Importance:Military medicine in the US was established to treat wounded and ill service members and to protect the health and well-being of our military forces at home and abroad. To accomplish these tasks, it has developed the capacity to rapidly adapt to the changing nature of war and emerging health threats; throughout our nation's history, innovations developed by military health professionals have been quickly adopted by civilian medicine and public health for the benefit of patients in the US and around the world.Observations:From the historical record and published studies, we cite notable examples of how military medicine has advanced civilian health care and public health. We also describe how military medicine research and development differs from that done in the civilian world. During the conflicts in Afghanistan and Iraq, military medicine's focused approach to performance improvement and requirements-driven research cut the case fatality rate from severe battlefield wounds in half, to the lowest level in the history of warfare.Conclusions and Relevance:Although innovations developed by military medicine regularly inform and improve civilian health care and public health, the architects of these advances and the methods they use are often overlooked. Enhanced communication and cooperation between our nation's military and civilian health systems would promote reciprocal learning, accelerate collaborative research, and strengthen our nation's capacity to meet a growing array of health and geopolitical threats.

Journal Article Response to Letter to the Editor concerning: Graduate Medical Education in the Military Health Get access Linda C Degutis, DrPH, MSN, Linda C Degutis, DrPH, MSN Department of Chronic Disease Epidemiology, Yale School of Public Health, Decatur, GA 30030, Georgia https://orcid.org/0000-0001-5861-007X Search for other works by this author on: Oxford Academic Google Scholar Arthur L Kellermann, MD, MPH, Arthur L Kellermann, MD, MPH Advisor and Consultant, Richmond, VA 23220, USA https://orcid.org/0000-0002-1682-6101 Search for other works by this author on: Oxford Academic Google Scholar Kevin M Jackson, OD, MPH, Kevin M Jackson, OD, MPH Office of the Dean, School of Medicine, Uniformed Services University of the Health Sciences, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA https://orcid.org/0000-0001-8484-4216 Search for other works by this author on: Oxford Academic Google Scholar Allen Middleton, MBA Allen Middleton, MBA Consultant, Haymarket, VA 20169, USA https://orcid.org/0000-0002-5993-5578 Search for other works by this author on: Oxford Academic Google Scholar Military Medicine, Volume 188, Issue 11-12, November/December 2023, Page 314, https://doi.org/10.1093/milmed/usad297 Published: 28 July 2023 Article history Received: 11 July 2023 Editorial decision: 13 July 2023 Accepted: 18 July 2023 Corrected and typeset: 28 July 2023 Published: 28 July 2023

INTRODUCTION:At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force.MATERIALS AND METHODS:The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems.RESULTS:This report proposes numerous short- and long-term courses of action in three areas:1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience.2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions.3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership.CONCLUSION:Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS's top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

ImportanceMilitary medicine in the US was established to treat wounded and ill service members and to protect the health and well-being of our military forces at home and abroad. To accomplish these tasks, it has developed the capacity to rapidly adapt to the changing nature of war and emerging health threats; throughout our nation’s history, innovations developed by military health professionals have been quickly adopted by civilian medicine and public health for the benefit of patients in the US and around the world.ObservationsFrom the historical record and published studies, we cite notable examples of how military medicine has advanced civilian health care and public health. We also describe how military medicine research and development differs from that done in the civilian world. During the conflicts in Afghanistan and Iraq, military medicine’s focused approach to performance improvement and requirements-driven research cut the case fatality rate from severe battlefield wounds in half, to the lowest level in the history of warfare.Conclusions and RelevanceAlthough innovations developed by military medicine regularly inform and improve civilian health care and public health, the architects of these advances and the methods they use are often overlooked. Enhanced communication and cooperation between our nation’s military and civilian health systems would promote reciprocal learning, accelerate collaborative research, and strengthen our nation’s capacity to meet a growing array of health and geopolitical threats.

