When Raquel Bono attended medical school on a Health Profession Scholarship, she understood she would “pay back” the scholarship with a stint in the military. She admits, in retrospect, she anticipated putting in her time, then leaving the Navy to pursue a civilian career. It just didn’t happen that way.

“It was my first tour of duty that really convinced me that a career in military medicine was a very viable way of pursuing both a professional and a service objective,” she says.

Today, her title is Rear Adm. Bono, Medical Corps, with the US Navy. She credits what she has accomplished to that initial tour of duty in the first Gulf War.

“I saw that what I was actually participating in was something that was much larger than myself,” Bono says. “It also gave me an opportunity to give back. And that’s when it really hit me that being a part of the military was so much more than just pursuing my professional passion as a physician and a surgeon—but also understanding that I could help advance a much larger mission.”

Bono says that, just as with most residents going through a training program, whether in a civilian or military setting, she did not know what to expect when first deployed. She found herself living in a tent, setting up a field hospital, and preparing to deal with casualties.

“There was this kind of ‘Oh my God, what have I gotten myself into’ experience,” she recalls. “That was a defining moment for me, personally and professionally.”

Returning from the Gulf War, Bono continued to perform her military duties in a naval hospital, where she taught other residents while providing medical care to military beneficiaries. She realized the work she was doing was not only rewarding, it was fun.

Finding herself at a crossroads, she opted to stay in the military “for another 4 or 5 years and see what happens.” What happened was the realization that perhaps she was in the right place.

“I saw that managed care was becoming a part of the healthcare picture,” Bono recalls. “And I realized that our military system was very much like the managed care system. We had a captive infrastructure, a captive patient population, providers, and we defined the benefit. I felt that my background in the military would prepare me for all the changes I saw happening in managed care.”

In addition, doors to new opportunities continued to open. Bono began taking on leadership and decision-making roles in ways her colleagues on the civilian level were not. She realized she had an opportunity to bring positive change to healthcare—not just in the military, but also on a national stage.

By the time she looked up and caught her breath, she had built a career in military medicine.

“I chose the medical profession because a part of my value system is being able to help take care of others who are in need; and being able to offer them health and well-being, or relief from suffering,” Bono says. “And for me, as a physician, being able to do that on a much wider basis to not only the men and women of the military, but then also to the overall effort of our country, that’s a very rewarding aspect for me.”

Capt. Glen Crawford, Medical Corps, US Navy, graduated from McGill University in Montreal, Quebec, with a BA in Canadian and French-Canadian Studies in 1988. He’s come a long way since then.

He was in Washington, DC, during the attacks on 9/11, assisting families that had been affected, and led a team of 60 Army and Navy reservists and civilian personnel in tracking all wounded US and Coalition forces transitioning through Landstuhl Regional Medical Center in Germany following Operations Iraqi Freedom and Enduring Freedom.

“Those opportunities make wearing a uniform and serving our sailors, soldiers, and airmen a very rewarding and fulfilling experience,” Crawford says.

Today, in addition to his military rank, Crawford is an assistant professor of psychiatry at the Uniformed Services University of the Health Sciences. He talks about the difference between helping members of the military recover not just from physical injuries, but emotional ones, as well.

“The [emotional] wound is not obvious to the human eye, at least not in the same way that a laceration, or a broken limb, or some other injury like that would be,” Crawford explains. “They’re often described as the invisible wounds of war. But military mental health has been very successful in returning service members to duty. Returning people to a level of functioning they had previously, not only as members of the military, but also with their families, with their coworkers, again, is very rewarding.”

Crawford has relocated frequently during his military tenure, living in Italy, Japan, Germany, and Guam. He says everyone has his or her own idea of adventurism, and he was excited to experience different cultures. In Italy, he lived in downtown Naples in an apartment owned by a local family that adopted him during his stay.

“I got to live like a Neapolitan,” he says. “I got to interact with people and learn a bit of the language. It made for a richer experience.”

And while he has experienced a wide range of emotions during his medical and military careers, he has taken the positives out of every experience.

