Is military medicine really that bad?

[mahnster13]

I am thinking about joining up with the ROTC program at UW for either the Army or the Air Force, and I would love to get into the HPSP program. I would honest-to-god not mind a career in the military. Even if I did not end up getting into medical school, I would still want to go in as an officer and just serve as long as I could that way. My point is, I would not be using HPSP "just to pay for med school." Hell, I might even decide to do FAP after that, I would just be that much closer to retirement after my service commitment was finally up. Now here is my real dilemma:

I hear that a LOT of people in military medicine are unhappy. I don't want to go Navy because I am not a huge fan of GMO tours, but why does it seem like a lot of Army and AF docs are not very happy? What is really so wrong with military medicine? Is it bad if you are considering a career in the military anyway? Also, is it even possible to go from ROTC directly to medical school on the HPSP scholarship?

I can't seem to find answers to SOME of those questions in the rest of this forum, so I figured I would just ask them flat out. Plus it seems like a lot of those thread are a couple of years old, has military medicine gotten any better for the docs practicing in the Army and the AF in this time?

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[IlDestriero]

I am thinking about joining up with the ROTC program at UW for either the Army or the Air Force, and I would love to get into the HPSP program. I would honest-to-god not mind a career in the military. Even if I did not end up getting into medical school, I would still want to go in as an officer and just serve as long as I could that way. My point is, I would not be using HPSP "just to pay for med school." Hell, I might even decide to do FAP after that, I would just be that much closer to retirement after my service commitment was finally up. Now here is my real dilemma:

I hear that a LOT of people in military medicine are unhappy. I don't want to go Navy because I am not a huge fan of GMO tours, but why does it seem like a lot of Army and AF docs are not very happy? What is really so wrong with military medicine? Is it bad if you are considering a career in the military anyway? Also, is it even possible to go from ROTC directly to medical school on the HPSP scholarship?

I can't seem to find answers to SOME of those questions in the rest of this forum, so I figured I would just ask them flat out. Plus it seems like a lot of those thread are a couple of years old, has military medicine gotten any better for the docs practicing in the Army and the AF in this time?

Yes, the military bureaucracy has suddenly and magically gotten better. I thank Obama. Oh wait, I mean worse.
There are good things about MilMed, but you really have to want to be a lifer to be happy there. Too much to lose for most.

 

[mahnster13]

Well that really was what I was trying to get at. So it isn't too horribly bad if you want a military career any way?

 

[AF M4]

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[DeadCactus]

It sounds as if you are non-prior service and most likely in high school or recently out. If I'm wrong, then the following is irrelevant. But assuming I'm correct, particularly on the first point, then:

"I would honest-to-god not mind a career in the military."

This statement is completely ridiculous.

In regards to the rest of the post, the sooner you commit to the military the sooner you give them power to override your goals and dreams for needs of the military. This is not exclusive to the medical side of things either. You need to decide what your priority is and what goals you want to accomplish first.

I'm going to assume we can take "Serve in the military" as a given goal.

Want to be an officer? Don't enlist.
Want to be a physician? Don't take ROTC.
Want to be a particular specialty? Don't take HPSP.

Want to try being enlisted before becoming an officer? Enlist.
Want to do a tour as a line officer before medical school? Take ROTC.
Want to take a few years to be a GMO and have last run of random adventures before continuing your training? Take HPSP.

Is it impossible to enlist and become an officer? No.
Is it impossible to take ROTC and then deffer your service to take HPSP? No.
Is it impossible to get straight through GME training? No.

The point is, take care of your own desires first. The military is not the place to sign a contract and hope for the best. Figure out what you want and sign up for that. Anything else is simply needlessly gambling with your personal, professional, and economic interests.

No one route is inherently right, but once you identify your goals there are a hell of a lot of wrong ways to pursue it.

 

[sethco]

I hear that a LOT of people in military medicine are unhappy. I don't want to go Navy because I am not a huge fan of GMO tours, but why does it seem like a lot of Army and AF docs are not very happy? What is really so wrong with military medicine? Is it bad if you are considering a career in the military anyway? Also, is it even possible to go from ROTC directly to medical school on the HPSP scholarship?

Although GMO tours in the AF are not as prevelant as the Navy, I would estimate that up to 30% of AF HPSP applicants will do GMO tours. This number is based on prior years match numbers (They did not publish this years list for security purposes).

As for why some docs are unhappy, look at some of the threads and the stickies, you will find more than enough varying answers.

 

[exafdoc]

mahnster 13, the apprehension you are feeling is similar to how a person would feel about walking down a dark alley at night in a bad neighborhood. Although you will probably be okay, the chances that something adverse will happy is significant enough that you should probably avoid it. Military medicinine is similar to this scenario, there is little to gain with significant risk of harm. There is good reason why "a LOT of people in military medicine are unhappy." Military medicine is a disaster with horrid and incompetent leadership. If I and others on this site could give you specific stories of how bad military medicine is, you would certainly not want to join (we are not allowed to communicate any specific stories of medical and instituitional negligence or we will be prosecuted). At my last AF hospital, the other doctors and I would refer to the facility as "the most dangerous place we had ever been." I am not criticizing the clinicians--they were pretty good. However, the institution makes medicine dangerous within the military. When I pointed out one particular problem with significant potential for medical mistakes, I was written up by my superior for "being too loud in my criticism" of the problem. I had only sent emails about the problem and am not sure how an email can be too loud. However, the message was clear, the leadership does not care to improve military medicine they only want to be sure that there is no sign of problems in there department so that they can get the next promotion. When I separated six months later, the problem had not been resolved and there had been adverse events.

I do not recommend that you risk your and your family's (whether you have now, or will have on) happiness and well-being. It is unfortunate because you, like many of us, truly feel an obligation to serve. If you choose to not go into military medicine you should know that the deficiency in character is not yours, but that of the institution of military medicine. Until military medicine is drastically improved, your joining will only enable to current state of neglect.

 

[Perrotfish]

Well that really was what I was trying to get at. So it isn't too horribly bad if you want a military career any way?

All else aside, as a physician when you sign on again to the military after your initial obligation is up they will pay you a huge bonus that is designed to bring your salary somewhat in line with your civilian peers. If you join ROTC, go to USUHS, or take FAP on top of an HPSP scholarship you are prolonging how long you will need to wait until you can start getting your bonus. You will be accepting pennies now for every dollar they would pay you later. It's just bad finances, even if you want this to be your career.

Also, on general principle, I don't think you should acuumulate more than a 5 year obligation to any organization, especially not at the age of 18. There is no number of questions you will ask on an internet forum that should make you sure enough to commit yourself through your mid 40s, which is what you're proposing to do (ROTC + FAP + HPSP = 13 year commitment POST RESIDENCY).

Conclusion: Even if you do want a career in military medicine, either don't accept any scholarships at all or only accept either HPSP or FAP. Don't acccept multiple scholarships, and DEFINITELY don't join ROTC.

 

[Mirror Form]

Before you make any big decisions, here is some math:

You're 18 y/o now. If you take ROTC, then HPSP, you'll have an 8 year committment. But, it won't start for a long time. You'll have four years of college, four years of medical school, and approximately four years of residency until you EVEN BEGIN to pay off your obligation. If you do a fellowship, it'll be even longer and you'll owe more time. And after all that time you may end up spending a few more years to finish off your 20.

During that whole 12 year training period (and possibly longer), the military will still own you (i.e., you will not be free). So if you sign up for ROTC with the intention of doing hpsp, you won't be free again for 20-30 years. That's a big part of your life to sign away at age 18.

 

[jabreal00]

My experience so far from the medicine standpoint is fairly good. I felt my residency training was above average. My fellowship is also above average. I wouldn't compare it to an MGH or Hopkin's but it was as good as any university based program/academic center.

The problem with milmed is when one gets out of the ivory towers of medical centers (Walter Reed, Brooke Army, National Navy medical center etc..). Most of the Army smaller medical treatment facilities (MTFs) are bastions of mediocrity and even stupidity. There's too much emphasis on military bureaucracy. I did a year at a small MTF after residency prior to fellowship. It was a horrible experience. I was not there by choice.

Things to keep in mind.

 

[mahnster13]

I appreciate all of your answers, and I have given them all due consideration. Yes, I am recently out of high school (I'm a college freshman). I guess my views are a little skewed, and I don't want my life and my dreams to be overridden just for the needs and wants of the military. If I get through medical school and still want to practice in the military a little bit, then I will consider FAP. I don't want to enable what seems to be generously called an imperfect system by signing my life away right now.Thank you all for your input!

 

[IlDestriero]

I felt my residency training was above average. My fellowship is also above average. I wouldn't compare it to an MGH or Hopkin's but it was as good as any university based program/academic center.

