Excellency of Military Medicine

[greatjoyousday]

Hello, I will be applying to medical schools next cycle and am currently debating whether or not I want to apply for the HPSP scholarship. I genuinely believe I would enjoy being in a military environment so my decision to apply isn't based solely on monetary needs. My primary concern of whether or not to join is the training I would receive in a military residency, and my opportunities for learning once my active duty service is completed. Above all else, I want to be an excellent doctor and I want to make sure that being an HPSP scholar will not impede this goal. Are military residencies of the same caliber as top civilian ones? I know any fellowship training I want to undergo as a military officer results in more years of required active duty service. So if I waited until after I served my time to do a fellowship, will this hurt me in any way as a professional? Obviously I would be older than the typical fellow at that point, but other than the age difference (which I'm not saying would hurt me, I'm just pointing out that it's there and important to consider), will my training and experience as a military doctor put me at a disadvantage for competitive fellowships or research opportunities?

As a bit of background, I am quite interested in pediatrics as well as emergency medicine and oncology. I know these interests may very well change when I am in medical school and actually experience them during third year, so nothing is set in stone. But if there are some specialties that are much better than others in the military, that would be very useful to know as well.

Thank you for your help as I try to figure out what course my life will take... or at least what course I think my life will take!

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[HighPriest]

All of these questions have been discussed very thoroughly in more than one previous thread. So, for detailed information, do a little searching.

The short of it is:
1 - If you want to be a doctor first, reconsider military medicine. The military wants officers first, and doctors second.
2 - Military residencies, like civilian residencies, range a gamut from good to poor. However, my opinion is that the breadth of that range is muted compared to the civilian world. In other words: the military doesn't have anything comparable to the best civilian programs in the country, BUT they also aren't close to the worst either. Military surgery residencies will train you to be a very competent community surgeon. (I can't comment on medical specialties). If you want to do research, skip the military. They're just bad at it. What you should be more concerned with is whether or not you'll be able to maintain your skills once your residency is over and you're out working for the military. Maintaining skills may be very easy, or nearly impossible, depending upon where the cards fall.
3 - Doing a fellowship after serving is very possible. The harder part is taking the pay cut and going from being a staff doc to a trainee again.
4 - Your military service will put you at a disadvantage for any research opportunities. Research in the military exists. It is generally not very good, hard to fund, excessively restricted by IRBs (much more so than civilian institutions that do a lot of research), and in many cases unavailable depending upon your duty assignment. If you see research in your future, you are better off not going in to the military.
5 - Oncology fellowships in the military are always going to be saddled with patient availability. Remember: this isn't the veteran's administration. It's military medicine. Most patients are 22 and healthy. Cancer happens, but the volume will not compare to civilian centers. Major military MTFs have oncologists. They do treat cancer. But they're often fighting to bring in retirees and VA patients.

 

[greatjoyousday]

All of these questions have been discussed very thoroughly in more than one previous thread. So, for detailed information, do a little searching.

The short of it is:
1 - If you want to be a doctor first, reconsider military medicine. The military wants officers first, and doctors second.
2 - Military residencies, like civilian residencies, range a gamut from good to poor. However, my opinion is that the breadth of that range is muted compared to the civilian world. In other words: the military doesn't have anything comparable to the best civilian programs in the country, BUT they also aren't close to the worst either. Military surgery residencies will train you to be a very competent community surgeon. (I can't comment on medical specialties). If you want to do research, skip the military. They're just bad at it. What you should be more concerned with is whether or not you'll be able to maintain your skills once your residency is over and you're out working for the military. Maintaining skills may be very easy, or nearly impossible, depending upon where the cards fall.
3 - Doing a fellowship after serving is very possible. The harder part is taking the pay cut and going from being a staff doc to a trainee again.
4 - Your military service will put you at a disadvantage for any research opportunities. Research in the military exists. It is generally not very good, hard to fund, excessively restricted by IRBs (much more so than civilian institutions that do a lot of research), and in many cases unavailable depending upon your duty assignment. If you see research in your future, you are better off not going in to the military.
5 - Oncology fellowships in the military are always going to be saddled with patient availability. Remember: this isn't the veteran's administration. It's military medicine. Most patients are 22 and healthy. Cancer happens, but the volume will not compare to civilian centers. Major military MTFs have oncologists. They do treat cancer. But they're often fighting to bring in retirees and VA patients.

Thanks for your response! I've been trying to find more information on this site but a lot of the military doctor posts seem to be quite negative. I suppose I was just hoping for a post that would highlight the good things about being a military doc. I'm sure this post exists somewhere, I just have a lot more digging to do on this thread. But I appreciate that you still answered me even though you have probably answered the same question 50 times!

