Thinking about HPSP/USUHS? READ THIS.

[AvoidMilitaryMedicine]

Will be updated to reflect the latest news in military medicine and GME.

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[WMMCDNLD1]

Well ****

 

[backrow]

Question for the OP bc I’m interested in what your perspective is: do you sit at a leadership level within GME or the hospital that would be sitting in on the discussions Or are you more at the “I’m getting the info from my consultant/other source”?

I am seriously interested because I think depending on what level one sits will seriously color what information they have and how they are processing that.

In my opinion there are changes afoot, they could be significantly involved; however, nobody really knows what the end is going to look like right now.

I do agree that one should take caution right now if not already involved and ask questions of people. If you are already in the system then recommend holding any significant “oh crap-itis” for a little while longer.


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[Perrotfish]

So what if you are a student and want to go into one of those specialties?
1) The military will no longer be able to train you in the military system. And,
2) Civilian deferments are not guaranteed.

Any source for this? I know the military is trying to cut billets they see as less essential, but I haven't heard anyone suggest that they were going to eliminate EVERY residency slot for Peds/Derm/Ob/whatever

 

[militaryPHYS]

Agree with @backrow

There are many unknowns right now and each person considering Milmed needs to truly be on board with the "military officer first" mentality. Changes are happening and we just don't know what the final product will be.

Regardless, all of your main points are the classic Pitfalls of Milmed that we all know and discuss regularly on here. I agree that the current environment contains a lot of questions on the future of Milmed, but there will always be something. It may be critical wartime specialties only, it could be a primary reserve force, it could be similar to what we have right now. We just don't know. But there will have to be something.

 

[AvoidMilitaryMedicine]

Question for the OP bc I’m interested in what your perspective is: do you sit at a leadership level within GME or the hospital that would be sitting in on the discussions Or are you more at the “I’m getting the info from my consultant/other source”?

I am seriously interested because I think depending on what level one sits will seriously color what information they have and how they are processing that.

In my opinion there are changes afoot, they could be significantly involved; however, nobody really knows what the end is going to look like right now.

I do agree that one should take caution right now if not already involved and ask questions of people. If you are already in the system then recommend holding any significant “oh crap-itis” for a little while longer.


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All of the relevant information is gathered from town halls, FB groups and emails from our consultant. It has been a near unanimous consensus (from O3 to O6) that the GME/MHS system will be dramatically changed for worse -- I didn't mention this earlier, however, more from a self-interested perspective, I am in a bucket 1 specialty, and I think there are enough med students and residents in the pipeline to buffer any immediate impact from these changes to bucket 1 docs, at least long enough until I get to the end of my ADSO.

I am just hoping that they don't call me back from IRR or not accept my resignation because of the mess they've made :-/

 

[AvoidMilitaryMedicine]

Any source for this? I know the military is trying to cut billets they see as less essential, but I haven't heard anyone suggest that they were going to eliminate EVERY residency slot for Peds/Derm/Ob/whatever

There is a presentation floating around that identifies Bucket 2 and Bucket 3 specialties -- although there are, yet, no mention in those slides of phasing out residencies -- I've been witness to plenty of email traffic that leads me to believe that's where it's going. In either case, even if those specialties were allowed in one capacity or another, what's the incentive to apply to them? A person won't be able to practice in it in any meaningful way, leading to dissatisfied docs, skill degradation and severely handicaps utility in the military and marketability for jobs outside of the military.

 

[backrow]

I am not involved in leadership or GME. All of the relevant information is gathered from town halls, FB groups and emails from our consultant. It has been a near unanimous consensus (from O3 to O6) that the GME/MHS system will be dramatically changed for worse -- I didn't mention this earlier, however, more from a self-interested perspective, I am in a bucket 1 specialty, and I think there are enough med students and residents in the pipeline to buffer any immediate impact from these changes to bucket 1 docs, at least long enough until I get to the end of my ADSO.

I am just hoping that they don't call me back from IRR or not accept my resignation because of the mess they've made :-/

So, I’ll say that I fit into one of those categories I mentioned above and have a slightly different perspective than your ultimate doom & gloom, although, yes it may end up that way.

I would agree that right now there is so much in the air that it would be hard for me to fully recommend a medical student consider military medicine.

It is obvious that Congress has gotten it’s wish and DHA will absolutely be taking over military medicine (and already has in some locations). What is less obvious is what the final impact to GME and future positions will be. In my lowly opinion there will likely be an initial overreaction and then some self correction, it is just a matter of what that will look like and how long a period of time we are talking. What is quickly becoming apparent is that GME remains a priority because this is what feeds the pipeline of GMOs and operational docs.

If the Services want GMOs (and they do, whether they are Board certified or one year wonders is a different debate) then you have to have GME. If you want GME programs then you have to follow ACGME and specialty Board rules. These rules are so intertwined between specialties that it is nearly impossible to have “wartime critical” specialties without having robust programs in the other non-“wartime critical” specialties. For example, you can’t have a general surgery program without Peds patients. EM needs deliveries. Ortho needs Peds patients. Etc, etc.

Ten plus years ago the Navy said they were getting rid of Peds and there was this similar “the sky is falling” warning.

Overall I think the ropes holding the sky up are fraying a little, I don’t want to pretend there aren’t changes coming and it could become just the scenario being painted by the OP, but for now all hope is not lost.

