who's who of SDN military med knowledge?

[USAFdoc]

I think his silence just proves my point that I made previously. His comments and his detachment from the reality of military medicine makes me believe he is not a physician. I think he is a Medical Service Corps type. Which means Ancillary staff, recruiter, detailor, occupational/prev med or rad health, something like that.

and in a similar way, this is one of the major problems with military medicine: ie...you have NON-PHYSICIANS having the decision making authority on how to run medicine and the Physicians have near ZERO authority. This does not mean that those NON-Physicians are "bad", just that they have very little insight as to what works and what doesn't because they have never done the job of those they are in authority over (not to mention, it is not thier license or their patients being affected by staff/admin decisions).

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[Galo]

and in a similar way, this is one of the major problems with military medicine: ie...you have NON-PHYSICIANS having the decision making authority on how to run medicine and the Physicians have near ZERO authority. This does not mean that those NON-Physicians are "bad", just that they have very little insight as to what works and what doesn't because they have never done the job of those they are in authority over (not to mention, it is not thier license or their patients being affected by staff/admin decisions).

Very well put!

This is one of those points I think cannot be overemphasized when discussing the decline of military medicine. Whether its a non-physician, nurse, or even worse, a physician that gradually but surely becomes an administrator usually because they are not that good of a physician, it's these type of people that really disrupt the flow of giving care. Not to mention that if you happen to have a person of the personality idg has portrayed himself as, you could be in for one hell of a confrontation that you will automatically loose.

 

[island doc]

You're both right, and I apologize for misreading Island Doc's post.

Apology accepted, thank you.

 

[chickendoc]

This clearly illustrates why military medicine is indeed "dangerous medicine". Here we have a military physician, have been compelled to practice with insufficient and inadequate training, admitting that he/she is not prepared to take care of a patient with an acute medical problem, which is in fact part of the basic skill set for any practicing physician. Pathetic...

Hate to break reality to you but outpatient medicine in the miliatry is not about taking care of acutely (maybe I should add seriously) ill patients. I know when to refer to the ER or consult out. I took very good care of all my patients and have diagnosed many illnesses which I help manage with consultation. I know my limitations and will not be able to manage a patient in DKA or one requiring vent support. I just don't remember that stuff well enough to manage a team. I know you are bitter but don't cast judgment about my medical care being dangerous. This is your opinion not fact.
Before you start ranting, let me say that I know there are a lot of issues with military medicine...I just don't believe that all GMO/FS practice bad medicine and if they do they will be bad whether tor not hey had additional training ....GMO/FS tours are about knowing your limits and referring when appropriate.

 

[usnavdoc]

Hate to break reality to you but outpatient medicine in the miliatry is not about taking care of acutely (maybe I should add seriously) ill patients. I know when to refer to the ER or consult out. I took very good care of all my patients and have diagnosed many illnesses which I help manage with consultation. I know my limitations and will not be able to manage a patient in DKA or one requiring vent support. I just don't remember that stuff well enough to manage a team. I know you are bitter but don't cast judgment about my medical care being dangerous. This is your opinion not fact.
Before you start ranting, let me say that I know there are a lot of issues with military medicine...I just don't believe that all GMO/FS practice bad medicine and if they do they will be bad whether tor not hey had additional training ....GMO/FS tours are about knowing your limits and referring when appropriate.

I agree with what you are saying, having spent 4 years as a GMO with the Marines. But I dont think Island was trying to slam GMOs. I think he was making the point about Military medicine in general.

The Bottom line with GMOs is that we do a PA/NPs job. There are enough specialists around that you are not completely alone while in Garison. While deployed to Iraq and Afghanistan you can find yourself in need of specialist assistance at times but they are generally a flight or ride away. Also in those situations that specialist would do nothing more than what you have already done. I mean you are limited by what you can carry.

Overseas can be a different story. Plenty of people found themselves as the sole physician at an isloated ED. This happened to me at Camp Fuji japan and camp Schwab okinawa. Closest US facility was an hour away by vehicle, closest Japaneese facility was just up the road. We took many acute injured people to the host nation facility and I dont think an FP would have done much different. Basically you have to know when things are above your level. This is generally not that hard a thing to know. The trick is being cautious with the chronic patients. And as above if the ER or FP doc was stationed at that isolated ED they would have the same resources that the GMO had and would be no more capable.

My personal belief is that I think GMOs should go away and the Navy should adopt the use of PAs instead. This would solve a few retention issues at the LT-LCDR level as well as solve the need for more specialists and BCPs. The reason nothing like this has happend is that monetarily they have not been forced to change their practice.

 

[USAFdoc]

Hate to break reality to you but outpatient medicine in the miliatry is not about taking care of acutely (maybe I should add seriously) ill patients. I know when to refer to the ER or consult out. I took very good care of all my patients and have diagnosed many illnesses which I help manage with consultation. I know my limitations and will not be able to manage a patient in DKA or one requiring vent support. I just don't remember that stuff well enough to manage a team. I know you are bitter but don't cast judgment about my medical care being dangerous. This is your opinion not fact.
Before you start ranting, let me say that I know there are a lot of issues with military medicine...I just don't believe that all GMO/FS practice bad medicine and if they do they will be bad whether tor not hey had additional training ....GMO/FS tours are about knowing your limits and referring when appropriate.

First of all, DO NOT take this personally.
Second of all, If I take a look at myself, I would without a doubt say that I am a better, more efficient doctor with more experience now that I was last year. And I was better one year after residency than I was on residency graduation, and I ws better after residency than after med school. That is all pretty common sense.

