Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education
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Abstract
Introduction Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm’s way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs.
Methods We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms “graduate medical education” and “military.” We included articles if they specifically addressed military curricula in residency with terms including “residency and operational” or “readiness training”, “military program”, or “military curriculum”.
Results We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs.
Conclusion We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.
Introduction
Graduate Medical Education (GME) in the Department of Defense (DoD), which encompasses all specialties and services, is tasked to provide the US Armed Forces with a pool of uniformed officer physicians available to support the global and domestic missions of the US Armed Forces. Each year, 3000 physicians or 25% of the military physician workforce are enrolled in GME training and have a military service requirement upon completion.1 Military physicians are expected to be deployable to austere environments immediately upon graduation.2 However, throughout the latter half of the 20th century and into the 21st century, and now through multiple wars, the DoD has issued limited and vague guidance as to what defines a ready and trained military physician.2–4 There have been persistent concerns that military skill levels among graduating residents vary considerably, given the breath of training across specialties, and the lack of a comparable military curriculum instituted among GME Programs.2
Although physicians graduating from GME are by and large competently trained to civilian standards within their specialty, there are no requirements for military proficiency at graduation set by military GME. Military residents attend programs approved by the Accreditation Council for Graduate Medical Education (ACGME) with the expectation that they become certified by their respective specialty boards, thereby meeting clearly defined civilian requirements. For the military side of their profession, trainees are merely expected to meet service-specific standards of military readiness, such as completing the Army’s initial medical basic officer leader course.2 5
The question of military readiness and military training within GME has been raised periodically. In the 1980s, the Senate requested a blue-ribbon panel to address problems associated with overall military medical readiness and force size. As a result, in June of 1986, then Secretary of Defense Caspar Weinberger established a DoD GME Advisory Committee, which, led by Dr Edward Brandt, had the aim of assessing the cost-effectiveness of the military healthcare system and guiding the DoD in improving the overall military readiness mission.4 This committee, subsequently referred to as the Brandt Commission, provided a number of recommendations, including that ‘GME programs should include in the curricula all of its graduate medical education programs those aspects of the practice of a medical specialty which are unique to the military’.4
As a result of this commission report, Secretary William Mayer, then Assistant Secretary of Defense for Health Affairs, formally tasked the Uniformed Services University of the Health Sciences (USU) to develop a military GME curriculum that identified the military unique applications of medicine that could complement traditional curriculum of residencies and fellowships.6 This in turn became known as the military unique curricula (MUC), which, through USU, identified nine medical areas graduating physicians were expected to be proficient in.7–9 However, these findings served as guidance and encouragement for integration of an MUC, not a requirement for implementation of a specific plan. As a result, MUC in GME have remained open to interpretation with no established programs across specialties or services since issuance of its guidance.2
For example, in the specific case of combat surgery, with the exception of the broad objectives listed in the USU MUC, which includes surgery-specific technical skills and military-specific medical knowledge, there has been little surgery-specific instruction issued since publication of the MUC.9 Although significant attention has been paid to identifying an attending surgeon’s required knowledge, skills and abilities for deployment and development of operative skill sustainment courses, there remains no clearly defined standards expected upon graduation for surgical trainees beyond ACGME requirements.10 11
The purpose of this review is to broadly capture previous attempts at developing or implementing an MUC in GME to improve military physician readiness and deployability upon graduation. Additionally, this review may inform the possibility of establishing a new MUC that would provide standardization of unique military requirements.
Methods
We performed a literature search that included three bibliographic databases and one DoD database through August 8, 2023. These included PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center (DTIC) using database-specific search strings with derivations of the initial terms “graduate medical education” and “military” developed with the assistance of a reference librarian from USU.
