Unified medical command

[Gastrapathy]

"The line always wins" Umm, no they don't. A line CO during combat operations always wins. Back in CONUS, I can LIMDU anyone anytime for any reason. If you are letting the line "always win" you are not taking care of your sailors. The line CO lacks insight into the medical implications of his decisions and will often focus only on the immediate cost of personnel losses.

As, for the rest of the posts, its attitudes like this from NAMI onward that make it so painful that I have done procedures that were not medically indicated. This dude is a GMO, probably did a surgical residency and he knows more about my specialty than I do. It's tools like him that make it impossible to explain to the patient why you aren't doing something. There is no data behind the requirements, its "expert opinion" at its finest. What makes it so ridiculous is that the dx that I'm complaining about doesn't even exist except in the waiver guide so how seriously can I take their expertise.

Oh, and there is no gastroenterologist at NAMI (its interesting you mentioned Rheum...) and never has been/never will be. I'm not going to say whether I was ever a FS but I would get rid of the entire program. FS see fewer patients than other GMOs and waste 6 months getting training that they don't need (AF FS do just fine at their job with a MUCH shorter pipeline).

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[ravager135]

You're wrong about what you presume about me on many accounts. There is a rheumatologist at NAMI, I am not him. Medical Corps offers suggestions to the line, not orders. You know this. You are extrapolating what I am saying into a larger context outside the original point of my original post:

Specialists can make a huge headache out of a waiver process. This is especially so when they have no aeromedical insight or are unwilling to speak with their colleagues there to change the process. When a specialist refuses to help with a consult for an aeromedical waiver, he leaves the GMO in the lurch. Help doesn't mean just blindly doing what NAMI wants, but instead taking an active role in what the GMO is requesting and communicating your concerns to NAMI. I have worked at the MTF. I realize specialists have alot of things to do in serving dependants, the fact remains active duty is the priority. If you disagree with that, that's another arguement all together. You have communicated to me that you do not like other people telling you your job, who are you to tell the flight surgeon, a RAM, or a flight surgeon specialist at NAMI that a pilot or NFO might have different aeromedical concerns than a regular patient. You could be wrong or you could be right but to throw that conversation to the GMO to have by not assisting is a cop out.

I do not work at NAMI, I have no vested interest in flight surgery other than I have experience with it. I do not presume to know anything about your specialty. The people at NAMI do and if you aren't willing to assist in a waiver process, set them straight. You aren't offending me. I could care less what you think is indicated or not. I just know I resented as a flight surgeon when specialists refused to help with a consult rather than just make it happen or assist with correcting an issue they felt was unneccessary.

You're beginning to sound like an angry physician making far more sweeping generalizations than you claim I do. But I do not know you.

 

[ravager135]

PGG, I do appreciate your perspective.

To the larger audience I am not suggesting anyone outside of someone's specialty tell that individual how to do their job. I am making the point against obstructionists. If you are truely passionate about your specialty talk to colleagues of yours who put these waiver requirements in place. No one likes ordering unneccessary tests, I made this point in my original post. Don't just say no, because sometimes you may be one of few or only people a GMO may be able to turn to.

 

[Gastrapathy]

Show me an inaccurate assumption in my post other than the flippant guess that you did a surgical internship.

And again, there is no one at NAMI who knows anything about my specialty. You could care less what I think is indicated. Enough said.

As I reflect on these posts, I think I will start refusing again.

 

[ravager135]

All assumptions are flippant. You haven't taught me any lesson.

I could be a GMO, I could be a board certified physician going back to fill a job as an FS for a tour, or I could be out of the Navy. Either way, by reading the frequency with which you post on the forums it's clear that you are bitter about something and it didn't start with this thread today.

 

[IgD]

I could be a GMO, I could be a board certified physician going back to fill a job as an FS for a tour, or I could be out of the Navy. Either way, by reading the frequency with which you post on the forums it's clear that you are bitter about something and it didn't start with this thread today.

What's up with the disrespect? We were having a good discussion here. You said in another post you are a flight surgeon getting out in 2013 looking to do a residency. I've been reading Gastrapathy's posts for some time and he doesn't come across as bitter at all.

I understand where you are coming from. I've got a FMF pin. Why not try to make your point with constructive remarks??

 

[pgg]

You're wrong about what you presume about me on many accounts. There is a rheumatologist at NAMI, I am not him. I do not even work at NAMI. I know everything there is to know about you now, but you know nothing about me. Don't presume to.

I presumed nothing, this is why I asked what you do and what your qualifications are.

I'm not asking for 600 dpi x 24 bit scan of your passport. If you value your anonymity to the point that you won't even disclose what your specialty is, or if you even have one, that's fine. I just won't take you as seriously as I would otherwise. (That too, is fine. It's only the internet.)

Medical Corps offers suggestions to the line, not orders. You know this.

