Unified medical command

[IgD]

News Article: Army, Navy want unified medical command
http://www.estripes.com/article.asp?article=37439&section=104

The Defense Department is shaping a final decision document to reorganize the military health-care system around a new unified medical command, say senior officials.

The command would be led by a four-star medical officer given unprecedented authority. He would take charge of what now are service-unique responsibilities for medical staffing, training, purchasing, operations and medical readiness across the Army, Navy, Air Force and Marine Corps.

Service and Defense leaders in early May received, for review and comment within 30 days, three options for a new command structure.

Under the first, which enjoys strong support from the Army and Navy surgeons general, the new medical command would be a major combatant command similar to the U.S. Special Operations Forces Command, and reporting directly to Defense Secretary Donald Rumsfeld....

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[jsnuka]

Now this could prove to be VERY interesting, in a good way, in the future.

 

[edmadison]

Yep, now those slacker Navy and AF docs can get deployed at the same rate as Us poor Army Joes.

Ed

 

[USAF_Dentman]

Yep, now those slacker Navy and AF docs can get deployed at the same rate as Us poor Army Joes.

Ed

But YOU chose the Army....Deal..

 

[Informer]

any updates on this? it's been 30 days just about

 

[NavyFP]

any updates on this? it's been 30 days just about

There is nothing on paper for the unified medical command. Under the current BRAC there will be a combining of enlisted training in San Antonio in the 2010-2011 timeframe. The budgetary limitations will most likely prevent such a position for the next 2-3 years, but that can change on a whim. Many think LTG Kiley is the front runner, but he recently suggested VADM Arthur would be a good person for the Job.

The Army being the 800lb gorilla it is, seems to have the edge in this potential future. There is already talk of purple suiting deployments. After all there is no reason an AF Spear team could not support an Army unit or a Navy Surgical Co doing the same.

 

[blife]

So, I'm bumping the old thread because I read an article last week that, crazily enough, sounds almost exactly like the paraphrase IgD gave.

For those of you in milmed, what do you think? Would a unified medical command potentially improve military medicine?

The article I read said the Air Force was against it, but didn't least reasons why.

 

[AF M4]

I vote that we should all be put under the command of the Coast Guard.

 

[Gastrapathy]

So, I'm bumping the old thread because I read an article last week that, crazily enough, sounds almost exactly like the paraphrase IgD gave.

For those of you in milmed, what do you think? Would a unified medical command potentially improve military medicine?

The article I read said the Air Force was against it, but didn't least reasons why.

The AF is against it because it would sabotage their strategy of shirking responsibility and passing as much work as possible to the other branches. Talk of this was all the rage around 2005. Even though we're combining stuff all over the place, there's really no discussion of this anymore. I, for one, am glad. A unified command would end up being basically an Army command and those dudes are nuts.

 

[backrow]

The only time I have heard this in the past couple of years was actually by some Senators in an article I read. I think it may have been Senator Webb, but it was more of a "having 3 surgeon generals is redundant" article and all the associated staff that goes along with having each service have their own medical. It seemed that in the current look at the number of flag officers that are around some are at least superficially looking at this.

There definitely isn't the press that there was several years ago and I still don't see it happening for many, many years.

 

[blife]

This was the article from June 16th

http://www.stripes.com/news/services-split-over-push-for-unified-medical-command-1.146744

 

[AF M4]

The AF is against it because it would sabotage their strategy of shirking responsibility and passing as much work as possible to the other branches. Talk of this was all the rage around 2005. Even though we're combining stuff all over the place, there's really no discussion of this anymore. I, for one, am glad. A unified command would end up being basically an Army command and those dudes are nuts.

Yeah, now it looks like both the Air Force and the Navy are against it while the Army is all for it. One guesses this is because the Army has responsibility for the lion's share of the work and facilities, and would like to be able to pull the manpower and resources of the other services into its orbit.

 

[pgg]

a unified command would end up being basically an army command and those dudes are nuts.

qft

 

[lmesina]

News Article: Army, Navy want unified medical command
http://www.estripes.com/article.asp?article=37439&section=104

across the Army, Navy, Air Force and Marine Corps.

The initial link from the OP is down. Anyone recall seeing anything about Public Health Commissioned Corps? Or is it just the defense oriented health systems?

 

[ravager135]

I, for one, would want absolutely nothing to do with this. I have never had a real positive experience working with any Army medical installation. This has far less to do with the providers in the Army and more to do with the overall attitude and the way that it is run from the top down.

Maybe I am bitter but I resent the way Walter Reed has merged with Bethesda. These sort of joint combined facilities end up being Army favored as mentioned above. There are distinct reasons many of us chose specific branches to serve in. I really don't care what the Army's self perception is, but I really want nothing to do with their branch, leadership, or mentality in dealing with their soldiers.

The Navy has many of its own problems, but the one thing I love most about my branch is that responsibility is placed at a very low level and accountability goes all the way to the top. The Army is almost an inverse of this attitude.

 

[psychbender]

Eh, I'll be the one guy that says that I don't particularly care for the Army's way of doing things often, but I really dislike the way things are handled at the Navy's "flagship" hospital. Even before the merger became serious, this place was filled with so much ass-backwards crap it makes me sick. Its going to be an interesting next few years, and not in a good way.

 

[Fabio001]

I find this all very interesting. Psychbender, would you mind elaborating on why you think the next few years will pan out in a negative way? The points you made seemed to be indicating that you feel it would be a good thing.

