Military Medicine: Pros, Cons, and Opinions

[WernickeDO]

Another year, another match and selection board, and another slew of disappointed GMOs. This is in continuation of a conversation that was initiated a year ago regarding Army policy (and only Army policy) with regards to GMOs returning to residency. A colleague of mine failed to match yet again and shared with me a feedback request email written by a PD within the specialty they applied to. The PD reiterated everything that I said in my earlier posts, namely that categorial intern spots are filled first by MS4s. If there are any spots left over then GMOs are considered. This suggests that GMOs can get one of these spots, but they would have to first beat out all the MS4s. FWIW, that's easier said than done. GMOs are already licensed and from a malpractice perspective they can't really do an audition rotation. Academics are what they are, but I assume most programs will almost always opt for a MS4 that has spent 4 weeks with them over a GMO that they meet for 4 hours during an interview. I ran into this myself when I applied; I contacted programs trying to do an audition rotation and the best they could offer me was a shadowing rotation. And this is in Army facilities, not civilian.

Is there a regulation out there that lays all this out? Probably not. What about your buddy/colleague/cousin/aunt that matched after a one year GMO in 2010? That was then, this is now. Do GMOs still match? Sure they do, but only if the class isn't filled first with MS4s. This means that GMOs are limited to the specialties that don't fill, which is usually FM, IM, psych, etc. This is still anecdotal with my n = 4, but the drum beat of PDs in different specialties all saying the same thing is getting too loud to ignore. If there are any Army PDs lurking out there who want to chime in, please do so.

Food for thought. Good luck.

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[DrMetal]

Another year, another match and selection board, and another slew of disappointed GMOs. This is in continuation of a conversation that was initiated a year ago regarding Army policy (and only Army policy) with regards to GMOs returning to residency. A colleague of mine failed to match yet again and

In what specialty?

The Navy is a little nicer to its GMOs. Still, there are plenty that don't match even after multiple GMO tours. The whole GMO model just needs to go away, but there doesn't seem like much of an impetus to do that. The more difficult problem is that we just don't have enough GME spots (especially true in the Navy). Let X = the number of junior physicians coming out of medical school, Y = total # of GME spots..... X >> Y ! If we got rid of all GMO billets, you'd have to increase Y (which you can't do at the MTFs, not enough acuity/volume.....you could possibly do it by deferring more people out). You could also reduce X by cutting down on the # of HPSP scholarships, making it more competitive, but nobody seems to want to do that either.

 

[WernickeDO]

In what specialty?

The Navy is a little nicer to its GMOs. Still, there are plenty that don't match even after multiple GMO tours. The whole GMO model just needs to go away, but there doesn't seem like much of an impetus to do that. The more difficult problem is that we just don't have enough GME spots (especially true in the Navy). Let X = the number of junior physicians coming out of medical school, Y = total # of GME spots..... X >> Y ! If we got rid of all GMO billets, you'd have to increase Y (which you can't do at the MTFs, not enough acuity/volume.....you could possibly do it by deferring more people out). You could also reduce X by cutting down on the # of HPSP scholarships, making it more competitive, but nobody seems to want to do that either.

OB/GYN.

You're right on with the X v. Y analogy. There is very clearly a feed for GMOs built into the system. There's nothing wrong with doing a GMO tour per se, but it's not right to let these people rot. If the Army is unable to train its docs, civilian deferment should be on the table. I think it's clear that milmed is not able to expand GME even if they wanted to.

If you're a pre-med reading this, considering HPSP, and your recruiter is telling you that a GMO tour nets a ton of points and opens up the door for returning to residency, know that this is not the case. Unless you have a close personal relationship with a PD that will fight to get you then you're likely limited to the specialties that don't fill.

 

[militaryPHYS]

So are you talking about GMOs returning to fill categorical intern spots in a new specialty or returning to PGY-2 spots in the same program they interned in? This is an important distinction. Repeating an internship in a new specialty vs. continuing on in your residency pathway is apples an oranges for GMO's.

 

[WernickeDO]

So are you talking about GMOs returning to fill categorical intern spots in a new specialty or returning to PGY-2 spots in the same program they interned in? This is an important distinction. Repeating an internship in a new specialty vs. continuing on in your residency pathway is apples an oranges for GMO's.