This is not the norm, not by a long shot. For example, a successful senior surgeon at a major university program is often a recognized expert in his field and may be a world expert on some specific procedure. These senior guys are getting the worst of the worst flown in to see them all the time. They are writing all the articles and chapters and books, lecturing at all the meetings. They are developing new techniques that are being adopted by others. That is not the caliber of the vast majority of surgeons in the military. By training in the military system, residents are not only losing out on the opportunity to work and train under these people, but you lose out on the opportunity to collaborate with them on projects while in training, and you lose out on the often significant network that these programs can provide.

I appreciate all of your answers, and I have given them all due consideration. Yes, I am recently out of high school (I'm a college freshman). I guess my views are a little skewed, and I don't want my life and my dreams to be overridden just for the needs and wants of the military. If I get through medical school and still want to practice in the military a little bit, then I will consider FAP. I don't want to enable what seems to be generously called an imperfect system by signing my life away right now.Thank you all for your input!

I always said, "If I can help only one person from making a big mistake, it would all be worth it..." You're on the right track now.

 

[narcusprince]

I just had a fellow at my program rotate at Walter Reed for a regional anesthesia month. Apparently the program is excellant(coming from a large academic center). Residents/Fellows had access to the latest ultrasound machines. The facilities were in good condition. The service was not inundated with patients. Staff had a good amount of time to teach the blocks to the residents. Minimal scutwork, also he felt people just treated each other better at the program. Their are some areas where military medicine truly shines and this is one of them.

 

[KJunior]

This is not the norm, not by a long shot. For example, a successful senior surgeon at a major university program is often a recognized expert in his field and may be a world expert on some specific procedure. These senior guys are getting the worst of the worst flown in to see them all the time. They are writing all the articles and chapters and books, lecturing at all the meetings. They are developing new techniques that are being adopted by others. That is not the caliber of the vast majority of surgeons in the military. By training in the military system, residents are not only losing out on the opportunity to work and train under these people, but you lose out on the opportunity to collaborate with them on projects while in training, and you lose out on the often significant network that these programs can provide.

:

I feel that this is a skewed statement, if not also possibly pompous and closed minded. I mean it might be the case if we're talking oncology or pediatrics or something, but military medicine has written the book in a few major fields of medicine. Obviously trauma and rehab/physical are some of them, ortho is another, and one might find this strange, but geriatrics is also on the list. I think it all depends on what you want to do and for what reasons. If you don't think you are going to get adequate training, you have to look at what type of medicine you want to be in, and if the military really serves that population. The military has (maybe had now, its been a few years) 2 of the top 10 ortho programs in the nation, and this is because of how many unique and total number cases they see. Think all of those airbornes with messed up knees, guys with shrapnel and pressure wave injuries, etc. Its a morbid way to look at it, but it's this special population that other top line programs don't see that makes the military special in this area. Like I said earlier, it depends on what you're going for as to how strong of an education you are going to get compared to other top programs. And it is also thinking like that of the quote that keeps people thinking negatively about military medicine. Its the bureaucracy that's crap, not the actual medicine.

And a side note on whether or not joining the military is right, I tell everyone of my friends that if you join for the money like I feel a lot of people do, you will NEVER be happy. But if you're joining to serve a subset of American citizens that you feel deserves the very best for what they've done, and that is your drive, all the bureaucratic crap will become white noise after awhile. The 20 grand signing bonus is awesome, the free medical school is great, but none of it will make you happy when you're doing paperwork a mile long and adhering the nuances that your commanders set in place. But if you're like me and wanted to be put through hell and wanted to forge brotherhood with a group of intelligent individuals and wanted a lifestyle that values organization, mental and physical fitness, and order, then you stand a good chance at fairing very well in the military. If you have any question about military medicine go to those that have served, not civilians. And make sure you get both sides of the fence, and find out what made the unhappy people miserable and what made those that went on to retirement so content, if not happy, with their choice.

 

[orbitsurgMD]

I feel that this is a skewed statement, if not also possibly pompous and closed minded. I mean it might be the case if we're talking oncology or pediatrics or something, but military medicine has written the book in a few major fields of medicine. Obviously trauma and rehab/physical are some of them, ortho is another, and one might find this strange, but geriatrics is also on the list. I think it all depends on what you want to do and for what reasons. If you don't think you are going to get adequate training, you have to look at what type of medicine you want to be in, and if the military really serves that population. The military has (maybe had now, its been a few years) 2 of the top 10 ortho programs in the nation, and this is because of how many unique and total number cases they see. Think all of those airbornes with messed up knees, guys with shrapnel and pressure wave injuries, etc. Its a morbid way to look at it, but it's this special population that other top line programs don't see that makes the military special in this area. Like I said earlier, it depends on what you're going for as to how strong of an education you are going to get compared to other top programs. And it is also thinking like that of the quote that keeps people thinking negatively about military medicine. Its the bureaucracy that's crap, not the actual medicine.

And a side note on whether or not joining the military is right, I tell everyone of my friends that if you join for the money like I feel a lot of people do, you will NEVER be happy. But if you're joining to serve a subset of American citizens that you feel deserves the very best for what they've done, and that is your drive, all the bureaucratic crap will become white noise after awhile. The 20 grand signing bonus is awesome, the free medical school is great, but none of it will make you happy when you're doing paperwork a mile long and adhering the nuances that your commanders set in place. But if you're like me and wanted to be put through hell and wanted to forge brotherhood with a group of intelligent individuals and wanted a lifestyle that values organization, mental and physical fitness, and order, then you stand a good chance at fairing very well in the military. If you have any question about military medicine go to those that have served, not civilians. And make sure you get both sides of the fence, and find out what made the unhappy people miserable and what made those that went on to retirement so content, if not happy, with their choice.

And you have exactly how much experience as a physician in the military?
None it would seem, but you are nonetheless pointing out how another poster who is an attending physician with recent experience of both military and civilian academic programs is wrong. So exactly why is he not correct?

You suggested he was "skewed" and even "pompous"--your words--then you bloviate without providing anything concrete about how military medicine has made such important contributions to trauma care and orthopedics and geriatrics, as if that was the same thing as demonstrating that the military is providing class-leading training in any one of those disciplines right now.

Normally I pay no attention to the smoke blowers when I know they have no way of knowing what they are writing about, but you have gone beyond that by calling out another poster who made a very valid point in criticism of the military's current academic programs. The attending you felt so qualified to challenge made a point about what distinguishes a class-leading program and faculty from just a run-of-the mill program. I think he is right. Without the defensiveness, perhaps you might illustrate why that isn't true, if you think differently.

 

[KJunior]

@ orbitsurgMD

I wrote that it was "possibly pompous and closed minded" as there was no information within this thread or his/her profile of military service, and due to the fact that there is an inherent thought in the civilian world that medical training in the military is not up to par with the rest of the world, I thought it possible that it was the same air of mind that makes graduates of civilian training programs somehow think they are better than military graduates. I also erred that I could be wrong by saying possibly, totally aware of that possibility. I also would like to point out the use of "I feel" indicating that I am not directly attacking the poster all the while taking ownership for my statement, meaning that my personal traits play a factor in my feelings and that they are not solely due to the posters comments (matter of fact on second reading I feel I might have read too far into it, but I still think the majority of my post has some valid points for consideration)

Secondly, I'm sorry that I didn't cite any specific references as to the contributions of military medicine to the rest of the world. I'm sure that you can find something worthwhile with a little Google search. You might want to try looking into the burn research center at Brooke Army Medical Center, I remember everyone raving about their research while I was at training this past summer.

Thirdly, I was not arguing that all military training programs are cutting edge leaders, but trying to say that they are respected for their ability to educate in certain fields, areas where they have a lot of population from which to draw upon. I wouldn't necessarily agree that there are not any experts training residents in military programs.

About your saying that you feel this attending is true in his assessment of military training programs,I took it that the attending was himself/herself saying that a military program was not as good as any university/academic program. Jabreal said " I wouldn't compare it to an MGH or Hopkin's but it was as good as any university based program/academic center" and IlDestriero said that wasn't the case by a long shot. This is where I think I read too much into it, but that's the way I took it. In my post I think I said that the military probably wouldn't compare well in peds or other such areas, but has a lot to offer in others. I also agree that Il Destriero has a very valid assessment of a leading program, but I think what is left out of his assessment of the military is that we rotate with other civilian programs, lending to that networking that is supposedly lacking, along with the potential (not guarantee) to work with revered members in each profession. I think networking within the military is amazing if you do HPSP, as you have friends from school, colleagues from the military, and a range of physicians you can meet as you are rotated throughout your career.

