Acad Psychiatry (2015) 39:402–409 DOI 10.1007/s40596-015-0368-z
COLUMN: "DOWN TO EARTH" ACADEMIC SKILLS
Pathways to a Career in Military Psychiatry Carroll J. Diebold 1
&
Stephanie L. Leong 1 & Steve Zuchowski 2 & Richard T. Gibson 1
Received: 15 June 2014 / Accepted: 5 May 2015 / Published online: 10 June 2015 # Academic Psychiatry (outside the USA) 2015
Psychiatric healthcare has been an essential aspect of the military medical mission over the past century. From very limited psychiatric services available during World War I to the development of multiple psychiatric graduate medical education training programs within the military healthcare system after World War II, psychiatry within the military has markedly evolved. With the onset of Operation Enduring Freedom in 2001 and Operation Iraqi Freedom in 2003, the USA embarked on the longest continuous conflict in its history, producing thousands of personnel suffering from combat-related psychiatric disorders and placing additional psychological stress on their spouses and children requiring the services of skilled psychiatric physicians both wearing the military uniform and serving as civilian healthcare providers in a military treatment facility. This paper will present an overview of the history of military psychiatric graduate medical education, current avenues of access to serve as a military psychiatrist either in uniform or as a civilian, and the opportunities and experiences one may expect working in the military healthcare system. Psychiatry Graduate Medical Education training has significantly evolved from the first known four Department of Defense psychiatric residents (two Army and two Navy) in 1909 who trained for 2 years at Saint Elizabeth Hospital in Washington, DC. However, very few psychiatrists were sponsored for training over the next several decades despite the evident need for psychiatric services in World War I when the total number of psychiatrists in the Army increased from 50 at the beginning of the war to nearly 700 when the Armistice was signed in 1918 [1]. Attrition from the military psychiatry ranks
post-World War I significantly reduced the inventory to less than 100 in 1940, necessitating another quick infusion of psychiatric physicians into the Armed Forces to include the establishment of a standardized 12-week neuropsychiatry course for non-psychiatric clinicians which produced 1300 graduates to augment the pool of neuropsychiatric services available for service members [2, 3]. In 1946, Congress passed the National Mental Health Act which provided funds for a number of mental health initiatives including the training of mental health professionals, and over the course of the next decade, eight military psychiatry residency programs opened and received certification from the Accreditation Council for Graduate Medical Education [4]. Since the 1950s, there has been significant change in the total number and location of military psychiatry training programs to include a significant restructuring during the 1990s in unison with the large drawdown of troops after Operation Desert Storm. Six Military Psychiatry Graduate Medical Education training programs are currently in operation. The demand for behavioral health services post-9/11 for both service members and their families greatly increased in the setting of continuous combat operations and quickly exceeded existing resources. This increase in clinical demand necessitated increasing the numbers of psychiatrists within military treatment facilities and thus expanded opportunities for entry into military psychiatry besides the traditional path of completing a military graduate medical education training program. A career in military psychiatry can now be achieved through several different pathways as discussed below.
* Carroll J. Diebold [email protected]
Pathways to Becoming a Uniformed Psychiatrist
1
Tripler Army Medical Center, Honolulu, HI, USA
2
University of Nevada School of Medicine, Reno, NV, USA
One may enter Active Duty Service before, during, or after medical school, during residency, or after completing psychiatry training. The following is a brief overview of the
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accession programs available. More detailed information can be acquired from each of the uniformed services’ respective recruiting commands [5]. Both the Active and Reserve Components offer Medical Corps accession programs which are summarized in Table 1. Active Duty Pathway Pursuing full funding for medical school through the Health Professions Scholarship Program or by attending the Uniformed Services University is the most common route to Active Duty Military Psychiatry [6, 7]. The Army, Navy, and Air Force participate in the Health Professions Scholarship Program and offer a current or soon to matriculate medical student attending an accredited medical school a 2-, 3-, or 4year scholarship option. The Uniformed Services University is a health science university run by the federal government in Bethesda, MD, to which premedical college students may apply through the American Medical College Application Service as like any other medical school. The Uniformed Services University F. Edward Hebert School of Medicine opened in
Table 1
1976 to train career military physicians to ensure an adequate physician force in the post-Viet Nam era and has an average class size of 167 students broken down by 63 Army, 51 Air Force, 51 Navy, and 2 Public Health Service students [8]. The average grade point average and Medical College Admission Test scores of selectees are 3.5 and 31 for the Uniformed Service University and 3.45 and 27 for Health Professions Scholarship Program, respectively [9]. Graduating medical students who accept a Health Professions Scholarship Program scholarship or who attend the Uniformed Services University must apply for military graduate medical education outside of the National Resident Matching Program. The military residency match, called the Joint Services Selection Board, occurs earlier than the National Resident Matching Program with applications due in midSeptember and is military specific. In the application, the student will rank order psychiatry training programs within the service they have been commissioned. Currently, there are six psychiatry residency programs in the military, Multi-Service (1): Walter Reed National Military Medical Center, Bethesda, MD; Air Force (2): San Antonio Military Medical Center, San
Active and reserve medical corps programs for psychiatrists
Program name
Type of program
Requirements
Financial benefit
Obligation after training
Uniformed Services University (AD)
Funded military medical school
Acceptance into USU
7-year AD service after residency
Health Professions Scholarship Program (AD) Financial Assistance Program (AD)
Scholarship for accredited Acceptance into accredited medical school medical school
Full tuition, books and supplies, pay and benefits afforded an O1 Full tuition, selected expenses stipend and bonus
1-year AD service for every year of funding
Monthly stipend of over $2000 and $45,000 annual grant Multiyear bonus for 2, 3, or 4 years $272,000 accession bonus
2-year AD service for the first year and 1/2 year every 1/2 year thereafter 2-, 3-, or 4-year contracts available Minimum 4 consecutive years
Financial support during civilian residency
Approval by Office of the Surgeon General Qualified physician
MAVNI (AD)
Bonus after completion of training Bonus after completion of training Repayment Program after training Recruiting after training
Health Professional Special Pay (R) Medical/Dental Student Stipend Program (R)
Bonus after completion of training Financial support during medical school
Direct Accession (AD) CWSAB (AD) ADHPLR (AD)
Specialized training Financial support during assistance program (R) residency training Health Professionals Loan Repayment Program (R)
Repayment Program after training
Qualified physician Eligible for Direct Accession or Retention Legal, non-US citizen licensed in the US and meeting criteria Qualified physician Acceptance into accredited medical school
Up to 3 years of up to $40,000 3 years as an AD psychiatrist per year loan repayment 3-year AD psychiatrist or 6 years selected reserve Up to a bonus of $75,000 over 3 annual payments Monthly stipend of >$2000
Residents enrolled in Monthly stipend of >$2000 accredited residency and in designated specialty Physician serving in Reserves Up to $250,000 repayment of education loans
Serve in a Reserve Capacity Incur 1 year of service for every 6 months of financial support Incur 1 year of service for every 6 months of financial support $40,000 repayment for every year of satisfactory service
