Considering Military Medicine

Doc.Holliday · Dec 26, 2005

I am considering both USUHS and HPSP, but as this is a relatively new consideration, my knowledge of how things would play out is limited. Ive read through this board, and learned a good deal about the time id be required to serve for the two options, and pay etc for each. It seems starting a family is quite possible, if not in some ways easier than as a civilian, and that pay during school and residency, either choice, is a big plus.

I have a few topics however that id greatly appreciate someone in the know to help me with.

-First, the ability to choose my specialty. Right now i dont know what specialty i want for sure, but i have absolutely narrowed it down to family practice, pediatrics, derm, orthopaedic surgery, cardio surgery, or plastic surgery. Long list i suppose, but any specific info on the chances of getting each etc...

-Also, any specific pros/cons as far as quality of experience/education and my options with each of those specialties after serving. Id like to know of both military career options and civilian. What is life like AFTER?

-and lastly, IF i decide this is the right path for me, will my lack of military experience/background be a huge obstacle? I was never in rotc (couldnt in HS, due to academics, and therefore didnt consider it for college, plus im on a full scholarship to a private school anyway, so the money issue was never considered). None of my immediate family is in the military, though the Navy seems to be a common career choice for other relatives (both grandfathers, one being very highly ranked, 3 uncles). My reasons for considering this option are primarily the honor of serving my country, or in this case serving those who serve my country. A long term military career is not out of the question, ive often considered it. I know ~50% of USUHS students had prior military service/experience, and im sure an even higher percentage have fathers/mothers in the military. Is this due mainly to the groups self selection, or is coming from such a background a unspoken requirement?

[edit] To help any advice be more on target, I would consider myself on the exceptional side of the med applicant pool. I am already guaranteed acceptance to a well respected private med school, and am an extremely determined individual. So for the most part, id like more info on the avg to upper ends of possibilities for a future in taking this path, dont try to scare me with worse case scenios. I have always been a succesfulll individual and have no reason to expect any less of my future.

AFSmiley · Dec 27, 2005

I'm just an undergrad, with big hopes and dreams too, and here's what I've gathered from my prestigous "10+ posts" here at SDN:
-Financially, you'll make more money in the long run going the civilian route.
-Starting a family, in medical school, and/or the military, ain't no picnic.
-Your options for residency really depend on the needs of the branch you're in, and vary from year to year. If they need GMO's, and you've got an MD/DO, guess what.....In addition, its hard to comment on your chances of getting certain residency positions without licensing exam scores, LORs, and what ever else is required.
-I think all Military Residency Programs are Accredited, and if you get Board Certified, you'll have the same oppurtunities as anybody else.
-All the branches have training programs to get you more acquainted with the service. There's a culture difference between military and civilian populations, approach life with a positive attitude, and you'll be fine. I read in another thread in this forum that the ~50% prior military experience at USUHS includes ROTC and Academy graduates; with a humble outlook and some willingness to adjust I bet you'd be fine.

About the last part of your post...........if there's anything I've learned in my 2 decades on Earth, it's that I don't know s**t abou s**t, and I won't know s**t abou s**t until I can say "been there, done that, here's what I think". So congrats on your acceptance and all, but let's not pin the stars on the shoulder just yet.

Doc.Holliday · Dec 27, 2005

JMPeffer said:
About the last part of your post...........if there's anything I've learned in my 2 decades on Earth, it's that I don't know s**t abou s**t, and I won't know s**t abou s**t until I can say "been there, done that, here's what I think". So congrats on your acceptance and all, but let's not pin the stars on the shoulder just yet.

hah, i know, i just didnt want the worst case scenario, im not saying i'll be the best doc or the best military doc in the world, but i do know that i'll be average at worst. Basically, im fine with the avg military docs experience (though the after part still eludes me). But i was interested to hear what opportunities are out their. So what does being an amazing military doc mean, i know they dont get paid more, but there must be something, what sort of interesting opportunities are there beyond just treating soldiers in a hospital somewhere.

USAFdoc · Dec 27, 2005

Doc.Holliday said:
hah, i know, i just didnt want the worst case scenario, im not saying i'll be the best doc or the best military doc in the world, but i do know that i'll be average at worst. Basically, im fine with the avg military docs experience (though the after part still eludes me). But i was interested to hear what opportunities are out their. So what does being an amazing military doc mean, i know they dont get paid more, but there must be something, what sort of interesting opportunities are there beyond just treating soldiers in a hospital somewhere.

the military will be chomping at the bit to get you, so forget about worrying about "no ROTC" etc.

you have to weigh the financial short term advantage and getting to serve your country vs the long term loss of your own freedom, and are you willing to gamble with the military hoping they will give you the specialty you want,and will you have any quality of life when you serve as a doc.

most docs on this site will tell you to stay away,most students will say"it can't be that bad"....you choose.

pgg · Dec 27, 2005

USAFdoc said:
are you willing to gamble with the military hoping they will give you the specialty you want

I honestly don't think this is a bigger gamble in the military than it is in the civilian world. Almost everyone I knew as a student and intern has wound up in their chosen specialty. I can think of exactly two of my fellow intern classmates who didn't get the residency they wanted after a single GMO tour - and in truth, neither had strong grades or board scores. Had they been civilians, they'd be on track to scramble after not matching.

