A serious problem of major import to all career officers and men exists in regard to the regular Medical Corps of the Navy. The “hard core” of career medical officers is gradually “eroding” and replacements are not entering the service. The result of this continuing process has serious implications for the type and quality of medical care available to naval personnel in the years ahead. It has a serious potential in the field of medical preparedness for national defense.
Prior to World War II a commission in the regulars was a desirable goal, and there were always more candidates for commissions than there were vacancies. From the beginning of the National Emergency through 1945, physicians and surgeons responded to the obvious need and accepted regular commissions. At the end of the war there were many who decided that they did not desire a career in the Navy and resigned. Resignations were accepted without question. The Navy could ill afford to lose these men. In certain grades the resignation rate approached 75%. Graduate training programs were instituted to meet both a real need and demand, and many officers remained in service for this special training. Reserve medical officers trained in whole or in part at government expense were available for call to active duty, and as a result the service as a whole did not suffer seriously from lack of medical manpower though seldom were sufficient doctors assured for any period of time.
With the outbreak of the Korean War resignations were no longer accepted from career officers. Increased numbers of physicians were called to active duty, and many reserve officers were called up for a second tour of duty. Public Law 779, 81st Congress, the “Doctor’s Draft Act” went into effect in September, 1950. During the three years of the Korean conflict there was grumbling from certain of the regulars that they were “captives” because resignations were not being accepted. Higher authorities felt this a necessary policy so long as reserves had to be called to duty. It did, however, tend to discourage young physicians from seeking regular commissions since they feared that once committed they too might not be able to obtain release if they desired. The regular service in the eight years from 1945 to 1953 suffered a 25% reduction in strength. Less than 1,500 regular doctors were in service in July, 1953. It was then announced that medical officers not obligated because of graduate training agreements could resign from the regular service. In the past two years nearly 20% of the regular medical officers have submitted resignations. Others, presently obligated because of graduate training, are planning resignation as soon as eligible. One of the results of the personal unrest in the Medical Corps of the Navy is reflected in the grade distribution as compared to the Line:
(12-31-54)
Table I. Approximate Distribution by Rank, Line and Medical, Regulars
|
Rank |
Line |
Medical Corps |
|
RADM |
230 |
16 |
|
CAPT |
1,900 |
350 |
|
CDR |
3,600 |
440 |
|
LCDR |
5,000 |
120 |
|
LT |
10,000 |
400 |
|
LTJG |
4,000 |
11 |
|
ENS |
3,500 |
— |
To meet the serious shortage of regulars in the lower grades and fulfill the mission of the Medical Corps it is obligatory to call reserve medical officers to duty. The extent of this need is shown by Table II, which roughly illustrates the current breakdown of the Medical Corps by regulars and reserves.
(12-31-54)
Table II. Approximate Breakdown of the Medical Corps, Regulars and Reserves
|
Rank |
Regular |
Reserves |
|
RADM |
16 |
— |
|
CAPT |
332 |
20 |
|
CDR |
392 |
21 |
|
LCDR |
101 |
104 |
|
LT |
334 |
1,025 |
|
LTJG |
14 |
946 |
|
|
1,189 |
2,116 |
While the foregoing figures are somewhat comparable to the situation in the Line, the relative position of the Medical Corps is not good. Recent legislation has exempted reserve medical officers from involuntary recall after they have completed a fixed number of months of military service. The pool of trained medical reserve officers is thus greatly reduced. Soon the Medical Corps will be in the position where practically the only reserves available for active duty in this “peacetime” service will be the officers of priority 3 who were not assisted financially in their education and who have not seen any military service, plus those obtained through the draft. This has been criticized as discrimination since other professional men such as young lawyers, engineers, or accountants are not specifically called to service. However, it is a military necessity in order to provide medical care for our servicemen.