 

[HighPriest]

If you're looking for positive answers only, then you're not looking for information you're looking for validation. There are plenty of threads and posters who comment on the positive aspects of military medicine. And while there is some disagreement on the forum, I have always and still do argue that the balance of happy vs disgruntled military physicians on this forum is more or less equivalent to what I saw in the Army. Most people aren't happy. Many are content but waiting to move on. A few are genuinely happy.

But if you ignore people who are trying to give you reasonable, and legitimate, advice that contradicts what you would like to hear about military medicine you're going to have a skewed view as well. There are actually very few people on this forum I disagree with - even those with very different opinions of military medicine than my own. They've had different experiences, and as you will discover as you read, so much of the milmed experience is completely out of your control and completely variable depending upon a number of factors. The only good reason to join is that you really want to be an officer in the US military. Beyond that, it's a complete toss up as to whether you'll get exactly what you want or nothing. So you can seek out good or bad experiences, but I think the smarter route is to read everything, decide if what they're saying is believable or not (even if its negative) and just realize that while you may have a completely different experience, you may not.

A lot of people make the mistake of coming on here and reading up and saying "well, I'm a pretty up-beat chap. I'm sure I won't fall prey to the troubles these blokes have experienced. I'll use the power of positive thinking!"

And that makes up for a lot. But the power of positive thinking only goes so far. It may not be enough if you're the guy who doesn't get his residency, doesn't get his fellowship, gets stationed in Fort Polk Louisiana where he has to drive 45 minutes to get groceries at Walmart, can't actually practice his field of medicine because he's a brigade surgeon for two years, etc., etc.

Maybe you can power-think your way past that stuff, I don't know you personally. But you need to realize that stuff can happen. May not. But it can. That's really the take home from this thread.

Anyone coming on here to tell you that milmed is great and everyone here is a negative nancy is either really lucky or selling you something. Even the most up-beat guys will tell you there's an occasional fly in the soup, if they're being honest.

 

[Perrotfish]

Hello, I will be applying to medical schools next cycle and am currently debating whether or not I want to apply for the HPSP scholarship. I genuinely believe I would enjoy being in a military environment so my decision to apply isn't based solely on monetary needs. My primary concern of whether or not to join is the training I would receive in a military residency, and my opportunities for learning once my active duty service is completed. Above all else, I want to be an excellent doctor and I want to make sure that being an HPSP scholar will not impede this goal. Are military residencies of the same caliber as top civilian ones? I know any fellowship training I want to undergo as a military officer results in more years of required active duty service. So if I waited until after I served my time to do a fellowship, will this hurt me in any way as a professional? Obviously I would be older than the typical fellow at that point, but other than the age difference (which I'm not saying would hurt me, I'm just pointing out that it's there and important to consider), will my training and experience as a military doctor put me at a disadvantage for competitive fellowships or research opportunities?

As a bit of background, I am quite interested in pediatrics as well as emergency medicine and oncology. I know these interests may very well change when I am in medical school and actually experience them during third year, so nothing is set in stone. But if there are some specialties that are much better than others in the military, that would be very useful to know as well.

Thank you for your help as I try to figure out what course my life will take... or at least what course I think my life will take!

I'm in Pediatrics:

Realize that if you take HPSP you are obligating yourself to participate in the military match. Your odds of matching a given specialty may be very different in the military match vs the civilian match. Not necessarily worse, but it can be. There is also much more variation from year to year. In the civilian world, for example, if you have a 210 on your step 1, interview intelligently, and don't fail any rotations or shelf exams you will be able to match into Pediatrics. In the military that's often true, but we have had years where Pediatrics was in high demand, and where the average matriculants step was significantly higher. We have also had years where we had more spots than applicants.

You will rarely hear anyone complain about the quality of military residencies. They aren't quite the same caliber as top residencies such as (for Peds) CHOP/CHLA/Boston Childrens, but very few students get into top residencies. The training provided seems to be well above the civilian average. There is a strong emphasis on being able to practice as a full scope, independent provider the day you leave residency. While that's good for your development as a clinician, unfortunately that means residency can involve a lot of hours compared to the civilian average. For example military FM residencies involve way more OB rotations than usual and military Peds residencies involve way more NICU than usual. There is little if any time set aside for research.

If you do a fellowship in the military you will owe an additional year of obligation for each year you were in fellowship. Most fellowships aren't available every year. For example if you want to be a Pediatric ID physician they might offer than fellowship only once every 5 or 10 years. If you do a 1 year fellowship you owe an additional 2 years afterwards.

After residency I think most people would agree that its best to be in FM, Pediatrics, Psych, or OB. ER, IM, anesthesia, and surgical specialties other than OB tend to have much lower volumes and acuities of patients than in the civilian world. That leaves you with the choice of moonlighting to keep your skills up (can be difficult depending on your command and your hours) or watching those skills you built up in residency begin to whither.

