There is room for improvement throughout the two worlds in which the medical officer lives and works; but, perhaps we should think in terms of six “communities” to which and through which the medical officer’s duties carry him sometime during his military service, rather than in terms of worlds. These communities are peopled respectively by: (1) brother naval medical officers, (2) civilian doctors, (3) the civilian population, (4) the Hospital Corps, (5) the U. S. Navy, and, (6) dependents and retired personnel.
Within all six communities, then, there are individual problems; and, perhaps, if we look close enough, there are solutions. We must strive very hard to find them if we are to accomplish our twin goals of reversing the present poor retention rate among physicians, and removing the dissatisfaction with the brand of medical care rendered, a dissatisfaction experienced both by some practicioners [sic] and recipients, which is the ultimate product of the present system.
Among Navy physicians who practice medicine afloat, and at the smaller installations not equipped with naval hospitals, there is an unhealthy undercurrent tantamount to apologies for the brand of medicine they practice. This is for the most part unspoken, but it is implicit in their practice.
Their efforts at continuing their education are not satisfying.
Their individuality, that only recently they heard expounded as a sacrosanct right, is lost in the isolation of their billet and the subjective sensation of being a small cog in an enormous wheel.
Particularly among the junior officers, and especially while the physician is a lieutenant, there are subtle innuendos concerning the rank the doctor inherited “without working for it.”
Being fresh from the ivory tower of university practice, where research is carried out as a daily routine and where VIPs seek their care, the new medical officer is acutely aware of having stepped down into the new job.
Not to mention the vagaries of the individual insecurity of being thrust away from the mother school, the environment he just left is replete with allusions to the inferior brand of medicine practiced anywhere except at the Great University. Such acronyms as “LMD” have come to have considerably more meaning than Local M.D. Thus, he has left behind optimal facilities, optimal treatment, and all that is holy in the educational sphere. But, of course, the same jump-off would be made into private practice.
The newly commissioned lieutenant (MC) has no concept of a limited medical practice. The idea of having to refer to a distant command a case that he feels deserves his good offices and attentions, in favor of continuing to see and treat the lines of waiting patients in the sickbay or dispensary, is distasteful.
Improvement of the physical facilities where medicine is practiced is a must. There can be only an incomplete sense of pride in a well done job where the plant is a 25-year-old refurbished “tempo” (temporary building). Modern equipment as befits the mission of the command should be housed in clean, efficient quarters that befit the dignity of the patients.
Continuing education is mandatory for the knowledgeable practice of medicine. The Bureau of Medicine and Surgery has set aside $300 per man per year for TAD to postgraduate training. This should never be allowed to go unused. At the local level, weekly journal clubs with other MOs provide the stimulus to keep up, and the expenses involved are deductible each April 15th.
All medical officers should be encouraged to visit the nearest naval hospital frequently, and become personally acquainted with those physicians with whom he will be dealing as consultants. The impersonality of sending a chart and a patient to the hospital, to be seen by other physicians who have no comprehension of the limitations of the referring facility, is not acceptable. Telephone consultations when appropriate add to the personalness of the services being offered. There is no need for the patient to be lost in the sea of uniforms. Conversely, the afloat MO should encourage his shorebound brethren to join him at sea for a familiarization cruise. Their understanding of the limitations imposed by being under way, plus what may be their only opportunity to “go to sea” is an advantage to both.
Lines of communications frequently have to be kept open with a lever, by virtue of the workload imposed or the operating schedule. If it takes a lever to do it, then a lever it should be, since communications can be as difficult to achieve from one end of the hall to the other as from one command to the other. Regularly scheduled meetings of MOs, within commands and within areas, amount to the intelligent practice of preventive medicine.
The assignment of collateral duties of an administrative nature to younger MOs will serve to get them involved, and help them to see the big picture.
Active interest in the young physician[’]s future intentions by his seniors with an eye to a career in the Navy should not be left to the career counselor office. Opportunities for a young MO to tour other installations and commands to see the scope of someone else’s problems may help him to see the limit under which he himself operates and suggest to him possible areas of improvement.
