Military VIrus/Cancer as virulent as ever

[Galo]

Well, it's been a long time since I posted/vented here. Wow, when I got out did I vent. As well as made virulent outspoken enemies who were glorified cheerleaders of the system, (this is not a call out for continued forum violence).

I still get emails on a semi regular basis from people actually doing research about what they are getting themselves into, but I'm sure the vast majority of physicians in the military get into it for the same stupid reason that I did...the need to pay for school/lack of money! (Plus I loved airplanes).

When asked, I merely suggest continued vigilance and communication with current active duty physicians, surgeons in my case, to gauge what the current tempo is since I've been out now for nearly a decade. I no longer obsess and watch this forum on a regular basis or make calls to old friends none of which are still on active duty.

However, I bumped into a colleague recently at a meeting. A surgical sub specialist who was taken out of clinical medicine to operate a desk for FIVE years!!! Is now ready to retire but who in their right mind would hire someone who has not operated in 5 years? So he is biting the bullet and staying in a clinical position to try and catch up with the changes that have occurred in the last 5 yrs.

I still get emails from Military.com news, and often see the problems that I experienced as a physician are just as bad in the line. For example:

http://www.military.com/daily-news/...iticizing-oxygen-system.html?ESRC=airforce.nl


No matter how much time passes from my negative experiences it seems that the military mindset does not, and is unlikely to ever change. You get a set of people with power, (rank), that are not necessarily the best in their fields, but get power because of attrition of the people who are good in their fields. At least that's the way it happens in medicine, (with few exceptions of course). What highly specialized physician is going to voluntarily stop doing medicine to take an administrative job and be paid a fraction of what they can make out in civilian medicine? Once again with few exceptions, ****ty ones.

I went on the forum today and on the first page there is a guy talking about being sent out onto the field to "lead" but not practice their profession for a year to be a battalion surgeon, (not really a surgeon as they seem to be mostly primary care physicians. Following is a well though out and rounded explanation by Homunculus who's been here as long as I can remember, and for the most part seems to be one of those exceptions of a good physician that tries to work within the system, (don't know how he does it).

The fact remains that to be a doctor in the military you must first commit to being a Military Officer, and second, a physician. If you can work within those parameters which means the need of the service come first, and yours second, then your experience may not be a bad one. However, if you expect that you will become the type of doctor that you want to be, (surgeon, gynecologist, oncologist, etc etc) and suddenly you are looking at a two year minimum of labor as an untrained physician, or as a trained physician in your field at a base where there is no operating room and your skills whither, then you might not have a good experience in the service.

Also, you may find yourself taking up a great cause that directly impacts your patients or your co-workers and find yourself in a position similar to this pilot.

Military medicine still sucks.

Surely this may elicit vehement responses. I no longer have it in me to fight about this on this forum. I feel there is no amount of physicians or any active duty members horrible experience that will change the system. Only if people have knowledge of what they can expect, may they be able to take it with less distress.

This is why I make the comparison of a virus or cancer. It is a self propagating system that infects or has it in itself to negatively influence other parts of the system often at the detriment of members who are trying to make situations better. It sucks.

Thank you all for your service to our country. I certainly wish it was a different system.

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[pgg]

Welcome back.

 

[backrow]

Wow, there's a blast from the past. I remember many of those threads.....If I remember right there was one about walking across the street....

 

[pgg]

All we need now is MedicalCorpse and militarymd to pop in!

 

[Homunculus]

whoa. no way, lol. welcome back

medicalcorpse is like beetlejuice-- i think you have to say it three times.

--your friendly neighborhood look what the cat dragged in caveman

 

[Galo]

Wow guys what a nice welcome. Where's the heat? Cheerleaders all gone? Sorry, no intention to start fights again, way beyond that.

I had forgotten I am no where near as outspoken as medicalcorpse. In case any of the young'uns have never seen it, the site is still up and certainly worth a look. His story is more like that F-22 pilot than mine ever was:

http://medicalcorpse.com/

In retrospect I brought on some of my grief, but to comprehend that walking across the street was partly responsible for me getting honorably discharged is something people hardly believe. I still think military medicine is a disaster.

They guy I bumped into at the meeting sort of confirmed (not purposely) that the "trainwreck" lecture that people still ask me for has not only come true for the Air Force, but it's actually much worse.

Homunculus, your one liners are classic. Hope you are well.

 

[Gastrapathy]

"Mil med is a virus" said with a matrix style voice is kinda therapeutic.


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[MaximusD]

Sigh. Please just never look at my (very) old post history regarding milmed optimism. I still think that it's tremendously honorable to serve your country in milmed, but the idea of doing this as a career seems akin to welcoming a 14g needling of my eye. I am thankful to have met the INDIVIDUALS with whom I've worked and some pretty amazing, talented individuals I've had as patients, but the bureaucracy, secondary duties, and lack of appreciation of devoted patient care have been infuriating. Don't get me started on the administrators who like to randomly reach into my locus of control and jack things up...

 

[Homunculus]

Sigh. Please just never look at my (very) old post history regarding milmed optimism. I still think that it's tremendously honorable to serve your country in milmed, but the idea of doing this as a career seems akin to welcoming a 14g needling of my eye. I am thankful to have met the INDIVIDUALS with whom I've worked and some pretty amazing, talented individuals I've had as patients, but the bureaucracy, secondary duties, and lack of appreciation of devoted patient care have been infuriating. Don't get me started on the administrators who like to randomly reach into my locus of control and jack things up...

i think you hit the nail on the head. not so much the needle, but the individuals. i work with great people, have met some great clinicians, and in rotating at some highly regarded civilian centers the medical care we provide is definitely on par, and in some cases probably better (due to not worry about imaging and medication costs). everyone is on the same page, and things for the most part run well. i don't know if virus or cancer is totally accurate-- at the basic level things are not bad. but like you said, the minute the administrators and random good idea fairies come through that environment is adversely affected. it's more like a gradual disconnect occurs from the worker bees to the leadership-- and it's literally so gradual you can't really pin it on any one level. but when you look at the bottom vs the top, the differences are clear. i don't think this is unique to the military-- it's probably just as much a problem at large corporations. and the line side is similar-- squads and platoons and companies have esprit de corps and work well together, then when they talk about the brigade everything is jacked up, lol.

my constant suggestion is to put their money where their mouth is when they espouse all this leadership training-- they show videos of WWII to demonstrate leadership qualities. great, well, if they did a little deeper into WWII they will notice a couple of things. 1) general officers were on a short leash and were replaced regularly-- not nearly as much of this privileged / tenured like status they have now and 2) lower and mid level leadership were given enough leeway and *true* delegated authority to actually do what they felt needed to be done to accomplish the mission. authority is delegated now mostly in theory. if you want a clinic to produce XX, tell the OIC this, give them their budget, and stay out of the way. when unions, nursing, contractors etc file complaints and resist, have the OIC's back. if it is a legit issue address it, but otherwise let it go. i could go on for awhile about how the culture creates and selects for our current leaders who specialize in micromanaging and short term sustainment and OER bullet collecting, but no one would read that far.

