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A Few of the Letters to the Editor Rob has penned:

News Flash: One of Rob's Letters to the Editor is finally published!

In its June, 2006 issue, U.S. Medicine finally published one of the many Letters to the Editor I have submitted since leaving the military in July, 2005. The online version is here: http://www.usmedicine.com/article.cfm?articleID=1324&issueID=88; below is the text as I submitted it (before their editorial tamperings ["Diplomat" indeed! I'm not very diplomatic, as anyone who knows me can attest. Painfully honest, yes; diplomatic, no.]).

To the Editor, U.S. Medicine:

With the imminent closing of Walter Reed Army Medical Center, and the transfer of the inpatient function of Wilford Hall Medical Center to Brooke Army Medical Center, the death of U.S. military medicine should be evident to the casual observer. Now that my alma mater, Wilford Hall, has devolved into a clinic, what shall we call Andrews AFB hospital: a doc in the box (singular)?

Ten years from now, our active duty troops, their families, and our honored military retirees will be treated by civilian contractor FMG physicians and non-physician active duty "providers": the bottom of the barrel caring for the "Tip of the Spear". The few USU-graduate physicians will be shunted into ineffectual positions on the org chart, so that the all-powerful Nursing Corps can continue to champion "empowerment" of nurses to command physicians, as well as the independent (mal)practice of nurse anesthetists on our troops (which remains a felony outside of military bases in most states) [Addendum: this was true in 2006]. Politicians and Generals will perseverate in touting the quality of health care in the military, while covering up Sentinel Events related directly to the lack of senior clinical physicians needed to provide "adult supervision" to the green staff M.D.s rotating in and out every four years. TRICARE (try and get care) will drop all pretenses of attempting to help military families; its goal of evolving into a for-profit cash cow for government contract corporations will be unmasked for all to see. And then, the final coup de grace: a nurse will be appointed as "Surgeon General" of a military department.

After 19 years on active duty, 15 of which was as a physician, I walked away from all retirement benefits last year, precisely because military medicine has been mismanaged into an early grave by shortsighted Pentagon bureaucrats and their spineless military medical underlings. I have written a website detailing my post-mortem observations regarding what was once a proud profession: U.S. military medicine...not "allied health professional-ship"...not "providership"...MEDICINE: [Addendum: web site on hiatus]

The mothers of those brave souls who are right now enlisting to defend our country deserve to know the truth: there will be no military medical system to care for them in a few short years, if current trends continue...and if there is one, it will be so dangerous due to lack of funding and qualified personnel,that self aid/buddy care would prove a far safer option.

Signed,

Robert C. Jones, M.D.
Ex-LtCol, USAF, Medical Corps
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, MD
Diplomate, ABA (1995)
Harvard '85, USU '90, Wilford Hall USAFMC residency 1994


Support Our Troops: 16 Simple Steps to Revive Military Medicine from the Brink of Death


Like the Wye Oak on June 5th, 2002, the imposing edifice of United States military medicine appears to be mighty and vigorous. Due to improved body armor and forward surgical capabilities, our injured troops are surviving better during the Iraq war than at any previous time in our military medical history. However, like the Wye Oak, there is a corrupting rot growing deep within the heart of military medicine like a fatal cancer. After 19 years of dedicated active duty, I am leaving the United States Air Force as a senior Lieutenant Colonel and resigning my commission and not joining the reserves, in protest of this rot. I am losing all retirement benefits permanently and speaking out publicly, because I am truly afraid that our honored retirees and the casualties of our NEXT war will be crushed by the falling trunk of what seemed to be so solid an institution. Like the death of the Wye Oak on June 6th, 2002, it will only take an isolated, freak storm of war to bring the proud profession of U.S. military medicine crashing to its death, unless drastic reforms are undertaken right now. Here, then, are my prescriptions for urgent life support treatment, gleaned from my experience as one of the most senior anesthesiologists in the entire American military:

