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The Surgeon General is part of a completely separate branch of uniformed services from the rest of the military. They are called the United States Public Health Service Commissioned Corps. Officers within these Corps are appointed and given direct commissions. They share the same pay grades as the U.S. Navy and wear similar uniforms, but wear different insignia to distinguish them. By law, specific positions are assigned pay grades. The Surgeon General necessarily holds the rank of Vice Admiral. A full 4-star Admiral, David Satcher, once held the position of Surgeon General. He was also serving as the Assistant Secretary for Health simultaneously, which is a 4-star office. Further reading: http://en.wikipedia.org/wiki/United_States_Public_Health_Service_Commissioned_Corps
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