Some questions about HPSP.

[FrankLake]

I'm interested in psych, neuro, IM (I'd be okay with being a hospitalist but would most likely want to subspecialize into cards), and EM, in that order.

How realistic is it to match into these specialties and avoid a GMO tour?

Let's say I match into psych. After completing my residency, will my payback period consist of me working as a psych doc for military personnel and their families for 4 years?

After serving my 4+ years will I be able to practice like my civilian counterparts or do I still have other obligations to fulfill?

How truthful are recruiters?

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[HighPriest]

For starters: any answer you get right now comes with a huge asterisk that relates to major changes occurring within military medicine right now, as the system switches control from the DoD to another organization. No one is sure what changes are going to occur, which will be sidelined, or how that will effect military medicine, specialty availability, or GMO tours. There is a ton of uncertainty, and anyone who tells you that they know how it is going to turn out is giving you their opinion, however optimistic or pessimistic it is.

GMO or not is somewhat service dependent. In the Army, you would definitively match without doing a GMO in to at least IM.*

If you complete a psych residency, then you will traditionally be working as a psychiatrist afterwards. The question always boils down to: what kinds of things will you be treating (patient population questions) and will you be forced into an operational (non-clinical) billet. For example: you will probably work with a lot of PTSD, and less severe uncontrolled paranoid schizophrenia because there's a decent amount of the former and much less of the latter in the military population. Operational-only billets are a thing in the Army, and I don't know how much it effects psyche, but it can definitely effect IM and even some subspecialties. This is when the military decides that it is more important for you to do paperwork and run a team of medics than it is for you to practice in the field of medicine in which you trained. It leads to dramatic skill atrophy, often making it difficult to return to practice afterwards. It is rare, but it's definitely a bad chamber to end up with when you're playing russian roulette. *

Once you're done with your obligation, you can leave or stay in the military. If you leave, and assuming you feel comfortable working (see the above), you just go get a job as a psychiatrist like everyone else.*

Recruiters are 100% untruthful, or at least you should assume that. They're not all bad people, but what I mean by it is: they have no idea what its like to be a physician. They have no idea what it is like to be a military physician. They have no idea what pitfalls are out there. They have no idea how that compares to civilian medicine. They're really just telling you what they're instructed to tell you by the military, with a lot of extrapolation, guesswork, and assumption mixed in. So even when they're accurate, it's by circumstance and not because they're being truthful. Think about it like this: if you worked for me and I told you to go out to the streets and tell everyone that the sky is blue and the earth is flat and you did that: are you being truthful? I mean, at most you're being honest if you tell people that you're just doing your job, but the information isn't entirely correct, is it?
i think a lot of them are trying to do the right thing, but there's just no way for most recruiters to relate to what you're talking about doing. Be wary of the recruiter who says he gets it because he was a medic, a nurse, or a PA. None of those are the same as doing HPSP and being a doc.*

 

[Medic741]

You *must* become informed on the changes occurring in military medicine.

Military Doctors In Crosshairs Of A Budget Battle — Kaiser Health News

 

[Detective SnowBucket]

You *must* become informed on the changes occurring in military medicine.

Military Doctors In Crosshairs Of A Budget Battle — Kaiser Health News

I'm also looking to take HPSP, reading through the article, I don't see why you should worry if you want to go in for a battlefield-necessary specialty. Of OP's choices, I'm only guessing the last of his specialty choices falls into this category but I also don't seeing them getting rid of his first choice specialty anytime soon.

So, if you are interested in a battlefield-necessary specialty, what's the worry?

 

[HighPriest]

Not knowing that you're going to go in to one of those specialties. Everyone thinks they know what they want to do, but most people don't until they're applying for residency (and even then it's questionable)
Not knowing what the training situation is going to be in the not-so-distant future, as the military may not be able to support GME without non-"battlefield" specialties.
Not knowing how reassignment to line units is going to effect clinical time.
Not knowing how not having non-"battlefield" specialties is going to effect "battlefield" specialties when it comes to garrison work. It'll be hard to be a good ER doc working in an ER who can't see anything worse than a hang-nail because they don't have any physicians covering call because there aren't any physicians. Patient in room 4 is having a heart attack....boy...that's a bummer...wish we had a cardiologist...
Not knowing how this is going to effect the necessity of operational billets. Fewer docs means more time behind a desk for the ones that remain.

