Military vs Civilian Residency for HPSP Students

A reader recently asked me a question about choosing residencies. Specifically, he wanted to know about the reasons why I chose to request civilian deferral for residency. I have also received several questions about the actual process of applying for a civilian deferral and going through the military and civilian match, and I wrote a post on that subject here.

For the purposes of this post, I will be using a hypothetical resident who is completing a four-year residency and who has a four-year active duty service commitment, such as someone who received a four-year HPSP scholarship.

If you aren’t sure whether you want a civilian deferral, there are several things to consider

  • Money
  • Career plans after your minimum active duty commitment
  • Specialty choice
  • Family considerations

First, let’s talk money. If you enter a civilian residency, as of 2015, you can expect to make about $50-55k/year. As a new O-3 (new medical school graduate) in a military residency, your total compensation is closer to $70-75k/year. In other words, you will make about $20k less per year in a civilian residency than you will in a military residency. You also pay more for your family’s medical care (and for child care) as a civilian than if you are in the military, making the effective pay difference bigger if you have a family.

Then there is the money you will make during your active duty service commitment. If you complete a military residency, you will accrue years of service. This means that you will make more money per year during your active duty service commitment (4 years for most HPSP students) if you complete a military residency than if you complete a civilian residency. If you complete a 4-year residency, that means you will make $1,300 more per month in the beginning of your active duty commitment if you complete a military residency.

If you decide to stay in the military, how much money will you lose over your career by doing a civilian residency?

If you decide to stay in the military, how much money will you lose over your career by doing a civilian residency?

These years of service also qualify you for promotion during your active duty service commitment which would be otherwise unavailable to you, and promotions also come with a pay raise.

The combination of additional years of service for pay, and a promotion to major, means that a resident on a 4-year scholarship who has completed a 4-year residency will make about $50k more during their 4 years of active duty service if they complete a military residency.

Overall, this means that, for a resident completing a 4-year residency and with a 4-year active duty commitment, the choice to do a civilian deferred residency will cost you about $130k over those eight years. Keep that number in mind as you read the rest of this post.

Next, it’s important to consider your career plans after your initial active duty service commitment. Those lost years of service will continue to hurt your paycheck as long as you stay in the military. If you plan to stay in until you reach retirement, that lost pay will continue to sting to the tune of $1k per month until you retire. Ouch.

If, on the other hand, you plan to leave the military at the end of your active duty commitment, it may be helpful to complete your residency in a civilian program. Why?

  • To get experience working in a civilian hospital. Civilian hospitals work differently than military hospitals in terms of staffing, reimbursement, charting, and some other aspects of patient care.
  • To build relationships and connections with civilians who you might want to work for in the future. If, for example, you know that you want to work in northern California after you leave the military, it may be helpful to do a residency in that area. That way, when you are getting ready to find a civilian job, you will have local connections who can vouch for you.
  • To see patients and pathologies that you may not see in a military program. Depending on your specialty, your patient population may be very different in the military than it will be in civilian practice. In my field (OB/GYN), for example, I found that certain diseases were much more common in the patients I saw at the civilian hospitals than in the military patients. In the civilian hospital where I am currently completing my residency, I regularly have patients roll into labor and delivery on an ambulance stretcher, screaming, with no prenatal care and a history of heavy cocaine use throughout pregnancy. That doesn’t really happen in the military programs. Since I am planning to spend most of my career in the civilian world, I wanted to gain practice and experience treating these patients for when I come across them as an attending.

Specialty choice also matters. Pediatrics may not be terribly different in the military vs in the civilian world – I don’t know. I mean, in general, kids are pretty healthy, right? In OB/GYN, civilian patients have a nasty habit of neglecting their medical care if they don’t have insurance (or are doing naughty things like shooting up heroin), and reappearing only when they have advanced cancer or are in labor. That’s less of an issue in the military, where people tend not to be smoking crack during their pregnancies (and medical care is free.)

And, of course, the pay difference between military and civilian work after residency depends on your specialty, which might influence your choice about whether to stay in. ENTs and neurosurgeons make a lot less money in the military than they do as civilians, but that difference is much smaller for, say, pediatricians.

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Think about your family obligations. Is your spouse limited to big cities by his job? Is your fiancee going through the civilian match and you want to couples match? Are your parents elderly and ill? Do you have a child with special medical or educational needs? Is your whole family in Texas and you really want to stay there? All of these are worth considering. Sometimes, civilian residencies can give you more geographic flexibility – for example, there are no Air Force OB/GYN residencies on the west coast, but there are plenty of civilian residencies. Just remember to balance this against the pay cut that you are taking. Maybe you want to live in New York City, but is it worth $130k? Is being in the same state as your parents (when you’re working 80 hours a week and have no time to socialize anyway) worth the cost of a small house?

