FYI: article on retention of neurosurgeon in the military. Much of the info relates to other specialties as well;
http://www.medscape.com/viewarticle/433291_4
Retention of Neurosurgeons
Retention of active-duty, experienced, productive neurosurgeons has historically been extremely difficult. Although many outstanding neurosurgeons have come through the military, they rarely stay beyond their training commitment. The high quality of military neurosurgeons is clearly reflected by their career paths after leaving active service. Many leaders of neurosurgery, both in the academic and the private practice arenas, have begun their neurosurgical careers in uniform.
There are many reasons why neurosurgeons do not continue to serve the military once their service obligation for training has ended. The most obvious is the extreme pay gap between the standard civilian neurosurgery practice and military practice. When an active-duty uniformed neurosurgeon finishes residency training, he/she becomes a major in the Air Force and Army, or a lieutenant commander in the Navy, and his/her total pay and allowances is approximately $100,000 per year. If that neurosurgeon serves a full 20-year career and advances to full colonel or Navy captain, then he/she can expect a yearly salary of approximately $150,000.[1] He or she can then retire with a pension of approximately $40,000 to 45,000 per year, which is then adjusted for inflation.[1] From data obtained from 2001 the MGMA Physician Compensation and Production Survey and the 2001 MGMA Academic Practice Faculty Compensation and Production Survey, the median salary of a private-practice neurosurgeon in the US is $410,593. The median salary for a neurosurgeon in an academic position is $275,000. According to Physician Search, an online medical manpower recruiter, in 2000 the mean salary for all neurosurgeons at least 3 years out of training practicing in the US was $438,000.
Military pay is broken down into three components. Basic Pay, the base salary for any military officer, is based on rank and time in service. Two bonuses include Medical Specialty Pay, which is $15,000 given yearly to all physicians, and ISP, which is an additional bonus based on medical specialty. The ISP is currently $36,000 for neurosurgeons. A third bonus option is the Multi-year Additional Specialty Pay, which ranges from $8,000 to 14,000 per year for those who agree to remain in uniform 2 to 4 years beyond any prior service obligation. There are also nontaxable allowances such as Basic Allowance for Subsistence, Basic Allowance for Quarters, and Variable Housing Allowance, which provide additional funds for housing in areas in which the cost of living is higher than average. For those that live overseas and are affected by currency fluctuations, there is Cost of Living Allowance that changes every 2 weeks based on the exchange rate between the US dollar and the local currency. All military members receive the same allowances based on rank and duty station. Other benefits include the aforementioned retirement plan, free health care, reasonable dental and life insurance packages, and a newly authorized thrift savings retirement plan option. Unfortunately, all the neurosurgery-related professional fees, organizational dues, and journals, must be paid by the individual neurosurgeon, further decreasing the military neurosurgeon's actual salary.
Prior to the mid-1980s all military officers were paid approximately the same for rank and time in service. Largely through the work of neurosurgeons Captain Robert Harris, MC USN(ret), and Colonel Eugene George, MC USA(ret), the ISP described was instituted to decrease the wide pay gap that made retention impossible, especially for the surgical subspecialties. The actual pay total was varied based on the subspecialty and the relative need for that subspecialty throughout the services. Congress mandated that the highest yearly amount any specialty group could receive was $36,000. The bonus pay did serve to improve morale within the neurosurgical ranks, but in reality it was inadequate to bridge the wide pay gap. Neither recruitment nor retention was significantly improved. Since that time many other subspecialties have received increases in the ISP to the maximum rate. Because this maximum rate has not increased over the last 15 years, most surgical subspecialists and many nonsurgeons currently receive the same level of compensation as the neurosurgeon. One decade ago the Army had 28 practicing neurosurgeons on active duty; today, because of retention difficulty, there are 17.
