Ahh, there it is. I was waiting for the derogatory post against military physicians who voluntarily accepted lower pay and lower volume/complexity to receive a scholarship and serve their country for a while.
I don't know, I didn't really see anything derogatory about the physicians there, except maybe the one guy who dumped his post-op care (?!?) on the network. Which is weird, but maybe he was deploying? Ordered TAD? I'm inclined to give him the benefit of the doubt.
Also, to nitpick a little, while we all went in eyes open about the lower pay and the service bits, I'm not so sure if I'd agree that new HPSP joins really have any idea what the caseload implications of service are, and how that inflicts long term damage upon their ability to be good doctors. And how the low caseload used to be a minor thing, easily overcome with some effort and maybe a bit of moonlighting - but is now a near insurmountable problem for most proceduralists who are essentially obligated to devote a significant amount of liberty and leave to ODE. Which many commands still discourage or make difficult.
Volume - at least complex, sick, old volume - has cratered in the last decade. When I joined in the 90s the Navy MTFs had respectable cardiac surgery programs. NMCP and San Diego quit doing hearts about six years ago and those programs are. Never. Coming. Back. I remember doing craniofacial cases on kids when I was a resident at Portsmouth.
Skill sustainability is at the forefront of areas that need to be improved to have the effective force listed above. The backbone of that is the right volume, complexity and clinic/OR management to make it possible. This is still a work in progress.
One of my deepest concerns has long been that even with the right leadership and policies, there may not exist sufficient volume and complexity to claw back into the MTFs. Getting back to cardiac surgery - when I retired from the Navy it was understood that even with 100% capture of all eligible beneficiaries in Portsmouth's catchment area, there weren't enough hearts to sustain two cardiac surgeons. The only thing to be done there was pay our two cardiac surgeons to go TAD to work for Duke (for free) for months at a time... but that deal didn't include anesthesia, OR nurses, ICU staff, residents or anyone else that relied on or benefited from a cardiac surgery program.
When it comes to skill growth and maintenance, I saw few meaningful efforts and zero meaningful results in the last 10 years of my Navy time. Plenty of flag officers doing town halls, waving their hands, telling us they "get it" and are working on it. But the only functional solution I ever saw to any piece of the problem was increasing the number of out rotations for our residents. For now, our residents still get decent to good training, in most specialties, largely on the backs of civilian programs who accept them as visitors. But there's no RRC-equivalent to lean on the Navy to fix the same problem for attendings.
The inescapable truth is that for the last 20 years milmed leadership has been content to burn through junior people to man operational units (obviously the top priority for milmed), while doing nothing to ensure the long term viability of the system.
Fortunately the pitfalls are at least acknowledged as opposed to ignored the way they used to be when I joined and most of you were early/mid career.
I think they're still being ignored and I think every milmed flag officer in every branch should be immediately relieved.
Currently retention is abysmal and the application pool (at least that comes through my interviews) is average at best. Although nationwide patriotism, satisfaction and sense of purpose/duty is at an all time low so I am not surprised. None of this is the fault of your average MilMed physician. They are just receiving the collateral damage from everything discussed in this thread.
I agree with all this - don't really blame the physicians on active duty at all, except the ones wearing stars.
And I say that, knowing a couple current flag officers, knowing that they're good people. One was a teacher and mentor to me for nearly 20 years. But the ship they're driving is aground and the engines are revving at flank speed to grind the ship further up the reef.
They, and other DOD leaders, and Congress (to the small extent that those subject matter not-experts are clued in by DOD leaders to what's going on) have leaned on patriotism and sacrifice to recruit and retain people. The dirty secret is they've let themselves believe that patriotism and a bit of money paid to debt-averse students would be sufficient, and that they didn't really need a world class healthcare system after all ...
And maybe they don't, to staff operational units and a handful of deployable trauma units. Maybe the real tragedy here is that the cynics and beancounters are right, and we don't need a top notch system to provide adequate wartime support to combatants.
In any case, there really isn't money for a world class healthcare system bolted onto the military any more - this isn't the pre-1989 Cold War. So why are we pretending we can still do it?
Their biggest sin has been pretending the system could continue to exist as-is without a fundamental overhaul and change of how the military gets its medical support. Their lack of vision and courage to effect the needed changes is what I can't forgive. No one denies the challenges. Their failure to meet them with decisive and bold action is where the shame lies. And I got sick, sick, sick of listening to them talk about KSAs and ERSAs and NTTC/Penn and other such nonsense.
The solution is an all-reserve force, with every MTF folded into the VA system. Operational units staffed in garrison with civilians who are paid market rates, plus reservists doing their weekend/two-week thing. Deployed operational units staffed with reservists.
Abandon the quaint notions that (a) there's some magic of "critical institutional knowledge" that will be lost between wars without a huge active medical corps, and (b) that the current system of churning through junior clinicians while retaining senior administrators would actually retain such capability if it existed in the first place (it doesn't).
I'll hold my breath while the kings (flag officers) decide to ask DOD and Congress to dissolve their kingdoms (MTFs) because the whole thing is obsolete and there's a better way to meet modern defense challenges than this failing pale shadow of a 40-year-old Cold War model.
