Future of Navy Pediatrics

[layman_3]

Hi all,

3rd year Navy HPSP here, trying to understand some basics about the Navy's plan for medicine. I went through medical school thinking I would probably end up in FM or IM, and am reasonably confident that those specialties will be present in the military going forward (albeit in more limited capacity). However, I recently discovered my love for Peds while on my pediatrics rotation. I'm not 100% decided, but there's a very real chance that pediatrics is what I want to specialize in.

My question is, can anyone offer any insight into the future of Navy Pediatrics? As far as I can find, there are <15 spots across the Navy, making it somewhat competitive and likely on the chopping block by Big Navy in their long-term quest to outsource military medicine. One mentor of mine is a Navy Peds grad from 20+ years ago, and she thinks peds residencies will be gone within the next decade. If this ultimately becomes what I want to do for my career, should I bank on doing GMO/GTFO? Do any residents get to go straight through anymore?

Thanks in advance.

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[SirGecko]

Actually it was 9 spots Navy wide this year. (https://www.med.navy.mil/directives/ENotes/NOTE 1524.pdf)

They say they aren't looking to cut any specialties or GME programs right now but who knows where they go in the future. I actually think its harder to get rid of peds than one might initially think so I doubt they actually get rid of the ability to do peds anytime soon but can't say they won't eventually go that way. The programs will probably still exist when you are applying though as I think they would have more lead time than that to shut down the program. I would assume if you do peds that you will go out to do a GMO tour at least in the next few years. They say they are getting rid of GMO tours for PGY-1 trained people in the next 7 years but they have said that before so we shall see on that. (I guess they want to make us more like the Army in that regard) Whether you go back to finish after the GMO tour in the navy or apply when you get out will be up to you and your career goals.

One piece of advice is to make sure you don't let your specialty choice be dictated by the Navy. (meaning if you have to get out to do what you want, do your time and get out) You are going to do this for the rest of your career.

 

[layman_3]

Thanks for the reply and advice. I hadn't heard about the plan to get rid of GMO tours at the PGY-1 level; it seems incompatible with the push for limiting non-surgeon/combat GME training given that not everyone wants to be (or could be) a surgeon. I signed up with the understanding that GMO/GTFO was an option, so hopefully I can still have that choice.

As someone in the pipeline, it seems myopic to me to orient military medicine only toward combat specialties given that there are many servicemembers not seeing combat at the moment who still need medical care in places like Guam or Twentynine Palms (good luck getting non-scholarship obligated American doctors to up and move to Guam to work for DOD pay).

 

[pawprint]

There is no push to eliminate gmo’s, the opposite is actually going on. I don’t know why that keeps going around. Programs keep sending more interns out to the fleet every year. Straight through spots are becoming non-existent.

Former Navy Peds intern here, currently out doing flight surgery tour. I was navy pediatric intern of the year and still got booted out to the fleet with all the other Peds interns to allow returning GMO’s to come back (and because of reduction in available pgy-2 spots).

Navy pediatrics is awesome, my intern year was the best year of my life. However, the programs are shrinking to shockingly low levels of patient management with nearly everything being outsourced to civilian medicine. ACGME will likely step into the situation in the next couple of years and remove program accreditation if things maintain the status quo. Not because of poor doctors, but because the patient volume is just so low now at the MTF’s as all care has now shifted away.

I recommend still doing the intern year as it was such a good experience, and then do your time and get out. And do Peds in the civilian world. If you like working with military families, just get hired as a civilian contractor at the military hospital.

 

[SirGecko]

There is no push to eliminate gmo’s, the opposite is actually going on. I don’t know why that keeps going around. Programs keep sending more interns out to the fleet every year. Straight through spots are becoming non-existent.

Former Navy Peds intern here, currently out doing flight surgery tour. I was navy pediatric intern of the year and still got booted out to the fleet with all the other Peds interns to allow returning GMO’s to come back (and because of reduction in available pgy-2 spots).

Navy pediatrics is awesome, my intern year was the best year of my life. However, the programs are shrinking to shockingly low levels of patient management with nearly everything being outsourced to civilian medicine. ACGME will likely step into the situation in the next couple of years and remove program accreditation if things maintain the status quo. Not because of poor doctors, but because the patient volume is just so low now at the MTF’s as all care has now shifted away.

I recommend still doing the intern year as it was such a good experience, and then do your time and get out. And do Peds in the civilian world. If you like working with military families, just get hired as a civilian contractor at the military hospital.

While like I said I have no clue how effective the transition will be, there is in fact a plan in place to transition from GMO’s to residency trained physicians doing the same role as an “Operational Medical Officer” in the next 7 years. It has been approved by the surgeon general for what that is worth. You can read more about it in the medical corps newsletter for winter 2021: Winter 2021 Medical Corps Newsletter

Functionally though I wouldn’t let this transition let you have unfounded hope that you for sure won’t got out as a GMO though OP. Likely timing wise (assuming it isn’t delayed or called off) and especially as a peds intern you may be in the awkward place of being one of the last people more likely to have to go do a GMO tour. They say they want to *start* sending less people out in academic year 2022 so you’d only be in the first intern year class this is impacting.

 

[MCCareer.org]

Hi all,

3rd year Navy HPSP here, trying to understand some basics about the Navy's plan for medicine. I went through medical school thinking I would probably end up in FM or IM, and am reasonably confident that those specialties will be present in the military going forward (albeit in more limited capacity). However, I recently discovered my love for Peds while on my pediatrics rotation. I'm not 100% decided, but there's a very real chance that pediatrics is what I want to specialize in.

My question is, can anyone offer any insight into the future of Navy Pediatrics? As far as I can find, there are <15 spots across the Navy, making it somewhat competitive and likely on the chopping block by Big Navy in their long-term quest to outsource military medicine. One mentor of mine is a Navy Peds grad from 20+ years ago, and she thinks peds residencies will be gone within the next decade. If this ultimately becomes what I want to do for my career, should I bank on doing GMO/GTFO? Do any residents get to go straight through anymore?

Thanks in advance.

I am the current Deputy Medical Corps Chief, and I briefed the SG on the plan to move to straight-through training. You can e-mail me at [email protected] and I will link you with the Peds Specialty Leader. You can discuss all of this with him and get the best answers we have.
This stuff is extremely complicated and typing it all out here is just too time consuming. Just being honest.

