US military surgeons are losing their skills at a “breakneck rate” as the number of surgeries performed in military hospitals has declined, study finds.

The number of general surgery procedures fell almost 26% from 2015 to 2019, while readiness for surgery – measured by the military health system standards for general surgery – declined by 19, 1%.

According to the study, published on October 27 in JAMA Surgery, 16.7% of army general surgeons in 2015 met army surgical standards, while only 10.1% met the threshold in 2019. The standards, defined by knowledge, skills and abilities, or KSAs, established for deployed surgeons, are designed to ensure that a surgeon can perform within combat settings.

Members of the Defense Health Board, an advisory committee to the Secretary of Defense on military medical issues, and military trauma surgeons have long been concerned about the loss of skills as a result of the decline in combat operations and the relatively low number of surgeries. carried out in military installations. compared to civilian hospitals.

The study, led by Dr Michael Dalton of Harvard Medical School and Brigham and Women’s Hospital in Boston, is the first to contain data to support these concerns, according to the authors.

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“The results of this study suggest that the loss of surgical workload has led to a further decrease in the readiness of military surgeons and may require substantial changes in the flow of patient care in the US military healthcare system to reverse the change. “, wrote the authors.

The reduction in surgical volume at military hospitals occurred at the same time as civilian establishments saw a 3.2% increase in surgical care for Tricare patients, including military personnel, families and retirees.

But this increase in procedures in civilian settings was not large enough to “fully count on the loss of procedures in military processing facilities”.

The authors did not say what explained the difference between the loss of procedures in military hospitals and the lower gains in civilian hospitals, but added that further declines in procedures in military hospitals would lead to continued skill erosion. .

Dalton noted that when patients leave military hospitals for civilian care, military facilities lose the opportunity to treat – and gain experience from – those patients. The procedures also come at a financial cost to the Department of Defense, with civilian care, known as “purchased care,” accounting for the largest share of Pentagon health care spending.

The military health system has been for five years in a health reform initiative that has placed control of military hospitals and clinics under the authority of the Defense Health Agency and realigned the medical forces of the services to focus on the support for active duty personnel and operations.

As part of the plan, the military, navy and air force are expected to cut more than 12,000 uniformed medical bills, and non-military patients will likely receive their care either in the community as part of the program. Tricare health care, either, depending on the place of duty, by civilian or contract doctors in military installations.

The study authors recommended that the military healthcare system retain patients to ensure that military hospitals can continue to provide high-quality care, with a focus on patients whose surgical needs would be directly related to patient care. wounded.

They also suggested partnerships for military surgeons to train and work in civilian trauma centers and for military facilities to treat civilians for trauma, as is done at Naval Medical Center Camp Lejeune, Carolina of the North, and at the Brooke Army Medical Center in San Antonio, would help maintain the skills of surgeons.

In a accompanying commentary, also in JAMA SurgeryDr Lesly Dossett and Dr Justin Dimick of Michigan Medicine said the partnerships do not provide the team training needed for frontline surgeries, including anesthesia, nursing and surgical technicians.

“The increasing regionalization of complex surgical procedures and decreasing volumes at military treatment facilities may create an environment in which maintaining surgeons ready for expeditions through a model based on military and active-duty treatment facilities is more achievable on a large scale, ”Dossett and Dimick said.

“Instead, military medicine may need to reconsider the optimal strategy for procuring the services of expedition-ready surgical teams, including the broader use of reservists who maintain busy clinical practices when they do. are not deployed or the use of civilian contractors, a strategy that has been used for other military support roles, ”they wrote.

Eileen Huck, deputy director of health care at the National Military Family Association, said the study illustrates the “complex demands of the military health care system” and should be taken seriously by those leading health care reform in the country. Pentagon.

The Defense Department must balance three priorities, according to Huck: force medical care, training of military medical providers, and care of beneficiaries.

This study indicates that there is a need for “soul searching and analysis,” she said.

“I think this should force the DoD to pause and think before moving forward with the right sizing,” referring to the plan to reduce medical positions, Huck said in an interview with Military.com Friday. “We are restructuring the military treatment facilities, and if we move beneficiaries, what does that do to patient charges for our providers? How will they be able to maintain their skills and expertise? “

For the study, Dalton analyzed general surgery workload at 147 sites in the military health system and measures of knowledge, skills and abilities established for surgeons deployed by the Uniformed Services University of the Health Sciences and the American College of Surgeons.

The authors noted that the study may have potentially underestimated case volumes for military surgeons, and they were unable to include surgeries performed by military surgeons at civilian facilities, such as those performed under partnerships with these facilities.

In a report released in August on downsizing of military medical personnel, the Defense Ministry said it was committed to “adjusting the timing, location and scope of changes if necessary,” according to availability of care in the community and operational requirements.

Pentagon officials have said they will hold public forums with beneficiaries before cuts are made and come under pandemic constraints.

– Patricia Kime can be contacted at [email protected] Follow her on Twitter @patriciakime.

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