military residencies

[yeeester]

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I am a senior considering an Army or AF HPSP for med school (I am taking a year off before applying to Med School). I want to be fully informed before I decide anything, so I was wondering if anyone has information as to how well respected the military residencies are. Specifically, Army surgical residencies, particularly neurosurgery, orthopedics, and the like. Any information would be wonderful. I assume that all the training would be fairly comparable to the best offerred on the civilian side, but anyone with some experience and some info please let me know.

Thanks.

 

[militarymd]

In general, military residencies are pretty good. You get pretty good training at the home hospitals, but the best part is that, you spend a lot of time in outside rotations....places that you can arrange yourself.

You can tailor your training to what you want.

However, the military residencies will never compare to the top ranked programs in the country. Part of the reason is that the faculty (active duty types) rotate so frequently. A problem for research, teaching, etc.

The DC area programs do have the advantage of being in close proximity to a lot of research opportunities.

Getting into the residencies may be the tough part.....chances of getting in change on a year to year basis based on the needs of the service

 

[mitchconnie]

I would disagree slightly with militarymd regarding the quality of military residencies. I think that historically they were fairly solid and comparable to most civilian programs, but all that changed with Tri-care (the military's HMO concept) in the mid-90's. A tremendous number of patients, and almost all those over 65 were shifted to the civilain sector, decimating the patient base for the medical centers. At my hospital, we went from 300+ beds to 30 (Yes 30!). Imagine what kind of training program we were left with. There were no cases for the surgical residents to do at all. Like militarymd, I think I ended up with good training, but only because all the residents were shifted to nearby civilian hospitals. Having seen what goes on in military hospitals, I would be highly suspicious of anyone who trained there from the late 1990's on. I think some of the big, prestigious programs (Walter Reed, Bethesda Naval) have managed to stay competitive with their civilian counterparts, but I see a STEEP drop-off after that. As a military surgeon, I don't have enough cases to keep my own skills current, let alone train competent residents.
I only have direct experience with a couple of programs, but be VERY wary of what you are told by military program directors. The military of today places no emphasis whatsoever on GME, and many programs are struggling to survive.

 

[militarymd]

mitchconnie,

I think we agree more than we disagree. I'm still AD, and am trying not to be too negative, but I read some of your other posts, and I think we both feel exactly the same way.

I trained in the first half of the 90's and did a civilian fellowship, and I can't wait to get out and practice real medicine and not military medicine which...lets be honest...kind of sucks right now.

Look up my posts, see if you agree on the things that I have been saying. I think medical students who are thinking about signing up, should really be aware of what we are aware of.

militarymd

 

[Rudy]

The last two posts are right on. More medical students thinking about HPSP/USUHS need to understand what military medicine is really like right now. There is a definite feeling that mil medicine is "circling the drain" as so many hospitals have been drastically scaled back into glorified clinics. The question is how long the military thinks it can still maintain GME while continuing to cut back; it seems that mil medicine is at a crossroads right now.

Remember, we are talking about how the LARGEST of military medical centers are downsizing and struggling to maintain a significant caseload. The real problem is after a military doc finshes training and is sent to a small base where there is nothing in terms of case variety or complexity. This is particulary tough on specialists.

 

[GMO_52]

I completed an IM internship at Balboa and went to USUHS. The problems with NNMC (caseload, glorified clinic) have been well-documented but I don't think it universally applies. We saw tons of over-65s in the new Tricare for Life world. My entire panel had 2 patients younger than 65. I can't speak to highly techincal subspecialty training but I think the general IM training was excellent. Board scores from Balboa back that up. I'd say our biggest deficiency is in numbers of procedures. You can make up for that with the outside rotations mentioned above.
The bigger question for GME, at least to me, is the work-hour restrictions. They are far too restrictive and actually force residents to leave when they feel that they should stay.

