What's the solution

[The White Coat Investor]

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Having "lurked" on this forum for years, I am quite aware of the various problems with military medicine and the complaints of its physicians. I have spent a great deal of time reflecting on the possible solutions to these problems, but I don't think the one occasionally espoused here is going to work...i.e. Let the system collapse so someone will fix it.

There are three main areas of difficulty within the military medical system:

1) Recruiting

The military cannot recruit enough physicians to do what it wants its physicians to do. Although it is possible that this will change, I think it is unlikely. The military needs a lot of battalion surgeons, flight surgeons, GMOs, DMOs etc. Few people want to pursue these fields of medicine as a career. It also needs a fairly large number of residency-trained primary care physicians and a limited number of specialists. It has the difficult task of having two separate missions, a war-time mission and a peace-time mission. Unlike pilots whose peace-time mission (training to fight) ends when they are deployed, physicians simply tack on the war time mission to what they are already doing. For instance, the Air Force has too many surgeons and emergency physicians for its peace-time mission, yet too few for its war-time mission. The manner in which the military recruits physicians (by selecting pre-med students who have no idea what field of medicine they want to go into), causes great conflict because it pits the needs of the military with the desires of its physicians.

Recruiting is also harmed by the current ops tempo. More people sign-up for HPSP/USUHS when our nation is at peace. Although just about everyone signing up for the military is aware he may be called upon to deploy, it seemed much less likely ten years ago than today. The risk of multiple inconvenient deployments and the very real risk of death or disability certainly makes recruiting difficult.

The current HPSP scholarship format works against military recruiting efforts. The stipend is too low for most students to live on without additional sources of income. The stipend is not indexed to the cost of living of the area where the student attends school. The scholarship also works against students who opt to attend a less expensive school. A student attending an expensive DO school is much more likely to take the scholarship than one attending a cheap state-school. Perhaps if the scholarship was for a set amount we could recruit more of those students attending state schools, and they could use the money not required for tuition to pay for living expenses. There is also no incentive for someone with prior service to take an HPSP scholarship as it provides no significant bonus for prior service.

The military match system works against military recruiting efforts. This is perhaps the single biggest downside of the HPSP/USUHS scholarships. The chances of not being allowed to train to do what you want when you want to do it are simply too high to not affect recruiting of pre-med students who are aware of this problem. Our current solution of trying to hide it from them only alienates and angers our physicians. This problem is closely related to the fact that we have not recruited the types of physicians we need. There are several solutions to these problems:

The first, which the Navy is currently doing, is to use minimally trained (internship only) physicians as GMOs, DMOs, and flight docs and then send them back to residency. While it has the added bonus (from a military perspective) of generally lengthening commitments and thus encouraging (forcing?) more officers to stay in, it demoralizes physicians, endangers patients, and hurts recruiting.

The second, which the Army is currently doing, is to allow (somewhat at least) physicians to train in their selected field, and then deploying them as a battalion surgeon or the equivalent, no matter what their training. The upside is that physicians get to train immediately after med school, make more money, and can get out faster (upside for the doc's morale); the downside is that it is extremely demoralizing to the physician and possibly endangers patients to deploy certain specialists and subspecialists as GMO equivalents.

The solution I would like to see implemented is to encourage physicians to undertake a GMO tour voluntarily. This can be done by allowing physicians a significant degree of choice in assignments and by providing a financial incentive to take them. Instead of paying GMOs less than everyone else, perhaps we should pay them MORE since that is what we as a military want more of. Alternatively, or possibly in addition to this solution, we could allow years spent in GMO service to count as payback for a residency-associated commitment not yet acquired, perhaps at a rate of 1 year per two years served. This way, a 4 year HPSP student who did 2 years of GMO time prior to a 3 year anesthesia residency would only owe 2 years active duty time after residency.

Another solution I would like to see implemented is to specifically recruit those pre-med students who are mostly likely to want to serve as GMOs, DMOs, and flight docs as well as those most likely to want to stay in until retirement. We really need to focus on prior service applicants and others who express interest in these unique aspects of medicine. Giving a larger HPSP stipend to prior service personnel would send the right message. Advertising the "cool" aspects of GMO-equivalent service would also help. Flying off carriers in F-18s, serving as a special forces doc, or being the only physician on board a ship is an aspect of medicine that appeals to some people. We need to find these people and recruit them specifically, so that those who do not want to do it are not forced to.

Additional recruiting emphasis (and financial incentives) needs to be used to recruit current residents and staff-level physicians. Increasing the FAP stipend and signing bonuses would help.

2) GME

Military GME programs do some things very, very well. They generally do a nice job with academic type issues. The residents tend to be mature and well-read, do excellent research, and perform well on board exams. Many programs however, struggle with having sufficient pathology to train their residents adequately in managing difficult patients and performing adequate number of procedures. Residents are also saddled with the hassles of military service (PT testing, CBT etc) and faculty are not infrequently deployed or recovering from deployment. It is difficult to teach and do research when spending time in Afghanistan or Iraq.

The solution to this problem involves outsourcing GME to the civilian sector. Many military programs partner with nearby civilian programs to provide these experiences. This needs to happen more frequently, to the point where residents spend more time away from the MTF than they do at the MTF. A more extreme solution is to abolish the military GME system altogether, perhaps while still maintaining military-specific internship programs for those interested in GMO-equivalent jobs. Although it would be difficult to abolish the military match completely, it would sure help recruiting if we could make it simply a formality, rather than a life and career changing event.

3) Practice-related problems

There are a number of irritating problems that cause our physicians to get out of the military. Many of these are caused by the inherent difficulty imposed by a military medical model which requires critical care and surgical skills for the war-time mission without providing a mechanism to maintain these skills at the peace-time job. The solution to this particular problem is to consolidate military treatment facilities so that all of the surgeons, emergency docs, anesthesiologists etc are working at facilities where they can better keep up their skills. Moonlighting in the civilian arena needs to be not only allowed, but expected and provided for.

Physicians also complain about being led by non-physicians in some cases. While better recruiting and better retention are the ultimate solutions to this issue, policy changes requiring physician leadership are also effective, at least in the short term.

