Graduate Education Bolsters Military Health Care

Graduate medical education programs take only a 1 percent bite from DoD's annual health care budget, but what they buy is experience. Residency training is "a major reason we're able to retain 30 percent of military physicians with greater than eight years of experience," said Army Dr. (Col.) Mike Dunn, DoD's director of clinical consultation.

"Graduate medical education produces a group of acculturated, military oriented physicians more likely to stay with us," Dunn said. "Having that group of senior, experienced physicians is essential not only for high quality of care in peacetime but also for success in combat. Combat health care is more challenging, and you really need a fair number of people with seniority and experience to make it work."

"There are many things about a doctor's training in civilian life that are relevant to readiness," said Air Force Dr. (Col.) Jerry Foster, former professional education director at Wilford Hall Medical Center, Lackland Air Force Base, Texas. "If you're going to be a surgeon, you better know how to cut. The real question is, 'What can we give the resident at Wilford Hall that he can't get at Harvard, for example?' We're starting to give our residents training they can't get at a civilian medical school -- through deployments, for example."

Wilford Hall sends residents on all medical deployments, said Foster, who retired from the Air Force in January. To prepare them, the in-house curriculum includes two weeks of briefings on doctrine, site conditions, infectious diseases they might encounter, local politics and medical specialty-related issues. After they complete these briefings, the residents then deploy alongside more experienced staff physicians, often on two-week visits to Latin American countries, where they provide medical services not locally available. The deployments expose them to field conditions and diseases they're most likely to face during military operations.

"However, they deploy with a much broader perspective than just solving the immediate medical problem," Foster said. "That's military unique."

Unique requirements aside, DoD health care still faces the same funding scrutiny as all other areas of defense. To retain a robust graduate education program, therefore, health care managers have sought -- and found -- ways to make the programs more efficient while ensuring no loss of medical readiness. They've done this by integrating the programs between service branches and with some civilian medical schools.

Integrating graduate medical education eliminates duplication, Foster said. For example, why should two major military medical centers, only miles apart, conduct the same programs? And with a common goal of improved patient care, teaming up makes further sense.

"We looked at how we provide our medical services to our patients and said, 'Let's set this up in the best possible way we can for them, and then let the graduate medical education follow suit,'" Foster explained.

Two years ago, monthly deliveries of newborns averaged 110 at Wilford Hall, 80 at Brooke Army Medical Center at Fort Sam Houston, Texas, and more than 300 at Darnell Community Hospital, Fort Hood, Texas. Darnell spent $1.5 million annually to send premature births to area civilian hospitals or to San Antonio for care at Wilford Hall or Brooke.

As part of reshaping pediatrics and neonatal education programs, Wilford Hall decided to open a neonatal nursery at Fort Hood and staff the nursery with graduate medical education program residents.

"We saved $1.5 million a year and improved the experience for our trainees," Foster said of the move. "Most importantly, we improved the quality of life for those people with premature infants at Fort Hood. They now are able to stay near home and not have to travel all the way to San Antonio [a four-hour drive]. Parents aren't geographically separated from their infants, and soldier parents aren't absent from duty for long periods of time."

Patient needs also drove realignment of obstetrics and gynecology services at the military hospitals. Now, Wilford Hall provides obstetrics and deliveries, while Brooke handles gynecology surgery. Training is integrated for both medical centers and includes Darnell, where residents get a high volume of delivery experience.

Wilford Hall has integrated 20 of its 23 graduate medical education programs. For the same reasons, Army, Navy and Air Force medical centers in the National Capital Region innthe Washington, D.C., area, integrated 37 education programs, sharing facilities and faculties to train residents. There aren't many other situations where large hospitals of different services are located in the same area. However, Dunn said integrating with medical school programs makes equally good sense.

For example, the hospital at Wright-Patterson Air Force Base, Ohio, integrated six graduate medical education programs with nearby Wright State University. Besides sharing training activities, however, the Air Force provides the work place for the university's medical school, which doesn't have its own medical center.

"Like Wright-Patterson, we are looking at the University of Texas Health Sciences Center as a major partner," Foster said. Wilford Hall already bases its nuclear medicine fellowship at the San Antonio campus, and other programs that could integrate with the school include family practice and plastic surgery, he said.

"It just makes sense to integrate duplicate training programs where we can," Dunn said. "But it goes way beyond nice, to being essential to success in combat. Combat health care is no place for an amateur force. We need experienced physicians with military-unique training, and our graduate medical education programs give us that."