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- Nov 18, 2002
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I've been waiting to write this for a long time. I decided it would be best to wait until I was out before sharing all the gory details. In many ways, I got very lucky. I had a lot of great breaks that prevented anything really bad from happening to me.
I never thought I'd end up in the military. I used to make fun of all the JROTC guys in high school. Then I went to college. Had a scholarship, worked my butt off during the summers while living at home to save up money, worked some during the year, and living very cheaply. Managed to get through with only $5K debt. Then I got married. There was no way she was going to live like I had for the last 4 years. And I felt this obligation to support the family. She was a military brat. All of her brothers were considering military careers, one was even in the academy. They suggested the HPSP scholarship. I was young and naive. I spoke to two military docs, one retired and one active. Both were quite positive. It was all good according to the military recruiter. I didn't even know enough to ask about the military match, much less a visit to a military hospital. There was always the possibility of being deployed, but it was 1999, and we hadn't had a real war in decades. At worst, I'd go somewhere for 3 months one time in my 4 years on active duty. I thought it would be a good chance to see the world and do something different for a few years before settling into a practice. I signed up.
Boot camp that summer sucked, but I can do anything for a month, and besides, the pay seemed really good. It was more than I'd ever made in a single month! Then they started giving me $921 a month, just to go to school. Between that and what my wife made with a part-time job while she was in school, we could actually live on a tight budget. We even owned a condo in med school.
I discovered SDN later that fall. I can only recall one attending on the site at the time, an ophthalmologist with a motorcycle in his avatar. He seemed pretty negative, but at that point I was committed, and all I could do was prepare myself for what was to come.
I went to the Air Force's Intro to Flight Med that next summer, then spent a month playing before school started again. All the other med students were just as cool and nice as the ones in my flight at boot camp. And to make it even better, the psychotic pharmacists and lawyers that plagued COT were nowhere to be seen. And again, I got that great pay! Then it was back to school. Thanks to SDN I had figured out how to do all the reimbursement stuff at my school. There were probably only 5 or 6 HPSP students in the whole school. That shouldn't have been a big surprise to me, given that in-state tuition was only $10K a year.
Third year came and went. I really enjoyed medical school. Hard work, but I could sense that I was good at it and my grades and scores were reflecting that. I was clearly headed for a top-notch residency in whatever I wanted to do, except maybe OB, man did I blow that test. Everything got a little scary after 9/11, especially with my wife on a plane at the time and my father in law at the Pentagon. That idea of rarely deploying seemed a bit far-fetched now, but truthfully, that didn't bother me much. A little adventure, some travel and some unique experiences were worth some family separation to me. I had been leaning toward emergency medicine for the last couple of years (although I initially thought family med when I started), and that was starting to solidify as my goal. I hadn't done anything with the military in nearly two years at this point, other than collect checks and send in reimbursement forms. But I knew I needed to get two more ADTs in. So I signed up for one in emergency medicine for September of my 4th year. I had already done two EM rotations, and I knew my stuff and, more importantly, I knew how to do well on a rotation. I chose to go to Wright-Patterson, since I hate Texas. It turns out I hate Ohio too, but I didn't know that at the time.
I arrived at the base and everyone was cool. The attendings and residents were all great people, just like almost all the other emergency docs I'd ever met. The ED was a joke. 12 beds with nothing but curtains separating them. No sick patients (one intubation in the department that month.) The residents were all glad they only had to spend 3 months of their residency at the base. But the real eye-opener was that I finally learned what the military match is and how it works. The first then I realized was the deadline was literally months before I had thought it would be. I had naively assumed it was like the civilian match. Fair, computerized, favors the applicant, you get to do several months of your 4th year before deciding on a specialty, you don't have to rank any program you don't want to go to etc. Nope. It was definitely a who-you-know type of process. 3 people sitting at a table deciding your fate. To make matters worse, it looked like it was going to be a very competitive process that year (I hadn't yet learned it was like that every year.) In the civilian match back then, a US grad had a 93% chance of getting into an EM residency somewhere. (That number is now in the mid 80s BTW.) But that year they were only planning to train 8 at the military program in San Antonio, and 4 at Wright-Patt (Wright State), and they didn't know how many deferments they were going to give out (it later turned out to be 12 or 13.) Well they'd already had 20 people rotate at Wright-State by the time I got there. And I had to assume there were at least that many rotating through SAUSHEC. I started to realize I was in deep doo-doo. It later turned out that 50 people wanted to do EM that year-leading to a 50% match rate, which is basically the same as derm in the civilian residency. I also learned that not only is the match heavily dependent on those 3 people (the EM specialty leader and the two program directors of the two AF EM programs), but it also uses a bizarre points system that gives tons of points for published research and prior military service, and not so much for being a kick-ass medical student. In fact, there was no way a medical student without published research could even beat out a mediocre intern with a case report! Panic set in. But I'd done this before. Just like getting into med school, this was a numbers game, and if I worked my tail off, and stacked the odds in my favor as much as possible, I just might pull it off. I'd been working on some research stuff, so I started emphasizing that. I arranged to interview at Wright-State while I was there, and I then flew at my own expense to San Antonio (even though I only HAD to interview at one of the institutions) just to tell the PD I really, really wanted to do EM, but that I didn't want to go to his program and ask him if he would pretty please with a cherry on top pick me to go into EM, but not stick me in his program (that was a really interesting interview by the way.) There was nothing I could do about my med school record at this point. I had already taken both Step I and II (and thankfully absolutely rocked them) and all my EM rotations and core rotations were all past. But I'd done what I could, and I sat on pins and needles until December 12 to find out if I was going to get to do what I wanted to with my career. I had gotten some reassurances that based on my record I should be able to do EM, and the program directors were super cool and I couldn't imagine them screwing me over just for fun, so I went ahead and started lining up interviews for the civilian match. I had actually done 6 interviews before the military match results came out. There are few times in my life when I've been this anxious, but my hard work and a little luck paid off, and I was selected for a deferment. At that point I could once more forget about the military.