 

[mitchconnie]

I wouldn't disagree that there are some isolated pockets of quality GME to be had in the military. I think that some primary-care, clinic-based subspecialties get very reasonable training. The initial post was really about surgical specialties though, and believe me, we have been wiped out. The population we serve is simply not big enough to produce sufficient numbers of tertiary-referral-type cases.
The military medical services have radically shifted their focus to operational medicine (which I would broadly define as primary care for the troops) and away from providing comprehensive healthcare. This makes perfect sense given the current world situation, and DOD bugetary constraints. But you can't run a comprehensive GME program and train sugical specialists when all you have is a bunch of outpatient clinics. You can't maintain a good teaching environment when 1/3 to 1/2 of the staff is deployed to the desert at any one time.
The military has not realized this, but I think the RRC is starting to catch on. When I was interviewing for my civilian fellowship, one of the faculty I met was on the RRC for surgery. Noting my own military training, he explained to me how poor he felt the nearby military training program was, and how he intended to force them to close or integrate with a civilian program. He cited the high staff turnover, lack of cases, and too many away rotations.
Again, there is still good training some places but the best option for the compettive applicant is a civilian deferrment.

To militarymd,

I agree with just about every single post you've made. All potential HPSP applicants should run a search for your posts and read them again, and again and again.

 

[Mirror Form]

Originally posted by mitchconnie
I wouldn't disagree that there are some isolated pockets of quality GME to be had in the military. I think that some primary-care, clinic-based subspecialties get very reasonable training. The initial post was really about surgical specialties though, and believe me, we have been wiped out. The population we serve is simply not big enough to produce sufficient numbers of tertiary-referral-type cases.
The military medical services have radically shifted their focus to operational medicine (which I would broadly define as primary care for the troops) and away from providing comprehensive healthcare. This makes perfect sense given the current world situation, and DOD bugetary constraints. But you can't run a comprehensive GME program and train sugical specialists when all you have is a bunch of outpatient clinics. You can't maintain a good teaching environment when 1/3 to 1/2 of the staff is deployed to the desert at any one time.
The military has not realized this, but I think the RRC is starting to catch on. When I was interviewing for my civilian fellowship, one of the faculty I met was on the RRC for surgery. Noting my own military training, he explained to me how poor he felt the nearby military training program was, and how he intended to force them to close or integrate with a civilian program. He cited the high staff turnover, lack of cases, and too many away rotations.
Again, there is still good training some places but the best option for the compettive applicant is a civilian deferrment.

I haven't done any ADT's yet, but most of the army's GME locations for surgical specialties are at hospitals like Brooke, Madigan, Tripler, and Walter Reed which are all huge facilities. Do these places really provide crappy training? Would you recommend applying for a civilian deferment if I plan on doing a surgical subspeciality (ortho, uro, etc)?

 

[Homunculus]

Originally posted by Sledge2005
I haven't done any ADT's yet, but most of the army's GME locations for surgical specialties are at hospitals like Brooke, Madigan, Tripler, and Walter Reed which are all huge facilities. Do these places really provide crappy training? Would you recommend applying for a civilian deferment if I plan on doing a surgical subspeciality (ortho, uro, etc)?

i think both militarymd and mitchconnie are naval physicians, so while their experiences are valid, i would make sure to rotate at the program you are interested in. while i'm sure things are similar, *some* things are different between the services. ask residents the questions militarymd and mitchconnie are posing, and take a good hard look at them from an education standpoint.

 

[Homunculus]

for some reason this didn't get bumped when i posted . . strange . .

 

[texdrake]

Im curious too...what branch are you guys in. Somehow I can't see Trippler or Walter Reed having issues with case load.

 

[R-Me-Doc]

Again, most places have a more than adequate primary care and, to a certain extent, subspecialty clinic caseload. The problem (and this is not unique to the military, it is happening at many civilian hospitals as well) is that inpatient services are dropping.
And, I have to agree with the above posters who note problems with surgeons getting adequate caseload. I'm not a surgeon but I've long heard them complaining about having not much to do around military facilities. The training you will get is good, but you need to make sure you get enough of it.
Also, with the possible exception of Walter Reed, none of the military hospitals are truly "full service" with regard to high-speed, cutting edge procedures or diagnostic equipment -- a lot of patients get sent out to civilian hospitals for things like interventional radiology, neurosurgical and spine procedures, etc.