An overwhelming percentage of civilian physicians have spent some time in the military. As human nature goes, those with the less than ideal experience or who were not well suited to the job, seem to do the most talking. They publicize the concept of Service medicine being second best.
In the communities where a military installation is present, there will always be some dependents who “doctor-shop” between the base and the downtown doctor. The patient usually has few compliments about whichever service he is currently not using, and may be vocal about it. Friction between the two factions may result.
Military physicians are, in essence, transients. Some of their downtown doctor colleagues were there, in the same office, 15 years ago, and will still be there 15 years hence. The military establishment in the civilian doctor’s community contributes to the economy of his town, and he probably wishes that it would keep right on performing. Its personnel are, however, by the nature of military assignments, strangers.
Naval medical officers should be required to attend scientific symposia at least annually, in uniform. It is important that the Navy doctor continue his education, and that the taxpaying professional community be aware of this. The Navy doctor should make a special effort to participate in the local civilian medical society meetings. Though he probably is not entitled to membership by virtue of licensing requirements, he will find that he is a most welcome guest. His interests in the community will please the local practitioners, and the groundwork for further liaison in the form of Saturday rounds at the local hospital and the inclusion of the military facilities in local disaster planning reap unexpected benefits for all concerned. Offers to assist in local community action programs such as education of high school students to the dangers of drug-abuse will further boost the image of the command and the Navy Medical Department.
Members of the civilian community simply do not have an awareness concerning the mission of the Navy Medical Department, though there is no lack of interest.
Any method that could improve the relationship between the civil and military should be considered, inasmuch as the current fad for demeaning the military establishment has ignorance as a perpetuating force.
The aloofness that characterizes relations with the local inhabitants by the military tenants exists at all levels except the public affairs office and the uppermost echelon of the command. It takes a certain amount of spark to overcome the traditional reserve.
All parties benefit when the barriers between the town and the command are down. Certain gifted MOs have a message that the civilian community wants to hear: “Medicine Afloat,” “Aerospace Medicine,” or “Submarine Medicine.” Local service clubs are always seeking luncheon speakers. Similar topics plus certain others (drug abuse) are appropriate for the high school level. The key to better community relations is simply “Get involved.” Everyone benefits.
Traditionally, the relationships between physicians and corpsmen have been more personal than official, and this is especially evident at small commands and in the Fleet. First name basis relations towards juniors is the rule rather than the exception.
Disciplinary and administrative type problems with the troops traditionally are left to the MSC officer to handle. The subtle expressions of individuality that creep into such aspects as dress and appearance among the MOs set a poor example and are not consistent with the principles of leadership.
Corpsmen who have served on the battlefield often are frustrated by what in comparison to the urgency and responsibility of their former duties, becomes humdrum and boring. Recognition of commendable performance is too often cursory.
Where MSC Officers are available to the everyday activities of the hospital corpsmen, the physician is reluctant to interfere. Under the guise of being too busy with his primary responsibilities, it is an easy way out to leave the realm of leadership to the MSC man. Where an MSC is not available, the MO is often out of touch so that he further avoids the job.
Since corpsmen have had a purely military background by virtue of their boot camp experiences, they have found out what a “real” naval officer should be.
Too often they will never again see one in their direct chain of command because their seniors are medical officers first and naval officers second. The necessary interest and encouragement with appropriate example is not forthcoming. In fact, the senior MO may sport a luxurious set of sideburns, yet require the corpsmen to have a GI haircut. This permissiveness is to be found nowhere else in the naval community. A physician’s salute as often as not resembles something out of a grade “B” World War II movie.