1) Return control of medical care to people who graduated from medical school. Undo the disastrous Air Force Objective Medical Group structure, whose mantra of "Corps neutrality" has put nurses and pharmacists in command of doctors. A little learning is a dangerous thing: unlike most Medical Service Corps commanders, many O-5 and O-6 nurses in positions of authority think they can and should second-guess physicians' medical decisions. This is especially true in the area of anesthesia care, where high-ranking CRNAs have attempted to divorce themselves from anesthesiologists in order to implement independent nurse anesthesia practice in all three services (except for VIPs in the Navy, it seems). This dangerous practice violates civilian standards of care in almost every state [Addendum: this was true in 2006], and jeopardizes the safety of our troops and their loved ones. The 1999-2000 civil war at Travis Air Force Base between CRNAs and anesthesiologists (and the patient brain damage and death that ensued) should have taught the military medical leadership the folly of the OMG; sadly, it has not...yet. Rewrite the official military Rules of Engagement so that physician anesthesiologists are always put in military command of nurse anesthetists, regardless of military rank (yes, this can be done!). Reinforce the scientifically-validated anesthesia team concept, with anesthesiologist M.D.s as unquestioned "Captains" of the team. Hint: this will require training more anesthesiologists, if the current retention rate of 0.0% continues.

2) Stop relying on physician extenders instead of physicians. Reverse the disturbing trend toward hiring vastly increasing numbers of non-physician LIPs ("licensed, independent providers"), including NPs, PAs, CRNAs, CNIs, housekeepers who watch cable TV health channels, etc., at the expense of physicians. Do you want your child's IED-induced brain injury to be fixed by a neurosurgical PA or a board-certified physician neurosurgeon? Would rather your appendicitis be diagnosed and treated by a doctor, or a nurse practitioner? Tick tock tick tock.

3) Reverse the pell-mell privatization of military health care. Contractors cost big money, and cannot be deployed to war zones (we couldn't afford their overtime charges). The esprit de corps and morale of the triservice Military Medical Corps are being systematically destroyed; pediatricians and obstetricians are being told, "Sorry, we don't need you on the frontlines. You can choose a different specialty, or leave...whatever." Instantly double the number of active duty physicians and their pay. Fund this by firing civilian contractor physicians who are paid three times as much for 40 hours per week as active duty docs are paid for 80 hours per week, without the possibility of a year-long vacation in lovely downtown Balad.

4) Reform TRICARE, the semi-private boondoggle which melds the altruistic sensitivity of big business with the raw efficiency of federal government bureaucracy. When my autistic son had three hour surgery under general anesthesia, it took months of struggling with functionally illiterate functionaries to get TRICARE to pay the $4000.00 plus bill. Several idiots with only a high school education told me, a physician and anesthesiologist, that coverage was denied because my severely handicapped son could have had the procedure done in a dentist's clinic without anesthesia (if the office found six large men to sit on him for three hours, that is)! The ONE beauty of our former socialized military medicine system was the lack of demoralizing red tape prior to receiving care: you showed your ID card, you got taken care of, you went home happy. Now that Military Treatment Facilities worldwide are being shuttered or gutted, TRICARE beneficiaries are forced to seek care in the outside world, where the TRICARE-covered are often treated like third-class pariahs. If the military insists on making troops and their families jump through flaming hoops of the broken civilian medical insurance reimbursement prevention model, why should we stay in?

5) Assure adequate adult supervision of green interns and residents. If the military can't train and recruit sufficient numbers of critical care specialist attendings to staff the ICUs, don't force anesthesiologists and nurse anesthetists to act in loco parentis as pseudo-intensivists. Instead, for the safety of our patients, admit the Emperor has No Clothes, throw off the bondage of administrative Denial, Anger, and Bargaining, and close the ICU. The need to have an Air Force General Officer in command at a "Medical Center" at Andrews (for example) should not outweigh the need to match clinical services offered to actual capabilities. Anyone familiar with the budget- and personnel-slashing MAPPG-06 plan should recognize that Malcolm Grow is no longer a "Medical Center", but rather a community hospital rapidly devolving into a superclinic due to shortsighted staffing and funding cutbacks, combined with sheer mismanagement at the highest levels. Reverse the insane decision to close the Flagship of Army (and military) Medicine, Walter Reed Army Medical Center, where so many of our injured troops have been operated on and rehabilitated, and where my eldest son was born (before they closed OB). When I asked a surgeon in the OR at Andrews where our sickest Malcolm Grow patients would go when Walter Reed closed, the surgical technologist piped up: "Heaven." Sad, but true.

