Officer first, doctor second?

[sojourner75]

I'm a little confused by your post. There are some pretty serious valid ethical and professional conflicts surrounding the whole officer vs. physician thing that have been discussed here and in other forums. Are you trying to dismiss them as getting "wrapped around the axle"?

As far as your Jewish/Christianity example, I wonder if that O6 Rabbi ever ordered the O4 Christian to perform a Jewish ceremony. That's what is happening at times in military medicine today when professional boundaries are being crossed.

The original question suggests mutual exclusivity. But officers and physicians are both professionals. Both are expected to make the best professional (ethical, military, technical) judgment, under the circumstances and within their abilities. The question then, is not whether one does his job "as an officer first and ___ second." One simply thinks and acts like a professional.

It would be deplorable if one has to ponder about his/her professional boundaries during a crisis. It is not easy, but that's why professionals get paid the (relatively) big bucks. And yes, the mil med stories call into question the lack of professionalism of certain individuals and/or the institution. I agree the system is broken somewhere if its members have to deal with professional conflicts regularly. I'm further saddened that fine individuals have to leave the institution as a result. Like SgtDoc I am a Marine, and Marines tend to fault the 5% dirt-bag individuals first, rather than the institution. Brainwashed or institutionalized, Marines have a high degree of trust toward their institution, and vice versa. An institution, BTW, is an idealized construction, and is therefore blameless. What are at fault are bad processes and the 5% dirt-bags that screw up in execution.

My examples are for illustration only. I'm afraid there are not many good analogies to the mil med situation. "Wrapped around the axle" refers to the "physicians commanded by nurses" complaint, and not the valid "professional conflicts" complaint. "Command" implies a higher leadership potential, and not necessarily technical or intellectual potential. One can not measure a leadership structure via a "technical proficiency" yardstick. As a Marine, I assume that any given O-6 nurse is a professional, more experienced in "leadership skills" to serve the command billet than any given O-4 physician. If she is not, and does not understand her professional boundaries, then of course all bets are off. One should not let dirt-bags distract them from their professional duties.

The discussion always gets heated when professional boundaries are ill-defined or ignored. Example: military men making political comments, politicians second-guessing on military or technical matters, medical personnel make the call first as a Christian or bureaucrat, etc. etc. A legit and important question would be "am I a Christian first or physician first?" The "officer first" line, however, is simply rhetorical flourish, and not meant to be taken literally. One can simultaneous discharge his duties, I believe, as both an officer and a physician.

If the conflict is in fact irreconcilable, a professional must then find a different profession (or place of employment) all together.

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[sojourner75]

Exactly. I can't be the only one who considers the title "Doctor" higher than military rank.

Again, "doctor" speaks to technical proficiency, and military rank speaks to leadership potential (and incidentally to a small degree, seniority).

This reminds me of a military joke. At the officer wifes' tea party, the general asks the ladies to line up according to their rank. Ladies shuffle back and forth, finally achieving the desired order. General shouts, "Your husbands carry ranks, you all do not!"

When one speaks to patients, one is a doctor. When one speaks to his/her boss in the hospital, one is likely speaking as an officer. Just different roles for different situations, or two roles (doctor AND officer) in one situation.

 

[AF M4]

The original question suggests mutual exclusivity. But officers and physicians are both professionals. Both are expected to make the best professional (ethical, military, technical) judgment, under the circumstances and within their abilities. The question then, is not whether one does his job "as an officer first and ___ second." One simply thinks and acts like a professional.

....

One can simultaneous discharge his duties, I believe, as both an officer and a physician.

If the conflict is in fact irreconcilable, a professional must then find a different profession (or place of employment) all together.

I am trying to discern your purpose in writing and, please forgive my prejudice, but I think it would help if you could remind me if you are a med student, doc, or something else.

The reason I'm asking is that while your post is technically proficient, it lacks grounding in real life, particularly the last line. You talk about ethical theory, doc vs. officer, etc., and then at the end you say that if you can't resolve the differences then you should quit your profession or place of employment.

Unfortunately, the above conflicts don't occur in boardrooms or in ethics papers. When a doc runs into an "officer vs. physician" conflict, the battleground is invariably over a patient and their care. And you're saying when these conflicts arise, we should simply toss up our hands and leave the patient twisting in the wind? Find a different job where the decisions aren't so tough?

Sure it sounds simple to just disengage from the conflict and go do something else, but no physician worth anything is just going to walk away without making sure that his patient, especially an active duty member, has been taken care of.

I'm no ethicist, I don't have any specific yardstick or line as to where exactly the division of officer vs. physician is in my head. In the end, as nebulous or feel-goody as it sounds, I do whatever lets me sleep at night.

 

[sojourner75]

Unfortunately, the above conflicts don't occur in boardrooms or in ethics papers. When a doc runs into an "officer vs. physician" conflict, the battleground is invariably over a patient and their care. And you're saying when these conflicts arise, we should simply toss up our hands and leave the patient twisting in the wind? Find a different job where the decisions aren't so tough?

I'm USU class of 2013, and spent ten years as a Marine Officer (BS and MS in electrical engineering, if that matters). In previous posts, some made a note that SgtDoc is not a doctor. I'm not yet a doctor either. But it does not matter. My perspective is from a leadership/command angle, which I think is one main source of the conflicts in discussion. Professional conflicts happen in every profession. I simply do no see them as "officer vs. physician" conflicts.

Yes, the decisions are tough. No, one does not hang patients out to dry. As professionals (officer, physician, or otherwise), we should advocate for their welfare until OUR faces turn blue.

I mentioned the dimensional yardstick because some posts give a perception that doctors are intellectually superior, or that they are righteous merely because they are doctors. Some contributors can not get over the fact that they COMMANDED by nurses. However, in order to understand the source of the frustration (the 'mil-med conflicts' or horror/stupidity story of the day) it may be good to take off the doctor hat and look at the problem from a leadership point of view. It may not solve the problem, but it provides a different perspective.