Sure, there's no possibility to scramble if the military GME board doesn't give you a spot ... but the problem there is a weak application, not military malevolence. The bottom line is that if your grades & board scores aren't good enough to get you the military residency you want, then those grades & board scores were probably going to make getting your preferred civilian residency tough, too. You make it sound as if the military GME selection board forces people into specialties they don't want. They don't - you can always choose to pay back your obligation as a GMO making $70-80K/year before taking a civilian residency.

If you're a competitive applicant, you'll get what you want. If you suck, it's a roll of the dice. What's more, if you suck, the military might even give you a better shot at certain moderately competitive residencies, because you can accumulate GMO points, seniority points, research points, etc and add them to what is essentially a very objective point-based system.

Want to do FP or IM in the Navy? If you've got a pulse and can get through a GMO tour sans court martial, you're in. Want something competitive? You'd better have a strong application, inside or out.

Otherwise, I agree with you on weighing the immediate $ advantage and the benefits of service vs. the lost freedom, potential to get "stuck" as a GMO for a couple years, etc. You have time in service post-residency and a perspective I lack; I respect your views, and so should any potential HPSP/USUHS applicant. There are reasons to avoid a military scholarship, but fear of The Man ordering you into OB/GYN or another field you don't want shouldn't be one of them.

militarymd · Dec 27, 2005

Doc.Holliday said:
I am considering both USUHS and HPSP, but as this is a relatively new consideration, my knowledge of how things would play out is limited. Ive read through this board, and learned a good deal about the time id be required to serve for the two options, and pay etc for each. It seems starting a family is quite possible, if not in some ways easier than as a civilian, and that pay during school and residency, either choice, is a big plus.

I have a few topics however that id greatly appreciate someone in the know to help me with.

-First, the ability to choose my specialty. Right now i dont know what specialty i want for sure, but i have absolutely narrowed it down to family practice, pediatrics, derm, orthopaedic surgery, cardio surgery, or plastic surgery. Long list i suppose, but any specific info on the chances of getting each etc...

-Also, any specific pros/cons as far as quality of experience/education and my options with each of those specialties after serving. Id like to know of both military career options and civilian. What is life like AFTER?

-and lastly, IF i decide this is the right path for me, will my lack of military experience/background be a huge obstacle? I was never in rotc (couldnt in HS, due to academics, and therefore didnt consider it for college, plus im on a full scholarship to a private school anyway, so the money issue was never considered). None of my immediate family is in the military, though the Navy seems to be a common career choice for other relatives (both grandfathers, one being very highly ranked, 3 uncles). My reasons for considering this option are primarily the honor of serving my country, or in this case serving those who serve my country. A long term military career is not out of the question, ive often considered it. I know ~50% of USUHS students had prior military service/experience, and im sure an even higher percentage have fathers/mothers in the military. Is this due mainly to the groups self selection, or is coming from such a background a unspoken requirement?

[edit] To help any advice be more on target, I would consider myself on the exceptional side of the med applicant pool. I am already guaranteed acceptance to a well respected private med school, and am an extremely determined individual. So for the most part, id like more info on the avg to upper ends of possibilities for a future in taking this path, dont try to scare me with worse case scenios. I have always been a succesfulll individual and have no reason to expect any less of my future.

Search and read my posts from dec 2003 forward.

Mirror Form · Dec 27, 2005

pgg said:
I honestly don't think this is a bigger gamble in the military than it is in the civilian world. Almost everyone I knew as a student and intern has wound up in their chosen specialty. I can think of exactly two of my fellow intern classmates who didn't get the residency they wanted after a single GMO tour - and in truth, neither had strong grades or board scores. Had they been civilians, they'd be on track to scramble after not matching.

I'd strongly disagree with you here. I know plenty of people who were unable to match into their chosen specialty (especially with air force), and not always in competitive fields either. I know a decent army applicant who did several years as a GMO but still never got accepted into PMR (since the military only has a couple slots and there seem to always be about 12 applicants). He would have easily matched at a civ program of course. I also know another very strong intern that was greating great evals, but lost his pgy2 slot b/c he failed a PT test.

Also, most of us expect to get deployed for 9 months here and there, but thats a deployment. When you fail to match and get stuck with a duty station in northern south korea, away from your fiance, that's pretty crappy compared to what would happen in the civilian world.

Now there is a flipside of course. Radiology didn't even fill for the army last year, whereas many people in the civ world didn't match. However, all the variability seem pretty risky to me, I think it's safer to take you chances with the civ world, and thereby not get stuck with a gmo tour if you don't match. That's why I think FAP is a better alternative. You're still a military doctor, but you have control over your own training.

pgg said:
Sure, there's no possibility to scramble if the military GME board doesn't give you a spot ... but the problem there is a weak application, not military malevolence.

No, the problem is that if you don't match in the civ world, you have lots of options. Whereas, your options suck if you don't match in the military. You basically have to do a GMO tour. This leaves you with two options. Option A is to freaking do a gmo tour for four years, and then recommence training (meanwhile having the threat of being pulled out of your training). That's a pretty crappy option. Option B is to reapply after your gmo tour. That effectively lengthens your commitment time since you'll re-accrue your obligation during residency. So basically you tend to get screwed either way. Whereas in the civ world, you have lots of options if you don't match. You can do research for one year, or take a prelim year and reapply to pgy2 slots, scramble, etc.

pgg said:
The bottom line is that if your grades & board scores aren't good enough to get you the military residency you want, then those grades & board scores were probably going to make getting your preferred civilian residency tough, too. You make it sound as if the military GME selection board forces people into specialties they don't want. They don't - you can always choose to pay back your obligation as a GMO making $70-80K/year before taking a civilian residency.

yeah, and the fact that that is the best option you have when you fail to match in the military system is part of the reason that the military match is so much more risky.