If I had to guess this is what I think the future holds:
-Drastic reduction of active duty numbers over next 5-10 years
-Drastic increase in the number of civilian physicians (not sure where these folks are going to come from at the current pay scale though)
-GME opportunities for subspecialty training may be reduced (likely is probably a better guess here than “may”)
-Deployment tempo could increase for those remaining in uniform
-overall GME residency opportunities will stay about the same, maybe some programs have some decreased numbers for a while, until second and third order effects kick in and the numbers are increased.
-Increase in number of docs getting out at end of commitment.

We shall see, it is definitely a buyer beware time right now because not even hospital CO’s have an idea of what exactly is going on. Heck, for Navy looks like even BUMED was caught a bit off guard by some of the recent changes sent down.


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[Gastrapathy]

I’m not sure why the military needs GME to make GMOs. Civilian residencies can do that too.

 

[psychbender]

For the intertwined subspecialty requirements for ACGME, some can be dealt with through rotations at civilian institutions. They already did this back when I was in training, and can use it to ensure residents get the numbers required. Obviously, that's less helpful than continuous exposure throughout training, but it meets the minimum standard, so I can see the military continuing to work with ACGME to do it this way.

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[DrMetal]

For the intertwined subspecialty requirements for ACGME, some can be dealt with through rotations at civilian institutions. They already did this back when I was in training, and can use it to ensure residents get the numbers required. Obviously, that's less helpful than continuous exposure throughout training, but it meets the minimum standard, so I can see the military continuing to work with ACGME to do it this way.

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But if trainees spend most (or a substantial amount) of their time outside of their program, you kinda wonder if the program should exist at all (or is sustainable)? If they significantly cut fellowships and sub-specialties, they should probably cut GME altogether. You can't/shouldn't half-a$$ it...either you make a good GME program, or none at all.

With respect to chatter....we've seen this all before, let's see how the rubber actually meets the road. The changes described above make perfect sense, with respect to the war fighting communities. The medical corps exists to support them....the war fighters don't exist to support the specialty of rheumatology. But again, we'll see what actually happens. My bet is nothing dramatically changes any time soon.

The one thing that should definitely change is how we recruit. It should be made abundantly clear to people that when they join the military (a voluntary service), they may lose several degrees of freedom (their choice of professional education, training, their geography, etc etc). Nothing is guaranteed. Those who have heartache about it, need not apply, or can go about their civilian routes and join later. I hope recruiters are making this clear (likely not)....but with resources like SDN, I think (I hope) most know what they're sort of getting into. I have sympathy for those who joined 20 years ago and had no such resources...not so much sympathy for those who joined this decade and beyond.

 

[backrow]

I’m not sure why the military needs GME to make GMOs. Civilian residencies can do that too.

I think there are lots of potential issues:

1: there aren’t enough residency slots for current US grads nationwide. Dump around 400-500 more per year into that system and you’ll quickly realize not all your military interns have a place to train.

2: there is a huge difference between a GMO that did a military internship and one who did not. Although this ends up evening out it takes many months.

3: military GME is a source of quality control.

4: military internship (at least for Navy) has curriculum items that are not covered in civilian internships. For example: psych interns doing OB/Gyn, OB interns doing ortho, etc. Navy GMO credentials are wide ranging: who is going to sign off that a psych intern from XYZ location is competent to do a toenail removal?

And several others.


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[backrow]

For the intertwined subspecialty requirements for ACGME, some can be dealt with through rotations at civilian institutions. They already did this back when I was in training, and can use it to ensure residents get the numbers required. Obviously, that's less helpful than continuous exposure throughout training, but it meets the minimum standard, so I can see the military continuing to work with ACGME to do it this way.

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This is actually not wholly correct. Many ACGME requirements have a limit to the number of “out” rotations that can be done (emergency medicine is one, GenSurg is another) and several require that other programs be within the same sponsoring institution.

There’s a whole spiderweb that develops with some programs when you dig deep into the requirements.


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[a gray man]

So.... would any of you active duty docs offer some advice for a current student in the class of 2020 already obligated to the military? How does this affect my decision making for next year? So far the administration is little help and just says “don’t listen to any rumors.”

 

[Gastrapathy]

@backrow

The Navy GMO system isn’t ethical now. I wasn’t proposing putting interns out to the fleet but if they are going to, I wouldn’t pretend that 4 weeks of L&D matters. It’s a myth that a couple rotations can turn a psych intern into a PCP.

The shortage of GME slots isn’t the military’s problem. They will bring their own funding so they will be fine.

 

[Gastrapathy]

So.... would any of you active duty docs offer some advice for a current student in the class of 2020 already obligated to the military? How does this affect my decision making for next year? So far the administration is little help and just says “don’t listen to any rumors.”

Try to choose a specialty where you will be happy without subspecialization. Don’t choose to delay any part of your training for a cool assignment. If you don’t get what you want, wait it out and quit.

Also, these changes might end up being for the best. The current system is beset by poor quality, low procedural/surgical volumes, and a host of other problems. They have tried to be everything to everyone without the resources. They’ll probably screw it up but at least this is an effort to change the paradigm.

 

[backrow]

@backrow

The Navy GMO system isn’t ethical now. I wasn’t proposing putting interns out to the fleet but if they are going to, I wouldn’t pretend that 4 weeks of L&D matters. It’s a myth that a couple rotations can turn a psych intern into a PCP.

The shortage of GME slots isn’t the military’s problem. They will bring their own funding so they will be fine.

Oh, I’m definitely not going to argue that the current system in regards to GMOs is the best way to practice medicine.