 

[Homunculus]

Originally posted by R-Me-Doc
a lot of patients get sent out to civilian hospitals for things like interventional radiology, neurosurgical and spine procedures, etc.

which makes me wonder-- why doesn't the military maintain its primary care fields, while "outsourcing" it's specialties? make military GME primary focused and fund slots for military physicians in civilian programs. sort of like "buying" a slot from a residency. i think they'd spend the same amount of cash for better training, and the program they join will get another resident essentially for free. then when they're done, bring them into the military system. i dunno, just a random idea, lol.

 

[militarymd]

Originally posted by Homunculus
which makes me wonder-- why doesn't the military maintain its primary care fields, while "outsourcing" it's specialties? make military GME primary focused and fund slots for military physicians in civilian programs. sort of like "buying" a slot from a residency. i think they'd spend the same amount of cash for better training, and the program they join will get another resident essentially for free. then when they're done, bring them into the military system. i dunno, just a random idea, lol.

H,

Am I not getting my points through? Military medicine is not what everyone is telling you. There is no planning beyond a flag officer's 3 year tour. Nobody really cares. Things swing one way than another, depending on the whims of whoever happens to be in charge, and needs to have a fitrep bullet for their promotion. Everybody has a great idea, like yours, but no one keeps a job long enough to see it through.

Have you not noticed the tones of all the posts? Those who have finished training and served....done their tours, etc....have a lot of negative things to say and are warning young doctors to be, while those who haven't done it and are just hearing about it, are saying all these great things about military medicine.

Now who do you think has the goods on what's true? What incentive would myself or mitchconnie or others have to tell the "truths" as we see them to you all. Do you think we want to make your lives more difficult by encouraging a closer look at loans (done by most medical students)? Do you think we would benefit by harming our great military? We gain nothing by telling you guys these "negative" things. We've done our times and are getting out.

We would like new doctors to not have to suffer through what we did. That's why we are posting. I'm sure mitchconnie would agree.

 

[Homunculus]

Originally posted by militarymd
H,

Am I not getting my points through? Military medicine is not what everyone is telling you. There is no planning beyond a flag officer's 3 year tour. Nobody really cares. Things swing one way than another, depending on the whims of whoever happens to be in charge, and needs to have a fitrep bullet for their promotion. Everybody has a great idea, like yours, but no one keeps a job long enough to see it through.

Have you not noticed the tones of all the posts? Those who have finished training and served....done their tours, etc....have a lot of negative things to say and are warning young doctors to be, while those who haven't done it and are just hearing about it, are saying all these great things about military medicine.

Now who do you think has the goods on what's true? What incentive would myself or mitchconnie or others have to tell the "truths" as we see them to you all. Do you think we want to make your lives more difficult by encouraging a closer look at loans (done by most medical students)? Do you think we would benefit by harming our great military? We gain nothing by telling you guys these "negative" things. We've done our times and are getting out.

We would like new doctors to not have to suffer through what we did. That's why we are posting. I'm sure mitchconnie would agree.

actually your idea *is* getting through-- you have the same theme in in all of your posts. yes, you distrust officers. yes, you've gotten screwed over in the past. i'll tell you what. compose your militarymd manifesto and i'll sticky it to the top of the forum so you won't have to use it in all your replies-- you can just link to it as necessary.

i appreciate having your input, be it positive or negative. having people who have been there, done that is an invaluable tool for those of us just getting started with our medical careers. that being said it seems like at times you are trying too hard to emphasize your points. believe it or not, most army physicians i have spoken with, retired and active duty, have enjoyed most of their experiences in the military. granted, i have been exposed to mostly army physicans and army teaching hospitals and you and mitchconnie are naval physicians, but i tend to go with the majority on this. the most disgruntled people i've talked to have been naval physicians. to me this indicates it *may* be a naval issue and not a military wide issue. maybe, maybe not, it's just my opinion and my limited experience.

there is always a vocal minority-- there was a vocal minority at OBC b*tching about this and that, but most people tolerated it and enjoyed themselves. the military isn't all sunshine and good times-- but neither is life in the civilian world. yes, i think the leadership can make things worse or better depending on their competence. but to dwell on it as much as you do is beginning to make me start to discount your posts. i haven't gone back and looked, but have you posted a single thing positive about your naval time? there has to be something. no one is *that* miserable unless they had absolutely 100% no clue as to what they were getting into. so it's good that you are informing people of your negative experiences, but for the love of god, buck up a little. you've gotta be almost done, right? wouldn't that be a positive thing?

