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GME in the Military

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Duval County Medical Society CME Portal, June 2019

Graduate medical education in the military: Training to serve your country

LCDR Stephen McMullan, MD,2
and LCDR Cesar Mojica Vazquez, MD3

1Program Director, Naval Hospital Jacksonville Family Medicine Residency Program
2Family Physician, Naval Hospital Jacksonville Family Medicine Program
3Resident, Naval Hospital Jacksonville Family Medicine Residency Program

Address Correspondence to:

CDR Kristian E. Sanchack, MD, MHA, FAAFP
Naval Hospital Jacksonville Family Medicine Residency Program
Email: Kristian.e.sanchack.mil@mail.mil
Phone: (904) 508-7357

Date of Release: June 1, 2019
Date Credit Expires: June 1, 2021
Estimated Completion Time: 1 hour
Background:

The Duval County Medical Society (DCMS) is proud to provide its members with free continuing medical education (CME) opportunities in subject areas mandated and suggested by the State of Florida Board of Medicine to obtain and retain medical licensure. The DCMS would like to thank the St. Vincent’s Healthcare Committee on CME for reviewing and accrediting this activity in compliance with the Accreditation Council on Continuing Medical Education (ACCME). This month, the DCMS CME Portal includes an article, “Graduate Medical Education in the Military: Training to Serve Your Country” authored by CDR Kristian E. Sanchack, MD, MHA, FAAFP, LCDR Stephen McMullan, MD, and LCDR Cesar Mojica Vazquez, MD, which has been approved for 1 AMA PRA Category 1 credit.TM For a full description of CME requirements for Florida physicians, please visit www.dcmsonline.org.

Faculty/Credentials:

CDR Kristian E. Sanchack, MD, MHA, FAAFP, Program Director, Naval Hospital Jacksonville Family Medicine Residency Program, LCDR Stephen McMullan, MD, Family Physician, Naval Hospital Clinic Cherry Point, and LCDR Cesar Mojica Vazquez, MD, Naval Hospital Jacksonville Family Medicine Residency Program.

Needs Assessment:

As the cost of attending medical school rises, many prospective doctors consider military service. Military service provides an attractive financial solution to avoiding debt accumulation. When an individual agrees to military service for medical school training, they are also highly likely to receive their graduate medical education (GME) through the military system. While there are some resources available, this manuscript provides a comprehensive comparison of military GME training to that of its civilian peers by reviewing accreditation, curricular development, the match system, assessment and evaluation, scholarly activity, the practice model, and the unique occupational environments of the military

Objectives:
  1. Identify the accreditation standards for the military graduate medical education.
  2. Discuss the role of a general medical officer and how it relates to graduate medical education.
  3. Describe the difference in practice model, as well as list at least three special occupational exams that are required in military healthcare. 
CME Credit Eligibility:

A minimum passing grade of 70% must be achieved. Only one re-take opportunity will be granted. If you take your test online, a certificate of credit/completion will be automatically downloaded to your DCMS member profile. If you submit your test by mail, a certificate of credit/completion will be emailed within 4 weeks of submission. If you have any questions, please contact the DCMS at 904-355-6561 or dcms@dcmsonline.org. 

Faculty Disclosure:

CDR Kristian E. Sanchack, MD, MHA, FAAFP, LCDR Stephen McMullan, MD, and LCDR Cesar Mojica Vazquez, MD report no significant relations to disclose, financial or otherwise with any commercial supporter or product manufacturer associated with this activity.

Disclosure of Conflicts of Interest:

St. Vincent’s Healthcare (SVHC) requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by SVHC for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

Joint Sponsorship Accreditation Statement:

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of St. Vincent’s Healthcare and the Duval County Medical Society. St. Vincent’s Healthcare designates this educational activity for a maximum of 1 AMA PRA Category 1 credit.TM Physicians should only claim credit commensurate with the extent of their participation in the activity.

Graduate medical education in the military serves the purpose of preparing new physicians for expertise in a specialty as well as providing care in a military unique environment. This article compares military GME training to that of its civilian peers by reviewing accreditation, curricular development, the match system, assessment and evaluation, scholarly activity, the practice model, and the unique occupational environments of the military. The similarities in training ensure a consistent well-trained expert in each field. The differences ensure a physician who is confident, prepared, and willing to provide care for the active duty population, their families and those that have retired from military service

As the cost of attending medical school rises, many prospective doctors consider military service.1 Military service provides an attractive financial solution to avoiding debt accumulation.2 Some prospective physicians will have a family tradition of service to the country that prompts combining military with medical service. Others may have already served in the military in other capacities, providing a sense of familiarity with the military practice environment. When an individual agrees to military service for medical school training they are also highly likely to receive their graduate medical education (GME) through the military system.

