Care Under Fire: United States Army Physician Survey

United States Army healthcare has faced increasing criticism in recent years from its own active duty physicians. Internal surveys of active duty physicians demonstrate a lack of successful intervention in an annual exodus countered only by ongoing recruiting efforts. Anecdotal experience suggests much more widespread discontent due to numerous factors than has been reported publicly. This cross-sectional survey study of 94 active duty physicians paints a vivid picture of an organization in crisis: a majority of physicians planning to separate at the end of their obligation, leadership out of touch with the needs of physicians, and systematic deterioration of clinical skills. Subgroup analysis offers insight into why reforms are unlikely to come from within the medical corps. Prospective recruits are also provided the most comprehensive view yet of life as an active-duty Army physician with a majority reporting unmet expectations, a willingness to accept a financial debt in exchange for early separation, and a low likelihood to recommend participating in the current Army medical recruitment programs. Reorientation of recruiting efforts to focus on attending physicians is discussed to address core deficiencies with multiple downstream effects.


Introduction
The public concept of military medicine inspires the imagination with visions of battlefield valor in dangerous Care Under Fire scenarios when care is first rendered to an injured soldier still in harm's way. Graduating from medical school without the burden of financial debt builds on this admirable framework, and the very notion of a military officer assumes unrivaled leadership experience. A career as a military physician appears to sell itself, and indeed it does for a number of our nation's ambitious pre-medical students. Why, then, do the Armed Forces struggle so much with physician retention [1]?
Currently, nearly all military physicians are recruited through one of two training programs: the Health Professions Scholarship Program (HPSP) and the Uniformed Services University of Health Sciences (USUHS). Both offer medical students a blend of full scholarship and living expenses in exchange for an active duty service obligation upon completion of training. Though recruitment mechanisms do exist for fully trained physicians, there are numerous challenges to this method such as direct competition with civilian pay and lifestyle [2].
A 2018 Government Accountability Office study demonstrated that the number of active duty physicians remains well below their authorizations despite the relative success of USUHS and HPSP recruitment efforts [3]. More notably, most physicians will leave active duty as soon as their obligation is met, creating a revolving-door phenomenon of experienced physicians being continually replaced by new graduates [2,4]. Factoring in the blended retirement option suggests further shortfalls can be expected moving forward as the 20-year retirement benchmark loses its attraction [4].
Efforts to define the issues driving physicians out have not been translated into successful intervention. For example, an unpublished 2020 Army Medical Command study of physicians asked nearly identical questions, and produced very similar results, as the published 2018 Army Medical Command study of Army physician satisfaction [5]. While pay differentials between the military and civilian sector receive the most attention because they are easily described and quantifiable, viewing the issue strictly through a financial lens ignores the more challenging task of addressing qualitative job satisfaction and quality of life issues.
Related concerns about critical skill maintenance have attracted attention even beyond military circles. A 2019 US News and World Report survey of active duty surgeons raised serious concerns regarding their employability after the Army due in large part to low case volume [6]. This mirrors ongoing discussions within the emergency medicine community, most recently reflected in a 2020 study by Carius et al discussing very low volumes of emergency procedures performed at military treatment facilities -precisely the type of procedures needed by injured soldiers and severely ill medical patients alike [7].
To date, studies have fallen short of aptly describing the overall military physician experience in a holistic manner and of accurately framing the systemic barriers that hold needed reforms at bay. The logistical challenges in studying this population without the Army's cooperation must be weighed against expected censorship of any negative results obtained by an Army-approved study. Our civilian-organized crosssectional survey of active duty physicians was designed with no pre-publication military review and with an emphasis on respondent anonymity. Special focus was on physicians planning to separate at the end of their current obligation as this demographic represents the majority of active duty physicians as graphically demonstrated by Wiesen et al [4]. Sampling all active duty physicians at any given point in time underrepresents this group due to the survivor bias resulting from those separations. This survivor bias also inherently leads to this group's underrepresentation within senior Army medical leadership. In this study, we looked to directly compare the perspectives of those Army physicians planning to separate with physicians planning to continue on with their Army career. By highlighting these contrasts, our hope is to re-orient the discussion to explain the current lack of reform generated by career Army physician-leaders and prompt movement in a new direction. Furthermore, our study helps lend transparency to those premedical students considering accepting an HPSP or USUHS scholarship and thereby obligating themselves more than a decade into the future before they will have treated their first patient.