An additional current problem is the required reduction in total number of medical officers on duty. The Corps was directed to reduce its strength by 839 officers. This was required to meet the present policy of allowing only 3.26 medical officers per 1,000 strength. This policy has been established by Secretary of Defense directive based on a recommendation by the Rusk Committee. This reduced complement is a far cry from the allowance of 6.5 medical officers per 1,000 personnel authorized by Congress, which is still the legal limitation. It comes at a time when naval forces must be dispersed over much of the world and when a true status of peace does not exist. It comes at a time when we are maintaining our largest peacetime military establishment. It comes when advances in methods of warfare are requiring more medical men to become proficient in the extra-clinical medical fields. Serious military medical problems require further study. Many examples could be given of the sort of problems requiring solution which the young civilian physician might not find particularly interesting. Naval flight surgeons must deal with problems such as improved utilization of helicopters for close support of fighting forces and for mass evacuation of military and civilian casualties, improvement in personal survival and protective equipment such as anti-exposure suits, anti-G and high altitude pressurized suits, ejection seats and capsules, crash helmets and anti-noise protective devices. Many visual problems brought about by the extreme speed and altitude reached by new jet planes remain unsolved. Military psychiatrists face the problems of utilization of marginal manpower, prevention of panic in troops as well as communities, improved selection methods for highly skilled expensively trained specialists in the arts and sciences of war. New advances in power plants for submarines increase markedly the military potential of these vessels and at the same time raise many new medical and psychological problems in regard to the crews. Advances in the techniques of amphibious warfare bring new problems in medical support of engaged troops. Deadly new chemical agents increase the duties and responsibilities of the regular medical officer. Each advance in clinical medicine and surgery requires cognizance and proficiency on the part of the regular medical officer so that his patients may continue to receive the best of medical care. Adequate numbers of trained regular medical officers along with other research personnel have a direct bearing on our medical military preparedness. Funds for research are useless without trained personnel to do the work.
This reduction in medical personnel comes at a time when dependent medical care is still considered a factor in the pay and benefits of the serviceman. This matter of dependent care is probably one of the important factors which has led to the reduction in allotted billets for medical officers. It is one which private practitioners often criticize. Yet all career men and officers in the Navy have been led to believe that such care for dependents is a part of their privileges in service and that this was considered as a part of their compensation when service salaries were officially studied by the Hook Commission. Further acknowledgement of the responsibility of the service to provide medical care of dependents was made by the Moulton Committee. It is becoming increasingly obvious that curtailment in this care of dependents will automatically result from the shortage of medical personnel to provide it. Dependents simply cannot be taken care of as before without limitation of the medical care available to the servicemen themselves. Responsible authorities cannot and will not permit this latter to happen.
All these men are real problems and serious problems that require the attention and interest of all senior line officers. If highly trained medical specialists continue to resign from the Navy after 10-15 years of service, thereby voluntarily forfeiting all this credit toward retirement unless remaining active in the Naval Reserve (and resignations so far show a striking percentage of certified specialists), if practically no young graduates accept commissions in the regular Medical Corps, and months pass without a single new commission being granted, and if the pool of trained medical reserves will soon be exhausted, what can personnel of the Navy expect in the years ahead both as to the availability and quality of medical care by the Medical Corps? In fact, will there be a Medical Corps?
Let us look at some of the reasons for this undesirable state of affairs.
Criticisms
Many or most of the criticisms volunteered by officers leaving the service are pertinent not only to medical officers but to the Line and all other Staff Corps. These criticisms have been pointed out in the public press. Reduced commissary and post exchange privileges, weight restrictions on transfer, inadequate per diem, restrictions on concurrent travel of families on overseas assignments, and other limitations of the past few years do not strike solely at medical officers. Similarly such things as changes in “terms of contracts,” with increased retirement restrictions and reduced disability benefits, along with the inadequacy of pay raises to enable a military person to keep up with the cost of living, affect all service personnel alike.
Over and above these, it is in two closely related fields that medical officers center their dissatisfaction. The first might be called an ego factor. No longer does a military officer have the recognition from the public that has long been accorded him. A medical officer constantly is confronted with “Why are you in the service?”—as if to imply— “What’s wrong with you?—You look intelligent!”. Even the medical officer who has a sense of patriotism and responsibility to his country, who adapts to military life and does a satisfying job in his profession begins to wonder, “Is there something wrong with me?” when he continually meets these comments. An organization which must constantly “draft” young colleagues into service and where little or no selectivity or screening for career officers is possible cannot long retain any delusions of being an elite group. Professional ego suffers—and valuable men, sensitive to public criticism, leave the service for civilian professional careers where the worthy man is accorded this necessary esteem.