6) Cut out demoralizing and insulting "crazymakers". Forcing physicians to keep track of work hours via impossible to use, computerized timesheets is fraud, waste, and abuse when officer staffing levels are pulled out of the air (or the nether parts of their anatomy) by top brass during closed Pentagon meetings. Forcing physicians to do patient care coding a la the civilian world on their lonesomes, while hiring an inadequate number of coding "advisors" to nitpick doctors' coding decisions, destroys clinic productivity and morale. When the medical clinics close at 1600, make sure that the hospital orderly room, military personnel flight, and finance offices are open and staffed until at least 1800 to provide critical services to hard-working docs. If base finance thinks it's a good idea to set up "self-help" stations for service after 1300, then I'll set up a "self-help" anesthesia station so they can put THEMSELVES to sleep for their surgery after hours and on weekends. Stop having the least competent individuals running the critical Medical Readiness function. Reverse the trend toward consolidating officer and enlisted clubs on base; this attempt at false economy harms morale more than it improves the bottom line. Replace laborious and redundant Computer Based Training (CBT) with HOT (Hands On Training) or briefings in nice, air-conditioned lecture halls (at least the naps can refresh one's vigilance).

7) Allow patients to carry their medical records to appointments, just as in the old days. [Addendum: This paragraph will be superseded when DoD implements an effective, all-service Electronic Medical Record system that is functional and user-friendly, unlike GENESIS. Clearly, we are not there yet.] I trust our patients to safeguard their records more than I trust our airmen in the outpatient records section not to lose them. Every military member has a horror story about hospitals losing the medical records of themselves, their spouses, or children... when have you ever heard of a patient losing his or her own record? The current "Closed Medical Records" system ensures that people show up for preoperative evaluation with no, zero, bupkis records whatsoever, because their caregivers won't release them...and won't copy them in real time. If the military hierarchy insists on maintaining the broken status quo, then create an electronic outpatient medical record DVD-RW which the patient can carry from Andrews to Walter Reed, with secure VPN internet updates to the "master" record at their PCM's base; unify lab and test report CHCS database across the world, so that physicians at Walter Reed can instantly look up patients' labs in Landstuhl the day before. Good medical diagnosis and treatment cannot occur in an information vacuum.

8) Reform the Air Evac System. Recognize that the Air Evac system is twenty years or more behind the times. Prevent non-critical-care physicians and nurses from running CCATT "Extender" Teams. Admit that non-specialist Flight Surgeon General Practitioners are not trained to manage the sickest patients during RON (Remain OverNight) status at rinky-dink military hospitals like Andrews. Strengthen the continuity of high levels of care by transferring Air Evac patients to fully staffed hospital wards with residency-trained attendings (Hint: RAM doesn't count), rather than forcing our brave, injured troops to languish on cold, field-expedient Aeromedical Staging Flight holding pens set up on the tennis court at the Andrews base gym (I kid you not).

9) Make anesthesiologists co-equal to surgeons. Pull the independent medical specialty of anesthesiology out from under the boot of tyrannical military surgeons. Anesthesiologists are specialist physicians trained to preserve life and treat pain; surgeons are specialist physicians trained to intervene with knives and instruments to fix problems and save lives. This inherent yin-yang relationship between anesthesiologists and surgeons means that anesthesiologists are continually subjected to undue military command pressures to violate accepted standards of care in order to avoid canceling sexy (or expensive-to-transfer) cases. No anesthesiologist ever gets in trouble with commanders for saying "Yes" to a procedure and killing the patient dead; we only get in trouble when we say "No", and thus save the patient's life by destroying our careers. Ideally, promote anesthesiology to parity with surgical specialties, as in the civilian world org chart paradigm. Otherwise, reassign military command of the "internists of the operating room" to the Medical (not Surgical) Operations Squadron. At least pulmonologists and cardiologists care about airway, breathing, and circulation foremost, rather than focusing on testosterone-fueled, rank-driven, Alpha male primate dominance displays intended to bully anesthesiologists into letting the godlike surgeon cut whenever and wherever he or she wants to, regardless of accepted international medical care standards.

