Since it seems most posters on here who took the HPSP scholarship hated it...

[idq1i]

Don't get me wrong...I think that an FP grad is superior to a 2-yr GMO in most ways. I just don't think that Sports Med is one of them.

I probably had as many Sports Med cases in my first 4-months as a FS as an FP resident had through their entire residency. Have I made mistakes? Sure...but I don't think that they were mistakes unavoidable by a recent FP grad. Don't poo poo self learning. I have always learned best by reading and doing...and there is always a SMO available somewhere to bounce ideas off of. I am very confident that I could enter a Sports Med fellowship tomorrow, without a residency under my belt, and do very well amongst FP grads. I couldn't say that about most specialities...but Sports Med, absolutely.

Sorry if I have offended FPs out there. That absolutely wasn't my intent.

That reminds me of a recent argument I had with a local primary care PA who kept ordering the wrong type of study for the wrong reason. His excuse was that he has had 14 years of "orthopedics" experience and he doesn't have to listen to me... As the post above me states, you don't know what you don't know.

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[j4pac]

That reminds me of a recent argument I had with a local primary care PA who kept ordering the wrong type of study for the wrong reason. His excuse was that he has had 14 years of "orthopedics" experience and he doesn't have to listen to me... As the post above me states, you don't know what you don't know.

A green-FP grad doesn't know what he doesn't know in regards to Sports Med...with their vast orthopedic experience. Give me a break.

 

[notdeadyet]

And because most of the individual programs are, on the whole, comparable in quality to middling-to-upper-tier civilian programs.

I'd agree with this, assuming you're talking about non-academic community programs. From what I've seen, I'd compare most military medicine programs to middle-of-the-road Acme County ____ Residency, but I don't think most of the military GME quality is close to even a middle-tier academic program in most specialties. This is not a knock. I just feel the "sweet lemons" around SDN gives a false bill of goods to potential HPSP-takes. You can get better residency training as a civilian. Not at the community programs that will take any English-speaker with a pulse, but not at Duke, either.

Fellowships and employers like ex-military. Good work ethic, able to do more with less, and spent at least 4 years drug free. But I'd be curious how often folks hear fellowships or employers say, "You did your residency at MADIGAN? Your clinical skills must be amazing?" And I'd be suspicious of those that do just saw too much MASH.

 

[notdeadyet]

Anytime you rotate outside, you are free labor, speak English and show up on time. It doesn't take much more to succeed. Military physicians are a predictable and above average commodity. I tend to think that this is because of the quality of the people rather than the quality of the education.

This.

 

[notdeadyet]

A green-FP grad doesn't know what he doesn't know in regards to Sports Med...with their vast orthopedic experience. Give me a break.

Irony...

 

[pgg]

Don't get me wrong...I think that an FP grad is superior to a 2-yr GMO in most ways. I just don't think that Sports Med is one of them.

I probably had as many Sports Med cases in my first 4-months as a FS as an FP resident had through their entire residency.

I should back up. The problem with this line of discussion is that you're cherrypicking the ONE piece of a GMO's practice where (a) the gap between a seasoned GMO's care and a newbie FP's care may be fairly narrow, and more importantly (b) where the consequences for mismanagement are not very damaging.

Because if you miss something, order radiological studies inappropriately (or don't order them at all), try PT and Motrin when they really need an ACL reconstruction, whatever ... the patient doesn't get better, comes back, eventually finds his way to an orthopod who handles it. In broad general terms, the worst case scenario from sports med mismanagement at the first clinic contact is typically a delay in treatment. Long term morbidity from delayed diagnosis for typical operational sports injuries isn't frightening, and there's practically no mortality to speak of.

It's the rest of a GMO's practice where the real danger lies.

I used to think like you did on this subject. I really did. At the time I felt pretty confident that I was doing a great job as a GMO. Referring the stuff beyond me, handling the stuff within my capabilities, not doing anything dangerous. I was arguing in the opposite direction, to replace GMOs with PAs, not attending physicians. Somewhere on this forum, I'm sure those posts can be found.

