New Navy Residency/GMO Program - Beware

[pawprint]

I had some conversations with some higher up folks last month that I figured I'd share here so that people considering HPSP are aware what's coming down the pipe.

In the past until now, as a 4th year medical student, you would apply for an intern year position in the specialty of your choice. During your intern year, you would apply to continue your residency to go straight through. If you were not selected, you would be sent to complete a GMO tour (which happens to a large number of people). At the conclusion of your GMO tour, you could either apply back to a military residency, or you could complete a second GMO tour and separate from the Navy once you completed your HPSP payback of 4 years and complete residency as a civilian and enjoy civilian life onward.

This past year, the Navy introduced a new program for 4th year medical students applying for residency. This program allows 4th year medical students to apply for a PGY-1 position with a guaranteed PGY-2 position, as long as they complete a single GMO/flight medicine/dive medicine tour between PGY-1 and PGY-2. This means that these students will not have to apply during their PGY-1, or upon completion of their GMO tour. They only have to apply once, as a 4th year med student, and their spots are secured throughout the process.

I wanted to bring attention to this because I feel like medical students may not understand the implications of this new program. It effectively increases your payback for the HPSP scholarship if you are not selected to go straight through and eliminates your ability to get out following GMO time. Under the current/old system, an HPSP student who was not selected for straight-through residency would typically be in the military for 5 years (intern year + 4 year payback as a GMO). Under this new system, it will automatically create a longer career in the military for those who do not match straight through. You will have to do intern year + GMO tour (2 years for GMO, 3 years for flight/dive) + residency + residency payback as you incur obligation for residency training). This is a total of 7-8 years minimum, and longer for longer residencies that incur longer payback. So overall, this new program ensures the military is keeping its doctors for at least 2-3 years more than what the HPSP alludes to, and it gets away with the ability to "GMO and get out".

Higher ups are realizing that the Operational Medical Officer model (using board certified doctors to fill operational billets) isn't working well, particularly in the flight/dive community. This new system ensures that they will have GMO's to fill their billets, and still get their board certified doctors at the end with a utilization tour before they have the ability to separate.

I will say, its smart on behalf of whoever came up with it. This new system will allow the military to continue to fill its GMO/flight/dive billets with young doctors who don't have board certification requirements to worry about, and it will allow them to force these folks to finish their training in the military system, and get at least 1 utilization tour in those specialties post-residency.

The big thing I don't like about it, is that a person who is applying to medical school at 21/22, has no idea what their life or the military is going to look like 12 years down the road. And this is effectively forcing anyone who signs up for HPSP to stick around the military for 12 years after they sign up for the scholarship (4 years of med school, then your 7-8 years as described above). College students need to be made aware of that timeline, that its not just "4 years after intern year" that the scholarship alludes to. You are signing up to be a part of a system for over a decade after you sign your paperwork with no off-ramp.

---

Members don't see this ad.

 

[backrow]

While there’s nothing incorrect about your statement I think the thing you miss is the fact that it is guaranteeing a residency position that previously you would have had to compete again for. Also, despite the machinations on this board there are still some folks who really want to do a GMO tour before going to residency and with the significant shift to straight through training this option prevents one from getting “locked out” so to say.

Yes, people should do their due diligence when considering this pilot program (which was all of something like
If you want to do GMO and get out that still exists, and there’s nothing to prevent you from saying “no thanks” when the time comes to go back to residency if one wanted.

 

[DrMetal]

Under this new system, it will automatically create a longer career in the military for those who do not match straight through. You will have to do intern year + GMO tour (2 years for GMO, 3 years for flight/dive) + residency + residency payback as you incur obligation for residency training). This is a total of 7-8 years minimum, and longer for longer residencies that incur longer payback.

Yeah, but this is also true in the traditional pipeline as well. Yes, you always incur a payback from training. You payback the larger number (obligation from training vs. medical school). That hasn't changed, and certainly, applicants should be well aware of it.

This is a total of 7-8 years minimum, and longer for longer residencies that incur longer payback. So overall, this new program ensures the military is keeping its doctors for at least 2-3 years more than what the HPSP alludes to, and it gets away with the ability to "GMO and get out".

