No more Navy GMO's?

[OnlyLiveOnce]

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I recently asked a few questions about Navy Medicine. This is what a recruiter said to one of them:

"does the Navy mandate that students do a GMO tour before residency?

The Navy is converting to a straight through training system. by the time you graduate, most of the "GMO" positions will be converted to residency trained positions. "


Is this the truth? Does this mean the next generation of Navy HPSP students don't have to worry about doing a GMO tour before residency?

 

[IgD]

At best I think it's a half-truth. I'm sure the Navy "intends" to replace GMOs with residency trained docs but they won't put it in the doctrine. For example, they won't strip clinical privileges of non-residency trainined physicians. Speculation is the motivation for the conversion is the decreased number of physicians coming through the medical education pipeline. If things changed I bet you would see a re-emergence of the GMO.

If you really want to join Navy medicine, do it but realize you have little control over so many different aspects of your life including whether you match into a residency or get shipped out as a GMO.

 

[usnavdoc]

I recently asked a few questions about Navy Medicine. This is what a recruiter said to one of them:

"does the Navy mandate that students do a GMO tour before residency?

The Navy is converting to a straight through training system. by the time you graduate, most of the "GMO" positions will be converted to residency trained positions. "


Is this the truth? Does this mean the next generation of Navy HPSP students don't have to worry about doing a GMO tour before residency?

Dude I was told the same crapola back in 97 when I signed up. I ended up doing 4 years as a GMO and got out. Think twice about believing a recruiter.

From Big Navy perspective, there are alot of logistical/financial/manpower problems with replacing the GMO workforce with residency trained physicians that will not be solved in the near future. But the main reason it wont be solved is that it is easier to live with the status quo than to rock the boat and fix things.

 

[Perrotfish]

This has been discussed before, I'm just a medical student, but from what I was told here:

1) the navy has announced a 5 year plan to convert 100 GMO slots per year to board certified slots

2) They have successfully gone through with 1 year of this plan

3) There are several members of this board that remember this same announcement being made before... and not happening.

4) Even if they suceed in this plan, the plan is still to 'share the misery' by making everyone do a post residency GMO tour, meaning even if you get an OB/Gyn cert you still have to spend 2 of your 4 years working with the Marines in a billet that is essentially an FP slot (or a nurse slot, depending on who you ask).

 

[edmadison]

I never applied to the Navy because I didn't want to do a GMO tour. I did Army HPSP instead. I am now a board-certified pediatrician in a battalion surgeon position -- a GMO. By the time I finish with this assignment, I will have been out of residency between 18 and 24 months without ever seeing a single child. In retrospect, It would have been much better for me to have done a GMO trour after internship. Everyone's experience will vary, but thus far (11 months into my deployment) I have seen virtually no patients requiring a physician's care. A good phone triage nurse could take care of 80% of what I see (MS complaints, Gastro, URIs). The next 19% are consults, mostly for chronic ortho or mental health issues. There is a small nugget -- 1% that my skills are actually needed for. Of course the GMO post internship track is a trap into getting extra service time out of you.

The best solution is to stay away.

Ed

 

[The White Coat Investor]

I never applied to the Navy because I didn't want to do a GMO tour. I did Army HPSP instead. I am now a board-certified pediatrician in a battalion surgeon position -- a GMO. By the time I finish with this assignment, I will have been out of residency between 18 and 24 months without ever seeing a single child. In retrospect, It would have been much better for me to have done a GMO trour after internship. Everyone's experience will vary, but thus far (11 months into my deployment) I have seen virtually no patients requiring a physician's care. A good phone triage nurse could take care of 80% of what I see (MS complaints, Gastro, URIs). The next 19% are consults, mostly for chronic ortho or mental health issues. There is a small nugget -- 1% that my skills are actually needed for. Of course the GMO post internship track is a trap into getting extra service time out of you.

The best solution is to stay away.

Ed

That's a really sad story.

 

[OnlyLiveOnce]

The email I sent was to a current Navy attending. He gave me some short answers and then forwarded my email to some recruiters, who replied to my questions (including the answer I asked about above) without bothering to remove his message that he tagged onto the email, which included:

"wanted to make sure this person was on your radar"

ROFL. Nice to know how they look at you.

 

[orbitsurgMD]

This has been discussed before, I'm just a medical student, but from what I was told here:

1) the navy has announced a 5 year plan to convert 100 GMO slots per year to board certified slots

2) They have successfully gone through with 1 year of this plan

3) There are several members of this board that remember this same announcement being made before... and not happening.

4) Even if they suceed in this plan, the plan is still to 'share the misery' by making everyone do a post residency GMO tour, meaning even if you get an OB/Gyn cert you still have to spend 2 of your 4 years working with the Marines in a billet that is essentially an FP slot (or a nurse slot, depending on who you ask).

