Question about IM fellowships

[residentphysician20]

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I graduated from IM residency not long ago and deployed almost immediately after graduation. The deployment was better than I expected but needless to say I do NOT want to do it again. I never wanted to do a fellowship, but now I am thinking about doing one (GI is really the only thing I would consider) just to minimize my chance of another deployment later on; I did ROTC for undergrad, which means I will be in the army for a good while.

Is it still possible to do a fellowship in the army? I do not want to do a civilian program (added commitment), but I know that army fellowships like GI are very competitive. Fortunately, I did well enough in residency and my deployment experience should give me a leg up.

I hate to say it but one of the primary reason that I am thinking about a fellowship is to lower my chance of deployment in the future. To my understanding, subspecialists are more likely to be stationed at big hospitals and deploy less. However, I also know that subspecialists can be deployed as a general IM doctor, which would be even worse if I were to do a fellowship. Also, with the way DHA is going, I am worried about skill atrophy if I were to pursue a specialty like GI.

 

[MedicalCorpse]

I hate to say it but one of the primary reason that I am thinking about a fellowship is to lower my chance of deployment in the future. To my understanding, subspecialists are more likely to be stationed at big hospitals and deploy less. However, I also know that subspecialists can be deployed as a general IM doctor, which would be even worse if I were to do a fellowship.

I remember rumors/stories of radiologists and pathologists being ordered see sick call downrange in Iraq and Afghanistan.

The common refrain from their nurse commander was: "Well, you're a doctor, aren't you?"

Does anyone have any knowledge whether this is true or just wasteland legend?

PS For a few months in 2003, I was assigned to an MICU deployment team to fill a respiratory therapist slot.
When I formally told command that I was a board-certified anesthesiologist who was not competent to do
everything an RT does, including troubleshooting malfunctioning ventilators, etc., I was told, "Thank you, LtCol Jones,
now shut up."

Who knows, you could deploy as an OB/Gyn if your command orders it so. "You did that in internship,
right? Don't forget to pack your catcher's mitt."

You will just be a physician body. They won't care if you are a Pediatric GI subspecialist or a GMO.

 

[DrMetal]

I graduated from IM residency not long ago and deployed almost immediately after graduation. The deployment was better than I expected but needless to say I do NOT want to do it again.

You're not supposed to like it. Nobody looks forward to deployment, unless you're trying to get away from your family. Deployment is also maybe desirable if you're on a naval vessel; it turns out being deployed out at sea is easier (in terms of your workload) than being in port.

I hate to say it but one of the primary reason that I am thinking about a fellowship is to lower my chance of deployment in the future.

A terrible idea, not true. You can still be deployed as a general internist, which will make you feel even dumber (as a trained rheumatologist).

Do the fellowship if and only if you're truly interested in the subject matter.

 

[residentphysician20]

Thanks for the straight advice.

From my observations, it seems most senior physicians who are able to stay at one place for 10-20 years and rarely (if ever) deploy are sub-specialists. Because of my long ADSO, this is something I want for myself. My spouse will also benefit from me staying at one place instead of moving every 3-4 years.

 

[Correlate Clinically]

I can't speak to IM specifically and my experience is USAF, not Army.

It's not so much that a fellowship means you are less likely to deploy in your AFSC. The taskings are tied to primary AFSC, not your fellowship: A cardiologist can deploy to fill an IM slot, a neurorad to fill a general rad slot, etc. I deployed with an Endo filling a hospitalist position.

Fellowship trained folks tend to concentrate in the major MTFs and GME programs. Being at a major MTF means there is a much larger pool of people when the tasking comes down. Usually, that is. Some specialties like ENT just don't have a lot of AD guys anywhere. But being in a bigger pool reduces your relative chance of deploying.

The major MTFs are generally supposed to be tasked more often than smaller places. Sometimes consultants redirect and try to balance that out, but it varies.

If you are one of 2 IM guys at base X, you have a pretty good chance of deploying if your base or command is in line for a tasker. If you are at SAMMC with 20+ (or however many they have) staff, your individual chances are proportionally lower if there is a tasking. In theory, the chances of a tasking to a place like SAMMC are higher than they are at Fort middle of nowhere. It doesn't always work out that way.