Funding doesn’t matter if the ACGME doesn’t approve the slots. Some programs already have excess capacity without funding, but it is nowhere near the need if military GME closed.


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[Gastrapathy]

Funding matters because programs will take the free AMG resident preferentially over the bottom half of the applicant pool. Maybe bad for society but not a .mil problem.

 

[backrow]

So.... would any of you active duty docs offer some advice for a current student in the class of 2020 already obligated to the military? How does this affect my decision making for next year? So far the administration is little help and just says “don’t listen to any rumors.”

Agree with Gastrapathy above.

There will likely be more clarity on this issue by summer so you’ll have better information on which to base your decision.

I would say that if a 5th grader can look at a subspecialty and say “yep, you need that for war” then you will likely continue to see that trained in fellowships. So, critical care, surgical trauma, ortho trauma, etc will probably be trained. Things where the “generalist” is what is needed to deploy (peds, OB, rads, anesthesia, Ophthalmology, ENT, etc) will likely see their fellowship opportunities dwindle.

If we see dwindling sub specialists then one might ask how would they continue to support the residency.....this is where I see the civilians coming in. I have qualms that they will be able to hire what they are going to “need” though.

For immediate suggestion: I’d say try not to worry about what’s going on. You have absolutely no way to control what is happening or going to happen if you’ve already signed. Continue to do well in your studies to put yourself in the best possible position. Apply to what you want and consider doing your time and bailing if your “calling” isn’t offered anymore.


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[Mace1370]

Bucket 2 here. We have already been told that our fellowships are cut (with the caveat that nothing is final and that there is an extremely slim chance some fellowships may be granted). Also, incoming residents to my specialty are being decreased for this year. Everything still in flux, but I feel horrible for incoming med students who signed without visibility to this stuff.

 

[Matthew9Thirtyfive]

Try to choose a specialty where you will be happy without subspecialization. Don’t choose to delay any part of your training for a cool assignment. If you don’t get what you want, wait it out and quit.

If we’re interested in primary care but through the course of 3/4 year and pgy-1 we discover we’re really interested in a subspecialty of something like IM or peds, would it be better to gmo and gtfo, then go to civilian residency and right into fellowship, or would it be better to go straight through if possible, knock out the 4 years and then apply for fellowship?

Does it make any difference? Other people can answer too. I’m years away from worrying about this, but I will have to decide between USUHS and HPSP (God willing), and 3 extra years can be a lot.

 

[colbgw02]

If it were me, I would GMO and pop smoke. Military experience is a net positive when it comes to applying to fellowships, but you know what's a bigger net positive? Being an outstanding resident at a department that also has all/most of the relevant fellowships.

 

[Perrotfish]

Bucket 2 here. We have already been told that our fellowships are cut (with the caveat that nothing is final and that there is an extremely slim chance some fellowships may be granted). Also, incoming residents to my specialty are being decreased for this year. Everything still in flux, but I feel horrible for incoming med students who signed without visibility to this stuff.

Has anyone even heard a rumor about what happens to the people that are training for a subspecialty right now? Do they pull them? Are they planning to make them practice as generalists? What about the subspecialists who have been attached to the big hospitals for the past 10+ years? Is there any chance that they might actually move them?

 

[AvoidMilitaryMedicine]

So.... would any of you active duty docs offer some advice for a current student in the class of 2020 already obligated to the military? How does this affect my decision making for next year? So far the administration is little help and just says “don’t listen to any rumors.”

If I were you, I would definitely not do a fellowship and if you are 50/50 about your choice -- consider going into a bucket 1 specialty and/or a specialty where a high/relevant caseload isn't absolutely essential to maintain skills and/or could be supplemented by moonlighting.

 

[AvoidMilitaryMedicine]

Try to choose a specialty where you will be happy without subspecialization. Don’t choose to delay any part of your training for a cool assignment. If you don’t get what you want, wait it out and quit.

Also, these changes might end up being for the best. The current system is beset by poor quality, low procedural/surgical volumes, and a host of other problems. They have tried to be everything to everyone without the resources. They’ll probably screw it up but at least this is an effort to change the paradigm.

Agree on all counts.

 

[AvoidMilitaryMedicine]

If it were me, I would GMO and pop smoke. Military experience is a net positive when it comes to applying to fellowships, but you know what's a bigger net positive? Being an outstanding resident at a department that also has all/most of the relevant fellowships.

I have a friend who got selected for Army anesthesia, withdrew last minute to go GMO and is now an anesthesia resident at Stanford.

 

[AvoidMilitaryMedicine]

If we’re interested in primary care but through the course of 3/4 year and pgy-1 we discover we’re really interested in a subspecialty of something like IM or peds, would it be better to gmo and gtfo, then go to civilian residency and right into fellowship, or would it be better to go straight through if possible, knock out the 4 years and then apply for fellowship?

Does it make any difference? Other people can answer too. I’m years away from worrying about this, but I will have to decide between USUHS and HPSP (God willing), and 3 extra years can be a lot.

If you are USUHS, going GMO is rough because that's 7 years of being a glorified intern with little to no clinical volume. I'd recommend strongly considering a bucket 1 specialty where you can easily compensate for the inevitable skill degradation.

Going GMO is less daunting for HPSP and 3 to 4 years handing out ibuprofen and inspecting humvees will (hopefully) not waste everything you learned in medical school.

If you are a strong HPSP candidate and know for sure that you will not be happy doing anything other than Derm, Neurosurgery, RadOnc... I'd recommend going GMO and getting out ASAP.