“It’s certainly compelling when someone has been severely injured as a result of their service,” Crawford explains. “Not everyone who came through Landstuhl was injured to a severe extent. But the ability to be part of getting them where they need to go, getting them home, was emotional in a very positive and very rewarding sense.”

The military bug bit Lt. Cmdr. Eric Deussing, MC (FS), US Navy, a supervisory public health emergency officer, when he was still an adolescent.

Forbidden by his parents from watching the Tom Cruise film 

, because he was too young, he watched it on the sly at a friend’s house. From that point on he was convinced that he wanted to be in the Navy.

Armed with that determination, Deussing, at the age of 12, mailed a business reply card that he tore from a magazine to Naval Recruiting stating he wanted to join. The letter he received from a Navy captain in return, accompanied by a poster, encouraged him to “look into the Naval Academy or ROTC when he got to high school.”

Deussing began examining different scholarship programs, and eventually took a Navy ROTC scholarship to Tulane University. He was determined to become a naval flight officer, and added medicine to the equation while doing his undergraduate work. His dream came true when he graduated from the Naval Aerospace Medical Institute’s flight surgery program in Pensacola, FL.

“Navy flight surgery is probably one of the best jobs in the world,” Deussing says. “The navy flight program is really unique in that you actually get to do the same course work that the pilots and naval flight officers go through.”

While he spent 2 months in a classroom learning aerospace medicine—primary care relating to G-forces, altitude, and decreased oxygen&mdash;the rest of the time was spent with flight students learning aerodynamics, navigation, engine systems, and going out and flying the airplane.

“It’s really an amazing experience,” he says. “And you might think it sounds like an adventure vacation experience, but it’s really to prepare doctors who are then going to go out and take care of these squadrons. We understand the physical challenges that come with flight, because we’ve flown the airplane.”

Deussing says the most rewarding aspect of his career is the relationships he formed within the naval flight community. It’s a unique role, he says, to be the physician, but also a peer to members of the squadron.

“It’s one of those unique opportunities that you just can’t do at Duke or (Johns) Hopkins if you were a staff doctor there,” Deussing says. “You can do a lot of great things, but you’re not going to be a navy flight surgeon.”

By her own admission, Capt. Mae Pouget was a preacher’s kid and a Navy brat, but had no intention of signing up. Her father, Thomas Parham, became the second black chaplain in the US Navy in 1944, and, 22 years later, the first black officer to attain the rank of captain. But Pouget actually turned down a scholarship from the Air Force early on.

“When I was about 10 years old, I realized I was a very good listener,” Pouget explains. “I didn’t know my grandfather, who was a general surgeon, but when I visited my grandmother’s house I would read his surgical books because I found them interesting. And so, by third grade, with my listening skills and fascination with medicine in general, I thought that might not be a bad career choice.”

But during her residency she realized that “the civil hospital lifestyle wasn’t really appealing to me.” She contacted a local recruiter, said she was interested in joining the Navy, and signed on. She has not regretted the decision.

“I talk to my peers in the civilian sector, and the variety that we have in the military system is just fantastic,” Pouget says. “Not that medicine isn’t interesting anyway, but I just didn’t see myself going 9 to 5 to a job for 30 years at the same place. Because I’m a navy brat, I never lived anywhere longer than 5 years. And when I get too close to 5 years, I start getting really uncomfortable—rearranging furniture, feeling like I need to do something. Adding in my interest in medicine made it a perfect fit for me.”

Today, Pouget’s rank is captain, Medical Corps, and she’s the Navy Medicine Chief Diversity Officer, as well as the Special Advisor on Diversity to the Surgeon General. Diversity, she explains, is critical to success from both a military and medical standpoint.

“As an organization, we’re competing with civilian organizations for the best and the brightest,” Pouget says. “And we need to be able to relate to diverse people to recruit into our organization. Our patients are diverse, from all over the world, all different kinds of backgrounds; we need to be able to understand their culture in order to provide the care for them.”

And while Pouget says her father would have been proud of her even if she’d become a bag lady, she acknowledges he was excited when she joined the Navy.