The use of GMOs does not mean that the GMO practices "bad" medicine, all the time, or ever. But it does mean that the military is using people with MINIMUM experience, MINIMUM skills, etc.............and that does present more OPPORTUNITY for missed diagnosis and suboptimal care, AND, more stress on those providers/physicians as they are more likely to feel overwhelmed due to a lack of experience and many times, colleagues with experience to go to for questions. I saw many times, new PAs seeing brand new patients in renal failure, seizure disorders, trauma patients (all in our Family Med clinic). Why? because that was all the manning we had...

It is sad that that was the best the USAF could do for its patients and staff.

 

[usnavdoc]

First of all, DO NOT take this personally.
Second of all, If I take a look at myself, I would without a doubt say that I am a better, more efficient doctor with more experience now that I was last year. And I was better one year after residency than I was on residency graduation, and I ws better after residency than after med school. That is all pretty common sense.

The use of GMOs does not mean that the GMO practices "bad" medicine, all the time, or ever. But it does mean that the military is using people with MINIMUM experience, MINIMUM skills, etc.............and that does present more OPPORTUNITY for missed diagnosis and suboptimal care, AND, more stress on those providers/physicians as they are more likely to feel overwhelmed due to a lack of experience and many times, colleagues with experience to go to for questions. I saw many times, new PAs seeing brand new patients in renal failure, seizure disorders, trauma patients (all in our Family Med clinic). Why? because that was all the manning we had...

It is sad that that was the best the USAF could do for its patients and staff.

Look what we are talking about in my situation is AD Marines. Which means 99% healthy 18-25 yo atheletes. And in an infantry battalion there are roughly 500 Marines per doctor. We dont see dependants. A busy day for me is seeing 10 sick call patients in the AM, which range from STDs, sports med injuries, gastroenteritis, and people trying to get out of work. And follow up patients in the afternoon. The follow ups are being managed by specialists at the hospital and you are simply coordinating care. This is really not a big deal. Would you propose to have an FP replace me? of course not. They would be underutilized and bored out of their minds. As well as the Navy would never fund them.

We do the job that a PA can handle comfortably. Flight surgeons and Dive medical officers are in the same situation. The only Navy GMOs that I see that could fit your criteria are shipboard GMOs on smaller ships(amphibs LPDs LSDs), but they have plenty of support on the LHDs which accompany them to sea.

In your example the AF placed new PAs in positions that should have been staffed by FPs. This is not the case with GMOs. Is the military using providers with minimum experience. Yes. But compare the access to a physician with that of civilians. We work in the same space with Marines. All they have to do is walk across the hallway to see a doctor. You dont find that level of care anywhere in the civilian world.

I am not for GMOs at all. I just dont think your arguements against having them holds water. The better argument is to replace them with PAs which cost less. Allowing physicians to proceed through residency and fill your undermanned hospitals and clinics.

 

[USAFdoc]

Look what we are talking about in my situation is AD Marines. Which means 99% healthy 18-25 yo atheletes. And in an infantry battalion there are roughly 500 Marines per doctor. We dont see dependants. A busy day for me is seeing 10 sick call patients in the AM, which range from STDs, sports med injuries, gastroenteritis, and people trying to get out of work. And follow up patients in the afternoon. The follow ups are being managed by specialists at the hospital and you are simply coordinating care. This is really not a big deal. Would you propose to have an FP replace me? of course not. They would be underutilized and bored out of their minds. As well as the Navy would never fund them.

We do the job that a PA can handle comfortably. Flight surgeons and Dive medical officers are in the same situation. The only Navy GMOs that I see that could fit your criteria are shipboard GMOs on smaller ships(amphibs LPDs LSDs), but they have plenty of support on the LHDs which accompany them to sea.

In your example the AF placed new PAs in positions that should have been staffed by FPs. This is not the case with GMOs. Is the military using providers with minimum experience. Yes. But compare the access to a physician with that of civilians. We work in the same space with Marines. All they have to do is walk across the hallway to see a doctor. You dont find that level of care anywhere in the civilian world.

I am not for GMOs at all. I just dont think your arguements against having them holds water. The better argument is to replace them with PAs which cost less. Allowing physicians to proceed through residency and fill your undermanned hospitals and clinics.

I agree with you in the details; in YOUR situation, if you are ONLY seeing young active duty marines, there is probably little risk (not zero) in you or anyone missing a tough diagnosis because there is NO tough diagnosis to miss; everybody is healthy. Although not optimal care, I would be less concerned about having a PA or GMO provide that care. Now I would also argue that is is not a great way to learn medicine, but that another argument.

I would also agree that when appropriate, replacing GMOs with PAs is probably the better way to go.

My argument is in using incompletely trained physicians (or PAs for that matter) to provide care to out troops and retirees. One must look at the details of the patient population to make that decision and determine the level of risk the patients are being placed under.

 

[usnavdoc]

I agree with you in the details; in YOUR situation, if you are ONLY seeing young active duty marines, there is probably little risk (not zero) in you or anyone missing a tough diagnosis because there is NO tough diagnosis to miss; everybody is healthy. Although not optimal care, I would be less concerned about having a PA or GMO provide that care. Now I would also argue that is is not a great way to learn medicine, but that another argument.

I would also agree that when appropriate, replacing GMOs with PAs is probably the better way to go.

My argument is in using incompletely trained physicians (or PAs for that matter) to provide care to out troops and retirees. One must look at the details of the patient population to make that decision and determine the level of risk the patients are being placed under.

IMO I would say a GMO will miss a tough diagnosis about as much as an experienced PA or NP would. Maybe slightly more depending on background and internship of the GMO and comparing good general practice PAs.