Why is this pride lacking—why does the public tend to look down on the service medical officer? Aside from the fatigue of the public with war and anything or anyone connected with the military, there are other factors. Medical personnel were admittedly not always utilized well in World War II, and many were loud in their post-war criticisms. Attempts at democratization by the Doolittle Board indicated some of this resentment of things military and at the same time seriously reduced the esprit and self esteem of the regulars in service. The general apathy of the public over the Korean War and the fact that this conflict became a matter of public political dispute added little to the enthusiasm of medical men for service careers. All these things are recognized as
Table III. Comparison op Gross Income or Navy Doctor versus His Colleagues in Civil Life, Salaried, Independent, Specialist and General, Group or Solo
|
Gross Income Navy |
|
Net Income-Average Civilian |
|
|
Lieutenant (jg) |
$ 6,000 |
Salaried General practitioner |
$ 9,063 |
|
Lieutenant (6 years) |
$ 7,297 |
All physicians—salaried Indep. general practitioner |
$10,314 $14,098 |
|
Lieut. Commander (10 yrs.) |
|||
|
General |
$ 8,546 |
General practice—Solo |
$13,819 |
|
Specialist |
$ 8,546 |
Full specialist, salaried |
$11,374 |
|
Commander (17 years) |
|||
|
General |
$ 9,640 |
General practice—independent |
$14,098 |
|
Specialist |
$ 9,640 |
Specialist—independent |
$17,112 |
|
Captain (22 years) |
|||
|
General |
$11,419 |
All physicians—independent |
$15,262 |
|
Specialist |
$11,419 |
Full specialists—gr. pr. |
$17,478 |
the minor criticisms and detractive factors—- but one other problem outweighs them all in the frank private conversations of regular medical officers. This is the major matter of
Economics
Part of a man’s self esteem depends on his ability to provide for his family with a reasonable degree of comfort, and some security for his later years. It is human nature to compare one’s self to one’s colleagues, friends, and professional associates. What does the career medical officer find when he does this?
Medical Economics conducted a survey of the incomes of physicians. The average civilian physician had an income of $25,000 in 1951, with a net income of $15,300. Specialists as expected earned more than general practitioners and private practice was more remunerative than salaried positions. The above table contrasts various sub groups with the income of medical officers in various ranks. These figures are striking. They are vital to the future of navy medicine. Note that a certified specialist in the grade of Lieutenant Commander grosses $2,000 a year less than the average salaried physician, $3,000 less than the salaried specialist, and nearly $9,000 less than the average net of the independent specialist.
No medical officer has any criticism of his civilian colleague but there is a universal desire on the part of the medical officer to more closely approach his rewards.
Table IV. Comparison Between Average Civilian Physician’s Net Income and a Theoretical “Average” Naval Medical Officer 1928-1951
|
|
1928 |
1935 |
1943 |
1947 |
1951* |
|
1. LtCDR MC USN (Over 12 years) |
$4,278 |
$4,278 |
$5,826 |
$5,986 |
$8,094 |
|
“Average” |
$5,000 |
$5,000 |
$6,100 |
$6,500 |
$8,850 |
|
2. CDR MC USN (Over 15 years) |
$5,607 |
$5,607 |
$6,581 |
$7,019 |
$9,609 |
|
3. Average Civilian Physician (Net) |
$5,806 |
$3,792 |
$9,186 |
$11,300 |
$15,262 |
* Includes “equalization” pay.
How does the income of the naval medical officer compare historically with that of the physician in private practice? Medical Economics (October 1952) reported a comparison of civilian practitioners’ incomes at intervals from 1928 to 1951. To compare service medical officers’ incomes two examples are used. One is a medical officer in the rank of Lieutenant Commander with over 12 years service. Two is a medical officer in the rank of Commander with over 15 years service. Note the increasingly unfavorable comparison.