The consensus seems to be that fellowship candidates coming from the military do very well. I have no data to back that up, though.

 

[Perrotfish]

I suppose I was just hoping for a post that would highlight the good things about being a military doc

Sure:

1) There is a lot of support from subspecialists. In the first few years out of residency when you're establishing your practice patterns it really helps to have experienced subspecialists you can ask. Unfortunatley those are the years when the civilian system is most likely to dump you in an unsupported doc in a box clinic. It's nice that I can always get ID/cards/whatever on the phone for a consult.

2). There is one insurance plan and it pays for everything. No pre auths

3). For primary care it's nice to have integrated, in house imaging and labs. I don't need to send anyone to the ER just for a CT.

4). The patient population is great.

5). It pays for medical school and looks good on a resume when you're done.

Of course the bad stuff is also true. High arministartive buden, support staff may or may not be useless, computer system that breaks frequently and is not great even when its working, inability to fire noncompliant/abusive patients, high patient turnover, insane emphasis on minimizing patient complaints and maximizing various metrics, and of course the standard military uncertainty of never knowing if you will be moved/deployed/on indefinite Q1 call.

 

[HighPriest]

I want to chime in and say, as I mentioned earlier, I frequently agree with people when they mention the upsides of milmed.

I agree with basically everything Perrotfish said here with regards to the good things.

 

[Mace1370]

I’m going to throw in a plug for military pathology. The training I have seen at military hospitals for pathology is on par with good to very good civilian programs. Probably not as good as top tier. Similar to what Perrotfish mentioned, military pathology residencies expect you to hit the ground running and practice as a general pathologist day one after training. This expectation is omnipresent all throughout training and is totally different than what I have seen at civilian programs (for reference, I did several rotations at civilian programs as a resident and did a civilian fellowship). Many trainees on the civilian side for pathology are excused from a lot because they are going into fellowship X and that’s all they will be doing after training. In the civilian world path residency can be a check box for some as they end up doing 2-3 fellowships and then only practicing in the areas of their fellowship training (I think this is ridiculous). Fellowship opportunities are not as abundant on the military side, but many people get to do one. Furthermore, you practice as a generalist as well as a subspecialist which I think is ideal for pathology. When you get out of the military you will be extremely marketable, because you will be competent at general pathology as well as your fellowship.

We also have free rain to order additional workup on pretty much every case that comes through the door. This is absolutely not the case in civilian institutions (even high profile ones that often receive cases from semi-shady arrangements like client billing). Civilian institutions also sign cases out with extremely quick turn around times for client satisfaction and to maintain high case volumes for a good salary. You have more time in military pathology to give cases the scrutiny they deserve.

To be fair, we do have our fair share of administrative problems that result from the military environment (cases coming out late, high admin burden, poor computer systems, poor support staff, etc).

 

[militaryPHYS]

I agree with basically everything Perrotfish said here with regards to the good things.

That was the most positive post I have ever seen from Perrotfish. I feel like I’m taking crazy pills.

After residency I think most people would agree that its best to be in FM, Pediatrics, Psych, or OB. ER, IM, anesthesia, and surgical specialties other than OB tend to have much lower volumes and acuities of patients than in the civilian world.

I guess I’m confused...I feel like so much time is spent on SDN discussing negatives about milmed primary care yet we think it is best? I feel horrible for my friends who are FP and peds when the command and USMC keeps asking more and more from them while compensating them the least. Just like everything, it’s a balance. You want to be doing something and stationed somewhere where you are maintaining or improving your skills but also should be able to take advantage of the unique places and situations the military gives you.

Skill atrophy is very real, but can be salvaged once out of a bad duty station or billet. I wouldn’t want to be worked like a dog for an entire career just to avoid the potential for skill atrophy. But then again, I’m also biased because I ended up steering away from primary care because of what I saw during my military rotations

In the end you have to do what makes you happy and will keep making you happy for a lifetime, just make sure you understand what it is you will actually be doing for the rest of your life.

 

[Ziehl-Neelsen]

gets stationed in Fort Polk Louisiana where he has to drive 45 minutes to get groceries at Walmart

The Walmart in Leesville is only 10 minutes away from Fort Polk The casino in Lake Charles is 45 minutes away, but the craps table minimums are too high and the buffet sucks.

My primary concern of whether or not to join is the training I would receive in a military residency, and my opportunities for learning once my active duty service is completed. Above all else, I want to be an excellent doctor and I want to make sure that being an HPSP scholar will not impede this goal. Are military residencies of the same caliber as top civilian ones?