 

[numberwunn]

I am the current Deputy Medical Corps Chief, and I briefed the SG on the plan to move to straight-through training. You can e-mail me at [email protected] and I will link you with the Peds Specialty Leader. You can discuss all of this with him and get the best answers we have.
This stuff is extremely complicated and typing it all out here is just too time consuming. Just being honest.

 

[Matthew9Thirtyfive]

While like I said I have no clue how effective the transition will be, there is in fact a plan in place to transition from GMO’s to residency trained physicians doing the same role as an “Operational Medical Officer” in the next 7 years. It has been approved by the surgeon general for what that is worth. You can read more about it in the medical corps newsletter for winter 2021: Winter 2021 Medical Corps Newsletter

Functionally though I wouldn’t let this transition let you have unfounded hope that you for sure won’t got out as a GMO though OP. Likely timing wise (assuming it isn’t delayed or called off) and especially as a peds intern you may be in the awkward place of being one of the last people more likely to have to go do a GMO tour. They say they want to *start* sending less people out in academic year 2022 so you’d only be in the first intern year class this is impacting.

Haven’t they been working on this transition for like a decade? I would just assume you’re going to do a GMO and then if you don’t, that’s a pleasant surprise. Unless you’re doing psych or nsg. (General you, not you specifically.)

 

[DrMetal]

Haven’t they been working on this transition for like a decade? I would just assume you’re going to do a GMO and then if you don’t, that’s a pleasant surprise. Unless you’re doing psych or nsg. (General you, not you specifically.)

For 2 decades . . . what seems to be different now is that there's a real civilian impetus (now that states are refusing to license interns). It's sad that it take such a civilian impetus to force the Navy's hand to do the right thing, but so be it.

Still, I'll believe it when I see it. It's going to be hard to get rid of those GMO billets. It's going to be even harder to convince a residency trained surgeon to be a 'GMO' on an LSD/LPD (a job that involved no surgery, and hardly any complex medical care).

What they could do is keep GMOs (only PGY1 trained), send them out to the fleet working under another doctor's license, in the same vein as IDCs.

The real problem here is that we have too many medical students in the pipeline, making too many PGY1s, a small fraction going on to PGY2, then the rest need something to do. We should cut the HPSP and USUHS programs, each by say 15-20% (we don't need 60 new Navy doctors from USU . . . that number can be 40. We don't need 300 from HPSP, that number can be 200).

 

[SirGecko]

For 2 decades . . . what seems to be different now is that there's a real civilian impetus (now that states are refusing to license interns). It's sad that it take such a civilian impetus to force the Navy's hand to do the right thing, but so be it.

Still, I'll believe it when I see it. It's going to be hard to get rid of those GMO billets. It's going to be even harder to convince a residency trained surgeon to be a 'GMO' on an LSD/LPD (a job that involved no surgery, and hardly any complex medical care).

What they could do is keep GMOs (only PGY1 trained), send them out to the fleet working under another doctor's license, in the same vein as IDCs.

The real problem here is that we have too many medical students in the pipeline, making too many PGY1s, a small fraction going on to PGY2, then the rest need something to do. We should cut the HPSP and USUHS programs, each by say 15-20% (we don't need 60 new Navy doctors from USU . . . that number can be 40. We don't need 300 from HPSP, that number can be 200).

Do they actually have to convince anyone? Some people might fight it but I’m pretty sure they can just tell people to take the job.

 

[pgg]

Do they actually have to convince anyone? Some people might fight it but I’m pretty sure they can just tell people to take the job.

Orders like that would have consequences with regard to recruitment and retention.

Of course the military can issue any lawful order and it'll be obeyed. That's not in question. Lawful orders can still be counterproductive, harmful, and result in mission failure.

 

[pgg]

Haven’t they been working on this transition for like a decade? I would just assume you’re going to do a GMO and then if you don’t, that’s a pleasant surprise. Unless you’re doing psych or nsg. (General you, not you specifically.)

When I interviewed at USUHS 24 years ago they said GMOs were being phased out and likely wouldn't be a thing by the time I graduated. I don't think that interviewer was lying - I bet he'd been told the same thing in the 1980s, believed it was happening, and just repeated that idea in good faith to me.

It's a hard problem. The billets can't get wished away, the line wants their doctors. A Marine LtCol infantry battalion commander (for example) is going to be very resistant to a change that alters the concierge-level service "his" GMO provides.

 

[backrow]

When I interviewed at USUHS 24 years ago they said GMOs were being phased out and likely wouldn't be a thing by the time I graduated. I don't think that interviewer was lying - I bet he'd been told the same thing in the 1980s, believed it was happening, and just repeated that idea in good faith to me.

It's a hard problem. The billets can't get wished away, the line wants their doctors. A Marine LtCol infantry battalion commander (for example) is going to be very resistant to a change that alters the concierge-level service "his" GMO provides.

I certainly understand the skepticism. I’ve been around long enough to hear the mantra of “gmos are going away” in several iterations. The difference this time is there is actually a plan that has been developed and approved that will drastically cut the # of billets filled by PGY1 graduates. The good gentleman above knows much more than I seeing as he pretty much developed it; however, in my opinion it is a feasible plan that continues to support the needs/desires of the operational fleet.

Not all PGY1 billets will go away just as they never have with Army & Air Force, but I think you will see the Navy approach parity. This time is definitely different as there is a plan and not just lip service.

 

[DrMetal]

Do they actually have to convince anyone? Some people might fight it but I’m pretty sure they can just tell people to take the job.

Yeah, there used to be a time in the mil when you could actually order people around.

When I interviewed at USUHS 24 years ago they said GMOs were being phased out and likely wouldn't be a thing by the time I graduated.

Yeah, same here, 13 years ago.

They can't get rid of the GMO billets if they don't reduce the # in the PGY1 class (either by reducing the # of scholarships, or completely defer them out to civilian residencies).

For any particular class, if you're graduating 270 Navy PGY1s from internship, about 50 of them may go straight through. What do you do with the other 220??? Most cannot apply to civilian PGY2 spots (because there aren't that many, the civilian world trains everybody straight through), so you have to send them off to GMO land. We need the GMO billets!

