Military and Civilian Surgery Partner for Innovation, Effectiveness

Imagine the waiting room of a US Level I trauma center, filled with the tense hush of the relatives of a patient undergoing trauma surgery. When a door finally opens and a surgeon walks out, ready to give the family the update they’ve been longing for, they will no doubt address the physician as “Doctor.”

But would a title like “Major,” “Lieutenant Colonel,” or “Colonel” be more accurate?

If the surgeon was Colonel Jennifer M. Gurney, MD, FACS, MC, the military appellative would be appropriate. But if the moment allowed, Dr. Gurney also could confirm that arrangements placing military surgeons and surgical teams in civilian settings to provide surgical care—military-civilian partnerships—are now part of a growing number of US hospitals.

These partnerships benefit both patients undergoing care in civilian settings and patients who these military surgeons may later treat in armed conflict zones. Dr. Gurney, who is chief of the Joint Trauma System for the US Department of Defense, an institution serving as a center of excellence for trauma care of combat casualty care, explained, “During times of peace, we have to heavily rely on and leverage the civilian trauma learning experience to be able to not just maintain our skills as surgeons, but also to codify and evolve the lessons learned from the military during wartime service into civilian trauma care.”

Historical Connection

Overlaps between military and civilian healthcare workforces are not new. In an interview, C. William Schwab, MD, FACS, FRCS, a retired US Navy Commander and emeritus professor of surgery and founding chief of the Division of Traumatology and Surgical Critical Care at the University of Pennsylvania Medical Center in Philadelphia, said, “If you go back and look at the first 200-plus years of the history of the US, military and civilian service were joined at the hip and especially strong, historically, between military-civilian medical commitments. American physicians, nurses, allied health professionals, and administrators rallied to the call.”

In fact, innovations created by surgeons in multiple armed conflicts have had rapid and enduring influence on civilian healthcare. As Lester Martinez-Lopez, MD, MPH, former Assistant Secretary of Defense for Health Affairs explained in his Martin Memorial Lecture at Clinical Congress 2024, “Many concepts we take for granted today were first proven in the battlefield, including triage systems, specialized surgical teams, wound management techniques, blood transfusion practices, prosthetics development, trauma resuscitation, and medevac capabilities—all things that benefit military and civilian patients alike.”

Indeed, the very concept of a trauma system first came to fruition in the US during war. Between the First Battle of Bull Run in July 1861 and the end of the US Civil War in April 1865, both Union and Confederate armies made substantial inroads in organizing trauma care.

Innovations from this period include critical advancements in surgical hygiene and anesthesia, the creation of the first ambulance corps, groundbreaking data collection practices, federal legislation supporting the development and use of battlefield medicine, and the implementation by both sides of the Lieber Code, an early form of international humanitarian law that included standards on medical practice.^1,2

The pattern of innovation in armed conflict continued through World War I, World War II, the Vietnam War, and the armed conflicts in Iraq and Afghanistan. These lengthy engagements each fomented significant changes in military trauma care, including new strategies for providing damage control surgery to soldiers with  critical injuries.³ As a result, soldiers survived with more grievous wounds than in previous conflicts, from a slim minority in the US Civil War to rates as high as 98% in Afghanistan.⁴

Defeating the Walker Dip

However, none of these important innovations stopped the changing sociocultural attitudes and end of the US military draft in the mid-1970s. Combined, these circumstances left US civilian and military medicine interactions dormant for years.

“Essentially, after that, the American public—and I think Congress—generally ignored the need for a very strong military medical combat-ready service,” Dr. Schwab said.

During the first Gulf War in 1991, though, it became clear to military officials that a ready medical force was lacking.

“Combatant commanders and medical commanders who served in that short war came back and said, ‘We’re not ready for any type of armed conflict that comes up in the world,’” Dr. Schwab explained, noting that a 1993 opinion article by trauma surgeon Donald Trunkey, MD, FACS, in the Archives of Surgery was particularly influential in making this point.

Today, the problem Dr. Trunkey (who also was influential in the ACS Committee on Trauma, including serving as its Chair between 1982 and 1986) and others named is known as the “Walker Dip.” Long noted but named in 2018 by Alasdair Walker, CB, OBE, QHS, FRCS, a surgeon vice admiral and past surgeon-general of the British Armed Forces, it refers to “a pattern whereby military medical care improves in wartime and these advances are lost by the time the next conflict occurs.”⁵

In other words, although major innovations relevant to civilian medical care will spread beyond the military and endure well past the conflicts that created them, the readiness of individual military physicians and the trauma system, as well as the focus of leaders on combat casualty care, will  atrophy during  peacetime for lack of exposure to the kind of high-volume, high-acuity healthcare environments that war generates.