 

[j4pac]

I should back up. The problem with this line of discussion is that you're cherrypicking the ONE piece of a GMO's practice where (a) the gap between a seasoned GMO's care and a newbie FP's care may be fairly narrow, and more importantly (b) where the consequences for mismanagement are not very damaging.

Because if you miss something, order radiological studies inappropriately (or don't order them at all), try PT and Motrin when they really need an ACL reconstruction, whatever ... the patient doesn't get better, comes back, eventually finds his way to an orthopod who handles it. In broad general terms, the worst case scenario from sports med mismanagement at the first clinic contact is typically a delay in treatment. Long term morbidity from delayed diagnosis for typical operational sports injuries isn't frightening, and there's practically no mortality to speak of.

It's the rest of a GMO's practice where the real danger lies.

I used to think like you did on this subject. I really did. At the time I felt pretty confident that I was doing a great job as a GMO. Referring the stuff beyond me, handling the stuff within my capabilities, not doing anything dangerous. I was arguing in the opposite direction, to replace GMOs with PAs, not attending physicians. Somewhere on this forum, I'm sure those posts can be found.

I'm certainly not a FS/GMO fanboy. I do believe that they are often liabilities and our patients would be better served with residency trained attendings. I'm not cherrypicking...my post was in response to deuist's statement when flight surgeons send home patients with broken ankles without ever bothering to do an x-ray or place a splint because they think that their physical exam skills can rule out a fracture. I agree with him that GMOs should be phased out. However, I believe that primary care training of sports med is WEAK, and mismanaged Sports Medicine/back pain patients isn't monopolized by GMOs.

Does a recent FP grad even know how to perform a comprehensive ankle exam and evaluation? Do they know that 5th metatarsal avulsion fractures are a common cause of acute lateral ankle pain and that it is poorly visualized by an ankle film? Are they looking for talar dome fractures on x-ray? Do they know that proximal lower leg films are required in the evaluation of a high ankle sprain? There are lots of ways to delay treatment...even for attendings with limited Sports Med instruction and experience.

I'm willing to wager that the PCMs who are good at Sports Med aren't good because of their residency training...they're good because they went out of their way to learn about their patients in practice.

 

[idq1i]

If I read your post correctly, you agree that GMO needs to go away. If so, why not just provide extra msk training for milmed-trained PCMs in residency? This way, there is no longer half baked physicians OJTing on a captive population of naive kids?

 

[HighPriest]

If I read your post correctly, you agree that GMO needs to go away. If so, why not just provide extra msk training for milmed-trained PCMs in residency? This way, there is no longer half baked physicians OJTing on a captive population of naive kids?

You are striking at the heart of milmed.

 

[idq1i]

You are striking at the heart of milmed.

I'm so frustrated when I see mismanagement and OJT when it comes to all these 17-20 year old soldiers (I call them children-because that's what they are). There's little I can do because of my MOS, but I try my best. At least I was able to win the fight of medics ordering studies and Meds independently

 

[HighPriest]

At my current station, I have regularly felt like the Army institution of "doing more with less" has creeped into the zone of "doing more than you should with what you have." There's an apparently fine line there.

 

[j4pac]

If I read your post correctly, you agree that GMO needs to go away. If so, why not just provide extra msk training for milmed-trained PCMs in residency? This way, there is no longer half baked physicians OJTing on a captive population of naive kids?

In an ideal world GMO would go away. We would have nothing but a bunch of highly training residency trained physicians running the show. But until military GME improves I could never endorse taking GMO away. GMO is an option to get out and seek civilian training. Without GMO...I would be in an enormous world of hurt right now. I would have to decide between FP (yuck) and Neurology (meh). Quite honestly, I would consider going into a different line of work.

 

[idq1i]

I don't understand why you would have to completely change milmed gme to eliminate GMOs.

1-expand the number of slots for FP residency.
2-designate a percentage of these slots as operational. Offer a $ bonus if needed. Be honest as to what "operational" means
3-include msk training as part of residency as sel/electives. This way ACGME wouldn't be a problem
4-utilize these people as GMOs and BDE surgeons
5-win/profit. No more GMO, no more suspecialty Bde surgeons, etc. Happier staff, possibly higher retention.

idq1i gets another MSM...

 

[j4pac]

I don't understand why you would have to completely change milmed gme to eliminate GMOs.