Dealing with Tri-care is irritating and embarrassing for military physicians. We tire of apologizing to our patients for our inept system. The current debacle at Walter Reed regarding the bureaucratic problems (not the trivial aspects such as mold and holes in dormitory walls) could just as easily have been about Tri-care. Tri-care needs to be made into a preferred insurance company for our patients as well as community doctors. This will require a lot of money and good leadership, but is certainly do-able. There are many HMOs in the country that provide good care and good value for the dollar. Tri-care is not one of them.

Lack of control over aspects of clinical practice frustrates many docs. Being forced to use a poorly designed and implemented electronic medical record (AHLTA anyone?) is just one example of this. Every specialty has their own unique problems that can be solved if the leadership cared to do so. These problems are often quite solvable with the right leader.

Doctors also complain of poorly trained nurses and techs and simply not having enough of them. High-clinical-quality, experienced nurses are unlikely to stay in the military when there is so much more control over their hours and so much more pay outside the military. A nursing special pay system would help, as would aggressively recruiting and retaining those who enjoy and thrive in the military environment.

Drastically increased patient panels and long hours drive out many good primary care specialists. Perhaps if we paid ISP that indicated we actually valued their training they would be willing to stick around a little longer. With improved retention and recruiting in these fields, the patient panels would be more manageable, and the hours more reasonable.

Poor leadership and an increased focus on metrics irritates many physicians. As we work to recruit and retain our best physicians and move them into leadership positions, we will be better equipped to only focus on those numbers that matter.

Finally, many physicians get out simply for financial reasons. Why do we expect to retain physicians willing to put their life on the line and separate from their family for 4-12 months at a time for 40-80% of the pay they can make in the civilian world? Shouldn't these physcians make MORE than their civilian counterparts? Want quality physicians in the military? If you raise the pay enough we'll be able to pick and choose who we take.

In summary, the military offers several very real benefits...a way to acquire medical training with minimal debt, serve our great country, enjoy a fantastic patient population, have less professional liability, and to focus less on the business aspects of medical care. At this time the negatives of military service outweigh the positives for far too many people. But I have come to believe that the solution to the problem is not to hurt recruiting by discouraging all pre-meds from accepting military service, but rather to specifically encourage those who will thrive in and enjoy the military environment and to make changes to recruit and retain trained physicians by aligning their pay with the civilian world and providing them with the best possible work environment, both for the peace-time and the war-time missions. This will require a lot of money, effort, and political capital, but after watching the Walter Reed Scandal play out, I think Americans believe that our military personnel deserve the best medical care money can buy. Let's see if they'll put their money where their mouth is.

 

[IgD]

Here is what I would like to see:

1. Abolishment of the GMO tour. "Doctor" implies a fully residency trained physician. If you have a situation where you need less than a doctor use a physician assistant or nurse practitioner.

2. Straight through training for all interns. Applying for a GME2 position in 1970 was how it was done but the standard for medical education in 2007 is straight through training. Anything else is unacceptable.

3. Complete revamp of the physician pay system. No annual bonuses. Every physician would receive monthly bonuses based on specialty with no strings attached. None of this memo and approval red tape. Physicians must be paid at least the US annual average doctor's salary for their specialty.

4. More physician power and autonomy.

5. Replacement of the all or nothing retirement system with 401K/TSP with matching.

I think we should come to agreement on the key points of reform and then post a full page ad in the New York Times or Washington post.

I also don't agree anti-recruiting is the right choice. On the other hand, we can't enable the military to maintain a broken system. We have to be honest and set limits.

 

[AF Anesthesia]

Thanks for posting! I wish I'd known all the reasons not to join before I signed those papers 8 years ago, however, there's nothing I can do to change it now. It's good to have some food for thought and semi-positive focus for those of us who are committed for better or worse.

 

[DNA Helicase]

excellent ideas.

 

[BigNavyPedsGuy]

Those are good ideas. The big problem is that most of those cost money, and our national deficit is climbing as the cost of the war increases. I applaud you for not just complaining and putting forth realistic solutions.

 

[USAFdoc]

Those are good ideas. The big problem is that most of those cost money, and our national deficit is climbing as the cost of the war increases. I applaud you for not just complaining and putting forth realistic solutions.

the below is an exerpt from a memo I wrote and forwarded up the chain of command several years ago.

A. REPRIORITIZE. I would submit that the following be a list of the TOP 5 priorities of our Family Practice Clinic, and in this order of importance:
1. Patient Care and Safety
2. Clinic Work Environment and Staff Morale
3. Education and Training
4. Patient Satisfaction
5. Administrative Goals and Metrics
I now also submit that without question, our clinics have been run backwards in terms of these goals. Administration emphasis has been entirely focused on meeting certain "Metric" numbers and hoping enough patients place compliment cards in feedback boxes. There is almost non-existent education and training as far as relating to medical care. Staff morale is terrible. If given the opportunity, many would resign immediately. Perhaps our best civilian nurse did just that this past week. Several months earlier another civilian nurse did the same and our best military nurse chose to separate rather than stay in this system despite having over 15 years of service. No-one has ever witnessed a new USAF family physician remain in the military beyond their initial obligation. Ideas to improve patient safety, provider training and education are quickly dismissed as soon as it is realized that clinic "numbers" might be adversely affected. Nearly 100% of all committee meetings are void of any provider input (attendance by providers goes against patient access to care).
The Surgeon General’s office has listed their own priorities (access, HEDIS, PIMR), and it is these priorities that have driven our clinics (and driven the priorities of our local administration). In this environment, with 20-60% of clinic providers and staff gone on any given day, we have in-place a plan for failure. After years of attempting to make a failed PCO concept work, we have markedly degraded the quality of care given. Again, reprioritization on all levels is a key if we are to change this.

B. SITE VISITS. I do not know when or why “site visits” fell out of favor and were replaced with computerized metrics, but this must change. Why senior administration is willing to place more weight on inaccurate metrics, than on the word of their officer physicians is beyond me. One cannot shoehorn everything that goes into providing excellent health care into some conceptual pie chart framework. In addition, the metric numbers are frequently wrong. For example, the metrics on me personally show that I have 10-15 un-booked appointments everyday. The truth is I can count on one hand the number of un-booked appointments I have had, ever. Has anyone ever looked at the accuracy and validity of the numbers that steer the course of our clinics? While metrics have there usefulness, they should not become numeric substitutes for real objectives like excellent health care. Metrics are like vital signs on a patient. They are great to have, but if the patient is gasping and cyanotic, having an O2 sat of 100% should not be reassuring.

