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Fellowship Training

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					FELLOWSHIP TRAINING
Maj Barton Staat
OBJECTIVES
 Describe the process of fellowship application and
  various types of opportunities available
 Discuss the various pros and cons of fellowship
  training
 Identify potential financial considerations of
  fellowship training both within the military and
  as a civilian
ARE THERE FELLOWSHIP SPOTS EVERY
YEAR?

   Health Professions Education Requirements
    Board (HPERB)
     Previously known as Integrated Forecast Board (IFB)
     All Corps (MC, NC, DC, MSC, BSC) define approved
      training requirements
   Joint Service GME Selection Board: Nov/Dec
       Selection and placement of all AF obligated
        physicians / medical students in residency and
        fellowship specialty training
WHAT IS THE BOARD?
   Joint Service Graduate Medical Education
    Selection Board
   Process by which all obligated officers are
    selected for residencies and fellowships
   All obligated officers must apply to and be
    approved by the JSGMESB in order to enter a
    GME program (military or civilian)
BACKGROUND ON THE BOARD
   Tri-service process
   Panel members - Senior Medical Corps officers
     Specialty consultants
     Residency / Fellowship Program Directors

   Specialty panels score applicants and present
    selections to:
       1) Management Level review panel (MLR)
           Identify issues of concern
       2) Board President panel
           Board President has final decision in selection process
WHY DON‟T WE HAVE MORE FELLOWSHIP SPOTS?
    Health Professions Education Requirements
     Board (HPERB)
    Process by which Air Force determines number of
     training positions to be offered in each specialty
    Train according to Military needs
      Approved
      Approved unfunded
      Civilian Sponsored
      Deferred
AIR FORCE HPERB RESULTS
OB/GYN 2011
 Residency, OB/GYN 3-SAMMC; 3-WP/WS ; 1-USUHS 48
  Jul-12 2-Portsmouth; 11 Def/Rdef 48 months
 Fellowship, Endoscopy 1-Civilian Sponsored 24

 Fellowship, Oncology 1-Walter Reed 48 months

 Fellowship, REI 1-Civilian Sponsored 36 months

 Fellowship, MFM 1-Civilian Sponsored 36

      http://airforcemedicine.afms.mil/afphysiciangme
ARMY FELLOWSHIPS
   GYN Oncology at NCC-Walter Reed,
   Gynecologic Minimally Invasive Surgery at NCC-
    Walter Reed (2012 Start)
   Maternal Fetal Medicine at Madigan Army Medical
    or Army sponsored civilian training
   REI Civilian sponsored
   GYN Laparoscopy as well as Reproductive
    Endocrinology and Urogynecology at Army sponsored
    civilian training at the National Institute of Health
    (NIH) - in collaboration with the National Capital
    Consortium. Applicants who desire training in
    Reproductive Endocrinology or Urogynecology at the
    NIH/NCC program must indicate their training
    preference as civilian sponsored under Army on their
    DoD application

   http://www.mods.army.mil/MedicalEducation/
SPONSORED, DEFERRED OR AD?
CIVILIAN SPONSORED
   You will be AD during             You will continue to
    civilian fellowship                progress in years of
     Same pay as OB Staff             service
      (approximately twice            You will be eligible for
      what you would earn as           promotion
      a civilian fellow)
     Minimal military                Progress towards
      obligations                      retirement
           (PT test, urine drug      Some programs view
            screen, medical and
            dental appt)               sponsored as highly
                                       desirable (they can‟t pay
   You owe one additional             you/you are free labor)
    year for each year of
    sponsored training that
    will be served after
    other obligations
SPONSORED, DEFERRED OR AD?
   Civilian Deferred
     Rarely offered for fellowship training
     Average pay for fellow
        $65K
SPONSORED, DEFERRED OR AD?
ACTIVE DUTY
   Staff pay                   Additional commitment
   Continue to gain years       is served consecutively
    towards                      (IE if you have 4 years
    promotion/retirement         of HPSP obligation you
                                 would not owe more
   Less choice in program
                                 than the 4 already but if
    selection
                                 you only owe 2 years
                                 before fellowship you
                                 will add an extra year
                                 for 3 year fellowship)
                                Typically not as
                                 extensive of research
                                 opportunities/mentors
                                 at AD fellowships.
WHEN WILL I KNOW ABOUT FELLOWSHIP
SPOTS?