 

[crazybrancato]

I'm USU class of 2013, and spent ten years as a Marine Officer (BS and MS in electrical engineering, if that matters). .

No! none of that matters! (sarcasm)

You're gonna get pounced on here (especially from the resident group of bitter AF priors, who seem to be multiplying!) for not being a doc, as if medical school/training is a requirement for common sense and good leadership.

I'd put my money on you, a Marine w/ a decade of prior service, to be the better doc in the future. Why? b/c you're less likely to get peeved when a nurse bosses you around (which may be totally justified, especially when said nurse has years of clinical training on you). You're more likely to swallow your pride for the sake of education, training, and progress. It's not unlike when you came out of IOC as an O-1, was put in charge of a squad, but you knew all along that you were'nt really "in-charge"; your Gy was running the show, b/c he'd been an infantryman since you were in grade school.

I'd also put my money on you b/c in the event that a conflict does arise--say you're an O-4 attending and an O-5 nurse tries to boss you around--you'd have no problem tell said nurse to F off. You'd also have no problem challenging any repurcussions that said nurse tries to impose.

This idea of nurses (or replace nurses with whatever you like) bossing docs around . . . is nothing unique to the military. It's a power struggle, and such struggles occur everywhere in civilian/mil medicine, everywhere in life for that matter. If you have conviction and you're confident in what you're doing, and if you have the follow-through . . . then I think you'll be just fine.

Now, I shall brace for my pouncing.

 

[AF M4]

I'm USU class of 2013, and spent ten years as a Marine Officer (BS and MS in electrical engineering, if that matters). In previous posts, some made a note that SgtDoc is not a doctor. I'm not yet a doctor either. But it does not matter. My perspective is from a leadership/command angle, which I think is one main source of the conflicts in discussion. Professional conflicts happen in every profession. I simply do no see them as "officer vs. physician" conflicts.

Yes, the decisions are tough. No, one does not hang patients out to dry. As professionals (officer, physician, or otherwise), we should advocate for their welfare until OUR faces turn blue.

I mentioned the dimensional yardstick because some posts give a perception that doctors are intellectually superior, or that they are righteous merely because they are doctors. Some contributors can not get over the fact that they COMMANDED by nurses. However, in order to understand the source of the frustration (the 'mil-med conflicts' or horror/stupidity story of the day) it may be good to take off the doctor hat and look at the problem from a leadership point of view. It may not solve the problem, but it provides a different perspective.

Certainly. And unfortunately, from a leadership point of view, medicine is vast sinkhole of money and time with either a tie-lose outcome: either you get the active duty member back in something close to their original working condition, or you don't get them back at all.

And in a system where folks and positions are designed to be interchangeable to better carry on the mission, the individual person can easily become and be viewed as disposable, especially if injured or otherwise unable to carry on with their job.

If the doc isn't in there fighting for the patient, the list of allies for that person grows terribly thin. I can see the leadership's point of view in all of this, but I simply can't afford to advocate it if I want to do right by my patients.

 

[sojourner75]

No! none of that matters! (sarcasm)

You're gonna get pounced on here (especially from the resident group of bitter AF priors, who seem to be multiplying!) for not being a doc, as if medical school/training is a requirement for common sense and good leadership.

Thank you for the vote of confidence and encouragement. I do sympathize with the "bitter AF priors". I hope I would fare batter in Navy Mil Med.

The Corps is not without its faults. It achieves good efficiency because it is ruthlessly efficient in using the individual Marines as a (dispensible) means to an end. But Marines generally understand and accept that. (It is spelled out in the fine prints in our enlistment/commssioning docs. LOL).

No worries on the pouncing. The first two skills I learned from the Corps are:
1. grow some thick skin (for taking constructive criticism) and balls (to defend the institutional mission).
2. pick your battles to win (variation: stay in your own swim lane of expertise).

 

[Mirror Form]

I'm USU class of 2013, and spent ten years as a Marine Officer (BS and MS in electrical engineering, if that matters).

Okay, so in other words you have zero medical experience and you're taking their experience on the line and applying it to medicine? It's true that medicine and the marines are both part of the military, but they're still very different. I doubt that you'll find your experience on the line to be very applicable to the medical setting.

Likewise, if you're the doctor in charge of sick patients, and the buck stops with you, you won't just be analyzing any roadblocks in your way of caring for them as "ethical dilemmas." You'll be mad as hell.

For example, lets say you're a surgeon, and then get deployed for 6 months, and during that time lose some of your surgery skills. Then you go back to your base in the middle of nowhere. If you have unnecessary complications on your first few cases upon return are you just going to brush it off? What are you going to tell the patients whom you'll now be seeing every week for the next year to manage the complications that you caused?

 

[sojourner75]

A legit and important question would be "am I a Christian first or physician first?" The "officer first" line, however, is simply rhetorical flourish, and not meant to be taken literally. One can simultaneous discharge his duties, I believe, as both an officer and a physician.

If the conflict is in fact irreconcilable, a professional must then find a different profession (or place of employment) all together.

An example of irreconcilable conflict: medical personnel withholding contraceptives because of their personal, religious beliefs. In this instance, a "professional" would make the hard choice and pick one: observe the religious beliefs in the privacy of his own home, OR, do the jobs as dictated by medical necessity.

We are of course engaging in theoretical debates here, with a theoretical beer in hand, sitting in the officer club. And we have not touched on the legal aspect yet.

 

[crazybrancato]

Okay, so in other words you have zero medical experience

What I tellya, almost right on cue.

and you're taking their experience on the line and applying it to medicine? It's true that medicine and the marines are both part of the military, but they're still very different. I doubt that you'll find your experience on the line to be very applicable to the medical setting.

