Educating and training US Military health professionals in various service branches is an enormous, complex task as MS&T’s Robert W. Moorman discovered.

The number of people to be served underscores the need for an evolving education and training system for US military doctors, nurses, medics and related staff. The US Military Health System (MHS), a unit of the US Department of Defense (DOD), provides health care to 1.4 million active duty and 331,000 reserve personnel as well as retired service members.

Education Avenues

First, some basic information on initial training/education and cost. Numerous doctors, nurses, medics and other health-related professionals serving in the MHS obtain their initial training at civilian medical schools. Others go to the Uniformed Services University of Health Sciences (USUHS) in Bethesda, Maryland. Enlisted Solders, Sailors, Airmen and Coast Guard personnel receive fundamental instruction at the San Antonio, Texas-based Medical Education and Training Campus (METC), a university-like administration with around 50 programs of study available. Some foreign military students are accepted. MHS also provides ongoing training and continuing education at various locales/bases throughout the US to keep members’ skills current and ready for deployment. Each military medical treatment facility (MTF) has its own education and training facility as well. The Defense Health Agency (DHA), established in 2013, work to coordinate and standardize these efforts.

Avenues exist for medical students wanting to defray the cost of education. Prospective military doctors can apply to the Health Professions Scholarship Program (HPSP) before entering the first year of medical school. The military pays 100% tuition for HPSP students, along with a $2,000 plus stipend for officer physicians. Some specialist physicians can receive a $20,000 signing bonus. Medical students also are eligible for low interest loans through the Active Duty Health Professions Loan Repayment Program (ADHPLRP). Loans vary from $120,000 to $250,000, for physicians with certain specialties. In exchange, the military requires doctors to serve a minimum of two years or longer if they accept a signing bonus or tuition aid. If students join HPSP before the first year of med-school, they owe the military four years of active duty service. Students, who attend and graduate from USUHS, must serve a minimum of seven years, not including obligations previously incurred or after graduation, according to DHA. Primary difference between HPSP and USUHS attendees is their military status. HPSP students are commissioned as officers in the Individual Ready Reserve, whereas USUHS graduates are active-duty officers, who spend more time in the military.

Civilian Connections

Partnerships play a critical role in training and maintaining skills of military medical professionals. “Many military medical treatment facilities have a patient population and case-load that are not ideally suited to some of the skills military medics [doctors and nurses] need, so MHS works with other government (i.e. Veterans Health Administration), private and university health systems across the country,” said USAF Brigadier Gen. Anita Fligge, Deputy Assistant Director, Education and Training, DHA. “Training in an outside environment allows for better immersion in a simulated deployment setting. Some partnerships are established at the military level and some at the individual MTF level to address the specific skills needed at that installation.”

Partnerships can involve international partners, such as the United Kingdom National Health Service and US civilian hospitals, said Fligge.

Medical LVC

Many of the training programs, such as life support/cardiopulmonary resuscitation (CPR) and automated electronic defibrillator (AED) utilize medical modeling and simulation technologies as well as manikins or simulators. Some medical training blends Live, Virtual Reality (VR) and Augmented Reality (AR) disciplines. Technologies of Live-Virtual-Constructive & Gaming (LVC-G), combined with AR or VR, “are proving to be important and useful innovations” in training military medical personnel,” said Fligge.

Training starts with Live training typically, then moves to a “Virtual” environment at various locations, then to “Constructive,” which is a combination of Live-Virtual. “The programs finish with simulation gaming to solidify the training,” added Fligge. Additionally, METC’s training allows students to hone their skills using advanced human-patient simulators, digital anatomy tables, mock intensive care units and operating rooms. The use of simulated combat settings prepares doctors, medics and nurses for in-theatre operations.

Cooperation

Colorado Springs, Colo. is home to numerous military installations. UCHealth's Southern Colorado Region has an agreement with Evans Army Community Hospital at Fort Carson, the Air Force Academy (AFA) Hospital, and Peterson Air Force Base (whose personnel use Fort Carson’s hospital) to share staff and provide a venue for skills sharpening of military doctors, nurses and medics. UCHealth is an Aurora, Colorado-based non-profit health care system with hospitals and facilities throughout Colorado. Three Air Force and two Army surgeons rotate at UCHealth Memorial Hospital Central, a designated Level 1 trauma center. The number of surgeons can vary due to deployments and official travel. Military nurses work alongside doctors in the emergency room and in the intensive care unit at the hospital. “It is evolving,” Ron Fitch, Vice President of Operations and Military Affairs for UCHealth’s Southern Colorado Region said of the partnership. “A unique aspect of the Colorado Springs area is that we have a military health system that involves numerous military establishments.”