I went to the rest of my interviews, matched into my # 1 pick for an EM residency at a prestigious residency that was a great fit for me and ticked off my last ADT as a Sub-I that I simply didn't care about enough to do more than pass. I followed along on SDN (it was a far more accurate source of information on military medicine than anything else) since there weren't any other HPSP folks in my hospital, much less my residency program. Once a year I had to fill out a sheet with my weight on it and have one of my attendings sign it saying I was reasonably healthy. I got great training, took care of tons of trauma patients, did difficulty airways, managed medical disasters, did lots of peds and ultrasound and all that good stuff you get at a top notch EM program.
Around came my last year of residency. I got something in the mail asking me to make a rank list of where I wanted to go. We agonized over it and finally ranked from top to bottom all 15 places that they sent EM docs in the AF. Then nothing. For the next 2 months I didn't hear a thing. Another HPSP EM guy had transferred into my program halfway through and one day he tells me he's going to Nellis. I couldn't figure out how he knew and I didn't, so I finally got on the phone and called the assignment officer (once I found out there was such a thing.) He said he had me penciled in for Keesler. Well, Keesler was #15 on that list, and I was having a hard time understanding why they had me make it in the first place. The reason it was that far down was that Mississippi was my idea of a living hell, aside from the fact that a hurricane had literally just destroyed the hospital. He then asked if I had a family (again I asked myself why I bothered filling out that form which clearly had information about my dependents on it) and when I said yes, he saw his chance. "Well, there's one other place that might work for you....at Langley." I covered the phone, and whispered to my wife "Where's Langley." She was also standing there contemplating her fate for the next 4+ years, but she knew where Langley was, so she answered, "Virginia...take it...take it." She didn't want to go to Mississippi either! Langley hadn't been on my original list...because it didn't have an emergency department. But it turned out they needed one emergency doc there for a deployment package. I spoke to the specialty leader, and was reassured that I wouldn't be working much in the urgency care center at Langley, but that she had arranged for me to work all my clinical shifts at the nearby Navy tertiary care center where there was an EM Residency program. That sounded pretty good to me. I would have a chance to teach residents, to see some real acuity, and wouldn't have to go to Texas or Ohio to do it. I wasn't thrilled about Virginia, but it was better than Mississippi. So we packed things up and drove across the country.
Well, when I got to Langley I was greener than green. I got to speak with the guy I was replacing very briefly. Man was he happy. He was leaving in July (meaning he didn't take his ISP that last year) but I didn't realize what that meant at the time. People were nice. My direct boss was an FP, who hated the clinics so badly he had finagled his way into a job directing the urgent care. I met with the squadron commander, and quickly realized that my squadron/group leadership did NOT think much of the specialty leader and had no intention of letting me go to Portsmouth to work all my clinical shifts. When all was said and done, I ended up doing 2/3 of my shifts that year at Portsmouth, and 1/3 in a very high volume, very low acuity urgent care center at Langley. I was the only emergency doc on the base. It was the crappiest hospital I've ever worked in. 95% of the admissions were to the labor deck. Only 2% or so of the patients coming to the urgent care were admitted to the hospital. The cafeteria was open for an hour or two at breakfast, and an hour or two at lunch, monday through friday. (If you know anything about emergency medicine, you know that most shifts are evening shifts, and that you work just as many nights, weekends, and holidays as weekdays. A cafeteria that's only open 10 hours a week is only open 5% of the time that you need it open. At least there was a bowling alley that was open til 10 pm that would grill you something. So brown bag it was. There was no doctors lounge, and it was easy to see why. Doctors were not considered particularly important to this operation. There was no doctors parking. In fact, the hospital parking lot was under construction for most of the 4 years I was there and so all the hospital staff were parking two parking lots away at the BX. It was faster for me to ride my bike to work than to drive, park at the BX, and then walk. The enlisted leadership were out patrolling the parking lot ensuring staff weren't parking out there. Then they closed the bowling alley. There was now no hot meal available on shift. Ever. Unless you count ravioli heated up in the microwave. The OR was dead. The general surgeons were lucky to do 5-10 cases a month. Somehow Langley had been allotted a crazy number of anesthesiologists/anesthetists. They were going home at 10 am because there was nothing left to do unless they had OB call that day. The FPs were getting killed, the urgent care was in crisis mode most of the time, and every other specialty in the hospital was on cruise control. The leadership was operating under this crazy idea that they were going to turn Langley into a tertiary medical center. Never mind that it was only a half hour away from Portsmouth, had 10 inpatient beds (outside of the labor deck), no ICU, minimal inpatient specialties, RT coverage only 40 hours a week, no echos, no stress tests (well, treadmills once a week), no MRI, no lactate, CRP, CO or other essential lab tests and 50 clipboard carrying nurses chastising docs for not making love to AHLTA.
Portsmouth was the saving grace for me that year. I probably would have committed suicide without it, or at least said I would so I could get out of the military like all those guys in the Navy. (Far more prevalent in the Navy than the AF by the way, especially as a deployment was coming up.) The NMCP ED was nice, well-equipped, and staffed by a good core group of attendings, at least by military standards. There were actually practicing doctors who carried a rank higher than O-4, unlike at Langley. They didn't want me to do anything but teach residents and see patients. No silly war games. No idiotic PT tests (I have zero respect for anyone who can't pass an AF PT test BTW.) The residents were quite bright, academically perhaps one of the sharpest residencies I've ever been around. Several of them outranked me (and had practiced for longer than me) but would never have said anything about it. A number of them were inspiring in their dedication to military medicine. Unfortunately, the experience offered to the residents was downright ****ty. Critical patients were rare, intubations and central lines were even rarer, and traumas and sick pediatric patients simply didn't show up. The patient base was way too well to provide good residency training. They would do 8 months or so out at other hospitals, but I couldn't imagine that would be enough. Their PICU rotation was a joke. They might have one patient in the unit. We always had a full unit spilling onto the floor where I trained. I recall one night when I had two kids die on me within a few hours. I don't think 2 kids died at NMCP in any given year.
