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Divided by duty: While a doctor serves the country, the practice must still serve patients

When a physician is called to war, the emotional and financial toll can ripple throughout the practice.

By Karen Caffarini — Posted Oct. 20, 2008

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Two days after Hurricane Gustav stormed through Louisiana, Col. Stephen Ulrich, MD, was at a National Guard base in Columbus, Ohio, wearing camouflage and flooded with paperwork. As the state surgeon for the Ohio guard, he got a call-up to review the medical records of 1,500 soldiers who would be helping with relief duties.

Meanwhile, about 55 miles east, the five other physicians in Dr. Ulrich's family practice were trying to conduct business as usual in their Zanesville and New Lexington, Ohio, offices. But first there was some scrambling to make sure Dr. Ulrich's patients were seen.

That wasn't a new challenge for this practice. Dr. Ulrich has been called away twice before -- once for three months, once for six. He served as a flight surgeon in Balad, Iraq, flying with aircraft crews, doing clinical work and flight physicals, and being "just a regular doctor."

Tours of duty can take a toll, not just on doctors going to the war zone but also on those left behind. Both groups must work together to adequately plan for the absence and notify insurers, affiliated hospitals and others.

The emotional stress also extends to both groups. "You listen to the news and just pray he's not in danger. We say a lot of prayers around here when he's gone," said Melody Field, a nurse practitioner for Dr. Ulrich.

This time, Dr. Ulrich spent only a few days in Columbus. As the soldiers left for Louisiana, he was back in his office.

When the National Guard calls a physician to duty in the Middle East, it provides several months' notice to allow for working out a plan for the practice, contacting patients and making arrangements, said Maj. Randall Short, a Guard spokesman.

Col. Joan Sullivan, MD, one of eight physicians in an obstetrics-gynecology practice in Ithaca, N.Y., is part of the New York Army National Guard's Medical Support Company. Dr. Sullivan is on a one-year tour in Afghanistan as brigade surgeon, and was previously in Iraq as a ranking officer, according to Guardsman Lt. Col. Eric Durr.

Dr. Sullivan, calling AMNews from Afghanistan, said that as soon as she learned of her pending deployment, she informed her partners, staff and patients. She said all were supportive, and no problems have arisen.

This is because the practice has figured out what steps are needed, said nurse practitioner Lorene Jump, who works with Dr. Sullivan in Ithaca. One key step is being supportive before, during and after deployment. "They will be the ones coming home to changes, not us," she said.

The practice aims to contact Dr. Sullivan weekly, Jump said. "Dr. Sullivan has been gone quite a bit during the last seven years, but there wasn't one time it couldn't be handled. We saw more patients, but no one was hurt by it."

Before his two tours, Dr. Ulrich sat down with Shelly Dunmyer, MD, another family medicine physician in his Zanesville practice, and worked out a plan. They hired a locum tenens physician to see patients in the office and divided Dr. Ulrich's on-call duties between the other physicians in their group. Dr. Ulrich took a leave of absence from hospital duties, naming Dr. Dunmyer as his backup. She also took his place on hospital committees.

Dr. Ulrich told his patients he would be gone and let them know the measures he took to make sure their medical needs would be met. After deployment, he wrote a series of articles for the local newspaper. "It was like he wrote each patient a personal letter," Dr. Dunmyer said. "The patients would ask us, 'Did you see that latest article?' "

Dr. Ulrich used e-mail to keep in contact with his practice. This offered Dr. Dunmyer a way to ask questions about patients and also assured colleagues of Dr. Ulrich's safety. "You don't just dial 1-800-IRAQ," Dr. Dunmyer said.

Even though Dr. Dunmyer knew when she was hired eight years ago that Dr. Ulrich was a Guardsman, at that time deployment was an abstract concept. "I absolutely did not think there would be a war and he would be called to fight in it. Not until after 9/11. Then it was clear to me. The writing was on the wall," she said.

Dr. Ulrich didn't hesitate. "I was determined not to let my Ohio people go to war and not be there with them."

Dr. Sullivan said that when she joined her practice in 1991, neither she nor her colleagues thought she would be called to war -- twice. "Anyone in the military has an opportunity to get an invitation to the dance. I got two invitations this time."

Will the practice survive?

Many deployed physicians sustain financial hardships during their time overseas. Some lose patients and some have lost their practices. Many physicians also lose their office-based health insurance coverage.

The National Guard has started offering Tricare insurance to members all the time, not just during deployments, said Terri Ulrich, Dr. Ulrich's wife and practice manager.

While the Guard pays its physicians on deployment, neither Dr. Ulrich nor Dr. Sullivan draw pay from their practices. But Dr. Ulrich's office pays for his professional liability insurance while he's gone, as well for the locum tenens's.

Physicians who are being deployed are not obligated to inform their state medical boards, but they are responsible for arranging for the continuing care of their patients and assuring access to their patients' records, said Joan Wehrle, executive staff coordinator of the State Medical Board of Ohio.

Physicians also are required to keep up with their continuing medical education hours, although Terri Ulrich said CME requirements can be suspended if a deployed physician applies for a hardship. Dr. Ulrich tries to get his hours in before leaving.

Other preparation includes contacting hospitals to suspend Dr. Ulrich's privileges and contacting his contracted health plans, most of whom will accept the locum tenens. These parties also must be notified upon his return.

Dr. Ulrich said his deployments have been tough on patients, especially those in the underserved area of New Lexington. "I know I have lost some patients because of my absences. I don't know how many."

