Military Medicine: Pros, Cons, and Opinions

[ArmyTiger]

Oh, I read them. I just thought I also read on this forum that GMOs get priority in the Navy. Maybe that's in points only, which may not mean anything. I'm not even in med school yet, but from my own clinical experience (~10,000 hours), I'm pretty sure I want FM. I do know a Navy GMO trying for rads though. Hope she matches, because she's super smart.

10,000 hours? After that, you should be an attending. What are you doing?

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[Matthew9Thirtyfive]

10,000 hours? After that, you should be an attending. What are you doing?

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Between the civilian world and the military, I have about a decade of experience in the OR as an OR tech and now in my command's medical/sick call. I'm a little non-trad and will be 34 when I apply.

 

[AvrgPreMedKid]

Hey all; I've been reading the back-and-forth about GMO's recently, and i feel like i keep reading conflicting information.

Within the last year i had read people saying the Army was no longer doing GMO's, that the Air Force still did some, and that the Navy had the most likely chance of it. These more recent posts suggest nothing i've read is accurate. I'm applying to med school next summer and the USUHS is my #1 pick for a variety of non-mercenary reasons (ultimately would be shooting for psychiatry), but my greatest hesitation is that i would end up in one of these GMO tours; or worse, several of them.

I have looked but cannot find the metrics myself: How can i find out, truly, what the stance of each branch of the military has on GMO's and how frequently they utilize GMOs today in 2016?

M1 Army HPSP here. One of my professors is a retired colonel in the army (he was a physician). He and many other sources I have spoken with indicate that the army does not do the internship->GMO tour thing anymore. Apparently, it has become frowned-upon to send out people with only one year of post-grad training to take care of soldiers.

That being said, I have heard of residency-trained physicians being sent on GMO tours. I would assume these are typically FM/IM docs. I doubt they would send a general surgeon to be a brigade/flight surgeon (misnomer).

I chose the army because I felt it offered the most options compared to the other branches - it is the biggest. From what I have heard, you are pretty much guaranteed to do a GMO tour with the navy. The navy actually has it written into one of their EM residency curriculums that you do a GMO tour in the middle of the residency. And air force is small.

The way I see it, if you do well in school, on the boards, and have good rotations, you shouldn't get thrown into something you hate. But then again, it's the army, and it is very possible. Another part of why I signed up is because I'm not sure what I want to do and I'm kinda down for some adventure.

 

[Gastrapathy]

Army still has GMOs. People from a variety of specialties and subs are ripped for brigade surgeon tours. Your performance as a student does not protect you from the green weenie.

 

[WernickeDO]

M1 Army HPSP here. One of my professors is a retired colonel in the army (he was a physician). He and many other sources I have spoken with indicate that the army does not do the internship->GMO tour thing anymore. Apparently, it has become frowned-upon to send out people with only one year of post-grad training to take care of soldiers.

That being said, I have heard of residency-trained physicians being sent on GMO tours. I would assume these are typically FM/IM docs. I doubt they would send a general surgeon to be a brigade/flight surgeon (misnomer).

I chose the army because I felt it offered the most options compared to the other branches - it is the biggest. From what I have heard, you are pretty much guaranteed to do a GMO tour with the navy. The navy actually has it written into one of their EM residency curriculums that you do a GMO tour in the middle of the residency. And air force is small.

The way I see it, if you do well in school, on the boards, and have good rotations, you shouldn't get thrown into something you hate. But then again, it's the army, and it is very possible. Another part of why I signed up is because I'm not sure what I want to do and I'm kinda down for some adventure.

You are completely and utterly wrong about who gets tabbed for GMO tours. I personally know plenty of brilliant docs who matched to competitive specialties get pushed into a GMO tour because they either a) made a career change into a different specialty; b) get pushed out of a general surgery residency to make way for a returning GMO; or c) simply have bad luck and didn't match. These are all docs who were graduates from prestigious MD schools who just had circumstances break against them. Frankly, the perception that GMO's are the bottom of the barrel grates on me.

Your retired COL professor has absolutely no idea what is going on in Army medicine unless he is sitting in on the meetings with the advisors to the Surgeon General or is an active duty doc in the trenches. The Army or Navy could not function without GMO's. Frankly, us intern trained docs are perfectly suited to a GMO tour. Yes I'm bored with the lame crap I see in my office but I am not trained enough to see or manage anything complex. I am qualified to handle the sore throats and stuffy noses and ankle pain and STD treatment.

Radiologists, neonatologists, pediatric gastroenterologists have all been pushed into brigade surgeon tours. No one is immune. Even general surgeons take on command type jobs in order to make O5/6.

If you are in the military, there is a possibility that you will either do a GMO tour, do a brigade surgeon tour after residency, or take a command position to get promoted.

 

[WernickeDO]

As a continuation to an earlier conversation, 2 more of my GMO colleagues have told me that the latest Army policy is to fill up residency spots with MS4's first and to consider GMO's second. There are no more protected slots for GMOs, now it's just whatever is available if the MS4 pool isn't enough to fill up. Now it's a n=3, so still anecdotal, but there should be an awareness of this for pre-meds considering HPSP.

 

[AvrgPreMedKid]

You are completely and utterly wrong about who gets tabbed for GMO tours. I personally know plenty of brilliant docs who matched to competitive specialties get pushed into a GMO tour because they either a) made a career change into a different specialty; b) get pushed out of a general surgery residency to make way for a returning GMO; or c) simply have bad luck and didn't match. These are all docs who were graduates from prestigious MD schools who just had circumstances break against them. Frankly, the perception that GMO's are the bottom of the barrel grates on me.

Your retired COL professor has absolutely no idea what is going on in Army medicine unless he is sitting in on the meetings with the advisors to the Surgeon General or is an active duty doc in the trenches. The Army or Navy could not function without GMO's. Frankly, us intern trained docs are perfectly suited to a GMO tour. Yes I'm bored with the lame crap I see in my office but I am not trained enough to see or manage anything complex. I am qualified to handle the sore throats and stuffy noses and ankle pain and STD treatment.

Radiologists, neonatologists, pediatric gastroenterologists have all been pushed into brigade surgeon tours. No one is immune. Even general surgeons take on command type jobs in order to make O5/6.

If you are in the military, there is a possibility that you will either do a GMO tour, do a brigade surgeon tour after residency, or take a command position to get promoted.

First of all, starting off your argument with ,"You are completely and utterly wrong" makes you sound like a complete and utter d**che. This isn't a presidential debate. Second of all, the professor I'm referring to was in the Army for 40 years and still has connections. I was just on MODS and saw an anesthesia residency which said it had a reserved spot for a GMO. I have seen other specialties with this, as well. So, maybe MODS and everybody I know are lying. Maybe you are right. You are the first person I've heard say that there aren't spots held for GMO's. Are you also saying it's no longer true that GMO's get extra "points" when applying for residency compared to MS4's? Anyways, I'm sorry you ended up as an intern->GMO.

 

[Gastrapathy]

Keep those blinders on kiddo. You're already committed and it will help you sleep at night.

 

[WernickeDO]

First of all, starting off your argument with ,"You are completely and utterly wrong" makes you sound like a complete and utter d**che. This isn't a presidential debate. Second of all, the professor I'm referring to was in the Army for 40 years and still has connections. I was just on MODS and saw an anesthesia residency which said it had a reserved spot for a GMO. I have seen other specialties with this, as well. So, maybe MODS and everybody I know are lying. Maybe you are right. You are the first person I've heard say that there aren't spots held for GMO's. Are you also saying it's no longer true that GMO's get extra "points" when applying for residency compared to MS4's? Anyways, I'm sorry you ended up as an intern->GMO.