So that first year I was in a bit of a honeymoon stage. Within 2 or 3 months I had decided I was just going to do my 4 years and get out. I never really thought I was going to stay for a career, but I had an open mind until then. It only took that long to realize that what all the detractors on SDN were saying was nearly 100% accurate. But that first year I was able to play one hospital off the other enough to give myself a reasonable lifestyle and it was nice to be making more than $100K finally (my residency was paying $34K when I matched.) We bought a nice little townhouse and were paying its mortgage down aggressively. I had to put up with some shifts at Langley, where the patient load was annoyingly heavy (3-6 patients an hour, where a typical emergency doc sees 2), but the techs and nurses were nice, although under-trained since they had never worked in a real ED. I was told I wouldn't deploy until after I had done my boards that Spring.
Like clockwork year 2 rolled around. I was doing lots of fun war games to prepare for deployment. My assignment finally came in....Qatar. While it was only 50 miles from Iran, it's a 2 hour flight to Iraq. I clearly wasn't going to see much trauma. But at least it was a pretty cush place to hang out. We arrived in Qatar. This is the point at which I finally felt like I was in the military. But it was all the bad parts of the military. I would have thought Catch-22 was written by someone who spent a portion of his life at Al Udeid Air Base. The leadership and politics in the med group were maddening. The pace of life, incredibly slow. The medicine, immensely boring. Military medicine will always be low acuity. We don't let sick people in and we throw them out if they get sick. But when you deploy, there is an additional screen that keeps anyone with anything interesting away, and of course you don't see any retirees or dependents. So 4+ months of knee pain, fungal skin infections, diarrhea, and colds. That describes 95% of my clinical encounters in Qatar. The camaraderie was good, the food was better than I eat at home, there was plenty to do (movies, a bar, special events etc) and I worked out for at least 2 hours a day, putting on 20 lbs of muscle. But 4 months of being away from family, literally being locked down on a 1/2 mile X 1/2 mile compound, and feeling like your skills are wasting away doing something an IDT could do with one or two phone calls a day to the States, helped me to realize that was not an experience I wanted to repeat if at all possible.
I learned while in Qatar that it was possible to PCS overseas after 2 years at Langley. The catch was that a PCS would add another year to my commitment. I started spending time talking to the assignment officer (now that I knew how the system worked) and finally made a decision to PCS to Germany. I had always wanted to live in Europe and it would give me the adventure I had sought when signing up for the military. Germany had been #1 on my list 2 years earlier. Besides, it would get me out of Langley. Pressure had been building there to put me in charge of the urgent care center, I was down to 1/2 time at NMCP now, and the hospital environment was just as crappy as ever. To make things worse, the leadership had swapped out just before the deployment and was now even worse. The Squadron commander wasn't even a doc any more. It was bad enough to have a doc out of touch with clinical medicine. It was far worse to have a non-physician trying to run a hospital. So I told the assignment officer I'd pick up the extra year if he sent me to Germany. Just before going home, he called me back to tell me he had to give that slot away to someone whose pediatrician spouse had just finished a Korea tour....but what about England? I told him thanks but no thanks and resigned myself (silently) to 2 more years at Langley. At this point the recruiting to pick up a 2nd tour steadily grew. It was amazing to me how I went from being offered my last choice a year earlier to now having the pick of the litter. But someone on SDN had mentioned that one thing you never do is sign on for more time, no matter how good it looks. That's still good advice.
The best experience of my military career came that next summer. As part of this recruiting effort, I was given a plum assignment in England. 6 weeks at Lakenheath back-filling for a doc who had been deployed. I didn't want to spend 3 years at Lakenheath, but a summer sounded awesome. They even approved a rental car for me, so I took my family along. 3 shifts, then 3 days in London. 3 shifts, then 3 days in Wales. 3 shifts, then 3 days visiting the countryside. 3 shifts, then 4 days in Scotland. And so it went, all summer long. At the end, I took a week of leave and went to the continent, visiting 6 or 7 countries along the way. Very cool. Except that gas was literally $12 a gallon. But we didn't let that hold us back.
Upon returning to Langley the volumes had been getting higher and higher. We had to add more shifts. Unfortunately, we didn't get the manning for it. For the most part, we were able to piece together enough contractors to cover them, but every year the contractors were cut as more emergency docs were sent to Langley. Someone had gotten the bright idea to turn the urgent care back into an emergency department as part of this trend to become a tertiary care center. Well, it was never an emergency department in the first place, and nothing changed a few years ago when they demoted it to an UCC. So nothing was going to change now that we were going to call it an ED, except the contractors (who wanted as many hours as I could give them and never deployed) were being swapped out for brand new residency-graduating military docs being deployed like it was going out of style. My FP boss separated and I was put in charge. There was literally no one else to do it. My clinical time at NMCP was down to about 1/4 time at this point. The only benefit of being in charge was I got to make my own schedule, but I felt so guilty about it I always ended up overscheduling myself. I spent most of my time trying to protect the department (and its patients) from the crazy decisions of the hospital leadership and provide some type of reasonable lifestyle to my docs. It became more and more difficult as time went on. We eventually had 8 docs, 5 with short commitments and 3 with longer ones, all itching to separate, or at least PCS out of there. I was doing my time and getting ready to punch out at the earliest opportunity. The entire medical executive committee of the hospital was in the same boat as me. 2-3 years out of residency and all itching to separate, and trying desperately to hide that fact from local and specialty leadership. We saw the bad things that happened to those who made things like that known-crappy, long deployments. You didn't get to go to Balad or Bagram if you were punching out. You went to Qatar or Manas. And you were much more likely to go in the first place.
