By Dr. Charles Patterson, WCI ColumnistA career in medicine through the Armed Forces can be an exciting, rewarding, and fulfilling experience. Even a shorter period of service can be a foundational and worthwhile venture. For those well disposed to the opportunities and lifestyle, the idiosyncrasies and challenges are an acceptable tradeoff. But because one can never fully know what it is to live a monumental career decision until they are committed, it is critical to understand the systems, processes, and cultures that define it, especially if you're interested in becoming a military doctor.
There are countless websites, blog posts, recruiters, and individuals eager to share this opinion or that experience. Finding a well-balanced set of perspectives is paramount in navigating the decisions that make or break a service commitment. Here at The White Coat Investor, you will find a trove of resources, from career considerations to a community of active, separated, and retired military physicians.
Sifting through the noise to find the answers that support career progression is a tedious process. In the following paragraphs and through associated references, we will provide a framework for building your answers. Generalities and common wisdom will be introduced, with credence to individual circumstances. No single strategy fits all, as our responsive, diverse, and growing body of military white coat investors can attest. Our goal is to promote financial literacy, bolster wellness, and highlight critical resources in your military journey.
Determining Whether a Career in Military Medicine Is Right for You
The Armed Forces are composed of a diverse population of servicemembers, all focused on the mission at hand. With respect to advances in broader representation of the American people, most who go through basic training will notice that those around them come from every state, all walks of life, and from every creed and philosophical background. Everyone has a story, just as each has their own reasons for entering. Identifying and internalizing your motivations is critical. But whatever your reasons for considering military service as a medical professional, it would behoove you to carefully consider the following questions:
- Do you want to be a military officer? Physicians, nurses, and mid-level providers all serve as officers. Understanding the basics of officership is crucial in determining whether this pathway is a good fit.
- What are your 10-year career goals? Especially if entering service through medical school, a commitment to the military may mean years of operational service and/or training prior to board certification. While the commitments themselves may be as little as 2-3 years, knowing where you want your career to be in 10 years is invaluable.
- What does your best life look like in 20 years? Let's face it: while the decision to join up shouldn’t be all about money, physicians in the military can make substantially less than their civilian counterparts. Understanding what post-service life could look like will help in filling in your decision matrix. There are many worse things in the world than a military pension.
- What are your family and personal goals? It's easy to join when you are 18 and tomorrow is the only day that ever will be. But having the foresight to research and imagine military family life (the good and the bad) will cage expectations, anticipate future frustrations., and plan for resource utilization.
- What are your ideal work conditions? Military service affords some unique practice opportunities, from aerospace medicine to humanitarian and global health initiatives. While not always predictable or mandatory, these can be exciting—equal parts strenuous and career-defining. Are you well disposed to them?
- How will this affect my financial life? The decision to take the “military scholarship” is not as simple as signing up for the Health Professions Scholarship Program (HPSP). Be forewarned, there is no free lunch, and there is no free medical school. Having a written financial plan that incorporates savings goals and a timeline for financial independence is paramount. The Medical Corps, while not for everyone, can be constructive for your financial plans and life balance.
This is by no means an exhaustive list of critical questions, but it's an important start. Regardless of your decision to join, thorough consideration of the above will help you to know yourself and the Armed Forces just a little bit better.
How to Become a Military Physician
There are many roads to Dublin and several into the Medical Corps. The majority of physicians enter through the HPSP, which is more appropriately termed a contract rather than a scholarship. In exchange for financial benefits during medical school (tuition, required fees, equipment, and a living stipend), the enrollee (and future officer) incurs an obligation for military service referred to as an Active Duty Service Commitment or ADSC. Prior to the HPSP, a fair amount of military physicians began their careers in ROTC or through a service academy, which incurs an additional service commitment. Independent of the HPSP program, the Department of Defense (DoD) operates its own medical school, the Uniformed Services University of the Health Sciences (USU) in Bethesda, Maryland. USU is generally recognized as an excellent teaching institution that prepares its students well for a career in medicine.
While these platforms are by no means the only way to start a military career, they serve as good introductions to the culture for students who are enthusiastic about officership.
The pathway that one takes to become a military physician dictates the length of the service obligation. For instance, a student who begins at age 18 at a service academy (five-year commitment), then enters USU (seven-year commitment), and then goes through orthopedic training and a spine fellowship may not begin to repay their 12-year obligation until they are 32. Conversely, should a student receive all of the same education and training through civilian institutions and traditional student loans, programs such as the Health Professions Loan Repayment Program (Reserves) and Financial Assistance Program can offset loan burden as a benefit to signing on without the extensive service obligation. Limitations and eligibility requirements apply to each program, and compensation and benefits packages are also dependent on the avenues taken.
