quality of military vs civilian residencies

[MEDUSA23]

I just finished my M1 year and am considering army HPSP. My main concern is the quality of military residencies vs civilian residencies since it is difficult to obtain concrete statistics on this topic. I have looked at other posts, but would still like more information/anecdotal stories. I do not want to sacrifice training by joining he army, but I am not certain that this would be the case. At this point, I am most interested in OB/GYN (possible Uro-gyn or gyn-onc fellowship later on) and DERM.

---

Members don't see this ad.

 

[colbgw02]

I just finished my M1 year and am considering army HPSP. My main concern is the quality of military residencies vs civilian residencies since it is difficult to obtain concrete statistics on this topic. I have looked at other posts, but would still like more information/anecdotal stories. I do not want to sacrifice training by joining he army, but I am not certain that this would be the case. At this point, I am most interested in OB/GYN (possible Uro-gyn or gyn-onc fellowship later on) and DERM.

I can't speak to OB/GYN or dermatology, but I was pleased with the quality of my residency. It definitely wasn't an elite-level experience, but I benefitted from being at a resident-run program - whereas many civilian teaching programs in my field are fellow-driven. As a result, I feel like I was better prepared on day 1 of independent practice than most, and the experience of military fellows from my specialty at civilian university programs supports my claim.

I liken military vs. civilian GME to choosing between the elite private college vs. the in-state public university. At top university residencies, like at big-name colleges, you're much more likely to get a good education just by "showing up." Whereas, at the gigantic state university and in military GME, you really have to want it and be a good steward of your own education.

I think most people are relatively satisfied with their training. It's their practice after training that bothers most people. Too many people end up in BFE with little to no acuity or pathology while being saddled with administrative tasks.

Overall, I would put quality of GME pretty far down on the list of reasons to avoid military medicine.

 

[MEDUSA23]

I can't speak to OB/GYN or dermatology, but I was pleased with the quality of my residency. It definitely wasn't an elite-level experience, but I benefitted from being at a resident-run program - whereas many civilian teaching programs in my field are fellow-driven. As a result, I feel like I was better prepared on day 1 of independent practice than most, and the experience of military fellows from my specialty at civilian university programs supports my claim.

I liken military vs. civilian GME to choosing between the elite private college vs. the in-state public university. At top university residencies, like at big-name colleges, you're much more likely to get a good education just by "showing up." Whereas, at the gigantic state university and in military GME, you really have to want it and be a good steward of your own education.

I think most people are relatively satisfied with their training. It's their practice after training that bothers most people. Too many people end up in BFE with little to no acuity or pathology while being saddled with administrative tasks.

Overall, I would put quality of GME pretty far down on the list of reasons to avoid military medicine.

How BFE can it get? I am from a town of 2,000.

 

[Cooperd0g]

How BFE can it get? I am from a town of 2,000.

Not much more BFE than that. I can only think of one place with docs smaller than that, but I'm not familiar with all the Army locations as I'm a Navy guy.

 

[colbgw02]

How BFE can it get? I am from a town of 2,000.

Don't confuse BFE from a social standpoint with BFE from a professional perspective. I'm referring to the latter. You may be at a post with tens of thousands of soldiers or even in a relatively populated part of the country, but that correlates pretty loosely with seeing the acuity and variety needed to maintain your skills. You really need the dependents and - more importantly - retirees to have a well-balanced practice, and those just don't exist in sufficient number around many MTFs. There's also the consideration of colleagues and support services: imagine being a perinatologist without a NICU or a neuroradiologist without a neurosurgeon. The Army doesn't consider this type form of "overlapping fields of fire" well, nor does it care to learn. These are recipes for skill atrophy, and that's without even mentioning the chance of getting to play desk jockey for a year or two as a battalion or brigade surgeon.