AD Active Duty, R Reserve, CWSAB Critical Wartime Accession Bonus, ADHPLR Active Duty Health Professionals Loan Repayment, MAVNI Military Accessions Vital to the National Interest
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Antonio, TX, and Wright Patterson Air Force Medical Center, Dayton, OH; Army (1): Tripler Army Medical Center, Honolulu, HI; and Navy (2): Naval Medical Center, Portsmouth, VA, and Naval Medical Center, San Diego, CA [10]. Occasionally, an applicant will be selected to train at another service’s program if all the positions of the applicant’s service have been filled. Very infrequently, a student may apply for a civilian training deferral and subsequently be allowed to train outside of the military system through the National Resident Matching Program. Graduating medical students selected for a military internship will enjoy the benefits of being an Active Duty Officer while receiving training in a psychiatry program accredited by the Accreditation Council for Graduate Medical Education with the additional benefit of specialized training in military psychiatry. In addition, the military offers the full breadth of fellowship training to include Addiction Psychiatry, Child and Adolescent Psychiatry, Forensic Psychiatry, and Psychosomatic and Geriatric Psychiatry. Other pathways offer education-related funding and provide financial support during medical school and residency training. The Financial Assistance Program (FAP) provides the civilian resident a $45,000 annual grant and $2000 monthly stipend. The recipient in turn will be expected to provide 2 years of active duty service for the first year and 1 year every year thereafter. The Uniformed Services established a loan repayment plan called the Active Duty Health Professionals Loan Repayment which offers a maximum of 3 years of loan repayment up to $40,000 per year for 3 years of Active Duty service as a military physician [11, 12]. A board-eligible or board-certified psychiatrist may enter Active Duty through direct accession, opting for the Critical Wartime Skills Accession Bonus, or via the Military Accessions Vital to the National Interest recruiting program. Direct accession offers a multi-year bonus for 2, 3, or 4 years with commiserate service obligation, while the Critical Wartime Skills Accession Bonus offers a onetime bonus and a 4-year commitment to serve on active duty. Military Accessions Vital to the National Interest is a recruiting program that allows certain legal, non-citizens to commission into the Army for 3 years on Active Duty or 6 years in the selected Reserves [13–15]. Uniformed Military Psychiatrist Career Progression The active duty uniformed psychiatrist does have some flexibility in molding one’s career path after the first several assignments by pursuing specific clinical, operational, academic, research, or administrative areas of concentration. However, upon completion of residency training, the uniformed psychiatrist will either join the staff of a military treatment facility in a clinical role or be assigned to an operational unit as the commander’s subject matter expert in military behavioral health issues while also maintaining a clinical practice. With
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each subsequent assignment, the uniformed psychiatrist will be expected to assume positions of greater responsibility and complexity in order to be competitive for selection to the next rank. For example, potential progressive duty positions within a military treatment facility include staff psychiatrist, service chief, division chief, and department chief. With increased responsibility, more time will be required to perform administrative tasks, so the uniformed psychiatrist must endeavor to reserve time to perform patient care. Some uniformed psychiatrists become interested in serving in operational units for which duties consist mainly of being in a behavioral health advisory role to the unit commander, focusing on the overall psychological well-being of the unit while also addressing specific behavioral health issues of unit members. In the Army, a uniformed psychiatrist with a broad interest in operational medicine may opt to compete for selection for command of a Combat Stress Control unit in addition to later on pursuing more senior level command positions for units such as a combat support hospital or a medical brigade. Pursuit of interest in academics mainly involves being selected to become faculty at one the Psychiatry Graduate Medical Education training programs listed above. Making oneself a viable faculty candidate consists of performing well during residency and fellowship training while demonstrating an interest in scholarly activity, excelling in several diverse assignments after completion of training, and attaining all expected military-related professional milestones such as timely completion of military education and training requirements. For uniformed psychiatrists desiring to pursue a full-time academic or research position, each of the uniformed services have faculty assignments at the Uniformed Services University, and the Walter Reed Army Institute of Research also has researchrelated assignments for uniformed clinicians. After completion of several assignments primarily as an office-based clinician or in an operational role, a uniformed psychiatrist may decide to pursue a more administrativeoriented career path. Such a career track will necessitate leaving one’s primary specialty and compete for command and staff positions with other officers also having healthcare backgrounds. Due to the demands of such positions, the clinician will most likely have minimal opportunity to provide direct patient care or engage in teaching or other academic activities unless such is aggressively pursued, most likely on one’s personal time. All uniformed psychiatrist assignments will require a progressively larger supervisory role with a greater scope of responsibility as the clinician gains more seniority. To be selected for promotion, the uniformed psychiatrist has to demonstrate success in positions of progressively greater complexity and responsibility rather than simply being a good clinician as was the parameter for military physicians in the past. As one achieves more seniority, leadership as well as administrative responsibilities increase, and demonstration in proficiency in
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these areas is essential for promotion in rank. Such opportunities to serve in positions of greater responsibility and complexity will most likely necessitate moving to another duty location every 3 to 5 years which is the expectation of all branches and specialties within the military. In terms of specific assignment and overall career opportunities, each branch of the military offers positions related to their service needs and should be considered when deciding to pursue a career as a uniformed psychiatrist. In addition to successfully serving in duty positions which demonstrate clear evidence of professional maturation, the uniformed psychiatrist must ensure successful completion of military education courses and training in order to be competitive for selection to the next rank and be eligible for specific types of leadership assignments. Each uniformed service has its own process to fulfil such requirements. Reserve Pathway Similar to the Active Duty Pathway, one may enter Reserve Service before, during, or after medical school, during residency, or after completing psychiatry training. Reserve Officer Programs summarized in Table 1 include Health Professional Special Pay, Medical/Dental Student Stipend Program, Specialized Training Assistance Program, and Health Professionals Loan Repayment Program [16–19]. For ongoing financial support during medical training, the medical student option is the Medical/Dental Student Stipend Program and for residency is the Specialized Training Assistance Program. Both programs provide financial support in the form of a monthly stipend of over $2000 and obligate the recipient to 1 year of service for every 6 months of support. Reserve psychiatrists may serve in varied duty positions to include deploying to combat areas, participating in humanitarian missions, and providing coverage at military treatment facilities for active duty colleagues who are deployed. The Reserve psychiatrist will either be assigned to a specific unit with whom they train and are activated or are classified as an individual mobilization augmentee, not assigned to a specific reserve unit and therefore can be slotted into a wide range of duty assignments.