--your friendly neighborhood military culture MIC calculating caveman

 

[Perrotfish]

Sigh. Please just never look at my (very) old post history regarding milmed optimism. I still think that it's tremendously honorable to serve your country in milmed, but the idea of doing this as a career seems akin to welcoming a 14g needling of my eye. I am thankful to have met the INDIVIDUALS with whom I've worked and some pretty amazing, talented individuals I've had as patients, but the bureaucracy, secondary duties, and lack of appreciation of devoted patient care have been infuriating. Don't get me started on the administrators who like to randomly reach into my locus of control and jack things up...

See, the problem is that this is also the experience I have had with civilian medicine so far. Minus the likable patients (or parents, in my case)

 

[Perrotfish]

Double post

 

[HighPriest]

See, the problem is that this is also the experience I have had with civilian medicine so far. Minus the likable patients (or parents, in my case)

If I can find a civilian hospital in a few years that is anything like any of the places I've moonlighted, or worked as a resident in the past, there's no comparison.

 

[notdeadyet]

I've yet to see bureaucracy, secondary duties, or physicians being utilized inappropriately anywhere in the civilian sector (county, private, or academic) that holds a candle to military.

Some of it is fact-of-life of military service, but if you find a compatible environment on civilian side, you can cross town to a more appropriate employer.


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[Perrotfish]

If I can find a civilian hospital in a few years that is anything like any of the places I've moonlighted, or worked as a resident in the past, there's no comparison.

So far I've rotated through 6 civilian hospitals between medical school and residency. I always felt like civilians just had different metrics than the military, and all of their metrics started with dollar signs. That did make some things easier: better ancillary staff support, more privileges for physicians (especially specialists with high profit margins like surgeons), faster OR turnover, etc. However the priority was always to keep costs low and profits high. Insanely high volumes, mostly farmed out to midlevels and residents who aren't adequately supervised. Large scale operations to sell CAM placebos to desperate/dying patients for cash. The never ending wrangling with social workers whose sole job is to hurl your Medicaid/non-payer patients out of the hospital as quickly as possible. All in all my experience in military hospitals have been much less depressing, even counting all of the ancillary duties we get stuck with.

 

[HighPriest]

So far I've rotated through 6 civilian hospitals between medical school and residency. I always felt like civilians just had different metrics than the military, and all of their metrics started with dollar signs. That did make some things easier: better ancillary staff support, more privileges for physicians (especially specialists with high profit margins like surgeons), faster OR turnover, etc. However the priority was always to keep costs low and profits high. Insanely high volumes, mostly farmed out to midlevels and residents who aren't adequately supervised. Large scale operations to sell CAM placebos to desperate/dying patients for cash. The never ending wrangling with social workers whose sole job is to hurl your Medicaid/non-payer patients out of the hospital as quickly as possible. All in all my experience in military hospitals have been much less depressing, even counting all of the ancillary duties we get stuck with.

That is absolutely no different than the way they run things at either of the Army hospitals I've worked, except that they replace dollar signs with a metric that is supposed to represent productivity, but really doesn't represent anything useful (like OR utilization without regard to case complexity for example). Command is only interested in how things look on paper - patient care is the last thing on their minds. If you feel ethically and professionally obligated to expedite care for a patient, that means nothing to them unless it is going to look good on an OER that is only concerned with arbitrary metrics.

There may be less incentive to offer longshot procedures to terminal patients, but 1: we don't get many terminal patients, and 2: that's a product of socialized medicine more than it is military medicine. And we had our issues with social workers at Madigan as well (we don't really have a need for social workers where I am not because we don't really deal with anything but Tricare Prime) - the deal we had with social work at Madigan was that we as residents would essentially do their entire job, and they would put the documentation in a filing cabinet for us. Additionally, accepting medicare or medicaid is only a non-issue for military hospitals because of the nature of military hospitals and the Tricare system. I wouldn't tout that as a big benefit for military medicine. It's like saying cats are great because cats are soft and fuzzy. That ain't the cat's doing.

The difference is that on the civilian side, if you know how to make your request look profitible, you can make an argument to get what you need to do your job. On the military side, there is very little logic to how decisions are made and to what is considered beneficial to the hospital. It changes daily, in fact. And above all else, the priority isn't patient care. Case and point, I've spent the last two weeks in meetings discussing how we need to see more patients and operate more because command thinks that will save the hospital from closure. Today, I've responded to three e-mails mandating that I close my clinic so that I can attend officer professional development courses, unit PT, and a 2 hours lecture on a minor change to the EMR.

There are a few benefits:
1. you get to take care of soldiers. that's great....usually.
2. in certain specialties you can make a good deal of money without having to do a great deal of work.
3. If you like the idea of being a soldier (sailer, whatever) first, then you'll probalby be very happy. If not......

 

[Perrotfish]

The difference is that on the civilian side, if you know how to make your request look profitible, you can make an argument to get what you need to do your job. On the military side, there is very little logic to how decisions are made and to what is considered beneficial to the hospital.

I think you're minimizing the difficulty of dealing with a profit driven board of directors. You can't make something you request 'look' profitable, it is or it isn't. Whatever you're buying they know what it costs, they know it bills for, and they can make a reasonable estimate on the potential throughput. If its not profitable you won't get it, whether you need it or not. That's one of the reason military hospital priorities change daily: military hospitals are driven by patient care and CV bullet points, and because different people think that different things need to be prioritized the mission changes with each change in command. On the other hand civilian hospitals are extraordinarily consistent because they're out to maximize the profits and math doesn't change. They only need to change their model of healthcare when someone changes the Medicaid reimbursement rates on them. Consistent problems are still problems: the hundredth child you see turfed to a socially dysfunctional home with a sure to be infected PICC because the hospital won't eat the cost of the stay is every bit as exhausting as the first, and the civilian mandate for ever shortened exam times (down to 7 minutes at one place I worked, not counting the mid-levels the physicians 'supervise') are in their own way just as bad as the military's frequent clinic closures for over the top admin.

All in all my civilian experiences have not left me with a clear feeling that the grass is greener from a patient care prospective. There is certainly more done in civilian hospitals to keep attendings happy in terms of pay and perks, because they're profitable employees, but the big money decisions concerning patients seem to be very tightly regulated. Also, watching the way that civilians dump on their residents makes me think that even from a grief standpoint the military option might average out to be the overall winner, at least over the initial commitment for HPSP.

 

[HighPriest]

I think you're minimizing the difficulty of dealing with a profit driven board of directors. You can't make something you request 'look' profitable, it is or it isn't.



Absolutely untrue. In the most basic sense, ths might be the case, but you can sell something based upon potential value, rather than absolute dollars. I have a good friend in Seattle who purchases most of his equipment that way. Now, if you're asking for something with no real value, then yes, there isn't an argument that'll save it. But if you think that's different in the military, you're in for a huge surprise. I get more requests granted as a moonlighting physician at a hospital where I am a lowly associate than I do at a military hospital where I am the chief of my department.

