Emergency Physicians in the United States Military: A Primer

Transcription

1 EDUCATION/RESIDENTS PERSPECTIVE Melisa W. Lai, MD (CAPT RIANG [USAF] MC) Matthew R. Lewin, MD, PhD From Harvard Affiliated Emergency Medicine Residency, Massachusetts General Hospital/Brigham and Women s Hospital, Boston, MA (Lai), and the Emergency Medicine Residency Program, University of California, San Francisco Fresno, Fresno, CA (Lewin). Section Editor Matthew R. Lewin, MD, PhD University of California, San Francisco Fresno Emergency Medicine Residency Program Fresno, CA Copyright 2003 by the American College of Emergency Physicians /2003/$ doi: /mem Emergency Physicians in the United States Military: A Primer [Ann Emerg Med. 2003;42: ] There are many opportunities for emergency medicine trained physicians to serve in the United States military and multiple avenues to join. This article reviews the structure of the military medical corps and our roles in it as emergency physicians during peacetime and during war. The obligations and benefits of military service are discussed in detail. HEALTH CARE FOR OUR MILITARY IN GENERAL It is important to be familiar with each service s medical corps to understand an emergency physician s role in the military. Our country has 7 uniformed services: 4 branches organized under the Department of Defense and 3 managed under the Departments of Health and Human Services, Homeland Security, and Commerce. In addition, there is an eighth uniformed service managed under the Department of Transportation. The familiar Department of Defense branches are the Army, Air Force, Navy, and Marine Corps. All but the Marine Corps have their own medical corps. The Army and Navy have residencies in emergency medicine. Table 1 describes the general organization of the United States Military health care and emergency medicine training programs. ACTIVE DUTY, GUARD, AND RESERVE Of the approximately 2.2 million citizens serving in our armed forces today, just over half are active duty members: regular full-time military personnel whose jobs are part of and within the military. 1 The rest of our armed forces are composed of reservists who serve in either the Guard or the Reserve. These citizens are the weekend warrior part-time personnel who hold regular full-time civilian jobs while also serving in the military. Reservists train part time, amounting to at least one weekend a month plus a 2-week block per year, outside of their civilian jobs. Reservists and Guardsmen are considered military personnel even while at their civilian jobs. They undergo the same training as active duty personnel, often with regular members. They leave their full-time civilian jobs for weeks to months at a time to meet their military training requirements or to fill mission positions. Their rank, promotion, uni- 100 ANNALS OF EMERGENCY MEDICINE 42:1 JULY 2003

2 forms, and chain-of-command are identical to those personnel on active duty. Reserve units are mirror forces under the direction of the federal government and command of the President of the United States. Members are trained to back-fill or step into roles of active duty service members deployed to other bases and jobs. Most Reserve units are located in active duty bases. The Guard is under the direction of state governments and command of state governors during peacetime. These are the forces called to assist in state emergencies, including weather disasters and riot control. During wartime and national emergencies, the President s authority trumps that of the states, and Guardsmen can be federalized into active duty in their respective services. There are several other subcategories of reservists, such as individual mobilization augmentees, which are not discussed in this article. MILITARY AND MEDICAL HIERARCHY The built-in hierarchy of medicine is a well-matched counterpart to the concept of rank and promotion in the military. Our military forces are simply divided into enlisted personnel and commissioned officers. Among the enlisted are also noncommissioned officers. Rank and promotion are based on education, training, and experience. The enlisted are the ancillary services backbone of the military. They are the privates, airmen, and seamen. All enlisted personnel enlist for 2-year tours of duty, after which time they may re-enlist or leave. An enlisted person can expect to be promoted to the level of a noncommissioned officer after 4 to 6 years. Commissioned officers, comprising approximately 15% of our total forces, 1 are the supervisors, highlevel managers, and chief executive officers of the military. With few exceptions, officers have a bachelor s degree at the time of their commissioning. All citizens with professional degrees (MD, DO, JD, RN, DVM, DDS, DMD, NP, and PA) who enter the military with the purpose of performing that professional job Table 1. Health care and emergency medicine training programs in the US Military, its branches, and its administration. * Service Abbreviation Oversight Postgraduate Emergency Medicine Training? Commissions/Comments Air Force USAF DOD No MC: Active duty, Guard, and Reserve commissions are available. Army USA DOD Yes (3 residencies): 1. Madigan University of MC: Active duty, Guard, and Reserve commissions are Washington, Tacoma, WA, founded in 1979 PGY available. The Madigan University of Washington 1-3; 2. Darnall Army Community Hospital, Fort program