Site visits also are important to prevent the filtering out of important information as it makes its way to senior officials. Brig. General Barbara Brannon, our assistant Surgeon General, visited our base in the Fall of 2003. I will never forget her comment of how wherever she goes she hears “how wonderful the PCO Concept is working.” I have spoken with USAF Family Physicians from coast to coast and never heard anything like that when describing the PCO concept. Currently there is no meaningful structure in which physicians can voice concerns.

C. LET COMMANDERS COMMAND. In a 6 week period - Fall of 2002, our clinic lost 3 of it's 5 Family Physicians (deployment, hardship, change of career field). Our Clinic Commander worked through TRICARE and arranged to have civilian providers available to provide care to the tremendous overflow of patients. Despite TRICARE approval of this, our senior leadership in Washington (MAJCOM) basically told our commander the following: "Either completely empanel those civilians just hired, or you will lose your military providers." Our commander also tried to open an urgent care center in an attempt to assist us, and again met with complete MAJCOM opposition. The system we now have, where leadership a thousand miles away denies the local leadership the tools necessary to provide safe and effective patient care must be changed.

D. APPROPRIATE PANEL SIZE. As stated earlier, inappropriate panel sizes are the foundation of our current problem. We should form a committee of civilian and military Family Physicians who can determine the correct empanelment for military physicians. Included would be contingency plans for deployments, military duties, physician extender supervision, and understaffed PCO teams. As a possible alternative to marked changes to panel size, have non-empanelled “float” providers and staff to fill-in for the 20-60% of personnel gone each day. At a minimum this should be 2 complete PCM teams.

E. DEVELOP A HEALTH CARE SYSTEM THAT ENCOURAGES PHYSICIANS TO STAY.
When physicians opt to leave the USAF after their initial obligation, much is lost. Physicians lose what may have once been a career goal (as in my case). The Air Force also loses, and perhaps more. By creating a health care system that is so blatantly “anti-physician”, they lose out on all of the 2 - 4 years invested in providers during which they learned to function within an ever-more complicated medical system. A new provider must learn how to do MEBs, Profiles, and navigate CHCS and PGUI (computerized patient health record programs). There are multiple training schools and pre-deployment requirements. I have already discussed the fact that physicians are out of clinic 17-18 weeks per year (conservatively). Much of this time would be eliminated if physicians stayed in, not to mention the USAF would have a better, more seasoned provider.

It is not the raising of physician payment bonuses that will change the current retention predicament. Physicians will not continue to be part of the current healthcare system no matter what viable pay increases are seen.

It is not a change to the current high probability of deployment environment either that will help. When I raised my hand and became an USAF officer I knew that I could be required to sacrifice my life for my country. That I fully agreed to. What I did not agree to was to serve in a healthcare system that endangers those I swore to protect and serve in another oath I took years earlier; those of my patients.

It will be the creation of a clinic in which the physicians have the opportunity and some measure of control to provide good health care and develop into even better doctors. It will be the execution of a plan that gives the opportunity to be both “warrior” physician and family physician and do both with excellence. These opportunities do not exist in PCO.

Many of the problems facing military physicians are also found in the civilian work place. This makes now the perfect time to improve the USAF clinics and encourage physicians to stay. Unfortunately, the Air Force has taken the worst attributes of non-military healthcare, and made them their own (10).

F. TRIAGE PATIENTS to CIVILIAN PRACTICES. Those patients with the most severe, complex, and unstable health conditions should be transferred to civilian doctors. There they may get better continuity of care. Additionally, most physician extenders are not prepared to care for these patients and they are very likely to be the ones covering when Physicians are deployed/out of clinic. They are also the most at risk should labs and diagnoses be missed. For clinics like ours (without a hospital), this would also provide for better post-hospital care.

G. CAPTURE THE UNCOUNTED. The thousands of Reservist and Non-DMIS patients that we have been seeing day after day need to get enrolled and count in our panel size. This should not be a passive undertaking. Do not wait for them to come to us. Find out who they are and get it done.

H. CHAIN of COMMAND. How is it that in a Family Practice Clinic, there are virtually no Family Physicians in my entire chain of Command? In fact, there are probably few to none in the entire chain of command going all the way to the Surgeon General. I have the utmost respect for those officers that currently and in the past served as my superiors. Some of the most outstanding people I have ever known are in my chain of command. However, at the very least, they are placed at a huge disadvantage at attempting to effectively run a clinic that is not their specialty. I am hard pressed to name any profession where the supervisors have NEVER performed the job of those they supervise, yet that is how our clinic is run. In our clinic, we have inexperienced nurses with the rank of Captain who are in the leadership positions over doctors with higher ranks of Major and Lt. Colonel.

I. SAFEGUARD SYSTEMS. We should implement plans and procedures to prevent the types of mistakes noted in the “Malpractice and Near Misses” section above. This would at a minimum include a way to track abnormal labs and imaging results. Patients should be notified of all their lab results, not just the abnormal. In addition, patients new to a clinic would have 30 minute "initial evaluation" appointments to allow some time to completely review and update charts. Charts also need to be upgraded in terms of completeness and organization. While our current chart system may be adequate most active duty personnel, it is nearly non-functional for our retirees. Dictation systems, if used, must be held to high standards of timeliness. Supervision, education, and training (especially for new physician extenders) must become a reality.

 

[The White Coat Investor]

Here is what I would like to see:

1. Abolishment of the GMO tour. "Doctor" implies a fully residency trained physician. If you have a situation where you need less than a doctor use a physician assistant or nurse practitioner.

2. Straight through training for all interns. Applying for a GME2 position in 1970 was how it was done but the standard for medical education in 2007 is straight through training. Anything else is unacceptable.