Notable alternatives to the HPSP include the HSCP, the National Health Service Corps, and the Indian Health Service. Further loan repayment and assistance are available through the Financial Assistance Program, which may afford more flexibility in your specialty choice. Guard and Reserve positions are also possible and bring with them nuance and flexibility that differentiates them from active duty.
Should I Join the Military to Pay for Medical School?
As a general rule, money alone is not a compelling reason to join the military as a physician. Despite the HPSP “scholarship,” possible bumps in pay for active duty training platforms, incentive pays, and bonuses, many (if not most) civilian pathways are still more lucrative in the long run. But if we're talking about general rules, we should also note the exceptions. If you are a dumb doctor and are prone to dumb doctor tricks, neither private practice nor the Medical Corps is likely to save your investment accounts from yourself. If, on the other hand, you are entering a highly compensated medical specialty and are both financially literate and diligent, the time spent in service may set your lifetime earnings back magnificently.
How you calculate cost and value matters. For primary care physicians, officer compensation may not be that far off from civilian peers. Medical benefits packages, tax efficiency, education programs, and retirement benefits bring total lifetime earnings (and security) to near parity. Frankly, however, so much depends on one’s financial behavior that comparisons devolve as quickly as exceptions present. One does not join the military to get rich. One can become wealthy via this route, but that endpoint is predicated on habit, not mechanism.
The short answer to the question is that one should become a military physician if there is a desire to serve as an officer and if one would reasonably find fulfillment in working in the Medical Corps. With prudent savings and investment, you will come out of that service in a fine position. But joining for the money alone is unwise. Those who pursue a life in medicine for the money are likely those looking for a pathway into industry or to practice entrepreneurship, or they have an ownership stake of some kind.
For the rest of us, the decision to enter medicine was made on the promise of helping fellow humans and with the goal of doing well by doing good for others. Income is important, and the pay discrepancy is a deal breaker for many considering service. But fulfillment in your career—like contentment in a relationship—is predicated on more than finances.
What Are the Benefits of Being a Doctor in the Military?
Service benefits are both objective and intangible. For those looking to avoid monetary debt, service under the military umbrella affords one the option of receiving an income through training and coming out the other end without a mountain of student loans. While the paycheck isn’t massive, it can provide a household with a positive net worth early in the career. Access to employer-matched retirement accounts, a pension, affordable healthcare, and increases in pay in high cost of living areas and inflation can buffer the challenges of balancing quality of life and savings. Programs such as the GI Bill, Yellow Ribbon Program, and VA loan program help offset some of life’s largest expenses. Additionally, access to military facilities like gyms and grocery stores and receiving services such as car repair, veterinarians, and recreation centers provide a cost-effective means of maintaining a comfortable and enjoyable life.
There exists in the Armed Services opportunities otherwise unavailable to most civilians. Thus far, I have undergone survival training, participated in freefall jump (parachute), rappelled out of helicopters, cared for refugees abroad, traveled extensively, coordinated mass casualty response teams, led multiple clinics, and had a seat at the table for medical planning at an organizational level. These are just the start. It has been fun: good, tiring fun.
Military physicians practice in a unique setting. Naturally, deploying to areas in conflict or in the throes of a humanitarian crisis will present the physician with pathology rarely seen in the US. For the majority of the time, the practice setting will be stateside in a medical treatment facility. Resources can be spartan, but dealing with insurance is less of a headache (that's been my experience, but I appreciate those with different opinions on this point). Administrations—like at all civilian hospitals—can be burdensome or incredibly valuable depending on the command. But the folks with whom you work are generally motivated, competent, and diverse. Large organizations like the Defense Health Agency can be cumbersome and confusing, but the people who work with you day to day tend to be helpful and engaging. Some of my closest friends and mentors were made in military health facilities, and if I am not grateful for the system, I am certainly grateful for them.
To me, the benefits of being a doctor in the military supersede the paycheck. The medical profession is enriched by a spirit of altruism (and soured by a litigious, algorithmic, and dehumanizing culture). The intangible benefits of military medicine are an extension of that principle. Part of one’s compensation for military service is inherent to the service itself. It's a messy business: tedious and sometimes mind-numbing. Not everyone will be enriched by a military commitment, but those well suited to it can take distinctive pride in the ability to help warfighters and their families.