If you train civilian, you will have to pay for the move from med school to residency on your own. If you do a military residency, the military will pay for it.

 

And, of course, remember that you may not have much of a choice in the matter. The Air Force tends to hand out a fair number of civilian deferrals (depending on the specialty and the year), while the Navy almost never sends people out to the civilian world for training. Even in the Air Force, you may be selected for a civilian deferral if you ask for it (see this post for more on that).

 

 

So, what’s the bottom line? Should you pursue a civilian deferral?

 

It may be worth seriously considering a civilian deferral if

  • You are going into a highly-paid specialty
  • You plan to leave the military as soon as your commitment is up
  • You are going into a specialty where your work will be very different as a civilian doctor
  • You have serious family considerations (geographically limited spouse, special needs kids, etc)

 

It probably makes more sense to do a military residency if

  • You have prior military service (you get paid more)
  • You are planning to stay in the military until retirement
  • You are going into a specialty where you get paid the same or less in the civilian world (mostly primary care specialties)
  • You are single, or have a spouse who can easily relocate with you
  • You have other debts like undergraduate loans, car loans, etc., and the extra money makes a big difference

Questions? Comments? Use the comment function below and let’s talk about it!

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13 comments

  • Harpreet

    Dear INDY, I am a physician trained in FM but want to go to army reserve and at the same time want to do IM residency and a Fellowship. I do not want any financial assistance from the army. My question is 1. Can I join a civilian residency while in army reserves. If yes , does that change my commitment with the army ??? considering that I am not getting any financial assistance from army. 2. Do people do civilian residency while in army reserves ??? Any experience how civilian residency programs think (during the selection process) about a candidate who can be deployed by the army. Thanks in advance for your help. Harpreet.

    • Indy (admin)

      Thanks for your comment! Joining the reserves while in residency is essentially a no-go, because you would be unable to fulfill your reserve commitments while you are in residency. The people who are military reservists during residency are inactive reservists, meaning we are in a holding pool between, say, military-funded med school and an active duty commitment. If you want to do a civilian residency and then join the reserves, and don’t want any financial assistance from the military, the way to do that would probably be to complete your civilian residency and fellowship and then join the reserves.

  • Bill

    INDY,

    I’m a civilian deferred Air Force intern (almost resident) with 10 years of prior active duty service attending a VA residency at a major military hospital. Have you ever heard of someone appealing a situation like this and getting put back on active duty? I figure I’m losing about $500K through the 5 total years I’ll here and retirement years as well. Any advice? Thanks!

    • Indy (admin)

      I’m not aware of any sort of appeals process. They make a big point of saying that the JSGME results are final, and I don’t know of any way to transfer into a military program from a civilian program. The only thing I can think of would be to talk to your Program Manager at Physician Education Branch. The latest phone number I have for their office is 210-565-2638, email afpc.dpame@us.af.mil.

  • Scott

    I’m a current Navy intern being sent out to GMO. I’m in a situation where I’m not in the specialty I’m wanting to pursue (the type of program I want is not offered within the military). Are you aware of civilian deferments prior to completion of the commitment followed by payback or do you have to do all your GMO time and finish up the commitment prior to leaving and pursuing the program of your choice? I would take the hit to years, retirement, and pay; I’m more concerned about all the loss of years toward my training than the pay right now (I could have been finished with civilian training before my commitment will now be paid back and I’m already on the older side for an intern).

    • Indy (admin)

      The civilian deferment situation varies greatly by branch of service. I’m Air Force, so that is what I know the most about. For us, there is an option for civilian deferment prior to completion of your military commitment. I know that the Navy tends not to give civilian deferments in general – from what I have been told, civilian deferments are offered on a case-by-case basis in emergencies only. My understanding is that the Navy typically doesn’t offer civilian training in specialties in which they don’t have a residency of their own. As with all of this, of course, your mileage may vary. I would strongly suggest talking to your JSGME point of contact, and a military doc in the specialty that you want to pursue. I think it’s likely that you will be stuck doing your active duty commitment before you pursue your residency of choice. I’m sorry.

  • Eliska Ortega

    I just graduated from medical school in a foreign country and do not have family financial support to take medical license or to get a job, my questions are: 1. If I join the army would help pay expenses for get my medical license? or help me get work so I can get my medical license? 2. In the event that I can get to a military medical residency and private work? 3. That would suit me more, enlisted or reservation?

    • Indy (admin)

      Thank you for your questions! There are a few things that would need to be addressed here. Are you a U.S. citizen? Have you applied for or completed a residency program? Have you taken any of the three USMLE exams? The military can provide a lot of financial benefits, but they also have very strict eligibility criteria for each of their programs.