 

[psychbender]

Regarding ACGME and out-rotations: I am aware that there is a max that can be done externally, and that several programs already come close to that just to ensure minimums. I don't think it's a good idea, and believe that training is better when the subspecialties are firmly incorporated into the core rotations. For anesthesiology, sure you can do two months of Peds at a Children's hospital, knock out all of the ACGME required cases, and not do any during the rest of residency, but that's a bad idea. The lessons learned are then not reinforced throughout training, and quickly forgotten. Same goes for trauma, neuro, cardiac, thoracic, etc. If programs have to hit the max allowed just to meet the minimums, then the military should really consider whether or not they should continue training that specialty.

 

[AvoidMilitaryMedicine]

Has anyone even heard a rumor about what happens to the people that are training for a subspecialty right now? Do they pull them? Are they planning to make them practice as generalists? What about the subspecialists who have been attached to the big hospitals for the past 10+ years? Is there any chance that they might actually move them?

I doubt anyone would get pulled -- during all the briefs and townhalls, somehow 'pediatrics nephrologists,' got targeted as the useless (only in the military) specialty that was going to get the axe. The impression that I got was that non-bucket 1 sub-specialists will get moved over to military admin positions (i.e., brigade surgeon, division surgeon) or function as GMOs.

 

[colbgw02]

I would also guard against allowing the .mil to push you toward a bucket 1 specialty. Subconsciously, I'm sure it's easy to gravitate toward mission-critical specialties because of the near-term consequences of wanting to be a subspecialist.

 

[militaryPHYS]

If you are USUHS, going GMO is rough because that's 7 years of being a glorified intern with little to no clinical volume. I'd recommend strongly considering a bucket 1 specialty where you can easily compensate for the inevitable skill degradation.

Going GMO is less daunting for HPSP and 3 to 4 years handing out ibuprofen and inspecting humvees will (hopefully) not waste everything you learned in medical school.

If you are a strong HPSP candidate and know for sure that you will not be happy doing anything other than Derm, Neurosurgery, RadOnc... I'd recommend going GMO and getting out ASAP.

Totally agree with this. I have to admit that your follow up discussion on this all seems reasonable and I don't disagree with anything discussed thus far.

What really grinds my gears is the lack of transparency from Milmed Leadership and new DHA leadership. I recently discussed recent issues of Milmed with a surgical sub-specialist specialty leader who lives/works in the beltway and even he is kept 100% out of the loop. Publishing articles in medical journals, political-type town halls don't send the right message. We need BLUF statements. Heck, create scheduled secret level security briefs if they don't want all details in the public right now.

I've already been telling new interested students the basics of what has been listed in this thread. Milmed still has a place for the right applicant, but even the most gung-ho military premed (me 15 years ago) would have a hard time signing up for something when the only guarantee is that you can train in a critical wartime specialty OR do 4 as a GMO and be done. Too many unknowns and specialty changes that can happen.

 

[Matthew9Thirtyfive]

If you are USUHS, going GMO is rough because that's 7 years of being a glorified intern with little to no clinical volume. I'd recommend strongly considering a bucket 1 specialty where you can easily compensate for the inevitable skill degradation.

Going GMO is less daunting for HPSP and 3 to 4 years handing out ibuprofen and inspecting humvees will (hopefully) not waste everything you learned in medical school.

If you are a strong HPSP candidate and know for sure that you will not be happy doing anything other than Derm, Neurosurgery, RadOnc... I'd recommend going GMO and getting out ASAP.

Well, obviously I won’t know until clinicals, but I’m pretty primary care gung ho.

 

[TheGingerCroat]

My fiancée and I have been currently applying to the HPSP for dental (her) and medical corps (me). The main reason is after talking to military docs/dentists we know personally, we like what mil-med can entail. I have a lot of military history in my family as well so I like that aspect. And I’m not going to lie, coming out of school NOT $500,000+ in debt (both of us combined) sounds really nice. However, I’m not 100% sure what I want to specialize in. I believe primary care (IM or FM) isn’t for me...leaning mostly towards neuro/ortho spine surgery. Or PM&R or even MSK neuro.

Is HPSP a viable option at this point? We’re in the process of applying right now and this post has me worried about the future of military med. Any thoughts would be seriously appreciated!


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[backrow]

My fiancée and I have been currently applying to the HPSP for dental (her) and medical corps (me). The main reason is after talking to military docs/dentists we know personally, we like what mil-med can entail. I have a lot of military history in my family as well so I like that aspect. And I’m not going to lie, coming out of school NOT $500,000+ in debt (both of us combined) sounds really nice. However, I’m not 100% sure what I want to specialize in. I believe primary care (IM or FM) isn’t for me...leaning mostly towards neuro/ortho spine surgery. Or PM&R or even MSK neuro.

Is HPSP a viable option at this point? We’re in the process of applying right now and this post has me worried about the future of military med. Any thoughts would be seriously appreciated!


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My personal opinion is that I cannot in good faith recommend anyone sign up for HPSP right now. That may change back in a few months, but right now with the amount of uncertainty out there it is just not something my conscious can let me fully recommend.

There are a few people out there who it’s still probably a good decision, but those should be having long discussions with many people before signing. I say this with a bit of sadness bc these folks are going to be my doctors one day and I want really bright, talented individuals to be my care team when I need them.