There is a repetitiveness to these announcements that is not unlike hearing from addicts how they plan to kick their habit in steps over time.

 

[NoMoreAMCAS]

I never applied to the Navy because I didn't want to do a GMO tour. I did Army HPSP instead. I am now a board-certified pediatrician in a battalion surgeon position -- a GMO. By the time I finish with this assignment, I will have been out of residency between 18 and 24 months without ever seeing a single child. In retrospect, It would have been much better for me to have done a GMO trour after internship. Everyone's experience will vary, but thus far (11 months into my deployment) I have seen virtually no patients requiring a physician's care. A good phone triage nurse could take care of 80% of what I see (MS complaints, Gastro, URIs). The next 19% are consults, mostly for chronic ortho or mental health issues. There is a small nugget -- 1% that my skills are actually needed for. Of course the GMO post internship track is a trap into getting extra service time out of you.

The best solution is to stay away.

Ed

How do they get more time out of you? Does the time spent as a GMO not count towards your service commitment?

You did Army HPSP. So you owe them 4 years. Will you not simply have 24-30 months left after you complete your 18-24 month GMO rotation?

Sorry, I'm just curious because I'm fidgety as hell about applying to USUHS and don't want to lock myself into something that i will seriously regret.

 

[NoMoreAMCAS]

The email I sent was to a current Navy attending. He gave me some short answers and then forwarded my email to some recruiters, who replied to my questions (including the answer I asked about above) without bothering to remove his message that he tagged onto the email, which included:

"wanted to make sure this person was on your radar"

ROFL. Nice to know how they look at you.

Hahaha, ****in military.

 

[Perrotfish]

How do they get more time out of you? Does the time spent as a GMO not count towards your service commitment?

You did Army HPSP. So you owe them 4 years. Will you not simply have 24-30 months left after you complete your 18-24 month GMO rotation?

It's complicated. Your internship year is obligation neutral, meaning it doesn't affect your payback in any way. Your resideny/fellowship, though, is 'concurrent payback', meaning for every year you do, you take one year off your pre-residency obligation and add one year to your post residency obligation. This doesn't add to your obligation... until your pre-resideny obligation reaches 0. Then you start adding more payback time. A GMO tour, therefore, means that some of the longer residencies effectively extend your obligation.

Examples

Straight through Training
You do 4 year HPSP, you now owe 4 years, you do a 1 year internship followed by 4 more years to finish up that Ortho residency. Your internship was neutral, you paid back 4 years of preresidency obligation and gained 4 years of obligation from residency. You now owe 4 years. Total time obligated to the service outside of residency: 4 years.

GMO and short Residency
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You now do a 2 year GMO, you now owe 2 years. You do 2 more years to wrap up an IM residency. You paid back 2 years of pre-residency obligation and accumulated 2 more years of obligation. You now owe: 2 years. total time obligated to the service outside of residency: 4 years

GMO and long Residency
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You now do a 2 year GMO, you now owe 2 years. You now do 4 years to wrap up an Ortho residency. You paid back your 2 remaining years of pre-residency obligation and picked up 4 years of obligation from the residency. You now owe: 4 years. Total time obligated to the service outside of residency: 6 years.

GMO all the way through
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You then do a 2 year GMO, you now owe 2 years. You do 2 more years GMO (always an option, you never have to take a residency). You're done. You can do a civilian residency and use the GI bill to significantly increase your pay. Total time obligated to the service outside of residency: 4 years.

Keep in mind the GMO thing with a long residency hurts you even if you want to make a career out of the military: a major part of your pay as a career military physician is the bonus you get when you sign up for another however many years. If you're still paying down time, you don't get that bonus, so your pay is effectively lower than the guy who got straight through training even though you've both done the same job for the same amount of time.

 

[BigNavyPedsGuy]

I never applied to the Navy because I didn't want to do a GMO tour. I did Army HPSP instead. I am now a board-certified pediatrician in a battalion surgeon position -- a GMO. By the time I finish with this assignment, I will have been out of residency between 18 and 24 months without ever seeing a single child. In retrospect, It would have been much better for me to have done a GMO trour after internship. Everyone's experience will vary, but thus far (11 months into my deployment) I have seen virtually no patients requiring a physician's care. A good phone triage nurse could take care of 80% of what I see (MS complaints, Gastro, URIs). The next 19% are consults, mostly for chronic ortho or mental health issues. There is a small nugget -- 1% that my skills are actually needed for. Of course the GMO post internship track is a trap into getting extra service time out of you.

The best solution is to stay away.

Ed

I'm feeling similar frustrations as a GMO satust post Peds Internship. I can't imagine the frustration your feeling. They've talked on and on about replacing some GMO billets with PAs. I think that a good, clinically expreienced PA could easily do my job.

