Military Physician Recruitment and Retention: A ...

MILITARY MEDICINE, 174, 5:529, 2009

Military Physician Recruitment and Retention: A Survey of Students at the Uniformed Services University of the Health Sciences 2LT Samuel L. Holmes, MS USA; 2LT Daniel J. Lee, MS USA; 2LT Grigory Charny, MS USA; 2LT Jeff A. Guthrie, MS USA; 2LT John G. Knight, MS USA ABSTRACT Recent strategies employed in response to military physician recruitment shortfalls have consisted of increasing financial incentives for students in the Health Professions Scholarship Program (HPSP) while offering no increased incentive for attendance at the Uniformed Services University of the Health Sciences (USUHS). To gauge the impact of these incentive increases on the decision of medical students to attend USUHS, a prospective e-mail survey of current USUHS medical students was conducted. The survey was distributed to 674 USUHS medical students from all four class years, of which 41% responded. Students were asked to prioritize incentives and disincentives for military service and USUHS, as well as respond to whether recent incentives applied solely to the HPSP would have affected their decision to attend USUHS. Data were assessed using a weighted scale with responses ranked highest receiving a score of 3, responses ranked second receiving a weighted score of 2, and those ranked third receiving a weighted score of 1. The total weighted sum for each question response across the respondent population was then tallied in aggregate and assigned a weighted score to identify factors consistently ranked highest among the students. Patriotic duty and serving uniformed personnel were ranked most appealing about military service. Combat and deployment considerations were ranked least appealing about military service. Also of note, numerous survey comment box responses highlighted the perceived advantages of pooling resources between the two programs to benefit military medical student recruitment and training. Survey results suggested that current enhanced financial incentives and shorter service obligation offered by the HPSP make attendance of USUHS less appealing for current USUHS students and may negatively impact recruitment and retention of USUHS medical officers. Commensurate incentives such as promotion and credit for time in service while attending USUHS were identified by current USUHS medical students as a possible means of improving USUHS appeal.

INTRODUCTION Recruitment of physicians is a challenge for the military health system for many reasons. Not only must the military health system compete with the lucrative civilian healthcare sector, but it must also manage and maintain 41 physician specialties to meet its mission.1 Management of the accessions processes is further complicated by the varying lengths of physician training, coordination of active and reserve components, and different medical asset requirements during peace and war. For example, the Army Medical Department is composed of 19% National Guard, 34% Army Reserve, and 47% active duty personnel.1 Each of these components has unique training, staffing, and supply issues. Despite these challenges, the military health system has enjoyed periods of success in meeting recruiting goals, particularly during the relatively peaceful 1980s and early 1990s. Recruitment of medical officers becomes much more difficult during times of war. Military healthcare recruiting suffered dramatically during the first series of major combat F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4799. The views expressed are those of the authors and not of the Uniformed Services University, the United States Department of Defense, or the United States Government. This manuscript was received for review in May 2008. The revised manuscript was accepted for publication in February 2009.

operations following the transition to an all-volunteer military, Operations Desert Shield/Desert Storm.2 At the beginning of Desert Shield, recruiter contacts at medical conventions fell 75%, declination rates for accepted applicants rose, active duty accessions fell 16%, and reserve accessions fell 43% from the previous year.2 Beyond the obvious concerns about combat service and the disparity between military and civilian physician compensation germane to the issue, reserve component physicians cited the prospect of losing their civilian practices during extended deployments as the primary reason for requesting release from active duty.2 Similar trends are developing amid the ongoing conflicts in Iraq and Afghanistan today, and with analogous results. Recruiting statistics were at their lowest for the Army and Navy in 2005 when the Army achieved 77.2% of its stated physician recruitment goal and the Navy achieved 54.9% (Table I).3 Recruitment statistics have only marginally increased for the Army and Navy in following years and have steadily declined for the Air Force. Dr. S. Ward Casscells III, Assistant Secretary of Defense for Health Affairs, affirmed the gravity of the situation by stating, “In the midst of our war on terrorism, retention of these trained and capable leaders has become more of a challenge. And recruitment of new personnel is no less so.”4 The authors view current Tri-Service recruiting and retention shortfalls as a repeat of the pattern seen during and after Operations Desert Shield and Desert Storm.2 However,

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Survey of Military Physician Recruitment and Retention TABLE I.

