IT IS TIME TO completely dismantle the military medical system and close all military hospitals.
The reason for undertaking this radical surgery on military medicine is simple: Military medicine has succumbed to bureaucratic inertia and is no longer responsive to the peacetime needs of its patient population or prepared for the combat requirements of troops in the field. Indeed, although there are some excellent physicians in the armed forces, the military provides a haven for doctors who would rather not -- or are unable to -- stand up to the rigors of civilian medicine.
The benefits would be significant, both short- and long-term. Elimination of salaries for physicians and allied health care professionals and the drastic reduction in yearly operating expenses for equipment and maintenance would save the government hundreds of millions of dollars on an annual basis. These savings would provide adequate funding to underwrite a health-care delivery system operated through private insurers at favorable rates and subject to the quality standards of civilian medical practice.
The sale or lease of military medical facilities, located on prime property in Bethesda, the District of Columbia, San Diego, Honolulu, San Francisco and other locations would provide equally large sums as revenues to the federal government.
To meet the military's wartime needs, a reserve corps of physicians -- reflecting the full range of specialties needed -- would be created. These physicians might be required to serve a minimal amount of time in the military in peacetime, but could be called to duty at a moment's notice in the event of war or a national emergency.
The official rationale for a military medical corps is based on the perceived need for a standing body of physicians prepared to meet the anticipated medical requirements of war. But does this perception square with reality? And what of peacetime? The military promises free health care, not only for active-duty personnel, but also for their dependents, for retirees and for dependents of retirees. It purports to do this through a large system of dispensaries, clinics and small hospitals located on military bases. Additionally, several hospitals fully equipped to deal with the most complex illnesses operate both in the continental United States and overseas.
Quality of care varies widely, according to the facilities in a particular location, rank of the patient and demand for services. Dissatisfaction caused by wide variations in the quality and availability of medical care is compounded by what many patients see as an attitude problem among military physicians and staff. Patients often complain about being treated in an abrupt and off- hand manner, being told or made to feel that they are a nuisance or a burden to the system. Their phone calls are often not returned and their complaints dismissed as a symptom of malingering.
Medical records and X-rays are too frequently lost, compromising later care. Requests for consultation by other physicians are treated as a bother, rather than as an expression of confidence in the consultant and a genuine call for help. Informed consent is a joke -- enlisted personnel have been threatened with discharge for failing to agree with their physician's recommendation, despite the risk.
Active duty patients have been ordered back to duty, or out of the service, before being fully recovered, while others have languished for months, occupying a hospital bed thousands of miles from home and family, because of some paperwork glitch. Among scores of such cases I remember during 10 years of service was a young sailor who was treated for a benign tumor, which was successfully removed; but he was kept in the hospital for months while awaiting some disposition even though he was perfectly healthy.
A number of patients with back problems have been sent back to duty without a specific diagnosis or adequate treatment. These patients were unable to perform their jobs and were discharged, losing their opportunity to earn retirement benefits and compromising their future employability.
Patients often find military clinics overcrowded, their physicians too busy or too rude to answer questions or attend to the amenities of sound medical practice. Adding insult to injury, patients are then required to wait long hours in overcrowded pharmacies, only to receive a limited amount of medication, necessitating frequent returns to obtain refills and contributing, in turn, to further overcrowding.
Poor attitude, lack of courtesy and unresponsiveness to their cares and concerns alienate patients and drive those who can afford it to seek private health care. Those who can least afford it are foced to remain within the system and endure these indignities. They tolerate this for one reason only: It is free.
According to regulations, active-duty personnel, except in emergencies, must be treated in military facilities. Provision of military care for dependents is optional, however, depending upon a number of factors, and treatment may be provided either by military or civilian physicians.
Uniformed personnel stationed in metropolitan areas such as Washington, for example, may have access to care at relatively well-equipped military hospitals. Even here, however, questions have been raised about the professional qualifications of some physicians on staff. Dependents and retirees may, or may not, be accepted at these facilities depending upon the interest generated by their particular medical problem, availability of hospital beds or clinic space, or their political connections.