Basically, my opinion is that the training process for medicine is very long. Therefore, you don't want to take any risks with having your training messed up. FAP avoids the risks.

USAFdoc · Dec 27, 2005

I honestly don't think this is a bigger gamble in the military than it is in the civilian world. Almost everyone I knew as a student and intern has wound up in their chosen specialty. I can think of exactly two of my fellow intern classmates who didn't get the residency they wanted after a single GMO tour - and in truth, neither had strong grades or board scores. Had they been civilians, they'd be on track to scramble after not matching.

I could NOT disagree more. The military option is WAY MORE of a gamble. At least in the civilian path, you have options and are not tied to a decision for up to 10+ years of your life. Only somebody who is still a student could think that the military option is comparable. Again, students will have to choose who they will believe; other students or people that have been all the way through the process, the docs. As a doc, I just want to give you the ability to make an informed decision, the rest is up to you.

Mirror Form · Dec 27, 2005

USAFdoc said:
I can think of exactly two of my fellow intern classmates who didn't get the residency they wanted after a single GMO tour

Perhaps in the old system (and as I mentioned before, that system causes your obligation to increase, so you're still getting screwed). Now that the army has moved to continuous contract for most of it's competitive slots, how are you supposed to get into a field after doing a gmo tour?? Currently, in many specialties, there aren't many any slots available for returning gmo's.

The White Coat Investor · Dec 27, 2005

Doc.Holliday said:
I am considering both USUHS and HPSP,
-First, the ability to choose my specialty. Right now i dont know what specialty i want for sure, but i have absolutely narrowed it down to family practice, pediatrics, derm, orthopaedic surgery, cardio surgery, or plastic surgery. Long list i suppose, but any specific info on the chances of getting each etc...

[edit] To help any advice be more on target, I would consider myself on the exceptional side of the med applicant pool. I am already guaranteed acceptance to a well respected private med school, and am an extremely determined individual. So for the most part, id like more info on the avg to upper ends of possibilities for a future in taking this path, dont try to scare me with worse case scenios. I have always been a succesfulll individual and have no reason to expect any less of my future.

I was laughing at your list of specialties..."absolutely narrowed it down to ....family practice.....cardio surgery." The fact that you have both of these on your list indicates you haven't narrowed anything down, NOR SHOULD YOU HAVE. A personal example:

The match rate for Emergency Medicine is 93% in the civilian world and 50% in the military. 1/2 of the military people I know who wanted to do EM were denied. Other specialties are similar, with the exception of primary care. You probably will change your mind about your specialty during medical school, I certainly did. It is possible that you will become interested in a very competitive specialty like I did. The stress of the regular match is enough, the last thing you want to deal with is the stress of the military match on top of the regular match. You can always sign up for the military in residency if you really want to do it.

Don't forget the other downsides of HPSP besides the very real possibility of getting hosed in the match:

1)You may come out financially behind if you go into a high paying specialty and/or go to a cheap med school.
2) You will have to deal with the problems of military medicine (read extensive discussions on this site about this problem)
3) Boot camp. No, it's not that bad, but I can think of another use for those 4 weeks.
4) Deployments (4 month all expense paid vacation to hot sandy beaches, without the water.)
5) Minimal choice of location of practice (talking about where you get stationed, most of the time.)
6) High chance of having to train in a military residency (Again, search this site extensively.) As one who spent time at both military and civilian residencies, there is a quality difference. No, military residencies may not be the very worst residencies in the country, but they're nowhere near the top, an important consideration for a person who is "on the exceptional side of the med applicant pool."

island doc · Dec 28, 2005

Desperado said:
I was laughing at your list of specialties..."absolutely narrowed it down to ....family practice.....cardio surgery." The fact that you have both of these on your list indicates you haven't narrowed anything down, NOR SHOULD YOU HAVE. A personal example:

The match rate for Emergency Medicine is 93% in the civilian world and 50% in the military. 1/2 of the military people I know who wanted to do EM were denied. Other specialties are similar, with the exception of primary care. You probably will change your mind about your specialty during medical school, I certainly did. It is possible that you will become interested in a very competitive specialty like I did. The stress of the regular match is enough, the last thing you want to deal with is the stress of the military match on top of the regular match. You can always sign up for the military in residency if you really want to do it.

Don't forget the other downsides of HPSP besides the very real possibility of getting hosed in the match:

1)You may come out financially behind if you go into a high paying specialty and/or go to a cheap med school.
2) You will have to deal with the problems of military medicine (read extensive discussions on this site about this problem)
3) Boot camp. No, it's not that bad, but I can think of another use for those 4 weeks.
4) Deployments (4 month all expense paid vacation to hot sandy beaches, without the water.)
5) Minimal choice of location of practice (talking about where you get stationed, most of the time.)
6) High chance of having to train in a military residency (Again, search this site extensively.) As one who spent time at both military and civilian residencies, there is a quality difference. No, military residencies may not be the very worst residencies in the country, but they're nowhere near the top, an important consideration for a person who is "on the exceptional side of the med applicant pool."