I agree that the GMO system is disruptive to graduate medical education. I know this all too well. Im facing this issue now with going back to a civilian residency.

So you do not agree with using PAs in the military? They are fine in the civilian sector. I see no reason they should not be used by the military as well.

 

[island doc]

IMO I would say a GMO will miss a tough diagnosis about as much as an experienced PA or NP would. Maybe slightly more depending on background and internship of the GMO and comparing good general practice PAs.

I agree that the GMO system is disruptive to graduate medical education. I know this all too well. Im facing this issue now with going back to a civilian residency.

So you do not agree with using PAs in the military? They are fine in the civilian sector. I see no reason they should not be used by the military as well.

Excellent questions in regards to the best role of the PA. In my experience, the PA is not as well suited to practice independently as is the Nurse Practitioner. PA's are trained to be just that: An assistant to the Physician, not to replace them. Or in other words, to work beside the physician assisting by carrying out delegated tasks. They are better suited as assistants to specialists as opposed to primary care physicians. They have lesser formal education than do NP's.

The NP however is trained to function as an independent clinician, much like the CRNA. They are better capable of functioning as independant primary care providers, and have little role in specialized fields.

Despite all this, the military continues to misutilize the PA's by compelling them to function in a capacity for which they were not intended, or trained and prepared for-that being as independent primary care providers. If you do not believe me, just compare civilian utilization of PA's and NP's with that of the military. I would never even consider hiring a PA as an extender, to see patients alone in the office in my absence, but would hire an NP.

 

[usnavdoc]

Excellent questions in regards to the best role of the PA. In my experience, the PA is not as well suited to practice independently as is the Nurse Practitioner. PA's are trained to be just that: An assistant to the Physician, not to replace them. Or in other words, to work beside the physician assisting by carrying out delegated tasks. They are better suited as assistants to specialists as opposed to primary care physicians. They have lesser formal education than do NP's.

The NP however is trained to function as an independent clinician, much like the CRNA. They are better capable of functioning as independant primary care providers, and have little role in specialized fields.

Despite all this, the military continues to misutilize the PA's by compelling them to function in a capacity for which they were not intended, or trained and prepared for-that being as independent primary care providers. If you do not believe me, just compare civilian utilization of PA's and NP's with that of the military. I would never even consider hiring a PA as an extender, to see patients alone in the office in my absence, but would hire an NP.

PAs in the civilian sector function independantly by means of a chart review all the time. (Just look at your acute care clinics and fast track EDs.) The same is done here for GMOs and IDCs and would be done for PAs replacing GMOs.

Look bottom line is that I dont believe that GMOs provide bad medicine. That is what we are talking about. What level of care should be provided at what level? You will never get a FP to replace GMOs. Not good for the Navy nor the FP. However, PAs or NPs can replace the GMO. They would have FP backup at a higher level just as we do now. With Marines that would be a regiment as opposed to a battalion.

I agree that I think GMOs are not the way to go, but I believe that for different reasons. The main one being the detriment to the physicians training pathway.

 

[USAFdoc]

I more frequently find this forum emotionally wearing than informative. I've been trying to think of how those of us who are not spoiling for a fight can get more use out of it.

I was wondering whether we could make, and sticky, a list of people who have actually been doctors in the military and what their areas of expertise are/were. I expect there are lots of us non-medical prior-service types, but we frequently don't know about medicine.

I'm hoping there are lurkers out there who could contribute information but have no desire to contribute bickering, bashing, fighting, and insulting.

I'm thinking something like this (examples! some of this might be wrong. no offense meant ):

ID..................Service.....Specialty....Duration......would do it again?
USAFdoc.........AF...........FP.............19xx-20xx....never
usnavdoc........N.............FP.............19xx-20xx....?
Galo...............?.............?...............19xx-20xx.....no
IgD................?.............?...............19xx-pres.....yes & you should too

Homunculus -- you're the boss. Good idea? Good enough for a sticky?
Other opinions? Feel free to fix formatting etc.

Thanks
-Pemberley

Pemberly; what is your experience?

 

[USAFGMODOC]

Despite all this, the military continues to misutilize the PA's by compelling them to function in a capacity for which they were not intended, or trained and prepared for-that being as independent primary care providers. If you do not believe me, just compare civilian utilization of PA's and NP's with that of the military. I would never even consider hiring a PA as an extender, to see patients alone in the office in my absence, but would hire an NP.

I have to disagree with you on this one! I was a PA-C x 4 yrs in USAF and 1 yr after in civlian world. I trained NP's (personally about 5) as a preceptor for a University and let me tell you---- NP's are nurses with a 1.5 yr fluff course of lots of touchy, feely classes and most programs don't purposely cover pharm, systems based disease processes, anatomy and the likes for NP's but the are HEAVILY coverered for PA's. The NP's got most of their didactics on -- death and dying, being the patient advocate, how to treat different cultures and such. They (NP's ) are very, very, weak for the most part in clinical medicine because "they don't need that much since they already know it" (as I was told by the course supervisor).

I'm not saying all NP's are bad, some were very good, but those are the few that actually came from front line patient care and a strong clinical background in the ER or ICU.... Most NP's are desk jockey's for several years and deciding to get back in the clinical side b/c they see good pay....

If and when you hire an extender to your FP practice, you seriously need to consider the acuity/situation/#'s patients and interviews speak volumes IF you as the employer ask the right questions.... but do not automatically think an NP is better than a PA b/c that's what the USAF thought 10 yrs ago when they tried to replace PA's with NP's==== the experment failed b/c most NP's could not adjust to Family Practice and it's large scope of care, rather they were better situated for GYN or PEDs only practictioners (where they do extremely well).