10) Stop punishing physicians for transferring patients. Given the poorly-planned and precipitous downsizing of many former military "Medical Centers", institute a flexible policy of Evidence Based Referral to larger military or civilian hospitals for the sickest and youngest patients. Make the policy entirely dependent on the clinical judgments of the attending physicians directly involved with each individual patient (surgeons, anesthesiologists, internists). Tear up arbitrary cookie-cutter guidelines pulled out of the arses of non-specialist, non-physician administrators (e.g., "long bone fracture repairs in 8 year old kids bad; long bone fracture repairs in 9 year old kids good, 'cuz we say so."). Lack of facility support for appropriate patient care or preoperative workup (inpatient pediatrics, neurology, interventional cardiology, trauma care, ICU, etc.) should not mean "proceed with the case"; it should mean "stabilize and transfer patient"There needs to be a new, non-political litmus test for patient transfers. Commanders, ask yourselves: "What would I want for my own child or father?"...rather than, "What would look better on my Officer Performance Report so I can get promoted?"

11) Implement Corps-specific Professional Military Education (PME). Why do doctors or nurses need to know how to launch nuclear weapons to ensure the greatest civilian damage (countervalue) vs. striking at military targets (counterforce)? Physicians should review care of chemical, biological, and nuclear casualties as part of their PME, rather than being forced to read computer-based training written by non-physician morons every single year. Remove the insulting requirement to take PME by correspondence before being allowed to take it in residence; I didn't have to pass Organic Chemistry on CD-ROM before I was allowed to sit in the Chem 20 classroom at Harvard.

12) Separate Church and State. Repudiate and cease unconstitutional efforts to shove Fundamentalist Christian evangelism down the throats of the captive military audience. Cut the Air Force "Fourth Wellness Tiedown" of spirituality, which is merely a code word for Christianity in its most organized, monotheistic, dogmatic, and proselytizing form. Recognize that the United States is not, and was not EVER, a Christian nation; rather, our Deist forefathers (and foremothers) enshrined tolerance and freedom from State imposition of religion in any form into our Constitution. Realize that there are Pagans, Hindus, Buddhists, Objectivists, and, yes, atheists, who are right now fighting and dying for our country in the military. Contrary to popular belief, not everyone believes in a single higher power; this is a monotheistic fallacy. As the Air Force Academy scandal shows, non-Christians feel like second class citizens in the context of One Air Force Under Jesus. Revert to the stance promulgated by the 1997 little #FFFF99 Air Force Core Values book: religion and spirituality are the private concerns of each military member, and are not to be discussed/reviewed/criticized during yearly official feedback sessions (as if my Christian Commander can bring me closer to my Goddess, the Tao, or Buddha!).

13) Maintain the firewall between doctors and torturers. Reiterate and enforce biomedical ethics and Hippocratic Oath values, regardless of mealy-mouthed lawyerisms about loopholes in the Geneva Convention statutes. For five thousand years before the Geneva Conventions and the Convention Against Torture were adopted, and regardless of legal/illegal combatant status, physicians have been forbidden to assist in torture, interrogation, or, say, intentional poisoning of pizza with anesthetic drugs to subdue mock terrorists during a training exercise on November 18th, 2004. Doctors must only use their deep knowledge of human biology to help people; any (and I mean any) use of medical and/or psychological training to harm humans in any way is an immoral and unethical abomination. Non-physician military or civilian commanders declaring a person an "enemy of the state" or "illegal combatant" does not and cannot EVER trump the physician's Prime Directive: "First Do No Harm". Any uniformed physician who assists in torture or interrogation should be charged with war crimes against humanity after appropriate court-martialing for conduct unbecoming a medical officer. While we're at it, stop allowing non-physicians to practice medicine by injecting prisoners with "chemical restraint" poisons prior to transfer to or from GITMO without appropriate provisions for airway management or vital sign monitoring en route. "Chemical restraint" is specifically forbidden by U.S. Army regulations in Army hospitals due to the inhumanity and severe patient danger involved...how much more should it be forbidden on aircraft when administered by medically-unsupervised non-physicians? See, for example, http://www.seoul.amedd.army.mil/webshare/files/129/resource/Restraint%20Policy.doc: "The use of a medication as a chemical restraint is inappropriate. It is not the policy of the 18th MEDCOM to use chemical restraints."