 

[psychbender]

I find this all very interesting. Psychbender, would you mind elaborating on why you think the next few years will pan out in a negative way? The points you made seemed to be indicating that you feel it would be a good thing.

Not on an open forum.

 

[ravager135]

I just think it boils down to the fact that each branch specializes in a specific mission, the medical support of each of those missions is unique because of the type of warfighter you are supporting. Yes perhaps with time in a unified "purple" uniform command people will adapt to servicing all branches but as a flight surgeon I have dealth with many other armed forces health care providers that have no concept of what I do or how certain aspects of operational medicine work. We have this problem just within the Navy itself let alone trying to communicate with other branches of service.

Example, I was processing a waiver for an aviator. Waivers usually require over-the-top workups and tests because we are dealing with individuals who fly expensive air craft. I work at a small clinic with few resources. I called a much larger Navy hospital for a referral for my pilot so that we could complete the required testing for his waiver. I was put in touch with an Army hematologist (could have been any branch, but an example). She refused to take my consult, said there was no indication for the patient to be seen and thought that I was an intern. She literally told me, we call interns flight surgeons. Obviously wrong. Obviously somebody with zero operational experience. Obviously somebody that doesn't realize that I am complying with a NAMI requirement not the American College of Hematologists (if such a thing exists) recommendation. I literally had to speak with my senior flight surgeon who thankfully outranked her and spoke directly to the head of heme/onc just to get this done.

This is just one, perhaps extreme example of how unified commands fail. It's bad enough that people in the Navy sometimes don't understand the mission of it's components it is evan more frustrating when dealing with other branches. Just the flight waiver/approva/physical process alone is different among the three branches and has taken years to unify the paperwork. Which by the way, AERO gets set back every month. It's a logistical nightmare.

 

[IgD]

Example, I was processing a waiver for an aviator. Waivers usually require over-the-top workups and tests because we are dealing with individuals who fly expensive air craft. I work at a small clinic with few resources. I called a much larger Navy hospital for a referral for my pilot so that we could complete the required testing for his waiver...

On the flipside medical waivers might be better handled by a joint medical command. There would be a single cohesive medical fitness standard for all branches of the military. It's something that any primary care provider could handle. An aviation form might be a multi-page document for a physical exam and tests that would be decided by a consensus committee. Isn't that the way it is done in the FAA? Government workers get medical fitness evaluations all the time. Maybe there might be 1-2 "flight surgeons" for the entire DoD whose full time job is to work on outlying situations that can't be handled at the primary care level.

Just out of curiosity what test did you insist needed to be done and was it really medically necessary?

 

[IgD]

Another thought. I suspect each branch has its own "NAMI". Why not consolidate all into a single joint command? Consolidation might improve efficiency and cost effectiveness.

 

[ravager135]

There short answer is no. Every medical condition and every case requiring review for waiver is unique. We have a waiver guide that we will follow for common sense conditions for which precedent has established reasonable guidelines. The kind of case I am discussing is the other 50 percent of waivers where there is no precedent and each case needs to be looked at and reviewed individually. Almost like a medical board. We are not talking about fitness for duty, we are talking about being physically qualified to fly an aircraft that cost the government millions.

I do think it is erroneous that often times the decision to grant a waiver comes down to one or two individual who work in Pensacola. I agree that a more standardized set of rules should be followed for waivers but again you are limited with the fact that each condition is unique, each airframe is unique, and each class of aircrew is unique.

A specialist has zero, not one inch of desire of learning all the requirements for individuals in a flight status. That's precisely why they stick people in flight surgeon tours essentially out of internship. Nothing I do is hard but what my post was getting at is that communicating what I am trying to accomplish is only further made difficult by the idea of a joint command. It doesn't matter what test I wanted or even if it was just a consult. It doesn't matter as at all if it is medically neccessary. To get a waiver for this individual, it needed to be done. If that's what a flight surgeon who is board certified in a specialty related to this service member's condition wants down in Pensacola, and he has authority, it's what should be done at my local MTF.

Convening one granting authority is the model we are moving towards. However that so much isn't the source of my frustration as it pertains to communicating what I need from individuals who do not understand what it means to be in a flight status. I think this is getting off topic anyway. It isn't about what I do so much as communicating what I do to an Army hematologist in a Navy hospital.

 

[kingcer0x]

Even if the AFMS was somehow integrated with the other branches, or dissolved outright, the operational medicine side of the house would survive. In the AF, this would be Flight Medicine. Although there are similarities between AF, Navy, and Army flight medicine, there's no way this could be integrated without flying ops being affected. Ultimately the line would want AF physicians trained in the AF way of doing things deciding the fate of their aviators and medical programs at all levels of command (squadron / wing / MAJCOM / HQ).

As radical as it sounds, I could see AF medicine changing: where only primary care and flight medicine exist CONUS, and specialists are 'tasked' for deployments and overseas billets. I can see GME going away, specialists asked to volunteer for overseas deployments, serving in the reserves until needed. Heck, non flight surgeon PCMs could even be given a crash course in flight medicine and be allowed to do physicals, aeromedical dispos, perhaps even without flying. Granted, its hard to get perspective on what flyers can and cant do with medical issues without doing it yourself, but honestly they could do the job. We are already sending many AD and dependents off base for specialty care. I have not seen the numbers, but from what I heard recently, financially this is not that much different than training/recruiting/ maintaining specialists at the MDG.