True. So don't sign up for this option if you're not interested, it's not mandatory. You still have the freedom to GMO out. (What's your consternation?)

While there’s nothing incorrect about your statement I think the thing you miss is the fact that it is guaranteeing a residency position that previously you would have had to compete again for.

True. It's worth considering if you want to do a GMO tour and a military residency afterwards. Not worth considering if you want to do a civilian residency.

 

[Gastrapathy]

@pgg remember when GMO tours were “being phased out” circa 1997

As long as the docs can back out/extend in place, this may not be a bad deal for them.

The primary problem with this is that American medicine has moved passed the one year wonder in nearly every situation except for the Navy and this is designed to keep foisting undertrained pseudo-PCPs on sailors. I wish I could say I don’t believe it but this makes perfect sense.

 

[orbitsurgMD]

Does "guaranteeing a PGY2" slot at a point 3 years after finishing internship entail a contract or not? What happens if the specialty is overmanned and the number of slots for PGY2 is reduced. Does this apply to all specialties or only those undermanned? I will say this: they have done this very thing before, selecting for advance years (and failing to tell potential applicants who had 2+ years of FS/GMO orders to complete that they should apply early for these out years) and the plan was predictably met with displeasure that there were residency slots being filled for out-years. I predict this will not have a positive effect on morale and will motivate many to elect as early a departure as their service obligations allow. My guess is that better candidates have been heading for the doors to get better civilian residencies. Can't blame them. This seems like another ill-fated deposit from the BUMED good-idea fairies.

 

[DrMetal]

Does "guaranteeing a PGY2" slot at a point 3 years after finishing internship entail a contract or not? What happens if the specialty is overmanned and the number of slots for PGY2 is reduced. Does this apply to all specialties or only those undermanned? I will say this: they have done this very thing before, selecting for advance years (and failing to tell potential applicants who had 2+ years of FS/GMO orders to complete that they should apply early for these out years) and the plan was predictably met with displeasure that there were residency slots being filled for out-years. I predict this will not have a positive effect on morale and will motivate many to elect as early a departure s their service obligations allow. My guess is that better candidates have been heading for the doors to get better civilian residencies. Can't blame them. This seems like another ill-fated deposit from the BUMED good-idea fairies.

I don't think it'll move the needle either way.

What's really stupid in the Navy is the concept of a "Flight Surgeon" or a "Dive Medical Officer". You can take any PCM and train them to do flight and dive physicals, in about 1 month (it's all checklist stuff, you need to know what to order, what guidelines to follow, etc). Fine, 2 months. Its not that hard. We could make every (or nearly every) physician in the Navy "flight" and "dive" qualified (to at least do occupational medicine type exams, up and down chit folks as needed). (not to say they'll actually be flying or diving)

But no, we've made a 9-month school out of it, total of 3 years orders, we deploy the crap out of them and insist only they can fill said billets.

So be it. We sleep in the bed we make.

 

[j4pac]

Will you be able to guarantee a PGY-2 spot into PM&R?

 

[DrMetal]

Will you be able to guarantee a PGY-2 spot into PM&R?

No. This is a pilot program, pertaining only to a few specialties (I forget exactly which ones, but I think it's the large ones, FM, IM, GS, maybe OB).

 

[backrow]

Will you be able to guarantee a PGY-2 spot into PM&R?

PM&R is unlikely to be part of the program. Right now it is geared towards the primary care specialties during this pilot program.

For those unaware of this program it is only available to those specialties indicated on the BUMEDNOTE and you cannot be forced to do it. It’s 3yrs as a GMO and at least for this year if you wanted flight or dive you’d have to apply for that as an intern (personally I think this is part of the program that needs to be adjusted). The residency position you are slotted for is effectively filled by you and won’t be available for someone to match into in 3 yrs. They are effectively assigning that slot to you.

For some, this is a good option, for others: not so much. Nothing wrong with giving people options. The other option to fill GMO billets is to just make you go GMO without any residency guarantees, which was the default for many years.

BTW: Air Force has been doing this for several years now, this isn’t novel.

