Military medical service no longer has MD at helm

Barbara Sibbald

CMAJ 2000;162:561

The military is also going to start relying heavily on civilian physicians and clinic managers to provide care for its 60 000 personnel. This isn't surprising: the CFMS is supposed to have 2089 personnel, but hundreds of positions are unfilled and it is considered stretched too thin to provide adequate care, particularly in light of well-publicized recruitment problems and heavy overseas deployments.¹

Defence Minister Art Eggleton hopes the moves will breathe life into a system that is "broke . . . and [in need of] fixing." He is backed by a 124-page review document in which personnel complained about the quality of military health care and physicians sounded off about serious morale problems.

"We found very, very dedicated people on the verge of burnout," said Brigadier-General Lise Mathieu, who was appointed the first director general health services in January. A surgeon general will be named later; Surgeon General Claude Auger was fired in December after only a year in the post.

Mathieu must now implement the changes outlined in the review, but she likely won't have any extra money to do it. Eggleton wouldn't say how much the new plan will cost, but he did say that the forces' existing $200-million health budget will be spent more effectively.

The proposals come too late for Lieutenant (N) Ron Goldstein, a 36-year-old physician at CFB Petawawa, Ont., who is returning to civvy street in July, primarily because of the time he must spend away from his young family.

"If this had happened a year or two ago, it would have affected my decision to leave," he said. "Overall I'm very positive about their plans. But we need money . . . all the [military] branches are underfunded." (Military funding has been cut by 23% since 1993.)

Goldstein's major criticism involves the lack of effort in recruiting and retaining doctors. The military has been battling physician-supply problems for the past 20 years. In the early '80s, it responded by hiring some Irish and English doctors; South Africans have also been hired. Eggleton didn't rule out further overseas hiring as the shortage reaches "critical levels." Within 2 years, only 43 of the armed forces' 151 clinical positions at the unit level may be filled. Reasons for leaving range from "deployment fatigue" to limited opportunities for specialty training and inconsistent CME opportunities.

The review also pointed to severe morale problems, with 63% of physician respondents saying that they found work in the military frustrating. In addition, 80% of medical staff felt the military didn't adequately consider their career needs and 71% felt it offered limited career opportunities.

Most medical officers also confront unique ethical issues, with 85% reporting that, within the past year, someone of higher rank had taken action affecting a patient that wasn't in accordance with the doctor's recommendations. This was particularly true when they tried to move personnel off duty for medical reasons; 57% of medical officers felt their recommendations were not respected by superiors. This was confirmed by commanding officers, 71% of whom said they had to overrule doctors in matters relating to patient care if they were to meet operational needs.

Meanwhile, patient satisfaction is low. Only 44% of focus-group participants agreed or strongly agreed that the CFMS met their health care expectations. Continuity of care was identified as a key problem, because soldiers and medical staff are continually being moved. The plan calls for base clinics staffed by a full-time complement of civilian doctors, with military staff providing support when available. Clinic management will also be contracted out to civilians, and each clinic will be surveyed to ensure that it meets national standards.

Goldstein wonders where these civilian physicians will be found, particularly at remote bases. He also wonders how civilian doctors will cope with military medicine's special requirements, and speculates that an increase in the number of civilian doctors may actually worsen the physician shortage. "Your contract ends and you can be back the next week wearing a tie and doing the same job for more money and fewer hours," says Goldstein. "It's already happening on some bases." The civilian physicians earn $500 to $600 a day; DND physician salaries range between $82 000 and $92 000 annually, but rise substantially for those who stay longer than 4 years. Military doctors also receive subsidization worth more than $30 000 a year while in medical school.

The full text of the Review of Canadian Forces Medical Services is available at www.dnd.ca/hr/medservices.

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1. Sullivan P. Military set to offer large signing bonuses, higher pay in face of unprecedented MD staffing crisis. CMAJ 1999;160(6):889-91.

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