It's playing the odds.

As far as being ordered to do things outside scope: It has happened a very small number of times in my career, but I just say no. There is a difference between a military and a medical order. There's also a difference between the risk I am willing to accept deployed (during OIF/OEF) vs at home station. I may have just been lucky, but so long as I have maintained a poker face and been respectful I have not had permanent adverse consequences. Someone else could have had a different experience.

 

[DrMetal]

Thanks for the straight advice.

From my observations, it seems most senior physicians who are able to stay at one place for 10-20 years and rarely (if ever) deploy are sub-specialists. Because of my long ADSO, this is something I want for myself. My spouse will also benefit from me staying at one place instead of moving every 3-4 years.

Well look, you can do WTF you want, I still think it's a bad idea to be sub-specializing, solely to escape from general IM or to avoid deployments (none of this is guaranteed). When the next big conflict comes, they'll still deploy you.

It's also the rest of your life we're talking about, so make sure you pick something you like. I known many who sup-specialized to get away from general IM, only to later find out that life isn't so great as a civilian nephrologist (when you're covering 5 dialysis centers, have a hospital consult list > 50, and you're getting paid the same or slightly more than a hospitalist).

 

[militaryPHYS]

You want to 1) not deploy again and 2) stay in one place for your career??

This means you need to get out as fast as possible. Please do not stay in and then get mad at everyone else and the military for doing what it does and has done for decades.

Stay in because you want to continue to serve and go where the military tells you to go. Sub-specialize while still in if you want additional commitment so that you can stay in and do what the military tells you to do.

 

[residentphysician20]

You want to 1) not deploy again and 2) stay in one place for your career??

This means you need to get out as fast as possible. Please do not stay in and then get mad at everyone else and the military for doing what it does and has done for decades.

Stay in because you want to continue to serve and go where the military tells you to go. Sub-specialize while still in if you want additional commitment so that you can stay in and do what the military tells you to do.

I get what you are saying.

It's just that I am still a bit bitter about being sent to the box right after residency. It's what I signed up for, I get it, but seeing plenty of peers/mentors not deploying once over their ADSO makes me a bit bitter. I am not afraid to admit it. It's how I feel.

Now, if there is a way to decrease the likelihood of moving and deploying in the future by pursuing a fellowship, then that's something I am willing to do. However, that appears to not necessarily be the case with the navy and AF, based on the above responses.

 

[DrMetal]

It's just that I am still a bit bitter about being sent to the box right after residency.

Your bitterness is noted, warranted, and your honesty is appreciated.

I've seen medical officers make O-6 without ever leaving the confines of a MTF. Of course, they claim their promotion is deserving, given the academic "juggernauts" that they've become (seeing 8 patients/day, and managing residents who spend 50% of their time away from the MTF).

Such is life. It's definitely not a fair world.

 

[Correlate Clinically]

If it's something you want to do anyway, it may or may not help you. Don't box yourself into a subspecialty if you don't actually like it. You'll be stuck with that fellowship forever. The military just sometimes feels like forever.

I understand the feeling about the deployment. I remember heading out pretty soon after residency and seeing guys finishing up their 4 yr commitment with no deployments at all. I knew I had a long commitment and would probably be going again. There were times away from my family that I was pretty angry. It's natural.

 

[Gastrapathy]

Army Gastroenterologists deploy. Those O6s you’re seeing snuggled up at Walter Reed might not so guess who does when the tasker reaches their desks.

GI is good.

 

[residentphysician20]

Army Gastroenterologists deploy. Those O6s you’re seeing snuggled up at Walter Reed might not so guess who does when the tasker reaches their desks.

GI is good.

Do army GIs deploy as GIs or do they fill IM slots? Both?

 

[DrMetal]

Do army GIs deploy as GIs or do they fill IM slots? Both?

Both! probably more the latter (general IM). You're not doing many advanced endoscopies in the deployed setting, where you don't have much ICU nor general surgery support. If someone needs a stat ERCP, they usually get medevaced. So you're more likely to play the role of a general internist.