How true this is! I know firsthand. I was an ER GMO already classified and working as an "emergency services physician", yet was rejected for a military EM residency!!!

pgg · Dec 29, 2005

Sledge2005 said:
I know a decent army applicant who did several years as a GMO but still never got accepted into PMR (since the military only has a couple slots and there seem to always be about 12 applicants). He would have easily matched at a civ program of course.

OK ... so he does a 4th year as a GMO, finishes his obligation, and gets a civilian program.

Sledge2005 said:
I also know another very strong intern that was greating great evals, but lost his pgy2 slot b/c he failed a PT test.

Oh, well, no sympathy there. It's not like the standards or the consequences of failing are kept secret.

Perhaps I should clarify that my observations are coming from the Navy side of military GME. I don't know the first thing about Army or Air Force match rates, categorical internships, the chances of getting a residency after a GMO tour, etc. I still contend that any HPSP'er can get whatever residency he wants and is academically qualified for - if he's willing to wait for it. Sometimes that means waiting 4 years and getting out of the military.

You and others bring up GMO tours as universally undesirable, as if the horror of being a GMO is self evident.

I'd only recommend the military to a prospective applicant if he thinks he'd be happy serving as a GMO. I don't think one should choose military medicine for the up-front money ... the people who are going to be happiest are the ones who join because taking care of the E2 with a rifle is rewarding in its own right. For those people, a GMO tour is an opportunity, not an inconvenience.

usnavdoc · Dec 29, 2005

pgg said:
You and others bring up GMO tours as universally undesirable, as if the horror of being a GMO is self evident.

I'd only recommend the military to a prospective applicant if he thinks he'd be happy serving as a GMO. I don't think one should choose military medicine for the up-front money ... the people who are going to be happiest are the ones who join because taking care of the E2 with a rifle is rewarding in its own right. For those people, a GMO tour is an opportunity, not an inconvenience.

For the vast majority of doctors and med students a GMO tour is undesirable. And a large percentage of us were never given the full story by the recruiters. That is why I think it is important to give the other side of things to would be applicants.

Taking care of the E2 with the rifle is not always that exciting or rewarding. Like today having sent a Marine to prev med for the 9th time for an STD.

Most of us make the best of our GMO time. And for me personally if I had not done a gmo tour I would probably have changed residencies or been a very unhappy general surgeon. So having the time to decompress and find anesthesiology was nice. Especially now since I get out in a few months.

orbitsurgMD · Dec 31, 2005

usnavdoc said:
For the vast majority of doctors and med students a GMO tour is undesirable. And a large percentage of us were never given the full story by the recruiters. That is why I think it is important to give the other side of things to would be applicants.

Taking care of the E2 with the rifle is not always that exciting or rewarding. Like today having sent a Marine to prev med for the 9th time for an STD.

Most of us make the best of our GMO time. And for me personally if I had not done a gmo tour I would probably have changed residencies or been a very unhappy general surgeon. So having the time to decompress and find anesthesiology was nice. Especially now since I get out in a few months.

Taking care of the E2 with the rifle is one thing. Doing that with the barest minimum amount of residency training, poor backup in many cases, poor educational support and in an uncertain status as to when you will be able to resume your training is something else. You may find your GMO experience exhilirating and liberating. Indeed, it may give you a different enough perspective on medicine that you will change your career plans. That still doesn't make this kind of assignment ethical or desirable.

Most doctors are highly disciplined, hard-working and resourceful, and military doctors particularly so (despite the laughable hairsplitting some do). Making the best of a GMO assignment is what most in that situation will do. Most doctors will have no negative clinical experiences during their GMO service; the statistical bias of caring for a physically-screened and young patient population favors you, trauma and youthful stupidity notwithstanding. But assuming that you were adequately prepared for that responsibility just because you managed not to get into trouble is a fallacy, it is failing to know that you don't know.

The GMO tour should be seen as undesirable because it is unethical. It is an improper assignment of an incompletely trained physician by an organization that has the resources but not the will to do differently and better by its doctors and their patients. The real shame is just how many senior medical corps officers persist in endorsing this use of personnel. Theirs is a failing of moral courage, but one which hasn't escaped the observation of their juniors.

pgg · Dec 31, 2005

orbitsurgMD said:
Taking care of the E2 with the rifle is one thing. Doing that with the barest minimum amount of residency training, poor backup in many cases, poor educational support and in an uncertain status as to when you will be able to resume your training is something else.

[...]

But assuming that you were adequately prepared for that responsibility just because you managed not to get into trouble is a fallacy, it is failing to know that you don't know.

The GMO tour should be seen as undesirable because it is unethical. It. is an improper assignment of an incompletely trained physician by an organization that has the resources but not the will to do differently and better by its doctors and their patients. The real shame is just how many senior medical corps officers persist in endorsing this use of personnel. Theirs is a failing of moral courage, but one which hasn't escaped the observation of their juniors.

That's an interesting perspective, but one that doesn't mesh with the experiences I've had personally. I have been adequately prepared for the responsibility I have - hell, a PA could do my job (and should, IMO, if the Navy had any sense).

