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Decisions decisions (apologies for the long post)

Discussion in 'Military Medicine' started by Dr. Dukes, Mar 9, 2007.

  1. Dr. Dukes

    2+ Year Member

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    So, its come time (more or less) to make a decision on where I go to Med School. It has come down to USUHS vs. New York Medical College. This is obviously a big difference in commitment between USUHS (4 years school + residency & fellowship+ payback for school and fellowship) and NYMC (4 years school). I've posted my thoughts on USUHS and the decision below, any comments would be appreciated.

    Since I was little I have been very interested in the military, and always thought/wondered what a career in the Army would "look like". When it came time to apply to college I didn't apply to the service academies because I wasn't a competative applicant. As I got closer to making the decision to applying to med school, I started to think about HPSP and USUHS. I quickly decided against doing HPSP for two reasons: 1) I don't need the money to pay for school, and 2) I'm planning on doing surgery residency andd fellowship, which would make my commitment much longer (after all the payback I would owe 1 year less from HPSP than USUHS, but I would have taken in a lot less money). As such, FAP also doesn't make much sense, cause I won't have loans to fork over to the Army.

    I applied to USUHS for two main reasons. I think a career as an Army physician would be increadibly interesting and rewarding, and I like several aspects of their curriculum.

    However, from reading this forum and from the Walter Reed scandal (sic) I have several concerns. As a civilian surgeon it is quite possible I will move several times (med school -> residency -> fellowship -> my "real" job). However, these moves will be on my terms. If I am moved by the Army to a base for a couple of years to be a general surgeon between residency and fellowship, and then somewhere after fellowship, that would be fine and wouldn't bug me. However, if I am PCSed every year, or sent to Alaska or somewhere I didn't want, I could see myself getting very disillusioned very quickly. The Walter Reed thing has scared me because the "good name" of Army healthcare (patient care) is being dragged through the mud because of an administrative nightmare. I know I will be a skilled and competent doc, and I worry about my reputation as a care giver being sullied by the non patientcare aspects of healthcare. Deployments aren't that big a deal to me, I get that being in the Army means I can be deployed.

    My real problem is this: I have a choice between USUHS and NYMC. Had I just gotten into USUHS, I would go without reservation and I would enjoy it. Had I not gotten into USUHS I would go to NYMC without reservation and I would enjoy it.

    Any constructive comments are much appreciated. I respect and admire everyone in uniform and your opinions, and am simply trying to gather as much info as I can before I make this decision.
    Thank you very much,
     
  2. R-Me-Doc

    R-Me-Doc Now an X-R-Me-Doc
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    First of all, congrats on your acceptances.

    I bet there are a lot of people running these same thoughts through their minds right now. I understand your dilemma: very pricey civilian school where I am in debt up to my ears vs a place where they pay me to go. (Although I'm not sure why you'd apply to USUHS if you had no interest in HPSP . . . ). I'm sure you've looked through this site and seen all the financial and other pro/con arguments.

    My "gut response" is: you can always join the military, but once you're in, you can't just leave if you don't like it. Go to NY med. Take loans if you need to (although it sounds like you may not). You can always do FAP (assuming it still exists, which I guess is a calculated risk) if you decided down the road you still want to go military. Plus, if you're reasonably sure you want to be a surgeon (also a calculated risk, since you may change your mind), the military right now is probably not the greatest place to get training due to small caseloads.

    Best of luck
    X-RMD
     
  3. The White Coat Investor

    The White Coat Investor Practicing Doc and Blogger
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  4. OP
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    Dr. Dukes

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    The reason I won't do HPSP at NYMC is purely financial. As I understand it, the HPSP payback is 4 years plus the length of your residency. As with USUHS, the residency time can be paid back along with the basic commitment time. However, since Army surgical residencies are six year long, I will owe six years for HPSP vs. seven for USUHS. If I go to USUHS I get free school and get paid ~45-50,000/year, while if I do HPSP I get free school and get paid ~25,000/yeah. In exchange for that extra year I get another $100,000, which is less (I think) than the difference between my salary as an Army doc or a Civilian doc during my final year of USUHS payback. Also, my thinking is basically: if I'm gonna do it (HPSP or USUHS) why not DO IT (USUHS)?

