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By Dr. Charles Patterson, WCI Columnist
To specialize or not to specialize: that is the question. Whether tis’ nobler has little to do with the decision; rather, one’s academic interest, lifestyle preferences, and income potential are the most critical inflection points. For most medical students, choosing a medical specialty is a function of their competitiveness for the training program. For fellowship, the same rules apply but to a much smaller pool of applicants. In the military, a critical need for particular specialists opens the door to advanced training. Thus, for well-qualified physician-officers, subspecialty training can be an opportunity to optimize job satisfaction, income potential, and career longevity.
The type of practice, the spectrum of cases, compensation, work environment, and retirement considerations all influence the decision to pursue a subspecialty in the military. In this column, we will take each in turn in our effort to examine the primary considerations which influence the selection of a military subspecialty.
What Medical Specialties Are Available in the Military?
The military adores a good multi-tool. This is reflected in the impressive number of Family Medicine training positions authorized each year by the Joint Service Graduate Medical Education Board, or JSGME. This stands to reason: many outstanding Family Medicine docs can be placed in the clinic, training program, ED, deployed ICU, or in leadership positions. I am not a Family Medicine physician but have observed this versatility with admiration.
However, at a given point, you just need an ED-trained physician, intensivist, surgeon, or anesthesiologist. For that reason, the military trains and retains these specialists (albeit in far fewer numbers). The Surgeon General, on the advice of consultant physicians, directs the number and type of specialty training positions each year. Applicants may then compete for the training spots in a process that is explained in this Military Match Day column.
Military GME sites host many primary residency training programs but fewer fellowship programs. As a result, it’s much more common to be trained through civilian fellowships via a sponsored or deferred contract. Since training at civilian institutions generally provides ample opportunities for research, longitudinal projects, with careful planning, may continue following the completion of training.
As one might expect, some specialties are rarely available: the military just doesn’t have the need or volume to support a robust complement of Pediatric Hepatologists or Retina-trained Ophthalmologists.
That said, one might be surprised at the array of possible opportunities. Just because the military doesn’t need many subspecialists, it is not to say that they do not need subspecialists at all. At our larger hospitals and training sites, one will find a diverse set of physicians of all stripes. From Maternal-Fetal Medicine-trained obstetricians to Adolescent Medicine-trained Pediatricians, there are few specialties that are not represented.
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Practicing as a Military Subspecialist
On any given day, you could be forgiven for mistaking a clinic in the military with a civilian practice. Save the uniforms, you will find the same banal-colored walls, the same smells, the same USPSTF-driven screening questions, and similar wait times. Our folks are special, but they follow the same professional standards with which you are no doubt intimately familiar.
The differences are striking, however. On any given day, word might be given of a short-notice tasking to provide humanitarian aid to Haiti or pandemic relief stateside. One might even be notified of deployment to [location redacted]. Further, caseloads may be fewer, and it's not uncommon for specialists to moonlight in civilian centers to keep their skills sharp and to add 1099 income. Pay can be considerably less, or it can be competitive, depending on bonuses and with respect to taxes and the benefits package.
It also stands to reason that the specialists who are most desired are those with procedural and emergency skills—Intensivists, Surgeons, Anesthesia, and ED to name a few. While a variety of factors play into one’s eligibility to deploy, the opportunity to practice in that environment is possible. Although deployment can be viewed as a positive, negative, or neutral experience, it is undeniably unique. There is tremendous upside if one is disposed to such a practice: unique clinical experiences with incredible teams with tax-free income and other incentives. I would be hard-pressed to name another organization that can move an ECMO patient across the globe within 24 hours. And to sweeten the deal: you don’t even need to worry about airfare! Geopolitical implications notwithstanding, military medicine affords an exclusive clinical experience. Reading that last sentence makes me think I should pick up a side gig as a recruiter.
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The Cost of Fellowship
Subspecializing in the civilian sector can be lucrative, with the noted exception of our esteemed Peds ID colleagues. (So says one such venerable attending: “What is the difference between a Peds ID doc and a pigeon? The latter can put a deposit down on a Lexus.”) Depending on how a physician goes about their training, the income, time in service, and future earnings calculus can favor subspecialization through the military.
So-called critical accessions bonuses (for highly sought specialists such as Surgeons, Anesthesiologists, Intensivists, etc), incentive pay, and retention pay may triple (or more) the pay earned by an equivalent non-physician officer. Eligibility for these bonuses depends on service commitment and the nature of one’s specialty. Thus, if one has attended USUHS, ROTC, or an Academy with the HPSP scholarship, eligibility for some of these bonuses may not mature until a decade or more after training.
Dedication to the military practice is paramount: a fellowship position typically comes with an additional service commitment served consecutive to the existing obligation. Thus, an internal medicine physician who initially owes three years of service from the HPSP scholarship after residency may, in turn, owe six years of service following a cardiology (or similar) fellowship. Of course, there is nuance here, and with that are ways to mitigate the service obligation. These might include vying for a civilian-deferred training position or entering the military after medical school (thus avoiding the HPSP “scholarship”). Positions in the Guard, Reserves, and Public Health Service are not covered by the JSGME. But to reiterate, completing training in a civilian-sponsored fashion incurs an additional commitment that would extend one’s military service.
Future earnings must also be considered when deciding to pursue a specialty. As Dr. Jim Dahle explains: it's far more important that one chooses a field that they will enjoy in the long run than one that reimburses more generously but incites burnout. One’s active duty career is an important fraction of one's working life. Spending a significant proportion of it in a practice that is either unfulfilling or toxically stressful will do little to promote a key portion of wealth-building: longevity. Further, a fulfilling practice prepares us for the greener pastures and bluer skies that await us thereafter. Retiring into a specialty that is practiced and familiar, having trained on the military dime, is an excellent segue into the encore career.
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Choosing a Specialty in the Military
Specializing through the military can be a powerful tool in furthering one’s earning potential, developing a skill set through unique practice opportunities, and contributing meaningfully to a field of academic interest.
The barriers are high enough, in terms of income differential and service obligation, that a fellowship should not be considered without a serious plan for post-military career and retirement. In the first place, this means a strong (if not overwhelming) desire to practice the specialty in the military. If it’s possible and preferable to train and practice as a civilian, you should probably do that.
Secondly, it means mitigating the inherent income loss associated with an active duty commitment. Creativity abounds in this quest: thoughtful planning with regard to bonuses, moonlighting, and taking advantage of military-specific benefits alleviate the opportunity cost burden. With that said, if a military practice is more tenable in the long term, then training should be very carefully considered.
Ideally, the military subspecialist would be fulfilled in their work, enjoying their selected field while contributing to its academic frontiers. They would be financially literate, adequately compensated, and content with the sacrifice of their service. But above all, they should be enlivened by the mission and the good folks executing it. For anyone who has served, this would seem to be a fabled and rosy picture of a military doc.
But they are out there. I know because they have mentored, guided, and inspired me. Their legend lives because of their experience, their demeanor, and the standard that they set. They are out there, that we mere mortals might aspire to join their ranks.
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.
Did you specialize while working as a military doc? Was it a good move? How did it impact your career once you left the service? Comment below!