 

[Pemberley]

Pemberly; what is your experience?

I started this thread to be a condensed and factual catalog of current and prior *medical* military officers' experiences for the rest of us (particularly prospective military medical officers) to refer to. It might seem silly to pretend that it still could be sticky-able and useful, as it has clearly degenerated into exactly the same discussion as every other thread in this forum.

However, I'm still daydreaming that it might be cleaned out and stickied to serve its original purpose, once IgD gets off his butt and posts something relevant (if he ever does). So instead of producing more clutter here, I'll refer you to previous posts, particularly
http://forums.studentdoctor.net/showthread.php?p=3367074#post3367074
http://forums.studentdoctor.net/showthread.php?p=3358629#post3358629
and I'll be happy to answer questions (if there are any, which I doubt; you'll find me fairly uninteresting but I don't want to be accused of an IgD-like dodge) in another thread.

-Pemberley

 

[Portier]

and in a similar way, this is one of the major problems with military medicine: ie...you have NON-PHYSICIANS having the decision making authority on how to run medicine and the Physicians have near ZERO authority. This does not mean that those NON-Physicians are "bad", just that they have very little insight as to what works and what doesn't because they have never done the job of those they are in authority over (not to mention, it is not thier license or their patients being affected by staff/admin decisions).

1) Admin Question: I've read some posts here about admin, I have some military experience, and I completed a MHA and a MPH (minus internships I'm doing in a couple months) during the first two years of DO school. I have a question which might better go on another thread, but I'll introduce it here:

Most of the docs on military SDN threads don't want to be burdened with doing things that aren't medicine. Breaking up their training and preventing their regular practice of medicine seems to be a common complaint. Even if said docs did want to do admin, they'd get paid significantly less than doing what they're trained for: Medicine....much less mention job satisfaction.

This lack of interest, I theorize, is why Nurses, MSC's, and other non-physician types get plugged into powerful policy making positions much to the chagrin of the working class hero docs. For a non-physician type the opportunity to advance to a position where they can make changes that make sense to them as support staff...well, let's just say common sense can becoem an uncommon virtue.

My question is: What the hell else is the bureaucracy to do?

If you can't get regular docs who are solid achievers and earners to stay in and inherit the "apple-polishing," "desk-warming" jobs, how is the system supposed to change?

(Note: There was a time when I was enlisted...on about the 6-7th year... when I made a conscious decision to join the bureaucracy. I couldn't get out and make as much money to do the same work with the health benefits, education benefits, and shift flexibility. So, I started playing ball as best I could with the lifers...then I became one.)

2) Homonculus: Did I meet you at the NCC Peds meet and greet on 17FEB06?

 

[USAFdoc]

1) Admin Question: I've read some posts here about admin, I have some military experience, and I completed a MHA and a MPH (minus internships I'm doing in a couple months) during the first two years of DO school. I have a question which might better go on another thread, but I'll introduce it here:

Most of the docs on military SDN threads don't want to be burdened with doing things that aren't medicine. Breaking up their training and preventing their regular practice of medicine seems to be a common complaint. Even if said docs did want to do admin, they'd get paid significantly less than doing what they're trained for: Medicine....much less mention job satisfaction.

Speaking for myself on this one; the FP USAF system was purposely designed to place nurses in the admin positions because that is how their "advancement" system was designed to wrok, Physicians were purposely excluded because they are "promoted" anyways, and then they have more time to see patients. This might work ok if the system was otherwise designed correctly. It is not.
So when you have novice or sometimes not novice nurses running the show/clinics that are terribly undermanned with docs and have serious flaws at most levels (charts, referral process, lab results, paperfiling admin lack of manning etc), at that point, excluding the docs from the decision making makes it impossible for the docs to at least adapt and make the best of what we have. What you end up with the "making a tough situation even worse.

This lack of interest, I theorize, is why Nurses, MSC's, and other non-physician types get plugged into powerful policy making positions much to the chagrin of the working class hero docs. For a non-physician type the opportunity to advance to a position where they can make changes that make sense to them as support staff...well, let's just say common sense can becoem an uncommon virtue.

very true

My question is: What the hell else is the bureaucracy to do?

If you can't get regular docs who are solid achievers and earners to stay in and inherit the "apple-polishing," "desk-warming" jobs, how is the system supposed to change?

you have to have an oversight committee to prevent "abuses" to the system (such as expecting an FP/IM clinic to run on 20% manning, lack of chart availability, 20 foot high pile of uncharted results not in charts etc. You need to give docs a voice and some authority to fix problems as they arise. The 100% responsibility/ZERO % authority current situation is a loser. Go ahead and make the docs meet a certain productivity level, but get out of our way and let us make it happen.

There are certainly other ideas that may work. But definitely the current system is broke.

 

[militarymd]

goto a civilian hospital....and model after it.

 

[USAFdoc]

goto a civilian hospital....and model after it.

I agree, great place to start.

Also, the reason the current admin (right on up to the SG office) do not have to improve things is that the biggest authority/freedom that a civilian doc has we do not have in military medicine.

That is the freedom to leave. Now I am certainly not advocating that all docs have the choice to quit the military with simply a 30 day notice, but because the military "has us" for usually a 4 years period, they can pretty much do what they want, no matter what the consequences. And unfortunately those consequences fall back on the shoulders of the docs in terms of quality of care/life/lawsuits etc.

You do NOT see a typical civilian healthcare system as poor as what I saw in the USAF because it could not exist, all the docs and nurses would quit within months. This in fact did happen at my last base with 100% of the civilian nurses quitting and 8 of 9 civilian docs.