 

[chillin]

Dudes,
One of my path professors was a Naval physician, and this guy has the greatest stories to tell. That being said. I think the experience of being in the military is worth every penny of scholarship you receive. Wait...you get paid to learn and see all this cool shxt. I think just being able to walk around in one of those uniforms is pretty freakin cool. Plus, you tell someone your a military doc and they have just that much more respect for you. Now I'm sure that the military has a lot of bureaucratic bullcrap that goes on, but so do HMO's. One other thing, not having a $200,000 loan to think about every night before you go to bed is a nice thing too.
chillin

 

[edmadison]

Originally posted by chillin
Dudes,
Plus, you tell someone your a military doc and they have just that much more respect for you.

Maybe the layman does, but I can tell you from my personal experience and that of my father (a practicing physician for 30 years, then in medical management) that many in the healthcare industry look down on military physicians. I DON'T SHARE THIS VIEW (so don't yell at me), but it should be a factor in chosing to work for Uncle Sugar. Will this hurt your chances of getting a fellowship or job? I don't know, but trust me the feeling is out there.

Ed

 

[texdrake]

I would have to echo the comments that almost all of the "bad experiences" I have heard about, wether on SDN or in "the real world" were from Naval Physicians.

On another note. I don't want to spoil it MilitaryMD but being in the military have you had a chance to work in the private sector? Much of what you complain about is the same. Plus a ton of other headaches as well. If you hate Tricare, wait until you have to deal with 20 HMO's simultaneously. The medical world is in shambles right now. Insurance policies are crap, hospitals cut corners, and no one really lets you practice real medicine...only sufficient medicine.

Finally I do have to agree that it seems like no one stays in long enough to see their idea through...but it may not be just for the reasons you listed. Many, in fact most, go into it with the intention of getting out from the begging. Its not like many use to stay and now few do...its been that way for a long time.

 

[militarymd]

I have not been in private practice, but I'm looking forward to it. For the last 5 years, my partners have been getting out 1 at a time as their committments run out (i think about 3 to 5 per year). I have been keeping in touch with them (need contacts for jobs), and every single one loves the civilian side as compared to military. I asked if any of them would consider coming back in, and I get pretty much an unanimous "Are you crazy?" The contract that I have signed is fabulous. I've met with the hospital administrators, and they're kissing my butt already, not like the military administrators who kind of treat me pretty bad.

Please remember, I'm just trying to warn those who aren't sure, not those of you who are committed already.

I really feel that many would be happier if they never join. I just want to give them all the info before they sign.

Please, don't take any offense about what I have to say!!!! I hope other physicians in the same situation as myself (11 years active as a doctor) will chime in too.

 

[mitchconnie]

texdrake certainly has a point that there are hassles to deal with in any medical practice--military or civilian--and none is perfect. But at the end of the day, what can make it all worthwhile is doing what you enjoy--in my case taking care of severely ill patients and being in the OR. For myself, and probably for militarymd, we could laugh off the assignment politics, the career-climbing administrators, the hopelessly short-term planning, the outdated equipment, etc. if we were also taking care of patients, doing operations, and teaching our residents.

But the fact is, on the surgical side of the house, our day to day practice is profoundly unfulfilling, and our skills are not ultilized. And unlike my non-military peers, I cannot leave, and have very little voice in my own practice environment.

This is a common sentiment among surgical subspecialists I have encountered, and it's not limited to one branch of the service. I'm not in the Navy, but have encountered the same environment as militarymd.

There are certainly some positive points about military practice (like plenty of time to spend with the family), but the opportunity to develop and hone your surgical skills will not be there.

 

[FliteSurgn]

I echo all that militarymd has said. I have been intimately involved with the military since I was 18 and enlisted in the Army. I later switched to the Air Force for HPSP. I served as a flight surgeon for 2 years and then returned to civilian residency for general surgery. I am just about done and I am not at all looking forward to returning to serve my last two years beginning this summer.