Your example of the Army hematologist is a good one. I run into this problem sometimes and it irks me. If I write 'this is for a flying waiver' in a consult request to an AD physician they should understand what is going on without berating me. I give them plenty of information and let them know exactly what I need for the waiver. There should be no discussion about the 'necessity' of the consult; unless of course they have read AFI 48-123 and the Waiver Guide and know something I don't. Luckily, most experienced AF specialists are not operationally clueless and deliver with a beautiful consultation that writes the aeromedical summary for me. These individuals rock.

 

[ravager135]

You are lucky. I have zero knowledge of Air Force health care. I may be speaking out of turn, but I feel the fact that perhaps the Navy has more access to AD specialists we get alot of board certified physicians who never leave the MTF and have no idea how operational medicine work. We do refer alot of cases out to civillians for speciality care but The majority of our bases and fleet are located reasonably close to one of our hospitals. I see this as both a benefit and a burden. More often we get the interventional cardiologist who has never set foot on a ship or overseas who despite the detail of my consult (wording almost identical to what you described) who has no clue what I am talking about.

I always had this perception that the Army would absorb the AF first. The AF functions in a very unique role that the Army for the most part lacks. The Navy on the other hand is relatively self sufficient with the Marine Corps, our surface fleet, and naval aviation. Again I have no clue what I am talking about in this respect but am merely offering perception. It seems already as if those two branches are more closely intertwined than we have been.

I would also add that we are all going to be sensationalized on this new BS Combat Hospital show on ABC.

 

[AF M4]

On the flipside medical waivers might be better handled by a joint medical command. There would be a single cohesive medical fitness standard for all branches of the military. It's something that any primary care provider could handle. An aviation form might be a multi-page document for a physical exam and tests that would be decided by a consensus committee. Isn't that the way it is done in the FAA? Government workers get medical fitness evaluations all the time. Maybe there might be 1-2 "flight surgeons" for the entire DoD whose full time job is to work on outlying situations that can't be handled at the primary care level.

Just out of curiosity what test did you insist needed to be done and was it really medically necessary?

We already have this. It's called the MEPS station, and it already implements a single baseline medical fitness standard for all the branches of the military; i.e., the duckwalk. Don't you remember that day of fun???

As far as how much good the consolidation of the various medical services for things like waivers would do, that question can be answered as well. The AFMS already does something similar, in that the AF is split up into various commands (ACC, AMC, AETC, etc), all of which have the authority to pass 95%+ of the waivers for the flyers under their particular commands. These commands are overseen by AFMSA, which gets the extra <5% of the really weird conditions that are asking for waivers. And so you already have a functioning command structure that is roughly analogous to whatever a joint command would look like things for things like waivers.

So how does it work? For easy stuff, generally pretty fast. For slow stuff, it can be ACHINGLY slow. Updating the medical standards for things like PRK eye surgery, allergy medications and such takes years longer than you think it should.

And I will suggest that this is the way things should be. There are plenty of healthy airmen out there who want to be flyers and who don't need an Exception to Policy from the Secretary of the Air Force to ride in the back of a tanker.

I don't think that a joint medical service would change much as far as your regular GMO is concerned, unless you count drastically increasing your chances of spending a year in the desert filling an Army billet.

 

[kingcer0x]

...unless you count drastically increasing your chances of spending a year in the desert filling an Army billet.

 

[jabreal00]

I just think it boils down to the fact that each branch specializes in a specific mission, the medical support of each of those missions is unique because of the type of warfighter you are supporting. Yes perhaps with time in a unified &quot;purple&quot; uniform command people will adapt to servicing all branches but as a flight surgeon I have dealth with many other armed forces health care providers that have no concept of what I do or how certain aspects of operational medicine work. We have this problem just within the Navy itself let alone trying to communicate with other branches of service.

Example, I was processing a waiver for an aviator. Waivers usually require over-the-top workups and tests because we are dealing with individuals who fly expensive air craft. I work at a small clinic with few resources. I called a much larger Navy hospital for a referral for my pilot so that we could complete the required testing for his waiver. I was put in touch with an Army hematologist (could have been any branch, but an example). She refused to take my consult, said there was no indication for the patient to be seen and thought that I was an intern. She literally told me, we call interns flight surgeons. Obviously wrong. Obviously somebody with zero operational experience. Obviously somebody that doesn't realize that I am complying with a NAMI requirement not the American College of Hematologists (if such a thing exists) recommendation. I literally had to speak with my senior flight surgeon who thankfully outranked her and spoke directly to the head of heme/onc just to get this done.

This is just one, perhaps extreme example of how unified commands fail. It's bad enough that people in the Navy sometimes don't understand the mission of it's components it is evan more frustrating when dealing with other branches. Just the flight waiver/approva/physical process alone is different among the three branches and has taken years to unify the paperwork. Which by the way, AERO gets set back every month. It's a logistical nightmare.

It's silly and a waste of resources to send a generally healthy pilot to a subspecialist to fill out waivers or order non-medically indicated tests. An internist or a flight surgeon at any reasonably large medical treatment facility should be tasked to do this. I could understand why she was annoyed. I am a gastroenterologist, I'd be frustrated if I had healthy pilots, marines, or infantry guys coming to my clinic for physical exams, waiver paper-work and blood work.

 

[backrow]

It's silly and a waste of resources to send a generally healthy pilot to a subspecialist to fill out waivers or order non-medically indicated tests. An internist or a flight surgeon at any reasonably large medical treatment facility should be tasked to do this. I could understand why she was annoyed. I am a gastroenterologist, I'd be frustrated if I had healthy pilots, marines, or infantry guys coming to my clinic for physical exams, waiver paper-work and blood work.