In this case I'm talking TY's in the Army only. In times past general surgery would only match to an intern year and have to re-apply to continue their training, but those days are now over. In the Army, even if you match to a specialty that requires an traditional intern year (derm, rads, ophtho) your career path is still intern year ==> PGY2 in your given specialties. If you match to any other specialty, you go straight through (unless you resign, get fired, etc). If you're a TY because you failed to match to EM or ortho or whatever, your chances of going back to GME in the more competitive specialties are slim and the specialty would have to first NOT be filled by MS4's. This is Army only; I know the Navy and AF have their own way of doing things.

 

[Perrotfish]

So are you talking about GMOs returning to fill categorical intern spots in a new specialty or returning to PGY-2 spots in the same program they interned in? This is an important distinction. Repeating an internship in a new specialty vs. continuing on in your residency pathway is apples an oranges for GMO's.

They're discussing GMOs trying to return to a PGY-2 spot in their original specialty, and prior transitional year GMOs trying to match into any specialty as either a PGY1 or PGY2.

The Navy is the only service that is even kind of set up for either scenario, in that we have PGY-2 spots that are reserved for returning GMOs and at least somewhat prioritize the points system that favors ex GMOs for PGY-1 slots. In the Army and the AF most of their GMOs were given transitional years that they didn't request, and then aren't really given an opportunity to match as either a PGY-1 or a PGY-2 at the end of their first 2 years as a GMO. Even in the Navy, though, there isn't a program that I know of that has as many PGY-2 slots as PGY-1 slots, which means that they are expecting at least some of their GMOs not to come back.

I agree the GMO thing needs to go away. We just need to suck it up and pay for more family docs.

 

[militaryPHYS]

If you're a TY because you failed to match to EM or ortho or whatever, your chances of going back to GME in the more competitive specialties are slim and the specialty would have to first NOT be filled by MS4's

Crazy. Wouldn't it be nice if we all did things the same way? At least it would make providing advice a little easier...

 

[WernickeDO]

Crazy. Wouldn't it be nice if we all did things the same way? At least it would make providing advice a little easier...

I actually think it makes giving advice easier: don’t join


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[Matthew9Thirtyfive]

I actually think it makes giving advice easier: don’t join


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So glad I didn't find this forum before I joined.

 

[backrow]

Even in the Navy, though, there isn't a program that I know of that has as many PGY-2 slots as PGY-1 slots, which means that they are expecting at least some of their GMOs not to come back.
.

To be fair let’s look at the 1524. For Navy the following programs have the same number of PGY1 and PGY2 slots:

Emergency Medicine
Family Medicine
OB/GYN
Ortho

The following have more PGY2 slots than PGY1 slots (because PGY1 isn’t selected, unlike Army & Air Force)

Aerospace
Anesthesia
Dermatology
Ophthalmology
Pathology
Radiology
Occ Med
Prev Med
Urology

And currently no interns because they are switching to a straight through model:

Otolaryngology


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[BlackFrancis33]

I'm not sure why this is surprising? If you are a GMO and not competitive out of medical school doing a GMO doesn't make you more competitive in many cases (especially in ER, Derm, Ortho). Being a GMO doesn't make you less competitive, I haven't seen anything or heard anything to make me believe that. But again, if the MSIV you are competing against is better than you were out of medical school, you probably won't get the residency slot.

 

[dwb8p]

Radiology is one of the few specialties in the Army that still reserves a spot for GMOs. Those who fill these slots and excel are usually prior surgical residents or people who would have otherwise been competitive for radiology as med students but applied for another specialty during an unlucky year. The remaining prior GMOs are usually people who weren't competitive for radiology as medical students, and as a result, often turn into the weakest residents of each cohort.

I don't feel too bad for repeatedly unmatched GMOs in the Army, because most are in their predicament as a result of poor performance in medical school or lack of insight. If you apply unsuccessfully 3 times for ER, derm, or ENT, it's probably because you went to a brand new D.O. school, scored a 350 on your comlex, and/or can't pass an APFT. Just do your 4 years of GMO time and move on to greener pastures in the civilian world; you'll be debt free, be able to use the G.I. bill as a supplement to your civilian resident pay, and may be able to land a spot in a specialty outside of primary care.