Physician Scholarships Awarded Compared to Service Goals for Selected Years, by Service3 Army

Fiscal Year Goal 2002 2003 2004 2005 2006 2007

318 284 292 307 295 295

Navy

Percent Goal Reached

Goal

Recruited


Goal

Recruited


326 319 294 237 232 242

102.5% 112.3% 100.7% 77.2% 78.6% 82%

362 290 275 295 300 290

346 289 232 162 199 181

95.5% 99.6% 84.3% 54.9% 66.3% 62.4%

201 201 211 191 191 223

232 225 213 224 208 211

115.4% 111.9% 100.9% 117.2% 108.9% 94.6%

current hostilities have lasted much longer and produced many more casualties. As of January 22, 2009, Operations Iraqi Freedom and Enduring Freedom (Afghanistan) have resulted in 4,868 service member deaths and 33,648 service member injuries.5 With the continuing wars in Iraq and Afghanistan, the medical corps is at risk for significant physician shortages. VADM A.M. Robinson, Surgeon General of the Navy, referred to this crisis in a memorandum addressed to all Navy medical officers dated January 15, 2008, “In recent years we have fallen behind on recruiting goals and as a result generally have a shortage of medical professionals in every corps in both the active and reserve component. If we do not take aggressive action now, we will find ourselves in extremis and unable to provide adequate service to our sailors, marines, and their families.”6 A militarywide physician crisis will lead to dire consequences in the care of active duty, veteran, and family populations, thus placing excessive strain on the military health system and threatening deployment readiness for both the active duty and reserve components. MILITARY PHYSICIAN COMMISSIONING SOURCES Three major accession programs exist to recruit military physicians. The Health Professions Scholarship Program (HPSP) and the Uniformed Services University of the Health Sciences (USUHS) recruit medical students and are responsible for generating more than 93% of the military physician workforce.7 The direct accessions program recruits practicing physicians utilizing a number of incentives including the Health Professions Loan Repayment Program, the Financial Assistance Program, and substantial accession bonuses.8 Congressman F. Edward Hebert simultaneously sponsored the HPSP and USUHS programs in 1972 as a means to improve physician recruitment across all three services. HPSP and USUHS were modeled upon existing Reserve Officer Training Corps and Service Academy commissioning programs, respectively. HPSP students hold reserve commissions and serve on active duty for 6 weeks during each year of medical school. USUHS students continuously serve on active duty from the time they begin medical school.9 Both HPSP and USUHS students remain in the pay grade of O-1 during their 4 years of medical school and are recomissioned in the grade of O-3 with zero time in service upon graduation.

530

Air Force

Recruited

As of fiscal year 2009, HPSP students serve in reserve status and receive full tuition and reimbursement for required books, equipment, and fees to a civilian medical school, and a stipend exceeding $1,900 per month. They incur an active duty service obligation of 1 year for each year receiving the scholarship (with 2 years minimum obligation) and an additional 4-year reserve service obligation.10 Students at USUHS receive full tuition, books, equipment, and fees as well as pay and benefits befitting their status as an active duty O-1. They incur a minimum 7-year active duty service obligation with an additional 6-year reserve service obligation.9 In addition to their medical studies, USUHS students are required to fulfill the normal responsibilities of a junior military officer including additional military training, as well as administrative and personnel duties. As active duty officers, USUHS students are an anomaly insofar as they are prohibited by law from being promoted to O-2 and thus remain in the grade of O-1 for 4 years until graduation. Furthermore, USUHS students do not receive credit for time in service while on active duty at USUHS.9 HPSP students comprise over 80% of new medical officer accessions and its graduates serve an average of 2.9 years after completion of their residency training.7 USUHS students comprise roughly 13% of new medical officer accessions and its graduates serve an average of 9.2 years following completion of residency training.7 Because of the difference in active duty service obligation and average number of years served, USUHS graduates comprise 23% of the total medical corps and 33% of medical officers serving in the grade of O-5 and above.7 In 2007, legislation was passed increasing the maximum authorized HPSP stipend to $30,000 per year (roughly equivalent to O-1 pay with under 2 years of service).8 In January 2008, legislation was passed authorizing a $20,000 signing bonus for HPSP students. Given the current challenges to HPSP recruiting, the services are expected to rapidly utilize these increased benefits to attract more applicants. Indeed, the Army and Navy have already implemented the $20,000 signing bonus and increased the monthly stipend from approximately $1,200 in 2006 to over $1,900 in 2008.10 METHODS The authors received full Institutional Review Board approval to conduct a prospective e-mail survey of 674 current USUHS