 

[residentphysician20]

Both! probably more the latter (general IM). You're not doing many advanced endoscopies in the deployed setting, where you don't have much ICU nor general surgery support. If someone needs a stat ERCP, they usually get medevaced. So you're more likely to play the role of a general internist.

Why not just deploy IM physicians then? Are there not enough of us to go around that the army/navy/AF must deploy sub-specialists so that the overall optempo is tolerable/fair to all?

 

[DrMetal]

Are there not enough of us to go around that the army/navy/AF must deploy sub-specialists so that the overall optempo is tolerable/fair to all?

In a sense, yes, but there doesn't need to be a rhyme or reason to it all.

There's also (sometimes) this sentiment that newly trained sub-specs (because they're young, and have known nothing but the academic-PGY life) need to be deployed or placed in some operational billet (to 'pay their dues', so to speak).

It's absolutely stupid, and can even be construed as waste-fraud-and-abuse (when you take a brand new rheum and throw her into a monkey operational role, while we're deferring our rheum patients out to the civilian network).

But of course, we seem to hit the 'stupid' button a lot in this business.

Anyway, bottom line: don't do a fellowship solely for the purpose of avoiding deployments/operational tours.

 

[afteranesthesia]

Hahaha I was at Bagram just a few years ago before it closed down with a GI doctor who was essentially acting like an internist. A total waste of their time. I think it's cute you think a fellowship will prevent a deployment. If you really want to dodge deployments, try vascular surgery. They do not deploy. Unsure what else doesn't. Maybe OB.

 

[Baron Samedi]

My friends, they put me in a general billet straight out of fellowship. When I was faculty, they put brand new fellowship grads into flight surgeon billets. I know a guy who got tasked with manning MEPS.

Fellowship won't protect you from garbage stateside, let alone while deployed.

 

[xffan624]

Why not just deploy IM physicians then? Are there not enough of us to go around that the army/navy/AF must deploy sub-specialists so that the overall optempo is tolerable/fair to all?

Certainly during the height of Afghanistan/Iraq wars, there were a lot of deployments to go around. Sending just the IM doctors would have been unacceptable. An IM doc doesn't have much to challenge them in a deployed environment either. My roommate in Iraq was an IM doctor and she definitely lamented of her skills being wasted in a low resource MTF with mostly healthy soldiers and the occasional National Guard soldier who's getting free healthcare and wants the doctor to fix their ten year old back pain and every other medical problem they have while deployed.

 

[militaryPHYS]

If someone can't handle a 6-12 month block of time away from patient care at any time post-training, Military Medicine is not for you.

If someone can't handle the possibility of being utilized in your basic board certification (vice sub-specialty training) to fill "needs", Military Medicine is not for you.

If someone can't handle being pulled from a O6 promotable position at a large MTF practicing in your specialty to be placed in to a senior O3 or Junior O4 operational billet to fill needs, Military Medicine is not for you.

Any questions?

So either don't sign up for Military Medicine, sign up and then b!tch and complain when known things like this happen to you, or sign up and then utilize it for what it is (while probably still b!tching and complaining). What I mean by this is that if you plan to stay in, operational tours are part of life, usually short (~2 years), and often can provide ample "free time" to pursue other passions/goals like a masters, PhD, exotic cooking for beginners, more time with family when not deployed, warfare pins, locums, etc.

 

[residentphysician20]

If someone can't handle a 6-12 month block of time away from patient care at any time post-training, Military Medicine is not for you.

If someone can't handle the possibility of being utilized in your basic board certification (vice sub-specialty training) to fill "needs", Military Medicine is not for you.

If someone can't handle being pulled from a O6 promotable position at a large MTF practicing in your specialty to be placed in to a senior O3 or Junior O4 operational billet to fill needs, Military Medicine is not for you.

Any questions?

So either don't sign up for Military Medicine, sign up and then b!tch and complain when known things like this happen to you, or sign up and then utilize it for what it is (while probably still b!tching and complaining). What I mean by this is that if you plan to stay in, operational tours are part of life, usually short (~2 years), and often can provide ample "free time" to pursue other passions/goals like a masters, PhD, exotic cooking for beginners, more time with family when not deployed, warfare pins, locums, etc.