You said something completely and utterly wrong. I called you on it.

Where on MODS did you see this? Did you click on the information button and get the quick blurb about the program goals, PD, phone numbers, etc? If so, know those sometimes go years without getting updated, and it is not official Army policy. I'm not saying that GMOs don't match, I am saying that the idea of a points system for GMOs and doing a tour makes it easier to match is not accurate. It's hard to quantify this, because the Army doesn't publish the data on GMOs matching, and the so called "slots for GMOs" vary from year to year. What I am saying is that the number of slots is contingent on what the MS4 pool looks like. This is in direct opposition to what was sold to me and other HPSP students, which was that a GMO tour nets you a ton of points, especially if you deploy, and you can pretty much write your own ticket after that. This may have been true at one point. I am saying it is not true anymore.

I'm sure your professor has connections. I am relaying what was straight from the mouth of multiple program directors who are currently making these decisions, taking instructions from Big Army, and who are in the thick of it right here, right now. I have made it very clear that this is anecdotal but 3 different program directors in different specialties makes for a compelling case. Take from that what you will. I think it's important because it contradicts one of the selling points of HPSP; namely, that doing a GMO tour can increase your chance to match. In your professor's day, it WAS true that people who got tabbed for a GMO tour usually went right back to training. This is not the case anymore, evidenced by the giant logjam of GMOs who are trying to get back to training, even compromising their specialty choices to do so. Many of my attendings in general surgery had done GMO tours. The difference is that there spots were waiting for them when they got back next year. Those spots are now gone.

And let's say there are spots held for GMOs. Let's use last years EM match data points to compare. There were 40 MS4 applicants for 30 spots. That's a 75% match rate. There were 28 GMO applicants for 6 spots, making it more like 21%. This means that either 22 of 28 applicants were so sub-par that even the points they earned for operational tours, deployments, or research could not overcome the MS4 applicants (the vast majority of whom would have no military experience), or it means that MS4's are preferred. If the points system were real (in that success = matching to your preferred specialty) then what could explain that discrepancy? The truth is that the points system only helps you compared to other GMOs, and the number of slots for GMOs is first determined by the shape of the MS4 class. Even then, it can be slanted however they want it, with points awarded for the nebulous "potential as an Army officer" that can push someone over the top.

As for being sorry for me being an intern->GMO, please be assured that I am sorry too. I was cut from general surgery to make way for a GMO with family connections. I was cut after the application deadlines had all passed, so I didn't even have a chance to apply to another specialty. It was a $#itty thing to do to me and my family. Let me advise you against condescension to other medical professionals. You are brand new in this game, and there have been many people who have gone before you, done everything right, and gotten screwed on (in?) the backend. Things don't always work out the best for people, but they grin and bear it and move forward. Maybe someday you will too.

 

[HighPriest]

I can promise you that wehad little interest and no spots "held" for GMOs in my specialty. I'm sure we would have considered one if they were the best possible applicant, but they certainly would have needed to beat out all of the MS4s, and probably all of the TY interns as well. I'm not saying that was right, but it is a fact.

And your contact spent 40 years in the Army? 40? As a physician? Maybe that's accurate, but that would be some highly unusual $&@t. What is he, 75? Maybe he just doesn't remember how things we're. Senility is a bastard.

 

[Gastrapathy]

If he did spend 40 years, then odds are he spent 20 as an O6 in some protected gig watching the rest of us work and deploy.

 

[Helpful Troll]

If he did spend 40 years, then odds are he spent 20 as an O6 in some protected gig watching the rest of us work and deploy.

Without doxing AvgPreMedKid - I did look at the likely faculty member/retired Army Medical Officer (Pathology and Aerospace Med). He enlisted and served in Vietnam, commissioned, and went to med school mid career.

This doesn't change how quickly guidance from apparently reputable sources is inaccurate/incomplete. The regulations are broad and execution changes annually if not more often. MilMed is capricious.

 

[AvrgPreMedKid]

You said something completely and utterly wrong. I called you on it.

Where on MODS did you see this? Did you click on the information button and get the quick blurb about the program goals, PD, phone numbers, etc? If so, know those sometimes go years without getting updated, and it is not official Army policy. I'm not saying that GMOs don't match, I am saying that the idea of a points system for GMOs and doing a tour makes it easier to match is not accurate. It's hard to quantify this, because the Army doesn't publish the data on GMOs matching, and the so called "slots for GMOs" vary from year to year. What I am saying is that the number of slots is contingent on what the MS4 pool looks like. This is in direct opposition to what was sold to me and other HPSP students, which was that a GMO tour nets you a ton of points, especially if you deploy, and you can pretty much write your own ticket after that. This may have been true at one point. I am saying it is not true anymore.

I'm sure your professor has connections. I am relaying what was straight from the mouth of multiple program directors who are currently making these decisions, taking instructions from Big Army, and who are in the thick of it right here, right now. I have made it very clear that this is anecdotal but 3 different program directors in different specialties makes for a compelling case. Take from that what you will. I think it's important because it contradicts one of the selling points of HPSP; namely, that doing a GMO tour can increase your chance to match. In your professor's day, it WAS true that people who got tabbed for a GMO tour usually went right back to training. This is not the case anymore, evidenced by the giant logjam of GMOs who are trying to get back to training, even compromising their specialty choices to do so. Many of my attendings in general surgery had done GMO tours. The difference is that there spots were waiting for them when they got back next year. Those spots are now gone.

And let's say there are spots held for GMOs. Let's use last years EM match data points to compare. There were 40 MS4 applicants for 30 spots. That's a 75% match rate. There were 28 GMO applicants for 6 spots, making it more like 21%. This means that either 22 of 28 applicants were so sub-par that even the points they earned for operational tours, deployments, or research could not overcome the MS4 applicants (the vast majority of whom would have no military experience), or it means that MS4's are preferred. If the points system were real (in that success = matching to your preferred specialty) then what could explain that discrepancy? The truth is that the points system only helps you compared to other GMOs, and the number of slots for GMOs is first determined by the shape of the MS4 class. Even then, it can be slanted however they want it, with points awarded for the nebulous "potential as an Army officer" that can push someone over the top.

As for being sorry for me being an intern->GMO, please be assured that I am sorry too. I was cut from general surgery to make way for a GMO with family connections. I was cut after the application deadlines had all passed, so I didn't even have a chance to apply to another specialty. It was a $#itty thing to do to me and my family. Let me advise you against condescension to other medical professionals. You are brand new in this game, and there have been many people who have gone before you, done everything right, and gotten screwed on (in?) the backend. Things don't always work out the best for people, but they grin and bear it and move forward. Maybe someday you will too.

Well, ****. There go my plans of doing flight surgery -> specialty. I thought I could enjoy being a flight surgeon for some time with my aviation interests and then use that to get into a good specialty after. Hmm. Thanks, army. And sorry if I came off disrespectful. Thank you for your willingness to serve.

 

[WernickeDO]

Well, ****. There go my plans of doing flight surgery -> specialty. I thought I could enjoy being a flight surgeon for some time with my aviation interests and then use that to get into a good specialty after. Hmm. Thanks, army. And sorry if I came off disrespectful. Thank you for your willingness to serve.

