Navy EM

[oldjeeps]

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Anyone on here in Navy emergency medicine?

If so, I'll have a few questions for you.
thanks

 

[Gastrapathy]

Anyone on here in Navy emergency medicine?

If so, I'll have a few questions for you.
thanks

Not EM, but good friends with a couple. Fire away if you'd like. If I don't know, I should be able to get an answer.

 

[oldjeeps]

Not EM, but good friends with a couple. Fire away if you'd like. If I don't know, I should be able to get an answer.

Gastrapathy,
thanks I'll have a few questions for them...
any idea how long they have been in and at what point in their careers they joined?

 

[Gastrapathy]

PM inbound

 

[EvoDevo]

Not EM, but good friends with a couple. Fire away if you'd like. If I don't know, I should be able to get an answer.

Hey man, thanks for doing this:

1. Any idea how long Navy EM types are deploying for?
2. Where are they usually based (MTFs? Shipboard PCP?)
3. Deployment optempo?

Basically I'm between Navy and Army and trying to figure out which will better utilize my skills.

Thanks!

 

[EvoDevo]

FYI, I am in residency and would be doing FAP program.

 

[EMDoc0411]

I'm livin the dream. 1 year out of residency. Got a full deferment and trained at a civilian program (best thing I ever did). Of course I work with quite a few poor souls who trained in the military and of course did their GMO time in the sandbox. A few of my colleagues are over there now as EM physicians. One just got back and has wonderful stories to tell about his well spent time over there. Feel free to PM me for more details.

 

[The White Coat Investor]

Basically I'm between Navy and Army and trying to figure out which will better utilize my skills.

Thanks!

Uhhh...most likely neither. If you want to use your skills, remain a civilian. If you want to be in the military, then it doesn't matter so much which you choose. I don't know an EM physician in any branch that doesn't believe their skills are deteriorating the longer they stay in.

 

[NavyC]

I feel like the phrase "skill atrophy" seems to be thrown out a lot but I honestly don't see any evidence of it, especially from the doctors I've talked to (and they weren't recruiters) Can you give specific examples, like which hospitals don't provide a good patient population for EM and leads to physicians loosing their skills.

And I'd like to add, physicians in even civilian jobs may experience skill atrophy if they happen to be in wrong location. I shadowed one EM physician who rarely saw any "real emergencies," just because of where the hospital is, I mean not every EM doctor can work in the inner cities where all the crimes are. An infectious disease doctor who only gets AIDs patients you could say that he or she is loosing their skills. Can someone tell me why training in the Navy med EM would be bad, I've been told part of the training is at USC which has one of the best EM residency programs. Also I was talking with some of the EM doctors at USC and they said they love the Navy doctors because according to them "they get things done and they are polite."

 

[BigNavyPedsGuy]

I feel like the phrase “skill atrophy” seems to be thrown out a lot but I honestly don’t see any evidence of it, especially from the doctors I’ve talked to (and they weren’t recruiters) Can you give specific examples, like which hospitals don’t provide a good patient population for EM and leads to physicians loosing their skills.

And I’d like to add, physicians in even civilian jobs may experience skill atrophy if they happen to be in wrong location. I shadowed one EM physician who rarely saw any “real emergencies,” just because of where the hospital is, I mean not every EM doctor can work in the inner cities where all the crimes are. An infectious disease doctor who only gets AIDs patients you could say that he or she is loosing their skills. Can someone tell me why training in the Navy med EM would be bad, I’ve been told part of the training is at USC which has one of the best EM residency programs. Also I was talking with some of the EM doctors at USC and they said they love the Navy doctors because according to them “they get things done and they are polite.”

None of the Navy Med Centers are trauma centers. Sure, they rotate out for a few months. Who do you think gets better training: the navy resident who spends three months at USC doing trauma or the USC resident who sees trauma every single shift s/he works for their entire residency?

I know which one I'd trust more. (no offense to my Navy colleagues, you play the hand you are dealt and most HPSP folks did the best they could with what they're offered).

 

[Gastrapathy]

None of the Navy Med Centers are trauma centers. Sure, they rotate out for a few months. Who do you think gets better training: the navy resident who spends three months at USC doing trauma or the USC resident who sees trauma every single shift s/he works for their entire residency?

I know which one I'd trust more. (no offense to my Navy colleagues, you play the hand you are dealt and most HPSP folks did the best they could with what they're offered).

Not really fair since trauma centers have designated teams that are typically run by GS housestaff and a supervising trauma surgeon. EM residents rotate on those services part-time. However, our EDs are often glorified acute care clinics and most of the ED staff I know moonlight so that they can see higher acuity patients (and make some $$).

