Military Surgeons Are Losing Medical Skills, Study Says. Could Off-Base Care Be Why?

As the number of general surgery procedures done in military hospitals has dropped since 2015, surgical skills have declined, according to a new study.

By Patricia Kime

U.S. military surgeons are losing their skills at a "precipitous rate" as the number of surgical procedures performed in military hospitals has declined, a study has found.

The number of general surgery procedures dropped by nearly 26% from 2015 to 2019, while surgical readiness -- measured by the military health system's standards for general surgery -- declined by 19.1%.

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According to the study, published Oct. 27 in JAMA Surgery, 16.7% of general surgeons in the military in 2015 met the military's surgical standards, while just 10.1% met the threshold in 2019. The standards, defined by the knowledge, skills and abilities, or KSAs, established for deployed surgeons, are designed to ensure that a surgeon can perform in 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 raised concerns over the loss of skills following the decline of combat operations and the relatively low number of procedures done in military facilities compared with civilian hospitals.

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

"The findings of this study suggest that loss of surgical workload has resulted in further decreases in military surgeon readiness and may require substantial changes in patient care flow in the U.S. Military Health System to reverse the change," the authors wrote.

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

But that increase in procedures in civilian settings was not large enough to "fully account for the loss of procedures at military treatment facilities."

The authors didn't say what accounted for the difference between the loss of procedures at military hospitals and the smaller gains at civilian hospitals but added that further declines in procedures at military hospitals would lead to the continuing erosion of skills.

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

The military health system is five years into a health reform initiative that has placed control of military hospitals and clinics under the Defense Health Agency and realigned the services' medical forces to focus on supporting active-duty personnel and operations.

As part of the plan, the Army, Navy and Air Force are expected to trim more than 12,000 uniformed medical billets, and non-military patients likely will receive their care either in the community under the Tricare health program or, depending on duty location, by civilian or contract physicians at military facilities.

The study authors recommended that the military health system retain patients to ensure that military hospitals can continue to provide high-quality care, focusing on patients whose surgical needs would directly correlate to combat casualty care.

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

In an accompanying commentary, also in JAMA Surgery, Dr. Lesly Dossett and Dr. Justin Dimick of Michigan Medicine said that partnerships don't provide the team training needed for frontline surgical procedures, including anesthesia, nursing and surgical techs.

"The increasing regionalization of complex surgical procedures and decreased volumes at military treatment facilities may create an environment in which maintaining expeditionary-ready surgeons via an active-duty and military treatment facility-based model is no longer feasible on a large scale," Dossett and Dimick said.

"Instead, military medicine may need to re-examine the optimal strategy in procuring the services of expeditionary-ready surgical teams, including the broader use of reservists who maintain busy clinical practices while 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 for health care at the National Military Family Association, said the study illustrates the "complex demands on the military health system" and should be taken seriously by those driving health care reform at the Pentagon.

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

This study indicates that there is a need for "introspection and analysis," she said.

"I think it should compel DoD to pause and think before it moves forward with right-sizing," referring to the plan to cut medical billets, Huck said in an interview with Military.com on Friday. "We're restructuring the military treatment facilities, and if we're moving beneficiaries out, what does that do to the patient loads for our providers? How will they be able to maintain their skills and expertise?"

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

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

In a report published in August on the military medical personnel force reductions, the Defense Department said it was committed to "adjusting the timing, location and scope of the changes as necessary," depending on availability of care in the community and operational requirements.

Pentagon officials said they would hold public forums with beneficiaries before any reductions are made and are subject to pandemic constraints.

-- Patricia Kime can be reached at Patricia.Kime@Monster.com. Follow her on Twitter @patriciakime.