The Military Health System (MHS) has a medical research program aimed at a wide range of health-, disease-, and injury-related topic areas that works with civilian academic institutions and the biomedical industry to accomplish its goals. There are many opportunities for civilian academic institutions and the biomedical industry to engage with this program, but its unique features are important to understand to optimize the chances for successful partnerships. Unlike the National Institutes of Health, which uses an "investigator-initiated" approach, the Department of Defense (DoD) aligns its funding with specific needs, also referred to as requirements; thus, DoD research is often described as "requirements-driven" research. At the highest level, requirements are aligned with the National Security Strategy and National Defense Strategy, though requirements documents list specific areas in medicine with unmet needs. Military labs and the Uniformed Services University of the Health Sciences, which can also receive DoD appropriations to conduct medical research, serve as hubs that interface with civilian academic institutions and the biomedical industry and organize and track the overall progress of DoD investments. As a mechanism to propel findings from "bench to bedside," the military budgets funds for the various phases of research and development for a given topic area. Research programs are most effective when they are integrated into the MHS learning health system, which allows MHS clinical communities to inform and track research investments and evaluate the utility of research products in real clinical practice settings. This Perspective provides introductory information and a basic framework for those interested in performing DoD-funded medical research or collaborating with researchers in military labs. It is hoped that as academic institutions and the biomedical industry look to increase efficiency in medical research, they will find ways to engage with DoD research opportunities and consider elements of the military's approach useful.

This Viewpoint reviews Centers for Medicare and Medicaid Services' Emergency Triage, Treat, and Transport (ET3) model, a voluntary payment model that will reimburse emergency medical service (EMS) agencies for handling 911 calls with non-emergency department dispositions including on-scene or telemedicine treatment and transport to alternative sites (urgent care clinics, physician offices, behavioral health centers), and outlines the patient safety, quality, and regulatory issues that must be addressed for the concept to move from demonstration project to established policy.

AffiliationsAll of the authors are with the Department of Preventive Medicine and Biostatistics, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.

To the Editor: We read with great interest the recent study from Marcu and colleagues1 comparing the effectiveness of various financing strategies for medical school education. One critical factor that was not included in the investigators’ otherwise meticulous models was the potential opportunity cost of self-financing a medical education. For those who self-finance, the money they pay in tuition could have been invested with equivalent or higher returns than the interest rates on educational loans. Given that the investigators did not take into account the opportunity cost of self-financing medical education, it seems that they arrived at an intuitively obvious conclusion—that starting one’s medical career without any debt is the most advantageous in the long run. Understanding the influence and magnitude of potential opportunity cost is essential to enabling prospective medical students and families to weigh the decision of investing family resources into self-financing medical school versus diverting these resources into other equally high-priority family investments (i.e., retirement, stocks, housing). Oanh Kieu Nguyen, MD, MASAssistant professor, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas; ORCID: http://orcid.org/0000-0002-4614-0215; [email protected] Anil N. Makam, MD, MASAssistant professor, Departments of Internal Medicine and Clinical Sciences, UT Southwestern Medical Center, Dallas, Texas; ORCID: http://orcid.org/0000-0001-7072-9946.

We thank Drs. Nguyen and Makam for their remarks. For the independently wealthy, his observations are germane. However, we did not conduct our study to determine whether these fortunate few are better off paying cash for a medical degree rather than investing their money in other ways. The primary objective of our study was to determine whether the benefits of national service scholarships (and other paths to avoiding debt, such as institutional scholarships) offset the lower earnings these graduates may accrue during varying lengths of public service. Our analysis revealed that, for most aspiring physicians, attending medical school with the help of a national service scholarship is an excellent deal. We hope that our findings will encourage federal and state officials, policy makers, and institutional donors to expand the number and range of scholarships so more young people from low- and middle-income families can attend medical school without the need to take on large debts. Arthur L. Kellermann, MD, MPHDean, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; [email protected] Mircea Marcu, PhDEconomist, U.S. Office of Personnel Management, Washington, DC.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Surgery HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Surgery journal