1-expand the number of slots for FP residency.
2-designate a percentage of these slots as operational. Offer a $ bonus if needed. Be honest as to what "operational" means
3-include msk training as part of residency as sel/electives. This way ACGME wouldn't be a problem
4-utilize these people as GMOs and BDE surgeons
5-win/profit. No more GMO, no more suspecialty Bde surgeons, etc. Happier staff, possibly higher retention.

idq1i gets another MSM...

No...I agree with you. I think that GMOs could easily be eliminated. I don't think that there is any question that it would be in the best interest of our patients.

But let's think about what we would be doing. Here are my two concerns:

1) We would be taking a board certified FP and having their skills atrophy in a GMO billet. There will be FPs who would complain. There are attendings who complain about skills atrophy in their HOSPITAL jobs while being in military! I know that if it was me...I would rather my skills atrophy between internship and residency than AFTER residency. Skills atrophy AFTER residency is a huge patient health concern for our patients who are actually sick in the hospital when their attending is a returning GMO.

2) GMO currently serves as an out for medical students who sign up for the military, only to find out that their desired specialty is not a military priority. I didn't know about PM&R until my 3rd year of medical school...and come to find out...the Navy has only trained one PM&R resident at Walter Reed over the last 10+ years. I applied to the program twice, while being plenty competitive, the program loved me...no luck. Because I had the option to apply civilian after completing my GMO tour, lo and behold, I match to Mayo Clinic. It is incredibly common for people to do their 4-year payback as GMOs and move on to better opportunities on the outside. And we aren't talking about competitive residencies such as Neurosurg, Derm, Urology, and ENT. We are talking about strong competition for Peds, Neurology, and PM&R...all specialties that are fairly easy to match in the civilian sector. Eliminating GMOs will funneling young military physicians to FP...essentially against their will. I see a problem with that.

 

[idq1i]

My point is to create a separate milmed FP track, with financial enticements so that there are no complaints. Increase the $ incentive until there are takers

 

[j4pac]

My point is to create a separate milmed FP track, with financial enticements so that there are no complaints. Increase the $ incentive until there are takers

I like that plan and I could see lots signing on for it. How would signing occur? Would you essentially be trying to match into that spot?

I honestly think that military GME should go away if GMO goes away. I couldn't recommend HPSP to anyone who doesn't have the opportunity to abandon ship if their selected residency is not available. I could endorse FAP, however, which offers significant more flexibility and options for training.

 

[idq1i]

I like that plan and I could see lots signing on for it. How would signing occur? Would you essentially be trying to match into that spot?

I honestly think that military GME should go away if GMO goes away. I couldn't recommend HPSP to anyone who doesn't have the opportunity to abandon ship if their selected residency is not available. I could endorse FAP, however, which offers significant more flexibility and options for training.

I think there should be 2 FP paths:
One path is the standard FP where you'd work in a clinic/hospital/wherever. You may get deployed, you may not.

The second path is the operational FP, where you'd also match into a dedicated slot where you'd go through the standard residency, supplemented with extra MSK/psych training that would make you a better GMO-type provider. This way, you'd know what you are getting yourself into, you are compensated fairly for your choice, the patients are cared for by a fully competent MD. There is also the skill atrophy issue here, but that would be a choice that a senior medical student would have to make.

$$$+operation medicine vs. fully maintained skills...

 

[HighPriest]

What if I want to be a FP-trained GMO/Special Forces/Genetically enhanced super soldier/Cyborg? Can I do that additional training during medical school? What kind of incentives would I get?

 

[HighPriest]

Can I HALO drop into North Korea and punch Kim Jung Un in the taint, and then distribute Polio vaccines from a t-shirt cannon to the serfs? Is that something you can do as a military physician?

 

[j4pac]

Can I HALO drop into North Korea and punch Kim Jung Un in the taint, and then distribute Polio vaccines from a t-shirt cannon to the serfs? Is that something you can do as a military physician?

Pretty sure that idq's "war doc" path would be the best opportunity to do that.