It has nothing to do with pay or the obligate BS that you put up with in the military either. It mainly has to do with the incredibly thin workload for surgeons in the military. That is probably the biggest reason that I did a civilian residency as well. Outside of Wilford Hall, the surgeons that I have known in the Air Force are sitting around letting their skills go to waste. It's sad. The surgeon that was at my old base would literally jump up and down if I sent him a hernia. A freaking hernia...big whoop, but to him it was a case! What a way to spend your first few years out of residency!

I've known quite a few that moonlight at the civilian hospitals with trauma call simply to keep their skills up. (And most of them HATED trauma, but they HATED losing their skills even more.) I get more depressed everytime I ponder which crappy little base I am going to where I'll watch my skills rot away.

Have a nice day.

 

[texdrake]

Well I thank you all for your input, I think it is invaluable to this board. I myself have no intention of doing surgery and maybe that is where are paths differ. Still I will make sure to bring up your points with those thinking of the scholarship that our considering surgery.

That being sad, I don't think I would have taken this scholarship had I wanted to go into surgery.

 

[The White Coat Investor]

Originally posted by chillin
Dudes,
One of my path professors was a Naval physician, and this guy has the greatest stories to tell. That being said. I think the experience of being in the military is worth every penny of scholarship you receive. Wait...you get paid to learn and see all this cool shxt. I think just being able to walk around in one of those uniforms is pretty freakin cool. Plus, you tell someone your a military doc and they have just that much more respect for you. Now I'm sure that the military has a lot of bureaucratic bullcrap that goes on, but so do HMO's. One other thing, not having a $200,000 loan to think about every night before you go to bed is a nice thing too.
chillin

Dudes? chillin? the greatest stories? paid to learn? respect for military docs? Which planet.....?

I wish I had an $80,000 loan to think about every night as I lie here in my tent in Baghdad. Air Force. Not happy. Wish I'd taken the loans. Damn glad I qualified for a deferment by virtue of some lucky scores on Step I and II.

Okay, the tent part isn't exactly true.....but I'm sure it will be before I'm done.

 

[Masonator]

Originally posted by Sledge2005
I haven't done any ADT's yet, but most of the army's GME locations for surgical specialties are at hospitals like Brooke, Madigan, Tripler, and Walter Reed which are all huge facilities. Do these places really provide crappy training? Would you recommend applying for a civilian deferment if I plan on doing a surgical subspeciality (ortho, uro, etc)?

I rotated at gensurg for Walter Reed and Tripler. If you are considering surgery in the Army these are the two hospitals to go to. Tripler is the main hub for the pacific theatre, Walter Reed is the main hub for the Atlantic theatre. They saw a decent variety of cases comparable with a solid 2nd tier academic program. Madigan is hyped, but all they do is bread and butter general with minimal trauma and subspecialty exposure. If you want to do research and are interested in academics, go to Walter Reed, the research there is amazing and is on par with any top NIH funded lab. However military MD does make some good points...
I picked the Army so I wouldn't have to deal with the GMO issue, and because the Army has the best residency training of all the military.

 

[militarymd]

bump

 

[NAVYLABTECH08]

I am a senior considering an Army or AF HPSP for med school (I am taking a year off before applying to Med School). I want to be fully informed before I decide anything, so I was wondering if anyone has information as to how well respected the military residencies are. Specifically, Army surgical residencies, particularly neurosurgery, orthopedics, and the like. Any information would be wonderful. I assume that all the training would be fairly comparable to the best offerred on the civilian side, but anyone with some experience and some info please let me know.

Thanks.

A wise neurosurgeon once told me that if you want to be a good doctor and serve good people, the military is hands down teh best option. However, if you be the best, you should not consider military medicine. in simple terms, the best are around the best and see and experience great training. there are more average docs in the military than exceptional and being around average workers makes you average. Not becasue you did not strive to be the best, but becasue you are not given the same changes to gain the insight and experiences that all "great" doctors went through to become great. In your vast year, you need to consider what is most important to you. Rememberm average does not = bad doctor. If you are a neurotic who is obsessd with being teh world's greatest plastic surgeon, i would think twice about the military option. if you want merit in you work and a little extra on the side knowing you are defending our nation and knowing that families sleep at ease knowing that you will care for them if they need medical help, choose the military.

