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Published: 1 March 2009
Air & Space Power Journal - Spring 2009
Lt Col Stephen Podnos, USAFR*
The US Air Force is transforming its medical capabilities to perform as an expeditionary force. This transformation includes reducing large, fixed facilities for health care, as well as training and preparing small, flexible health-care teams for quick, global deployment. In addition, the military in general has been tasked to provide increased capacity for dealing with situations other than war, including response to domestic and international disasters. Because the medical service consists of both an active duty and a reserve component, we need a steady supply of new and retained physicians to staff the US Air Force Reserve (USAFR) for its domestic and global missions. Recent efforts towards recruiting physicians and dentists for the Air Force produced less than 10 percent of the goal.1 A study of the US Army Medical Reserve’s physician supply also predicted a shortfall this decade of nearly 35 percent of desired medical positions.2 Recruiting, training, and retaining more physicians to support the efforts of the USAFR’s medical tasking are clearly difficult, yet ensuring a reliable supply of volunteer physicians for this role is vital to our nation’s security.
The factors that encourage physicians to join the USAFR are crucial to understanding a successful process of recruiting and retaining a physician corps. Primary motivating elements may include compensation, a sense of meaning and purpose, and a chance for interesting experiences. Many physicians in the Reserve may have received prior benefits via scholarships or matriculation through the military medical school and residency system. Further, the issue of Reserve compensation is likely to be significant only for these and other physicians who have already served on active duty and may therefore qualify for retirement benefits by extending their service.3 In contrast, the level of direct compensation offered by military service (compared to that available in civilian employment) usually deters physicians with no prior service. If they join the Reserve in their late 40s (as I did), they will not be entitled to retirement benefits. An additional issue that may discourage the recruitment of civilian physicians to the Reserve involves the cost of maintaining an office (including malpractice insurance) while serving on active duty. Moreover, the commitment of performing weekend drills, along with at least two weeks of active duty annually, represents a significant amount of time away from a private medical practice. Further, making arrangements for other physicians to cover the reservist’s practice during active duty can prove laborious, time consuming, and costly.
To mitigate the aforementioned concerns, the USAFR has at least three potential options to assure the necessary supply of physician manpower.
Implementing a Physician Draft
This option, last employed during the Vietnam War, was discussed earlier this decade at top government levels.4 Though acceptable when nonphysicians were also subject to complusory service, a draft specific to physicians might cause considerable friction and detract from maintaining a cohesive and cooperative medical force. A significant draft would also disrupt civilian medical systems.
Using Private Contracting
This alternative is occurring at an accelerating rate nationwide, especially for staffing military and Veterans Administration medical centers. The USAFR could obtain physicians via contracts for positions of support in the continental United States, freeing up other active duty and Reserve personnel for overseas deployments. Contract physicians might also fill certain deployment taskings. Limited by availability of physicians at the times needed (since contractors may not be able to supply them quickly), this is probably the most expensive of the options. Other considerations include the inability of the military command structure to enforce discipline with contractors and the potential exposure of noncombatant personnel in battlefield areas.5
Enhancing a System of Incentives
The optimal approach to recruiting and retaining physicians with no prior service (as well as those with prior service) must focus on providing a meaningful and rewarding experience.6 Because survey data of Reserve physicians identify service to country as a paramount reason for participation, we should emphasize this feature of recruiting and retention.7 Direct financial compensation is unlikely to be a primary, meaningful motivation for many potential USAFR physicians; therefore, both altruistic purposes and the opportunity to gain new skills and experiences would become attractive reasons to join the military effort. For example, the prospect of traveling domestically and internationally as well as offering expeditionary-type care for both personnel and victims of disasters would lure many physicians. Additional incentives and programs to overcome barriers to Reserve duty might include the following:
• Offering “long weekend” active duty programs in interesting medical topics also pertinent to Reserve mission training (e.g., in advanced cardiac life support; advanced trauma life support; and chemical, biological, radiation, nuclear, and high explosives).
• Considering whether a nondeployable physician service with less intense training and physical requirements might fill the domestic needs of the Reserve, leading to a higher percentage of deployable medical personnel.
• Continuing medical education credits for courses during weekend drill service.
