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U.S. military surgeons lost practice and proficiency at a 'precipitous' rate in recent years, according to a study.

The number of general surgery procedures in military hospitals fell by 25.6% from 2015 to 2019, corresponding to a 19.1% drop in the clinical readiness of the military surgeons as measured by the military's Knowledge, Skills, and Abilities (KSA) metric.

In 2015, a meager 16.7% of general surgeons accumulated enough KSAs to meet the threshold of combat readiness set by the Defense Health Agency. By 2019, that number dropped to 10.1%, according to Michael Dalton, MD, MPH, of Harvard Medical School and Brigham and Women's Hospital in Boston, and colleagues, writing in .

While military hospitals experienced a significant reduction in surgical volume, civilian hospitals saw a 3.2% increase in purchased surgical care from service members with TRICARE, the U.S. military's health insurance program. However, this increase isn't large enough to account for the major decline in military surgical volumes, study authors argued.

Issues with the quality of surgical training at military hospitals have been . A on inadequate surgical volumes in military hospitals revealed that as of 2016, no facility met the recommended volume thresholds for a selection of ten high-risk surgeries.

Concrete solutions to these problems are lacking.

"There have been many meetings and lots of discussion, but in my opinion there haven't been significant changes that solve the problem. There have been small efforts at change," said John Holcomb, MD, of the University of Alabama at Birmingham, who is former commander of the U.S. Army Institute of Surgical Research.

Dalton's group noted that recapture is one approach prioritized by the Defense Health Agency. This would entail , perhaps specifically targeting the surgeries that provide the greatest clinical value to combat casualty care personnel.

When the U.S. military transitioned to TRICARE in the mid-to-late 1990s, it in a move that enabled retirees to skip military hospitals and seek treatment directly at civilian ones. Today, civilian or purchased care represents the and shows no signs of decreasing, according to the authors.

Yet "the basic concept that elective surgical cases can substitute for routine high-volume trauma care flies in the face of the civilian trauma system experience in the U.S.," Holcomb said. "It is time to come up with a different solution than 'recapture' complex surgical cases."

Military-civilian partnerships also provide opportunities for military surgeons to treat a larger volume of patients. These partnerships have been successful in several trauma centers across the U.S., including at Ryder Trauma Center, R Adams Cowley Shock Trauma Center, and the Los Angeles County Trauma Center, according to the study authors.

However, the scope of these military-civilian partnerships is limited, complained Lesly Dossett, MD, MPH, and Justin Dimick, MD, MPH, both of Michigan Medicine in Ann Arbor.

"Although improving the readiness of the individual surgeon, these partnerships largely have not addressed the preparation of the broader forward surgical team, including anesthesia clinicians, perioperative nurses, and surgical technicians," they said in a .

"The increasing regionalization of complex surgical procedures and decreased volumes at MTFs [medical treatment facilities] may create an environment in which maintaining expeditionary-ready surgeons via an active-duty and MTF-based model is no longer feasible on a large scale," said Dossett and Dimick.

"Instead, military medicine may need to re-examine the optimal strategy in procuring the services of expeditionary-ready surgical teams, including the broader use of reservists who maintain busy clinical practices while not deployed or the use of civilian contractors, a strategy that has been used for other military support roles," the duo suggested.

"Without urgent attention to decreasing case volumes for surgeons, the ability to maintain a ready medical force may be threatened," Dossett and Dimick maintained.

The Defense Health Agency is set to in an effort to centralize and potentially downsize the MTF system.

Dalton and colleagues had performed an analysis of the workload across the U.S. Military Health System, which includes both military and civilian centers. There were 147 surgical sites included in the report.

Each surgery was assigned a KSA value, a measure of the skills gained by the operator per procedure. The Uniformed Services University of Health Sciences, in partnership with the American College of Surgeons, had established 487 unique KSA relevant to deployed surgeons.

TRICARE records provided information about use of healthcare among active and non-active duty military personnel, their dependents, and retirees in various military and community hospitals.

A major limitation of the study was the potential undercounting of case volumes for military surgeons: study authors had been unable to count surgeries performed by military surgeons outside of MTFs, whether due to off-duty employment in civilian hospitals, participation in civilian-military collaboratives, or other types of outside work.

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