Survey of Military Physician Recruitment and Retention TABLE II. Year Group 1st Year 2nd Year 3rd Year 4th Year

120/171 78/169 39/167 38/167

Survey Respondent Demographics

Branch Army Navy Air Force Public Health Service

Gender 104/252 83/204 83/204 5/14

School of Medicine students from May 1 through May 21, 2007, of which 41% responded (275). Of the roughly 170 students in each class, 70% of first year medical students (120), 46% of second year medical students (78), 23% of third year medical students (39), and 23% of fourth year medical students (38) responded. See table below for additional survey respondent demographics, numbers reported as response proportions of total surveyed population (Table II). Initial preparation entailed collecting general information about issues concerning recruitment and retention from various sources including students, faculty members, and members of the USUHS administration with the aim of reducing bias and ensuring adequate coverage of intended survey goals. After determining which factors were relevant to USUHS student concerns about recruitment and retention, a Web-based survey of 35 questions was developed as a means of rapidly collecting data and maintaining confidentiality. Question topics included class year, branch of service, gender, ethnicity, experiences with medical school application, motivations behind joining the military, and comparisons of USUHS and HPSP recruiting incentives. Students were e-mailed an invitation to participate in the survey through their USUHS e-mail accounts and had up to 3 weeks to complete the survey. The survey was conducted by automated software, ensuring the authors were blinded from all identifying information and encouraging a candid exchange of information. Because of a desire to obtain results in a relevant and timely manner, this survey was not validated before its dispersal. The survey contained two types of questions: select one or all that apply and prioritization from a list of options. Select one or all that apply questions were used to collect demographic information and provide supporting information via simple yes or no questions. The core questions of the survey were of the prioritization type and asked what was most appealing and least appealing about military service and USUHS, and what methods would best improve USUHS’s appeal (Fig. 1). Comment boxes were also provided after each question to allow tailored feedback. Data compilation employed a weighted scale to reflect prioritization of concerns and the authors’ belief that an item ranked number 1 (highest priority of concern) is more important to the ranker than an item ranked number 2, and so on. Items ranked 1 were multiplied by a weight factor of 3, items ranked number 2 by a factor of 2, and items ranked number

Male Female

Ethnicity

214/468 61/206

FIGURE 1.

White/Caucasian Black/African American American Indian/Alaskan Native Asian Native Hawaiian/Pacific Islander Hispanic/Latino Unreported

222/523 2/13 1/9 27/98 3/3 11/28 9

Example Prioritization Question Format.

3 by a factor of 1. Items ranked below 3 received zero weight, thus concentrating analysis on the top 3 concerns. In assigning weight values, the authors established a baseline value of 1 for items ranked third in priority and applied a proportional single whole integer increase to reflect each higher ranking. The total weighted sum for each question response across the respondent population was then tallied in aggregate and assigned a weighted score (WS). For example, if 100 respondents ranked an issue number 1 (100 × 3 = 300), 100 ranked it number 2 (100 × 2 = 200), and 75 ranked it number 3 (75 × 1 = 75), the WS would be 575 (300 + 200 + 75 = 575). By employing this method the authors were able to determine a single score that simplified analysis and identified which factors were consistently ranked higher based on the weighted score. Weighted scores are reported with margins of error for a 95% confidence interval. RESULTS Military Service Patriotic duty (WS 388 ± 39.9) and serving service members (WS 336 ± 43.1) were identified as most appealing