“There’s a plaque at home that has 3 shoulder boards: my brother’s (Naval Academy class of 1985), my dad’s, and mine,” she says. “And the plaque says, ‘The tradition continues from father to son and daughter.’”

Alex Blau, ENS, MS, US Naval Reserve, is currently attending The Philadelphia College of Osteopathic Medicine, and will go on active duty once he graduates. Medicine became his first interest when he began shadowing physicians at a hospital during his senior year in college.

When he spoke with several physicians who were former military doctors and learned of their experiences, he knew he’d found the entry point to his career.

Blau is taking advantage of the Health Professional Scholarship program. For every year of medical school the military pays for, he owes them one year of active duty service as a physician. His tuition, textbooks, materials like scrubs or stethoscopes, and even a stipend to live off are all covered by the military.

“The Navy’s goal is to make your experience in medical school less stressful, so you can just focus on doing what you need to do—which is getting through medical school,” Blau explains. “And the service component (while in medical school) is 45 days of active training every year. It’s not exactly boot camp, but it’s the equivalent. In the Navy we call it officer development school.”

Having just completed his first year of medical school, Blau says it’s way too early to forecast whether he’ll stay in the military at the end of his commitment, or move on to a civilian career. Either way, he points out, he’s going to be practicing medicine.

“That’s what I really want to do,” he says. “And the Navy thing has been such a great opportunity, I’m very excited and glad I made this choice.”

Articles

Cover Story

Although they came from different backgrounds, these physicians all took their medical degree to the US Armed Forces to care for soldiers and serve their country.

Serving Their Country With Stethoscope in Hand

Only 11% of Americans have taken a cruise in the last 3 years, and these non-cruisers likely don’t know what they’re missing out on.

Despite a couple of years where several cruise lines and their passengers have taken a beating with unfortunate results and for the bad publicity regarding health and mechanical issues, a cruise is still a great vacation—and for busy physicians, it’s almost a perfect one.

. It removes a lot of the problems associated with personal travel. You can almost take off your watch and for doctors—who live and die by their appointment schedules&mdash;this, by itself, gives credibility to a cruise.

We often hear southeast Asia is the new Europe. Let’s talk about that destination for a moment. It may not be the best trip to arrange for your 

 cruise, because air may be complicated, but it’s a good example of how a cruise can simplify a vacation.

 in the background of the top image; we cruised this part of Asia for 13 days along with 2,433 other passengers. We began the cruise in Hong Kong with stops in Bangkok (middle image) and Singapore (lower image).

Major cities can help to make a cruise memorable. Many people cruising on this particular ship said they never expected to visit those cities ever again so they were really pleased to get even a small exposure to places with such mystical reputations. And to get the exposure with so little activity on their part.

You’ll see a lot of boats, but none as comfortable as your cruise ship. And since Asia can be humid the assurance of returning to your ship’s air conditioning at the end of the day is most agreeable.

For those with Bucket Lists, a visit to places on them—even for a day visit by cruise ship&mdash;enables people to cross one more spot off the list. Tourist offices don’t criticize what might be seen as a superficial approach. They favor such visits because a quick look is often enough to make a tourist return for a longer stay.

So if, in Cambodia, you have a hankering to see, say, Angkor Wat you might find the easiest way is by cruise ship. And with upfront costs established, it may be both less expensive and less dangerous.

The karst islands of Ha Long Bay in the Gulf of Tonkin were formed when limestone eroded over millions of years.

Some parts of a foreign country spark interest from a traveler’s knowledge of history or a remembered scene in a movie or a photograph barely recalled from a high school’s geography text book. Such might be 

 off northeastern Vietnam—one of UNESCO’s 5 World Heritage Sites. The bay stretches over 620 square miles of awesome seascape and you can sail amongst those karst islands on a cruise ship excursion

There are karst mountains as well all across southeast Asia and in the rice fields locals work hard to reap what they have planted.