UCHealth Colorado has agreements with local Army and Air Force bases to share staff and provide a venue for skills sharpening of military doctors, nurses and medics. Image credit: UCHealth.

Schriever Air Force Base, ten miles east of Peterson AFB, is also part of the mix. UCHealth is developing a relationship with Buckley AFB in Aurora, an eastern suburb of Denver. Aurora also is home to the Center for Combat Research at the University of Colorado Anschutz Medical Campus (CU Anschutz), which houses the university’s six health sciences related schools and colleges. UCHealth has an additional cooperative agreement with the Army Special Operations Command at Ft. Bragg, North Carolina.

As for the cross-over benefit for military and civilian communities, Fitch added: “We are always ready to share best practices, posting special forces medics at educational sessions in the trauma and other departments of UCHealth. Civilian doctors, nurses and medics get to hear about what their military counterparts see on the battlefield.”

Those best practices include sharing methodologies on orthopedic and blunt force trauma, gunshot wounds, prosthetics and use of whole blood on patients, who’ve sustained significant blood loss due to trauma or surgery.

These collaborations are needed. According to a UCHealth news release, the American College of Surgeons published research years ago, in which the lead author, a pediatric surgeon at San Antonio Military Medical Center stated that “evidence suggests that we fall significantly below our civilian counterparts in both overall case numbers and in case complexity.”

Other examples of ongoing partnerships between civilian and military entities include: the Army’s Field Medic Training at Camp Bullis at Joint Base San Antonio (Texas) and with the Air Force Center for Sustainment of Trauma and Readiness Skills program at its locations in St. Louis, Missouri; Baltimore, Maryland; and Cincinnati, Ohio. The MHS, in conjunction with various military branches, also provides continuing education to help active duty and reservists maintain their skill levels. (see Post-Graduate Learning sidebar)

Ongoing Restructuring

The MHS, which has a $50 billion annual budget, is in the midst of a multi-year restructuring effort, where administrative responsibility for the military hospitals and clinics will come under the DHA. MHS is the umbrella under which the entire spectrum of military medicine resides.

Deputy Secretary of Defense David Norquist’s 90-day pause in transitioning military hospitals and clinics to the DHA due to the Department’s focus on Covid-19 efforts expired June 30. But, because the virus has spiked in numerous US states (22 as of mid-June), that pause in the transition is likely to be extended. Nevertheless, much is known about the restructuring and realignment plans. Next step is the planned transition of five markets, where a market is defined as a group of military hospitals and clinics working together in one region. The first markets will be Tidewater, Virginia; San Antonio, Texas; Colorado Springs, Colorado; Puget Sound, Washington; and Hawaii. The markets will operate as a system that shares patients, staff, budget and other functions to improve the capabilities of health services.

Eventually, DHA will establish 21 markets where DOD “has large concentrations of facilities and patients,” according to MHS senior officials, who provided input to questions posed by MS&T. “Markets will be concentrated at large medical centers and centers of excellence for specialty care that meets needs of beneficiaries across their region.” DOD plans to reduce operations at 48 facilities and “expand or recapitalize operations at two others.” Names of the two facilities were not divulged.

Around 200,000 of MHS's beneficiaries, two percent who receive care at MTFs, will transition to civilian providers in the TRICARE managed networks as 31 facilities transition from providing outpatient services to care for only active-duty personnel. This transition will take time – in some cases several years, said DHA. Partnerships with their civilian counterparts will continue to be an integral part of the MHS. Efficiency, cost-reduction and enhancement of care are factors, but there are other reasons for combining care systems and skills of military and civilian medical professionals.

“It exposes you to a wider range of medicine that you might not see on a military base alone,” said Dr. Keyan Riley, an Air Force Reserve trauma surgeon, who participated in the program. “There also is a tangible benefit to taxpayers when military surgeons take lessons learned in civilian trauma centers to the battlefield.” Some military medical professionals have personal reasons for sharing skills with their civilian counterparts and vice versa. “A number of former military surgeons, other doctors and nurses want to give back by teaching, being a mentor,” summed Fitch.