Materials And Methods
Military Outlook contacts were searched by job title for keywords matching "physician," variations of "surgeon," and common variations of specialties. A total of 702 email addresses of presumed active duty physicians were obtained. Results were screened to include only .mil email addresses and those individuals with rank of Captain or above (the minimum rank for Army physicians). Persons with indications of Reserve status were excluded.
The survey was built using the SurveyMonkey.com platform. Questions were created by the authors for the purposes of this study alone with review and editing by local Institutional Review Board staff of Carle Foundation Hospital. Physicians were contacted twice via email, first with an initial invitation and a followup approximately four weeks later. Emails included a weblink to the survey. To maximize anonymity and participation, weblinks were not recipient-specific and respondents were encouraged to share with peers who met inclusion criteria. The survey was open for 60 days and questions included a wide range of topics such as recruitment, quality-of-life, and clinical skills. Mental health assessment questions incorporated a widely-used screening tool, Patient Health Questionnaire-9, for signs of depression [8].
In contrast to civilian medicine, most military medical specialties adopt atypical or expanded roles in trauma care in the deployed setting. Therefore, we included questions about all physicians' clinical trauma skills. However, early in the survey process some respondents provided feedback that they would never have a trauma role. Consequently, we revised the survey and added this response option for relevant clinical skills questions. Due to a low number of responses before this addition and the vast majority of early responses reporting specialties that would be expected to provide trauma care, responses that were provided prior to this added response option were not felt to significantly skew the overall results.

Results
A total of 106 responses were returned; 94 met inclusion criteria of being either an attending physician or a fellow-level physician currently serving on active duty in the Army. Based on the respondent's answer to the question "How likely are you to remain on active duty past your current obligation?" the information was then divided into two groups, Separation and Retention. The Separation group was defined as those who responded "Not At All Likely" (67.02%) with the rest comprising the Retention group (32.98%). Chi-Square analysis was performed to determine statistically significant differences between the groups. Regarding Military Medicine Recruitment, only respondents who utilized the HPSP and USUHS programs were included (91 responses total, 60 in the Separation group and 31 in the Retention). Key questions and responses are reported in Tables 1-5. Full survey results can be found within the Appendix [ Table 6].            Ninety-one of 94 respondents participated in the HPSP or USUHS program. Of these 91 respondents as displayed in Table 1, 86% reported some degree of financial pressure led them to join the military, and 87% felt concerned by the prospect of carrying and repaying medical school debt. There was no statistical significance between groups on this matter, but other recruitment-related topics yielded significant differences. 70% of the Separation group felt they would be unlikely or very unlikely to recommend the HPSP program to a friend or family member, and 93% of this group reported they would be very unlikely to recommend the USUHS program. In contrast, a majority of the Retention group would recommend both programs. Ninety-two percent of the Separation group compared to 65% of the Retention group felt it would be very unlikely that an Army physician in sincere need would be allowed to separate from the military before their obligation was complete. Only 30% of the Separation group compared to 61% of the Retention group felt that better pay and benefits during medical training should be considered a very or moderately important factor in the overall cost-benefit assessment of the HPSP and USUHS programs. Sixty percent of the Separation group felt that a financial debt is somewhat or very preferable to an active duty service obligation, though 77% of the Retention group reported that an active duty service obligation is somewhat or very preferable. While 19% and 42% of the Retention group felt their experience has been very or moderately consistent, respectively, with their expectations at the time of recruitment, 0% and 12% of the Separation group felt their experience has been very or moderately consistent, respectively, with their expectations. While all respondents in the Separation group reported planning to separate at the end of their current obligation, 58% reported that they would be very likely and 23% would be likely to accept a reasonable financial debt for earlier separation. Fifty-seven percent of the Separation group would also be willing to accept a reasonable financial debt in exchange for early transfer into the Army Reserves, though this did not reach statistical significance between groups [ Table 1].
Respondents also gave candid free-response answers regarding their advice to those who may be considering an HPSP or USUHS scholarship which are reported within the Appendix of this publication [ Table 6].
