This thread got me curious about military medicine, so I tracked on over to the student doctor forums (kind of like this place, except for med. school applicants) to see what the experiences/opinions were on USUHS and the HPSP scholarships. There was also a fair bit of discussion on general medical practice in the military.
A fair bit is an understatement, haha. Remember that those posting on SDN (myself included) are a self-selected group as those who post here are and by far the vast majority who post there in the milmed forum are not the happiest of folks.
One thing I found interesting was that there is apparently a shrinking of residency programs in the service
I'm not sure I would qualify it as a shrinking of residency programs. As far as I can tell from the data there are just as many residency positions now as there have been for many moons. The AF has done the most in regards to changes over the last 5-10 years (BTW most of those who are upset on SDN tend to be AF). They have closed several hospitals over this time frame and have shifted some residents to work in Navy and Army hospitals.
, and that those who are specialists in surgical fields are getting few cases while in CONUS. It's clearly different while overseas where the fighting is. One poster, who seemed to be a malcontent, complained that as a general surgeon he mostly did colonoscopies while stateside. That was interesting to me, as GI docs are the ones who usually do that for civilians (at least with people I've known).
Most of this is entirely location dependent. If you are at a smaller hospital you simply aren't going to get the case load you will if you are working at WRAMC/BAMC/MAMC. Yes, general surgeons do colonoscopies, and it can be a big chunk of their patients if they are working at a hospital that does not have a gastroenterologist on staff as well.
Some of the complaints about milmed were centered on base hospitals becoming clinics, with few inpatient beds, and that the result was essentially the military becoming a primary care provider only (excluding the big hospitals like WR). The primary care (IM, FP, Peds, etc.) guys felt overworked,
This is true, they have closed many hospitals and changed several to more "super clinics". The Navy for instance has closed Oakland and Roosevelt Roads just off the top of my head and the hospital at charleston is now more a clinic than anything. The AF has also done this with places like Malcom Grow and combingin Wilford Hall with Brooke Army. They are however opening a nice new hospital at Ft Meade. The decrease in inpatient beds is multifactorial between cost, who is elgible for care, and many other factors.
Primary Care is getting hammered right now. Imagine a growing patient population (people keep retiring but they don't add more doctors) along with trying to support the wars. Primary care is deployed quite often and fills many billets with the line (battalion surgeon for instance in the Army).
and there was a general complaint that there were few opportunities to train to specialize via a residency(unlike their med school/civilian colleagues). Indeed, in concert with there being complaints about the reduction in available residencies, there was a resultant feeling that medical training was being interrupted. There was a feeling of MDs/DOs having to do a "GMO" tour (I believe this to mean General Medical Officer) at a higher rate, which was a point of consternation.
This is probably beyond the scope of being worthwhile to discuss on this board given the time it would take to give background and the like. The main issue is that people don't like not being able to go "straight through" in their training. They want to do it like in the civilian world. The military has some unique requirements and needs young doctors to fill some of these line unit medical positions. To do that they need to interrupt training for many physicians (less in the Army and AF, more in the Navy). There are a few specialties in which you are not allowed to train in the military (PM&R in the Navy for instance) and they also restrict how many people can be in any one specialty (we don't need 200 pediatricians and only 20 family practice docs) so that leads to restrictions. If you want more input on this particular aspect SDN has many, many posts.
The physicians on that forum were also displeased with having the hospitals/clinics run by nurses and/or hospital administrator types.
Nobody likes being told how to do something by someone who isn't "like" them. Doctors would prefer a doctor run the hospital because they believe they have a better understanding of what it's like to do patient care. Not sure this is necessarily true, but it's the pervasive thought.
I think it'll also be interesting to hear about the difference between practice while deployed and while back in CONUS. I have to imagine that surgeons in Iraq and Afghanistan were/are crazy busy. Also, given that the mortality rate for servicemen wounded in action is so much lower than in years past, I have to believe that the physicians treating our troops are top notch and can handle big-time trauma (which would imply good training before deployment).
The CONUS vs deployed practice really depends on what type of doctor you are. If you are primary care, well your job is going to be pretty much the same. If you are a surgeon you will see some of your "bread & butter" cases (appendicitis, gall bladder, etc), but you will also be seeing a bit of trauma. Also depends on your location on deployment. If you are in a very far forward base you might not see as much trauma because they will be flown right over your head to a higher level of care. I like to think the increased survival odds is due to our care, but I think it's also due to advances in armor and body protection.
sprog said:
I'd also be curious to hear about the officer/physician dynamic. Are there high numbers of physicians leaving the military when the obligation is over? If so, is this because higher rank means less practical experience? As someone in a profession like medicine, I can see how becoming an administrator is not something one would easily embrace (maybe that's why there are so many nurses running the clinics).
Currently many physicians are leaving (also somewhat specialty dependent). The high deployment tempo (many docs have multiple, multiple deployments) in combination with the pay disparity is a hard bullet to bite for many.
To answer the question about increasing rank I'll also discuss patentesq's post. In military medicine there is generally three "pathways" that most think about (Some services this is more codified than others): MTF/Clinical, Operational, and Research. You pretty much self select for these, but you can choose to go into "Executive Medicine" (aka Administration) at around the O5/O6 mark. For those who go the clinical route you basically are seeing patients and that's what you do. The operational guys are the ones who are staffing positions as Brigade Surgeons, Unified Command Surgeons, JTF surgeons, etc etc. They usually have some clinic, but alot of their duties surround advising the combatant commander on medical issues. Research is research, not a ton of positions for pure research only and no clinic, but there are a couple.
As you progress in rank you eventually get to the point where you need to decide if you want to command a hospital or not. If you desire this you put in a package to do "executive medicine". Basically a command screening board. If you are selected for that then you basically kiss your practice away and you become a hospital XO and then CO and then can progress to any number of billets after that. You don't necessarily need that to make flag rank, but it's the most common path. If you don't want to do that then basically you just stay in clinic until you decide to retire. I know plenty of 20+ yr physicians who still see clinic as their primary duty. At some point to make O5/O6 you will probably serve as a dept head of your dept or possibly as Director of Medical Services or Director of Surgical Services or similar position in the hospital, but that's more for FitRep bullet material.
patentesq said:
I expect that once the troops return home in the coming years (barring anything unforeseen happening), we will start seeing the beds filling up in the CONUS hospitals.
Might have the opposite effect, without the war wounded you might see fewer people. The main limiting factor on this is simply budget. The military hospitals usually don't see many people over the age of 65 because Medicare becomes the primary payer and therefore the hospital can say they don't have room for them (which they usually don't actually) and those individuals end up seeing docs in town and when they need to go into the hospital they go to the civilan hospital. Unfortunately as we continue to age and more and more people are military healtchare beneficiaries it drives the cost up which then reduces by the same amount how many "bullets" DoD can buy.
Overall though I personally am very happy as a military physician. It has some unique issues that some who come into military medicine don't realize until they've already signed on the dotted lines and then they become bitter and post on SDN
It's definitely not for everyone, but I would say that in general if you are a fan of West Point that you would be more than happy as a military phsyican.
