All Branch Topic (ABT) milmed + fellowships

[CSCH]

Hello all!

I'm looking into military medicine (specifically looking at USUHS, but also at HPSP), and as much as I appreciate this forum, it's hard to replace one-on-one communication. So, if you or someone you know in military medicine is willing to exchange emails or phone calls with me, I would greatly appreciate it! Bonus points if they did an IM residency, and double bonus points if they now practice in critical care medicine or did any other fellowship. (But current students/residents/fellows are welcome and appreciated, too!) Stories on this thread also welcome, but what I'm hoping to find is some people who can answer specific questions and also who could be a resource for me to run things by as I communicate with recruiters, etc.

To the general population: How many military physicians do you know what did fellowships? Did their fellowship immediately follow their residency, or did they have to act as a GMO/etc, deploy, and/or practice in their field of residency before they entered a fellowship? Any info regarding critical care in particular?

Thanks in advance!

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[DrMetal]

You can pose whatever questions you want here, and someone might address them....you don't have to go 'one-on-one'. Quite honestly if you search hard enough, you'll probably find what you're looking for (many questions have already been answered).

Fellowships are never guaranteed. Most physicians in the military are generalists in their field. Most fellowships are onesies twosies (at least when compared to the generalist pool). The military is just not all that interested in sub-specialty care, it's easier to defer out.

Having said that, anything is possible, but not guaranteed. PCC is pretty popular now in IM. If you were a 3rd year IM resident today, it would be a good time to apply (not so much for cards or GI). Who knows what things will be like in 10 years. I personally think the mass of critical care folks we're training (and that we're not training in other sub-specs) is a grave mistake, and that pendulum is gonna come crashing back down like a wrecking ball.

If you want total control of your professional destiny, don't sign up for hpsp or usuhs. Joint after you've completed your training.

 

[Gastrapathy]

10 years ago, Pulm/CC was quite competitive. Now, it can’t be since they have slots for half the graduating residents. 10 years from now...well, who knows.

You also might find that the mystique of the ICU fades over time and you’d rather be the dropper-offer than the dropped-on.

IM subs are a little different than surgical subs in that a general surgeon can do trauma but a general internist can’t do cardiology. The IM subs might survive the purge because of that. Or, they could just get outsourced. Internists running forward ICUs is not that hard to imagine (it’s reality).

 

[CSCH]

Thanks for the answers.

Based on what I've seen posted elsewhere (albeit, very old posts) it seems like not every military ICU is staffed by intensivists. In your experience, who generally staffs the ICU (hospitalists, intensivists, civilian intensivist/hospitalist contractors)? How is it different at different sites (Walter Reed vs Podunk General)? Any differences between the branches?

Also, can you provide any info about how critical care is delivered in deployment areas?

Also also, any word or whisperings regarding the military allowing EM>>CCM pathway? It seems to be growing on the civilian front.

And finally, say I did go straight in, USUHS, got an IM residency. After graduating, assuming no fellowship, how likely am I to be placed in a clinic vs hospitalist position? This forum is filled with many acronyms, none of which have any meaning to me yet, so any help there would be wonderful.

Basically, my overall gist is that I'd really like to serve in the military, I'd really like to be an intensivist or at the very least work primarily in a hospital setting, and I'm trying to figure out what that would look like and/or if the two are mutually exclusive.

 

[HighPriest]

I would be worried less about whether or not fellowship-trained PCC docs are staffing all of the ICUs and more about whether or not you’ll actually be taking care of critically ill patients when you’re a fellowship trained PCC doc working in a military ICU.

 

[militaryPHYS]

If you deploy (even if you are fellowship trained) you will more than likely deploy as a senior medical officer for a unit, i.e. you will be the subject matter expert on all things medicine as it relates to your troops. The majority of this will be primary care type stuff. Some infectious disease, some random stuff, but mainly primary care.

