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When did the trouble start?

Discussion in 'Military Medicine' started by BigNavyPedsGuy, Apr 13, 2007.

  1. BigNavyPedsGuy

    BigNavyPedsGuy Junior Member

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    So any regular on this forum knows that there are problems with milmed that seem to have a negative inertia. But I know that many refer to a time when it was good. The doc I talked to before signing up really liked it (orthopod got out mid 90s). I've heard other people refer to the 90s as a positive period.

    As part of my quest to be informed: when did the trouble start? I've heard Rumsfield is to blame. Was it actually much better 10-15 years ago? Does that have to do with the Commander in Chief or SecDef at the time?

    I'm really not trying to start a political debate. I'm trying to get an accurate picture of current events/recent history/policy evolution.

    When did the trouble start?
     
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  3. HumptyDumptyMil

    HumptyDumptyMil Almost done...

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    It's scary and hopeful at the same time if indeed, things can change so much in milmed in 10-15yrs. Scary b/c of the unpredictability. Hopeful b/c the pendulum can swing from the current bad situation to the good situation by the time I start my payback. I still believe everything in this world is in balance, so if things are bad now, they should become better. Hopefully by the time I enter the field. :thumbup:
     
  4. delicatefade

    delicatefade ASA Member

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    I'd say late 90's was when it started to get bad. All the docs I have spoken to that were in before that time period were pretty happy with military medicine.
     
  5. mitchconnie

    mitchconnie Member

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    From my perspective in the AF, the big decline started in the mid-90’s when I was an MS4—PGY1. This was the period when Tricare began and our whole military healthcare paradigm changed. Before that, the Air Force tried to run a comprehensive, cradle-to-grave healthcare system, which took care of nearly all its beneficiaries in-house. There was a large network of smaller hospitals which referred a complex care to the larger med centers—robust institutions with a high volume of complex cases from all over the country and the world. In the Early 90’s, places like Wilford hall, NNMC, and Walter Reed were massive 700-1000 bed hospitals. Then post-Tricare, the priorities shifted to cost-control, and providing essential medical services to active-duty personnel. Smaller hospitals were shuttered and non-active-duty patients were increasingly sent to civilian providers. Referrals to the major medical centers dried up, and they downsized accordingly—becoming essentially mid-size community hospitals. Once-busy hospital wards were turned into offices for managers who handled the Tricare contracts. At the base where I was stationed, we went from a 250-bed hospital with CT surgery, Interventional cardiology, oncology, etc; to a 30-bed “super-clinic” with minimal subspecialty services. This took place over a four-year period from 1996-2000. The Air-Force seems to be out front with the whole downsizing program, so I suspect that the Army and Navy started later. The war seems to have accelerated the downward spiral, but it began well before 9/11.
     
  6. megadon

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    It was during the wonderful Clinton years, when we shot all our Tomahawk missiles and weren't given the money to replace them.
     
  7. Ex-44E3A

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    I'm no Clinton fan-boy, but you can't lay all the blame on him. It couldn't have happened without the assistance of congress.
     
  8. orbitsurgMD

    orbitsurgMD Senior Member

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    Before Clinton. Try Reagan and then Bush I, the patron saint of modern conservative economic administration. It was during the 1980s that the military started disallowing retirees access to the military medical system and sending patients out permanently on CHAMPUS. The academic departments started cutting back on training slots as case numbers dwindled and meeting ACGME and specialty society training standards became an issue. This was also the time when DOPMA legislation took effect making the required number of years to meet a retirement minimum longer and pay for military doctors lower, calculated on a reduced number of years of creditable service. As fewer training slots were available, longer service requirements as a GMO became the rule; it used to be only one year. This was also the time of closing of several long-established military medical centers ( Letterman Army MC, Oak Knoll Naval Hospital,) and the significant closure of many bases in some areas of the country, particularly California.
     
  9. a1qwerty55

    a1qwerty55 Attending

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    There once was this unwritten understanding that the discrepency in pay between military physician and civilian pay was offset by professional and personnal benefits of military service. For example, work hours were generally less, hassles (insurance, billing etc) less, and the system worked much like a traditional academic medicine system with time for CME, GME and research.

    Then the HMO craze started becoming the norm in the civ sector so the government started to try to apply civilian performance metrics on military providers with providing them with any of the resources and incentives that HMO's provided their docs.

    Roughtly the same time the bean counters figured, hey let's unload the retirees - and make them use medicare and go civilian - not a good move for residencies or for subspecialists who need old people with old people diseases.

    They started collecting bogus metrics ala UCAPERS, RVU's, whatever which were based on totally erroneous data. With flawed data, they started to cut positions since it was so apparent to them that we (military docs) were a bunch of inefficient dolts. Panels increased, and life got really bad for the primary care docs in particular. Time for research disappeared and lifestyles were degraded....

    JCAHO then became this plaque that appeared and administrative requirements went through the roof. As we increasingly lost sight of the real mission PATIENT CARE, we started to alot days for sexual harrassment training, Consideration of other training, NO FEAR training, Ethics, Customer service, Sex abuse responder training, HIPAA, CBRNE and a zillion other training requirements which only served to degrade patient care further. We have closed my clinic several times this year to try to get this generally useless training accomplished.

