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American society has a history of turning to physicians during times of extreme need, from plagues in the past to recent outbreaks of communicable diseases. This public instinct comes from a deep seated trust in physician duty that has been earned over the centuries through dedicated and selfless care, often in the face of personal risks. As dangers facing our communities include terroristic events physicians must be adequately prepared to respond, both medically and ethically. While the ethical principles that govern physician behavior-beneficence, nonmaleficence, autonomy, and social justice-are unchanging, fundamental doctrines must change with the new risks inherent to terroristic events. Responding to mass casualty disasters caused by terrorists, natural calamities, and combat continue to be challenging frontiers in medicine. Preparing physicians to deal with the consequences of a terroristic disease must include understanding the ethical challenges that can occur.

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Objective: Stapedectomy remains a key indicator case reportable to the Accreditation Council of Graduate Medical Education despite the decline in the incidence of otosclerosis over the last half century. This study compared the rates of stapedectomy performed by otolaryngologists at academic and nonacademic centers. Study Design: Retrospective review. Setting: Tertiary referral academic centers, nonacademic centers, and civilian purchased-care across the Department of Defense between 2015 and 2020. Patients: Department of Defense beneficiaries with otosclerosis near a military treatment facility with an otolaryngologist. Interventions: Stapedectomy (Current Procedural Terminology codes 69,660, 69,661, and 69,662). Main Outcome Measures: Number of stapedectomies performed by setting.Results: From 2015 to 2020, 426 stapedectomies were performed at or near a military treatment facility with an otolaryngologist (274 directly by military otolaryngologists, 152 by community providers). Military providers performed 94% of stapedectomies at or near military academic centers, versus only 30% at or near nonacademic centers ( p < 0.0001). Among the 60 stapedectomies performed at nonacademic centers, only 30 were performed by general otolaryngologists (7% of all stapedectomies performed; 11% of procedures by military providers) while the rest were performed by fellowship-trained otologist or neurotologist. Conclusions: Low stapes surgical volume by military general otolaryngologists reinforces recent epidemiologic trends and suggests that few general otolaryngologists graduate residency with sufficient competency to pursue independently performing stapedectomy or have difficulty maintaining competency after graduation.