   Mid June     Sept 15th     Mid Dec
   HPERB       JSGMESB       JSGMESB
   releases    application     results
    results       due         released
WHAT DO I HAVE TO SUBMIT?
   DOD Application               Current PD evaluation
       2 page application         form
       CV                        PD evaluation form
       Personal statement         from previous programs
       Education summary         Current fitness test
       Other supporting           score
        documents
                                  Copy of unrestricted
   USMLE / COMLEX                 medical license (for
    scores- Steps 1, 2 and 3       trainees in year PGY3
   Medical school records         or greater)
       Transcripts               Current Interns, STEP
       Dean‟s Letter (MSPE)       3
   Program Director‟s
    Interview sheet
   Letters of
    recommendation
WHAT IF I WAIT UNTIL I‟M STAFF?
   PD evaluation form from residency program(s)
   Current fitness test score
   Copy of unrestricted medical license
   Commander‟s letter of recommendation
   Last 5 OPR / TRs
       „07, „08, „09, „10, and „11 reports
   Board Certification
   Other issues
     Time on station, DEROS (overseas applicants), 2nd
      residencies, Colonels or Colonel selects
     May require waiver by board president to enter GME
WHAT WILL THEY LOOK AT?
   Application factors considered
       Applicant‟s motivation toward specialty
       Medical school performance
       Residency performance
       Active duty tours
       Interview sheet
       Personal factors (joint spouse, family issues, etc)
   Priority is to fill active duty programs first
HOW DOES THE BOARD RANK YOU?
   Tri service scoring
   Rating based on
       Preclinical med school performance
       Clinical med school performance
       Internship
       Residency
       Operational tour
       Potential for success
   Bonus points
       Research
       Prior service
WHAT CAN I DO TO BOOST MY SCORE?
   Up to 4 points can be awarded for research
   Each scoring panel determines their criteria for
    awarding research points
   Sample guidelines
     One poster / abstract              1 point
     Two or more                        2 points
     Single pub (peer reviewed)         3 points
     Multiple pubs                      4 points
   Current medical students can only receive a
    maximum of 2 research points
WHEN TO APPLY R3, R4 OR STAFF?
   Carpe Diem!
     Difficult to predict when fellowship positions will be
      available for various specialties. Some specialists
      stay in longer than predicted and some get out
      unexpectedly
     Some years there may be one or two fellowship
      opportunities and then there may be several years
      without a fellowship position and hard to tell how
      competitive the military board will be.
 R3 if given a spot will go straight through from
  residency to fellowship
 R4 would be staff for one year prior to fellowship,
  it will require coordination and likely to stay on
  as staff
I WAS SELECTED! NOW WHAT?
TIPS TO BETTER YOUR CHANCES OF
GETTING SELECTED

   Whole person concept
   Perform well on rotations in your desired
    specialty
   Contribute to your residency program
   Make fellowship PD aware of your interest
   Present at regional and / or national meetings
   Turn abstracts into papers
   Meet deadlines - Deadlines are firm
   Consider doing a tour as a staff physician
   Have a back up plan
TIPS FOR FELLOWSHIP SELECTION
   I attended the SMFM meeting as a 3rd year resident and
    met with fellowship directors from programs I was most
    interested in.
       Most fellowship directors are required to attend the specialty
        meeting ASRM, SGO, SMFM , AUGS
   Explain what civilian sponsored means
       Many programs have not ever had a military fellow
       May open some doors, especially with tight academic budgets
   Make sure if you want to go to a certain program that they
    know your desire to attend their program
   Know what types of research the program does
   ½ of time in fellowships are spent doing research and part
    of graduation requirement and board certification is a
    thesis
   Consultants and fellowship programs will ask you about
    your research interests. (hint “I don‟t really like research”
    has been said and is poor form)
CIVILIAN FELLOWSHIP LINKS
   MFM
       https://www.smfm.org/MFM%20Fellowship%20Page.cf
        m
   REI
       http://www.socrei.org/uploadedFiles/Affiliates/SOCREI/
        Fellowships/REIFellowshipPrograms.pdf
   Gyn-Onc
       http://www.sgo.org/Membership/Resources_for_Candid
        ates_and_Fellows/Fellowship_Programs/
   Urogyn
       https://www.augs.org/Fellows/FellowsResources/tabid/2
        12/Default.aspx
FINANCES
 Obviously you should do a fellowship because you
  are passionate about the specialty
 But…what will the pay difference be within the
  military if I stay for retirement and when are pay
  implications when I get out?
MILITARY PAY (LOTS OF ACRONYMS!)
Bonuses:
 VSP