    Guess what? The "benefits" of military service - quality of life, access to training, research etc, disappeared and people started to head for the exits. The exodus wasn't really noticed because we had like 8 years worth of docs in the pipeline either in residency, or obligated through HPSP or USUHS. Adding the "War on Terror", to the mix further demoralized staff especially as deployment decisions were in many ways not equitable, and the increased workload required on nondeployed staff ballooned. Then, more headed for the exits (more than could be filled by HPSP and USUHS accessions). Add to that the decrease in HPSP enrollment in the past 2 years and in 4-5 years you face a cataclysmic collapse in the system.

    So where are we? In a very bad place.

    Attempts to privatize military healthcare or high civilian contractors is almost uniformly a failing enterprise. Let's face it, the civilian job marked it very tight and pay higher there, so who do we end up hiring? A bunch of FMG's who have no buy-in to the system and don't feel any particular ownership or appreciation for the military beneficiary.

    I wish I had reason to be more optimistic but our rating systems do not allow for the best and brightest to become policy makers and GO's, thus in some respects the crap floats to the top. Lastly because we do not have a seperate funding stream distinct from that where beans and bullets are procured, there will always be attempts to raid medical funds to support ongoing combat ops - further degrading care and morale.

    My solution - a unified medical command, a competely seperate budget stream, a rating scheme which is based on clinical skills/excellence, bedside manner, in addition to administrative skills. Protected and dedicated funds to each doc for CME. Reasonable work hour guidelines, taking into account mission creep - "do more with less".
     
  10. BigNavyPedsGuy

    BigNavyPedsGuy Junior Member

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    I know this got shot down recently, and is a perpetual rumor. But is there any chance this will actually come to fruition?

    Great posts everyone, it's really provided a lot of insight. Please keep them coming.
     
  11. Sgt Whizzo

    Sgt Whizzo Male Member

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    a1: That is clearly an insightful analysis which should be thoughtfully considered by decision makers. Problem is, far as I can tell, the current mil med leadership seems to have blinders on and has sold out to concerns other than realistic analysis and correction of problems in milmed. I have seen too many commanders at all levels accept ridiculous deployment taskings, budget changes, and manning documents rather than speak up that something is going to break. As I told some of my colleagues...as far as I can tell, primary care docs will work under a progressively more futile system...commanders will continue to focus on achieving their metrics whatever the cost and the cost will be that the doctors and ultimately the patients get "broken". We will break before the system is exposed as failing. As long as primary care guys carry the system on their backs and commanders get their metrics, things will merrily continue to spiral down. We don't seem to have visionaries who are willing to put their necks out and say that AHLTA was a waste (time to cut our losses?), that the way our MTF's are run is not in the best interest of readiness, quality patient care, retention, etc.
    Thanks for sharing your perspective on how we got here.
     
  12. Galo

    Galo Senior Member
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    A very well written description of the decline of military medicine, and the increasing likelihood that it will get worse before it gets better.

    What I am wondering is why one of the staunchest advocates of military medicine since he joined this forum is so carefully describing its massive failings? Are we getting the same treatment/experience IDG got?
     
  13. Ex-44E3A

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    Wondered that myself, Galo. Isn't this the same A1 who refers to the ex-military docs on this forum as "carping bitches?"

    What gives, A1? Do you just enjoy playing devil's advocate as a rhetorical game, or do you actually believe what you just wrote? Sometimes I wonder if you're not a couple of people using a common account... you're like the Beaumont/Stark character from Stephen King's "The Dark Half."
     
  14. Galo

    Galo Senior Member
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    Seems that all who start out with this rosy ideal of what they expect, or been told, or believe milmed should be, and defend it to the death lots of times without even having experienced yet, will eventually come around once they get a taste of incompetency and the insidious apathy of mediocracy. IDG now seems perfectly able to tell what he is experiencing, and does not like it. I remember that jail cage feeling, and it almost drove me nutty, no it did. I remember when I got out, I felt like a two ton weight had been lifted of my chest. I still experience alot of anger when I think about it, but this forum has been so cathartic. I just want people to know what they are getting into in this day and age when it comes to military medicine.

    Its the LtCol, and above, that have just become too tainted, and do not even realize it. But I guess the ovious comes to all at some point. It must be a real sad epiphany to wake up one day and realize that you are helping to perpetuate the crap that milmed has become, (I am not addressing this to anyone specific, so this is not a personal attack).

    I think one of the most important and relevant points A1 made was how because of attrition "crap floats to the top." That is unfortunately such a true statement, (with rare exeptions), and its one of the main reasons that leadership has become so disconnected with whom they are responsible for.

    Keep ON!!
     
  15. a1qwerty55

    a1qwerty55 Attending

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    I think I have been very consistent in my posts .. at least the sober ones.

    Believe me, my earlier posts have alluded to my own frustrations and dissappointments with the system. I have never taken the tack that the military is a great place to practice medicine. It is however a very important place to practice medicine.

