You're in the military or must depend on military care and want a second opinion or even a chance to see a civilian doctor. What really happens?
A few weeks ago I asked readers that question. I've heard from both the satisfied and the dissatisfied: those who have been successful and those who have been spectacularly unsuccessful in getting other medical views.
The dissatisfied are in the majority. That could mean simply that they're more likely to write letters, but some of their stories are arresting.
I've also heard from a Gaithersburg family physician, Dr. Cheryl Winchell. She is married to a Public Health Service scientist, which means she and her family receive military medical care, except when she gets a "non-availability" form, authorizing some federal payment for civilian care of dependents and retirees.
She tells of a frustrating series of Catch 22s.
First: "As anyone who is eligible for military medicine benefits knows, the bigger problem is getting someone to answer the phone and give you an appointment. Frequently all you get is a recording telling you that all the appointments for that month are gone and to try again next month after 7 a.m. on the first."
Then: "They are accepting no new appointments at all in pediatrics at the Naval Medical Center , so my child, who needs his adenoids out, can't be seen in ENT ear, nose and throat , because the rules say he has to go to pediatrics first."
As a result: "I have arranged outpatient surgery for him with a private ENT specialist , but I have only one month to obtain the elusive 'non-availability form' from the Navy prior to his surgery, or CHAMPUS the Civilian Health and Medical Program of the Uniformed Services, which can help pay for civilian care won't cover the surgery. Of course, when I call, all I get is a recording. I have been working on this for two weeks now."
She reports at this writing that: "Now it's three weeks." Some good reports: Sherry Morse was at an Army hospital in West Germany, when she was told she needed emergency surgery for a ruptured disc. "My family in California was saying, 'Get another opinion.' As it turned out, I didn't need to . . . Four or five neurosurgeons discussed and considered each case . . . allowing the patient to ask questions. Before surgery, there were several opinions considered. I was a major's wife, but I believe everyone was getting basically the same treatment."
Mary Richmond of Alexandria, a retired officer's wife, had a routine mammogram taken at Mount Vernon Hospital. A doctor there recommended a biopsy, so she had the results sent to her doctor at DeWitt Army Hospital, Fort Belvoir, Va. The radiologist there had another mammogram taken. His findings were negative. He conferred with a surgeon and the biopsy was cancelled, but "at the same time, the surgeon offered to let me obtain a second opinion from the doctor of my choice."
A retired Navy captain tells of two operations she had in the past four years at the Naval Medical Center in Bethesda, with encouragement in both for several opinions, military and civilian. In the last case, an operation for cancer, her Navy doctor "told me he would be available by phone to other physicians and would send any pertinent records with me." A tumor board from the Navy, Walter Reed and the National Cancer Institute reviewed her case and others. "I found nothing but support . . . I saw dependent wives of the lowest-rated sailors being treated with the same courtesy and care."
David Taylor of Bethesda says he and his wife are Navy hospital corpsmen, and "our experience at Bethesda, Newport Naval Hospital and in Okinawa has always been that second opinions are available, even encouraged. Fellow corpsmen tell of patients at isolated duty stations such as Keflavik, Iceland, who were medically evacuated or sent to local civilian facilities when qualified Navy physicians weren't available for second opinions." But also: Katherine Browning, widow of a recently deceased Navy captain and a long-time patient at Bethesda Naval, says "we were never allowed to see civilian doctors. I have tried several times, as did my husband, but to no avail. I think it would be an excellent idea if this was brought to the attention of the commanding officer."
"I was in the Marine Corps for 25 years," says a retired sergeant major. "In a military hospital, you've got about as much chance as a snowball in hell of changing doctors. Go into Bethesda or Fort Belvoir at 8 o'clock some morning and see the people lined up. Whether you're a full colonel or a PFC or a lady with a baby, you get in line and take your turn and get whoever gets to you, whether a doctor or a hospital corpsman."
Another retired Marine says he was seen at Bethesda "several times during October and November 1983 with severe back and neck pain," also leg numbness and trouble walking. "I was told there was nothing wrong with my back. I requested to see another doctor and was refused. Finally I got an appointment as a retiree in 1984 and was operated on twice . . . Second opinion? Yes sir, if you are an officer of significant rank. Imagine even an E9 sergeant major with 30 years being refused a second opinion."
But from a Navy captain's wife: "My husband was hospitalized for cancer." A colon cancer was also suspected, and "Dr. X wanted to perform a colostomy removing a section of colon ." She insisted on a second opinion, "which Dr. X strongly opposed. He was incensed to the point of calling me at home and castigating me over the telephone." The captain did see a civilian doctor. When the colon was finally explored at the Naval Hospital, no cancer was present. As to Dr. X, "I have never seen such cantankerous behavior by a doctor . . . 'Forget it' to second opinions."
And from Hampton Roads, Va.: "When a patient asks for a second opinion, the answer will be, 'I have discussed it with my colleagues and they agree with my treatment.' " In a system with hundreds of hospitals and thousands of doctors, thousands of things can obviously happen. A civilian official in the military medical program says: "There is no central formal policy on second opinions. The information I get from representatives of each of the military services is: "It is not a policy issue, but it is standard medical practice that second opinions are good to have, and anyone having a procedure who wants one is free to get one.' "
Or, obviously, should be.
CHAMPUS policy is to pay for second opinions for dependents and retirees. Active military personnel generally must go to other military doctors or pay for a civilian opinion, though civilian doctors are used as consultants at many military facilities. And some civilian doctors are willing to see a military person in need for a lowered fee, if told of the circumstances.
Military doctors, like doctors everyplace, are more accustomed to second opinions today than they were just a few years ago. This and many matters at military hospitals are now getting closer scrutiny, and military leaders say they will be using external peer reviewers -- civilians -- to keep a continuing eye on the medical establishment.
They also say that given a current shortage of military doctors -- and difficulty in meeting the military's own needs -- they are considering turning over much more care of dependents and retirees to civilian medicine.
One can hope that both future plans and future scrutiny will include such matters as second opinions, waiting times, appointment times, courtesy and humanity, as well as the technicalities of effective medicine.Next Week: Malpractice and you -- Is the crisis affecting the way your doctor takes care of you?