By Monica J. Smith
The majority of physicians who pursue a career in military medicine set their sights on that goal before they even begin medical school as they seek eligibility to participate in the Health Professions Scholarship Program (HPSP), which funds students’ education in exchange for required periods of duty in the U.S. Army, Navy or Air Force.
The benefits of this approach are clear: The scholarship covers most or all of their education and training, books and materials, as well as provides a monthly stipend and military pay. In return, doctors serve one year for each year of the military’s support, with a minimum commitment of two years. They begin their careers free of medical school debt, and if they choose to continue in the military, which about two-thirds of HPSP participants do, they can look forward to retiring relatively young with a healthy benefits package.
But there is a small proportion of military physicians who enter through direct accession later in life, sometimes after years or even decades in civilian practice, occasionally beginning their military career at the point when an HPSP recipient would be retiring. The common thread that unites these late joiners is a desire to serve their country and take care of those who defend it.
When U.S. Navy Capt. (ret) Norris Childs, MD, finished his residency, he set out to pursue his surgical career as a solo practitioner in Philadelphia. He regularly received letters from the armed services spelling out the perks and benefits of joining, letters that he ignored. But a letter that he received in 1988, simply stating a desperate need for physicians, touched a chord.
“There were no promises of money, adventure, allure or anything like that. Just ‘we need doctors badly,’ and that appealed to me,” Dr. Childs said.
Rear Adm. Michael Baker, MD, chairman of surgery at John Muir Hospital, in Walnut Creek, Calif., who spent 30 years in uniform, did everything he could think of to avoid the military while attending college and medical school during the Vietnam War.
“I even went into U.S. Public Health Services for a while,” he said. But as his residency came to a close, he felt so grateful to have had the chance to get the education and training to become a surgeon that he no longer had qualms about service.
“By that time, the Vietnam War was nearly over, but I decided that no matter what the politics were, I could put on a uniform and take care of those who had served our country,” Dr. Baker said.
Maj. Paula Oliver, MD, FACS, spent 20 years in a single-specialty practice when her involvement with an army officer exposed her to the acute shortage of general surgeons in the military, and she felt her own call to duty. At the same time, she was feeling increasingly frustrated with practice in the civilian setting, and this is another common thread among physicians who enter the military later in life: Medical practice isn’t what they’d expected, or a once-satisfying career is beginning to turn sour.
“I often see that there is a general dissatisfaction with life in the civilian surgical world, a feeling that there is no higher sense of purpose in what they are doing,” said Col. Tommy Brown, MD, general surgery consultant to the Surgeon General.
At the time that Dr. Childs decided to join, part of his practice was taking care of nonpaying, inner-city trauma patients. “Occasionally I’d come across a person who was totally unappreciative. I knew I’d never get paid for taking care of that patient, and there was a high risk of being sued for unhappy results,” he said. “I had this fantasy that in the military I might find a more appreciative audience for my trauma care. I’d say in the 22 years I served, the military has not disappointed me in that regard at all.”
Dr. Brown’s perception of the majority of physicians who choose to serve as military doctors is that they are deeply satisfied with that decision. “Most people are pretty happy with the change,” he said. “As a surgical oncologist, I take care of a lot of cancer patients, which is a very appreciative group. But when you go downrange and take care of these young kids who are in combat, it really is just you pulling them out of these life-and-death situations. It’s extremely professionally rewarding.”
For those with little or no exposure to the military, enlisting with the armed services, even to do the work of a physician, can feel like an alien endeavor. For some, it requires a suspension of disbelief and willingness to examine long-held opinions and beliefs, especially if they grew up in a culture ambivalent about or hostile toward the military.
Christopher Dillon, MD, a colonel in the Medical Corps, U.S. Army, Adolescent Medicine Specialist/Physician Recruiting and Accessions Liaison, HPSP, realized early in medical school that his expectations about the costs were unrealistic, so he entered the program, which covered his remaining three and a half years of training.
“I thought I’d made a deal with the devil to pay for medical school because I was really going into the unknown. I had no comfort level with the military, but I was not going to go into that kind of debt,” he said.
As a physician recruiter, Dr. Dillon finds one of the hardest problems in reaching potential military physicians is overcoming myths and preconceived notions. “I’ve seen people whose families say, ‘we’ll mortgage the house, whatever it takes,’” he said. “But we’re physicians. We’re noncombatants. We are expected to be as safe as possible to take care of our people, plus anybody else.”
Dr. Baker’s perceptions of the military were largely informed by television and movies, and his decision to join came as quite a surprise to his entire family. “Even by the time I got to the rank of admiral, my own mother couldn’t understand what I was doing in uniform,” he said.
For Dr. Childs, joining the military was anathema to his spiritual beliefs and practices. Although his grandfather and father had both served in the military, Dr. Childs was raised a Quaker.
“Quakers are pacifists and have a definite antiwar sentiment and an antimilitary bent, so this weighed on my mind. But the Quaker educational tradition [dictates that] you should seek out independent inquiry and not just take other people’s word about how things are,” he said. “It was in keeping with this tradition to explore the real truth, to find out if these people were as evil as they were made out to be, to find out what the military was really like.”
Qualifying, Committing, Deploying
To qualify for active duty, a physician is required to be a U.S. citizen, and for the reserves, a legal resident. Physicians going into the military through direct accession are required to be board-certified in their specialty and to have an active license to practice medicine. The military is not a solution for physicians who are faring poorly in civilian practice.
“We look closely at people. If we see that someone has had a lot of litigation, that’s questionable. Especially if someone has something still hanging, that’s not acceptable,” Dr. Dillon said. “For general surgeons, the entire CV packet … is sent to the general surgery consultant who contacts the surgeon and gives a thumbs up or thumbs down.”