There are a lot of unknowns. These aren't changes that will effect just a few people, leaving the others unscathed. This is part of the concern - they clearly haven't thought out all of the possible effects yet.

 

[Medic741]

I'm also looking to take HPSP, reading through the article, I don't see why you should worry if you want to go in for a battlefield-necessary specialty. Of OP's choices, I'm only guessing the last of his specialty choices falls into this category but I also don't seeing them getting rid of his first choice specialty anytime soon.

So, if you are interested in a battlefield-necessary specialty, what's the worry?

Because what happens when you’re stateside? How will you be utilized?

What pt population will you serve to maintain skills?

How will .mil maintain GME?

How will you keep skills up if there’s not a war?

 

[Detective SnowBucket]

I shadowed a team of orthopods stateside in milmed and they had plenty cases, they were at a military hospital doing operations all day long, across multiple days.

 

[HighPriest]

I shadowed a team of orthopods stateside in milmed and they had plenty cases, they were at a military hospital doing operations all day long, across multiple days.

Ah, well then I guess it's cool. What the hell does anyone else know?

Hopefully you end up in orthopaedics, and you're happy doing primarily sports medicine for young healthy patients, and you end up at that hospital and not in BF Missouri at a 10 bed facility. As long as all that happens, you should be ok.

Unless your hospitalists aren't comfortable taking care of your patients for you because they only see jock itch and muscle pain and so you have to take care of your own patients. Because that's antithesis for most orthopods.

And hopefully they can expand your outpatient GME experience so that you can actually do hips and spine and cancer so that you can complete an ACGME residency, because they won't be doing that stuff at the military centers anymore, ostensibly.

And hopefully none of that changes as the new order of things unfolds. I mean, it shouldn't right?

 

[colbgw02]

LOL

@Detective SnowBucket , maybe you should sit the next few plays out

 

[militaryPHYS]

How realistic is it to match into these specialties and avoid a GMO tour?

What will happen with MilMed due to current changes is anyone's guess. Hopefully it will be better than what we've had but the transition will be rough. BUT, no matter what, if this is your first question regarding finding out more about MilMed then you are at risk of joining for the wrong reasons. OR you just haven't spent enough time researching yet.

Never sign up with goal of avoiding a GMO tour. You will be a wanna-be civilian doctor trapped in a uniform for a long amount of time. It is a set up for Misery and Disappointment.

The worst places for Navy Ortho are Lemoore, CA and certain overseas billets (mainly the Europe ones). Lemoore is 1 of 1 and essentially and outpatient sports practice. Good for those who like sports and NO CALL, but bad for those who want to do joints, trauma or any other subspecialty. Europe locations having very low numbers to the point where you struggle to collect enough board cases to sit for Part II. Otherwise most places aren't horrible to go to. I guess 29 Palms is not highly desired due to location and only 2 persons to cover call.

 

[militaryPHYS]

LOL

@Detective SnowBucket , maybe you should sit the next few plays out

I have to disagree and I hate to think we would be ridiculing someone who directly engaged with a Milmed specialty to observe first hand. This is the best thing you can do when considering MilMed. It was also how I chose Milmed Navy Ortho. You find the thing you are most interested in and seek out direct exposure to it. Factor in unknowns of how your life may not be the same as those you are working with or shadowing and decide if the risk is worth the benefit.

When I was going through Navy ortho had consistently happy milmed physicians who kept a good volume within Milmed. The majority get out due to income difference but while they are in most are pleased. Therefore I directly sought it out.

I can't predict how DHA and such will change that for the future, but all we can rely upon are the facts currently presented to us.