What my post was really trying to convey was that mahnster shouldn't just listen to what I took as a civilian's point of view, that this poster should get out and make the effort to talk to military doctors that are both happy and not and what made them feel that way about their service. They should see for themselves what really makes the difference between military med and civilian med if there is one, and not buy into that air of superiority that is out there. My apologies if you yourself or Il Des took offense.

 

[IlDestriero]

I feel that this is a skewed statement, if not also possibly pompous and closed minded.

Skewed, pompous, and closed minded? Do you know what you're talking about? I do.
I'm an Anesthesiologist. The more challenging the cases are that you get routinely during training, the better training you have. It's pretty much just that simple. In the OR, the better training that you have, the easier it is to recognize and handle emergent things as they happen, where the margin for error is slim and the risks are high. I've had the opportunity to train and work at a couple of the top ranked hospitals in the country, world class referral centers, as well as the Naval Medical Center San Diego.
Here's a little reality check about Navy Anesthesia/Surgery at NMCSD. The "Starship of Navy Medicine." THE Navy referral center for the pacific rim. How much trauma does NMCSD get? None. They farm the residents out to UCSD, which doesn't even get a lot of trauma. How much complex Peds does NMCSD get? None. They farm the residents out to Rady Children's Hospital for experience with complex peds cases. When I was there the number of Cardiac surgeons went from 3 to 1. Not good for training, they had to send the residents out somewhere else for more cardiac experience, somewhere with PP anesthesiologists that did not know or trust them. Sounds like great training. How many vascular surgeons were there you ask? One, think he was operating every day? How many anesthesiologists were staff in the ICU? None, they had to send the residents to Texas, Texas!, for their ICU time. How much transplant experience do the residents get? None. How many anesthesiologists, or surgeons, had ongoing clinical trials? None in the 3 years that I was there, that I was aware of. I know about trials that the surgeons are doing at my current hospital, even if we (anesthesiologists) are not directly involved with drugs, etc. How many talked a big game about research that they did during their civilian training that they wanted to take up again after they got out, and got back into academics? Many. How many anesthesiologists were actively engaged in research? 2, sort of. Was any of that research funded by the NIH, etc? No. How many publications came out of the department in the 3 years that I was there? None in any remotely major journal, though there were a couple of case reports and some abstracts. How many anesthesiologists were involved with the anesthesia boards (question writers for the written exam or oral examiners)? None, though there were some former staff and residents involved. Did any of the anesthesiologists have any significant role, other than membership, in one of the Anesthesia societies? No, none. How many chapters for major textbooks were written or co written by the staff? None. What was the ratio of junior staff (<8 yrs) to senior, experienced, staff? I think that you know the answer. How many of the senior staff were burned out and forced, by rank and seniority, into BS, non clinical, command functions? Most. One of the most senior and talented anesthesiologists there got pulled out into a "leadership" position that cut his clinical time by 50%. That alone hurt anesthesia training. The one thing that the hospital did have was all the toys. If you needed some new system or gadget, you could probably get it.
You know what happened when a really, really complex case came in to be evaluated, something that required an expert team with substantial experience in these super complex procedures? They sent them out to the major university referral centers for treatment. And it was the right thing to do, but not good for the residents.
Now ask these same questions about an academic referral center affiliated with a major university. I think just about every answer is the opposite.
After I left, it actually got worse. Tricare, or whatever it is called now, was farming the older and sicker patients out to the community hospitals. One of my old colleagues referred to it as "the largest ambulatory surgical center in the world" and another joked that it was "the starship of outpatient surgery". Do you really think that the training at this place compares to that at a major referral center? Do you really think that the military system will give anyone better than average training?
How many of these anesthesiologists and surgeons were nice, smart and competent, working WELL below their potential? Almost All! How many were great teachers that really cared about mentoring and maximizing the potential of the residents? Almost all.
The problem is simple. It is that the complex caseload was just not there. Regular complex caseload is what separates adequate training from great training. Why would anyone want to simply get adequate training?
I don't think that NMCSD, THE Navy hospital on the West coast, is some random outlier.
I'm not pompous, I'm a realist, and you don't know what you are talking about. Some of these things may have changed a bit, like the number of surgeons in a particular field at any given time, or maybe someone in the department is serious about research now (until he is transferred to Guam for 3 years) However, the general themes remain the same. Those are the facts, no exaggeration, no BS. I was there. I have seen both sides of the coin. A reasonably challenging day for one of my residents and/or fellows now is 3 times harder than any day that I had at NMCSD. Decide for yourself. After all, I'm sure that the other military hospitals are much better...
P.S. I can't comment on anything other than my anesthesia experience, I have no idea how the surgical training is or how it compares to a major referral center, but I hope that they had a lot of time at other facilities to get regular exposure to very complex cases.
P.P.S. I didn't join for the $$, and I'm not bitter at all about the time that I served, so don't go there my young friend. The military has a lot of problems, but I'm proud to have served, and hope that other talented physicians join the military and provide exemplary care to our soldiers and veterans. However, I don't recommend training in the military, that's all. If you're an above average student, or even an average one at a top 20 medical school, you're doing yourself a disservice to train at one of these pseudo-academic pseudo-referral centers. Go train elsewhere and come back in and bring your talents with you, and than get out.
P.P.P.S. I think that the time when the military was the leader in cutting edge plastics, trauma, burns, etc. was during Vietnam, sorry. Though, I would bet that there might be some new trauma and ortho stuff related to Iraq/Afghanistan coming out from military physicians now, if they use their own personal time to write it up for publication. But, having said that, I'd still rather have the Trauma surgeon that trained at USC or Baltimore Shock Trauma taking care of me when I get in a serious MVA. There also may be some programs at some centers much more involved in research, etc. But they still don't hold a candle to what is going on at any of the major referral centers all around the country.

 

[IlDestriero]

but I think what is left out of his assessment of the military is that we rotate with other civilian programs, lending to that networking that is supposedly lacking, along with the potential (not guarantee) to work with revered members in each profession. I think networking within the military is amazing if you do HPSP, as you have friends from school, colleagues from the military, and a range of physicians you can meet as you are rotated throughout your career.

This is just not correct. Here is one simple example. When you're a surgical resident at military hosptial 1 that does not do trauma, you rotate out for your (minimal) required trauma time. Great. However the resident from the hospital that you trained at does the same 3 or 4 months of trauma as you, but is also there in the trauma ICU, and again for more trauma call, and again as the chief of the trauma service, etc. You don't go back for any of that. What about all the fascinating cases that are discussed every other week at M&M, or CQI as we call it now? Who comes out with better training?
As for networking, I'll give you another example. When NMCSD anesthesia residents rotate out to UCSD for trauma, do you work with Benumof, Drummond, Ahadian or any of the other senior faculty there who are writing books, doing funded research, taking active roles in the anesthesia board and societies? Maybe once or twice if you are lucky. Do you think that he's going to call you up to co-author a chapter, or work with him on some research project? Is he going to call the Chair at Stanford and get you a job, or the Fellowship Director, that he trained, at Harvard to get you a coveted fellowship spot? Unless you are the brightest superstar that ever set foot in the hospital and can gargle ether and walk on water, he won't have any idea who you are. And, unfortunately for you, most of the military attendings don't have the connections to do more than write you a good letter of recommendation. That is another place where large University Hospitals shine. Of course if you're an average Joe, they're not going to make that call for you anyway.
BTW, before you call people out as pompous, closed minded windbags, you might want to check your facts.

 

[KJunior]

IlDestriero: first off let me say I'm sorry for including the possibly pompous and closed minded. I had made the assumption that you were a civ doc with no experience with the military, as I couldn't find any indication in your profile or the thread that said otherwise. That's what I get for assuming, and I do apologize. I just get a lot of flack for even considering the military from people who, unlike you, have zero idea of what they're talking about and just have gone on that they've heard military medicine isn't worth a hoot.

Secondly, I should have made it clear that my main experience is with the Army in particular. I find it odd that every doctor affiliated with the Navy that I've had contact with (with one exception, the writer of GruntDoc) has had a negative view of medicine in the military. This was my main reason for going Army in the first place. The top student in the class of '08 at my school was Navy, and scored in the 99th percentile on his boards. He wanted to do ortho and wanted out of the Navy, but the Navy wouldn't let him out of contract. They tried to work him through a loop hole to get out into a civilian residency by having him apply for a spot that would likely get filled and thus would have to bump him since he could definitely get a spot in a better institution. Unfortunately there was a shortage that year and the spot didn't get filled and he had to take it. His advice to me was don't do it for the money, do it because you want to go military. He wasn't bitter because the Navy screwed him over, but because he said he didn't realize that there were other ways he could have wound up paying for his school.