• Implementing a “practice care” system to help physicians with the administrative and financial burden of running their civilian practices during deployment.8
• Considering retirement benefits for less than 20 years of service for older physicians who enroll in the Reserve.
• Increasing selective bonus and loan-repayment programs for specialties in high demand.
• Considering the recruitment of academic physicians, who earn less than those in private practice and do not have a financial overhead.
The looming national shortage of physician manpower poses a threat to the success of both incentive programs and private contracting. In the 1980s, a RAND study of the military’s medical recruitment foresaw a physician glut, which in fact did not occur.9 The supply of physicians is not keeping up with the growing population, and the productivity of doctors is dropping for a variety of reasons. Developing a system of incentives would require leadership at local and higher levels.10 Indeed, many of the incentives suggested above will require top-level vision and critical discussion. However, each wing commander should consider which local incentives can best support this effort.
Of the three possible solutions mentioned here for ensuring the supply of USAFR physicians, the most desirable calls for increasing the numbers of volunteers through a variety of incentives. Although some of these would require the support of high-level Air Force leadership, local wings can initiate and continue a number of incentives. Successful wing-level efforts to recruit and retain physicians have included emphasizing the aspect of service to country and publicly recognizing outstanding service to the unit. Providing interesting and rewarding training opportunities is also important. Adequate efforts both locally and forcewide would require annual measurement of staffing needs versus fulfillment. Maintaining a motivated and skilled physician component for the USAFR will continue as a major but important challenge for the foreseeable future.
*The author, a pulmonary/critical care physician in Merritt Island, Florida, is a member of the 920th Rescue Wing at Patrick AFB, Florida. He is training for the wing’s Critical Care Air Transport Team program.
1. House, Presentation to the Military Personnel Subcommittee, Committee on Armed Services, United States House of Representatives, Subject: Overview of Recruiting and Retention, Statement of Lieutenant General Roger A. Brady, Deputy Chief of Staff, Manpower and Personnel, United States Air Force, 110th Cong., 1st sess., 15 February 2007, 3, http://armedservices.house.gov/pdfs/MilPers021507/Brady_ Testimony021507.pdf.
2. COL James M. Fetter III, “Sustaining AMEDD [Army Medical Department] Professional Strength in the Reserve Components” (thesis, US Army War College, 2004), 1, http://stinet.dtic.mil/cgi-bin/GetTRDoc?AD= ADA423389&Location=U2&doc=GetTRDoc.pdf.
3. Victoria L. Daubert, Retention of Volunteer Physicians in the U.S. Air Force, RAND Project Air Force, R-3185-AF (Santa Monica, CA: RAND, 1985), 5–9, 24, 40, 63–65, http://www.rand.org/pubs/reports/2006/ R3185.pdf.
4. Robert Pear, “U.S. Has Contingency Plans for a Draft of Medical Workers,” New York Times, 19 October 2004.
5. Lt Col Stephen M. Blizzard, “Increasing Reliance on Contractors on the Battlefield: How Do We Keep from Crossing the Line?” Air Force Journal of Logistics 28, no. 1 (Spring 2004): 8–12, http://www.aflma.hq.af.mil/ lgj/Vol%2028%20No%201%20www.pdf.
6. LTC Garland M. Knott Jr., “U.S. Army Reserve Medical Command” (thesis, US Army War College, 2000), 5–10, http://stinet.dtic.mil/cgi-bin/GetTRDoc?AD=ADA378265&Location=U2&doc=GetTRDoc.pdf.
7. Fetter, “Sustaining AMEDD Professional Strength,” 11.
8. Ibid., 15.
9. Daubert, Retention of Volunteer Physicians.
10. Frank R. Hunsicker, “Organization Theory for Leaders,” in AU-24, Concepts for Air Force Leadership, ed. Richard I. Lester and A. Glenn Morton (Maxwell AFB, AL: Air University Press, 2001), 153–58, http://www.au. af.mil/au/awc/awcgate/au-24/hunsicker.pdf.
The conclusions and opinions expressed in this document are those of the author cultivated in the freedom of expression, academic environment of Air University. They do not reflect the official position of the U.S. Government, Department of Defense, the United States Air Force or the Air University
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