To defer for a civie residency or do a Navy residency?

[bobbyseal]

Hey folks,


Lately I've been wrestling with a bit of a decision. Should I try and get a deferment for a civilian surgical residency or should I just do a Navy residency and suck up the long years in the Navy?

I'm really torn. And it's probably because I have no clue what it's like to practice in Navy medicine. I suppose I'll get a better idea of it as I do my clerkships this summer, but I just wanted to ask people what they thought of teh pro's and con's of a Navy residency.

One of the big pro's that I thought was the fact that I could likely pay down most if not all of my education debt while a Navy resident. Since I ended up paying for college + living expenses at med school, I'll be pushing over $60K in debt. The larger salaries seen by Navy residents compared to civie people would really help out there. Otherwise, I'd have to forbear on my loans and then start paying them off when I begin as a Navy attending - with a higher balance due to interest accumulation, all the while making the not so big bucks to pay it off.

What do you all think?

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[Mirror Form]

It depends what your grades are like. If you a very competitive applicant and can get into a tier 1 civ gen surg program, you'll probably get a much better education there. You'll be better off for your entire career if you do your residency at a presitgious institution.

 

[Navy Dive Doc]

1. Bobbyseal, are you prior service? This will make a huge difference in pay if you are. O-3 over 4 vs civilian salary is $25k a year.

2. How many deferments are they giving in Gen Surg these days? I would set up your 4th year early on to do rotations at 2 of the big 3 Naval hospitals, unless you already know which one you want. If you do, do one rotation there in the dept. and then use your other AT to do something cool and low key, like Flight surgery at Pensacola or something equally relaxing and warm.

3. I agree that the residencies are not Tier 1, and if reputation and academics is a huge factor for you, push for the deferment. If all you want to do is practice in a group somewhere, I wouldn't worry about it. The residencies are fine, and the hospitals are first rate. Also, if you plan to subspecialize, the Navy outsources those, and because you are free meat to a fellowship program (Navy pays you, they don't) you can go to essentially any prestigous fellowship you want. I know Portsmouth has a research track residency, it adds a year but that year is done at a civilian location. Prior folks have done Critical care at Penn, Gen Surg research at Duke, Cardiac at Cleveland clinic, etc. The other residencies probably have this as well, so that could help with the prestige factor.

4. I would stay away from Bethesda, because the volume is very low. I'd stick with Portsmouth or Balboa, you'll do a lot more, especially early on in internship.

5. Remember, a normal GMO tour is only 2 years, so that's not all that many years to "suck up". You never know, you might join the rest of us who went out and realized surgery wasn't something we wanted to return to. Botom line, it's a tough call, I just went through the same thought process about whether to get out for residency. There will not be an easy, absolute answer, but I don't think you'll go wrong either way.

 

[chillin]

You can do an AT in your fourth year in flight surgery? That's great to here. One other question. Is it easy to defer your intership year in the Navy, and if so how will that affect your chances on doing flight surgery?
thanks,
chillin

 

[tomplatz]

careful, if you defer your intern year you could end up getting deployed and then you'll be in limbo as to when residency starts. once you're in a program you can't be deployed, short of WWIII.

 

[r90t]

I would "guess" from the conversations that I had with interns in deferred status, that it is harder to get a FS/UMO position. You have to apply through the same process as for applying for residency. The problem that you may run into, say if you are in Iowa, that you don't have access to a navy FS to do the physical, a physiologist to do the required measurements, etc...the billets are competitive, as several of my intern classmates did not get a FS position.
Talk to the GS folks. The number of applicants is way down, and last year there were rumors that the navy may take 1-2 intern applications for PGY-2.

 

[Navy Dive Doc]

I think it is relatively easy to get a deferment for internship only in the Navy (harder for a full residency). I had a guy in my DMO class that had done a civilian internship, and the guy coming to relieve me in this job did a civilian internship before a FS tour (he's now a DMO on his second tour, after completing his FS requirement.) It is tougher, but not impossible, and if you jump through all of the hoops it shows strong motivation to the seleciton board, which actually helps. Historically, DMO spots are much harder to get than FS spots, so plan accordingly. If you are doing a civilain internship and want to do FS or DMO, I would definitely recommend doing something in one of those communities as a 4th year. You won't learn much medicine, but you could have a good time with a unit somewhere warm (Mobile Diving and Salvage Unit 1, Pearl Harbor comes to mind).

You could also get all of the physical exam and related stuff (biometrics for FS, Pressure test for DMO) out of the way, so you wouldn't need to do it as an intern. That would be a nightmare, especially at a remote location.

Certainly talk with some of the GS program directors to get a feel for straight through training. Navy residency reflects civilain trends, so as GS gets less desirable in the civilian world, the Navy does as well. I'd still say it's unlikely, and have a back-up plan as you're negotiating orders during the application process.