 

[pgg]

Not all PGY1 billets will go away just as they never have with Army & Air Force, but I think you will see the Navy approach parity. This time is definitely different as there is a plan and not just lip service.

The Army's solution, broadly speaking, has been the "brigade surgeon" aka placing a BC/BE physician into those positions for multi-year tours.

I've always looked at that with a sort of mild horror. While this might be merely sorta harmful to someone in primary care, it's catastrophic to procedural specialists. It's certainly not good for any of these physicians, in terms of their knowledge or skills. I suppose if their desired career path is a move out of clinic work and into administrative work, it's OK.

It is better for the patients of course, to have fully trained physicians responsible for their care. A group of BC/BE physicians who are gradually wasting away is still a safer option than a group of PGY-1s who can't even get licensed in many states.

Use of intern grads in an unsupervised setting is not something I'll ever agree with, no matter the justification (cue the usual "it's OK" rationalizations like pre-screened mostly healthy AD patient population, phone consult availability, manpower issues, line commander "wants", tradition, cost, etc.)

If I was the Emperor-King of the DOD, I would put BC/BE primary care physicians in those billets for 6 month accompanied TAD stints. No PCS moves. Treat it like a deployment. It would cost more and the line would hate the revolving door and the loss of "their" docs. But it would be a better arrangement for literally every human being in uniform except the ones wedded to sacred org chart.

It couldn't happen, of course. Cost is the main obstacle, but inertia and belief in "institutional memory" and the way the line overvalues an embedded "unit doc" are just as problematic, if not more so.


Meanwhile, while we're on the topic of long talked-about but not implemented reforms, despite about 20 years of talking up civilian partnerships, I can't help but note that the best we have to show for it is a clone of the NTTC in LA standing up soon at UPenn.

Which is great, don't get me wrong, but so long overdue and so tiny in scope that it's essentially irrelevant. We need these partnerships with every VA within 50 miles of a MTF, and as many universities as possible. These need to be alternate work locations for ALL physicians at MTFs, not PCS destinations for a lucky handful of people to disappear to for a couple years, before returning to the low volume, low acuity MTFs that made those PCS orders necessary in the first place.

In the last 10 years, I have personally set up ERSAs and gotten myself (and when I was a DSS, my people) plugged into two VA hospitals and two civilian hospitals. Each time it was 100% individual effort, with precisely zero interest, guidance, or support from BUMED or DHA. I had to write one of the VA MOUs essentially from scratch.. It's just too much, too hard, to expect individuals to be able to do this themselves, reinventing the wheel every time. It has to be done by DHA, or maybe even Congress.

The only conclusions I can draw about both of these issues (GMO transitions and civilian partnerships) is that either there isn't the will to overcome resistance from the line, or that the cost is too high.

I remain ever hopeful, but I'll believe it when I see it.

 

[militaryPHYS]

Thanks for the reply and advice. I hadn't heard about the plan to get rid of GMO tours at the PGY-1 level; it seems incompatible with the push for limiting non-surgeon/combat GME training given that not everyone wants to be (or could be) a surgeon. I signed up with the understanding that GMO/GTFO was an option, so hopefully I can still have that choice.

As someone in the pipeline, it seems myopic to me to orient military medicine only toward combat specialties given that there are many servicemembers not seeing combat at the moment who still need medical care in places like Guam or Twentynine Palms (good luck getting non-scholarship obligated American doctors to up and move to Guam to work for DOD pay).

Because you are already committed to the HPSP program the good thing is that you're already engrained in MilMed but still have options moving forward. If you were a PREMED who was pediatrics-or-nothing we would all be having a totally different conversation.

They are are still training pediatricians. They haven't gone away yet and may never go away. If you apply and get a pediatric internship AND then can go straight through for residency I would still do it. Only reason not to take a gift given to you is if you were concerned about quality of the AD residency program. You just got go ahead for direct communication with @MCCareer.org to connect you with the Pediatrics specialty leader to discuss these issues. I would take him up on this offer.

Long story short, the pediatric programs are still here and have good training, but verify you agree by talking with the specialty leader. Apply for what you want to do. If you get it, great. If not, GMO and get out.

 

[DrMetal]

Use of intern grads in an unsupervised setting is not something I'll ever agree with, no matter the justification (cue the usual "it's OK" rationalizations like pre-screened mostly healthy AD patient population, phone consult availability, manpower issues, line commander "wants", tradition, cost, etc.)

Of course it's a terrible idea. So terrible, it might come to fruition! But that's essentially what we have now. Yes, GMOs have a medical license, but we all know that doesn't equate to adequate training (this is likely the impetus leading states to change their licensure requirements).

And if we, as a Navy, feel comfortable making an IDC the sole provider on a cruiser--a 'national asset', O-6 command, crew of 600, it can carry and launch nukes--then who knows what we'll do.

It's a crazy world. Here in the People's Republic of California, a NP now can practice independently. But a doctor having completed medical school and PGY1 can't get a license.

 

[Matthew9Thirtyfive]

And if we, as a Navy, feel comfortable making an IDC the sole provider on a cruiser--a 'national asset', O-6 command, crew of 600, it can carry and launch nukes--then who knows what we'll do.

Hey now. They have two whole junior quad ball corpsmen with them.

But yeah. To be fair, the crew complement on a cruiser is about 330-350, and they ain’t carrying nukes lol. But otherwise I completely agree with you.

 

[Dr. Wexler]

(this is likely the impetus leading states to change their licensure requirements).

Which states have changed and when?

 

[MCCareer.org]

Which states have changed and when?

I don't have the states off hand, but there is a Federation of State Medical Boards page where you can look here - FSMB | State Specific Requirements for Initial Medical Licensure

There are 20 states that require > 1 year of GME for licensure. A few years ago it was 17, and a few years before that it was 14, so it is clearly moving in the wrong direction.

 

[MCCareer.org]

Because you are already committed to the HPSP program the good thing is that you're already engrained in MilMed but still have options moving forward. If you were a PREMED who was pediatrics-or-nothing we would all be having a totally different conversation.

They are are still training pediatricians. They haven't gone away yet and may never go away. If you apply and get a pediatric internship AND then can go straight through for residency I would still do it. Only reason not to take a gift given to you is if you were concerned about quality of the AD residency program. You just got go ahead for direct communication with @MCCareer.org to connect you with the Pediatrics specialty leader to discuss these issues. I would take him up on this offer.