Lots to unpack here, and its more difficult because I don't think any of us know what you mean when you say "excellent doctor"...

I obviously can't speak for all military residencies, but my residency was excellent and the general opinion of others on this board was that their residencies were similarly excellent with regard to what military residencies are meant to do--train a competent generalist within a particular specialty who is ready for practice on day one post-graduation, handle ~90% of stuff that comes their way, and has the appropriate knowledge (and humility) to know when something is beyond the individual's or the institution's ability. If your idea of "excellent doctor" is becoming an extremely competent general physician in your specialty, a military residency will not hinder you in that regard (though I've got new for you, for physicians, the quality of the clay matters far more than the quality of the potter, if you catch my drift).

Others have stressed this above, but this idea of the super-competent generalist is becoming an anachronism in this day and age's era of hyperspecialized, academic medical practice where physician's do just a couple of things over and over. I completed a military residency and did general practice in my specialty for a few years before I entered a hyper-specialized subspecialty fellowship (military-sponsored) at a civilian academic institution that is considered hyper-elite/top-5 in my field. By the end of fellowship, I had multiple attendings asking me to consider joining the institution if I left the military. If your idea of "excellent doctor" is a hyper-specialized academic medical practice where you're published in all the journals with regard to your specific niche, the military will not provide that for you., but it won't necessarily close those doors. You'll just have to get out of the military as soon as possible to get into one of these hyper-specialized tracks and understand that you'll be ~4 years behind the fellows who started building their academic careers as fellows while you were practicing "general insert medical specialty here" at Fort Campbell/NAS Lemoore/Eglin AFB.

As has also been mentioned above, military training is not the issue at all. It's what happens in those first 4-6 years after residency that matters with regard to becoming an "excellent doctor". I went from residency to a large medical center where I was constantly challenged with both volume of cases, high-dificulty cases, and versatility of responsibilities which I know allowed my abilities to increase by leaps and bounds. One of my residency classmates went to a low-volume center where (her words) "she could feel herself getting dumber each day. There's an element of randomness to it that you have little control over. If that "uncertainty" doesn't jive with your life's goals, you should stay away from military medicine.

 

[HighPriest]

The Walmart in Leesville is only 10 minutes away from Fort Polk The casino in Lake Charles is 45 minutes away, but the craps table minimums are too high and the buffet sucks.

Oh! So it's more like Monaco, then.

 

[notdeadyet]

I can't think of any military residency that I would consider better than a good solid community program in any particular field. There's absolutely nothing wrong with that, but if you're looking for better training than that, going civilian and joining via direct accession or FAP is the way to go.

The only real exception that that was probably pathology back in the day, when it was one of the best, but that was back in the day.

 

[ArmyTiger]

I can't think of any military residency that I would consider better than a good solid community program in any particular field. There's absolutely nothing wrong with that, but if you're looking for better training than that, going civilian and joining via direct accession or FAP is the way to go.

The only real exception that that was probably pathology back in the day, when it was one of the best, but that was back in the day.

Madigan general surgery routinely scores at the top of the ABSITE as a program, and has a high case volume for military programs too. I'd guess most military programs fall between mid level community and mid level academic programs, but that guess is about as useful as the US News and World Reports college rankings.

Sent from my Pixel XL using Tapatalk

 

[militaryPHYS]

You'll just have to get out of the military as soon as possible to get into one of these hyper-specialized tracks and understand that you'll be ~4 years behind the fellows who started building their academic careers as fellows while you were practicing "general insert medical specialty here" at Fort Campbell/NAS Lemoore/Eglin AFB.

There is a lot to be said for those 4 years practicing if you want to get out, 3 years if you are staying in (only 2 if you go OCONUS) that you spend practicing/operating. Confidence increases, board certification is done and you have established yourself as a physician, not just a physician in training like the preceding 9+ years when you include medical school, internship and residency. If you decide to stay in and IF the FTOS (Full-Time Out Service) spots are available for your hyper-specialized goals...and I REPEAT the IF there...then its a win-win. You are paid for by the military which makes you sought after by the best programs in the country (free-labor), they get to bill for you as a second surgeon for every case you do (because you are board certified) and you continue to collect your military pay w/ bonuses (much higher than any real civilian fellow makes). The FTOS or in service spots are not guaranteed though (not by a long shot), but also your success as a civilian doc and acceptance at civilian fellowships aren't either. But, as a civilian you don't have to worry about GMO tours, Deployments, NDAA's messing up your long term plan. Therefore, stick with being a civilian if you want to only be able to blame yourself when you don't get to do your Plan A.