How Much Do Military Doctors Get Paid?
As an officer in the Armed Forces, military physicians are entitled to compensation commensurate with their specialty, certification, seniority, and duty station. The pay structure is publicly available, and it starts with basic officer pay, which increases with rank and time in service. Allowances for food, housing, and cost of living adjustments (COLA) for high-cost-of-living areas are also applied. A broad suite of bonuses is also offered for board certification, specialty incentivization, and retention. In combination, these bonuses can double (or more) the basic pay package.
Eligibility for these, of course, depends on certification and service commitment status. Depending on specialty and route of entry, loan repayment, critical wartime accession bonuses, and BRS Continuation Pay may apply. Tax breaks (in the form of non-taxable housing allowances) can be substantial. Moonlighting opportunities typically depend on command approval, but they are a fairly common practice.
Stated plainly (but with emphasis), military physicians earn less than their civilian peers. In some cases, this pay discrepancy can be more than six or seven digits. A pre-pandemic Government Accountability Office (GAO) report highlighted the disparity in intra-specialty pay, and while recommendations were made with regard to changes in the incentive and pay structure, few have been adopted. Whether this will change anytime soon is anybody’s guess, but most are betting against it. The reason is simple: physicians are among the highest-paid members of the DoD, and unless there is a recruitment or retention deficit, the political will to add to their paychecks is nonexistent.
What Are the Specialty Choices Available in the Military?
The Department of Defense needs most medical specialties. However, it may not need many of a given type, and, thus, the opportunity to train in one’s preferred field may be limited. The blueprint for vectoring into a given specialty in the military should be known and well understood prior to committing to the HPSP or another recruitment program. Every year, on the advice of consultant physicians, the Surgeon General publishes a list of residency and fellowship training positions for which eligible students and officers may compete. Training may be at military-specific sites, integrated military/civilian programs, or at solely civilian institutions. Mindful that funding and sponsorship type directly impact service commitment, applicants vie for the platform of their choice in a cycle that roughly mirrors the ERAS process.
The Military Match can be complicated. For students without military experience applying for the first time, it can be an intimidating and disorienting venture. The good news is that there are well-vetted resources that can be of tremendous help in navigating it. Knowing your desired specialty, embracing it as an officer, and setting reasonable expectations are foundational in a successful match experience. There is much, much more to be said on the topic of the Military Match. Familiarity with its idiosyncrasies is a good starting point.
For those who do not match into their desired specialty, options for PGY-1 only (typically Internal Medicine, Surgery, or Transitional) are executed. Thereafter, most will either re-enter the Military Match process or serve their commitment as a General Medical Officer (GMO) or Flight Surgeon and separate to complete residency as a civilian.
Finally, a physician may enter service having already completed their training and certification. This pathway foregoes the need to participate in the Joint Services Graduate Medical Education (JSGME) process, and it can apply to Active Duty, Guard, or Reserve positions. While there is no guarantee of availability, it serves as a route of entry for those looking for more flexibility before a commitment.
What Insurance Do I Need as a Military Officer?
As much as any other physician, military docs need to insure against catastrophe. All servicemembers are eligible for Servicemembers' Group Life Insurance, or SGLI, which provides up to $500,000 in death benefits at the cost of $30 per month. This is a fine start but is unlikely to come close to the amount of term life insurance advisable for folks with dependents. Additional term life insurance is widely available commercially and is typically unencumbered by military affiliation. Insurers abound for all other types of insurance (home, auto, renter, umbrella, etc.), and there are several reputable WCI affiliates that I have personally used and have provided great service.
Unique coverage considerations for military physicians include malpractice and disability. Military physicians practice as agents of the United States government, and malpractice claims brought against them are adjudicated under the Federal Tort Claims Act (FTCA). The interpretation of the law, known as the Feres Doctrine, has meant that indemnification of military physicians practicing medicine on behalf of the Service is very difficult for plaintiffs. This policy has been the subject of inquiry and challenge for the last 70 years. In spite of several recent reforms, doctors don’t typically carry malpractice insurance for their military practice. Importantly, the FTCA does not apply to moonlighting or non-service-related employment. Thus, malpractice insurance may be a necessary consideration for off-duty medical practice.