 

[pgg]

You did Army HPSP. So you owe them 4 years. Will you not simply have 24-30 months left after you complete your 18-24 month GMO rotation?

Sorry, I'm just curious because I'm fidgety as hell about applying to USUHS and don't want to lock myself into something that i will seriously regret.

Inservice residency training while in the military incurs additional 1:1 obligation, which is served concurrently with HPSP or USUHS obligations. Depending on the length of the residency you choose, and whether or not you do it before or after a GMO tour, you may end up owing more years than your HPSP or USUHS obligation.

USUHS is a great school. The potential downside is that USUHS grads are essentially committed to a military residency, and military GME isn't what it used to be. Downsizing, clinicification of hospitals, and Tricare have been unmitigated disasters for residencies in virtually every field. A critical part of residency in any specialty is taking care of as many sick people as possible. The current trend in milmed is to refer more and more of these patients out of the system.

You're applying to med school now, presumably for the class entering in 2009, graduating in 2013. That puts internship & residency sometime through 2016 and 2018, depending on the specialty you choose. If someone tells you they know what kind of training you'll be able to get in a military program ten years from now, they're lying. No one knows. Furthermore, you don't know what specialty you'll choose, so you can't take any comfort in knowing that the military has great opportunities in your chosen specialty. (You may think you know, but odds are you'll change your mind.)

Unless you have prior military service, I don't think USUHS offers any substantial advantages that outweigh the above GME risks. If you want to serve, HPSP or FAP are probably better choices.

 

[notdeadyet]

Very nice summary, Perrotfish. Hopefully this will clear up the whole HPSP obligation thing. It can take a while to get your head around it.

One caution though:

GMO all the way through
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You then do a 2 year GMO, you now owe 2 years. You do 2 more years GMO (always an option, you never have to take a residency). You're done. You can do a civilian residency and use the GI bill to significantly increase your pay.

I'd be careful with this. If you're currently looking to get out of the service, you can use the old GI Bill, which designates the monthly payout while you're in residency. But the new GI Bill (which is the only option for folks who are going to enter HPSP now) has not yet addressed payouts for residency, if they are to happen at all.

The old GI Bill paid a monthly fee to you for while you were in any approved form of school or training, including residency. You could use it for tuition (if in college) or for living expenses (if in residency).

The new GI Bill is slated to pay a percentage of public school-comparable tuition. If you are a full-time student, it will also give you a living allowance (E5 BAH, I beleive). The new GI Bill doesn't mention giving benefits to physicians being paid in residency.

The new GI Bill may end up covering residency, but it may not or it may cover less. I wouldn't count on that money until its explicitly dealt with. Until then, it would be safest not to count on it.

 

[BigNavyPedsGuy]

Very nice summary, Perrotfish. Hopefully this will clear up the whole HPSP obligation thing. It can take a while to get your head around it.

One caution though:

I'd be careful with this. If you're currently looking to get out of the service, you can use the old GI Bill, which designates the monthly payout while you're in residency. But the new GI Bill (which is the only option for folks who are going to enter HPSP now) has not yet addressed payouts for residency, if they are to happen at all.

The old GI Bill paid a monthly fee to you for while you were in any approved form of school or training, including residency. You could use it for tuition (if in college) or for living expenses (if in residency).

The new GI Bill is slated to pay a percentage of public school-comparable tuition. If you are a full-time student, it will also give you a living allowance (E5 BAH, I beleive). The new GI Bill doesn't mention giving benefits to physicians being paid in residency.

The new GI Bill may end up covering residency, but it may not or it may cover less. I wouldn't count on that money until its explicitly dealt with. Until then, it would be safest not to count on it.

You can choose to use the old GI Bill. The new GI Bill didn't replace the Montgomery GI Bill. I can still use it for my fellowship when I get out.

 

[Perrotfish]

You can choose to use the old GI Bill. The new GI Bill didn't replace the Montgomery GI Bill. I can still use it for my fellowship when I get out

Also the new GI bill increased the monthly payout of the Mongomery GI bill. Actually you'll be getting more than you would have before Senator Webb's legistlation passed. You can only use one GI bill or the other, though, not both.

 

[notdeadyet]

You can choose to use the old GI Bill. The new GI Bill didn't replace the Montgomery GI Bill. I can still use it for my fellowship when I get out.

Members serving in the military now are grandfathered so that they can use the old GI Bill. I would want to see it in writing that folks who are not in the military yet will be able to enroll in the old GI Bill. I'd be curious to see that this is the case and if so, for how long.

 

[notdeadyet]

Also the new GI bill increased the monthly payout of the Mongomery GI bill. Actually you'll be getting more than you would have before Senator Webb's legistlation passed.