No one's saying that your experiences in the line are completely applicable or transferable to milmed. Your skills at taking out a target from 1000 yards w/o a scope aren't going to come in handy in a hospital . . . although you never know. The point is that your prior line service will help you deal with the admin/leadership issues.

For example, lets say you're a surgeon, and then get deployed for 6 months, and during that time lose some of your surgery skills. Then you go back to your base in the middle of nowhere. If you have unnecessary complications on your first few cases upon return are you just going to brush it off? What are you going to tell the patients whom you'll now be seeing every week for the next year to manage the complications that you caused?

yeah, and you could be in Fallujah circa Nov 2004, and you could have a lot of work on your hands! Or, you could be on a ship and bored out of your mind. The point is deployments come in many flavors. Do your best, do your best to keep up with your skills if you can. If not, when you return home, be man enough to admit that you're not comfortable doing said surgery alone and would like someone else to lead. That sort of admition is leadership in and of itself.

And so what do you suggest? Surgeons should never deploy? argh! you're clearly AF

 

[mitchconnie]

I mentioned the dimensional yardstick because some posts give a perception that doctors are intellectually superior, or that they are righteous merely because they are doctors. Some contributors can not get over the fact that they COMMANDED by nurses. However, in order to understand the source of the frustration (the 'mil-med conflicts' or horror/stupidity story of the day) it may be good to take off the doctor hat and look at the problem from a leadership point of view. It may not solve the problem, but it provides a different perspective.

Line officers are routinely dismissive of physician concerns about the loss of professional boundaries (i.e. a chain of command increasingly dominated by non-physicians). And yet in many areas, the line is FAR more rigid about their own professional boundaries. How many Air Force fighter squadrons are commanded by non-pilots? How many times has the head of Air Combat Command been a non-pilot? I haven't done all the research, but I would virtually guarantee that the answer is zero. An aircraft maintainance officer or procurement officer may well become Air Force Chief of Staff, but he/she will never be in command of a fighter squadron in war-time. No one would argue that it should be otherwise, and yet command views all of the medical/nursing/dental/MSC officers as somehow interchangeable.

Perhaps there are similar examples in the Marines. Are Marine combat divisions in Iraq typically led by career supply-officers, or protocol officers from the pentagon who have zero field experience? I don't know, but I'm guessing not. It's not a matter of who's smart, it's a matter of who has the most relevant training and experience.

The Air Force actually maintained separate physician and nursing chains of command untill the late '90's when they instituted the so-called "Objective Medical Group." This change effectively castrated the physician leadership and has been one major factor in the overall destruction of AF physician morale that is so painfully evident on this board. Witness the legions of "bitter AF priors, who seem to be multiplying" that crazybrancato so eloquently calls to our attention.

Does horrible physician morale lead to reduced effectiveness? Well...you be the judge, but I think anyone who takes an honest look at the current state of the AF medical services will see that the answer is obvious.

 

[sojourner75]

Perhaps there are similar examples in the Marines. Are Marine combat divisions in Iraq typically led by career supply-officers, or protocol officers from the pentagon who have zero field experience? I don't know, but I'm guessing not. It's not a matter of who's smart, it's a matter of who has the most relevant training and experience.

The Air Force actually maintained separate physician and nursing chains of command untill the late '90's when they instituted the so-called "Objective Medical Group." This change effectively castrated the physician leadership and has been one major factor in the overall destruction of AF physician morale that is so painfully evident on this board. Witness the legions of "bitter AF priors, who seem to be multiplying" that crazybrancato so eloquently calls to our attention.

This confirms my point that it is a leadership/management problem from the top down. Didn't the SecDef sack the top two AF mil leadership recently?

Marines face the same challenges, though we have more built in mechanisms to deal with them. Our peer pressure tends to be direct and immediate. Marines are broken up into two groups: combat arms (infantry, armor, artillery), and combat support (everyone else). Combats arms units are always commanded by combat arms Marines. Everything we do is in support of that ground commanders. Hell has seen no greater furry if the ground commanders failed due to a rear-echelon or combat support f***-up.

 

[sojourner75]

Okay, so in other words you have zero medical experience and you're taking their experience on the line and applying it to medicine? It's true that medicine and the marines are both part of the military, but they're still very different. I doubt that you'll find your experience on the line to be very applicable to the medical setting.

Likewise, if you're the doctor in charge of sick patients, and the buck stops with you, you won't just be analyzing any roadblocks in your way of caring for them as "ethical dilemmas." You'll be mad as hell.

For example, lets say you're a surgeon, and then get deployed for 6 months, and during that time lose some of your surgery skills. Then you go back to your base in the middle of nowhere. If you have unnecessary complications on your first few cases upon return are you just going to brush it off? What are you going to tell the patients whom you'll now be seeing every week for the next year to manage the complications that you caused?

Skill retention is a resource management challenge that Marines deal with regularly. Given our shoe string budget and stubborness, some of us actually believe we can OJT a brain surgeon. We always envy the number of PhDs from other services, competing for resources against us within the beltway. All the Marines can stand on is just our reputation...

But, we don't go around and say "hi, I am a ****hot Marine, and you are not. You just don't get me and can't help me.". I don't do that to fellow Marines, my mechanic, my chaplain, my grocer, my lawyer, my accountant, my real estate agent. They all have opinions, professional or personal, and I appreciate their potential usefulness to my daily well-being.

As Godfather puts it, don't hate your enemy; it affects your jedgement.

Don't hate me because I have not yet join the milmed rank.

 

[AF M4]

Skill retention is a resource management challenge that Marines deal with regularly. Given our shoe string budget and stubborness, some of us actually believe we can OJT a brain surgeon. We always envy the number of PhDs from other services, competing for resources against us within the beltway. All the Marines can stand on is just our reputation...

But, we don't go around and say "hi, I am a ****hot Marine, and you are not. You just don't get me and can't help me.". I don't do that to fellow Marines, my mechanic, my chaplain, my grocer, my lawyer, my accountant, my real estate agent. They all have opinions, professional or personal, and I appreciate their potential usefulness to my daily well-being.