 

[Gastrapathy]

Hey man, thanks for doing this:

1. Any idea how long Navy EM types are deploying for?
6-15 months. Mostly in the 6-7 month range unless they get IA'd into an Army GMO billet (aware of a single example at my MTF in the past year of that)
2. Where are they usually based (MTFs? Shipboard PCP?)
Based at MTFs for the most part, deploy to the sandbox
3. Deployment optempo?
q2 years +/- 1 year

Thanks!

see above

 

[NavyC]

Not really fair since trauma centers have designated teams that are typically run by GS housestaff and a supervising trauma surgeon. EM residents rotate on those services part-time. However, our EDs are often glorified acute care clinics and most of the ED staff I know moonlight so that they can see higher acuity patients (and make some $$).

Hi Gastrapathy

so are you saying that EM doctors in the civilian side rotate in the trauma centers about the same amount of time as EM docs in the Navy?

 

[The White Coat Investor]

Hi Gastrapathy

so are you saying that EM doctors in the civilian side rotate in the trauma centers about the same amount of time as EM docs in the Navy?

YOu need to be careful as to whether you are talking about residents or staff.

"Rotating on a service" is very different from seeing trauma in the ED. As a civilian resident, we didn't call the trauma team for 50% of the trauma that came in, only the most serious. Even at that, WE were responsible for their ED management. We intubated the patients, put in lines, put in chest tubes etc. It really all depends on what your EM residency program has worked out with the Gen Surg residency program. However, when your EM residency program is at another hospital and you're just a guest rotator, well, you're not going to have much negotiating power with the Gen Surg rotation. Rounding on used trauma isn't quite as useful to the aspiring EP as managing 4 trauma patients who roll in within 5 minutes of each other.

Also, it should be noted that the initial management of most trauma patients is done by emergency docs in this country. I moonlight at a level 2 (there are also level 3s out there.) The requirement for a level 2 is that the Gen Surgeon be within 30 minutes of the hospital. Anything that patient needs done within the first 30 minutes will be done by me, or not done at all. Most trauma is like that. Most general surgeons aren't interested in it once they leave residency (heck, most aren't interested by the time they're chiefs.)

 

[The White Coat Investor]

I feel like the phrase “skill atrophy” seems to be thrown out a lot but I honestly don’t see any evidence of it, especially from the doctors I’ve talked to (and they weren’t recruiters) Can you give specific examples, like which hospitals don’t provide a good patient population for EM and leads to physicians loosing their skills.

And I’d like to add, physicians in even civilian jobs may experience skill atrophy if they happen to be in wrong location. I shadowed one EM physician who rarely saw any “real emergencies,” just because of where the hospital is, I mean not every EM doctor can work in the inner cities where all the crimes are. An infectious disease doctor who only gets AIDs patients you could say that he or she is loosing their skills. Can someone tell me why training in the Navy med EM would be bad, I’ve been told part of the training is at USC which has one of the best EM residency programs. Also I was talking with some of the EM doctors at USC and they said they love the Navy doctors because according to them “they get things done and they are polite.”

I'm not saying skill atrophy can't happen in civilian institutions, it can. If you go do urgent care work straight out of residency you're going to lose your skills just as quickly as a military doc. Here are two examples of skill atrophy relevant to the situation.

1. The guy I replaced when I arrived had been working only in a military "ED" for the last 4 years (no moonlighting.) He told me he no longer felt qualified to take care of sick patients and took an urgent care job when he separated. Less money and much fewer options.

2. I didn't start moonlighting until I'd been on active duty for 2 years (I delayed it to take my boards, then I deployed so I set it up after the deployment.) On my first shift or two I intubated 2 patients. That was 2 more than I'd intubated in the previous 2 years (including the deployment.) On the first one, I forgot to put the patient on versed or a propofol drip to keep him down when the etomidate and succinylcholine wore off. He ended up extubating himself and puking all over me. A rookie mistake for sure, and one I NEVER made as a resident doing this week in and week out. I blame it on skill atrophy.

It isn't that skill atrophy can't be reversed, but the worse it is the harder it is to reverse it. I think there are several things one can do to minimize it:

1) Train as a civilian if possible. The better your skills are initially, the longer they take to atrophy.

2) When you deploy, fight to get sent to the busiest place in the AOR. Sick call deployments not only drag on, but also contribute to atrophy.

3) Do way more CME than required, even at your own expense and on your own time.