Again, the old GI Bill paid out cash to folks in training, including residency. The new one gives a basic living expense plus percentage of tuition. I had thought the old GI Bill with kicker could pay $1,400/month or so, no?

What is the living expenses component of the new GI Bill? Isn't it E5 BAH? How much does that come to a month? Unless it's $1,400/mo, the new GI Bill will not pay out as much for residents as the old.

And this is all operating under the assumption that residents will be covered by the new GI Bill. The new language is very tuition-centric. I'll be curious to see what it pays out to residents (if anything) in another four or five years when folks are forced to take the new GI Bill. Folks won't be grandfathered into the old GI Bill forever.

 

[Perrotfish]

From what I understand (open to corrections):

There are two GI bills, the Montgomory and the 9-11. Both are in writing, and neither goes away until someone in Congress writes legistlation to make it go away. You're not 'grandfathered in' to the Montgomery bill because that implies that it's going away, the old GI bill is just still there. You only get to use one of them, but you can use either one.

The legislation that created the 9-11 GI bill also increased the payout from the Montgomory bill, if you decided to use that instead. The E5 pay thing applies only if you decide to use the 9-11 bill, which you won't unless you for some reason decide you want a PhD. Also you don't need to pay anything in to use either GI bill.

So, one more time, you don't need to worry about the new GI bill paying less, because the old one is still there.

 

[NoMoreAMCAS]

It's complicated. Your internship year is obligation neutral, meaning it doesn't affect your payback in any way. Your resideny/fellowship, though, is 'concurrent payback', meaning for every year you do, you take one year off your pre-residency obligation and add one year to your post residency obligation. This doesn't add to your obligation... until your pre-resideny obligation reaches 0. Then you start adding more payback time. A GMO tour, therefore, means that some of the longer residencies effectively extend your obligation.

Examples

Straight through Training
You do 4 year HPSP, you now owe 4 years, you do a 1 year internship followed by 4 more years to finish up that Ortho residency. Your internship was neutral, you paid back 4 years of preresidency obligation and gained 4 years of obligation from residency. You now owe 4 years. Total time obligated to the service outside of residency: 4 years.

GMO and short Residency
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You now do a 2 year GMO, you now owe 2 years. You do 2 more years to wrap up an IM residency. You paid back 2 years of pre-residency obligation and accumulated 2 more years of obligation. You now owe: 2 years. total time obligated to the service outside of residency: 4 years

GMO and long Residency
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You now do a 2 year GMO, you now owe 2 years. You now do 4 years to wrap up an Ortho residency. You paid back your 2 remaining years of pre-residency obligation and picked up 4 years of obligation from the residency. You now owe: 4 years. Total time obligated to the service outside of residency: 6 years.

GMO all the way through
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You then do a 2 year GMO, you now owe 2 years. You do 2 more years GMO (always an option, you never have to take a residency). You're done. You can do a civilian residency and use the GI bill to significantly increase your pay. Total time obligated to the service outside of residency: 4 years.

Keep in mind the GMO thing with a long residency hurts you even if you want to make a career out of the military: a major part of your pay as a career military physician is the bonus you get when you sign up for another however many years. If you're still paying down time, you don't get that bonus, so your pay is effectively lower than the guy who got straight through training even though you've both done the same job for the same amount of time.

Thank you, that was a very informative post. I understood almost everything and it was what I had expected (only your years outside of residency count towards your obligation). I'm just not understanding the bolded example.

You do 2 years GMO, so you now owe 2 more years. You enter and complete your 4 year residency (these years do not count at all towards your obligation). So at the end of your residency, why dont you just owe those last 2 years? Are you saying you acquire an extra year of service for each year of residency?

I always thought it was set up that those years just didn't count. Here's a slightly more extreme example of how I thought it was. HPSP - you finish med school owing 4 years. You do 2 GMO, you now owe 2 more years (outside of residency). You do a neurosurgery or cardiothoracic residency for 9 years. You finish residency and serve the 2 years you have remaining. I'm assuming this is wrong now that i've read your post, but I'm just not sure where the extra years come from.

 

[Kingfisher]

Thank you, that was a very informative post. I understood almost everything and it was what I had expected (only your years outside of residency count towards your obligation). I'm just not understanding the bolded example.

You do 2 years GMO, so you now owe 2 more years. You enter and complete your 4 year residency (these years do not count at all towards your obligation). So at the end of your residency, why dont you just owe those last 2 years? Are you saying you acquire an extra year of service for each year of residency?

I always thought it was set up that those years just didn't count. Here's a slightly more extreme example of how I thought it was. HPSP - you finish med school owing 4 years. You do 2 GMO, you now owe 2 more years (outside of residency). You do a neurosurgery or cardiothoracic residency for 9 years. You finish residency and serve the 2 years you have remaining. I'm assuming this is wrong now that i've read your post, but I'm just not sure where the extra years come from.

