www.olsonconsultingmi.com
Highly recommended for anyone interested in military medical career to listen to. I rarely have the patience to listen to podcasts, but this one is well worth your time if you are considering a military medical career.
Executive summary of non-retirement parts (first half or so). Comments by me are marked as (comment --MC).
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1) Commitments: Extremely honest and clear discussions of different commitments from ROTC vs. Service Academies vs. HPSP vs. USUHS
The way you look at contract when you're 18 or 21 is different than when you're 39
ROTC vs. Service Academy: you are thinking about how to get school paid for; not thinking about how much revenue I can generate through my career lifespan
<20% of AD physicians have undergrad commitment; normally HPSP or USUHS commitment only as physicians
Remember that you are committing your time down the road when you have a much higher earning potential
2) Money: He notes that remuneration in the military is specialty specific
"In general surgery in the military, you make around 50% of what your peers outside of the military would make. The more specialized you get, this will dip down to 20-25% of what your peers make
"Every year you add to your commitment, you are decrementing your earning potential by that amount."
He advises keeping your commitment as short as possible. That way you have the control if you want to stay in or not.
If your commitment is complete, you can get bonuses that increase your income if you choose to stay in.
3) Skill Atrophy: "What do a lot of military doctors need to do to keep their skills sharp?"
"We generally do not have extremely high acuity/complex patients in our military hospitals" (Outside of Brooke Army Medical Center in San Antonio/the new Walter Reed=old Naval Hospital Bethesda --MC).
Big differences in military treatment facilities (Walter Reed vs. Offutt). We are much lower volume (than civilian world --MC). It's the nature of our system. There is lots of discussion of skill atrophy, especially with procedural physicians (surgeons, gastroenterologists, interventional radiologists, interventional cardiologists,
etc.--MC).
Also, "we're not as busy in the deployed setting as we used to be, so many of our deployments are low volume, which leads to skill atrophy."
"Phenomenon of skill atrophy is real. The military is aware that it's a problem. But until now we don't have a lot of great solutions during your active duty time."
Moonlighting at a busy place is win: win
--get experience and money as 1099 contractor
"If you have a long commitment and have not been able to find a solution to the low volume problem, it may impact your post-military employability:
--How fast are you?
--What are your surgical outcomes?
--Are you going to be competitive in the market?
--What is your career plan for post-military?"
"Not only are you sacrificing revenue down the line while on active duty, you are also existing in a low-volume environment."
Example: Orthopedic surgeon had done total joint fellowship right out of residency before starting military service at Keesler. After four years of doing general orthopedics because he was "one of the few ortho docs we had", he got out of the military and had to repeat the same fellowship over again "because he felt his skills had atrophied in a very narrow, subspecialized area of orthopedics"
4) Skill Maintenance: "Any suggestions for people in the middle of a long commitment to keep skills sharp?"
1) Moonlighting in a busy place-- all off duty employment has to be approved by command, based on local commander. Gets you additional revenue as 1099 contractor. Need to arrange for your own (civilian) malpractice insurance with tail and local state medical licensure. Locums companies can help you with that, so you don't have to do it by yourself, or you can negotiate directly with hospitals.
2) There are some TAAs (training affiliation agreements) -- base lends him downtown to private sector on military time-- basically volunteer work-- no additional revenue generation (over his normal Air Force pay --MC)
90-95% of his volume is TAA-based rather than on base. Air Force has embraced TAAs for a decade; other services are slowly accepting this model. Local politics involved.
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End summary
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A few counterpoints from the point of view of an anesthesiologist:
1) Most military surgeons worry about skill atrophy from low volume, because they only get maybe one day a week of OR time per surgeon. They like the idea of moonlighting to keep up skills and make bucks. Commanders happily give them permission, because the squadron commanders (or equivalent) are almost always surgeons too.
2) Unlike surgeons, anesthesiologists have been shunted to the biggest (remaining) hospitals, at least in the Air Force. That means that your chance of being assigned to a cushy job in the boonies with a 7:30-2 PM OR schedule three days per week has gone the way of the dodo. All of the remaining outlying hospitals that still do surgery/OB are likely staffed by CRNAs operating completely independently.
3) Thus, anesthesiologists can be forced to work up to seven days per week in the OR, depending on assignment/ops tempo/deployment status, including ridiculous call schedules. I never had any "free time" to moonlight in my 11 years post-residency. Command would have laughed in my face if I had asked for permission, given how tight our staffing was, especially after 1998 or so. Don't even think of moonlighting without command permission.
4) Whereas surgeons worry about low volume and boredom, most military anesthesiologists worry about three major things;
--Being worked to death from short staffing due to dangerous personnel cutbacks/deployments/incapable ROAD scholars on the duty roster who can no longer take call or manage cases;
--Patient safety issues from low volume/high risk surgery by the specialist surgeons that are plonked down in small community hospitals which are no longer safe for any surgery more challenging than lumps and bumps;
--Being micromanaged by pointy-haired surgeon squadron commanders who want to force you to do sexy but dangerous cases to keep their surgical golf buddies happy as your MTF hemorrhages talent and resources to make TRICARE contract corporations happy.
5) When you're a hammer, the whole world looks like a nail. If your podunk, drastically-downsized hospital has a vascular surgeon assigned to it, you will be forced to do one or two AAAs and/or aorto-bifems/year with dramatically worse outcomes than a civilian hospital that does 100/year or more. It's the whole scorpion stinging fable cliche thang. Make sure you keep an OR room free for the inevitable takebacks for bleeding/lost pulses at 0-dark-30.
6) It's not just surgeon or anesthesiologist or nursing or intensivist skill atrophy; it's that the
entire system isn't designed for low volume/high risk quality care through the continuum of the patient's stay. Explaining this to surgeons who really, really want to surge on symptomatic anterior mediastinal mass patients will take up more of your time than you can possibly imagine.
7) All of what I said is from my experience as an anesthesiologist from 1994-2005. Much is changing very rapidly. Your mileage may vary. No one knows what military "health care" will look like 8-10 years from now when you finish medical school and residency. However, it is still worthwhile to learn from the past...