 

[Gastrapathy]

That sounds really bad for anyone interested in ENT right now

 

[HighPriest]

ENT is just -now- switching to a straight through th in the Navy? Yeah, that sucks pretty bad. Just another way the military is way behind the curve.

That being said, Army has had a straight through ENT system for some time, and the match rates still vary considerably. Some years it’s like 1.2 applicants to 1 position, and some years it’s 4:1. And my experience was -always- that GMOs were never considered as strongly as new students. There were always great new students.

 

[Gastrapathy]

But that means that no interns can be selected for how many years??? Just shows how arbitrary the system can be. Then all the folks who weren't selected for the zero spots will be out there in gmo land competing with currently favored MS4s. Seems fair.

As for not feeling bad for unmatched GMOs, I do. Nowhere else in our system is that an acceptable outcome.

 

[WernickeDO]

I'm not sure why this is surprising? If you are a GMO and not competitive out of medical school doing a GMO doesn't make you more competitive in many cases (especially in ER, Derm, Ortho). Being a GMO doesn't make you less competitive, I haven't seen anything or heard anything to make me believe that. But again, if the MSIV you are competing against is better than you were out of medical school, you probably won't get the residency slot.

It's surprising because it is in opposition to what myself and other HPSP pre-meds were sold, and judging from the chatter of some of the pre-meds and MS1s on this forum it's still being sold. My purpose in having this conversation is to dispel this myth that the point system is set up to favor GMOs. In reality, MS4s are considered first, and then GMOs. With this system, a competitive GMO can languish unselected (it may shock you to learn that there are GMOs that can realistically be considered for the more competitive specialties). So in that manner, being a GMO can make you less competitive in a system that considers your application on a second pass after handing out the lion's share to the MS4 class.

Again, it's all anecdotal. But when multiple PDs in multiple specialties are all saying the same thing I think it's worth having a conversation about it. Not so much for those who are already in and stuck, but for the sake of pre-meds who know nothing about medical training and how the Army does business.

 

[backrow]

But that means that no interns can be selected for how many years??? Just shows how arbitrary the system can be. Then all the folks who weren't selected for the zero spots will be out there in gmo land competing with currently favored MS4s. Seems fair.

As for not feeling bad for unmatched GMOs, I do. Nowhere else in our system is that an acceptable outcome.

This is the 2nd of 3 years. They did this to give all those out there who already did the internship a chance to come back to residency. My understanding is this is more RRC driven than Navy driven (similar to how if you stay out longer than 3 years and return to EM you get to repeat all of internship).

You are correct though, it really sucks for a few great candidates over these 3 years.


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[Gastrapathy]

So then what happens? The people who miss the chance now are not given the chance to come back from GMO?

 

[pgg]

Historically the Navy has treated GMO applicants favorably. I honestly don't know if that has changed. I didn't really scrutinize this year's GMESB list the way I usually do. I'm far enough away from it that the last few years I haven't recognized many names. Everyone I went to school with or trained with is done with training and/or long gone. I don't even know what the intern vs GMO mix for next year's class coming to my own department will be.

So then what happens? The people who miss the chance now are not given the chance to come back from GMO?

That's exactly what has happened, but I think the absolute numbers we're talking about are pretty small. And for most it I think it has worked out OK. They finish off their ADSOs as GMOs, get out, and match civilian. These are people who failed to match because the system changed policies and left them out in the cold, not necessarily because they were poor candidates. I would think that most are going to land on their feet, unless they were genuinely weak applicants, in which case there's blame to spread around.

I don't mean to defend the phenomenon of PGY-1 GMOs - my opinion on this is well documented - and there's no denying that the reason their landing is uncertain in the first place is because of an abrupt policy change that they couldn't control or anticipate.

I also think the military does owe GMOs some preference in the match, both as a reward for that service as well as an acknowledgement that some growth does occur.


I feel a little anxious and sad for the irony that in the future (if not now), the civilian match may actually think better of GMO time than the military match.

 

[WernickeDO]

They finish off their ADSOs as GMOs, get out, and match civilian. These are people who failed to match because the system changed policies and left them out in the cold, not necessarily because they were poor candidates. I would think that most are going to land on their feet, unless they were genuinely weak applicants, in which case there's blame to spread around.

