Hello,
I'm a second year in the 3 year HSPS scholarship.
I've been told by some active duty docs that skill atrophy isn't a huge deal with moonlighting and the retiree population, but I imagine that varies based off specialty and location.
I'm interested in primary medicine: Internal, Emergency and Family. Are any of these specialties at risk for serious skills atrophy during my time in the military?
I imagine that if I cannot moonlight, emergency medicine would be the most at risk of atrophy. I'm also very interested in practicing out in Japan; to are these locations very low acuity, or do you end up treating the local population as well to keep up skills?
Thanks all.
It's a big problem for most specialties at most locations, particularly "procedural" specialties. I would call it straight up catastrophic for surgeons, anesthesiologists, interventional cards/radiology ... with some narrow exceptions like orthopedics and OB.
ERs at military medical centers are glorified urgent care clinics. There has been an effort to get civilian trauma into some of them. This year, Portsmouth started accepting civilian trauma. It's not as easy as just hanging out a flashing neon O P E N sign though. Time will tell how many cases, and how many complex cases, actually come through the door. I hope it's a flood, but my fear is that it'll go from zero to a trickle and stay a trickle. Before I left 3 months ago, we were starting to get some cases, so there's room for a little optimism there.
Primary care tends to be a little less at risk. Their patient volume is better, sort of. Their workdays are definitely full, but they still see fewer patients than their civilian counterparts, mainly because the Navy refuses to invest in the support staff required to make them efficient. (The ability for any branch of the government to hire permanent civilian staff is a very complex, difficult process that comes up against some hard ceilings set in law. Blame for this chronic problem belongs not so much with individual hospitals but rather with big Navy leadership and Congress.)
Overseas locations tend to be extremely low volume, which is further compounded by the fact that the active duty & dependent population there are screened to have no serious chronic health problems, and there are also few/no retirees there. We don't take care of locals as part of official duties - and there's a whole 'nother dimension of licensing and insurance and language that is just essentially insurmountable for individuals who would like to moonlight. A US doctor can't just go to another country and start working - and there are no shortcuts for US military doctors. Short version: overseas duty stations are exceptionally bad with regard to skill atrophy. (I have heard Guam can be OK.)
Some commands are making attempts to track critical "KSAs" or "knowledge skills and abilities" and come up with ways to maintain them through simulation or other means. For example, some things, like central line placement, can benefit from reps on a good simulator, to a degree. My personal opinion is that this entire scheme is mostly bull**** handwaving. There is no substitute for appropriate case volume, and it just isn't there. Tracking KSAs might help define and bring attention to the problem, but solutions are tougher.
I'm a little bit of an extreme example. I'm an anesthesiologist with cardiothoracic fellowship training. About 6 months after I got back from fellowship, the cardiac surgery program closed. For a while the Navy let me do some TAD work at a VA hospital 90 minutes away. By "let" I mean they let me make contact with the VA, let me talk the VA into allowing me to come work for free for them, let me write the memorandum of understanding, let me push it through legal on the Navy side and the VA side, let me jump through the credentialing hoops, let me schedule the days there, and let me leave my home and live in a hotel for a few days or a week at a time to work there. (The Navy did pay for the hotel and my to/from mileage.)
And this is pretty typical - for all the words the Navy flag medical leadership says about being concerned with skill atrophy, and establishing ERSAs (external resource sharing agreements) with civilian hospitals to get our staff there to work, they're just words they've been saying for 10-15+ years with no real progress. Just PowerPoints and meetings with green and yellow and red boxes that result in action officers tracking "KSAs" and the like. I know some of them are working hard and trying hard to address the issue. In the end though, I have to judge them harshly by their simple, stark, abject failure. You can be mad about their failure ... or you can just accept it for what it is, and resolve to solve the problem for yourself.
I returned from my final Navy deployment in June 2020, after 10 months overseas, during which I did exactly zero cases. Between August 2020 and May 2022 when I retired from the Navy, I burned about 120 days of accumulated leave, and retired with a leave balance of 0. I used all of this leave ...
all of it ... to moonlight at a local civilian hospital doing a mix of non-cardiac surgeries, and at a university hospital several states away to do cardiac surgeries. It worked out to about 20 full M-F weeks of working elsewhere. One week per month for almost two years. I also worked nearly every free weekend covering call at a local civilian hospital, and I also worked locally on nearly every post-call day. And during that time, I did 3-4x as many cases in my moonlighting work as I did on active duty. 100% of my cardiac case numbers, 90%+ of my thoracic case numbers. And more subjectively, typically far sicker and more complex patients.
On the plus side, beyond earning an extra $150-200K/year moonlighting, I retired with a respectable (though not great) case load and comfortably current skills. I had no trouble getting hired and then credentialed with my post-Navy private practice group, and I was able to easily step into a busy and complex case load without any strain or problems. On the down side, I spent all my vacation time working for about two years. This is not a great way for a human to live.
In short, skill atrophy is an enormous problem and there aren't at present good solutions besides working outside the Navy.
In full disclosure, there are other people who don't fully agree with my dire assessment. A lot of people in my own specialty don't moonlight at all - and when they leave the Navy, they don't have any trouble finding work or being successful. As a subspecialist I'm a little bit of an outlier in what I need to stay current. YMMV - there's a wide range of experiences that individuals have.
I'm very familiar with that particular case, because I tried and failed to get a certain CT anesthesiologist included in the package deal to go TAD to Duke for months at a time also. 
There's a lot of leeway for doing things that are judged to be "in the best interest of the Navy" ... and it's certainly not in the Navy's best interest to have CT surgeons rotting away, not operating at a MTF, rusting away the skills the Navy paid for them to go get. Skills that might be essential at a Role 3 overseas if someone needed a thoracic surgeon. Our MTF simply did not have enough patients in our catchment area, even with unrealistic 100% recapture, to maintain a safe cardiac surgery program. You have to realize we straight up closed the CT surgery program at that MTF and there was nothing for them to do, unless you wanted them to slide back into a general surgeon role. It was an odd but good outcome for a very bad situation.