The subspecialist does none of those things for aviation waivers.

The aviators are referred to subspecialists when their waivers require it. Those waivers are written by a board certified Internist (if it involves an IM issue) who has made it part of the requirement to be seen by a specialist who knows the most about whatever condition he has a waiver for. It then is signed off and "ordered" by BUPERS. All the specialist usually needs to do is see the person and comment on if their need to be any changes or if the person is doing well. That's it, there is no other paperwork needed. The flight surgeon then takes the AHLTA note and puts that into that persons flight physical.

If the specialist thinks the person should only be seen every X years or not again then they can write that in their note and it can be submitted to potentially have that portion of the waiver requirement rescinded.

 

[kingcer0x]

It's silly and a waste of resources to send a generally healthy pilot to a subspecialist to fill out waivers or order non-medically indicated tests. An internist or a flight surgeon at any reasonably large medical treatment facility should be tasked to do this. I could understand why she was annoyed. I am a gastroenterologist, I'd be frustrated if I had healthy pilots, marines, or infantry guys coming to my clinic for physical exams, waiver paper-work and blood work.

Usually the specialist just has to see the patient, write an AHLTA note with saying that theyre fine, their condition is stable, when they want to see them again, and thats it. The flight surgeon takes care of the rest (believe me, I've killed more than a few trees doing this). Yeah, theyre usually healthy, and yeah, the indication for consultation might be weak, but ITS THE LAW. And by law, I mean, the reg specifically says 'hematology/gastroenterology/orthopedic surgery consult required'. If you don't like it, get a staff job and rewrite the system. Simple.

One time, I referred a patient to a neurologist for a flying waiver because it was specifically required by AETC and AFMSA, and he saw the patient, got really mad, and cut an paste an entire up-to-date article teaching the referring physician about this condition (me). Next time, in the consult request, i'm going to cut an paste an entire AFI, as much as AHLTA will let me fit in. It's good thing the other neurologist at the unname MTF I send people to knows a thing or two about the operational site of the house.

:bailing out:

 

[AF M4]

Usually the specialist just has to see the patient, write an AHLTA note with saying that theyre fine, their condition is stable, when they want to see them again, and thats it. The flight surgeon takes care of the rest (believe me, I've killed more than a few trees doing this). Yeah, theyre usually healthy, and yeah, the indication for consultation might be weak, but ITS THE LAW. And by law, I mean, the reg specifically says 'hematology/gastroenterology/orthopedic surgery consult required'. If you don't like it, get a staff job and rewrite the system. Simple.

One time, I referred a patient to a neurologist for a flying waiver because it was specifically required by AETC and AFMSA, and he saw the patient, got really mad, and cut an paste an entire up-to-date article teaching the referring physician about this condition (me). Next time, in the consult request, i'm going to cut an paste an entire AFI, as much as AHLTA will let me fit in. It's good thing the other neurologist at the unname MTF I send people to knows a thing or two about the operational site of the house.

:bailing out:

Hahaha....oh yeah, I had this happen to me a couple of times. Usually the consultant wasn't such a jerk as to put an entire Up-to-Date article in the note, but they'd say something like "condition can be managed by PCM" which is code for "stop sending me these easy cases you lazy bastard." Towards the end I or my clinic nurse would give the consultants' offices a call beforehand (especially if they were civilian) and tell them what's up.

I'd end up telling the consultant that (a) yes, the pilot is currently perfectly healthy; (b) yes, I know that there's no medical reason for him to see the consultant and (c) it's a government requirement for his job, at which point I'd quote the line from the AFI where he had to see X specialist. Then I'd say sorry for using the consultant's time like this, but it can be a very quick visit - just put in the note that he's perfectly fine (if he is) and everyone will be happy.

This also helped keep the consultants from doing random things to the patient like starting them on new PPIs for the heck of it because the consultant felt they had to do SOMETHING to earn their paycheck.

 

[Gastrapathy]

From the consultant perspective, these are a pain too. NAMI requires an endoscopy in several situations where clinically it isn't indicated. If I had a complication from a procedure with no indication, it won't be the CO of NAMI who has to explain that. Everyone knows that they will retroactively claim that they didn't really require it. However, if I refuse, its a huge pain for the aviator and waste of my time while we argue about it.

 

[pgg]

From the consultant perspective, these are a pain too. NAMI requires an endoscopy in several situations where clinically it isn't indicated. If I had a complication from a procedure with no indication, it won't be the CO of NAMI who has to explain that. Everyone knows that they will retroactively claim that they didn't really require it. However, if I refuse, its a huge pain for the aviator and waste of my time while we argue about it.

I'm the last person to criticize anyone for succumbing to military expediency, but if an aviator's inconvenience is the only price for avoiding a non-indicated procedure, why give in and do it?

With my bad attitude I'd be inclined to refuse to do the procedure, and simply let these aviators have their career hiccups because the waiver couldn't be completed. If enough pilots got sidelined because of this stupidity, the system could change. Not that I really fault you for following the rules of the game you find yourself in.

I almost wish I had the opportunity to throw some passive-aggressive resistance back at the machine like this. Almost. As it is, nobody ever asks anesthesia for this kind of thing.