I can't think of any military residency that I would consider better than a good solid community program in any particular field

False. Orthopedic surgery training is top notch in the Navy. Broad exposure, military and civilian rotations, high case volume with early hands on experience. Much better hands on experience then many of the civilian programs I witnessed via outside rotations. Much better confidence and applicable skills than a lot of the civilian trained guys I have worked with. Navy ortho @ Portsmouth hasn't had a resident fail their boards in over 17 years. Even the top civilian programs have a couple fail every few years. I am sure that there are many other examples of stellar military residencies that would be better than your average programs, just no objective data at this time. As we discuss very often, you are not getting substandard training in the military residencies. They are all ACGME accredited and will get you average training if not above average training from what I have seen. If you don't succeed in fellowship or job applications later on in life then you only have yourself to blame.

 

[Gastrapathy]

The quality of the people going through the program is not the same as the quality of the program. The question isn’t whether Navy Ortho residents are better than the average resident but whether the program serves them as well as an average program. We don’t take tests for a living. Operative volumes with appropriate variety and complexity is the issue.

What I saw was rampant double counting of cases and the need to do outside rotations to get enough cases, limited fellowship opportunities and high faculty turnover. That’s not “above average” to me regardless of whether the residents made it work.

 

[HighPriest]

We never did any double-counting. We did do a lot of outside rotations, which for me was a huge benefit. Frankly, I'd have rather done training at my military program, with outside rotations, than I would have done training at the university where we did outside rotations. They are a great university, but their residents don't operate very much and they were frankly worse in the OR by a significant margin. They also regularly failed their inservice exams, but yet they're considered a top program because they make research like booze makes single mothers.

I don't think my program was a top tier program. But, some of that depends upon what you're looking for. i do think it was a very good community program that trained very competent surgeons to do bread-and-butter cases. However, my definition of what is "bread-and-butter" is also pretty broad based. Compared by my current civilian partners, who trained outside of the military, things I consider bread and butter are often things that they've always sent out to a sub-specialist.

The amount of hands-on operating that we do in the military translates into being much more comfortable than average upon graduation, which leads to turning away fewer cases in those first few critical years after residency, where you're deciding what you're going to keep doing and what you're going to give up on.

I have no doubt that there's variability between training programs within the military, however. Can't speak for any of the rest of them, but I have worked with guys who graduated from the other programs and they all seem pretty well put together.

So, BLUF: the Army doesn't have top-tier programs. If you want do to research, the military is not your guy. I also agree that fellowship opportunities are very limited, and that is coming from a guy who applied for a fellowship and that fellowship was across-the-board denied for the first time in many years. No way to even predict it. And this is a fellowship that, if you wanted it on the civilian side you would have gotten it.

We had very little faculty turnover during my residency, but I do think it's something to consider because that can be hit-or-miss. We had one O-6 retire in my R2 year, but he wasn't doing much. We had another O-6 retire in my R4 year, but he was doing even less. So it made very little difference. Then we gained another doc, which certainly didn't harm training in any way. But, we were also a very small department, relative to IM or FM, etc. That being said, I don't consider faculty turnover to be a necessarily bad thing. I learned quite a bit from the guy who came in, and in a very short period of time. It definitely made me a better surgeon.

In the end, however, I think my training was very appropriate for someone who wants to operate a lot in a community setting.

 

[pgg]

I think the out rotations I did as an inservice resident were a net positive. It was good to get some exposure to other hospitals and ways of doing things. Some of these truly top tier programs suffer from a little bit of inbreeding and tunnel vision, in my opinion. I did some of my out time at highly regarded institutions, including one of the big names in Boston. I did not feel outclassed by the other residents. I felt I got better 1:1 teaching at my home program, and a better case load at the other places (but with marginal teaching, to be honest). The balance was good on the whole.

Faculty turnover wasn't bad at all during my 3 year residency. We actually have a group of contractors that are very stable - I was a resident from 2006-2009 and five of the ones who taught me as a resident 10+ years ago are still here. A sixth just retired a few months ago. One of my residency classmates just got hired as a contractor.

Research is largely terrible in the military. I don't think anyone will really dispute that.

Bottom line, there are dozens and dozens if not 100s of military residency programs. Some are better than others. Few if any could be called top tier (then again, 95% of civilian programs aren't either). Training is solid on the whole.

Fellowship opportunities are in short supply for many specialties. This is a problem.

Skill atrophy post training is another problem.

 

[notdeadyet]

I'd recommend applicants talk to folks in their field that they respect and ask impressions of military residencies. You will find a fair number of ex-military folks at civilian programs (particularly surgeons, in my experience). Explain what you are looking for in a program and ask how specific military programs compare with civilian counterparts. Do this repeatedly. The problem with asking me about my residency is that I'll tell you it's awesome. Because I have a vested interest in believing and advertising it as such.

