ADM Bono wrote the article herself and published it in JAMA on very specific things that will happen. If I think those things are good and you think they are bad thats fine, but it doesn't change what we know right now.
The very first question she fielded last week - and she answered fairly extensively - was about that very JAMA article.
I don't want to accidentally misquote her, so I won't try to be exact. I think she was honest, open, and sincere. One of the things she briefly mentioned was MEDMACRE, something that's now pushing 6 or 7 (?) years old. I think most of us believed it laid out in pretty specific terms what the enterprise's targets were for specialties to be expanded and reduced. Yet she referred to it as just one tool of several that would be used to shape the force. The implication is that none of it is a done deal.
I'm just saying. I think your confidence in where we'll all be in 5 or 10 years is excessive.
We all know that there are economic forces pushing us very, very strongly in certain directions.
We all know that the medical corps' mission goes beyond merely cost effective health care delivery, and extends to supporting a warfighting machine that doesn't need to be "profitable" in the sense that civilian institutions must. Given that, I'm not the least bit convinced that all of these cost-oriented reforms are actually going to happen at all, much less in the ways one might expect, because the Truest thing of all True things said about the military and the medical corps, is that the line gets what the line wants.
With regard to integration with non-military hospitals - again, I'll believe in meaningful widespread integration when I see it, because
1) It's been
decades (literally the early 1980s) since Congress directed us and the VA to share resources and staff, and all you've got to do is look at AHLTA and VistA, and count the number of AD physicians and nurses whose daily place of duty is a VA hospital (and vice versa), to see how seriously we've taken that directive.
2) A few years ago I was the DSS at a Navy hospital, and we put together an ERSA to get our surgeons to a civilian hospital in town to do surgery. We essentially invented that wheel - and by that I mean it was a locally initiated, locally driven project, done as our response to the implementation of the Small Hospital Study (which closed our inpatient wards and would've skeletonized our surgeons' practice).
3) Just a couple weeks ago I finalized a MOU to allow me to go work at a VA hospital to keep my subspecialty skills up. Where did the MOU come from? I wrote it. I actually had to take a MOU that our GME office uses to get residents to work at outside hospitals, and heavily edited it so that I could practice as an attending at a VA hospital. If the military and the VA are working so closely together, why was this so hard? Why isn't there an enterprise-wide MOU covering this, or at least a template that's had some legal review?
The simple honest truth is that the handful of locations where military hospitals are well integrated into the local civilian/VA system (e.g. San Antonio) are notable
exceptions to the blindingly obvious rule: Army/Navy/AF-wide, at the enterprise level, there is
no meaningful organization or push to do any of this integration. There just isn't. If there was, guys like me wouldn't have to write MOUs.
Will this change, as we get purpler as DHA starts leading us all? I hope so.
But the first time I heard the term purple medical corps I was a MS1 at USUHS, over 20 years ago. There's some of it happening ... we have a few Army & AF staff at our Navy hospital, and I was a Navy IA to an Navy unit on an Army base for my last deployment. I hope for VA/civilian integration, but I'll believe it when I see it.
But military medicine is a great deal for the right person who understands what they are getting in to.
I do agree. There's another thread in here started by Perrotfish,
the skyrocketing value of the HPSP scholarship, which has a lot of detail and discussion.
I'm actually a bit of an outlier here in that I've had a pretty good run in the Navy, and a mostly positive experience. Some of that is deserved just rewards 'cause I'm a great guy and all, and some of it is pure blind squirrel luck. I'm glad I joined, and I'm glad I'm still serving. A few years ago, I was eligible to get out at 12 years of creditable service, and I stayed.
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