And you know this is irrelevant to the topic under discussion. We're not talking about the specialist issuing orders or even suggestions to the line; we're talking about the specialist handling a consult in a manner other than what the line prefers.

If you're going to continue confabulating this issue into some kind of officer vs physician "we serve the line" nonsense, there's really no point in continuing.

Specialists can make a huge headache out of a waiver process. This is especially so when they have no aeromedical insight or are unwilling to speak with their colleagues there to change the process.

I have no doubt of that.

The point is that what the line may perceive as needlessly making a huge headache out of something may actually be a physician practicing good medicine.

You're beginning to sound like an angry physician making far more sweeping generalizations than you claim I do.

If I've assumed anything in this thread, it's your non-residency-trained status, and only because you've been cryptic and dodged the question.

If I've made any generalization in this thread, it's that specialists (in CONUS non-battlefield conditions) should practice in a manner consistent with the standards of their specialty. NAMI ain't part of that.

And angry? Heh. If anything I have even less of a vested interest here than you do, because I was never a flight surgeon nor have I ever received a consult concerning a waiver for a pilot.

It's all academic and hypothetical to me.

Don't just say no, because sometimes you may be one of few or only people a GMO may be able to turn to.

Sometimes NO is the correct answer.


I don't do waivers, but every once in a while I have to say NO to a patient (+/- the surgeon too) who wants surgery because for one reason or another they're not ready for an elective procedure.

I wouldn't be doing my job if I just went along with everything everyone else wanted, and I'm not obligated to 'phone a friend' to discuss the decision. If it's not a clear cut issue, I might discusse it with a colleague. But ultimately the person who says YES or NO is me.


Tell you what ravager135, if I ever do get some kind of consult for a waiver, and they're asking me to do something against my better judgment, I'll give all parties involved a fair chance to convince me I'm wrong and they're right. And after all that, if I still think they're wrong, they can go bone themselves or seek a 2nd opinion.

 

[ravager135]

This thread has clearly derailed from my original point which was mentioned above. PGG, the last post wasn't directed at you but at Gastropathy for a scathing out of context reply to my original point. I do appreciate the breakdown with your points being made, but it wasn't directed at you. I see we have some agree to disagree issues. And you are absolutely right, this is the internet and who cares.

Do enough homework on me and it's clear to see where I am posting from experience wise. I don't bring it up because assumptions are always made when people classify themselves which is the direction I did not want this thread to go and it has. I have no vested interest in what NAMI does or in telling a specialist how to do their job. I was playing devil's advocate and used one example of how a specialist made a process difficult and didn't need to. In my original post, the descrepency was from a difference of service and less about being a specialist. That WAS the original point of this thread.

I don't take any exception in being disagreed with.

 

[backrow]

So this is now way off topic; however, here's my thoughts on this particular topic.

There are a set of "rules" that are put out for people in the Naval Aviation community. Those rules are set by NAMI and published and therefore have at the very least tacit approval by the Surgeon General. Therefore the requirements contained within are meant to be complied with by all providers in the Navy. Individual waivers are written by NAMI; however, the approval authority is BUPERS, meaning they are now line side requirements and as staff officers we are here to support the line.

Now, if you as the referred physician don't agree with the requirement then I believe you have a couple options:
1)Do it anyway
2)Don't do it, but find the person someone who will
3)Get on the phone to the appropriate authorities (NAMI) and discuss the requirements and what you need to do to get it changed.

The "I'm not doing it and too bad" attitude doesn't help anyone. Play that card and you might find yourself sitting in the hospital XO or CO's office explaining your side of the story after either an ICE complaint or a direct call/email from the operational CO to the hospital CO. Not that anything further would happen, but it sure is a waste of your professional time to have to deal with that.

That same card can cause all sorts of headaches at the squadron. Flight schedules are already very, very tight and yes, the loss of one pilot/nfo/aircrew can mean the difference between a squadron being able to support an RFF (request for forces) or not.

 

[AF M4]

So this is now way off topic; however, here's my thoughts on this particular topic.

There are a set of "rules" that are put out for people in the Naval Aviation community. Those rules are set by NAMI and published and therefore have at the very least tacit approval by the Surgeon General. Therefore the requirements contained within are meant to be complied with by all providers in the Navy. Individual waivers are written by NAMI; however, the approval authority is BUPERS, meaning they are now line side requirements and as staff officers we are here to support the line.

Now, if you as the referred physician don't agree with the requirement then I believe you have a couple options:
1)Do it anyway
2)Don't do it, but find the person someone who will
3)Get on the phone to the appropriate authorities (NAMI) and discuss the requirements and what you need to do to get it changed.

The "I'm not doing it and too bad" attitude doesn't help anyone. Play that card and you might find yourself sitting in the hospital XO or CO's office explaining your side of the story after either an ICE complaint or a direct call/email from the operational CO to the hospital CO. Not that anything further would happen, but it sure is a waste of your professional time to have to deal with that.