 

[Matthew9Thirtyfive]

When I was going through Navy ortho had consistently happy milmed physicians who kept a good volume within Milmed. The majority get out due to income difference but while they are in most are pleased. Therefore I directly sought it out.

It’s anecdotal, but this is exactly how my AF orthopod cousin feels. He’s getting out in a year to make more money and not move again, but he’s really enjoyed his time in.

 

[HighPriest]

I can't predict how DHA and such will change that for the future, but all we can rely upon are the facts currently presented to us.

Except that in this case you can’t. Because these changes are likely to directly influence this experience on some way. It’s like saying “I was in Damascus in 2002 and it seemed nice.”

Ok. Well, you probably can’t rely on that anymore. Things have changed.

Now, I’m not saying I know exactly how the changes will effect the ortho experience described above, but to say that that information is predictive at this point isn’t necessarily accurate or helpful. It will probably be influenced in some way. It’s all farts and mist at this point.

No ridicule in doing an ortho rotation and doing your best to make decisions with the information that you can glean. You have to do it. Especially if the military already owns your soul. But to pass that experience as an expectation to potential applicants is disingenuous without adding the caveat that “this is how it was recently, but who knows...”

 

[Matthew9Thirtyfive]

Except that in this case you can’t. Because these changes are likely to directly influence this experience on some way. It’s like saying “I was in Damascus in 2002 and it seemed nice.”

Ok. Well, you probably can’t rely on that anymore. Things have changed.

Now, I’m not saying I know exactly how the changes will effect the ortho experience described above, but to say that that information is predictive at this point isn’t necessarily accurate or helpful. It will probably be influenced in some way. It’s all farts and mist at this point.

No ridicule in doing an ortho rotation and doing your best to make decisions with the information that you can glean. You have to do it. Especially if the military already owns your soul. But to pass that experience as an expectation to potential applicants is disingenuous without adding the caveat that “this is how it was recently, but who knows...”

This is a serious question, so don't think I'm trying to be snarky. But what do you think could possibly change so drastically that orthopods will have significantly different experiences than that? What could change so much that orthopods are no longer operating? Is the military suddenly going to shunt all the orthopods into non-clinical roles?

 

[HighPriest]

This is a serious question, so don't think I'm trying to be snarky. But what do you think could possibly change so drastically that orthopods will have significantly different experiences than that? What could change so much that orthopods are no longer operating? Is the military suddenly going to shunt all the orthopods into non-clinical roles?

I addressed all of those questions in my post above. This isn't a small change that's going to effect one portion of milmed - at least not if its implemented as planned. Orthopedic surgeons don't operate in a bubble. Small, outpatient sports-related surgeries may not be effected much. Larger procedures, GME training, and support probably will. Smaller MTFs may not be able to support an OR at all, meaning orthopedic surgeons will be compacted into the larger facilities. This may be good, or it may be bad, depending upon how it is handled. Fewer docs in general does, in fact, mean more specialists in non-clinical roles. Those operational positions aren't going away, and the Army clearly feels they're more important than clinical competency as evidenced by, well, all of Army history (can't speak for the Navy or AF). At the very least, the system will be gummed up by the lack of subspecialists. Need cardiac clearance? Well, the patient has to go to primary care, then be referred to a civilian cardiologist. That guy is going to get a Tricare patient in in 3-4 weeks. Then maybe he needs further workup. By the time he's in the OR, 2-3 months have gone by for a patient that might have been on the table in 2 weeks if things were handled in house.

Or maybe none of that happens. The point is no one knows. But assuming that ortho will continue to operate exactly as is inside some sort of protective bubble is someone naïve.

