Experience as an IM military attending

[iMirai23]

I have been considering Naval HPSP, but have been reading about some of the horrors of skill atrophy especially with proceduralists; I was kind of getting the sense that one becomes board certified and then you sometimes end up not even practicing in your field of expertise to a significant extent.

I did not readily see as many discussions on the experience of IM. What does military IM entail? Is there minimal hospital work, and it ends up being more outpatient primary care?

Could someone also elaborate more on officer duties (and even military bureaucracy)?

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[Gastrapathy]

I feel like this specific question gets asked fairly frequently. It matters. A lot. Low acuity medicine, ICU admissions for stable floor patients, low volumes and a lack of effective support are all very real.

 

[DOswag]

I'm Air Force psychiatry so maybe can't speak specifically to IM. But similar to what I've experienced, if you're not stationed at one of the large hospital MTF's, then you just won't be exposed to the same patient population that you will be during residency. For me that means far less SMI such as schizophrenia or bipolar etc. Mostly bread and butter depression, anxiety, adjustment disorder, personality disorders. Plus for psychiatry we only see active duty. Residency was split military/civilian so we got to see lots of pathology in the civ hospital on inpatient and consults. I've been straight outpatient for 4 years now (about to rejoin the civilian side soon though as I'm completing my ADSC)

 

[DrMetal]

I have been considering Naval HPSP, but have been reading about some of the horrors of skill atrophy especially with proceduralists; I was kind of getting the sense that one becomes board certified and then you sometimes end up not even practicing in your field of expertise to a significant extent.

I did not readily see as many discussions on the experience of IM. What does military IM entail? Is there minimal hospital work, and it ends up being more outpatient primary care?

Could someone also elaborate more on officer duties (and even military bureaucracy)?

You'll get taken care of as a Medical Student and as a Resident. You'll see enough patients, you'll get adequate training (whether it be in or outside of your home institution). We have to make sure of this, because there are civilian governing bodies (LCME, ACGME, etc) that set requirements and govern us, in that regard. Amen.

The true travesty of military medicine starts when you become an Attending. The problem is (and this goes for every specialty), there's just not enough volume to keep students, trainees, and Attendings busy. The trainees do most of the work (and even that was slim pickings sometimes, I went a whole weekend once as a resident without admitting a patient). Attendings are in supervisory roles really not doing much on their own. And there's no strict requirements to keep the attending skilled or occupied.

 

[Carcassonne]

Three other thoughts (me being an IM outsider):
1. For IM subspecialties, the pandemic hit their patient referrals and census hard. While COVID shut nearly everyone down, the DOD hospitals seem to have been even slower to recover. A lot of nurses were lost, especially the DOD contractors. Also, the active duty personnel were sent across the nation (NYC, North Dakota, etc.) for COVID deployment. Then there was the Afghan refugee crisis... Meanwhile, the home stations suffered. Concrete examples: Heme/Onc was only treating active duty soldiers/airmen, *not even their spouses*. I have no idea how their fellowship fared, but it felt like the patients were being sent out into a void (and weird stuff can happen in the outside). Gastroenterology also suffered- scope numbers plummeted. Even after COVID restrictions were lifted, GI didn't recover due to lack of staffing. I quit scoping due to the chaos. While is COVID is over, any national 'emergency' can affect the military staff and hospitals.

2. DHA realignment seems to hit IM particularly hard. There are some with more knowledge on this topic, but DHA wants to emphasize physicians who deploy, e.g. surgeons. They ravaged pediatrics and gyn, and I think IM (e.g. nephrology) allocation also got hit. While you may want to be a true generalist / hospitalist, your mind could easily change. And if the subspecialists are suffering, that means your training rotations suffer. They will try to satisfy ACGME, but they may have to duct tape together outside rotations.

3. Deployments for IM are generally awful. That's mainly an outpatient GP / brigade surgeon / flight surgeon gig. Deployment IM consists of musculoskeletal injuries, STDs, and a morass of URTIs with malingering. In the midst of this, bet on one true zebra which will be mind boggling, and generally the service member will suffer and be flown out, and then the Monday-morning-quarterbacking will begin. In wartime, rheumatologists are sent to Forward Operating Bases to be family med, and hospitalists at the Role III are serving as trauma surgery residents / PAs, i.e. ward monkeys. Some of them are understandably ticked because the trauma czar wants them to be fluent in trauma care. Occasionally, there will be a legit MI, and if the cardiologist is around, they will shrug their shoulders, consider heparin, and try to evac the patient ASAP. Then the cardiologist will return to the ward to write progress notes. If you're not busy, then they'll try to hook you into command or policy making (COVID was really bad for this). Maybe you would like it, but most doctors don't.