Becoming a Civilian Psychiatrist in the Military Healthcare System Civilian psychiatrists interested in serving military service members and their families in a military treatment facility setting within the military healthcare system may do so via two primary pathways: as a Department of Defense employee or as an employee of a private corporation that has contracted with the Department of Defense to provide behavioral health services for military beneficiaries. The number of non-active
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duty behavioral health clinical positions has increased significantly since 2001 to meet the demand for behavioral health services, and the corps of civilian psychiatrists providing care in military healthcare settings has proven invaluable to the overall success of the military behavioral healthcare mission. The experience of practicing psychiatry in any military health care setting is quite variable. There are differences from branch to branch, and like in most civilian practice settings, the military psychiatrist’s work environment is heavily dependent upon their immediate supervisors, support staff, and colleagues. Performance expectations are similar to those in civilian practice where there are demands to see more patients, complete paperwork, and attend trainings. However, military behavior health is an area where a civilian psychiatrist can positively impact the health of a population in need of service while working in an environment which values and supports the clinician’s professional development. Positions within the Department of Defense can be found at USA Jobs, at recruitment agencies, and through contact with colleagues in military behavior health [20]. In contrast, positions with contract companies are frequently advertised in medical specialty trade publications. A Department of Defense-employed psychiatrist who demonstrates clinical acumen, good professional bearing, and leadership potential can have the opportunity compete for behavioral health leadership positions within the military treatment facility. Due to the requirement for military officers to demonstrate success in leadership positions of greater responsibility and complexity to be competitive for promotion in rank, the majority of leadership positions will be filled by uniformed personnel. However, due to the ongoing shortage of active duty psychiatrists, a motivated Department of Defense civilian psychiatrist may have the opportunity to be selected for a clinic or service leadership position. In addition, the civilian psychiatrist may have the opportunity to gain valuable leadership experience covering for the active duty chief while they are deployed. Contract psychiatrists are not eligible to be in a leadership or supervisory role. Comparing DOD-Employed vs. Contractor-Employed Psychiatry Positions Working directly for the Department of Defense has all the advantages and disadvantages as working for any other organization within the US Government. Advantages include relative job security, competitive salaries, and good benefits, including health and life insurance as well as retirement. Positions with contract agencies are often perceived as less stable because contracts have an expiration date and are subject to rebid, and the contract psychiatrist may find their employer and possibly the terms of their employment subject to modification. Presumably, positions could be eliminated upon change of contract, but the current environment of growth
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due to increased demand for services makes this less likely. Rather than recruit new professional staff, a contract agency is more likely to seek to retain the psychiatrist employees of the prior contract company provided they have exhibited good productivity in providing safe patient care. Also, in order to compete for psychiatrists, federal contractors may offer higher starting salaries, more paid time off, and similar fringe benefits when compared to Department of Defense-employed positions. Because these are private companies, the prospective employee of a federal contractor may be able to negotiate terms of employment whereas a Department of Defenseemployed position has a set salary and benefits package. Ultimately, specific employment opportunities will have to be evaluated by the individual psychiatrist.
The Journey Along the Pathway Regardless of the mode of entry onto the psychiatry pathway within the military healthcare system, a person destined to practice psychiatry in a military healthcare facility must undergo a period of acclimation into the military culture. Such familiarization may occur as early as undergraduate studies either as a student at one of the military service academies or via participation in a Reserve Officers Training Corps program at a civilian college or university. Initial contact with the military culture can also occur during medical school either through matriculation to the Uniformed Services University or participation in the Health Professions Scholarship Program which provides the opportunity to perform funded clinical rotations at military treatment facilities. This initial familiarization with military medicine is further reinforced through the completion of a psychiatry residency in a military treatment facility. Depending on the point of entry onto the military healthcare provider pathway, the novice military residency trained psychiatrist will have between 4 and 12 years of exposure to military culture, structure, and function; however, even with such an extensive connection to military medicine during Graduate Medical Education, the learning and acclimation process for the active duty psychiatrist continues throughout one’s military career. In contrast, for the civilian psychiatrist embarking on the pathway without any prior military experience, the initial exposure to military culture can be quite challenging. The candidate may be a seasoned psychiatrist possessing varied and impressive clinical, academic, and administrative credentials reflecting years of training and experience in the civilian healthcare sector, but the unique aspects of practicing psychiatry within a military treatment facility will require a period of focused familiarization with numerous military healthcare-related topics and acclimation to both the nuances and requirements of medical practice within this healthcare delivery system. Since the level of prior experience for civilian healthcare providers within the military
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healthcare system varies from the recently retired career military psychiatrist who transitions directly into a civilian position to the psychiatrist who has very limited knowledge of the military but has had an entire clinical or academic career with little to no interaction with military culture, each provider’s development along the pathway will be unique but hopefully fulfilling with significant growth. As with any endeavor requiring the mastery of a specific set of skills, proper orientation, mentoring, and performance assessment of the psychiatrist new to the military healthcare system is essential as multiple areas pertaining to clinical service delivery differ from the civilian sector. Uniformed psychiatrists are exposed to such variance very early in Graduate Medical Education training, whereas the civilian psychiatrist entering the pathway with no prior experience within military medicine will have to absorb and incorporate into their clinical practice a great quantity of administrative policy related to service member care. Some military facilities offer an introductory course in military life, structure, and terminology for civilian behavioral health providers such as the pilot program developed by Brent and Kovell in 2009 and conducted at the Schofield Barracks Health Clinic, HI, while other locations will appoint an experienced colleague to function as a mentor for the provider new to the military healthcare system. One very important factor which the acclimating psychiatrist encounters early on along the pathway is the dual agency issue within military psychiatry that recognizes a duty to both the patient and the institution. While providing the best possible care for the patient, the psychiatrist must be sensitive to their patient’s role within the unit’s mission, ensuring it is not compromised due to a psychiatric condition [21]. Additionally, the unique mission of the military and the related duties required by service members occasionally necessitate limits to confidentiality within the physician-patient relationship with related requirements for the process and structure of providing evaluation feedback to the service member’s commander [22, 23]. In performing an occupational assessment in the context of the service member’s psychiatric condition, the psychiatrist must have some understanding of the service member’s specific duties and develop a focused treatment plan to include appropriate duty restrictions if indicated and referral to the Integrated Disability Evaluation System if a medically disqualifying behavioral health condition is diagnosed [24, 25]. The psychiatrist entering the pathway must also become familiar with other service-specific behavioral health-related regulations and policies such as the requirement for coordination of behavioral healthcare or substance abuse treatment continuity for service members transferring duty stations and whether a service member taking a specific psychotropic medication is eligible for a waiver to deploy to a combat zone [26, 27]. In addition to providing psychiatric care for service members, the psychiatrist working in a military treatment facility contributes to overall military unit readiness by performing
