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Surgeons sitting idly during deployments may be leaving military patients at risk

Chadian military and U.S. Army Reserve medical professionals partner to perform an excision of back lipoma surgery during Medical Readiness Training Exercise 17-3 at the Military Teaching Hospital in N'Djamena, Chad, May 4, 2017.

SHEJAL PULIVARTI/U.S. ARMY

By NANCY MONTGOMERY | STARS AND STRIPES Published: November 19, 2017

Military surgeon Maj. Joseph Lee deployed to a remote Cameroon hospital recently. But he didn’t perform surgery.

He did hold a retractor for a Cameroonian surgeon, he said, and spent several hours holding up a patient’s leg in traction.

A colleague of Lee’s deployed to Afghanistan for nine months as part of a small, mobile medical team supporting special operators. He caught up on his reading. And he did one surgery a month.

“It’s very concerning — your skills can atrophy,” said Lee, who’s assigned to the 212th Combat Support Hospital in Miesau, Germany.

Assignments like these have military surgeons increasingly concerned about a high deployment tempo that paradoxically may be leaving them less skilled to do their jobs — and could be putting their patients at risk.

The relatively few surgeries being performed, both on deployment and in garrison, is “the biggest challenge Army general surgeons face today,” said Col. Mary Edwards and Col. Shawn Nessen, surgery consultants to the Army Surgeon General, in a joint email to Stars and Stripes.

“As military surgeons, our number one priority is to provide safe, quality care for our patients, and it weighs heavily on our minds that in the current environment our operative skills are at risk.”

Edwards, a pediatric surgeon at San Antonio Military Medical Center and lead author of an influential article published last year in the Journal of the American College of Surgeons, found that deployed surgeons in 2014 and 2015 on average performed less than one surgery a month.

Dr. Martin Zielinski, a Mayo Clinic trauma surgeon, said that didn’t put surgical skills merely at risk.

“I would go one step further than Col. Edwards and say that one operation a month is insufficient to maintain your operative skills,” Zielinski said.

Most military hospitals do far fewer surgeries than civilian surgery centers and lag behind civilian surgeons in case numbers and complexity.

Garrisoned military surgeons performed an average of 131 surgeries a year, or about 11 a month, compared to 533 annual surgeries, or roughly 44 a month, by civilian surgeons, Edwards’ article said.

It was debatable, Edwards wrote in her article, whether military surgeons could sustain their surgical skills in garrison and be prepared for deployed trauma surgery, “let alone reinvigorate them after a long deployment” on which they did even fewer surgeries.

Decades of studies have shown that surgeons and hospitals that do more procedures produce more positive outcomes for patients, compared with low-volume surgeons and hospitals.

“There is no doubt that the outcomes of elective surgery — as measured by postoperative mortality, complications, or a wide array of other measures — are better when an operation is done by a surgeon or in a hospital with a high procedure volume,” Dr. David Urbach, a Canadian expert, wrote in the New England Journal of Medicine in 2015.

The reason why seems obvious. “Practice makes perfect; experience creates better physicians,” according to Dr. Ashish K. Jha, a public health professor at Harvard and an internist at the Veterans Affairs Boston Healthcare System.

Jha, writing in the Journal of American Medicine, said that experienced multidisciplinary teams at high-volume hospitals also contributed to better outcomes.

The demand for small, mobile surgical teams and a focus on austere environment training — part of the Army’s planning for near-peer conflict – has added a new wrinkle to the problem.

Not only do deployed surgeons rarely operate, but they’re put at odds with civilian surgical practice increasingly reliant on minimally invasive technology, advanced imaging and other sophisticated tools, Lee said.

But there was little or no evidence that surgical care had suffered, Edwards and Nessen, whom the Army Medical Command declined to make available for phone interviews, wrote in their email in answer to written questions.

“In spite of the very real challenges Army general surgeons face, to date as a whole they have continued to provide excellent care to their patients,” they wrote.

In 2014, a 634-page review of the military health system found that it generally provided quality care comparable to that found in the civilian sector. But it also found “wide performance variability,” with spots of excellence and other areas performing below national benchmarks.

The review, ordered by former Defense Secretary Chuck Hagel, found higher-than-expected rates of surgical complications at more than half of the military hospitals that had submitted data. Surgical patients’ death rates were within the expected range.

The review also found low infant mortality rates at military hospitals but determined that babies were more likely to be injured during birth and mothers more likely to hemorrhage than at civilian hospitals.

Military medical officials have responded in recent years, sometimes citing costs, by downsizing some hospitals to health centers, shuttering their obstetrical centers and surgical facilities and sending patients to local civilian facilities.

They have also encouraged medical commands to forge agreements with nearby civilian trauma centers and Department of Veterans Affairs hospitals to allow military physicians to practice there. That effort is being expanded, according to the Army Medical Command.

Since Edwards’ article was published, progress had been made, Edwards and Nessen said.

“There is a definite level of awareness that operative volumes are critically important for surgeon readiness and that this needs to be quantified and evaluated prior to deployment,” they wrote in their email to Stars and Stripes. “There is no question that the military surgical community, working with our military and civilian surgical leaders, is taking this issue very seriously.”

montgomery.nancy@stripes.com

U.S. Army Maj. Warren Johnson, an emergency room physician assigned to the 212th Combat Support Hospital, and Cameroonian Elvis Akem Tambe, a general practitioner, review a patient's X-ray at the Regional Hospital of Garoua during Medical Readiness Training Exercise 17-5 in Garoua, Cameroon, Aug. 11, 2017.
SHEJAL PULIVARTI/U.S. ARMY

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