On land, shore excursion guides know where they want the drivers to stop. Their tips from passengers may depend on whether the foreigners get good photographs with their smartphones. Their tips also depend on whether they get passengers back to the ship before it sails. (The ship will always wait for its shore excursion passengers, but not for those on their own personal travel if they are late coming back.) Vietnam has many canals and bridges are lifted up at irregular times for boats that need to pass.

That said, the 98 million people in North and South Vietnam seem to have forgotten the war that devastated America. The war ended in 1975 and more than 60% of the population has been born since. Douglas MacArthur was wrong: old soldiers 

 die. And once they are gone, young people forget the issues.

On the road from Da Nang to Hue lies a memorial for North Vietnamese soldiers killed in the Tet Offensive. A mother shows her child the statue of a local girl, then age 17, who helped dig a tunnel here to hide a wounded Vietcong. The girl, a combatant, holds her weapon high in her right hand but from her left hand, ready to fly, is the white dove of peace.

A memorial for North Vietnamese soldiers killed in the 

. A farmer on his way to market. Asian live theater. Ha Long Bay still fascinates even at night.

Autonomous travelers in southeastern Asia would have trouble finding those places where cruises take them. Or finding locals who speak English and can explain what they are seeing. Even with a cruise to Vietnam and Cambodia, it takes time for ship personnel to arrange a visa for United States travelers.

Tourism in Vietnam is still in its infancy and American travelers staying independently in the country after a cruise would do well to choose an upscale hotel group like 

, which has Vietnamese resorts like the Anantara Hoi An and the Anantara Mui Ne with their reputation and ability to help if they run into problems.

But guides cannot completely enlighten Americans, who visit a foreign country hoping to gain better understanding of the world. We had an uncle who used to say, “Travel broadens the … feet!”

The Andersons, who live in San Diego, are the resident travel & cruise columnists for Physician's Money Digest. Nancy is a former nursing educator, Eric a retired MD. The one-time president of the NH Academy of Family Practice, Eric is the only physician in the Society of American Travel Writers. He has also written 5 books, the last called

The Man Who Cried Orange: Stories from a Doctor's Life

Travel and Leisure

Cruises not only simply the vacation experience, but they also enable visits to countries that might be difficult to navigate otherwise.

How a Cruise Can Simplify Your Vacation

While many Americans came out of the recession feeling like they were in 

, one age group has definitely been the most affected by the financial crisis of 2008.

Two surveys have found that millennials (people between the ages of 18 and 36) are more proactive about financial planning than their older counterparts and that their financial views differ greatly from the majority.

Northwestern Mutual’s 2014 Planning and Progress Study

financially disciplined than older generations

. Only 14% are aiming high and pursuing investments that have a lot of growth. The study found that 30% favor “slow and steady” when it comes to financial planning, and another 30% would prefer to be 

 cautious, but feel they have a lot of catching up to do.

"While not quite putting money in the mattress, Gen Y definitely takes a more retro approach to how they handle their finances," Greg Oberland, Northwestern Mutual executive vice president, said in a statement. "I'm guessing they're making a lot of grandparents very proud."

Money and Finance

While many Americans came out of the recession feeling like they were in better control of their finances, one age group has definitely been the most affected by the financial crisis of 2008.

The Danger in Being Too Risk Averse

Adding private equity funds to your portfolio can lead to higher returns and lower risk over the long term, but selecting a private fund takes much more due diligence than selecting a mutual fund.

Private equity funds are typically limited partnerships with a lifespan of about 10 years. Some have a minimum investment as low as $100,000 and are available to ordinarily affluent people; some are only for the ultra-wealthy. Because these funds are illiquid no one should invest in them unless he or she can easily handle funds being tied up for 10 years or more.

For the right investor, the rewards can be substantial.

Private fund managers can take a more active role with the companies they acquire and potentially wring out higher returns than mutual fund managers. They use leverage (borrowing), which can make for higher returns. Using leverage, the funds buy up companies, and the manager looks to markedly improve operations and profits.

Investors should look for managers who generate returns by making significant operational improvements to portfolio companies, rather than those who rely on excessive leverage, which adds risk. However, with judicious use of leverage, a skilled manager can deliver excellent results.