This reality means that a ready medical force is hard to maintain between deployments, unless access to civilian trauma care environments can be found. Indeed, one study found that as of 2019, just 10.1% of surgeons met goal readiness threshold for combat casualty care.⁶

“Just because we understand the Walker Dip does not mean we have to accept it,” Dr. Martinez-Lopez said in the Martin Memorial Lecture.

The best option, as Drs. Trunkey, Walker, Martinez-Lopez, and others have articulated, is to place military surgeons in civilian trauma centers so that these surgeons can maintain and increase their skills. This approach addresses the need for a surgeon to gain or retain trauma surgery expertise away from the battlefield and ensures their enduring readiness for deployment, which in turn helps ensure that troops in armed conflict zones receive  optimal care (and, perhaps, that the innovation borne of such conflicts can occur).

In addition, embedding military medical trauma teams promotes bidirectional learning, permits collaborative research efforts, alleviates the workforce shortages in some civilian hospitals and thus helps ensure high-volume, high-acuity centers provide high-quality care.

Dr. Gurney, who was the 2023–2024 President of the Excelsior Surgical Society, noted that the applications of these collaborations are broader. “It doesn't have to be war” that calls for a military-civilian partnership, she said. “It can be a natural disaster. It can be many other threats. If the military and civilian trauma system are not integrated and working in concert, our patients don't do as well. It's all about providing the best trauma care, anytime, anywhere.”

Advocacy that Succeeded

Such military-civilian partnerships slowly emerged after the Gulf War. Per Brian Eastridge, MD, FACS, the Medical Director of the ACS Military Health System Strategic Partnership, “They’ve existed in some form or another for about 3 decades.”

But the concept reached fuller realization after a post-September 11 US faced long-running conflicts in Iraq and Afghanistan. For his part, Dr. Schwab said he learned of the experiences of several surgeon colleagues deployed into these conflicts, and over time embraced the view that additional civilian training would be an important advancement.

As a result, when he gave the prestigious Scudder Trauma Memorial Lecture at Clinical Congress 2014, he used the opportunity to call for just such an arrangement. He later published a white paper further elucidating his support for embedding military trauma personnel at US academic medical universities for trauma combat casualty care.⁷

At the same time, experts (including Dr. Schwab) also were meeting under the auspices of the National Academies of Sciences, Engineering, and Medicine (NASEM). In 2016, this organization released A National Trauma System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury,⁸ a 530-page report advising, among other things, that military surgeons work in civilian trauma units for both troop readiness and improvements to civilian care.

The ACS helped bring this idea to fruition. Over the next several years, the College and other entities advocated for the passage of laws that would create these partnerships. Dr. Schwab, who has been a part of the ACS for approximately 40 years, participated in that effort. He described Senator Tammy Duckworth, who is a veteran from Illinois, as “just unbelievably supportive,” adding that “a number of other senators, including Bob Casey from Pennsylvania, my own senator” were likewise helpful.

As a result of this support and other efforts, the Military Injury Surgical Systems Integrated Operationally Nationwide to Achieve ZERO Preventable Deaths Act, more commonly known as the MISSION ZERO Act, was signed into law in June 2019 as part of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act. The act authorizes military-civilian partnerships in US trauma centers.

In the same year, through the John S. McCain National Defense Authorization Act (a yearly law that authorizes funding and authorities for the US military and other defense priorities), US Congress again directed the military to create these military-civilian partnerships, also appropriating funding for this to occur.

87 and 1

By a count Dr. Gurney completed in 2022 with a research team, at least 87 unique partnerships supported by the MISSION ZERO Act exist.⁹ Prominent examples include The University of Alabama at Birmingham, where a well-established partnership embeds US Air Force Special Operations Surgical Teams;¹⁰ Penn Medicine’s  Penn Presbyterian Medical Center, where a deployment-eligible multidiscipline surgical team and a healthcare administrator from Navy Medicine are embedded; a collaboration between the US and United Arab Emirates armed forces at the high-level trauma center within Sheikh Shakhbout Medical City in Abu Dhabi; and a partnership with University Hospitals Cleveland Medical Center in Ohio.

Dr. Gurney continues to pursue the creation of a single registry that can capture quality improvement measures for all such partnerships, while noting that varying approaches, extents, and durations make them hard to count or describe succinctly.