 

[bobbyseal]

Originally posted by Navy Dive Doc
1. Bobbyseal, are you prior service? This will make a huge difference in pay if you are. O-3 over 4 vs civilian salary is $25k a year.

Unfortunately, I'm not. But I think the difference will still be there. For instance, since I want to do surg or uro, by the time I'll be chief, I'll likely be O-4 with 6-7 years of experience. My estimates would be making around 80-90k a year compared to a civie chief resident making 50k.

2. How many deferments are they giving in Gen Surg these days? I would set up your 4th year early on to do rotations at 2 of the big 3 Naval hospitals, unless you already know which one you want. If you do, do one rotation there in the dept. and then use your other AT to do something cool and low key, like Flight surgery at Pensacola or something equally relaxing and warm.

I hear Gen surg is a critically manned specialty. So, they're trying to train as many as possible. As for uro, they're looking to defer about 2 a year. So, it seems like there will be spots out there.

3. I agree that the residencies are not Tier 1, and if reputation and academics is a huge factor for you, push for the deferment. If all you want to do is practice in a group somewhere, I wouldn't worry about it. The residencies are fine, and the hospitals are first rate. Also, if you plan to subspecialize, the Navy outsources those, and because you are free meat to a fellowship program (Navy pays you, they don't) you can go to essentially any prestigous fellowship you want. I know Portsmouth has a research track residency, it adds a year but that year is done at a civilian location. Prior folks have done Critical care at Penn, Gen Surg research at Duke, Cardiac at Cleveland clinic, etc. The other residencies probably have this as well, so that could help with the prestige factor.

Yeah, so here's the point. I am somewhat worried about the quality of training in the Navy. I've heard a few things about civie hospitals being much better, but at the same time, the Navy boasts that their programs are as good or better than any other hospital out there. Thus, one needs to be able to match at a large academic residency.

4. I would stay away from Bethesda, because the volume is very low. I'd stick with Portsmouth or Balboa, you'll do a lot more, especially early on in internship.

That's surprising that Bethesda isn't that great for gen surg. I'd figure that it's the main teaching hospital with usuhs right there. Hmm...

5. Remember, a normal GMO tour is only 2 years, so that's not all that many years to "suck up". You never know, you might join the rest of us who went out and realized surgery wasn't something we wanted to return to. Botom line, it's a tough call, I just went through the same thought process about whether to get out for residency. There will not be an easy, absolute answer, but I don't think you'll go wrong either way.

That's a good point dive doc, but that's one of the reasons why I'd be worried about doing a gmo. Getting used to hanging out in an outpatient clinic and just seeing vd and sprained ankles all day could make one lazy enough to try and become a radiologist or a anesthesiologist. Must try hard not to become lazy...

 

[bobbyseal]

Shoot, I had a lot of other things in that reply as well. Didnt' realize that I couldn't type in the middle of the quote.

Nuts.

 

[Navy Dive Doc]

Yeah, sure, I know you just wanted to bash the radiologists...you'll see the light (or dark) soon enough.

 

[mitchconnie]

Allow me a couple of philosophical points about surgery training in the military since I've been a resident and an attending in both military and civilian programs.
Anybody can say "our program is as good as civilian" and maybe they believe it, but there are significant problems with surgical training at military institutions. Number of cases is CRITICAL for your training--there is no substitute--and in the military you will never do as many cases your civilian counterparts. Will you meet minimum RRC requirements? Yes. Will it be enough to be really confident in the OR? Maybe.
Secondly, there are problems getting the complex tertiary referral cases. The hospital administration has no interest AT ALL in transplant, major hepatobiliary, surgical oncology, major vascular, peds. surg. etc. Are you going to be a liver transplant surgeon? Of couse not, but you better have some experience operating on the liver when you are staring at an open belly with a grade 4 liver laceration in the middle of Iraq.
Ironically, the military even has no interest in doing trauma at it's training hospitals. I know of only one military hospital that takes level I trauma. Nothing sharpens the mind like being the chief resident in the ER at County General, managing a thoraco-abdominal gun-shot wound by yourself. You will not have that experience in the military.
You get most of those big cases and all your trauma at off-site rotations. This is a sub-optimal way to train. Operative surgical training is an apprenticeship with experienced senior surgeons who know you well. You work hard for the faculty for a few months or a year, then they get to know and trust you, and then they let you do the cases and manage the patients. A military resident rotating for 1-2 months at some civilian institution will NEVER be given major responsibilty for a case. You will never have priority over the civilian resident who knows the faculty on a first-name basis.
My suggestion is that you not put training for your life's work at risk for a few thousand dollars a year. If you must do a military residency, look for one that is fully integrated with a nearby civilian program--where you regularly rotate through the civilian hospitals throughout your training and really get to know the staff. Look at the case numbers of the military residents, and how many of the cases are done off-site--cases done at away rotations are likely worthless.
A military residency is a nice way for a less competitive applicant to get reasonable surgical training. The programs are not abusive like some low-end civilian programs and you will meet minimum training requirements. You will have plenty of time on your hands to study for the boards (which military residents all pass--as the program directors tell you).
If, however, you are a top-notch applicant (or maybe not so top-notch--the general surgery match has been pretty easy of late), deferment probably is your best bet.
I don't know the specifics of the Navy programs, but I can't see that training conditions would be vaslty different than the Army and AF.