 

[Matthew9Thirtyfive]

I addressed all of those questions in my post above. This isn't a small change that's going to effect one portion of milmed - at least not if its implemented as planned. Orthopedic surgeons don't operate in a bubble. Small, outpatient sports-related surgeries may not be effected much. Larger procedures, GME training, and support probably will. Smaller MTFs may not be able to support an OR at all, meaning orthopedic surgeons will be compacted into the larger facilities. This may be good, or it may be bad, depending upon how it is handled. Fewer docs in general does, in fact, mean more specialists in non-clinical roles. Those operational positions aren't going away, and the Army clearly feels they're more important than clinical competency as evidenced by, well, all of Army history (can't speak for the Navy or AF). At the very least, the system will be gummed up by the lack of subspecialists. Need cardiac clearance? Well, the patient has to go to primary care, then be referred to a civilian cardiologist. That guy is going to get a Tricare patient in in 3-4 weeks. Then maybe he needs further workup. By the time he's in the OR, 2-3 months have gone by for a patient that might have been on the table in 2 weeks if things were handled in house.

Or maybe none of that happens. The point is no one knows. But assuming that ortho will continue to operate exactly as is inside some sort of protective bubble is someone naïve.

Interesting points. You're definitely right in that experiences prior to the changes can't be assumed to be predictive.

 

[HighPriest]

More orthos at larger MTFs might mean more complicated cases, but it also means dilution of case volume and less time in the OR due to competition. I don't necessarily think the former issue is that big a deal, as most military orthos don't work as much as their civilian counterparts. But competition for OR space is an actual issue. Wait until the military starts telling surgeons they should just buddy up on all their cases in order to maintain case volumes on paper. Three ortho docs all huddled around an arthoscopy and all counting it as a primary case.

What if you want to train your residents do to a hip on a VA patient, but that guy has some cardiac issues, maybe a little emphysema. Might need some time in the ICU, but you don't have an intensivist. Maybe you can talk the general surgeons in to taking care of him for you. maybe not. Maybe it's just easier and cheaper for the VA to send him to the local civilian hospital.


I think you can't safely have the opinion that one specialty is too important for the DoD or the DHA to make changes to it. I also think it's really overestimating the federal government to think that they have the foresight and understanding of how a medical system works to understand how changing something at "point A" effects "point B" no matter how important "point B" is to them. This is a complex issue for hospital systems that are efficient and profitable, let alone the DoD or federal government, who are never either or those things. it might as well be the butterfly effect for DHA. If they were good at managing healthcare, we wouldn't be in this position to begin with.

 

[colbgw02]

I have to disagree and I hate to think we would be ridiculing someone who directly engaged with a Milmed specialty to observe first hand.

Oh, is that all he did? Seemed like he took a single anecdotal experience to make wide sweeping conclusions and contradict people who have done and do this all day, every day. But yeah, props on the shadowing.

 

[militaryPHYS]

the Army clearly feels they're more important than clinical competency as evidenced by, well, all of Army history (can't speak for the Navy or AF).

Even those who are old enough to know some Army history know that these changes are unprecedented and like nothing military medicine has experienced before. Relying solely on experiences of waste/fraud/abuse of current and previous MilMed I think is naïve.

Those of us who have been in the system a while and have had a positive experience are more optimistic that anticipated changes will improve MilMed overall. Those of us who have been burned by the previous system tend to fear that the whole thing will go down in a blaze of glory.

Truth is. Nobody knows! You can make grave predictions about what consolidation and streamlining will mean for MilMed, but I can also predict the positive things the changes will eventually provide us. But again, nobody knows! But I do know what is going on in MY community right now and what my leadership is telling me. Not much else to go on right now.

Care will be consolidated. Surgeries and the subspecialists (even the ones everyone thinks will go away completely) will be consolidated at bigger centers. Small MTF's who do low volume, low acuity will be shut down and seen in town (yes, Tricare reimbursement is a problem). The plan, as far as I can tell is that the larger number of docs kept at the big centers will have MOU's in place to operate/practice out in town like we are already doing in many locations. It has been successful (for Navy ortho at least) and I think they are trying to capitalize on lessons already learned and the success it is having. Unfortunately consolidation means that areas they want to trim will experience direct horrible experience during the transition (bad billets, low incentives, etc. etc.). That unfortunately is inevitable but can't be used as anecdotes on the future for who remains.