This would be an interesting concept...i.e. hire PAs/NPs as flight docs, GMOs, DMOs etc. There are a couple of problems I see with it. The first is that PAs are supposed to be supervised. I can assure you that GMO-equivalents are frequently in places where it would be a farce to consider them supervised. The other downside is that PA/NP training is not the same as med school + internship. I think an internship trained physician is intermediate between a PA and a residency-trained doctor. Per many of the physicians I have talked to who have done GMO tours, the assignments given to GMO-equivalents are generally perfect for the GMO level of training. Presumably, to me this would mean that a PA/NP would be in over their head much more often than our current GMOs are.

The straight-through training would be nice for the physicians, but it ignores the problem that the military has medical needs that are not served well by residency-trained physicians. Witness the Army vs Navy plan I discussed above.

3. Complete revamp of the physician pay system. No annual bonuses. Every physician would receive monthly bonuses based on specialty with no strings attached. None of this memo and approval red tape. Physicians must be paid at least the US annual average doctor's salary for their specialty.

5. Replacement of the all or nothing retirement system with 401K/TSP with matching.

I agree. The pay system could be easily changed. Pay out special pays on a monthly basis. Institute a TSP match or allow personnel to choose either the pension plan or the TSP match plan. Even a "mini-pension" for staying 10 years would be nice, although probably not politically workable. At any rate, I would like to see the retirement include medical special pays in its calculations. Of course, these changes require money, something that at times seems to be in short supply.

4. More physician power and autonomy.

I also don't agree anti-recruiting is the right choice. On the other hand, we can't enable the military to maintain a broken system. We have to be honest and set limits.

Generalizations don't help anyone. You've got to be more specific with your solutions. If docs want more power, they need to be willing to advance up the chain of command, which sometimes requiring severe cut-backs in clinical time. Military officers will never have the autonomy of their civilian counterparts. How would you like marines to have lots of autonomy? I can see it now:

"All right men, on the count of three we charge."

"No way man, can't we take a vote? Joe at the factory back home in Michigan never has to charge a machine gun nest."

Any viable solution must acknowledge that the military (and hence, our country) has some very real needs for medical resources.

 

[The White Coat Investor]

It is not the raising of physician payment bonuses that will change the current retention predicament. Physicians will not continue to be part of the current healthcare system no matter what viable pay increases are seen.

It is not a change to the current high probability of deployment environment either that will help. When I raised my hand and became an USAF officer I knew that I could be required to sacrifice my life for my country. That I fully agreed to. What I did not agree to was to serve in a healthcare system that endangers those I swore to protect and serve in another oath I took years earlier; those of my patients.
.

While I applaud the sentiment here, let's get real. There are a lot of people willing to work in USAF clinics when the pay is higher and the likelihood of deployment is lower. They are called contractors, and I work with 5-6 of them, all of which are happy with their job. You really don't think we can hire people willing to work in the current clinic environment for $400,000 (insert whatever figure you want here) per year? You're fooling yourself. The clinics are in bad shape, but not that bad.

H. CHAIN of COMMAND. How is it that in a Family Practice Clinic, there are virtually no Family Physicians in my entire chain of Command? In fact, there are probably few to none in the entire chain of command going all the way to the Surgeon General. I have the utmost respect for those officers that currently and in the past served as my superiors. Some of the most outstanding people I have ever known are in my chain of command. However, at the very least, they are placed at a huge disadvantage at attempting to effectively run a clinic that is not their specialty. I am hard pressed to name any profession where the supervisors have NEVER performed the job of those they supervise, yet that is how our clinic is run. In our clinic, we have inexperienced nurses with the rank of Captain who are in the leadership positions over doctors with higher ranks of Major and Lt. Colonel.

Let's be realistic. There are no FPs in your chain of command because there are no FPs who are willing to do it or who have the requisite experience to do it. If they all bail after 3 years, how can they be made squadron commander? Sure, it would be ideal to have physicians as flight commanders, squadron commanders, and group commanders; but this requires physicians to take the job when it is available too. And it isn't always a very fun job. If physicians are willing to lead and are then passed over, that is a different story. In my med group, there are physicians willing to lead and they do lead, but they don't necessarily understand my specialty-specific needs. That is up to me to explain to them.

Otherwise, I think you have lots of great suggestions.

 

[USAFdoc]

While I applaud the sentiment here, let's get real. There are a lot of people willing to work in USAF clinics when the pay is higher and the likelihood of deployment is lower. They are called contractors, and I work with 5-6 of them, all of which are happy with their job. You really don't think we can hire people willing to work in the current clinic environment for $400,000 (insert whatever figure you want here) per year? You're fooling yourself. The clinics are in bad shape, but not that bad.



.

1)I agree with you, but, you missed a key word in the paragraph........ "viable".

2) yes, you would have people lined up to make 400K per year. But that is NOT an viable option. Truthfully, I would not have stayed there in that "environ" for 150K, 200K, 250K..........yes, as the number goes up, so does how much you may sacrifice. But there is no viable $$$ that would get a FP to work in the conditions I saw. And in 10+ years at that clinic, the retention rate is ZERO% (although 2 docs did stay to go admin).

3) my opinion is that if nothing else changed in my clinic except I got the going civilian FP salary (about 150K), I would not stay, and neither would anyone else.

4) In my clinic we had 8 of 9 civilian hires quit/leave over 2 years.
5) 100% of civilian nurses resigned/quit over 2 years.

 

[Galo]

Having "lurked" on this forum for years, I am quite aware of the various problems with military medicine and the complaints of its physicians. I have spent a great deal of time reflecting on the possible solutions to these problems, but I don't think the one occasionally espoused here is going to work...i.e. Let the system collapse so someone will fix it.

There are three main areas of difficulty within the military medical system:

1) Recruiting

The military cannot recruit enough physicians to do what it wants its physicians to do. Although it is possible that this will change, I think it is unlikely. The military needs a lot of battalion surgeons, flight surgeons, GMOs, DMOs etc. Few people want to pursue these fields of medicine as a career. It also needs a fairly large number of residency-trained primary care physicians and a limited number of specialists. It has the difficult task of having two separate missions, a war-time mission and a peace-time mission. Unlike pilots whose peace-time mission (training to fight) ends when they are deployed, physicians simply tack on the war time mission to what they are already doing. For instance, the Air Force has too many surgeons and emergency physicians for its peace-time mission, yet too few for its war-time mission. The manner in which the military recruits physicians (by selecting pre-med students who have no idea what field of medicine they want to go into), causes great conflict because it pits the needs of the military with the desires of its physicians.