 

[Member 1337]

In all seriousness, I always wanted to be a doc like Dr. McCoy on Star Trek, like he was a military doc and could do all sorts of stuff and discover cures, and do brain transplants (http://en.wikipedia.org/wiki/Spock's_Brain). My question is when in the military as a doc if you deploy and have to do a brain transplant can you do one in the field if people get injured far away from the hospitals? Like during a HALO drop into North Korea?

 

[idq1i]

Can I HALO drop into North Korea and punch Kim Jung Un in the taint, and then distribute Polio vaccines from a t-shirt cannon to the serfs? Is that something you can do as a military physician?

Yes. Only when he is meeting al Baghdadi

 

[pgg]

My point is to create a separate milmed FP track, with financial enticements so that there are no complaints. Increase the $ incentive until there are takers

The better plan would be to
a) recruit/hire more physicians so that operational tours could be distributed amonst more people and be short enough that skill atrophy would not be a significant problem
b) split their time while in garrison between the low acuity / high admin operational side, and a practice that sees the full spectrum of patients in their specialty

But that would cost money (particlarly part a), and the system is deemed to be adequate as is.

 

[HighPriest]

But that would cost money (particlarly part a), and the system is deemed to be adequate as is.

By everyone except patients and reported complication rates.

 

[BigNavyPedsGuy]

Can I HALO drop into North Korea and punch Kim Jung Un in the taint...

This might be the single best line I've ever seen on SDN.

 

[HighPriest]

In all seriousness, I always wanted to be a doc like Dr. McCoy on Star Trek, like he was a military doc and could do all sorts of stuff and discover cures, and do brain transplants (http://en.wikipedia.org/wiki/Spock's_Brain). My question is when in the military as a doc if you deploy and have to do a brain transplant can you do one in the field if people get injured far away from the hospitals? Like during a HALO drop into North Korea?

You can. You'll have to do dual residencies in Family Medicine and Neurosurgery and a fellowship in xenobiology. You should have time between residencies to attend ranger school and SEER school, which you will need to avoid capture while doing brain transplants. This is what military medicine is all about.

 

[j4pac]

Dr. McCoy...pssttt. Rubbish.

Dr. Sherman Cottle was responsible for the healthcare of the entire human race...and doing so with practically no resources. McCoy had all of the resources in the world...all of his special health screening gadgets. All Cottle had was has hands, his brain, and a cigarette.

 

[HighPriest]

Did Cottle do a brain transplant? If so, then you might be on to something. Although I don't know if you can use "surgeon for all of mankind" when all of mankind lives in a single ship. It's kind of misleading. But then again, McCoy didn't smoke, so he didn't look as cool while he worked...

 

[IlDestriero]

If I was the only doctor for the remains of the human race, I'd smoke too, and get paid in whisky.

 

[HighPriest]

If I was the only doctor for the remains of the human race, I'd smoke too, and get paid in whisky.

Of course you would. Who's going to say something? Who's gonna do a better appendectomy: the last doctor in the universe, but he's drunk, or some jerkoff with no medical training?

 

[HighPriest]

This thread is a rollercoaster of fantastic.

 

[j4pac]

Did Cottle do a brain transplant? If so, then you might be on to something. Although I don't know if you can use "surgeon for all of mankind" when all of mankind lives in a single ship. It's kind of misleading. But then again, McCoy didn't smoke, so he didn't look as cool while he worked...

I'm not trying to trivialize Dr. McCoy's accomplishments, but a 21st century doctors just completed the first skull/scalp transplant. It's not quite a brain transplant, but it's getting close.

http://insider.foxnews.com/2015/06/...rst-ever-skull-and-scalp-transplant-texas-man

 

[HighPriest]

Yeah, apples and oranges. They're doing face transplants with skeleton. No a huge difference. Some exposed dura. No big deal.

This is closer:
http://www.dailymail.co.uk/news/art...-head-transplants-mice-says-monkeys-next.html

 

[HighPriest]

So is this:


Be careful with that one. It's...kind of disturbing. I know it seems questionable, but I have read several sources verifying it.

 

[HighPriest]

And just in case you thought the Chinese and Russians were cornering the market:



Robert White's experiments.

 

[HighPriest]

Look how happy the monkeys look in those diagrams.

 

[j4pac]

Dude, what? That's like saying that doing a skin graft is getting close to a leg transplant.