    Also, as far as the surgical training is concerned, I'm not sure how much operative caseload matter. I have spoken to several docs, Army and civilian with no ties to the Army (and therefore no reason to not give me the unvarnished truth), and they have all said what really matters is where you do your fellowship (cause that is where you learn to ply your craft). Since the Army sends all (well, everything but WRAMC Vascular fellowship) of its surgeons to civilian fellowships, I will top notch training. One of the docs I spoke to is an ex HPSPer who was actually trying to talk me out of USUHS/HPSP told me that when he did his Army sponsored fellowship he was given much more responsibility than his classmates. He was already board certified, and had worked as a general surgeon for a couple year before fellowship, while his classmates came straight from residency. His attendings let him roam alone a bit more, he got to assist with cool random elective stuff, and they paid him on the side to manage their patients on the wards.

    I still haven't made up my mind, but I wanted to update my thoughts.
     
  5. Croooz

    Croooz Senior Member
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    Your payback info is inaccurate. USU is the longer payback. After HPSP you owe the 4 for school plus whatever you do as a residency. After USU you will owe 7 for school plus whatever you do as a residency. Total time for HPSP is ~10, where USU will be ~13.
     
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  6. usnavdoc

    usnavdoc Senior Member
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    You have alot of misconceptions here. I advise you to review this website and the gen surg forum. Caseload during residency does matter. It actually matters a great deal!!!
     
  7. OP
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    Dr. Dukes

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    But the payback (as it has been explained to me) can be concurrent. For example, someone who does HPSP and a three year residency owes four years for HPSP and three for residency. The three years of residency gets paid back at the same time as the four years of HPSP, so you serve a minimum of four years. However, with Surgery (a six year residency) you pay back the first four years of Surgery at the same time you pay back HPSP, but you still have to pay back the other two years. With USUHS you have a seven year commitment, so no matter what residency you do you can get out after seven years. So, a HPSPer who does Surgery ends up serving six year after training, while a USUHSer who does Surgery ends up serving seven years after training, yet making ~$100,000 (from the extra USUHS salary) more than the HPSPer.
     
  8. Croooz

    Croooz Senior Member
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    You do payback during residency but you also accrue more time. I find it best to think of total time in uniform vs payback after training or whatever. In your scenario you will wear the uniform 3 years longer as a USU grad than as HPSP. Any income difference the USU grad has you can more than make up for during your earlier exodus.

    HPSP: 4 years of service + 6 year residency = 10 years of total service. So you will owe 4 years after your residency to the military.

    USU: 7 years of service + 6 year residency = 13 years of total service. So you will owe 7 years after your residency to the military.

    If I've deciphered your post correctly it appears you believe that regardless of what residency a USU grad does they will wear the uniform for 7 years and nothing more. That is not correct.
     
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  9. OP
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    Dr. Dukes

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    I didn't mean to imply this at all. In considering whether or not to go to USUHS I have been thinking about the "downsides" of military medicine, and not the upsides. If I go to USUHS and like army medicine I will stay in for longer, but from reading this forum I have found that not everyone likes it, so I am considering how long I will be "stuck" if it isn't right for me.

    As always, any comments or corrections are greatly appreciated.
     
  10. Croooz

    Croooz Senior Member
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    IF you choose USU and IF you get into surgery, then barring any GMO or fellowship training you will wear the uniform for 17 years.
     
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  11. psychbender

    psychbender Cynical Member
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    Your numbers here are incorrect.

    Person A goes the HPSP (4yr scholarship) route, and goes to a 6yr general surgery residency. Person A owes 4 years AD payback (from HPSP), and 6 years AD payback (from surgery residency). The two are paid back concurrently, meaning that person A will owe 6 years of AD after finishing residency. Total time on active duty is 6yrs (residency) + 6yrs (payback) = 12 years.