Recruiting is also harmed by the current ops tempo. More people sign-up for HPSP/USUHS when our nation is at peace. Although just about everyone signing up for the military is aware he may be called upon to deploy, it seemed much less likely ten years ago than today. The risk of multiple inconvenient deployments and the very real risk of death or disability certainly makes recruiting difficult.

The current HPSP scholarship format works against military recruiting efforts. The stipend is too low for most students to live on without additional sources of income. The stipend is not indexed to the cost of living of the area where the student attends school. The scholarship also works against students who opt to attend a less expensive school. A student attending an expensive DO school is much more likely to take the scholarship than one attending a cheap state-school. Perhaps if the scholarship was for a set amount we could recruit more of those students attending state schools, and they could use the money not required for tuition to pay for living expenses. There is also no incentive for someone with prior service to take an HPSP scholarship as it provides no significant bonus for prior service.

The military match system works against military recruiting efforts. This is perhaps the single biggest downside of the HPSP/USUHS scholarships. The chances of not being allowed to train to do what you want when you want to do it are simply too high to not affect recruiting of pre-med students who are aware of this problem. Our current solution of trying to hide it from them only alienates and angers our physicians. This problem is closely related to the fact that we have not recruited the types of physicians we need. There are several solutions to these problems:

The first, which the Navy is currently doing, is to use minimally trained (internship only) physicians as GMOs, DMOs, and flight docs and then send them back to residency. While it has the added bonus (from a military perspective) of generally lengthening commitments and thus encouraging (forcing?) more officers to stay in, it demoralizes physicians, endangers patients, and hurts recruiting.

The second, which the Army is currently doing, is to allow (somewhat at least) physicians to train in their selected field, and then deploying them as a battalion surgeon or the equivalent, no matter what their training. The upside is that physicians get to train immediately after med school, make more money, and can get out faster (upside for the doc's morale); the downside is that it is extremely demoralizing to the physician and possibly endangers patients to deploy certain specialists and subspecialists as GMO equivalents.

The solution I would like to see implemented is to encourage physicians to undertake a GMO tour voluntarily. This can be done by allowing physicians a significant degree of choice in assignments and by providing a financial incentive to take them. Instead of paying GMOs less than everyone else, perhaps we should pay them MORE since that is what we as a military want more of. Alternatively, or possibly in addition to this solution, we could allow years spent in GMO service to count as payback for a residency-associated commitment not yet acquired, perhaps at a rate of 1 year per two years served. This way, a 4 year HPSP student who did 2 years of GMO time prior to a 3 year anesthesia residency would only owe 2 years active duty time after residency.

Another solution I would like to see implemented is to specifically recruit those pre-med students who are mostly likely to want to serve as GMOs, DMOs, and flight docs as well as those most likely to want to stay in until retirement. We really need to focus on prior service applicants and others who express interest in these unique aspects of medicine. Giving a larger HPSP stipend to prior service personnel would send the right message. Advertising the "cool" aspects of GMO-equivalent service would also help. Flying off carriers in F-18s, serving as a special forces doc, or being the only physician on board a ship is an aspect of medicine that appeals to some people. We need to find these people and recruit them specifically, so that those who do not want to do it are not forced to.

Additional recruiting emphasis (and financial incentives) needs to be used to recruit current residents and staff-level physicians. Increasing the FAP stipend and signing bonuses would help.

2) GME

Military GME programs do some things very, very well. They generally do a nice job with academic type issues. The residents tend to be mature and well-read, do excellent research, and perform well on board exams. Many programs however, struggle with having sufficient pathology to train their residents adequately in managing difficult patients and performing adequate number of procedures. Residents are also saddled with the hassles of military service (PT testing, CBT etc) and faculty are not infrequently deployed or recovering from deployment. It is difficult to teach and do research when spending time in Afghanistan or Iraq.

The solution to this problem involves outsourcing GME to the civilian sector. Many military programs partner with nearby civilian programs to provide these experiences. This needs to happen more frequently, to the point where residents spend more time away from the MTF than they do at the MTF. A more extreme solution is to abolish the military GME system altogether, perhaps while still maintaining military-specific internship programs for those interested in GMO-equivalent jobs. Although it would be difficult to abolish the military match completely, it would sure help recruiting if we could make it simply a formality, rather than a life and career changing event.

3) Practice-related problems

There are a number of irritating problems that cause our physicians to get out of the military. Many of these are caused by the inherent difficulty imposed by a military medical model which requires critical care and surgical skills for the war-time mission without providing a mechanism to maintain these skills at the peace-time job. The solution to this particular problem is to consolidate military treatment facilities so that all of the surgeons, emergency docs, anesthesiologists etc are working at facilities where they can better keep up their skills. Moonlighting in the civilian arena needs to be not only allowed, but expected and provided for.

Physicians also complain about being led by non-physicians in some cases. While better recruiting and better retention are the ultimate solutions to this issue, policy changes requiring physician leadership are also effective, at least in the short term.

Dealing with Tri-care is irritating and embarrassing for military physicians. We tire of apologizing to our patients for our inept system. The current debacle at Walter Reed regarding the bureaucratic problems (not the trivial aspects such as mold and holes in dormitory walls) could just as easily have been about Tri-care. Tri-care needs to be made into a preferred insurance company for our patients as well as community doctors. This will require a lot of money and good leadership, but is certainly do-able. There are many HMOs in the country that provide good care and good value for the dollar. Tri-care is not one of them.

Lack of control over aspects of clinical practice frustrates many docs. Being forced to use a poorly designed and implemented electronic medical record (AHLTA anyone?) is just one example of this. Every specialty has their own unique problems that can be solved if the leadership cared to do so. These problems are often quite solvable with the right leader.