I lucked my way onto a team that was supposedly protected from deployment. We were supposed to be America's 911, you know, if Seattle gets nuked we go set up an EMEDS there and save the day. Of course, we couldn't get anywhere in less than 3 days, and the mission eventually morphed into something like we'd take care of the army while they dug the city out of the rubble. But it did keep me out of the deployment cycle that year. Meanwhile, the deployments were increasing in length (now 6+ months rather than 4+) but we couldn't complain when we saw the Navy guys doing 7 or 8 or the Army guys doing 12-15. They were also increasing in frequency. Some of the guys in my shop were gone again, just 13 months after finishing a 6 monther. I could see the writing on the wall. I was trying to lay low as I finished out my time. Clinical time at NMCP was completely gone by my 4th year, as were most of our contractors. People were being deployed for 6 months with 3 days notice here, a week's notice there. Some to cool places, but still....
Finally, I had my separation papers in, I was putting my house on the market to sell, I had my civilian job lined up with a start date and everything, and I was taking one last vacation before saving the rest of my leave for terminal. I had decided not to take the ISP that last year to get out sooner and start making the big bucks (I was still only making ~$130K a year as a major, not counting a little moonlighting) but mostly I was just hoping to avoid 6 months in the desert. What seemed like a great adventure for a noble cause when I was 23, didn't seem so fun at 34 with 3 kids and a true vision of what you really do on deployment as a doc. 3 months from the start of terminal leave I get a call (while on shift at my moonlighting job) at 11 pm. You're leaving in the morning. Where? Chile. For how long? At least 90 days. My parents were flying in from Alaska 4 days later so my wife and I could go to Puerto Rico for a week. Nope, I was definitely the guy they wanted. 24 hours later I was in Texas, and the day after that was lying in a jump seat on a C-17 (which naturally took off 8 hours late to ensure we would start our trip with maximum fatigue.) Again a great group of people, lots of camaraderie, some bizarro rules (A small farming town in Chile might not be a war zone, but dammit you guys aren't leaving the base for security reasons), and a chance to see a country I've always wanted to see. It was pretty boring medically speaking, since the Chileans didn't actually need us, they just needed an OR in a tent since their hospital broke in the earthquake, but it was an interesting cultural experience, what we could see from the fence around the base anyway. We were all glad when the 90 day deployment turned into a 23 day one. And they did let us off the base that last day. Not nearly as cool as my summer in England, but still an overall positive experience. And my wife went to Puerto Rico without me. (we were going with another couple.)
Unfortunately, being gone kept me from getting my house on the market in time to get it sold when things were hot with the tax rebate, so I'm still trying to sell that, but the rest of my time went pretty well, all things considered. The DITY move was flawless (pays as well as ISP and has a lot less commitment) and my DD214 and last few paychecks came through without any issues.
I was surprised that my prospective employers looked on my military time as valuable experience. None of them were concerned about the lack of acuity in my practice. It helped that I had moonlit at a local trauma center, but it seemed I was worried more about losing skills than they were. I often get questions from nurses, techs, and docs about being in the military and in general, society has a great deal of respect for those who serve. They are a bit misguided about the sacrifices, imagining that everyone is getting shot at all the time, when the real sacrifice is being underpaid and overworked, being constantly on call for deployment, and being away from family for months at a time. I'm working about 25% less than I was in the military, making maybe 40% more (100% more once I make partner in 18 more months), and paying a lot more in taxes. I miss very little about being in the military. I didn't enjoy living in Virginia, working in military hospitals, or being at the beck and call of the military (the constant anxiety of impending deployments cannot be overestimated by the prospective HPSP student). I am treated with the respect physicians generally get, eat for free at all hours in my hospital and park outside the door to the ED. If I work more in any given month, I am paid more.
My practice is different. The acuity is higher and I have some additional headaches I never had before. There are far more drug seekers outside the military, more homeless, more Jerry Springer situations, more real psych (rather than sailors trying to get out of the Navy), and more people who can't get care because they don't have insurance. Although I worry much less about most patients getting follow-up care. With Tricare, I was never really sure if/when that patient was going to get that MRI or neuro consult or whatever.
I have calculated in the past that I lost ~$180K by doing HPSP instead of doing loans. This was because of several factors-
1) I did a relatively well-paying specialty
2) I went to a relatively inexpensive school and
3) I graduated in 2003, when my classmates refinanced their student loans at 1.9%.
I would have to modify that figure somewhat. I have definitely come out ahead by being able to buy my big "attending house" in 2010, after a 25% haircut and with rates at all time lows (my mortgage is at 3.625%...without a buy down.) So perhaps I've made up for some of that money I lost.
So, to sum it all up, I got lucky in a lot of ways:
I got what I wanted out of the military match. It cost me a lot of blood, sweat, treasure, and tears, but it worked out perfectly in the end.
I spent less than 6 of my 47 months in the service deployed, ate well and wasn't mortared in either place.
I had that great summer in England.
Got to practice in a variety of clinical settings (6 very different hospitals on 4 continents in 4 years) and gain experience on hospital committees, as an EMS director, and as an ED director I would have never gotten to do as a civilian that early in my career.
Got a chance to live on the East Coast. While I didn't want to go, and left as soon as I could, I did get to see and do a lot of cool stuff out there, from Broadway, to Jamestown to Kiteboarding on the Outer Banks.
Have no student loans.
At times I felt very patriotic and was proud to be in uniform. Some of the capabilities of the military (even military medicine) are incredibly impressive. I got to take care of people who were present at key moments in history-Iwo Jima, Khobar Towers, Gulf Wars, Navy Seals etc. I was well aware that whatever sacrifice I thought I was making, it was nothing compared to most of the people I was taking care of. And it was fun to be part of something that was bigger than myself.
But to pretend that it was overall a positive experience? No, I don't think I could ever do that. I came home and told my wife I hated my job far too many times for that. Far too much mickey mouse leadership, bureaucratic BS, and simple facts of military life that will never change, could not ever change for that. The military has forever changed the way I view life. In some ways for the better, in many ways for the worse. I'm sure in 10 or 20 years I'll remember it more fondly than I now do, but I have yet to have even a twinge of regret about separating.