4) When a procedure is borderline necessary, lean toward doing it. If the patient probably needs a central line, put one in. Have a low threshold for intubating. Keep the patient at your facility as long as is safe before transferring etc. Don't punt the few good patients you get in the military.

5) Moonlight. Start early and do it consistently, even if it is only a couple days a month. Find the highest acuity place you can find to do it. No point in moonlighting in urgent cares.

6) Separate as soon as eligible, and make sure your first "real" job is a high acuity one. You can always go to a lower acuity place, but it is hard to go in the other direction.

Good luck.

 

[NavyC]

Thanks ActiveDutyMD

I will definitely keep you advise in mind.

 

[oldjeeps]

5) Moonlight. Start early and do it consistently, even if it is only a couple days a month. Find the highest acuity place you can find to do it. No point in moonlighting in urgent cares.

How easy is it to moonlight? Is that easily done or are you tied to the whims of your CO?

6) Separate as soon as eligible, and make sure your first "real" job is a high acuity one. You can always go to a lower acuity place, but it is hard to go in the other direction.

does that also translate to if not currently tied to the military to stay far away?

 

[NavyC]

I am kind of Confused! In response to ActiveDutyMD's post how can the skill atrophy be as bad as you say??? I mean why would the military build huge hospitals if there are no patients, and why is the Navy complaining of physician shortages if there are not enough patients to see physicians! and wouldn't all the poor soldiers be dying at the hands of these unskilled doctors with the degree of skill atrophy you describe, I mean some doctors have forgotten how to intubate properly?!

 

[pgg]

I am kind of Confused! In response to ActiveDutyMD's post how can the skill atrophy be as bad as you say??? I mean why would the military build huge hospitals if there are no patients, and why is the Navy complaining of physician shortages if there are not enough patients to see physicians!

A general surgeon whose days are filled with colonoscopies and hernia repairs is not going to remain at the top of his game. A cardiothoracic surgeon who gets into a chest twice per month is rotting away. I don't believe there are any military hospitals receiving trauma any more. It's not that there are no patients, it's that so few of them are really sick.

And the military isn't building huge hospitals. The military has been closing, merging, and downsizing them left and right for many years now. Much of the non-routine patient population that's left is being deferred out to civilian institutions.

My little hospital deferred a patient for a lap chole because she was deemed too fat, for chrissake. I did my residency at one of the "big 3" Navy hospitals, and about a year ago they closed half of the ICU/step-down unit. You could walk past the remaining dozen or so beds in that unit and it wouldn't be unusual to see ZERO patients on a ventilator.

and wouldn't all the poor soldiers be dying at the hands of these unskilled doctors with the degree of skill atrophy you describe, I mean some doctors have forgotten how to intubate properly?!

First, it's surprisingly hard to kill a healthy person. Second, my impression is that skill atrophy isn't much of an issue while in the military because all of the patients are healthy (that's why the skills are deteriorating) - it's when you get out and are suddenly faced with a population that isn't 90% young, fit 18- 30 year old active duty members with minor problems.

How easy is it to moonlight? Is that easily done or are you tied to the whims of your CO?

It's very dependent upon specialty and location. COs and department heads do have veto power over moonlighting, but in general moonlighting is regarded as good for the physician and the service, provided it doesn't interfere with the physician's military day job. There are rules regarding hours and time off between civilian and military shifts, but they're not unreasonable or hard to work with.

From what I can tell, the local civilian market where you happen to be stationed is more likely to be the limiting factor. There are many opportunities where I am, but my residency classmates at other Navy hospitals are less fortunate (although two are at a large MTF where their case load is much more diverse than mine).

 

[NavyC]

THis makes me very sad. I am attending one of the best med schools in the country, and 80% of the people at my school match in their top 2 choices and in good residency programs but I joined the Navy because I want to serve this country and take care of our brave troops but I didn't know that I would be inadequately trained. I want to be a good officer and a GOOD DOCTOR. If I get accepted into a good residency program outside of the NAvy what is the chance of a civilian deferment?

 

[TheGoose]

THis makes me very sad. I am attending one of the best med schools in the country, and 80% of the people at my school match in their top 2 choices and in good residency programs but I joined the Navy because I want to serve this country and take care of our brave troops but I didn't know that I would be inadequately trained. I want to be a good officer and a GOOD DOCTOR. If I get accepted into a good residency program outside of the NAvy what is the chance of a civilian deferment?

you could always do GMO's to payback your time and then go back to the civilian world to get your top-2-choice-residency-program

 

[BigNavyPedsGuy]

THis makes me very sad. I am attending one of the best med schools in the country, and 80% of the people at my school match in their top 2 choices and in good residency programs but I joined the Navy because I want to serve this country and take care of our brave troops but I didn't know that I would be inadequately trained. I want to be a good officer and a GOOD DOCTOR. If I get accepted into a good residency program outside of the NAvy what is the chance of a civilian deferment?