 

[Portier]

You have a very good point there. Not being able to quit when you want to is an issue I personally wrestled with, and I know lots of other people do on a daily basis.

There's an aspect of it that's like Shawshank Prison: "These walls are kind of funny. First you hate 'em, then you get used to 'em. Enough time passes, gets so you depend on them. That's institutionalized. They send you here for life, that's exactly what they take. The part that counts, anyways."

I feel like that with the Navy sometimes. I've been doing it so long, the idea of stopping the moving every 3 years is just plain scary to me...forget professional autonomy and admin pogues.

Let me get back to the point:

By design, the government contracts people for a period of time. Sometimes it's a good thing, because it gives you time to get used to a job before you jump ship. Sometimes it's bad because you end up retaining pond scum who couldn't hack it on the outside...so they sclump along doing the bare minimum.

I don't know that an organization that by nature works on draconian contracts could ever work excactly like a civilian hospital. Especially if you consider how hard it is to fire those Civil Service guys who make all the rest of the Civil Service guys look bad.

 

[USAFdoc]

You have a very good point there. Not being able to quit when you want to is an issue I personally wrestled with, and I know lots of other people do on a daily basis.

There's an aspect of it that's like Shawshank Prison: "These walls are kind of funny. First you hate 'em, then you get used to 'em. Enough time passes, gets so you depend on them. That's institutionalized. They send you here for life, that's exactly what they take. The part that counts, anyways."

I feel like that with the Navy sometimes. I've been doing it so long, the idea of stopping the moving every 3 years is just plain scary to me...forget professional autonomy and admin pogues.

Let me get back to the point:

By design, the government contracts people for a period of time. Sometimes it's a good thing, because it gives you time to get used to a job before you jump ship. Sometimes it's bad because you end up retaining pond scum who couldn't hack it on the outside...so they sclump along doing the bare minimum.

I don't know that an organization that by nature works on draconian contracts could ever work excactly like a civilian hospital. Especially if you consider how hard it is to fire those Civil Service guys who make all the rest of the Civil Service guys look bad.

the president of the USAFP said it well a few issues ago when he compared pilots and docs. He stated that basically the FP system in the USAF was broken and it will remain so until the USAF begins to treat physicians like they do pilots. What he meant by that was the "support staff/admin" focus their goals/work on what is needed to get the pilot ready to fly, to fly, etc.
The admin in the medical area focus their goals elsewhere from the doc. They could care less what I needed as a doc (like support staff, equipment, a computer that works etc). They "get away" with that because as the doc I am the supervisor of nobody. In the USAF chain of command I am just another cog in the wheel, to be seen and not heard, despite the fact that the physicians I worked with were some of the most motivated, intelligent, and managerally more experienced than the frequently changing adminn staff over us.

And again, I have no problems letting somebody else run the "admin show", but when things are broken and it is affecting my life, my ability to provide timely and excellent care, I want to fix it if they won't. And as you guessed it, they didn't fix it, wouldn't let the docs fix it, so the docs are leaving.

 

[DeanWormer]

as a GMO and specialist in the Navy. I saw many "very weak" PAs who ran around thinking they were real docotrs and many good NPs who came from years of a specialty service. A psych NP is a invaluable resource and PA prescribing psychotropics is whatever the sales rep taught them. Both are extenders for doctors bottom line. you may spilt hairs if you desire but in the end NPs can work independently in the USA PAs can not.

 

[island doc]

as a GMO and specialist in the Navy. I saw many "very weak" PAs who ran around thinking they were real docotrs and many good NPs who came from years of a specialty service. A psych NP is a invaluable resource and PA prescribing psychotropics is whatever the sales rep taught them. Both are extenders for doctors bottom line. you may spilt hairs if you desire but in the end NPs can work independently in the USA PAs can not.

Amen! This is exactly the point I was trying to get across, thank you for confirming it. I refuse to hire a PA because they cannot handle a practice by themselves, and I need someone who can run the show by themselves while I am out of the office. An NP can do this, a PA cannot. A PA can certainly help you in the office/hospital working along side you, but you cannot walk away from them and leave me alone, but you can an NP.

 

[usnavdoc]

Amen! This is exactly the point I was trying to get across, thank you for confirming it. I refuse to hire a PA because they cannot handle a practice by themselves, and I need someone who can run the show by themselves while I am out of the office. An NP can do this, a PA cannot. A PA can certainly help you in the office/hospital working along side you, but you cannot walk away from them and leave me alone, but you can an NP.

This point is not valid within the world of the GMO. Which is what we were talking about. The physician (even though they are the OIC of their BAS) do not run the clinic/BAS. The Chiefs do. We are there as providers, to give advice to the CO, and for medical admin mostly.

PAs by state law do not have to have physician presence in any state. Although standards are different the usual requirements are that a physician needs to be available by telecommunications, 10% chart review each month, and an initial period of evaluation.

PA or NP it doesnt really matter. I think the GMO should be replaced by one or the other. In terms of seeing bad PAs and good NPs. Im sure there are 100 different people with 100 different opinions. I personally have seen some very good PAs. Ive never seen a NP in the military except a nurse midwife at portsmouth, who everyone generally thought was a crackpot. This has no bearing on all NPs or PAs though.

For reference: http://www.aapa.org/gandp/statelaw.html

 

[USAFGMODOC]

Since I was a former PA, trained NPs and PA's and have 7 years of family practice/urgent care-- i thought "real world" knowledge would somehow let you see the true light, but alas, this is just like talking on the deaf ears of the military NC/Admin/out of touch others in Military Medicine!

When it comes to those who KNOW about something and those who "think" they know, I have learned a long time ago be impartial, but listen to those with more experience... part of the reason USAF-doc/Galo and others have been harping on since the beginning of time...