Would I do it again if I could see the end from the beginning? Even knowing I would get lucky as much as I did? No.
I never thought I'd end up in the military. I used to make fun of all the JROTC guys in high school. Then I went to college. Had a scholarship, worked my butt off during the summers while living at home to save up money, worked some during the year, and living very cheaply. Managed to get through with only $5K debt. Then I got married. There was no way she was going to live like I had for the last 4 years. And I felt this obligation to support the family. She was a military brat. All of her brothers were considering military careers, one was even in the academy. They suggested the HPSP scholarship. I was young and naive. I spoke to two military docs, one retired and one active. Both were quite positive. It was all good according to the military recruiter. I didn't even know enough to ask about the military match, much less a visit to a military hospital. There was always the possibility of being deployed, but it was 1999, and we hadn't had a real war in decades. At worst, I'd go somewhere for 3 months one time in my 4 years on active duty. I thought it would be a good chance to see the world and do something different for a few years before settling into a practice. I signed up.
Boot camp that summer sucked, but I can do anything for a month, and besides, the pay seemed really good. It was more than I'd ever made in a single month! Then they started giving me $921 a month, just to go to school. Between that and what my wife made with a part-time job while she was in school, we could actually live on a tight budget. We even owned a condo in med school.
I discovered SDN later that fall. I can only recall one attending on the site at the time, an ophthalmologist with a motorcycle in his avatar. He seemed pretty negative, but at that point I was committed, and all I could do was prepare myself for what was to come.
I went to the Air Force's Intro to Flight Med that next summer, then spent a month playing before school started again. All the other med students were just as cool and nice as the ones in my flight at boot camp. And to make it even better, the psychotic pharmacists and lawyers that plagued COT were nowhere to be seen. And again, I got that great pay! Then it was back to school. Thanks to SDN I had figured out how to do all the reimbursement stuff at my school. There were probably only 5 or 6 HPSP students in the whole school. That shouldn't have been a big surprise to me, given that in-state tuition was only $10K a year.
Third year came and went. I really enjoyed medical school. Hard work, but I could sense that I was good at it and my grades and scores were reflecting that. I was clearly headed for a top-notch residency in whatever I wanted to do, except maybe OB, man did I blow that test. Everything got a little scary after 9/11, especially with my wife on a plane at the time and my father in law at the Pentagon. That idea of rarely deploying seemed a bit far-fetched now, but truthfully, that didn't bother me much. A little adventure, some travel and some unique experiences were worth some family separation to me. I had been leaning toward emergency medicine for the last couple of years (although I initially thought family med when I started), and that was starting to solidify as my goal. I hadn't done anything with the military in nearly two years at this point, other than collect checks and send in reimbursement forms. But I knew I needed to get two more ADTs in. So I signed up for one in emergency medicine for September of my 4th year. I had already done two EM rotations, and I knew my stuff and, more importantly, I knew how to do well on a rotation. I chose to go to Wright-Patterson, since I hate Texas. It turns out I hate Ohio too, but I didn't know that at the time.
I arrived at the base and everyone was cool. The attendings and residents were all great people, just like almost all the other emergency docs I'd ever met. The ED was a joke. 12 beds with nothing but curtains separating them. No sick patients (one intubation in the department that month.) The residents were all glad they only had to spend 3 months of their residency at the base. But the real eye-opener was that I finally learned what the military match is and how it works. The first then I realized was the deadline was literally months before I had thought it would be. I had naively assumed it was like the civilian match. Fair, computerized, favors the applicant, you get to do several months of your 4th year before deciding on a specialty, you don't have to rank any program you don't want to go to etc. Nope. It was definitely a who-you-know type of process. 3 people sitting at a table deciding your fate. To make matters worse, it looked like it was going to be a very competitive process that year (I hadn't yet learned it was like that every year.) In the civilian match back then, a US grad had a 93% chance of getting into an EM residency somewhere. (That number is now in the mid 80s BTW.) But that year they were only planning to train 8 at the military program in San Antonio, and 4 at Wright-Patt (Wright State), and they didn't know how many deferments they were going to give out (it later turned out to be 12 or 13.) Well they'd already had 20 people rotate at Wright-State by the time I got there. And I had to assume there were at least that many rotating through SAUSHEC. I started to realize I was in deep doo-doo. It later turned out that 50 people wanted to do EM that year-leading to a 50% match rate, which is basically the same as derm in the civilian residency. I also learned that not only is the match heavily dependent on those 3 people (the EM specialty leader and the two program directors of the two AF EM programs), but it also uses a bizarre points system that gives tons of points for published research and prior military service, and not so much for being a kick-ass medical student. In fact, there was no way a medical student without published research could even beat out a mediocre intern with a case report! Panic set in. But I'd done this before. Just like getting into med school, this was a numbers game, and if I worked my tail off, and stacked the odds in my favor as much as possible, I just might pull it off. I'd been working on some research stuff, so I started emphasizing that. I arranged to interview at Wright-State while I was there, and I then flew at my own expense to San Antonio (even though I only HAD to interview at one of the institutions) just to tell the PD I really, really wanted to do EM, but that I didn't want to go to his program and ask him if he would pretty please with a cherry on top pick me to go into EM, but not stick me in his program (that was a really interesting interview by the way.) There was nothing I could do about my med school record at this point. I had already taken both Step I and II (and thankfully absolutely rocked them) and all my EM rotations and core rotations were all past. But I'd done what I could, and I sat on pins and needles until December 12 to find out if I was going to get to do what I wanted to with my career. I had gotten some reassurances that based on my record I should be able to do EM, and the program directors were super cool and I couldn't imagine them screwing me over just for fun, so I went ahead and started lining up interviews for the civilian match. I had actually done 6 interviews before the military match results came out. There are few times in my life when I've been this anxious, but my hard work and a little luck paid off, and I was selected for a deferment. At that point I could once more forget about the military.