I would ballpark a deferment at about 1%. There is a shortage of med school graduates in the Navy b/c recruiting was down 4 years ago. The Navy will fill its spots before they grant deferements, and they don't have enough people to fill spots.

The GMO and out option isn't terrible if you're deadset on ER.

NavyFP might have more to add with deferment status . . . . . that guy seems to know everything that's going on.

 

[The White Coat Investor]

THis makes me very sad. I am attending one of the best med schools in the country, and 80% of the people at my school match in their top 2 choices and in good residency programs but I joined the Navy because I want to serve this country and take care of our brave troops but I didn't know that I would be inadequately trained. I want to be a good officer and a GOOD DOCTOR. If I get accepted into a good residency program outside of the NAvy what is the chance of a civilian deferment?

You mean you don't know how the HPSP program works? I'm really sorry, because you're in for a rude awakening. The same one I got in 2000 when I realized how it works as an MSI. You have to get the civilian deferment before you can even enter the civilian match. It has nothing to do with whether you can get accepted into a good residency program.

Adequate is very different from very well trained. I don't know of any military residencies that don't give adequate training. And take a good student and give them adequate training, and they can often still become very good doctors. But realize you'll have to work harder in a military residency to get to the same level you would automatically get to in a good civilian program for many specialties.

 

[The White Coat Investor]

How easy is it to moonlight? Is that easily done or are you tied to the whims of your CO?



does that also translate to if not currently tied to the military to stay far away?

1) Pretty easy for emergency docs at most bases.

2) You said it, not me.

 

[The White Coat Investor]

It's better than 1%, I'd ballpark it at around 10% of applicants. Remember that a certain percentage don't get selected for EM at all, then they fill San Diego and Portsmouth, then if they need more than they can squeeze into those classes, they give deferments. It has become more common in the Navy the last few years, but was pretty rare before that. But who knows what the needs of the Navy will be in 3 or 4 years. Hard to project as you don't know how many will retire or separate.

 

[apoptosisisfun]

A general surgeon whose days are filled with colonoscopies and hernia repairs is not going to remain at the top of his game. A cardiothoracic surgeon who gets into a chest twice per month is rotting away. I don't believe there are any military hospitals receiving trauma any more. It's not that there are no patients, it's that so few of them are really sick.

So what exactly, are the trauma surgeons doing? (Honest question)

 

[BOHICA-FIGMO]

So what exactly, are the trauma surgeons doing? (Honest question)

I know they do FTOS, full time out service, fellowships. What do they do when not deployed? I imagine just gen-surg stuff.

 

[EvoDevo]

Thanks for all of the great responses on this thread, guys. Lots to chew over.

 

[pgg]

So what exactly, are the trauma surgeons doing? (Honest question)

I don't know, I'm not a surgeon. Maybe moonlighting if they can. Regular active duty / family member / retiree gen-surg stuff if they can't.

I've always wondered though that even if they saw a lot of trauma in the US at military hospitals, how well that would prepare them for war casualties when the injuries people sustain in Iraq/Afghanistan (blast and high-velocity GSWs) are so very different from the trauma that happens in the US (MVAs, stabbings, handgun GSWs).

 

[MSS07]

Yeah Pgg asks an interesting question, I am curious too.

 

[MSS07]

Is there a site that shows the match statistics in the Navy, like how many people applied for each program and how many people got a spot. Also does anyone know the exact percentage of people who got a civilian deferment last year, just curious. I know they are rare, but I actually personally know two people who got a civilian deferment in the Air Force so it got me thinking that maybe they are more common than I thought.

 

[TheGoose]

dont think that because they are common in the AF that they are common in the navy or army

 

[Gastrapathy]

Is there a site that shows the match statistics in the Navy, like how many people applied for each program and how many people got a spot. Also does anyone know the exact percentage of people who got a civilian deferment last year, just curious. I know they are rare, but I actually personally know two people who got a civilian deferment in the Air Force so it got me thinking that maybe they are more common than I thought.

This info is not available. Each year a select list comes out which shows selectees and alternates (but doesn't show people who failed to select for either). These are bad years for deferments because of the low numbers of HPSP-types accessioned 3 years ago. What specialty are you considering (we can give a general sense of competitiveness, although there is always variability).

 

[MSS07]

Hi Gastrapathy,

I am only a first year, so I not set on a specialty yet. Do you know the general competitiveness for Internal Medicine, and EM.