Military medicine has a long and proud tradition in the United States dating back to 1775. Military GME is much younger. In the United States, military GME was limited in development until after World War I. In 1920, a small internship program was created to train physicians from Class A Medical schools as graded by the Flexner report. However, this ceased during the Great Depression and did not restart until after World War II. In 1947, military residency training began with the intent of increasing the procurement of well-trained physicians, improving the delivery of quality medical care, and improving retention. This pool of physicians proved to be an important resource when the Korean War began in 1950. After the conversion to an all-volunteer military service, the Health Professional Scholarship Program (HPSP) program and Uniformed Services University of Health Sciences was created by congress in 1972 with goals of recruitment, retention, and avoidance of shortages of critical specialties to military healthcare delivery.3 Military GME has since grown to 201 programs with 2,880 trainees, representing about 2.4 percent of the total Accreditation Council of Graduate Medical Education (ACGME) approved residencies and fellowships in the United States.4

 

Accreditation and Curriculum Development

By direction and instruction, military GME meets and maintains all requirements of the ACGME.5,6 All civilian institution standards apply equally to military training programs. The military adheres to duty hour restrictions, and military residents are non-deployable while in training status, except for electives and in case of a national emergency. Faculty and program leadership must meet all of the standards, and administer the curriculum as defined by the common program requirements of their specific specialty training program. Additionally, military treatment facilities (MTF) are inspected by both the Joint Commission and ACGME Clinical Learning Environment Review for institutional compliance.

The ACGME does allow latitude in how curriculums are carried out, which is why there is variation in all programs whether they are military or civilian. This common-sense approach allows sites to adapt for program size, location capabilities, and populations served. However, the core requirements of total patient volumes, case-loads, procedural tracking, and subject mastery are the same regardless of whether it is a military or civilian program.7

A military unique curriculum is required within military GME programs.8 The curriculum identifies ways in which that specialty may be providing high quality medicine both for military readiness and for austere or wartime environments. Just as every marine is a rifleman and every sailor is a fireman, every military doctor is trauma ready! During the first postgraduate year (internship), each program includes topics essential to practicing medicine in the military. This is augmented by an orientation to field medicine known as the Combat Casualty Care Course (C4) and includes certification in advance trauma life support (ATLS). This certification is required to be maintained for any provider who is overseas or deployable after completion of GME training. These military unique experiences help maintain the military identity, demystify deployment, and highlight the outstanding work of military physicians while reinforcing the expectations about upholding one’s professional military responsibilities.9

 

The Military Match

The match system within the military occurs prior to the civilian match. All candidates have already been accessioned to the military through either the Health Profession Scholarship Program (HPSP), Health Services Collegiate Program (HSCP), or through the Uniformed Services University of Health Science F. Edward Hébert School of Medicine. Military candidates can apply to train in a variety of specialties upon successful gradation of medical school training. There are additional slots for funded training in the civilian sector or service deferments to the civilian sector. These additional slots are dependent on the needs of the military services and vary year to year. Funded and deferred selectees in the military match are still required to match in the civilian sector. 

Candidates that apply to match in a military residency must apply through the program known as Medical Operational Data System (MODS). Through MODS, candidates enter all their information just the same as civilians and get ranked on a merit-based point system. While board scores, scholarly activity, interviews, and medical school performance are included, there is also consideration for prior military service and experience. The match process is complete by the second week of December. 

Civilian graduate medical education parallels include categorical and preliminary positions. The Army and Air Force use more categorical selections while still offering transitional internship training. The Navy’s approach, which includes transitional internships, requires the vast majority of candidates to reapply for PGY2 training for categorical specialty training.

An additional difference is the match is targeted for the internship year, and the services vary in how many residents will be given continuous categorical selections to complete residency training. Nearly all Navy residents will require application for PGY2 training, while those in the Army and Air Force may be limited only to those selected for non-categorical programs such as transitional internships. Some trainees will elect to apply for training as Flight Surgeons or Undersea Medical Officers. Others will elect to serve as a General Medical Officer (GMO) prior to returning to specialty training.

