Path to specialization (i.e. fellowships)

[DrMetal]

Hi all, have some detailed questions about the path to specialization in milmed.

So, say you're in your last year of residency (say IM), and you'd like to apply for a fellowship (say cards or GI).

1. So, I know typically you're expected to do a utilization tour as an internist before you start your fellowship. This makes sense if you're applying FTIS (in-service fellowship) b/c there are so few spots. But what if you apply FTOS and get accepted into a civilian program? Would you be allowed to go straight from residency to FTOS, or are you still likely to do a utilization tour in between?

2. What exactly is the proper sequence of events? Do you apply in your last year of residency, are accepted, go on your utilization tour, then come back 2-3 years later to enroll in the fellowship program? Or, is your acceptance into the fellowship precluded until you complete your utilization tour?

3. If you're really interested in a particular specialization (and don't care about the difference in payback), is it wise to apply FTIS and FTOS at the same time?

Thanks!

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[Yellowstone]

Hi all, have some detailed questions about the path to specialization in milmed.

So, say you're in your last year of residency (say IM), and you'd like to apply for a fellowship (say cards or GI).

1. So, I know typically you're expected to do a utilization tour as an internist before you start your fellowship. This makes sense if you're applying FTIS (in-service fellowship) b/c there are so few spots. But what if you apply FTOS and get accepted into a civilian program? Would you be allowed to go straight from residency to FTOS, or are you still likely to do a utilization tour in between?

2. What exactly is the proper sequence of events? Do you apply in your last year of residency, are accepted, go on your utilization tour, then come back 2-3 years later to enroll in the fellowship program? Or, is your acceptance into the fellowship precluded until you complete your utilization tour?

3. If you're really interested in a particular specialization (and don't care about the difference in payback), is it wise to apply FTIS and FTOS at the same time?

Thanks!

1. It probably doesn't matter if you apply FTIS or FTOS - you would still most likely have to do a utilization tour.

2. You can always apply, but are less likely to get accepted until after a utilization tour. Some fields pre-select 1-2 years in advance. But you would probably apply during the last year of your utilization tour.

3. Is there a difference in payback between FTIS and FTOS; I don't think there is. I'm not sure how it works, but I think you apply for either FTIS or FTOS.

 

[IgD]

I would say its almost a given that you would complete a utilization tour after residency and before a fellowship. The military determines the number of fellowship spots per year. During your last year of residency or utilization tour, you have to apply to the selection board and go through a murder board type process. Be careful, if you do an out-service fellowship the payback is CONSECUTIVE while an in-service fellowship is CONCURRENT. The other thing is the military will try to fill its in-service spots before it lets people apply to civilian programs.

 

[J-Rad]

Given the linguistics of your question you are asking about the Navy pathway (on this site it's always a good idea to specify which service you're inquiring about since, quite often, someone from a different service will chime in with info that is correct for their own service, but not for another's).
I'm AF but trained in a Navy program and saw this year's match list and observed matches for the years I was in residency. You can apply any time you want. Whether you are selected depends on multiple factors and a utilization tour isn't going to hurt your chances. But I have seen multiple people selected for fellowship right out of residency with no utilization tour (this is in the peds world, but I knew of others in other specialties as well).
As for the FTIS/FTOS questions, here's where I'd take the following with a grain of salt since I didn't apply through the Navy (but am on the equivalent of FTOS): If both exist for a certain specialty (Because some specialties will ONLY have out-service training) you'll likely apply to both and you'll state a preference for location (if more than one) and/or for FTIS vs FTOS. You may also apply for civilian deferred in some cases (depends on how bad you want it and how much of a pay cut you can tolerate during training). As for payback, I believe it is similar across services: FTIS incurs no additional obligation (or an obligation that will run concurrently) and FTOS will incur a 1:1 AD service obligation in addition to whatever is already owed.

 

[DrMetal]

Yeah i was thinking Navy (sorry I didn't mention that). Anyway, thanks all . . .that answers my questions.