Overlapping into many more fields than just the area of the relations with the Hospital Corps, the failure of the naval MO to consider himself a naval officer is a major discrepancy. The remedy can only be effected by education of the MO. As part of the pre-flight stage of naval flight surgeon training, a two-week course of orientation including chain of command, traditions, courtesy, leadership, formation, marching, and foreign policy have already set the flight surgeon apart from his confreres. All MOs should be exposed to the same type of training opportunity, wherein problems such as those presented in this paper are also discussed. Thus oriented, he will be better able to deal with his responsibilities to his corpsmen, and necessarily, with his nonprofessional military brethren. Hopefully, such prior training would alert him to the problems in the communications with his future troops and cause him to be thinking of how to solve them before they are a fait accompli. He would then be in a position to assume responsibility in leadership instead of having the MSC man take it by default. He would be aware of the necessity for his own appearance being consistent with the high naval standards, and be proud to do so.
Public recognition of achievement by his troops on a regular basis through such awards as “Corpsman of the Quarter” give the hospitalman additional pride in his work, and recognizes a basic human need. At a departmental level, although making clear that the actual decision-making will be done by the senior medical officer, there should be a regular sounding board open to the more senior petty officers, not unlike the department heads’ meetings at the command level.
The knowledgeable MO will be able to discuss advancement opportunities intelligently with the outstanding members of his command, and be able to point the way for those who have the capability for the MSC pipeline.
Without detracting from the cordiality of the intra-departmental relationships, there is room for more of the military-oriented courtesies. HMs who are unaccustomed to operating within the military structure that would be expected in almost any other division in the command, become a liability in dealing with seniors who are not from within the realm of medicine. In the past, this has been interpreted as insubordination and discourteousness. Rank among officers does not have the same connotation to the HM as with another enlisted man. This problem starts in the medical department, and should have its solution there.
Doctors are necessary evils. They serve an important function, but in effect are almost a part of someone else’s Navy. Their contributions are limited for the most part to the sphere of medicine only. Though this is perhaps commendable in itself, it is not sufficient. The physician may be respected for his professional dedication and prowess, but too often he is thought of as a second rate naval officer. Are the concepts of physician and naval officer mutually exclusive?
Whether by design or by accident, and whether a reason or an excuse, the burden of responsibility for the health of the military community has become associated with less-than-ideal orientation among the younger MOs. The fierce independence traditionally associated with the practitioner in the civilian community, since the MO’s medical education was necessarily civilian, is easily carried over into the military. As long as the practice of medicine continues to be more art than science, there will continue to be individual judgments reinforcing the validity of the concept of non-conformity. No adequate effort has been made to point out the inappropriateness of eccentric individuality in the military. Indeed, some younger doctors fail to realize at all that non-conformity in the military is prejudicial to good discipline or morale. In fact, they are unaware that there exists any such problem as is here under discussion. What makes “a good outfit” has never entered his mind. Eventually he will learn it, but why waste all the time waiting? Can this be accomplished in a more timely fashion?
As discussed under doctor-corpsman relationships, the deficits in the military behavior of the physician can be remedied in a course offered prior to his active duty assignment. Should the didactic approach prove insufficient, he should then be allowed the opportunity to exercise clinical judgment in a field type situation demonstrating the pitfalls of the second rate officer. He would in all probability get the message. Care should be exercised in assigning these individuals, those embittered few who feel put upon unjustly by virtue of having been drafted.
“When in Rome . . .” is common sense. In the present context it means attention to military appearance, courtesy, etiquette, and knowledge of traditions and mission. Acquisition of this knowledge through experience should be the reinforcement of what has already been taught, not the primary mode of learning.
The roles of Kindly Physician and Good Naval Officer are not mutually exclusive, though they are a unique and difficult combination.
Let us talk for a moment about dependents and retired personnel. Being ostensibly free of charge, Navy medicine suffers unfavorably in the light of the current concept of cost and value. Much as the youngster who has given the Good Humor man his dime, he expects his ice cream in the flavor he wishes, and right now! Other aspects of the problem follow logically from the basic failing. It takes too long to get to see the doctor. There is a limited availability of drugs. There is no genuineness in the doctor-patient relationship, since as often as not, the patient will not be seen by the same doctor twice.
Though the brand of medicine practiced in the cellar of the neighborhood settlement house may be the equal of, or even superior to, that practiced on upper Park Avenue, it doesn’t look that way. Similarly, patients entering a 25-year-old “tempo” draw some conclusions about the products and services available there. Whether their conclusions are valid is beside the point, since these are the people we wish to please.