The crux of your argument seems to be that it's unethical to stick a non-residency-trained physician in a GMO's job because of the lack of backup in some cases. I've never been without reasonable support, and I make use of it frequently.

In garrison - Camp Lejeune - there's fantastic backup and support at the Naval hospital there. Specialty consults or just a chat with IM or FP are a phone call away and they're always happy to help. I don't need to be residency trained to handle sprained ankles and URIs. Hell, 80% of my sick call is handled by my IDC.

They're starting to push FP doctors out to the regimental surgeon positions. Here, in Iraq, the regimental surgeon (my immediate superior on the medical side), is an FP. I think a better system, at least for Marine units, would be FPs at each regiment supervising PAs at the battalion level.

In Afghanistan last year, I was at two bases (Bagram and Salerno) that had field hospitals with surgeons, ER doctors, anesthesiologists and/or CRNAs, etc. For short periods I was at more secluded compounds where it was just me, but it was never any problem to refer someone to a specialist if I wanted to.

In Iraq this year, my battalion is colocated with a shock trauma platoon - two surgeons, two anesthesiologists, an ER physician ... frequently other surgeons stop by also to augment them during operations. The other GMO with my unit is at a smaller compound about 10 miles from us where he's the only physician - but again, he's 30 minutes away from support here.

Even though I've enjoyed being a GMO, I personally think that GMO tours are a bad idea because they're a foolish way for the Navy to squander payback years. I owe 7 years of service for USUHS. If I'd gone straight through to residency, the Navy would've had at least 7 years of my service as an anesthesiologist. Instead, I've done 3 years of duty that could have been easily done by a PA, and the Navy is only assured of getting 4 years of my time as an anesthesiologist.

GMO tours are a waste of resources, but I don't see them as being unethical. The job we're asked to do is well within the capabilities of an intern, provided appropriate backup is there. I've always had that backup, in garrison, and on two deployments.

I disagree your assertion that I was inadequately prepared for my job as a Marine GMO - again, a PA could do my job with minimal supervision. Every GMO has a state-issued license to practice medicine. If you really think we're not qualified to do the basic, basic primary care we're asked to do, then perhaps your concerns would be better addressed at the level of state medical boards.

I fully recognize that I'm a glorified intern, and live/practice with an appropriate level of humility and fear of stepping outside the bounds of what I know.

Mirror Form · Jan 1, 2006

pgg said:
OK ... so he does a 4th year as a GMO, finishes his obligation, and gets a civilian program.

Oh yeah, sure! Who cares if your training is interrupted for four years to do something you find miserable and unethical

And you're also ignoring the fact that he could be called back up out of residency. That makes him a much less desirable applicant when he does enter the civilian match.

pgg said:
Oh, well, no sympathy there. It's not like the standards or the consequences of failing are kept secret.

Very true, but residents don't have a greater need to be in shape then GMO's. So it's just ridiculous. And for some people with certain builds, it can be tough to stay in passing shape during intern year when working out isn't your priority.

pgg said:
I still contend that any HPSP'er can get whatever residency he wants and is academically qualified for - if he's willing to wait for it. Sometimes that means waiting 4 years and getting out of the military.

So what's your opinion of how army seems to be moving toward continuous contracts? Almost every available slot in most specialties who's pgy2 slot begins in 7/07 are already filled by med students. So how is a GMO supposed to match into a residency program if there are no available slots?

Don't forget the first rule about joining the military . . . things can always change.

pgg said:
You and others bring up GMO tours as universally undesirable, as if the horror of being a GMO is self evident.

The vast majority of med students and interns don't want to do a GMO tour. Do you disagree with that?

pgg · Jan 2, 2006

Sledge2005 said:
Oh yeah, sure! Who cares if your training is interrupted for four years to do something you find miserable and unethical

Gee, that's just too ****ing bad. People who think that spending time as a GMO would be miserable and unethical shouldn't have accepted an HPSP scholarship in the first place. And the ones who bleat "I didn't know!" should have spent a little more time looking into the consequences of accepting a $100K+ "gift" before agreeing.

Any person who accepted an HPSP scholarship without taking the time to visit a MTF, look at one of the places they were agreeing to work, talk to staff/residents/interns/students, and get clued in on potential career paths in the military ... that kind of idiocy is its own reward.

And that is the extent of my sympathy or pity.

Sledge2005 said:
Very true, but residents don't have a greater need to be in shape then GMO's. So it's just ridiculous. And for some people with certain builds, it can be tough to stay in passing shape during intern year when working out isn't your priority.

Yeah, wearing a uniform that doesn't look like crap, saluting superior officers, etc, that's all ridiculous too. I didn't say it was easy for everyone - just that you're obligated to do it because you're an officer.

Those standards aren't negotiable because you're a doctor, or a radio operator, or nuclear engineer on a missile sub, or paper-pushing admin pogue. And if you blow them off because you think they're inconvenient or ridiculous, it will affect your military career - including military GME.

Sledge2005 said:
So what's your opinion of how army seems to be moving toward continuous contracts? Almost every available slot in most specialties who's pgy2 slot begins in 7/07 are already filled by med students. So how is a GMO supposed to match into a residency program if there are no available slots?

I think the Navy should do away with GMOs too. It's a waste of resources - it's foolish to squander years of MD obligated service by having GMOs do a PA's job, when the obvious alternative is to finish training them and have them serve their time as a surgeon, anesthesiologist, etc.

