The peacetime effect refers to the interwar erosion of the unique military medical skills required to manage the first casualties of the next war. While overall combat mortality rates have generally improved since World War II, case fatality rates historically tend to be higher at the start of large-scale combat operations (J Trauma, 2020. 89, S8-S15). This article provides a broad overview of Military-Civilian Partnerships (MCP) and describes three partnership models recently implemented to combat the peacetime effect and maintain the readiness of forward-deployed caregivers and surgical teams.
Figure 1. MCP Organizational Tiers and Relationships
Since the first Gulf War (1990-1991), there has been a focus on establishing MCP to provide trauma training and skills sustainment for deployable providers (J Trauma, 2022. 92, e57-e76; ACS Blue Book). Figure 1 gives examples of the organizational tiers and types of relationships that can occur between military and civilian organizations including at the locoregional, national, and international levels.
Three functional categories of clinical MCPs have been described including Just-In-Time Training, Integrated, and Skill-Sustainment MCPs. Just-In-Time Training are those MCP where military providers, usually as a team, receive trauma-specific training through didactics, model and/or cadaver high fidelity simulation, and clinical trauma care exposure at civilian trauma centers just prior to deployment typically facilitated by an embedded cadre of military providers. Each service has long-standing national-level partnerships using this model including the Navy Trauma Training Center in Los Angeles, the Army Trauma Training Center in Miami, and the three Air Force C-STARS (Center for the Sustainment of Trauma and Readiness Skills) programs in Baltimore, St. Louis and Cincinnati (J Trauma, 2022. 92, e57-e76).
In skill-sustainment MCPs, military providers maintain their skillset through clinical experiences at regular intervals in a civilian center. In the recent past, skill sustainment MCPs usually develop organically at the locoregional level. Finally, there are integrated MCPs where military providers are embedded full-time in civilian trauma centers, typically as faculty members. Integration with Graduate Medical Education (GME) programs can also occur, where trainees are comprised of both civilian and active duty members (J Trauma, 2022. 92, e57-e76).
Strategic Surgical Readiness Initiative – Womack Army Medical Center, Fort Bragg
Military Treatment Facility (MTF) surgical volume tends to be static during periods of relative peace or low operational tempo, and individual surgical volume is calculated by dividing the total number of surgical cases by the number of surgeons assigned to that location. Consistently increasing MTF surgical volume (the numerator) may be achievable over time but has proven difficult to date. At Womack Army Medical Center (WAMC), the focus has been on decreasing the denominator by providing additional platforms for active duty (AD) surgeons to access volume and complexity while increasing the volume of cases captured by individual surgeons working within the MTF. At WAMC, these lines of effort include locoregional MCPs, strategic MCPs, and integration with the Veterans Administration (VA).
Figure 2. Strategies to Increase Individual Active Duty Surgeon Operative Volume
Local MCPs are especially beneficial for non-trauma surgical subspecialists (for example, colorectal, surgical oncology, and minimally invasive surgery). Local community hospitals may not offer these specialties, and complex cases would otherwise be transferred to a specialty center. Local MCP allows an AD surgeon to spend a portion of their week within the local hospital providing surgical care within their subspecialty. For non-trauma surgical subspecialists, the opportunity to practice the full breadth of their surgical specialty at both MTFs and through local MCPs may improve professional satisfaction and surgeon retention.
The strategic US Army MCP beneficial to WAMC is with the University of North Carolina (UNC) where an AD Army trauma surgeon is embedded. Through a local Skills Sustainment rotational agreement, AD general surgeons can spend 2-4 weeks on the trauma service providing trauma resuscitation and surgical interventions with UNC trauma surgeon oversight. This platform allows general surgeons a high-caliber and safe environment to maintain their trauma-related skillset while remaining relatively close to home.
While military health system (MHS) and VA integration has many benefits for the AD surgeon, the differences between the two systems can be challenging to overcome. Despite this, the WAMC general surgery department has established VA clinics staffed by AD surgeons and created a process where VA patients can be brought to the MTF for complex surgery and AD outpatient surgery patients can be brought to the VA. Through this relationship, WAMC has accepted over 300 emergency general surgery transfers from the VA within the past 18 months increasing case volume and complexity for AD surgeons.
Military GME is the force generator for military medicine and must be carefully considered as partnerships are established. The WAMC MCPs with UNC and Carolina Medical Center have strengthened the WAMC surgery residency program by adding additional rotation sites and broader exposure to surgical diseases. WAMC’s diversification of readiness platforms in a coordinated effort has resulted in increased case volume and complexity for AD surgeons and has strengthened both the general surgery department and the residency, and is key to combating the peacetime effect.