3*. Once again, if you're not busy, even at your home station, they may turn you into a bureaucrat / commander. Writing officer performance evals, public health stuff, disease prevention, educating personnel beyond their scope of practice (less onerous but gets tiring), teaching ACLS, etc.

Yeah... I wouldn't do IM... I would just do Family Practice..

 

[DOswag]

Three other thoughts (me being an IM outsider):
1. For IM subspecialties, the pandemic hit their patient referrals and census hard. While COVID shut nearly everyone down, the DOD hospitals seem to have been even slower to recover. A lot of nurses were lost, especially the DOD contractors. Also, the active duty personnel were sent across the nation (NYC, North Dakota, etc.) for COVID deployment. Then there was the Afghan refugee crisis... Meanwhile, the home stations suffered. Concrete examples: Heme/Onc was only treating active duty soldiers/airmen, *not even their spouses*. I have no idea how their fellowship fared, but it felt like the patients were being sent out into a void (and weird stuff can happen in the outside). Gastroenterology also suffered- scope numbers plummeted. Even after COVID restrictions were lifted, GI didn't recover due to lack of staffing. I quit scoping due to the chaos. While is COVID is over, any national 'emergency' can affect the military staff and hospitals.

2. DHA realignment seems to hit IM particularly hard. There are some with more knowledge on this topic, but DHA wants to emphasize physicians who deploy, e.g. surgeons. They ravaged pediatrics and gyn, and I think IM (e.g. nephrology) allocation also got hit. While you may want to be a true generalist / hospitalist, your mind could easily change. And if the subspecialists are suffering, that means your training rotations suffer. They will try to satisfy ACGME, but they may have to duct tape together outside rotations.

3. Deployments for IM are generally awful. That's mainly an outpatient GP / brigade surgeon / flight surgeon gig. Deployment IM consists of musculoskeletal injuries, STDs, and a morass of URTIs with malingering. In the midst of this, bet on one true zebra which will be mind boggling, and generally the service member will suffer and be flown out, and then the Monday-morning-quarterbacking will begin. In wartime, rheumatologists are sent to Forward Operating Bases to be family med, and hospitalists at the Role III are serving as trauma surgery residents / PAs, i.e. ward monkeys. Some of them are understandably ticked because the trauma czar wants them to be fluent in trauma care. Occasionally, there will be a legit MI, and if the cardiologist is around, they will shrug their shoulders, consider heparin, and try to evac the patient ASAP. Then the cardiologist will return to the ward to write progress notes. If you're not busy, then they'll try to hook you into command or policy making (COVID was really bad for this). Maybe you would like it, but most doctors don't.

3*. Once again, if you're not busy, even at your home station, they may turn you into a bureaucrat / commander. Writing officer performance evals, public health stuff, disease prevention, educating personnel beyond their scope of practice (less onerous but gets tiring), teaching ACLS, etc.

Yeah... I wouldn't do IM... I would just do Family Practice..

This was just sad to read. Bless you all who go into IM in milmed. Hell bless everyone who goes into milmed period. Glad I'm seeing the light at the end of the tunnel that I'm confident isn't a train this time.

 

[armytrainingsir]

IM docs take care of old folks with chronic organ disease/failure. Or young folks with weird diseases.
Well, milmed has been out of the old person game for two decades, and young folks with weird diseases generally aren’t kept around too long. But, the mil thinks it needs lots of MDs to watch PowerPoint shows, make a (single) PowerPoint slide for the boss, sign things, go to meetings, and train ancillary staff about stuff, so I’ll let you do the math on what a mil IM career would be like.

 

[DrMetal]

“Weak people revenge. Strong people forgive. Intelligent people ignore.”​

― Albert Einstein
-------Michael Scott

At my stage, in the MilMed, I think I'm well into the 'ignoring' phase.