Note:  I have met Gen. Carlton in person (1994 while on call as an 
anesthesiology resident; and 2000 during his visit to Travis AFB); 
he is a very charismatic person and, in my experience, an excellent surgeon. 
I have great respect for him as a physician and USAF officer. 
My objections have to do with the policies he pursued (or failed to overturn) 
as USAF SG, and are not intended as an ad hominem attack on his person.



General (Redacted): 

Thank you again for e-mailing me.  I appreciate your giving me permission to
quote your perceptive feedback on my website.

Just to recapitulate, the primary objections I have to LtGen. P.K. Carlton's
actions while USAF SG are the following:

1) He personally stated in my presence during a Commander's Call at
David Grant Medical Center, Travis AFB, CA, that his daughter
was an ADN, and that she was just as good as any RN in the audience.
He shared his "vision" of replacing expensive, college-educated RNs
with inexpensive, enlisted, high-school-educated ADNs.

2) At the same meeting, he questioned the need for expensive
anesthesiologists (such as myself), when nurse anesthetists can do
just as good a job for less money.

3) He did not reverse the tragically boneheaded Objective Medical
Group policy, which, from Oct 1997 onward (OMG II), eviscerated
military medicine by placing nurses, pharmacists, and other
non-physicians in command of doctors.  The OMG's "Vision" was that
MDs were just like pilots, while nurses were just like navigators.  This
blind, line-side attitude completely denigrates military PHYSICIAN
leadership of what used to be called military medicine (but which is
now called "Military Healthcare", in order to empower the nurses,
PAs, optometrists, and others who have been put in command of
military docs).  In  July 2000, under Gen. Carlton's watch, BG
Barbara Brannon, RN,  was selected as commander of Malcolm Grow
Medical Center, Andrews AFB, MD.  Col. James H. Young, a pharmacist,
was made commander of the West Coast's only USAF Medical Center
(David Grant, as you know).  At David Grant, as part of a rank power play,
the optometrist commander booted the physician ophthalmologists out
of the 1st floor clinic they had shared with the optometrists since the 
hospital opened ca. 1988; as of 2000, the poor, sight-impaired patients who needed 
cataract surgery started wandering the halls of the hospital peering around for the new 
ophthalmology clinic, which had been stuck on the third floor of the inpatient wing
on the opposite side of the hospital from the new Optometry Clinic.  Yet,
bizarrely, the ranking Col. ophthalmologist allowed this to happen without
much of a fight (as far as I know); she later came out to Andrews to
take over as my Squadron Commander: a retinal surgeon tied to a desk
job.  Sad.  [Addendum: During Gen. Carlton's time as USAF SG, CRNAs
were granted completely independent practice at Travis AFB...a dangerous
policy that directly resulted in the death of a young airman in 2003.
I had spent from Jan 1999 to my departure from Travis in July 2000 fighting
against this policy; as a result, I was fired as "Medical Director of
Anesthesia" (under the command of a CRNA Element Leader) for my vocal
advocacy of Medical (rather than nursing) Direction of Anesthesia.  Gen.
Carlton evidently approved of this independent practice policy; it meshed
completely with the "vision" he promulgated in my presence in the 
David Grant Medical Center auditorium (see above).]

4) During his tenure as USAF SG, our honored military retirees continued
to be turned away from MTFs.  It was not until April 2001 (after my wife
left the service as a senior Major in disgust) that pharmacies were 
re-opened to those retirees over age 65.  By that time, so many military pharmacies 
had been shuttered (Mather, for example), that it didn't make any practical
difference to retirees who suddenly found they had to drive 100 miles or
more to get a prescription filled on base, rather than at a civilian 
pharmacy (with its attendant, and ever-increasing, co-pay requirement).

5) General Carlton continued the disastrous policies of his predecessor,
Gen Roadman, with regard to "force tailoring", i.e., slashing military
Graduate Medical Education (GME) residency slots, gutting MD
staffing vs. cheaper "physician extenders" (PAs, NPs, CRNAs), and
downsizing or closing MTFs across the world.

To quote this web page:

http://www.milbank.org/reports/2001ValuePurchasers/011001valuepurchasers.html

"Roadman believed that prevention and maintenance were the keys to cost 
control, and he was willing to take a long-term view. He created a goal structure for the 
AFMS,with customer satisfaction as the capstone, supported by four strategic 
pillars: readiness, deployment of TRICARE, force tailoring, and building healthy
communities. When General P.K. Carlton took over the Air Force Medical
Operation Agency command, he essentially kept that goal structure intact."

The problem is that TRICARE has been so broken since its inception, and
the both the number and quality of military physicians have declined so precipitously, 
that customer satisfaction, the "capstone" of their PowerPoint slide Vision, was
(and is) impossible to achieve. [Addendum: Doing more with less until we
do everything with nothing is not a recipe for "Excellence in All We Do", but
rather mediocrity and patient endangerment.  Happily, the fewer TRICARE
beneficiaries that survive to old age, the less the government has to pay
for their medical care, so slipshod medical care is a WIN-WIN situation
from the perspective of penny-pinching bureaucrats...especially given the
Feres Doctrine and other policy limitations on malpractice suits against military
healthcare "providers".]

Again, I don't want to minimize the importance of TRICARE for Life, or
LtGen Carlton's contributions to that cause.  However, as a former
military physician "in the trenches", my experience was that Gen.
Carlton continued and accelerated the trend toward neutralization
of physician leadership of military medicine by pell-mell outsourcing
to civilians outside of the chain of command; and by ill-considered
empowerment of less-trained, less-educated, less-capable non-physicians
over physicians, in an effort to save, not patients' lives, but rather, as
you put it, Sir, money, money, money.

                       Sincerely,

                                Rob 

P.S.  I was at DGMC from August 1994 (straight out of WHMC
residency) to July 2000.  The reason I was able to stay so long was
because I have two handicapped (autistic) children; the USAF was
unable to find many assignments for me which would enable my
EFMP kids to get appropriate treatment.  This did not stop AFPC
from trying to send me to Elmendorf for 3 years unaccompanied on
an accompanied billet as retaliation for my speaking out at Travis
for patient safety.

P.P.S. As far as checking my 6, well, my 6 is just going to
have to take care of itself.  My former Col. Flight Commander used
to tell me that the Air Force's policy on 360 degree review of commanders
could be boiled down to the phrase: "Check your own 6 instead".
I wish more of our leaders were paying attention to 12 (the way
forward, with boldness and integrity) rather than their own 6s.
Sigh.  Perhaps I am still too young and idealistic at age 42.


----- Original Message ----- 
From: (redacted)
To: "Rob Jones, M.D." 
Sent: Monday, June 19, 2006 1:26 AM
Subject: Re: A Memorial To Military Medicine


> On Sun, 18 Jun 2006 21:09:30 -0400, you wrote:
>
>> I respectfully request permission to excerpt your comments
>>(anonymously, if you wish) on my "Responses" page.  Thank you,
>>again, General, for your feedback.  Your positive take on my thoughts
>>makes my effort worthwhile.
> Rob
> Go right ahead
> I do take exception to your thoughts on PK.
> This is not done in a critical way. Be back at you later
> When were you at DGMC
> chk6
(redacted)