You will owe no less than the total number of years that you spent in residency. So, yes, if you do a 2 year GMO and a 4 year residency you would owe 4 years. I'm not sure the military has a 9 year residency 🙂confused: do they?), but if they did, you would owe 9 years afterwards.

 

[notdeadyet]

There are two GI bills, the Montgomory and the 9-11. Both are in writing, and neither goes away until someone in Congress writes legistlation to make it go away. You're not 'grandfathered in' to the Montgomery bill because that implies that it's going away, the old GI bill is just still there. You only get to use one of them, but you can use either one.

My apologies. I stand corrected. I thought the Montgomery was being replaced by the new. If both are sticking around, then it's win-win. Good stuff.

 

[Perrotfish]

Thank you, that was a very informative post. I understood almost everything and it was what I had expected (only your years outside of residency count towards your obligation). I'm just not understanding the bolded example.

The bolded example is sort of the key point. Don't sign until you understand it.

Again, only your Intern year doesn't count. Everything else is 'concurrent payback'. That means that each year that you're a resident, you pay pack 1 year of the obligation from before your residency and add 1 year of obligation from the year of training you just did. It doesn't matter how little you owe. If you do 3 years of GMO, at the end of those three years you're down to 1 year of time life, right? But then you do a neurosurgury residency... which is 6 years long. At the end of that residency you owe 6 years, just like if you hadn't done the GMO at all.

I realize this is confusing, and I'm sorry but I can't think of a simpler way to write it. Keep reading it till it make sense, it's good practice for the MCAT verbal.

 

[BigNavyPedsGuy]

already been said . . .

 

[pgg]

You can choose to use the old GI Bill. The new GI Bill didn't replace the Montgomery GI Bill. I can still use it for my fellowship when I get out.

Are you a USUHS grad? Thought you were, but maybe I'm thinking of someone else.

 

[BigNavyPedsGuy]

Are you a USUHS grad? Thought you were, but maybe I'm thinking of someone else.

Nope, HPSP through and through

 

[adismo]

the residency to GMO issue is a painful reality that military medicine will have to fix in the future. the internship to GMO makes more sense, which is why i chose Navy.

as gmo with a marine infantry unit for two years (following civilian internship) , i think that gmo billets should be manned by a combination of MD's or PA's alongside senior enlisted medics trained as independed providers. the problem is that these providers don't bring their own respective medical license, so at minimum, the unit needs one licensed physician to dispense band aids and lamisil out of the aid station. 😀

which is exactly what i've been doing this deployment. granted, i intubate, throw in chest tubes, and manage multiple trauma on occasion as well, but this is the exception, not the rule. it goes from the mundane to the terrifying out here in a heartbeat.

so as my experience shows, there is also the argument that if things do get nasty enough, and they certainly can depending on where you are, you will need a physician as well as PA's and senior medics.

the fix, imo, should begin with the problem - deployments. no one wants to go from chief resident to GMO, so change all GMO billets to be staffed by PA's while in garrison. on deployment, attach a small shock trauma platoon contingent to the battalion or regiment, to be staffed by two physicians which rotate every 3 months (yes, the Canadian model) and a few nurse corps officers.

 

[IgD]

...i intubate, throw in chest tubes, and manage multiple trauma on occasion as well, but this is the exception, not the rule...

Is a non-residency trained physician really credentialed and properly trained to treat acute trauma like that? I'm curious what the American College of Surgeons or other professional association would say about that.

 

[encourageable]

This is a question for bignavypedsguy or someone else in IM or peds.

After 4 year HPSP, internship, 2 year GMO, then 2 year residency, you owe 2 years. Are there 2 year tours available? I thought the Navy only pcs'd people for 3 years. What if you were chief resident for a year? Would you then get a 1 year job? Would these short tours probably keep you in the same city as your residency?

 

[rotatores]

Are you a USUHS grad? Thought you were, but maybe I'm thinking of someone else.

Are you thinking of me?

 

[adismo]

Is a non-residency trained physician really credentialed and properly trained to treat acute trauma like that? I'm curious what the American College of Surgeons or other professional association would say about that.

ATLS, OEMS, NTTC all say yes. i dont open up the belly, so im not sure what you mean about "treating acute trauma like that". there are trauma trained FP doctors and independent duty corpsman (recon) out with other units that certainly can. the real GMO world is alive an well in some parts of the operational theatre. there isnt a starbucks or green bean for miles and miles. 😀

 

[edmadison]

there isnt a starbucks or green bean for miles and miles. 😀

Oh the horror! By far the best day here in Iraq was when the Cinnabon got a got a cappuccino machine. Now I can get my morning latte!