I do have concerns when I hear folks brag about the number of external rotations they do in residency and how this is a strength for the sake of "diversity." I've heard folks make the same claim for the osteopathic med schools (not all of them) in which you are scattered to the wind for MS-3 and MS-4 years. Really good schools and residencies don't have you do this because home training is not limited. It sounds a lot like trying to make a feature out of a bug.

 

[HighPriest]

Some of these truly top tier programs suffer from a little bit of inbreeding and tunnel vision, in my opinion

Fact.

I do have concerns when I hear folks brag about the number of external rotations they do in residency and how this is a strength for the sake of "diversity." I've heard folks make the same claim for the osteopathic med schools (not all of them) in which you are scattered to the wind for MS-3 and MS-4 years. Really good schools and residencies don't have you do this because home training is not limited. It sounds a lot like trying to make a feature out of a bug.

I don't think that's it. It is, of course, better to not have to do outside rotations. It is definitely a weakness that the military needs them to survive. And, as I've stated multiple times before, I think the military should get out of the GME business entirely. I think they have no business doing it. -However- The outside rotations do exist, and there are benefits. I wouldn't consider it a strength. But I would say that had I not done outside rotations, my residency simply wouldn't have had the numbers of complex cases it required (and the zebra stuff that we ultimately never end up doing without a fellowship anyway but that you're still required to do in residency). And, had I done my whole residency at the university, I'd have graduated woefully unprepared to operate, without a lot of confidence in my skillset, feeling like I needed a fellowship to actually become an effective surgeon, but with a ton of research experience. So there is an aspect of balance here that in my opinion simple illustrates some of the weaknesses in ACGME accreditation reflected in both institutions.

I have this brewery nearby. It has great beer. They don't serve food. But there's a food truck that comes by every day and serves great food in the parking lot. So, on one hand, it sure would be better if the great brewery just served good food. It'd be even better if the food truck served beer and just came to my house, but I don't live in a fantasy world, unfortunately. So while it isn't the ideal situation, I still enjoy going to the brewery and eating at the foodtruck. I understand it could be better, but I can appreciate the situation for what it is.

or, put another way, they got their chocolate in my peanut butter. NBD.

 

[militaryPHYS]

We don’t take tests for a living. Operative volumes with appropriate variety and complexity is the issue.

What I saw was rampant double counting of cases and the need to do outside rotations to get enough cases, limited fellowship opportunities and high faculty turnover.

You can’t double count anymore. ACGME changed case log policy back in 2012. That issue was rampant everywhere, not just the military. No matter what your case volume was during residency, your residency was worthless if you can’t pass your boards, so yes, we do take tests for a living until you are board certified and then can take a break for 10 years and start making a living operating and seeing patients.

Most endless loop arguments on here stem from complaining about things in the military that none of us can change. i.e. skill atrophy at certain MTFs, low acuity and lower level 1 trauma stuff, people lucking out or getting screwed sometimes based off of beurocratic BS rather than personal qualifications/merit, etc. Instead of focusing on ways people/programs have adapted to compensate for unchangable facts, we just complain about the issue. Non productive, no actionable tips.

Majority of MTFs aren’t level one trauma centers or high volume and acuity centers. But programs have adapted by establishing MOUs with great programs to supplement the deficiency. I knew this wasn’t Harvard when I signed up and if you don’t understand that and accept it you’re destined for disappointment and misery. I thrived and enjoyed my time at outside rotations because we saw a lot, operated some and had the perceived prestige of these institutions shattered. I saw guys so renowned publicly yet were so stuck in their ways they end up operating like complete hacks (or not at all because they have fellows and junior attendings to do their cases for them). I saw surgeons who loved long hours, Porsche’s, divorce lawyers and trust funds for their kids. I also saw their senior residents unable to make decisions or operate independently. I would have hated being inbred with no perspective of how well or poorly I was being trained. I also wasn’t tunnel visioned in my approach to injuries and treatment options because I had broad exposure to many great (and poor) instructors. It made me really appreciate the senior AD guys I had teaching me who cared about my education but also cared about my family, my finances and my overall perspective on life.

If you think having outside rotations is a negative because all it means is that you’re not at prestigious named program or high volume institution then I’m not sure what you were expecting when you signed up. Thankfully most military programs are adapting by setting up great opportunities for us instead of just complaining about how the military stinks and there is no hope.

 

[notdeadyet]

I have this brewery nearby. It has great beer. They don't serve food. But there's a food truck that comes by every day and serves great food in the parking lot. So, on one hand, it sure would be better if the great brewery just served good food. It'd be even better if the food truck served beer and just came to my house, but I don't live in a fantasy world, unfortunately. So while it isn't the ideal situation, I still enjoy going to the brewery and eating at the foodtruck.