Another doctor I talked to is an ER physician out here who did Navy HPSP and hated his time in the military. He never mentioned anything about training but went on and on about bureaucracy. Yet another doctor I talked to was an ophthalmologist and chief medical officer aboard the service ship they sent to aid Katrina victims. He seemed less down than the others about his service but told us if we wanted to do something like spinal ortho or neurosurgery or any other high paying minute specialty to stay away from the military because it's hard to get trained in those areas and it just doesn't compare to the civilian world. That was the closest I've ever had someone come to telling me training in the military wasn't good, at least with experience to say so. And I have to say it really doesn't surprise me in the Navy, with all three of their actual military training centers (one of THE major reasons I did Army as we have 6 along with some civilian programs that sponsor mil residents).

I value what you've pointed out about Navy anesthesia, but I've had a much different picture painted from people I've met in the Army. I've met doctors and residents at two hospitals, Walter Reed and BAMC in Texas, probably the two best places you can get trained in the military. The ortho resident at Walter Reed loved what she was doing and said she got interesting cases all the time as it's the first place soldiers coming back from war stop. The chief of neurosurgery that met us also seemed to love it, or least the 60-70 hours he put in a week still after 20 years of service spoke to an interesting career. I don't know if this stuff is still cutting edge anymore but while we were there he spoke of mending people's skulls by using plastic models generated from CT/MRI scans to create polymer plates to replace parts of the skull lost in combat, probably not something you get to see all the time elsewhere.

When I was at officer training at Ft. Sam we got to tour BAMC and talk to residents and doctors there as well as ones that had flown in from other sites to talk about their programs. The only ones that seemed bored with their jobs were the dermatologists and pathologists. You mentioned that there was little trauma care at NMSCD, but BAMC hosts a level 1 trauma center with training programs in EM and a slew surgery fellowships. They also host a burn unit that is rather unique. You mentioned little research but we talked to a few doctors who were actively doing research, the one I remember the best was a nuclear medicine guy. He said it can be difficult with rotations to Iraq and stuff but if it's what you really want to do it's certainly possible. He also said you won't see much in terms of NIH dollars because if the military and DOD actually thinks your research will benefit them and allows you to do it, they front the majority of the money.

What I'm getting at here is that you painted a very good picture of mediocrity and I really can't argue with your experience. But I think the Army is a good place to alleviate some of those woes, though some will always be around as the nature of the beast (like getting pulled to do administrative work, you can get around it but you'll never rise in rank and that's a decision point for doctors, whether to homestead or get out and practice or to pursue the military career and take the cut in practice time to get the higher rank). Sometimes the complex caseload just will not be there for certain specialties because the military does little referring in from the civilian sector. I said it in another post and I'll say it again, but you really have to look at the specialty you want and the population which the training program you're considering serves. While I was being recruited they actually told me the programs to not join for, because you serve an organization that screens out people with chronic health problems. Of course you wouldn't see many tough cases in anesthesiology because the majority of people in the military are fit, don't smoke or abuse drugs, are there for routine procedures, etc. They also told me there is a lot of BS in dealing with non-medical commanders, but that is why they try to promote those with experience so that things will be better run. Yes, it can hurt training programs and other areas, but it also helps things run more smoothly than letting just the people with business administration degrees make all the rules. And you can't rule out combat experience as a means of making great doctors in some areas. When its you alone as the medical officer at the forward aid station taking sick call or doing triage care you learn quickly about not only medicine but about yourself, strengths and weaknesses, areas you need to improve to become a better doctor. When its you and two other surgeons operating to save the 3-15 wounded from an IED, I'm sure you learn to do good work and do it quick, as well as see things that you rarely see stateside. One of the attendings in the ER at BAMC had just gotten back from a tour of duty and the night prior had taken a call for a gunshot wound. He said while he was treating the patient he thought to himself "where's the other holes" because he's so used to treating multiple wound injuries now.

All I'm trying to say is that if you're going to go into the military you have to go in knowing what you're looking for. It's just like any other program, you have to do your research. And all be it fair to say the center you worked for wasn't the greatest, I still hold that there are good education opportunities out there with the military. I'm sorry I called your statement skewed, but hopefully you can see why with our differences in experiences.

 

[dr zaius]

I was at BAMC/ISR for 2 summers as a research intern and saw a great deal of clinical and laboratory research. Every Friday the burn unit had a research meeting prior to rounds where someone would present their research or discuss new ideas for studies. A large portion of the staff was involved- research nurses, those involved in rehabilitation, surgeons, critical care doctors- and even residents were heavily involved. Many of the surgical residents had their own studies under the guidance of a PI. Is this not common at most large military facilities? Surely something similar must occur at Walter Reed at least.

I've made my decisions so now I must deal with them. I talked to countless military residents, attendings, and those who have left the service in order to find the good and bad of military medicine. There were some that hated it and some that loved it. I tried to mute any bias that I might have had in my decision to sign for the HPSP. It seems as though it is a tricky situation. I feel you can never really know how military medicine truly is until you are a military physician.

 

[IlDestriero]

Your mileage may vary. The training is certainly not bad, just not great. I only know what I saw and experienced.
Most people's best option would likely be to train at the best possible major university hospital/referral center that they can match into and come in through FAP. You retain total control of your training, where, when, what and how.
Re: the Ortho guy that got "screwed" and matched in the military program. There is no way that the Navy would have "let him out of his contract". Why would they, he knew what he was getting into. FYI, he did not have to take the Navy spot, he could have just done his time as a GMO, got out and went to his first choice Ivory Tower ortho program. That's where superstars go, not average programs. He chose to accept the military residency. If I was "Dr. 99th percentile" I would have served my time, got out and got the 99th percentile training that I deserved. Settling for anything less is wasting your talents. If he still wanted to serve/a Navy career, he could have come back in after, and maybe even taken the FAP as well. And, military medicine would have been better off with him doing just that. They need more superstars.

 

[pgg]

KJunior, here's one more opinion from a military-trained anesthesiologist.

IlDestriro speaks the truth about military training in surgical fields. I don't disagree with anything he says. I'm a recent grad from the Portsmouth anesthesia program and most of what he said regarding case load, research, staff turnover, etc applies to my program too.

I was very concerned as a resident about the overall lack of acuity and complex cases in my program. It wasn't such a big deal the first year as low acuity patients are fine for learning the basics. But come my final two years, I was starting to worry. I made it known to the schedulers that I was interested in the sickest patients and biggest cases any time, but so were other residents, and there was only so much to go around. I made quite an effort to get additional "out" rotations during my CA-3 year. People thought I was crazy for asking for a month in UVA's thoracic/cardiovascular SICU, I went back to the childrens hospital, did a complicated OB elective at Brigham ... in addition to the required two months of cardiac at Washington Hospital Center in DC. In the end I feel I got very good training, but I spent fully half my final year at other institutions, chasing sick patients.


I made a couple trips to the Univ of Virginia. Expected to be impressed and outshined by the great residents at a well regarded, solid university program ... but I was underwhelmed. They didn't suck, but they weren't any better than my classmates. Most of their attendings, despite their Names and Reputations, actually taught a whole lot less than the non-famous junior attendings at Portsmouth. But the cases I did were great.

Likewise, I wasn't particularly impressed by residents from a couple of other Named institutions who I worked with while on the road. Again, they weren't BAD, but there wasn't a huge gulf between them and us, either. Kind of lazy on the whole. Anesthesia is a hard field to really judge fellow residents though, since we so rarely work with each other.

The one exception was B&W, where I thought NONE of the residents I came into contact with were weak, ALL the faculty I worked with were outstanding, and the overall academic environment just superb. But hey, that's a Harvard hospital.

I've never had much interest in participating research, so that gap wasn't a very big deal to me. I know, I know, we're all supposed to love research and be driven to advance the field, but I'm happy just doing anesthesia.

Academically I felt very well prepared by my military residency. I repeatedly crushed the in-training exams and the written board exam (and this was after admittedly unimpressive scores on the USMLEs); my military classmates also scored very high. But to an extent that's a very individual effort. We felt a lot of program pressure to do well on the exams, and OR time + book time is a zero sum game. I read a lot. So I'm hesitant to point to board scores (where virtually all military residencies excel) as clear reflections of top tier training.

In summary, I feel I got solid training, and full credit is due to my military teachers at Portsmouth for helping me overcome the relatively healthy caseload. These days I'm the only anesthesiologist at a small, isolated Navy hospital, and I don't live in fear of what might come through the door. I moonlight in the civilian world and feel comfortable and capable with their sick patients.


Tricare and "rightsizing" have not been kind to military GME. Some fields are much better off than others. There are risks and downsides to inservice training. The uncertain future of residency training in the military is the one thing that prevents me from endorsing HPSP to non-prior-service applicants.