I owe the Navy 7 years for USUHS. The Navy chose to have me serve as a GMO for 3, and an anesthesiologist for 4. Especially considering how much trouble the Navy is having keeping anesthesiologists, that's just stupid.

I don't know much about how the Army does things, but it certainly seems unfair to tell a returning GMO that he needs to stay a GMO because there are no slots available. The smart thing to do would be to offer them deferments if Army residency slots are full - and then take advantage of their fully-trained services later.

Sledge2005 said:
Don't forget the first rule about joining the military . . . things can always change.

I think the problem a lot of HPSP'ers have in the first places is that they forgot they joined the military, which has objectives that don't revolve around what's best for the individual.

Sledge2005 said:
The vast majority of med students and interns don't want to do a GMO tour. Do you disagree with that?

Of course not. I didn't want to do a GMO tour either - though it turned out that I enjoyed it very much.

Mirror Form · Jan 2, 2006

pgg said:
Gee, that's just too ****ing bad. People who think that spending time as a GMO would be miserable and unethical shouldn't have accepted an HPSP scholarship in the first place. And the ones who bleat "I didn't know!" should have spent a little more time looking into the consequences of accepting a $100K+ "gift" before agreeing.

Well, since many recruiters play down the liklihood of doing a GMO, what we have is our current situation. If the military recruiters were more honest about GMO tours, we'd probably have even more trouble recruiting doctors.

pgg said:
Any person who accepted an HPSP scholarship without taking the time to visit a MTF, look at one of the places they were agreeing to work, talk to staff/residents/interns/students, and get clued in on potential career paths in the military ... that kind of idiocy is its own reward.

I bet the majority of all people who accepted HPSP scholarships didn't have a chance to visit a military MTF. And even if they did, it's not as though "life at walter reed" is anything like "life at the northern most station of south korea." Although it's a convenient way to justify your POV!

pgg said:
I don't know much about how the Army does things, but it certainly seems unfair to tell a returning GMO that he needs to stay a GMO because there are no slots available. The smart thing to do would be to offer them deferments if Army residency slots are full - and then take advantage of their fully-trained services later.

Yeah, but do you really think that's going to happen?

USAFdoc · Jan 2, 2006

pgg said:
That's an interesting perspective, but one that doesn't mesh with the experiences I've had personally. I have been adequately prepared for the responsibility I have - hell, a PA could do my job (and should, IMO, if the Navy had any sense).

The crux of your argument seems to be that it's unethical to stick a non-residency-trained physician in a GMO's job because of the lack of backup in some cases. I've never been without reasonable support, and I make use of it frequently.

In garrison - Camp Lejeune - there's fantastic backup and support at the Naval hospital there. Specialty consults or just a chat with IM or FP are a phone call away and they're always happy to help. I don't need to be residency trained to handle sprained ankles and URIs. Hell, 80% of my sick call is handled by my IDC.

They're starting to push FP doctors out to the regimental surgeon positions. Here, in Iraq, the regimental surgeon (my immediate superior on the medical side), is an FP. I think a better system, at least for Marine units, would be FPs at each regiment supervising PAs at the battalion level.

In Afghanistan last year, I was at two bases (Bagram and Salerno) that had field hospitals with surgeons, ER doctors, anesthesiologists and/or CRNAs, etc. For short periods I was at more secluded compounds where it was just me, but it was never any problem to refer someone to a specialist if I wanted to.

In Iraq this year, my battalion is colocated with a shock trauma platoon - two surgeons, two anesthesiologists, an ER physician ... frequently other surgeons stop by also to augment them during operations. The other GMO with my unit is at a smaller compound about 10 miles from us where he's the only physician - but again, he's 30 minutes away from support here.

Even though I've enjoyed being a GMO, I personally think that GMO tours are a bad idea because they're a foolish way for the Navy to squander payback years. I owe 7 years of service for USUHS. If I'd gone straight through to residency, the Navy would've had at least 7 years of my service as an anesthesiologist. Instead, I've done 3 years of duty that could have been easily done by a PA, and the Navy is only assured of getting 4 years of my time as an anesthesiologist.

GMO tours are a waste of resources, but I don't see them as being unethical. The job we're asked to do is well within the capabilities of an intern, provided appropriate backup is there. I've always had that backup, in garrison, and on two deployments.

I disagree your assertion that I was inadequately prepared for my job as a Marine GMO - again, a PA could do my job with minimal supervision. Every GMO has a state-issued license to practice medicine. If you really think we're not qualified to do the basic, basic primary care we're asked to do, then perhaps your concerns would be better addressed at the level of state medical boards.

I fully recognize that I'm a glorified intern, and live/practice with an appropriate level of humility and fear of stepping outside the bounds of what I know.

there are many states that do have laws discussing how PAs should be used. Rules such as new patients and patients with new chronic dz diagnosis must be seen first by a physician.

Can a PA, even a new PA do many of the things I do as a physician, absolutely. But the wider truth is many office visits are medically speaking, uneccessary, the patient would do fine with or without treatment. It is those 10% of patients that really benefit from a doctor with experience, sometime that experience can save a life, sometimes save a lawsuit. How many civilian docs go right from medical school to practicing on their own? ONLY, ONLY in the military does such a disservice to the docs and patients happen.