Good analogy. I guess my issue is that in this case, a lot of folks who frequent this brewery claim that the availability of the food trucks make the brewery a good restaurant.

I don't have a dog in this hunt. Folks who trained civilian seem happy with their training (for the most part). Folks who trained in military residencies seem happy with their training (for the most part). I just think that when folks consider things like HPSP that they look at the quality of military GME with both eyes open.

But it's hard for discussions like this to not feel personal. We put a lot of blood, sweat, and tears into medical school and residency so we all have a strong vested interest in feeling that our training was high quality.

 

[HighPriest]

Good analogy. I guess my issue is that in this case, a lot of folks who frequent this brewery claim that the availability of the food trucks make the brewery a good restaurant.

I don't have a dog in this hunt. Folks who trained civilian seem happy with their training (for the most part). Folks who trained in military residencies seem happy with their training (for the most part). I just think that when folks consider things like HPSP that they look at the quality of military GME with both eyes open.

But it's hard for discussions like this to not feel personal. We put a lot of blood, sweat, and tears into medical school and residency so we all have a strong vested interest in feeling that our training was high quality.

You are 100% accurate. The brewery isn't a great restaurant at all. But, the overall situation is pretty reasonable.

I think there's a lot of defensiveness inherent in the subject. And, people should know what they're getting in to. But I think it would be inaccurate to say that military programs are subpar because they do outside rotations. I also think it would be inaccurate to say that they're good specifically because of the outside rotations. They are what they are. They're training programs at hospitals that shouldn't be doing GME, who make up for that fact by sending residents to real (and quite good) universities. It's impossible to defend the fact that the MTF is subpar. But it's impossible to ignore the fact that you essentially get to back door into a great training program. And, you can't ignore the fact that there are some benefits inherent to working at a facility where no one can sue. Lots of hands-on experience. There's no research (or no real research), which could be a bad thing, but what ends up happening is that residents spend a lot more time actually working on patients, which is good.

All of that being said, there aren't many things about my military time for which you'll find me setting up any kind of defense. But, my training is one of those things. I was happy with it. I never wanted to be a researcher. I did want to do a fellowship, and at the time I was very upset that I was told I couldn't even apply. In hindsight, however, I'm pretty happy I didn't do one and the training I had really prepared me well for the work I now do.

 

[Gastrapathy]

Outrotations are often less invested in the trainees. If someone is terrible, they just wait it out. Not worth having hard conversations.

It is not true that you can’t be sued unless you only practice on AD. You have good malpractice insurance but can still be sued, named to the database, etc.

 

[HighPriest]

Outrotations are often less invested in the trainees. If someone is terrible, they just wait it out. Not worth having hard conversations.

It is not true that you can’t be sued unless you only practice on AD. You have good malpractice insurance but can still be sued, named to the database, etc.

Possibly true, although my experience (and the experiences of my colleagues) were that we often operated more than the local residents at our outside rotations.

And yes, you can be sued, but don't pretend for a minute that it's the same as being sued as a civilian. Or that the difference doesn't come to play in the way medicine is practiced in milmed. Getting sued in milmed is not good. But it's not as bad either. I can't think of one person I ever met in mildmed in my specialty who was sued. I know a LOT of guys who were sued on the outside. And my experience was very much that this was a factor in how often you ended up being the guy at the other end of the scalpel in the OR.

 

[Gastrapathy]

https://www.supremecourt.gov/opinions/12pdf/11-1351_aplc.pdf

This case hung over a docs head from O4 to O6 before finally working out ok.

I’m personally aware of an ENT (that’s you right?) settlement for large amounts. Missed cancer case.

But you are very well-insured.

 

[HighPriest]

Edit: I actually did say "no one can sue." My mistake, that is not accurate, and I know that is not accurate. That is not exactly what I meant. More of a hyperbole, but a large number of your patients can't sue (unless you operate on someone without consent, as above, which frankly deserves the attention), and the ones that can are, as you say, covered by a very good insurance policy.

My argument isn't that you CANNOT be sued. I've always known that wasn't the case. My argument is that it's a LOT harder, it's a LOT less frequent, and therefore it isn't as big of a deal for most people. It effects the way they practice. It effects what they let residents do, compared with how things work on the civilian side of things.

Compared to the two examples you've mentioned, I've met at least four ENT docs in just the last year who have all been sued more than once during their careers for known complications of minor procedures. They either won or settled every case, but it's a huge stressor, it's a huge burden, it's a financial obligation, and it's bad PR even if you win.