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psychiatric assessments on service members identified during mandatory health screenings. By regulation, all service members undergo a physical screening annually by a primary care provider and may subsequently be referred for a psychiatric assessment if clinically indicated [28]. In addition, a deploying service member will undergo health screening assessments within 60 days of deploying, within 30 days of redeploying, and an additional assessment at 90 to 108 days postdeployment as psychosocial issues can arise after the service member has reintegrated into the home environment [29]. A mechanism for more streamlined acclimation into the military behavioral healthcare system for civilian psychiatrists entering the pathway is found in the Embedded Behavior Health structure within combat units and will expand to the rest of Army units in the next several years. Developed at Fort Carson, CO, in 2010, the concept involves a cohort of mostly civilian behavioral health providers formed into an interdisciplinary team to serve a specific unit of approximately 3500 soldiers. The providers get to know the subordinate commanders and non-commissioned officers in the unit which greatly aids with the access to care and referral processes in addition to providing timely advice to the unit leadership regarding administrative issues such as duty limitations due to psychiatric conditions or potential medication side effects, fitness to deploy, and recommendation for the soldier to undergo the medical disability evaluation process. The majority of behavioral health providers staffing the Embedded Behavioral Health teams are civilian clinicians, many of whom have no prior experience working within the military healthcare system [30]. While a large portion of the psychiatrist’s duties will most likely be directly related to issues involving uniformed service members, an equally important part of the military behavioral health mission is the well-being of the military family. The ongoing military operations in the Middle East has resulted in multiple deployments for hundreds of thousands of service members placing families under a great deal of stress and necessitating the availability of behavioral health professionals possessing the insight and experience to provide appropriate assessment and treatment for family issues unique to the deployment process [31]. All psychiatrists completing an accredited general residency program have baseline training in addressing family dynamics and performing assessments of children and adolescents, while child and adolescent fellowship trained psychiatrists have more focused and specialized experience; however, if such training did not occur in a venue which had a large cohort of military families, the psychiatrist entering the pathway after Graduate Medical Education training will need to become familiar with the issues confronted by this population such as the stress upon all family members related to multiple deployments, reintegration of the redeployed service member into the family dynamic, and adjustment to frequent moves which require acclimation to new environments and cultures [32, 33].
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Stress within the military family may first surface during an evaluation or treatment by a psychiatrist with the child or spouse in the role of the identified patient, but further exploration reveals significant impact upon the dynamics of the family corresponding to a military-related issue. In addition to providing clinical services to the child, spouse, or family as a unit, the psychiatrist must also be aware of policies specific to addressing potential significant psychosocial issues within the military family. Should the psychiatrist have any suspicion of physical or emotional abuse or mistreatment by one family member towards another in an active duty military family, such concern must be reported to the local military Family Advocacy Program for investigation, intervention, and appropriate treatment [34]. Remaining sensitive to the well-being of family members is essential for the psychiatrist when constructing a treatment plan to include assessment of the availability of needed psychiatric resources. The requirement for such ongoing specialized services mandates referral to the Exceptional Family Member Program and potentially limits the locations where the family can be stationed [35].
Final Thoughts The military has duly recognized the vital role that all behavioral health providers perform with an emphasis to retain these skilled healthcare professionals within the military healthcare system by enhancing career advancement and professional development for both military and civilian clinicians. In 2013, the US Army Medical Command established a corporate-level Behavioral Health Service Line by restructuring its behavioral healthcare delivery process into a standardized model across the system with priorities of quality, access, and consistency of services [36]. Such standardization is important as military beneficiaries move every few years to a new duty station and have the appropriate expectation that the same type and quality of healthcare will be available wherever they relocate. Standardization is also of importance to the behavioral health providers working in the system as they also tend to periodically relocate, and standardized healthcare delivery across the military healthcare system will make transition easier and hopefully enhance retention of both active duty and civilian psychiatrists. The establishment of the Behavioral Health Service Line also provides civilian psychiatrists more opportunity to compete for behavioral health leadership positions and enhances the potential for career advancement. Due to the unique aspects of military behavioral healthcare, psychiatrists working within the military healthcare system perform a vital role in enhancing the readiness, resiliency, and overall well-being of service members in addition to serving as an essential consultant to unit commanders in the successful execution of the military mission. Though the pathways into military psychiatry are certainly diverse ranging
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from the military academy and Uniformed Services University educated, military Graduate Medical Education program trained career officer to the civilian psychiatry residency graduate with no military background, all are part of a behavioral health treatment team that provides the highest quality psychiatric care to the most worthy of beneficiaries, the men and women of the US Armed Forces and their families. As the prolonged post-9/11 conflicts wind down after 13 years of stress on our service members and their families, highquality psychiatric services will continue to be needed and must be expertly provided by a dedicated group of healthcare professionals of diverse backgrounds with the common goal of conserving the fighting strength of our Armed Forces and alleviating the suffering of our military beneficiaries. Disclosures On behalf of all the authors, the corresponding author states that there is no conflict of interest. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government.
