Discussion
This study is the first to hear from military general surgery trainees directly and analyze how they view their readiness to serve as combat surgeons and identify areas of training improvement. Overall, general surgery trainees are satisfied with the training they receive in adult trauma and acute care surgery, critical components of combat care. However, a third still did not feel confident they would be ready to deploy on completion of residency training. Interestingly, trainees at civilian hospitals felt more confident to serve as combat surgeons after residency than those at training at military centers.
Given the current relative interwar period characterized by a limited casualty burden compared with the previous 20 years of war in Iraq and Afghanistan, it is imperative to maintain a ready military medical force capable of caring for combat casualties during the next conflict. As military surgeons often deploy soon after completing residency training, the fact that a third of senior military residents surveyed are not confident in their readiness to deploy is a concerning finding and suggests the need for a standardized MUC during GME training. History has demonstrated that medical advances made during battlefield experience are quickly lost during interwar periods and negatively impacts the survival of the first casualties of the next war. This phenomenon known as either the “Walker Dip” or peacetime effect is well described.13 14 A MUC during general surgery training may help to blunt the effect of the Walker Dip on future combat casualty care, ensuring that the next generation of combat surgeons have the knowledge, skills, and abilities necessary to save lives on the battlefield at the start of the next war.
Another concerning finding is that military residents training in civilian GME programs were more confident in their readiness to deploy than those trainees in MTF-based residency programs. Although the reason for this is unknown, there are a couple of speculative options worth mentioning. This may be reflective of the perception of training and volume seen at their home institutions, with trainees at civilian institutions feeling more confident due to a perception of receiving adequate volume and exposure to high-acuity patients than those at MTF-based residency programs. Although this was unable to be truly elucidated from the current study, the lack of combat-related trauma exposure has previously been documented as a weakness of GME training at military treatment facilities.15 Furthermore, a recent analysis of military surgical residents in MTF-based GME programs by Choi and colleagues found that although most trainees were satisfied with their GME training, more than two-thirds of residents surveyed did not plan to stay in the military beyond their current service obligation. The main reason for this is declining patient volume at their home MTF.16 Another speculative reason for the increased perception of readiness to deploy from those training at civilian institutions may be a lack of insight regarding the demands of and skills necessary to be a combat surgeon as a result of fewer military faculty and fewer military patients.17 18
Although we ultimately found this difference in perceived confidence between civilian and military training programs intriguing, more studies are necessary to directly compare readiness between military and civilian programs. This study’s scope was broader and was not designed to adequately capture the differences, given the fewer number of senior resident respondents from civilian programs. Some partnerships with civilian residencies are newer, and do not yet have senior residents. We think additional studies are necessary comparing outcomes of residents who trained in military verses civilian programs.
Although a third of senior military residents expressed decreased perceived levels of confidence in treating combat injuries, fellowship training appeared to increase confidence levels in managing those complex injuries—especially those including the pelvis, liver, pancreas, liver/portal vein, vena cava, and neck. Fellowship training may increase confidence levels among military surgeons, yet fellowship training opportunities are limited within the military and based on antiquated quotas of specialty requirements across the services that have not been wholistically analyzed across the military health system in the context of current and future needs in decades.
As a result, opportunities such as the development of a MUC may exist to facilitate additional skill improvement during residency training.19 Trainees (both in military and civilian programs) may be satisfied with their trauma training, which primarily occurs at civilian hospitals, but given their lack of confidence in treating more complex injuries, these trauma skills learned in civilian hospitals may not necessarily be transferable to treating battlefield casualties. For example, Clinical Practice Guideline from the Joint Trauma System describes some of the skills required for a combat surgeon that may not be obtained from civilian training. This includes accepting a different clinical mindset whereby “medical decisions are made in the context of the following variables: time and distance to the next role of care, capability of the next role of care, availability of blood products, sterility, anticipation of further casualties, evacuation capability, security, mobility, and patient holding capacity”.20 Unlike well-resourced academic and military hospitals where residents train, they may not be prepared for austere environments where there may be no senior partner available to assist (or any partner), no CT scanner, no experienced surgical assistant, and limited blood, medications, and supplies. Using such pre-existing programs as the Joint Trauma System weekly conference could be an opportunity to provide additional lectures and integrate a resident-specific program on a weekly or monthly basis that covers non-operative requirements of military medicine including principles of medical evacuation, triage or response to chemical or biological weapons. This would also enable trainees to engage with military faculty who had significant combat or operational experience for residents in both civilian and military training programs. Additionally, these are skills that could be obtained by encouraging trainees to attend military courses during their research year.