Vulcan physiology is apparently very different from humans. Spock was able to survive WITHOUT A BRAIN...let me repeat that...SPOCK WAS ABLE TO SURVIVE WITHOUT A BRAIN! There is no chance that Dr. McCoy would have had a favorable outcome without an instruction manual for a "reverse brain transplant" and a unique patient that had a very accommodating body. If he would have performed the same procedure on Scotty, then I would have been impressed.

 

[razor]

It's funny how people throw out, "Do your time as a GMO, get out, and match to a civilian residency" so haphazardly. There are very real challenges for those who choose to go down that route.
...
Fourth, there are programs who are smart and can sniff out the weaknesses of an applicant who has been outside of inpatient medicine for 4+ years. It is a question that I encountered on interviews, and it is a question that I had a weak answer for. The truth is that my inpatient skills HAVE atrophied. There is no denying it...and it was inevitable by being out of a hospital for so long. Will I be able to relearn the material? I believe so...but to say that it isn't a weakness of mine is utter bull****. About of a third of the programs I applied to have interviews who also had concerns about skills atrophy.

3rd year HPSP student here with a question regarding the above quote. My ultimate goal is to separate from the Army and move back to my home state as a hospitalist as soon as I finish my ADSO (for personal/family reason, not because I am anti-Army so early in my HPSP time).

So my concern is, just like you mentioned with residency programs sniffing out atrophy, will I be able to get a job as a hopitalist after I spend my 4 ADSO years pushing paperwork in some BFE clinic? This is why I'm stuck between GMO-ing my way out for civilian residency and going straight through residency and suffering 4 years of atrophy then looking for a job after separating.

Is there any benefit to splitting up the 4 years AD time and doing a 2 yr GMO stint, then residency, then whatever kind of BS job they would stick me with for 2 more years? This way I wouldn't have 4 continuous years of mostly admin work in between either PGY1-Residency or Residency-civilian job.

Any thoughts/recommendations greatly appreciated. Like I said, I will likely gtfo as soon as I reasonably can (not necessarily looking for quickest way out, just not planning on making a .mil career) and want to set myself up for decent job opportunities back home.

 

[Red Lobster Actual]

Is there any benefit to splitting up the 4 years AD time and doing a 2 yr GMO stint, then residency, then whatever kind of BS job they would stick me with for 2 more years? This way I wouldn't have 4 continuous years of mostly admin work in between either PGY1-Residency or Residency-civilian job.

Seems possible. 1 year internship + 2 year GMO + 2 year internal medicine residency + 2 year utilization tour. Since hospitalists generally go through IM if I am not mistaken.

This is more like a Navy route though since Army likes to train their medical students straight through...

 

[IlDestriero]

I would think that the skill atrophy they're talking about above would be related to gmo after internship and not when you are a residency trained staff physician in practice. No one questioned my skills at my fellowship interviews. I was in practice using those skills. I rarely did kids (was applying for peds anesthesia) but that's the point of the fellowship.
They did question me about my willingness to go from an attending and division head back to a fellow, but I had an answer for that and it wasn't a problem. My answer assured them that I had thought about it and prepared. And of course being an attending for several years and board certified already and a proven leader put me above most applicants. Everyone loves a veteran. I saw it everywhere I went.
I guess I wasn't really a vet at the time, I was an active duty officer during war time. It doesn't get any better than that.

 

[IlDestriero]