Special risks apply to military physicians participating in fun such as combat operations, flight status, ordnance disposal, diving, and parachuting. While basic income is intact when injured and on active service, long-term disability is expensive and difficult to secure. It stands to reason: insurers know that there are corporeal risks associated with what military physicians do. As a result, you will pay more, and a myriad of exclusions will apply. The VA’s Traumatic Injury Protection (TSGLI) will provide short-term coverage in the event of an injury but will not replace the potential income of an encore civilian career in the event you are maimed while in uniform.
In asking dozens of peers in the Medical Corps over the years, I have found that exactly zero have sought supplemental disability insurance. Most didn’t see the need for the expense (especially on an officer’s salary), and most were not in heavy operational billets. Whether this represents prudence or hubris, I am unsure. However, at the very least, the individual should be aware that their risk of injury is higher while serving in the military.
[FOUNDER'S NOTE FROM DR. JIM DAHLE: I had a disability policy when I entered, and I maintained it throughout my service. It would have paid had I been injured or gotten sick, except as an act of war.]
While retirement benefits include healthcare coverage for those who have reached eligibility, Long Term Disability Insurance (LTC) is not guaranteed. At the time of this writing, no federal option is available and, as such, is a moot point. However, for those who determine that insuring against financial devastation at the end of life is in the best interests of their dependents, LTC may be worth pursuing. This is a family-specific decision, and provisions to ensure it at a reduced rate at a governmental level are not promising.
Should I Buy a House While in the Military?
For most active duty members, buying a house is not advisable. For the associated transaction and operating costs to be worthwhile, physicians are best served by acquiring a mortgage on a home that they are likely to stay in for as long as possible—typically a minimum of 4-5 years. Even if your housing needs and wants don’t change in those years, the ideal appreciation is not guaranteed. Because most duty assignments are 3-5 years in duration and they can end unpredictably, anchoring your financial life to a large fixed expense in a transient location should only be done with eyes wide open. Cautionary tales of home ownership on active duty abound, and the hard-learned lessons of others should be considered with gravity.
That being said, there are exceptions to this rule. Many military physicians, myself included, have done very well buying and selling homes throughout their careers. Whether this is due to thorough planning, dumb luck, or a mix of both is arguable. To maximize the odds of success, though, there needs to be some contingency plan to either keep a home as a rental following reassignment in the event of an interval market downturn or return to it after separation. If you have no plans of returning to a duty location, you don’t want to be a long-distance landlord, or you can’t afford to sell the home at a significant loss, home ownership in the military is probably not for you.
What Retirement and Investment Accounts Are Available in the Military?
There are several retirement and investment accounts specific to members of the DoD. First and foremost, military members have access to the government-structured 401(k) called the Thrift Savings Plan or TSP. This account follows most of the same rules as a 401(k) from a civilian provider with the most obvious differentiating factor being the investment choices. Funds available within the TSP mirror the large cap, small cap, international, lifecycle, and fixed income funds of the large investment houses, and they are both low-cost and tax-efficient. The G Fund is a fund unique to the TSP, and it provides Treasury bond yields with money market risk.
Servicemembers have a Roth option, and newer features include the ability to invest in outside funds. The Service matches TSP contributions up to 5% for those enrolled in the Blended Retirement System (BRS). This is in addition to the retirement annuity, giving those with career aspirations added confidence in an aggressive portfolio. IRAs—and (for those inclined to pursue 1099 income) SEP-IRA or solo 401(k) accounts—can be arranged independent of work in the Armed Forces.
Savings specific to the military are paired with deployment and are intended to help relieve financial burdens at home. For those deploying, the Savings Deposit Program and increases in TSP contributions paint a silver lining on an otherwise inconvenient work trip. Wills can be set up free of charge on base and updated periodically for the same price. If one’s assets need further protection or they demand specific attention, trusts can also be established. While servicemembers do not have access to Health Savings Accounts, they can participate in the Dependent Care FSA, which is designed to provide some amelioration from the costs of child care and the care of physically impaired or developmentally delayed dependents.
When Should I Leave the Military?
The decision to leave the military can be as difficult as the decision to join. Both require soul-searching and robust planning. How a government-backed annuity and lifetime medical care factor into your strategy for attaining financial independence must be balanced with the tolerability of the work and personal goals. Playing with a simple Excel spreadsheet will illuminate the break-even point (the amount of time in service at which staying for retirement eligibility is the more financially sound choice).