Long story short, the pediatric programs are still here and have good training, but verify you agree by talking with the specialty leader. Apply for what you want to do. If you get it, great. If not, GMO and get out.

Pediatrics cannot go away. We continue to have Pediatric requirements/jobs/billets/deployments, but perhaps less than previously. Plus, you can't have an Ortho residency without a Peds residency. It is an ACGME requirement.

 

[MCCareer.org]

For 2 decades . . . what seems to be different now is that there's a real civilian impetus (now that states are refusing to license interns). It's sad that it take such a civilian impetus to force the Navy's hand to do the right thing, but so be it.

Still, I'll believe it when I see it. It's going to be hard to get rid of those GMO billets. It's going to be even harder to convince a residency trained surgeon to be a 'GMO' on an LSD/LPD (a job that involved no surgery, and hardly any complex medical care).

What they could do is keep GMOs (only PGY1 trained), send them out to the fleet working under another doctor's license, in the same vein as IDCs.

The real problem here is that we have too many medical students in the pipeline, making too many PGY1s, a small fraction going on to PGY2, then the rest need something to do. We should cut the HPSP and USUHS programs, each by say 15-20% (we don't need 60 new Navy doctors from USU . . . that number can be 40. We don't need 300 from HPSP, that number can be 200).

The longer it takes to make you and the more specialized you are (surgeons), the less likely it is that you would have to an Operational Medical Officer (OMO) tour. We don't have enough GMO billets for everyone to have to do an OMO tour anyway.

We don't have too many medical students coming on AD. We have a mismatch in intern spots (250) and PGY-2 spots (200). As part of the transition, we are planning on making these numbers meet in the middle. Most years we bring about 285 med students on AD. If we have 225 straight-through GME spots after we transition, then the other 60 would get deferments for civilian training.

 

[MCCareer.org]

I certainly understand the skepticism. I’ve been around long enough to hear the mantra of “gmos are going away” in several iterations. The difference this time is there is actually a plan that has been developed and approved that will drastically cut the # of billets filled by PGY1 graduates. The good gentleman above knows much more than I seeing as he pretty much developed it; however, in my opinion it is a feasible plan that continues to support the needs/desires of the operational fleet.

Not all PGY1 billets will go away just as they never have with Army & Air Force, but I think you will see the Navy approach parity. This time is definitely different as there is a plan and not just lip service.

Correct. The Army and AF both still have 100 or so GMOs. Navy has 400+. We think we can get down to a similar number as the Army and AF.

 

[orbitsurgMD]

I am convinced the services generally and the Navy most significantly lack the will and the motivation to eliminate the use of GMOs/flight surgeons/UMOs with internship-only training. Having a cadre of HPSP recipients that can be treated as an essentially short-term semi-expendable professional workforce is just too easy to use as-is, and the alternatives that require re-inventing the type of assignments that fully-trained physicians might do are just too difficult and meet with too much misinformed resistance to be overcome. The line isn't motivated to do better and the staff, both the medical corps and the JAG either don't have the interest or the power of leadership to force change. Even the Congress, which at one time apparently instructed the services' leaders to eliminate use of intern GMOs has not been heeded. I suspect it would take a true act of Congress, as in making it required under the U.S. Code to fully train all military physicians to the completion of an ACGME-approved residency. Short of that, waiting for states to change their state laws is all there is, which isn't much. State law requirements are generally lagging--significantly lagging--civilian standards where board-eligibility is essential for applications to hospital staff, insurance panels and surgery centers. In most cases, the time allowance to achieve board-certification is limited to two or three years. On the civilian side, it doesn't much matter that a state only requires a single year of postgraduate training, it is nearly impossible to be gainfully employed as a physician without completing a residency, except of course as a military doctor.

 

[pgg]

Pediatrics cannot go away. We continue to have Pediatric requirements/jobs/billets/deployments, but perhaps less than previously. Plus, you can't have an Ortho residency without a Peds residency. It is an ACGME requirement.

Can you clarify what this means? Do you anticipate hiring civilian pediatricians?

I completely agree that we need peds for the other residency programs. And OB. And the NICU and PICU. And oncology. And endocrinology. And every other specialty you won't find in a Role 2 tent, because they're what makes a tertiary medical center a tertiary medical center, and not a big outpatient surgicenter clinic.

What I struggle to understand is how DHA can see this clear need to keep these specialties present and strong, for the sake of GME, yet has embarked on a path to devalue these specialties and encourage those physicians to get out.

The changes in special pays that have removed those physicians' ability to sign longer term and more lucrative contracts are a clear signal.

And barely a year or two ago, the plan was to drastically slash the number of billets for specialties like OB. Thankfully that didn't happen, but someone thought that was a workable idea.

If pediatrics gets a significant pay increase when the higher ceilings in the NDAA are brought to bear on FY22 special pays, that'd be a step in the right direction. But such a move would be at odds with what DHA has done already.

Are you able to comment on what will be done to keep pediatrics around?

 

[didja]

Just chiming in that at the end of my 20 years, the pendulum swing that peds has gone through in all 3 services has been nuts. I was a general pediatrician for the my first 7 years (3 years residency, 4 years as an attending) then trained and have served as a subspecialty for the rest of my career. As an active duty pediatrician, I advocated for my patients in ways that even incredibly well-trained, motivated and caring civilian pediatricians wouldn't be able to. In the most extreme examples, when parents of my patients were KIA, even though I'm not a grief counselor or a chaplain or a child psychiatrist, my clinic and I were able to make a big impact for these families when they needed us most.

If peds is reduced or made to serve as operational docs to both kids and adults, a lot of that will be lost. To be blunt, if active duty peds is significantly cut back and kids are leaked to Tricare network, we'll be turning them into medicaid recipients and a lot of their care will be shifted to midlevels, especially in outlying bases.

Finally, the operational toll of eliminating peds will be higher than people think. If someone is holed up in forward location and has any concern at all that their kids aren't being taken care of at home, I can't imagine the type of mission degradation that is possible. If they are hearing about Humana denials of meds for their kids on the Skype calls back home, it will cause significant morale problems for our deployed warfighters in particular.

 

[MCCareer.org]

Can you clarify what this means? Do you anticipate hiring civilian pediatricians?