We then evaluated sources that included the following terms: residency and operational or readiness training, military program, or military curriculum. We also reviewed citations of key articles to capture additional relevant articles. The PubMed, Embase, and Web of Science results were then loaded to reference manager (Zotero), and a review was performed that first examined title and abstract. We then completed a full-text review if deemed appropriate. We reviewed 100 of the available DTIC results in the DTIC search engine. We included articles if they described or advocated for additional military training during GME, described military leadership or professional development, or discussed military-specific curricula or programs. We excluded articles that were not in English, referenced international GME programs, failed to address military readiness or training during GME, described attending level training or military–civilian partnerships for trained surgeons, or focused on military medical school education or military dental, medic, nursing, or physician assistant training. Studies were then categorized based on whether they described a need for military GME or an MUC, development of an MUC, or implementation of an MUC.
Results
We reviewed a total of 1455 articles for inclusion based on title and abstract; 111 articles then had a full-text review. 64 articles were included (including articles from citation and organization review) and 51 articles were excluded as they did not meet primary or secondary inclusion criteria. An additional four articles were included based on citation search and from internal organization documents (figure 1).
Depiction of articles included and excluded in literature review. MUC, military unique curricula.
Upon review of the articles, we determined that 64 articles fell into the following categories: (1) descriptions of perspectives, attitudes, recommendations or the historical context of MUC; (2) surveys within the literature identifying readiness gaps or needs assessment for an MUC; (3) military-specific programs or curricula incorporated into residency training; or (4) military-specific residency programs.
Defining a need for an MUC
In the late 1980s, the Senate-directed Brandt Committee concluded that military GME programs needed a military curriculum that could provide military and specialty-specific training to all military residents.4 12 The USU was tasked with developing overall instructional objectives for GME, with the goal of providing the military physician with an ‘awareness’ of elements of their profession that was unique to the military to ‘better prepare’ them for both combat and deployment. The curriculum specifically differentiated what was required between surgical and non-surgical providers.9 Within a decade after the publication of the MUC, a DoD audit of military GME programs even after the publication of the USU MUC found military readiness training to (1) be inadequate, (2) lack reasonable comparability in the types of readiness curricula taught and (3) not have an adequate system to monitor physician readiness.2 The audit subsequently formally recommended the Assistant Secretary of Defense (Health Affairs) issue medical readiness training, guidance and standards, in addition to providing military manuals and medical textbooks specific to military medicine.2 Additionally, they recommended trainees participate in operational opportunities including humanitarian missions and the DoD Combat Casualty Care Course.2
Since issuance of the initial MUC and the audit, there have been several other publications describing the role of an MUC in military GME. In this review, we found 21 articles that explored the perspectives, attitudes, and recommendations on the need for an MUC in GME (table 1).
Table 1
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Perspectives, recommendations and attitudes on the historical need for an MUC
Several publications emphasized the dual roles and responsibilities of a military physician, with military physicians expected to be both physicians and military officers. These articles highlighted the need for an MUC because military physicians are expected to have an extended skillset beyond what is required of civilian counterparts.13–17 Articles also described integrated military/civilian programs and found that military residents had additional expectations because they had to meet unique military requirements while also fulfilling requirements set by their civilian programs, yet there were no concrete references to what those requirements actually entailed.1 18–20
Several of the articles examined the idea of standardizing military training within GME with a set program for military physicians. However, articles noted that although there was no guidance for issuing military medical readiness training across GME programs, they expressed a need for military education in GME with a specific military curriculum.3 21 22 One author in a Military Medicine op-ed went so far as to suggest that in its current form, with lack of standardization, to be a professional medical officer, the ‘duty to uphold the position of officer lies on the shoulders of residents.’23 Standardization of military requirements was a gap identified in the literature by many of the articles calling for an MUC.