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COLUMN: "DOWN TO EARTH" ACADEMIC SKILLS
Pathways to a Career in Military Psychiatry Carroll J. Diebold 1
&
Stephanie L. Leong 1 & Steve Zuchowski 2 & Richard T. Gibson 1
Received: 15 June 2014 / Accepted: 5 May 2015 / Published online: 10 June 2015 # Academic Psychiatry (outside the USA) 2015
Psychiatric healthcare has been an essential aspect of the military medical mission over the past century. From very limited psychiatric services available during World War I to the development of multiple psychiatric graduate medical education training programs within the military healthcare system after World War II, psychiatry within the military has markedly evolved. With the onset of Operation Enduring Freedom in 2001 and Operation Iraqi Freedom in 2003, the USA embarked on the longest continuous conflict in its history, producing thousands of personnel suffering from combat-related psychiatric disorders and placing additional psychological stress on their spouses and children requiring the services of skilled psychiatric physicians both wearing the military uniform and serving as civilian healthcare providers in a military treatment facility. This paper will present an overview of the history of military psychiatric graduate medical education, current avenues of access to serve as a military psychiatrist either in uniform or as a civilian, and the opportunities and experiences one may expect working in the military healthcare system. Psychiatry Graduate Medical Education training has significantly evolved from the first known four Department of Defense psychiatric residents (two Army and two Navy) in 1909 who trained for 2 years at Saint Elizabeth Hospital in Washington, DC. However, very few psychiatrists were sponsored for training over the next several decades despite the evident need for psychiatric services in World War I when the total number of psychiatrists in the Army increased from 50 at the beginning of the war to nearly 700 when the Armistice was signed in 1918 [1]. Attrition from the military psychiatry ranks
post-World War I significantly reduced the inventory to less than 100 in 1940, necessitating another quick infusion of psychiatric physicians into the Armed Forces to include the establishment of a standardized 12-week neuropsychiatry course for non-psychiatric clinicians which produced 1300 graduates to augment the pool of neuropsychiatric services available for service members [2, 3]. In 1946, Congress passed the National Mental Health Act which provided funds for a number of mental health initiatives including the training of mental health professionals, and over the course of the next decade, eight military psychiatry residency programs opened and received certification from the Accreditation Council for Graduate Medical Education [4]. Since the 1950s, there has been significant change in the total number and location of military psychiatry training programs to include a significant restructuring during the 1990s in unison with the large drawdown of troops after Operation Desert Storm. Six Military Psychiatry Graduate Medical Education training programs are currently in operation. The demand for behavioral health services post-9/11 for both service members and their families greatly increased in the setting of continuous combat operations and quickly exceeded existing resources. This increase in clinical demand necessitated increasing the numbers of psychiatrists within military treatment facilities and thus expanded opportunities for entry into military psychiatry besides the traditional path of completing a military graduate medical education training program. A career in military psychiatry can now be achieved through several different pathways as discussed below.
* Carroll J. Diebold [email protected]
Pathways to Becoming a Uniformed Psychiatrist
1
Tripler Army Medical Center, Honolulu, HI, USA
2
University of Nevada School of Medicine, Reno, NV, USA
One may enter Active Duty Service before, during, or after medical school, during residency, or after completing psychiatry training. The following is a brief overview of the
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accession programs available. More detailed information can be acquired from each of the uniformed services’ respective recruiting commands [5]. Both the Active and Reserve Components offer Medical Corps accession programs which are summarized in Table 1. Active Duty Pathway Pursuing full funding for medical school through the Health Professions Scholarship Program or by attending the Uniformed Services University is the most common route to Active Duty Military Psychiatry [6, 7]. The Army, Navy, and Air Force participate in the Health Professions Scholarship Program and offer a current or soon to matriculate medical student attending an accredited medical school a 2-, 3-, or 4year scholarship option. The Uniformed Services University is a health science university run by the federal government in Bethesda, MD, to which premedical college students may apply through the American Medical College Application Service as like any other medical school. The Uniformed Services University F. Edward Hebert School of Medicine opened in
Table 1
1976 to train career military physicians to ensure an adequate physician force in the post-Viet Nam era and has an average class size of 167 students broken down by 63 Army, 51 Air Force, 51 Navy, and 2 Public Health Service students [8]. The average grade point average and Medical College Admission Test scores of selectees are 3.5 and 31 for the Uniformed Service University and 3.45 and 27 for Health Professions Scholarship Program, respectively [9]. Graduating medical students who accept a Health Professions Scholarship Program scholarship or who attend the Uniformed Services University must apply for military graduate medical education outside of the National Resident Matching Program. The military residency match, called the Joint Services Selection Board, occurs earlier than the National Resident Matching Program with applications due in midSeptember and is military specific. In the application, the student will rank order psychiatry training programs within the service they have been commissioned. Currently, there are six psychiatry residency programs in the military, Multi-Service (1): Walter Reed National Military Medical Center, Bethesda, MD; Air Force (2): San Antonio Military Medical Center, San
Active and reserve medical corps programs for psychiatrists
Program name
Type of program
Requirements
Financial benefit
Obligation after training
Uniformed Services University (AD)
Funded military medical school
Acceptance into USU
7-year AD service after residency
Health Professions Scholarship Program (AD) Financial Assistance Program (AD)
Scholarship for accredited Acceptance into accredited medical school medical school
Full tuition, books and supplies, pay and benefits afforded an O1 Full tuition, selected expenses stipend and bonus
1-year AD service for every year of funding
Monthly stipend of over $2000 and $45,000 annual grant Multiyear bonus for 2, 3, or 4 years $272,000 accession bonus
2-year AD service for the first year and 1/2 year every 1/2 year thereafter 2-, 3-, or 4-year contracts available Minimum 4 consecutive years
Financial support during civilian residency
Approval by Office of the Surgeon General Qualified physician
MAVNI (AD)
Bonus after completion of training Bonus after completion of training Repayment Program after training Recruiting after training
Health Professional Special Pay (R) Medical/Dental Student Stipend Program (R)
Bonus after completion of training Financial support during medical school
Direct Accession (AD) CWSAB (AD) ADHPLR (AD)
Specialized training Financial support during assistance program (R) residency training Health Professionals Loan Repayment Program (R)
Repayment Program after training
Qualified physician Eligible for Direct Accession or Retention Legal, non-US citizen licensed in the US and meeting criteria Qualified physician Acceptance into accredited medical school
Up to 3 years of up to $40,000 3 years as an AD psychiatrist per year loan repayment 3-year AD psychiatrist or 6 years selected reserve Up to a bonus of $75,000 over 3 annual payments Monthly stipend of >$2000
Residents enrolled in Monthly stipend of >$2000 accredited residency and in designated specialty Physician serving in Reserves Up to $250,000 repayment of education loans
Serve in a Reserve Capacity Incur 1 year of service for every 6 months of financial support Incur 1 year of service for every 6 months of financial support $40,000 repayment for every year of satisfactory service
