Surgical care has now become increasingly subspecialized and highly dependent on minimally invasive technology. Military surgeons face a unique challenge in that they serve as a 'jack-of-all-trades' in an austere environment while deployed, only to return home to the expectation that they will compete with the standards of civilian surgical care.
To address this issue, authors of a new article appearing online in the Journal of the American College of Surgeons ahead of print publication propose a new education and training paradigm that will benefit military surgeons and ultimately their patients in both practice environments.
"The biggest hurdle we have to overcome is lack of operative activity. Evidence suggests that we fall significantly below our civilian counterparts in both overall case numbers and in case complexity," said lead author U.S. Army Colonel Mary J. Edwards, a pediatric surgeon at San Antonio Military Medical Center, Texas.
- Core surgical competence: the basic credentials, training, and skills, usually obtained through graduate medical education and in-garrison surgical care, which form the foundation for readiness skills.
- Basic and advanced medical combat readiness skills: the basic essential medical skills required for all military medical personnel deploying to a war zone, and advanced surgical readiness skills that allow members of surgical teams to deploy and optimally perform in their assigned roles.
- Mission specific medical readiness skills: the required skills to perform a specific deployed surgical mission.
In terms of Level 1 of their proposed training, the article's authors suggest that stateside Military Treatment Facilities (MTF) be evaluated to become verified trauma centers within their community and with the American College of Surgeons (ACS). This proposal would expand the role of the MTFs which the military currently relies on for its local credentialing committees to ensure the clinical proficiency of their surgeons.
Further, every military hospital would actively develop cooperative agreements with surrounding hospitals to allow military surgeons to provide care for civilian patients-stationing military physicians at Level I trauma centers will ensure these providers are constantly engaged in active trauma practice and are available to mentor additional military trainees, according to the authors.
However, maintaining critical skills for military surgeons runs in two directions. Not only is there a need for a closer relationship between military and civilian surgical care, but military surgeons also need to possess a unique set of skills for performing operations while deployed.
"Wartime surgery requires specific skills that cannot be completely obtained with practice at modern civilian trauma centers alone," the authors noted. "War surgery requires aggressive operative intervention, frequently with staged procedures and often in an austere environment with no access to basic X-ray and lab capability and no local subspecialty support."
For military surgeons to be properly prepared, training such as The Tactical Combat Casualty Care Course and the Operational Emphasis version of the ACS Advanced Trauma Life Support (ATLS) course should be ongoing, and all deployed surgeons should receive timely training in war surgery evaluation and treatment and the Joint Trauma System's clinical practice guidelines, according to study authors.
However, training alone does not suffice for military surgeons to be properly prepared to compete with civilian care. "No amount of predeployment training can make up for lack of operative activity on a day- to- day basis," said Dr. Edwards. "This shortcoming is the biggest challenge our surgeons in uniform face today."
Authors suggest that because maintaining a complete set of trauma-ready skills for all military active duty and reserve general surgeons may not be achievable, emphasizing a team approach is important. They suggest the designation of surgeons being deployed as either 'trauma ready' or 'trauma assist', with trauma ready surgeons being matched to high-volume missions and solo surgeon locations, and trauma assist surgeons being matched to a location that already has a trauma ready surgeon.
"The military views every surgeon who at one point completed a surgical residency equally in terms of their ability to provide combat casualty care," according to the authors. "This [viewpoint] potentially sets the provider and the care team up for failure."
Authors suggest that trauma surgical capabilities be shared jointly between the Army, Navy, and Air Force, and the most qualified surgeons be deployed as 'trauma ready', regardless of service or active/reserve status. Further, authors suggest that a fellowship-trained trauma medical director be designated for every area of operations to function as the area leader in trauma system development and performance improvement.
"As surgery in the United States becomes more subspecialized and technology dependent, the military must leverage its requirement for general surgeons who are able to function in austere environments with limited communications and equipment, with the appropriate expectation of a very high standard of surgical care to our beneficiaries when returning to the United States," the authors noted.