The closest thing to that is I've somehow found myself providing "anesthesia" for routine vasectomies in the main operating room of our hospital. And by "anesthesia" I mean a couple mg of Versed and some oxygen. But booking these cases in the OR with anesthesia apparently inflates the RVUs and pleases the bean counters. At first I was almost violently opposed to getting involved in these cases, but in the end I just gave in and took one for the team. But they weren't asking me to do anything unsafe, just wasting my time.

 

[AF M4]

I'm the last person to criticize anyone for succumbing to military expediency, but if an aviator's inconvenience is the only price for avoiding a non-indicated procedure, why give in and do it?

With my bad attitude I'd be inclined to refuse to do the procedure, and simply let these aviators have their career hiccups because the waiver couldn't be completed. If enough pilots got sidelined because of this stupidity, the system could change. Not that I really fault you for following the rules of the game you find yourself in.

I almost wish I had the opportunity to throw some passive-aggressive resistance back at the machine like this. Almost. As it is, nobody ever asks anesthesia for this kind of thing.

The closest thing to that is I've somehow found myself providing "anesthesia" for routine vasectomies in the main operating room of our hospital. And by "anesthesia" I mean a couple mg of Versed and some oxygen. But booking these cases in the OR with anesthesia apparently inflates the RVUs and pleases the bean counters. At first I was almost violently opposed to getting involved in these cases, but in the end I just gave in and took one for the team. But they weren't asking me to do anything unsafe, just wasting my time.

That's more than a bit cold my friend; that is someone else's career and livelihood you're screwing with in defense of your principles. If you don't want to comply with military (or any organization's regs) then you need to leave; in the interim they're paying your salary so you're obligated to play ball. And do you really think that an aviator and his operational commanders are going to let some medical weenie punk them? Nah. Standing in front of this particular tank is only going to get you run over and they'll just have the next guy do it anyway, leaving you behind as so much street pizza.

Furthermore, despite what some would have you believe, these waiver guides are NOT iron-clad. As someone who has done more than a few of these things, I have on more than one occasion talked with a specialist who said that the procedure the waiver regs wanted was not indicated. I told them great, just mention that in your note. Then I called up the guy at the waiver approval authority and said hey, this guy has X diagnosis and I sent him to the consultant who believes the risks outweigh the benefits for doing the procedure in the waiver guide. He's said so in his note, and I'd rather not expose my flyers to unnecessary tests. More often then not, the waiver got approved without the test having to be done.

It's really more about CYA than anything. If you can convince the waiver authority that the CYA quotient has been fulfilled in lieu of the specific waiver requirements, you're golden.

 

[Gastrapathy]

pgg, i totally hear what you are saying. I've done what you say but the member wants me to just scope him and be done with it every time. They put up with far more risk than my procedure and universally want to deploy. So, I ask every ROS question I can, "Have you ever had the slightest difficulty swallowing...ever?" etc, and try to mine an indication from their story.

When I've resisted, they are grounded and inevitably, its been right before deployment. So I make 20 phone calls trying to actually reach someone with any authority to explain, never get anywhere with all that wasted time, the unit deploys without the member and another GI consult gets generated. NAMI could care less about the individual member, in my experience.

I guess I've been beaten into submission. So far, I haven't hurt anyone on a procedure that I didn't really think I should be doing. Hopefully I never will. I do tell them that I don't think its indicated and, if they want, I will fight to not have to do it. All of them have said "please just scope me and let me get back to work."

 

[Gastrapathy]

Furthermore, despite what some would have you believe, these waiver guides are NOT iron-clad. As someone who has done more than a few of these things, I have on more than one occasion talked with a specialist who said that the procedure the waiver regs wanted was not indicated. I told them great, just mention that in your note. Then I called up the guy at the waiver approval authority and said hey, this guy has X diagnosis and I sent him to the consultant who believes the risks outweigh the benefits for doing the procedure in the waiver guide. He's said so in his note, and I'd rather not expose my flyers to unnecessary tests. More often then not, the waiver got approved without the test having to be done.

It's really more about CYA than anything. If you can convince the waiver authority that the CYA quotient has been fulfilled in lieu of the specific waiver requirements, you're golden.

Great in theory. Not been my experience in practice. Look at the NAMI Aeromedical Waiver Guide for "gastritis" (they mean dyspepsia but use a totally meaningless nonspecific pathologic diagnosis instead). Anywhere from 9-40% of the population has functional dyspepsia. The guidelines are very clear about who needs a scope for this exceedingly common complaint and very few do. Anyone with "gastritis" needs a scope per the waiver guide to be considered for a waiver.

The GERD guideline is a little better but still leads to unnecessary scopes.

 

[pgg]

That's more than a bit cold my friend; that is someone else's career and livelihood you're screwing with in defense of your principles.

Whoa, back up. Resisting the bureaucracy to avoid an unnecessary procedure isn't just making a stand for the hell of it. There's a reason we don't ordinarily do things that carry risk without an indication.

The military is the entity with the disease here. Aviator and physician alike are the victims.

Though it may have come across that way, I'm not really throwing stones at Gastrapathy for doing these scopes. We all have to function within this crazy system.

 

[AF M4]

Great in theory. Not been my experience in practice. Look at the NAMI Aeromedical Waiver Guide for "gastritis" (they mean dyspepsia but use a totally meaningless nonspecific pathologic diagnosis instead). Anywhere from 9-40% of the population has functional dyspepsia. The guidelines are very clear about who needs a scope for this exceedingly common complaint and very few do. Anyone with "gastritis" needs a scope per the waiver guide to be considered for a waiver.

The GERD guideline is a little better but still leads to unnecessary scopes.