accepts civilian applicants. Hood, TX, founded in 1980 PGY 1-3; 3. San Antonio Uniformed Services Health Education Consortium, Ft. Sam Houston, TX, founded in 1977 PGY 1-3 Marine Corps USMC DOD No Treating physicians are from US Navy. Navy USN DOD Yes (2 residencies): 1. Naval Medical Center, MC: Active duty and Reserve commissions are available San Diego, CA, founded in 1984 PGY 2-4; 2. Ports- (no Guard). mouth Naval Hospital, Portsmouth, VA, founded in 1992 PGY 2-4 Coast Guard USCG DHS No Treating physicians are from USPHS. Public Health Service USPHS DHHS No Active duty only, no reserves; officers only, no enlisted members. USPHS is the Uniformed service of DHHS. Commissioned Corps NOAA DOC No Active duty only, no reserves; officers only, no enlisted of the National Oceanic and Atmospheric Administration members. Merchant Marines USMM DOT-Maritime No Peacetime commercial mariners; all hold commissions Administration with the US Navy Reserve or USMC Reserve. USAF, US Air Force; DOD, Department of Defense; MC, Medical Corps; USA, US Army; USMC, US Marine Corps; USN, US Navy; USCG, US Coast Guard; DHS, Department of Homeland Security; USPHS, US Public Health Service; DHHS, Department of Health and Human Services; NOAA, National Oceanic and Atmospheric Administration; DOC, Department of Commerce; USMM, US Merchant Marines; DOT, Department of Transportation. * The 4 familiar Department of Defense branches of service are the US Army, Air Force, Navy, and Marine Corps. The Marine Corps, although its own branch of service, stems from and integrates many of its missions and services with the Navy. The 3 non Department of Defense services are the US Coast Guard, the Commissioned Corps of the US Public Health Service (ie, the uniformed service of the Department of Health and Human Services), and the Commissioned Corps of the National Oceanic and Atmospheric Administration, which operates through the Department of Commerce. An eighth uniformed service is the US Merchant Marines. Merchant Marines are trained in the maritime and transportation industries and are officially under the direction of the Department of Transportation s Maritime Administration but function as part of the United States Naval Order. Merchant Marines are considered to be civilians in their daily duties but hold commissions as US Navy Reserve officers. JULY :1 ANNALS OF EMERGENCY MEDICINE 101

3 receive officer commissions (Table 2). Commissioning obligations are a minimum of 4 years, and unlike enlisted military, officers are not recommissioned after their obligation is up. Barring violations of the Uniform Code of Military Justice, officers may retain their commission as long as they like and may resign their commission at any time after completing their initial service obligation. 2 MEDICAL RANK AND FILE: WHO ENLISTS, WHO IS COMMISSIONED? Those with professional degrees can enter no lower than the lowest officer rank. Those serving in ancillary support roles usually enlist (eg, emergency medical technicians, phlebotomists, optical technicians, public health administrative assistants). Medical students, although not yet having received their professional degree, are directly commissioned into the military at the lowest officer rank (second lieutenants and ensigns). Undergraduate college students on Reserve Officer Training Corps scholarships or cadets at the service academies (Appendix 1) are not commissioned as actual officers until they receive their bachelor s degrees. 3-5 PHYSICIANS AND THE MILITARY What distinguishes physicians from nonphysician citizens who join the military is that physicians are used as physicians. A nonphysician member s military-wartime role might not be the same as his or her civilianpeacetime role, particularly in the Guard or Reserve. Policemen in the civilian world might be phlebotomists in the reserves, and civilian phlebotomists might serve as reservist military police. For purposes of wartime chain of command and issues regarding prisoners of war and rules of engagement, medical officers (physicians and nurses) are considered distinct from line personnel (ie, everyone else). Medical officers are not authorized to take command of any nonmedical unit or mission. Their role is specifically to mind the health of our fighting forces. ENTERING THE MILITARY AS A PHYSICIAN Since the abolition of the draft in 1973, ours has been an all-volunteer force. 6 Physicians who join the military enter 1 of 3 tracks: those who will be active duty career military, those who are active duty fulfilling a ser- Table 2. Military officer ranks and basic pay scales. * Navy, Active Duty Base Guard/Reserve Coast Guard, Pay Per Month Pay Per Monthly Branch Army, USPHS, as of January 1, 2003 Drill (2 Weekend of Air Force, CC of the NOAA, (and Monthly Days=4 Active Duty Service Marine Corps Merchant Marines Housing Allowance) Day Equivalents) O 10 General (GEN) Admiral (ADM) $12,100 12,800 ($1,020 $1,250) NA O 9 Lieutenant General (LTG) Vice Admiral (VADM) $10,500 $11,300 ($1,020 $1,250) NA O 8 Major General (MG) Rear Admiral Upper Half (RADM [UH]) $7,400 $10,250 ($1,020 $1,250) $1,000 $1,400 O 7 Brigadier General (BG) Rear Admiral Lower Half (RADM [LH]) $6,200 $9,100 ($1,020 $1,250) $830 $1,200 O 6 Colonel (COL) Captain (CAPT) $4,600 $8,000 ($940 $1,130) $610 $1,050 O 5 Lieutenant Colonel (LTC) Commander (CDR) $3,800 $6,500 ($900 $1,100) $510 $870 O 4 Major (MAJ) Lieutenant Commander (LCDR) $3,300 $5,500 ($830 $960) $440 $740 O 3 Captain (CAPT) Lieutenant (LT) $2,900 $4,700 ($670 $850) $390 $670 O 2 1st Lieutenant (1LT) Lieutenant, Jr. grade (LTJG) $2,500 $3,500 ($530 $770) $330 $540 O 1 2nd Lieutenant (2LT) Ensign (ENS) $2,200 $2,750 ($450 $700) $290 $450 USPHS, US Public Health Service; CC, Commissioned Corps; NOAA, National Oceanic and Atmospheric Administration; NA, not applicable. * Officers of different branches of service might hold the same rank but have different titles and wear different rank insignia. Across the board, officers might denote their rank simply by what level their rank is (first column): letter O for officer, hyphen, and rank level number. Otherwise, title and insignia are divided by either land and air, as used by the US Army, US Air Force, and US Marine Corps or maritime, as used by the US Navy, US Coast Guard, US Public Health Service, US Merchant Marines, and Commissioned Corps of the National Oceanic and Atmospheric Administration. O-1 is the lowest officer rank. Pay is based on rank and time in service. The wide salary ranges reflect the diversity of entry points and experience. For example, an attending physician with 10 years civilian experience might enter as an O-4 and be paid $3,800 per month initially, whereas a physician who is promoted to O-4 after serving several years as a general medical officer and several as an active duty junior attending physician might be paid $5,000 per month by their 10th year as a physician. Active duty service members are also provided a housing allowance (in parentheses). The housing allowance range accounts for whether a service member has dependents. There is also special pay for active duty medical officers ranging from $100 to $1,000 per month depending on board certification and years of medical experience. Guard/Reserve members are paid for each drill or part of a drill they attend. A standard monthly drill is 2 weekend days divided into 4 pay units (2 mornings and 2 afternoons). Figures in this table are pay ranges based on a full monthly drill. 5,16, ANNALS OF EMERGENCY MEDICINE 42:1 JULY 2003

4 vice obligation, and those who would like to contribute part time as a reservist (Figure). PHYSICIAN FULL TIMERS (ACTIVE DUTY) Physicians serving full time in the military are composed mostly of those with pre-existing active duty obligations from education received at a US Service Academy (Appendix 1), the Uniformed Services University of the Health Sciences, or through Reserve Officer Training Corps or Health Professions Scholarship Program scholarships. 7 Some physicians enter active duty on their own, seeking a military career, but these are a minority. Those who stay in the military after fulfilling service obligations might segue into the role of having a military career and practice simply because of time already spent in the military. Pay scale in the military is based on rank and job. Military physicians are automatically tracked into a medical promotion track that is essentially automatic up to the fifth-level (O-5) officer rank on the basis of satisfactory performance and job availability (Table 2). Figure. Examples of service obligation incurred and payback calculations on the basis of a 4-year emergency medicine residency and choosing to enter medical school immediately after college when possible: A, full-time (active duty) payback calculations; B, part-time (Guard and Reserve) payback calculations. AD, Active duty; ROTC, Reserve Officer Training Corps; IRR, Inactive Ready Reserve; EM, Emergency Medicine; USUHS, Uniformed Services University of the Health Sciences; HPSP, Health Professions Scholarship Program; GMO, general medical officer; HPSLRP, Health Professions Student Loan Repayment Program; G/R, Guard/Reserve. A Gray block Black block Bolded & italicized text Time spent with military paying for eduction in full (scholarship) Time owed on AD paying back military scholarship Time applied toward meeting 8-year statutory service obligation; if AD payback has been completed, remaining balance is spent on IRR list as noted Years ROTC/Academy College AD Line Officer Med school (IRR) EM residency Attending... ROTC/Service Academy scholarship: 4 years of college are paid for. Student pays back 4 years on AD as a regular military line officer. Student still has 4 years left of IRR but can attend medical school and enter residency without further AD service obligation. 20 ROTC/Academy College Medical school EM residency AD physician Attending (IRR) ROTC/Service Academy scholarship then directly to medical school: 4 years of college are paid for. Student receives deferment to attend medical school. After completing residency training, 4 years is spent as an AD military physician as payback for college. Physician can enter civilian practice thereafter without further service obligation but still has 4 years left of IRR. USUHS/HPSP College Medical school EM residency AD physician Attending (IRR) USUHS/HPSP scholarship: College is not paid for by the military; medical school is. Payback is begun after residency training. Physician can enter civilian practice thereafter without further service obligation but still has 4 years left of IRR. ROTC+ USUHS/HPSP College Medical school EM residency AD physician ROTC+USUHS/HPSP: Both college and medical school are paid for by the military. Upon completion of residency training, physician owes 8 (4+4) years of AD time as a physician. Physician may enter civilian practice thereafter without any military obligation, including time on the IRR list. USUHS/HPSP with College Medical school GMO EM residency Attending... 