Using GMOs, and unsupervised PAs is gambling with the health of the patients. Now granted that most of the time that gamble will not have dire consequences, I still would not let my parents be the patient of a GMO or an unsupervised PA, nor would I recommend it to anyone. If that is the best there is, well ok, but my question is WHY IS THAT THE BEST THE MILITARY CAN DO? They could just as easily redesign the system with residency trained docs.

orbitsurgMD · Jan 2, 2006

USAFdoc said:
there are many states that do have laws discussing how PAs should be used. Rules such as new patients and patients with new chronic dz diagnosis must be seen first by a physician.

Can a PA, even a new PA do many of the things I do as a physician, absolutely. But the wider truth is many office visits are medically speaking, uneccessary, the patient would do fine with or without treatment. It is those 10% of patients that really benefit from a doctor with experience, sometime that experience can save a life, sometimes save a lawsuit. How many civilian docs go right from medical school to practicing on their own? ONLY, ONLY in the military does such a disservice to the docs and patients happen.

Using GMOs, and unsupervised PAs is gambling with the health of the patients. Now granted that most of the time that gamble will not have dire consequences, I still would not let my parents be the patient of a GMO or an unsupervised PA, nor would I recommend it to anyone. If that is the best there is, well ok, but my question is WHY IS THAT THE BEST THE MILITARY CAN DO? They could just as easily redesign the system with residency trained docs.

The simple fact that it is just about impossible now to join the staff at any respectable community hospital (never mind tertiary center) without at least being board-eligible is evidence both of how wide the departure has now become between the practices of the military services' medical corps and the broader medical community and of how indifferent the services have become to what should be the minimum level of training for a physician to practice.

A GMO is not even really an intern in staff clothing. House officers are closely supervised by well-qualified senior house officers and by the covering staff attending. Their actions and their management are reviewed daily by their seniors. They are never put in the position of GMOs. If it is professionally unacceptable to leave a PGY2 resident uncovered and unsupervised, why is it somehow different for a physician who has been permitted to complete only one year of GME?

The state license saw is an old one and irrelevant. No one in any position of professional respectability and responsibility would consider a physician's having a state license as sufficient evidence of his professional qualification to practice. Sure, you won't get prosecuted for being an unlicensed practitioner, but the general standards for training and requirements for hospital privileges have long ago exceeded state law standards. Most state licensing laws are antiquated (except for CME, an irony). The fact that most have not been changed only points to the fact that these most minimum requirements are so far below the common and expected standards for training that changing them is not seen as particularly important. In the civilian world in the community, patients rarely encounter a physician who has not at least become board-eligible.

What is particularly unfortunate is how the services exploit this difference, even offering up to their public the chestnut that all their doctors are fully licensed, as if that were some sort of special claim instead of the simple fact that they had not yet stooped to making their patients see unlicensed physicians. That is chutzpah that borders on depravity. The truth is that most military healthcare beneficiaries, including a surprising number of senior line officers, are utterly clueless about the process of medical education and training and what qualifications matter and which are expected but have no special merit. They think that if you have a medical degree and the military put you in that job, then everything must be OK, and that is exactly what the services want them to think.

deuist · Jan 2, 2006

orbitsurgMD said:
The GMO tour should be seen as undesirable because it is unethical. It is an improper assignment of an incompletely trained physician by an organization that has the resources but not the will to do differently and better by its doctors and their patients. The real shame is just how many senior medical corps officers persist in endorsing this use of personnel. Theirs is a failing of moral courage, but one which hasn't escaped the observation of their juniors.

Here, here! I don't why the military wants to spend all that money on a physician, only to treat him like a glorified PA. The whole reason I went to medical school was to become a specialist.

I noticed that an earlier poster mentioned that EM (my top choice) has a low match rate. Are there any specialties that are reversed from the civilian world to being made less competitive---e.g., someone wrote that the army's rads slots didn't fill?

pgg · Jan 4, 2006

USAFdoc said:
They could just as easily redesign the system with residency trained docs.

How? By "redesign" the system, I take it you mean they should eliminate GMOs and replace them with board certified physicians. Where are they going to come from?

If you need N physicians to serve in GMO billets, and you instead choose to take your N physicians and put them through residency before sending them to be flight surgeons or Marine battalion surgeons ... you're not going to wind up with N primary care physicians. A minority of them are going to go into FP or internal medicine. Then what?

Are you going to assign general surgeons, obstetricians, pathologists, anesthesiologists, etc to GMO duty so they can treat sprained ankles and URIs? Are you going to reshape military GME such that more FPs and fewer ophthalmologists are trained, in order to meet your operational needs? That's even worse than the current situation in terms of wasted resources, and unfair to those physicians who'd be unwillingly shoved into primary care residencies.

How could you redesign the current Navy GMO system in a way that puts FP/IM trained physicians in every billet, without drastically increasing the number of physicians in the military, or condemning radiologists to treating STDs and low back pain?

PAs make perfect sense for the medical officer billet of a Marine infantry battalion, provided there's appropriate backup available. I, as a GMO, have never been without residency-trained backup. I'm sitting in a desert wasteland right now, arguably one of the most austere environments imaginable, and have five residency-trained physicians within shouting distance of me. The other GMO in my battalion is "on his own" about 10 miles from here.

The truth is that GMOs have done just fine at this job for many years, and there's no reason that a PA couldn't do it just as well.