The General Medical Officer

Military GME aims to create a physician who can maintain a medically-ready warfighting force for forward deployment and provide high quality care in austere environments. Although the first year of GME varies slightly by military branch, it is geared towards creating a physician capable of taking care of a wide array of conditions not only centered to their particular residency but towards all aspects of medicine. As an example, the pediatric intern will have a general knowledge and practice to be able to not only focus on children but also be able to take care of combat casualties and trauma. This curriculum provides training for the potential GMO. The GMO has a broad-spectrum internship training aimed to maintain health of the active duty troops, and forward deploy.

There are many benefits to serving as a General Medical Officer. Doing so often provides some time in practice to help a young physician determine what specialty they feel best suited to pursue. Serving as a GMO also provides time to improve general medical skills before specialization, and service generates experience that is credited toward the merit-based system for applications to highly competitive military specialties. The aviation and undersea communities also provide training unique to the military environment. 

When the Navy PGY1 applies and competes for a PGY2 categorical position, they not only compete with peers from the same year group, but also with returning GMOs. The returning GMO physician has already finished an internship and has served at least two years with a military unit, often in an operational environment. By doing so, they have obtained real life experience taking care of the active duty population. When the GMO decides to return to finish their respective residency specialty, they bring forth experience, knowledge, and life lessons to their training programs. This added experience can provide a wealth of confidence to the trainee as well as provide support to their peers in residency training.

 

Assessment and Evaluation

Military GME trainees are routinely assessed in the six core competencies including patient care, medical knowledge, professionalism, practice-based learning, interpersonal skills and communication, and systems-based practice. These are evaluated on rotations and twice yearly through milestone evaluations that are specialty dependent. Academic progress is assessed, monitored, and evaluated. There is due process for lapses in academic and/or professional performance of trainees.7 If this exceeds program level remediation, the case is reviewed at the military command’s graduate medical education committee, which can recommend probation and/or termination. This can potentially lead to separation from military service. In addition to these evaluations, trainees also receive annual military evaluations and mid-year counseling that reviews overall performance. Officers in GME training are accountable for military physical fitness standards, medical readiness, and military training. As an indicator of quality, the services have tracked first time board pass rates. In a 2015 report by the congressional defense committees, all three services noted first time board examination pass rates that continued to exceed 90 percent, well above the national average, at that time.4 

 

Scholarly activity

The military has made many advances in modern medicine, particularly in trauma care.10 However, scholarly contributions from military medicine are not limited to wartime efforts. Indeed, all GME programs must meet the requirements of ACGME for scholarly activity for their residents and faculty. Opportunities and barriers to scholarly activity in the military mirror that of our civilian counterparts, but also have some unique opportunities and challenges. One challenge includes normal rotation of active duty personnel. Particularly in primary care specialties, it may be difficult to keep faculty for more than a standard three-year tour. This creates a challenge with completing adequate scholarly activity and mentoring resident learners. 

To promote scholarly activity, the military has multiple educational seminars and conferences at local, regional, and national levels that receive strong support from military commands for funded travel and attendance. There are also opportunities for military residents and faculty to present at foreign military medical conferences all over the world. In addition to Federal Practitioner, a publication for all federal service medical personnel, there is also Military Medicine, a Pub-Med indexed journal entirely dedicated to military relevant medical subjects. Another successful strategy (published out of a military residency) is the use of resident (peer) research coordinators as class leaders facilitating completion of requirements.11 An innovation that could be tested is the creation of military billets known as “Master Academicians,” who would have prolonged tours at one location, specifically geared to facilitate scholarly activity.12

 

Practice Model

To some, “One Payer System” is a derogatory term; to others it represents utopia in medicine. The Military Health System (MHS) has a unique perspective on a single payer model, with its providers in a tiered salary system regardless of Relative Value Units or productivity, procedure repertoire, or location. The salaries are tied, however, to specialty and time in service. Any geographic considerations for salary are the same for all officers in the military and are not medically related. This leads to a practice environment without any competition for patients, no monetary incentives to perform procedures, and no reimbursement tied to productivity. The overlying program for patients referred to network providers outside the MHS for reimbursement is called TRICARE, with respective regions of the continental United States and overseas having different vendors who execute this function. TRICARE Prime is the military version of an HMO (A patient centered medical home model with patients enrolled to a Primary Care Manager [PCM], care is captured at the clinic/hospital a patient is enrolled to, etc.) and TRICARE Select is the military’s version of a PPO (typical model of premiums, copays, and deductibles, although usually at lower rates than civilian plans). The Veterans Affairs (VA) health system is a separate entity from the military health system. Military providers in an active status do not directly train out of any program at the VA but may have memorandums of understanding allowing for excellent training opportunities with patients in that population.13