Whatever you're buying they know what it costs, they know it bills for, and they can make a reasonable estimate on the potential throughput. If its not profitable you won't get it, whether you need it or not. That's one of the reason military hospital priorities change daily: military hospitals are driven by patient care

Don't take offense, man, but that is actually laughable. I have yet to speak to anyone in the Army (can't speak for the other services), who feels that their hospital's priorities are patient-care driven. From all of my experiences, nothing could be further from the truth. That's not saying that civilian hospitals are care-driven, it's just also not the case when it comes to military institutions. In theory, they should be all about the patient. In practice, they are not. Command will tell you that patient care is important to them, but so will anyone on a civilian hospital board of directors if you ask them - but BS talks and actions are all that matter.
Military hospitals priorities change daily because no one running the hospital knows how to run a hospital. They get put in these positions because "hospital commander" or "DHCS" was the next thing they needed to do to advance their careers. They come into their position not knowing what they need to do to make a hospital work, and they're only around for a short time before they move on to something else. On top of that, OTSG is constantly changing what they expect a hospital to do in order to be what they consider productive - again, the definition of which is measured by arbitrary indirect measures. They're all the measures that civilian hospitals use, but instead of looking at all of the metrics one would commonly use, they pick and choose metrics that by themselves (out of context) don't mean anything and then extrapolate.



and CV bullet points, and because different people think that different things need to be prioritized the mission changes with each change in command.

The problem is that no one ever checks to see if these bullet points actually helped the system. Here's how an OER works: at the beginning of your rating period, you state what your goals are: "I will do x, y, z." At the end of that period, if you can say that you did in fact accomplish x, y, and z, then you did a good job. It doesn't matter what x, y,mor z are, as long as they sound like a good idea, and can be measured in some nominal way. If after you left, x lead to your hospital being $40 million dollars in debt during your tenure as commander, it doesn't matter. That's the next guy's problem. I know of one specific example of those exact circumstances that lead the "successful" hospital commander to a high position at OTSG. Most commonly, the OER will lock on to one of those arbitrary metrics, like I had mentioned: "I will increase OR utilization to 80%'" but the Officer who chose that metric doesn't understand what it means in context, or if they do they don't care. Last year, we had to have our OR utilization at 85% or higher. Until someone pointed out the actual literature stating that it isn't possible to do that practically based upon the way OR utilization is calculated. The Commander hadn't actually checked to see what the metric he chose actually means. Unfortunately, that seems to be the rule in my experience, rather than the exception.


On the other hand civilian hospitals are extraordinarily consistent because they're out to maximize the profits and math doesn't change.

Which is at least predictable.

They only need to change their model of healthcare when someone changes the Medicaid reimbursement rates on them. Consistent problems are still problems: the hundredth child you see turfed to a socially dysfunctional home with a sure to be infected PICC because the hospital won't eat the cost of the stay is every bit as exhausting as the first, and the civilian mandate for ever shortened exam times (down to 7 minutes at one place I worked, not counting the mid-levels the physicians 'supervise') are in their own way just as bad as the military's frequent clinic closures for over the top admin.


I have 10 minutes to see patients. My wife, even as the spouse of a physician, literally cannot get an appointment to see a physician for a primary care appointment. PAs and NPs only. And even then it takes literally three weeks minimum to get in. And this is in a system that is supposed to be built for soldiers and their families.

All in all my civilian experiences have not left me with a clear feeling that the grass is greener from a patient care prospective.

I hear you man, but just as I see the grass as somewhat greener on the civilian side, you seem to see the grass as pretty green over here. I don't think civilian healthcare is some kind of provider utopia. That's obviously not the case. But my argument is that all of the problems I ever hear about coming from the civilian side of medicine are present on the military side, save for inability to pay. That is instead replaced with the government's inability to pay. But military healthcare cones with the added bonus that your leaders actually don't know how to run a hospital (often through no fualt of their own I mean the Army thinks ILE and War College teach you everything you should need to know about running a hospital ), and their priority is that you've done your UA and hit weather training before patient care commences.



There is certainly more done in civilian hospitals to keep attendings happy in terms of pay and perks, because they're profitable employees, but the big money decisions concerning patients seem to be very tightly regulated. Also, watching the way that civilians dump on their residents makes me think that even from a grief standpoint the military option might average out to be the overall winner, at least over the initial commitment for HPSP.


Can't comment really. I was never dumped on by any of my civilian or military staff as a resident. That being said, one of my co-residents in general surgery had a newborn baby intubated in the ICU and a wife on the floor, and his military program director told him that not only could he take no time off, but that if he came late to rounds or left early they would fire him from the program. So that $#!T is definitely not isolated to the civilian sector.



[/QUOTE]

 

[HighPriest]

Listen, there are definitely guys who prefer military medicine. And occasionally, I'll see someone come back after being on the civilian side. That's pretty rare, and there are always rumors that they weren't able to hack it on the outside (none of which have ever been verified to me). But most people crawl off of the burning ship, swim to shore, and never ever look back. Maybe it's just because they make more money, but I can't imagine that's the only factor. I was actually neutral to positive when it came to my opinion of military medicine until about my chief year, and it's been a nose dive since then. Having worked on the civilian side at least a bit, my opinions have only become stronger. Currently, the only way I could see being happy is if I cared far more about being a soldier than I do about being a physician. But ethically, I can't feel that way.

Just my opinion.

In any case, healthcare is in a bad way across the board. Just depends how runny your $#!T sandwich is.

 

[pgg]

See, the problem is that this is also the experience I have had with civilian medicine so far. Minus the likable patients (or parents, in my case)

I get what you're saying. I used to think that it couldn't get worse than JC and med IG evil admin weasels descending on a hospital. And then I saw CMS troll through one of the places I moonlight. CMS is a group of very bad people, whose dark souls feed on the pain of others.

The admin problems and non-physician leadership exists on the civilian side, but the culture is different.

In the civilian world physicians bring patients, admissions, procedures, and money to hospitals. The more they do, the more money the hospital makes. The hospitals do small things to make physicians happy, to make their jobs easier. Reserved parking. A lounge with comfortable furniture. One place I work has all-you-can-eat free food at the cafeteria. When a computer goes down or a password locks out, someone from IT puts on a bunny suit and comes to the OR right away to fix it.

I have been places in the military where physicians are viewed as expenses. The more we do, the more it costs, and the less ammo the Marines can buy. The atmosphere of being viewed as an expense became exhausting.


That said, my experiences moonlighting, though they have been mostly enjoyable and very lucrative, were a factor in my decision to stay in the few extra years to get the retirement cheese. It's nice out there, but it's not that much nicer. If I were a HPSP'er with a 3 year commitment, I'd have left, but my commitment was longer, and it would've been a big financial hit to get out. Absent the monetary incentive to get out, it was just a matter of picking which flavor of admin headaches.

Also ... in the end, a little bit of rank and seniority goes a long way to ease the military abuses. When I was an O3 and junior O4, there was no shortage of admin pogues with leverage over me, and they used it. These days, not so much.


And as always, I'll throw in the caveat that my experience probably isn't typical. I've been blessed with a series of excellent COs and bosses who were good people and "got it" all the way back to the day I left USUHS. A couple of brief exceptions.