Already did that for my deployment shortly after residency. Would rather not have to repeat it. But that may or may not happen given the optempo, luck, etc.

Looks like I'll put the fellowship decision on the back burner for now.

 

[backrow]

If someone can't handle a 6-12 month block of time away from patient care at any time post-training, Military Medicine is not for you.

If someone can't handle the possibility of being utilized in your basic board certification (vice sub-specialty training) to fill "needs", Military Medicine is not for you.

If someone can't handle being pulled from a O6 promotable position at a large MTF practicing in your specialty to be placed in to a senior O3 or Junior O4 operational billet to fill needs, Military Medicine is not for you.

Any questions?

So either don't sign up for Military Medicine, sign up and then b!tch and complain when known things like this happen to you, or sign up and then utilize it for what it is (while probably still b!tching and complaining). What I mean by this is that if you plan to stay in, operational tours are part of life, usually short (~2 years), and often can provide ample "free time" to pursue other passions/goals like a masters, PhD, exotic cooking for beginners, more time with family when not deployed, warfare pins, locums, etc.

I mean that’s great and all but it’s only that way because military medicine isn’t optimized and it’s struggling even worse right now.

I’m not an MHS basher or fall really too far on either side of the “its the best thing since sliced bread” vs “it’s the worst thing ever”; however, the arguments you make above don’t make for the best medicine and for the best for every sailor, soldier, etc.

If we are going to “Get Real, Get Better” we have to get real about what creates the best chance of survival for our warfighters on the battlefield AND for the healthcare of them and their families at home. Pulling an O6 fellowship trained specialist from that O6 billet at a large MTF for 2 years ain’t it. That means you’re pulling someone who is around 10-12 years out from fellowship (in most cases) which means they should be at the pointy edge of excellence in their field. That’s not the person you pull to go be an admin person or a general medical officer.

There is much that is done right in military medicine, but there is a lot of room for improvement. We need people in the military who question the system and look for change.

 

[Baron Samedi]

If someone can't handle a 6-12 month block of time away from patient care at any time post-training, Military Medicine is not for you.

If someone can't handle the possibility of being utilized in your basic board certification (vice sub-specialty training) to fill "needs", Military Medicine is not for you.

If someone can't handle being pulled from a O6 promotable position at a large MTF practicing in your specialty to be placed in to a senior O3 or Junior O4 operational billet to fill needs, Military Medicine is not for you.

Any questions?

So either don't sign up for Military Medicine, sign up and then b!tch and complain when known things like this happen to you, or sign up and then utilize it for what it is (while probably still b!tching and complaining). What I mean by this is that if you plan to stay in, operational tours are part of life, usually short (~2 years), and often can provide ample "free time" to pursue other passions/goals like a masters, PhD, exotic cooking for beginners, more time with family when not deployed, warfare pins, locums, etc.

How many 21 year old college juniors considering HPSP/USU know this at all or, if they do, know the ramifications of what you're talking about?

Even the pre meds reading this thread have no idea what you actually mean and how it will impact them and their future careers. It's no fault of theirs, but they can't possibly understand just how bad those scenarios are without going through it themselves.

 

[pathophysiologist]

My friends, they put me in a general billet straight out of fellowship. When I was faculty, they put brand new fellowship grads into flight surgeon billets. I know a guy who got tasked with manning MEPS.

Fellowship won't protect you from garbage stateside, let alone while deployed.

Just curious, how long ago was this? Can’t believe this is still going

 

[Baron Samedi]

Just curious, how long ago was this? Can’t believe this is still going

Within the last year

 

[militaryPHYS]

I mean that’s great and all but it’s only that way because military medicine isn’t optimized and it’s struggling even worse right now.

I’m not an MHS basher or fall really too far on either side of the “its the best thing since sliced bread” vs “it’s the worst thing ever”; however, the arguments you make above don’t make for the best medicine and for the best for every sailor, soldier, etc.