Fifty-two percent of the Separation group who would be expected to treat trauma patients on deployment felt their personal performance at trauma care on day one would be worse or much worse than a civilian peer based in a trauma center, while only 23% of the Retention group reported similar feelings. The Separation group had similarly negative views about the typical military physician's trauma skills as 60% felt the care rendered would be worse or much worse. The Retention group has nearly evenly split in their opinions regarding typical military physicians' trauma care. When respondents were asked to rate their clinical skills as they relate to trauma patients against a civilian physician in their specialty in general, significant differences were found again between groups with similar opposing trends [ Table 2].
There was no significant difference between groups when asked about how the Army's impact on their skill maintenance would affect the outcomes of wounded soldiers if deployed today. However, both groups clearly trend toward physicians' Army positions causing a deterioration of critical trauma skills and increased risk of harm to wounded soldiers [ Table 2]. While there was a significant difference between the groups when asked about the impact of respondents' Army positions on their ability to treat complex trauma patients, there was no significant difference when questioned about complex medical patients with clear trends in both groups indicating their Army positions have had a negative or very negative impact on their ability [ Table 2].
No difference was identified when respondents were asked to compare the number of opportunities to perform relevant procedures and patient care to the number needed to maintain their desired clinical skills. Forty-three percent and 30% of all respondents felt they received far fewer or fewer procedure opportunities than would be adequate, respectively. Twenty-six percent and 34% felt they received far fewer or fewer patient care opportunities with 28% reporting just enough opportunities [ Table 5].
Sixty-eight percent of the Separation group disagreed or strongly disagreed that senior Army medical leadership positions are held by individuals who are promoted and assigned to positions based on their leadership skills and administrative training with 21% neither agreeing or disagreeing [ Table 3]. The Retention group offered no clear trend on this matter though the difference between groups was significant. Similarly, 65% of the Separation group felt Army medical leaders provide inferior or far inferior leadership and administrative guidance compared to corresponding civilian counterparts, and no respondents in the Separation group felt Army medical leaders provided superior leadership. While 37% of the Retention group felt Army medical leaders provided equivalent leadership and administrative guidance, 47% felt it to be inferior to corresponding civilian counterparts. Both groups gave poor marks to the role of Army medical leadership in identifying the needs of and advancing the interest of active duty physicians, including deployment readiness, with the Separation group offering significantly worse marks across these inquiries [ Table 3].
Sixty-seven percent of the Separation group felt that Army medical leaders discourage or strongly discourage efforts by physicians to improve Army healthcare, while no clear trend was identified in the Retention subgroup [ Table 3]. No statistical difference was identified between groups with regards to raising concerns to leadership, though data trended toward the Separation group feeling discouraged or very discouraged from doing so (54%) as opposed to encouraged or very encouraged (13%). The Retention group offered no clear trend on this matter. Significance was met on perceptions of the likelihood that concerns will be adequately addressed. Thirty-eight percent and 48% of the Separation group felt their concerns would be unlikely or very unlikely to be adequately addressed, respectively, compared to 35% and 16% of the Retention group, with 39% of the Retention group reporting their concerns would be neither likely nor unlikely to be adequately addressed. Seventy percent of the Separation group felt they did not feel empowered at all to enact change in their organization compared to 23% of the Retention group, though only two respondents in the Separation group and one respondent in the Retention group felt very empowered. Finally, the Separation group reported feeling significantly more personal risk of retribution due to speaking out against policies and decisions that they disagree with than the Retention group. Only 29% of the Separation group and 23% of the Retention group felt little to no risk, but 30% of the Separation subgroup felt significant personal risk compared to 6% of the Retention subgroup [ Table 3]. Respondents from both groups offered similar rates of concern over different specific forms of retribution [ Table 5].
Significant differences were found throughout inquiries probing physicians' assessments of local and senior leadership's valuing and supporting the pursuit of continuing medical education and/or off-duty employment in maintaining skills. While 49% and 70% of the Separation group felt local and senior leadership, respectively, show little to no understanding, no clear trend was identified in the Retention group. The Separation group was mixed on their opinions of the role local leadership plays in these pursuits, but 42% felt that senior leadership discourages or strongly discourages these pursuits, with 49% feeling that senior leadership neither supports nor discourages. Conversely, 63% of the Retention group felt local leadership supports or strongly supports these pursuits, though this trend was much less pronounced regarding senior leadership's role [ Table 3].
