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.