14) It's Retention, Stupid! Do something-anything-- to retain good clinical physicians (and nurses) in military service. Like Dilbert , the surest way to recognize the best and brightest military physicians is to look at the long list of those who have left in disgust. When I told my Commanders that I intended to leave the Air Force after 15 years toward retirement, the only response the Air Force Personnel Center gave was: "He's lying. No one leaves after putting in that much time. We have him by the gonads" (or words to that effect). I retorted that this was an excellent way to insure retention of Harvard-educated, board-certified physicians in wartime-critical specialties: impugn their honor and integrity. No one in the chain of command EVER asked me to come to his or her office to reconsider my decision to leave the Air Force as a senior Lieutenant Colonel. When I wrote down a detailed list of my grievances and concerns (similar to this one, but with far more acronyms) at the behest of the hospital Chief Physician (SGH) in November, 2003, nothing ever happened. Poof! It went into the magical black hole of the military circular file reserved for all honest suggestions for process improvement...the same massive singularity that sucks in and destroys the results of the interminable Workplace Climate Surveys sent out (and ignored) year after year. Given this lack of retention of good doctors, who stays in? That's right, the bad and mediocre doctors who could not make it on the outside, because their clinical skills have atrophied to the point of uselessness after years of getting bedsores on their bottoms from doing e-mail, attending meetings, and typing Letters of Reprimand instead of treating patients. After addressing physician retention, do something to encourage retention of highly trained clinical nurses, who are fleeing the military like proverbial intelligent rats who see the murky and deep depths toward which military nursing is headed. Stop making nurses give up direct patient care to "fly desks" in order to make rank. The best medical and surgical care in the world can be undercut and destroyed by a 2nd lieutenant ward nurse who has no idea that we don't routinely stick arterial lines in the patient's chest, rather than wrist; or who ignores hours of critically-low blood pressure or troubled breathing because their ignorant inexperience prevents them from recognizing dire emergencies.

15) There can be no imperialistic Pax Americana. Stop invading countries that do not threaten our core American national security. Democracy cannot be created by force; it must grow from within. Reverse the PNAC-inspired march toward the forging of a global American Empire most U.S. citizens do not want and which we certainly cannot afford, either in blood or treasure. Protect our ally, the state of Israel, without blindly following special-interest prodding for the U.S. to destroy, occupy, and/or neutralize every single Middle Eastern nation that might even theoretically threaten THEIR (not our) homeland. Why have we ignored North Korea and the Taiwan issue, if not because neither place A) has oil or B) directly threatens Israel? Move toward a just and equitable solution for the Palestinian problem. Realize that the best way to undercut rabid Islamist jihadists is to demonstrate with deeds that the U.S. is serious about forging a democratic and secure Palestinian state, even if this means forcing Israel to make uncomfortable concessions in the interest of American homeland security and world peace. Recognize that the suppression of U.S. domestic dissent and insistence upon blind, lockstep loyalty to the President emanating from the corridors of military and civilian power smack of fascism and National Socialism, not conservative, traditional, American democratic (and Republican) values. The corrosive attitude: "My country right or wrong" reflects cowardly stupidity, not patriotism. A true patriot stands up for what is right for the nation, not the ruling elites of political parties or war-profiteering, multinational corporations. Jingoistic military physicians who sign up to support the Imperial States of America at the cost of our Republic will not prove to be the cream of the crop, but rather the bottom of the barrel. This is why a medical draft appears so frighteningly likely to many who see the way the winds of Orwellian eternal warfare are blowing.