I don't mean to defend the phenomenon of PGY-1 GMOs - my opinion on this is well documented - and there's no denying that the reason their landing is uncertain in the first place is because of an abrupt policy change that they couldn't control or anticipate.

I also think the military does owe GMOs some preference in the match, both as a reward for that service as well as an acknowledgement that some growth does occur.


I feel a little anxious and sad for the irony that in the future (if not now), the civilian match may actually think better of GMO time than the military match.

The irony you fear is alive and well. I'm on the (civilian) interview trail now and my time in the military is uniformly regarded as positive. That's not to say the Army doesn't value it but unmatched GMOs will find little solace in this appreciation.

I agree that the military does "owe" some preference to GMOs, but file it under wishful thinking rather than actual execution. Not in the sense that an average applicant matches to derm, but rather that GMOs get more than the table scraps left over from the MS4 class.

 

[BlackFrancis33]

It's surprising because it is in opposition to what myself and other HPSP pre-meds were sold, and judging from the chatter of some of the pre-meds and MS1s on this forum it's still being sold. My purpose in having this conversation is to dispel this myth that the point system is set up to favor GMOs. In reality, MS4s are considered first, and then GMOs. With this system, a competitive GMO can languish unselected (it may shock you to learn that there are GMOs that can realistically be considered for the more competitive specialties). So in that manner, being a GMO can make you less competitive in a system that considers your application on a second pass after handing out the lion's share to the MS4 class.

Again, it's all anecdotal. But when multiple PDs in multiple specialties are all saying the same thing I think it's worth having a conversation about it. Not so much for those who are already in and stuck, but for the sake of pre-meds who know nothing about medical training and how the Army does business.

Again, I do not believe it makes you less competitive. I know of no rule, written or unwritten, that indicates you are less competitive or lose preference if you have done a GMO. But a GMO will not put you ahead of an MSIV with a better application, you do not gain preference over better applicants. I would speak from personal experience that a GMO is a feather in your cap if you are equal (or better) than the other applicants. I do sense that PDs may have told you or others to 'Do a GMO to make yourself more competitive' and this is disingenuous. To state reality, 'do a GMO and hope you compare more favorably to the applicants in 2 or 3 years.' Personally, I would not give this advice without a stern warning as it comes with considerable risk.

 

[HighPriest]

Again, I do not believe it makes you less competitive. I know of no rule, written or unwritten, that indicates you are less competitive or lose preference if you have done a GMO. But a GMO will not put you ahead of an MSIV with a better application, you do not gain preference over better applicants. I would speak from personal experience that a GMO is a feather in your cap if you are equal (or better) than the other applicants. I do sense that PDs may have told you or others to 'Do a GMO to make yourself more competitive' and this is disingenuous. To state reality, 'do a GMO and hope you compare more favorably to the applicants in 2 or 3 years.' Personally, I would not give this advice without a stern warning as it comes with considerable risk.

Simply from being involved (as a fly on the wall) as a chief resident (and unofficially in years before that) with the selection process, this seems very accurate.

 

[WernickeDO]

Again, I do not believe it makes you less competitive. I know of no rule, written or unwritten, that indicates you are less competitive or lose preference if you have done a GMO. But a GMO will not put you ahead of an MSIV with a better application, you do not gain preference over better applicants. I would speak from personal experience that a GMO is a feather in your cap if you are equal (or better) than the other applicants. I do sense that PDs may have told you or others to 'Do a GMO to make yourself more competitive' and this is disingenuous. To state reality, 'do a GMO and hope you compare more favorably to the applicants in 2 or 3 years.' Personally, I would not give this advice without a stern warning as it comes with considerable risk.

Specialty X has 40 slots. The MS4 class is considered first. 55 MS4s apply, and 38 are qualified. They are matched. Then the GMO/FS/TY pool is considered. 20 apply, 7 are qualified. 2 are matched, 18 unmatched. Of those 18, 7 were qualified, so in this hypothetical there are 5 academically qualified applicants who had every realistic right to go after the specialty of their choice who don't match because the majority of the class was made up with MS4s.