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[AvoidMilitaryMedicine]

My fiancée and I have been currently applying to the HPSP for dental (her) and medical corps (me). The main reason is after talking to military docs/dentists we know personally, we like what mil-med can entail. I have a lot of military history in my family as well so I like that aspect. And I’m not going to lie, coming out of school NOT $500,000+ in debt (both of us combined) sounds really nice. However, I’m not 100% sure what I want to specialize in. I believe primary care (IM or FM) isn’t for me...leaning mostly towards neuro/ortho spine surgery. Or PM&R or even MSK neuro.

Is HPSP a viable option at this point? We’re in the process of applying right now and this post has me worried about the future of military med. Any thoughts would be seriously appreciated!


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Do NOT do this -- any debt you have, annoying and burdensome as it is, is not worth torpedoing your career before you even start. You can pay off BOTH your debt and your wife's debt a lot faster with your civilian ortho/neuro pay -- it's not even close. I have peers who went civilian in my specialty w/o HPSP and graduated with 200k+ debt and have already paid it off (and they weren't wealthy to begin with). This pay disparity will continue to widen as it literally takes an act of Congress to throw a few bucks our way (averaging about 1 specialty raise every 10 years or so).

 

[absolutdokta]

...So for the remainder of your contract, be prepared to hand out Ibuprofen, treat the common cold, foot/ankle/back pain, sit in meeting after pointless meeting, and make powerpoints for generals.

Word.

I’m a 62B. Boarded in my primary care specialty and still need to moonlight to keep some semblance of what I should be doing as a “doctor”. Hell, I get hard when one of my soldiers come in on BP meds and they’re not well controlled. I’ve tossed around the idea of joining the reserves when I get out but have decided I’m gonna run away and never come back (though I might go the VA route as a civilian, just won’t ever put the uniform on again). What bothers me is the big army mentality and the endless RFIs and tasks from brigade. Yeah, yeah....they want us to see ourselves as officers/soldiers first but the thing is you can’t. Please don’t make me go to the field for a range week and then sit in my bunk and watch movies all day for the one soldier that comes to sick call (and it’s for a rash he’s had for a couple months to boot). I will admit that the shroud of secrecy that is medicine is nice. When it all boils down though, they don’t really know what we do and “I’ve got clinical duties and charting” has sometimes meant “leave me the f#ck alone I’m sick of your pointless requests” and they just nod and say “roger that, sounds good”.

 

[militaryPHYS]

My fiancée and I have been currently applying to the HPSP for dental (her) and medical corps (me). The main reason is after talking to military docs/dentists we know personally, we like what mil-med can entail. I have a lot of military history in my family as well so I like that aspect. And I’m not going to lie, coming out of school NOT $500,000+ in debt (both of us combined) sounds really nice. However, I’m not 100% sure what I want to specialize in. I believe primary care (IM or FM) isn’t for me...leaning mostly towards neuro/ortho spine surgery. Or PM&R or even MSK neuro.

Is HPSP a viable option at this point? We’re in the process of applying right now and this post has me worried about the future of military med. Any thoughts would be seriously appreciated!

You both need to be all in or all out. One of you can't be HPSP and the other stay civilian. It will be tough to stay together (location wise) and hard to find jobs for the civilian one when the HPSP one becomes staff. Therefore, the easy answer is to say DONT DO IT.

Despite me being more cynical and wary of MilMed currently, I am still a very conservative person and I do not like unknowns when it comes to finance. When I got in to the military I was OK with the unknowns of deploying, specialty, etc. because I knew it was a rock solid paycheck, no debt and benefits. I like having those things, others are OK without them. I also get so enraged when I see what universities are charging for tuition these days. Eventually people will realize the education isn't worth the money or our generation will be so strapped with student loan debt it will cause some other implosion of the economy.

Just like you can't bank on certain specialties being available in MilMed, you also can't make your decisions based off of an ortho or neurosurgeon salary. Maybe your scores will suck. Maybe you don't match. Maybe you end up in Primary Care anyway and could have been earning a similar salary in the military. Dental reimbursement is also not great unless you find a great private practice gig or do a fellowship (from what I understand). I know a lot of dental corps friends and it seems like a good deal for them. They offer fellowships and from what I understand the practice and reimbursement is comparable to on the outside. BUT, like I said, you both need to be IN or OUT (in my opinion).

I don't think the decision is as black and white as the other two who chimed in make it seem. Depends on the person(s) and what keeps you up at night. I slept and focused a lot better in med school and residency knowing that no matter what I would be making a good salary, I had no debt and I was maxing out my retirement savings day 1 of medical school. This was at the risk of not being able to do what I wanted to do later on down the road and the risk of having to delay my training until I paid back my commitment. Eventually it worked out for me, but I gravitated towards a wartime specialty and chose a high-volume subspecialty within ortho to keep me busy even at any MTF.

I'm staying neutral. I can't say one choice is better than the other, but at least make sure you are considering both sides of the equation with the points I listed.

 

[TheGingerCroat]

You both need to be all in or all out. One of you can't be HPSP and the other stay civilian. It will be tough to stay together (location wise) and hard to find jobs for the civilian one when the HPSP one becomes staff. Therefore, the easy answer is to say DONT DO IT.

Despite me being more cynical and wary of MilMed currently, I am still a very conservative person and I do not like unknowns when it comes to finance. When I got in to the military I was OK with the unknowns of deploying, specialty, etc. because I knew it was a rock solid paycheck, no debt and benefits. I like having those things, others are OK without them. I also get so enraged when I see what universities are charging for tuition these days. Eventually people will realize the education isn't worth the money or our generation will be so strapped with student loan debt it will cause some other implosion of the economy.

