Point of Views about a Blue Angels Flight Surgeon

[r90t]

My little navy hospital in Washington had a cap on patients in the FP clinic. The only people they would add were E-5 and below. This was the rule, not the exception, due to staff to patient ratio. We had contract FP physicians to ease the AD workload. Retirees were sent out into the community. If you were retired and lived x number of miles from the hospital you were tricare'd out as well. Our CO was concerned about the patient to physician ratio and the ability to deliver quality care without causing an undue burden on the primary care staff. Other navy/AF/army bases may be different.

I did the GMO tour and did not feel undertrained for the routine things that came into the department. If I had medical problem that I was unsure of, I had a secure computer to chat with the SMO on Nimitz with a medevac available from our airdet that would take 30 minutes to get a sailor to a higher level of care.

USAFdoc-could you train an intern over the course of 12 months to manage your healthy 18-40 year olds that have been pre-screened by you before being assigned to him? I'll bet you could and give him the wisdom to seek your guidance whenever he is unsure of his decision. GMOs in the fleet do not have a 10 minute appt limit with each pt and can spend more time with each visit. You also know your patient population very well when you live with them for an extended time period.

MilMD-Politics suck. I see it and don't agree with it. I have a big mouth, but fortunately not so big of a foot, so when I insert foot in mouth it is easily removed. I told my last skipper my opinion of career medical officers. My idea that I pitched to him was to bring in MC officers (more FTOS/Deferred trained officers) with the expectation of being in for residency+payback only. You would have to get special consideration to stay on AD after that. Leave the leadership jobs (and retirement) to our USUHS counterparts. That would remove the top heavy MC of the burden of carrying around too may O-5s. The younger physicians would train nationwide and deliver modern medicine, instead of what we did in 1985.

pgg-You hit the GMO nail right on the head. GMO is a compromise in the system that if utilized properly, works. When a GMO is set to run an ER/Clinic by himself, that is totally inappropriate. Put a GMO under the guidance of an FP/ER or other residency trained physician, and you have added an asset to your team. I will argue that certain internships prepare one better for GMO billets than others, i.e. FP/transitional/IM vs peds/obgyn/GS. I'll knock the GS interns because they were the ones that had trouble with STEP 3 in my class due to their non-primary care oriented 1st year of training.

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[USAFdoc]

My little navy hospital in Washington had a cap on patients in the FP clinic. The only people they would add were E-5 and below. This was the rule, not the exception, due to staff to patient ratio. We had contract FP physicians to ease the AD workload. Retirees were sent out into the community. If you were retired and lived x number of miles from the hospital you were tricare'd out as well. Our CO was concerned about the patient to physician ratio and the ability to deliver quality care without causing an undue burden on the primary care staff. Other navy/AF/army bases may be different.

your clinic sounds like it was doing several things myself and other docs requested for years, and had admin ignore; even more than that, go in the iopposte direction. Again, my direct experience was with USAF primary care, and other than the academy and overseas, everywhere was out of control. I did speak with a lone SE Navy base office manager at one of my seminars and they had a 700 patient/provider cap and it sounded as if they had a pretty well run clinic.



FYI: realize that ONLY the USAF has gone PCO "Primary Care Optimization" and only the USAF increased its panel sizes on paper to 1500-2000 patients per doc (in reality this was 2500-3000+ patients per provider considering the manning at 50% covering panels for docs not there anymore) and if you consider the panels of the PAs under the doc liscense, panel sizes of 6000 patients per doc. Compare that to the USN of 700 patients (then probably higher due to missing docs as well).

the reason PCO should matter to everyone is that the SG of the USAF touts his failed plan as the best thing since sliced wonder bread and this puts pressure on other services to implement their own version, not just in primary care, but other specialties as well.

rT90 please respond; Question, what were you panel sizes????

 

[orbitsurgMD]

r90t said:

"pgg-You hit the GMO nail right on the head. GMO is a compromise in the system that if utilized properly, works. When a GMO is set to run an ER/Clinic by himself, that is totally inappropriate. Put a GMO under the guidance of an FP/ER or other residency trained physician, and you have added an asset to your team. I will argue that certain internships prepare one better for GMO billets than others, i.e. FP/transitional/IM vs peds/obgyn/GS. I'll knock the GS interns because they were the ones that had trouble with STEP 3 in my class due to their non-primary care oriented 1st year of training."