Purpose To understand the long-term economic implications of key pathways for financing a medical school education. Method The authors calculated the net present value (NPV) of cash flow over a 30-year career for a 2013 matriculant associated with (1) self-financing, (2) federally guaranteed loans, (3) the Public Service Loan Forgiveness program, (4) the National Health Service Corps, (5) the Armed Forces Health Professions Scholarship Program, and (6) matriculation at the Uniformed Services University of the Health Sciences. They calculated the NPV for students pursuing one of four specialties in two cities with divergent tax policies. Borrowers were assumed to have a median level of debt ($180,000), and conservative projections of inflation, discount rates, and income growth were employed. Sensitivity analyses examined different discount and income growth rates, alternative repayment strategies, and various lengths of public-sector service by scholarship recipients. Results For those wealthy enough to pay cash or fortunate enough to secure a no-strings scholarship, self-financing produced the highest NPV in almost every scenario. Borrowers start practice $300,000 to $400,000 behind their peers who secure a national service scholarship, but those who enter a highly paid specialty, such as orthopedic surgery, overtake their national service counterparts 4 to 11 years after residency. Those in lower-paid specialties take much longer. Borrowers who enter primary care never close the gap. Conclusions Over time, the value of a medical degree offsets the high up-front cost. Debt avoidance confers substantial economic benefits, particularly for students interested in primary care.

INTRODUCTION Over the past 150 years, military medical research has made significant contributions to American health care. In the past decade alone, military medicine has achieved significant advances in combat casualty care by demonstrating the value of tourniquets, damage control resuscitation and surgery, new infection management guidelines, transcontinental critical care transport, advanced prosthetics, and new techniques in rehabilitation. This pioneering research cannot occur in a vacuum. As in civilian settings, medical research must be nested in an academic architecture. In the Military Health System (MHS) the foundation for cuttingedge research is built at the Uniformed Services University of the Health Sciences and through military Graduate Medical Education (GME).

It is widely believed that anesthesia-related mortality has decreased dramatically during the past 25 to 50 years.1 In a seminal study from the 1950s based on nearly 600,000 anesthetics, Beecher and Todd2 estimated that anesthesia was the primary cause of death in 1 of 2680 cases. In its report, To Err Is Human: Building a Safer Health Care System, the Institute of Medicine (IOM) reports that anesthesia mortality rates have decreased from 1 in 10,000 to 1 in 200,000 to 300,000.3 The accuracy of the low mortality estimate cited in the IOM report has been strongly challenged. Lagasse4 estimates that the anesthesia mortality rate is 20 times higher than the IOM estimate: 1 death per 10,000 anesthetics, rather than 1 in 200,000. Using a narrow definition of anesthesia-related outcomes, which includes only very rare complications such as esophageal intubation or cardiac arrest on induction, creates the impression that anesthesiology is safer than it actually is. If, in fact, the commonly cited statistic of 1 death in 200,000 to 300,000 anesthetics3 is accurate, then the practical limits of what is achievable for anesthesia patient safety may already have been attained. However, if more common but still major complications, such as acute kidney injury, postoperative myocardial infarction (MI), respiratory failure, and stroke, are caused as much by anesthesia as by surgical management,5 then surgery can be made safer by further improving anesthesia care. One of every 150 hospitalized patients experiences a lethal adverse event, and nearly half of these events involves surgical patients.6 More than 50% of surgical adverse events may be preventable.7 If surgical outcomes vary across anesthesiologists, then further improvements in Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000522 Society of cardioVaScular aNeStheSiologiStSreSearch report

A report from the National Academies of Sciences, Engineering, and Medicine examines the U.S. military's reduction of morbidity and mortality after injury and the possible implications of its work for improving care in civilian settings.

Objective:To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment. Background:In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes. Methods:Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies. Results:Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95–1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, &kgr; 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group. Conclusions:Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.

150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality. METHODS: Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidi- ties, and hospital quality. RESULTS: Anesthesiologist performance was quantified using fixed-effects modeling. The vari- ability across anesthesiologists was highly significant ( P < 0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%–3.58%) as patients man- aged by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%–2.10%). This performance gap was observed across all patient risk groups. CONCLUSIONS: The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients. 2015;120:526–33)