 

[militarymd]

An active duty neurosurgeon? I think you should spend some time with our neurosurgeons in DC before you go taking this advice to heart. You might be suprised.

Uhh...I've seen military neurosurgeons...and I've now seen pp neurosurgeons.......the difference is AMAZING

 

[militarymd]

Great. I know the neurosurgeons who are running the show right now, and I have no doubt they would chuckle at the above description.

Plus, you see these guys interact with their patients? You see their postop management? You see their outcomes? I never really get why anes comments on the skills of surgeons, since all you have to base it on your watching them from over the drape and word of mouth.

You know...I did do a critical care fellowship...I'm not your average gas guy...

and when I describe what military neurosurgeons are like to the PP ones, they chuckle also.

 

[NAVYLABTECH08]

An active duty neurosurgeon? I think you should spend some time with our neurosurgeons in DC before you go taking this advice to heart. You might be suprised.

is there something special in the water with the neurosurgeons in DC? The advice I was told was a generalization of the overally perspective. If you would have looked a couple of lines ahead, I mentioned that there are exceptional military doctors However, the ratio of exception to average leans heavily to favor the average.

 

[350011]

Yeah, that's where the (only) residency program is.

Quick neurosurg question, prefaced with the fact that I'm going to start med school in august and my exposure is 3 years of neurovascular research at Chicago: isn't neurosurg one of the big civ deferment specialties in the Navy? I know there's only one spot at NNMC and there aren't that many apps but from what I can find it seems as though they offer differments every year beyond that one person--granted it looks like there is only one or, at most, two deferments on top of that lone spot.

 

[Galo]

Do you actually do critical care? I got the impression from your posts that you just did perioperative medicine.

Is that a navy designation for anesthesia?? "perioperative medicine"??

In this last few exchange of posts I see that you've done a single or are in the middle of one year surgical intership, headed for GMO land. From the way you answer some of your posts, I thought you were in a secure surgical position. I though back about my first year of surgery, and in seeing how you reply, (argue), and I have to say, you've got so much more to learn. I hardly see how doing a rotation lets you set apart excellence in neurosurgeons, orthopods, or general surgeons, but like I said, you have so much more to learn. I hope your GMO time goes by quick, and you make a decision you are happy with regarding whether you stay in 4 yrs, or alot more. I also hope you continue to post your experience as you have promised before, because I have the unfortunate suspicion your tone will eventually change to reflect the reality of military medicine.

This is not another invite for a fight, just take it for what it is.

 

[militarymd]

Do you actually do critical care? I got the impression from your posts that you just did perioperative medicine.

I practiced CCM for 5 years...

 

[Galo]

But when you work 100hrs/wk for these guys, take care of their patients in both short and long term followup, and read their literature, you do get a feel for their work. .

Now I'm sure you are held to the mandatory 80 hr work week?? Although if a resident had followed a case I would not care, the jerk who was the boss would string them up if went over.

 

[NAVYLABTECH08]

Whether it is my personality, or my medical school education with some very aggressive surgeons, I truly believe that it is the responsibility of every intern and resident to ensure that they take ownership of their patients. In my case, that means never signing out a tough case to cross-cover, never leaving an unstable patient, and always sticking around to find out the results of urgent tests.

Nonetheless, as I tell anyone that asks, my time sheet (in 3 different time-keeping systems!) shows strict adherence to the ACGME 80hr work-week.

Man, which branch of the service. Let me guess, army???

 

[militarymd]

Whether it is my personality, or my medical school education with some very aggressive surgeons, I truly believe that it is the responsibility of every intern and resident to ensure that they take ownership of their patients. In my case, that means never signing out a tough case to cross-cover, never leaving an unstable patient, and always sticking around to find out the results of urgent tests.

Nonetheless, as I tell anyone that asks, my time sheet (in 3 different time-keeping systems!) shows strict adherence to the ACGME 80hr work-week.

typical military BS (although i do think the acgme80 rule is bs)