Army Brigade Surgeon

[pgg]

Obviously, the point of specialization and subspecialization is that we diverge from that line, and it makes sense to me that it may be difficult or even dangerous for us to attempt to return to "general medicine".

Totally agree. I would not see sick call. I imagine this would upset a bunch of people and make my own life a lot harder than if I just played along and semi-competently plowed through the clinic.

If it was specified as my place of duty for a period of time and I was so ordered, I would attend or participate in "remediation" (and I think we all know that any "remediation" ordered would be specifically to cover their asses, not meaningfully improve the physician's qualifications) . And then I would not see sick call. I'm far enough removed from that world that the only "remediation" that I'd be satisfied with would need the ACGME tag of approval.

Glad this is a moot point in the Navy world. Drawing that line in the sand would be very unpleasant.

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[Homunculus]

BDE surgeons aren't immune from sick call. Like pediatric subspecialists, my specialty has been hit hard by this, so I've been in touch with a number of recently christened, reluctant brigade surgeons. Like so many other things about being a brigade surgeon, your breadth of practice is almost exclusively up to the brigade commander. I agree that it is largely an administrative job, but that's of little comfort if your CO mandates you see sick call, as has happened to a number of my colleagues. The disconnect in the system is so blatant that the local MTF - who is responsible for credentialing all of the line unit PAs and MDs - refused to grant privileges to see sick call based on lack of qualifications and experience, in at least once instance. This person had to go through a period of remediation just to see sick call.

Also, I'm not following your logic about the PA thing. It seems like it's only a catch-22 if you consider a PA and any physician to be at two points on a linear training scale that I'll call "general medicine". Obviously, the point of specialization and subspecialization is that we diverge from that line, and it makes sense to me that it may be difficult or even dangerous for us to attempt to return to "general medicine". Even if we can, I see nothing inconsistent in demonstrating to a commander that the point on the line to which we might return is substantially down the training scale than even a PA.

actually seeing sick call regularly is a rarity from the people i've spoken to (unless you are a flight surgeon or are actually wanting some clinic time). much more likely is the scenario you depicted-- trying to get your underlings credentialed and arranged. but like most things, people's experiences vary depending on the unit and commander expectations.

i am with you on the PA issue. i'm not speaking of my own opinion-- i was speaking on behalf of the line. i know that once we've gone down the subspecialist route that the distance from "x" (being GMO medicine) is much greater than a general practice PA. there are obviously some PAs that are specialized as well, but in general we don't have them in AD-- they are normally GS or contracted. from the lines perspective, we are all on a continous scale-- like a tech tree on starcraft or skill tree on whatever MMORPG you choose. to them, if you can do WXYZ, then of course you should be able to do V and W because you had to do them at some point to get there. they don't understand that it is not a tech tree issue but a class switch issue. maybe this kind of analogy should be brought up at the next smoke filled room meeting where they channel satan and make these plans up, lol. clerics can't tank.

--your friendly neighborhood for the hive caveman

 

[Homunculus]

Totally agree. I would not see sick call. I imagine this would upset a bunch of people and make my own life a lot harder than if I just played along and semi-competently plowed through the clinic.

If it was specified as my place of duty for a period of time and I was so ordered, I would attend or participate in "remediation" (and I think we all know that any "remediation" ordered would be specifically to cover their asses, not meaningfully improve the physician's qualifications) . And then I would not see sick call. I'm far enough removed from that world that the only "remediation" that I'd be satisfied with would need the ACGME tag of approval.

Glad this is a moot point in the Navy world. Drawing that line in the sand would be very unpleasant.

the thing is, the army doesn't need ACGME approval. you are licensed for "medicine and surgery" in most states and likely have an unrestricted medical license. you are covered under the federal tort claims act as well and won't see family members-- only non-suing active duty folks. commands have no asses to cover. absolute refusal may work but it would be very painful and likely costly. i know people who have put this up as a barrier and it didn't last-- but they probably don't have the same concrete conviction that you do, lol. again, i am in no way defending them, just trying to add a little dose of reality to any lurkers who may try this approach. if someone out there has titanium balls and pulls it off (or has pulled it off) please post about it-- would be the feel good story of the year it's the same as deployment-- a lawful order is a lawful order. they aren't asking you to perform surgery, just do basic sick call. it's not rocket science, trust me. you could pick it up in less than a week.

--your friendly neighborhood 800mg ibuprofen and drink some water . . next! caveman

 

[colbgw02]

Thanks for the clarification. Of course you're right that the line doesn't draw the distinction between the family practitioner and the neurosurgeon. To them, it's just a warm body with a caduceus on our class As. I think this discussions highlights another of the absurdities about military medicine - the disconnect between civilian standards to which we're held and the unique practice environments imposed on us by the military. And no, I'm not talking about deployments.

The military's residency programs are ACGME accredited. Its physicians are required to hold an unrestricted medical license granted by a state government. The obvious, albeit eventual, goal is to become certified by a civilian specialty board. Our hospital commanders bend over backward in order to get and maintain Joint Commission accreditation. And if we mess up, then our mistakes are ajudicated in a civilian courtroom. We are expected to train and practice to these standards, but the moment those standards inconvenience the military, they get thrown out the window. This happens on macro levels, like the entire GMO system and this brigade surgeon debacle, as well as on the micro level (wasn't BigNavyPedsGuy forced to run adult codes despite formally objecting that he was not properly trained?). And to reiterate, I'm not talking about in an austere environment, particularly during a deployment, where clearly the rules change and understandably so. I sometimes think that military medicine would be better off divorcing itself from civilian medicine, inasmuch as it can, and just own the fact that they're playing by their own rules.