When there is a shortage of neurosurgeons in service, contracts are given to civilian neurosurgeons. These contracts are usually quite reasonable, as yearly salaries range from $300,000 to 400,000. Although essential for the delivery of care, these contracts frequently have a detrimental effect on morale for the uniformed neurosurgical personnel. Civilian-contract neurosurgeons often have restricted duty hours and fewer administrative duties, no readiness requirements, and no deployment responsibilities despite the fact that they receive substantially higher reimbursement.
Another factor affecting the retention of neurosurgeons in the Armed Forces is the lack of support personnel, such as nurses, physician assistants, and administrative assistants. Because military neurosurgeons must complete many routine clerical duties themselves, their efficiency as surgeons is decreased compared with their colleagues in the civilian world. The average civilian neurosurgeon performs approximately 250 procedures a year. In the military most neurosurgeons perform only 100 to 200 procedures. This is largely the result of operating room time limitations and the decreased support infrastructure, which burden the neurosurgeon with routine administrative obligations associated with the care of each patient. Typically there are three to four support personnel per each neurosurgeon in an efficient civilian practice. In many military treatment facilities, one clerical person supports two to four neurosurgeons. Neurosurgeons frequently type their own letters and clean their own examination rooms. Although these duties clearly need to be performed, a neurosurgeon can be much more efficient if allowed to spend more time directly care for patients. Such inefficiencies are detrimental to the morale of neurosurgeons who have been trained to be very efficient and effective. Recent experience at Walter Reed Army Medical Center revealed that with the addition of physician assistants, nurse practitioners, and nurse case managers, the efficiency of the neurosurgical service increased dramatically without an increase in the number of neurosurgeons. In most medical communities, neurosurgeons are seen as revenue generators and accordingly are provided with support infrastructure. The fixed budgetary realm of military medicine is sometimes challenged by the expense of supporting complex neurological services with equipment and personnel. Fortunately, the hospital commanders uniformly desire to provide quality state-of-the-art care to all the patients, and the military neurosurgeon will generally be supported in efforts to obtain equipment and resources.
Although the slow bureaucratic processes remain a frequent source of dissatisfaction, most MTFs at which neurosurgeons practice are superbly equipped with state-of-the-art equipment and instrumentation.
More recently, surgery-related case volume has become an issue in some military hospitals. Because the new TRI-CARE program of care and because of a fleet of aging medical transport aircraft, some neurosurgical cases traditionally performed in military MTFs have been undertaken instead by civilian neurosurgeons. This process has evolved differently depending on locations and has contributed to downsizing and even eliminating neurosurgical care at some military hospitals. In a few isolated instances, newly graduated military neurosurgeons have found difficulty accumulating adequate cases to qualify for the oral boards. Low case volume also has implications regarding maintenance of competency. Just as the aviators must keep flying to hone their skills, neurosurgeons must perform a reasonable number of procedures to maintain surgical capabilities. In some isolated commands, the issue may be more related to a lack of operating room availability than patient caseload.
With decreased retention there are fewer individual neurosurgical bodies to meet operational and deployment requirements, which increases the deployment rate for those few on active duty, resulting in more time spent away from family and practice. Some deployment and overseas assignments can be seen as desirable, but others are significantly less desirable. Many neurosurgeons consider the increased deployment tempo a significant disincentive to being in the military.
At present there are only three O-6 (colonel in Army and Air Force or captain in Navy) neurosurgeons on active duty, of whom only one is in full-time clinical practice. Because no neurosurgeons stay beyond their training obligation and because those with training obligations come right after training, only 12 of the 38 active-duty neurosurgeons are board certified. Clearly, the military lacks adequate staffing with senior neurosurgeons who offer the complex and critical corporate knowledge of military neurosurgical experience. The Society of Medical Consultants to the Armed Forces strives to bring that experience and expertise to the Army, Navy, and Air Force Surgeons General. This is a dedicated group representing experienced senior military and civilian physicians from all specialties who meet annually to advise the Surgeons General and senior service leadership on military medical-related matters. A number of civilian neurosurgeons and one active military neurosurgeon are currently members of this society.