Deployment and return dates are subject to several factors, including weather conditions. "The last deployment didn't start until a week later than it was supposed to," Terri Ulrich said. "This is lost time -- you can't work because you can't schedule patients and you can't get paid by the National Guard, either."

The deployments, especially the longer ones, have been trying. "Being gone six months was my choice, but it was very difficult," Dr. Ulrich said. "It took a much longer time to get readjusted to the different way things are done back home.

"When you come back home, your thoughts are preoccupied by the people you left behind. Certain noises cause you to startle. Everything is more pronounced."

Readjusting to private practice also brings challenges. "There are some medications I use here that I hadn't used in awhile. I have to look them up," he said.

Not every deployment ends in the Middle East. Dr. Sullivan was called to New York's ground zero twice after the Sept. 11, 2001, attacks, and both she and Dr. Ulrich have responded to natural disaster relief. While the Guard's needs in those cases are brief, they're also immediate.

Such was Dr. Ulrich's call to Columbus.

With no time for sit-down planning, Dr. Ulrich left e-mails for Dr. Dunmyer, the nurse practitioners and other staff. The receptionists started calling his patients to explain and reschedule. Patients with pressing needs were squeezed in.

Dr. Dunmyer was busy. The waiting room was full, as were the examining rooms.

"I'm proud I'm able to pick up Steve's calls so he can do what he does," she said. "One of the physicians in our call group said he was never in the service, but by taking some of Dr. Ulrich's calls, he feels he is."

Dr. Ulrich knows he could be called again to serve in the Middle East. "At the end of the day, I can say I did my part when my country needed me, although my part was very small."

Dr. Sullivan said her years with the Guard have given her an experience of a lifetime. "If not in the military, I would never have gone to Afghanistan and witnessed history -- an election, females in position of authority and more in school."

It's also presented a different perspective of practice, she said. "Here [in Afghanistan] you need to trust the person you're working with. You know that person would lay down their life for you. You don't see that every day."

Still, after 31 years, Dr. Sullivan plans to retire from the Guard after returning home in early 2009. "It's been a great ride, but I believe it's time for other people to pitch in."

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ADDITIONAL INFORMATION

Physicians in the Guard

The National Guard is authorized to recruit a certain number of physicians in both the Army and Air Force divisions but has fallen short in both areas. The Guard hopes to bridge this gap with financial incentives for medical student members.

Physicians in Army: 753 authorized with 481 in service (64%)

Physicians in Air Force: 752 authorized with 420 in service (56%)

Times most physicians have been deployed since 2001: 3 or 4

Percentage of in-service doctors in deployment at any time: less than 10%

Length of deployments: 120 days total, 90 days in Iraq or Afghanistan, two weeks' training beforehand and two weeks spent at camp when they get back. It can be extended voluntarily.

Time between deployments: 18 months, Army; 30 months, Air. This can be extended if lengths of deployments are increased.

Maximum age at which a retiring physician can be called back: 67.

Source: Maj. Randall Short, media officer, Public Affairs & Strategic Communications, National Guard Bureau

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When a doctor is being deployed

  • Notify the patient population.
  • Identify patients who need to be seen before the physician leaves.
  • Arrange for call coverage and determine if a locum tenens is needed.
  • Suspend hospital privileges and arrange for coverage of committee leadership as well as clinical duties.
  • Contact contracted health plans.
  • Tell yourselves the deployment will not interrupt the practice's level of care.
  • Be supportive of the physician taking the leave.

Sources: Lorene Jump, nurse practitioner for Col. Joan Sullivan, MD; Terri Ulrich, practice manager for Col. Stephen Ulrich, MD

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Making the transition from military to private practice

When David McCarthy, MD, decided to open a family practice after 24 years in the Air Force Medical Corps, he knew there would be significant differences.

He was able to lessen these by basing his new practice on the military model. He chose a location in O'Fallon, Ill., near Scott Air Force Base, so many of his patients would be military retirees. He hired other former military physicians and physician assistants. What he hadn't learned in the military -- marketing and revenue generation -- he studied on his own.

Ten years later, Dr. McCarthy's approach has proven successful and his practice has grown.

"I enjoyed military practice with the Air Force immensely, and I have enjoyed my civilian sector as I set it up. Of course, I cheated. I set it up as much like the military as I could."

Scheduling also follows a military pattern. His practice has been open every day since September 1998, including 8 a.m. to noon on Saturdays and holidays and after church on Sundays. The weekday schedule is 7 a.m. to 6 p.m. "People don't expect a doctor's office to be open on Christmas, but we are," he said.

There are some distinct differences to civilian practice. A need to expand his patient base was one. Dr. McCarthy opted for ads on cable TV.

Licensing was another challenge. As an Air Force physician Dr. McCarthy could practice in any state. As a civilian, "I had a Nebraska license and needed one in Illinois. At the time, it took a very long time to get," Dr. McCarthy said.

Liability -- specifically the cost of professional liability insurance -- was another new worry.

"In the Air Force, I did vasectomies routinely, but if I did them in private practice, it would cost me substantially more in malpractice insurance," he said. "We don't do them."

Dr. McCarthy advises other military physicians wanting to start a private practice to first take a long, hard look at the pros and cons, then consider waiting a few years.

"The value of staying in the military until retirement is very hard to understand. I knew when I retired that I would have a colonel's retirement pay and insurance, which is incredibly valuable. It gave me flexibility with my practice. If I had stayed in another eight or nine years, it would have made life financially better."

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