Just like you can't bank on certain specialties being available in MilMed, you also can't make your decisions based off of an ortho or neurosurgeon salary. Maybe your scores will suck. Maybe you don't match. Maybe you end up in Primary Care anyway and could have been earning a similar salary in the military. Dental reimbursement is also not great unless you find a great private practice gig or do a fellowship (from what I understand). I know a lot of dental corps friends and it seems like a good deal for them. They offer fellowships and from what I understand the practice and reimbursement is comparable to on the outside. BUT, like I said, you both need to be IN or OUT (in my opinion).

I don't think the decision is as black and white as the other two who chimed in make it seem. Depends on the person(s) and what keeps you up at night. I slept and focused a lot better in med school and residency knowing that no matter what I would be making a good salary, I had no debt and I was maxing out my retirement savings day 1 of medical school. This was at the risk of not being able to do what I wanted to do later on down the road and the risk of having to delay my training until I paid back my commitment. Eventually it worked out for me, but I gravitated towards a wartime specialty and chose a high-volume subspecialty within ortho to keep me busy even at any MTF.

I'm staying neutral. I can't say one choice is better than the other, but at least make sure you are considering both sides of the equation with the points I listed.

Thank you to everyone who responded! You’ve all given me some good points to think about and discuss!

I definitely stand with you on multiple points, we are both only considering doing this if we BOTH get in. From everything I’ve heard it’s just easier when your spouse is mil too.

We both fall on your side of the coin when it comes to finances as well...I honestly couldn’t care less what “x” physician makes on the civilian side because I grew up in a household making much less than $100,000/year and I considered my family blessed financially. We both really love that you’re guaranteed to earn a solid paycheck without debt and you can start investing in retirement right away. I don’t need to make $500,000 a year UNLESS I was in that much or more in debt.

The major thing concerning me is specialty choice. I’ve shadowed a lot in primary care and I don’t necessarily enjoy it, however I am open for that to change. I am fascinated by both the MSK and neuro systems right now and like I said...my mind is open for that to change. But I’m not certain I like the idea of doors closing before I even get a chance to look through them. Maybe I’ll gravitate towards a war-time specialty. Maybe I won’t. So I’m not entirely sure how to take the changes in funded specialties.

It’s all a lot to consider and I thank every one who responded for their input!


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[Matthew9Thirtyfive]

Maybe I’ll gravitate towards a war-time specialty. Maybe I won’t. So I’m not entirely sure how to take the changes in funded specialties.

While I think a lot of people on this forum are overly cynical, one thing I've seen oft repeated that I 1000% agree with is this: if freedom to pick your specialty is more important to you than serving, you should not do HPSP. Not sure what branch you were thinking, but in the Navy now you have to select two specialties--a primary and a backup. You could just do your primary and a transitional year probably, but that still sets you back if you don't match into your primary. It's just less freedom than it seems like you want. You can always join later if you still want to serve.

If you can be okay with that, it's a different story.

 

[TheGingerCroat]

While I think a lot of people on this forum are overly cynical, one thing I've seen oft repeated that I 1000% agree with is this: if freedom to pick your specialty is more important to you than serving, you should not do HPSP. Not sure what branch you were thinking, but in the Navy now you have to select two specialties--a primary and a backup. You could just do your primary and a transitional year probably, but that still sets you back if you don't match into your primary. It's just less freedom than it seems like you want. You can always join later if you still want to serve.

If you can be okay with that, it's a different story.

Thanks for responding!

I only state the specialty thing as a concern because I’m undecided and unsure of what I want to pursue. Serving is an important aspect for me so worst case scenario I’ll probably be fine in whatever. At least surgery isn’t off the list because I’ll probably end up going that direction.


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[Matthew9Thirtyfive]

Thanks for responding!

I only state the specialty thing as a concern because I’m undecided and unsure of what I want to pursue. Serving is an important aspect for me so worst case scenario I’ll probably be fine in whatever. At least surgery isn’t off the list because I’ll probably end up going that direction.


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Yeah it seems like surgery will always be on the table. Maybe not some of the surgical subs, but something.

 

[armytrainingsir]

@backrow

It’s a myth that a couple rotations can turn a psych intern into a PCP.

That ship has already sailed.
Our society has signed off that a nurse with a mostly online degree is a PCP.
So a medical school graduate most certainly meets the new standard.

Right or wrong, like it or not, agree or disagree , that’s the new standard for primary care.

 

[HighPriest]

Yeah it seems like surgery will always be on the table. Maybe not some of the surgical subs, but something.

Definitely not the surgical subs. Frankly, the Army doesn't need a stable of ENT docs. Sure, I can explore a neck, diagnose and treat cervical esophageal perforations, tracheal injury (assuming they're still alive when I see them), or even a minor vascular injury. But so can a vascular surgeon with a general surgeon to back them up, plus those guys can treat gut shots, etc. I can treat facial fractures, but OMFS does the vast majority of that in the military. The Army doesn't need a whole team of guys who are deployable who can treat sinusitis and thyroid disease.

 

[Matthew9Thirtyfive]

Definitely not the surgical subs. Frankly, the Army doesn't need a stable of ENT docs. Sure, I can explore a neck, diagnose and treat cervical esophageal perforations, tracheal injury (assuming they're still alive when I see them), or even a minor vascular injury. But so can a vascular surgeon with a general surgeon to back them up, plus those guys can treat gut shots, etc. I can treat facial fractures, but OMFS does the vast majority of that in the military. The Army doesn't need a whole team of guys who are deployable who can treat sinusitis and thyroid disease.

