Representatives of the U.S. military health system met Sunday for the Excelsior Surgical Society meeting, and a highlight of the daylong session was the fifth annual Army Major John P. Pryor Lecture by retired U.S. Air Force Colonel Mark W. Bowyer, MD, FACS, Ben Eiseman Professor of Surgery; surgical director of simulation; and chief, division of trauma and combat surgery, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD.
In his lecture, Bridge over Troubled Waters: Trials, Tribulations, Triumphs, and Training, Dr. Bowyer began by speaking about the late Dr. Pryor, to whom the lecture is dedicated, and how Dr. Pryor’s words and actions showed him as a surgeon “committed to service” and who exhibited perseverance to his goal of becoming a military surgeon. Perseverance is “an important quality in this time of turmoil in our services,” Dr. Bowyer said.
Dr. Bowyer explained that when he was training, “military residencies were very robust and very busy,” and residents had regular, expansive experience with a variety of surgical procedures. For a range of reasons, this breadth and depth of experience for military surgeons during times of peace and before deployment has diminished, leading to the “troubled waters” military surgery is now experiencing. “You need to be tested in order to perform,” said Dr. Bowyer, noting that the formerly strong bridge between conflicts is “in need of maintenance.”
“This is a challenging time to be a military doctor,” said Dr. Bowyer, referring to recent articles suggesting that the Military Health System isn’t producing surgeons ready to treat traumatic war wounds. Although there may some disagreement in how that narrative is being presented, the underlying ideas are rooted in fact—in recent years, the average number of cases military surgery trainees are performing have gone down sharply in comparison to civilian colleagues. This translates into a less confident military surgeon cohort. “We need to prepare surgeons to competently care for combat casualties,” said Dr. Bowyer, noting that current operative experience and curriculum do not ensure this.
Military surgeons need to be at least competent in a multitude of surgical areas, including thoracic, orthopaedic, neurosurgery, and maxillofacial surgery, among others. “We have identified the skill sets, but we have a challenge in achieving currency and competency,” Dr. Bowyer said. Additionally, general surgeons in training are performing very low numbers of some of the key procedures required to treat battlefield injuries.
The situation sounds discouraging, he acknowledged, but there are opportunities to improve. Echoing Dr. Pryor’s words, Dr. Bowyer said that the U.S. military “has some of the greatest medics, nurses, and physicians in the world, but we need to make sure they have the skills and the tools to maintain those skills.” To that end, education is the key.
Dr. Bowyer said that military surgery needs a standardized training platform and data collection to identify areas of weakness, allow for remediation of skills, and allow optimal timing for refreshment training.
“The existing ASSET [Advanced Surgical Skills for Exposure in Trauma] course is a logical foundation” for that education, he said, noting that an expanded course covers the skills pertinent to military surgery. The two-day course has a one-to-one student to faculty ratio, with students being evaluated and advised on procedures on the first day, and then returning on the second day to perform the same procedures in front of different faculty to judge their progress and ability. “The real value of the course is that after two days, each student has been assessed by four experienced trauma surgeons,” Dr. Bowyer said. Student response to this course was universally positive, showing greatly increased confidence in performing trauma surgery.
The goal is to make the expanded ASSET course a part of the bedrock of military surgery training and to make sure skills are assessed on reliable, validated metrics. According to Dr. Bowyer, there is significant work to be done to meet that goal, but military surgeons must do it for their patients. Quoting Dr. Pryor’s words, Dr. Bowyer said, “Do right by the patient. Do everything you can to heal them. Put in 110 percent, and the rest will follow.”