You have to manage the spin. Sell your strong points and experience, avoid emphasis on weaknesses.
Example.
When being interviewed by the head of peds cardiac at Boston children's I didn't discuss that I hadn't done a peds heart in 5 years or even an adult heart in the last 4. She asked how I managed as the only anesthesiologist at my small rural hospital where I was at the time. I noted that the buck stopped here and with me. If I couldn't do something like a line or airway, or whatever, it wasn't going to happen and I'd have to work without it. There was nobody to call for help. I also had to work in a team with the surgeons and staff in bad situations unlike the Us vs them at the university hospital. Before she could lead me where I didn't want to go, I dropped an example.
GSW to the face, pre arrest, ETA 2 minutes to ED trauma bay. You assess your limited resources and give people a job that that they can do, in the order it needs to be done. There's no trauma team coming, no armband designations of roles and back ups.
Patient hits the door...
Surgeon doing cut down femoral lines, ED attending running rescuss, nurse or corpsman placing another IV and pushing fluid and meds, corpsman ready for compressions, X-ray tech on the way, and me doing surgical cricothrotomy to secure an airway. "You mean you assisted the surgeon placing the airway?" "No. I did it myself, he was busy placing a volume line." Boom. **** just got real.
Do you think she still had questions about my ability to get **** done in a bad situation?
It's not even hard, but it sounds impressive and few anesthesiologists have ever had to do one. That's the kind of unusual experience the military gives you that you can use to your advantage.
How about leadership? The most a resident can play is the chief card. Well that's great, but I did that, 3 or 4 years ago, and had attending level leadership now. Things most faculty don't have until the 2nd half of their careers. That's the nature of the military. They love to give the junior officers leadership duties. And I was at a small command. I had real collateral a duties, headed a committee or two, etc.
Exploit those experiences and skills. Few can compete. Same for when it's time for a civilian job.

 

[razor]

Thank you for your feedback. I guess my concern is whether I will even have anything to "spin." I'm worried, mostly from SDN-milmed-hatin', that I'm going to spend 4 years post-residency at the troop clinic looking at blisters and hungover 18y olds trying to get out of PT.
If I have a job with any semblance of hospital work then I will own it for sure; Thank you for your examples!

 

[asdf123g]

Thank you for your feedback. I guess my concern is whether I will even have anything to "spin." I'm worried, mostly from SDN-milmed-hatin', that I'm going to spend 4 years post-residency at the troop clinic looking at blisters and hungover 18y olds trying to get out of PT.
If I have a job with any semblance of hospital work then I will own it for sure; Thank you for your examples!

do military people just like not get sick?? lol

 

[Gastrapathy]

Young attendings leaving the military have no trouble getting jobs. The older guys can find it harder.

 

[razor]

do military people just like not get sick?? lol

Since I'm assuming it is unlikely that I will get a duty assignment at a MEDCEN, I would anticipate the average age on-post at Ft Middle-of-Nowhere is in the low 20s. Probably won't be writing-up case reports on the internal medicine I expect to see here.

 

[BigNavyPedsGuy]

Thank you for your feedback. I guess my concern is whether I will even have anything to "spin." I'm worried, mostly from SDN-milmed-hatin', that I'm going to spend 4 years post-residency at the troop clinic looking at blisters and hungover 18y olds trying to get out of PT.
If I have a job with any semblance of hospital work then I will own it for sure; Thank you for your examples!

I was a little worried about that since I hadn't really done any inpatient (other than nursery) for 3.5yrs. However, I was VERY surprised how the fact that I was in the Navy made people assume I was a competent good doctor. To be fair, they know I can show up on time, do what I'm told, etc. I'm also a big extrovert and interview pretty well.

You'll be fine. I would just try and go straight through and then payback my time. If nothing else you'll get paid a lot more as a staff doc for 2 years than you would as a GMO.

 

[deleted480308]

slightly off topic question here but since people are talking residency issues I'll ask......

is there a great reason that the military has to have it's own residencies? would it not work to just have the docs go to the much larger civilian system for training and then have them show up for work when they are done?

 

[Shikima]

Young attendings leaving the military have no trouble getting jobs. The older guys can find it harder.

There is the VA.

 

[psychbender]

It would certainly cost less to stop GME, and the associated level of care needed to maintain it. However, the argument would be made that we maintain a greater level of consistency in care when we train within the system. That was one of the reasons cited for keeping nearly all of the stateside combat casualty care at Reed and Brooke. Then, there's also the arguments about maintaining military customs, courtesies, behaviors, and understanding military life (eventhough there's actually very little real military in military GME).

 

[HighPriest]

slightly off topic question here but since people are talking residency issues I'll ask......

is there a great reason that the military has to have it's own residencies? would it not work to just have the docs go to the much larger civilian system for training and then have them show up for work when they are done?

Answers: no. They keep doing it because it's tradition, like church on Sunday's or hanging the confederate flag. And yes, that would be better.