Unfortunately not all billets are manned this way. I certainly agree that GMO utilization is a compromise; it is compromise in training standards and patient safety that the services get away with most of the time. It exists solely out of the convenience to the services and only because of their ability to exploit archaic state medical licensing requirements for postgraduate training; requirements that nearly every civilian hospital finds insufficient, preferring completed residency training and board eligibility at a minimum. The services are alone in this perverse preference to use undertrained medical personnel. And just because the GMO can be put to good use--ends justifying the means, here--doesn't make that kind of tasking any more ethical or desirable. Having "healthier" young patients in the panel is no reason to staff clinics with less well trained doctors.

The HPSP numbers are telling the Navy something. And it isn't just about the risks of service in wartime.

 

[GMO_52]

r90t said:
I certainly agree that GMO utilization is a compromise; it is compromise in training standards and patient safety that the services get away with most of the time.

The question is also what the options are to replace the GMO. Convert every billet to a residency-trained physician...well there aren't enough and their skills would atrophy seeing my old GMO patient panel or (and this is what I think would happen) convert many back to IDC billets. Everyone talks up IDC's but most aren't even ACLS certified. I'm of the view that there should be as few GMO billets as possible and they should all be operational in settings in which one would replace them with a PA, NP, IDC, etc (clinic GMO's make no sense to me).

Hey r90t, how's life?

 

[orbitsurgMD]

The question is also what the options are to replace the GMO. Convert every billet to a residency-trained physician...well there aren't enough and their skills would atrophy seeing my old GMO patient panel or (and this is what I think would happen) convert many back to IDC billets. Everyone talks up IDC's but most aren't even ACLS certified. I'm of the view that there should be as few GMO billets as possible and they should all be operational in settings in which one would replace them with a PA, NP, IDC, etc (clinic GMO's make no sense to me).

Hey r90t, how's life?

Why not just get rid of the GMO? If you think of the problem as one where the GMO option wasn't available, what would you do? Hire more FPs and ER docs, rotate them sooner from deployed billets to high-clinical-intensity shoreside jobs (and back) so that their skills wouldn't atrophy. And yes, spend more money. It will surely cost them more, but quality often does.

The bugbear of the Navy is that they somehow always are able to rationalize keeping the GMO around, and thus never manage to find their way out of their own self-imposed dependency. Laziness, inappropriate thrift, lack of imagination, failure to insist on better options even if it means butting heads with the line are all explanations. It is time that they did better, whatever the cost.

 

[r90t]

As a GMO at the hospital: 500 for myself with any open appt slots taken with walk in pts. Initially I had 30 min/pt, then dropped to 20 minutes/pt. I did have FP staff to turn to if I had any doubt about my dx/plan.

USAFDoc-The FP providers had a panel of approx 1000-1200. If a civilian provider left, instead of deviding up the panel to the other remaining physicians, they seemed to poach physicians from the local civilian group. My CO was a very dynamic individual and a great leader. ER doc by training. He wanted to hear opinions, good and bad, about the command. He could be seen policing up loose papers in a waiting room when nobody was around. When I transferred from his command, I was given his personal email/telephone with the instructions to call if I had any troubles. Wow. In another thread Dr. J.R. wrote the Proceedings article about navy medicine. My boss appreciated that type of input.

GMO_52: life is good. Back in training, doing non-primary care medicine. Great population for oncology patients. I think I am truly seeing the worst of the worst, being a catch basin from El Salvador to the US. This residency is the reverse of the navy population, i.e. no health care until a 10 cm tumor sprouts out of there neck. FTOS is great. We had to get together for the PRT in November. It was a bunch of 35+ physicians running around the track right before the ROTC unit had to do theirs. I didn't realize there were so many navy guys around me in training.

 

[Trajan]

If you think that giving a GMO the responsibility of caring for a limited number of healthy 18 to 40 year olds is outrageous, what do you think of putting a recent college graduate through eight weeks of training and then giving him command of a Marine platoon in Vietnam or Iraq?