USAFdoc · Jan 4, 2006

pgg said:
How? By "redesign" the system, I take it you mean they should eliminate GMOs and replace them with board certified physicians. Where are they going to come from?

If you need N physicians to serve in GMO billets, and you instead choose to take your N physicians and put them through residency before sending them to be flight surgeons or Marine battalion surgeons ... you're not going to wind up with N primary care physicians. A minority of them are going to go into FP or internal medicine. Then what?

Are you going to assign general surgeons, obstetricians, pathologists, anesthesiologists, etc to GMO duty so they can treat sprained ankles and URIs? Are you going to reshape military GME such that more FPs and fewer ophthalmologists are trained, in order to meet your operational needs? That's even worse than the current situation in terms of wasted resources, and unfair to those physicians who'd be unwillingly shoved into primary care residencies.

How could you redesign the current Navy GMO system in a way that puts FP/IM trained physicians in every billet, without drastically increasing the number of physicians in the military, or condemning radiologists to treating STDs and low back pain?

PAs make perfect sense for the medical officer billet of a Marine infantry battalion, provided there's appropriate backup available. I, as a GMO, have never been without residency-trained backup. I'm sitting in a desert wasteland right now, arguably one of the most austere environments imaginable, and have five residency-trained physicians within shouting distance of me. The other GMO in my battalion is "on his own" about 10 miles from here.

The truth is that GMOs have done just fine at this job for many years, and there's no reason that a PA couldn't do it just as well.

rebuttle;
1)if you are a PA or GMO and you have back-up (right there) great. That works for me, especially if you are seeing sprained ankles and not new diabetics.
2)there will be "pain" to initially start to use physicians instead of "GMOs" or interns, to be peoples doctors (where appropriate). This will mean there will be more board certified physicians in the military; that is a good thing. It will take a few years of not pulling docs out of training early. That will mean the military will have to get other propperly selected docs to fill those spots for that time. It will cost some $$ but care will be better and morale better. You simply design the system to NOT use docs until they are finished with their training; wow, what a concept, allow training to be finished before you are placed in the position!
3) of course I would not use surgeons or OB docs to fill "GMO" slots.
4) if the military had done this right the first time, we would not be in this position.
5)a gradual replacement would likely be more feasible, with less strain.

pgg · Jan 4, 2006

USAFdoc said:
rebuttle;
1)if you are a PA or GMO and you have back-up (right there) great. That works for me, especially if you are seeing sprained ankles and not new diabetics.
2)there will be "pain" to initially start to use physicians instead of "GMOs" or interns, to be peoples doctors (where appropriate). This will mean there will be more board certified physicians in the military; that is a good thing. It will take a few years of not pulling docs out of training early. That will mean the military will have to get other propperly selected docs to fill those spots for that time. It will cost some $$ but care will be better and morale better. You simply design the system to NOT use docs until they are finished with their training; wow, what a concept, allow training to be finished before you are placed in the position!
3) of course I would not use surgeons or OB docs to fill "GMO" slots.
4) if the military had done this right the first time, we would not be in this position.
5)a gradual replacement would likely be more feasible, with less strain.

Fair enough, I can't argue with any of that.

But what you're really advocating is more physicians in the military, which is somewhat different than your initial statement that a simple redesign was all that was needed. What's needed is more money. More money because residency-trained doctors for the infantry cost more than GMOs, more money because you won't keep existing doctors without it, and more money because you won't recruit more doctors without it.

At least for the Marine Corps billets, I still think that two physicians (of any flavor) is more than 800 healthy 20-24 year olds need. PAs with backup in the form of an FP trained doctor at the regimental level, or a PA+FP at the battalion level seems appropriate.

pgg · Jan 4, 2006

USAFdoc said:
1)if you are a PA or GMO and you have back-up (right there) great. That works for me, especially if you are seeing sprained ankles and not new diabetics.

Oh, and one other comment.

I have seen (one) new diabetic, and I referred him to int med. I've also been unlucky enough to have had four cancers present in the last two years (a 22 yo with esophageal adenocarcinoma, a 21 yo with ALL, and two testicular cancers), and I referred all of them, too.

I've seen a number of cases that were beyond my ability and qualifications to manage myself, and I referred them all. The ability to recognize that a referral is necessary is not something a PA can't learn too.

HumptyDumptyMil · Jan 4, 2006

I'm just glad to hear that the system is working somewhat successfully in the military, like in the case of pgg.

Is there any other specialists out there who can share their experiences? Many of the threads seem to be focused on how the primary care setting is not so great...

USAFdoc · Jan 4, 2006

some background on USAF primary care; the USAF "sold their soul" to Humana, the TRICARE "rep" that was the lowest bidder to run our "HMO" style of medicine. This placed decision making that directly effects manning and patient care in the hands of civilians who have $$$$$$$$$$$$ as the major focus and have no clue as to what is actually going on in the clinics. Primary Care Optimization was our Surgeon Generals failed plan to rework primary care in the USAF. basically it was a plan to see "how much more" you can do "with how much less". Specialist, Dental etc. are planned to undergo similar "optimizations" in the future. Other services (USN, Army etc) are also considering the USAF model and staffing. As I separated, USAF docs had on paper, numbers of about 1600 patients per doc (in reality about 3000 + due to missing docs being covered). Other services had about 700 patient (USN) and 1000 patients (Army) at that time.

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