    Person B goes to USUHS (7yr commitment), and the same 6yr general surgery residency. Person B owes 7 years AD (from USUHS), and 6 years AD (from surgery residency). Again, these two are paid pack concurrently, making the total time on active duty 6yrs (residency) + 7yrs (payback) = 13 years.

    As both options are more than 8 years AD, IRR is taken out of the picture.

    Additionally, while time spent at USUHS does not count as time to retirement (bummer), it does count as time in service with regard to pay. As such, the USUHS resident/attending will make more money (and, I believe, be promoted faster) than the resident/attending who went through HPSP, as he has 4 more years in service.

    To the OP, where did you get $25,000 per year for HPSP? With the stipend as it is now, you get more like $16,000 per year (1200/month x 10.5 months + 1.5 months AD--at about 2400/month). I believe that's about how it worked out for me last year. If you were referring to the stipend increase, keep dreaming, I doubt that'll come anytime soon.
     
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  12. Gastrapathy

    Gastrapathy no longer apathetic
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    This is incorrect. You need to think of your pre-GME and GME obligations separately. Your pre-GME obligation (service academy, ROTC, HPSP, USU) cannot be served concurrently with other pre-GME obligations. Meaning, ROTC plus USU equals 11 years, HPSP alone equals 4 years, etc.

    However, these obligations ARE served concurrently with your GME obligation.

    GME obligation is a minimum of 2 years or the length of the training program. GME obligations also cannot be served concurrently with each other (so residency+fellowship increases your committment).

    So, if you do a 6 year residency, and already owe 11 years, you still owe 11 years BUT if you do a 6 year residency and only owe 4 years, you finish residency owing 6 years (GME obligation is longer). This is exacerbated by a GMO tour (lets say you finish med school with a 3 year HPSP scholarship, complete internship, then do a 2 year GMO: at that point you'd owe 1 year, come back for 4-5 years of gen surg and owe 4-5 years again).

    The bottom line is that you need to know your pre-GME obligation and your GME obligation and realize that you are obligated for which ever is longer.

    So for your HPSP example:
    4 year HPSP + 6 year residency = 6 years of obligated service
     
  13. OP
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    Dr. Dukes

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    As I remember, for USUHS you owe seven years active plus six IRR. For every year above seven two years get taken off of IRR. So, if you serve 8 years you owe 4 IRR, 9 years is 2 IRR, and 10 years is free and clear (assuming they don't call you back cause you're an officer...).

    Also, USUHS time doesn't exist until you hit 20 years active duty, then you all of a sudden become 24 years. So, if you retire 19.5 years after USUHS grad you get nothing, if you retire 20.01 years after USUHS grad you've got 24 years as far as your pension is concerned.

    I guess I messed up with the ~$25,000/year figure. However, if it is lower, that makes the USUHS instead of HPSP argument, FOR A SURGEON, much better. That extra year of payback because of USUHS gets you way more in initial money than the difference between a military salary and a civilian salary (not even counting the time value of that extra money).
     
  14. Gastrapathy

    Gastrapathy no longer apathetic
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  15. psychbender

    psychbender Cynical Member
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    Really? I could have sworn I read that somewhere.
     
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  16. Croooz

    Croooz Senior Member
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    Thanks Gastra. Either way you look at it makes no sense to make a decision today that will affect you for 12-15 years...but that's just me.
     
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  17. IgD

    IgD The Lorax
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    Bobcat, I think you need more information. I would recommend traveling to your nearest military hospital, hanging out with some doctors and asking them about it face to face. The commitment is irreversible and lengthy for USUHS. Whether you join or not that's great just understand what you are getting into.
     
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  18. grumbo

    grumbo Member
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    It sounds to me like you have just about as much info as you are going to get from doing research on this on your own. The good and bad of military med has been rehashed time and again on this board and it's time to look elsewhere for advice. As posted above, I agree that it would be a good idea to try to talk with some docs face to face for more info. However, I disagree with the general sentiment that USUHS is an evil committment to be avoided. Most students that I've talked to at USUHS like it here, and there are plenty of docs I've run into who, believe it or not, actually enjoy their time in the military.
     