That same card can cause all sorts of headaches at the squadron. Flight schedules are already very, very tight and yes, the loss of one pilot/nfo/aircrew can mean the difference between a squadron being able to support an RFF (request for forces) or not.

Ahhh, another turn in the hedge maze. I'm 99.9% certain this is true in the AF too - the waiver guide/medical requirements are written by docs but fall under line-side jurisdiction. Technically. In practice, the line guys are going to defer to the medical guy with the most rank in the room.

Gastrapathy, in what way will you refuse? I'd be very interested in hearing how it goes if you follow the path of saying no to the procedure while explaining why and documenting the flyer's good health in the note. My personal experiences with the AF waiver process make me thing that that has a better than even chance of working on its own; can't speak for the Navy side.

 

[IgD]

This discussion reminds me of military psychiatry. Each branch had different standards for what meds and conditions were deployable vs. non-deployable. At one point the Navy had a rule requiring certain sailors with mental health conditions to receive a flag officer waiver. There are a whole lot of docs who don't do much of anything but sit around and pontificate about these situations. It seems rationale to me to consolidate all of this into a single psychiatry administrative branch that falls under the DoD and would be applicable to all branches.

 

[ravager135]

So this is now way off topic; however, here's my thoughts on this particular topic.

There are a set of "rules" that are put out for people in the Naval Aviation community. Those rules are set by NAMI and published and therefore have at the very least tacit approval by the Surgeon General. Therefore the requirements contained within are meant to be complied with by all providers in the Navy. Individual waivers are written by NAMI; however, the approval authority is BUPERS, meaning they are now line side requirements and as staff officers we are here to support the line.

Now, if you as the referred physician don't agree with the requirement then I believe you have a couple options:
1)Do it anyway
2)Don't do it, but find the person someone who will
3)Get on the phone to the appropriate authorities (NAMI) and discuss the requirements and what you need to do to get it changed.

The "I'm not doing it and too bad" attitude doesn't help anyone. Play that card and you might find yourself sitting in the hospital XO or CO's office explaining your side of the story after either an ICE complaint or a direct call/email from the operational CO to the hospital CO. Not that anything further would happen, but it sure is a waste of your professional time to have to deal with that.

That same card can cause all sorts of headaches at the squadron. Flight schedules are already very, very tight and yes, the loss of one pilot/nfo/aircrew can mean the difference between a squadron being able to support an RFF (request for forces) or not.

Thank you. This is all I have been getting at the entire time. If a GMO says it he is telling a specialist how to do his job and doesn't know any better but if an attending states it, it carries merit. The truth is the truth regardless and Backrow has it correct.

 

[AF M4]

This discussion reminds me of military psychiatry. Each branch had different standards for what meds and conditions were deployable vs. non-deployable. At one point the Navy had a rule requiring certain sailors with mental health conditions to receive a flag officer waiver. There are a whole lot of docs who don't do much of anything but sit around and pontificate about these situations. It seems rationale to me to consolidate all of this into a single psychiatry administrative branch that falls under the DoD and would be applicable to all branches.

Man! You just want to kick a bunch of O-6's to the curb, don't you? They're people too, you know.

 

[grotto]

I don't think a total consolidation of the medical corps is a terrible idea, it will just be incredibly difficult, painful and expensive to implement. The French do this, but it requires a completely different service (i.e. Army, Navy, AF, MC, and Medical Corps) with its own service chief reporting directly to the CJCS or whatever their equivalent is. I did spend some time talking to a few French doctors just last week who went to the french military medical school (in Paris) and were doing some GME here.

Of course the size of the French military is minuscule compared to the US, but they do have what is probably the largest and most capable Army and Navy in Europe - and are actually very widely deployed, especially in Africa and Asia, for a european country. Their doctors work pretty much as civilians when not deployed and select the service that they will train with after they get their MD. They deploy as needed, but not usually as a unit. Most of their deployment time is spent in the various French ex-colonial disaster zones down in Africa and polynesia where they have medical missions.

No admiral or general wants to be the one who gives up a traditional mission to another service, unless they can blame it on congress. The services are perfectly happy to continue running their fiefdoms in perpetuity. Thus, the onus is on Congress to make consolidation happen. The Goldwater Nichols act was needed in 1986 to force joint readiness and mission consolidation on the military after a few epic screwups, and not even that went far enough.

 

[IgD]

I'm not sure it would ever happen either. The idea is too radical a change and differs greatly from tradition. Would definitely take an act of congress.

 

[backrow]

I'm not sure it would ever happen either. The idea is too radical a change and differs greatly from tradition. Would definitely take an act of congress.

I think it may have had a better chance before the closure of Joint Forces Command. Could have possibly been a nice place to integrate the medical branch under that; however, alas it is no more.