When I worked with students in the military, as long as they weren't total jerkoffs, I'd let them do whole cases with me just watching. If they had a known complication, I wouldn't be happy, but I wouldn't sweat it that much. Now, I let students do only what I think they can't screw up because I don't need the risk. Even if it's a lawsuit I'd ultimately win, or that would ultimately be settled, it's not worth it.

That was also my experience - with few exceptions - comparing my rotations at the university versus in the MTF. And we operated as much or more on our outside rotations than the university residents did, but there was always more of a limit on what we were allowed to do. And there was FAR more oversight for inpatient care at the university.

Would be very interested to know who the ENT doc was (don't expect you to tell me). I've never heard that story from anyone.

 

[militaryPHYS]

Outrotations are often less invested in the trainees. If someone is terrible, they just wait it out. Not worth having hard conversations

They are less invested if you are a dud of a resident. The places we went loved to have us because most of us as military residents worked harder, had confidence and functioned more independently than their residents. But again, this is all specialty, residency and person specific type stuff.

Bottom line, you will get a good to great education via military residencies. You will have outside rotations, for better or worst depending on your perspective. Military residencies will NOT hinder your ability to excel later in life. Often times it can help your CV.

What happens after residency based on your specialty choice, duty station and personal motivation determines whether or not you will succeed. Even the best surgeon stuck at the worst duty station can do something during his time there to improve him or herself, even if they can't directly improve their surgical skills or practice volume due to location.

 

[Gastrapathy]

Agree with the first paragraph completely. It’s the “dud” residents who are the issue. They become dud attendings. Outside rotations don’t want to lose the rotators, so they just let it slide. Decreases the true observation time.

 

[Gastrapathy]

Would be very interested to know who the ENT doc was (don't expect you to tell me). I've never heard that story from anyone.

West coast H&N Onc circa 2008

 

[HighPriest]

West coast H&N Onc circa 2008

Well that certainly narrows it down. If I had to guess, that would have been my guess.

 

[militaryPHYS]

I love going back to the OP and seeing how far we end up straying from topic of conversation.

 

[HighPriest]

I love going back to the OP and seeing how far we end up straying from topic of conversation.

ILE? Pay changes?

 

[militaryPHYS]

I'd like to discuss the role of MSC and nurse corps in MilMed leadership.

FYI I'm kidding. Let's not

 

[pgg]

I'd like to discuss the role of MSC and nurse corps in MilMed leadership.

I was just starting to like you, too.

 

[deleted314957]

I’m going to throw in a plug for military pathology. The training I have seen at military hospitals for pathology is on par with good to very good civilian programs. Probably not as good as top tier. Similar to what Perrotfish mentioned, military pathology residencies expect you to hit the ground running and practice as a general pathologist day one after training. This expectation is omnipresent all throughout training and is totally different than what I have seen at civilian programs (for reference, I did several rotations at civilian programs as a resident and did a civilian fellowship). Many trainees on the civilian side for pathology are excused from a lot because they are going into fellowship X and that’s all they will be doing after training. In the civilian world path residency can be a check box for some as they end up doing 2-3 fellowships and then only practicing in the areas of their fellowship training (I think this is ridiculous). Fellowship opportunities are not as abundant on the military side, but many people get to do one. Furthermore, you practice as a generalist as well as a subspecialist which I think is ideal for pathology. When you get out of the military you will be extremely marketable, because you will be competent at general pathology as well as your fellowship.

We also have free rain to order additional workup on pretty much every case that comes through the door. This is absolutely not the case in civilian institutions (even high profile ones that often receive cases from semi-shady arrangements like client billing). Civilian institutions also sign cases out with extremely quick turn around times for client satisfaction and to maintain high case volumes for a good salary. You have more time in military pathology to give cases the scrutiny they deserve.

To be fair, we do have our fair share of administrative problems that result from the military environment (cases coming out late, high admin burden, poor computer systems, poor support staff, etc).

Boy, I can second this post! This has been EXACTLY my experience since
decades ago when I did my internship, residency and fellowship in
the USN.

 

[DrMetal]

Things are pretty Excellent, as long as Dr. Metal is practicing...

 

[deuist]

4). The patient population is great.

Maybe because all of the malingerers and dependents ended up in the emergency department, but I found that this often repeated phrase was not true for my specialty. I saw lots of, "Doc, I pooped twice today. That means I have diarrhea and I need quarters."

You'll just have to get out of the military as soon as possible to get into one of these hyper-specialized tracks and understand that you'll be ~4 years behind the fellows who started building their academic careers as fellows while you were practicing "general insert medical specialty here" at Fort Campbell/NAS Lemoore/Eglin AFB.

I averaged one intubation and one central line a year at one of the Air Force's busier emergency departments. I had to get a civilian moonlighting job just so I could be competent in my specialty. Still loss is definitely a problem for emergency physicians.