 

[ieatpizza]

Your mileage may vary. The training is certainly not bad, just not great. I only know what I saw and experienced.
Most people's best option would likely be to train at the best possible major university hospital/referral center that they can match into and come in through FAP. You retain total control of your training, where, when, what and how.

I made a couple trips to the Univ of Virginia. Expected to be impressed and outshined by the great residents at a well regarded, solid university program ... but I was underwhelmed. They didn't suck, but they weren't any better than my classmates. Most of their attendings, despite their Names and Reputations, actually taught a whole lot less than the non-famous junior attendings at Portsmouth. But the cases I did were great.

Likewise, I wasn't particularly impressed by residents from a couple of other Named institutions who I worked with while on the road. Again, they weren't BAD, but there wasn't a huge gulf between them and us, either. Kind of lazy on the whole. Anesthesia is a hard field to really judge fellow residents though, since we so rarely work with each other.

IlDestriero, it sounds as if you did med school and/or residency at an "ivory tower" and/or currently work at one. I have similar sentiments as you graduating from an "ivory tower" this year and feeling a bit let down by moving on to a military residency rather than an "ivory tower" residency like my classmates will be moving on to. However, I tend to agree more with pgg that the gap is not monstrous between military and civilian programs, although the gap differs greatly depending on specialty. For example, anesthesia and general surgery (I have heard that case volume/acuity in certain surgical subspecialties is not adversely effected by farming out, ENT being one of them) having the greatest gaps and having a real effect on clinical competency, whereas internal medicine (the specialty that I'm going into) definitely having a gap when compared to the elite civilian IM programs, but not to the point where clinical competency is compromised at all, I feel.

You have to realize that most people in HPSP are not interested in academic practice. I am, but not a research-heavy academic practice, more of a clinician-educator academic practice. Research is obviously valuable for advancement in your field of medicine, but research does not mean crap in terms of clinical competence if that is your outcome measure. Research activity, however, is generally a requirement for advancement in academic practice and for competitive residency/fellowship/faculty positions, so an ivory tower is obviously beneficial if your goal is a research and/or academic practice. There is benefit in learning from the thought-leaders and innovators of your specialty, but I do not really think interaction with one of these thought-leaders on a relatively infrequent basis is going to make you a better clinician. The true benefit of these "ivory towers" is the overall higher quality of all house officers, fellows, junior faculty, and senior faculty--even if they are not considered "thought-leaders" in their field--with whom you will interact with on a daily basis. This is where you may gain an edge in clinical competency in addition to the larger volume and higher acuity.

However, the medical student who goes to the "ivory tower" medical school and aims for the "ivory tower" residency is a minority in HPSP. As I've said previously, if you're an average-to-slightly-above-average student at an average allopathic school or any osteopathic school, I don't think you are missing out on better civilian training opportunities by going with HPSP and a military residency, unless you are talking about anesthesia/general surgery, etc. But if you're a top student at an average allopathic school or a student at one of the top medical schools, you are missing out on better civilian training opportunities. How large that gap is depends on specialty. How a person deals with this is also somewhat individual. Do I feel that I am missing out on better training? Absolutely. Do I feel cheated? No, I cannot because I know I will still be trained to be a competent clinician in my specialty of choice (IM) and will also likely receive very good training in my subspecialty of choice. Clinical competence in the specialty/subspecialty I'm passionate about is my main goal. If my goal were an academic/research career or a lucrative subspecialty practice or private practice, I would likely be less satisfied.

FYI, he did not have to take the Navy spot, he could have just done his time as a GMO, got out and went to his first choice Ivory Tower ortho program. That's where superstars go, not average programs. He chose to accept the military residency. If I was "Dr. 99th percentile" I would have served my time, got out and got the 99th percentile training that I deserved. Settling for anything less is wasting your talents. If he still wanted to serve/a Navy career, he could have come back in after, and maybe even taken the FAP as well. And, military medicine would have been better off with him doing just that. They need more superstars.

BTW, re: the above, I doubt he'd be competitive for an elite ortho spot after being a GMO. Although I'm not familiar with ortho programs, I doubt many take these non-traditional route candidates. I also doubt KJunior really meant 99 percentile and likely meant 99 two-digit score--big difference.

 

[pgg]

You have to realize that most people in HPSP are not interested in academic practice.

It's a leap of faith to think that any pre-med's thoughts regarding specialty choice or practice environment will survive their first week of clinical work.

(Shadowing as an undergrad does not count.)

For example, anesthesia and general surgery [...] having the greatest gaps and having a real effect on clinical competency, whereas internal medicine (the specialty that I'm going into) definitely having a gap when compared to the elite civilian IM programs, but not to the point where clinical competency is compromised at all, I feel.

On the contrary, I think Navy anesthesia residency training, supplemented as it is by out rotations, is solid. Not top tier - no military residency is really elite - but solid.

And IM training, at least at Portsmouth, struck me as weak. They didn't have out rotations. The sum total of their critical care experience was a couple months in a pseudo-ICU where the house staff typically outnumbered the patients (who'd have been step-down at other hospitals).

 

[ieatpizza]

It's a leap of faith to think that any pre-med's thoughts regarding specialty choice or practice environment will survive their first week of clinical work.

(Shadowing as an undergrad does not count.)

True.

On the contrary, I think Navy anesthesia residency training, supplemented as it is by out rotations, is solid. Not top tier - no military residency is really elite - but solid.

And IM training, at least at Portsmouth, struck me as weak. They didn't have out rotations. The sum total of their critical care experience was a couple months in a pseudo-ICU where the house staff typically outnumbered the patients (who'd have been step-down at other hospitals).

I guess it's very institution-dependent, isn't it? I guess that's what I get for over-generalizing. What I said previously still stands specifically to my specialty AND institution. I still stand by my opinion about which students are really losing out on better training opportunities (the minority of HPSP students) and which students are not (the majority of HPSP students). But again, it's very situation-dependent, and this is obviously not a ringing endorsement for HPSP, just that you're not entirely eff'ed if you end up in HPSP.

 

[AF M4]

Lol, that's gotta be the new recruiting slogan;

"HPSP: You're not entirely eff'ed if you take it."

 

[StarboardMD]

Lol, that's gotta be the new recruiting slogan;

"HPSP: You're not entirely eff'ed if you take it."

That's summarizes my attitude exactly right now! Gotta stay positive...

 

[IlDestriero]

You have to realize that most people in HPSP are not interested in academic practice. ...
However, the medical student who goes to the "ivory tower" medical school and aims for the "ivory tower" residency is a minority in HPSP. As I've said previously, if you're an average-to-slightly-above-average student at an average allopathic school or any osteopathic school, I don't think you are missing out on better civilian training opportunities by going with HPSP and a military residency, ...

The problem with this logic is that top tier training gives you outstanding, far above average, training. That superior training benefits the resident for the remainder of his/her medical career, in academics or private practice. If you can handle the worst of the worst, the most complex patient load during training, you can handle the moderately complex patients or random disasters with ease. That's the training everyone should aspire to receive.
Also, when most students are signing on the dotted line, committing themselves to HPSP, they have no idea what they are going to do, how they will perform in medical school, or where/how they want to practice in the future.

BTW, re: the above, I doubt he'd be competitive for an elite ortho spot after being a GMO. Although I'm not familiar with ortho programs, I doubt many take these non-traditional route candidates. I also doubt KJunior really meant 99 percentile and likely meant 99 two-digit score--big difference.

He was, by report, the #1 guy in his medical school class, so I'll bet that means that he was in the 99th percentile. He looked at what he had done, signing the contract before knowing his potential and what he was interested in, and regretted it and, it seems, tried unsuccessfully to get out of his contract. He than made things worse by accepting average training. I hope he is a real standout in residency and gets a premier fellowship. With regard to being competitive for a tier 1 residency after a GMO, I could not disagree more. He still has his 99th percentile USMLE scores, #1 medical school rank AND 3 or 4 years of real experience that he can WOW them with during his interviews. The very nature of his unique GMO experience will make him stand out. It is all how you spin it.
"I was basically a primary care doctor for a 200 super healthy Navy pilots, crew and support guys. Yeah, we went to Iraq, but we were, for the most part, out of harms way. No bullets flying overhead."
v.s.
"I went to flight school in with the elite Naval pilots for the first part of their training and now have my civilian pilots license. I try to get up as much as I can. During my 4 years with them, we deployed to the combat zone in Iraq twice. I was directly responsible for the health of MY 200 person team, making sure that they were healthy and ready for combat at all times. I supervised 6 Navy corpsmen and 4 physician assistants in my clinic. I was responsible for the entire medical department, managing everything from emergency transfers to supplies and scheduling and answered directly to the XO."
I want to give the 2nd guy a medal and give him a residency spot today. He's already proven that he's smart, and he has been through the ringer and came out on top. I know that he will get things done, and done well, every time. He is already the guy to beat to be Chief Resident.