Thirty-three percent and 52% of the Separation group disagreed or strongly disagreed, respectively, that the reliable replacement of physicians leaving active duty by new graduates with active duty service obligations encourages leadership to work to improve the active duty physician experience [ Table 4]. While 57% and 17% of the Retention group also disagreed or strongly disagreed, respectively, this difference met significance. This result was reinforced by the question being inverted: 30% and 49% of the Separation group agreed or strongly agreed, respectively, that this mechanism discourages leadership from working toward improvement. While 60% and 13% of the Retention subgroup agreed or strongly agreed as well, this difference also met significance [ Table 4]. Differences were not identified when respondents were queried regarding their expectations of the impact on limiting recruitment to attending physicians instead of aspiring medical students. Of all respondents, 24% strongly agreed and 38% agreed that this change would likely encourage leadership to work to improve the active-duty physician experience, with only 16% disagreeing or strongly disagreeing [ Table 5]. Only four respondents indicated that limiting recruitment to attending physicians would discourage improvement [ Table 4].

Discussion
Results of this survey study describe an organization struggling to meet the needs of its physicians across a broad spectrum of issues. Breaking responses into Separation and Retention groups reveals a striking dichotomy between the physicians who plan to separate at the end of their obligation and those who will remain in the military and offers a unique perspective compared to prior studies of military physicians [2,4,5]. The active duty service obligation functioned as an unintended screening tool for those with an approving view of the Army physician experience. These physicians are not only more likely to recommend the HPSP/USUHS program but also to view more positively their own clinical skills and those of the average military physician [ Tables 2,3]. Additionally, those opting to stay felt more comfortable taking concerns to leadership and felt significantly more positive about Army medical leadership's understanding and handling of physician issues across numerous inquiries [ Table 4]. Due to the heavy attrition rate and the nature of physician promotion within the medical corps being based primarily on time-in-service, one can reasonably expect the Retention group represents physicians who will be or are in senior leadership positions. This selection bias may help explain the disconnect that exists between leadership and the physicians represented by the Separation group.
For example, the HPSP/USUHS programs are generally seen as successful, though internal approval varies. The Retention group views these programs favorably and will likely carry these positive opinions into leadership positions that will, in turn, reinforce these same recruiting methods [ Table 2]. Unfortunately, survey results indicate the majority of physicians recruited in this manner disapprove of the programs [ Table  2,6]. While both groups reported financial pressure and concern over debt were key factors in their decision to join the Army, significantly more of the Separation group felt their expectations were not met and most of this group felt a financial debt would be preferable to the lengthy service obligation. Over 75% of the Separation group even reported they would be willing to accept financial debt in exchange for early separation and would also be willing to accept a transition into the Army Reserves [ Table 2]. This marked disconnect should raise alarms. From the vantage point of the Separation group, these recruiting programs share more overlap with a predatory loan than with a benign and beneficial scholarship program.
Even more disconcerting is the reported shortfall in clinical abilities. Physicians in the Separation group believed their clinical trauma skills to be inferior to civilian physicians, and even the Retention group respondents voiced concerns about their trauma training [ Table 3]. Placing physicians in administrative roles or in low-acuity medical treatment facilities without the opportunity for ongoing clinical trauma experience, a common practice in Army medicine evidenced by 22.6% of physician respondents in the 2018 MEDCOM survey reporting majority-administrative duties, can only result in skill regression [5]. Expecting physicians to balance the practiced trauma skills needed on deployment, the routine care and health maintenance needed by Army units in garrison, and the typical clinical skills required for physicians to transition into civilian practice may be viewed by some as reflective of a versatile medical corps that meets the needs of the Army. To many who answered this survey and others living in a modern medical world of specialization, this more likely reflects inferiority in one or more of those medical niches as physicians are placed in roles that are misaligned with their level and area of training. This sentiment is reflected in our survey results where 64% of all respondents reported increased risk of harm to wounded soldiers due to the Army's negative impact on clinical skill maintenance [ Table 3]. For these reasons and others, physicians who do successfully transition from military to civilian practice more often do so in spite of, rather than because of, their Army experience.