 

[colbgw02]

The admin problems and non-physician leadership exists on the civilian side, but the culture is different.

In the civilian world physicians bring patients, admissions, procedures, and money to hospitals. The more they do, the more money the hospital makes. The hospitals do small things to make physicians happy, to make their jobs easier. Reserved parking. A lounge with comfortable furniture. One place I work has all-you-can-eat free food at the cafeteria. When a computer goes down or a password locks out, someone from IT puts on a bunny suit and comes to the OR right away to fix it.

I have been places in the military where physicians are viewed as expenses. The more we do, the more it costs, and the less ammo the Marines can buy. The atmosphere of being viewed as an expense became exhausting.

Well said. When I leave military service, I don't have any illusions about civilian practice. I realize that I'll be a cog in a machine, just like I am now. In my mind, the difference is that I'll get oiled in the civilian machine because someone realizes that the machine won't work without me. As it is now, it feels like the military is ticked off that there's a machine in the first place, so why would they bother to oil any of the cogs?

 

[HighPriest]

I

.


. If I were a HPSP'er with a 3 year commitment, I'd have left, but my commitment was longer, and it would've been a big financial hit to get out.

.

That is always a factor. How long you ADSO is, where you're stationed, clearly what branch of service, and what your specialty is, your rank, and generally (not speaking for pgg specifically) whether being a soldier is as important to you as being a physician - all of these things factor into an individual experience in military medicine. I can't tell one person or another that they will or will not have a good experience. I can only speak for my personal experiences, and the general gestalt of my colleagues. 8 years ago, I was talking people into milmed. 4 years ago, I was preaching the benefits, but cautioning about the possibilities, now it would steer almost anyone in the other direction. That seems to be a common trend amongst my colleagues as well.

 

[HighPriest]

Well said. When I leave military service, I don't have any illusions about civilian practice. I realize that I'll be a cog in a machine, just like I am now. In my mind, the difference is that I'll get oiled in the civilian machine because someone realizes that the machine won't work without me. As it is now, it feels like the military is ticked off that there's a machine in the first place, so why would they bother to oil any of the cogs?

Right. Exactly how I feel about it, and how I've been treated on both sides. On the outside, you're a cog in a machine that produces healthcare for profit. You may not be running things, but they need the cog to function. In the military (Army at least), you're not even really a cog. You're not a necessary part of the machine because the machine doesn't produce healthcare, it produces soldiers. And you're a part of the maintenance routine - a tertiary, necessary, but delay-able part of the system.

 

[Galo]

WOW,

How civilized this forum has become. People putting forth simple ideas based on experience, and simple responses, some based on belief, but not with personal attacks.

I did a little perusing and the same questions exists, is it worth it money wise, is residency the same, is training adequate, ,etc etc.

For one thing, I know when I got out I was MAD AS HELL! I could not figure out though how personally some people took my affront to military medicine. Even now I vaguely recognize people who were in school or in training, who now have lived the life and see that the problems in military medicine are unique and troublesome to a medical career. I encourage them keep letting others know what they are going through. Information is a powerful tool. Before people make a decision to take military money, they should know what to expect.

I would never defend civilian medicine which is not without its multiple faults. But the HUGE differences are that in civilian medicine you are actually a Doctor first, you get compensated fairly for your work, but most importantly, you have the ability to practice what you chose with minimal obstacles compared to the military. And if your job sucks, YOU CAN LEAVE!!!

Military medicine in my opinion will continue to be a place where practicing medicine is ultimately more challenging and difficult. Without doubt it is a privilege to take care of our soldiers, and there are people that are cream of the crop in every field. Unfortunately they are rare and drowned out by the majority *****s who make the service so difficult to be in, particularly medicine.

 

[colbgw02]

WOW,

How civilized this forum has become. People putting forth simple ideas based on experience, and simple responses, some based on belief, but not with personal attacks.

I did a little perusing and the same questions exists, is it worth it money wise, is residency the same, is training adequate, ,etc etc.

For one thing, I know when I got out I was MAD AS HELL! I could not figure out though how personally some people took my affront to military medicine. Even now I vaguely recognize people who were in school or in training, who now have lived the life and see that the problems in military medicine are unique and troublesome to a medical career. I encourage them keep letting others know what they are going through. Information is a powerful tool. Before people make a decision to take military money, they should know what to expect.

I would never defend civilian medicine which is not without its multiple faults. But the HUGE differences are that in civilian medicine you are actually a Doctor first, you get compensated fairly for your work, but most importantly, you have the ability to practice what you chose with minimal obstacles compared to the military. And if your job sucks, YOU CAN LEAVE!!!

Military medicine in my opinion will continue to be a place where practicing medicine is ultimately more challenging and difficult. Without doubt it is a privilege to take care of our soldiers, and there are people that are cream of the crop in every field. Unfortunately they are rare and drowned out by the majority *****s who make the service so difficult to be in, particularly medicine.

I remember when you started posting regularly about the time you separated, and you're right, you were mad as hell. I remember some people defending military medicine against your claims, and maybe you count me among them, but I also remember you being insistent that your experience was emblematic, even in the face of evidence to the contrary. I don't have any doubt that your military medical experience was how you describe it, but it's important to recognize the tremendous diversity of experiences among military physicians. My impression is that you were so angry about your experience, and I'm sure justifiably so, that you didn't do a great job of acknowledging that others could legitimately feel differently. If there has been any 'progress' on this forum, it's been because of fewer appeals to authority (e.g, I'm an attending; you don't know what you're talking about), and more conveyances of seemingly commonplace experiences and letting others decide on their own.

 

[deleted592694]

Your statement about the diversity of experiences is absolutely true. Obviously there are some very negative aspects about practicing in the civilian world, and I would contend that most milmed apologists/supporters have had a relatively easy road compared to their peers. (Generalizing I know so please don't flame me for that statement)

I've had a good friend and intern classmate go straight through residency, pick up two fellowships in a row, first Cardiology (mil), then EP (civ), then go on about making O-4 pay in an awesome city, wondering why I was bitter after unsuccessful experiences with the military match and being a GMO. This person will probably never step foot outside one of the large MTFs or deploy after their training is done (will have been 9-10 years in before ever getting a non-training billet) and be able understand the plight of remote MTFs anywhere. This is an example of the perfect poster child for military medicine. There are great experiences to be had in milmed, but they are few and far between, and the fortunate few who've had few to no bumps in their training/career can't possibly understand why undertrained GMOs in remote locations CONUS or overseas or attendings with rotting skills complain while they get assigned to places like NMC San Diego for their first utilization tour.

I can say that I am proud to have served, and it has set my family and I up quite nicely for a transition to civilian residency next year in a way that wouldn't have been possible had I just slogged on through civilian training had I declined the scholarship, but I will never speak highly of the process it took to get me there or paint HPSP in a positive light to anyone

I remember when you started posting regularly about the time you separated, and you're right, you were mad as hell. I remember some people defending military medicine against your claims, and maybe you count me among them, but I also remember you being insistent that your experience was emblematic, even in the face of evidence to the contrary. I don't have any doubt that your military medical experience was how you describe it, but it's important to recognize the tremendous diversity of experiences among military physicians. My impression is that you were so angry about your experience, and I'm sure justifiably so, that you didn't do a great job of acknowledging that others could legitimately feel differently. If there has been any 'progress' on this forum, it's been because of fewer appeals to authority (e.g, I'm an attending; you don't know what you're talking about), and more conveyances of seemingly commonplace experiences and letting others decide on their own.