 Board Certified Pay

 ASP

 ISP

 MSP

 MISP/MSP

 ECISP
   MILITARY PAY: VSP
   VSP
           Variable Special Pay
           “Pay for being a doctor” – Yes, even an intern
                   No commitment, no contract

Pay   Under ≥ 3                   ≥6      ≥8        ≥ 10      ≥ 12      ≥ 14   ≥ 18      ≥ 22
Grade 3     <6                    <8      <10       <12       <14       <18    <22
Intern        $100

Thru 06                 $416.66   $1000   $958.33   $916.66   $833.33   $750   $666.66   $583.33

Above         $583.33
06
MILITARY PAY:BOARD CERTIFIED
 Board Certified Pay
   – ABMS recognition
   – “Pay for being board certified doctor”
      • No commitment, no contract
     Pay     Under     ≥ 10      ≥ 12      ≥ 14      ≥ 18
     Grade    10       < 12      < 14      < 18

     All     208.33   $291.66   $333.33   $416.66   $500

   – So, by 22 yrs, you will lose $420/m VSP, and
     gain $290/m on board certified pay
BONUS SYSTEM
  ASP
       Additional Special Pay
       “Pay to retain you as a physician post residency”
       Pay period:
         Upon GME graduation
         typically 1 Jul – 30 Jun

       Rate is fiscally decided, presently $15,000
           i.e. 1 Jul 2010 ASP rate set on 1 Oct 2009
       Commitment
         1 Year
         Concurrent
BONUS SYSTEM
ISP
     Incentive Special Pay
     “Pay for being a specialist or subspecialist”
     Pay period:
       DoD policy generally precludes payment of and ISP during the
        fiscal year in which the qualifying residency training is
        completed.
       Upon GME graduation

       typically 1 Oct – 30 Sep, unless fellowship

     Rate is fiscally decided
       i.e. 1 Oct 2010 ISP rate set on 1 Oct 2010
       Typically delayed…

     Commitment
       1 Year
       Concurrent
BONUS SYSTEM
ISP
     Rate: General OB/Gyn - $31k, Subs - $36k
     Pay period: Fiscal Year – 01 Oct thru 30 Sep
     Exception: A medical officer with an existing single-year ISP
      contract may terminate that contract on or after October 1, of
      that fiscal year, in order to enter into a new single-year
      contract only when the new contract will result in a higher
      ISP rate than the ISP contract being terminated.
      Example: Fellowship training
     NOTE: This provision is not intended to allow medical
      officers to arbitrarily terminate an agreement solely for the
      purpose of changing the anniversary date to coincide with an
      Additional Special Pay agreement or a resignation/release
      from active duty.
BONUS SYSTEM
MISP/MSP
     Multiyear Special Pay
     “Pay to retain you longer as a specialist”
     Pay period:
       Except, must have 8 yrs creditable service
       CAN BE RENEGOTIATED AT ANYTIME DURING MSP

        PERIOD
       Typically 1 Oct – 30 Sep for 2, 3 or 4 years

     Rate is fiscally decided
         i.e. 1 Oct 2010 MSP rate set on 1 Oct 2010
     Commitment
       2, 3, or 4 years                   MISP        2     3      4
       ** Consecutive **         Gener   $31k     $17k    $25k   $35k
                                  al
                                  Subs    $36k     $21k    $31k   $45k
WHAT DO I MAKE NOW?
   Assumptions            VSP $1000/mo
   Major                      $12,000
   10yr                   BCP $208.33/mo
   Living in San Antonio      $2,500