 

[DrMetal]

For those unaware of this program it is only available to those specialties indicated on the BUMEDNOTE and you cannot be forced to do it. It’s 3yrs as a GMO and at least for this year if you wanted flight or dive you’d have to apply for that as an intern (personally I think this is part of the program that needs to be adjusted). The residency position you are slotted for is effectively filled by you and won’t be available for someone to match into in 3 yrs. They are effectively assigning that slot to you.

And all of this is on paper, a contract of some sort? Is the residency location guaranteed?

 

[pawprint]

Yes, I totally understand it is a "novel program" and is currently being tested out. My conversation I had with someone higher up involved in this process was that this is being tested so that it can move towards full implementation. The goal for the future would be that you will have 2 options: either apply for intern year -> GMO -> residency -> residency payback, or apply for intern year -> residency -> residency payback. No GMO and out option. You are either locked in as a GMO who has to return to residency, and then do your residency utilization tour, or you go straight through to your utilization tour. This will help mix folks who have straight through training with folks who obtain operational experience. GMO and out doesn't help the Navy at all as that operational experience is lost, so this system helps force that experience to stay in the system long enough to help those who don't have it.

Which is why college students looking to sign an HPSP contract now need to hear about it. Because by the time they get through medical school and are 4th years, they may being doing more time than they thought they would be on their initial signing if they are only presented these two options when its time for residency application. One of the reasons why I was okay with doing HPSP was because I knew that if I didn't match the specialty I wanted, I could always do 4 years as a GMO and get out and apply to civilian programs in whatever specialty I wanted. Its more comforting knowing you have an out at the 5 year mark if the system doesn't work in your favor.

Again, I understand its currently a "pilot program". But the reason its being introduced is to test it out, and if it works well, then that's the direction they are going to want to go. The OMO idea isn't working like they thought it would; nobody is signing up for these tours at the levels they were hoping. Ensuring that interns go through the GMO system without losing them to the GMO->out model is looking to be a way to help keep operational billets staffed, bring operational experience back into the hospital training environment, and fix retention for the areas they need (ie: undesirable billets that typically are given to newly graduated residents).

 

[DrMetal]

No GMO and out option. You are either locked in as a GMO who has to return to residency, and then do your residency utilization tour, or you go straight through to your utilization tour.

I don't think that's going to happen. We still have way too many GMO billets, we can't fill all of them with GMOs-contracted-for-residencies. Maybe we try to fill the billets with post-residency physicians (as we're doing now), but we still need single 'undesignated' GMOs. And our intern classes are still too big; there will be plenty who don't match into straight thru training nor into GMO-contracted residency spots. And we don't have enough residency spots.

All of that said: I think the lone 'undesignated' one-hit-wonder GMO is here to stay, at least for the near future.

The right answer to this problem would be to permanently close some GMO billets (especially the useless shore ones), and to decrease the size of the incoming pool of physicians. If each of the hospitals has say 75 new Navy interns/year, or ~225 interns total, that's honestly too many, given we only have about 100 PGY2 spots. Stop handing out so many HPSP scholarships, reduce that number to say 150 interns/year, then we'll make some headway in shutting down the GMO model. [These things will never happen. Takes an act of Congress to close a billet, and nobody wants to recruit less, even if that's the right thing to do.]

 

[orbitsurgMD]

So the (claimed, touted) straight-through training plan is rejected in favor of this. Instead, they are spending the future value of a residency slot for otherwise annual residency applicants on a scheme to lock in some trainees to a residency of uncertain quality at the expense of a three year fleet commitment and an additional year ("hey what's a year, you're in for 26, right?) and they don't have to do the straight-through deal. I am assuming some other arrangement applies to USUHS and the few direct accessions, or is this a "one size fits all" plan? Of course the inside the Beltway spin on this is that it costs nothing, it is just more strings attached to training that is still being delayed and withheld. Apparently the folks on the post-residency side don't want to go back to the fleet (did we know this?) And they are probably seeing some--probably quite a few-- HPSP grads they might have wanted to keep electing to leave at minimum EAOS, GMO and out. It is hard not to see this as failure in the birthing: spend nothing and get nothing.