 

[Kilgoretrout 65]

Could it be that a more reasonable discussion about military medicine and whether to stay in or leave is taking place on this forum because civilian practice has actually gotten worse?
My field has had mergers, ACO headaches, reimbursement cuts, and a mediocre job market. My former military colleagues are constantly either defending their turf, trying to take someone else's,
or accepting the smaller hospital contract with each renegotiation. A lot of them tell me I am lucky I stayed in, which is easy for them to say as they are still making 2-3x what I make.

The only thing that keeps the oil flowing onto the cog is if your services are in demand, such as a shortage in your specialty or increased demand for your services.

I will say it is unlikely that I would accept a job where I earn the same as the military but work twice as hard. Even it it means no more clip board nurses and someone critiquing my push up style.

 

[HighPriest]

Whereas I feel like, given the choice at this moment, I would leave medicine and work in another field (consulting, research, maybe high school janitor) if it was the only way to get out of the Army. Medicine isn't my first career. While I love what I'm trained to do, I could be happy doing something else if push came to shove. But as it stands, the Army makes me dislike what I do (primarily due to all of the barriers they erect to prevent me from doing it).

 

[idq1i]

I've had a good friend and intern classmate go straight through residency, pick up two fellowships in a row, first Cardiology (mil), then EP (civ), then go on about making O-4 pay in an awesome city, wondering why I was bitter after unsuccessful experiences with the military match and being a GMO. This person will probably never step foot outside one of the large MTFs or deploy after their training is done (will have been 9-10 years in before ever getting a non-training billet) and be able understand the plight of remote MTFs anywhere.

Precisely why premeds naive to the military should NOT join before residency completion (ie HPSP). You don't know what you are getting yourself into. There is no transparency. There is no fairness. There is no meritocracy. There is no respect. Your career progression is completely divorced from your clinical skills. Your boss is in his position because he was too incompetent or lazy to get a clinical job outside the military (that is, if s/he is even a doctor)

If you want to serve your country, join after your training is done.

 

[Perrotfish]

Could it be that a more reasonable discussion about military medicine and whether to stay in or leave is taking place on this forum because civilian practice has actually gotten worse?
My field has had mergers, ACO headaches, reimbursement cuts, and a mediocre job market. My former military colleagues are constantly either defending their turf, trying to take someone else's,
or accepting the smaller hospital contract with each renegotiation. A lot of them tell me I am lucky I stayed in, which is easy for them to say as they are still making 2-3x what I make.

And keep in mind that your specialty is one of the higher income higher margin specialties, and I think most of your friends went to school before student loans went to crap. My friends in civilian Peds have all the headaches you mentioned, and all the uncertainty, but in addition to that most of them are so buried in debt and so poorly paid that their long term financial plan is basically to pay 10-15% of their gross income as a student loan tax for all eternity and hope the rules for student loans never change for the worse. Meanwhile their debt gets bigger each and every year despite the payments, because 10-15% doesn't even cover the interest.

 

[Perrotfish]

Precisely why premeds naive to the military should NOT join before residency completion (ie HPSP). You don't know what you are getting yourself into. There is no transparency. There is no fairness. There is no meritocracy. There is no respect. Your career progression is completely divorced from your clinical skills. Your boss is in his position because he was too incompetent or lazy to get a clinical job outside the military (that is, if s/he is even a doctor)

If you want to serve your country, join after your training is done.

The problem is that every reason not to join military medicine is also a valid reason not to go to medical school at all. You have no real idea what you're getting into and can't really quit once you go. Your career progression is based on arbitrary standards (brown nosing ability + scantron tests) that have only a nominal connection to your actual abilities as a physician. You are signing up for almost a decade, minimum, in an abusive environments where you bosses (who may or may not be physicians) are selected more by attrition than by merit. You can be moved to the ass end of America for years at a time by almost random medical school, residency, and fellowship selection processes and every few years you need to pick up and more again regardless of the need of your family. The rules of the game change on you almost daily and you have no choice but to keep playing.

To me the biggest difference is that the military signs an iron clad contract with you stating that, 4 years after you complete your medical training, if you want to be done you can be (IRR aside, and even that has a time limit). A military doctor who came in via HPSP is, in that sense, no worse off than your average junior enlisted Marine. On the other hand civilian physicians are stuck in this profession for a minimum of 10 years after residency before they can even get rid of their non-dischargeable debt, 15 before they can mitigate the rest of the financial damage, and then who can switch careers in their mid 40s? You're basically signing up for life.

 

[HighPriest]

The problem is that every reason not to join military medicine is also a valid reason not to go to medical school at all. You have no real idea what you're getting into and can't really quit once you go. Your career progression is based on arbitrary standards (brown nosing ability + scantron tests) that have only a nominal connection to your actual abilities as a physician. You are signing up for almost a decade, minimum, in an abusive environments where you bosses (who may or may not be physicians) are selected more by attrition than by merit. You can be moved to the ass end of America for years at a time by almost random medical school, residency, and fellowship selection processes and every few years you need to pick up and more again regardless of the need of your family. The rules of the game change on you almost daily and you have no choice but to keep playing.

To me the biggest difference is that the military signs an iron clad contract with you stating that, 4 years after you complete your medical training, if you want to be done you can be (IRR aside, and even that has a time limit). A military doctor who came in via HPSP is, in that sense, no worse off than your average junior enlisted Marine. On the other hand civilian physicians are stuck in this profession for a minimum of 10 years after residency before they can even get rid of their non-dischargeable debt, 15 before they can mitigate the rest of the financial damage, and then who can switch careers in their mid 40s? You're basically signing up for life.

You and I had very different medical school experiences. Hopefully, you and I will have had very different military experiences. And hopefully that doesn't involve a brigade surgeon or equivalent position, which I have yet to see forced onto a civilian.

 

[Perrotfish]

You and I had very different medical school experiences. Hopefully, you and I will have had very different military experiences.

I know I've been very lucky so far. Lots of time left on the clock, though.

 

[notdeadyet]

You have no real idea what you're getting into and can't really quit once you go.

Operative word being "really." Unlike the military, you CAN quit. Even after you finish a year of med school, you can pull the plug and pay off $70k in loans, which beats the alternative for many. This is not an option in the military.

Your career progression is based on arbitrary standards (brown nosing ability + scantron tests) that have only a nominal connection to your actual abilities.

True for med school, not for residency. Unless you are in a toxic residency, which is not a matter of chance civilian-side.

You are signing up for almost a decade, minimum, in an abusive environments where you bosses (who may or may not be physicians) are selected more by attrition than by merit.

I don't see civilian side residency as an abusive environment. I'm sure they are out there, but it's largely a matter of choice and expectations. And for many-to-most academic spots, the faculty positions are sought after and competitive, so you're not seeing the attrition factor that you may be seeing on military equivalents.