Although physicians do not go through the type of boot camp training that a new recruit would experience, there are physical standards they must meet. “The physical exam trips up a lot of people,” Dr. Dillon said. Pre-existing conditions, including eczema, can disqualify a candidate. “Usually that waives, but it is a process. The Army is very stringent about making sure people are physically fit to serve, and that standard is the same whether you’re talking about a private or a more senior officer.”
Full-time military physicians on active duty receive a compensation package that includes health care for themselves and their families, malpractice insurance, a retirement fund, a relatively good salary that in some specialties is higher than they would earn in civilian practice and a paid vacation plan rarely experienced by other workers: 30 days that, if not taken, roll over into the next year.
“You get time with your family,” Dr. Dillon said. “One of the reasons the military sets it up that way is that you’re part of a security force and you can potentially be deployed, but life when you’re here is very, very good.”
For the past 11 years or so, most Army surgeons have deployed to combat theater every one or two years. “Generally you have a one- to two-year dwell time on the ground in the U.S. before you go downrange again,” Dr. Brown said.
Dr. Oliver was deployed eight months after she joined, and she was warned during her interview of this possibility. But she was ready for it. “I can’t imagine volunteering for the military and being surprised that you have to deploy, although I’ve heard others were surprised by this scenario,” she wrote.
Reservists serve one weekend per month and one two-week commitment each year, usually at a reserve center near their home. “The goal of this is primarily to provide some relevant training to what your mission will be if you’re called up and deployed,” Dr. Baker explained. “This might mean you go to Bethesda Naval Hospital for two weeks, work there in your specialty and learn the ways of military life in the hospital.”
Reservists are paid for these periods of employment, and can retire after 20 years with a pension that starts at age 60 and enduring military health coverage. In exchange, they are obligated to answer the call to duty when it comes.
“The price you pay is that … when the U.S. government decides to go to war with Iraq, they call you up and say, ‘your unit has been mobilized, you need to show and be ready to go to Saudi Arabia.’ And that’s what happened to me,” Dr. Childs said. “Within 15 months of joining the Navy, I got my wish, got to go to war and see what all these evil people were like.”
What he found was that the vast majority of his colleagues were committed to doing the right thing for their country. “They felt it was their duty to put themselves in harm’s way, to protect the things we stand for in this country, and that everybody had a pretty good vision of what the right thing was,” Dr. Childs said.
But he also found, during his first deployment, that war is hell. “You can say you won the war, and we won that war. But everyone in my unit lost the war,” he said. “They lost their job, they lost their wife. Some of them lost kids.”
The day that Dr. Childs was called up, his middle son broke his neck in a wrestling accident and was paralyzed from the neck down. “It was the most devastating day of my life, yet here I was committed to going overseas, leaving my wife alone with this injured kid. It made me think a lot about why we sacrifice to do these things. Everyone pays the price in the long term. It made me even more of an antiwar person.”
His son received prompt and excellent care after his accident, and was able to stand, move his hands and feed himself by the time Dr. Childs left for the Gulf. “I knew in my heart that he was going to get better, and I thought, this is why I’m going to Saudi Arabia—so I can take care of some kid like him and get him back to his mom or his wife or girlfriend.”
That rationale is unarguably noble, but Dr. Childs is honest about the fact that serving his country as a military physician also allowed him to indulge his sense of adventure. “Staying in the military was a way for me to do things I would never have gotten to do in a civilian practice. I’ve been to places I would not have been allowed to go.”
For Dr. Baker, every tour of duty presented an opportunity to learn or do something new, such that his career as a physician took a more military bent than he possibly could have anticipated. After his second tour, the Navy reserves offered him a position as a general medical officer with a Navy Special Warfare Unit.
“That turned out to be a magnificent assignment because there was so much to do. I had to learn how to be a Navy officer instead of just a doctor who is in the Navy uniform,” he said.
He became a river warfare–qualified officer for patrol boats, which got him heavily involved in day-to-day proceedings. “I was leading people and learning how to captain a small boat, reading maps and calling in helicopter support. I was heavily involved in the planning and execution of real missions, which was a quantum leap from what I was doing as a doctor and surgeon,” Dr. Baker said.
“I learned lessons about leadership, teamwork and taking care of your people that I use every day in my civilian practice and in the operating room,” he said.
Following his stint in the first Gulf War, Dr. Childs spent about 10 years in the reserves before being mobilized again in spring 2005. He spent a full year on active duty, including six months in Portsmouth, Va., where he was required to repeat his trauma training course.
“At the end of the course, they said they’d detected I had instructor potential. So they sent me to a training course in Fort Sam Houston, Texas, and I became an instructor,” he said. Even now as a retiree, Dr. Childs returns to Fort Sam Houston five or six times per year to teach young military doctors how to take care of trauma patients.
“It’s always a thrill to go there because they’re young and enthusiastic to do the right thing for soldiers, sailors and Marines, and it always energizes me when I go and teach these kids,” he said.
Dr. Baker retired from the Navy in 2005, and although he is deeply satisfied with his civilian practice, there’s a part of him that still wants to be involved as current events unfold. “Particularly when my brothers and sisters in arms are conducting combat operations somewhere, it’s pretty hard to sit on the sidelines,” he said. “But the reality is that it’s time for younger and faster people to take your place, and to hope that you’ve groomed good people to move up and provide leadership.”Post-retirement, he stays connected with the military by teaching abroad two or three times per year in Korea as part of a conference of U.S. and Korean medical personnel called the 38th Parallel Medical Society, and in Germany. “All the casualties coming out of Iraq and Afghanistan go there to be reoperated and restaged, so I’ve gone a number of times as a mentor to train young trauma surgeons,” he said. “It’s a very rewarding experience, although emotionally difficult. But I learn as much as I teach.”