At Military Treatment Facilities, the enrolled patients are TRICARE Prime (a small percentage may also have dual insurance of Medicare or other insurance providers, but they have supplemental coverage through TRICARE). The benefit of training in this system is a decreased -but not absent- worry about whether a patient can afford a certain lab test, radiology study, or medication/treatment option that was deemed best by the treating provider. In fact, a recent study noted that the military system did not have the post-operative outcomes due to healthcare disparities that are commonly found in some civilian systems.14

This is quite a luxury compared to a GME environment where these considerations are regular topics of discussion. This certainly doesn’t mean that cost is not considered when delivering care within the MHS. These conversations are regularly part of diagnostic and treatment planning but are not viewed as barriers to patient care. This practice model also allows for innovation of care delivery systems to best fit a military patient’s needs. Compensation not being tied to an appointment or procedure opens the door to deliver care in non-traditional ways. These include secure messaging, virtual visits (phone call follow ups) built into clinic schedules, nursing protocols, tele-health, integrated practice units and e-consultation – all of which are normal practice or beginning to develop as pilot programs for the MHS. The MHS can continue to be a leader in novel care delivery models based on the advantages of salaried staff and one-payer reimbursement,15,16 and this includes learning these principles in the residency training environment.

Military occupational exams are also distinctive as there are many different programs not only for dependents (family members of active duty members) but also for active duty members. These exams include the Periodic Health Assessment (yearly physical and health questionnaire for active duty), Exceptional Family Member Program (for dependents with comorbid conditions to determine support services and locations based on resources needed), Overseas Screening (for active duty and dependents being stationed overseas, to see if the gaining location can support their medical conditions), Special Operations Physicals, Explosive Ordnance Disposal Physicals, Post Deployment Health Assessment, Flight Physicals, Dive Physicals, Arms Ammunition and Explosives Screening, to name a few. Also, as active duty members acquire injuries or develop illness, they may need to have their case reviewed by a medical board assessing their fitness for duty (ability to perform their primary job). These can pose a unique challenge to administrative time management that may offset mountains of prior authorizations or pre-approvals for patients at civilian GME programs. Military GME trainees are exposed to many of these specialty exams throughout training as a part of their military unique curriculum

 

Military Unique Environments and Experiences

A unique aspect of military based residency is being the Medical Officer. Serving as an officer is synonymous with being a leader. There is a need for dedicated leadership training, however even the military GME system can struggle with barriers to introducing formal curriculums during training. Training may be more accidental and experiential than by formal leadership curriculums. It is not unusual for military graduates to immediately take leadership positions after graduation from training, potentially running entire medical units or departments, while being forward deployed or located overseas.17 While medical skills are being consolidated, physicians are expected to be involved in collateral or primary leadership duties. All trainees are highly encouraged to stay involved in hospital committees and take collateral and leadership roles within their GME class. 

One area of education leadership that is common during military GME is that residents are expected to help teach the support staff. Many of the support staff in military treatment facilities are Medics and Hospital Corpsman. These are typically younger individuals who get a cursory training in the basics of patient care before arriving at the duty station. If they have had prior tours, their level of expertise particularly in the primary care setting can vary. Often, oversight and hands on training is provided by nurses and physicians (including residents) to teach and mentor these future battlefield heroes. This is not hyperbole – Hospital Corpsmen have earned 22 Medal of Honor awards.18 As Dr. Jonathan Letterman said in 1866, “A corps of medical officers was not established solely for the purpose of attending the wounded and sick. The leading idea is to strengthen the hands of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privation, and for fighting.”15 His words are as true as ever today. 

Military and civilian GME carry many more similarities than differences. However, the differences that do exist are critically important to the military’s unique occupation and offer prospective physicians a wide variety of exciting opportunities beyond simply free education. Military GME provides the pipeline for military medicine and ensures retention and a sense of belonging. Military GME programs have an obligation to include military unique training; developing physicians who are confident, prepared, and willing to provide care in many different environments, to a population that is entrusted by the nation for protection, while maintaining a keen sense of ethics. The nature of military service is selective and challenging but can be very rewarding.

 

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.

 

I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties 

 

1.      Greysen SR, Chen C, Mullan F. A history of medical student debt: observations and implications for the future of medical education. Acad Med. 2011 Jul;86(7):840–5.

2.      Marcu MI, Kellerman AL, Hunter C, et al. Borrow or serve? An economic analysis of options for financing a medical school education. Acad Med. 2017 Jul;92(7):966-75.

3.      Kussman MJ. The future of military graduate education. United States Army; 1992 May 14. 52 p. Report number: 92-12848.

