American College of Obstetrics and Gynecology (ACOG)

Armed Forces District (AFD) Junior Fellows’

Medical Student Handbook -

A Guide to the Residency Application Process

This guide was prepared specifically to address the process of applying for GME (Graduate Medical Education) in the Armed Forces.  Although this information will be most useful to those medical students in their third and fourth years of training, advance knowledge of the military process as well as how it differs from the civilian match can be quite beneficial at all times in your career (applying for medical school, residency, fellowship, etc).  Many of the excerpts below are taken directly from the individual Armed Forces’ GME websites.  Specifically, the AFPC (Air Force Personnel Center) website, the AMSA (American Medical Student Association) website, and the individual training programs websites were referenced.  This handbook is not all-encompassing and will be kept relatively brief.  For further details, please refer to the referenced websites.  The GME in the Armed Forces is rapidly changing and with it are the training environments and their locations.  While each branch of the military differs slightly in their goals and needs each year, the JSGMESB (Joint Services Graduate Medical Education Selection Board) process takes place at the same time for all services.  Specific questions should be directed to your personnel center.  

Background.  Each service is unique in its needs, its training environments, and its goals.  While the majority of military medical officers are trained in the active duty programs, a substantial number of obligated physicians (especially in the Air Force) are trained in civilian programs. Some of the civilian trained officers are in deferred status and some are in sponsored status (see definitions below).   Another unique feature becoming more common is the integration of active duty programs with civilian universities and their residency programs. Among the many advantages to this structure are civilian faculty stability in the face of increased deployments and turnover of military faculty, exposure to diverse educators and education opportunities, and a broad spectrum of clinical teaching sites.

The IFB.  The annual Graduate Medical Education (GME) cycle begins with the release of the Integrated Forecast Board (IFB) results.   Here is how the process works.  Every year between May and June, the three services conduct a Forecast Board.  The Physician Education Offices of each service works with the Assignments Office,   the Specialty Consultants and the Command structures to project how many physicians in each specialty will be required in a given ‘impact year.’   For example, the 2008 Forecast Board will project requirements, based on GME (residencies and fellowships) that will begin in 2009 and 2010.   We will use OB/GYN as an example.  OB/GYN residency training is 4 years.  The ‘impact year’ for OB/GYN in this year's Forecast Board is 2013.   A medical student graduating in 2009, wanting to train in OB/GYN, would enter training in 2009 and finish in 2013.  The Forecast Board is typically available to the public in early June.  It is published on each of the branch specific GME websites.  If you are aiming to continue residency uninterrupted, applying for the GME-1 year is the first step.   Categorical position/slots are those that have automatic approval to continue thru to the rest of the residency. Most pediatrics, OB/GYN, and psychiatry residencies are categorical positions. 

Applications.  Medical students, residents and field applicants will start submitting applications for post-graduate specialty education beginning in July.  Core applications are typically due in early September.  The supporting documents are usually due in early October.  This typically allows medical students to rotate/interview at 2-4 places prior to the end of the application process.  Interviews should be completed by the end of October.  The Tri-service Joint Services Graduate Medical Education Selection Board (JSGMESB) meets in Washington, D.C. the week after Thanksgiving.  Typically, an application year entails 600 program director/consultant attendees from all three services, 53 selection panels, and 2,000 physician applicants.   This process is similar to the ‘civilian match,’ however the military match is only for students who have been sponsored by the military scholarship programs (HPSP) or USUHS graduates (the military medical school).  The results are released in late December so that students know who have been selected, before the ‘civilian match’ in March.  

Big Concerns.  Fourth year medical students applying to the JSGMESB have many questions about the process.  Specifically, they want to know the probability that they will be able to train in the specialty of their choice, at their preferred location and their preferred venue (military or civilian programs).   Each military branch GME office begins fielding phone calls shortly after the IFB results are released.  A very common concern is focused on the degree of control that the student has over their future specialty choice and whether the military forces students into non-desired specialties.  The Armed Forces never forces you to train in a specific specialty.  Nor is anyone encouraged to become a psychiatrist when he or she wanted to be an OB/GYN.  Every student is encouraged to pursue their heart’s desire regardless of how competitive or sought after some specialties are compared to others.   Obligated military medical officers seek the same specialty training as their civilian counterparts.   The more competitive or popular specialties such as Anesthesiology, Radiology, Emergency Medicine, and the Surgical sub-specialties have a higher non-selection rate than some of the Primary Care specialties.  This parallels the outcomes in the civilian match through the National Residency Match Program (NRMP).   Again, you will never be told you have to do something you do not want to do.  However, if you are competing for a very selective specialty, you may have to become a GMO/flight surgeon/dive officer for a few years after internship prior to going to residency. 