For a 20-year career, the retirement approximation tool (called the BRS calculator) estimates the value of the government annuity and benefits between $2.5 million and $3 million (depending on time in service, asset allocation, and performance, the total value may be even greater). Some military physicians may be eligible for the pension by their mid-40s, leaving them with an inflation-adjusted annuity, lifetime healthcare, and ample time for an encore career. If you are a retina specialist and capable of pulling in seven figures per year, separating with 16 years of service may still be the right move from a financial standpoint. But for those in primary care and non-procedural specialties, the break-even point is far sooner. As a rule, the less lucrative one’s specialty, the less time in service is necessary for making “staying” financially palatable.
For generalists and those with less civilian income potential, it may only take 4-6 years of active service to reach the break-even point. But 20 years of service is a long time, particularly for those ill-suited to military life. The measuring stick becomes far less objective when considering the stresses on kids and families, the burden of administrivia, subjection to military culture, and the vulnerability to geopolitics.
Several of my mentors have shared this piece of advice with me, and I think it's sage wisdom: when the military is no longer fun, it's time to leave. There are innumerable circumstances and policies in the DoD that are less than fun, but if you are starting to experience burnout, it's a good sign that the military is no longer your ideal employer. Money is an important contributing factor to the decision to enter, stay, or leave, but it is only one of many equally important considerations. If on your quest to retirement eligibility (or financial independence), you burn bridges with your spouse, your kids, and your friends while losing sight of the goodness of your work, I dare say it probably was not worth it.
The Bottom Line
The purpose of this article is to introduce and briefly comment on the most prescient questions facing prospective and current military physicians. White coat investors represent a diverse readership, many of whom carry a wealth of experience in military medicine. They will be quick to point out the gaping holes, nuances, and exceptions to the answers delivered above. But while each question is worthy of an expansive response, it's beyond the scope of this introduction. Fortunately, the robust library of articles posted on this site—in conjunction with reader responses, the WCI Forum, and the WCI podcast—provide up-to-date policies, interpretations, and opinions. Navigating the ins, outs, and in-betweens of military life can be difficult without a roadmap. The resources here at The White Coat Investor are in place as a living guide.
The decision to serve as a military officer and physician is personal. The truth is that it's a difficult life that is less lucrative than the civilian sector. Financial implications notwithstanding, decisions to enter, stay, or separate are challenging, and miscalculations can have profound implications on your quality of life. But this life of service need not be destructive to your long-term personal and professional goals. Whether it's discerning a career, bolstering financial literacy, or considering options for separation or retirement, The White Coat Investor community is here to help military physicians plan for financial security, maximize resources, and thrive through adversity.
What other questions do you have about life in the military as a doctor? Were you a military physician? What was your experience like?
The views expressed in this article are those of the author and do not reflect any official position of the Department of Defense or the US government. These writings are not authorized, approved, or endorsed by any of the above entities.
One additional key financial consideration that you touch on only tangentially is the likely impact on a spouse’s earnings. Many doctors are married to other individuals with high earnings potential, but it’s much harder to develop a career when you’re moving every 3-5 years.
Eva, that is absolutely correct-thank you for that addition. Our moves have without question had an impact on my wife’s career.
I was drafted during the Viet Nam era right out of internship , served 2 years, and then was able to use the GI education benefits for my EM residency.
The program has changed since then.
I enlisted at 17 in 1978 and retired in 2009. At 17, I wanted to be a captain and sail the seas. My parents said no and told the recruiter to give me hospital work. Otherwise, they wouldn’t sign for me to go in. The military wanted more women to serve and did heavy marketing. To this day, I see the Navy as “its not just a job, its an adventure.” SNL did a skit with Belushi swabbing a deck which floats around in my head whenever I think of my Navy time.
I used the VEAP for my undergraduate, got accepted into USUHS. Moved every 2-3 years after residency bouncing from stateside to overseas. Moving is extremely stressful and is right up there with death, divorce, and bankruptcy. Even with the government paying for the move, money is still spent to move. Rental cars, hotels, eating out. It adds up.
I built a practice in each duty station only to have to close it down and move to another base and rebuild that practice. After a while, the military becomes smaller and you run into the same people, but I left behind retirees and young people who didn’t do the time I did. In some duty stations, I would be minding my own business tending to my patients when someone somewhere decided I need to go to the woods for training or to another base for a short time. My surgeries would be cancelled, my patients would be left hanging. While the adventure of travel is great the disruptions it caused left me feeling less productive and sometimes angry, very angry. With that said, I still wouldn’t change my path using the military to achieve my goals.