“Some of them are just for surgeons,” she explained. “Other ones are for teams. Others are rotational, or they are embedded or fully integrated, where they have an admitting privilege and don't have to be supervised. These partnerships depend a lot on the ecosystem of the trauma care delivery in that region as well as the governance of that civilian hospital.”

If no military-civilian partnerships existed, how many military-only hospitals could offer experience in a high-volume, high-acuity trauma centers to military surgeons? Just one, Dr. Gurney said—the only Level I trauma center solely within the military health system, at Brooke Army Medical Center in Fort Sam Houston, Texas.

“Right now, unless you’re working at Brooke Army Medical Center, valuable high-volume, high-acuity trauma care is within the military-civilian  partnerships,” she said.

Quantifiable Achievements

The positive impact of military-civilian partnerships is clear. Dr. Schwab admitted that documenting impact on the civilian trauma system because of military surgeon participation remains a challenge, as military surgeons remain a small percentage of all trauma personnel in the trauma system nationwide.

But he and Drs. Gurney and Eastridge point to positive reports from existing partnerships, as well as a general desire for hospitals to create new ones—despite the bureaucratic burden associated with military collaborations—as signs of success.

The findings are more than anecdotal. Research has shown quantifiable benefits from military-civilian partnerships, in that participating military surgeons in civilian units can meet their deployment readiness goals^6,10 while developing surgical outcomes on par with civilian surgeons¹1 and increasing their research output¹²—an outcome that suggests the long-standing pattern of military innovation in surgery continues. These data have validated that the key goal of these partnerships, which is ensuring military trauma surgeons are ready for deployment, can be met without deleterious effects on civilian centers in which they serve.

That finding underplays the assistance that these surgeons can give to the trauma centers in which they serve. “There's this tremendous source of pride. There's a significant halo effect for these hospitals with respect to many of their communities,” Dr. Eastridge said.

What’s Next?

For all this success, however, there is a contradiction at the heart of these connections. While military-civilian partnerships clearly aid military surgeons and surgical teams by keeping their skills sharp in peacetime, the political capital to create and maintain these partnerships rises when other military-inspired innovations do: during wars. With few US troops deployed to active conflict zones at present, will the progress of these programs be sustained?

Dr. Gurney believes they will be: “Punctuated equilibrium, where you have a lot of intensity followed by no intensity or complacency, is the natural ebb and flow of things. It needs policy, it needs leadership, and it needs both top-down and bottom-up solutions to keep the momentum. Yes, it is more difficult in an interwar period. But I think that we've codified a lot of things from the NASEM report, and we've had the right leadership in place so that we should be able to keep the momentum for the foreseeable future.”

To that end, important efforts are underway. The ACS will launch the Military-Civilian Partnership Portal. Via a page on the ACS website, facs.org, military surgeons can find potential sites for service, while healthcare centers can publicize existing or nascent military-civilian partnership sites. The hope is that the portal will bolster the efforts of surgeons and hospitals to create and sustain military-civilian partnerships.

At minimum, it will fill an important gap in information access. “I can't count the number of emails in my inbox, saying ‘How do I do this? How does my hospital engage or develop a partnership?’” Dr. Eastridge said. “There's nowhere out there to get these questions answered.”

Building on the ACS guidelines document, Military-Civilian Partnerships for Trauma Training, Sustainment, and Readiness (The Blue Book), Dr. Eastridge is leading a review of multiple current military-civilian partnership sites, with the aim of releasing a white paper this year with renewed perspectives on best practices.

Another crucial step is the continuation of the legislation that authorizes and funds these partnerships. Representatives Kathy Castor of Florida and Michael C. Burgess, MD, of Texas, reintroduced the MISSION ZERO Act in 2023. The ACS Division of Advocacy and Health Policy continues to advocate for the passage of legislation supporting military surgery.

Still others have expressed an interest in further ACS involvement. In the Martin Memorial Lecture, Dr. Martinez-Lopez called for other forms of professional development: “We need to develop military trauma leaders using the time between conflicts to work with our civilian partners, such as the Committee on Trauma, to formally mentor military surgeons and foster new leaders.”

For now, Dr. Schwab, who received the 2024 ACS Distinguished Lifetime Military Contribution Award, said support continues to endure for the military-civilian partnership concept: “It has rekindled the national spirit. It has increased our morale and our optimism, and it has brought an unbelievable respect, for one, the US and the Department of Defense, and number two, for the men and women who serve in those uniforms.”

Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

References

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