I went to the rest of my interviews, matched into my # 1 pick for an EM residency at a prestigious residency that was a great fit for me and ticked off my last ADT as a Sub-I that I simply didn't care about enough to do more than pass. I followed along on SDN (it was a far more accurate source of information on military medicine than anything else) since there weren't any other HPSP folks in my hospital, much less my residency program. Once a year I had to fill out a sheet with my weight on it and have one of my attendings sign it saying I was reasonably healthy. I got great training, took care of tons of trauma patients, did difficulty airways, managed medical disasters, did lots of peds and ultrasound and all that good stuff you get at a top notch EM program.
Around came my last year of residency. I got something in the mail asking me to make a rank list of where I wanted to go. We agonized over it and finally ranked from top to bottom all 15 places that they sent EM docs in the AF. Then nothing. For the next 2 months I didn't hear a thing. Another HPSP EM guy had transferred into my program halfway through and one day he tells me he's going to Nellis. I couldn't figure out how he knew and I didn't, so I finally got on the phone and called the assignment officer (once I found out there was such a thing.) He said he had me penciled in for Keesler. Well, Keesler was #15 on that list, and I was having a hard time understanding why they had me make it in the first place. The reason it was that far down was that Mississippi was my idea of a living hell, aside from the fact that a hurricane had literally just destroyed the hospital. He then asked if I had a family (again I asked myself why I bothered filling out that form which clearly had information about my dependents on it) and when I said yes, he saw his chance. "Well, there's one other place that might work for you....at Langley." I covered the phone, and whispered to my wife "Where's Langley." She was also standing there contemplating her fate for the next 4+ years, but she knew where Langley was, so she answered, "Virginia...take it...take it." She didn't want to go to Mississippi either! Langley hadn't been on my original list...because it didn't have an emergency department. But it turned out they needed one emergency doc there for a deployment package. I spoke to the specialty leader, and was reassured that I wouldn't be working much in the urgency care center at Langley, but that she had arranged for me to work all my clinical shifts at the nearby Navy tertiary care center where there was an EM Residency program. That sounded pretty good to me. I would have a chance to teach residents, to see some real acuity, and wouldn't have to go to Texas or Ohio to do it. I wasn't thrilled about Virginia, but it was better than Mississippi. So we packed things up and drove across the country.
Well, when I got to Langley I was greener than green. I got to speak with the guy I was replacing very briefly. Man was he happy. He was leaving in July (meaning he didn't take his ISP that last year) but I didn't realize what that meant at the time. People were nice. My direct boss was an FP, who hated the clinics so badly he had finagled his way into a job directing the urgent care. I met with the squadron commander, and quickly realized that my squadron/group leadership did NOT think much of the specialty leader and had no intention of letting me go to Portsmouth to work all my clinical shifts. When all was said and done, I ended up doing 2/3 of my shifts that year at Portsmouth, and 1/3 in a very high volume, very low acuity urgent care center at Langley. I was the only emergency doc on the base. It was the crappiest hospital I've ever worked in. 95% of the admissions were to the labor deck. Only 2% or so of the patients coming to the urgent care were admitted to the hospital. The cafeteria was open for an hour or two at breakfast, and an hour or two at lunch, monday through friday. (If you know anything about emergency medicine, you know that most shifts are evening shifts, and that you work just as many nights, weekends, and holidays as weekdays. A cafeteria that's only open 10 hours a week is only open 5% of the time that you need it open. At least there was a bowling alley that was open til 10 pm that would grill you something. So brown bag it was. There was no doctors lounge, and it was easy to see why. Doctors were not considered particularly important to this operation. There was no doctors parking. In fact, the hospital parking lot was under construction for most of the 4 years I was there and so all the hospital staff were parking two parking lots away at the BX. It was faster for me to ride my bike to work than to drive, park at the BX, and then walk. The enlisted leadership were out patrolling the parking lot ensuring staff weren't parking out there. Then they closed the bowling alley. There was now no hot meal available on shift. Ever. Unless you count ravioli heated up in the microwave. The OR was dead. The general surgeons were lucky to do 5-10 cases a month. Somehow Langley had been allotted a crazy number of anesthesiologists/anesthetists. They were going home at 10 am because there was nothing left to do unless they had OB call that day. The FPs were getting killed, the urgent care was in crisis mode most of the time, and every other specialty in the hospital was on cruise control. The leadership was operating under this crazy idea that they were going to turn Langley into a tertiary medical center. Never mind that it was only a half hour away from Portsmouth, had 10 inpatient beds (outside of the labor deck), no ICU, minimal inpatient specialties, RT coverage only 40 hours a week, no echos, no stress tests (well, treadmills once a week), no MRI, no lactate, CRP, CO or other essential lab tests and 50 clipboard carrying nurses chastising docs for not making love to AHLTA.
Portsmouth was the saving grace for me that year. I probably would have committed suicide without it, or at least said I would so I could get out of the military like all those guys in the Navy. (Far more prevalent in the Navy than the AF by the way, especially as a deployment was coming up.) The NMCP ED was nice, well-equipped, and staffed by a good core group of attendings, at least by military standards. There were actually practicing doctors who carried a rank higher than O-4, unlike at Langley. They didn't want me to do anything but teach residents and see patients. No silly war games. No idiotic PT tests (I have zero respect for anyone who can't pass an AF PT test BTW.) The residents were quite bright, academically perhaps one of the sharpest residencies I've ever been around. Several of them outranked me (and had practiced for longer than me) but would never have said anything about it. A number of them were inspiring in their dedication to military medicine. Unfortunately, the experience offered to the residents was downright ****ty. Critical patients were rare, intubations and central lines were even rarer, and traumas and sick pediatric patients simply didn't show up. The patient base was way too well to provide good residency training. They would do 8 months or so out at other hospitals, but I couldn't imagine that would be enough. Their PICU rotation was a joke. They might have one patient in the unit. We always had a full unit spilling onto the floor where I trained. I recall one night when I had two kids die on me within a few hours. I don't think 2 kids died at NMCP in any given year.