The military can be very difficult even for those who do 20 years. Difficult for wives and children, too. Service people have to weather deployments and RIF’s (Reduction in Force or layoffs). Then there are the collaterals. (Ugh) In addition to your full time doctoring job, there is the chair-ing of some committee that is a 2nd full time job. If you want to get that retirement you gotta chair something, cause you won’t make rank. And to stay in, you gotta make rank. I knew fantastic shipmates who didn’t make rank and got the boot at 16 or 17 years. People treat you differently when you don’t make rank. People avoid you, dismiss you….it’s awful. Let’s not forget the twice yearly weigh ins and physical readiness testing which puts many members on the chopping block. Fail the tape or PRT and you are treated differently by your peers.
I punched and kicked the Navy around in my comments. I do want those who are thinking about a military career that I did participate in our Nation’s history. How many can say that? There is something comforting about seeing a Navy ship whether in port or at sea or the Marines in action. As long as we have the military, I know that we’ll be alright.
Is it easier to get into medical school through the military?
I suppose some people will get their only acceptance to USUHS, but I don’t think it’s particularly less competitive than other schools. Most docs come in through HPSP, and you have to be accepted to med school before you can even apply for the “scholarship.” So I’d say overall, not easier to get in through the military.
No, it isn’t. However if you want one of the Os etc. you might be awarded a residency spot you couldn’t have gotten otherwise by paying your dues- a few years as a GMO at a terrible place- if things can still work that way. In fact I bet given the financial benefits- free med school etc., and just math- it’s tougher to get a military scholarship/ USUHS admission. Disclaimer I may be out of date with these opinions.
I suspect it’s easier given how much easier PSLF is getting these days. The military is having trouble competing with the nearly free med school at least half of med students are currently expecting via all federal loans/SAVE/PSLF.
One option that the author didn’t address is the option to continue serving with the Guard or Reserves after leaving active duty. Depending on your employer, traditional reserve component service could be an excellent idea or a terrible idea. If you leave active duty to take a position with the Veterans Administration, you can buy back your active duty time as credit towards civil service retirement, continue to drill with the Guard or Reserve, and earn two pensions and health care coverage for life.
On the other hand, a solo dermatologist, plastic surgeon, or dentist who owns his or her own practice might not be able to risk being activated for a year or more of military service. That could destroy your private practice, interrupt care for your patients, and put your employees out of work. Sometimes staying in the Guard or Reserve makes sense, some times it almost certainly does not.
That last part is a spot on. I’m very glad I served 8 active and 8 reserve but I would not stay in reserves until retirement bc if in private practice you can lose a lot. You still need to pay all your overhead when gone. That’s not an issue if you work for a university but it’s a huge risk if in private practice.
Why does the military pay for doctors to do survival training or rappel out of helicopters? Is it just for recruiting purposes to get 26-29 year old med students and residents to sign up and make up for the lower pay? Seems like the money would be better spend on more medically related training or having their physicians do physician work.
Survival training is easy from an Air Force perspective – the majority of people don’t do a full course of survival training (cadets and USU students do a short course that gives the basics) unless we are going to be actively flying (which many of us do get involved in). We fly all over the world and it is definitely possible for a plane or helicopter to go down and have us in a situation requiring those skills. Unlikely, but possible. Lots of our military training covers unlikely scenarios, but if we were in that scenario, not having the knowledge could be catastrophic.
You might think flying is not physician work, but we have had physicians involved in flying from the earliest days and we are heavily involved in the safety side of things, including observations while in-flight.
All services do have physicians very near the front lines of fighting, which has been shown to improve combat survival. A lot of training is associated with this.
That last part is incorrect. This is why the military now stabilizes and ships to Germany or wherever. It’s also why the Army no longer deploys a MASH but only smaller units. Outcomes are just better by flying over the units in theatre to a base.
Rex, what part is incorrect? You are correct, MASHs don’t exist in the Army any longer, but we do have large facilities still (theater hospitals).