You can be moved to the ass end of America for years at a time by almost random medical school, residency, and fellowship selection processes and every few years you need to pick up and more again regardless of the need of your family.

Nope. This is definitely a military feature. In the civilian side, my number of moves is determined by my abilities and interests. If I am very good at what I do, I can stay in one spot for medical school, residency, and fellowship. You lose this ability in the military, regardless of talent.

The rules of the game change on you almost daily and you have no choice but to keep playing.

This is very true. Just a feature of medicine...

 

[Perrotfish]

Operative word being "really." Unlike the military, you CAN quit. Even after you finish a year of med school, you can pull the plug and pay off $70k in loans, which beats the alternative for many. This is not an option in the military.

Yes and no. The first time you really know what you got yourself into is after you've done a few rotations in third year, which at my school meant you had 210K of non-dischargable debt. Now you're right that you CAN leave then, in much the same sense that you can leave the a 10th story office via the window rather than taking the stairs, but its not really an option. You have to finish to get the residency which you have to finish to get the job which you need to do for 10 years to pay off the debt which you need to pay off so that you're not screwed for the rest of your life.

Nope. This is definitely a military feature. In the civilian side, my number of moves is determined by my abilities and interests. If I am very good at what I do, I can stay in one spot for medical school, residency, and fellowship. You lose this ability in the military, regardless of talent.

If you are very, very good at what you do and want to do something very uncompetitive and you also have a great deal of luck you can stay in one place. Of course, that's true for the Navy too: the shining star has a small but non-zero chance of never leaving Bethesda or San Diego. However that's not how medical school really works. My circle of friends was not particularly dumb: most of us were above the average on the MCAT and step one, top half or top quartile of the class, and no one wanted derm. No one got to stay where they wanted. Not a single one of us had particularly planned on being where we were for medical school, no one got their top choice residency (and many didn't even rank their top choice location first, since they knew it was too competitive). Most of my friends had a series of mandatory moves that were every bit as bad as what the military puts you through. A pretty typical friend of mine: college in CA, got shipped to Louisiana for medical school, then New Mexico for residency, and now who knows where for fellowship (not New Mexico, they don't have one). Random ass move ever 2-5 years, and everyone one of them to somewhere she didn't want to live. The only difference is the military at least pays to move you.

True for med school, not for residency. Unless you are in a toxic residency, which is not a matter of chance civilian-side.

Its a matter of chance. You get one interview day where everyone has to put on their best face and then you sign a contract of indentured servitude that lasts 3-7 years. No one has the slightest clue if they're going somewhere toxic or not. Heck, at least in the military everyone rotates pretty much everywhere they can match, which exerts some pressure on the residency to make life reasonable for their residents, since a monthis long enough to see how the residents are really treated. In civilian residencies/medical school there's no reason your residents' quality of life should have any real impact on recruiting. Just pay for a nice restaurant for the interview dinner and ignore the rest.

 

[HighPriest]

Point 1: in the worst case scenario, you can default on your loans and go into bankruptcy. It's a horrible thing, it'll scar you for years, but it isn't jumping off a building. Not that I'm endorsing it, but it's better than spending 10 in A federal pen on a UCMJ violation. In any case, your point is that you're locked into a career whether you choose the military or not. That is, in practicality, true. The question is in which situation you're more likely to end up locked in to something you despise. I would argue, based upon my experiences and contacts both within and outside of the military, that you are far more likely to regret your decision to join the military. I base this on the fact that I don't have a single colleague at my current duty station, bad probably only 1 or two at my last station, who wouldn't give their left arm to get out of the military. There are a lot of unhappy civilian docs out there too, but the attrition rate is nowhere near the rate at which military docs leave the service.

Point 2: as a counter argument, I have a lot of civilian friends who matched in places they wanted to be. Most of them, in fact. Most of them didn't even interview in places they knew that they wouldn't be able to stand living in. And most of them were applying for very competitive spots. So yes, it is possible that you could match somewhere you aren't happy in the civilian match. In the military, especially in the Army, your chances of ending up somewhere that you wouldn't choose to live if your life depended on it are exponentially higher. There are no medical schools, residencies, or fellowships in places like Fort Polk, LA or Fort Sill, OK. Where you end up, contrary to what you're saying,has little to nothing to do with your merit in the military.

Point 3: to some extent it is a matter of chance if you end up in a malignant program. That is also true in the military. What is not true is the idea that everyone gets to rotate everywhere they might match. I spent my elective rotations at military hospitals, and I was only able to spend time at 2 locations. For Uniformed Services students, they often do get to rotate at multiple institutions, but I can tell you for a fact that they don't get to actually spend time on-service, in their field of choice, everywhere they might want to go. There are relatively malignant programs in the military. Just as there are fewer training programs in the military, there are also fewer malignant programs in the military. But they do exist, and unfortunately if you've signed on the dotted line, and one of those malignant programs happens to be in your field of interest, you've got a decent chance of ending up there. In any case, my point is this exists on both sides of the fence. If you're completely blindsided by a malignant program, military or civilian,then you didn't really do your research before you ranked. That's not saying that you might get cornered into one as an only option.

 

[pgg]

WOW,

How civilized this forum has become. People putting forth simple ideas based on experience, and simple responses, some based on belief, but not with personal attacks.

Usually. It's hard sometimes, what with trollish headlines like "Only idiots would join Navy medicine" and "Military Virus/Cancer as virulent as ever" ...

 

[Perrotfish]

Point 1: in the worst case scenario, you can default on your loans and go into bankruptcy. It's a horrible thing, it'll scar you for years, but it isn't jumping off a building. . .

Just so you know, there are only two kinds of debt you can't discharge in bankruptcy: criminal judgments and student debt. Nothing makes student debt go away other than paying it off and (theoretically) completing repayment programs like income based repayment. Also unlike any other form of debt there is no asset they cannot seize to collect on your student debt: if they get rid of IBR tomorrow the very next day they can seize your home, your IRA, and even your social security checks (usually all protected) to pay back the debt. All defaulting means is that you are so broke they can't even seize enough to keep you on a payment plan. The debt is still there, growing exponentially and waiting for you to have an income again.

BTW I definitely see and mostly agree with your points about the stressors and miseries of the military. At this point medicine is kind of like owning a house in Nevada: whatever side of the fence you're on, chances are the grass isn't very green.

