Medicine in the Military

21 01 2013

Goodness, it’s been a while!

Since I last updated, I’ve finished my neurology rotation for medical school as well as my first ‘real’ semester of graduate work for the MPH program.  As far as the MPH is concerned, I’ve had the opportunity to study several social issues in medicine and my perspective on the social and behavioral determinants of health has broadened considerable.  For this post, it’s all about the neurology experience.

My neurology experience was divided into 3 parts: outpatient, inpatient, and pediatrics.

For the outpatient portion, I was assigned to the clinic at the military base on the outskirts of town.  This was a unique opportunity not only to learn about neurology, but also about the military’s health care system.  My preceptor was a physician who was an irritating combination of brilliant, cocky, and logical.  He knows he’s brilliant and will never hesitate to demonstrate that he knows more than you about anything within his field, which was a quality that I appreciated because demonstrating his knowledge inevitably led to teaching.  As I have stated before, I relish having a preceptor who actually teaches enough to put up with the moderate arrogance.

Military medicine is a very interesting entity.  Most military physicians make considerably less money in the military than they would in a civilian practice (with the exceptions of family medicine and pediatrics).  However, military employees have their medical school education paid for and get an excellent pension plan where they are allowed to retire from the military, join a civilian practice, and receive both salaries.  It’s called ‘double-dipping,’ and almost every physician does it (according to one of the neurologists).

One interesting thing about the system is that the majority of primary care providers are nurse practitioners.  Even the physicians see nurse practitioners for minor things like heartburn and minor orthopedic injuries.  Personally, I think this is grossly inappropriate.  Not one of those physicians will ever really trust their NPs, who got far less training than they did.  I wouldn’t either.  Truth be told, I see a NP for the requisite annual Pap, but those require almost no thought and if anything were to be out of the ordinary, the first thing she would do is get the doctor.  One of the other neurologists basically steers his own diagnostic and treatment courses because he doesn’t trust his NP’s training and the NP knows she doesn’t have the knowledge base to contradict him.  It might save money, but it’s uncomfortable on all sides.

The other cool thing about military medicine is watching the function of a care provider that is also the payer.  It’s much more difficult to see a specialist, order a lab, or get clearance for certain surgeries.  It’s also exceedingly difficult to hire a new staff member.  While I was on rotation, one of the 2 radiologists was deployed.  Rather than simply hiring another, they stopped doing MRI scans on anyone who was not active duty.  This meant that every other MRI scan (and I saw quite a few ordered) had to be referred to an outside provider, and it was significantly more costly to the system.  Why not just hire another radiologist?  Because the funding for the two are very separate, and in order to get the funding for another staff radiologist the paperwork would have to go all the way to the Department of Defense in Washington.  The MRI costs could be offset internally, and of the two, this was the smaller headache.

The doctors also work considerably less.  The hospital is down to skeleton staff on all federal holidays and on most weekends.  The neurologist I worked with saw, at max, 9 patients in a day.  In a day.  I saw 9 patients in 3 hours in family medicine, and that was only because 3 of them didn’t show for their appointments.  We started at 8 or 9am and always got out by 3:30 to do PT (which, might I add, results in some very good-looking men).  And they allow drug reps, which acted as a source of free food and entertainment—it was really fun to watch the two neurologists tear apart the drug company’s studies, say things like “no, I won’t prescribe your drug because it is not indicated for any of my patients,” and call out the drug rep on peddling a drug without knowing a thing about real physiology.

Easily the best part of the outpatient experience was the fact that it was longitudinal, which means I did one day a week in clinic over the course of 4 months.  This meant that I was able to follow almost a dozen patients over the course of that time, seeing all of them more than once.  It was really great to see, for the first time as a student, what it’s really like to care for a patient over a period of time rather than focusing on that one person with that one illness whom you’ll never see again—something that the traditional structure of medical school doesn’t allow.

One patient in particular touched me, a woman with signs and symptoms that looked to the neurologist like ALS (aka Lou Gehrig’s Disease).  She had been seen for 3 prior visits, and while my preceptor was very suspicious, he never mentioned the disease specifically to the patient.  He did, however, very gently steer her in the direction of thinking about a life insurance policy.  I asked why, and was told that, in order to tell the patient about his suspicions of ALS, he would have to document it in his notes, and once a diagnosis of that caliber was on record, the poor woman would never be able to get affordable life insurance for her family (she has 3 young kids).

There are, of course, more stories to tell, but I’m out of time for now and will continue later.  It definitely will not be another 10 weeks before I write again




So, what do you think?

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