Cost Neutrality of Fourth Year in Military Programs

We were delighted to read Douglass et al’s excellent article on financing the fourth year.1 We would like to augment their evaluation of four civilian programs with perspectives and outcomes from one of the US Navy 4-year sites: Naval Hospital Jacksonville (NHJ).

NHJ is a 13/13/13 full-scope program, approved to add a 4-year track as part of the Length of Training Pilot Project.2 Due to Navy Medicine restructuring, NHJ graduated seven 4-year residents between the 2016-2017 and 2019-2020 academic years. Four-year residents during this time outperformed their peers in scholarly activity,3 and their work became a model for integrating scholarly activity with global health engagement to meet military medicine’s new mandate of medical readiness.4

It is difficult to assess the relative cost of a fourth year in military medicine. This is in part because of the opacity of the federal budgeting system, and because most productivity comparisons rely on relative value units, which measure volume, not value, and undervalues primary care.5 Also, however, military medicine junior staff and residents tend to spend more time on inpatient obstetric and medicine services than their civilian peers, and further have unique military training requirements, none of which are captured in outpatient visits. However, while these make military-civilian comparisons challenging, they do not preclude a military-military comparison for relative value using Douglass et al’s construct.

The average military resident and junior faculty earn (including all bonuses) $88,694 and $159,256 per year, respectively.6 Using outpatient visits as a proxy for total work output, this means that a resident is cost neutral if they see roughly half the outpatient visits of junior staff. A staff family physician sees approximately 2,700 patients per year. A faculty physician sees approximately 800 patients directly and provides inpatient, maternity, and newborn care. During their fourth year, PGY-4 residents saw an average of 822 outpatient visits while also providing inpatient, maternity, and newborn care. While admittedly site specific, this data suggests that, like the civilian programs evaluated by Douglass et al, military family medicine programs are at least cost neutral regarding 4-year programs.

There are two other challenges to broader implementation of a fourth year in the military. First is the increased service commitment (each 4-year resident added a year to their service obligation), which may deter some students. Second is that the pipeline for graduate medical education is built to accommodate an anticipated number of needed physicians in a given year—not only for civilian-type billets in hospitals and clinics, but also to deploy in support of military operations. A precipitous delay of all graduates would be challenging. However, much like the transition from the interrupted to continuous training paradigms, a fourth year could be gradually phased in over time with minimal disruption. Further, as the military is currently divesting medical billets as part of its restructuring (Navy Medicine is slated to lose 24% of its family medicine billets), the services will be temporarily overmanned—a perfect time to implement extra training.