As Godfather puts it, don't hate your enemy; it affects your jedgement.

Don't hate me because I have not yet join the milmed rank.

Lol, no one hates you. C'mon, you're supposed to be a kickass Marine - are you gonna cry and play victim as soon as someone starts arguing with you?

In general, physicians don't worry about whether someone understands them. Docs are generally a very self-motivated and self-employed bunch, many of whom believe that no one does the job better than they do. We don't need hand-holding, or pats on the back. All we want is the support necessary to do our jobs and serve our patients as we see fit. That's it. Do that and you have a recipe for happy docs.

Substitute "Marines" for "docs" in the above paragraph and it still rings pretty true, no?

So exactly how much would it tick a group of Marines off if they had a group of administrators (who had never been Marines) telling them how to do their jobs and restricting their supplies, ammunition, etc. without the Marines' input and generally being resistant or lackadaisical whenever the Marines brought forth an idea for improving the situation?

 

[sojourner75]

Lol, no one hates you. C'mon, you're supposed to be a kickass Marine - are you gonna cry and play victim as soon as someone starts arguing with you?

So exactly how much would it tick a group of Marines off if they had a group of administrators (who had never been Marines) telling them how to do their jobs and restricting their supplies, ammunition, etc. without the Marines' input and generally being resistant or lackadaisical whenever the Marines brought forth an idea for improving the situation?

Good to know no one hates the new non-doctor here. I was worried for a minute.

Like any military men (doctor?), Marines complain a lot to each other, about everything. The shared misery bonds us to each other, and as a side effect we develop higher tolerance toward pain, admin BS, you name it. We try to police our own ranks so that we do not fail each other. But we don't complain DOWN the chain of command, or in front of outsiders, particularly civilians. We assume that outsiders may look upon us as the red-haired ******ed step children, and we return the favor (i.e. we try not to express anger toward said children).

Come to think of it, Marines are in their own universe, coincidentally the center of all other universes... very much like some bitter contributors here.

But joking aside, I felt very angry reading Medical Corpse's stories. I wonder how I would react in his shoes. Would I shoot someone instead of separating right before 20? The stories about AF bureaucratic BS and religious intolerance appeared to be pervasive in his case.

 

[IgD]

Like any military men (doctor?), Marines complain a lot to each other, about everything. The shared misery bonds us to each other, and as a side effect we develop higher tolerance toward pain, admin BS, you name it. We try to police our own ranks so that we do not fail each other. But we don't complain DOWN the chain of command, or in front of outsiders, particularly civilians. We assume that outsiders may look upon us as the red-haired ******ed step children, and we return the favor (i.e. we try not to express anger toward said children).

I've read your posts and I served with a Marine Corps unit for 3 years. Everything you say sounds logical. You must think we are crazy with some of the things we say here. I think you will have to experience it for yourself. The best way I can describe it is Navy medicine leadership is totally different than Marine Corps leadership. I had the opportunity to attend both Marine Corp and Navy medicine meetings and the difference in leadership style was striking.

The Marines talked about values, procedures for "proper staffing" and "leading from the front". I remember watching a COL disagree with the CG. The CG encouraged dissent and he said "fear no man". Decisions in Navy medicine tended to be political agreements and dissent was discouraged. Navy medicine seemed disorganized compared to the Marine Corps.

But joking aside, I felt very angry reading Medical Corpse's stories. I wonder how I would react in his shoes. Would I shoot someone instead of separating right before 20? The stories about AF bureaucratic BS and religious intolerance appeared to be pervasive in his case.

Wait until you see it face to face. A while back I went out and purchased a copy of Catch 22 and put it on my bookshelf because that's exactly what it is like. It's like the feeling the other poster talked about when the base decided to shut down radiology. You know you need radiology, its in the best interests of the patient, the command, the Air Force in general but you have no authority. All you can do is sit there with the skills to make a difference and have a cerebral hemorrhage because the nurse, MSC or "former physician" above you doesn't want to look bad in front of his his commander.

 

[Galo]

This confirms my point that it is a leadership/management problem from the top down. Didn't the SecDef sack the top two AF mil leadership recently?

Marines face the same challenges, though we have more built in mechanisms to deal with them. Our peer pressure tends to be direct and immediate. Marines are broken up into two groups: combat arms (infantry, armor, artillery), and combat support (everyone else). Combats arms units are always commanded by combat arms Marines. Everything we do is in support of that ground commanders. Hell has seen no greater furry if the ground commanders failed due to a rear-echelon or combat support f***-up.

Welcome to the forum. Unlike other line officers that come here to post what they think is gospel and easily transmissible to military medicine, you at least have had the decency to act as a professional and not a condescending *****. Also I've yet to see you attack someone personally as responsible for their bad experiences due to moral torpitude, personality problems, or not being a patriot. If you spend alot of time reading this forum, you will see that physicians, residents, (no med student has become an attending that I know of), who initially started out defending the system, once faced with the immensity of the problem finally start speaking out how it really is based on personal experience, and not some ideal of what their line side job was as an officer, or what they learned in a 4 week indoctrination camp.

I think from having dueled with IDG, I understand where he was coming from since he was on the Marine side of the equation, which based on his, yours, and others description, seems to be what the real military ought to be like. A place where responsibility and ACCOUNTABILITY are prominent tenets. Unfortunately, as physicians, many of us, (6 yrs AF General Surgery for me), not only saw those tenets as pipe dreams, but often saw what would constitute criminal behavior either endorsed, or ignored by people of rank as a favor to people of rank.

I understand how foreign the stories we, (Medical Corpse), tell must seem to you. As unbelievable as they may seem, they are real. Once you experience them for yourself, without the ability to hold anyone accountable the frustration will be incomprehensible. Having had the military experience that you do, you may be able to navigate some of the dilemmas we faced in a different light, but many you will not, and I hope you remember your times on this forum where you thought what you thing now.