AD Active Duty, R Reserve, CWSAB Critical Wartime Accession Bonus, ADHPLR Active Duty Health Professionals Loan Repayment, MAVNI Military Accessions Vital to the National Interest
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Antonio, TX, and Wright Patterson Air Force Medical Center, Dayton, OH; Army (1): Tripler Army Medical Center, Honolulu, HI; and Navy (2): Naval Medical Center, Portsmouth, VA, and Naval Medical Center, San Diego, CA [10]. Occasionally, an applicant will be selected to train at another service’s program if all the positions of the applicant’s service have been filled. Very infrequently, a student may apply for a civilian training deferral and subsequently be allowed to train outside of the military system through the National Resident Matching Program. Graduating medical students selected for a military internship will enjoy the benefits of being an Active Duty Officer while receiving training in a psychiatry program accredited by the Accreditation Council for Graduate Medical Education with the additional benefit of specialized training in military psychiatry. In addition, the military offers the full breadth of fellowship training to include Addiction Psychiatry, Child and Adolescent Psychiatry, Forensic Psychiatry, and Psychosomatic and Geriatric Psychiatry. Other pathways offer education-related funding and provide financial support during medical school and residency training. The Financial Assistance Program (FAP) provides the civilian resident a $45,000 annual grant and $2000 monthly stipend. The recipient in turn will be expected to provide 2 years of active duty service for the first year and 1 year every year thereafter. The Uniformed Services established a loan repayment plan called the Active Duty Health Professionals Loan Repayment which offers a maximum of 3 years of loan repayment up to $40,000 per year for 3 years of Active Duty service as a military physician [11, 12]. A board-eligible or board-certified psychiatrist may enter Active Duty through direct accession, opting for the Critical Wartime Skills Accession Bonus, or via the Military Accessions Vital to the National Interest recruiting program. Direct accession offers a multi-year bonus for 2, 3, or 4 years with commiserate service obligation, while the Critical Wartime Skills Accession Bonus offers a onetime bonus and a 4-year commitment to serve on active duty. Military Accessions Vital to the National Interest is a recruiting program that allows certain legal, non-citizens to commission into the Army for 3 years on Active Duty or 6 years in the selected Reserves [13–15]. Uniformed Military Psychiatrist Career Progression The active duty uniformed psychiatrist does have some flexibility in molding one’s career path after the first several assignments by pursuing specific clinical, operational, academic, research, or administrative areas of concentration. However, upon completion of residency training, the uniformed psychiatrist will either join the staff of a military treatment facility in a clinical role or be assigned to an operational unit as the commander’s subject matter expert in military behavioral health issues while also maintaining a clinical practice. With
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each subsequent assignment, the uniformed psychiatrist will be expected to assume positions of greater responsibility and complexity in order to be competitive for selection to the next rank. For example, potential progressive duty positions within a military treatment facility include staff psychiatrist, service chief, division chief, and department chief. With increased responsibility, more time will be required to perform administrative tasks, so the uniformed psychiatrist must endeavor to reserve time to perform patient care. Some uniformed psychiatrists become interested in serving in operational units for which duties consist mainly of being in a behavioral health advisory role to the unit commander, focusing on the overall psychological well-being of the unit while also addressing specific behavioral health issues of unit members. In the Army, a uniformed psychiatrist with a broad interest in operational medicine may opt to compete for selection for command of a Combat Stress Control unit in addition to later on pursuing more senior level command positions for units such as a combat support hospital or a medical brigade. Pursuit of interest in academics mainly involves being selected to become faculty at one the Psychiatry Graduate Medical Education training programs listed above. Making oneself a viable faculty candidate consists of performing well during residency and fellowship training while demonstrating an interest in scholarly activity, excelling in several diverse assignments after completion of training, and attaining all expected military-related professional milestones such as timely completion of military education and training requirements. For uniformed psychiatrists desiring to pursue a full-time academic or research position, each of the uniformed services have faculty assignments at the Uniformed Services University, and the Walter Reed Army Institute of Research also has researchrelated assignments for uniformed clinicians. After completion of several assignments primarily as an office-based clinician or in an operational role, a uniformed psychiatrist may decide to pursue a more administrativeoriented career path. Such a career track will necessitate leaving one’s primary specialty and compete for command and staff positions with other officers also having healthcare backgrounds. Due to the demands of such positions, the clinician will most likely have minimal opportunity to provide direct patient care or engage in teaching or other academic activities unless such is aggressively pursued, most likely on one’s personal time. All uniformed psychiatrist assignments will require a progressively larger supervisory role with a greater scope of responsibility as the clinician gains more seniority. To be selected for promotion, the uniformed psychiatrist has to demonstrate success in positions of progressively greater complexity and responsibility rather than simply being a good clinician as was the parameter for military physicians in the past. As one achieves more seniority, leadership as well as administrative responsibilities increase, and demonstration in proficiency in
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these areas is essential for promotion in rank. Such opportunities to serve in positions of greater responsibility and complexity will most likely necessitate moving to another duty location every 3 to 5 years which is the expectation of all branches and specialties within the military. In terms of specific assignment and overall career opportunities, each branch of the military offers positions related to their service needs and should be considered when deciding to pursue a career as a uniformed psychiatrist. In addition to successfully serving in duty positions which demonstrate clear evidence of professional maturation, the uniformed psychiatrist must ensure successful completion of military education courses and training in order to be competitive for selection to the next rank and be eligible for specific types of leadership assignments. Each uniformed service has its own process to fulfil such requirements. Reserve Pathway Similar to the Active Duty Pathway, one may enter Reserve Service before, during, or after medical school, during residency, or after completing psychiatry training. Reserve Officer Programs summarized in Table 1 include Health Professional Special Pay, Medical/Dental Student Stipend Program, Specialized Training Assistance Program, and Health Professionals Loan Repayment Program [16–19]. For ongoing financial support during medical training, the medical student option is the Medical/Dental Student Stipend Program and for residency is the Specialized Training Assistance Program. Both programs provide financial support in the form of a monthly stipend of over $2000 and obligate the recipient to 1 year of service for every 6 months of support. Reserve psychiatrists may serve in varied duty positions to include deploying to combat areas, participating in humanitarian missions, and providing coverage at military treatment facilities for active duty colleagues who are deployed. The Reserve psychiatrist will either be assigned to a specific unit with whom they train and are activated or are classified as an individual mobilization augmentee, not assigned to a specific reserve unit and therefore can be slotted into a wide range of duty assignments.