Ed

 

[IgD]

Reminds me of last week: Marine gets assaulted in town, +LOC, multiple abrasions and areas of bony tenderness. I call the ER planning to send him up there for head/face CT & multiple xrays, you know, the standard trauma workup.

ED doc declines to see the patient: "You know, you can do a lot out of your BAS if you just coordinate it directly yourself."

Please tell me the Marine was seen in the ER.

 

[adismo]

welcome to the green side. is your BAS also a condemned building?

 

[edmadison]

ED doc declines to see the patient: "You know, you can do a lot out of your BAS if you just coordinate it directly yourself."

How can the ED decline to see a patient. Send him over there and make the courtesy call to the ED. If they give you any static go with the: "I'm sorry, I don't feel comfortable taking care of the patient because I'm just a GMO".

Ed

 

[adismo]

they can and they do. if they wouldn't, ED's become the GMO's dumping ground for anything GMO's "dont feel comfortable with"

i looked at my ED attendings as the attendings of my "GMO service" and occasionally (few times a month), gave them a call to present a patient and outline my plan of care. id have bloodwork sent up, get films, maybe even run a CT scan (if it sounds justified to the radiologist), and then admit to ED (sounds silly doesnt it) to hold until the specialist will consult. my last such experience was an appy.

 

[i want out]

they can and they do. if they wouldn't, ED's become the GMO's dumping ground for anything GMO's "dont feel comfortable with"

i looked at my ED attendings as the attendings of my "GMO service" and occasionally (few times a month), gave them a call to present a patient and outline my plan of care. id have bloodwork sent up, get films, maybe even run a CT scan (if it sounds justified to the radiologist), and then admit to ED (sounds silly doesnt it) to hold until the specialist will consult. my last such experience was an appy.

Call either the ED or the specialty clinic that you want to send a patient to. Then the tricky part is actually getting someone with a medical license on the phone.

Once you have Dr. whoever on the line, tell them what your sending, if they decline, and tell you what you should do, then you write everything they say down, and mention at the end of the phone call that you will be putting their name in the chart as the person that gave the advice, and then mention, that if they are certain enough of their diagnosis without actually seeing or examining the patient, that they should have no problem with this.

Now you will run across some people with big cajones in the .mil, but I never ran across anybody that would refuse a consult with the above, when you make it clear that its coming from an independently practicing GMO.

You have to learn to play the game, or the game will play you.

i want out (of IRR)

 

[The White Coat Investor]

I accept all patients from GMOs. I often give advice that says something to the effect of "this is probably no big deal and you can manage it there (and I give them some idea of what to look for), but if you're in any way uncomfortable, put the patient on a helicopter, send him on in, and I'll take a look at him." Sometimes they send the patient, sometimes they don't.

 

[OnlyLiveOnce]

i want out (of IRR)

Really, why? I thought IRR was a piece of cake where all you have to do is just get a medical exam once a year, and that you don't have to actually do anything...

GMO all the way through
You do 4 year HPSP, you now owe 4 years. You do a 1 year internship: you still owe 4 years because internship doesn't affect your obligation. You then do a 2 year GMO, you now owe 2 years. You do 2 more years GMO (always an option, you never have to take a residency). You're done. You can do a civilian residency and use the GI bill to significantly increase your pay. Total time obligated to the service outside of residency: 4 years.

This is interesting. I have several questions about this option.

1) Based on what I've heard, GMO tour involves a bunch of work that you as an MD are overqualified for. How does the fact that your training was put on hold for 4 years, in which you basically acted like a nurse (albeit in a tough environment), impact your application for CIVILIAN residencies? Positively/negatively/neutral? And how severely?

2) Do civilian residencies make you repeat the internship year (or do they honor the one you did with the military)?

3) Would you still owe IRR time after residency?

4) Is a 4-year GMO tour bad for a newly-wed couple? (assuming the wife has a career of her own and remains in the US while you're on tour)

5) Can a GMO get stop-lossed, or is he guaranteed freedom after 4 years?


These questions are about the Navy, obviously, but other branches' perspective is also welcome. If your answers are specific to a particular branch, please specify.

 

[orbitsurgMD]

Really, why? I thought IRR was a piece of cake where all you have to do is just get a medical exam once a year, and that you don't have to actually do anything...

The only issue is that they can legally recall you to active duty. They have recalled others but not those in medical. An IRR recall would likely result in yanking doctors out of civilian residency programs almost exclusively, since the medical IRR rolls are filled mainly by those medical corps officers who departed active duty after a three or four year GMO payback and are returning to training as civilians. (Those training in military programs will have exhausted their repayment obligations under the minimum 8 year term of obligatory commissioned service from which the IRR usually draws its members, and when they get out, they seldom have any obligated term remaining. The only exceptions might be doctors who commissioned directly after completing residency--not from HPSP--and the few who go directly through a short residency of three years and have only three or four years to pay back.)