In 1928 commissions in the medical corps were eagerly sought and candidates were numerous. In 1935 entrance into the medical corps was highly competitive and only a very few were accepted. 1947, a year of “peace,” shows service pay approximately 57% that of the average civilian physician. This was a year of continuing exodus of regular officers. But—in 1951 service pay approximated only 51% of that of civilian physicians! A 5% pay increase awarded in 1952 fell short in meeting the need. The officer who lives to retirement does have a modest retirement pay awaiting him. This however stops immediately upon his death. If he should die shortly before retirement there is only the small pension for his wife from the Veteran’s Administration. He actually acquires no equity in retirement pay which would be paid his family at his premature death. Recent legislation permits provision for surviving dependents after an officer’s death provided he died after retirement, and had accepted reduced retirement income prior to his death.
How does the military compare with civilians in government service? Most military medical officers recall quite keenly that in 1951 civil service employees were granted a 10% retroactive pay raise, while service personnel later got approximately a 5% raise which was not retroactive.
How does the military medical officer compare with physicians in the Veteran’s Administration? The Veteran’s Administration offers a top salary in field positions of $12,800. On their basic salaries a 25% bonus is paid for certification as a specialist. Not limited by rank distribution they are able to pay this 25% bonus to all who qualify. Thus with highly trained physicians and surgeons approximately three out of four of their medical staff draw this bonus. Most of their physicians are in the $10,000-$ 12,000 salary range. Deductions for quarters are admittedly nominal, averaging appreciably less than paid by those few service personnel who can get government quarters. But is this salary scale adequate? “Definitely not” according to their officials who are realistically seeking and expect to obtain Congressional approval to raise the limits to a top of $15,000 in order to attract and keep a sufficient number of specialists to care for our great load of veterans. I shall not make this contrast any more specific for there is a basic and important difference between a military career officer and a civilian employee.
It is unnecessary to point out to naval readers the economic problems faced by the service medical officer because these same problems are faced by every enlisted man and officer in the Navy. Rear Admiral George Dyer in an address before the San Diego Chamber of Commerce recently made this point very clear in commenting on the reenlistment rate.
Recent legislation has corrected one serious inequity. Now the career service man can purchase a home with assistance similar to that accorded veterans. This is a distinct improvement. It is one less inducement to leave the service.
Advantages
There are many satisfying attributes to a service career. Many regular officers take justifiable pride in their patriotism, the fact that they are integral members of an important part of our national defense team. Many, regardless of the criticisms and complaints of others, wear (heir uniforms with pride.
Professionally an exceptionally high caliber of medical care is provided service men and, where possible, their dependents. Facilities in general are equipped exceedingly well and special departments, such as X-ray, clinical laboratory, and electrocardiography, are available and well staffed. Post graduate training programs have assured officers the opportunity to achieve the goal of certification as a qualified specialist. The Navy doctor usually has grateful patients. He can prescribe any reasonable treatment for his patients without regard for their ability to pay for it. He works usually no more hours per week than his civilian colleague unless his station is particularly short-handed and extra night watches are necessary or he is assigned to dependent’s care. As his experience and ability increase he goes up in rank to positions of increased prestige and responsibility within his own group. He is a member of a proud organization—the U. S. Navy—with a proud heritage of selfless service—and he finds friends and shipmates wherever he has duty. The young medical officer can specialize in deep sea diving and submarine medicine, or take graduate training in aviation medicine and obtain flight training. He can make a career for himself in medical research. In his daily duties he is assisted by loyal and well trained nurses, medical service corps officers, and hospital corpsmen.
Some few economic advantages remain. When facilities are available he can get hospitalization for his wife and children at economical cost. He can get a small life insurance policy at a rate lower than most commercial insurance.
When all disadvantages and advantages are compared it leads to the conclusion that a naval medical officer must decide whether or not he can accept the reduced financial status in exchange for the pride to him of wearing the uniform. Can he accept the questions of his associates as to why he remains in service when there are more lucrative positions available? Can he afford the hardships of the unsettled life of the career officer for the inadequate rewards and questionable security now offered?
The problem of the serious shortage of career medical officers has been presented as it affects the Navy as a whole. Before attempting to make recommendations as to possible ways to alleviate the problem, certain assumptions will be postulated.
Assumptions
(1) A Medical Corps closely associated with the Line, functioning as a Staff Corps, and controlling its own hospitals and dispensaries is highly desirable. Such an organization with medical officers in uniform is preferable to a unified medical organization, of civilian status, functioning under the Secretary of Defense, charged with the care of all military personnel regardless of service. Factors of morale, administration, command, military readiness, intra-service competition in proficiency, and utility to their patients figure in this assumption.