16) Practice the Air Force Core Values we preach. Overturn the current practical philosophy of "Integrity Last: Blind (and Silent) Obedience First". Reward military members who demonstrate outspoken "Integrity First" with commendations and promotions, not unjust, career-ending reprimands and cruel reprisals. Recognize that "Service before Self" for military physicians MEANS speaking out as a selfless patient advocate for rational and optimal care, regardless of careerist pressures to shut up and not make waves in the face of a neglected and broken medical care system. Accept that "Excellence in All We Do" cannot possibly happen when an insufficient number of inadequately trained non-physicians are tasked to do the job of the experienced docs who have left the service, been deployed, or who have simply not been recruited due to myopic mismanagement. Do something-anything-to stanch the hemorrhage of competent and experienced clinical physicians who continue to flee the military after up to 19 years of honorable service in support and defense, not of nursing control over doctors; not of compromising medical care in the interest of political expedience; not of the radical, imperialistic, Neocon agenda; but of the Constitution of the United States of America, and the eternal freedoms and values for which it stands.


In Praise of Disruptive Anesthesiologists: Another way to "Support Our Troops"

Update 19 May 06: An extremely redacted version of this editorial was published in the ASA Newsletter here. The ASA Newsletter editor and the ASA's lawyers wanted me to remove all references to poor care in the military, due to fear of government reprisal, it seems...

"The only one who should decide whether a surgery should proceed is the surgeon."

--LtCol (Dr.) Surgeon, to myself and senior LtCol CRNA, David Grant Medical Center, Travis AFB, CA

In response to the Feb 2006 ASA Newsletter article describing "Leadership and Problem Physicians: Managing the Disruptive Physician: The Responsibilities of Leadership" (pp. 23 & 25), as well as to the page 8 reference to U.S. military anesthesiology, I would like to bring the following thoughts to the attention of your readers, and to the ASA leadership.

The medical specialty of anesthesiology is inherently disruptive. This is not to say that we have an inherent tendency lose our tempers and lash out at our colleagues inappropriately. Rather, we are disruptive in the sense of "disruptive technology" (Christensen, Clayton M. [1997]. The Innovator's Dilemma, Harvard Business School Press. ISBN 0875845851; http://en.wikipedia.org/wiki/Disruptive_technology). Unlike the cardiologists, gastroenterologists, and surgeons who require our services, we do not generally (outside of pain management) intervene positively to improve our patient's lives directly. Instead, we disrupt the processes of pain, hypotension, hypoxia, and death that would otherwise afflict our patients during procedures in our absence. When we, at the last minute, identify patients who are not ready to survive a procedure due to inadequate medical workup, we disrupt the operating room schedule and the surgeon's income (or sense of authority in the military, as will be addressed later). When we determine that a patient with severe sleep apnea needs to be admitted overnight after general anesthesia for respiratory monitoring, we disrupt the patient's plans for "in and out" surgery. When children are air-evaced from Guam for completely elective surgery under GETA and develop a severe URI en route, our discussion of perioperative anesthesia risk with the parents is seen as "poisoning the waters" (Major [Dr.] Pediatric Surgeon, 1996), rather than as an attempt to treat our patients as we would have our own children treated. Every single day, anesthesiologists around the world are subjected to verbal abuse, complaints to administration, and, in the case of the military, career-ending reprimands for doing our jobs as we understand them: to act as perioperative physician consultants whose key role is to ensure optimal patient care during the totality of the patient's perioperative experience-preop, intraop, and, yes, postop.

Sadly, in my 15 years as a military physician, I found that our treasured role as perioperative physicians co-equal to surgeons in importance to our patient's life was seen by every single high-ranking (O-6 and above) administrator, including one board-certified anesthesiologist hospital Vice Commander, as incompatible with good military order and discipline. In the civilian world, the fear of lawsuits somewhat (somewhat) modulates the surgical tendency to force anesthesiologists to commit malpractice in order to "just get the case done". In the U.S. military, the lack of fear of malpractice lawsuits due to the Feres Doctrine; the QA process that shields military physicians from the National Practitioner Data Bank; and the graciousness of military retirees and dependents; allows surgeons to push anesthesiologists to live beyond the edge of safe practice because they say so. This has led to a bizarre dynamic in which discussions of possibly canceling anesthetics (I never cancel surgery) due to inadequate patient preparation or hospital inadquacies routinely devolve into power struggles characterized by aggressive, alpha-male, primate dominance displays, during which "pulling rank" and airstrikes from non-clinical, e-mail-decubitus-suffering administrators trump all notions of appropriate, scientific, and humane anesthesia care. In every single U.S. military medical organization, anesthesiologists are lumped into Surgical Operations Squadrons (or their equivalents in the Navy and Army), where their necks are placed under the military command boot heels of surgeons, who exercise nearly unfettered life-and-death power over their subordinates' careers through the line-oriented military (in)justice system (UCMJ). Fear and reprisals are routinely used as bludgeons to silence all attempts by military anesthesiologists to increase their scope of responsibility from that of gas-passing, intraoperative technicians whose only military duty is to shut up and follow orders, regardless of patient safety.

