Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education

Abstract

Background Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. Methods Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. Results The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 ( P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program ( P < .0001). Conclusions There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

Perceptions of general surgery residents at military treatment facilities: Excellent training with crisis of confidence

“…The American Board of Surgery reports show that military surgery residency programs have higher first-time examination pass rates than the national average. 9 Hall et al reported that the average graduating case volume from a military program is 1189.5, 7 which is above the 70th percentile of programs nationally. 10 Rolland et al also report that military general surgery programs also have a lower rate of attrition compared with the national average.…”

“…Hall et al reported that there has been a steady decrease in the proportion of cases that surgery residents perform at MTFs, such that by 2020 less than 50% of graduating military surgery residents' cases were done at an MTF. 7 While military program directors maintain their residents' clinical training, the added burden of increasing off-site rotations may have negative consequences on their residents' wellbeing and attitudes toward military service.…”

Refocusing the Military Health System to Support Role 4 Definitive Care in future large-scale combat operations

“…24 During peacetime conditions, military GME programs have been challenged by reduced numbers of combat casualties while caring for a relatively healthy active-duty military population. 25 To meet Accreditation Council for Graduate Medical Education requirements, military GME programs have partnered with civilian programs, allowing military residents to rotate at civilian hospitals to augment case complexity, volume, and trauma exposure. Likewise, there are multiple integrated military-civilian residencies including the orthopedic surgery residencies in El Paso, Texas (William Beaumont Army Medical Center/Texas Tech University Health Sciences Center El Paso 26 ) and Fayetteville, North Carolina (Womack/Cape Fear Valley Health 27 ).…”

“…During peacetime conditions, military GME programs have been challenged by reduced numbers of combat casualties while caring for a relatively healthy active-duty military population 25 . To meet Accreditation Council for Graduate Medical Education requirements, military GME programs have partnered with civilian programs, allowing military residents to rotate at civilian hospitals to augment case complexity, volume, and trauma exposure.…”

Perceptions are reality: Narrowing the gap to prevent the crisis of confidence from becoming a crisis of competence

“…The lack of MTF operative volume has forced surgical program directors to augment resident case logs through outsourced civilian rotations, which have undoubtedly helped provide the needed case numbers to graduate residency, contributed to low surgical resident attrition rates, and yielded high first-time board pass rates 12,13 . However, the survey responses illustrate the degradation of the MTF as the institutional home of military GME and allude to a much more concerning readiness crisis.…”