If you're interested in flight surgery, you can either do the residency in aerospace medicine (RAM, you become boarded in occupation med and earn an MPH), or you can request a flight job after residency. This might be your best option, because if you find yourself in a more specialized or procedural based specialty (surgery/EM/OB/rads) you may change your mind about wanting to do flight. But your best bet is to get through residency first, then see what kind of operational stuff to do.

 

[deuist]

Frankly, us intern trained docs are perfectly suited to a GMO tour.

That is a statement that always grates me. As an internship-only trained GMO, you don't know what you don't know. I did a general surgery internship before heading off to residency in emergency medicine. By the end of my first year of surgery, I did not know how to evaluate or treat musculoskeletal injuries, treat chronic medical conditions such as hypertension or diabetes, or handle any gyn-related issues. Having seen one GMO miss an ankle fracture because he thought it was merely a "sprain" while another missed multilevel vetebral compression fractures on a patient who had been seen half a dozen times previously in the flight medicine clinic for neck pain, I'm wary of incompletely trained physicians practicing independently. I really do think that GMO is best suited to family physicians or occasionally internists or even emergency physicians who wish to practice more on the urgent care side.

 

[WernickeDO]

That is a statement that always grates me. As an internship-only trained GMO, you don't know what you don't know. I did a general surgery internship before heading off to residency in emergency medicine. By the end of my first year of surgery, I did not know how to evaluate or treat musculoskeletal injuries, treat chronic medical conditions such as hypertension or diabetes, or handle any gyn-related issues. Having seen one GMO miss an ankle fracture because he thought it was merely a "sprain" while another missed multilevel vetebral compression fractures on a patient who had been seen half a dozen times previously in the flight medicine clinic for neck pain, I'm wary of incompletely trained physicians practicing independently. I really do think that GMO is best suited to family physicians or occasionally internists or even emergency physicians who wish to practice more on the urgent care side.

You're certainly right. I know that I have missed things too. And after a year of GS I has to brush up on the primary care topics that GMOs deal with. An IM/FM doc would be much better in this situation. But the mil is unable/unwilling to fully train a significant portion of its docs, so you are left with large pool of interns who would otherwise have nothing to do.

 

[DrMetal]

That is a statement that always grates me. As an internship-only trained GMO, you don't know what you don't know.

I disagree. I agree with WernickeDO......a well-trained PGY1 is perfectly fine for a GMO tour. I've been doing it for 3 years. You just have to know when to ask for help, and you have to track your patients carefully. I've seen PAs and nurses do it (operational tours), there's no reason why a PGY1 trained MD can't do it (but again, you have to know when to ask for help...ie consults and medevac's galore). I'd rather do this GMO job post-PGY1 than post BC'd specialty. Putting a BC'd internist/FP/EP in my job right now would be an incredible waste of resources.

I did a general surgery internship before heading off to residency in emergency medicine. By the end of my first year of surgery, I did not know how to evaluate or treat musculoskeletal injuries,.

Why not? After PGY1, you should at least know the basic algorithm (XRAYS-->PT--> MRI-->Ortho Consult). You can skip the PT if it looks bad....and if you're not sure what to do, consult Ortho right away, they'll tell you. This isn't rocket science.

treat chronic medical conditions such as hypertension or diabetes, or handle any gyn-related issues.

You don't have to, consult to the appropriate service. And quite honestly, if they have a bad chronic condition, they shouldn't be in an operational billet. You should LIMDU them away. I've caught people on my ship with an A1C > 13%. (I ordered the lab, an intern is capable of doing this.....I did nothing to manage his DM, consulted Medicine right away).

Having seen one GMO miss an ankle fracture because he thought it was merely a "sprain" while another missed multilevel vetebral compression fractures on a patient who had been seen half a dozen times previously in the flight medicine clinic for neck pain

That's a bad GMO. Again, a PGY1 trained physician should be perfectly capable of realizing that--if given trauma or the proper mechanism of injury---Xrays first always (or at least follow the patient closely for a couple days), then PT, then MR, then Ortho....not hard. An astute IDC knows this.

I really do think that GMO is best suited to family physicians or occasionally internists or even emergency physicians who wish to practice more on the urgent care side.

I'd rather our BC'd physicians stay at our big MTFs, taking care of those chronic patients and everything else I'm consulting them for. The operational active duty military is mostly young and healthy...a PGY1-trained GMO suits them just fine.

 

[Gastrapathy]

@DrMetal I felt that way as a GMO too. Couldn't disagree more at this point. I saw patient after patient mismanaged by "bad" GMOs. Why do AD patients deserve a lower standard of care than the vast majority of Americans who walk into their doctor's office? You just don't know what you don't know. You're not a midlevel. You are a physician.

 

[WernickeDO]

It's certainly not optimal. A better solution is to put fully trained docs into those jobs, but that would require either an expansion of GME or more civilian deferments, and neither are likely.

 

[DrMetal]

@DrMetal I felt that way as a GMO too. Couldn't disagree more at this point. I saw patient after patient mismanaged by "bad" GMOs.

Fine, but what makes a bad GMO? It's rarely their lack of medical knowledge/training. They're usually bad because they don't care enough, they don't work hard enough, and they're not humble enough to ask for help. If you do care enough, work hard, and ask for help....you can (in a sense) make up for you lack of medical knowledge/training. These are usually personality flaws that are not related to medical training and likely wont resolve with more medical training (sorry, I'm a pessimist).

Why do AD patients deserve a lower standard of care than the vast majority of Americans who walk into their doctor's office?

It's not that they deserve a lower standard of care. If they're young and healthy, serving in an operational unit...then you don't need a hepatologist treating their VGE with Zofran. What are we to do, send out BC'd physicians to every operational unit? Scrap IDCs on subs, require they be manned by BC'd MDs only? I think not.

I'm not a huge fan of the GMO model, but I get why the Navy does it, and I get why they're staffing GMO tours with intern-trained physicians vice BC'd ones.

 

[WernickeDO]

But I also think that interns can handle the basic stuff: treat minor injuries/illnesses, consult higher levels of care when appropriate, and assess the overall medical readiness of their battalion. A BC doc would be better, but an intern can handle the vast majority.

 

[Gastrapathy]

The root cause isn't really the issue. Whether they are bad GMOs because of a lack of training or lack of interest isn't relevant to the patient that is left to suffer. I also can reflect on mistakes that I made and I'd like to think I was interested and tried to get trained as best I could. Training does eventually make up for laziness to a degree and the most disinterested don't stay in primary care.

The argument that they are young and healthy belies the demographics of the modern military. And again, young and healthy civilians can see a real board-certified primary physician. So when we justify it with these excuses, we are saying that the AD military member who is captive and can't make his or her own choices deserves a lower standard of care than is provided to the 30 year old teacher or police officer or even the military member's spouse. A GMO is not a primary care doctor equivalent. We wouldn't be able to get away with that if they were free to choose.

As for how to manage manning in isolated areas, I would start with the premise that every physician should have completed a residency. If a given unit is too small or isolated to spend that resource, that is the right place for experienced midlevels with appropriate board-certified back up. I would scrap IDCs with their 4 months of clinical training. The reality is that this is a tiny part of the milmed bureaucracy. There just aren't that many submarines or small surface ships. Instead of having 10,000 people working for BUMED pushing paper, we need to focus the right resources at the people who are most deserving. The whole structure is failing and the GMO is an anachronism born out of that failure.