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about military service. Combat (WS 267 ± 38.6) and deployment considerations (WS 231 ± 34.6) were identified as least appealing (Table III). These results support the common conception and documentation on how the ongoing conflicts in Iraq and Afghanistan are hampering recruitment and contributing to a military physician crisis. USUHS Credit toward service upon retirement (WS 311 ± 35.3) and campus atmosphere (WS 256 ± 38.5) were ranked most appealing about USUHS. Increased service obligation compared to HPSP (WS 548 ± 38.7) and lack of USUHS name recognition (WS 340 ± 38.4) were least appealing. Promotion to O-2 upon completion of second year (WS 545 ± 40.5) and credit toward time in service (WS 510 ± 34.2) were identified as the best methods to improve recruiting at USUHS (Table IV). Regarding legislation passed to increase the HPSP stipend to $30,000 per year, students were asked if this would have influenced their decision to attend USUHS if offered at the time of their application. Of 275 responses, 180 responded yes (65%). Regarding the role of healthcare recruiters, 49 of 275 (18%) responded that a healthcare recruiter tried to talk them out of attending USUHS. TABLE III.

Military Service Question/Response Options

What was most appealing about becoming a military physician?

What was unappealing about becoming a military physician?

Patriotic duty Serving soldiers/airmen/seamen Combat Carry on family tradition Status Financial compensation Travel Adventure Gain experience Military benefits Diverse opportunities

Combat Deployment considerations Family life Military life (uniform, customs and courtesies, on base living, etc.) Military benefits Bureaucracy Rigorous demands of service Lack of autonomy Length of military obligation Financial compensation

TABLE IV.

Comment Boxes A primary theme regarding the lack of commonality and coordination between USUHS and HPSP efforts emerged from feedback provided via comment boxes. A set of comments expressed frustration with separate, but dual application requirements for USUHS and HPSP. Additional comments spoke to the perceived advantages of pooling resources between the two programs to benefit military medical student recruitment and training across the board (Table V). A second theme involved comments advocating the employment of hometown recruiting strategies to boost physician recruiting efforts. This strategy involves sending a medical student or physician to their hometown or alma mater to discuss experiences in the military with prospective applicants, thus providing a positive and concrete example of military medicine. The local recruiter is able to capitalize on this relationship and improve rapport with the community as a result (Table V). DISCUSSION Limitations to the study include low response rate (41%), lack of instrument validation, and ranking questions limited to the provided response options. Additionally, survey participants self-selected by volunteering to participate in and complete the survey, thus reducing generalizability. This selection bias was observed in the breakdown of participants by class year. Overall, 44% of respondents were first year students, 28% of respondents were second year students, 14% of respondents were third year students, and 14% of respondents were fourth year students. The results of this study provide a useful starting point on possible directions for USUHS recruiting and retention. These recommendations are of course speculative only and are designed to initiate dialogue on the issues. They should not be construed as empirically derived or manifest from the presented data. The major utility of the survey is the data’s suggestion that enhanced incentives selectively applied to HPSP in recent

USUHS Question/Response Questions What would make USUHS more appealing and have the greatest impact on recruiting?

What was most appealing about USUHS

What was unappealing about USUHS

Reputation Location Perceived prestige Active duty pay Military benefits (health care, basic allowance for housing (BAH), etc.) Additional service-related curriculum (military medicine, etc.) Campus atmosphere (facility, resources, staff, students) Military training Credit toward service upon retirement

Increased service obligation compared to HPSP Name recognition Location Additional service curriculum (military medicine, etc.) Campus atmosphere (facility, resources, staff, students) Military training

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Promotion to O-2 upon completion of MS II year (credit toward promotion) Credit toward time in service/pay/retirement Curriculum changes (provide suggestions in comment box) Reduced active duty service obligation Marketing strategy (provide suggestions in comment box) Recruiter emphasis (provide suggestions in comment box) More flexible active duty service obligation plan/options (provide suggestions in comment box) Nothing


Survey of Military Physician Recruitment and Retention TABLE V.

Sample Comments Selected by the Authors to Provide a Sense of the Range of Narrative Commentary of the Respondents

What was most appealing about becoming a military physician?

What was unappealing about becoming a military physician?

“Serving the country and our men/women in uniform.” “Humanitarian aspect of the service.” “Freedom of practice, lack of malpractice.” “It is much easier to serve in the military when you and your family are taken care of financially and medically.”