 

[pgg]

Apparently the folks on the post-residency side don't want to go back to the fleet (did we know this?)

I assume this is rhetorical but absolutely obviously yes, the vast majority of residency-trained specialists don't want to go to the fleet in GMO billets where they won't practice the specialty they just trained in.

It's not necessarily career suicide, but it's definitely cliff jumping into water your drunk buddy says is probably deep enough.

@pgg remember when GMO tours were “being phased out” circa 1997

Sure do, interviewed at USUHS in Dec 1997, asked everyone about the Navy GMO thing, soon to be rare or optional.


This whole idea is disturbing to me. My primary reservation about advising any premed to join via HPSP or USUHS is that both demand programs they commit now to future inservice GME, 5-10 years in the future (with GMO & out a reasonable early exit for HPSP'ers but not USUHS grads).

A new program to contractually defer someone another 2-3 years has no real upside to the individual.


Do we know for sure that these people can't change their minds and GMO-&-out? Generally there are harsh consequences for backing out of a residency match.

 

[j4pac]

No. This is a pilot program, pertaining only to a few specialties (I forget exactly which ones, but I think it's the large ones, FM, IM, GS, maybe OB).

So if that’s the case, saying GMO and GTFO is dead, like implied in the OP, isn’t accurate. You cannot force someone to do a specialty they don’t want to do. If it’s the way you explain it, the program has the potential of helping applicants more than hurting them.

 

[pawprint]

So if that’s the case, saying GMO and GTFO is dead, like implied in the OP, isn’t accurate. You cannot force someone to do a specialty they don’t want to do. If it’s the way you explain it, the program has the potential of helping applicants more than hurting them.

The current pilot version of the program is only for a few specialties, but the intent is to have it applied across all specialities down the road (this was the first year it’s been an option).

My reason for positing was to make those considering HPSP to know that this thing is brewing out there. Will it actually come to fruition across the board? Maybe, probably not, but as someone considering the scholarship they should at least know that this discussion is happening and at least starting to get rolled out.

 

[Brouillet2017]

You cannot force someone to do a specialty they don’t want to do.

Even Army and Air Force still have some GMOs who go GMO and out, sometime for this reason.

 

[pawprint]

Even Army and Air Force still have some GMOs who go GMO and out, sometime for this reason.

Whats stopping them from making them do a residency in a specialty?

They can say: do your intern year as a TY, then do GMO, and come back as family med or IM or peds or whatever. You can rank whatever specialties you like for pgy2, but you have to rank something and you’ll get one of them.

Right now, the mindset is if you don’t match into a pgy2 you don’t want, then you can get out as a gmo and try on the civilian side. This new pathway allows them to get rid of that option, and tell you that you have to rank different pgy2 specialties and they will give you one of them after you finish your 1 gmo tour.

The only barrier that prevents them from doing this, as mentioned above, is the lack of overall pgy2 spots. They would have to have their intern year numbers match their pgy2 to make this possible.

 

[j4pac]

Whats stopping them from making them do a residency in a specialty?

They can say: do your intern year as a TY, then do GMO, and come back as family med or IM or peds or whatever. You can rank whatever specialties you like for pgy2, but you have to rank something and you’ll get one of them.

Right now, the mindset is if you don’t match into a pgy2 you don’t want, then you can get out as a gmo and try on the civilian side. This new pathway allows them to get rid of that option, and tell you that you have to rank different pgy2 specialties and they will give you one of them after you finish your 1 gmo tour.

The only barrier that prevents them from doing this, as mentioned above, is the lack of overall pgy2 spots. They would have to have their intern year numbers match their pgy2 to make this possible.

From what others are saying, that’s not the case

 

[DrMetal]

I assume this is rhetorical but absolutely obviously yes, the vast majority of residency-trained specialists don't want to go to the fleet in GMO billets where they won't practice the specialty they just trained in.

And can it not be construed as waste fraud and abuse? Taxpayers paying for the education and training of a Vascular Surgeon, only to have that member do flight physicals? (meanwhile, the local MTF Vascular clinic is deferring patients out to the network).