(2) Integrated military medical specialists fully cognizant of the particular problems of aviation, submarines, general military and field medicine are a prime requirement.
(3) Continued medical research into problems associated with health, manpower, and military medicine is essential to our national defense efforts.
(4) Continued specialization under an aggressive graduate training program is essential.
(5) Medical specialists are vital to proper professional care of naval personnel. A medical officer’s value to the service increases appreciably after he has post graduate specialization.
(6) More medical officers in junior ranks will always be needed.
(7) Changes in privileges and prerogatives of career officers are detrimental to morale when made unilaterally.
(8) Retirement for physical disability in a career officer with honorable service should be a right, and sufficient for the maintenance of his family and his self respect.
(9) Any military officer functions more effectively when financial stresses are not a pressing day to day problem.
(10) Career medical officers’ income should be roughly comparable to that available elsewhere if young medical officers are to again seek and retain commissions.
(11) Physicians increased from 175,382 in 1940 to 211,680 in 1952, a 21% increase compared to a population increase of 15%. Thus any actual shortage of physicians is less acute, although there is a greater demand for services, particularly as people are able to pay for more medical care.
(12) Very few medical men who have been in private practice are interested in a military career, and only a small per cent of medical graduates ever seriously consider a military career. With more than 6000 graduates annually from medical schools only 4-5% are required by the Navy each year to keep the regular Medical Corps in a healthy state, and maintain a ratio of 2 regulars to 1 reserve.
(13) Any solutions to the medical manpower problem should point toward retention of current medical officers, procurement of young graduates for careers, and inducements to these young officers to continue in service after reaching high degrees of professional competence.
Suggested Solutions
Based on these assumptions and on conditions as they now exist in the Medical Corps, the following suggestions are offered as possible solutions to some of the acute problems:
(1) Inauguration of a scholarship program to provide funds for eligible college students to complete four years of medical education in return for four years of service in the naval medical corps upon graduation.
(2) Authorized approval of 20 year retirements at one half of base pay upon application by the individual officer.
(3) Construction of sufficient government quarters at each permanent naval base to house at least 75% of the complement of personnel.
(4) Modification of career plans to allow a medical officer to progress through one of three separate routes, research, clinical, or administrative with equal opportunity for all to reach flag rank. This would eliminate the necessity of a highly qualified professional man leaving his specialty to become Executive Officer and in time, Commanding Officer, of an installation in order to have a reasonable chance at selection.
(5) Continued emphasis on graduate training in order to provide high caliber care to service men and to keep senior medical officers professionally progressive.
(6) Modify disability retirement legislation so that an officer has to complete only 10 years’ service before being eligible for retired pay, with a choice as at present that retired pay be based either on per cent of disability or years of service. Below 10 years’ service the severance pay method would continue to be the settlement for all separated with less than 30% disability.
(7) Institute a 25% bonus for qualified medical specialists, and limit this to officers in the grade of Lieutenant Commander through Captain. This involves adequate career planning.
(8) At the end of four years’ service in the Medical Corps provide an “extension of service” agreement with a bonus of four months’ base pay in grade for a four-year extension agreement.
(9) At the end of the 8th year of service provide a bonus of 8 months’ base pay to the medical officer agreeing to an 8 year “extension of service” agreement.
(10) Regular medical officers currently having between 8 and 16 years’ service would receive one month’s base pay as a bonus for an “extension of service” agreement for each full year of service remaining prior to their 16 years’ total. Medical officers having under 8 years’ service would receive one month bonus pay for each year of “extension of service” to the 8th year, and be eligible for the arrangement of item (9).
Discussion
Scholarships for needy students with a four-year service agreement would do much to provide the necessary 200 or more new medical officers each year.
Twenty-year retirements with a moderate retired pay will enable many officers to plan a career involving a real contribution to the military effort in their earlier years and civilian practice upon reaching middle age when fixed homes are so desirable in so many families.