  • If you are selected for a military residency, you will start working at a military health care facility as an active-duty physician, and you will be paid as a captain in the Army and the Air Force, or as a lieutenant in the Navy. Keep in mind that your time in residency will not count toward your service commitment, but it will count toward your eventual promotion, pay longevity and retirement.

  • Jason Stark

    Hello Indy,

    I have the similar question. I have graduated from Foreign Medical school and taking the USMLE exams. I have joined the Army Reserve through MAVNI program and will be going for Basic training and AIT in a couple of months. I will be naturalized during that period. After that I am planning to apply for Residency programs in Civilian hospitals and AMEDD as well. I will still be doing Reserve drills – 1 weekend a month. Can you please let me know what is the outcome and what to expect?

    Appreciate your time.

    • Indy (admin)

      Thanks for your comment. It sounds like you are in a really tight spot!

      To make sure I understand the situation, you are saying that you have signed an Army Reserve contract, correct? The standard 6-year reserve contract? Did you enlist? What will your job be in the Army Reserves? As I understand it, MAVNI requires that you have been in the US for at least two years. How long ago did you complete medical school? What kind of residency are you planning to apply to?

      As I understand it, it is nearly impossible to be a resident while you are a drilling reservist. Drill weekends cause a real problem with your residency duty hour requirements. The ACGME prohibits any employment outside of your residency for first-year residents, and mandates the number of hours and days off that you must have as a resident, and drill weekends would interfere with that. If you were deployed (or activated in any way), that would interfere with your ability to complete your training. The ACGME will only allow you to be absent from residency for a certain number of total weeks during your entire residency, which means any military activation could lead to finishing residency late. It also can cause serious problems for your co-residents, who have to do your work while you are gone, so I have a hard time imagining a residency program hiring a resident who is an active reservist. For these reasons, the Army says on their website about MAVNI that, as a doctor, you need to be residency complete or in your final year of residency training.

      The only thing I can think of is that you can, under certain circumstances, be released from your military contract in order to pursue advanced training in the military, such as a military medical residency. I don’t know about the Army’s process for this, but in the Air Force this goes through your unit commander. I would call your recruiter and a military medical recruiter to see what options, if any, you have.

  • Brian Meyer

    Hello Indy,
    I’m having a bit of a tough choice here. I have 11 years of naval enlisted service and I am headed to medical school next year. I am doing HPSP, however I am very interested in either Neuro or Orthopedic surgery. The Navy has very few slots available for those specialties, would it be worth it doing the civilian residency in those specialties?

    • Indy (admin)

      Brian,

      Thanks for your message, and congrats on your acceptance to medical school! Have you already signed an HPSP contract? As you said, neurosurgery and orthopedic surgery have very few spots in the Navy. The Navy sends very few people directly through residency – most Navy HPSP folks have to do a PGY-1 (intern) year when they finish medical school, then spend a few years as a GMO before they are allowed to complete their residency. It is extremely rare for the Navy to let anyone do a civilian residency. They match you to a specialty first, based on the needs of the service. Then they fill the military residencies in that specialty. So they will only let someone do a civilian residency in, say, neurosurgery, if they decide that they need to train more neurosurgeons that year than they have military neurosurgery residency spots. I wouldn’t really worry about whether it is worth trying to do a military residency in the Navy, because it is extraordinarily unlikely that you will be offered that choice. Does that make sense?

      For more information on this, take a look at these other posts. explains the differences between the branches, including a bit about GMOs. This one explains more about the civilian deferral process, but it is written from an Air Force perspective, and the Air Force sends a LOT more people out to train in civilian programs than the Navy does.

      If you are offered a civilian spot in the Navy in one of those specialties, I would think about how long you plan to stay in after residency. With 11 years of prior service, if you get 4 years of HPSP funding, you will owe 4 years of active duty service. That gets you to 15 years. If you do an active duty residency in orthopedic surgery (5 years), then at the end of your payback time, you will be at 20 and you can walk away if you want to with full retirement benefits. If you do neurosurgery (7 years), that’s the same. On the other hand, if you do a 7-year civilian neurosurgery residency, that delays your 20-year retirement clock. I’m going to assume for the sake of math that you enlisted at 18 and got your bachelor’s degree while on active duty. So I’m assuming you are 29 now. When you start residency, you’ll be 33. 7 years of neurosurgery, and you’ll be 40. 4 years of active duty service commitment, and now you’re 44 and have 15 years of active duty time, meaning you’re making a fair bit less in base pay than your colleague who has 22 years of active duty time (because he did a military residency and was on active duty for those 7 years of training). Plus, he made $20k/year more than you for 7 years of residency… As a rule of thumb, the shorter the residency, the more it makes sense to do your training as a civilian.

      Does that answer your question? If not, please let me know and I’ll try again!

      Indy

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