“Frequency and length of deployments is the single most influential factor for me and all those I talk with.” “I hate that my family, once I have a family, will have to move around the country/world so much.” “It would be more lucrative to be a civilian doctor, without a doubt.” “The bureaucracy is certainly unappealing.”

What was most appealing about USUHS?

What was unappealing about USUHS?

“It was the friendliest place I interviewed. Everyone was quite helpful and seemed to be enjoying life.” “It would have been much more difficult to support my wife and three kids on a HPSP scholarship, so that was a big factor.” “I chose USUHS over civilian medical school because of the military components.” “Most appealing was the atmosphere fostered at USUHS of a team environment among classmates.” Application Process “When a student applies for HPSP or USUHS, they should go through the same process. They should fill out one form, have one physical, etc.”

“The fact that no one knows about USUHS makes me feel the need to constantly validate it.” “Taking a pay cut and resigning my original commission was a bit of a disincentive.” “The longer service requirement is unappealing.” “Way too many credit hours compared to HPSP.” Pooling Resources “Joint training, social functions, email/listserv communications, and just keeping HPSP in the loop with USUHS students and in the military community.” “I had HPSP recruiters either discourage me away from USUHS or tell me they had no idea that the military had its own medical school. Aren’t we all supposed to be playing on the same team?”

legislation presents the possibility of competition between HPSP and USUHS for the same pool of applicants. It is the authors’ speculation that with increased incentives comparable to that of an active duty O-1, a shorter active duty service obligation, and lack of active duty service requirements, HPSP holds a distinct recruiting advantage over USUHS. Although this advantage will bolster HPSP numbers, it may ultimately lead to a reduction in the quantity and/or quality of applicants for USUHS. More physicians with less service obligation (HPSP) and fewer physicians with more service obligation (USUHS) simply results in rearrangement of numbers on one side of the equation without producing a net increase in physicians. Current administrative practices also threaten to amplify dissonance between the two programs. The finding that 18% of respondents reported that a recruiter tried to talk them out of USUHS in favor of HPSP presents a potentially counterproductive approach to improving overall physician recruitment. Given the lack of credit healthcare recruiters receive for USUHS matriculants, it comes as no surprise that recruiters would promote HPSP at the expense of USUHS. This approach may be sending the wrong message about cohesiveness within the military health service while failing to capitalize on an opportunity to improve recruitment for both programs via complimentary and collaborative efforts. The separate but dual application process for HPSP and USUHS is another such opportunity. Currently, the HPSP

What would make USUHS more appealing and have the greatest impact on recruiting? “Retain rank and promote like everywhere else in the military.” “Better advertising.” “Teaching by organ system, not by subject.” “More flexible active duty options.” Hometown Recruiting “Incorporate an idea used in enlisted recruiting called ‘home town recruiting’. This allows soldier that recently finished training to return to their hometown to work with a recruiter for two weeks.”

and USUHS application processes are entirely separate entities with largely parallel requirements. This means an applicant wishing to apply to both HPSP and USUHS must communicate with separate HPSP and USUHS representatives, submit separate recommendations, essays, transcripts, and complete two separate physicals. Survey comments indicated that these dual requirements are a barrier to recruitment efforts. The HPSP and USUHS recruiting programs should be restructured so that efforts are synergistic. Increased financial incentives for HPSP were essential given recent recruitment difficulties. Similar incentives are now critical for USUHS to continue attracting quality applicants and maintain the intricate balance between the two programs. The survey identified promotion to O-2 after 2 years and credit for time in service while at USUHS as a means to accomplish this. Synchronizing recruiting efforts holds vast potential to strengthen both programs. Starting with the application process, both programs should review policies to make it as easy as possible for USUHS applicants to simultaneously apply for HPSP and vice versa. A common application for both, although ideal, is difficult given the nature of the American Medical College Application Service. However, steps can be taken to link USUHS and HPSP within the application process to improve the opportunity to apply for both. Attributing equal credit to healthcare recruiters for enrolling applicants in either program is another ideal step that