We have multiple small surgical units within a few miles of the front line. Most casualties go there first, then they go to a hub in country (Bagram, Balad, etc) where they stay for a few days often (depends on air flow) before they are then flown to Germany and then on to the USA. Sometimes the casualties go directly to a hub if they are closer, but we move the small surgical teams around to be near the fighting. Until we pulled out of Afghanistan, all of the bases there got shot at regularly. Iraq has rare incoming rounds at this point, but it does still happen several times a year. Sometimes, we have surgeons who are exactly where the shooting is (literally waiting outside the house being entered). And the reason the medical teams (all of them, not just the super close) are that far forward is because the data has shown the faster the life saving care, the higher the survival. We have tons of data about forward care thanks to the Joint Trauma System and the associated registry. Yea, I know a little about this stuff, I was the commander of these teams (made up of Army, Navy, and Air Force) in Afghanistan for 17 months.
I havent been on active duty in a while now but i deployed for the invasion in 2003. At that time, the evidence showed that it was better to just stabilize them and move them. People too often dont have exactly the correct equipment or the exact expertise and at times it would appear go beyond their training thinking they just had to do it. This was also an issue at the time with a much larger army in theatre that you just only have so many medical personnel and having physicians in individual units at the actual front was sort of wasting them. For sure you need somebody to stabilize the individual but definitive care at that time by how it was then configured was shown to better further back even with the wait.
“Stabilize” has a wide enough meaning that you are both right.
The reasons survival rates were so high in Iraq/Afghanistan were primarily:
1) Body armor so most wounds were to limbs not core
2) An extremely advanced EMS system that got people in the hands of surgeons very quickly for damage control surgery
3) The use of whole blood
Definitive surgery might have been in Balad/Bagram or even Germany though.
Thanks for the clarification on your time served (Thanks!) Rex.
The joint trauma system registry taught us many things and one of them was early in the war, we were moving folks too fast (depending on injury). We really beefed up places like Bagram and Balad so that we had a lot of specialties and equipment in response to this issue. Severe head injuries are a good example, they need to fly within 24 hours or wait several days (I admit, I can’t remember what the neurosurgeons were pushing as far as criteria to evacuate to Germany but we held head injuries for over a week at times).
You would also be amazed what the special forces medics are now doing at the site of injury and we are using fellow soldiers as pre-screened walking blood banks now (another lesson learned, faster they get blood and the less saline they get, the better major traumas do).
Thanks Jim, excellent summary of systemic things done to improve survivals.
Yea, walking blood banks are awesome. The vampires on onto something with the ultra fresh blood thing. Sitting around in fridges with preservatives isn’t good for blood.
In addition to forward (closer to battle) physician duties the military physicians train/ supervise the training of the even further forward medics. The medics I commanded in my clinics needed to know I was a soldier and officer not just a doctor, and had done some of the military training they were doing and more advance military medical training (eg ATLS type stuff). The soldiers we cared for needed to know the same- my jump wings and a colleague’s Ranger tabs improved our patient/doc relationship. In Occ Med my spouse being a pilot helped him better care for pilots. And while I never went to war (thanks COL Doyne and my spouse for letting him deploy instead of me when I was still breastfeeding) and haven’t yet used my fun training for survival it was a great benefit to get to rappel zipline parachute and go camping and for spouse to fly jets and planes and helicopters on the military’s dime.
Really nice summary of military service for doctors. I’d push back a little bit on the idea that you have to have a desire to be a military officer before joining to pay for medical school. I signed up for the HPSP purely for practical reasons (I felt I’d rather pay back time than money). I also had an inkling that I’d pursue a primary care specialty (I did) and thought the Army gave me a quicker way to pay off my debt (through time). I definitely had very little interest in being an officer, but I’ve since learned to appreciate a lot about being an Army officer and signed on for 4 more years (again maybe more for practical reasons than loving the Army). So, I do think your reasons for joining don’t need to be a noble desire to serve or to love the idea of being an officer. You do need a certain level of open-ness to not hate it once you’ve joined, though. There are certainly things about being an Army doctor that are frustrating, but the same could be said about being a civilian doc. Overall, I think the HPSP is a good option even if you’re on the fence about your desire to be a military officer. Thanks again for the informative article.
I think you’re pretty rare. Most people who don’t go in primarily because they want to be in are not only miserable during their commitment, but don’t stay afterward.
I don’t know that most docs are miserable, but there certainly are some. Last time I saw the data for the Air Force (3 years ago), 85% of physicians leave at the first opportunity, so they clearly are not loving it either.
I’m not sure anyone has ever surveyed military docs about their happiness. Probably varies depending on the deployment tempo. Clearly most leave when the commitment is up, but that might just be a primarily financial decision. It’s impossible to know if they’d stay if the military paid them the same as the civilian world. Maybe you can extrapolate the data from the folks in lower paying specialties?