From what others are saying, that’s not the case

Correct. Too many junior physicians, Too many GMO billets. You have to reduce both numbers to make meaningful change. Good luck with that. Until then, the lone-ranger GMO is still a viable path.

 

[HQCare]

The Navy has repeatedly been told to phase out General Medical Officers. Here is a news article from 1998 describing this:

Points of Interest: Navy Told to Phase Out Undertrained Doctors

Many Navy physicians servin

www.usni.org

"The move to upgrade physician quality was ordered by Dr. Edward Martin, acting Assistant Secretary of Defense for Health Affairs. He concluded the military no longer can risk having undertrained doctors provide unsupervised care. The doctors in question are called general medical officers (GMOs). There are roughly 1,500 on active duty, mostly in the Navy and Air Force. They serve primarily on ships, with Fleet Marine Force units, in undersea medicine, or as flight surgeons. GMOs are medical school graduates who spend only one year as interns...

Martin said it is time the military raised physician standards to match trends in mainstream America. "The judgment is that [the GMO program] might have worked 10 or 20 years ago, but today they're not adequately trained to provide care, particularly in isolated duty," Martin said."

More recently from the Medical Corps Chief in 2021

https://mccareer.files.wordpress.com/2021/01/medical-corps-newsletter-winter-2021.pdf

"Our plan is to start moving to straight-through training for medical students beginning in academic year 2022 and proceeding over the next 5 years. This will allow us to offer GME to as many GMO/UMO/FSs as possible while ending more and more medical students straight-though GME. During this transition period, when a GMO returns for GME or resigns from the Navy, they will most likely be replaced by a residency-trained physician, what we are calling the Operational Medical Officer or OMO. The OMO will be a residency trained physician trained to serve with the Surface or Fleet Marine Forces or as a UMO or FS..."

The GMO issue has been unresolved for decades. As you progress through the Navy medical system you will see what a mess and how bad the leadership is. It leaves you scratching your head wondering if you they are dishonest or maybe its so disorganized and chaotic that they really cannot decide about the GMO issue. There are many issues like this you will encounter. There isn't much you can do about it. I think it would take an act of Congress to fix the system. Just do the best you can, focus on any available training opportunities and what you can control. Don't complain the Navy is notorious for retaliation...

 

[Konigstiger]

Even if you match into this program, can't you still do your intern year, do your 2/3 year GMO tour, and then reject your guaranteed residency spot and do a second GMO tour for your payback? That would essentially be the same as the original GMO-and-out pathway, and I'm pretty sure the pilot program stated you would be allowed to reject your guaranteed spot.

For people who want to do a GMO tour, I don't really see the downside to this program. At least now you won't have to repeat intern year in the civilian world or submit a second military and/or civilian residency application once you are finished your GMO tour.

 

[orbitsurgMD]

There is a solution to this. It will cost some money, but it will work better than any of the other proposals. "OMO" assignments should be delegated to those best trained to perform those tasks: board-eligible or board certified medical officers in IM, FP and EM tasked on a rotating basis to do operational tours lasting no more than one year every four years. In the non-operational interim, those officers would have assignments in their own specialty or be permitted to have fellowships or additional residencies or advanced degree work with full support of their service branch. During the year of their OMO duty, they should receive an amount the equivalent of their total pay as a bonus and half that amount in the year following the OMO tour. This payment, along with the follow-on career opportunities should be seen as a fair and reasonable compensation for the additional burdens of deployment.

 

[HQCare]

Having good leadership, clear vision, and direction regarding this issue might save money in the long run. Retention would be increased, quality of care would be increased, physicians would have a better career pathway, the system would feel more stable instead of at the whims of whoever is in charge and the operational units would appreciate having a fully trained MD.

 

[armytrainingsir]

Until the HPSP pipeline dries up, there is little incentive to meaningfully change anything, although plenty of incentive to spend endless amounts of time in emails, meetings, briefings, blogs, etc etc both decrying the problem and self promotion as being a ‘leader’ and ‘physician champion’, lol.