 

[J-Rad]

One thing to add: The Navy is much nicer than the AF in regards to people asking to train outservice on their own dime (i.e. deferred) even though it might not be listed on a particular year's GME list. I doubt it is common, but I've known of a few people who have successfully said "I want to do this, and I'm willing to give up my AD pay while I train" (the AF, to my knowledge, never does this). Of course, I also know that, had one of those people waited a year, their specialty would have come up on the GME listed for FTOS funding.

 

[DrMetal]

ok thanks. let me ask a more specific hypothetical (Navy) scenario.

say you're in your last year of IM at San Diego, or in the middle of a utilization tour. Say you wanna do GI at San Diego, for which there are 2-3 spots a year. Say there's 8 people waiting for the GI fellowship in SD (in other words there's a significant backlog). Say you're clearly a great candidate (high grades med school, great board scores, papers published throughout your training, maybe even a couple case papers during your utilization tour, etc).

Could you compete for a Navy FTOS spot to complete your GI training elsewhere, so as to avoid the backlog at the mil programs?

Or:

would the Navy take the mentality: "We're not going to allow you to go FTOS for a program that we have internally. You're just going to have to wait, become the 9th person on the waitlist for FTIS GI at San Diego." And if this is the case, will they bump people up on the waitlist depending on qualifications, or is all first come first serve?

(unfortunately, for where I think I'm going to be in my life at this stage, I don't think a civ deferment would work for me).

 

[IgD]

ok thanks. let me ask a more specific hypothetical (Navy) scenario.

say you're in your last year of IM at San Diego, or in the middle of a utilization tour. Say you wanna do GI at San Diego, for which there are 2-3 spots a year. Say there's 8 people waiting for the GI fellowship in SD (in other words there's a significant backlog). Say you're clearly a great candidate (high grades med school, great board scores, papers published throughout your training, maybe even a couple case papers during your utilization tour, etc).

Could you compete for a Navy FTOS spot to complete your GI training elsewhere, so as to avoid the backlog at the mil programs?

Your community and selection board will determine how many fellowships are given out per year. If the Navy only needs 3 GI fellows per year and there is an in-service training program with 3 spots there would be no need for out-service training. The needs change year to year so its impossible to predict.

would the Navy take the mentality: "We're not going to allow you to go FTOS for a program that we have internally. You're just going to have to wait, become the 9th person on the waitlist for FTIS GI at San Diego." And if this is the case, will they bump people up on the waitlist depending on qualifications, or is all first come first serve?

I think that is pretty much the mentality. It doesn't make sense for the Navy as an organization to let the in-service programs go unfilled. Like I said its a murder board type process. They will look to see how you stack up against the other applicants. Are you "owed" a position because of something you did? Will giving you a fellowship keep you in the military? Did you complete a utilization tour? My experience was those factors outweighed scholarship when looking at these decisions.

 

[Gastrapathy]

The competitiveness for IM subspecialties in the Navy varies considerably year to year. The board sets a total number of IM subspecialty fellows per year. This number includes FTIS, FTOS and deferred programs and is partially dictated by the number of internists needed. The specialties that have FTIS training are less likely to be given FTOS spots because they are competing with the other IM subs for those slots (and those other subs have no other way but FTOS to generate subspecialists). So, for GI, over the past 8 or so years, I'm aware of 2 people being selected for FTOS training. Cards has had a couple as well, I think.

There are 4 spots for GI and 4-5 for Cards per year. These are typically quite competitive. However, they are not necessarily more competitive in the Navy than the subspecialties that are typically non-competitive in the civilian world (ie Rheum, endo, ID) because we always train someone in GI and Cards, whereas the number of trainees in those other fields is much more variable. 2 applicants for 0 slots is more competitive than 15 applicants for 4 spots. That being said, if you want one of the less competitive fellowships, you'll get it eventually if you have patience.

It helps your application to do a utilization tour but there are people who occasionally go straight-though. Most of these people did GMO tours, so their training was still interrupted. It is a better strategy to go straight-through in IM and take your chances with an IM utilization tour than to do a GMO to become competitive for fellowship. You get paid more in aggregate and a staff currently completing a utilization tour is viewed more favorably than a prior-GMO resident (even though both are the same number of years out of med school). Further, you might get lucky and get selected right away.