With the caveat my data is getting old, specialty docs left at the highest rate and primary care docs left at a lower rate (but still over 50% left, but I don’t recall the exact number). General dentists retention is much better as well, especially dentists who left private practice to join the Air Force. So I agree, money is a factor in people leaving. Absolutely not the only reason, but a factor.
15.5 years in with Navy, Active Duty.
I would add that the Pension system has changed. It is no longer 50% of your Base pay for retirement for all ranks as it once was (plus 2.5% for each year beyond 20), but it switched to BRS which is 40% (2% x 20) plus 2% for each additional year.
So that was a significant drop.
Thankfully I was grandfathered into the original system, but I don’t know if I would have stuck around for 40%.
I also agree with most of the article, the biggest issue at MTF (IMO) is the spartan resources and the constant fight with budgeting/personnel while waiting for congress to approve a budget. I have never been in a hospital that wasn’t in some sort of hiring freeze, although they call it something else.
I think the other issue is the Military Match can definitely keep you from ever getting the residency that you wanted. As a commenter pointed out, its a small community, and if you are subspecializing enough, a single person can blackball you out a specialty for any reason, “I don’t think you have the right personality type for this specialty” (true story). The worst part is you spend 18 months setting yourself up for the match and don’t ever get an explanation why, maybe applying multiple years in a row with the same outcome. I just happened to know the person who blocked me, and could inquire.
I would also add that the vote to stay definitely depends on your career path. An average FM/Psych/Psychologist will likely make more in the military.
Lastly family is huge. As a Single Income No Kids person, where the military sends me is a non-issue. I don’t care about local school quality, or a place for my spouse to work. However I have watched it be a burden plenty of times, to the point that spouses don’t move with the Military Doctor, because you can’t get their type of job where they are PCSing.
Anyways, always a good topic to revisit.
I intend to finish my 20 years and then hard retire from Navy and Medicine.
Retired female anesthesiologist, mostly co-located with non-physician Navy spouse.
The article and comments are great. I would add–
I had paid maternity leave, not as generous as the current policy, but non-existent for my civilian cohorts, and now there’s paternity leave too. Childcare arrangements for a dual career family, both with duty and potential deployment obligations were challenging and expensive, especially when we were overseas. Sigh of relief when my kids aged out of requiring full time care. Eventually, the transferability of the GI bill was a huge benefit to our family’s finances.
Spouse flexibility is mandatory. If it’s not, then separation from the military or the spouse is common. Besides the physical disruption and expense of relocating and disrupting kids schooling, there’s the separation from friends, extended family and communities (church, neighborhood), though internet connections can mitigate some of these.
Unique opportunities to provide trauma care during deployments, or care in austere environments during humanitarian missions, overseas, remote facilities or shipboard are challenging but enlightening experiences. Many of my colleagues are ‘educated’ by their military experience and therefore more comfortable with volunteering for humanitarian service. The opportunity and adventure to live and travel overseas, although avoided by many, was incredibly enriching to our family’s experience. You have to balance the adventure with uneven school quality, extended family separation, and uncertain spouse employment or career development.
The burden of insurance administration is negligible, but there are still issues with care coordination, availability, utilization review, productivity pressure etc. Overall, my burden with these areas is less than my civilian colleagues.
I’ve always appreciated the intangible reward of working with military patients, retirees and family members. They are in many ways healthier, have stable access to medical care, and mostly appreciative of their care. My colleagues have been, for the most part, competent and congenial, many have become great friends.
The hardest part of deciding whether military medicine is the right path for anyone is that the future is unpredictable. So many aspects have changed since I took the HPSP contract. Women are deployed and utilized in many more areas, the nature of conflicts have changed, internet connectivity exists, even the availability of civilian insurance through Affordable Care Act has changed whether some people stay in the military (due to pre-existing medical conditions, large families or affording care for disabled family members).
I know I’m coming to this post a little late so this might not be seen a lot but my own little soapbox when it comes to military financial benefit is to remind people to apply for transfer of their GI bill benefits at the first opportunity to do so. The vesting period only begins after the initiation of transfer and you can definitely lose the benefit through inaction! A lot of physicians get out around the mid career mark and the difference of even a year in forgetting to start the transfer process can mean a loss of a significant benefit.
Great reminder. When I was in, you needed six years of AD service to get the GI bill. I wasn’t willing to do that, so I took the $1,000 or something instead.