  19. island doc

    island doc Senior Member
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    If such is the case, then please explain to me why every single one of the other active duty military physicians with whom I worked who had an active duty service committment for training separated immediately upon completion of that committment.

    If they so enjoy their time, why don't they stay beyond their initial active duty service committments?
     
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  20. USAFdoc

    USAFdoc exUSAFdoc
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    1. USUHS is NOT the evil committment....the problem is when you become the DOCTOR in the milmed system. I do not think USUHS is broken, its the majority of the rest of milmed that is.

    2. Please get a hold of all those docs who really enjoyed their time in milmed STATESIDE......it would be a great thing to know where all the good milmed clinics are. And please do not include docs no longer seeing patients full time. They may be out there, I have just never yet met someone from there. I will say that I know someone who xferred from my last base to the USAF Academy, and said things were decent there. I also had 100% of doc FPs say that being deployed was preferrable to being in our clinic.:idea:
     
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  21. grumbo

    grumbo Member
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    That's why I love this board. You say one positive thing and you get jumped all over. I said that the USUHS route is not evil, not "USUHS is not evil". I was trying to say owing 7 years after residency is not the end of the world and does not need to be avoided like the plague. If you think going to USUHS is a good fit for you, then it might be. I also said I know several docs who enjoy military medicine. I did not say every doc I talk to wants to stay on active duty forever. I agree, the vast majority of doctors get out after their commitment. However, I know several who have signed up for more time (and yes see patients). I've met a couple of docs who entered active duty after having been practicing physicians in the civialian world for some time. And most of the docs I talk to are enjoying themselves while on active duty, but will go civilian when the time is up.
     
  22. USAFdoc

    USAFdoc exUSAFdoc
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    1. wow, you think my response to you was "getting jumped all over"? get real. You were not slammed. And the USUHS ROUTE, or just USUHS, .........the education is probably great, the committment you have to your country admirable. What I am saying is that much of milmed is UNSAT when you get to the point where you are the doc. And the "7 years thing" is again missing the point. I spent 9 years active duty. My complaint is not that I spent 9 years active duty, my concern is that the final 3 I spent as a doc were as part of a nearly completely broken medical system that placed pts at risk, was unprofessional, and was consistently presented to the public with dishonesty.

    2. Please get some of those friends/docs that are having good experiences on this site so we can steer med students that way. You make it sound like there are so many docs out there working in quality clinic etc. I am being completly honest when I say I never met or even talked with one doc who would call milmed a "quality" thing.
    Are the docs you are speaking about in residencies/instructors/academy etc. I would just be amazed if they are in a regular clinic environment.

    3. And in the end, it doesn't matter if I say "bad" you say good. What matters is the truth. The details I have stated (lost charts, labs, 10-20% manning, threats, shredded charts etc) are real and there is NO EXCUSE for them.:thumbdown:
     
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  23. grumbo

    grumbo Member
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    Yes, the docs I speak of are at hospitals with residencies because those are the only places I've rotated. Maybe when I get out of an academic setting, life will suck. In the mean time, I continue to meet enough people that enjoy what they're doing to give me hope that I can enjoy my career too. To the OP, it seems we both agree that your next step is to try to contact military docs in your area and see what they think.
     
  24. USAFdoc

    USAFdoc exUSAFdoc
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    10-15 years ago, it was my FP rotation at TRAVIS that was the deciding factor for me to go FP; I really believed (and still do) that the residency there, and the instructors were top notch.

    my guess is at those places, the visability, and the fact that the docs probably still have alot of control in terms of the "quality" of the "program. Believe me when I say that what I recently experienced and found in USAF "clinics" was a far cry from what I saw at Travis residency 10-15 years ago.
     