IM subs are a pretty good deal in the Navy because you are paid as a staff internist to do a subspecialty. Particularly for those subspecialties that are at the bottom end of the pay scale, you'll actually make more in the Navy when you factor in this difference (which approaches $100,000/year more than a civilian fellow).

 

[Gastrapathy]

Your community and selection board will determine how many fellowships are given out per year. If the Navy only needs 3 GI fellows per year and there is an in-service training program with 3 spots there would be no need for out-service training. The needs change year to year so its impossible to predict.

I think that is pretty much the mentality. It doesn't make sense for the Navy as an organization to let the in-service programs go unfilled. Like I said its a murder board type process. They will look to see how you stack up against the other applicants. Are you "owed" a position because of something you did? Will giving you a fellowship keep you in the military? Did you complete a utilization tour? My experience was those factors outweighed scholarship when looking at these decisions.

Actually, the need for IM subspecialists is, and will probably remain, pretty constant because we have no retention. So, I think you can be pretty sure we will train 4 fellows/year for at least the next few years. I also don't think anyone is "owed" fellowship and I haven't seen that in selection. They take the best people. The one exception to that is that you simply won't be competitive as a resident against current staff. We have enough staff applicants, however, that it remains competitive and we get good people.

 

[DrMetal]

The competitiveness for IM subspecialties in

great! Thanks for this input, that helps a lot.

 

[usafcards]

Hello I think Im in the same boat as you...

I am in the AF, but I got a FAP loan/scholarship as I was worried about what specialty I would be allowed to do in the AF...anyway Im in my 3rd year of residency and applied this year to the GME, and was looking for a position inside the AF, not a position sponsored where I would have to pay back more time, and I matched into my 2nd choice (pulmonary) which I am refusing.

Interestingly enough, I applied through the civilian match in hope of deferment and got offered a position in Boston, and matched in Stanford but was not able to defer as they said they dont need more than 3 cards people this year, and they wil not allow me to go...leaving me with the choice of doing 2 years and reapplying for the AF fellowship, or finishing my 3 years and applying civi again (expensive interviews again, and my letter writers might not be willing to put their neck on the line again), with the GI bill money as well that we can get during a civi fellowship...My issue is if I do 2 years, I owe another 1, if I do fellowship inside the AF I dont want to owe 4 more years, and I dont know if the commitment is consecutive or at same time (concurrent), I would be willing to do 3 years as I like San Antonio and the pay is not bad for fellowship and you can moonlight as staff...

anyhow I hope I get deployed somewhere decent, but as I come from a top residency and med school, and matched at a great place I feel cheated by my goodwill toward the military, and I am upset with my staff that talked me into it.I joined because I alwys wanted some military experience, and am not unhappy so far, as I also believe its a great honor, just I think the military hould also appreciate MDs.They should know someone with USMLE of 90's, with tons of research from a top tier med school and residency will not forget this..anyones thoughts?

 

[IgD]

anyhow I hope I get deployed somewhere decent, but as I come from a top residency and med school, and matched at a great place I feel cheated by my goodwill toward the military, and I am upset with my staff that talked me into it.I joined because I alwys wanted some military experience, and am not unhappy so far, as I also believe its a great honor, just I think the military hould also appreciate MDs.They should know someone with USMLE of 90's, with tons of research from a top tier med school and residency will not forget this..anyones thoughts?

Unfortunately what you described is the way the military medical system is. There is no transparency about the matching process so it is hard to tell exactly where you stand. Wonder what the board scores and research points were for the applicants who were accepted?

I had a co-worker who was a very loyal environmental health officer who turned in his resignation after he was improperly prevented from enrolling in a PhD program. (An Admiral called him, apologized and explained the error).

I can't see how these situations help the retention rate any.

 

[mitchconnie]

I feel cheated by my goodwill toward the military, and I am upset with my staff that talked me into it.I joined because I alwys wanted some military experience, and am not unhappy so far, as I also believe its a great honor, just I think the military hould also appreciate MDs.They should know someone with USMLE of 90's, with tons of research from a top tier med school and residency will not forget this..anyones thoughts?