I completely agree that we need peds for the other residency programs. And OB. And the NICU and PICU. And oncology. And endocrinology. And every other specialty you won't find in a Role 2 tent, because they're what makes a tertiary medical center a tertiary medical center, and not a big outpatient surgicenter clinic.

What I struggle to understand is how DHA can see this clear need to keep these specialties present and strong, for the sake of GME, yet has embarked on a path to devalue these specialties and encourage those physicians to get out.

The changes in special pays that have removed those physicians' ability to sign longer term and more lucrative contracts are a clear signal.

And barely a year or two ago, the plan was to drastically slash the number of billets for specialties like OB. Thankfully that didn't happen, but someone thought that was a workable idea.

If pediatrics gets a significant pay increase when the higher ceilings in the NDAA are brought to bear on FY22 special pays, that'd be a step in the right direction. But such a move would be at odds with what DHA has done already.

Are you able to comment on what will be done to keep pediatrics around?

DHA is not the one driving changes to special pays or billets. That is the Services (Navy, Army, AF). First the services decide what they need for operational needs, work their pay and promotion plans to best meet those needs, and then the DHA is responsible for the delta between what an MTF needs and the services can provide. This could involve hiring civilians, but it also could involve utilizing the civilian network. It all depends on how it plays out.

As for the Navy, we will continue to keep pediatrics and have pediatric requirements and billets. Will it be as many as 5 years ago? Probably not, but as you mentioned it will depend on what ultimately happens to planned billet cuts or conversions.

 

[MCCareer.org]

I am convinced the services generally and the Navy most significantly lack the will and the motivation to eliminate the use of GMOs/flight surgeons/UMOs with internship-only training. Having a cadre of HPSP recipients that can be treated as an essentially short-term semi-expendable professional workforce is just too easy to use as-is, and the alternatives that require re-inventing the type of assignments that fully-trained physicians might do are just too difficult and meet with too much misinformed resistance to be overcome. The line isn't motivated to do better and the staff, both the medical corps and the JAG either don't have the interest or the power of leadership to force change. Even the Congress, which at one time apparently instructed the services' leaders to eliminate use of intern GMOs has not been heeded. I suspect it would take a true act of Congress, as in making it required under the U.S. Code to fully train all military physicians to the completion of an ACGME-approved residency. Short of that, waiting for states to change their state laws is all there is, which isn't much. State law requirements are generally lagging--significantly lagging--civilian standards where board-eligibility is essential for applications to hospital staff, insurance panels and surgery centers. In most cases, the time allowance to achieve board-certification is limited to two or three years. On the civilian side, it doesn't much matter that a state only requires a single year of postgraduate training, it is nearly impossible to be gainfully employed as a physician without completing a residency, except of course as a military doctor.

Congress never formally told the services to get rid of GMOs. It was in the draft NDAA for FY1999 but didn't make the final cut.

We are not ELIMINATING GMOs. We are moving to straight-through GME, which will reduce the number. No service, even the Army or AF who largely make this transition 15 years ago, has gotten rid of GMOs.

 

[MCCareer.org]

Just chiming in that at the end of my 20 years, the pendulum swing that peds has gone through in all 3 services has been nuts. I was a general pediatrician for the my first 7 years (3 years residency, 4 years as an attending) then trained and have served as a subspecialty for the rest of my career. As an active duty pediatrician, I advocated for my patients in ways that even incredibly well-trained, motivated and caring civilian pediatricians wouldn't be able to. In the most extreme examples, when parents of my patients were KIA, even though I'm not a grief counselor or a chaplain or a child psychiatrist, my clinic and I were able to make a big impact for these families when they needed us most.

If peds is reduced or made to serve as operational docs to both kids and adults, a lot of that will be lost. To be blunt, if active duty peds is significantly cut back and kids are leaked to Tricare network, we'll be turning them into medicaid recipients and a lot of their care will be shifted to midlevels, especially in outlying bases.

Finally, the operational toll of eliminating peds will be higher than people think. If someone is holed up in forward location and has any concern at all that their kids aren't being taken care of at home, I can't imagine the type of mission degradation that is possible. If they are hearing about Humana denials of meds for their kids on the Skype calls back home, it will cause significant morale problems for our deployed warfighters in particular.

If the Services reduce Pediatrics, it is on the DHA to pick that ball up and effectively run with it. That is the reason why Congress has delayed MTF changes and billet cuts. They are not certain DHA can pick up the slack. We'll just have to see how it all plays out.

Thanks for your 20 years of service to our country.

 

[didja]

I guess I don't have much faith in DHA to get the job done or substitute for decades of lessons learned in military medicine, and peds in particular. Military pediatricians have contributed to academic medicine and have been an excellent leaders in the service (the often outpunch their weight when one looks at O-6 and up). Covid-19 was an opportunity for physician leaders to take some command back from the clipboard-type at DHA but that window of intervention is closing.

As for DHA's plan to bring in a civilian workforce instead of active duty, while I have had excellent civilian colleagues (many of whom were prior military and either got sick of moving or had joint spouse reasons for getting out) I have also had colleagues who weren't competitive for other positions, had worked in the prison system or otherwise didn't represent the cream of the crop. As we shrink specialties, including peds, that opportunity to hire prior military civilians will shrink. Then again, as a seperate problem, HPSP recruiters spent too much time in the last decade hanging out at expensive, for-profit DO schools rather than recruiting from top 50 medical schools. The high cost HPSP scholarships in particular have swung from elite expensive private MD schools to for-profit, DO programs that often don't have strong academic hospitals with deep specialty choices. Many of those active duty docs end up doing fine anyway but I had colleagues who graduated from Harvard, Georgetown and UCSF med schools and see far fewer of those med schools represented in my resident match lists.

Also, MCCareer, thanks for all you do for Navy medicine and for contributing to the discussion on SDN.

 

[Brouillet2017]

Actually it was 9 spots Navy wide this year. (https://www.med.navy.mil/directives/ENotes/NOTE 1524.pdf)

If the Navy is wondering why recruiting numbers are low, this downward trend of spots allocated for certain "non-combat" specialties doesn't help. Tons of people told me when I started medical school "But doesn't the military not let you do certain specialties, like pediatrics or OBGYN? They don't need those, do they?" Now it looks like that's the ultimate goal. I don't doubt MCCareers.org at all, I'm pointing out that there is a problematic optics issue at play here.