Really? Wow. Just have experience with the AF version. That's a PPI and good to go.

 

[AF M4]

Whoa, back up. Resisting the bureaucracy to avoid an unnecessary procedure isn't just making a stand for the hell of it. There's a reason we don't ordinarily do things that carry risk without an indication.

The military is the entity with the disease here. Aviator and physician alike are the victims.

Though it may have come across that way, I'm not really throwing stones at Gastrapathy for doing these scopes. We all have to function within this crazy system.

Oh no man, I totally get the reasons why it's important to resist doing unnecessary procedures just for the hell of it. My beef was with the idea of being passive-aggressive about it and just letting people's careers languish. That's not really taking a stand, it's just dragging your feet before you end up doing it anyway. If you see some *******ery being perpetuated through the regs, do something about it!

Look, I've known the guys who write those regs. They have day jobs too, and they glance at those things maybe once a year. Maybe. They have very little incentive to go through the trouble to change them unless people are hassling them about it. So yeah, it takes 30 minutes and maybe 3-4 phone calls to find the right person to talk to, but you CAN get this stuff changed. Putting in the hour or so of effort to compile the research, send some emails and make some phone calls can end up saving GMOs across the land hundreds of hours of writing repetitive waivers and save who-knows-how-many flyers from getting unnecessary examinations. I've seen it happen.

 

[pgg]

Oh no man, I totally get the reasons why it's important to resist doing unnecessary procedures just for the hell of it. My beef was with the idea of being passive-aggressive about it and just letting people's careers languish. That's not really taking a stand, it's just dragging your feet before you end up doing it anyway. If you see some *******ery being perpetuated through the regs, do something about it!

No, I wasn't talking about delaying things, dragging my feet, then doing it anyway. I meant a simple flat no that wasn't negotiable.

This is all hypothetical anyway. It's easy for me to take this ideological stand when I'm not being asked to do anything, and there's no pilot in front of me saying he'll be grounded if I don't play the game.

I'm glad I'm out of GMO-land and in a specialty where I'm not put in this position. It'd be tough to say no to an informed patient who knew the risks of the procedure, understood the pointlessness of the system, and just wanted to go through with it so he could get on with his life and career.


The irony is that in the civilian world these patient-desired non-indicated procedures probably get done a whole lot more often ... so that a procedure can be billed.

 

[backrow]

Great in theory. Not been my experience in practice. Look at the NAMI Aeromedical Waiver Guide for "gastritis" (they mean dyspepsia but use a totally meaningless nonspecific pathologic diagnosis instead). Anywhere from 9-40% of the population has functional dyspepsia. The guidelines are very clear about who needs a scope for this exceedingly common complaint and very few do. Anyone with "gastritis" needs a scope per the waiver guide to be considered for a waiver.

The GERD guideline is a little better but still leads to unnecessary scopes.

You aren't kidding on that one! That is one area of the waiver guide that needs a serious review. If you were ever interested in getting that changed the best way is to ask a flight surgeon who the NAMI Internist is at that time and fire them an email offering to provide your expertise in reviewing the requirements. Maybe, just maybe we could get the incessant upper endoscopy requirement removed.

 

[IgD]

Look, I've known the guys who write those regs. They have day jobs too, and they glance at those things maybe once a year. Maybe. They have very little incentive to go through the trouble to change them unless people are hassling them about it...

Probably a good example of government waste. These guys draw paychecks as if they are doing full clinical workloads but don't really do much. I wouldn't be surprised if they were writing the regs to further entrench them into these positions. They may even be hurting readiness more than helping.

I think there are a lot of service specific things but there is also a lot of room for consolidation, increased efficiency and cost savings. Why not have a single GME system across the military? You could match to any military hospital in the DOD. Or how about a single "NAMI" for all three branches (there would be a single administrative command by flight surgeons in each branch).

 

[kingcer0x]

Really? Wow. Just have experience with the AF version. That's a PPI and good to go.

This gets at the original topic of the thread. You have the AF saying 'well controlled GERD with common PPIs' doesnt require a SCOPE or a WAIVER, and the Navy saying 'scope everything' that might qualify as dyspepsia. You would actually have to get all these specialty consultants together to agree on which is the most risk averse path.


I use my common sense as a physician advocating for my patient first, even though my paid job is to be an occupational medicine dude and the regs might tell me to act differently. Remember those threads about 'officer first, physician second'? Remember how every one who wasn't a medical student was nauseated?

Well, the military is risk averse, so perhaps they would rather CT Scan that 4mm lung 'nodule' which is really just a granuloma in a healthy 30 year old pilot applicant non smoker, or scope that GERD patient. Maybe I try to fight it but I get overruled by somebody above my pay grade. Well the guy wants to fly more than anything in the world so he'll sign any informed consent and go through with it. Maybe they find something. Maybe the chance of finding something potentially 'incapacitating' to an aviator outweighs the risk to the patient from the procedure/diagnostic test itself.

Wait, what? Did I really just compare the cost of a human being to the cost of an airplane? Do people out there think like that? DO I THINK LIKE THAT??? Now I'm nauseated.

 

[AF M4]

This gets at the original topic of the thread. You have the AF saying 'well controlled GERD with common PPIs' doesnt require a SCOPE or a WAIVER, and the Navy saying 'scope everything' that might qualify as dyspepsia. You would actually have to get all these specialty consultants together to agree on which is the most risk averse path.