The Cons.  The military match favors the program rather than the applicant.   They try to make the applicants happy, but the needs of the military come first.   If there are only 12 students applying for a residency and there are 12 active duty spots and 10 deferred (civilian residency) spots available for training, more than likely, no one is going to get a deferred spot, unless the applicant is someone the active duty residencies do not want and would rather not fill a spot (pretty rare).   The military residency programs will know your rank list as they rank you.   Your rank list is a part of the application for residency.   You have to list the specialty and then the training sites you prefer.   Specifically, each program director knows how you rank them.   You do not have to do a rotation at a certain program to get a position; however, unless you have amazing scores, letters, etc., you should try to go.   At the very least, you should interview at each possible location.  This is your time to impress the residents and staff by your hard work and knowledge.   If possible, you should try to go July through October.   You want to be fresh in the minds of the Program Directors and make your impression prior to the deadline in changing your rank list.   Program Directors are less likely to rank you high for their program unless they know you and know you desire to come there.  If you are vying for a deferred spot, you simply want to make sure you get a spot.  This needs to be conveyed delicately.  This is less important for those who have very favorable scoring sheets (taking the subjective portion out of the equation), but absolutely vital to those who may be on the cutoff of the total number of desired applicants.  The military attempts to make this process as unbiased as possible with the scoring sheets.  These sheets favor those further in their military and medical career.  This is where “playing the game” really matters. 

The Pros.  Why To Train In The Military.  If you owe a lot of time to the military, you should seriously consider an active duty program.  The 4 years of active duty residency training count towards the years for retirement which is important if you have any remote chance of staying in.   Even if you don't owe a lot of time, there are financial reasons to go.   First, you will be paid better during residency, roughly about $10,000 more per year, than your civilian counter-parts.  In addition, if you do a civilian deferred program, you will graduate residency as a captain with zero years of service versus graduating from an active duty spot with 4 years of service.   That is a substantial yearly base pay difference after residency ($13,500/year x 4 years = roughly $55,000).  This pay difference will continue to follow you for your entire military career if you choose to stay in for more than 4 years.  Other advantages of military residency include healthcare benefits for you and your family.  Major disadvantages not listed above may include less exposure to a select patient population (HIV, drug abusers, and transplant patients to name a few). 

Our Example.  Returning to the OB/GYN example and using the Air Force as an example service, let's say the Forecast Board determines that the Air Force will need 25 OB/GYNs in 2013.  This number is derived from equations considering how many 'obligated' OB/GYNs we will have on active duty in 2013, how many are eligible to complete their service and separate from the military, and how many patients and bases are projected to need OB/GYN.  The Selection Board will select the top 25 candidates who have applied to become OB/GYN to enter training in 2009 based on their JSGMESB scoring sheet (see below for the scoring system/sheet).   There are currently 4 active duty training programs for Air Force OB/GYN residents (possibly 5 once Keesler AFB obtains approval to re-open a residency training program).  These four programs can only train a total of 10 future OB/GYNs in any given year.  Based on this imaginary example, the Air Force will need to allow 15 future OB/GYNs to be 'deferred' to train in civilian programs.   Graduating medical students who do train in civilian programs almost always do so in a deferred status.   This means that you continue to train as a civilian in the Inactive Reserve.   You receive your salary from the civilian institution.   Occasionally, a graduating medical student may train in a civilian program in a ‘sponsored status.’   This means that you are training on active duty but in a civilian program.   You get the same pay and benefits as if you were in one of our military programs but you don’t wear a uniform.   You do, however, incur additional active duty service commitment for civilian sponsored training. 