 

[bustbones26]

Don't confuse BFE from a social standpoint with BFE from a professional perspective. I'm referring to the latter. You may be at a post with tens of thousands of soldiers or even in a relatively populated part of the country, but that correlates pretty loosely with seeing the acuity and variety needed to maintain your skills. You really need the dependents and - more importantly - retirees to have a well-balanced practice, and those just don't exist in sufficient number around many MTFs. There's also the consideration of colleagues and support services: imagine being a perinatologist without a NICU or a neuroradiologist without a neurosurgeon. The Army doesn't consider this type form of "overlapping fields of fire" well, nor does it care to learn. These are recipes for skill atrophy, and that's without even mentioning the chance of getting to play desk jockey for a year or two as a battalion or brigade surgeon.

Agreed!!

The military GME programs are solid and you will receive adequate training; however, the problem is what lies beyond military GME.

 

[Mt Kilimanjaro]

Don't confuse BFE from a social standpoint with BFE from a professional perspective. I'm referring to the latter. You may be at a post with tens of thousands of soldiers or even in a relatively populated part of the country, but that correlates pretty loosely with seeing the acuity and variety needed to maintain your skills. You really need the dependents and - more importantly - retirees to have a well-balanced practice, and those just don't exist in sufficient number around many MTFs. There's also the consideration of colleagues and support services: imagine being a perinatologist without a NICU or a neuroradiologist without a neurosurgeon. The Army doesn't consider this type form of "overlapping fields of fire" well, nor does it care to learn. These are recipes for skill atrophy, and that's without even mentioning the chance of getting to play desk jockey for a year or two as a battalion or brigade surgeon.

Most of the examples of problems with skill atrophy I have seen, including the ones above, are for sub-specialists. What about things like family medicine, EM, or general surgery? Are there similar problems with skill or knowledge atrophy at locations that lack the diversity of patients provided by a large MTF with lots of retirees and dependents around? In other words, can a BFE post work out alright for some specialties?

 

[MEDUSA23]

Don't confuse BFE from a social standpoint with BFE from a professional perspective. I'm referring to the latter. You may be at a post with tens of thousands of soldiers or even in a relatively populated part of the country, but that correlates pretty loosely with seeing the acuity and variety needed to maintain your skills. You really need the dependents and - more importantly - retirees to have a well-balanced practice, and those just don't exist in sufficient number around many MTFs. There's also the consideration of colleagues and support services: imagine being a perinatologist without a NICU or a neuroradiologist without a neurosurgeon. The Army doesn't consider this type form of "overlapping fields of fire" well, nor does it care to learn. These are recipes for skill atrophy, and that's without even mentioning the chance of getting to play desk jockey for a year or two as a battalion or brigade surgeon.

Is there a list of possible sites? I found an unofficial outdated list for AF online, but have not seen something similar for Army.

 

[idq1i]

Is there a list of possible sites? I found an unofficial outdated list for AF online, but have not seen something similar for Army.

http://www.mods.army.mil/medicaleducation/userlogon/GmeDelay.asp

 

[idq1i]

How BFE can it get? I am from a town of 2,000.

How BFE? I am working in a town of 2,500, scrambling to maintain my skills

 

[MEDUSA23]

http://www.mods.army.mil/medicaleducation/userlogon/GmeDelay.asp

I am looking for something similar to what is presented on this site:

http://lukeballard.tripod.com/ASSIGNMENT_POSSIBILITIES.html

 

[idq1i]

I am not aware of anything like that for the army
http://www.armymedicine.army.mil/hc/medfacilities/list.cfm is the closest I know.

90% chance of you not getting any medcen assignment after residency graduation, particularly without subspecialty training, and without knowing people who know people.

Think Fort Polk, Leonard wood, Sill. This is assuming you get a residency, and don't get GMOed.

 

[MEDUSA23]

I am not aware of anything like that for the army
http://www.armymedicine.army.mil/hc/medfacilities/list.cfm is the closest I know.

90% chance of you not getting any medcen assignment after residency graduation, particularly without subspecialty training, and without knowing people who know people.