The data showing a lack of satisfaction in obstetric/gynecologic and urologic surgical emergencies is not surprising since these specialties are not routinely taught in current general surgery residency programs. However specific training in these areas is needed for military surgery residents since these injuries related to these systems are seen on the battlefield.21 Furthermore, general surgeons are often called on to manage emergency obstetric, gynecologic and urologic surgical emergencies when forward deployed, particularly solo Navy surgeons deployed on US warships.1 22 23 Although general surgery residents are not required by ACGME or ABS to participate in obstetrics/gynecology or urology patients, having specific requirements may be an opportunity to obtain training in these areas. Given the availability of elective rotations in most training programs, residents could possibly be exposed to these patients on a community surgery rotation, for example, where there are often still practicing urologists and obstetricians/gynecologists.
Additionally, specific areas that may improve trainee readiness involve participation in surgical skills courses. Although the majority of senior residents and fellows had completed at least one of these courses, there were still a large number who had not; only 46% of PGY4s and PGY5s, for example, had not completed ASSET. Senior residents and fellows who had completed these courses were significantly more confident treating gastric, liver, portal vein, vena cava, and carotid artery injuries, in addition to performing neck explorations, temporary vascular shunting, and definitive vascular repairs. These skills courses have been previously validated among military and general surgeons as a mechanism to improve trauma surgery readiness—pertinent to the needs of a new general surgery trainee.24–26 Trainees also recognized the value of a skills-specific course, ranking having access to an annual skills course as being most valuable to developing their technical skills in a potential MUC. Academically, they identified having military faculty with combat experience or military mentors as most beneficial to their training. Training in military hospitals or robust military-civilian partnerships that expose trainees to the nuances of military medicine throughout the duration of their training may also improve deployment readiness on training completion.17–19 Additional funding and requirements for military general surgery residents to participate in these courses on a yearly basis would potentially improve their technical training during residency.
This survey provides valuable insight into the perceived readiness of military surgery trainees to serve as combat surgeons and identifies areas where a MUC may be beneficial. However, this study is not without limitations. Whereas a 43% response rate is fairly robust, the opinions of more than half of general surgery trainees are unaccounted for. This may be secondary to a degree of survey fatigue from the constant demand for their opinions on different matters.27 A second limitation of this study is access to trainees. Email addresses were collected from service general surgery consultants and program directors. Given the number of trainees and specialties, some trainees may not have been accounted for due to not having accurate contact information despite our best efforts.
Another factor in this study is the “Dunning-Kruger Effect”, whereby less competent individuals tend to overestimate their abilities whereas more competent individuals express less relative confidence.28 29 We recognize that this factor probably influenced this survey since it involves trainees and junior physicians, who have not completed the requirements to become a board-certified surgeon or practice independently. Additionally, most of them have never experienced surgical combat casualty care and may not fully understand the expectations placed on them as military officers or surgeons. Trainees may have limited insight into their own abilities, for better or for worse.
A further limitation of this study is that it did not explicitly address differences in training in military or civilian residency programs. It is important to note that the majority of military GME now occurs in civilian programs via outside rotations, because of the loss of inpatients at the MTFs. We think additional studies are necessary comparing outcomes of residents who trained in military programs with a significant portion of the training obtained via rotations in civilian hospitals versus residents trained in entirely civilian residency programs.
Despite these limitations, this survey provides valuable insights into areas where military general surgery training and education may be improved. A potential MUC that would address some of the concerns outlined in this survey includes annual surgical skills courses, minimum vascular, urology and obstetrics/gynaecology patient requirements obtained on community general surgery rotations, and non-operative education via such existing programs as the Joint Trauma System weekly conference call specifically geared towards residents. This would further provide military residents at military and civilian training programs with exposure to and engagement with military faculty with operational or combat experiences. Future studies are warranted to analyze faculty insights into MUC, and analysis of fellowship-level MUC, and expansion of surveys to include other surgical specialties that care for combat casualties.