For example, the AAP website has a section for military information dated 2019-2020 (https://www.aap.org/en-us/documents/sous_military_guide.pdf) that shows as many as 6 Navy Peds spots at Portsmouth and 8 at San Diego. Now according to SirGecko's link it's 3 and 5. Trends like that don't exactly make medical students line up in droves if they think they might want to be a pediatrician or are possibly considering it since it looks like it's too difficult to get trained to do it through the military. It certainly gives the appearance that the Navy is minimizing its desire to train pediatricians, trending towards zero in the future. That would seriously concern me if I were a premed trying to decide if military medicine is a feasible option for achieving my career goals.

 

[Matthew9Thirtyfive]

If the Navy is wondering why recruiting numbers are low, this downward trend of spots allocated for certain "non-combat" specialties doesn't help. Tons of people told me when I started medical school "But doesn't the military not let you do certain specialties, like pediatrics or OBGYN? They don't need those, do they?" Now it looks like that's the ultimate goal. I don't doubt MCCareers.org at all, I'm pointing out that there is a problematic optics issue at play here.

For example, the AAP website has a section for military information dated 2019-2020 (https://www.aap.org/en-us/documents/sous_military_guide.pdf) that shows as many as 6 Navy Peds spots at Portsmouth and 8 at San Diego. Now according to SirGecko's link it's 3 and 5. Trends like that don't exactly make medical students line up in droves if they think they might want to be a pediatrician or are possibly considering it since it looks like it's too difficult to get trained to do it through the military. It certainly gives the appearance that the Navy is minimizing its desire to train pediatricians, trending towards zero in the future. That would seriously concern me as a premed trying to decide if military medicine is a feasible option for achieving my career goals.

That info isn’t correct. Last year (in the 2019-2020 1524), there were 4 and 4. There is actually 1 more Navy peds spot than there were last year.

https://www.med.navy.mil/sites/nmpd...nt/Documents/BUMED NOTICE 1524 JMESB 2019.pdf

 

[Brouillet2017]

That info isn’t correct. Last year (in the 2019-2020 1524), there were 4 and 4. There is actually 1 more Navy peds spot than there were last year.

https://www.med.navy.mil/sites/nmpdc/professional-development/Documents/BUMED NOTICE 1524 JMESB 2019.pdf

You are correct - one spot was added to Walter Reed. I appreciate the correction because numbers matter in this conversation.

 

[orbitsurgMD]

Congress never formally told the services to get rid of GMOs. It was in the draft NDAA for FY1999 but didn't make the final cut.

We are not ELIMINATING GMOs. We are moving to straight-through GME, which will reduce the number. No service, even the Army or AF who largely make this transition 15 years ago, has gotten rid of GMOs.

I hope you didn't mean to offer that as a defense of DOD policy. The fact that the services escaped a mandate in an authorization bill 21 years ago is not exactly an endorsement. Moving to straight-through GME for every medical corps HPSP and USUHS accession would merely place the services at the same standard as is expected in the civilian community at large, a standard of training the military has badly and increasingly fallen behind.

 

[MCCareer.org]

If the Navy is wondering why recruiting numbers are low, this downward trend of spots allocated for certain "non-combat" specialties doesn't help. Tons of people told me when I started medical school "But doesn't the military not let you do certain specialties, like pediatrics or OBGYN? They don't need those, do they?" Now it looks like that's the ultimate goal. I don't doubt MCCareers.org at all, I'm pointing out that there is a problematic optics issue at play here.

For example, the AAP website has a section for military information dated 2019-2020 (https://www.aap.org/en-us/documents/sous_military_guide.pdf) that shows as many as 6 Navy Peds spots at Portsmouth and 8 at San Diego. Now according to SirGecko's link it's 3 and 5. Trends like that don't exactly make medical students line up in droves if they think they might want to be a pediatrician or are possibly considering it since it looks like it's too difficult to get trained to do it through the military. It certainly gives the appearance that the Navy is minimizing its desire to train pediatricians, trending towards zero in the future. That would seriously concern me if I were a premed trying to decide if military medicine is a feasible option for achieving my career goals.

There are not plans to go to zero for Peds or any specialty, but the trend you point out is certainly real.

 

[MCCareer.org]

I hope you didn't mean to offer that as a defense of DOD policy. The fact that the services escaped a mandate in an authorization bill 21 years ago is not exactly an endorsement. Moving to straight-through GME for every medical corps HPSP and USUHS accession would merely place the services at the same standard as is expected in the civilian community at large, a standard of training the military has badly and increasingly fallen behind.

Better late than never!

 

[pawprint]

How do you plan to get rid of GMO’s after internship if you continue to decrease GME spots? I’m out in the fleet now, and the interns from last year are all out in the fleet. If you push the next class of Peds interns straight through, that means I won’t be able to go back as a pgy-2 when I finish my tour unless you increase the amount of pgy-2 spots (which is the opposite of what’s happening right now).

either you stop accepting peds interns for 3 years while you bring back your gmo’s to finish pgy-2, or you increase your gme spots. Pgy-2 spots are unlikely to increase, so at some point some Hpsp students are going to get screwed over by this transition. Or your gmo’s like me trying to return after being thrown in the mud for 3 years.

 

[MCCareer.org]

How do you plan to get rid of GMO’s after internship if you continue to decrease GME spots? I’m out in the fleet now, and the interns from last year are all out in the fleet. If you push the next class of Peds interns straight through, that means I won’t be able to go back as a pgy-2 when I finish my tour unless you increase the amount of pgy-2 spots (which is the opposite of what’s happening right now).

either you stop accepting peds interns for 3 years while you bring back your gmo’s to finish pgy-2, or you increase your gme spots. Pgy-2 spots are unlikely to increase, so at some point some Hpsp students are going to get screwed over by this transition. Or your gmo’s like me trying to return after being thrown in the mud for 3 years.

I didn't say this was going to be easy. To be honest, approximately 30% percent of GMOs never come back for GME now, so we don't have to train everyone.