4-year GMO USUHS/HPSP and 4 years as a GMO: Medical school is paid for. Needs of the military are invoked, and medical school graduate spends 4 years on AD as a GMO, which counts as completed AD payback. Medical school graduate enters residency training afterwards without further service obligation but remains on IRR list for 4 years to meet 8-year statutory balance. Coinciding with residency completion, physician is off the IRR list and commences civilian practice without any further military obligation. USUHS/HPSP with 1-year GMO College Medical school GMO EM residency (IRR) Attending Attending... USUHS/HPSP 1 year as a GMO: Medical school is paid for. Needs of the military are invoked, and graduate spends 1 year on AD as a GMO, which counts as one year of AD payback. Medical school graduate continues on to residency training. Upon residency completion, physician owes 3 (4 1) years on AD. Completion of AD obligation coincides with meeting 8-year balance for remaining on IRR list. Upon entering civilian practice, physician has no further military obligation. Continued on p JULY :1 ANNALS OF EMERGENCY MEDICINE 103

5 SERVICE OBLIGATION Financial assistance equals military obligation. Any acceptance of financial assistance from the military at any point incurs further obligation. Usually there is a 1-to-1 ratio of assistance-to-active duty payback obligation time. There is one twist, however: every citizen who joins the military, whether enlisted or commissioned as an officer, incurs a basic 8-year statutory service obligation. This statutory service obligation means that, from the time of being sworn into the mili- tary, that citizen has until 8 years from that calendar date before being fully released from all military obligation, even after paying back any time for financial assistance. Time from completion of actual service obligation until the statutory obligation date has come and passed is usually spent in the Inactive Ready Reserve. The Inactive Ready Reserve does not require training time and is essentially a list of recently discharged service members with time left in their initial 8-year statutory service commitment. A typical example of this moneyfor-service model applies to medical students at the Uniformed Services University of the Health Sciences, the country s service academy medical school, and medical students on Health Professions Scholarship Program scholarships. Health Professions Scholarship Program scholarships are the medical school equivalent of undergraduate Reserve Officer Training Corps scholarships. 3-5 In return for 4 years of paid medical school education at the Uniformed Services University of the Figure (continued). B Gray block Gray text Black block Bolded & italicized text Time period spent accepting military supplemental financial incentives (Montgomery GI Bill during medical school and/or stipend during residency) Time period during residency with millitary paying off loans (HPSLRP) must have full license to accept loan repayment Time owed as Guardsman/Reservist Time applied toward meeting statutory service obligation (4 or 8 years depending on financial incentives accepted); if G/R service has been completed, remaining balance is spent on IRR list as noted G/R Years College Medical school EM residency Attending... G/R alone: Student enters G/R upon beginning medical school and does not accept any financial assistance. G/R and time on IRR are reached in 4 years. G/R with GI Bill College Medical school EM GI Bill residency EM res. (IRR) Attending... G/R and Montgomery GI Bill: Student enters G/R upon beginning medical school and GI Bill supplements income during medical school. Student incurs 6-year total obligation to serve with the G/R as well as the 8-year total statutory obligation. First 2 years of residency are spent with the G/R for a total of 6 years. The last 2 years of residency are spent with name on the IRR to meet 8-year total balance. G/R HPSLRP College Medical school EM residency Attending (IRR) HPSLRP G/R and Loan Repayment (HPSLRP): Resident enters G/R upon graduation from medical school. Resident is eligible for loan repayment beginning in second year of residency and loans up to $50,000 are paid over 3 years ($20,000, $20,000 and $10,000). Resident may leave G/R on completion of residency training, having fulfilled 4 years of service as G/R but remains on IRR for 4 years to reach 8-year statutory obligation balance. Attending... G/R Stipend College Medical school EM residency Attending Attending Stipend received G/R and Stipend: Resident enters G/R upon graduation from medical school and accepts stipend for all 4 years of residency, adding 8 years of G/R service to initial 4-year obligation. After 12 years total with G/R, physician has more than met 8-year statutory obligation. 20 G/R with GI Bill and Stipend College Medical school EM residency GI Bill Stipend received Attending G/R, Montgomery GI Bill and Stipend: Student enters G/R upon entering medical school and accepts the GI Bill, incurring a 6-year obligation that starts with medical school commission. As a physician, accepts stipend each year of 4-year residency, adding 8 years of G/R service for 14 years total. But payback for residency stipend does not commence until stipend payments are completed, so physician owes 16 years total, not 14, to the G/R. 104 ANNALS OF EMERGENCY MEDICINE 42:1 JULY 2003