Doctors also complain of poorly trained nurses and techs and simply not having enough of them. High-clinical-quality, experienced nurses are unlikely to stay in the military when there is so much more control over their hours and so much more pay outside the military. A nursing special pay system would help, as would aggressively recruiting and retaining those who enjoy and thrive in the military environment.

Drastically increased patient panels and long hours drive out many good primary care specialists. Perhaps if we paid ISP that indicated we actually valued their training they would be willing to stick around a little longer. With improved retention and recruiting in these fields, the patient panels would be more manageable, and the hours more reasonable.

Poor leadership and an increased focus on metrics irritates many physicians. As we work to recruit and retain our best physicians and move them into leadership positions, we will be better equipped to only focus on those numbers that matter.

Finally, many physicians get out simply for financial reasons. Why do we expect to retain physicians willing to put their life on the line and separate from their family for 4-12 months at a time for 40-80% of the pay they can make in the civilian world? Shouldn't these physcians make MORE than their civilian counterparts? Want quality physicians in the military? If you raise the pay enough we'll be able to pick and choose who we take.

In summary, the military offers several very real benefits...a way to acquire medical training with minimal debt, serve our great country, enjoy a fantastic patient population, have less professional liability, and to focus less on the business aspects of medical care. At this time the negatives of military service outweigh the positives for far too many people. But I have come to believe that the solution to the problem is not to hurt recruiting by discouraging all pre-meds from accepting military service, but rather to specifically encourage those who will thrive in and enjoy the military environment and to make changes to recruit and retain trained physicians by aligning their pay with the civilian world and providing them with the best possible work environment, both for the peace-time and the war-time missions. This will require a lot of money, effort, and political capital, but after watching the Walter Reed Scandal play out, I think Americans believe that our military personnel deserve the best medical care money can buy. Let's see if they'll put their money where their mouth is.

ActivedutyMD,

Thank you for your excellent post. Please do not take this as an insult, but I highly doubt you are in a surgical subspecialty. The level of frustration I experienced was impossible to do anything but survive in.

You have a huge number of excellent points, but unfortunately you say yourself why none of this will ever work, and I think the bottom line is the almighty DOLLAR. The military is the military, it will never change its command structure, and this is one of the main reasons military medicine is destined to fail. It is systematic to take a physician nearing or at the peak of their career, and steer them away from medicine towards management. This invariably selects out physicians who are not only poor physicians, but also extremely poor leaders who continue to ascend in leadership power and incompetence.

Everything you have written has been written before by many of us hundreds of times. Whether on the waste of time "climate assesment" form which I think were recycled into toilet paper, or the multitude of IG complaints, or letters of resignation, or speaking out at commander calls, all of these issues have been discussed before, because they make sence. They would completely change the face of military medicine. But to quote a past surgeon general, "change in the military is GLACIAL".

Please do not misunderstand my cynicism, its definitively not pointed at you or your excellent points, its obtained from living in a system for 6 years that continually showed me that striving for excellence was a punishable offence, but mediocracy, stagnation, and blind obedience was rewardable.

Unfortunately the only place where we separate is that I firmly believe until the system runs out of bodies, nothing will change, and it will only continue to get worse.

What's sad to me is that the Walter Reed thing is nothing new. Its the status quo, and MO for current military medicine, and as much as its in the news, it will be replaced by another Nicole, or Brittany while our soldiers continue to languish in third rate medicine. That is SAD!!

 

[The White Coat Investor]

1)I agree with you, but, you missed a key word in the paragraph........ "viable".

2) yes, you would have people lined up to make 400K per year. But that is NOT an viable option. Truthfully, I would not have stayed there in that "environ" for 150K, 200K, 250K..........yes, as the number goes up, so does how much you may sacrifice. But there is no viable $$$ that would get a FP to work in the conditions I saw. And in 10+ years at that clinic, the retention rate is ZERO% (although 2 docs did stay to go admin).

3) my opinion is that if nothing else changed in my clinic except I got the going civilian FP salary (about 150K), I would not stay, and neither would anyone else.

4) In my clinic we had 8 of 9 civilian hires quit/leave over 2 years.
5) 100% of civilian nurses resigned/quit over 2 years.

I think the clinic you were in was in worse shape than the average USAF primary care clinic is in currently. The FPs at my facility don't have much to complain about as far as total hours worked. I am curious as to how much you were paying those 8/9 civilians. Do you happen to know?

 

[IgD]

USAFDoc I think most of your points are to non-specific. The military could say it is already doing the things you mentioned.

I would like to add to my original list:

1. Abolishment of the GMO tour. "Doctor" implies a fully residency trained physician. If you have a situation where you need less than a doctor use a physician assistant or nurse practitioner.

2. Straight through training for all interns. Applying for a GME2 position in 1970 was how it was done but the standard for medical education in 2007 is straight through training. Anything else is unacceptable.

3. Complete revamp of the physician pay system. No annual bonuses. Every physician would receive monthly bonuses based on specialty with no strings attached. None of this memo and approval red tape. Physicians must be paid at least the US annual average doctor's salary for their specialty.

4. Work / productivity standards designed to safeguard patients and physicians. For example 1 primary care physician per x number of patients. Set work hours and call limits. No more we need a new doctor but its not logistically possible.

5. More physician power and autonomy. Can't think of a way to make this less vague?

6. Replacement of the all or nothing retirement system with 401K/TSP with matching.

 

[USAFdoc]

USAFDoc I think most of your points are to non-specific. The military could say it is already doing the things you mentioned.

I would like to add to my original list:

1. Abolishment of the GMO tour. "Doctor" implies a fully residency trained physician. If you have a situation where you need less than a doctor use a physician assistant or nurse practitioner.

2. Straight through training for all interns. Applying for a GME2 position in 1970 was how it was done but the standard for medical education in 2007 is straight through training. Anything else is unacceptable.

3. Complete revamp of the physician pay system. No annual bonuses. Every physician would receive monthly bonuses based on specialty with no strings attached. None of this memo and approval red tape. Physicians must be paid at least the US annual average doctor's salary for their specialty.

4. Work / productivity standards designed to safeguard patients and physicians. For example 1 primary care physician per x number of patients. Set work hours and call limits. No more we need a new doctor but its not logistically possible.