It is a fact of life that products and services are only as valuable as their cost. That which is free has already lost some of its otherwise innate value.
Directly or indirectly, the military and their dependents have been led to believe that medical care is their right. This, then, is also the obligation of the naval service and its medical personnel to render. The fact that medical care for the military per se is the mission of the medical department has not been made clear.
Dependent care is rendered as a favor, not the fulfillment of a legal contractual obligation. The smaller naval stations and naval air stations are not funded by the Bureau of Medicine, but in fact, prescription medicines may be in competition with aviation gasoline for monies. In a pinch, there really is no choice as to whether to restrict prescriptions or ground the planes.
Also, in too many cases, the MO is looked on almost the way one views the mailbox standing on the corner, ready to receive letters—or patients—at any time. And, when the personal element, the flesh-and-blood doctor, becomes lost, the patient becomes dissatisfied and so, too, does the doctor.
There is an erroneous feeling that care of Navy dependents ought to duplicate that which is offered in the civilian community. Most of the time it does, but this is an accident of the training of physicians, and not by design. The limited capabilities of the smaller commands necessarily incurs delays that anger patients and frustrate doctors. Consultations and specialized X-ray studies, certain laboratory work, and electrocardiogram interpretations are sent to distant commands for completion. Waiting lists and harried technicians populate the environs, lurking to complicate further that which seems as though it should only take a few minutes. And yet, in the civilian community, if the family doctor merely calls the consultant or laboratory, attention is then focussed [sic] upon the waiting patient. Answers and results pour out the other end of the funnel. It occasionally happens that the patient is unhappy with his care, in which case he discharges the attending physician and seeks another. There is no such choice in the Navy even though it is true that a matter of preference may sometimes be involved in his care.
The plush, clean, efficient offices of the civilian doctor imply—wrongly or rightly—affluence, organization, and good practice.
Clashes between dependent/retired patients and Navy physicians over what was an emergency and demanded odd-hour care, illustrate that the patient himself has a sense of guilt that needs only a slight amount of prodding to unmask. Navy physicians are called upon to treat minor ills and wounds that patients would never think of taking to a civilian doctor for whose services they would be required to pay.
A nuisance value fee in the neighborhood of two dollars, though not an effort at equating cost to value per se, would in effect restrict the use of medical services to those with a real need. It would be the death knell to after-hours visits prompted by such reasoning as, “I was in the area, and I thought that Johnny should have a checkup for the headache he had two weeks ago.” Waiting room time, waiting lists, overcrowding, and exasperated physicians would be significantly diminished. More attention could be given to those who actually were sick.
The two-dollar fee would be payable at each visit. The accruing funds could be channeled into whatever avenue the comptroller deemed proper. It is not how they are used that matters as much as their actual tendering. The obvious area towards which they could be applied is building upkeep and remodeling.
The commonly accepted belief that free dependent care is a right should be corrected. This care is available on a basis limited by operational commitments and available funds, and should not compete in any way with that available in the civilian community. All BuMed cognizance functions should be BuMed-funded and BuMed-responsible. Competition for funds then should be on an across-the-board level, at the same level, resulting in a more equitable distribution by the most knowledgeable people.
Taken out of context, any of the foregoing could be interpreted as a diatribe directed at a decadent institution. This conclusion would be grievously in error. Consistent with the mission to provide the best possible care to its patients, Navy medicine should be receptive to ideas meant to improve its image both inside and outside the naval professional community. The overwhelming majority of patients and doctors are perfectly willing to leave alone a time-honored and proven system. This does not exclude, however, the streamlining of procedures if doing so will improve the end product without tarnishing the image.
Not only does the Navy MO have to care for the sick and wounded, but he must minister to those who merely think they are. Furthermore, he must do so in a fashion that will avoid bringing discredit upon the naval service. He must perform so that not only are the greatest number of patients cured, but also pleased.