United States and United Arab Emirates (UAE) MCP
In 2019 the US and UAE established a Foreign Military Sales case committing US Department of Defense (DOD) personnel specialized in trauma surgery, emergency medicine (EM), critical care (CC) nursing, health care administration, and rehabilitation to a new international MCP in Abu Dhabi with the goal of building an interoperable trauma and combat casualty care capability aligned with US standards.
The first US DOD team arrived in Abu Dhabi in 2019; in close collaboration with the UAE Armed Forces Medical Services Corps established a new MCP with the hub trauma hospital in Abu Dhabi, Sheikh Shakhbout Medical City (SSMC). SSMC is a 741-bed acute care hospital managed jointly by the Abu Dhabi Health Services Company and the Mayo Clinic; SSMC houses Abu Dhabi’s largest adult trauma service (3,000 annual admissions) and the national burn unit. As a result of the partnership, both US and UAE military medical personnel from critical wartime specialties have been embedded within SSMC, enhancing military medical readiness and expanding trauma capacity. Improvements in SSMC trauma care include the establishment of a stand-alone trauma service, the launch of a formal performance improvement and patient safety (PIPS) plan, the hiring of trauma program staff, the implementation of evidence-based clinical practice guidelines, and efforts to integrate pre-hospital care.
While this international MCP provides an excellent skills maintenance opportunity for embedded DOD physicians and nurses, the strategic vision is to establish the first in-theater skills maintenance platform to mitigate the impact of highly non-clinical deployments. The future goal would be to allow deployed medical teams pre-positioned in the region to rotate through SSMC for skills maintenance in between individual taskings while forward deployed.
New Navy Medicine Surgical Team Based Partnerships
Navy Medicine has recently implemented two new MCPs in Philadelphia, PA, and Chicago IL. In September 2021 Navy Medicine implemented a strategic partnership with the University of Pennsylvania in Philadelphia, embedding 10 deployment-eligible caregivers and a healthcare administrator for three years with the Trauma Division at Penn Presbyterian Medical Center with the goal of augmenting trauma care and expertise for military clinicians between deployments. The Navy team consists of four physicians ( trauma and general surgeon, anesthesiologist, and EM physician), three nurses (EM, CC, and perioperative), one physician assistant, one surgical technician, one search and rescue medic corpsman, and one medical service corps officer. Over the last year, the Navy team has successfully integrated with the Penn Medicine team working both individually within their specialty and together as a team caring for complex trauma patients. An 8-month interim analysis of physician productivity has demonstrated that all have exceeded the required specialty-specific MHS Knowledge, Skills and Ability (KSA) readiness thresholds. Future emphasis will focus on team effectiveness, efficiency, and the development of future team educational strategies.
Since 2013 the Navy Medicine Readiness Training Command (NMRTC) at Great Lakes has had a locoregional partnership with the Cook County Trauma and Burn Unit at the John H. Stroger Hospital (CCH) where local AD surgeons, nurses, and corpsmen have had the opportunity to hone their trauma skills prior to deployment. In 2017, this relationship developed into a national-level MCP with Navy Medicine when the first group of corpsmen graduated from the corpsmen trauma training (HMTT) program.
With the growing realization by military medicine that ad-hoc austere single surgeon teams formed prior to deployment increase risk to the mission, force, and the surgical team (J Trauma, 2022. 93, S6-S11), the CCH partnership is expanding further by becoming Navy Medicine’s first MCP to integrate personnel from the Expeditionary Resuscitative Surgical System (ERSS), a 7-person austere single surgeon team. As most MTFs do not provide expeditionary relevant clinical skill sustainment opportunities in trauma, burn, and critical care, this MCP was implemented to ensure ERSS teams gain this experience prior to austere deployments. The first of three ERSS teams will integrate in the fall of 2022 for a 3-year assignment at CCH. Whenever teams are not deployed, they will be clinically active individually and as a team performing expeditionary-relevant care at CCH and working at their local MTF, re-sharpening any clinical skills lost during deployment.
Conclusion
Three new MCP paradigms in military medicine developed and implemented to mitigate the peacetime effect have been reviewed. For institutions interested in participating in an MCP, the Military Health System Strategic Partnership with the American College of Surgeons published The Blue Book: Military-Civilian Partnerships for Trauma Training, Sustainment, and Readiness. This excellent resource provides information for developing and sustaining MCP, including site selection guidance, institutional commitment, governance, administration, the human and physical resources required, and criteria to evaluate the quality of new and well-established MCPs.
An MCP can take many forms. What “right” looks like depends on the service-specific goals and those of the civilian centers. Regardless of the structure, military-civilian partnerships have become and will continue to be critical to the ability of surgical teams to mitigate the peacetime effect and maintain surgical readiness.