As for hepatologists, the Navy shouldn't have any hepatologists. Gastroenterology training is more than adequate to manage most hepatology problems. Transplant hepatology (which is the actual name of the sub-subpecialty and board exam) is for running transplant programs. The fact that we keep training transplant hepatologists just shows how silly we are. Hiring hepatologists is easy. If they need one for the fellowship (they don't because they have to send the fellows to a real transplant center to get trained anyway), they can hire a civilian.

 

[WernickeDO]

The root cause isn't really the issue. Whether they are bad GMOs because of a lack of training or lack of interest isn't relevant to the patient that is left to suffer. I also can reflect on mistakes that I made and I'd like to think I was interested and tried to get trained as best I could. Training does eventually make up for laziness to a degree and the most disinterested don't stay in primary care.

The argument that they are young and healthy belies the demographics of the modern military. And again, young and healthy civilians can see a real board-certified primary physician. So when we justify it with these excuses, we are saying that the AD military member who is captive and can't make his or her own choices deserves a lower standard of care than is provided to the 30 year old teacher or police officer or even the military member's spouse. A GMO is not a primary care doctor equivalent. We wouldn't be able to get away with that if they were free to choose.

As for how to manage manning in isolated areas, I would start with the premise that every physician should have completed a residency. If a given unit is too small or isolated to spend that resource, that is the right place for experienced midlevels with appropriate board-certified back up. I would scrap IDCs with their 4 months of clinical training. The reality is that this is a tiny part of the milmed bureaucracy. There just aren't that many submarines or small surface ships. Instead of having 10,000 people working for BUMED pushing paper, we need to focus the right resources at the people who are most deserving. The whole structure is failing and the GMO is an anachronism born out of that failure.

As for hepatologists, the Navy shouldn't have any hepatologists. Gastroenterology training is more than adequate to manage most hepatology problems. Transplant hepatology (which is the actual name of the sub-subpecialty and board exam) is for running transplant programs. The fact that we keep training transplant hepatologists just shows how silly we are. Hiring hepatologists is easy. If they need one for the fellowship (they don't because they have to send the fellows to a real transplant center to get trained anyway), they can hire a civilian.

As a GI doc is it a good use of your time to see every NVD that comes into sick call? Or would you allow your medics to triage who sees your PA, with the more severe cases being pushed up to you? Soldiers have an unbelievable amount of access to healthcare, all covered. It's hard for me to feel bad for them seeing me for the sniffles rather than a BC family doc.

And I doubt that the GMOs out there now are thrilled with just being intern trained. Most WANT to be fully trained and board-certified, but the mil is not letting them. I would trade GMO time for the ability to get trained. The opportunity has not been afforded to me or the other GMOs put out to pasture.

I don't know what I don't know but I can always refer out to people that do know. Maybe in a perfect world all GMOs would be BC but why pull an IM doc out of the hospital to see knee pain?

 

[Gastrapathy]

Medics doing triage without close supervision is another example of the broken system. They think someone is faking and they never let that person through to the doctor. Then, later on, it turns out that the whiny black girl who wasn't that racist/sexist medic's idea of a real Marine had a ruptured appy that he ignored for 6 months. Lots of access to substandard care isn't something to celebrate.

Low acuity medicine is always going to be unrewarding. The problem is that the real patients are hidden in the bull****. And that is why you pull the board-certified primary care physician out of the hospital. If all you see are sniffles, you are missing the real stuff.

I don't blame the GMOs except those individuals who came in planning to be one. I blame the system. Not knowing what they don't know means that the patients aren't identified as needing a referral in time. If you practice in the military after your GMO time, you'll come around. We aren't talking about combat casualty care here because we don't let GMOs do that. Most GMO malpractice happens back home and while there are terrible board-certified physicians, the combination of factor that comes with the GMO are a consistent set-up for failure.

They are undertrained by the current American standard. They can only be licensed in an ever-shrinking number of states as as result. They couldn't get privileges at most American hospitals. They couldn't bill most American insurers. You wouldn't accept a GMO caring for you or your family if you had a choice. You can do a dedicated ENT internship and then be a GMO.

They are usually not interested in being primary care physicians.

They are told how its ok because the patients are so easy to take care of. This reinforces their lack of interest.

They can pawn the clinical work off on midlevels or IDCs who they "supervise" despite not being able to practice without supervision at any American hospital.

This isn't about a perfect world. This is what we expect of every other American doctor.

 

[Perrotfish]

Medics doing triage without close supervision is another example of the broken system. They think someone is faking and they never let that person through to the doctor. Then, later on, it turns out that the whiny black girl who wasn't that racist/sexist medic's idea of a real Marine had a ruptured appy that he ignored for 6 months. Lots of access to substandard care isn't something to celebrate.

Low acuity medicine is always going to be unrewarding. The problem is that the real patients are hidden in the bull****. And that is why you pull the board-certified primary care physician out of the hospital. If all you see are sniffles, you are missing the real stuff.

I don't blame the GMOs except those individuals who came in planning to be one. I blame the system. Not knowing what they don't know means that the patients aren't identified as needing a referral in time. If you practice in the military after your GMO time, you'll come around. We aren't talking about combat casualty care here because we don't let GMOs do that. Most GMO malpractice happens back home and while there are terrible board-certified physicians, the combination of factor that comes with the GMO are a consistent set-up for failure.

They are undertrained by the current American standard. They can only be licensed in an ever-shrinking number of states as as result. They couldn't get privileges at most American hospitals. They couldn't bill most American insurers. You wouldn't accept a GMO caring for you or your family if you had a choice. You can do a dedicated ENT internship and then be a GMO.

They are usually not interested in being primary care physicians.

They are told how its ok because the patients are so easy to take care of. This reinforces their lack of interest.

They can pawn the clinical work off on midlevels or IDCs who they "supervise" despite not being able to practice without supervision at any American hospital.

This isn't about a perfect world. This is what we expect of every other American doctor.

This is a somewhat idealistic opinion of American primary care. While our inane system certainly considers an Intern year trained physician unqualified in all but a shrinking number of states, a completely untrained midlevel is considered to meet the standard of care in an ever growing number of states. Do you really think a GMO is less qualified than an effectively unsupervised midlevel? And its not like Intern trained PCMs aren't out there practicing as well. An Intern year still gets you a license in the majority of the US. I know at least one of the PCMs outside my base who never completed a residency, and there are even more effectively unsupervised midlevels.

I agree that GMOs are not ideal, but what exactly do you think the NNT would be to prevent one serious complication by replaced all GMOs with board certified FPs? What is the cost of care? Would that really be a more effective solution to improving our care than replacing the IDCs with qualified midlevels? Or sending the corpsmen to get the practical EMS experience they so desperately need to triage patients safely? Or maybe just having a single supervising sports medicine physician at the regimental level doing teaching and chart reviews? If you have a limited number of dollars, where do you put them?

 

[Gastrapathy]

This is such a small part of the Milmed bureaucracy. The massive waste is in the headquarters and small hospitals. The cost wouldn't be that high.

It's not idealistic to expect that our servicemembers receive the same care as a civilian govie.

As for actually measuring the number needed to harm, well, we all know that despite the huge bureaucracy, Milmed doesnt collect that data. They don't want to know. So it's all anecdotal. I'd say that I'd see about 2 harmed patients per month due to GMO negligence and probably twice that from IDCs and midlevels. Maybe using real primary care physicians would cut that rate in half.

I've already said: I would abolish the IDC and comparing GMOs to midlevels is wrong. GMOs are physicians and that is their standard of care. You know the other part of the govt where they hire some of their physicians without regard to residency completion? The answer is the prison system.