Keep on posting, keep us updated, but don't be surprised as you see the number of dissatisfied and angry ex military physicians continuing to grow on this forum, as the problems of military medicine continue to be ignored by the leadership.

 

[Mace1370]

So there is a lot of complaining in this thread (justified or not I have no idea, since I'm not in the military). It seems to be mostly about AF medicine or Navy medicine. I don't know that much about military structure, so is Marine medicine separate from Navy med? I assume it is. Anyways, what about the army? Is it stereotypically better, worse, or on par with the other branches as far as these complaints are concerned?

 

[sojourner75]

I was initially puzzled by the distinction and division between docs and "line officers." Why not docs vs upper echelon, for example? My professional instinct is to identify similarities and build bridges (having worked with Army as a liaison. LOL). Having said that, it just dawn on me that my definition of "officer" is very different from yours.

To be able to lead Marines, as an officer, is an honor and privilege. To us "officer" implies leadership. That is one of the "primary" reasons why many people join the Marine officer rank... the way many of you chose medicine as a primary profession. For the Marines, unprofessional conducts are sometimes put in the category of "conduct un-becoming of an officer."

Your definition for "officer" is justifiably derogatory. I got it.

 

[sojourner75]

I don't know that much about military structure, so is Marine medicine separate from Navy med? I assume it is.

Bless the Navy, who provide med and religious personnel to the Marines. Marines also depend on the Gator or Green navy for amphibious and pre-positioned ship assets. Each branch has sub divisions, competing with each other in healthy and not so healthy ways. The green navy is always short changed on amphib ships (which degrade Marine's ability to project its combat power on hostile shores). The blue, sub, and aviation navies get more funding allegedly, because they are top gun sexy. For Marines, the combat arms and aviation are the squeekiest wheels, for obvious reasons. Mil-med is not the only step child in the house, just the "sickest".

Marines motto is semper fidelis, always faithful. In a practical sense, one's loyalty are defined in layers like an onion. As I learned from this thread, conflicting loyalties are really bad for morale. In naval terms we call it cause for mutiny.

 

[a1qwerty55]

So there is a lot of complaining in this thread (justified or not I have no idea, since I'm not in the military). It seems to be mostly about AF medicine or Navy medicine. I don't know that much about military structure, so is Marine medicine separate from Navy med? I assume it is. Anyways, what about the army? Is it stereotypically better, worse, or on par with the other branches as far as these complaints are concerned?

This either/or line of fallacious reasoning comes up every 6 months or so.

Bottom line is that you do that which is morally correct - coming from your internal compass. In 90+% of cases the medically ethically correct thing is the same as the militarily ethically correct thing. Contrary to what one might believe military officers (line guys) have a higher standard for ethical conduct that let's say lawyers. I deal with ethical dilemmas on a regular basis - so far I think I have done right by both the patients and the military and have not had to somehow prostitute my values as a physician to the military or any other power.

Any either/or proposition or zero-sum argument is fallacious.

 

[a1qwerty55]

Line officers are routinely dismissive of physician concerns about the loss of professional boundaries (i.e. a chain of command increasingly dominated by non-physicians). And yet in many areas, the line is FAR more rigid about their own professional boundaries. How many Air Force fighter squadrons are commanded by non-pilots? How many times has the head of Air Combat Command been a non-pilot? I haven't done all the research, but I would virtually guarantee that the answer is zero. An aircraft maintainance officer or procurement officer may well become Air Force Chief of Staff, but he/she will never be in command of a fighter squadron in war-time. No one would argue that it should be otherwise, and yet command views all of the medical/nursing/dental/MSC officers as somehow interchangeable.

Perhaps there are similar examples in the Marines. Are Marine combat divisions in Iraq typically led by career supply-officers, or protocol officers from the pentagon who have zero field experience? I don't know, but I'm guessing not. It's not a matter of who's smart, it's a matter of who has the most relevant training and experience.

The Air Force actually maintained separate physician and nursing chains of command untill the late '90's when they instituted the so-called "Objective Medical Group." This change effectively castrated the physician leadership and has been one major factor in the overall destruction of AF physician morale that is so painfully evident on this board. Witness the legions of "bitter AF priors, who seem to be multiplying" that crazybrancato so eloquently calls to our attention.

Does horrible physician morale lead to reduced effectiveness? Well...you be the judge, but I think anyone who takes an honest look at the current state of the AF medical services will see that the answer is obvious.

Imagine if you would a service which might draw those more reticent to serve in the military, and then have them lead by nonclinicians who are eager to prove they are real military. Sounds like a recipe for disaster. Does this sound like the AF medical dept?

 

[BomberDoc]

Imagine if you would a service which might draw those more reticent to serve in the military, and then have them lead by nonclinicians who are eager to prove they are real military. Sounds like a recipe for disaster. Does this sound like the AF medical dept?

Yes it does.

Non-clinicians are the only people who get placed into leadership positions. Nurses, MSC, "former physicians," and the worst I have seen was a "former dentist" who had not seen a patient in a dozen years.

I'll even go one step further: those who are in power now are those who joined before 2001 when the military and the country as a whole took a massive shift. These are the people who joined the "corporate" military when it was just a job... before we were a nation and a military at war. One of my former evil nurse commanders racked up 18 years in the AF and still hasn't deployed. Somehow, she just got selected for O-6 and will be given even more power to use for evil instead of good. What I'm getting at is that those of us medics who came on active duty after 2001 have a different mindset... and to my knowledge the vast majority of us do one tour, serve honorably, fight the good fight, and then get the F--- out ASAP because we can't stomach the corruption and ineptitude of the "corporate" cronies who are supposed to be leading us.

 

[Galo]

Imagine if you would a service which might draw those more reticent to serve in the military, and then have them lead by nonclinicians who are eager to prove they are real military. Sounds like a recipe for disaster. Does this sound like the AF medical dept?

