Certification in military medicine

Military Medicine, Sep 2003 by Palma, Joseph, Rich, Norman, Roy, Michael J

Over the past two decades, an increasing amount of attention has been paid to the training of military physicians in the operational realm-preparing them for combat-related and humanitarian deployments. Military Unique Curricula have been published on two occasions,1,2 and various efforts have been made to try to implement instruction and skills training.3,4 As a consequence, consideration has also been given to assessing the success of interventions, determining how much militarily relevant knowledge and skills physicians actually possess, and, ultimately, whether certification in military medicine should be provided. At the 16th Annual Military Medicine Conference at Uniformed Services University, June 17-20, 2002, we convened a panel of experts to discuss the benefits and costs of certification, potential existing models for certification, and measures to take to establish a meaningful certification program.

Background

A review of the literature yields a number of thoughtful treatises touching upon the subject of certification in military medicine. In delineating the important competencies in military medicine, one can start to understand the chasm in understanding by delving into past experiences. Eiseman, a retired Navy Reserves Admiral, veteran of several wars, and highly respected civilian surgeon emphasized the need for physicians to engage in mass casualty planning, especially as it may apply to civilian settings.5 He noted that claimed mobilization from peacetime to a state of formal warfare or battle required weeks to months, with physicians involved in preparing for the type of casualties anticipated. However, he prophetically pointed out that terrorist attacks require a similar response from the medical community, with little or no lead time to prepare. Physicians must therefore be trained to deal with a wide range of potential scenarios. A corollary is that military medical responses may well need to be different from standardized civilian responses, so that training normally unavailable in civilian training programs must be implemented to facilitate an appropriate medical response to these events.

Military physicians quickly recognize differences between war and peacetime medicine, but the lessons learned in battle have often been forgotten between wars, only to be relearned during the next. Bellamy and Lajtchuk6 comment that physicians have long ignored knowledge of military weaponry, believing the knowledge to have little therapeutic value, but he asserts only knowledgeable medical officers will understand the intricacies of war injuries resulting from battle. For example, missiles of high velocity may require less exploration and debridement than those that are designed to fragment upon impact and further disrupt tissues. Military surgeons should be fully cognizant of the need for delayed closure of war wounds. Military physicians should also understand the difference among ammunition, fired from firearms; explosives and their blast effects; and flame or incendiary munitions with the additional medical compromise of thermal injury. Each of these imparts a different mechanism of action to injury and portends different physical, physiological, and psychological impacts. Knowledge of these issues raises the need for different medical and surgical training requirements and objectives than usually drive standard civilian and military training programs.

A series of articles in Military Medicine in the early 1990s addressed the issue of whether military medicine, or some of its components, has unique qualities that augur a need to standardize the discipline and in turn whether to certify those that complete the requirements. The purpose of certification would be to identify those with competence in their respective fields, facilitating the fielding of a capable medical force. Rignault7,8 in particular argued that "war surgery" should be considered a unique specialty. He notes that since 1950 the peacetime practice of civilian and military surgery has shifted from general surgery to increasing specialization and that although the surgical management of wounds continues to require a solid foundation in general surgery training, additional specific training in wartime surgery, historically unavailable in either civilian or military peacetime training programs, is necessary to avoid the significant challenges surgeons face in treating and sustaining the war wounded. Rignault6,7 emphasizes several key differences between peacetime and wartime surgery: war surgery deals with emergencies, providing almost exclusively lifesaving surgery, to be followed by evacuation and further staged surgeries in different locations of increasing sophistication. Wartime surgical and medical care is primarily provided in an unsophisticated medical environment, with minimal or no advanced diagnostic equipment, such as computerized tomography scans, and therefore requiring a heightened acumen in clinical diagnostic skills. War surgery, in large part, involves the need to sort large numbers of casualties simultaneously, requiring triage, stabilization (deriving its roots from the highly successful French Foreign Legion "reanimation " teams, whose purpose was to parachute in, stabilize casualties in far-forward areas, and evacuate them to safer areas for definitive hospital care, which dramatically reduced mortality in the 1970s), and evacuation to a higher level of care. The initial stabilization of war-injured patients is therefore incomplete. The military medical officer must exercise judgment based on his or her knowledge of the mechanism of injury, the injury or injuries themselves, surgical procedure(s), natural history of the military injury or injuries, the logistics and sustainability of the military operation, and the medical evacuation chain and system capability and capacity. The outcome for a given patient is significantly influenced not only by the host (injured casualty) and the environment simultaneously, but also the lag time between the injury and arrival to initial medical or surgical care, the quality of the care, and maintenance during transport.