   Has dependents         ISP $36,000/annual
   Board Certified        ASP $16,000/annual
   Sub-specialist         Basic pay $6,659.40/mo
                               $79,912.8
                           Housing $1,719/mo
                               $20,628
                           BAS $223.04/mo
                               2,676.48
                           $169,717.04
WHAT WOULD I MAKE AS A GENERALIST?
   Assumptions                VSP $1000/mo
   Major                          $12,000
   10                         BCP $208.33/mo
   Living in San Antonio          $2,500
   Has dependents             ISP $31,000/annual
   Board Certified            ASP $16,000/annual
                               Basic pay $6,258.60/mo
                                   $79,912.8
                               Housing $1,719/mo
                                   $20,628
                               BAS $223.04/mo
                                   $2,676.48
                               If generalist would be
                                $164,717.04
MY PAY
Subspecialist
Training:        Military or civilian residency (4)
                 Fellowship (3)
Commitments:             USAFA(5)
                 HPSP(4)
                 Residency(3 concurrent)
                 Sponsored fellowship 3 yrs after residency(3)
Obligated or “Creditable service” – 19 years ADSC
Only eligible for ISP, not MISP/MSP
So, ASP/ISP will not push beyond 20-yr service mark
Any MISP/MSP will be tacked on to end… i.e., >20 years
Last 4 yrs of career: ISP($36k)x4 = $144k
MY PAY IF I TRAINED AD FELLOWSHIP
Subspecialist
Training:        Military or civilian residency (4)
                 Fellowship (3)
Commitments: USAFA(5)
                 HPSP(4)
                 Residency(3 concurrent)
                 AD fellowship 3 yrs after residency(3 concurrent)
Obligated or “Creditable service” – 16 years ADSC
Eligible for ISP, and MISP/MSP starting at 16 years
So, ASP/ISP and up to 4 year MISP/MSP will not push beyond 20-yr
  service mark
Last 4 yrs of career: MISP/MSP($81k)x 4= $324k
Doing a Civilian Sponsored Fellowship over AD cost me $324k-
  $144k=$180K!!! (Assuming I stay in to retirement)
MY PAY IF I SKIPPED FELLOWSHIP
General OB/GYN staying in for 20
Training:      Military or civilian residency (4)

Commitments:            USAFA(5)
                HPSP(4)
                Residency(3 concurrent)
Obligated or “Creditable service” – 13 years ADSC
Eligible for ISP, and MISP/MSP starting at 13 years
So, ASP/ISP and up to 7 year MISP/MSP will not push beyond
  20-yr service mark
Last 7 yrs of career: MISP/MSP($66k)x 7= $462k
Doing a civilian sponsored fellowship over skipping fellowship
  and staying in for 20 years cost me $462k-($36k x 7
  years)=$210K!!!
      Retirement Savings
   Thrift Savings Plan
        Federal equivalent to 401k
        Pretax dollars (Roth coming… 2012)
        No matching of contributions
   Limits
        No limit to % of income, consider each bonus
         separately
        IRS cap at $16,500 in 2010
   Taxes
      Similar to traditional IRA
      Penalty for withdrawal before age 59 1/2
   Resources
        http://tsp.gov
FINANCES
   Let‟s assume they don‟t change retirement
       What is it worth?
     EXAMPLE OF MY RETIREMENT
  Assumptions                  Years Year        Monthl   Annual    Cumulativ
                                out               y Pay    Pay       e
  Retire with 20 years
                                1        2021     5,365    64,382    64,382
  Year 2021

  Rank 0-5
                                10       2030     7,312    87,746    755,291
  Would have to stay
        21 years for 0-6 retire 20      2040     10,315   123,775   1,820,704


                                30       2050     14,550   174,596   3,323,573


                                40       2060     20,524   246,285   5,443,519


http://militarypay.defense.gov/Tools/index.html
 FINANCES:
 WHAT COULD I EXPECT TO MAKE OUTSIDE OF THE
 MILITARY?
   Average Generalist $250K
       Average MFM $394K
       Average REI $317K
       Average Onc $413K
       Average Uro gyn not available

Many factors involved in pay such as practice type (academic
 vs private practice vs HMO), gender (females > male),
 location (urban vs rural)

Most MISP/MSP pay differences would be negated after a
 couple years in practice as MFM/Onc/REI unless comparing
 well paying private generalist position and academic sub-
 specialist

Source: Physician recruiters (CompHealth and
  InterimHealth) along with the American Medical Group
  Association
OTHER CONSIDERATIONS
   Limited sites to practice for sub-specialites
       Sub-specialists typically at residency centers only
 Wider variety of practice locations as generalist
 Doing fellowship will commit you to more
  commitment!
QUESTIONS?

				
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