I'm not trying to discredit all NP's, but if you would actually work with both of these types (PA/NP), you'd quickly change your opinion.....

 

[usnavdoc]

Since I was a former PA, trained NPs and PA's and have 7 years of family practice/urgent care-- i thought "real world" knowledge would somehow let you see the true light, but alas, this is just like talking on the deaf ears of the military NC/Admin/out of touch others in Military Medicine!

When it comes to those who KNOW about something and those who "think" they know, I have learned a long time ago be impartial, but listen to those with more experience... part of the reason USAF-doc/Galo and others have been harping on since the beginning of time...

I'm not trying to discredit all NP's, but if you would actually work with both of these types (PA/NP), you'd quickly change your opinion.....

Youre kidding me right. You are saying that I am like IGD? lol Have you ever read my posts at all? For your info the posters you have mentioned have never done a GMO tour. So who is talking from experience.

You guys dont want NPs or PAs to practice in the military. You dont want GMOs to practice either. What is it that you would recommend as a solution? BCP FPs in former GMO billets? Thats what you want? Fine. Volunteer to do it. That is the most ridiculous use of resources. An FP with a healthy patient panel of 500. Do you know how few FPs are in the military? Do you know how many extra FPs that would take to fill the GMO billets? Do you know what it would cost? Do you know that the Navy will never do it? What would be the incentive? Its not cost effective. It further thins out your available FPs.

You are a former PA and you say that despite state regulations you would not practice in any way except with direct supervision?

 

[USAFGMODOC]

Actually, I did do a GMO tour (just finished) and headed off to Rads... As far as GMO's, I don't have a problem with them b/c I feel they do serve a purpose... I'd be all for replacing GMO's with some PA's/NP's since there aren't enough docs around to fill all the slots and their retention is much worse than PA's....

I have never compared anyone to IgD on this site, I think he is in his own category (but I respect his right to give his opinion)....

 

[usnavdoc]

Actually, I did do a GMO tour (just finished) and headed off to Rads... As far as GMO's, I don't have a problem with them b/c I feel they do serve a purpose... I'd be all for replacing GMO's with some PA's/NP's since there aren't enough docs around to fill all the slots and their retention is much worse than PA's....

I have never compared anyone to IgD on this site, I think he is in his own category (but I respect his right to give his opinion)....

I apologize. I read your first paragraph and thought you were talking to me since I was the previous poster.

 

[XXBlockheadXX]

I am but a lowly grasshopper (med student); lowest of the hierarchy.

Yes, lower than the residents, lower than the nurses, lower than the PAs, lower than the techs, lower than the nurse assistants, lower than the interns, and lower than the guy who takes the garbage out at the end of the day.

I am the little leaguer hoping some day to play in the big leagues. Tee-ball sure is fun, though.

 

[island doc]

Since I was a former PA, trained NPs and PA's and have 7 years of family practice/urgent care-- i thought "real world" knowledge would somehow let you see the true light, but alas, this is just like talking on the deaf ears of the military NC/Admin/out of touch others in Military Medicine!

When it comes to those who KNOW about something and those who "think" they know, I have learned a long time ago be impartial, but listen to those with more experience... part of the reason USAF-doc/Galo and others have been harping on since the beginning of time...

I'm not trying to discredit all NP's, but if you would actually work with both of these types (PA/NP), you'd quickly change your opinion.....

Alas! I have indeed worked with and supervised both in the same exact setting at the same time, and the NP continuously out performed the PA's.

 

[IgD]

This lack of interest, I theorize, is why Nurses, MSC's, and other non-physician types get plugged into powerful policy making positions much to the chagrin of the working class hero docs...

If you were to actually break down the number of people in executive medicine (hospital CO, flag officer) I suspect you would find that physicians outnumber executives from the MSC and nurse corps.

The complaint that physicians aren't included in medical business decision making is a common one in the civilian world too. Non-physicians are commonly medical executives outside of the military. How many hospital or insurance plan CEOs are physicians? The sad truth is that physicians once held all this power but so mismanaged things that we got HMO's.

 

[militarymd]

If you were to actually break down the number of people in executive medicine (hospital CO, flag officer) I suspect you would find that physicians outnumber executives from the MSC and nurse corps.

The complaint that physicians aren't included in medical business decision making is a common one in the civilian world too. Non-physicians are commonly medical executives outside of the military. How many hospital or insurance plan CEOs are physicians? The sad truth is that physicians once held all this power but so mismanaged things that we got HMO's.

The above statement is OUTRIGHT wrong. I'm in private practice right now. No physician is in any administrative role, who do you think the administrators listen to about policy?

Why do the administrators listen to the physicians? The answer is simple. Patients don't go to the hospital to see administrators...they go to see doctors.....and in a free market....patients and the doctors can take their business elsewhere.

 

[Portier]

The above statement is OUTRIGHT wrong. I'm in private practice right now. No physician is in any administrative role, who do you think the administrators listen to about policy?

Why do the administrators listen to the physicians? The answer is simple. Patients don't go to the hospital to see administrators...they go to see doctors.....and in a free market....patients and the doctors can take their business elsewhere.

I have to give creedence to the MilitaryMD on this.... Over and over in the healthcare management literature it is clearly stated that the financial wellbeing of a healthcare organizatoin is dependent on the happiness of the physicians.

If physicians are pissed due to admin bs, the patients pick up on it and don't come back.

Hospitals that maximize the income of their physicians and give them more freedom note higher incomes for the hospitals.

Exactly as milmd says, "Patients go to see doctors, not administrators."