In brief, this issue (making room for GMOs) is why we are taking 5 years. Each specialty will need to clear out GMOs they want to train as best as they can before they move to straight through training. One of the ways that we can make room is to take less interns and do more civilian deferments. The same thing can be done with returning GMOs...we use more civilian deferments. Like I said, though, not everyone who is a GMO will be trained, and that is no different from the system we have now. If you are in the bottom X percentage of those applying, you will likely not select for training, and the X is different for every specialty. And some will choose to get out.

 

[Brouillet2017]

I didn't say this was going to be easy. To be honest, approximately 30% percent of GMOs never come back for GME now, so we don't have to train everyone.

In brief, this issue (making room for GMOs) is why we are taking 5 years. Each specialty will need to clear out GMOs they want to train as best as they can before they move to straight through training. One of the ways that we can make room is to take less interns and do more civilian deferments. The same thing can be done with returning GMOs...we use more civilian deferments. Like I said, though, not everyone who is a GMO will be trained, and that is no different from the system we have now. If you are in the bottom X percentage of those applying, you will likely not select for training, and the X is different for every specialty. And some will choose to get out.

Just to clarify, are you saying there will likely be more civilian deferments for PGY1s as part of this plan - across the board? For more than just the EM/GenSurg/NSurg/Ortho specialties?

 

[orbitsurgMD]

How do you plan to get rid of GMO’s after internship if you continue to decrease GME spots? I’m out in the fleet now, and the interns from last year are all out in the fleet. If you push the next class of Peds interns straight through, that means I won’t be able to go back as a pgy-2 when I finish my tour unless you increase the amount of pgy-2 spots (which is the opposite of what’s happening right now).

either you stop accepting peds interns for 3 years while you bring back your gmo’s to finish pgy-2, or you increase your gme spots. Pgy-2 spots are unlikely to increase, so at some point some Hpsp students are going to get screwed over by this transition. Or your gmo’s like me trying to return after being thrown in the mud for 3 years.

The services have long known most (more than 30%, BTW if you look at HPSP alone) will choose to leave. In fact, they have known that for most who do choose to leave, the decision to do so is made before finishing internship. That was revealed in an interview by the Navy Surgeon General Koenig. Junior medical officers were seeing enough of Navy Medicine to know they did not want to continue their training in the Navy's hospital system. They weren't leaving because they were not selected for training; they were opting out. Those retained may have been very competitive or motivated because of longevity of prior service or because of longer service obligations, USUHS, academy, ROTC, etc. It wasn't simply a matter of the services selecting the most competitive candidates and letting the rest go their way. The selecting was going both ways.

I very much doubt there will be any meaningful effort to retain the GMOs. There won't be funding for outservice training or much interest in granting deferments. The cohort in GMO billets will find it more difficult to return as there will be a need to reduce the number of PGY2 slots for returning GMOs as programs add straight-through contracts. That will be something that is new.

 

[orbitsurgMD]

How do you plan to get rid of GMO’s after internship

They will let them burn up their obligated repayment service as GMOs and most will by the second year of their GMO tour realize their opportunities will be better outside the service medical system. Those officers will apply for civilian residencies and drop their papers. If they are smart, they will refuse all new orders that might increase their service obligation beyond their EAOS, including any PCS orders that carry minimum service terms that might extend their obligations. They should absolutely refuse to be played. That might give some of the Navy detailers headaches--easier to fill a spot with a bigger pool of candidates--but there is no reason to accommodate an organization that uses deception about the availability of professional training opportunities as a regular recruiting tool. If that seems like eating glass to the BUMED, too bad. They deserve it.

 

[pgg]

GMOs who find there's no residency chair when the music stops will exit service and train as a civilian. This is OK for HPSP'ers who are looking at a 3 or 4 year gap in training. I feel for the USUHS grads +/- people with ROTC/academy obligations who'd have to spend the better part of a decade as a GMO ... but I guess that's extra motivation to be a competitive applicant.

Or perhaps there will be civilian deferrals authorized at the GMESB in those years. I don't know if I'd count on that though - the GMESB is definitely a force-shaping tool. Its primary charge is to train people to meet anticipated needs of the services, and going beyond that to meet individuals' career goals is perhaps too much to expect.


Also, we really ought to acknowledge that some of us are never going to be fully satisfied with the GMO solution, because there are some irreconcilable philosophical differences. I've come to the point of view that there should be zero GMOs, that all physicians engaged in independent patient care ought to be board certified or eligible. I have to acknowledge that there is no solution where GMOs exist that will satisfy me.

Junior medical officers were seeing enough of Navy Medicine to know they did not want to continue their training in the Navy's hospital system. They weren't leaving because they were not selected for training; they were opting out.

Elephant in the room, this is. The quality of inservice GME has undeniably declined in the last 20 years, except perhaps in the non-war-critical specialties like peds and OB.

HPSP recruitment has become heavily tilted toward new and expensive DO schools. Ivy Leaguers have become rare. (I don't want to turn this into a MD vs DO discussion; individuals are individuals but there's a different bell curve of academic achievement for the DO cohort vs the Ivy and prestigious public MD schools.)

Our residents do fewer index cases and spend more of their time rotating at outside institutions than they used to. We need more sick people, more old people, more dependents with chronic medical problems. Instead we're continuing on a trajectory to defer those patients to the network and devalue/downsize the specialties that used to take care of them.

I don't know what the answer is. We can't close GME but we can't keep on as we have.

 

[Homunculus]

There are not plans to go to zero for Peds or any specialty, but the trend you point out is certainly real.

this is interesting to me, I left active duty after 14 years and currently serving out my 20 in the reserves, and the last I saw multiple pediatric subspecialties were on the list for elimination--among those were peds endo (which i think was last on OML and was going to be the first to go). somewhere near the top was infectious disease which makes sense because you cannot swing a dead cat in a MEDCEN without hitting 2 or 3 pediatric ID docs. plus, their civilian pay is so poor the ones I know either stay in forever or get out and do gen peds. they have continued to take new fellows, but i would not going to a pediatric residency counting on subspecialty fellowship training being around in house. civilian deferred fellowship training was available, but those fellows were ending up signing longer contracts (i know of at least one NICU fellow) than the 3 year ADSO typically incurred.

secondly (and I am definitely dating myself here), the navy did get rid of pediatrics over the span of a week back in like 2004-2005-ish time frame. with a significant back lash from GME programs and the AAP, this was reversed but for a good 3 days or so our navy colleagues were literally in WTF mode. imagine being a GMO with no residency to return to. so in regards to eliminating peds-- it's possible, and they've tried it before. we can actually thank OIF/OEF for saving us, because we volunteered as offerings/tributes to the FORSCOM gods to "prove" our value as battalion/brigade surgeons. other than surgery and FP, for a good chunk of time pediatricians were in the top 3 deployed specialties in the army. without the draw down, it's only a matter of time before the good idea fairies return and peds is back on the chopping block.