No one took the oath and were reticent. We all looked to be part of something that was bigger than all of us. What we did not sign up for was a medical service that is in a shambles and makes it difficult to practice our profession. The part you have right is about the nonclinicians.

HOW??? is the army medical corps ANY different??? at least in regards as to who leads?? Are all your people in leadership positions in the medical field physicians??

 

[Gastrapathy]

No one took the oath and were reticent. We all looked to be part of something that was bigger than all of us. What we did not sign up for was a medical service that is in a shambles and makes it difficult to practice our profession. The part you have right is about the nonclinicians.

HOW??? is the army medical corps ANY different??? at least in regards as to who leads?? Are all your people in leadership positions in the medical field physicians??

I'm not sure this is such an off-base explanation for why Army docs are happier (if you accept that they are which I'm not sure about, since the only ones I saw were deployed and unhappy). There are definitely those who choose the AF and, to a lesser extent, the Navy who do so because it seems the "least military" of the services. They advertise to that concept (golf courses, 3 month deployments, etc). So you select for the people who are most likely to have chosen HPSP just for the money and then put them in the service that has downsized and minimized most aggressively.

 

[a1qwerty55]

I'm not sure this is such an off-base explanation for why Army docs are happier (if you accept that they are which I'm not sure about, since the only ones I saw were deployed and unhappy). There are definitely those who choose the AF and, to a lesser extent, the Navy who do so because it seems the "least military" of the services. They advertise to that concept (golf courses, 3 month deployments, etc). So you select for the people who are most likely to have chosen HPSP just for the money and then put them in the service that has downsized and minimized most aggressively.

My point exactly.

When I ask applicants on this board why they are opting for an USAF scholarship and have dismissed the Navy or Army out of hand, it usually centers around the premise (mistaken) that the AF is cushier, and has less hardship/sacrifice. Sure, the AF has better housing, o-clubs, less hardship on deployments (they consider Diego Garcia, Oman etc a deployment), but if you work for a bunch of pathologic leaders, have grossly understaffed clinics, can't practice your surgical specialty b/c of lack of support, patients etc, and actually have a Command structure which is more punitive and draconian those positives will be quickly negated.

 

[pgg]

No one took the oath and were reticent. We all looked to be part of something that was bigger than all of us. What we did not sign up for was a medical service that is in a shambles and makes it difficult to practice our profession. The part you have right is about the nonclinicians.

HOW??? is the army medical corps ANY different??? at least in regards as to who leads?? Are all your people in leadership positions in the medical field physicians??

I'm reluctant to pile on and slam the AF, but ...

While I'm sometimes frustrated by how many people at my big Navy hospital like to pretend they're not in the military, they've got NOTHING on the climate at the AF hospitals I've been to.

Nothing.

Generalities and stereotypes have some basis in truth ... I'll just say that the Air Force does not attract the kind of people who think it'd be cool to hang out in the dirt with the infantry (Army or USMC by way of USN).

 

[Galo]

I am not in dissagreement with anything anyone has said about AF milmed leadership, or the presumptions most assume when they choose the AF as a branch, though some may not understand the draw of "flight", be it real, or part of it. Anyways, does the army have SUCH distinct leadership in milmed that they do not experience the problems the AF, or even Navy do?? I'd bet NOT. The experience of ONE senior level doc (officer? not sure which he likes better?), does not match the experience of the vast majority of physicians, army, navy, or air force. Without a doubt, af milmed is polluted by a majority of *****S who care nothing about the mission other than how it affects their careers, and most are not even physicians. I'd venture to say, navy and army are not much behind this paradigm.

 

[mitchconnie]

I concur with Galo that there are not MAJOR differences in the medical culture between services. I've worked at Med centers in all three branches, and would note that all are affected by issues of marginal facilities, declining resources, high deployment tempo, poor support staff, dowsizing, etc. If you are unhappy in one branch, you would likely be unhappy in the others.

But having said that, there ARE some subtle differences which make life somewhat more miserable in the AF. The AF has downsized more agressively, making skills retention more difficult. The AF chain of command also seems to be totally dominated by career-climbing non-clinicians, nurses and MSC officers. Whether by tradition or by design, the Army appears to have resisted this trend. And lastly, the AF paradoxically seems to be the most "military" of the three branches when it comes to bureaucratic obsession with regulations (the least military when it comes to mission focus).

The only advantage I see to the AF is in residency, where you are much more likely to get a civilian deferment now that the AF has laid waste to it's residency programs.

I really don't understand why the AF has consistently been more successful with recruiting than the other branches. I guess they still retain that image as "the gentleman's service."

 

[sethco]

and the worst I have seen was a "former dentist" who had not seen a patient in a dozen years.

Gotcha beat on this one...

While I was deployed the med group commander was a licensed Veternarian (sp?) who had not seen a "patient" in almost a couple of decades. He often butted heads with SGPs that rotated through there

 

[a1qwerty55]

I concur with Galo that there are not MAJOR differences in the medical culture between services.

But having said that, there ARE some subtle differences which make life somewhat more miserable in the AF. The AF has downsized more agressively, making skills retention more difficult. The AF chain of command also seems to be totally dominated by career-climbing non-clinicians, nurses and MSC officers. Whether by tradition or by design, the Army appears to have resisted this trend. And lastly, the AF paradoxically seems to be the most "military" of the three branches when it comes to bureaucratic obsession with regulations (the least military when it comes to mission focus).

Those are subtle differences? Somewhat more miserable - you confirmed everything I've claimed, non-clinician chains, obsession with regulations, totally inadequate facilities and staffing, - These are subtle differences. Give me a break.

Come on, you are a USAF ENT correct? Your gripes have generally centered around poor OR support and poor case mix.