But truth is. I don't know, nobody knows! It could all go down in a blaze of glory. Hence CAUTION when signing up by understanding the unknowns.

 

[militaryPHYS]

Oh, is that all he did? Seemed like he took a single anecdotal experience to make wide sweeping conclusions and contradict people who have done and do this all day, every day. But yeah, props on the shadowing.

Is that what they did or did they just provide a generic statement on something they experienced to which some of us took as "sweeping conclusions" and the member trying to "contradict" people?

Interesting how we can interpret things however we would like on an online forum. Maybe they were trying to be snarky and provide inappropriate generalization. I don't know. but someone who reads this who wants to do Ortho would have found that piece of information very useful as they move forward. Unless they are being rude, malicious or inflammatory they shouldn't have to sit anything out.

 

[HighPriest]

Even those who are old enough to know some Army history know that these changes are unprecedented and like nothing military medicine has experienced before. Relying solely on experiences of waste/fraud/abuse of current and previous MilMed I think is naïve.

Those of us who have been in the system a while and have had a positive experience are more optimistic that anticipated changes will improve MilMed overall. Those of us who have been burned by the previous system tend to fear that the whole thing will go down in a blaze of glory.

Truth is. Nobody knows! You can make grave predictions about what consolidation and streamlining will mean for MilMed, but I can also predict the positive things the changes will eventually provide us. But again, nobody knows! But I do know what is going on in MY community right now and what my leadership is telling me. Not much else to go on right now.

Care will be consolidated. Surgeries and the subspecialists (even the ones everyone thinks will go away completely) will be consolidated at bigger centers. Small MTF's who do low volume, low acuity will be shut down and seen in town (yes, Tricare reimbursement is a problem). The plan, as far as I can tell is that the larger number of docs kept at the big centers will have MOU's in place to operate/practice out in town like we are already doing in many locations. It has been successful (for Navy ortho at least) and I think they are trying to capitalize on lessons already learned and the success it is having. Unfortunately consolidation means that areas they want to trim will experience direct horrible experience during the transition (bad billets, low incentives, etc. etc.). That unfortunately is inevitable but can't be used as anecdotes on the future for who remains.

But truth is. I don't know, nobody knows! It could all go down in a blaze of glory. Hence CAUTION when signing up by understanding the unknowns.

I actually never said things were going to get worse. I repeatedly said they may or may not, but that relying on n of 1 experiences as predictors at this point is foolhardy. But I was asked how things might change, and I have some examples. I also said they might not change at all.

The idea that the federal government, suddenly and against all of its history, is going to suddenly start running an effective and efficient healthcare system isn’t an “n of 1” example. They basically suck at running everything. So I have a bit more background on the prediction that things might not get better. Of course, that all depends upon how we define “better.”
Military waste and fraud has been the rule rather than the exception since the military has been around. That’s why you had guys like Eisenhower talking about the MIC.

I’m not anti-military by any means, but the system has a long history of waste, fraud, and inefficiency that we put up with because it’s a massive bull to grab by the horns and because anyone who really tries is branded anti-American. Milmed just happens to be one of the most wasteful aspects. I hope this fixes some of those issues. But who knows.

Understanding the unknowns is my point. You can come on here and read how one guy had a good ortho rotation, and you agree with him. And you can get a little perspective about how that may change, but that the jury is out. I do think people feel like “bucket 1” specialties somehow got a free pass, but if things change the way I read them I don’t think that’s the way it’ll pan out.

 

[HighPriest]

I know a guy. Total alcoholic. Been one for decades. Drunk every night and drunk every day.

One person meets him and says “you know, when I met him he was totally sober. And he says he’s going to change. Stop drinking. Get a job.”

But I’ve heard that before. It’s never worked out. This time is different, he says. He’s going to go to rehab. Move in to a halfway house for drunks. Straighten up.

I’d be happy it it were true. But the person who thinks he’s sober already would be naive to say he will be in three months, and it would be pessimistic but realistic (and certainly not naive) to think he will not.