GMOs aren't even cheaper than FPs by very much, particularly when you factor in the night hospital coverage the FPs provided as residents. They are appealing to the bosses because GMO tours extend obligations and spread the crappy jobs out to the future eye dentists, radiologists and dermatologists before they get their carrot.

 

[Perrotfish]

This is such a small part of the Milmed bureaucracy. The massive waste is in the headquarters and small hospitals. The cost wouldn't be that high.

It's not idealistic to expect that our servicemembers receive the same care as a civilian govie.

As for actually measuring the number needed to harm, well, we all know that despite the huge bureaucracy, Milmed doesnt collect that data. They don't want to know. So it's all anecdotal. I'd say that I'd see about 2 harmed patients per month due to GMO negligence and probably twice that from IDCs and midlevels. Maybe using real primary care physicians would cut that rate in half.

I've already said: I would abolish the IDC and comparing GMOs to midlevels is wrong. GMOs are physicians and that is their standard of care. You know the other part of the govt where they hire some of their physicians without regard to residency completion? The answer is the prison system.

GMOs aren't even cheaper than FPs by very much, particularly when you factor in the night hospital coverage the FPs provided as residents. They are appealing to the bosses because GMO tours extend obligations and spread the crappy jobs out to the future eye dentists, radiologists and dermatologists before they get their carrot.

I disagree that comparing GMOs to midlevels is wrong. The standard of care isn't based on the degree, it's based on the job. The job is primary care. Midlevels are the source of primary care for more and more of this country. And unlike GMOs they're not working with a panel of 1500 people, preselected for health, in the middle of a large, supportive network of consultants. They're seeing panels of 4,000 massively comorbid patients, in 12 minute appointments, with no real supervision or support. You can argue that that shouldn't be the standard of care, but right now that's where this country is at.

I also think you're underestimating how much skill rot an FP experiences in a GMO role. Primary care requires sick patients every bit as much as surgery, and rotating FPs through GMO roles either right out of residency, or repeatedly throughout a military career, is a wonderful way to turn a board certified FP into someone who isn't actually any more competent than an Internship trained GMO. FPs need the comorbid elderly, late pregnancies, and sick children to keep their skills up. An all FP GMO force would be extremely expensive if it cost us all of our good FPs

FWIW, if I was reforming milmed, what I would do:
1) Replace IDCs with junior midlevels and eliminate the IDC program.
2) Force our enlisted to earn medical degrees in order to advance. No one should make E4 unless they can challenge for MA or EMT-B and no one should make E5 unless they have an LVN or EMT-I. The LPO for any battalion should be either an RN or a paramedic, and they should have at least a year on the floors or in a truck to learn medicine before they're allowed to take that leadership role. The senior enlisted need to actually learn medicine so that the junior enlisted can learn it from them
3) Bar new GMOs from deployments and sea duty for at least 6 months after they graduate from Intern year/dive school/flight school. Everyone starts in garrison. Put all of the GMOs for the base in a single building rather than separate battalion aid stations (my base already does this). Have a supervising FP and a supervising sports medicine physician cosigning a portion of new GMO charts so that GMOs begin their career in a pseudo-residency environment. If the base is too small to support an FP supervisor than that's the base that needs a board certified GMO. I realize this still isn't as good as a board certified FP for every battalion but I think it would go a long way towards bridging the gap without incurring too much cost or skill rot.

 

[Gastrapathy]

If you accept the GMO vs midlevel comparison, you have accepted that you are a provider. I'm a physician.

You assume that a FP would have to be used in the same wasteful way we use GMOs. Skill rot is simply far less of an issue in primary care then procedural specialties but a little innovation is all it would take. Why not have 2 docs share a hospital and operational billet. Just remember, we do this to sailors and prisoners.

 

[DrMetal]

FWIW, if I was reforming milmed, what I would do:

Good ideas, totally agree...

shrinking number of states, a completely untrained midlevel is considered to meet the standard of care in an ever growing number of states.

...Quite true. Hell, in the civilian clinic I moonlight at, they hire PAs straight out of school and throw them right into the fire (seeing 20-30 patients per day, with little supervision). Me, they hired per diem on the spot (they asked me if I had a CA ML, my own DEA#, and if I can start in an hour). Grant it, it's a low acuity clinic, and we do have help (RADS, Orthopods, etc). I'm not saying any of it is right, but it is what it is.

If you accept the GMO vs midlevel comparison, you have accepted that you are a provider. I'm a physician.

What's with the whole provider vs physician bent? Don't physicians provide care, so why do we admonish the label provider? That comes off a little deuchy, I'm just sayin. Personally, I'd rather be called 'Heisenberg' or 'Neegan', but I doubt that'll happen.

You assume that a FP would have to be used in the same wasteful way we use GMOs.

It would be wasteful. My whole argument is based on my high regard for BC'd physicians like yourself. I'd hate to have you in my job, its thankless and too easy (seriously). Keep the GMOs operational, hell even give them the senior operational billets (==95% admin) too. I'd rather the BC'd physicians stay at the MTFs (or if forward deployed) tending to sicker patients.

Just remember, we do this to sailors and prisoners.

Not true....I tried to moonlight at a prison, they wouldn't hire me b/c I'm not BC'd.

 

[Gastrapathy]

I'm not sure that the fact that you found a prison that wouldn't hire you bolsters the proGMO argument. There's more than one system and some do hire with only a license. You have examples of where GMO style care exists in the community but you yourself won't even defend it.

The word provider is a calculated effort by nurses and others to devalue physician training and claim false equivalency. Your casual acceptance shows how they've won. Arguing equivalence between a GMO and a midlevel makes the argument for them. It makes me sad to hear a physician roll over like that. You've got to give those insidious mother****ers credit.

 

[DrMetal]

I'm not sure that the fact that you found a prison that wouldn't hire you bolsters the proGMO argument.

It doesn't, I was helping you out.

There's more than one system and some do hire with only a license. You have examples of where GMO style care exists in the community but you yourself won't even defend it.

True, I don't entirely defend it. The glorified-PGY1-trained GMO makes more sense to me in the operational military setting, where the situation might be more austere and resources more scarce. We gotta go with what we have to make that operational environment work. Again, I'd rather it be me than a BC'd general surgeon who likely wont do more than 4 cases during a 7-month deployment.

Your casual acceptance shows how they've won. Arguing equivalence between a GMO and a midlevel makes the argument for them. It makes me sad to hear a physician roll over like that. You've got to give those insidious mother****ers credit.

If the mid-levels were here to argue, I don't think they'd agree with you that they've 'won' anything. They'd likely state, akin to Chris Rock, 'We haven't wont ****, Everyday I look in the mail for my prize, nothing!'

Look, call us collectively what they will---provider, clinician, caregiver, care bear, healer, Lord Jesus Christ---we're not equivalent, they know that, we know that.....and (more importantly) the legal profession knows that. There's still a medical chain of command, and MDs are on top.

 

[orbitsurgMD]

>>>>. . . .
They are usually not interested in being primary care physicians.

They are told how its ok because the patients are so easy to take care of. This reinforces their lack of interest.

They can pawn the clinical work off on midlevels or IDCs who they "supervise" despite not being able to practice without supervision at any American hospital.

This isn't about a perfect world. This is what we expect of every other American doctor.

This is the bitter irony of the GMO "system." Usually it is the medical graduates with interests in surgery specialties or anesthesia, radiology and other competitive non-primary care specialties who get fed into the GMO pipeline precisely because GMO duty tours have become a selection criterion that cannot be avoided (ignoring the "potential for future service" which is the insiders gaming the points system.)