The Odds.  Getting a spot is the most important, first and foremost.  Deferment is always a highly desired option for HPSP, but has a reputation for being very competitive.  The difficulty is to ensure you get a spot (requiring a good scoring sheet and the approval of the Program Directors) but not end up desired in an active duty program.  This can be a very fine line.  A wise strategy may be to interview for military programs as well as applying for deferment.   While weighing the numbers, factor in the fact that graduating USUHS students are required to train in a military residency (not necessarily in their desired specialty, but it must be in the active duty programs) which can decrease the number of available spots.  As stated before, each service has its individual needs.   The Navy, for example, has many more GMO (General Medical Officer) positions (dive officers/flight surgeons/ship physicians/etc) than the other services.  These are positions typically filled by physicians that have completed an intern year only.  Thus, the Navy GME training options include GME-1 followed immediately by residency, GME-1 followed by a tour of duty, and deferment.   Many more Navy physicians follow the GME-1/tour of duty route, than the other service physicians. 

GMOs.  Historically, the Army sends fewer than 1% of their people to GMO per year, the Air Force sends about 22%, and the Navy, about 65%.   That said some people see doing a GMO year as a positive, and people in the Navy in particular have raved about their time as GMOs.  It's a kind of medical experience that one can only get through the military.   Those in deferred status will not become active duty until the completion of residency.    The option of completing a residency straight through also depends on the specialty desired.  For 2002-2006 classes, the percent of interns selected for straight-through training in the Navy was: OB/GYN 73%; Psychiatry 53%; Internal Medicine 57%, Pediatrics 56%; Family Medicine 51%; General Surgery 42%; Pathology 31%; Anesthesiology 21%; Orthopedics 7%; ENT 4%; Dermatology 0%; Radiology 0%; Emergency Medicine 0%; Ophthalmology 0%.    Conversely, the Air Force phased out many of their GMO positions during those years.  Thus they quoted a ‘selection rate’ in 2007 for the Air Force’s 526 applicants’ specialty choices of almost 70%.  For the medical students in the match, the selection rate was even higher, close to 75%.  Each year, this is variable. 

Non-Selection.  As demonstrated above, it is possible that a medical student in our example scenario may get 'non-selected' to train in a

specialty.   For instance, if 30 students apply to start OB/GYN training in 2009, and the Air Force has projected a requirement for 25 OB/GYNs in 2013, 5 students will not get selected.   Instead, these students will be allowed to train in a GME-1 internship of their choice: Internal Medicine, Transitional Medicine or General Surgery.  The will be allowed to reapply for OB/GYN the following year, do a GMO tour, or apply for another residency.   These students who were not selected have a greater chance of being selected the next year to start training as the scoring system awards points for the internship year (see below)

Fellowships.  To do a fellowship during your obligation, you have to apply again as part of the military match.  The IFB also lists available fellowship positions needed in the military.  There are active duty training sites, civilian sponsored slots, and deferred spots.   If you think you want to do a fellowship, doing an active duty residency can be key because you will get to know some of the military subspecialists who typically make the decisions on who gets to do fellowship training.

Military Obligation.  You will owe the military the greatest number years you spent in a training program.  For example, if you do a 3 year HPSP scholarship and a 4 year active duty residency, you owe 4 years.   If you do a 2 year fellowship on top of that, you now owe 6 years of active duty service total.   If your fellowship training is also in an active duty program, you will have 11 years total of active duty years toward retirement once your obligation time is completed.  Your training years do not count towards your obligation, but they do count towards retirement, which is why it can be a better deal to do your residency in the military if you know you want a fellowship and would like to stay in until retirement. 

Questions.  Each branch has a GME office.  The Army has a mentoring program that pairs physicians in training with practicing physicians.  You can also receive more information via your HPSP coordinators. For the Navy and AF, you are left with the professional specialty groups, such as the American College of Gynecologists and Obstetricians (ACOG) for example.   Recruiters can also be a great help, or past alumni of your school.  

References and Websites.

·                   Army GME:  http://www.mods.army.mil/MedicalEducation/

·                   Air Force GME: http://airforcemedicine.afms.mil/afphysiciangme

·                   Navy GME: http://navmedmpte.med.navy.mil/gme/annualgmeupdate.cfm

·                   AMSA: http://www.amsa.org/military/FAQs.cfm

JSGMESB Scoring Sheet

JSGMESB Scoring Guidance