To be successful, the military depends on people pushing their limits. It succeeds and fails as those individuals succeed or fail. Not an ideal system, but this is how it is done. Do your best.

 

[usnavdoc]

If you think that giving a GMO the responsibility of caring for a limited number of healthy 18 to 40 year olds is outrageous, what do you think of putting a recent college graduate through eight weeks of training and then giving him command of a Marine platoon in Vietnam or Iraq?

To be successful, the military depends on people pushing their limits. It succeeds and fails as those individuals succeed or fail. Not an ideal system, but this is how it is done. Do your best.

Although I do agree that a GMO can handle 95% of the medical problems in the AD Marine population with the remainder having specialist involvement. Your analogy really has no relevance. That recent college grad you mention has a SSGT or SGT guiding his decisions and teaching him unit leadership which they have learned by being enlisted for 6-8 years. There is no such person guiding the GMO with medical matters.

The question is not whether(IMO) can a GMO do the job. But with the state of navy medicine. Isnt the job better done by a PA so that the GMO can go straight through training to the specialty work force? With FPs in posiitions that endable them to oversee the PAs in the usual fashion. EX..Regiment physician would be a LCDR FP. Battalions who fall under regiment would have 2 PAs. There are generally 3-4 Battalions per regiment with 800-1200 Marines per battalion and another 400 or so per regiment. The fleet probably has some similiar arrangement that could follow this model.

Out of all the current GMOs at my present duty station over the last 4 years roughly 80% are leaving after their GMO obligation to pursue civ GME. The remainder are pursuing Mil GME but plan to leave service at a later date. I know of one individual who was contemplating a career, but with recent trends is second guessing that idea. This is the story all over the Navy with regards to the GMO.

 

[r90t]

For every PA you commission, you have to give up an officer billet from somewhere else. There is a cap on the number of commissioned officers you can have in the navy. Also, each command has a cap. An example, when we put MSC officers on carriers to do the radiation health programs, the command had to give up one officer billet that was already on the ship.

For more FPs to be commissioned, what surgical specialty are we going to cut?? Likely none. Get rid of peds, psych, ob/gyn, etc....to keep the MC at it's current numbers. I don't think many people want to here that either.

Also, where the heck are we going to get all of these people that want to do FP for a career???? I don't want to do it. Board certified FPs recommended that I stay away from it due to the current job/reimbursement climate (civilian FPs, not military).Seems like most of the GMOs are out there doing a GMO tour so they can get into a competitive specialty residency and to avoid a primary care career.

The GMO issue is a tough question with no easy solution.

 

[orbitsurgMD]

"For every PA you commission, you have to give up an officer billet from somewhere else."

So perhaps there is a need to revise manning limitations. Is that impossible? Of course not. It may take a bill to do that, but the military has Congressional liaisons and plenty of friendly, well-placed potential sponsors.

"For more FPs to be commissioned, what surgical specialty are we going to cut?"

Start by cutting GMO billets. Change the manning regulations if board-certified physicians cannot be swapped with GMOs.

"Also, where the heck are we going to get all of these people that want to do FP for a career?

Hire them. Advertise for them and offer them more money than they would get in civilian practice. Give them more leave. Make the field attractive. For those that volunteer to place themselves on a 12-month deployable status, say to a ship, offer even more--ideally an attractive amount more. If you value deployed physicians, pay them like you value them. The military is so used to being a bottom-feeder as concerns pay and benefits that it never seems to occur to them that they might get the results they want if they just paid better. With the right compensation and treating their people well, they might even be able to become selective again. Imagine that.

"Seems like most of the GMOs are out there doing a GMO tour so they can get into a competitive specialty residency and to avoid a primary care career."

Maybe true. Make primary care attractive by offering better support and better pay and working conditions and you might reverse that trend. Who says the military has to follow all the negative civilian trends?

"The GMO issue is a tough question with no easy solution."

Disagree: easy enough, just not cheap.

 

[militarymd]

For every PA you commission, you have to give up an officer billet from somewhere else. .

The civlian equivalent of this is: A new doc moved into town....we've got to kick one of the old ones out...

That's how *****ic military rules are.