 

[SirGecko]

You don't have to, consult to the appropriate service. And quite honestly, if they have a bad chronic condition, they shouldn't be in an operational billet. You should LIMDU them away. I've caught people on my ship with an A1C > 13%. (I ordered the lab, an intern is capable of doing this.....I did nothing to manage his DM, consulted Medicine right away).

I will say that limdu-ing a patient out of the hands of a GMO isn't always an option. For example at a small clinic, no other doctors (and only one NP provider) as a GMO I've actually had patients with multiple complicated medical problems transferred *to* me. From larger military treatment centers which have board certified physicians. Now they get referred out to the specialists relevant to their pathology but its still a GMO as their primary care physician.

 

[pgg]

[GMOs] are undertrained by the current American standard. They can only be licensed in an ever-shrinking number of states as as result.

So I got curious about exactly how many (and which) states required more than 1 year of GME for full licensure, so I looked it up.

19 states will not license a physician with only a completed internship. Four states require more than two years of GME:

Alaska
Connecticut
Illinois
Kentucky
Maine (requires 3)
Massachusetts
Michigan
Montana
Nevada (requires 3)
New Hampshire
New Jersey (requires 2 + contract for 3rd year of GME)
New Mexico
Pennsylvania
Rhode Island
South Dakota (requires COMPLETION of a residency program)
Utah
Washington
Wisconsin
Wyoming

It's an interesting list. There are states that have huge problems with physician shortages and access, and states that don't.

I felt that way as a GMO too. Couldn't disagree more at this point. I saw patient after patient mismanaged by "bad" GMOs. Why do AD patients deserve a lower standard of care than the vast majority of Americans who walk into their doctor's office? You just don't know what you don't know. You're not a midlevel. You are a physician.

I've written about this before, how my view of the care I delivered as a GMO changed during and after my residency. Don't think I harmed anyone. Maybe I did. I was freer with opiate prescriptions for injuries than I probably should've been ... but then again, so was everyone in those days. The rx painkiller addiction risk wasn't really widely appreciated then. Of course I'll never know if there was stuff I missed that got picked up by someone else weeks or months later.

If I was sent to a GMO-like billet today, Army brigade surgeon style, I would be anxious in a way that I'm not when I pick up a sick cardiac cripple on ECMO from the ICU. I'd be the most hated GMO on base as I referred every fifth patient to a consultant ...

 

[orbitsurgMD]

So I got curious about exactly how many (and which) states required more than 1 year of GME for full licensure, so I looked it up.

19 states will not license a physician with only a completed internship. Four states require more than two years of GME:

D.C. as well.

. . . . There are states that have huge problems with physician shortages and access, and states that don't.

Anymore, it is not so relevant. Without completing a residency, you can't get staff privileges, operate at an ASC, join private insurance panels, or work at many private urgent care centers. You could put up a shingle as a GP, take cash and maybe Medicare and Medicaid, but that is about it.

I've written about this before, how my view of the care I delivered as a GMO changed during and after my residency. Don't think I harmed anyone. Maybe I did. I was freer with opiate prescriptions for injuries than I probably should've been ... but then again, so was everyone in those days. The rx painkiller addiction risk wasn't really widely appreciated then. Of course I'll never know if there was stuff I missed that got picked up by someone else weeks or months later.

If I was sent to a GMO-like billet today, Army brigade surgeon style, I would be anxious in a way that I'm not when I pick up a sick cardiac cripple on ECMO from the ICU. I'd be the most hated GMO on base as I referred every fifth patient to a consultant ...

^^This. It is only with training that you get the full appreciation of expertise or its opposite, ignorance. The real shame of it is the lack of advocacy from the people at BUMED, the people who could change the antiquated GMO assignment practices, who pretend that it has some value in preparing physicians (for what is anyone's guess) and that it doesn't expose both the doctor and his patients to needless risk. I will never have a good opinion of the Navy's medical department for its refusal to change this immoral practice.

 

[DrMetal]

change the antiquated GMO assignment practices, who pretend that it has some value in preparing physicians (for what is anyone's guess) and that it doesn't expose both the doctor and his patients to needless risk. I will never have a good opinion of the Navy's medical department for its refusal to change this immoral practice.

I don't think any GMO would argue that the experience has any 'value in preparing physicians'....we regard it as something we just have to do. We'd vote with all of of our extremities for any change that eliminated GMO billets in favor of creating more GME opportunities...but this isn't going to happen. There's no real impetus for change. Quite honestly: the operational world likes us. The line officers like having a MD (even only a PGY-1 trained MD) in their wardroom to help them navigate the medical world.

GMOs are not well trained: I won't argue that point. I will argue though against the notion that GMOs are somehow 'dangerous' and are under-serving the active duty population. Not true in all cases. Again: in the operational environment, if you work hard and ask for help frequently, you'll probably serve these kids just fine.

The sad truth is if we eliminate GMO billets in the Navy, they likely will not be replaced with BC'd physicians...they'll be replaced with IDCs.

Speaking of asking for help, orbitsurgMD: are you an ophthalmologist? Can I ask you a question? I'll PM you if you're game.

 

[Gastrapathy]

Of course it's not true in all cases that GMOs are dangerous but it's true enough. Sailors aren't kids. The 50 yo Filipino CSCS is not a kid. GMOs spend the vast majority of their time in garrison. In fact, the real deployed medicine that saves lives is being performed by residency trained MDs.

The argument that it's ok because the leadership won't change is silly. The leadership won't change because they don't care. The change will have to come from outside the organization but that's not something to be proud of. IDCs are also unacceptable. Most practice in garrison. An IDC did my sep physical. IDCs and GMOs are medicine from a bygone era (like using IM sub specialists as general ward attendings) that continues in the military because there is no accountability.

The line officers like you because you provide VIP medicine and incredible access. You do well on the patient satisfaction front. Unfortunately, that has no correlation (or maybe a negative one depending on the study) with good outcomes.

The line is not in a position to know what to value. They want a MD who looks good in a uniform, maybe has a SSDR and a good conduct medal or two and is junior enough to know his place. I want the fat trauma surgeon who was medevaced for angina, got a stent for his CAD and came right back to sandbox. His uniform looks like **** but that dude is a doctor.

 

[DrMetal]

Of course it's not true in all cases that GMOs are dangerous but it's true enough. Sailors aren't kids. The 50 yo Filipino CSCS is not a kid. GMOs spend the vast majority of their time in garrison. In fact, the real deployed medicine that saves lives is being performed by residency trained MDs.

True. And you have plenty of them at your disposal. I deployed with a staff OB/gyn, x2 staff FPs, a general surgeon and a psychiatrist. Though not on my ship, they were readily accessible. When we had a suicide on my ship, the psychiatrist came over and helped treat about a dozen affected sailors, he was huge. The Surgeon cut out some lipomas (I think he was just bored), the OB/GYN worked on a bartholin cyst, the FPs helped in a variety of cases. I agree the 'real' medicine should be handled by residency trained MDs. As a GMO, if you're humble enough to understand and accept that, you should be fine.

The argument that it's ok because the leadership won't change is silly.