Why, you may ask, don't military surgeons fear malpractice lawsuits, and thus listen to anesthesiologists' cautionary medical opinions intended to promote patient survival? Three reasons:

1) The Feres Doctrine (U.S. Supreme Court, FERES v. UNITED STATES, 340 U.S. 135 [1950]) , which bars all lawsuits by active duty troops against the government for injuries or death during their time of service, even in cases of clear malfeasance by commanders or military physicians. Derivative suits by spouses and dependents (for loss of consortium, etc.) are likewise forbidden. Many retirees are under the false impression that this doctrine applies to them, as well.

2) The military Quality of Care review process, which acts as a buffer between the military physician and the National Practitioner Data Bank (https://www.npdb.hrsa.gov/ ). If a military physician is sued for malpractice by a dependent or retiree, but the standard of care is found to have been met after review by senior physicians in and out of his/her specialty, the physician is not reported to the Data Bank, even if the government settles. Sweet. As one of the most senior anesthesiologists in the U.S. military, I was called upon to review several such cases, including one involving a former attending. There is great pressure to uphold the medical omerta (Code of Silence) by finding that your colleagues met the standard of care, even when such is obviously not the case.

3) The inherent gratitude and graciousness of our retirees, veterans, and dependents, who, in these times of BRAC closures of Military Treatment Facilities (MTFs), TRI(to get)CARE civilian outsourcing woes, and asymptotically decreasing staffing and funding of MTFs, are giddy just to receive ANY treatment at a military facility, where they feel as though they are part of the military family once again. You really don't want to sue your family, now do you?

As a result of the above, the rate of malpractice lawsuits against the military is approximately half that of the civilian world (http://www.afip.org/Departments/legalmed/openfile99/graville's%20article.pdf). I dare anyone to claim, in 2006 (or 2024!--RCJ), that this is because the military provides better care with better access and more qualified personnel than the outside, because the truth is the opposite. Bamboozling JCAHO is the one growth industry in military health care.

Moreover, as the wars in Iraq and Afghanistan continue, and as the U.S attack on Iran looms, the ASA should recognize that fewer and fewer anesthesiologists are caring for our brave troops. The retention rate for anesthesiologists in the military is rapidly approaching 0.0%. The highly-educated young anesthesiologists who come onto active duty are uniformly shocked to find that the civilian paradigm of physician control of medical care is upended in the military. They are more likely to be commanded by a CRNA, an operating room nurse, or a pharmacist, than they are to be commanded by an anesthesiologist. Although they serve their country with honor during their four to seven years of military commitment, every single competent clinical anesthesiologist I knew became rapidly disillusioned and depressed by the disempowerment of anesthesiologists in the U.S. military, at the expense of empowerment of CRNAs, nurses, PAs, pharmacists, and other non-physicians. Virtually no anesthesiologist stays in to make the only rank respected by the command hierarchy (full-bird Colonel or Captain [O-6]); those second-rate doctors who do stay in to achieve that rank lack the courage to risk their careers and pensions by speaking out against the dangerous status quo. After all, they know what happened to me-- two Letters of Reprimand for inconveniently trying to save patient's lives in a non-politically-correct fashion. Despite multiple Sentinel Events and the lessons learned during several civil wars between military CRNAs and anesthesiologists, independent practice of CRNAs is now the de facto standard in the military, even at major medical centers with assigned anesthesiologists, and even in states where such practice outside the base gates would be illegal. Anesthesiologists have been ordered to act only as "consultants" to the CRNAs when the CRNAs ask for such consultation, which leaves anesthesiologists sitting in their offices surfing the web until a patient codes, and "pencil whipping" charts to provide a fig leaf to JCAHO that anesthesia care involves anesthesiologist oversight. I know of at least one young, active duty patient who has died as a direct result of this wrongheaded policy; many more will follow in the coming years, if the U.S. military's insane neutralization of "disruptive" anesthesiologists is not reversed.