This is a common sentiment, and a situation that recurs a thousand times over every year when people who have trained for years in civilian institutions finally engage with the military match and/or assignment system.

The simple fact is that the military match process can be a totally different game than the civilian side, and while people may be positioned well for the civilian match, they may not even understand the rules of the military game.

I saw it in this years match for my surgical subspecialty. We had a candidate who clearly was academically and technically superior in all respects-- someone with the kind of CV that would make him the top choice at the Mayo Clinic, Mass General, or Stanford. He had a personal letter from the president of our national society, multiple publications in the top journal in our field, etc. But he wasn't even close to getting a military spot. Why? Because he was competing against people who have already done utilization tours. He had effectively zero chance of matching.

Generating "goodwill" among physicians is not typically on the radar screen when it comes to residency selection and assignments. As you begin your payback, you may notice that the military seems to actively try and generate ill will among it's physicians.

 

[IgD]

I saw it in this years match for my surgical subspecialty. We had a candidate who clearly was academically and technically superior in all respects-- someone with the kind of CV that would make him the top choice at the Mayo Clinic, Mass General, or Stanford. He had a personal letter from the president of our national society, multiple publications in the top journal in our field, etc. But he wasn't even close to getting a military spot. Why? Because he was competing against people who have already done utilization tours. He had effectively zero chance of matching.

What a loss for military medicine. That guy had a lot of potential just like the internist above. He probably would have made a great department head or higher. Now he will leave at the end of his GMO tour and tell others about his experiences further exacerbating the recruiting problem.

What organization can sustain itself with that operating procedure?

 

[DrMetal]

forgive me, i know this has been hashed out elsewhere.

Suppose one has a payback balance of 2 years (2 years left to serve).

If that person does a 3-year FTOS, he will incur and additional 4 years of payback, upping the balance to 6 years, correct?

If that person instead does a 3-year FTIS, he will incur no additional payback, nor will he pay anything back, thus rendering his balance the same as when he started the fellowship ( = 2 years in this scenario). Correct???

Now, how does this scenario change if one has no payback left (a balance = 0) at the beginning of a fellowship?

 

[IgD]

forgive me, i know this has been hashed out elsewhere.

Suppose one has a payback balance of 2 years (2 years left to serve).

If that person does a 3-year FTOS, he will incur and additional 4 years of payback, upping the balance to 6 years, correct?

If that person instead does a 3-year FTIS, he will incur no additional payback, nor will he pay anything back, thus rendering his balance the same as when he started the fellowship ( = 2 years in this scenario). Correct???

Now, how does this scenario change if one has no payback left (a balance = 0) at the beginning of a fellowship?

You've pretty much got it. It would only be a 5 year obligation with the FTOS fellowship (2 years left to serve + 3 years FTOS = 5). If you have no payback prior to starting an inservice fellowship you would owe the length of the fellowship so that would be 2.

 

[DrMetal]

sweet, thanks.

 

[Gastrapathy]

forgive me, i know this has been hashed out elsewhere.

Suppose one has a payback balance of 2 years (2 years left to serve).

If that person does a 3-year FTOS, he will incur and additional 4 years of payback, upping the balance to 6 years, correct?

If that person instead does a 3-year FTIS, he will incur no additional payback, nor will he pay anything back, thus rendering his balance the same as when he started the fellowship ( = 2 years in this scenario). Correct???

Now, how does this scenario change if one has no payback left (a balance = 0) at the beginning of a fellowship?

Not exactly. It depends whether your payback is for GME or for med school (or college). If you owe 2 years for residency and then go to fellowship, those obligations are concurrent. But, assuming you owe 2 for HPSP and have paid off your GME obligation (a realistic scenario for a 4 year HPSP and a 2 year IM residency) and now do a 3 year FTIS fellowship, you would finish owing only 3 years. Confused? Don't worry about it. You probably won't want to do medicine anyway by then.