Switching gears, as a thought experiment, consider this scenario for a brigade surgeon. As a condition of many (most?) state medical licenses, a physician is required to maintain independent medical practice, meaning that he is not permitted to allow a non-physician (oh, let's say, like a brigade commander) to hold sway over his medical judgment. If a brigade surgeon judges that he is not capable of treating patient X, but is ordered to by his CO, what would happened if the doc responded that, if forced to treat the patient, he would be forced to contact his state's medical board in order to have his license suspended for failure to maintain independent practice. Therefore, the CO's insistence would be self-defeating, because then that doc would not be permitted to engage in any medical practice while the state's due process plays out.

 

[pgg]

absolute refusal may work but it would be very painful and likely costly. i know people who have put this up as a barrier and it didn't last-- but they probably don't have the same concrete conviction that you do, lol.

It's easy for me to have concrete conviction since there's zero chance of this ever happening to me.

Also, the normal progression of a military physician, lifer or not, is from periods of "I need the military more than the military needs me so I better not make waves" to "the military needs me more than I need it, what're they gonna do if I play a little ethics hardball on something I believe in" ... I'm trending towards the latter these days.

it's the same as deployment-- a lawful order is a lawful order. they aren't asking you to perform surgery, just do basic sick call. it's not rocket science, trust me. you could pick it up in less than a week.

I don't think it's the same as a deployment at all.

I could be lawfully ordered to any billet, and I'd pack my things and go, but I can't be lawfully ordered to do a pelvic exam any more than I can be ordered to remove an appendix or manage a 10-year-old type 1 diabetic. It goes further than that - I can't even be lawfully ordered to offer the same clinic services that some other phsyicians in my own specialty offer. For example, some non-fellowship-trained anesthesiologists run chronic pain clinics and interventional pain procedures like epidural steroid injections, SI joint injections, etc. I was asked a couple years ago if I was would stand up a pain clinic here, and I said no, I don't feel adequately trained to do that. Those are supplemental (not core) privileges.

Primary care (even if it's just called "only sick call") is absolutely not part of the core privileges of an anesthesiologist. People do residencies for that, or they should, anyway.


I was a GMO battalion surgeon for Marine infantry for 3 years, 2003-2006. In the usual Navy fashion, I had completed an internship (TY) and obtained an unrestricted medical license from a state that only required one year of post-grad training. I deployed twice with them for a total of 14 months in Afghanistan and Iraq. Did lots of sick call.

I'm not the same doctor I was 10 years ago. There's a set of knowledge and skills that have been unused and perhaps lost in that time. In addition, since I detached from 2MARDIV in 2006, did a residency, got board certified, and did ~5 years of staff tour plus another deployment ... my perspective on the whole GMO phenomenon has really changed. I look back on my "sick call" practice and some of the situations I was in while deployed, and though I felt OK about most of it at the time, I don't feel OK about it now and I'm really grateful that I didn't hurt anyone in those days. At least I think I didn't. Some of the things I did make neat stories ... but my judgment of the safety of it all has swung the other way.

Maybe it's because anesthesia is an unusually conservative field that is heavily, heavily invested in safety. (Check out some of our forum's threads with EM docs re: NPO guidelines and procedural sedation.)


Another wrinkle to this discussion is that a residency-trained physician assigned to a billet in which he does not practice his specialty is, by instruction, ineligible to receive ISP for his specialty. What happens if a doctor with an existing MSP contract gets orders to such a billet? (This seems to be unevenly enforced; I've known a number of people who did second residencies in anesthesia, most got the prior specialty's ISP while a resident, but one did not.)

 

[HighPriest]

Have to agree. In the past militaries to include our own have run into some trouble when it comes to doing things that are unethical just because you were ordered to do it. While this may not be water boarding or a gas chamber built like a shower, asking someone who isn't competent to practice a field of medicine to go ahead and do it anyway is still unethical. (Create your own spectrum as to "how" unethical it is). You can justify it in any way you'd like, but it doesn't change the fact. Yes, at one point as a medical student I did a pelvic exam (since that seems to be our baseline), but I also did a thoracotomy and fixed an aortic aneurysm. In both cases I was supervised. Should I be able to do both? Where is the line drawn?

It's all fine until something bad happens and then Anderson Cooper won't shut the hell up about it. Next thing you know, you're in Leavenworth writing bad poetry and getting a reputation for having deft hands.

 

[colbgw02]

Another wrinkle to this discussion is that a residency-trained physician assigned to a billet in which he does not practice his specialty is, by instruction, ineligible to receive ISP for his specialty. What happens if a doctor with an existing MSP contract gets orders to such a billet? (This seems to be unevenly enforced; I've known a number of people who did second residencies in anesthesia, most got the prior specialty's ISP while a resident, but one did not.)

This has, at least nominally, been covered. The MOU between MEDCOM and FORSCOM requires that the brigade surgeon be allowed to do enough to keep his privileges in his specialty, which is sufficient to keep ISP/MSP. The problem is that is all they're required to do. And because these requirements are a joke, it is no way a guarantee that a person can maintain competency.

 

[Simplestone]

It's all fine until something bad happens and then Anderson Cooper won't shut the hell up about it. Next thing you know, you're in Leavenworth writing bad poetry and getting a reputation for having deft hands.

Well this is highly specific.

 

[HighPriest]

Well this is highly specific.

There's a science to life.