6 Health Sciences or after receipt of a Health Professions Scholarship Program scholarship, these medical students owe the military 4 years of active duty service as a physician. After re-entering the civilian world as civilian physicians, their names are still on the Inactive Ready Reserve list until 8 years from the date of their initial commission. Physicians who accept military scholarship combinations toward college and medical school are subject to varying degrees of obligation duties, depending on when initial obligations are paid back and whether medical school is entered immediately after college. This scenario and those discussed previously are depicted in the Figure. RESIDENTS AND THE FULL- TIME MILITARY Active duty service obligations add another level of decisionmaking to the usual residency application and match process. Military medical students follow the same stepwise procedure for finding and completing a residency, with extra steps incorporated into the process. Health Professions Scholarship Program/Uniformed Services University of the Health Sciences students are first asked to enter the military match taking place in November. 8 The military match pairs students to residencies administered through the Army, Navy, and Air Force. Military residencies run the gamut of specialties spanning the primary care specialties from internal medicine to pediatrics, surgery, obstetrics and gynecology, and emergency medicine. There are residencies in psychiatry and preventive medicine and surgical subspecialties, such as urology. 8 Students who want to train in a specialty not offered in the military match or those who want to train in a civilian residency can apply for a civilian match deferment. If granted, students enter the regular National Resident Matching Program and are matched in March. Civilian students cannot enter the military match, but some civilian residencies might offer slots through the military match (in effect giving a military medical student a civilian deferment if he or she matches this way). Military medical students who receive a civilian match deferment and then match through the regular National Resident Matching Program match are effectively released for the duration of residency. During that time period, they are still commissioned officers (automatically promoted to the third-level officer rank [O-3] on graduation to Army/Air Force Captains or Navy/US Public Health Service Lieutenants) but are placed on inactive reserve status. Although time in residency is not applied toward their standing service obligation, they do not incur further obligation. On residency completion, these students enter the military on active duty and pay back their obligation. The same basic plan is laid out for military residents: they do not incur further obligation during residency (Figure). The obvious advantage to the military from this arrangement is that it gains a fulltime, active duty, residency-trained, board-prepared (soon to be board certified) physician for X number of years rather than a mere physician trainee. TRAINING TWISTS FOR THE RESIDENT TRAINEE WITH ACTIVE DUTY OBLIGATION Sometimes the needs of the service outweigh the training goals of the individual. If the military does not need any more pediatricians, a pediatric resident might be ordered to switch training programs and train in another specialty. This scenario might occur irrespective of whether the resident is currently enrolled in a military residency. Likewise, a resident training in a civilian residency might be ordered to fill an open slot in a military residency. As a military officer, the resident is obliged to comply with these orders. The military might also have a need for general medical officers in some locales. A general medical officer is a physician who has graduated from medical school but who has not yet completed residency training. Most general medical officers are fresh out of medical school, but some are residents who are reassigned to general medical officer positions during residency training. General medical officers usually work in clinic settings, often at overseas military bases, and attend to health maintenance issues. Medical school graduates might be obligated to serve as a general medical officer for up to 5 years before being allowed to enter or re-enter residency. The training interruptions resulting from general medical officer service count toward service obligation payback. A student with a 4-year obligation who serves as a general medical officer for 4 years can have her entire service obligation paid back before starting residency. A student with an 8-year obligation might serve as a general medical officer for 4 years, enter residency for X number of years, and, on residency completion, still owe another 4 years of active duty service (Figure). WHO GOES TO WAR? In wartime, emergency physicians on active duty are likely to be deployed to tertiary hospitals in the theater of operations (where the fighting is) to work as attending physicians. Emergency physicians in the Guard and Reserve might be called to backfill positions left by active duty physicians or can be ordered to specific JULY :1 ANNALS OF EMERGENCY MEDICINE 105