Adding private equity funds to your portfolio can lead to higher returns and lower risk over the long term, but choosing a private fund takes much more due diligence than selecting a mutual fund.

Pros, Cons of Investing in Private Equity Funds

Physicians who are proponents of Google Glass in healthcare are ever coming up with new uses for the device.

Surgeons use Glass to broadcast procedures using Google Hangout, a California-based startup is piloting a HIPAA-compliant platform for streaming audio and video, and, now, the device is going to be used in medical education.

Some of the circumstances where iMedicalApps is predicting Google Glass will become useful are during surgery for an intra-operative second opinion and for a physician to see a patient en route to the emergency room.

University of California Irvine announced

 it was the first in the nation to integrate Google Glass into the curriculum during all 4 years. The school plans to utilize the wearable device in the operating room and emergency department for third- and fourth-year students, and in anatomy labs, the medical simulation center, the ultrasound institute, and the basic science lecture hall for first- and second-year students.

“I believe digital technology will let us bring a more impactful and relevant clinical learning experience to our students,” Ralph V. Clayman, MD, dean of medicine, said in a statement. “Enabling our students to become adept at a variety of digital technologies fits perfectly into the ongoing evolution of healthcare into a more personalized, participatory, home-based and digitally driven endeavor.”

Physicians aren’t the only ones who can benefit from the use of Google Glass. 

 that Google Glass, and video glasses like it, can calm patients during surgery. The patients in the study by David Waldman, MD, PhD, at the University of Rochester Medical Center, were being tested for serious problems, were undergoing interventional radiology.

As part of the study, 25 patients were given glasses that could show videos, while another 25 were not given glasses. According to Waldman, the glasses had Disney movies as well as ones like 

Both before and after the treatment, patients answered 20 questions and rated how anxious or stressed they felt. Patients with the glasses reported anxiety scores 18% lower after compared to before. Those without the glasses were only 5.5% less anxious.

A larger patient population is needed, however, and the researchers will study 500 patients at 3 hospitals to determine which patients the glasses may help most.

As telemedicine grows ever larger in the United States, Google Glass can facilitate consultations between patients and care providers. Patients in rural communities can benefit the most by scheduling appointments with 

All of this great innovation does not mean Google Glass is acceptable in all healthcare situations or, even, that the device will endure. A decade from now healthcare providers may look back and reminisce on the time when everyone had such high hopes for that Google device no one can remember the name of.

Gadgets and Technology

Physicians Find Innovative Uses for Google Glass

Patients with advanced stages of cancer prefer to have frank end-of-life discussions early in the course of their therapy, while physicians often delay these dialogues, previous research has shown.

Physicians struggle further when balancing the options of treating cancer versus treating cancer pain. While prior studies have also explored baseline preferences in physicians and cancer patients for considering end-of-life options, there has not been a study on the influence of physicians’ baseline feelings over patient preferences.

In the first study of its kind, researchers explored the association between patient, caregiver, and physician preferences in discussions of end-of-life care and Medicare allocations.

JAMA Otolaryngology—Head & Neck Surgery

, found patients with cancer and their caregivers are influenced by their choices of quality of life over quantity of life, while physicians are unaltered by these preferences.

The study utilized a modified version of the Choosing Healthplans All Together (CHAT) tool, which examines individual versus group preferences in settings with limited resources. Daniel J. Rocke, MD, JD, and colleagues at Duke University Medical Center, Division of Otolaryngology, Head and Neck Surgery adapted the modified CHAT test further, creating an online, single-round survey.

Instead of 4 rounds, the faster model of the survey allowed physician participants to prioritize Medicare options for advance-stage cancer patients using limited resources. By removing the other 3 rounds of the CHAT tool, group prioritization and a second individual round were eliminated, though patients with cancer and their caregivers used all 4 rounds of the tool.