While my surgeons wouldn't rave about the support, they have good facilities and operate pretty frequently. The ENT's I have worked with have been excellent and seem pretty happy. I don't think any military surgeons feel that they have as much case load as they would like, but most I've worked with think they have enough to keep up their skills. This is dramatically different from the USAF.

The Army has a couple of successful MEDCEN's, and two really weak ones which probably should go away, but surgical volume seems respectable at the others.

 

[a1qwerty55]

No one took the oath and were reticent. We all looked to be part of something that was bigger than all of us. What we did not sign up for was a medical service that is in a shambles and makes it difficult to practice our profession. The part you have right is about the nonclinicians.

HOW??? is the army medical corps ANY different??? at least in regards as to who leads?? Are all your people in leadership positions in the medical field physicians??

Well, I don't know the USAF hospital structure but I can say that at least at Army Medical Centers the Chief's of Surgery or Medicine, still operate or attend. They are heavy in admin but I've never seen one with no clinical duties. The DCCS (Deputy Commander for Clinical Services) is always a physician and is in effect the Chief of the Medical Staff. That position is second to the Commander and is responsible for the quality of the medical care provided in the institution. The hospital Commander can be a nurse, vet whatever, but your chain is still doctors below that level.

Community hospitals and clinics are a different story which a much bigger nurse presence in leadership roles, fewer military physicians to look out for one another, and more generalists who don't get subspecialty surgery or medicine.

 

[mitchconnie]

Those are subtle differences? Somewhat more miserable - you confirmed everything I've claimed, non-clinician chains, obsession with regulations, totally inadequate facilities and staffing, - These are subtle differences. Give me a break.

The Army has a couple of successful MEDCEN's, and two really weak ones which probably should go away, but surgical volume seems respectable at the others.

Dude...I'm trying to agree with you here, if you'll let me. Don't let my partial agreement with your archenemy Galo distract you from the fact that I AM confirming most of your impressions of the USAF.

I'm also quite interested in which Army Medcens should go away. I'm guessing that the place where I work is one of them.

And incidentally, I'm General/Vascular Surgery.

 

[a1qwerty55]

Dude...I'm trying to agree with you here, if you'll let me. Don't let my partial agreement with your archenemy Galo distract you from the fact that I AM confirming most of your impressions of the USAF.

I'm also quite interested in which Army Medcens should go away. I'm guessing that the place where I work is one of them.

And incidentally, I'm General/Vascular Surgery.

No prob. I wasn't trying to give you a hard time. I was just trying to point out that I think the differences are pretty dramatic. Of course there are always similarities, but there are hospitals (perhaps not most) where standards are high and morale pretty good.

 

[disillusion]

First, to Crazybrancato and sojourner75...I have nothing but a world of respect for your prior service as line officers. Do not think that anything I say is meant to diminish that achievement. That being said...

Given our shoe string budget and stubborness, some of us actually believe we can OJT a brain surgeon.

Holy crap!!!! This is a prime example of the continuous disconnect between line officers and the physicians. The line officers have not clue one what it takes to do the jobs that each specialty does. The mind set seems to be that if we can cross train Armor to Infantry, why not Internal Medicine to Neurosurgeon?

I saw sojourner75's post where he indicated the the person he responded to had a different definition of officership and then indicated that it was a necissarily bad one. You were right. Non-prior physicians do have a different definition of officership. But it is not necessarily bad because it is not the combat arms definition.

Myself, I see my military rank as simply a means to pay me. Physicians do not lead anybody, at anytime. Tell me the last time you saw a physician leading troops. A physicians job is to take care of patient's. That's it.

Combat arms leaders continuously view and interact with physicians as O-whatever rather than as physicians. I had an O-6 come to me to tell me I had to change a soldiers profile. I respectfully declined. He then went to my DCCS and asked him to have me change the profile. The DCCS told him he could not do that. That's the bottom line. No one can tell a physician how to practice medicine, not even the SECDEF, Chief of Staff, etc.

 

[former military]

officer first, doctor second?

I think this is the key to your happiness in military medicine.
I was asked how to predict if they would do well as a doctor in the service.

I asked them in 12 years will you be answering the phone as?

Lt Col Johnson, general surgery or
Dr. Johnson, general surgery

 

[NavyFP]

officer first, doctor second?

I think this is the key to your happiness in military medicine.
I was asked how to predict if they would do well as a doctor in the service.

I asked them in 12 years will you be answering the phone as?

Lt Col Johnson, general surgery or
Dr. Johnson, general surgery

I think you can do both.

I answer the phone Dr. NavyFP.

I sign my name: NavyFP, MD
CDR MC USN

 

[disillusion]

There can also be some quasi-ethical problems with being an officer first and doctor second. Think back to the prison scandal in Iraq. Interestingly, I recently recieved a notification from the California State Board notifying their members in the military that if they were ever found to have participated in activities contrary to the Geneva convention they would lose their liscense and may be prosecuted. Our first duty should always be as physician.

 

[IgD]

There can also be some quasi-ethical problems with being an officer first and doctor second. Think back to the prison scandal in Iraq. Interestingly, I recently recieved a notification from the California State Board notifying their members in the military that if they were ever found to have participated in activities contrary to the Geneva convention they would lose their liscense and may be prosecuted. Our first duty should always be as physician.

To me being an officer and a physician are almost always in line with each other. If you get a put in a situation like that, you tell the commander it isn't right. It helps the command avoid a land mine and is consistent with a physician's duty at the same time. How would saying yes in a situation like that help the command?

 

[NavyFP]

I, for one, have never had an issue where my role as an officer has interfered with my obligation to my profession.

Does anyone care to share their stories of when this was an issue?

 

[a1qwerty55]

I, for one, have never had an issue where my role as an officer has interfered with my obligation to my profession.

Does anyone care to share their stories of when this was an issue?

Ditto.

Do what is right for the patient and you are almost always doing what is right for the military as well.

