How Shall We Train?

Military Medicine, Oct 2005 by De Lorenzo, Robert A

The prosecution of modern war and the competing missions of peacekeeping, humanitarian missions, and beneficiary care place great demands on the military medical system. Meeting the military medical training challenges of the new millennium requires the best trained and most experienced medical personnel possible. Various strategies for initial and sustainment (continuing) medical training are available to ensure that the medical force is ready for the next mission. Accredited programs both in and out of the military are the mainstay of training for both enlisted personnel and officers, with professional certification serving as the standard for competency. Clinical sustainment training can take place in military medical treatment facilities, civilian institutions, or a combination of the two. When direct patient care opportunities cannot provide the proper mixture of experiences to maintain certain skills, short courses, distance education, and patient simulators can play important roles. Because each training strategy offers certain advantages in different settings, it is likely that military medical departments will need to use all of them. An optimal training environment benefits from all strategies used, in combination or separately.

Introduction

The prosecution of modern war places great demands on the military medical system. The medical personnel that constitute this system must be capable of responding to military action anywhere in the world, with little or no warning, for a sustained period of time. The lethality and casualty-producing potential of modern war adds to the demand. It is risky to take comfort in the relatively light casualties experienced by U.S. and coalition forces in the maneuver phases of Gulf Wars I and II. Consideration must also be given to the massive casualties that could occur on the Korean peninsula or with a relatively weak enemy successfully using weapons of mass destruction.

Adding to the demands on the medical force is the breadth of modern military missions.1 Peacekeeping, peace enforcement, international humanitarian relief, national disaster response, and homeland defense are just some of the other missions of the military. In 2004, the U.S. military was deployed or forwardplaced in more than 120 countries and in all of the oceans of the world. Most recently, the occupation and insurgency in Iraq have added a new dimension to the delivery of medical support. Through September 30, 2004, the United States suffered 1,056 combat and noncombat deaths, with 7,532 wounded.2

Against this backdrop of unprecedented operational tempo and mission variety is a rising expectation for high-quality combat casualty care and reduced battlefield mortality rates.3·4 Compounding this challenge further is the need for bettertrained medical personnel in urban environments, such as those experienced in Mogadishu or, more recently, Baghdad.5 At home station, the constant requirement for quality care and the economics of Tricare continue to challenge the military health system.4

Meeting all of these challenges requires the best trained and most experienced medical personnel possible. Rigorous realistic training is codified in general military training manuals, and the Army mantra, "train as you fight," exemplifies this approach.6 Well-trained military medical personnel can readily shift from the peacetime Tricare setting to the combat or operational environment and fulfill both missions. The real-life medical experiences in Iraq, although valuable, are inadequate to keep the medical force ready and trained. Even if all troops wounded and killed through September 2004 are counted, the average is less than one casually case for each of the 9,461 Army Medical Department personnel in theater on September 24, 2004 (data from unclassified briefing, U.S. Army Medical Command, Fort Sam Houston, Texas). Although one patient can often train many providers, the average experience level would remain low, especially when considering the tens of thousands of Army, Air Force, and Navy medical personnel who have already rotated through the theater and are not included in the denominator. Thus, training before deployment is needed to achieve the "come as you are" requirement of rapid, no-notice operations expected in contemporary military missions. This article explores various general strategies for initial and sustainment (continuing) training, with a focus on acute, patient care-centered activities such as combat casualty care (Table I).

Initial Training

In-House Medical Education

Accredited programs both in and out of the military are the mainstay of training for both officers and enlisted personnel, with professional certification serving as the standard for competency. All three cardinal learning domains (cognitive, psychomotor, and affective) can be extensively trained and evaluated in a comprehensive in-house training program. A key advantage of in-house training is the advancement of military acculturation and esprit de corps.7 Excellent examples of inhouse programs exist, including the nationally recognized network of residencies and fellowships that make up the military graduate medical education (GME) system, the Uniformed Services University of the Health Sciences (USUHS) medical school, and many of the enlisted training programs in the three services (Fig. 1).