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would foster a more collaborative environment. Furthermore, healthcare recruiters could be given the opportunity to brief USUHS applicants about HPSP during on-campus interviews and both programs could share applicant information to ensure those interested in serving the military can find the right program to do so. Pooling resources and applicant information may potentially broaden the applicant base and enhance exposure for both programs. Recruiting efforts should also emphasize the positive but intangible aspects of caring for service memebers. As survey respondents sited patriotic duty and caring for service members as the most appealing aspects of military medicine, recruiting efforts for medical students and all health care professionals should strive to present this image of selfless service within the military health system. The military has long enjoyed success from hometown recruiting programs. The medical field should continue to expand upon this program by intensifying grassroots efforts to send current physicians, USUHS and HPSP students back to their undergraduate institutions, additional medical schools, and medical conferences to promote service in the military health system. The strength of the military health system is its people and this should continue to be a focal point for recruiting efforts. Similar programs have been implemented for the recruitment of military physicians in the past; however, comments received from this survey indicate that efforts have not yet generated extensive momentum. In summary, it is the authors’ belief that although increased financial incentives are a powerful means of increasing medical student recruitment, their implementation must be coordinated between HPSP and USUHS to achieve the ultimate goal of increasing the number of military physicians rather than siphoning applicants from one program to another. Additionally, financial incentives alone will not suffice to rectify current recruiting shortfalls. Military medical recruitment must strive to emphasize the positive aspects of caring for service members to potential applicants and synchronize recruiting efforts by all available means. These efforts include maximizing the exposure of potential applicants to current military physicians as well as USUHS and HPSP students and eliminating competitive or redundant application requirements for HPSP and USUHS. Both programs are inextricably linked and efforts to improve recruitment should leverage this relationship via unified command relationships, public affairs efforts, and incentives. Ultimately, the solution to military medical school recruiting difficulties is the recognition that HPSP and USUHS both have the same mission: produce

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military medical officers of the highest caliber to provide the best possible care for those serving in harm’s way. CONCLUSION This study yielded interesting survey data on USUHS student perceptions of recruiting and retention. Respondents ranked patriotic duty and serving service members and credit toward service upon retirement and campus atmosphere as the most appealing aspects of military service and USUHS, respectively. Respondents ranked combat and deployment considerations and increased service obligation compared to HPSP and lack of USUHS name recognition as the least appealing aspects of military service and USUHS, respectively. Respondents ranked promotion to O-2 upon completion of second year and credit for time in service as the best means to improve recruiting at USUHS. Respondents also stated that recently enhanced incentives applied to HPSP would have influenced their decision to attend USUHS if offered at the time of their application. Future military physician recruiting and retention efforts should consider these results when assessing means of improvement. ACKNOWLEDGMENTS The authors acknowledge Dr. Dale Smith for his invaluable advice and guidance.

REFERENCES 1. Fetter JM: Sustaining AMEDD Professional Strength in the Reserve Components. U.S. Army War College, 2004. 2. Clegg TA: After the storm: medical officer recruiting and retention. Milit Med 1992; 157(3): 149–53. 3. Croasdale M: Military doctor recruiting takes wartime hit. AMNews staff. Aug. 28, 2006. Available at http://www.ama-assn.org/amednews/ site/free/prl20828.htm; accessed January 22, 2009. 4. Casscells SW: MHS Refines Strategic Direction and Care Delivery to Enhance Care. US Med 2008; 44(1): 14. 5. Department of Defense. Operation Iraqi and Enduring Freedom U.S. Casualty Status. Available at http://www.defenselink.mil/news/casualty .pdf; accessed January 22, 2009. 6. Robinson AM Jr: VADM, Surgeon General of the US Navy, Correspondence to the Navy Medical Department, Ser M00C/07UM00C2140, 15 January 2008. 7. Dix M: Achievements of SOM Alumni. Uniformed Services University of the Health Sciences Journal. 2004; 5: 219–23. 8. Croasdale M: Military sweetens the deal to entice medical students. AMNews staff. July 7, 2008. Available at http://www.ama-assn.org/ amednews/2008/07/07/prsc0707.htm; accessed January 22, 2009. 9. U.S. Code. Title 10-Armed Forces, Subtitle A, Part III, Chapter 104, Uniformed Services University, Section 2114. 10. Department of the Army. Health Professions Scholarship (HPSP). Available at http://www.goarmy.com/amedd/hpsp.jsp; accessed January 22, 2009.