Becoming a Civilian Psychiatrist in the Military Healthcare System Civilian psychiatrists interested in serving military service members and their families in a military treatment facility setting within the military healthcare system may do so via two primary pathways: as a Department of Defense employee or as an employee of a private corporation that has contracted with the Department of Defense to provide behavioral health services for military beneficiaries. The number of non-active
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duty behavioral health clinical positions has increased significantly since 2001 to meet the demand for behavioral health services, and the corps of civilian psychiatrists providing care in military healthcare settings has proven invaluable to the overall success of the military behavioral healthcare mission. The experience of practicing psychiatry in any military health care setting is quite variable. There are differences from branch to branch, and like in most civilian practice settings, the military psychiatrist’s work environment is heavily dependent upon their immediate supervisors, support staff, and colleagues. Performance expectations are similar to those in civilian practice where there are demands to see more patients, complete paperwork, and attend trainings. However, military behavior health is an area where a civilian psychiatrist can positively impact the health of a population in need of service while working in an environment which values and supports the clinician’s professional development. Positions within the Department of Defense can be found at USA Jobs, at recruitment agencies, and through contact with colleagues in military behavior health [20]. In contrast, positions with contract companies are frequently advertised in medical specialty trade publications. A Department of Defense-employed psychiatrist who demonstrates clinical acumen, good professional bearing, and leadership potential can have the opportunity compete for behavioral health leadership positions within the military treatment facility. Due to the requirement for military officers to demonstrate success in leadership positions of greater responsibility and complexity to be competitive for promotion in rank, the majority of leadership positions will be filled by uniformed personnel. However, due to the ongoing shortage of active duty psychiatrists, a motivated Department of Defense civilian psychiatrist may have the opportunity to be selected for a clinic or service leadership position. In addition, the civilian psychiatrist may have the opportunity to gain valuable leadership experience covering for the active duty chief while they are deployed. Contract psychiatrists are not eligible to be in a leadership or supervisory role. Comparing DOD-Employed vs. Contractor-Employed Psychiatry Positions Working directly for the Department of Defense has all the advantages and disadvantages as working for any other organization within the US Government. Advantages include relative job security, competitive salaries, and good benefits, including health and life insurance as well as retirement. Positions with contract agencies are often perceived as less stable because contracts have an expiration date and are subject to rebid, and the contract psychiatrist may find their employer and possibly the terms of their employment subject to modification. Presumably, positions could be eliminated upon change of contract, but the current environment of growth
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due to increased demand for services makes this less likely. Rather than recruit new professional staff, a contract agency is more likely to seek to retain the psychiatrist employees of the prior contract company provided they have exhibited good productivity in providing safe patient care. Also, in order to compete for psychiatrists, federal contractors may offer higher starting salaries, more paid time off, and similar fringe benefits when compared to Department of Defense-employed positions. Because these are private companies, the prospective employee of a federal contractor may be able to negotiate terms of employment whereas a Department of Defenseemployed position has a set salary and benefits package. Ultimately, specific employment opportunities will have to be evaluated by the individual psychiatrist.
The Journey Along the Pathway Regardless of the mode of entry onto the psychiatry pathway within the military healthcare system, a person destined to practice psychiatry in a military healthcare facility must undergo a period of acclimation into the military culture. Such familiarization may occur as early as undergraduate studies either as a student at one of the military service academies or via participation in a Reserve Officers Training Corps program at a civilian college or university. Initial contact with the military culture can also occur during medical school either through matriculation to the Uniformed Services University or participation in the Health Professions Scholarship Program which provides the opportunity to perform funded clinical rotations at military treatment facilities. This initial familiarization with military medicine is further reinforced through the completion of a psychiatry residency in a military treatment facility. Depending on the point of entry onto the military healthcare provider pathway, the novice military residency trained psychiatrist will have between 4 and 12 years of exposure to military culture, structure, and function; however, even with such an extensive connection to military medicine during Graduate Medical Education, the learning and acclimation process for the active duty psychiatrist continues throughout one’s military career. In contrast, for the civilian psychiatrist embarking on the pathway without any prior military experience, the initial exposure to military culture can be quite challenging. The candidate may be a seasoned psychiatrist possessing varied and impressive clinical, academic, and administrative credentials reflecting years of training and experience in the civilian healthcare sector, but the unique aspects of practicing psychiatry within a military treatment facility will require a period of focused familiarization with numerous military healthcare-related topics and acclimation to both the nuances and requirements of medical practice within this healthcare delivery system. Since the level of prior experience for civilian healthcare providers within the military
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healthcare system varies from the recently retired career military psychiatrist who transitions directly into a civilian position to the psychiatrist who has very limited knowledge of the military but has had an entire clinical or academic career with little to no interaction with military culture, each provider’s development along the pathway will be unique but hopefully fulfilling with significant growth. As with any endeavor requiring the mastery of a specific set of skills, proper orientation, mentoring, and performance assessment of the psychiatrist new to the military healthcare system is essential as multiple areas pertaining to clinical service delivery differ from the civilian sector. Uniformed psychiatrists are exposed to such variance very early in Graduate Medical Education training, whereas the civilian psychiatrist entering the pathway with no prior experience within military medicine will have to absorb and incorporate into their clinical practice a great quantity of administrative policy related to service member care. Some military facilities offer an introductory course in military life, structure, and terminology for civilian behavioral health providers such as the pilot program developed by Brent and Kovell in 2009 and conducted at the Schofield Barracks Health Clinic, HI, while other locations will appoint an experienced colleague to function as a mentor for the provider new to the military healthcare system. One very important factor which the acclimating psychiatrist encounters early on along the pathway is the dual agency issue within military psychiatry that recognizes a duty to both the patient and the institution. While providing the best possible care for the patient, the psychiatrist must be sensitive to their patient’s role within the unit’s mission, ensuring it is not compromised due to a psychiatric condition [21]. Additionally, the unique mission of the military and the related duties required by service members occasionally necessitate limits to confidentiality within the physician-patient relationship with related requirements for the process and structure of providing evaluation feedback to the service member’s commander [22, 23]. In performing an occupational assessment in the context of the service member’s psychiatric condition, the psychiatrist must have some understanding of the service member’s specific duties and develop a focused treatment plan to include appropriate duty restrictions if indicated and referral to the Integrated Disability Evaluation System if a medically disqualifying behavioral health condition is diagnosed [24, 25]. The psychiatrist entering the pathway must also become familiar with other service-specific behavioral health-related regulations and policies such as the requirement for coordination of behavioral healthcare or substance abuse treatment continuity for service members transferring duty stations and whether a service member taking a specific psychotropic medication is eligible for a waiver to deploy to a combat zone [26, 27]. In addition to providing psychiatric care for service members, the psychiatrist working in a military treatment facility contributes to overall military unit readiness by performing
