VADM Harold Koenig USN (Ret) wrote:
“On February 16, 2004, I received the following note from an Air Force resident physician. I have omitted his name to preserve his anonymity. I am circulating his email and my reply widely amongst my friends in and retired from the military, as well as key civilians, because I see a huge communication problem here. Perhaps my reply to this young physician may help you help someone you know who's struggling with PBD 712 to better understand the larger process that is continuing:”

Dear Dr. Koenig,

I enjoy reading your articles about the future of military medicine. As an active duty resident physician in the Air Force, I appreciate the few tidbits of information I can get regarding the direction that military medicine is heading in this time of military medicine reshaping.

I have a specific question for you about a policy that I read in the military medicine discussion forum at Studentdoctor.net called “Program Budget Decision 712”. According to an anonymous active duty military physician in the forum, this policy is geared to aggressively replace military physicians with civilian physicians in those fields of medicine that are not directly involved with combat medical care. The policy is supposedly set to be implemented in 2005.

I know that the military has gradually and quietly been downsizing the medical corps for some time now, but this policy, if true, sounds like it will be much more definitive in reshaping the future of military medicine and would have huge implications for GME, dependent care and health care for retirees. Please let me know if you have heard of this policy and where I can get more information about it.

By the way, if you are not familiar with the studentdoctor.net website, there is a good forum that is specifically set up to discuss military medical issues. It is an interesting forum because it gives insight into the thinking of medical students considering a career in the military as well as current perspectives from resident and staff physicians. You may find some of the comments interesting, given your recent article on the declining applicant pool for HPSP and USUHS slots.

Thank you.


Here is the reply I sent:

Dear Steven,

Thank you for your email asking about PBD 712 and mentioning my article in the November issue of U.S. Medicine about declining interest in USUHS and HPSP. That was the last column I will write for U.S. Medicine. After five years of writing for them I have decided it is time to pursue other interests.

I am going to try and give you some insight into PBD 712, at least from my perspective. You have my permission to post it to the studentdoctor.net website.

I have only seen the impact PBD 712 will have on the Navy Medical Department, not the Army or Air Force. I suspect the impacts are similar. For the Navy Medical Corps the impact falls disproportionately on the primary care specialties, Pediatrics, Family Practice and Internal Medicine. There are impacts also on the Nurse Corps, Medical Service Corps and Dental Corps.

These cuts are no surprise to me. The U.S. Armed Forces began a drawdown as we saw the Cold War coming to an end. In 1988, two years before the Berlin Wall fell, the United States had its first round of Base Realignment And Closure (BRAC) followed by additional rounds in 1991, 1993 and 1995. The purpose of BRAC was to get rid of infrastructure (bases) that was no longer needed. This was a very controversial political process and the only way it could be accomplished was to “de-politicize” it by setting up an independent commission that would put together a list of bases to close and then submit it to Congress and the President who could only vote yea or nay on it. They could not make changes.

A lot of excess infrastructure was removed from the DOD inventory, communities suffered, but most recovered, got access to the land and are now better off economically than they were before. A few localities have not yet benefited because of local politics. There is another round of BRAC authorized for this year with the final decisions due in May of next year.

Coincident with the BRAC process, there was a need to downsize the force. That means get rid of people, not just in uniform, but civilians as well. That is as tough as getting rid of bases because good people lose their jobs. From the time of the first BRAC until the last, the number of people in uniform dropped from over 2.1 million down to about 1.4 million, a one-third reduction in manpower. Similarly proportional cuts were made in the number of civilian jobs in the Department of Defense.

The medical departments were not spared in this process. Hospitals and clinics that were on bases that closed were also closed. Along with their closure went proportional reductions in medical department end strengths, both uniformed and civilian. All of this caused a lot of anxiety among health care providers and their patients but most of the rest of the nation was pleased with the process because the nation was able to reap a “Peace Dividend.”

The drawdown was not proportional everywhere. Some states saw no bases closed, some saw a lot and suffered economically. But the biggest hits came overseas. Before the drawdown began and in fact up through 1991, we had over 300,000 men and women in uniform in Germany alone. We had eleven hospitals in Germany and a whole lot of clinics. Now we are down to about three hospitals and less than 100,000 uniformed people in Germany. Many of those people rotated back to the USA, but their positions went away. By the way, this process was economically brutal for the German people living in the communities with large U.S. bases that closed.

Now the United States is re-assessing its need for overseas bases again. It looks like we may see a near total pull out of U.S. Forces north of the Alps in Europe. This is not out of pique over recent disagreements over Iraq. This is because after over a half-century of presence we really are not needed there any more. If we aren't needed we shouldn't stay. Imagine how you would feel if there were foreign soldiers based in your community?

Some, but not all of these forces may be moved to other countries in the region that have emerged out of the former Soviet Union. Some of these countries need the protection and stability that the presence of U.S. Forces will provide. Again, we should remain there only as long as we are needed.

We are also looking at possible force reductions or at least relocations in the Far East. This again is because at least some countries in these areas have become more stable and self-sufficient. We should look at all of this as a victory to be celebrated, not a failure to be mourned. Of course, some people will suffer unintended consequences. They may lose their jobs and others may lose convenient access to health care and other services provided on military bases.

While re-assessing our need for overseas bases, we also need to look at our need for bases here at home. That is what the current round of BRAC will do. Along with that will come a need to somewhat proportionally reduce manpower. There is another factor at play here though that needs to be understood. As the force is reduced in size, there is a need to maintain as much of the fighting strength as possible. The military refers to this as “Tooth to Tail ratio.” I am sure you understand the meaning of that.

There are a lot of jobs in the military that can be done by people not in uniform. If those jobs are “civilianized” the “Tooth to Tail ratio” will improve. That is what PBD 712 is all about.

As PBD 712 plays out, keep all of this in mind. This is not about discrimination against certain medical specialties, or nurses, dentists, doctors, patients or any of the other myriad professional areas that can be “civilianized.” It is about maintaining America's military strength in the most efficient and effective way possible.

We are much more fortunate today than we were when all of this drawdown process began back in the late 1980's. Today we have Tricare in place. Then all we had was the old CHAMPUS benefit and Medicare for those over 65 who lost access to military medical facilities. That is an improvement that only those of us who were around then can appreciate.

Tricare just doesn't benefit patients. It also benefits health care providers who prefer to practice in the military environment, even if they have to do so out of uniform. Military medicine will continue to need pediatricians, family practitioners, internists and so on to provide care in its hospitals and clinics. Tricare allows for that with the resource sharing provisions in the contracts.

And finally, don't forget the reserves. There is an on going and perhaps increasing need for health care providers in the reserves, especially the Army Guard and Reserve.

In summary, I see PBD 712 not as bad news but as part of a long on-going effort to “right-size” our military forces and preserve its strength at the lowest cost possible. That is as it should be. There remains an important role for all of you to play in this.