If you deploy as an intensivist to fill and intensivist role you would be somewhere in some tertiary receiving hospital maybe taking care of ICU patients. This would depend on the theater of war and operational environment of whatever conflict we are in. You would be a stopping point for sick/vent patients being evac'ed from theater on their way back stateside. (google landstuhl medical center). But just like any sub-specialized physician deploying, you may be practicing the skills you learned in fellowship or you could be assisting on an exploratory laparotomy with the general surgeon. There is no way to predict. Set your expectations that there is a good chance you deploy in a purely medical support role. You could be very busy practicing all sorts of medicine stuff or you could be very bored and doing mainly unit physical training, barracks cleaning and chow.

And finally, say I did go straight in, USUHS, got an IM residency. After graduating, assuming no fellowship, how likely am I to be placed in a clinic vs hospitalist position? This forum is filled with many acronyms, none of which have any meaning to me yet, so any help there would be wonderful

There is honestly no way to predict this. If you want to be happy in the Military you need to sign up with the understanding that you could be placed in to either one. Expect the worst. If the worst is still OK with you and you can find the positive aspects of that situation for 3 years until you can change duty stations, then push forward. If you want the ability to say no to a position in hopes of a better one after residency then be a civilian.

 

[DrMetal]

Internists running forward ICUs is not that hard to imagine (it’s reality).

And that's been done in every major conflict: WWII, Korea, Vietnam (all back when there was no specific critical care sub-specialty), and it was done in Gulf War I and II. Many a general internist or general surgeon have staffed make-shift MICUs/SICUs in forward deployed environments. This notion that you absolutely need a critically-care trained physician in every forward environment is absolutely ridiculous. Plus it wouldn't be fair to the the critical care community, to call on them exclusively every time a deploying physician is needed. And that's not what happens; we've seen plenty of endocrinologists, GIs, Cardiologists etc deploy.

 

[CSCH]

HighPriest, can you expand? What kind of patients would I expect to see in a military ICU stateside? What about one overseas? Do the ICUs tend to be divided into medical, surgical, neuro, etc, or do most locations have a general med/surg ICU with a mix of patients?

 

[HighPriest]

My point is: a lot of military ICUs have a lower census, and often a lower acuity than most major civilian ICUs. Comparable to a community hospital with an ICU in some cases, and comparable to a civilian ICU that caters to younger people in some cases. Now, that is a broad statement. If you’re comparing a large state facility to anything else, it can be apples and oranges. But, the small hospital I work at now is certainly busier than the larger MEDCENs at which I spent time (at least, the census was definitely lower in the Army at any time I was in the unit). There is a spectrum, but that spectrum is not going to be a high volume setting compared to a large civilian ICU regardless. Thats not necessarily a bad thing. It depends upon what you’re looking for. I did know at least a few military ICU docs who were really hurting for experience while stateside, and many who did moonlighting to stay up to snuff. That’s a military-wise problem.

 

[Gastrapathy]

WRT acuity, every GIB, no matter how trivial went to the unit to support their numbers. Where I practice now, they have to be scary sick to get into the step down.

 

[HighPriest]

We were also encouraged to admit as much as possible to the ICU to help with their numbers. Usually, but not always, stuff that would have been on the floor at any other institution.

 

[CSCH]

Could it be compared to a community hospital ICU?

 

[HighPriest]

Depends upon which community hospital and which military hospital you’re comparing. The community hospital ICU where I work is busier than the ICU at the MEDCEN where I did my residency by a lot.

 

[armytrainingsir]

We were also encouraged to admit as much as possible to the ICU to help with their numbers. Usually, but not always, stuff that would have been on the floor at any other institution.

Pretty much every civilian hospital Ive been in loves to have the ICU full too, the sicker on paper, but not in person, the better. More $$$$$$.

 

[HighPriest]

Pretty much every civilian hospital Ive been in loves to have the ICU full too, the sicker on paper, but not in person, the better. More $$$$$$.

Of course they do. However, I’ve always found it difficult to justify to the critical care staff or the insurers as to why I’m admitting a standard, uncomplicated, post-surgical patient to the ICU. And the civilian ICUs I’ve worked with usually have a reasonable census, and aren’t hurting for bodies. They don’t need to beg me for patients who don’t belong there. I’ve never seen on the civilian side what I regularly saw in the Army.