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psychiatric assessments on service members identified during mandatory health screenings. By regulation, all service members undergo a physical screening annually by a primary care provider and may subsequently be referred for a psychiatric assessment if clinically indicated [28]. In addition, a deploying service member will undergo health screening assessments within 60 days of deploying, within 30 days of redeploying, and an additional assessment at 90 to 108 days postdeployment as psychosocial issues can arise after the service member has reintegrated into the home environment [29]. A mechanism for more streamlined acclimation into the military behavioral healthcare system for civilian psychiatrists entering the pathway is found in the Embedded Behavior Health structure within combat units and will expand to the rest of Army units in the next several years. Developed at Fort Carson, CO, in 2010, the concept involves a cohort of mostly civilian behavioral health providers formed into an interdisciplinary team to serve a specific unit of approximately 3500 soldiers. The providers get to know the subordinate commanders and non-commissioned officers in the unit which greatly aids with the access to care and referral processes in addition to providing timely advice to the unit leadership regarding administrative issues such as duty limitations due to psychiatric conditions or potential medication side effects, fitness to deploy, and recommendation for the soldier to undergo the medical disability evaluation process. The majority of behavioral health providers staffing the Embedded Behavioral Health teams are civilian clinicians, many of whom have no prior experience working within the military healthcare system [30]. While a large portion of the psychiatrist’s duties will most likely be directly related to issues involving uniformed service members, an equally important part of the military behavioral health mission is the well-being of the military family. The ongoing military operations in the Middle East has resulted in multiple deployments for hundreds of thousands of service members placing families under a great deal of stress and necessitating the availability of behavioral health professionals possessing the insight and experience to provide appropriate assessment and treatment for family issues unique to the deployment process [31]. All psychiatrists completing an accredited general residency program have baseline training in addressing family dynamics and performing assessments of children and adolescents, while child and adolescent fellowship trained psychiatrists have more focused and specialized experience; however, if such training did not occur in a venue which had a large cohort of military families, the psychiatrist entering the pathway after Graduate Medical Education training will need to become familiar with the issues confronted by this population such as the stress upon all family members related to multiple deployments, reintegration of the redeployed service member into the family dynamic, and adjustment to frequent moves which require acclimation to new environments and cultures [32, 33].
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Stress within the military family may first surface during an evaluation or treatment by a psychiatrist with the child or spouse in the role of the identified patient, but further exploration reveals significant impact upon the dynamics of the family corresponding to a military-related issue. In addition to providing clinical services to the child, spouse, or family as a unit, the psychiatrist must also be aware of policies specific to addressing potential significant psychosocial issues within the military family. Should the psychiatrist have any suspicion of physical or emotional abuse or mistreatment by one family member towards another in an active duty military family, such concern must be reported to the local military Family Advocacy Program for investigation, intervention, and appropriate treatment [34]. Remaining sensitive to the well-being of family members is essential for the psychiatrist when constructing a treatment plan to include assessment of the availability of needed psychiatric resources. The requirement for such ongoing specialized services mandates referral to the Exceptional Family Member Program and potentially limits the locations where the family can be stationed [35].
Final Thoughts The military has duly recognized the vital role that all behavioral health providers perform with an emphasis to retain these skilled healthcare professionals within the military healthcare system by enhancing career advancement and professional development for both military and civilian clinicians. In 2013, the US Army Medical Command established a corporate-level Behavioral Health Service Line by restructuring its behavioral healthcare delivery process into a standardized model across the system with priorities of quality, access, and consistency of services [36]. Such standardization is important as military beneficiaries move every few years to a new duty station and have the appropriate expectation that the same type and quality of healthcare will be available wherever they relocate. Standardization is also of importance to the behavioral health providers working in the system as they also tend to periodically relocate, and standardized healthcare delivery across the military healthcare system will make transition easier and hopefully enhance retention of both active duty and civilian psychiatrists. The establishment of the Behavioral Health Service Line also provides civilian psychiatrists more opportunity to compete for behavioral health leadership positions and enhances the potential for career advancement. Due to the unique aspects of military behavioral healthcare, psychiatrists working within the military healthcare system perform a vital role in enhancing the readiness, resiliency, and overall well-being of service members in addition to serving as an essential consultant to unit commanders in the successful execution of the military mission. Though the pathways into military psychiatry are certainly diverse ranging
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from the military academy and Uniformed Services University educated, military Graduate Medical Education program trained career officer to the civilian psychiatry residency graduate with no military background, all are part of a behavioral health treatment team that provides the highest quality psychiatric care to the most worthy of beneficiaries, the men and women of the US Armed Forces and their families. As the prolonged post-9/11 conflicts wind down after 13 years of stress on our service members and their families, highquality psychiatric services will continue to be needed and must be expertly provided by a dedicated group of healthcare professionals of diverse backgrounds with the common goal of conserving the fighting strength of our Armed Forces and alleviating the suffering of our military beneficiaries. Disclosures On behalf of all the authors, the corresponding author states that there is no conflict of interest. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government.
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