So that first year I was in a bit of a honeymoon stage. Within 2 or 3 months I had decided I was just going to do my 4 years and get out. I never really thought I was going to stay for a career, but I had an open mind until then. It only took that long to realize that what all the detractors on SDN were saying was nearly 100% accurate. But that first year I was able to play one hospital off the other enough to give myself a reasonable lifestyle and it was nice to be making more than $100K finally (my residency was paying $34K when I matched.) We bought a nice little townhouse and were paying its mortgage down aggressively. I had to put up with some shifts at Langley, where the patient load was annoyingly heavy (3-6 patients an hour, where a typical emergency doc sees 2), but the techs and nurses were nice, although under-trained since they had never worked in a real ED. I was told I wouldn't deploy until after I had done my boards that Spring.
Like clockwork year 2 rolled around. I was doing lots of fun war games to prepare for deployment. My assignment finally came in....Qatar. While it was only 50 miles from Iran, it's a 2 hour flight to Iraq. I clearly wasn't going to see much trauma. But at least it was a pretty cush place to hang out. We arrived in Qatar. This is the point at which I finally felt like I was in the military. But it was all the bad parts of the military. I would have thought Catch-22 was written by someone who spent a portion of his life at Al Udeid Air Base. The leadership and politics in the med group were maddening. The pace of life, incredibly slow. The medicine, immensely boring. Military medicine will always be low acuity. We don't let sick people in and we throw them out if they get sick. But when you deploy, there is an additional screen that keeps anyone with anything interesting away, and of course you don't see any retirees or dependents. So 4+ months of knee pain, fungal skin infections, diarrhea, and colds. That describes 95% of my clinical encounters in Qatar. The camaraderie was good, the food was better than I eat at home, there was plenty to do (movies, a bar, special events etc) and I worked out for at least 2 hours a day, putting on 20 lbs of muscle. But 4 months of being away from family, literally being locked down on a 1/2 mile X 1/2 mile compound, and feeling like your skills are wasting away doing something an IDT could do with one or two phone calls a day to the States, helped me to realize that was not an experience I wanted to repeat if at all possible.
I learned while in Qatar that it was possible to PCS overseas after 2 years at Langley. The catch was that a PCS would add another year to my commitment. I started spending time talking to the assignment officer (now that I knew how the system worked) and finally made a decision to PCS to Germany. I had always wanted to live in Europe and it would give me the adventure I had sought when signing up for the military. Germany had been #1 on my list 2 years earlier. Besides, it would get me out of Langley. Pressure had been building there to put me in charge of the urgent care center, I was down to 1/2 time at NMCP now, and the hospital environment was just as crappy as ever. To make things worse, the leadership had swapped out just before the deployment and was now even worse. The Squadron commander wasn't even a doc any more. It was bad enough to have a doc out of touch with clinical medicine. It was far worse to have a non-physician trying to run a hospital. So I told the assignment officer I'd pick up the extra year if he sent me to Germany. Just before going home, he called me back to tell me he had to give that slot away to someone whose pediatrician spouse had just finished a Korea tour....but what about England? I told him thanks but no thanks and resigned myself (silently) to 2 more years at Langley. At this point the recruiting to pick up a 2nd tour steadily grew. It was amazing to me how I went from being offered my last choice a year earlier to now having the pick of the litter. But someone on SDN had mentioned that one thing you never do is sign on for more time, no matter how good it looks. That's still good advice.
The best experience of my military career came that next summer. As part of this recruiting effort, I was given a plum assignment in England. 6 weeks at Lakenheath back-filling for a doc who had been deployed. I didn't want to spend 3 years at Lakenheath, but a summer sounded awesome. They even approved a rental car for me, so I took my family along. 3 shifts, then 3 days in London. 3 shifts, then 3 days in Wales. 3 shifts, then 3 days visiting the countryside. 3 shifts, then 4 days in Scotland. And so it went, all summer long. At the end, I took a week of leave and went to the continent, visiting 6 or 7 countries along the way. Very cool. Except that gas was literally $12 a gallon. But we didn't let that hold us back.
Upon returning to Langley the volumes had been getting higher and higher. We had to add more shifts. Unfortunately, we didn't get the manning for it. For the most part, we were able to piece together enough contractors to cover them, but every year the contractors were cut as more emergency docs were sent to Langley. Someone had gotten the bright idea to turn the urgent care back into an emergency department as part of this trend to become a tertiary care center. Well, it was never an emergency department in the first place, and nothing changed a few years ago when they demoted it to an UCC. So nothing was going to change now that we were going to call it an ED, except the contractors (who wanted as many hours as I could give them and never deployed) were being swapped out for brand new residency-graduating military docs being deployed like it was going out of style. My FP boss separated and I was put in charge. There was literally no one else to do it. My clinical time at NMCP was down to about 1/4 time at this point. The only benefit of being in charge was I got to make my own schedule, but I felt so guilty about it I always ended up overscheduling myself. I spent most of my time trying to protect the department (and its patients) from the crazy decisions of the hospital leadership and provide some type of reasonable lifestyle to my docs. It became more and more difficult as time went on. We eventually had 8 docs, 5 with short commitments and 3 with longer ones, all itching to separate, or at least PCS out of there. I was doing my time and getting ready to punch out at the earliest opportunity. The entire medical executive committee of the hospital was in the same boat as me. 2-3 years out of residency and all itching to separate, and trying desperately to hide that fact from local and specialty leadership. We saw the bad things that happened to those who made things like that known-crappy, long deployments. You didn't get to go to Balad or Bagram if you were punching out. You went to Qatar or Manas. And you were much more likely to go in the first place.