    I have tried to make the fundamental point that as the system is essential to national security and the welfare of about a million sons and daughters of this great country. We all can't just opt out of participating. I also would argue that we have always had a dysfunctional bureauocracy since the dawn of US military medicine. Just look to history, of how underfunded, and poorly administered military medicine has been at just about any time period.

    I have seen things change albeit in small yet tangible ways and usually not system wide. With that frame of reference I have attempted to point out the inconsistencies of most other posters here, extolling HPSP applicants not to join as a means of "changing the system" and strangely thinking this will somehow improve care for servicemembers.

    I have now seen probably 100 great colleagues leave the military and I supported them, as they in effect "did their time" for our servicemembers and contributed. I have decided to "stick it out" perhaps in the deluded idealism that I can effect some change from within.

    I hold on the belief that if you can give a Commander a easy fix which makes them look good, they will generally adopt it so long as there isn't much personal risk to them. It is unfortunate that the O-6's in the system - those who run hospitals and have no real reason to care about fit-reps, are the ones who seem to lack personal courage. I mean, what is to be lost by telling a General or Undersecretary that - they are flat out wrong, here is why, and he's how to fix it?? You retire with 22 years of service vs 23 and don't get a medal on retirement??

    There should be something empowering in being able to argue your point, stick to your guns and if you get "fired" for it you are punished by making more money, in a more supportive environment, and no longer have to deploy etc. Where's the downside?

    I'm like come on, nut up COL's, and shake some trees for the good of the soldiers and your subordinate doctors/nurses etc.
     
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  17. USAFdoc

    USAFdoc exUSAFdoc

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    1) I agree it has likely ALWAYS been a dysfunctional beuracracy (incl milmed). What is NEW, is having the SG set metric standards that expect a milmed clinic to operate/produce/generate the RVUs, patient visits, standard of care of a well functioning civilian clinic when the milmed clinic is compromised/undermanned/poor support staff etc. That is "new" since 2000 (Primary Care Optimization). This simply placed a 300% "load increase" on a system simply not designed to do that.

    2) If (thats a BIG if), milmed is to be fixed, it is either from within or without. I applaud you trying to do it from within, but I do not think the "character" of the military will allow for that. So if it will be "fixed" from outside the system, it will either be from the media/public or from the future docs (or the lack of them). The Walter Reed fiasco may trigger some change, but I still believe the DoD will sweep most of the momentum for improvement and for change under the rug.

    3) Will the lack of future docs be bad? YES! But milmed will get the docs somewhere (civilian docs) and be forced to fix the system.

    4) When will you know the system is better? When docs want to stay.
    5) Do I wish there was a better way? YES
    6) Do I think a "better way" is coming soon? NO
     
  18. alpha62

    alpha62 Banned
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    A joint commission nurse showed up on the DMZ to lend her experise. Screw that. the war is lost, another sign that the end is very near.
     
  19. Mirror Form

    Mirror Form Thyroid Storm

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    Probably not b/c the airforce would never want to combine with the army and navy.
     
  20. Mirror Form

    Mirror Form Thyroid Storm

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    1. it would ruin any chance they have of making general, although most probably aren't going for general.

    2. I'm sure many of them do talk about the problems with the generals, but there is definitely no easy fix. And generals typically care about getting their next star. So they're not then going to continue shaking the tree any further. A lot of the problems are due to decisions made by people a lot higher up in the food chain than O-7.

    Did Kylie make surgeon general by highlighting problems at Walter Reed and then fixing them??? No, he masked problems and pretended everything was wonderful. A great career move, although the media ruined it for him.
     
  21. West Side

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    "And I woulda pulled it off, if not for these meddling kids!"
     
  22. MacGyver

    MacGyver Banned
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    My limited impression of hte military medical system is that they let nurses and PAs do just about everything if there isnt a doctor around.

    So even if every doc left the military, I dont think the commanders care, they would just start letting the nurses do the surgeries.

    Isnt this the same military that was the first entity in the country to let psychologists script meds?

    I think the docs have zero leverage in the military, so people leaving the system isnt going to change anything.
     
  23. BigNavyPedsGuy

    BigNavyPedsGuy Junior Member

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    Due to the appropriate-ness when read in conjunction with that nutso report


    BUMP
     
  24. MaximusD

    MaximusD Anatomically Incorrect
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    Whoever thinks A1Qwerty was a blind optimist cheerleader should refer to this post. Good analysis.
     
  25. a1qwerty55

    a1qwerty55 Attending

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    Thanks.

    I still stand by the post. I don't avoid talking about the negatives, but I feel that the profession (military physician) is still important if not essential to the US and US servicemembers. It also does offer many positives, which can include job satisfaction (yes you can have high clinical standards in the military), personal and professional growth, among a few. I have reason to be a bit more optimistic as with the 20K bonus HPSP applications are up, and the deployment issues while still a major source of stress are more predictable, and there is reason to be requirements will go down if the situation in Iraq continues to stabilize/improve. They are finally making some progress on improving AHLTA and now we have bonuses for nurses (hopefully allowing us to keep some of the good junior ones), and re-enlistment bonuses have increased for some specialities.
     

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