The military doctorBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.b5437 (Published 06 January 2010) Cite this as: BMJ 2010;340:b5437
Jo Stephenson looks at a career in the armed forces and asks how recent events in Iraq and Afghanistan have affected the profession
Consultant anaesthetist Gavin McCallum was on a mission to pick up casualties in Iraq when he was shot.
He was in a helicopter with another doctor, an operating department practitioner, and some paratroopers, responding to one of the bloodiest incidents of the second Gulf War, when the craft was attacked.
“We came under sustained small arms and rocket propelled grenade fire,” he says. “Five people in the helicopter were seriously injured and I was clipped by a round.”
Shot in the calf, his first priority was to treat those who’d been gravely hurt. “It was a flesh wound,” he explains. “All I could see were two holes in my trousers with smoke coming out—then it was sore. But it didn’t stop me functioning. It was a high adrenaline situation.”
You might imagine tales like this would deter doctors from joining the armed forces. But contrary to expectations, recent and ongoing conflicts have led to increased interest in military medicine, according to the Royal Air Force (RAF), the Royal Navy, and the army.
Doctors are attracted by the chance to practise in challenging environments and the variety of military medicine and life.
Senior military medics say there is often a surge in interest from healthcare professionals in the light of high profile conflicts because doctors see that they are needed.
The experience of being injured while serving with the RAF Reserves didn’t put Wing Commander McCallum off. After two operations on his leg he went back to the NHS but continued with the Reserves as clinical director of his squadron and helped to train other military medics, joining the RAF regulars this year.
“A lot of the work is damage control on seriously ill people,” he says. “It is work you don’t do in the NHS. You wouldn’t see as much trauma in any other circumstances.”
Recruitment, roles, and training vary for doctors entering different forces and there are also roles in reservist organisations—the RAF Reserves, the Territorial Army, and the Royal Navy Reserves.
Most doctors enter the regular forces through cadetships and are sponsored through part of their medical degree.
Cadetships are managed by individual forces but are generally worth about £15 000 (€16 500;$24 000) a year for three years, plus tuition fees, in return for six years’ service after doctors have completed foundation year 1. A smaller number of doctors join at a later stage in their training or when they are fully qualified.
Medical cadets start specialist training one to three years after their NHS peers, depending on which force they go into. This is overseen by a joint forces Defence Postgraduate Medical Deanery.
The army awards up to 30 medical cadetships every year. Cadetships are popular but there are shortages of trained doctors such as general practitioners (GPs) and in a few hospital specialties.
“This situation will improve as more army doctors complete their specialist training,” says a spokeswoman. The army only takes fully trained general practitioners and hospital consultants as direct entry applicants, but from 2013 there should be space for those who’ve completed the foundation programme but who have not yet started specialist training, she adds.
Medical cadets are encouraged to get involved in military life. For example, navy cadets are encouraged to join their local university Royal Navy units, which have dedicated training boats.
After completing foundation training, doctors spend six months on officer and military medical training and about 18 months as general duties medical officers. Most are placed with one of six medical regiments. But a few, such as Captain Hamish Reid, are posted to specific army regiments.
Reid is based at the medical centre of the 22 Royal Engineer Regiment at Tidworth, Wiltshire and hopes to go on tour next year.
“I didn’t fancy going straight into the NHS rat race from one job to the next up the old career ladder,” he says. “I was keen to get some broader experience of medicine.”
He particularly values the independence he has as a junior doctor in the forces. He has his own general practice list and more freedom and responsibility than he would have in the NHS.
Captain Reid also relishes other aspects of military life, not least opportunities to do adventure sports—he’s planning to row the coast of Britain with a fellow army doctor—and get involved in regimental life, including going on exercises.
He has made the most of the varied training opportunities available to military doctors and is in the first year of a postgraduate masters degree in sport and exercise medicine.
Rehab work in the army is also very different to the NHS, where doctors tend to work with elderly patients. “You’re working with young, fit guys who can get back a real quality of life,” says Captain Reid. “That gives you a lot of job satisfaction.”
Once army doctors complete their specialist training, GPs serve as regimental medical officers caring for soldiers and their families in military practices in the United Kingdom, Germany, Cyprus, and Brunei. Many accompany their regiments on tours of duty for up to six months every two to three years.
As in other forces, hospital consultants work in NHS hospitals. Currently, army consultants are likely to be deployed to the Field Hospital in Afghanistan for up to three months every year.
Territorial Army medical services recruit medical students from year four onwards and recruit most types of surgeons and consultants when they are fully qualified.
The RAF can sponsor up to 25 medical cadets a year. “I could fill those slots three or four times over,” says Group Captain Gordon Allison, deputy assistant chief of staff for medical professional support. Doctors complete their foundation programme, then do the 13 week specialist entrant and re-entrant course before undergoing further military medical training split between RAF College Cranwell, the RAF Centre of Aviation Medicine, and the Defence Medical Services Training Centre at Keogh Barracks in Hampshire.
They generally benchmark a year later than their NHS peers. Before starting specialist training they’re sent to units in the UK or Cyprus where they do general duties for six months, seeing patients under supervision.
Doctors training to be GPs do hospital rotations in the NHS, usually in a Ministry of Defence hospital unit, and then go to a military unit such as an RAF station, which has its own trainers. They also usually spend time in an NHS practice.
Once they get their GP certificate they are deployed on operations, having had extra training including pre-hospital emergency care and how to handle a weapon to protect themselves and patients.
In time, medical officers on a unit can apply to train as consultants in public health, occupational health, or aviation medicine. They can also become GP trainers and develop a special interest.
As in other forces, consultants will be deployed to a field hospital a couple of months every year.