7 roles in the theater of operations, depending on mission need. The order of call-up is active duty boardcertified physicians, then reservist board-certified physicians, then active duty board-eligible physicians (fresh out of residency), and so forth. Call-up is initially voluntary, with those who would like to volunteer for a mission or position filling slots that are needed. If slots remain unfilled, physicians with active duty service obligations will be ordered to fill them. Fellows are eligible to be called up because they have complete residency training. Residents in both military and civilian residencies should not be called up except under the most dire situations. An invasion of the United States or an event of similar magnitude to that occurring on September 11, 2001, are examples of situations in which residents were (briefly) pulled from their civilian or military residency duties. Medical students who have been directly commissioned can always be called up to fill any manpower need deemed essential by the military. A medical student is last on the list of medical personnel to be called up but, although unlikely, could always be called up for a nonmedical job. MEDICAL PART TIMERS Physicians and medical students without existing service obligations can also serve part time by applying for a direct commission into the Guard or Reserve. The statutory service obligation (as a guardsman or reservist) is 4 years for those who do not accept financial incentives. However, once financial incentives are accepted, the statutory obligation increases to 8 years (Figure). FINANCIAL INCENTIVES FOR P ART TIMERS All reservists are paid a small compensation for attending drills. This pay is based on rank and time in the service, with rank based on experience at the time of entry into service. For example, an attending physician who is commissioned fresh out of residency will be commissioned at the third-level officer (O-3) rank but be paid less per drill than an O-3 who has been a member since medical school. Medical students are eligible for the Montgomery GI Bill, 9 which at present pays approximately $300 per month just for enlisting. Accepting payments from the Montgomery GI Bill extends one s part-time commitment to 6 years and statutory obligation to 8 years. Residents who have their full licenses can receive residency stipends, currently paying approximately $1,000 per month. Residents accept stipends for 6-month blocks of time. Stipends are flexible and can be accepted for some or all of a residency. Every 6-month period that a resident accepts stipend payments is worth 1 year of extended service obligation. Residents are also eligible for the Health Professions Student Loan Repayment Program, wherein if one is training in a needed specialty (usually emergency and critical care medicine or surgery), the military will directly pay off loans up to $50,000 over a period of 3 years. 3,10 Attending physicians (both boardprepared and board-certified physicians) are always able to accept signon bonuses in needed specialties. These are lump sum amounts that do not incur any further obligation. As with full-time military physicians, rank and pay scale are proportional. Guard and Reserve officers serve a minimum of 45 Unit Training Assemblies (one-half weekend day=1 Unit Training Assembly=1 weekday) a year by attending drills 1 weekend a month, 2 weeks a year, for a minimum of 4 years from their date of commissioning. Accepting sup- plemental financial incentives as detailed previously extends time in service and extends the statutory obligation to 8 years. All Guard and Reserve payback starts after all incentives have been received. Examples of part-time service obligation are also shown in the Figure. EDUCATIONAL OPPORTUNITIES FOR MILITARY PHYSICIANS All licensed physicians throughout all components of the military (eg, psychiatrists, pathologists, internists, emergency physicians) are expected to be able to handle general health maintenance duties (ie, physical examinations and basic resuscitation). Active duty physicians do just as their civilian counterparts do, whereas Guard and Reserve physicians often train to apply their civilian specialties to military missions. Flight surgeons, however, represent a unique military subspecialty. These are physicians of any specialty who have attended Aerospace Medical Primary school and are qualified to give flying physicals, meaning physicals to those who fly (eg, pilots, navigators, loadsmen). Flight surgeons are the physicians in the old-time war movies who tell the star pilot that he is grounded because of an ear infection that could put his life and crew in danger. What the flight surgeon says regarding the flying capability and health of a flight crew trumps all other orders, even those from the highest levels. They serve flight crews ranging from those who fly Air Force and Navy fighter jets and bombers to Army transport planes and helicopters. Any citizen who has graduated from medical school can, so long as he or she passes the flight physical examination, apply to attend Aerospace Medicine Primary school and become a flight surgeon. That means 106 ANNALS OF EMERGENCY MEDICINE 42:1 JULY 2003