 

[Homunculus]

interesting a thread title like this has people coming out and getting their therapy on, lol.

i think with time a lot of the "blind rage" folks eventually loose their taste for venting. their message is sometimes tainted by that passion. it's like one of the older docs i followed at a MEDDAC-- they guy was so vocal about all of the things wrong with the system he eventually wore everyone out-- even people who would have been allies.

the forum is like a wine or something-- with age and experience and more members you can't help but get to some kind of homeostasis of somewhere in the middle where the combined knowledge percolates and improves the place. it takes time and some wisdom to figure out that each person's situation is different, and for some the military is a living hell, but for others it's really not a bad gig. this is hard for some people (especially those hating it) to swallow, but i've seen about every type in my now 10 years of active duty. my opinions from when i started medschool to now have certainly changed, but i've never really gone over the edge either direction to the point of no return.

currently, i have more good days than bad, and if it weren't for the BDE SG nonsense i'd be pretty ok and *maybe* borderline optimistic about the future. some difficult decisions are coming for the DoD as a whole, and at least the discussion is happening regarding a defense health administration, dependent care, and small hospitals. the current situation is untenable, and regardless of operational posture needs to be addressed. and my problem with the BDE SG issue is that if i do it, i will be damned if i get out right after-- i feel like i need to parlay that into a nice position or location so i don't leave with them being up one on me, lol. i'm too competitive i guess.

i never set out intending to have a military career, but may end up inadvertently being in for 20 and would not shock me. that's a nice chunk of change at the end. it's hard to walk away at 14 years and get nothing in return (except for transferring GI bill benefits). it's like pgg said-- absent the monetary advantage of getting out (and he retirement for staying in) it's a matter of which stressors you want to deal with. this is why not *every* career physician is someone who couldn't hack it outside-- i know many who i would trust my own family to who are just as competent, if not more so, than civilian staff i've been exposed to. this obviously does not hold true across the board but there are many good people in the system and lumping everyone together as incompetents protected by the military system haven't seen the crazy ass stuff some civilians are up to, lol.

speaking from my own lane, the civilian side for peds and peds subspecialties is not lucrative, and those that make more have to work 2-3 times more to make it. people stress about money, stress about jobs, stress about producing research, getting grants, getting published, seeing enough patients, reimbursement changes-- and their administrative obligations aren't gone-- just different. and they can quit, sure, but often have noncompete clauses which basically require a "PCS" if they leave, or they leave their research lab behind. or their academic connections-- the list is different, but there.

i'm technically on the downhill slide now (10 years) but i'm not set either way at the moment. should be an eventful few years, i'm sure

an regarding bankrupty-- don't the feds always get theirs?

--your friendly neighborhood fake my death and move to the tropics caveman

 

[HighPriest]

Just so you know, there are only two kinds of debt you can't discharge in bankruptcy: criminal judgments and student debt. Nothing makes it go away other than paying it off and (theoretically) completing repayment programs like income based repayment. Also unlike any other form of debt there is no asset they cannot seize to collect on your student debt: if they get rid of IBR tomorrow the very next day they can seize your home, your IRA, and even your social security checks (usually all protected) to pay back the debt. All defaulting means is that you are so broke they can't even seize enough to keep you on a payment plan. The debt is still there, growing exponentially and waiting for you to have an income again

There are exceptions to this: https://www.nolo.com/legal-encyclopedia/student-loan-debt-bankruptcy.html

Again, I don't endorse it as an option. Another option, however, would be do take a job outside of medicine if you find that you're not happy with it during your clerkships. I have three friends who left medicine entirely - one after 1 year of residency, one after two, and one after completing his residency. Both had a substantial amount of debt (one spent four years at a university in Cambridge, starts with an H, and not inexpensive). One was able to prove hardship and had his loans "forgiven" with bankruptcy. I have no idea how easy that is. I imagine not very. I know he's single and works for barely over minimum wage. I also know that it wasn't really his choice to leave residency. One went into research, and one went to a consulting firm (making more than many physicians). So while there is a debt commitment earned with medical school, it is not the same as a commitment to Uncle Sam.

 

[HighPriest]

I don't buy into the idea that everyone who retires out of the military is a crap physician. I know more than a couple of exceptions to that concept. Usually they're right up against 20 with their ADSO and, as you say, it's very hard to turn down. And there are definitely crap physicians on the outside. However, maybe I'm just real lucky in my experiences, but I deal with a lot more idiocy in the military. I actually hate to say that (contrary to how it may seem), because my blood boils (quietly) when patients poo-poo the treatment they get in the military system. On one hand, I have a great deal of confidence that I can provide equivalent treatment to my civilian colleagues down the street (when I'm not canceling cases for another UA). On the other hand, when my wife sees a provider and tells me what they told her, it shatters that faith. When I review my consults at the military hospital, I feel like I want to stab out my eyes. My consults on the outside are far, far more reasonable. Some of that is the preponderance of non-physician providers, some is the lack of financial incentive to handle issues at the primary care level, but some of it sure seems like knuckle dragging schmuckery. Again, not isolated to the military, just seemingly a tad more common. Maybe it's because they're spending too much time at PT.

 

[pgg]

i never set out intending to have a military career, but may end up inadvertently being in for 20 and would not shock me. that's a nice chunk of change at the end. it's hard to walk away at 14 years and get nothing in return (except for transferring GI bill benefits). it's like pgg said-- absent the monetary advantage of getting out (and he retirement for staying in) it's a matter of which stressors you want to deal with. this is why not *every* career physician is someone who couldn't hack it outside-- i know many who i would trust my own family to who are just as competent, if not more so, than civilian staff i've been exposed to. this obviously does not hold true across the board but there are many good people in the system and lumping everyone together as incompetents protected by the military system haven't seen the crazy ass stuff some civilians are up to, lol.

This is very well put.

I'll confess that it irritates me when I see people write that the only people who stay in past their ADSOs are incompetent, helpless, slow, or institutionalized to the point that they can't function outside the slow, inefficient, malpractice-tolerant military system.

As a lifer myself, perhaps I do protesteth too much, but I'm none of those things. I know this not because my mother tells me I'm great, but because I've been moonlighting my ass off for the last 5 years and they tell me I'm great.

 

[Galo]

Its as true then as it is now. People that seem to flourish in a military environment, (for whatever reason) can't seem to take in stride or even consider as plausible the criticism of what seems like a vocal majority, (at the very least in this forum). Despite quite accurately pointing out why the military seems to incite disaster, not work efficiently, and treat its most important assets, (people) with a certain disdain, some people find it hard accept, like its an affront to them being part of the system.

It used to really astonish me when medical students, especially HPSP or prior service, would defend military medicine with such fervent ardour when they really had no basis or experience on which to base it on. Because some people tend to lean more to being an officer and not a physician first, its surprising to them that not all physicians feel military medicine is a really difficult and dare I say POOR place to exercise the practice of medicine. Sure, any and all of this can be taken personally even though I am not addressing one person in particular. Unlike in the past when I'd spout fire and brimstone against certain individuals.

There are just too many physician with many negative experiences to convince anyone that military medicine is a good place to work as a doctor.

As for the poster who mentioned being in civilian medical school and then residency and comparing them to the BY LAW commitment that you incur with military service, I just feel that is nonsense as was quite accurately countered by another poster.

I don't see writing the truth or someone's experience as trolling. Especially when there are multiple people with similar experiences.

Why is retention of military physicians so poor?

 

[idq1i]

This is very well put.

I'll confess that it irritates me when I see people write that the only people who stay in past their ADSOs are incompetent, helpless, slow, or institutionalized to the point that they can't function outside the slow, inefficient, malpractice-tolerant military system.