Think Fort Polk, Leonard wood, Sill. This is assuming you get a residency, and don't get GMOed.

I think I could handle small town living. Based on others posts, it also seems somewhat possible to gain more patients through moonlighting. But I have to say I ran across a site with some labor and delivery experiences and it has swayed me heavily against HPSP.

http://www.jcpost.com/2012/11/19/irwin-army-community-hospital-never-again/

I can't even imagine being apart of a system that functions this way. And this is not the only site I found with similar stories. Can anyone discount these claims or does this type of insanity go on?

 

[pgg]

I think I could handle small town living. Based on others posts, it also seems somewhat possible to gain more patients through moonlighting. But I have to say I ran across a site with some labor and delivery experiences and it has swayed me heavily against HPSP.

http://www.jcpost.com/2012/11/19/irwin-army-community-hospital-never-again/

I can't even imagine being apart of a system that functions this way. And this is not the only site I found with similar stories. Can anyone discount these claims or does this type of insanity go on?

I've never been to Ft Irwin. It might be as bad as that person describes. Stranger things have happened. There are lousy doctors/nurses and toxic hospitals out there. Military and non-military. Some civilian hospitals with large numbers of uninsured patients are really marginal.


But every military hospital where I've worked has had superb OB/GYN care. I moonlight at civilian hospitals and do some OB anesthesia outside the military - truthfully, I'd pick a random MTF most of the time. The only civilian hospital I've worked at that I thought had anything over a MTF was Brigham & Womens. All three of my kids were born in a MTF. I would be totally happy to have any of the OBs I currently work with manage my wife's care. And not just because they'd take extra special care of my wife because I'm a colleague. They take good care of everyone.


You really have to take these patient rants with a huge grain of salt. It is of course, one side of a story, and the other side can't be told because of HIPAA - even if the hospital staff were inclined to get in a public argument with a patient, which no sane person would ever have any interest in doing.

The fact is that 99% of patients really can't tell the difference between good care and bad care. They can't. To a layperson, "good care" is a polite receptionist, a short wait, and magazines in the waiting room that were published within the last three years. They're just not equipped to assess whether or not they were prescribed the right antibiotic, or if their kid's asthma is being managed optimally. Rude and obnoxious doctors and nurses are inexcusable, but this is a separate issue.

And I'll tell you this. In absolute seriousness. The WORST patients when it comes to assessing the quality of the care they get, are OB patients. They spend 10x as much time absorbing "facts" online and they are 10x as entitled. Pregnancy isn't like appendicitis or a broken arm, where the patient has a few hours of pain followed by a single encounter with the health care system. Pregnant women have 9 months to brood and ruminate on every aspect of the pregnancy, and there is no shortage of inexpert self-proclaimed experts to tell them what to think, and what to demand, and what they deserve, and what those stupid western-trained doctors don't know about the natural beauty of childbirth. The ones who come in with birth plans and doulas are typically the least informed and most strident.

All that said I really do like the OB side of my practice (anesthesia) because most patients are happy to be in the hospital, are reasonable people, and I enjoy my small part in making their happy event a little more comfortable (just an epidural) or safe (c-section).


tl;dr - I don't know anything about Ft Irwin, it could really be a malicious hellhole of malpractice and abusive staff ... but I bet that chick is crazy.

 

[NavyFP]

Pregnant women have 9 months to brood and ruminate on every aspect of the pregnancy, and there is no shortage of inexpert self-proclaimed experts to tell them what to think, and what to demand, and what they deserve, and what those stupid western-trained doctors don't know about the natural beauty of childbirth. The ones who come in with birth plans and doulas are typically the least informed and most strident.

I once had a patient bring in an Ortho nurse who CLEARLY knew more about L&D than I did. The patient wanted all natural child birth with an early epidural.

We joke that the biggest risk factor for a C-Section is a birth plan.

OB 99% fun, 1% total PIA.

