimes, but since we have other dedicated staff his time-out is tolerable. The tough part is that USMC thinks they are better off keeping their assets to themselves, even during garrison/peace-time. This will drive skill atrophy and make current problems worse. Locally we are fostering the communication piece to make sure that if not deployed or on a training mission that they should be 100% at the hospital to maintain skills. Better for everyone.

 

[militaryPHYS]

Your argument that this general surgeon somehow “deserved it” is completely ridiculous.

No, that is not my argument. Second time this week you have distorted text on a page with your own first impression. My point was, if someone's last command has no options for moonlighting, then maybe consider staying on to take orders somewhere that allows it...otherwise don't complain about your ability to get out of the military and practice as a civilian. Ortho guys in lower-volume subspecialties at NMCP would Locums all over the country during their last two years to get themselves spun up for the practice they were entering. Instead of taking terminal leave all of their leave was used up on moonlighting. Semper Gumby

 

[militaryPHYS]

And posters like me, HighPriest, Gastrapathy won’t stop telling the truth of these problems and injustices

All I ask is that you stop trying to use my overseas Navy Ortho billet, which you know nothing about, to help support your doom and gloom.

 

[Chonal Atresia]

No, that is not my argument. Second time this week you have distorted text on a page with your own first impression. My point was, if someone's last command has no options for moonlighting, then maybe consider staying on to take orders somewhere that allows it...otherwise don't complain about your ability to get out of the military and practice as a civilian. Ortho guys in lower-volume subspecialties at NMCP would Locums all over the country during their last two years to get themselves spun up for the practice they were entering. Instead of taking terminal leave all of their leave was used up on moonlighting. Semper Gumby

Are you saying he should have stayed on “extra time” past his ADSO to obtain the clinical experience needed to be hired as a civilian outside the VA? Just give the military an extra couple years because he was screwed over on his last assignment? We are going to have to agree to disagree. He served out his contract with integrity and honor but because of his last non-clinical billet (which was not his choice BTW), he was put in a dire situation. What is your response to those clinicians sent out as non-clinical brigade surgeons 2 years before their ADSO is up? Just voluntarily serve an extra couple years? I don’t want to “distort” your text with my interpretation.

 

[Chonal Atresia]

All I ask is that you stop trying to use my overseas Navy Ortho billet, which you know nothing about, to help support your doom and gloom.

Noted. I know nothing about your billet.

I won’t stop posting about the plethora of problems in military medicine, of which skill atrophy is just one of many.

 

[militaryPHYS]

Are you saying he should have stayed on “extra time” past his ADSO to obtain the clinical experience needed to be hired as a civilian outside the VA? Just give the military an extra couple years because he was screwed over on his last assignment? We are going to have to agree to disagree. He served out his contract with integrity and honor but because of his last non-clinical billet (which was not his choice BTW), he was put in a dire situation. What is your response to those clinicians sent out as non-clinical brigade surgeons 2 years before their ADSO is up? Just voluntarily serve an extra couple years? I don’t want to “distort” your text with my interpretation.

Army Medicine needs to be fixed. The stuff I hear about coming from Army Medicine we rarely ever see or hear about on the Navy side. So I can understand the disconnect when things might seem ignorant or naïve coming from me. Sorry if that happens.

I'm not saying this person did anything wrong. I'm thankful for his or her service and it sounds like the military screwed them. But I also don't know the intricacies of him accepting his twilight billet, their performance prior to said billet, their transition out or what the military did or did not do to royally screw them. My point simply is, if they did get royally screwed that isn't universal to military medicine. Anecdotes are great but address the minority. Minority problems are real problems and need to be understood and accepted prior to joining, but they cannot be applied to the group as a whole.

 

[HighPriest]

Army Medicine needs to be fixed. The stuff I hear about coming from Army Medicine we rarely ever see or hear about on the Navy side. So I can understand the disconnect when things might seem ignorant or naïve coming from me. Sorry if that happens.

I'm not saying this person did anything wrong. I'm thankful for his or her service and it sounds like the military screwed them. But I also don't know the intricacies of him accepting his twilight billet, their performance prior to said billet, their transition out or what the military did or did not do to royally screw them. My point simply is, if they did get royally screwed that isn't universal to military medicine. Anecdotes are great but address the minority. Minority problems are real problems and need to be understood and accepted prior to joining, but they cannot be applied to the group as a whole.

Neither argument can be applied to the whole. Not everyone has a good experience. Not everyone has a bad one. Your experience is that lost people have a good experience. My experience is that most do not.
I’ve never been interested in insinuating that no one had a good experience. But no one is going to join the military and be distraught that they had a good experience.

I’m more worried about the latter.

And yes, all signs indicate the Army is worse.

 

[Ziehl-Neelsen]

Ehh. USA MEDCOM is worse in a lot of ways, but as I've said before, the idea that one service is categorically worse or better than the others is bunk.

As much as some of the idiosyncrasies of Army Medicine piss me off and sometimes make me dream about life as a zoomie or a squid, when I talk to my Navy colleagues (from my joint Army-Navy residency) who are 3 quarters through their Navy career there are 2 major issues that I can't countenance and make me glad that I'm not Navy--scope of practice away from the big MEDCENS and promotion rate.

The Navy just does not have medium sized MEDCENS away from Balboa, Portsmouth, or Walter Reed that support a robust scope of practice for my specialty. I talk to my colleagues at Jax, Bremerton, Oki, Yokosuka, and the like; the skill atrophy for them is very real. Not the case in the Army where we have medium sized MEDCENS away from our big 3 that support a relatively robust scope of practice (Fort Bliss, Fort Bragg, Schofield Barracks) that reduce the skill atrophy to an ooze instead of a pulsatile arterial bleed. When I talk to my Navy colleagues who are out and away from the big 3 and hear about their case volume and complexity, I definitely feel better about my scope of practice at an Army MEDCEN. And this issue dovetails with the other issue nicely...

Most of my old residency mates who have gone to Oki, Yoko, Jax whatever, went there to get the administrative title and geographic change on their FitRep or OPR (I've been joint for so long now I can't even remember what the different services call their evals). In the past year I've been talking to most of them and listening to how a significant number of individuals (that were good solid doctors and people from my assessment of them in residency) were passed over for O-5. Now granted, I don't know how they've performed as attendings, but these are guys and gals that checked all the boxes (Marine GMO, good performance during residency, board certified, etc.) and I find it hard to believe that some of these individuals weren't deserving of being picked up for Commander on the first go-round. Again, it makes me a little less upset with the Army when I talk to these individuals who volunteered to go to a place where they knew their skills would atrophy specifically to make rank, and then have Lucy pull back the football at the last moment.

AAUUGGHH!