Again, military residency is not bad training at all, for the most part, it is average. Like most things in life, you get out what you put in. But, one can certainly train at a better facility, and you don't have to be #1 at Harvard Medical School to match into a top tier residency.

 

[ieatpizza]

IlDestriero, I pretty much agree with everything you've said, particularly to aspire to the best training you can obtain in terms of volume, acuity, complexity, etc. Maybe when you were in HPSP the caliber of medical student was different, but now it's overwhelmingly students from osteopathic and average allopathic schools. That is why I think the majority (at least 50%) of HPSP students are not missing out on better training because they would've matched at civilian programs with roughly equivalent or even worse training than military programs. I think osteopaths especially benefit from the military match as they can often match in specialties that would be difficult to get in the AOA or NRMP match. I am merely describing what I think is the typical situation of the HPSP student. However, this is by no means advice in support of HPSP as I think the best advice is yours, that if you wish to make your own luck and pursue the best training possible, HPSP and its limited post-graduate training options should be avoided.

You may be right about ortho. From my experience, anesthesia is known for taking a lot of non-traditional candidates, e.g. switching from different fields, as they seem to value that experience. However, I thought that was much rarer in ortho. Is it possible that this Navy student knew the ortho match well and felt he wouldn't be competitive had he went GMO and re-applied? That was likely part of his reasoning in addition to not wanting to delay residency training. Again, I'm not really familiar with ortho, so I don't know whether that is really true. Do you know of anyone who applied to civilian ortho after a GMO?

 

[JackADeli]

All else aside, as a physician when you sign on again to the military after your initial obligation is up they will pay you a huge bonus that is designed to bring your salary somewhat in line with your civilian peers...

I guess it all comes down to your specialty... However, I do not see any current military funding policies that bring higher end specialties remotely close to civilian dollar value. So, you get some 20-60 thousand military bonus, it's paid over what 4 years? Then you make what 120/150/180 thousand per year during that time?

I am not sure what one considers a "huge bonus" from the military either.... I am not sure what the "huge bonus" military comparison is... Do a google search for some PRIVATE sector jobs. GSurgeons can start at $250-350 thousand AND receive a $20-40 thousand signing bonus. Look up anesthesia, same thing. Look up ortho same thing. Look up any of them.... Also, You can work in the military for 20 years, and I do not think you can ever expect to achieve >$350 thousand/yr income. I don't know anyone that is striving for the VA benefits. I don't know anyone that feels they can't do better with a private sector retirement plan.

In the military, you get stationed where they want, stuck with the deployments they want, limited exciting training for physicians, you receive maybe 1/3 what you could in civilian practice.... I just don't see myself working for $150 thousand towards some pension when I could be earning $350 and up to start ....without all the government intrusion.

..."I went to flight school in with the elite Naval pilots for the first part of their training and now have my civilian pilots license. I try to get up as much as I can. During my 4 years with them, we deployed to the combat zone in Iraq twice. I was directly responsible for the health of MY 200 person team, making sure that they were healthy and ready for combat at all times. I supervised 6 Navy corpsmen and 4 physician assistants in my clinic. I was responsible for the entire medical department, managing everything from emergency transfers to supplies and scheduling and answered directly to the XO."....

Me, I will save some money and take as many flight/pilot lessons as I want. I will take care of 1000 or more patients per year. I won't have to worry that tomorrow morning I will be ordered to leave my family, community, patients to sit in Iraq for unspecified time. I won't have to worry that a military bcrat will decide today I need to do csections and ortho trauma as opposed to my chosen specialty. If a cardiologist, I won't have to worry about a bcrat deciding, no need for cards in this sand box, what we need is "sick-call" doctor to do H&Ps.... and you got your wings so we are sure you can handle it for maybe the next 6-9 months....


JAD

 

[backrow]

Me, I will save some money and take as many flight/pilot lessons as I want. I will take care of 1000 or more patients per year. I won't have to worry that tomorrow morning I will be ordered to leave my family, community, patients to sit in Iraq for unspecified time. I won't have to worry that a military bcrat will decide today I need to do csections and ortho trauma as opposed to my chosen specialty. If a cardiologist, I won't have to worry about a bcrat deciding, no need for cards in this sand box, what we need is "sick-call" doctor to do H&Ps.... and you got your wings so we are sure you can handle it for maybe the next 6-9 months....

I think you missed the whole point of his post....it wasn't expousing the virtues of going to GMO land...

 

[Perrotfish]

I guess it all comes down to your specialty... However, I do not see any current military funding policies that bring higher end specialties remotely close to civilian dollar value. So, you get some 20-60 thousand military bonus, it's paid over what 4 years? Then you make what 120/150/180 thousand per year during that time?

1) I am not saying the bonus is huge relative to the opportunity cost of being in the civilian world, I am saying the bonus is huge relative to the financial gain of an ROTC contract at all but the most expensive schools, so even if you want a military career it generally makes financial sense to wait until medical school (or, if you go to a state school, residency) to start adding obligation.

2) Medical special pays for a 4 year contract is 25-60K for every year of your contract, not 20K doled out over 4 years. Again, you're right this does a better job of bringing the low paid specialties in line with the civilian world than the higher paid specialties: a family medicine doc with 38K added to all his other pays and bonuses is probably doing better than the average civilian FM not even counting the benifits and no debt. An ortho is still making less than half of what his peers make despite the bonus. Also apparently your ISP can also up if you're recieving MSP regardless of the length of your MSP contract? Is that right? Anyway it looks like the highest paid specialties can get up to 300K over the length of a 4 year contract, which is approximately 10x the value of an ROTC contract in my in state school, so I think I was right in saying that ROTC is a poor decision even for those who want a career in the military.

 

[JackADeli]

2) Medical special pays for a 4 year contract is 25-60K for every year of your contract, ...this does a better job of bringing the low paid specialties in line with the civilian world than the higher paid specialties: a family medicine doc with 38K added to all his other pays and bonuses is probably doing better than the average civilian FM not even counting the benifits and no debt...

I will leave it to those "in the know". But, to throw something else out for thought... and clarification, I have heard this.

Your "pension" after ~20yrs of service is based on base salary and not base plus special pay. So, if you are FP and get like 80-100K base plus 40k special on top, then retire.... whatever percentage formula is used is based on the base of the 100k. Then you get those wonderful VA healthcare benefits. Sounds like low income to start compared to private practice, and major pay cut if you plan to depend on the pension....

Again, I defer to those that have more first hand....

 

[Perrotfish]

I will leave it to those "in the know". But, to throw something else out for thought... and clarification, I have heard this.

Your "pension" after ~20yrs of service is based on base salary and not base plus special pay. So, if you are FP and get like 80-100K base plus 40k special on top, then retire.... whatever percentage formula is used is based on the base of the 100k. Then you get those wonderful VA healthcare benefits. Sounds like low income to start compared to private practice, and major pay cut if you plan to depend on the pension....

Again, I defer to those that have more first hand....

First, the MSP is just your bonus for signing up again. By the time you hit retirement as an FP you'll be getting MSP (38), AP (15), VSP (7), Borad Certified pay (6), and ISP (20), so on top of your 100K base you're pulling in 86K in bonuses, which on top of base pay is much better than the average FP not even counting BAH and BAS.

As for the retirement, you're right that you'd be taking a pay cut to go on that pension. The thing is, everyone takes a pay cut when they retire, and generally their pay is cut to zero. That's why people save money in retirement accounts. The pension and healthcare benifits are on top of whatever it is you happened to save and require no contributions. Also, these people are 'retiring' in their late 40s, which isn't really retirement in the sense that you can't work any more so much as in the sense that you get to add you retirement pay to whatever you're making at your new job.

 

[IlDestriero]

You may be right about ortho. From my experience, anesthesia is known for taking a lot of non-traditional candidates, e.g. switching from different fields, as they seem to value that experience. However, I thought that was much rarer in ortho. Is it possible that this Navy student knew the ortho match well and felt he wouldn't be competitive had he went GMO and re-applied? That was likely part of his reasoning in addition to not wanting to delay residency training. Again, I'm not really familiar with ortho, so I don't know whether that is really true. Do you know of anyone who applied to civilian ortho after a GMO?

I don't understand why you think that doing your time as a GMO and getting out for civilian training is a negative in your application. If you have the scores and recommendations to get into a highly competitive specialty at the end of medical school, you still have what it takes 3 or 4 years later. Your time as a GMO doesn't decrease your potential or make you somehow dumber. It's not the same as quitting or washing out of another residency. If anything, your military experience and maturity make you more likely to succeed in whatever you want. Many of the interns that were in my class had no interest in a military residency. They planned to go GMO, flight or dive and get out to civilian residency.