I don't think it's ok, I'm just stating it is the way it is, and there doesn't seem to be any impetus for change. We've been talking about this for as long as SDN has been around (~15 years), and nothing seems to have changed. I ran into VADM Cowen (ret, former Navy SG) and asked him once about it....he told me they debated this vehemently (to get rid of GMOs) and they just couldn't find a way to do it (he didn't provide any details). So again I ask: what are we to do? If you get rid of the GMO, do you replace him with an IDC, a PA, a BC'd physician? It doesn't seem like there's a great solution with any of those choices. The BC'd physician is way overqualified for most GMO billets; she belongs on a big deck, a larger field hospital, or an MTF.

The line officers like you because you provide VIP medicine and incredible access

An affinity for golf and cigars helps too....

I would ask Navy Medicine to stop recruiting, especially in the HPSP programs. Look at this bloody GME selection list, where every specialty has an 'Alternate List' twice as long as the selected list....and who knows how long the non-select list is. They can't even fit us all into GMO spots...they're double- and triple-stuffing us in billets.

 

[Gastrapathy]

How I would do it:

Abolish the IDC. Change the IDC schoolhouse into PA school.

Primary Care Physicians deploy but are not attached to line units until late in the work up period. Programs are run by a nurse. The nurse can give immunizations, ensure people wear hearing protection, etc. All the non-doctor stuff that you do as a GMO is done by either a nurse or MAO. If you are on the pier or in the Marine Barracks, care is provided by real physicians at the MTFs.

The rare situation where you are isolated, we should try to place physicians in that role (there aren't that many of these), except maybe use PAs on subs. PAs should mostly be used in supervised situations (large decks, green side, etc).

Then pay them for deploying, enough that they want to. Want a bonus? Deploy. Incentivize what matters.

Cowen was told he had to get rid of GMOs, it was in an appropriations bill. He chose not to and no one since has had the courage to challenge the status quo. The solution above would cost very little when compared to the waste of all of the administrative physicians hiding out in the .mil.

If given the choice, i would do all of the above and close every conus facility. Make all the physicians reservists and have MAOs/case managers handle the fitness for duty stuff. You can't compete with civilian medicine, so stop trying.

 

[DrMetal]

I'm all in...let's do it.


Sent from my iPhone using SDN mobile

 

[WernickeDO]

This thread has gotten into my head. I've thought about it more than I would like to admit.

Interns are perfectly suited for GMO tours, in that you really can't do much else with a GMO. The other admin options are even worse. That doesn't mean that they are giving the best care. FM docs would be a better option, but usually the BC docs get moved to brigade and see hardly any patients at all.

I had to check my own Dunning-Kruger. I don't know what I don't know, but I have Up To Date and a pretty good network that is good about taking questions and assisting with the next best step. I'm thankful for that. I certainly hope that I haven't hurt anyone. I don't allow anyone in this clinic to be turned away without being screened. Chronic MSK problems get an appointment made, acute MSK get seen. Acute illnesses get seen. My problem children get an appointment. Appointments are usually given in the next couple of days. Point is, I at least lay eyes on them and make sure there is nothing emergent before I send them out. If they don't like my response and they want to go waste the ED's time I can't stop them.

I keep up with reading and still work shifts at the MTF to try to keep my skills up, but most days I'm sitting in my windowless office like a lump. This isn't a good use of a physician's abilities. GMO tours are an accepted part of the milmed experience, for better or worse, but no one should be left out here to rot. GME needs to be expanded, but we all know that's not going to happen.

So what to do? I could not really care any less for what milmed plans to do over the next decade. I will be out the second I am allowed to go and will try to find some solace in my service to my country. I feel like a ball player who knows he's getting cut in the near future so he's trying to play as much and as well as he can so he can get a decent contract in free agency. That doesn't always assuage the feeling of being an untrained oddball who really isn't qualified to do too much, and then has been rejected from the very institution that put him in that situation. I'm not going to lie, it's been a difficult few years on that front.

I do the best I can, the best I know how to. I can't really do much more than that.

 

[HighPriest]

I wouldn't take what people are saying as a personal affront. At least, I would hope that's not what they're doing, but a lot of these guys did GMO your themselves, so my take is that their frustration is with the system that would put you in that position, rather than what you're doing in that position.
My opinion is that using things like up-to-date (which, btw, isn't always accurate but then, what is?) is good, but the problems don't arise when someone sees a patient and knows what they're looking at or when you see a patient and you know that you don't know what you're looking at. It's when someone sees a patient and thinks they know what they're looking at, when in fact they do not. Then all the resources and questions asked in the world won't help, because you've already started down the wrong path. Research will only confirm that you're appropriately treating the inappropriate problem.
The argument is that residency should minimize this issue. If not for the studying, just for the volume and prolonged exposure to people who have already made those mistakes.

My experience has been that there's a huge difference between residency trained physicians and...well, everyone else. That includes PAs and NPs. Are GMOs worse? I honestly can't say. There aren't enough of them in the Army for me to make a solid statement.

But I can say that usually when I see a mismanaged patient in my clinic, they're not mismanaged because someone didn't know how to manage their problem - they're mismanaged because someone got their diagnosis wrong. and I'm not talking about differentiating between invasive fungal sinusitis and chronic invasive fungal sinusitis. I'm talking about differentiating between strokes and BPPV or Sinusitis and GERD or an ear infection and sudden onset deafness or a cholesteatoma. Common problems that are misdiagnosed simply because the provider doesn't actually know what the signs and symptoms are in the first place.
That's where the direct observation of an experienced physician makes a difference. Not down the hallway, not occasional chart reviews - direct mandatory observation.

The military puts you in a position where you have to fend for yourself. That's not your fault, it's theirs. And they do it at the expense of their soldiers/sailors/marines/airmen. They're selling a form of snake oil, and they're still pretending like it's PCN.

Another option would be to run GMOs (and PAs/NPs) like a non-accredited residency. Have a BC physician who's sole job as OIC is to attend and review. It's suck for that guy, but it would help the volume:quality problem.

 

[WernickeDO]

I wouldn't take what people are saying as a personal affront. At least, I would hope that's not what they're doing, but a lot of these guys did GMO your themselves, so my take is that their frustration is with the system that would put you in that position, rather than what you're doing in that position.
My opinion is that using things like up-to-date (which, btw, isn't always accurate but then, what is?) is good, but the problems don't arise when someone sees a patient and knows what they're looking at or when you see a patient and you know that you don't know what you're looking at. It's when someone sees a patient and thinks they know what they're looking at, when in fact they do not. Then all the resources and questions asked in the world won't help, because you've already started down the wrong path. Research will only confirm that you're appropriately treating the inappropriate problem.
The argument is that residency should minimize this issue. If not for the studying, just for the volume and prolonged exposure to people who have already made those mistakes.

My experience has been that there's a huge difference between residency trained physicians and...well, everyone else. That includes PAs and NPs. Are GMOs worse? I honestly can't say. There aren't enough of them in the Army for me to make a solid statement.

But I can say that usually when I see a mismanaged patient in my clinic, they're not mismanaged because someone didn't know how to manage their problem - they're mismanaged because someone got their diagnosis wrong. and I'm not talking about differentiating between invasive fungal sinusitis and chronic invasive fungal sinusitis. I'm talking about differentiating between strokes and BPPV or Sinusitis and GERD or an ear infection and sudden onset deafness or a cholesteatoma. Common problems that are misdiagnosed simply because the provider doesn't actually know what the signs and symptoms are in the first place.
That's where the direct observation of an experienced physician makes a difference. Not down the hallway, not occasional chart reviews - direct mandatory observation.