 

[Atlas Shrugged]

Until the HPSP pipeline dries up, there is little incentive to meaningfully change anything, although plenty of incentive to spend endless amounts of time in emails, meetings, briefings, blogs, etc etc both decrying the problem and self promotion as being a ‘leader’ and ‘physician champion’, lol.

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

 

[j4pac]

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

With that rationale, they really shouldn’t be making military service LESS attractive. Certainly, adding a guaranteed 2nd year will help retention but unless there is will a mechanism to GTFO, then it hurts intake even more. There is nothing that I’ve seen in this thread that makes me think that this change is a negative for HPSP students.

 

[Chonal Atresia]

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

I hope this is true. It is the only way meaningful change will happen. Destroy this broken, antiquated system from the bottom up.

Military medicine is in a world of s#@$ in 4-5 years if this statement is accurate.

 

[armytrainingsir]

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

Hard to imagine that big of a hit given the explosion of stupid expensive DO schools over the last five years.

Has USUHS seen a drop in applications?
I’d be surprised that going to a civilian medical school for four years and having a shorter obligation is less attractive than USUHS.

 

[pgg]

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

That seems unlikely.

Around 2006 HPSP didn't fill by a relatively small amount and the response was to quickly and significantly increase the monthly stipend and add a signup bonus. If they were really down 40% for the last couple years they'd throw more money at it.

 

[backrow]

I don’t have any official data or confirmation but I’ve been hearing HPSP has been filling 40% the last couple of years.

For Navy the number is closer to 90% filling HPSP slots. You can write the corps chief office to get the actual numbers if desired. I think they fell 20’ish short last year and they typically roll those over to 3yr scholarships, but it’s probably even harder to get 3yr HPSP’ers so that doesn’t always fill that gap.

Still, even a 10% shortfall is a big number because historically we lost about 300 physicians a year, but would gain about 300 in HPSP/USU. So combine and increased “get out” rate with a decreased recruiting rate and the impact is even greater.

Another issue with decreased HPSP is you have fewer interns to fill the needed in-service training slots, so there is less availability of NADDS, etc.

 

[orbitsurgMD]

If this idea fails (it will, because it is that bad) the blame falls squarely on BUMED. Instead of moving away from GMO assignments and toward straight-through training, this plan perpetuates the institution of the GMO with one year of GME. This is a tiny bone of truly dubious value being thrown to the HPSP accessions so that they don't all quit as soon as possible. This has the smell of desperation on it.

 

[orbitsurgMD]

Thirty-four states now have medical education loan forgiveness programs. The VA and USPHS have HPSP programs. Soon the USCG is starting its own HPSP program, or so I hear.

 

[orbitsurgMD]

With that rationale, they really shouldn’t be making military service LESS attractive. Certainly, adding a guaranteed 2nd year will help retention but unless there is will a mechanism to GTFO, then it hurts intake even more. There is nothing that I’ve seen in this thread that makes me think that this change is a negative for HPSP students.

How the offers are extended and for which specialties is what will matter. The problem will be for those specialties that are needed that the services don't have enough training slots in their own programs to fill. Sure, the option still exists for deferments, but those were always relatively few, USAF excepted. For the Navy particularly, where large entry classes of, say, 16 interns for surgery have two PGY2 slots for the program (and maybe 1 or 2 each for ENT and Ortho). If you fill up your out-year classes, you don't need to be a math genius to size up the narrowing odds for selection if you weren't one of the lucky ones. Add to that factors like prior service preference and you really have made the situation, and morale, worse. Most of the people will rightly come to believe they've been played.

It is hardly any surprise the OMO concept has failed. There isn't anything about it that would make it successful. And if there are the usual exemptions, like pregnancy card pulling, and you can see how the perception that a program like that wouldn't be perceived as fair. For anyone with the option to punch out, I can see where being detailed to OMO would be cause to look for the exit. The services have an unfortunate history of leaning on those who have done prior GMO duty to force them to do a repeat tour rather than looking for those who have never done a day of GMO duty to take their turn. There is nothing like a perceived lack of fairness (with attractive opportunities available elsewhere) to sour physicians on military careers.

The military services, and especially the Navy, have a cheap bas†ard problem. That is always going to have blowback.