I use my common sense as a physician advocating for my patient first, even though my paid job is to be an occupational medicine dude and the regs might tell me to act differently. Remember those threads about 'officer first, physician second'? Remember how every one who wasn't a medical student was nauseated?

Well, the military is risk averse, so perhaps they would rather CT Scan that 4mm lung 'nodule' which is really just a granuloma in a healthy 30 year old pilot applicant non smoker, or scope that GERD patient. Maybe I try to fight it but I get overruled by somebody above my pay grade. Well the guy wants to fly more than anything in the world so he'll sign any informed consent and go through with it. Maybe they find something. Maybe the chance of finding something potentially 'incapacitating' to an aviator outweighs the risk to the patient from the procedure/diagnostic test itself.

Wait, what? Did I really just compare the cost of a human being to the cost of an airplane? Do people out there think like that? DO I THINK LIKE THAT??? Now I'm nauseated.

The military is like any other human organization; no one wants to be the guy who takes the fall if something goes wrong. So they over-compensate on the regulations, so that every possible thing is covered. From that perspective, there is no downside to writing extremely restrictive waiver guides.

However, doing repeated and/or unnecessary tests is not a benign thing either. A small percentage of scopes, CT scans etc. can lead to complications via anesthesia, bleeding, unnecessary biopsies and so on. Those risks however are borne by the patient and the physician doing the procedures, not the waiver authorities. So you do have to introduce this perspective as well into the waiver authorities' calculus, and you start doing that by pointing out the risks of these procedures to the authorities.

Standardized across the services or no, you can still end up with the exact same problem of leaning towards over-restriction if there's no incentive on the other side of the scale.

And I assure you, there are many many people in the world who measure the cost of a person's life vs pieces of machinery or other things. It's kind of what being an actuary is about, for instance. We've all got a dollar tag next to our name in a spreadsheet somewhere; your commoditization does not require your permission.

 

[ravager135]

This is unbelieveable we have specialists on here telling us they will just flat out refuse to perform a procedure because in "their opinion" it isn't clinically indicated. Unless you also wear flight surgeon wings, you don't really know what is necessary for someone who flies an F-18. We aren't talking about being fit for duty. Most medical indications and guidelines are not made by military physicians but by the respective recommendations of the civillian colleges of that particular field of medicine. IE we perform screening colonoscopies at age 50 because thats the guidelines civillian and military alike.

That is not what we are discussing here. We are talking about being physically qualified to fly. That is why rheumatologists, gastroenterologists, etc at NAMI are wing wearing flight surgeons and they make the recommendation for the waiver, not you. If you feel that a procedure is unneccessary and you have such strong principles, you take two seconds to call your colleague in Pensacola who is a flight surgeon AND board certified in your specialty and you tell him to consider changing it. All you are doing is putting the GMO flight doc and his patient in a tough spot. And you aren't demonstrating any principles, you're saying no and doing nothing about it.

I'd really like to see who wins the arguement when it comes to a captain medical officer specialty leader and a skipper of a squadron when that skipper finds out his flight surgeon and pilot are complying with NAMI regulations and he can't get his best pilot in the air because you disagree with a consultation. Unless you made an attempt to communicate your disagreement with NAMI, I guarantee it won't end well for the specialist who won't see the consult.

The military is like any other human organization; no one wants to be the guy who takes the fall if something goes wrong. So they over-compensate on the regulations, so that every possible thing is covered. From that perspective, there is no downside to writing extremely restrictive waiver guides.

However, doing repeated and/or unnecessary tests is not a benign thing either. A small percentage of scopes, CT scans etc. can lead to complications via anesthesia, bleeding, unnecessary biopsies and so on. Those risks however are borne by the patient and the physician doing the procedures, not the waiver authorities. So you do have to introduce this perspective as well into the waiver authorities' calculus, and you start doing that by pointing out the risks of these procedures to the authorities.

Standardized across the services or no, you can still end up with the exact same problem of leaning towards over-restriction if there's no incentive on the other side of the scale.

And I assure you, there are many many people in the world who measure the cost of a person's life vs pieces of machinery or other things. It's kind of what being an actuary is about, for instance. We've all got a dollar tag next to our name in a spreadsheet somewhere; your commoditization does not require your permission.

 

[pgg]

This is unbelieveable we have specialists on here telling us they will just flat out refuse to perform a procedure because in "their opinion" it isn't clinically indicated. Unless you also wear flight surgeon wings, you don't really know what is necessary for someone who flies an F-18.

Sorry, I'm a board certified specialist. No one is telling me what's medically indicated or what to do, no matter your rank, or what some book of NAMI regulations or procedures says. I'm open to discussing the matter with another colleague in my specialty, including one who wears those shiny wings, and if he convinces me it's a reasonable thing to do, sure, I'll do it. But even other doctors don't tell other doctors what to do when it comes to practicing medicine.

Again, I'm an anesthesiologist so this is all theoretical pontificating. I never get consulted to do this kind of thing. But if I was consulted to do a procedure with non-zero risk for which I did not believe there was an indication, I would happily see the patient, write up the encounter, and try to help out with the waiver process - without doing the procedure.

To fabricate an example, if the line sends a pilot to me to get a cervical epidural steroid injection to treat his numb arm, and I don't think it's indicated, he's not getting a needle in his neck.

All you are doing is putting the GMO flight doc and his patient in a tough spot.

You're blaming the wrong entity here. I'm not putting them in a tough spot. That tough spot was created by the knucklehead - or more likely, committee of knuckleheads - who created the regulation in the first place.

