Proposed job cuts in the Military Health Service are fueling concerns about the future of the military's Uniformed Services University of the Health Sciences, which is known as the "West Point of Medicine," the medical school created to fulfill the military's demand for medical personnel after the end of the Vietnam-era draft.

Over the next three years, the Pentagon plans to trim approximately 18,000 uniformed medical personnel from the ranks and replace them with combatants, potentially draining thousands of doctors, nurses and other health care workers from military treatment facilities nationwide.

The proposed cuts will have an impact on medical education because they may potentially leave the military medical school without experienced professors needed to teach medical students. They will also hit hard because there will be fewer practicing specialists in military hospitals to mentor newly minted doctors pursuing specialty training.

The physicians most at risk are those in specialties that are considered less "combat relevant," such as OB-GYN, pediatrics, pathology and radiology, says a notice posted in the Federal Register in May.

"The cuts are real, and actionable information on how many positions and what types – doctors, surgeons, nurses, techs and medical corpsman – isn't readily available," Dr. Arthur Kellerman, a nationally recognized expert in emergency medicine and USU's dean. "There's considerable concern in the academic community, in the military and certainly on the part of my faculty."

Filling those jobs with civilians will be challenging – not least because it will be so expensive. The military pays physicians much less than physicians in private practice earn, Kellerman says. Actually, recruiting fully trained, practicing physicians – trauma surgeons, emergency physicians, anesthesiologists, pediatricians – into the military will be virtually impossible.

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"It will be extraordinarily difficult for people to decide at that point in their career that they're going to put on a uniform, serve their country and prepare to deploy," he says.

A May 17 Board of Regents report says the medical school's faculty, students and leadership are deeply concerned that these large scale cuts at military hospitals "will substantially harm" the school's ability to train doctors, nurses and technicians who care for active-duty members and their families and operate out of backpacks on the battlefront.

"Since these programs generate the future workforce on which the U.S. military depends, this could have far-reaching consequences," the report states.

A provision to delay or eliminate the cuts has reportedly been added to the already contentious 2020 National Defense Authorization Act. The act, which would allot more than $730 billion for the Department of Defense, contains such controversial appropriations as money for President Donald Trump's border wall. The House and Senate versions of the bill will be debated, and must be reconciled for the president's signature, in a joint conference committee after the August recess.

Opponents say the proposed cutbacks pose a significant threat, not just to graduate medical education, but also to the $50-billion Military Health System itself, says a high-ranking military physician who asked that his name be withheld to avoid retaliation from superiors. "Once you start pulling on the thread of graduate medical education, the whole Military Health System comes unraveled," he says.

That's because more than a quarter of the 4,500 doctors in the military are either recent graduates from the military's medical school in specialty training programs or faculty members who train them. Both play a vital role in caring for patients at military teaching hospitals.

The biggest hospitals – Walter Reed National Military Medical Center in Bethesda, Maryland, Portsmouth (VA) Naval Medical Center and the San Diego Naval Medical Center – will suffer the biggest cuts, officials say. They are also the nation's premier military teaching hospitals.

Walter Reed alone may lose a third of its workforce, roughly 1,000 of 3,000 uniformed medical jobs, which include about 1,600 Navy, 1,400 Army and 100 Air Force personnel, says Michael Heimall, Walter Reed's former commander.

One of the military's premier teaching hospitals may be spared some of the most Draconian cuts but no one is certain. Brooke Army Medical Center in San Antonio, is the military's only Level I trauma center. Nothing is more "combat-relevant" than trauma surgery.

"Honestly, we don't know yet," says Col. Patrick Osborne, BAMC's deputy commander of surgical services.

Because surgery plays such an important role in battlefield care, BAMC is doubly important, as a setting where experienced trauma surgeons can both polish their skills and teach the next generation of trauma specialists. "I think for the surgeons, pretty much everybody has some role in resident education," Osborne says.

Graduate medical education, experts say, is the infrastructure that locks young physicians and senior faculty members into the military. Medical students at the military's Uniformed Services University of the Health Sciences do not pay tuition. Instead, they're paid a salary "exceeding" $64,000 per year.

In return, they pledge to spend at least seven years in the Armed Forces after completing their residency. Most do much more. For some, it's an appealing alternative to civilian medical school – a way to make a living while in medical school and escape the crushing burden of student loan debt.

Dr. John Holcomb, who joined the Army to pay for medical school and rose through the ranks for 23 years – eventually heading up the U.S. Army Institute for Surgical Research – cautions that the Army exacts a price for a medical education.

Doctors who take advantage of military medical training must repay their debt by spending years in the service, moving from place to place and deploying to conflict zones for months at a time.

"The education isn't free," says Holcomb, director of the Memorial Hermann Texas Trauma Institute. "There's a time commitment – a very well-defined time commitment."

Doctors must serve one year in the military for every year of training, with a minimum commitment of seven years. The student's debt begins accumulating in medical school. With internship and residency training, that student's obligation can extend to a decade or more, which begins only after training ends.

A military general surgery residency, for instance, includes five years of intensive surgical training with an additional year for research – which is mandatory and adds one more year to the doctor's service obligation.

Subspecialty training in vascular or trauma surgery extends the obligation for three years or more. Once they've finished their training they're well on their way to earning full retirement, in 20 years, which nets the physician a full pension that over time can amount to millions of dollars.