 

[dwb8p]

First, the MSP is just your bonus for signing up again. By the time you hit retirement as an FP you'll be getting MSP (38), AP (15), VSP (7), Borad Certified pay (6), and ISP (20), so on top of your 100K base you're pulling in 86K in bonuses, which on top of base pay is much better than the average FP not even counting BAH and BAS.

As for the retirement, you're right that you'd be taking a pay cut to go on that pension. The thing is, everyone takes a pay cut when they retire, and generally their pay is cut to zero. That's why people save money in retirement accounts. The pension and healthcare benifits are on top of whatever it is you happened to save and require no contributions. Also, these people are 'retiring' in their late 40s, which isn't really retirement in the sense that you can't work any more so much as in the sense that you get to add you retirement pay to whatever you're making at your new job.

I think people often underestimate the value of a military retirement. Let's look at the math.

In order to retire as an O6 you most likely have to stay in for 21 years, which would entitle you to 52% of your base pay. In today's dollar that would be $56,757/year. That amount would be inflation adjusted each year and pay out for probably another 40 years, depending on when you die. This is like receiving an annuity with a present-day value of $1,351,286 with an interest rate of 3%. Adding in healthcare benefits over those 40 years, you could easily double that amount. That means a conservative estimate of the present-day value of a military retirement would come to about $2 million.

In other words, if you decided to get out at 10 years time in service, you'd have to earn $181k more per year for the next 11 years to break even with a military retirement as calculated above. Similarly, if you got out at 15 years, you'd have to earn $333k more per year for 6 years to break even. For a primary care physician that would be very difficult in not impossible to do.

PS: here's the annuity calculator I used: http://www.moneychimp.com/calculator/present_value_annuity_calculator.htm

 

[narcusprince]

Dr Destro
I am currently an Navy HPSP resident on deferment at a very large academic institution in anesthesia. Currently my case load is very complex, and extremly challenging, its been quoted that we have the most complex APACHE II scores in the country. I guess I may be someone whom would fit the mold well, as I would welcome having very healthy patients walking through my practice. My questions to you are as a staff in the Navy what were your hours? Did you have time to moonlight? And how difficult was it to optain a fellowship? And when you left were people knocking down your door to hire you? What were your assignments?

 

[JackADeli]

...By the time you hit retirement as an FP you'll be getting MSP (38), AP (15), VSP (7), Borad Certified pay (6), and ISP (20), so on top of your 100K base you're pulling in 86K in bonuses, which on top of base pay is much better than the average FP not even counting BAH and BAS.

As for the retirement, you're right that you'd be taking a pay cut to go on that pension. The thing is, everyone takes a pay cut when they retire, and generally their pay is cut to zero. That's why people save money in retirement accounts...

So, as for FP income in private sector... without deployment risk/family seperation/bcrats deciding your hours and station.... Median salary, not requiring you to reach retirement with base 100k plus earned 86k on top....

http://forums.studentdoctor.net/showthread.php?t=676050

$140,000-$175,000. $120,000 on the low end.

...According to the latest MGMA salary survey, the median income for FM w/o OB was $197,655.

[URL]http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm[/URL]

As for retirement.... if you actually get into the real world and actually invest and save, you should be able to not take any cut and just proceed to live the lifestyle you are accustom to living. On the military side, you leave military, no more military housing and allowances, etc.... Sure, I guess if you want to put up with all the bcrats, regs, relocation, military postings, etc... to earn the special pays to bring your income up to 180k per year towards retirement... go for it.

I just assume have my weekends and hollidays ~free, 4-5 day outpt work weeks, earn towards 150-190k from the start, invest, buy some real-estate (in geo local of my choosing), take vacations without fear of cancellation for deployment, etc....

I myself am not going to be able to put up with all those regs/deploys/bcrats in the hopes of one day getting "In order to retire as an O6 you most likely have to stay in for 21 years... 52% of ...base pay...that would be $56,757/year". I sincerely hope with good financial planning and savings I could do better then going from 180k to 57k per year!!! But that's just me. It all really comes down to the individual, their aspirations, their willingness to work. I am going to work hard, my income is going to be well above 180k (unless we get socialized by the marxists/progressives/communists/etc...), my savings will be large, my investments planned.... hopefully better then 3% return.

 

[ieatpizza]

I don't understand why you think that doing your time as a GMO and getting out for civilian training is a negative in your application. If you have the scores and recommendations to get into a highly competitive specialty at the end of medical school, you still have what it takes 3 or 4 years later. Your time as a GMO doesn't decrease your potential or make you somehow dumber. It's not the same as quitting or washing out of another residency. If anything, your military experience and maturity make you more likely to succeed in whatever you want. Many of the interns that were in my class had no interest in a military residency. They planned to go GMO, flight or dive and get out to civilian residency.

I'm probably wrong then. I just haven't heard of anyone doing this for ortho specifically.

 

[dwb8p]

So, as for FP income in private sector... without deployment risk/family seperation/bcrats deciding your hours and station.... Median salary, not requiring you to reach retirement with base 100k plus earned 86k on top....

http://forums.studentdoctor.net/showthread.php?t=676050

As for retirement.... if you actually get into the real world and actually invest and save, you should be able to not take any cut and just proceed to live the lifestyle you are accustom to living. On the military side, you leave military, no more military housing and allowances, etc.... Sure, I guess if you want to put up with all the bcrats, regs, relocation, military postings, etc... to earn the special pays to bring your income up to 180k per year towards retirement... go for it.

I just assume have my weekends and hollidays ~free, 4-5 day outpt work weeks, earn towards 150-190k from the start, invest, buy some real-estate (in geo local of my choosing), take vacations without fear of cancellation for deployment, etc....

I myself am not going to be able to put up with all those regs/deploys/bcrats in the hopes of one day getting "In order to retire as an O6 you most likely have to stay in for 21 years... 52% of ...base pay...that would be $56,757/year". I sincerely hope with good financial planning and savings I could do better then going from 180k to 57k per year!!! But that's just me. It all really comes down to the individual, their aspirations, their willingness to work. I am going to work hard, my income is going to be well above 180k (unless we get socialized by the marxists/progressives/communists/etc...), my savings will be large, my investments planned.... hopefully better then 3% return.

I'm having some difficulty discerning what your point is. Your post comes off a bit rambly. Also, my post was concerning primary care physicians only. If you are a specialist or someone who could easily gross 300k+ per year as a civilian, this does not really apply to you financially speaking. As an anesthesiologist, surgeon, radiologist, etc, you would almost always be better off financially by getting out early.

if you actually get into the real world and actually invest and save, you should be able to not take any cut and just proceed to live the lifestyle you are accustom to living

As a military primary care doc you have just as much if not more opportunity to save and invest as compared to a civilian primary care doc. 1) a significant portion of your pay is non-taxable. This means your marginal tax rate is lower, which would lessen the amount you pay on any taxable investments. 2) the military provides the lowest cost, non-matching 401k plan available anywhere -- the TSP -- and with the Roth option being implemented in 2012, it will be of even greater value.

The only advantage a civilian primary care doc might have is if they are eligible to contribute to a SEP-IRA, which is available to physicians running their own practice. A SEP-IRA allows you to contribute more money per year in a tax-advantaged account.

I just assume have my weekends and hollidays ~free, 4-5 day outpt work weeks, earn towards 150-190k from the start, invest, buy some real-estate (in geo local of my choosing), take vacations without fear of cancellation for deployment, etc....

You have a very valid point in that staying in the military carries social and lifestyle opportunity costs that cannot be be truly factored in when looking at the numbers.

I sincerely hope with good financial planning and savings I could do better then going from 180k to 57k per year!!! But that's just me.

I don't understand what you mean here. You would never be going from 180k to 57k per year in earnings, only if you stopped working as a physician upon military retirement, which is very unlikely.

I am going to work hard, my income is going to be well above 180k (unless we get socialized by the marxists/progressives/communists/etc...), my savings will be large, my investments planned.... hopefully better then 3% return.

Again, all of this is possible, financially speaking, as a military primary care doc. None of the things you mention here in this last quote are unique to civilian practice.

 

[dru2002]

So, as for FP income in private sector... without deployment risk/family seperation/bcrats deciding your hours and station.... Median salary, not requiring you to reach retirement with base 100k plus earned 86k on top....

http://forums.studentdoctor.net/showthread.php?t=676050

As for retirement.... if you actually get into the real world and actually invest and save, you should be able to not take any cut and just proceed to live the lifestyle you are accustom to living. On the military side, you leave military, no more military housing and allowances, etc.... Sure, I guess if you want to put up with all the bcrats, regs, relocation, military postings, etc... to earn the special pays to bring your income up to 180k per year towards retirement... go for it.