 

[Globus P]

IgD still has not identified himself.......again, I think he's a nurse.

 

[Galo]

If you were to actually break down the number of people in executive medicine (hospital CO, flag officer) I suspect you would find that physicians outnumber executives from the MSC and nurse corps.

The complaint that physicians aren't included in medical business decision making is a common one in the civilian world too. Non-physicians are commonly medical executives outside of the military. How many hospital or insurance plan CEOs are physicians? The sad truth is that physicians once held all this power but so mismanaged things that we got HMO's.

Clearly the ramblings of a fool, or a totally inexperienced non-physician. When are you going to stop vomiting your B.S.?? At least give some credence to your spoutings by telling us with what life experience you can make such outlandish statements. You have become nothing but a joke.

You guys should check out his latest on the stickied CON thread, before homunculus erases it. I think his alter ego may be posting there as well. It gave me a good long hard laugh.

Idg you are pathetic!

 

[usnavdoc]

Clearly the ramblings of a fool, or a totally inexperienced non-physician. When are you going to stop vomiting your B.S.?? At least give some credence to your spoutings by telling us with what life experience you can make such outlandish statements. You have become nothing but a joke.

You guys should check out his latest on the stickied CON thread, before homunculus erases it. I think his alter ego may be posting there as well. It gave me a good long hard laugh.

Idg you are pathetic!

You mean the "Pros section"

 

[Galo]

You mean the "Pros section"

My mistake,

CHECK THE PROS SECTION QUICK!!

 

[RichL025]

The above statement is OUTRIGHT wrong. I'm in private practice right now. No physician is in any administrative role, who do you think the administrators listen to about policy?

Why do the administrators listen to the physicians? The answer is simple. Patients don't go to the hospital to see administrators...they go to see doctors.....and in a free market....patients and the doctors can take their business elsewhere.

Ugghh, milmd, not to dispute that you may have landed at a great institution or something, but that same complaint (non-MDs run the hospital, make important policy, etc) IS heard in the civlian world a fair bit. Or, the related complaint that the only MDs who participate in the hospital administartion are there because they were poor clinicians.

Are you disputing that this is a common complaint in the civilian world?

 

[Galo]

Ugghh, milmd, not to dispute that you may have landed at a great institution or something, but that same complaint (non-MDs run the hospital, make important policy, etc) IS heard in the civlian world a fair bit. Or, the related complaint that the only MDs who participate in the hospital administartion are there because they were poor clinicians.

Are you disputing that this is a common complaint in the civilian world?

Having been out only over one year, I can tell you that the difference in the civilian world, is that even administration has to shoot for excellence, and is not so far, been as opposing to growth, developement, and looking ahead, when compared to military administrators who are usually there out of default.

So even if the complaint is there, it has nowhere near the implications we saw in the military.

 

[militarymd]

Ugghh, milmd, not to dispute that you may have landed at a great institution or something, but that same complaint (non-MDs run the hospital, make important policy, etc) IS heard in the civlian world a fair bit. Or, the related complaint that the only MDs who participate in the hospital administartion are there because they were poor clinicians.

Are you disputing that this is a common complaint in the civilian world?

ABSOLUTELY....in capital letters.....Civilian physicians may complain about things, but they are complaining as compared to their practice in the 1980's...when physicians did pretty much RULE healthcare.

Currently, there is more of a balance between physician WANTS and greater good of cost containment, but take those civilian complainers and put them in the Navy....and they'll have a stroke within 20 minutes of dealing with a Cowmander with a clipboard.

 

[RichL025]

So, yes you dispute it, but then you agree that it is a matter of degree !

Look, once again, I am not disputing either of yours personal experiences or observations. But let's be clear: civilian physicians bitch about hospital administrators also (and NOT just about hurting their income). I will not dispute that you found it worse in the Navy, but as I

... but take those civilian complainers and put them in the Navy....and they'll have a stroke within 20 minutes of dealing with a Cowmander with a clipboard.

If that is the theme of your "ABSOLUTELY" dispute, I accept it, but cannot believe that you think all civilian physicians are happy with hospital administration... EVERYBODY complains, just in your view, the ones complaining about the military have greater validity.

 

[militarymd]

I do anesthesia for a lot of surgeons, and a lot of them complain about the administration.

Here are a few examples of what they complain about:

1) the menu in the doctors (that's right...only doctors allowed) lounge does not meet their tastes

2) The OR's aren't ready for them when they are 2 hours late

3) "Why can't I take a break in the middle of my OR schedule to go out for lunch?" while the OR just sits and waits on them

4) I need 2 rooms to run my schedule

5) The doctor's parking is full, I had to park across the street...I had to walk an extra 10 yards to get inside the hospital..

Yeah, they whine and moan a lot about the civilian administrators....

 

[USAFdoc]

Having been out only over one year, I can tell you that the difference in the civilian world, is that even administration has to shoot for excellence, and is not so far, been as opposing to growth, developement, and looking ahead, when compared to military administrators who are usually there out of default.

So even if the complaint is there, it has nowhere near the implications we saw in the military.

I would concur with GALO; in fact I would go a step farther in that if civilian hospital were given the TOTAL control that military admin has, they would eventually develop some of the same "Money and metrics" to the total exclusion of other just as important or more important things such as safety, morale, retention etc. The big difference again being that civilian admin must make the work place one that physicians feel is fair and safe, knowing that physicians will leave and go somewhere else if needed. The military has not lost enough physicians YET to change its ways. However, the "heat" is on with manning levels continuing to drop. Hopefully an improved healthcare system is around the corner.

 

[aatrek]

I do anesthesia for a lot of surgeons, and a lot of them complain about the administration.