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  25. Jet915

    Jet915 Shi*ter's Rule
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    I would go to NYMC. I had a simliar chose between civilian vs. usuhs and went w/civilian cause I had no prior military experience and wasn't sure what I would be getting myself into. I've always been interested in the military since I was a kid and always saw myself serving my country, so I decided to do the 3 year HPSP route. It so far has worked out well for me as I have decided to go into internal medicine so if I went straight through IM, I'd have 3 years of payback which works great for me. If you are sure you are going into surgery, I'd probably go to NYMC cause I've heard caseload for surgery in the military is hit and miss. If you knew you were gonna do a primary care specialty, then HPSP isn't a bad option but as a M1, you really don't know for sure.
     
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  26. g293

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    I'm an active duty surgeon. Case load in residency matters a lot--it's how you get your basic skills. That aside, what you should really be looking at is your case load in the military. Take colonoscopy, hernias and lipoma resections away and look at how many cases the average general surgeon is doing. The OIF/OEF casualty receiving hospitals like Landstuhl or Walter Reed may be busier for now, but I know in the Air Force that stateside assigned surgeons are doing very little. I have done one major open case and one major lap case since last October. I am watching my surgical skills suffer as I see more and more clinic and operate less. Your training may be great, but if you do nothing for 4-6 years while you're on active duty, that training doesn't really matter.

    Also, do not count on getting a fellowship. The military only needs so many fellowship trained surgeons, they need far more warm bodies to deploy all over kingdom come than sub specialists.
     
  27. OP
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    Dr. Dukes

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    First of all, I would like to thank everyone for all of their helpful comments.
    I have decided to go to NYMC and put off a career in the military until later (I will revisit this decision after residency/fellowship). My question is this, I still want to serve my country as a physician and treat the men and women in uniform. My questions is: what is the best way to do this? Should I join the National Guard, the Army Reserve, or simply my local DMAT and maybe an IMSuRT if that works with my field/location?
    Again, thank you very much for your service and for your comments.
     
  28. gastrodoc

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    If you want to serve your country go active. There is NO benefit from being in the reserves, trying to to continue a civilian practice as you are deployed.
    As far as caseload goes, you won't get the giant whacks in the Army unless you're at WRAMC or BAMC.
    There have been 5 whipples at my institution over the past 5 years. (large Meddac in CONUS).
    AS for surgical fellowships in the military, plan on doing a utilization tour as a general surgeon. The training sites (civilian deferred) are good (sloan, fox-chase, BI) everyone wants a free fellow. Of course it's a 2:1 pay back for those.
     
  29. HumptyDumptyMil

    HumptyDumptyMil Almost done...
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    when you guys say a 6year GS residency, does that include the intership year? If internship year is included, will that not mean you have a 5 year payback instead of a 6 year payback? I heard that the internship year does not incur any additional years...
     
  30. OP
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    Dr. Dukes

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    It is my understanding that internship incurs a year of payback, but because of concurrent payback it doesn't end up mattering.
     
  31. HumptyDumptyMil

    HumptyDumptyMil Almost done...
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    so do a six year residency program (1 internship year + 5 year residency program), you will have to pay back 6 years? I heard and read that internship doesnt count. you only add one year after any five year residency according to:

    http://lukeballard.tripod.com/HPSP.html

    The math works out if the PGY-1(internship year) is considered the first year of the residency program (5 year residency program- 1 year internship= 4 years payback). I know some aspects of this website are out of date already, but I havent heard anything about the internship year counting toward additional commitment.

    No offense to you bobcat. I'm just hoping I'm right, so I dont have to accumulate additional payback.:scared:
     
  32. Bubblehead-to-MD

    Bubblehead-to-MD Emergency Blow!
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    Internship does not accrue an additional service obligation - it is neither time accrued nor time paid back. Think of it this way, the Navy could not utilize you as a GMO if you did not complete your internship.

    Anyways, check out the USUHS bulletin using the link below. Look under service obligation.

    http://www.usuhs.mil/adm/catalog/GradEdMed0406.pdf
     

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