cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

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