Exactly what I was thinking.

 

[HighPriest]

Frankly, I'm not sure why they need urologists either. I don't know how many episodes of combat-related testicular torsion happen every year, but I'm going to say low. And I'm going to assume that a general surgeon could help that in a pinch. I know a ton of urologists in the military, and of all of the guys hit by skill atrophy, they're up at the top simply because of the age-distribution of patients at MTFs.

 

[HighPriest]

I guess I'll throw my opinion in as well, because everyone needs to hear it or my ego won't survive. Also, It's a forum where people basically just post their opinions.

So:

I'm not entirely sure if DHA will be good or bad for milmed. I think it really depends upon who's perspective you're interested in. From the standpoint of an incoming med student: I think it could be catastrophic. I agree that things will probably shake out somewhere in between the worst case scenario and where we are now, but eliminating sub-specialty options (or even just minimizing them) is a big issue. My #1 concern on signing up for HPSP was not knowing for sure if I would have the opportunities that my civilian counterparts had when it came to match time. I can't see any way that it won't be a bigger problem in the future unless they come to some sort of compromise wherein they train sub-specialists and simply have them in a reserve status. The other option would be to dramatically alter HPSP to make it a repayment program after medical school or residency as opposed to a commitment up front (which I have to assume will severely impact the number of applicants). Medical students simply don't know what they want to do when they join. Asking them now to not only commit to the military but to also commit to a subset of medical specialties is pretty harsh.

On the other hand, from the standpoint of the military, this actually makes perfect sense. My opinion is that the military has been way out in the weeds when it comes to their medical corps. A standing military (or a military at war) needs medical staff. That's been proven in every conflict in history. But they only need the medical staff that makes sense in war time. Again, you just don't need ENT docs in the military. You don't need rheumatologists. You don't need pediatric ophthalmologists. The military was given carte blanche for it's medical corps at some point, and it decided it was going to be a fully fledged hospital system that occasionally deploys it's providers. There are reasons for that, to be sure. It's nice to keep things under one roof. Theoretically, it could be done at lower expense. Plus, it really does make sense to take care of family members from a morale standpoint (plus, on a soldier's pay it'd be hard to afford civilian insurance for your family).

The problem is that in many cases you're not keeping things under one roof. That only works at major MEDCENs. Everyone else is sending complex cases out anyway. It's almost certainly not at an overall lower expense. Sure, you're paying your uniformed providers less, but you're overpaying your contractors who don't work very hard and because it's the federal government it exists in a quagmire of federal unions and administrative burdens. Top that with the fact that they then ask people who really have no business running a hospital to do just that, and I'd be shocked if the operating costs of a military hospital are significantly less than that of a similarly-sized civilian hospital. So, the only reason to have a full medical staff is to take care of family members. I sympathize with that, I really do. But what is the actual difference in expense of just sending those people to the community? Is it really that much cheaper to run a whole, multi-service, medical corps including all of the administration, facilities, etc.?

From the standpoint of the patients: I honestly think they'll be happier. I think that, depending upon which service we're discussing, the military offers good medical care. At least, I think the surgical care is overall quite good. But patients don't trust milmed. My experience both in and out of the military has been that, right or wrong, if you give a patient the choice between going to a military facility or a civilian facility they'll usually choose the civilian facility. There are exceptions. There's that one guy you took care of who just loves military medicine and is truly grateful for it. And we all love that guy. But I've definitely run in to more people (especially now) who feel like they had to fight to get out of the military system and are terrified that I'm going to suggest that they go back. I had a patient the other day who had a kid with a medical problem that needed a sub-spec ENT who could have easily been cared for at the local MEDCEN. She stated that she had to fight to get to me because she didn't trust military docs (she clearly didn't read my bio). I suggested the MEDCEN and she begged me not to go there. So I referred her to a military doc who works at that MEDCEN, but moonlights locally. I mean, $#!t, when I had elective surgery while AD I was very happy to have my AD partner do the surgery, but I did everything I could to have the surgery done at a local hospital where we had an ERSA.

If it really is cheaper to have them managed in the milmed system, then I'd say tough love is in order. But I'm not sure that it is.

So far as GME: the military should get out of it. Doesn't make sense. Again, my opinion is that military GME is a situation in which the military used its carte blanche to go into the business of running a medical empire, when that really should not have been the point. It doesn't do it better than the civilian side. It doesn't do it cheaper. It doesn't even have the volume in many cases to do it. But they do it anyway because no one every told them no. And I LIKED my residency.

I think it's like giving your spouse a checkbook and asking them to go out and get something for dinner and they come back with a nationwide restaurant franchise. What the hell were they thinking?

 

[Perrotfish]

So since we are registering opinions, I will disagree with all of the above. The military didn't create an entire medical system accidentally. Its an unavoidable outgrowth of the American approach to foreign policy. Other countries don't have military healthcare systems because in other nations the military, when not actually fighting a war, is stationed almost exclusively within those nations' borders and usually near their major population centers. The US is currently the only country in the world that, even during peace time, has isolated bases ranging from the Ukrainian border to the Korean Border, in almost every allied nation, island, and atoll in between, and within parts of our own nation that are so desolate that our military can conduct ground shaking live fire exercises day and night. That means we need to carry our own healthcare system with us.