Adequate quarters simply have not been built to house the expanded military forces. With a long period of cold war apparently ahead, the service officer should not be forced to depend on expensive and often inadequate private rentals which usually cost much more than his allowance.
Much very fine medical talent is currently lost because a career medical officer, after about 22-24 years of service and in his late 40’s, must give up his specialty and become Executive Officer or Commanding Officer of a hospital if he is to have his chance to be selected to flag rank. It is recognized that medical men are necessary in such administrative posts. It is suggested that medical men desiring administrative careers should have this opportunity, and that men making a professional career in a clinical specialty should have an equal chance for the highly competitive reward of selection to Rear Admiral. Likewise research men should be accorded an equal opportunity for this recognized honor. This change in career planning would make a military career more attractive to many young physicians.
Continued graduate specialty training is vital to a progressive Medical Corps and will assure a high quality of care to servicemen.
Formerly an officer physically disqualified for continuance on active duty was retired at 75% of the base pay of his rank. With the Career Compensation Act of 1949, often privately called the “Officer Insecurity Act of ’49” an officer must complete 20 years’ service to be entitled to retirement pay unless he has at least 30% disability. This means an officer of 19 years’ service could be 25% disabled according to standard tables and receive only severance pay. To illustrate the problem of disability, consider the case of a commander nearing 40 who was retired for multiple sclerosis, an insidiously fatal neurologic disease. This officer has had 3 attacks of blindness of several months’ duration, two attacks of paralysis causing several months of invalidism, is completely impotent, and must rest for several hours each day. He has had to give up all his community activities. His life expectancy is seriously reduced. But officially he is only 30% disabled. He is fortunate in that his illness was service connected but such a disability rating is not comparable to the financial security afforded by retirement plans prior to the Career Compensation Act of 1949.
The Navy cannot maintain the generally desirable running mate system for staff corps officers and pay one corps at a different basic salary from another. The extra cost of a medical education and the delayed start of an officer’s earning years were recognized by the $100 a month equalization pay bill passed some years ago. The problem of medical personnel is now more acute. One important approach would be to offer a bonus of 25% of base pay in the ranks of Lieutenant Commander through Captain (this would range from $110 a month to Lieutenant Commanders to $160 a month to Captains) for those who will study sufficiently to meet standards of qualification in a medical specialty.
Similarly the Navy can realistically recognize that a medical officer’s value to the Navy increases roughly in two increments. In his first tour of say four years he gets acquainted with military medicine and probably completes a tour of sea duty. He is then “worth more” to the Navy, and this could be recognized by a bonus of 4 months’ pay for a 4 year extension agreement not to voluntarily resign during this period. During this second 4 year period he is increasing in medical experience, and possibly pursuing graduate study at a naval hospital in a field of special interest. At the end of about 8 years’ service he is a valuable medical officer, often well along toward completion of specialty training. His value to the Navy could then be suitably recognized by his agreement to extend his service for a period of 8 years, for which he would be paid 8 months’ base pay as a bonus. After 16 years no further bonuses are warranted. He could serve for 20 years, for 30, or until 62 years of age, as he wished, or as the circumstances of his career permitted. It is felt this relatively small inducement at the end of 4 and at the end of 8 years’ service, amounting to a total of 1 year’s base pay, around $4,600 in the ranks then attained, would lead to many valuable medical officers remaining in service and be an attraction to other young officers, particularly if coupled with the 25% of base pay bonus for qualified specialists, and 20 year retirement privileges.
Conclusion
The present situation in the Medical Corps is not the fault of any individual. Neither have intelligent Congressmen maliciously taken actions to harm naval officers. In the press of many problems of greater national import, this serious development in the Medical Corps has simply not had the attention focused on it that is required. Steps taken on a policy level have been given careful thought with a view to correcting the personnel problems. But the changing economic picture, including the dollar’s insidious loss of purchasing power, the gradually increasing living costs, and the increasing rewards offered by private medical practice, have combined with a subtle loss of prestige by career officers to put the Medical Corps of the Navy in jeopardy.
Career medical officers remaining in the service love the Navy, cherish its traditions, wear their uniforms proudly—and want to see this serious personnel crisis solved. The problem is acute. Drastic treatment is needed if the Corps is to regain its health or, perhaps even to survive. The remedy seems obvious.