I am not talking about academically inferior applicants displacing others by merit of their GMO time. I'm talking about two pools of applicants: MS4s and GMOs. If they were considered on merit in tandem then this wouldn't be an issue. But to consider one pool first and giving the left overs to the others is...I hate to say unfair, so instead I will just call it crappy. The fact that there are two pools of applicants is directly from an email by an adviser to the OTSG, written to me.

I do hope that the most meritorious applicants obtain training slots. But what happens when there are qualified applicants in the GMO pool that have no where to go? There is of course no policy that indicates a GMO making you less or more competitive, but if this is their model, you can see logically that GMOs are at a disadvantage.

An no, a PD never told me to go do a GMO. I was a general surgery intern that survived the initial culling and was encouraged to re-apply, only to learn after the deadlines had passed that I was being replaced (irony of ironies) by a GMO. So I never saw the GMO as a vehicle to improve my competitiveness for GME. I knew it was a distinct possibility that if I went GS that I could end up as a GMO. So I did my time like a man and hoped for better luck the next go-round. Then I learned how the Army does business. Now that the curtain has been pulled back a bit, I am trying to share my (anecdotal and hypothetical) knowledge. And if I were a pre-med considering HPSP, I would want to know this, or at least consider the truth and how capricious milmed can be.

 

[backrow]

Specialty X has 40 slots. The MS4 class is considered first. 55 MS4s apply, and 38 are qualified. They are matched. Then the GMO/FS/TY pool is considered. 20 apply, 7 are qualified. 2 are matched, 18 unmatched. Of those 18, 7 were qualified, so in this hypothetical there are 5 academically qualified applicants who had every realistic right to go after the specialty of their choice who don't match because the majority of the class was made up with MS4s.

I am not talking about academically inferior applicants displacing others by merit of their GMO time. I'm talking about two pools of applicants: MS4s and GMOs. If they were considered on merit in tandem then this wouldn't be an issue. But to consider one pool first and giving the left overs to the others is...I hate to say unfair, so instead I will just call it crappy. The fact that there are two pools of applicants is directly from an email by an adviser to the OTSG, written to me.

I do hope that the most meritorious applicants obtain training slots. But what happens when there are qualified applicants in the GMO pool that have no where to go? There is of course no policy that indicates a GMO making you less or more competitive, but if this is their model, you can see logically that GMOs are at a disadvantage.

An no, a PD never told me to go do a GMO. I was a general surgery intern that survived the initial culling and was encouraged to re-apply, only to learn after the deadlines had passed that I was being replaced (irony of ironies) by a GMO. So I never saw the GMO as a vehicle to improve my competitiveness for GME. I knew it was a distinct possibility that if I went GS that I could end up as a GMO. So I did my time like a man and hoped for better luck the next go-round. Then I learned how the Army does business. Now that the curtain has been pulled back a bit, I am trying to share my (anecdotal and hypothetical) knowledge. And if I were a pre-med considering HPSP, I would want to know this, or at least consider the truth and how capricious milmed can be.

One of the nice things the Navy has done is explicitly listed how many slots for interns are available and how many slots for GMOs are available for the PGY2 match on the precept. That isn’t to say that they have to take that many interns straight through, but it’s a max allowable. Army and AF are a little different though as shown by your example.


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[BlackFrancis33]

Wernicke DO - I am just not aware of this 'separate pools' concept. It is not consistent with the matches I have been involved, involving Army or Navy. I'm not aware of any specialties which separately evaluate the MS4 and GMO pool. I would be vehemently against this as I want to rank all applicants based on merit, and would never rank an MS4 ahead of a more qualified GMO.

 

[Gastrapathy]

@BlackFrancis33 the MS4 match (including the ever increasing number of straight through contracts and deferments) is completely separate from the PGY2 match for Navy. It is absolutely two separate pools and competitions. If you end up in a non-straight through inservice internship, you then do compete in the same pool as GMOs.

 

[BlackFrancis33]

@BlackFrancis33 the MS4 match (including the ever increasing number of straight through contracts and deferments) is completely separate from the PGY2 match for Navy. It is absolutely two separate pools and competitions. If you end up in a non-straight through inservice internship, you then do compete in the same pool as GMOs.

I’m talking primarily about the Army, which is what I thought what we were all talking about here. I understand the differences in the Navy match.