Post Graduate Learning

The David Grant USAF Medical Center (DGMC) at Travis AFB in Northern California is the Air Force’s largest medical center in the US. DGMC also is Joint Commission-accredited teaching hospital with training affiliations with several California hospitals, universities and other institutions. They include: The University of California-Davis School of Medicine, Children’s Hospital Oakland, Kaiser Permanente, Northbay Healthcare and VA Northern California Health Care System. DGMC (in-house and through these affiliations) offer 18 graduate level medical education courses for doctors, nurses, medics, social workers and others. Students include enlisted personnel. Courses include: family medicine, radiology, social work, emergency medicine, oral and maxillofacial surgery and trauma care.

“We want to expose students to a broad range of health care subjects,” said Col. Heidi Gaddey, Director of Medical Education at the DGMC. “So, our affiliations with these med schools offer the full range of services.”

Gaddey added: “Many of our active duty physicians, who need to maintain their skill set in trauma care, are able to go to our civilian partners and obtain experience to prepare them for deployment.”

For doctors, the length of the residency program is based upon the speciality in which the residence will practice. Ex: Davis Grant has a three-year, in-house family medicine program. The radiology curriculum is a four-year program. Gaddey was a graduate student in family medicine at DGMC from 2001 to 2004. She returned to Davis Grant in 2007 as a faculty member in the family medicine program. Since her return, the civilian partnerships have grown. Gaddey was part of the creation of a general, vascular, cardio-thoracic, and emergency surgery programs. In the last year, she helped create an orthopedic residency-training program. “We are focusing on the skillsets of what military physicians will need to meet future demands, both for our beneficiaries here at home and those deployed.”

The Navy Way

Upon graduation from medical school, US Navy physicians are required to attend the five-week Officer Development School in Newport, R.I. that covers the responsibilities of a Navy Medical Corps officer. Then, newly minted physicians receive post-graduate study in their chosen field. At present, Navy medicine offers 30 different specialty areas, including aerospace medicine, neonatology, neurology, reconstructive surgery, various forms of internal medicine as well as treating trauma.

Training aids in support of US Navy medical training and education. Image credit: US Navy/Steven Hoskins.

The Navy does not have trauma centers in the US. So, this branch got creative years ago by sending doctors, nurses and medics (corpsman) to Stroger Hospital in Chicago’s Cook County for instruction on treating penetrating trauma, in this context, bullet wounds. The hospital’s trauma unit treats numerous gunshot victims annually and it was a no-brainer for the Navy to send its medical personnel there for training. The Navy sends its medical personnel to other sites for trauma instruction as well. Corpsmen can obtain training with the Navy Medicine’s Hospital Corpsman Trauma Training Program at Naval Hospital Jacksonville. The corpsmen receive two weeks of training, which includes simulation labs and a Tactical Combat Casualty Care course. This is followed by five weeks at UF Health Jacksonville, a Level 1 trauma center. There, the corpsmen rotate in the emergency department, intensive care unit, rapid response team and become proficient in trauma resuscitation and wound management.

To qualify for employment as a Navy physician, the candidate must be a US citizen; graduate from an AMA-accredited medical school; have a current medical license; be between the ages of 21 and 64; pass a qualified medical exam; and willing to serve a minimum of two years of active duty.

Bits of Interest

• The F. Edward Hébert School of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md. offers advanced degrees in medical and clinical psychology, public health and related fields. Students must be American citizens and have a bachelor’s degree from an accredited university in the US, Canada, Puerto Rico or another US territory.
• The Daniel K. Inouye Graduate School of Nursing (named after the late war hero and US Senator from Hawaii) offers a Ph.D. in Nursing Practice and other fields.
• Defense Medical Readiness Training Institute at Ft. Sam Houston, Texas offers numerous medically related courses. They include: The Joint Senior Medical Leaders Course (Resident), designed to prepare senior Medical, Dental, Medical Service, Biomedical Sciences and Nurse Corps Officers from all services for leadership positions; Pre-Hospital Trauma Life Support (Resident, Exportable), a 2-2½ day course designed to increase participant’s pre-hospital trauma management skills; and the Advanced Burn Life Support (Resident and Exportable), a 1-day course that focuses on the assessment and management of burn patients during the first 24 hours after injury.
• The US Army claims to lead the services in the number of nurses, hospitals and opportunities for advanced medical training. Army nurses begin their services as a 2^nd Lieutenant.