5. More physician power and autonomy. Can't think of a way to make this less vague?

6. Replacement of the all or nothing retirement system with 401K/TSP with matching.

quite frankly, you could write a small book on just about every aspect of how the system is broken. My list is not meant to be a step by step connect the dot "milmed for dummies" (although that is probably what is needed)

the point is that there are unacceptable problems. Problems that have been around for years, and problems that will not be fixed with the same current "design" of milmed, and command structure of milmed. Thank God that those problems do not effect me personally anymore, but if there is anything good I can do to get the leaders of milmed off their status quo and improve things for milmed patients and staff, I 'll do it.

 

[IgD]

I think if we are serious about reform we need to come up with about 10 very brief and specific points on how to fix the system and advocate for that.

 

[Galo]

I think if we are serious about reform we need to come up with about 10 very brief and specific points on how to fix the system and advocate for that.

To whom??

You can see where the Walter Reed thing goes as it is being investigated at the highest levels of goverment, and then see what chance our ten points have of ever happening. Realize some of those points totally deviate from military doctrine/tradition/structure!

You have chosen optimism and I applaude you for it since you are now in the system and realized that there is much that needs to change. Unfortunately for those of us who lived in it before you, much of all these suggestions have been made. Maybe not to the right person, but then I ask again, to whom?? Who has the power to make all these changes??

 

[Re3iRtH]

**post deleted**

 

[resxn]

As I've said in previous posts, when I started at my base 2.5yrs ago, there were 9 surgeons, today there are 5, and when I leave in 4 months there will be only 1. Why? Not from PCSing but from separating b/c they HATE their jobs in the military. Not because of deployment, not because of the pay (although it isn't fantastic) but because of this simple microcosm of the whole picture:

At our MDG Commander's Call soon after the Holidays, our commander stood on stage and asked us to shout out our New Year's resolutions. Many of the enlisted shouted out the things you might expect. One of our 2 orthopods stood up and said, "Sir, we in orthopedics have resolved to do more with less." He got a standing ovation--mostly from the other docs who nearly tripped over themselves applauding his gonads for saying it.

But that's it. We're asked to do more than we can with less than we should have.

We are rewarded with knowing we served, avoiding some of the business aspects of medicine, and having great patients. However, for most of us it's not enough.

I've requested and have been granted the opportunity by our MDOS cc to have him come to a meeting with the departing surgeons (4/5 remaining) so that we can list those reasons why we're leaving and what we think would need to change to make it tolerable. Our MDOS commander is a great one, the first great leader I've had in my local chain of command since being on AD. He'll listen and he'll care, but he can't do anything about it. He can compile the list and send it up the chain, but what would happen? Maybe somebody will get early (if being an O-7 with 28yrs in is early) retirement in an attempt to "send a message."

Look, this machine is too big to just retool. It needs to be disassembled and completely reassembled by those involved who care about their patients and not their rank. It needs to be complete from top to bottom and needs to involve not only the medical groups but the TriCare system as well. Whether that begins with a unified medical service, a Walter Reed like scandal DoD-wide, or a simple quiet involution, it doesn't matter. It's really the only way something meaningful can take place. Above all it has to be a patient-advocate system. Not an administration-advocate system, not a doctor-advocate system.

Witnessing this machine from both the outside as a civilian-trained MD and now as an AD soon-to-separate surgical specialist, I can honestly not envision meaningful change without a complete and total rewrite.

 

[kzjonez]

I have a short solution to the problem. The solution has been already proposed but shot down already by people that thrive in the status quo.The solution would be a separate Medical Command with a structure more like the civilian side even seeing civilians that pay a premium for our services/insurance.This would mean building a system from the ground up. That is the only solution I see to this problem.

 

[IgD]

I have a short solution to the problem. The solution has been already proposed but shot down already by people that thrive in the status quo.The solution would be a separate Medical Command with a structure more like the civilian side even seeing civilians that pay a premium for our services/insurance.This would mean building a system from the ground up. That is the only solution I see to this problem.

I don't think creating a separate medical command is the answer. It is just going to create more red tape and friction between the line and medical corps.

 

[kzjonez]

I don't think creating a separate medical command is the answer. It is just going to create more red tape and friction between the line and medical corps.

That's just it. It can be build without most of the red tape from the current system. As for friction with the line side; If we are are separate and don't depend on a budget controlled by the line side, there is less chances for problems. They won't see us as draining "their" resources since we are not part of them.The will only have to ask for medical support and we are entrusted with delivering it.I also think we would benefit from providing care to civilians, by doing this we will be bringing some income into the system, improving quality of and quantity of medical pathology exposure instead of just draining money out of a budget that is already squeezed tight by the line side.

 

[orbitsurgMD]

That's just it. It can be build without most of the red tape from the current system. As for friction with the line side; If we are are separate and don't depend on a budget controlled by the line side, there is less chances for problems. They won't see us as draining "their" resources since we are not part of them.The will only have to ask for medical support and we are entrusted with delivering it.I also think we would benefit from providing care to civilians, by doing this we will be bringing some income into the system, improving quality of and quantity of medical pathology exposure instead of just draining money out of a budget that is already squeezed tight by the line side.

The system worked better when it actually was a system. Piecemeal disassembly and spinning off of segments of the patient population has resulted in a smaller, incoherent and increasingly incapable medical care system for not just the retirees--now just about gone--but increasingly for the active duty as well. When the military medical care system had a full range of patients in the active duty population and among retirees, the quality of training was better and the amount of opportunities for doctors to train within and remain within the medical system was better. Research was possible, residency and academic opportunities were more plentiful, and retirees sought care within the system as it was both familiar and inexpensive. The devolution of military medical care has led away from all of these things and has diminished the educational value of military practice experience and now--inevitably--made recruitment and retention difficult. What is surprising is the amount of head scratching by the leadership at this outcome; it should have been obvious.

A separate military medical service, if under-funded, won't do any better than service specific corps do now. If consolidation is to be considered, then it is worthwhile looking at the other large federal medical care service, the DVA, to see whether their administrative costs are any less. Some allowances would need to be made for the absence of active-duty age patients and the needs for OB, GYN and Peds support that the military has but the VA doesn't. I suppose there is some merit to keeping the line away from medical at least as concerns funding. But that aspect of management could be accomplished without the purple suits by making the budgetary and appropriation channels straight from the secretary level at DOD, apart from the line funding sources, and directly under DOD civilian authority.