Let’s see how drunk Teddy does, eh? But let’s realize it’s a long road that may or may not lead anywhere good.

Im not saying that the good ortho experience on a rotation in the past isn’t good information. I’m just saying that I don’t know what it has to do with the price of tea in China after these changes are implemented.

 

[colbgw02]

Is that what they did or did they just provide a generic statement on something they experienced to which some of us took as "sweeping conclusions" and the member trying to "contradict" people?

Interesting how we can interpret things however we would like on an online forum. Maybe they were trying to be snarky and provide inappropriate generalization. I don't know. but someone who reads this who wants to do Ortho would have found that piece of information very useful as they move forward. Unless they are being rude, malicious or inflammatory they shouldn't have to sit anything out.

Context matters. The single post, in a vacuum, is a neutral statement. Coming on the heels of a post where he asked why someone should worried, in a thread full of people explaining why everyone should be worried? That’s a head-in-the-sand mentality that I’ve seen for a long time around here and I was even guilty of as a student.

Also, of course it’s useful information, but that’s not the point. The point is that a type of confirmation bias is going on, i.e. ignoring perspectives and opinions that don’t fit a preconceived notion based upon a pretty limited experience.

 

[militaryPHYS]

I’m stuck for many years unless they kick me out. Can’t help but me more positive than negative I guess. But I’m also getting info that supports maintained optimism and I have no solid evidence to tell me this will all fail.

I’m interested to see how drunk teddy does. I should be around long enough to tell you.

 

[HighPriest]

I’m interested to see how drunk teddy does. I should be around long enough to tell you.

Me too, man. I want him to do well. He's my buddy. I just wouldn't loan him money.

 

[Gastrapathy]

Can i change my screenname to drunk teddy?

 

[Matthew9Thirtyfive]

Can i change my screenname to drunk teddy?

lol you can change it to whatever you want (within reason, obviously).

 

[notdeadyet]

I'm interested in psych, neuro, IM (I'd be okay with being a hospitalist but would most likely want to subspecialize into cards), and EM, in that order.

How realistic is it to match into these specialties and avoid a GMO tour?

Let's say I match into psych. After completing my residency, will my payback period consist of me working as a psych doc for military personnel and their families for 4 years?

After serving my 4+ years will I be able to practice like my civilian counterparts or do I still have other obligations to fulfill?

How truthful are recruiters?

Since you asked and listed psych first in your order of preference and no one addressed it:

Matching- Civilian side, you’re golden. Milmed? Meh... Psych tends to be a less popular specialty, but it’s ticked up in popularity in general and any uptick in popularity civilian side can have a big ripple in military match since it’s a much smaller pool. Psych had more applicants than spots in the last match based on someone’s posting of the results (Navy, maybe?). Your odds of matching directly into psych is better than most specialties, but not guaranteed. If avoiding a GMO is a deal-breaker, don’t take HPSP.

Payback- You will work as a psychiatrist for military personnel. For their families is going to be more and more questionable in the coming years based on indications for DHA and milmed. Personally, if it’s going the direction many fear, this will make military residencies in psych worse than they already are. Many to most psych issues are disqualifying, so you will lose a lot of experience on many disorders (including all peds and Geri). A lot of the drama about docs being pulled into administrative rolls will likely be less for psych than other because psych is excluded from Field Surgeon and other roles, limiting you to Brigade Surgeon, Division Surgeon, etc.

After serving- Once you finish your requisite obligations you can leave. You will be board certified and can have a practice. Unlike IM or IM sub specialty, your psych skills wont’ have atrophied much. Except for management of severe mental illness, but you may not have had much of that in residency anyway so less to forget!

Truthfulness of recruiters- It’s a mix between untruthful and uninformed. Some have great intentions but no recruiters have actually done what you’re trying to do.

Disclosure- I’m reserve component psych. I enjoy serving in the Army. I considered HPSP and am glad I ruled it out. When I work with active duty folks, I feel blessed I did a civilian residency.