The problem with a healthcare system is that it is, well, a system. You can't take out half the parts and expect it to work any more than you can take parts out of your engine and still expect it to run. If you need a hospital in Guam and Korea then you need OBs to work the labor deck and Pediatricians to cover deliveries, and you can't recruit civilians there even if the government pay matched civilian pay. They need major hospitals that can train those physicians, and consultants that those physicians can actually get on the phone. They need people actually willing to stay for 20 years and provide leadership for their specialties, which for at least the last 20 years has meant subspecialists almost exclusively. They need people within the system who are qualified to evaluate the thousands of EFMP, medical board, and overseas screening requests and who are motivated to not just fill out the form however their patients request.

I feel like the line doesn't understand why we can't just be the UK. After all, they recruit only combat physicians, and even then they keep them in the reserves until they are needed. They forget that the UK's military is now mostly stationed in the UK. Back when the UK actually had bases all across the world they also had a medical corps that looked a lot like ours does now.

We'll see if I'm wrong, but I don't think they're going to be able to sustain a medical Corps made up of ortho and EM. If it does end up being a mistake I think they will realize that the MC will be a lot harder to rebuild than it was to tear down.

 

[Perrotfish]

Maybe you end up in Primary Care anyway and could have been earning a similar salary in the military.

Just FYI, Primary care doesn't earn anything even close to an equivalent salary in the military. They were pretty close when I joined, but primary care salaries then increased at nearly 10% per year while military pay actually decreased in real value because the bonuses aren't indexed to inflation. If you count medical school tuition primary care still comes out ahead, but once you get out of the initial payback for HPSP the military is a huge money loser for pretty much everyone now.

 

[HighPriest]

So since we are registering opinions, I will disagree with all of the above. The military didn't create an entire medical system accidentally. Its an unavoidable outgrowth of the American approach to foreign policy. Other countries don't have military healthcare systems because in other nations the military, when not actually fighting a war, is stationed almost exclusively within those nations' boarders and usually near their major population centers. The US is currently the only country in the world that, even during peace time, has isolated bases ranging from the Ukrainian border to the Korean Border, in almost every allied nation, island, and atoll in between, and within parts of our own nation that are so desolate that our military can conduct ground shaking live fire exercises day and night. That means we need to carry our own healthcare system with us.

You should read what I wrote before you disagree with all of it. I never said, nor did I insinuate, that the military accidentally built a medical empire. Nor did I say or insinuate that they shouldn't have a medical system. In fact, I specifically said the opposite. What I am saying is that they drastically over-reached the goal by building a completely independent hospital system that doesn't necessarily support a military mission. They need general surgeons, orthopods, primary care. They don't need allergists or dermatologists. What they built was definitely intentional. It was just a mistake. which brings us to point 2:

The problem with a healthcare system is that it is, well, a system. You can't take out half the parts and expect it to work any more than you can take parts out of your engine and still expect it to run. If you need a hospital in Guam and Korea then you need OBs to work the labor deck and Pediatricians to cover deliveries, and you can't recruit civilians there even if the government pay matched civilian pay. They need major hospitals that can train those physicians, and consultants that those physicians can actually get on the phone. They need people actually willing to stay for 20 years and provide leadership for their specialties, which for at least the last 20 years has meant subspecialists almost exclusively. They need people within the system who are qualified to evaluate the thousands of EFMP, medical board, and overseas screening requests and who are motivated to not just fill out the form however their patients request.

So here's where we have a legitimate disagreement. Respectfully, I think you can definitely run a system without having a complete cadre of subspecialists. It's done all of the time. Oil companies hire and deploy necessary medical personal to places like Qatar. I know docs who work there. They pay them well, but they work hard while they're there. The same thing happens with a lot of companies that are headquartered in Puerto Rico. The question is: is it cheaper to pay a few people well to be where you NEED them, or is it cheaper to have a bunch of docs who you pay less working everywhere all of the time? I could definitely see myself towards the end of my practice being willing to take a year and go to Guam to work at 1/4 speed for reasonable pay. Plus, again, you can have people in a reserve unit and deploy them to Guam without having them twiddling their thumbs the other 330 days of the year. I'd love to see the schedule of a urologist or ENT doc in Guam, just to see how much their doing and how much of it really needed to be done there.

But again, it's a cost issue. Would it be more expensive to pay well and get the necessary specialists to go to Guam on annual or bi-annual contracts, or is it cheaper to just run a nationwide, full sized hospital network?

And you can get consultants on the phone without actually training and hiring them. I work for a private, completely independent practice yet somehow (miraculously, I guess) I can get a CT surgeon on the phone if I need one. If you're in guam, and you need a CT surgeon, you're evacuating that patient anyway and you can call the hospital in Honolulu just as easily as you can Tripler. In a perfect world, we'd just have specialists all over the place all of the time waiting to hear from us. But this is reality, and cost is a factor.

So, ultimately it comes down to: what do you actually NEED in guam? It's not a full tertiary referral center.


Everything else you've mentioned here could be managed by a smaller stable of necessary physicians. No reason to get rid of general surgeons, etc. You don't need to have an ENT doc waiting around for 20 years to take a non-clinical leadership role.

 

[Detective SnowBucket]

My personal opinion is that I cannot in good faith recommend anyone sign up for HPSP right now.

Would you still not recommend if you're exclusively interested in bucket 1 specialties (ortho spine/trauma, gen surg w/sub specialty, EM, anesthesia are my picks in order). I ask this as a UG senior matriculating in the fall and have been in talks with a Navy recruiter for a while, planning on 4 year HPSP. Would it make a significant difference if I did 3 yr HPSP?