 

[Homunculus]

Originally posted by mitchconnie
I know of only one military hospital that takes level I trauma.

Wilford Hall (air force) and Brooke Army Medical Center (army) are both level I trauma centers. that's 2. and if the one you were thinking of wasn't one of those, then there are at least 3.

seriously though, you bring up some very good points. surgery probably isn't the best in the military, but i would argue the problems you talk about aren't *strictly* military ones. unless you are lucky enough to get into one of the top tier civilian programs (especially when considering trauma) you're *always* going to get the bulk of that experience on out rotations. it's like that with EM as well. while the primary care military programs can probably be considered mid to upper level, the surgery programs, unless you are at a high volume system, probably aren't as good as what you could get accepted into in the civilian world with the same qalifications. if that makes any sense, lol.

good post

 

[militarymd]

Originally posted by mitchconnie
Allow me a couple of philosophical points about surgery training in the military since I've been a resident and an attending in both military and civilian programs.
Anybody can say "our program is as good as civilian" and maybe they believe it, but there are significant problems with surgical training at military institutions. Number of cases is CRITICAL for your training--there is no substitute--and in the military you will never do as many cases your civilian counterparts. Will you meet minimum RRC requirements? Yes. Will it be enough to be really confident in the OR? Maybe.
Secondly, there are problems getting the complex tertiary referral cases. The hospital administration has no interest AT ALL in transplant, major hepatobiliary, surgical oncology, major vascular, peds. surg. etc. Are you going to be a liver transplant surgeon? Of couse not, but you better have some experience operating on the liver when you are staring at an open belly with a grade 4 liver laceration in the middle of Iraq.
Ironically, the military even has no interest in doing trauma at it's training hospitals. I know of only one military hospital that takes level I trauma. Nothing sharpens the mind like being the chief resident in the ER at County General, managing a thoraco-abdominal gun-shot wound by yourself. You will not have that experience in the military.
You get most of those big cases and all your trauma at off-site rotations. This is a sub-optimal way to train. Operative surgical training is an apprenticeship with experienced senior surgeons who know you well. You work hard for the faculty for a few months or a year, then they get to know and trust you, and then they let you do the cases and manage the patients. A military resident rotating for 1-2 months at some civilian institution will NEVER be given major responsibilty for a case. You will never have priority over the civilian resident who knows the faculty on a first-name basis.
My suggestion is that you not put training for your life's work at risk for a few thousand dollars a year. If you must do a military residency, look for one that is fully integrated with a nearby civilian program--where you regularly rotate through the civilian hospitals throughout your training and really get to know the staff. Look at the case numbers of the military residents, and how many of the cases are done off-site--cases done at away rotations are likely worthless.
A military residency is a nice way for a less competitive applicant to get reasonable surgical training. The programs are not abusive like some low-end civilian programs and you will meet minimum training requirements. You will have plenty of time on your hands to study for the boards (which military residents all pass--as the program directors tell you).
If, however, you are a top-notch applicant (or maybe not so top-notch--the general surgery match has been pretty easy of late), deferment probably is your best bet.
I don't know the specifics of the Navy programs, but I can't see that training conditions would be vaslty different than the Army and AF.

Concur.

 

[denali]

mitchconnie,

GREAT post! One of the most informative I've read in a while.

Is this generally true of all surgical specialties, specifically ortho and CT?

 

[bobbyseal]

What do you think is the deal with subspecialties that the military trains?

Right now I'm actually leaning towards uro. But, since the military is full of old men with big prostates, shouldn't I get a decent experience?

Same deal with ortho and ENT?

 

[militarymd]

Originally posted by bobbyseal
What do you think is the deal with subspecialties that the military trains?

Right now I'm actually leaning towards uro. But, since the military is full of old men with big prostates, shouldn't I get a decent experience?

Same deal with ortho and ENT?

One of the problems that I've seen lately with Tricare, is that the military hospitals are deferring a lot of Medicare eligible patients out to civilian hospitals so that we can concentrate on taking care of active duty and dependents....who, right or wrong, have priority.

So all the 65 year old + guys with prostate problems are frequently being deferred out except for teaching hospitals to some extent.