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, which has become increasingly subspecialized and highly dependent on minimally invasive technology. To address this issue, authors of a new article in the Journal of the American College of Surgeons are proposing a new education and training paradigm that will benefit military surgeons and ultimately their patients in both practice environments.

The research team, consisting of surgeons from the San Antonio (Texas) Military Medical Center, the Naval Medical Center, Portsmouth, Virginia, and the Department of Defense Joint Trauma System, US Army Institute of Surgical Research, San Antonio, identified three levels of surgical education and skills training for military surgeons to participate in to sustain surgical skills:

  • Core surgical competence: the basic credentials, training and skills that are usually obtained through graduate medical education and in-garrison surgical care that 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 Level 1 of their proposed training the authors suggest stateside Military Treatment Facilities (MTF) be evaluated to become verified trauma centers within their community and with the American College of Surgeons (ACS). This would expand the role of the MTFs the military currently relies on for its local credentialing committees to ensure the clinical proficiency of their surgeons.

In addition, every military hospital would actively develop cooperative agreements with surrounding hospitals to allow military surgeons to provide care for civilian patients. The authors say 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.

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, the authors say 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.

However, training alone does not suffice for military surgeons to be properly prepared to compete with civilian care, according to lead author U.S. Army Colonel Mary J. Edwards, MD, FACS, a pediatric surgeon at San Antonio Military Medical Center, Texas. “No amount of predeployment training can make up for lack of operative activity on a day- to- day basis,” she says. “This shortcoming is the biggest challenge our surgeons in uniform face today.”

The authors suggest emphasizing a team approach is important, because maintaining a complete set of trauma-ready skills for all military active duty and reserve general surgeons may not be achievable. 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.

They also suggest that trauma surgical capabilities be shared jointly between the Army, Navy and Air Force, the most qualified surgeons be deployed as “trauma ready,” regardless of service or active/reserve status, and 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.

(The other article coauthors are Kurt D. Edwards, MD, FACS, COL, MC, USA; Christopher White, MD, FACS, COL, MC, USA; Craig Shepps, MD, FACS, CAPT, MC, USN; and Stacy Shackelford, MD, FACS, Col, MC, USAF.)