 

[Mt Kilimanjaro]

I think I could handle small town living. Based on others posts, it also seems somewhat possible to gain more patients through moonlighting. But I have to say I ran across a site with some labor and delivery experiences and it has swayed me heavily against HPSP.

http://www.jcpost.com/2012/11/19/irwin-army-community-hospital-never-again/

I can't even imagine being apart of a system that functions this way. And this is not the only site I found with similar stories. Can anyone discount these claims or does this type of insanity go on?

I think (hope?) this comment is supposed to be a joke, but I would just point out that it is also presented as anecdotal evidence that IACH medical providers are incompetent in the comments section below the article cited above:

January 7, 2013 - 12:52 pm

I was sent to the Irwin OB/GYN section even though I was a 36 year old MALE Staff Sergeant, 11B. They insisted that I have a Pap smear and an ultrasound of my uterus. I kept telling the sick call people that I was a man, was not pregnant and did not have a uterus. They threatened to inform my command that I was not being “cooperative” with the staff. When I went to Irwin, they put me on a table with stirrups and conducted their “pap smear” I kept telling them that they were smearing my rectum, but they would hear none of it, as “they were the experts”. I never went to sick call again after that.

 

[Gastrapathy]

I think (hope?) this comment is supposed to be a joke, but I would just point out that it is also presented as anecdotal evidence that IACH medical providers are incompetent in the comments section below the article cited above:

January 7, 2013 - 12:52 pm

I was sent to the Irwin OB/GYN section even though I was a 36 year old MALE Staff Sergeant, 11B. They insisted that I have a Pap smear and an ultrasound of my uterus. I kept telling the sick call people that I was a man, was not pregnant and did not have a uterus. They threatened to inform my command that I was not being “cooperative” with the staff. When I went to Irwin, they put me on a table with stirrups and conducted their “pap smear” I kept telling them that they were smearing my rectum, but they would hear none of it, as “they were the experts”. I never went to sick call again after that.

You aren't really this naive are you? This is pretty funny.

Uber-entitled OB patients and the equally entitled helpers are no better at judging quality than the patient sitting in the next bed over from where I'm standing who has a headache that is only cured by pain meds starting with the letter D.

Just for clarification, Irwin Army Hospital isn't at Fort Irwin.

For the OP, overall military residencies are on-par with solid community programs. There are exceptions in both directions. Nearly everyone trained in our system becomes competent and some become exceptional physicians. The biggest problem is the inability of anyone to see into the future and there are serious storm clouds on the horizon. The other larger issue is whether you will get to practice the full scope of your training thereafter. You want to be a place where you can keep doing, keep learning, etc. Instead, you will likely be in a place where you are expected to teach (right out of training) and share your cases with trainees or a place where there isn't the necessary diversity or volume.

 

[UltimateDO]

Most of the examples of problems with skill atrophy I have seen, including the ones above, are for sub-specialists. What about things like family medicine, EM, or general surgery? Are there similar problems with skill or knowledge atrophy at locations that lack the diversity of patients provided by a large MTF with lots of retirees and dependents around? In other words, can a BFE post work out alright for some specialties?

Skill atrophy is very real for all specialties. I just got back from 12 months in Afghanistan, I was very good at trauma and sport injuries when I got back but was EXTREMELY rusty in transitioning back to inpatient care, especially in the MICU. I am just now (6 months later) getting back to the state I was in before I left. This is very typical for any operational tour. I am moving to an operational slot with the understanding with the command surgeon that I can spend a week a month back here at WAMC on the wards or MICU to maintain my skills.

 

[upchit]

I can't attest to sub-specialties but I did a primary care internship and thought I received excellent training. I logged far more procedures than my civilian counterparts at the hospital across town and while I probably worked more total hours than they did, I like to think I have some good experience under my belt.

I think it's all about what you put into it. If you don't want to study for your in-training exam and just wing it to get by and pass then you will have a different experience than if you set high goals for yourself, which is true no matter where you are.