 

[BomberDoc]

Military medicine needs to be COMPLETELY abandoned. Enroll everybody at the nearest civilian hospital. They will get better care, better continuity, and have residency trained docs. For the DMO, FS, and deployment type jobs, use the money saved by dismantling milmed to pay outrageous sums to contractors. This will keep people coming back to these jobs and keep them full. There should be zero active duty medical personnel. Every day I am disgusted by the fraud, waste, and abuse that is the milmed system.

 

[BKK]

Military medicine needs to be COMPLETELY abandoned. Enroll everybody at the nearest civilian hospital. They will get better care, better continuity, and have residency trained docs. For the DMO, FS, and deployment type jobs, use the money saved by dismantling milmed to pay outrageous sums to contractors. This will keep people coming back to these jobs and keep them full. There should be zero active duty medical personnel. Every day I am disgusted by the fraud, waste, and abuse that is the milmed system.

That's nice....How do you propose to care for the troops deployed with these high proced mercenary docs?

 

[island doc]

Per many of the physicians I have talked to who have done GMO tours, the assignments given to GMO-equivalents are generally perfect for the GMO level of training.

Bullcrap. "Generally perfect for the level of training" is the last way a GMO feels working ALONE in an emergency department. All because the military is too cheap to hire someone prepared. Just goes to show how little they actually care about the patients.

 

[The White Coat Investor]

Bullcrap. "Generally perfect for the level of training" is the last way a GMO feels working ALONE in an emergency department. All because the military is too cheap to hire someone prepared. Just goes to show how little they actually care about the patients.

Obviously working a single coverage ED is outside the scope of a GMO. I think that is the exception rather than the rule.

 

[orbitsurgMD]

Obviously working a single coverage ED is outside the scope of a GMO. I think that is the exception rather than the rule.

No, that is the rule, not just the exception.

And there is no excuse for it either way.

 

[Gastrapathy]

No, that is the rule, not just the exception.

And there is no excuse for it either way.

I struggle with the GMO question. The notion that we can "just hire NPs and PAs" to fill these roles is a fiction. There are hundreds of GMO billets in the Navy and there really isn't a supply of NPs and PAs waiting to take those jobs. So, then the question becomes, what is the standard of care that a physician should be expected to provide and how do we balance that with the realities of the situation.

I think that there probably is more than one standard of care. The standard of care for a combat zone under fire during a mass casualty is different than that expected in a CONUS ER. GMO's, in my view, cannot meet the latter standard reliably (myself, at that time, unquestionably included). However, they probably can provide ATLS and do okay with the former standard.

Second, if we abolish GMO tours, who fills those billets? The answer is the generalists, who already deploy a ton. This would simply destroy FP/IM/Peds and you can see the effect in the AF, where they have done away to some degree with GMOs. The current system shares the load of the operational billets with our future radiologists, otolarygologists, etc.

I tend to see GMO tours as an operational necessity. But I would never, ever put a GMO in a clinic, hospital or ED.

 

[orbitsurgMD]

I struggle with the GMO question. The notion that we can "just hire NPs and PAs" to fill these roles is a fiction. There are hundreds of GMO billets in the Navy and there really isn't a supply of NPs and PAs waiting to take those jobs. So, then the question becomes, what is the standard of care that a physician should be expected to provide and how do we balance that with the realities of the situation.

I think that there probably is more than one standard of care. The standard of care for a combat zone under fire during a mass casualty is different than that expected in a CONUS ER. GMO's, in my view, cannot meet the latter standard reliably (myself, at that time, unquestionably included). However, they probably can provide ATLS and do okay with the former standard.

Second, if we abolish GMO tours, who fills those billets? The answer is the generalists, who already deploy a ton. This would simply destroy FP/IM/Peds and you can see the effect in the AF, where they have done away to some degree with GMOs. The current system shares the load of the operational billets with our future radiologists, otolarygologists, etc.

I tend to see GMO tours as an operational necessity. But I would never, ever put a GMO in a clinic, hospital or ED.

I don't see the logic in your conclusion. If you must put a physician in a resource-constrained environment, it makes sense to use one with more training and experience rather than one with less. If what you are saying is that the best person is a provider with less training than a physician, then the answer should be corpsmen.

The military services need someone to see sick call and someone to do physicals and someone to do emergency treatment. Sick call is already screened in many places by corpsmen, and on subs is solely screened by independent-duty corpsmen, a solution the military sees fit to apply to some of its most valuable assets. I suggest this is under-utilized.

Forward deployment of physicians should be an assignment for residency-trained physicians. Making it a professionally satisfying assignment may never be possible, but there are reasonable ways to make the burden less painful for those tasked. Tying preferred follow-on assignments to forward duty, preferred selection for additional professional training such as fellowships, reducing repayment obligation and increasing special-duty bonus payment are all instruments that could be used as incentives to seek these assignments.

It is the basic honey vs vinegar idea. The military has never been sufficiently creative in this effort, and they have no one but themselves to blame for the situation of declining HPSP enrollment when the purpose of that program has become merely a ready source of young physicians the military feels entitled to abuse.

 

[Gastrapathy]

Forward deployment of physicians should be an assignment for residency-trained physicians. Making it a professionally satisfying assignment may never be possible, but there are reasonable ways to make the burden less painful for those tasked. Tying preferred follow-on assignments to forward duty, preferred selection for additional professional training such as fellowships, reducing repayment obligation and increasing special-duty bonus payment are all instruments that could be used as incentives to seek these assignments.

quote]

These are fair criticisms but the burden on these communities would be so great that you can't give everyone preferential treatment. "Preferred follow-on assignments, etc" can't work if they are owed to everyone multiple times over. I also disagree with the premise that if you can't have a residency trained physician, then all you need is an IDC. I've worked with quite a few IDC's and there is clearly a difference in the quality of care the average GMO provides compared to an IDC. This is admittedly an intermediate standard compared to what one expects of a residency trained primary care physician and that is why I struggle with this.