If we are going to “Get Real, Get Better” we have to get real about what creates the best chance of survival for our warfighters on the battlefield AND for the healthcare of them and their families at home. Pulling an O6 fellowship trained specialist from that O6 billet at a large MTF for 2 years ain’t it. That means you’re pulling someone who is around 10-12 years out from fellowship (in most cases) which means they should be at the pointy edge of excellence in their field. That’s not the person you pull to go be an admin person or a general medical officer.

There is much that is done right in military medicine, but there is a lot of room for improvement. We need people in the military who question the system and look for change.

I get it and I agree, but the mission of MilMed is to support the fighting forces. Someone has to man the ships and/or fill wing surgeon billets. The Navy held on to GMO’s (the intern level ones) longer than anyone but finally recently gave in. Army and Air Force have been using board certified experts to fill operational billets for a long time.

Somebody has to do it. People complain that interns aren’t qualified but also complain that board certified docs have better things to do. We’ll never find a solution that pleases everyone.

 

[militaryPHYS]

How many 21 year old college juniors considering HPSP/USU know this at all or, if they do, know the ramifications of what you're talking about?

Even the pre meds reading this thread have no idea what you actually mean and how it will impact them and their future careers. It's no fault of theirs, but they can't possibly understand just how bad those scenarios are without going through it themselves.

I also agree that premeds may have no idea what this will actually mean for them but I’m bringing it up so they can start to think about it, ask about it, consider the issues.

It’s a part of MilMed because we support the line. It’s been this way for decades and we all know plenty of people who have been pulled away and figured out how to make it work and then successfully retired/separated and did very well in their new practice.

Point is, it’s something one has to accept as possible, even probable, if they are signing up so they aren’t surprised post-residency/fellowship

 

[Gastrapathy]

I’m curious about the claim that we have done away with GMOs. Given the persistent mismatch between the number of interns and PGY2 slots both in service and out, it seems like they must be going somewhere

 

[backrow]

I’m curious about the claim that we have done away with GMOs. Given the persistent mismatch between the number of interns and PGY2 slots both in service and out, it seems like they must be going somewhere

They haven’t gone away completely for the Navy (nor AF or Army); however the number of folks who go into GMO billets after internship is drastically reduced from 5-10-20 years ago. I don’t have the numbers in front of me; however, something like 70% plus of medical students in the Navy are now matched for straight through training.

Pretty much every (if not every) specialty now matches at least some for straight through training and some, such as ENT, Ortho, Ophtho (and probably others) essentially match 100% for straight through training.

The vast majority of people going GMO over the last 2-3 years were people who ended up as “unmatched” TY’s with a handful being people who tried to match something and instead got their #2 (or below) choice and were not selected for a continuous contract. A very small minority (but likely growing) are part of the GMO Pilot program where they are selected for both residency and GMO, meaning they complete internship and go off to a 3 year GMO tour, but are already guaranteed a residency spot in 3 years without having to re-apply.

 

[pathophysiologist]

Within the last year

I am not IM so I am curious as to the reason behind putting fellowship trained specialists in general flight surgery billets. Did the army train too many rheumatologists and didn’t have enough rheumatology billets for everyone? Or is there not enough people to fill these other billets and every specialty has to now chip in? What’s the reason behind the madness?

 

[Baron Samedi]

I am not IM so I am curious as to the reason behind putting fellowship trained specialists in general flight surgery billets. Did the army train too many rheumatologists and didn’t have enough rheumatology billets for everyone? Or is there not enough people to fill these other billets and every specialty has to now chip in? What’s the reason behind the madness?

I'm also not IM.

The biggest issue is that there are no such thing as "subspecialists" in the Army. You are your primary MOS and your subspecialty is irrelevant for staffing.

 

[pathophysiologist]

I'm also not IM.

The biggest issue is that there are no such thing as "subspecialists" in the Army. You are your primary MOS and your subspecialty is irrelevant for staffing.

This I know, but I was not aware how widespread this is. At least at my small MTF, the personnel are utilized appropriately in the right billets.

 

[Gastrapathy]

@backrow thanks for the explanation, so probably still ~100 GMOs a year? I’m glad we’ve moved partway towards what they promised when they identified this problem in 1996.