I just assume have my weekends and hollidays ~free, 4-5 day outpt work weeks, earn towards 150-190k from the start, invest, buy some real-estate (in geo local of my choosing), take vacations without fear of cancellation for deployment, etc....

I myself am not going to be able to put up with all those regs/deploys/bcrats in the hopes of one day getting "In order to retire as an O6 you most likely have to stay in for 21 years... 52% of ...base pay...that would be $56,757/year". I sincerely hope with good financial planning and savings I could do better then going from 180k to 57k per year!!! But that's just me. It all really comes down to the individual, their aspirations, their willingness to work. I am going to work hard, my income is going to be well above 180k (unless we get socialized by the marxists/progressives/communists/etc...), my savings will be large, my investments planned.... hopefully better then 3% return.

I'm not a smart man so maybe I'm just not understanding you. So I'm going to try and tease this out and you let me know where I'm going wrong.

Straight civilian FP making 180K a year. From this 180k I am going to invest some of it in a 401K/IRA, stocks and other financial instruments right?

Military FP making 180K a year (using Perrot's numbers didn't work the numbers). From this 180k I am going to invest some of it in a TSP/IRA, stocks and other financial instruments right? Plus on top of it I get an inflation adjusted 57K a year.

So where did I go wrong?

For many reasons the military isn't the way to go but for an FP I don't think it is future retirement planning.

 

[JackADeli]

I'm going to ramble some more....

As a military ...a significant portion of your pay is non-taxable...

I'm not sure that is the case. If someone can clarify it would be appreciated. i.e. of the 100k base and 80k bonus.... what is tax exempt???

....In order to retire as an O6 you most likely have to stay in for 21 years, which would entitle you to 52% of your base pay. In today's dollar that would be $56,757/year....

Those are a good number of years for a 57k per year pension... that you can start collecting at what age? To go along those lines, how much are you earning per year as fresh resident grad? Is it 180k (i.e. base and bonuses)? Cause fresh grads are making upwards of 150k with rapid advances depending on practice styles/etc.... They likely are not taking 21 years to reach the 197k mark. Most FPs I know earn well over 190k, work 4-5 days outpt per wk, take telephone call very little, no OB... etc...

...You would never be going from 180k to 57k per year in earnings, only if you stopped working as a physician upon military retirement, which is very unlikely...

Again, are you looking at 180k from the start or is that about where you top out? And, are you going from your top out to retirement after 21 years? I guess the big question is how many years are you going to give to military service and then go into private practice for how many more years?

...advantage a civilian primary care doc might have is if they are eligible to contribute to a SEP-IRA, which is available to physicians running their own practice. A SEP-IRA allows you to contribute more money per year in a tax-advantaged account...

This could be a very big advantage... especially if you are a hard charging private/civilian FP that gets to median of 190k fast and goes beyond into the 200k+ category. This goes towards retirement and investment opportunities.

...You have a very valid point in that staying in the military carries social and lifestyle opportunity costs that cannot be be truly factored in when looking at the numbers...

It goes beyond social and lifestyle. But, I think those are very, very important and often overlooked. In fact, the military tries to distract you and encourages your overlooking these. Thus, they pull out income charts and the retirement, etc.... You could have some earnings on the chart, but you find yourself and your family living in the middle of nowhere. Or, you find yourself seperated from your family living in the sand somwhere. Either situations can severely restrict your ability to invest and grow wealth. It is hard to invest in real-estate if you are relocating at a military notice. It is hard to purchase rental prperties if you are unable to consistently manage.... etc/etc... All of these things factor into finances/lifestyle/family/social/etc.... Are you going to go 21yrs for that brass ring and 50+k/yr pension?

Again, each there own. You have to decide your priorities and sacrifices. For a career in medicine, everyone sacrifices (physician/family/friends). A great deal of "living" is delayed and/or put on hold. I myself do not see putting things on hold for another 10-21 years and adding the additional restrictions as outlined above to be such a great investment. But, that is my opinion. If you see a possible 50k+/yr pension as a worthy goal, worth these sacrifices, go for it.

Again, maybe too rambling for some....

 

[Perrotfish]

I'm not sure that is the case. If someone can clarify it would be appreciated. i.e. of the 100k base and 80k bonus.... what is tax exempt???

What is tax exempt is BAH and BAS, another huge chunk of money that I hadn't added in to physician pay because it varies by rank, time in service, with how many kids you have, and of course where you live.

BTW the number in the poll you posted are WAY above the average I've seen in other physician salary surveys for FPs or what was presented to me at the AAFP conference. Are they not subtracting malpractice, or are they counting health benifits as income, or what?

 

[JackADeli]

What is tax exempt is BAH and BAS, another huge chunk of money that I hadn't added in to physician pay because it varies by rank, time in service, with how many kids you have, and of course where you live...

I guess "huge" is a matter of perspective and again.... it is time in service dependent and apparently depends on some aspects of family costs....

...BTW the number in the poll you posted are WAY above the average I've seen in other physician salary surveys for FPs or what was presented to me at the AAFP conference...

Every hospital and recruitment firm I have dealt with uses and/or cites these or similar numbers:.

...According to the latest MGMA salary survey, the median income for FM w/o OB was $197,655.

[URL="http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm"][URL]http://www.cejkasearch.com/compensation/amga_physician_compensation_survey.htm[/URL][/URL]

Just so there is no confusion.... If someone wants to serve in the military, by all means do so. My purpose in replying and posting is to help expand the discussion and hopefully encourage some additional areas of thought and consideration. Folks spend years in school and training earning nothing/very little. The numbers thrown out by recruiters can be quite enticing. I encourage you to think about them and what are the unspoken costs and how many years you need to put in for some congress dependent future return.... It's been my opinion that it is real embarassing to see "above avaerage highly educated" physicians whining and crying about their military obligation and how they didn't know before signing and how unfair it is and etc....

 

[dwb8p]

I'm not sure that is the case. If someone can clarify it would be appreciated. i.e. of the 100k base and 80k bonus.... what is tax exempt???

As stated, it would be BAS and BAH if you chose to live off-post. In DC for example, that would be $32k/year for a married O3 and $38k/year for a married O6. That would be 25% and 20% of your gross income, respectively, that you would not be paying taxes on.

Those are a good number of years for a 57k per year pension... that you can start collecting at what age?

Immediately upon retirement, so around age 47 for most. So if you lived till 87, that'd be 40 years of entitlements.

To go along those lines, how much are you earning per year as fresh resident grad? Is it 180k (i.e. base and bonuses)? Cause fresh grads are making upwards of 150k with rapid advances depending on practice styles/etc.... They likely are not taking 21 years to reach the 197k mark. Most FPs I know earn well over 190k, work 4-5 days outpt per wk, take telephone call very little, no OB... etc...

A fresh FP attending in DC, who is married, would make $128,120 gross. This include the non-taxable portion, which adds to the effective value. Also, as a fresh military attending you would have no student loans, presumably unlike the civilian fresh attending making $150k.

Again, are you looking at 180k from the start or is that about where you top out? And, are you going from your top out to retirement after 21 years? I guess the big question is how many years are you going to give to military service and then go into private practice for how many more years?

Using the same scenario as above (married, DC) you would go from $128k as an O3 to $191k as an O6 over those 21 years. These numbers are in terms of TODAY'S dollar (spending power). Obviously inflation would adjust those earnings each year, just as it would civilian pay.

After those 21 years, you would get out and go civilian for as many years as you wish. You might be slightly disadvantaged in terms of civilian networking and partnerships, however.

This could be a very big advantage... especially if you are a hard charging private/civilian FP that gets to median of 190k fast and goes beyond into the 200k+ category. This goes towards retirement and investment opportunities.

You're right, but for it to be an advantage, you must be already contributing the maximum to the tax-advantaged retirement accounts available to you through the military (TSP - $16500/yr, Roth IRA - $5000/yr).

 

[JackADeli]

...as a fresh military attending you would have no student loans, presumably unlike the civilian fresh attending making $150k...

Not necessarily true.... plenty of folks in the military carry student loans. Even the HPSP folks may have undergrad loans...

 

[dwb8p]

Not necessarily true.... plenty of folks in the military carry student loans. Even the HPSP folks may have undergrad loans...

Sure, there are always exceptions, but do you really think the average indebtedness of an HPSP/USUHS graduate is anywhere near $150k?

 

[JackADeli]

Sure, there are always exceptions, but do you really think the average indebtedness of an HPSP/USUHS graduate is anywhere near $150k?

No. But, not all military physicians are HPSP. Plenty take stipends once in residency, after incurring undergrad and med-school debt.