I lucked my way onto a team that was supposedly protected from deployment. We were supposed to be America's 911, you know, if Seattle gets nuked we go set up an EMEDS there and save the day. Of course, we couldn't get anywhere in less than 3 days, and the mission eventually morphed into something like we'd take care of the army while they dug the city out of the rubble. But it did keep me out of the deployment cycle that year. Meanwhile, the deployments were increasing in length (now 6+ months rather than 4+) but we couldn't complain when we saw the Navy guys doing 7 or 8 or the Army guys doing 12-15. They were also increasing in frequency. Some of the guys in my shop were gone again, just 13 months after finishing a 6 monther. I could see the writing on the wall. I was trying to lay low as I finished out my time. Clinical time at NMCP was completely gone by my 4th year, as were most of our contractors. People were being deployed for 6 months with 3 days notice here, a week's notice there. Some to cool places, but still....
Finally, I had my separation papers in, I was putting my house on the market to sell, I had my civilian job lined up with a start date and everything, and I was taking one last vacation before saving the rest of my leave for terminal. I had decided not to take the ISP that last year to get out sooner and start making the big bucks (I was still only making ~$130K a year as a major, not counting a little moonlighting) but mostly I was just hoping to avoid 6 months in the desert. What seemed like a great adventure for a noble cause when I was 23, didn't seem so fun at 34 with 3 kids and a true vision of what you really do on deployment as a doc. 3 months from the start of terminal leave I get a call (while on shift at my moonlighting job) at 11 pm. You're leaving in the morning. Where? Chile. For how long? At least 90 days. My parents were flying in from Alaska 4 days later so my wife and I could go to Puerto Rico for a week. Nope, I was definitely the guy they wanted. 24 hours later I was in Texas, and the day after that was lying in a jump seat on a C-17 (which naturally took off 8 hours late to ensure we would start our trip with maximum fatigue.) Again a great group of people, lots of camaraderie, some bizarro rules (A small farming town in Chile might not be a war zone, but dammit you guys aren't leaving the base for security reasons), and a chance to see a country I've always wanted to see. It was pretty boring medically speaking, since the Chileans didn't actually need us, they just needed an OR in a tent since their hospital broke in the earthquake, but it was an interesting cultural experience, what we could see from the fence around the base anyway. We were all glad when the 90 day deployment turned into a 23 day one. And they did let us off the base that last day. Not nearly as cool as my summer in England, but still an overall positive experience. And my wife went to Puerto Rico without me. (we were going with another couple.)
Unfortunately, being gone kept me from getting my house on the market in time to get it sold when things were hot with the tax rebate, so I'm still trying to sell that, but the rest of my time went pretty well, all things considered. The DITY move was flawless (pays as well as ISP and has a lot less commitment) and my DD214 and last few paychecks came through without any issues.
I was surprised that my prospective employers looked on my military time as valuable experience. None of them were concerned about the lack of acuity in my practice. It helped that I had moonlit at a local trauma center, but it seemed I was worried more about losing skills than they were. I often get questions from nurses, techs, and docs about being in the military and in general, society has a great deal of respect for those who serve. They are a bit misguided about the sacrifices, imagining that everyone is getting shot at all the time, when the real sacrifice is being underpaid and overworked, being constantly on call for deployment, and being away from family for months at a time. I'm working about 25% less than I was in the military, making maybe 40% more (100% more once I make partner in 18 more months), and paying a lot more in taxes. I miss very little about being in the military. I didn't enjoy living in Virginia, working in military hospitals, or being at the beck and call of the military (the constant anxiety of impending deployments cannot be overestimated by the prospective HPSP student). I am treated with the respect physicians generally get, eat for free at all hours in my hospital and park outside the door to the ED. If I work more in any given month, I am paid more.
My practice is different. The acuity is higher and I have some additional headaches I never had before. There are far more drug seekers outside the military, more homeless, more Jerry Springer situations, more real psych (rather than sailors trying to get out of the Navy), and more people who can't get care because they don't have insurance. Although I worry much less about most patients getting follow-up care. With Tricare, I was never really sure if/when that patient was going to get that MRI or neuro consult or whatever.
I have calculated in the past that I lost ~$180K by doing HPSP instead of doing loans. This was because of several factors-
1) I did a relatively well-paying specialty
2) I went to a relatively inexpensive school and
3) I graduated in 2003, when my classmates refinanced their student loans at 1.9%.
I would have to modify that figure somewhat. I have definitely come out ahead by being able to buy my big "attending house" in 2010, after a 25% haircut and with rates at all time lows (my mortgage is at 3.625%...without a buy down.) So perhaps I've made up for some of that money I lost.
So, to sum it all up, I got lucky in a lot of ways:
I got what I wanted out of the military match. It cost me a lot of blood, sweat, treasure, and tears, but it worked out perfectly in the end.
I spent less than 6 of my 47 months in the service deployed, ate well and wasn't mortared in either place.
I had that great summer in England.
Got to practice in a variety of clinical settings (6 very different hospitals on 4 continents in 4 years) and gain experience on hospital committees, as an EMS director, and as an ED director I would have never gotten to do as a civilian that early in my career.
Got a chance to live on the East Coast. While I didn't want to go, and left as soon as I could, I did get to see and do a lot of cool stuff out there, from Broadway, to Jamestown to Kiteboarding on the Outer Banks.
Have no student loans.
At times I felt very patriotic and was proud to be in uniform. Some of the capabilities of the military (even military medicine) are incredibly impressive. I got to take care of people who were present at key moments in history-Iwo Jima, Khobar Towers, Gulf Wars, Navy Seals etc. I was well aware that whatever sacrifice I thought I was making, it was nothing compared to most of the people I was taking care of. And it was fun to be part of something that was bigger than myself.
But to pretend that it was overall a positive experience? No, I don't think I could ever do that. I came home and told my wife I hated my job far too many times for that. Far too much mickey mouse leadership, bureaucratic BS, and simple facts of military life that will never change, could not ever change for that. The military has forever changed the way I view life. In some ways for the better, in many ways for the worse. I'm sure in 10 or 20 years I'll remember it more fondly than I now do, but I have yet to have even a twinge of regret about separating.
Would I do it again if I could see the end from the beginning? Even knowing I would get lucky as much as I did? No.