As a lifer myself, perhaps I do protesteth too much, but I'm none of those things. I know this not because my mother tells me I'm great, but because I've been moonlighting my ass off for the last 5 years and they tell me I'm great.

It's always great to be in a place that allows you to do that. Not all of us are in a place that allows it , be it because of geography, or ******ed command. Where would you be, in your estimation, without ODE?

 

[Kilgoretrout 65]

Why is retention of military physicians so poor?

I think the system is set up for 03's and 04's to work hard and take what is dished to them and get out. Why else would our bonuses go down the more senior we get?

 

[pgg]

Where would you be, in your estimation, without ODE?

I'd have left after 2 years to PCS back to one of the big 3, so professionally I think I'd be OK, just poorer.

As it was, with ODE to keep me professionally happy, and a happy wife living close to family, and happy kids in good schools, and not really minding living out in the sticks away from civilization, I asked to extend my orders, and here I am.

 

[Gastrapathy]

I'm not sure that retention really is that poor from a big navy perspective. We don't retain anyone that well (I think somewhere south of 10% of all accessions stay to retirement). We have enough folks with endless obligations, a few that are good and stay by choice and a group that couldn't survive in the real world. I don't think they want to retain any more than that.


Sent from my iPhone 6 using Tapatalk

 

[Perrotfish]

There are exceptions to this: https://www.nolo.com/legal-encyclopedia/student-loan-debt-bankruptcy.html

Again, I don't endorse it as an option. Another option, however, would be do take a job outside of medicine if you find that you're not happy with it during your clerkships. I have three friends who left medicine entirely - one after 1 year of residency, one after two, and one after completing his residency. Both had a substantial amount of debt (one spent four years at a university in Cambridge, starts with an H, and not inexpensive). One was able to prove hardship and had his loans "forgiven" with bankruptcy. I have no idea how easy that is. I imagine not very. I know he's single and works for barely over minimum wage. I also know that it wasn't really his choice to leave residency. One went into research, and one went to a consulting firm (making more than many physicians). So while there is a debt commitment earned with medical school, it is not the same as a commitment to Uncle Sam.

Everything I have ever read about hardship discharges is that they are incredibly rare and difficult to obtain. Suing for discharge can take years (sometimes over a decade), requires a very competent lawyer, and mostly provides an insane combination of both terrible luck (you have to prove you have been trying to make these payments for years, failed, will continue to fail indefinitely, and your failure is keeping you from providing minimal support for yourself and your family) combined with just the right amount of good luck (you need a pro-bono layer willing to support you through a multi-year process, or alternatively you need to be an unemployable law school grad). Of the nearly 70,000 people each year who go bankrupt with student loans, less than 150 will have those loans discharged: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1894445. I'm not sure that's worse than the odds of getting discharged from the military and having your obligation forgiven. Student debt sucks.

 

[HighPriest]

Everything I have ever read about hardship discharges is that they are incredibly rare and difficult to obtain. Suing for discharge can take years (sometimes over a decade), requires a very competent lawyer, and mostly provides an insane combination of both terrible luck (you have to prove you have been trying to make these payments for years, failed, will continue to fail indefinitely, and your failure is keeping you from providing minimal support for yourself and your family) combined with just the right amount of good luck (you need a pro-bono layer willing to support you through a multi-year process, or alternatively you need to be an unemployable law school grad). Of the nearly 70,000 people each year who go bankrupt with student loans, less than 150 will have those loans discharged: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1894445. I'm not sure that's worse than the odds of getting discharged from the military and having your obligation forgiven. Student debt sucks.

That may be true. Do you know how long it takes to get out of your military contract if you just get tired of it? The same time it takes to finish your ADSO. If you do get discharged, the military reserves the right to bill you for your student loans anyway. I think we may be fixating on the wrong detail, rather than the overal message here. The point of the comment was that while none of the options are good options, you have more options outside of the military than you do IN the military, many of which I mentioned in my previous post that have nothing to do with debt cancellation or bankruptcy. As I mentioned, I know one person who had his loans forgiven. That doesn't make him the norm. I have yet to meet someone who decided one day they didn't want to be in the military who then had their ADSO cancelled for no other reason.

 

[HighPriest]

Everything I have ever read about hardship discharges is that they are incredibly rare and difficult to obtain. Suing for discharge can take years (sometimes over a decade), requires a very competent lawyer, and mostly provides an insane combination of both terrible luck (you have to prove you have been trying to make these payments for years, failed, will continue to fail indefinitely, and your failure is keeping you from providing minimal support for yourself and your family) combined with just the right amount of good luck (you need a pro-bono layer willing to support you through a multi-year process, or alternatively you need to be an unemployable law school grad). Of the nearly 70,000 people each year who go bankrupt with student loans, less than 150 will have those loans discharged: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1894445. I'm not sure that's worse than the odds of getting discharged from the military and having your obligation forgiven. Student debt sucks.

Hey, brother. You should read the abscract you sent.

Abstract:

For years, academics have argued that the undue hardship standard for discharging student loans in bankruptcy is both unduly burdensome and applied in an inconsistent manner. By reviewing a nationwide sample of student loan bankruptcy disputes, this study shows that neither criticism is warranted. First, judges grant a hardship discharge to nearly forty percent of the debtors who seek one. Second, successful debtors differ from their unsuccessful counterparts in three important respects. They are (1) less likely to be employed, (2) more likely to have a medical hardship, and (3) more likely to have lower annual incomes the year before they filed for bankruptcy.

The real failing of the student loan discharge process is lack of participation by those in need. Incredibly, only 0.1 percent of student loan debtors who have filed for bankruptcy attempt to discharge their student loans. That statistic is even more surprising in light of this Article’s finding that a debtor does not need to hire an attorney to be successful. In fact, debtors without attorneys were just as likely to receive discharges as debtors with attorneys were. Ultimately, the low rate of filing shows that, although the system is broken, many of its flaws stem from a failing not previously discussed in the literature

In any case, I still agree with you that bankruptcy isn't a great option. But it is yet another option that you don't have when you sign up for HPSP.

 

[a1qwerty55]

Well, I'd hate to miss the reunion party

I appreciate the civility - but it does make for a far more boring forum.

I'm one of the "cheerleaders" for military medicine - actually a pretty ridiculous assertion since I've been scathing in my assessment of AMEDD leaders, information systems etc. My point has always been that no doubt military medicine is supremely screwed up on many levels, but despite this there are a lot of individuals working hard to ensure the care they and their departments provide is top notch (despite those in Command actively undermining them). I also have asserted that these people are performing a patriotic duty which is to be commended. I must say the last 3-5 years have been a time of precipitous decline in terms of quality and morale. This is directly related to a promotions system which allows the worst of the worst to float to the top and non-clinicians taking the reigns. I, like many around me have had many positive experiences. In my example, I'm better qualified than the vast majority of my peers because of opportunities I created for myself in the system. Accordingly, I had many many options and because of the retirement income have been able to choose a practice environment which allows me to do what I want and not focus entirely on money. There is good and bad, but right now, I think the good is losing. Best wishes to all have have signed on. Try your best to make a difference in your little part of the world, and serve for as long as you feel you should and enjoy the job.