8 that physicians fresh out of medical school, residents, and board-certified physicians of all shapes and specialties can, on entering the military, apply to become flight surgeons. Military physicians can also take advantage of the continuing medical education opportunities offered by the military. One course is the previously mentioned Aerospace Medical Primary, a 7-week course. Physicians who meet physical examination requirements (there are restrictions on height, weight, eyesight, and hearing) train to become flight surgeons. 11 The curriculum covers aerospace physiology, aerospace medical, and survival training. Another popular course is the Combat Casualty Care Course (C4). This is a 9-day training exercise teaching first-responder skills in extreme situations. 12 The military often covers civilian continuing medical education training expenses for Guard and Reserve physicians and holds its own military medical conferences, which offer continuing medical education courses to both active duty and Guard and Reserve physicians. THE MILITARY AND EMERGENCY PHYSICIANS: A UNIQUE NICHE Emergency physicians are in demand because we are the closest to being trained in how to treat combat casualties in time of war. In peacetime, emergency physicians on active duty are tasked to work as emergency physicians in military hospital emergency departments and to go on missions in which an emergency physician might be needed. Presently, the military has developed manning packages, which are teams of MDs, RNs, registered respiratory therapists, and emergency medical technicians called to fill specific missions. Usually these missions are medical evacuation missions: the team goes in to pick up, stabilize, and transport an injured or ill military member to a tertiary care hospital. Emergency physicians serving with the Guard and Reserve also fill manning package roles for missions, sometimes even supervising active duty members. In the post 9-11 era, disaster management specialists, hazardous materials experts, and toxicologists are in particular need, and the military provides a synergistic outlet for these emergency medicine specific areas of expertise. LEAVING THE MILITARY Leaving active duty usually means transferring to the Guard or Reserve or being discharged to civilian life (while possibly remaining listed as part of the Inactive Ready Reserve). As long as the initial active duty service obligation has been met, there is no barrier to leaving. Leaving the Guard or Reserve means being discharged or listed as part of the Inactive Ready Reserve if time remains on the statutory service obligation. As long as initial Guard and Reserve service obligations have been met, individuals are free to leave at any time. Leaving to retire from active duty, the Guard, or the Reserve means an officer has served at least 20 years in some combination of active duty, Guard, or Reserve. Retirees earn a standard military pension and all military retiree benefits. LEAVING EARLY AND THE DON T ASK, DON T TELL POLICY As a physician, one is allowed to leave without any inconvenience, as long as the initial service obligation is met. Leaving before one s initial service obligation is met is possible but discouraged. If time in service is being served to pay back financial assistance received, leaving early means paying the balance on money received. If a student accepts a scholarship toward 4 years of medical school worth $150,000 and leaves after serving only 2 years (ie, half of the service obligation) on active duty, $75,000 is owed to the military (ie, half of what the military paid for school). There is a list of general reasons under which an officer and hence a physician can leave before service obligation is fulfilled, including financial hardship, being the sole surviving son or daughter of a family, and miscellaneous. Service members who are homosexual or bisexual wishing to disclose their orientation as the reason for leaving the military must prove to their commanding officer that their orientation is not heterosexual. However, by doing so, a gay officer is risking a court martial for violating the much-maligned catch-22 don t ask, don t tell, don t pursue, don t harass provision of the Uniform Code of Military Justice. Lesbians, gays, and bisexuals continue to serve with distinction in the military. Because the procedures and investigations surrounding this disclosure are so complicated and risky, a gay physician wishing to leave under these grounds is strongly advised to contact the Servicemembers Legal Defense Network before making any announcements to military colleagues. 2,13-15 Only an honorable discharge qualifies a service member for military benefits and pensions. Although gay officers are authorized for honorable discharge, they are at risk for general or other than honorable discharges. BENEFITS AND DISADVANTAGES First and foremost, there is the cornysounding yet true patriotic benefit to the physician who joins. Service to JULY :1 ANNALS OF EMERGENCY MEDICINE 107

