Civilian-military partnerships

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To the Editor:
The “Position statement of the ACS COT the NASEM Report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury” makes specific recommendations to address the need for retaining and sustaining the lessons learned and skill set of military surgeons, including “pursue the development of integrated, permanent joint civilian and military trauma system training platforms to create and sustain an expert trauma workforce.”1
I propose escalating this innovative idea further; expand the mission of all of the Military Treatment Facilities (MTF) in the United States to include the medical care of the poor and disadvantaged patients in those communities and to include those who are Medicaid-eligible and the less fortunate in addition to caring for service members and their families. We need to be innovative to find a solution to address the problems of limited clinical volume and the need for sustainment of clinical skills and to tackle the ongoing problem of caring for poor and underserved civilian Americans. My recommendation to expand the civilian/military collaborative will address the needs of all parties.
The reason for the expansion beyond trauma care may not be intuitive; however, there is more than trauma care that is needed to maintain competency and readiness of all military medical personnel in war and in peace. Not only are surgeons deployed in times of war and for disaster assistance, but there are also many other physician specialties and ancillary healthcare providers who deploy and need to maintain their skills and competence when at home in order to be ready to deploy. In war and in disaster relief, in addition to care of service members, the military medical professionals often care for the local population. This may include cardiac care; infectious disease; care of children, mothers, and pregnant women; Internal Medicine; Pediatrics; OB; Radiology; and Pathology, among others.
Expanding access to the MTF for Medicaid-eligible and otherwise economically disadvantaged civilians beyond trauma care would allow the sustainment and maintenance of skills for more than just military surgeons. It would increase the number and types of patients in the MTF, providing ongoing experience for all of the military personnel who work there. This would provide opportunities for all providers to sustain and improve their skills for times when they are deployed. This expanded mission may add job satisfaction by increasing the scope and number of medical problems and patients seen. Offloading this population of patients from local emergency rooms may benefit the local community hospitals, which may well encourage additional collaboration between the civilian and the military hospitals for patient care, education, and research.
MTFs are needed to support their military installations, so they need to be funded sufficiently to provide care for their patients. This can be a costly mission. Many of the expenses in a hospital are those to maintain the facility itself, the brick and mortar, and “keeping the lights on,” even if the average daily census is consistently low. At times because of low volume, limited experience, or limited staffing, patients will be transferred to the local community hospital for their care. With fewer patients, the providers have less experience. This may produce a cycle of low volume, resulting in less experience and even lower volume.
An alternative to paying for the infrastructure and ongoing costs of military health care may be to close the MTF, sending all of their patients to the community hospitals. This may create an excessive burden to those hospitals that would be tasked to care for many more patients. This could possibly overwhelm the local resources, a potentially harmful result.
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