--your friendly neighborhood rumors of my demise have been greatly exaggerated caveman

 

[didja]

this is interesting to me, I left active duty after 14 years and currently serving out my 20 in the reserves, and the last I saw multiple pediatric subspecialties were on the list for elimination--among those were peds endo (which i think was last on OML and was going to be the first to go). somewhere near the top was infectious disease switch make sense because you cannot swing a dead cat in a MEDCEN without hitting 2 or 3 pediatric ID docs. plus, their civilian pay is so poor the ones I know either stay in forever or get out and do gen peds. they have continued to take new fellows, but i would not going to a pediatric residency counting on subspecialty fellowship training being around in house. civilian deferred fellowship training was available, but those fellows were ending up signing longer contracts (i know of at least one NICU fellow) than the 3 year ADSO typically incurred.

secondly (and I am definitely dating myself here), the navy did get rid of pediatrics over the span of a week back in like 2004-2005-ish time frame. with a significant back lash from GME programs and the AAP, this was reversed but for a good 3 days or so our navy colleagues were literally in WTF mode. imagine being a GMO with no residency to return to. so in regards to eliminating peds-- it's possible, and they've tried it before. we can actually thank OIF/OEF for saving us, because we volunteered as offerings/tributes to the FORSCOM gods to "prove" our value as battalion/brigade surgeons. other than surgery and FP, for a good chunk of time pediatricians were in the top 3 deployed specialties in the army. without the draw down, it's only a matter of time before the good idea fairies return and peds is back on the chopping block.

--your friendly neighborhood rumors of my demise have been greatly exaggerated caveman

I'm not Navy but I absolutely remember when the Navy threatened to fire all their pediatricians. A not insignificant number of Navy pediatricians did retrain in other specialties to be able to stay in because they were close enough to retirement or otherwise loved the Navy. I recall a few retraining in rads who I knew so I think the repercussions were felt for longer than a week.

 

[Helpful Troll]

Those officers will apply for civilian residencies and drop their papers. If they are smart, they will refuse all new orders that might increase their service obligation beyond their EAOS, including any PCS orders that carry minimum service terms that might extend their obligations. They should absolutely refuse to be played.

@orbitsurgMD Is another significant date the initial entry to AD as a GMO or to first duty station after inservice GME for Intern year? Don't some attempting to get back to civilian residency training on time after their commitment get held on AD (1-2 months) unexpectedly because they reported to their first duty station later? July vs May for example? It may only apply if their command denies terminal leave but I've read it here a number of times.

 

[orbitsurgMD]

@orbitsurgMD Is another significant date the initial entry to AD as a GMO or to first duty station after inservice GME for Intern year? Don't some attempting to get back to civilian residency training on time after their commitment get held on AD (1-2 months) unexpectedly because they reported to their first duty station later? July vs May for example? It may only apply if their command denies terminal leave but I've read it here a number of times.

I am too long away to be of any use to you on this. As I recall, several factors applied to a departure date. EAOS for HPSP repayment service was only one, but as long as nothing else supervened, it was usually the earliest and fell on the mid-year meridian (the repayment clock starts at 00:00 on July 1) in time for starting a PGY-2 as a civilian. The traps were taking an annual bonus payment on a cycle that didn't end at the same time as the EAOS (I forwent my last bonus because they insisted on a full year for a full payment and no part-year for part-payment option was permitted. I hope I have made them pay for that miserliness). Another was to opt for PCS orders on less than a two-year remaining payback. In some places, they could extend until EAOS. Some of my colleagues did this. One was a GMO on a ship going into the shipyard (or decomm, I can't recall) and he dug in and refused any new orders as he was getting out to do a urology residency in Boston and wasn't having any Navy interference by their typical chicanery. He got to stay where he was, but I think he really didn't have a billet proper for his last year. I think that was a more flexible requirement and the Navy would move officers on less than a two year set of orders but they usually pretended that they couldn't (they lie, of course, and they can and will pay to move you if it suits them.)

 

[militaryPHYS]

I've come to the point of view that there should be zero GMOs, that all physicians engaged in independent patient care ought to be board certified or eligible. I have to acknowledge that there is no solution where GMOs exist that will satisfy me.

second

 

[MCCareer.org]

Just to clarify, are you saying there will likely be more civilian deferments for PGY1s as part of this plan - across the board? For more than just the EM/GenSurg/NSurg/Ortho specialties?

There is no way I can promise anything, but there should be more NADDS deferments, in general. The specialties are 100% dependent on Navy needs and the number is dependent on recruiting:

# NADDS = # graduating medical students - # military PGY1 spots we need to fill

 

[MCCareer.org]

The services have long known most (more than 30%, BTW if you look at HPSP alone) will choose to leave. In fact, they have known that for most who do choose to leave, the decision to do so is made before finishing internship. That was revealed in an interview by the Navy Surgeon General Koenig. Junior medical officers were seeing enough of Navy Medicine to know they did not want to continue their training in the Navy's hospital system. They weren't leaving because they were not selected for training; they were opting out. Those retained may have been very competitive or motivated because of longevity of prior service or because of longer service obligations, USUHS, academy, ROTC, etc. It wasn't simply a matter of the services selecting the most competitive candidates and letting the rest go their way. The selecting was going both ways.

I very much doubt there will be any meaningful effort to retain the GMOs. There won't be funding for outservice training or much interest in granting deferments. The cohort in GMO billets will find it more difficult to return as there will be a need to reduce the number of PGY2 slots for returning GMOs as programs add straight-through contracts. That will be something that is new.

Well, I was there and this past year we already granted way more deferments than normal, so I don't agree with your comment that "there won't be...much interest in granting deferments."

 

[orbitsurgMD]

Well, I was there and this past year we already granted way more deferments than normal, so I don't agree with your comment that "there won't be...much interest in granting deferments."

And this year?