9 country through the military can be personally and intellectually satisfying. There is always the added benefit to the military that, by joining, physicians from varying backgrounds can add to the diversity pool in the military and help make our military a better reflection of the society it protects and defends. In kind, physicians who are in the military can be role models to civilians, showing the diversity within the military. Those seeking academic and research careers have ample opportunity and resources through military residency programs and research hospitals, such as the Walter Reed Army Hospital, where Dr. Reed made his pioneering discoveries about malaria and yellow fever more than a century ago. Other benefits include a retirement pension after 20 years of service and commissary privileges, which offer discounted food and shelter necessities. Space A travel (space available travel; ie, one has the opportunity to hitch hike and hop military flights all over the world) is just one more of the perks available to service members. Another popular benefit is membership in the United States Automobile Association, a private insurance and financial-planning company catering exclusively to citizens who have served in the US armed forces and their family members. Some of the drawbacks to military service are those described in this article and are largely related to the caprices of military need and politics. Even if a physician disagrees with US foreign policy, when called for duty, there is an obligation to serve and increased risk for injury or death. The military can dictate the military physician s specialty and the location of practice. Gay persons in the military must navigate especially delicate social and political waters. Ultimately, the military is a large national corporation running a con- sortium of health care centers with needs parallel to the civilian public at large. It holds its own well-defined hierarchy and executes an explicitly defined mission statement. It hires emergency physicians in a variety of positions, always as an emergency physician but also as a uniformed service officer. Emergency physicians can be commissioned in 4 of the 7 uniformed service branches: Army, Navy, Air Force, or US Public Health Service. Beginning as medical students awaiting full-time active duty payback after residency or jumping into the Guard or Reserve at any point along the medical training path, there are multiple avenues to join ample emergency medicine related opportunities to contribute to the advancement of emergency medicine and to national service. We thank James Marques, COL RIANG MSC, James V. Hennessey, COL RIANG SAS, David Ashley, LTC RIANG FS, and the members of the 143d MDS for their help and perspective, as well as Marsha Lee, MD, and Michael Alberts, MD, for their suggestions. Address for reprints: Matthew R. Lewin, MD, PhD, University of California, San Francisco Fresno, 445 South Cedar Avenue, Fresno, CA 93702; fax ; aplysia99@yahoo.com. REFERENCES 1. Patterson G. United States Military Reserve components. University of Kentucky Web site. Available at: Groves%20presentation.ppt. Accessed March 30, Uniform Code of Military Justice. The Military Network Web site. Available at: Accessed March 30, Uniformed Services University of the Health Sciences frequently asked questions. Uniformed Services University of the Health Sciences Web site. Available at: Accessed March 30, Reserve Officer Training Corps (ROTC) official Web site. Available at: Accessed March 30, Benton JC. Air Force Officer s Guide. Mechanicsburg, PA: Stackpole Books; Selective Services System Web site. Available at: Accessed March 30, Ballard L. US Public Health Service Commissioned Corps. Available at: HPSP.html. Accessed March 30, The Military Medical Students Association. The Military Match [Creighton University Medical Center Web site]. Available at: creighton.edu/mmsa/match.html#army. Accessed March 30, The Montgomery G.I. Bill. Available at: Accessed March 30, US Department of Health and Human Services (HRSA). National Health Service Corps Loan Repayment Program, Fiscal Year 2003: Applicant Information Bulletin [National Health Service Corps Web site]. Available at: applications/2003lrpbulletin.doc. Accessed March 30, Aerospace Medicine Primary Course (AMP) Web site. Available at: web/af/amp.htm. Accessed March 30, Combat Casualty Care Course Web site. Available at: Accessed March 30, Servicemembers Legal Defense Network Web site. Available at: Accessed March 30, Uniform Code of Military Justice. Uniform Code of Military Justice, Subchapter Ten-Punitive Articles, Article 125-Sodomy. Available at: Accessed March 30, Shilts R. Conduct Unbecoming: Gays & Lesbians in the US Military. New York, NY: St. Martin s Press; Defense Finance and Accounting Service. Complete active duty and reserve monthly drill pay tables, effective January 1, 2003; updated January 30, 2003 [Defense Finance and Accounting Service Web site]. Available at: paytable.pdf. Accessed March 30, US Department of Defense. Military ranks. Available at: almanac/people/insignias/officers.html. Accessed March 30, ANNALS OF EMERGENCY MEDICINE 42:1 JULY 2003

10 APPENDIX 1. United States undergraduate military service academies. Army: US Military Academy in West Point, NY Navy: US Naval Academy at Annapolis, MD Air Force: US Air Force Academy in Colorado Springs, CO Coast Guard: US Coast Guard Academy at New London, CT Merchant Marines: US Merchant Marine Academy at Kings Point, NY APPENDIX 2. Selected Web resources. Army: Air Force: Navy: Marine Corps: Coast Guard: US Public Health Service: Commissioned Corps of the National Oceanic and Atmospheric Administration: noaacorps.noaa.gov/ Merchant Marines: Program Support Center, US Public Health Service Commissioned Corps: usphs.gov/ Today s Military Homepage: todaysmilitary.com/indexreal.php JULY :1 ANNALS OF EMERGENCY MEDICINE 109