The military puts you in a position where you have to fend for yourself. That's not your fault, it's theirs. And they do it at the expense of their soldiers/sailors/marines/airmen. They're selling a form of snake oil, and they're still pretending like it's PCN.

Another option would be to run GMOs (and PAs/NPs) like a non-accredited residency. Have a BC physician who's sole job as OIC is to attend and review. It's suck for that guy, but it would help the volume:quality problem.

I'm not taking this as an affront. I was just kind of unloading I guess. I hate being in this position but I don't dare say anything. I have friends who do nothing but retirement physicals and others who write NARSUMs all day. I agree with what the more experienced docs are saying.

When I applied to HPSP I picked Army specifically because I thought there was less of a chance of being a GMO. I guess that's still accurate, but when it happens to you it's 100%. The GMO tour is a relic of the past that needs to go away, but as long as milmed refuses to train its doctors it's not going anywhere. And the bean counters/lifers/bullet point rangers/desk jockey officers are more than happy with it, so nothing will change.

 

[Gastrapathy]

I don't blame the folks that tried to train straight-through and were derailed into a bad situation. I do think that joining with the intention of being a GMO because flight suits are cool is wrong.

 

[deuist]

I do think that joining with the intention of being a GMO because flight suits are cool is wrong.

The Air Force is problematic in that it touts its pilot-physician program as the fast-track the Surgeon General. The only way to become a pilot is be under the age of 30 (unless you are applying for a remotely piloted vehicle)---and being a doc under the age of 30 with one flight surgery under your belt is difficult without forgoing residency.

 

[Perrotfish]

My experience has been that there's a huge difference between residency trained physicians and...well, everyone else. That includes PAs and NPs. Are GMOs worse? I honestly can't say. There aren't enough of them in the Army for me to make a solid statement.
.

They are, without question, better. Leaving aside questions of intelligence, work ethic, and volume of training (they are superior in all 3), there is a value in simply telling someone that they are inadequately trained. It makes them much more likely to confirm that they know what they think they know. I have seen several new NPs and PAs in action. They never have clinical experience before starting anymore, 100% of their clinical experience now comes from their 2 year program. They are sure that they are fully trained and the peer of any residency trained physician, and superior to any GMO because they are fully trained and the GMO is not. That makes them much, much less likely to ask for help or consider that they might be going down the wrong track.

Abolish the IDC. Change the IDC schoolhouse into PA school.

Here's a question: what would it take to replace our in hours IDCs with a program to turn senior enlisted into certified midlevels? Who runs the IDC program? Who makes this decision? There is a lot of griping about a lot of things on the board, this seems like the easiest practical target. IDCs are definitely the farthest beneath any civilian standard of care. It seems like this is something that we could actually affect, if we pushed hard enough.

 

[Gastrapathy]

It would take senior leaders who actually cared about quality rather than just claiming they do. Think for a second about all the HRO talk and how hollow it rings in this context.

 

[BlackWolf22]

I am 29 years old. I have no military experience and I dropped out of college to work. I am extremely my bright scored a 1400 on my SAT. I have no money, and no financial help for school. I have a soldier mentality. I am coachsble. I want to become a doctor to help others and I am focused on patient/doctor relations. I'm not in it for the money and I have no real expectations. I don't have much to lose in life at this point. I want to sign up ARMY and become a doctor. Should I do this? What does it entail, what are the basic mechanics of the process? I am wondering if at my age (29) if there is even a chance for me to see this through chronologically due to my age. My goals are to be a doctor, to serve my country, to help others, to have financial stability and be able to carry this over into civilian life later on. I have no fear of going to war. I have no problem being deployed or sleeping in the dirt. I am calm under pressure and can execute. I can stay positive through training and score well in school, I can Side step the bureaucratic and political side of the military. I can work hard all day for little pay. Honestly being tasked and productive and a place to sleep and eat would be a great start for me forward to the camaraderie and fraternity created through the military experience. What I need to know is how do I start is it Med School then you serve 1 year for each year in school. Is it all paid for? What do I need to know? I can't afford Med school as a civ, but I am not looking for the GI bill alone. I have many reasons to serve. Patriot. Family. Career. I want the army to take my raw talent and turn it into a degree and position me to where I can help others. Talk to me people!

 

[WernickeDO]

I am 29 years old. I have no military experience and I dropped out of college to work. I am extremely my bright scored a 1400 on my SAT. I have no money, and no financial help for school. I have a soldier mentality.

Have you completed undergrad? If not, and you have financial need and want to serve in the Army, ROTC, NG, or reserves may be a good option

I am coachsble. I want to become a doctor to help others and I am focused on patient/doctor relations. I'm not in it for the money and I have no real expectations. I don't have much to lose in life at this point. I want to sign up ARMY and become a doctor. Should I do this? What does it entail, what are the basic mechanics of the process?

Reading this forum and using the search functions for your questions is a good start. No one can answer whether or not you should join. The best you can do it learn as much as possible and try to make an informed decision.

I am wondering if at my age (29) if there is even a chance for me to see this through chronologically due to my age.

Being older is by no means a deal breaker.

My goals are to be a doctor, to serve my country, to help others, to have financial stability and be able to carry this over into civilian life later on. I have no fear of going to war. I have no problem being deployed or sleeping in the dirt. I am calm under pressure and can execute. I can stay positive through training and score well in school, I can Side step the bureaucratic and political side of the military. I can work hard all day for little pay. Honestly being tasked and productive and a place to sleep and eat would be a great start for me forward to the camaraderie and fraternity created through the military experience. !

You can't sidestep the politics and red tape of the military. No one can.

What I need to know is how do I start is it Med School then you serve 1 year for each year in school. Is it all paid for? What do I need to know? I can't afford Med school as a civ, but I am not looking for the GI bill alone. I have many reasons to serve. Patriot. Family. Career. I want the army to take my raw talent and turn it into a degree and position me to where I can help others. Talk to me people!

Keep reading this forum and get a sense to the frustrations that active duty docs deal with. There is plenty of rah-rah and positivity to join, the reality is somewhat different. And frankly I wouldn't trust the Army to mold Jell-O, much less a doctor's career. Good luck.

 

[memos87]

Prior GMO (Army) here after getting picked up for residency. Army still does GMOs for people that want to match a competitive specialty in the military, but don't (they don't like having GMOs but send them out every year regardless to places that need a DO/MD slot filled, and keep doing so despite all of the preselect spots out of med school). Each specialty fluctuates in terms of competitiveness for the most part (seems like ortho and ER are always up there along with radiology, PM&R), and GMOs fill the spots when there aren't enough quality medical students to fill those slots in my experience, or there is a Major/LtCol that somehow wants to do another residency. Depending on the residency director, they may be very open to telling applicants "Hey there's going to be spots this year" or "no don't bother applying but thank you for continued interest".

In terms of PAs vs GMO straight out of intern year...yeah I did that. UptoDate was my friend, and speed dials were the local gastroenterologist, cardiologist, orthopedist (all 4 hours away), and the physical therapist for MSK stuff locally. I worked with a PA with over 20 years in medical field, and it was super weird as I was technically their superior, but we ended up learning from each other. I'm sure that I screwed some things up, but definitely knew that I didn't know diddly about a lot of things, and tried to make the best of it...whether or not it was good medicine to my patients, well I'd say it depended on the complexity of the patient...

I've had friends complete fellowships and then do a GMO tour as their isn't a slot for them somewhere else (who hadn't seen a sprained ankle since intern year...), so I'm hoping that since I've done one already that someone else might get picked instead of me...but no guarantees.