4.      Carson BR. Department of Defense improvements to oversight of medical training for medical corps officers: fifth annual report to the congressional defense committees. Department of Defense; 2015 Apr 30. 13 p.

5.      Carson BR. DoD Instruction: Accession and retention policies, programs, and incentives for military health professions officers (HPOs). Department of Defense; 2015 Dec 30. 45 p. Report number: 6000.13.

6.      Chief, Bureau of Medicine and Surgery (Department of the Navy). 2017 joint service graduation medical education selection board application procedures. Depart of the Navy; 2017 Jun 13. 18 p. Report number: BUMED 1524.

7.      Common program requirements [Internet]. Chicago (IL): Accreditation Council for Graduate Medical Education; 2018 [cited 2018 Mar 28]. Available from:  http://www.acgme.org/What-We-Do/Accreditation/Common-Program-Requirements.

8.      Bailey S. Memorandum: military unique training in DoD-sponsored graduate medical education programs. Department of Defense; 1999 Jun 28. 2 p. Report number: HA Policy 99-00020.

9.      Nagy C. The importance of a military-unique curriculum in active duty graduate medical education. Mil Med. 2012 Mar;177(3):243-4.

10.  Butler FK Jr, Blackbourne LH. Battlefield trauma care then and now: A decade of Tactical Combat Casualty Care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):395-402.

11.  Lennon RP, Oberhofer AL, McNair V, et al. Curriculum changes to increase research in a family medicine residency program. Fam Med. 2014 Apr;46(4):294-8.

12.  Borgman MA, Elster EA, Murray et al. Military graduate medical education research: challenges and opportunities. Mil Med. 2016 May;181(5 Suppl):7-10.

13.  Tricare. Plans and eligibility [Internet]. Falls Church (VA): Defense Health Agency; 2018 [cited 2018 Mar 28]. Available from: https://tricare.mil/Plans.

14.  Schoenfeld AJ, Jiang W, Harris MB, et al. Association between race and postoperative outcomes in a universally insured population versus patients in the state of California. Ann Surg. 2017 Aug;266(2):267-73.

15.  Kellerman A. Rethinking the United States’ military health system [Internet]. Bethesda (MD): Health Affairs; 2017 Apr 27 [cited 2018 Feb 11]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20170427.059833/full/#.WnnInIE.

16.  Todd WE, Phillips A, Collins DC, et al. The move to value based care in Navy medicine. N Engl J Med Catalyst; 2017 Apr 17 [cited 2018 Mar 28]. Available from: https://catalyst.nejm.org/value-based-care-navy-medicine/.

17.  Hartzell JD, Yu CE, Cohee BM, et al. Moving beyond accidental leadership: a graduate medical education leadership curriculum needs assessment. Mil Med. 2017 Jul;182(7):e1815-e1822.

 

18.  Navy Medicine. Medal of Honor [Internet]. Falls Church (VA): Bureau of Medicine and Surgery; 2018 [cited 2018 Jun 18]. Available from: http://www.med.navy.mil/bumed/nmhistory/Pages/Medal-of-Honor.aspx.

 

To take the test and earn CME credit, click here.

 

1. Military Graduate medical education must meet all the standards of the:

a. Military Accreditation Governing Board

b. Accreditation Council of Graduate Medicine

c. Department of Defense Graduate Medicine Council

d. Department of Defense Medical Examination Board


2.  A military unique curriculum involves training in:

a. Advanced Trauma Life Support

b. Combat Casualty Care Course

c. Training to provide care in austere environments

d. All of the above


3. The military match for residency selection occurs prior to civilian match.

a. True

b. False


4. Military GME can allow for a learner to complete internship and practice medicine as a General Medical Officer with operational units prior to completion of residency training.

a. True

b. False


5.      The General Medical Officer may acquire specialized training in:

a. Flight medicine

b. Undersea medicine

c. Operational environments

d. All of the above


6. Military residents receive assessments and evaluations which include:

a. Core competencies and milestones

b. Fitness reports

c. Physical Readiness testing

d. All of the above


7. Military GME requires residents to complete scholarly activity.

a. True

b. False


8. The military health system’s system for enrollment and care of patients occurs through:

a. Medicaid

b. Medicare

c. TRICARE

d. World Health Organization


9.  Military occupational exams include:

a. Periodic Health Assessment

b. Exceptional Family Member Program

c. Overseas Screening

d. All of the above


10. Graduates of military residency programs are frequently placed into immediate leadership positions upon graduation.

a. True

b. False