If the dependents or retirees are not accepted for treatment, then they seek treatment from civilian physicians under the CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), a federally-funded Defense Department program.
In areas distant from these facilities, clinics and hospitals are generally understaffed, without a full complement of physicians; equipment is lacking, and medical treatment may be substandard. Referral out of such hospitals may be necessary for adequate evaluation or treatment of complications.
Major surgical procedures are performed in some base hospitals in rural areas and overseas -- such as Plattsburgh Air Force Base in New York, Adak Naval Station in Alaska and Guantanamo Bay Naval Base in Cuba -- without an anesthesiologist on staff or available. In such instances, a nurse anesthetist administers the anaesthesia. If a complication occurs requiring an anesthesiologist, one is requested from a nearby civilian hospital. Whether one is available in those circumstances is another matter.
Alternatively, depending upon financial or staffing considerations, rather than medical indications, care for dependents may be denied at the military hospital and the patient shifted into the CHAMPUS program. But because the fees the program pays are well below those normally paid civilian doctors, this program provides little financial incentive for the civilian physician to treat the patient. As a result, the patient may face unexpected out-of-pocket expenses or not be able to purchase care.
Were this state of affairs simply necessary to ensure a combat-ready medical corps, it would be serious enough to warrant grave concern. But there are equally serious shortcomings in preparedness for treatment of combat casualties. Current doctrine in military planning is that "when the balloon goes up" it will be a "come-as-you-are war," i.e., time for deployment may be exceedingly short and reliance upon traditional methods of draft and mobilization is inappropriate.
Despite this assumption, projected requirements for specialty care are not being met within the military medical system. There are particular shortfalls in the surgical specialties, which would be in most acute demand for the treatment of battlefield casualties. The military simply does not have adequate manpower in the required disciplines to treat anticipated casualties. The Navy has seven neurosurgeons on active duty with a projected need for 100 in case of war, according to Navy sources. The Navy has 13 thoracic surgeons, with a probable need for 150 to 200. Only 80 orthopedic surgeons are on active duty, a mere fraction of the combat need. Army and Air Force figures are comparable.
Excuses for this failure to attract the necessary physicians tend to focus on the differential between salaries paid to physicians in the military and those earned by their civilian counterparts. Although this discrepancy certainly exists, the explanation, of itself, is inadequate. How else to explain the large numbers of physicians attracted to academic practices and prepaid plans, where salaries may be considerably lower than in private practice?
Indeed, there are other inducements for physicians to serve in the military. These very incentives, however, are at the heart of the problem. Simply stated, the military provides an atmosphere for the practice of medicine that does not particularly reward excellence or initiative; promotions and pay raises are awarded for time-in-grade rather than quality of care.
Freedom from responsibility, freedom from administrative details and a short work- day, the cornerstones of recruiting for the military medical corps, are attractive primarily to those who are not up to the challenges and responsibilities of civilian practice. They find the sheltered environment of military medicine attractive and less risky than establishing a practice in the civilian community, where they are more likely to come under professional and legal scrutiny.
Some very good physicians remain in the military. I know a number of them and they do the best they can, in spite of the system, under conditions of adversity. Many others have left, disenchanted with an overwhelming atmosphere of mediocrity. Of physicians now entering the military, many do so in a virtual state of indentured servitude, as a result of obligations incurred by training in the Uniformed University of Health Sciences, or by having accepted a military scholarship.
In the absence of such obligations, the vast majority of young, aggressive and well- trained physicians specializing in neurosurgery, thoracic surgery, orthopedics, cardiovascular surgery and other fields do not find this environment either attractive or appealing. As a result of these critical manpower shortages, the military remains incapable of providing adequate treatment for casualties anticipated from any significant combat.
