Military Docs May Not Be Getting Enough Training and Practice

NEW YORK (Reuters Health) – Even as the surgical volume has been increasing at U.S. civilian medical centers, it has been declining at military facilities, a new study finds.

An analysis of general surgery workload between 2015 and 2019 across the Military Health System (MHS), including military and civilian facilities, revealed that the number of general-surgery procedures performed at military hospitals decreased by 25.6% at the same time as there was a 3.2% increase in civilian care settings.

“A gradual shift in the volume of surgical cases from Military Treatment Facilities (MTFs) to civilian hospitals has led to a precipitous decline in the clinical preparedness of military surgeons for combat medical care,” said Dr. Joel Weissman of the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston, who worked on the study.

“It is well known from years of research in the civilian literature that surgical volume is related to the quality of care,” Dr. Weissman told Reuters Health by email. “Without sufficient volume of cases, military surgeons are finding it increasingly difficult to maintain their skills. Furthermore, shifting cases away from MTFs and into civilian hospitals is expensive.”

He added, “There are two main options for addressing the problem. One, the military can facilitate the opportunity for military surgeons to practice in civilian medical centers. Second, the MTFs could open their doors to non-military patients, especially those that are high value to military surgeons.”

To take a closer look at how much practice military surgeons were getting, the researchers focused both on the volume of surgeries as well as a metric named Knowledge, Skills and Abilities (KSA). The KSA metric was developed by a partnership of the military surgical community and the American College of Surgeons, which established a list of 487 unique KSAs relevant to general surgeons in a deployed setting.

The analysis used data from TRICARE, the U.S. Department of Defense’s health insurance, which covers not only active-duty service members, but also non-active-duty personnel, including dependents and retirees. Beneficiaries receive care in two parallel systems: Department of Defense-owned and -operated military treatment facilities (MTFs) where patients are treated by military healthcare professionals, and civilian hospitals with civilian healthcare professionals, with TRICARE functioning as a fee-for-service health insurance.

The researchers obtained TRICARE claims from both direct and purchased care from the MHS Management Analysis and Reporting Tool database. They identified 147 military treatment facilities and military units which had generated general surgery KSA points between 2015 and 2019.

Their analysis revealed that the number of general surgery KSA point-generating procedures in military treatment facilities decreased from 128,377 in 2015 to 95,461 in 2019. They saw a corresponding 19% reduction in the number of general-surgery KSA points generated in military treatment facilities from 7,155,563 in 2015 to 5,790,001 in 2019.

During the same time period, there was an increase both in the number of procedures (from 419,980 to 433,495) and KSA points (from 21,071,033 to 21,748,984) in the purchased-care environment.

“The findings suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the MHS to reverse the change,” the researchers conclude.

SOURCE: and JAMA Surgery, October 27, 2021

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