I only use my rank when I'm making a phone call to get some flunky off his ass to help, otherwise I go by my first name or doctor - much like all my colleagues regardless of rank.

 

[IgD]

I, for one, have never had an issue where my role as an officer has interfered with my obligation to my profession.

Does anyone care to share their stories of when this was an issue?

An active duty service member presented to the clinic saying he had used cannabis once. The physician calls the command and reports him harming the patient with the intent of protecting the unit. This would never have been an issue in the civilian world.

 

[IgD]

Patient no shows to clinic several times. Medical officer calls command to report this harming the patient. Clinic would never call employer to report missed medical visits in civilian world.

 

[a1qwerty55]

An active duty service member presented to the clinic saying he had used cannabis once. The physician calls the command and reports him harming the patient with the intent of protecting the unit. This would never have been an issue in the civilian world.

Doesn't pass the common sense test. I would argue neither the patient nor the military benefited. We actually do have to engage brain before calling the Command.

 

[a1qwerty55]

Patient no shows to clinic several times. Medical officer calls command to report this harming the patient. Clinic would never call employer to report missed medical visits in civilian world.

First, the military is no doubt different - we have different confidentiality regulations but that being said in general the ethos has been you still use only disclose that which is relevant to the safety of the soldier, or the unit, and even then, disclosure is only the the Commander or his/her designee and only the relevant details not all the salacious details are released.

With regards to no shows. Presumably the soldier had a medical condition which needed evaluation or treatment and didn't show - usually we don't contact the Command unless there is a pattern of no shows.

This actually can benefit the patient/soldier - some soldiers avoid the medical establishment to avoid being nondeployable, with at times severe consequences. I had a soldier try to deploy with untreated cancer. Had I not aborted that one with a call to the Command who would have benefited. If soldier shows, soldier presumably is more healthy - good for soldier his family and the Army.

One other point about the no show thing. Since there are no financial downsides to the soldier, there isn't much disincentive to just blowing off an appt. This limits access to care for others so to this system this is a problem.

Lastly in the civilian world you actually DO contact employers when patients no show or are noncompliant (infrequently)- think bus drivers with OSA noncompliant with CPAP, or drivers with seizure disorders. Nothing in medicine is that black and white.

 

[NavyFlightDoc]

First, the military is no doubt different - we have different confidentiality regulations but that being said in general the ethos has been you still use only disclose that which is relevant to the safety of the soldier, or the unit, and even then, disclosure is only the the Commander or his/her designee and only the relevant details not all the salacious details are released.

With regards to no shows. Presumably the soldier had a medical condition which needed evaluation or treatment and didn't show - usually we don't contact the Command unless there is a pattern of no shows.

This actually can benefit the patient/soldier - some soldiers avoid the medical establishment to avoid being nondeployable, with at times severe consequences. I had a soldier try to deploy with untreated cancer. Had I not aborted that one with a call to the Command who would have benefited. If soldier shows, soldier presumably is more healthy - good for soldier his family and the Army.

One other point about the no show thing. Since there are no financial downsides to the soldier, there isn't much disincentive to just blowing off an appt. This limits access to care for others so to this system this is a problem.

Lastly in the civilian world you actually DO contact employers when patients no show or are noncompliant (infrequently)- think bus drivers with OSA noncompliant with CPAP, or drivers with seizure disorders. Nothing in medicine is that black and white.

amen to the above.

plus, in civilian practice, you CAN choose to stop scheduling patients that consistently make appointments in a busy clinic and don't show up, thereby costing you money, since you may have been able to fill that spot with a patient who would bother to show up.

 

[IgD]

Young female officer attached to a ship about to deploy comes to the clinic reporting she has an eating disorder vomiting several times per day. She is extremely high functioning and well respected. She works up her courage and presents to a Navy family practice doc asking for help. The FP calls the ship and disqualifies her from duty. The patient storms out of the clinic and vows never to ask for help again.

 

[crazybrancato]

Young female officer attached to a ship about to deploy comes to the mental health clinic reporting she has an eating disorder vomiting several times per day. She is extremely high functioning and well respected. She works up her courage and presents to a Navy family practice doc asking for help. The FP calls the ship and disqualifies her from duty. The patient storms out of the clinic and vows never to ask for help again.

a1 is right on the money; there's a thousand examples of civilian jobs that require medical checkups, some with more stringent requirements than the military. some where if one missed appt earns your a termination. at least the military gives you a few chances before they start busting your nads.

i'm not sure what your point is bringing up these examples, which are all very military specific. I think we can all agree that indeed, these are cases when the milmed and civmed world diverge.

since you brought up this specific example, i'll give my two cents: the FP would exactly be in the right, to call up her CO and preclude her from duty, or say from the next deployment. Let's assume she's on a ship. Does the CO want to take here underway, only to have her become malnourished, then have to medivac her off, or pull into port to transfer her? No, no CO in his right mind would want that situation. Even if it would upset her--and sometimes people don't know what's good for them--she should stay back, get treated, then go out to meet her ship. She should also be given counseling to assure her that she did the right thing, in essence benefiting herself and her unit.

 

[IgD]

You are fresh out of residency and sent to a terrorist prison. Your job will be to provide medical care for inmates. A senior O6 pulls you aside and tells you will be part of a team. He tells you your job will be to provide medical care but also collaborate with the team on collecting intelligence and managing behavior. What do you do?

 

[IgD]

- And since when did "intelligence gathering" become the opposite of "providing medical treatment"? You can't do both? I mean hell, I read all about the Tarasoff decisions, and it seems to me that you're out of sync with the law here. You don't report your civilian patients when they tell you they're planning to kill their wives?

...A report by the AMA's Council on Ethical and Judicial Affairs (CEJA), which was laboriously crafted and recrafted until just days before its approval by the AMA House of Delegates last month, states that physicians must not participate in interrogations; to do so "undermines the physician's role as healer and thereby erodes trust in the individual physician-interrogator and in the medical profession."