Should Residents Deploy?

Military Medicine, Feb 2007 by De Lorenzo, Robert A

Disclaimer: The opinions or assertions are those of the author and do not necessarily reflect those of the Army Medical Department or the Department of Defense.

A senior resident in our program recently asked to arrange an elective in the combat zone of Iraq. He knew several of our faculty members were assigned to a level III field hospital in theater and he planned to capitalize on this unique educational opportunity. In self-motivated fashion, he had already thought through many of the details of travel, learning objectives, and such. As program director I wanted to support my resident's professional and educational development. But having been engaged in this issue in previous years, I knew of the challenges and complexities involved.

The discussion begins with a look back to Gulf War I when active-duty residents (in emergency medicine programs, mostly) were involuntarily deployed. Although the individuals involved served with honor and pride, the deployments resulted in disruption in training. Subsequently, potential adverse actions by the Accreditation Council for Graduate Medical Education (ACGME) caused all three services to rewrite the regulations governing resident deployments. The net result was a general prohibition on deploying residents in military residency programs, short of all-out war. While these policies technically don't prohibit educationally focused deployments, a lingering reluctance to repeat the Gulf War I experience remains. It is interesting to note that during the first Gulf War a number of residents assigned to the reserve component were also deployed when their units were mobilized (1,2).

More recently, rules have been relaxed slightly and residents have deployed on humanitarian and other operational missions. Pediatrics at the San Antonio Uniformed health Education Consortium, for example, has maintained a regular mission to South America. The internal medicine residency at Walter Reed Army Medical Center, in contrast, identified a number of challenges in their efforts to develop deployed experiences prior to Gulf War Il (3,4). However, combat deployments have not been approved at the service level despite periodic discussion among program directors and military graduate medical education (GME) staff.

The arguments in support of combat deployments are readily apparent. Military medical residents are ultimately training for the wartime mission, so it makes sense to provide a deployment-focused educational opportunity. Few could argue the clinical value and relevance of resuscitating combat casualties. A combat medicine rotation also goes to the heart of military GME relevancy and the military-unique curriculum (5,6). It is therefore curious that four years into war have essentially no residents deployed on a structured combat zone experience. The answer lies in understanding the challenges created by the complex interplay of resident, education program, military, and the public.

The ACGME, through its individual specialty Residency Review Committees (RRC) governs the structure and learning environment of virtually all residency programs. While specific rules for each specialty differ in the details, a consistent theme is the requirement for a safe, sound, and educationally appropriate experience with qualified faculty supervision at all times. In the combat zone, assuring quality of teaching and continuity of supervision will be challenging (although not impossible). Carefully linking deployed residents to faculty could mitigate supervision concerns. More difficult will be accrediting the field hospital or deployed unit as a teaching institution. Simply put, GME is not on the mission-critical list of most units, and in wartime, secondary missions are rarely given priority. It will also be difficult to convince the ACGME that a safe learning environment can be assured. No matter how it is explained to civilian authorities, safety in a designated combat zone is not likely to sound convincing. Nevertheless, a comprehensive curriculum combined with strong program, institutional, and service commitment could conceivably overcome any ACGME skepticism.

There are also practical program and military issues to consider. Funding for elective temporary duty (TDY or TAD) is very scarce, and permissive TDY is not allowed since regulations prohibit the conduct of official business while in PTDY status. Even if TDY orders are funded, authority rests with the theater combatant commander and not the service or program. Thus, control of timing, duration, and assignment is not assured. This can be problematic since poor timing can result in missed regular rotations for the deploying resident or schedule disruptions for other residents in the program. Worse, if the deployment, to include any pre-deployment train-up, gets extended much beyond one month (even by a few weeks), RRC rules regarding time away may take effect. An extension of training will likely be required and the late-graduating resident will exacerbate existing service staff shortages. Lastly, there is the issue of providing a deployment experience for all residents in a program. While setting up a rotation for a single resident is challenging enough, establishing one across a class of a dozen or more residents is a huge task. If all the military residents in just one small specialty (emergency medicine, for example) participated, approximately 50 rotations in the combat zone would be needed for each class each year. A systematic, Department of Defense-wide approach would be needed to meet this high demand.