This is interesting. I have several questions about this option.

1) Based on what I've heard, GMO tour involves a bunch of work that you as an MD are overqualified for. How does the fact that your training was put on hold for 4 years, in which you basically acted like a nurse (albeit in a tough environment), impact your application for CIVILIAN residencies? Positively/negatively/neutral? And how severely?

2) Do civilian residencies make you repeat the internship year (or do they honor the one you did with the military)?

3) Would you still owe IRR time after residency?

4) Is a 4-year GMO tour bad for a newly-wed couple? (assuming the wife has a career of her own and remains in the US while you're on tour)

5) Can a GMO get stop-lossed, or is he guaranteed freedom after 4 years?


These questions are about the Navy, obviously, but other branches' perspective is also welcome. If your answers are specific to a particular branch, please specify.

1) Yes and no. It can also involve work you are under-qualified for.

2) Depends on what you did the internship in and how long before. Most programs that start at PGY2 accept the year. True for Ophtho, Derm , Anaesthesia, Rads, etc. Ditto for EM. I doubt many IM programs would think you fit to take over a ward/unit team coming back from three or four years in the fleet. Can't say for general surgery; I think that would depend.

There are also issues about eligibility for CMS support. Usually if you did a military internship it isn't a concern. If you are deferred for a civilian internship, it could be an issue if you had to repeat your PGY1 year.

3) Depends on how long the residency is. Maybe. IRR is where you are put when you have less than 8 years on your commissioning clock (from graduation) if you are not either on active duty, drilling reserves or deceased.

4) Depends. If you have young children and you are deployed for long periods or frequently for even short periods, I imagine it could be a challenge.

5) a. Yes. b. No.

 

[OnlyLiveOnce]

Those training in military programs will have exhausted their repayment obligations under the minimum 8 year term of obligatory commissioned service from which the IRR usually draws its members, and when they get out, they seldom have any obligated term remaining.

But those 8 years are 4 years of active duty and 4 years of IRR, right? All of which begins once they finish residency?

3) Depends on how long the residency is. Maybe. IRR is where you are put when you have less than 8 years on your commissioning clock (from graduation) if you are not either on active duty, drilling reserves or deceased.

Meaning, in one way or the other, you MUST serve the military for a total of (at least) 8 years?

5) a. Yes. b. No.

I assume you mean "yes" to stoploss and "no" to guaranteed freedom?

 

[orbitsurgMD]

But those 8 years are 4 years of active duty and 4 years of IRR, right? All of which begins once they finish residency?

No. IRR is where you are assigned if you are no longer on active duty or serving in a ready reserve unit but you still have less than 8 years of service since taking your superceding commission (i.e., the re-commissioning to O-3 that takes place on graduation from medical school, not your first commissioning as an O-1 in HPSP).

Meaning, in one way or the other, you MUST serve the military for a total of (at least) 8 years?

Those 8 years are continuous, uninterrupted.

I assume you mean "yes" to stoploss and "no" to guaranteed freedom?

Correct.

 

[BigNavyPedsGuy]

This is a question for bignavypedsguy or someone else in IM or peds.

After 4 year HPSP, internship, 2 year GMO, then 2 year residency, you owe 2 years. Are there 2 year tours available? I thought the Navy only pcs'd people for 3 years. What if you were chief resident for a year? Would you then get a 1 year job? Would these short tours probably keep you in the same city as your residency?

Late reply, I know. You will most likely be able to get out once your orders are up. UNLESS, you take 3 year overseas orders, then you're stuck for 3 years. But if you get 3 year orders to say, Jacksonville, as a pediatrician, you'll be able to get out after 2 years. There is always the risk of stop-loss, but that hasn't happened yet.

As to the argument about GMOs really practicing, it's a strange dichotomy. In port, the ER or subspecialist can almost always take care of complicated situations better than I can on the ship, if for no other reason than I'm on the ship and they're in the hospital. But underway, it's just the ship and you work with what you have. It's strange because the philosophies are VERY VERY different and it's a hard shift to make. GMO's probably practice more 'real medicine' while deployed, but the patients generally, probably get 'better care' while in port. I have to be able to work both systems.

 

[IgD]

And no, IgD, I did the trauma workup out of my BAS. Took 3 times as long as it would have in an ER, and I stayed several hours later than I should have, but it had a good result, so I didn't care.

I'm not saying what you did was wrong. However, one of the pitfalls of GMOs I've observed is they have trouble knowing their limits. That is something you learn during residency. You also learn how to stand up to other physicians if you have to. I am skeptical about the benefit of having non-residency trained physicians.

