Maintaining clinical competencies of military surgeons at the beginning of the 21st century: the French paradigm

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Dear Editor,
Maintaining the clinical skills of military surgeons in the modern era is a true challenge owing to the impact of repeated deployments and the evolution of the surgical practice in France.
At this time, five French forward surgical teams (FSTs) are permanently deployed all over Africa, and one FST is occasionally deployed on a boat. Surgical activity during a deployment is irregular owing to the nature of modern warfare. Long periods of inactivity may follow the treatment of several simultaneous catastrophically bleeding combat casualties. This is, however, partially compensated, since the French Military Health Service (FMHS) provides surgical support of our allies in deployment. It is also our national doctrine to provide humanitarian surgical support to local civilians, particularly in Africa (civilian collateral casualties, nonbattle surgical emergencies, or elective surgical lists). Nevertheless, the volume of surgical activity remains commonly low during these deployments. Furthermore, back from deployment, the French military surgeons face another significant obstacle regarding the maintenance of their surgical skills: a delay of 4 to 6 weeks is usual to recover a normal flow of patients in their clinics and through referrals. Concerning the specific problem of management of polytrauma, only two of the nine French military hospitals are Level I trauma centers in which most polytraumas are blunt trauma and not penetrating trauma.
The second problem is the surgical trend to the subspecialization of surgeons and the development of minimally invasive surgery. This is a real pitfall, with regard to the extended skill set, which is necessary in deployment surgery.1
This situation is shared by other armed forces and specifically by the US Armed Forces as shown by Edwards et al. in 2016.2,3 The solutions of the FMHS aimed at maintaining clinical competencies of military surgeons apply to deployments and the initial and continuing education.
Several measures have been put in place. First, the time of deployment of our FST is limited to a period of 3 months and the number of deployment limited to one per year as far as possible. Furthermore, the patient holding capability, which is a mandatory part of the French FST, allows maintaining a regular pace of activity as well as battle injuries, nonbattle injuries, and humanitarian surgery. Our standard FST team is manned by 12 health care professionals among whom two surgeons (one visceral/general surgeon, one orthopedist, and one anesthetist). It allows running elective lists (humanitarian surgery for the local population), sets up as much as possible in coordination with the local medical network in order not to disturb the local professionals. Our special operation surgical team (Module de Chirurgie Vitale [MCV]) is manned by five personnel (one general/trauma surgeon, one surgeon deputy, one anesthetist, one scrub nurse, and one anesthetist nurse). The MCV supports the special forces in their progression, has no patient holding capability, and cannot maintain a regular set of interventions. Therefore, the team rotation is, as far as possible, every 3 to 4 weeks to return to their normal routine in their military hospital.
With regard to education, the FMHS established a specific approach to prepare the military surgeons. During their initial specialized training in the civilian and military teaching hospitals, the military trainees follow a core surgical curriculum (6 years). However, in the near future, major difficulties may rise as the general surgery specialty is due to disappear in 2018. It is likely that future surgical trainees will be less familiar with urology or vascular surgery, creating a potential expertise gap with the extended skill set, which is necessary in deployment surgery.
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