Additional publications that advocated for the establishment of an MUC included the idea of establishing a Department of Military Medicine to oversee military training based on the requirements of the Brandt Commission.12 Other articles emphasized leadership training throughout GME to meet readiness requirements, or a pre-deployment curriculum for graduating residents to learn skills not covered during surgical residency.24 25 Many of these topics were captured in a literature review of an operational medicine curriculum, although the review was not specific to the development of a military curriculum for GME (table 1).26
Existing needs-based assessments for establishing a military program or MUC
We identified seven needs-based assessments that identified readiness gaps in military residencies and supported establishing MUC. Surveys of residents addressing MUC included four pertaining to internal medicine, two for family medicine and one single-institution resident survey addressing all GME specialties (table 2). The surveys specifically addressed confidence in practicing operational medicine, adequacy of training and preparation for practice or humanitarian mission, need for an MUC, or need for development of a leadership program.
Table 2
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Surveys within the literature identifying readiness gaps or needs assessment for an MUC
Development/implementation of MUC
In this review, we identified 27 articles that described the development or implementation of an MUC in GME residency or fellowship. Since 1989, 13 different specialties have had components of an MUC implemented within residency training, which included didactics, military leadership training, expert lectures, training exercises or operational experiences, for example. These programs included four in which all specialties were included, four that were family medicine specific, three for psychiatry, three for internal medicine, three for emergency medicine, three for general surgery, and one each for ophthalmology, obstetrics/gynecology, dermatology, anesthesia, orthopedic surgery, urology, and infectious disease fellowship.
The breadth of specialties represented in the literature indicates the significant degree to which military GME has recognized the need for a military-specific program as part of specialty training. Additionally, it shows the efforts invested to develop or implement an MUC. Specific program objectives identified during the review included 12 focused on operational medicine, 7 pertaining to military readiness, 3 focused on professional development, 2 on leadership and 2 on military ethics. There were a total of 11 programs that were joint in nature, with 6 belonging solely to the Army, 5 to the Navy, and 2 that were combined Army/Air Force or combined Army/Navy, respectively. The Air Force did not have any military unique programs or curricula that were specific to their service. Table 3 provides details of the military-specific programs, topics or curricula integrated into GME residency training.
Table 3
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Military-specific programs or curriculum incorporated into residency training
Military occupational, environmental, preventative and aerospace medicine residencies
Perhaps the most military-focused residencies within the DoD identified in the literature are the occupational and environmental medicine (OEM), preventative and aerospace medicine residencies. OEM generally comprises a small specialty with the DoD training 20% of specialists. The DoD residency itself is the largest of OEM residencies and its mission is to ‘develop physician leaders in OEM, with specific expertise in support of the health of military service members, civilian employees, and family members within the scope of DoD programs.’ A significant portion of the program includes obtaining a master’s degree in public health, where there is flexibility to tailor it to military requirements. The remaining clinical rotations can also be adjusted to meet the needs of the Armed Forces.27 Gaydos et al describe how the original Army OEM residency that existed from 1960 to 1996 was designed to meet the military-specific needs of the Army which included occupational health for the soldier, military unique exposures, support for the military industrial base, and environmental medicine in support of military installations and deployed forces.28 29
Similarly, the preventative medicine residency that previously coexisted with the Walter Reed Army Institute for Research was described to have significantly more leeway and funding for identifying pathogen threats to military personal, until it was most recently restructured in 2017 due to various downsizing initiatives within military medicine. However, since then, with the downsizing, there is concern that army preventative medicine with its military-trained physicians is no longer as prepared to ‘take care of its own’ when it comes to emerging threats.30
Additionally, military residencies in aerospace medicine (RAM) have been established that address the preventative medicine needs of military aviators since the profession has unique physiologic stressors and occupational hazards. RAM is ACGME approved and is comprised of a primary care internship, a Master of Public Health degree and aerospace medicine-specific clinical studies. These programs in turn are designed to provide optimal care to a ‘defined community’ within the military.31 Although the RAM programs within the military remain well supported, the OEM and preventative medicine residencies, with their military-specific mission and underlying military unique program, have changed over the years due to reorganization and funding changes, making them less robust than they once were.