 

[BigNavyPedsGuy]

I am skeptical about the benefit of having non-residency trained physicians.

I'll say it again: a good clinically experienced PA could easily do my job and in some ways s/he would be more prepared for it than I am.

 

[IgD]

I'll say it again: a good clinically experienced PA could easily do my job and in some ways s/he would be more prepared for it than I am.

Can PAs practice independently? My understanding is they require supervision from a family practice doc. I don't think you could deploy a PA alone in support of a Marine battalion for example.

 

[crazybrancato]

Can PAs practice independently? My understanding is they require supervision from a family practice doc. I don't think you could deploy a PA alone in support of a Marine battalion for example.

Good question. I don't see why not. An IDC can take care of an entire Cruiser all by himself, don't see why a PA couldn't serve by him/herself in a deployed role . . . .

Another question: During your GMOs, if you have a lot of downtime for lack of work, can you study? (say for your upcoming residency or next Step of the boards). Is that allowed? Or are you always on your feet, trying to look busy?

 

[orbitsurgMD]

Good question. I don't see why not. An IDC can take care of an entire Cruiser all by himself, don't see why a PA couldn't serve by him/herself in a deployed role . . . .

Another question: During your GMOs, if you have a lot of downtime for lack of work, can you study? (say for your upcoming residency or next Step of the boards). Is that allowed? Or are you always on your feet, trying to look busy?

Most GMOs have a regular day job, seeing sick call, doing physicals, occupational health monitoring clinics and also covering the ED/ Urgent Care. Most also take call when in port/non-deployed and when deployed. Sometimes you can be effectively on call 24/7 depending on manning and your station. I usually had a full clinic schedule every day, at least 25-30 patients during working hours. Overnight call could vary between nothing and all-night.

Sure, you can read. You generally will have to to maintain your Category 1 CME hours as funding for travel and meetings can and has been re-directed to other purposes. Nearly every year I served, the GMOs were told early on not to waste our time applying for CME funding since the allocated funds had been re-allocated for other BUMED purposes, among other things for reservist training. I got one trip to NAMI for a weekend course in four years. I am sure YMMV.

 

[pgg]

During your GMOs, if you have a lot of downtime for lack of work, can you study? (say for your upcoming residency or next Step of the boards). Is that allowed? Or are you always on your feet, trying to look busy?

You'll be done with the USMLE steps by the time you do GMO time (since you need to have an unrestricted state medical license).

As a Marine GMO, it was very hard to do much reading while at home, because the pre/post deployment admin monkey was always on my back in a big way. Lots of long days. I had the opportunity to spend some time at the local naval hospital doing some cases, but never did because I couldn't really justify spending more time away from home in between deployments.

Deployment was another matter. I was bored out of my skull 90% of the time. I took 4 or 5 anesthesia textbooks and a handful of review books with me, and tried to study. Without the context of patients though, it was very hard to retain anything. The stuff I love reading now (as I prepare or review specific cases) put me to sleep then. Maybe you're smarter than me and can make it work. I had the best of intentions and read a lot of pages, but didn't really feel like I was learning much until I actually started residency.

But yes, there is a lot of time to study for residency.

 

[core0]

Can PAs practice independently? My understanding is they require supervision from a family practice doc. I don't think you could deploy a PA alone in support of a Marine battalion for example.

As usual with the Government its a little more complicated. In the US a PA must work with a licensed physician (of any type). The supervisory requirements usually dictate that the physician must be available either in person or electronically (different states have different rules on this and how far a physician can be physically). There is no requirement for direct supervision.

The Military has several different issues. In many states the PA license has to be attached to a physician license. However pretty much every state has allowance to allow military PAs to be licensed without a physician. In general the responsibility passes to the first physician in the chain of command.

There are also two sets of rules. One is for non-deployed status. They essentially mimic state rules where there must be a physician available to consult at a minimum. This is especially important when seeing civilians and dependents.

In deployed situation the military takes a certain amount of freedom with the rules. In most cases a PA in a military unit either serves as the assistant battalion surgeon or as a member of a team in a higher level service. The nature of a BN medical platoon allows it to be split into two parts if the mission requires. This essentially places the PA in an independent position. While technically the physician is available by radio the realities of the battlefield make this unlikely. This is also the case when there is no BN surgeon assigned or the BN surgeon is absent. In this case the PA becomes the acting BN surgeon reporting to the brigade surgeon.

The Navy is a little different. By their manual its supposed to be two physicians as the BN and assistant BN surgeon. However, anectdotally they seem to be PAs deployed in these positions. There was a plan at one time to replace the IDCs with PAs. My understanding is that it was scrapped due the Navy PA shortage.

David Carpenter, PA-C