THanks

 

[The White Coat Investor]

Hi Gastrapathy,

I am only a first year, so I not set on a specialty yet. Do you know the general competitiveness for Internal Medicine, and EM.

THanks

Yea. Not so competitive and very competitive. Good luck. Don't choose a specialty based on how competitive it is. Remember this is what you will do for the next 20-40 years.

 

[Gastrapathy]

Yea. Not so competitive and very competitive. Good luck. Don't choose a specialty based on how competitive it is. Remember this is what you will do for the next 20-40 years.

I'm not sure EM is "very competitive". Based on what I've seen, I'd say its somewhat competitive. In fact, everyone who I knew who wanted EM got it (although one spent an extra year as a GMO). IM is not competitive at all, some IM subs are quite competitive.

 

[MSS07]

On the civilian side the average USMLE step 1 score for EM is 220-230, and for IM its 210-220, is this comparable to the average in the Navy. Also is research as important to get a good residency in the Navy. Sorry for turning this thread into a question and answer session.

 

[Gastrapathy]

On the civilian side the average USMLE step 1 score for EM is 220-230, and for IM its 210-220, is this comparable to the average in the Navy. Also is research as important to get a good residency in the Navy. Sorry for turning this thread into a question and answer session.

No idea. I have an N of 1 for USMLE and IM (me), its the same as my N of 1 for GI fellowship (so, by my data they are equally competitive).

Research can get you bonus points. Whether or not points matter anymore is beyond me with the new match rules, etc.

 

[BOHICA-FIGMO]

Research can get you bonus points. Whether or not points matter anymore is beyond me with the new match rules, etc.

Umm, what new match rules ? I still thought they used the JGMESB points system (except for a few FM and psych continuous contracts). Did I miss some fine print somewhere?

 

[Gastrapathy]

Umm, what new match rules ? I still thought they used the JGMESB points system (except for a few FM and psych continuous contracts). Did I miss some fine print somewhere?

I'm not really sure. I think the intern match is being handled differently (rank lists, more of a true match rather than a selection board) but for PGY2+ I don't know if anything has changed.

 

[The White Coat Investor]

I'm not sure EM is "very competitive". Based on what I've seen, I'd say its somewhat competitive. In fact, everyone who I knew who wanted EM got it (although one spent an extra year as a GMO). IM is not competitive at all, some IM subs are quite competitive.

As with most things, it is year and service specific. In my year and service, the match rate into EM was 50%. When compared to the civilian match, that's like trying to get into derm. Very competitive? Yes, at least in the military match. (Civilian match rate is something like 93% for US grads, much less competitive.)

I'm sure the initial Navy match rate for a medical student is MUCH lower than 50%. It probably doesn't approach that number until you become a GMO.

 

[BOHICA-FIGMO]

As with most things, it is year and service specific. In my year and service, the match rate into EM was 50%. When compared to the civilian match, that's like trying to get into derm. Very competitive? Yes, at least in the military match. (Civilian match rate is something like 93% for US grads, much less competitive.)

I'm sure the initial Navy match rate for a medical student is MUCH lower than 50%. It probably doesn't approach that number until you become a GMO.

I don't know about the fleet, but there are more interns than a barrel full of monkeys trying for EM this year.

 

[EMDoc0411]

Take this information for what it's worth, but I heard from someone who is interviewing for Navy EM that there are 24 applicants for 18 residency spots. That's pretty good odds if you're applying, but a sad state of affairs for the specialty of EM in the Navy.

 

[The White Coat Investor]

Take this information for what it's worth, but I heard from someone who is interviewing for Navy EM that there are 24 applicants for 18 residency spots. That's pretty good odds if you're applying, but a sad state of affairs for the specialty of EM in the Navy.

Ummm.....75%? That's worse than ophtho or ortho in the civilian match. Not quite derm bad, but way worse than the 93% EM sees in the civilian match.

 

[BOHICA-FIGMO]

Take this information for what it's worth, but I heard from someone who is interviewing for Navy EM that there are 24 applicants for 18 residency spots. That's pretty good odds if you're applying, but a sad state of affairs for the specialty of EM in the Navy.

Umm, I'd take that with a large, blood pressure raising, grain of salt. There are at least a dozen interns at my medical center who want to do EM. Assuming there are equivalent numbers at the other two med centers, plus folks from the fleet, that's WAAAAY more than 24. Then again, I'm assuming all of those people are applying to go straight through. Your source may be quoting the number of people who have called to ask for interviews so far. That's a lot different than the number of people applying.