I'd really like to see who wins the arguement when it comes to a captain medical officer specialty leader and a skipper of a squadron when that skipper finds out his flight surgeon and pilot are complying with NAMI regulations and he can't get his best pilot in the air because you disagree with a consultation.

Curious - exactly what do you think would happen if such an argument did take place?

Or do you actually think a physician can be ordered to perform a procedure against his professional judgment? Or be disciplined if he refuses?

Unless you made an attempt to communicate your disagreement with NAMI, I guarantee it won't end well for the specialist who won't see the consult.

Again, what are they going to do?

I'd certainly communicate my disagreement with everyone involved. I'd have thought that was implicit in my refusal to perform the procedure.

They're free to send the consult to someone else for a 2nd opinion. Maybe that guy will do the procedure. If he's a civilian and needs the business (even at Tricare rates), he probably will.


Have you done a residency? Are you a flight surgeon now?

I was a GMO and believe me, I can sympathize with the frustration GMOs have getting things done when med boards and consults and deployability questions are involved. But the problem isn't the specialist working within the standards of his specialty.

I fully understand the pressure to do things 'their way' when 'they' are people with rank and authority. For chrissakes we've been doing vasectomies in the main OR to appease the RVU-counting machine.

But suppose there is a complication during the procedure. Say I core out a couple mm of a guy's spinal cord, or Gastrapathy perforates an esophagus. Suppose a non-indicated diagnostic test produces a false positive (more likely if the test isn't indicated in the first place) and potentially harmful further testing or treatment ensues. How on earth would you defend that? (I know Feres protects us, but that would be small comfort to the servicemember or physician.)

 

[ravager135]

Then essentially you agree with my points. Talk to the specialist at NAMI who wears wings. What is indicated or not is different between a healthy patient who does not fly and one who does. That is why the specialists wearing wings st NAMI might request procedures you do or do not agree with.

If you don't like something don't refuse it to prove a point, communicate your concern and either prove a colleague of yours wrong or learn something yourself.

I never implied any discipline would be taken against a doctor for not doing a non medically indicated procedure, but that the line would inevitably win. My point was that the medical corps serves the line. Plain and simple. When the line and medical corps argue over a point, the line usually wins. IE pilot can't get waiver despite he and flight surgeon doing all the required items as indicated by NAMI and you are the only impediment to that process... Yeah the CO of that pilot is gonna bitch and he will prolly get what he wants. No one is going to ever force a specialist to do anything they don't wanna do. But the line CO is certainly not wrong by any means, whereas you may need to correctly or incorrectly explain why the waiver process is wrong.

I don't need to explain to you what I do or don't do. I have been around long enough to know how flight surgery, being a specialist, and being in the Navy works. This is forum of opinion not a credentialing office, I respect yours.

 

[ravager135]

And your point is taken, a second opinion is always an option and available for someone at a larger Navy command. However in a place like Iwakuni or another more remote facility. You may be the only neurologist, hematologist, etc to perform that waiver requirementand therefore be the only impediment to that process.

 

[pgg]

What is indicated or not is different between a healthy patient who does not fly and one who does.

When it comes to invasive procedures, we're going to have to agree to disagree on that.

My point was that the medical corps serves the line. Plain and simple. When the line and medical corps argue over a point, the line usually wins. IE pilot can't get waiver despite he and flight surgeon doing all the required items as indicated by NAMI and you are the only impediment to that process... Yeah the CO of that pilot is gonna bitch and he will prolly get what he wants.

If he gets what he wants without me doing the procedure, more power to him.

I still fail to grasp why an upset CO should concern me if
a) I'm practicing safe medicine to the best of my ability
b) He can't hurt me

I feel for the pilot and FS and even the CO who have these silly hoops laid out in front of them, I really do, but to paraphrase the Fat Man, NAMI is the one with the disease.

I don't need to explain to you what I do or don't do.

No, you don't. I'm not trying to de-anonymize you. It'd just be interesting to see where you're coming from.

We get an endless supply of pre-meds and med students coming through here with strong opinions about what's what with HPSP and military medicine. You come across as a GMO with strong opinions about what's what with being a specialist who receives consults.

I'm not trying to be a dick. As a GMO I sure cursed the name of a specialist or two who 'obstructed' my consults to get Marines deployable. They had their reasons.

We serve the line, they are why the MC exists; I get it. In non-battlefield, non-triage conditions though, we serve the patients' best interests first.

I have been around long enough to know how flight surgery, being a specialist, and being in the Navy works. This is forum of opinion not a credentialing office, I respect yours.

And I respect yours; simply interested in your perspective.

 

[IgD]

This is unbelieveable we have specialists on here telling us they will just flat out refuse to perform a procedure because in "their opinion" it isn't clinically indicated...

When you consult a professional colleague you are asking for their opinion and help. It's not proper etiquette to tell colleagues what to or demand things. It is also inappropriate to tell someone who has more training than you what to do. You will likely find that if you do either of those things your efforts will backfire. Part of being a specialist is saying no. Part of being a military doctor is balancing the needs of the military against the needs of the patient. It is possible the patient's needs could be met without exposing them to unnecessary risk or wasting the tax payer's money.

 

[IgD]

...That is why rheumatologists, gastroenterologists, etc at NAMI are wing wearing flight surgeons and they make the recommendation for the waiver, not you...

No offense to you but I can't believe the Navy needs a full compliment of subspecialists at NAMI to make these decisions. There is no way it can be cost effective. There has to be a better way.