Results also support criticism of the institution as being recalcitrant to change. Command climate responses describe a generally suppressive atmosphere that stifles physicians from attempting to improve the system, with perceived threats of retribution and an overwhelming air of futility expressed by the Separation group in particular [ Table 4]. Acceptance of the status quo then becomes a de facto requirement for career advancement which, over time, results in the next generation of leadership continuing the same policies that are driving high attrition rates. In aggregate, the command climate inquiries of this study reflect a resounding vote of no-confidence in Army medical leadership's ability to maintain physician skills and improve overall physician satisfaction [ Table 4].
There are limitations and challenges of studying an active-duty military population that must be acknowledged. Several senior Army medical officers were contacted with a request for a comprehensive list of physicians that would meet inclusion criteria. Human Resources Command was also contacted in an attempt to obtain more objective demographic data related to recruitment and retention. These requests were declined or ignored. The imperfect method used in lieu of an email listserv resulted in many email invitations failing to be received (though it is unclear how many). Anecdotally, a decline in an individual's motivation is typically accompanied by less diligent Army Outlook compliance and likely served to decrease participation by many of the more disenfranchised physicians. Furthermore, the cumbersome process of accessing Army Outlook accounts is typically done on government computers which offer warnings that users' communication may be monitored. This likely added to apprehension among participants and limited both data analysis and participation. For example, several respondents declined to provide their specialty with one response explicitly stating, "I would prefer to not provide this information as I fear reprisal for being honest about the quality of army medicine." However, allowing respondents to share the survey invitation may have introduced a snowball effect of like-minded individuals. Still, we feel the breakdown in Retention and Separation group numbers are reasonably consistent with Army physicians overall and support the results. The Army could repeat this study with the entire listserv which may clarify certain results and produce more reliable trends, especially within the smaller Retention group.
Appropriate analysis of the mental health components of this survey remains planned but beyond the scope of this report.

Conclusions
We authors suggest the results of the survey support our premise that the failure of meaningful reform stems from inherent, organizational resistance to change and a leadership is simply out of touch with the majority of Army physicians. Our proposed change of eliminating the HPSP and USUHS programs deserves strong consideration for its relative simplicity to enact by civilian overseers and expected multidimensional benefits. From an ethical standpoint, these programs are questionable at best, legally obligating recruits to up to 14 years of active duty service with, as these results demonstrate, frequently unmet expectations.
With a majority of all respondents willing to accept financial debt in exchange for early separation and a lack of clear evidence that these programs produce superior military physicians, their greatest strength appears to be locking pre-medical students into long obligations. On the other hand, re-focusing recruitment on attending physicians may increase retention and satisfaction as attendings are better equipped to make better informed decisions with less financial pressure, leading to more accurate expectations of their commitment. This would finally provide direct feedback from prospective physician-recruits (as opposed to pre-medical students) and accountability to Army medical leadership if and when recruiting goals are not met. It is important to note that the HPSP/USUHS recruitment pipeline is years-long and even sudden elimination would not be felt at the clinical level for at least four years; longer if the effect of fewer resident physicians at medical centers are discounted. Other solutions such as shifting to a largely Reserve force warrant consideration if the military cannot guarantee sufficient clinical skill maintenance while physicians serve on active duty.
In the meantime, potential recruits should be aware of the discrepancies between physicians planning to remain in the military and those planning to leave, and they should seek out references from both. To be clear, neither this data nor anecdotal experience suggests any recruitment effort is malignant or underhanded. The Retention responses demonstrate that many physicians genuinely believe the HPSP and USUHS programs to be excellent choices while the Separation group sees these programs as helping reinforce a broken system that erodes the very clinical skills it pays for.
Every year, a truly exceptional group of Americans accept the many unknowns and risk of military service to provide care to our nation's soldiers. The concerning narrative that this survey supports may well be one of the most unexpected realizations during their time in service: that the quality of this care is under fire by the very system it serves. Due to the combination of well-intended but misguided recruiting practices, a selfreinforcing mechanism of leadership selection, and the longstanding administrative negligence regarding clinical skill maintenance described here, it is unlikely that sustainable and meaningful reform will come from within the organization. We believe significant transformation can only be achieved through civilian oversight and concrete action should be taken as swiftly as possible. I would advise them to be sure that they understand they are signing up to join the Army and that they will be expected to support the Army's mission first. This may mean that they have to learn to practice outside of their particular training specialty. Additionally, they will be expected to represent the Medical Corps as officers in the Army and should make every effort to learn the Army's processes and procedures.