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perceived as having the best lifestyle among military medical system. Specifically, our principal hypothesis was that this
students, yet more than half of the cohort chose primary care increased institutional momentum would result in students
or a specialty that was viewed as having a “non-controllable” more frequently selecting operational specialties. Second, we
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lifestyle. Overall, the MHS environment likely results in dif- hypothesized that there would be a decrease in retrospective
ferent factors influencing future physicians’ specialty choice student satisfaction with the decision to attend medical school
compared with their civilian counterparts. due to students perceiving less control in choosing their future
specialty. To test this hypothesis, we conducted a retrospective
Defense Health Agency Transition analysis of survey data from USU classes from 2015 to 2020.
In addition to the inherent financial influence of an MSO, op- Our goal is to provide insight into how the DHA transition in
erational needs in the MHS have affected specialty availability 2017 impacted USU students’ specialty selection and satisfac-
and, therefore, may also influence specialty selection within tion with the decision to attend medical school.
the military.
Methods
The Defense Health Agency (DHA), a medical combat support
agency founded in October 2013, oversees and unites different In 2021, we conducted a retrospective analysis of anonymized
aspects of military medicine. The DHA’s role drastically in- responses (from the years 2015 to 2020) to the Association of
creased in 2017 with the passing of the National Defense Au- American Medical Colleges (AAMC) Medical School Gradua-
thorization Act (NDAA). Specifically, the 2017 NDAA tasked tion Questionnaire (GQ). The GQ is a national questionnaire
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the DHA with overseeing the various Military Treatment Fa- administered by the AAMC. It is voluntary, anonymous, and
cilities (MTFs) and implementing critical changes to medical administered via a secure, individualized web link to medical
personnel operating at those MTFs. Critically, the NDAA also students throughout the United States. 8–10 While the GQ in-
provided authority to convert military medical authorizations cludes a variety of questions, we analyzed responses pertaining
to civilian positions if positions were deemed unnecessary to to career intentions and the satisfaction with having attended
meet the needs of the operational medical force. This change medical school in retrospect for our study.
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paved the way for specialties to be deemed “non-operational,”
considered to have less wartime relevance. Importantly, the The study was limited to responses from students attending
DHA has not formally defined which specialties are consid- USU. The participants in this study consisted of post-match
ered “operationally” or “wartime” relevant. USU fourth-year medical students from the years 2015–2020.
These years were specifically chosen on the basis of the passing
With the expansion of the DHA, there has been investigation of the NDAA in 2017. This study was reviewed in January
and scrutiny directed toward the low numbers of physicians 2021 by USU’s Human Research Protections Program Office.
trained in “critical wartime specialties,” such as critical care As the data were collected anonymously, known by students to
medicine, trauma surgery, aviation medicine, and cardiotho- be released in aggregated form to the public, and posed no risk
racic surgery. In an official congressional report, there was a to participants, it was determined to be research not involving
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question of why the military does not “channel students into human subjects (protocol DBS.2021.198). This study was ap-
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residencies for the specialties in most critical need.” Congress proved by the USU Institutional Review Board.
subsequently reported these specialties as having “critical gaps”
and demanded corrective action be taken to address the short- Classification of Specialties by Operational Capability
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age. A separate investigation filed to Congress by the Govern- Although the DHA has not formally defined or labeled opera-
ment Accountability Office reported similar data, with gaps in tional relevance, information about the operational relevance of
several wartime specialties below 80% of authorized levels. 3 the various specialties was communicated via briefs to military
medical students applying for the match. For the purposes of
In a July 2021 report to the Congressional Armed Services our analysis, we assigned different specialties a specific opera-
Committees, the NDAA for FY 2020 section 719(c) recom- tional label based on what was communicated to medical stu-
mended and planned for the realignment of 17,500 uniformed dents leading up to the match process. Specifically, we assigned
billets (later reduced to 12,801) from the MHS into opera- specialties to one of three potential operational categories: clear
tional forces in fiscal year 2020. The goal was to “increase the operational capability, limited operational capability, or mini-
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number of operational billets needed for lethality,” matching mal/no operational capability. Specialties and their respective
similar sentiments from the NDAA in 2017 and prior congres- operational capacity categories have been designated in Table 2.
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sional reports. The 2021 report further stated that in cir-
cumstances where GME requires a specialty that is considered Analysis
non-operational, it will utilize civilian hiring or a network We analyzed general demographics, baseline characteristics,
solution, implying that non-operational specialties may not be and responses to the following two questions: (1) “When
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available for active-duty personnel in the future. While the thinking about your career, what is your intended area of prac-
proposed elimination of non-operational specialties has not tice?” and (2) “If you could revisit your career choice, would
yet come to fruition, such verbiage has provided a strong sig- you choose to attend medical school again?” A Fisher exact
nal to current and future medical students. Of note, the terms test with Monte Carlo simulation was used to evaluate statisti-
“wartime” and “operational” are considered interchangeable cal differences in baseline characteristics among students from
for the purposes of this study. 2015 to 2020. This method was also used to compare whether
the distribution of responses to the variables of interest varied
We suspect that the MHS’s increased emphasis toward oper- significantly over time.
ational specialties may impact military medical students’ ca-
reer preferences in the same way that civilian students respond In addition to analyzing for variation in the provided responses
to the supply and demand model of the civilian healthcare to the GQ, we sought to answer whether there was a potential

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