Here are a few examples of what they complain about:

1) the menu in the doctors (that's right...only doctors allowed) lounge does not meet their tastes

2) The OR's aren't ready for them when they are 2 hours late

3) "Why can't I take a break in the middle of my OR schedule to go out for lunch?" while the OR just sits and waits on them

4) I need 2 rooms to run my schedule

5) The doctor's parking is full, I had to park across the street...I had to walk an extra 10 yards to get inside the hospital..

Yeah, they whine and moan a lot about the civilian administrators....

Mil MD,
although I agree with much of what you said earlier.. having just came out of four civilian hospitals.. I can tell you that the surgeons complains are way way way more serious than what you stated here.
I personally know doctors that sold their practice and moved to another state because of how bad it is, and know three surgeons that will not take high risk cases (only elective simple cases) because of mal. pract. issues.
I can give you many other examples of how hard it has become .. however, I will add that I practiced in the TWO worst states in the nation for this issue and in big cities (thus the worst places in those states)...

just some food for thought..
a.

 

[USAFdoc]

Mil MD,
although I agree with much of what you said earlier.. having just came out of four civilian hospitals.. I can tell you that the surgeons complains are way way way more serious than what you stated here.
I personally know doctors that sold their practice and moved to another state because of how bad it is, and know three surgeons that will not take high risk cases (only elective simple cases) because of mal. pract. issues.
I can give you many other examples of how hard it has become .. however, I will add that I practiced in the TWO worst states in the nation for this issue and in big cities (thus the worst places in those states)...

just some food for thought..
a.

aatrek,
thanks for the snack, I completely believe you and have read various journals that support your experience.

There are various aspects of civilian family medicine and certain FP docs that have had "bad" stories to tell on how poorly FP in certain areas is going.

My point; at least those doctors have an option to leave/move out of the state if things get that bad. As a military physician, there is no such option. I believe the military has a duty to the patients and physicians to maintain a certain level of care, and not feel satisfied that they can compete with the "WORST" that a few civilian heathcare senarios have to offer.

 

[militarymd]

Mil MD,
although I agree with much of what you said earlier.. having just came out of four civilian hospitals.. I can tell you that the surgeons complains are way way way more serious than what you stated here.
I personally know doctors that sold their practice and moved to another state because of how bad it is, and know three surgeons that will not take high risk cases (only elective simple cases) because of mal. pract. issues.
I can give you many other examples of how hard it has become .. however, I will add that I practiced in the TWO worst states in the nation for this issue and in big cities (thus the worst places in those states)...

just some food for thought..
a.

Malpractice is a different issue.....and I do believe reform is on its way....Anesthesia malpractice has been going down over the years because of reform.

As for the folks who quit and leave, well.....that's what you can do and should do if the administration does not support you.....You have no choice in the military.

 

[Portier]

Malpractice is a different issue.....and I do believe reform is on its way....Anesthesia malpractice has been going down over the years because of reform.

As for the folks who quit and leave, well.....that's what you can do and should do if the administration does not support you.....You have no choice in the military.

Whatever, dude...

Just get on that bike you're always standing next to....then you can draw your katana (Like Blade does in the 16 movies he's made) and do some cutting.

Cowmanders (which I love as a slight!), Clipboard Commandos, and MSC admin types.

 

[USAFdoc]

Whatever, dude...

Just get on that bike you're always standing next to....then you can draw your katana (Like Blade does in the 16 movies he's made) and do some cutting.

Cowmanders (which I love as a slight!), Clipboard Commandos, and MSC admin types.

MilitaryMD;

just realize that for every IgD or Portier out there, there are several others that at least have some idea of what might be awaiting them on the other side of residency. You and I and other physicians certainly could be spending time doing other things other than informing students, but IT IS time well spent, and it is the right thing to do.

 

[GMO_52]

MilitaryMD;

just realize that for every IgD or Portier out there, there are several others that at least have some idea of what might be awaiting them on the other side of residency. You and I and other physicians certainly could be spending time doing other things other than informing students, but IT IS time well spent, and it is the right thing to do.

Yet another hijacked thread. We're really working hard to make this forum useless. I hoped the stickies would allow us to actually have discussions other than the pointless bickering and constant rehashing of the same complaints. Oh well.

 

[Galo]

I think an unintended consequence of this thread is that it shows how unbalanced things are. Basically there are 4 disgruntled former military physicians here and myself. I guess everyone else is neutral.

I would suggest appointing an additional moderator from the neutral category such as yourself maybe (?). It's very hard for me to make any pro-military point when I get 4 reflexive name calling replies.

Do not blame milmd and usafdoc, you can see that the 6th post on this thread was where the hijacking began, once again by idg who has repeatedly failed to identify himself/herself in anyway. That's where the problem lies.

 

[Pemberley]

Do not blame milmd and usafdoc, you can see that the 6th post on this thread was where the hijacking began, once again by idg who has repeatedly failed to identify himself/herself in anyway. That's where the problem lies.

The most frustrating part for those of us trying to use this forum to learn something is that every thread ends up having exactly the same topic -- or should I say, exactly the same disorganized mish-mash of topics.

For example, some of the RN/PA discussion a few pages back was useful and interesting, but it was found on the 2nd or 3rd page of a thread that nominally biographies people with military medical experience! I think both topics are less usefully discussed by being scrambled with several others.

So, frequent posters, any suggestions how to keep threads on-topic, even though there will always be trolls trying to draw them off-topic? I've already expressed my preference for our friendly neighborhood caveman to give himself some less restrictive ROEs for pruning and/or moving posts. Any seconds?

Just trying to make the board more useful.

-Pemberley