Furthermore, the urgent transfer to the theater of operations of those physicians already on active duty in stateside military hospitals would, immediately, leave these facilities uncovered, even allowing for rapid mobilization of reserve units to replace them. There will, therefore, be an urgent demand for large numbers of civilian physicians, organized into a multi-specialty reserve component, to provide appropriate levels of medical care.
This demand would be consistent with previous experience in wartime, where physicians newly inducted into the military provided the bulk of medical care. The contention that a large number of active duty physicians is required at all times, in order to preserve organizational integrity, simply does not hold up under scrutiny.
Physicians are already accustomed to hierarchical systems by virtue of their training and practice patterns; learning to salute is irrelevant. Behavior under combat conditions is not and cannot be taught during service in peacetime; it must be learned in actual combat, where innovation and improvisation carry the day and contribute to the advancement of medical knowledge. Non-medical, administrative functions could readily be subsumed under the direction of medical service corps officers and appropriately trained line officers.
Eliminating the military medical apparatus would bring other benefits, as well. In the face of decreasing lengths of patient stay and relative underutilization of hospital beds in the private sector, the cost of health care and medical insurance has skyrocketed nationwide. Shifting military beneficiary care to the civilian community would reduce the federal budget and add a large number of young, healthy individuals (active duty personnel) to the population base, reducing the per-patient cost of insurance across the board.
At the same time, addition of the entire beneficiary population to the present civilian population would increase the patient bas for most hospitals across the country, permitting more efficient utilization of civilian facilities at a higher percentage of bed occupancy.
Given this combination of factors, there is no longer sufficient justification for perpetuating a separate corps of physicians serving the military. Its elimination will not compromise the quality of health care currently delivered to military beneficiaries, but should actually improve it.
The entire active duty, dependent and retired population could be shifted into the civilian health care system and absorbed without undue difficulty. Counter-arguments that military physicians are required overseas also beg the issue. High quality medical care abroad is frequently provided by local facilities and physicians in emergencies and transfer of patients back to the continental United States is already common under less urgent conditions.
Similarly, attempts to justify the use of U.S. military medical facilities under limited combat conditions have proved, in the recent past, both awkward and inappropriate. The aero-medical evacuation of military casualties from Lebanon to a U.S. Army hospital in Germany bypassed first-rate hospitals in Israel, with large numbers of physicians skilled in the treatment of battlefield injuries.
This egregious example of poor utilization violated generally accepted prinicples of medical triage and all tenets of wartime medicine, which mandate the prompt removal of battlefield casualties to the nearest fully equipped facility. What then would remain of military medicine? One could envision the continued need for a limited number of family practice physicians serving in unique settings, to provide triage and referral of medical problems to civilian facilities, to maintain communication with civilian physicians and to treat minor problems on-site.
Specially trained physicians, such as flight surgeons and submarine medical officers, without civilian counterparts, would also be required in a limited number of circumstances. With those exceptions, the three service medical corps would cease to exist. Instead, civilian physicians would be encouraged, by a combination of tax incentives and practice benefits, to enter multi-specialty reserve units for periodic training and to accustom themselves to working together as a unit. If these incentives proved inadequate, drafting physicians could be re-instituted.
A great deal of time away from home or practice should not be required, their medical expertise already having been established and verified. This program, in turn, would provide a larger base than currently exists, from which physicians could be drawn as necessary, during wartime.
This proposal is radical and certain to provoke hostility from those with a vested interest in perpetuating the status quo. It is time, however, to recognize that the current crisis in military medicine has been building for some time and satisfactory solutions have not been forthcoming. Nor is there evidence that any other proposal currently under consideration has a significant chance of reversing the downward spiral toward mediocrity and inadequacy.
This approach will enable the military beneficiary to receive higher quality care than is now available, while cutting expenditures required for maintenance of a huge and ineffective military medical establishment. That this change would also go a long way toward correcting the problem of rapidly increasing costs of health care for the entire population would be an additional benefit of almost immeasurable significance.