The researchers compared the single round of physician data to the fourth round of individual participation, which allowed the patients and caregivers more time to familiarize themselves with medical jargon. The Medicare support options to choose from were: advice, cash, cosmetic care, complementary/alternative, dental/vision, drugs, emotional, home care, home improvements, house calls, nursing facility, other, palliative care, primary care, treatment for cancer, though participants did not have to utilize each resource.

All advanced care patients—defined as a cancer that is not generally curable and is expected to shorten a person’s life&mdash;and their caregivers were invited to participate. Members of the American Academy of Otolaryngology-Head and Neck Surgery (OHNS) were invited to participate in the study via email to create their own personalized Medicare plans for cancer patients.

Before using the modified CHAT tool, all participants answered 3 health attitude questions:

1.    Would you rather have 1 year of life at 100% health or 10 years of life at 10% health?

	2.    Would you rather have 2 years of life at 50% health or 4 years of life at 25% health?

	3.    Would you rather have 4 years of life at 25% health or 8 years of life at 12.5% health?

The researchers then compared the physicians’ responses to the 146 patients’ and 114 caregivers’ responses. No significant differences between patients’ and caregivers’ responses were found, so the 2 groups were combined for analysis purposes.

Doctors who favored 100% health for 1 year of life in the first question tended toward allocating more cash for their personalized Medicare plan. Patients and their caregivers who favored 1 year of life at 100% health allocated their resources toward other medical care and palliative care, but fewer resources for cancer treatment.

In the second question, physicians who preferred 2 years of life with 50% health over 4 years of life with 25% health more commonly allocated resources for less drug coverage. Patients and caregivers who favored 2 years of life at 50% health chose more coverage to other medical care and palliative care, but less care for cancer treatment and home improvement.

OHNS physicians who preferred 4 years of life at 12.5% health in the third question elected less home coverage and more nursing facility coverage. Those patients and caregivers that preferred the same wanted more coverage in palliative care and less coverage in complementary/alternative care.

“The main point of these questions was, broadly speaking, to separate those who value quality of life from those who value quantity of life,” the authors wrote. “However, the benefit categories that were significantly different for each question did not always present a consistent pattern as each respondent group progressed from question 1 to 3.”

No consistent trend emerged for physicians, which suggests to the authors the answers to the 3 questions do not factor into physicians’ end-of-life care decision making. However, consistent trends emerged for patients with cancer and their caregivers: the answers to the first and second questions significantly affected treatment for cancer and other medical care.

“I think physicians should recognize that there are differences and that these differences persist even when physicians ‘put themselves in the patients' shoes,’” Rocke said. “So we can't overcome these differences with just a mental exercise. I think a recognition of these differences would make physicians enter into these conversations with fewer assumptions about what their patients are thinking, and maybe the physician would spend more time listening.”

The authors recommend an open acknowledgement of these differences between patients, caregivers, and physicians to allow more effective end-of-life discussions between the parties.

Feature Article

Patients and caregivers prefer thinking in terms of quality of life over quantity of life, though their physicians may not be on the same page.

Doctors, Patients Differ on End-of-Life Care Preferences

If you ask Sampson Davis, MD, what it was like growing up in Newark, NJ, he will pull no punches in describing it as the 1980s Hunger Games.

“I was always caught in this warped world that I was born into,” Davis recalls. “And as a kid, I didn’t know any different. I didn’t realize that I was living in poverty. I didn’t realize that it was crime riddled with despair and desperation. It was only as I started to get older that I realized that my reality wasn’t everybody’s reality; that the world that I was living in was a warped world, if you will, and that in order for me to not fall into that, I had to find a way to escape.”

Davis did escape, but not in the literal sense. He rose above the fray to graduate from nearby Seton Hall University, obtain his medical degree from Robert Wood Johnson Medical School, and complete his residency in emergency medicine at Newark Beth Israel Medical Center—the same hospital where he was born.

Today, as a board-certified emergency medical physician at St. Michaels Medical Center in Newark, he’s giving back, and fulfilling a pact he made with 2 of his high school friends.

Physician Voices

Emergency medical physician Sampson Davis is giving back to the community where he grew up and fulfilling a pact he made with 2 of his high school friends.