As a result of the repeated verbal harassment, unsafe policies, and unjust reprisals I suffered during my years as a senior Air Force anesthesiologist for speaking such disruptive truths to power, on 30 June 2005 I tendered my resignation as a Regular Air Force Lieutenant Colonel with 19 years of honorable active duty service to my country (15 toward retirement). Although I forfeited all retirement pay and benefits, I kept my honor intact. During my new incarnation as a civilian anesthesiologist in private practice, despite longer working hours and fewer Federal holidays, I have prospered. The CRNAs employed by my group uniformly appreciate the honest respect and collegial friendship I give them as critical and valued members of the anesthesia care TEAM. The PA who assists us in perioperative evaluation and treatment knows I deeply value his wisdom and vital contributions to our mission. The surgeons with whom I work have come to recognize my inherent conservatism with regard to medical care of my patients as an asset that protects their patients' lives and the surgeons' interests, rather than as a liability. I have never had an administrator, ever, tell me how to practice my specialty. I hope to continue to act as a "disruptive physician" in the interest of both patient safety and rational practice of my beloved specialty, so long as my "disruption" involves saving lives and increasing the critical role of anesthesiologists as perioperative physicians.

SIGNED

Robert C. Jones, M.D.
Ex-LtCol, USAF, Medical Corps
Ex-Medical Director of Anesthesia, Travis AFB, CA
Ex-Assistant Chief Anesthesiologist, Andrews AFB, MD
Diplomate, ABA (1995)
Harvard '85, USU '90, Wilford Hall USAFMC residency 1994

Nemo Me Impune Lacessit.


To the Editor, ASA Newsletter, in response to the March, 2006 issue on Military Anesthesiology:

(never printed, of course)

I am appalled that the ASA allowed the USSA (Uniformed Services Society of Anesthesiologists) to present its propaganda in the ASA Newsletter without providing any balance or perspective regarding the key role the U.S. military has played in destroying the proud profession of military anesthesiology. As a former USAF Lieutenant Colonel anesthesiologist who resigned my commission after 19 years on active duty in part to protest this situation, I would ask that the ASA present the following facts for discussion:

1) FACT: The Air Force Objective Medical Group (OMG) made command billets "Corps Neutral". In other words, nurses were placed in command of doctors, and CRNAs were placed in command of anesthesiologists.

2) FACT: The OMG reorganization placed anesthesiologists under the direct command of surgeons. Anesthesiologists who speak out for patient safety and/or promote the concept of perioperative physician jeopardize their careers (I have two Letters of Reprimand to prove it).

3) FACT: The U.S. military has championed CRNA independent practice. For years, CRNAs have practiced completely independently at many small bases and overseas. They are supposed to call anesthesiologists to "consult" on ASA III+ patients or children under 2 years old. However, Air Force Instruction 44-119 guarantees CRNAs autonomy in all other cases (see: http://www.e-publishing.af.mil/pubfiles/af/44/afi44-119/afi44-119.pdf).

4) FACT: DoD has systematically destroyed military anesthesiology Graduate Medical Education (GME). In 1997, the number of USAF residency slots was slashed from 10 to 3. Surprisingly, 4 years later, in 2001, there were only 2 clinical anesthesiologists at Andrews AFB (down from 10 two years prior). In order to maintain ORs and surgeons' productivity, anesthesiologists were forced to provide direct care to patients while "supervising" CRNAs.

Our brave troops, their dependents, and honored military retirees are poorly served by a Military "Health Care" System which has systematically promoted CRNAs and surgeons over both anesthesiologists and patient safety.

SIGNED

Rob Jones, M.D.
Ex-LtCol, USAF, MC