Only in the RAF can anaesthetists be part of a critical care air support team, which transfers patients who are injured but stable to the UK. Or—as in the other armed forces—they may be part of a medical emergency response team, which resuscitates casualties in situ and brings them back to base.
Need for GPs
The RAF is keen to recruit more GPs and, as with other forces, direct entry GPs and other specialist groups may be eligible for a golden hello of about £50 000.
The retention rate for military GPs is often slightly lower than the NHS because of family ties and because pay does not match the highest NHS GP salaries—although it is above average.
Nevertheless, Group Captain Allison, who joined the RAF after the first Gulf War, has seen a considerable increase in interest. “I have got about 20 qualified GPs in the pipeline for recruitment,” he says. “In the past if I had three I thought I was doing well.”
The RAF Reserves are currently looking for GPs, orthopaedic surgeons, general surgeons, and general physicians.
The Royal Navy
The Royal Navy offers about 15 medical cadetships a year. “We get quite a few applications as it’s an attractive package and there’s such a variety of opportunities,” says Lieutenant Alison Embleton, specialist recruiter for nurses, dentists, doctors, and medical reserves.
Foundation year 1 doctors do a placement in a Ministry of Defence hospital unit, then officer training at Dartmouth plus a new entry medical officers’ course at the Institute of Naval Medicine. The navy also recruits about five direct entry doctors a year.
The Royal Navy Reserves only take consultants. About 35 are trained by specialist reserve units, attending weekly sessions, several training weekends, and a fortnight’s training each year.
Most reservist doctors are deployed, when needed, to the navy’s Primary Casualty Receiving Facility, the Royal Fleet Auxiliary Argus, which has a 100 bed hospital on board.
Surgeon Commander Stuart Millar is career manager for navy medical officers.
His father and grandfather were military doctors and he joined the navy as a medical cadet, serving in Sierra Leone, Kosovo, and Afghanistan. He says his time in Afghanistan was “professionally the three most rewarding months of my career.”
“Everything we do is about supporting ops,” he says. “That was when the impact of the work I was doing was most tangible—giving direct support to the guys on the ground. The people we treated were going out the front gate into a very dangerous environment.”
Pros and cons
Nevertheless, he’s straight with medical students and doctors about the pros and cons of navy life.
“The pros are general duties time, shared ethos and values, and working for a very professional organisation,” he says. “Doctors have diverse roles on a ship and then there’s the officer side of things such as leadership and management as well as opportunities to practise in a challenging environment and different situations, some of them extreme.”
Then there are the cons. “You’re going to be three years behind compared to the outside world. And there are specialties we don’t have in the navy, such as obs and gynae, paediatrics, and geriatrics, so you need to be sure you don’t want to do those.”
In the navy, junior doctors do general duties for two and a half to three years, having been assigned to a submarine, the Royal Marines, or a ship.
A junior doctor may be the only doctor on board a ship for a seven month stint, but he or she will have access to support and advice from senior medical officers on shore and will be well prepared through training, says Surgeon Commander Millar.
Doctors who go to a Royal Marine unit have the chance to undertake the all arms commando course and earn a coveted green beret.
As part of specialist training doctors can apply for overseas fellowships that might include working at US trauma centres or even with flying doctors in Australia.
But unlike in other forces, navy GP practices in the UK don’t cater for families, so GPs tend to do two days in a navy practice and three days in a general one. The opportunities are exciting in all three forces, but Millar is keen to hammer home one point.
Service comes first
“The needs of the service come first—recruits are serving Queen and country,” he says. “We try to accommodate personal wishes and ambitions, but basically if they’re told to do something they have to do it.”
Medics do face danger, but Wing Commander McCallum is believed to be the first doctor wounded in action since the second world war.
“You have to be fit. It’s a rough, tough life living in tents and you don’t get to see your family,” adds McCallum, who has two young sons. But he’s driven by a conviction that military personnel deserve top quality medical care.
“Infantry soldiers in particular do a job I really wouldn’t like to do, and do it really well,” he says. “We as taxpayers are sending them out to get shot at, so they deserve the very best level of care.”
Case study: Squadron Leader Ken Murray
Squadron Leader Ken Murray joined the RAF after working as a GP partner in a Glasgow practice and in a rural practice in Stornoway.
He was initially posted to Cyprus for three years. Now a senior medical officer, he runs the medical centre at fast jet station RAF Wittering. There are three full time doctors for 2500 patients.
“One advantage in the military is you have more time to spend with patients and to practise quality medicine,” he says. “The RAF has a very high doctor-patient ratio.”
His first deployment was to the Falklands and he was in Iraq for two months in 2007.
“That involved some pretty scary flights over the roof tops of Basra to pick up people who had been mortared or hit with rounds,” he says. “But you’re very well trained. I went from GP to pre-hospital care doctor in a war zone, which was quite frightening at times but also exhilarating, as you felt you were saving lives.”
His most recent deployment was to Afghanistan, which included transferring casualties on night flights from Bastion to Kandahar.
“You look after the enemy as well as civilians caught up in the fighting,” he says. “People may wonder: how does a doctor and war go together? But we’re trying to reduce casualties and the amount of death and pain on both sides.”
He likes the variety. “I can be in a consulting room dealing with a chest infection then five minutes later I’m in a helicopter.”
He’s also taken advantage of funded training to become a member of the Royal College of General Practitioners and a GP trainer and has done a diploma in occupational medicine. Next summer he starts a four year training programme in the RAF to become a consultant in occupational medicine.
Squadron Leader Murray admits it is hard being away from his family, but he enjoys the camaraderie in the forces.
“There’s a great sense of family in the RAF,” he says. “Sometimes in the NHS you feel you’re just a doctor in a box. Here you’re very much part of a team.”