Just found this article on atrophy here's a extract since I can't post a link for some reason:
Military medical officials have responded in recent years, sometimes citing costs, by downsizing some hospitals to health centers, shuttering their obstetrical centers and surgical facilities and sending patients to local civilian facilities.
They have also encouraged medical commands to forge agreements with nearby civilian trauma centers and Department of Veterans Affairs hospitals to allow military physicians to practice there. That effort is being expanded, according to the Army Medical Command.
Since Edwards’ article was published, progress had been made, Edwards and Nessen said.
“There is a definite level of awareness that operative volumes are critically important for surgeon readiness and that this needs to be quantified and evaluated prior to deployment,” they wrote in their email to Stars and Stripes. “There is no question that the military surgical community, working with our military and civilian surgical leaders, is taking this issue very seriously.”
From what you practicing physicians see, is it true that the leadership is working towards fixing this issue and trying to prevent atrophy. Do you think they will succeed in atleast reducing it?
I would answer that with a qualified yes. But there's a long way to go yet.
The basic problem we're working through right now is that there doesn't seem to be any top-down, enterprise level leadership to establish these relationships with civilian or VA facilities. In every case I have observed and been a part of, these arrangements (when they occur) have very much been driven by individual commands or individual physicians. There's good and bad to this delegation of responsibility to individual physicians, but it's mostly bad, because it results in absolutely monumental duplications of effort and wasted man-hours.
Recent personal example - I'm a fellowship trained subspecialist at a large MTF that recently stopped providing a subset of that subspecialty care. I can still practice a limited subset of the subspecialty, and there's value in having me here as part of the residency program faculty, but its far from ideal in terms of maintaining the full spectrum of my skill set, much less advancing it.
So, my options for continuing to practice in my subspecialty are
1) Moonlighting. This requires expending personal leave, finding a place to work, getting credentialed, obtaining a license in that state, securing liability insurance, obtaining permission from my command, and filling out monthly audit paperwork so they track it all. This hassle is admittedly offset by the fact that large sums of money are then paid to me. This is a good option for physicians who have vacation time to burn, who practice in specialties conducive to shift work, and who want to work extra hours.
2) Getting temporary duty orders to another military hospital where that subspecialty is needed. Typically, when it comes to subspecialty care, other military hospitals also have low volume, and they have their own people just like you who are looking for more work.
3) Working at a VA hospital. Sounds perfect, actually - they're federal hospitals where any state license is good, liability insurance is covered by the federal tort claims act (it's the physician's military place of duty for the day), and oh by the way Congress has been explicitly telling the military and the VA to cooperate and share personnel and other resources for more than 30 years now. Easy answer, right?
The VA option sounds ideal for skill maintenance. But it's not a straightforward solution -
It took me about six months to get credentialed at one. I actually needed to miss a day of work at my Navy hospital to go to the VA hospital for a pre-employment physical and another day so I could go and swear the oath of office in person. Fingerprinting and background checks. It's just utterly bizarre that an active duty physician with a secret or better security clearance would need to do this.
In my case, the VA hospital is almost two hours away from my current duty station. If I spend a day or a week there, I'll need a hotel. TAD funding is going to have to come from my department's budget.
There was no existing memorandum of understanding between this VA hospital and my Navy hospital. One had to be conjured from scratch and approved by both institutions. Who wrote it? The VA's lawyers? The Navy's lawyers? No. I did. I took a MOU that our residency program uses when our residents do outside rotations, and rewrote the parts describing supervised practice and evaluations so that they reflected the intent of this whole endeavor. I'm not going there to be someone's student or scut monkey; I'm a fully credentialed, licensed, multiply-boarded subspecialist physician and I expect to practice as one.
In theory, the military and the VA
could plan for regularly scheduled, predictable blocks of time where the military physician is at the VA facility. The VA could open up more clinic time, or operating room time, and improve their patients' access to care. A greater volume of work
could be done. But what actually happens is the VA does the same fixed volume of work, and merely takes advantage of the intermittent, sorta unpredictable presence of an extra body from the military. There's no efficiency gain here, no added value to taxpayers, no reduction in VA patients' wait times. Sharing of staff and resources between the military and the VA
could be something wonderful and efficient, but it's not - because it's still so uncommon, inconsistent, and individually driven.
If the enterprise was really "taking this issue seriously" there would be nationwide, tri-service, cooperative infrastructure and agreements in place between the DOD and the VA. If travel was required, it would be paid for by DHA, not the individual physician's department's operating funds. Military physicians would coordinate their daily place of duty with their department's scheduler and the VA's scheduler and that would be the end of it.
What we have are arrangements that are very much local/individual one-off phenomena. I expect that in time, these circumstances will improve. Efforts are being made. We have a ways to go yet.
I'm sure you all have discussed this in the recent past anyway.