Discussion
In this review of MUC within GME, we have sought to identify previous efforts that discussed or incorporated elements of military training into residency and fellowship. Policy leaders, administrators, and military physicians, including program directors, have recognized since the late 1980s, that because a military physician has a unique place in medicine and in the military, their training must reflect their niche role. However, this review has highlighted the difficulty in identifying and defining the role of the military physician and the training they need to execute their dynamic missions across services and specialties. Although the Brandt Commission in 1987 recommended a set MUC with certain areas of knowledge that could be implemented across GME, this review has shown the complexity of doing so.7 Within the literature, there is a consistently demonstrated need for additional military-specific training owing to added responsibilities of the military physician. However, although over 13 specialties have incorporated elements of an MUC into their residency programs, these programs lacked broad adaptation, standardization, and continuity, and this reflects lack of consistent leadership at the highest levels.
It appears a major hindrance to creation and implementation of a blanket MUC is not only the difference in training requirements across specialties, but also the fact that military GME programs are required to comply with civilian ACGME requirements to maintain their accreditation; no elements of an MUC are required for residency accreditation, nor monitored by the ACGME or the services for compliance. Anecdotally, residency program directors do not consistently or routinely implement MUC elements into their programs because doing so may compete with ACGME requirements, and training time is limited by both recent changes to work duty hours and need to maintain civilian certifications. Because MUC elements are not mandated by any governing body, implementation is dependent on individual programs.
In contrast to the constraints in programs with limited training time and numerous civilian requirements, RAM, OEM and preventative medicine residencies were historically designed to support the military mission, and had training that could be flexed to meet the requirements of the Armed Forces and was integrated throughout the duration of the residency.28–30 Surgical specialties in contrast, which had a limited representation in the literature, had shorter skills-based courses to augment and prepare residents for operational requirements, without advocating for additional operational training.25 32 33 Given the limited training time, Navy surgery has developed a textbook that encompasses their MUC given the time constraints inherent in training general surgeons, although there is no standardized implementation.34 Non-primary-based procedural specialties including psychiatry, family medicine, internal medicine and emergency medicine included more examples of operational training including field-based training, joint exercises and simulation training, likely owing the differences in overall training requirements set by civilian governing bodies.35–39 For example, emergency medicine residencies are traditionally 3 years, but the military has 4-year programs that enable trainees to participate in asynchronous operational experiences through the program, given the flexibility with increased training time.37 The variation in requirements across specialties shows the difficulty in creating a universal MUC, as each specialty has a different interpretation of which skills and additional training are necessary to prepare military physicians.
Given this review, it appears that there is an established and justifiable need for military-specific training during GME, although a standardized regimen remains to be seen. The primary mission of a military physician is to be prepared to go to war, in that, aptly put, ‘the combat ready soldier, threatened by injury or disease, counts on having a combat ready doctor to debride his wounds, preserve his health, and treat his ills.’40 However, we found that in this review, that a single MUC is unlikely to be applicable to all specialties and services. It appears that an MUC tailored to a specific specialty is the best course to meet the needs of the military physician upon residency graduation, which National Defense Authorization Act of 2017 required that GME programs fully support operational medical force readiness.41 This review has explored the significant body of work that exists describing the history, development, and implementation of MUC across services and specialties, and further studies are needed to develop an MUC that is both feasible within the constraints of civilian training requirements and realistic to providing military physicians with the knowledge and skills they need. Additionally, leadership across GME, and within each service and specialty will need to establish who would ultimately be responsible for both developing, implementing, and upholding MUC standards.
Conclusion
The purpose of this review was to broadly describe the history of development and implementation of MUC within GME training across all specialties and services. This review found that given the broad scope of specialties and variation in missions and readiness requirements across services, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard. However, this review demonstrates that an MUC is necessary, and that ideally, it should be tailored to specific specialties so that immediately upon residency graduation, military officer physicians are prepared to lead and provide care across the globe.
