A Model for Military-Civilian Collaboration in Academic Surgery Beyond Trauma Care

Abstract

This article discusses the collaboration between the David Grant US Air Force Medical Center and University of California, Davis Medical Center, a military-civilian partnership that provides surgical training to military surgeons.

Providing comprehensive surgical training and sustaining medical readiness of military surgeons remains challenging, especially during peacetime. We summarize a military-civilian partnership that extends beyond trauma.

Methods

We evaluated the collaboration between surgeons of the David Grant US Air Force (USAF) Medical Center (DGMC) at Travis Air Force Base in Fairfield, California, and the University of California, Davis (UCD) Medical Center. The UCD facility is the only level I trauma center in Sacramento, California, and is the main tertiary care center in Northern California, serving a catchment of 2.5 million people. Successes and challenges in the areas of graduate medical education and faculty engagement in research and clinical duties were identified. This study was exempt from the UCD institutional review board, as it was determined not to be research.

Results

The partnership began in 1995 with a USAF general surgery residency rotation in trauma surgery at UCD. In 2003, the residencies merged. Of 9 categorical general surgery residents in each class at UCD, 2 are designated for USAF residents. Also, UCD hosts a preflight surgery internship (11 residents), as well as the military’s only integrated vascular (4 residents) and cardiothoracic (1 resident) surgery residencies (Table 1). There is no difference between the surgical rotations of the military and civilian residents. All residents rotate at all UCD training locations, including DGMC, the Veteran’s Affairs Medical Center, and community hospitals.

Table 1. Number of Faculty and Residents, Military vs Civilian, as of February 2017.

Group	Active Military	Civilian
Faculty
Trauma and acute care surgery	6	12
Thoracic surgery	1	2
Vascular surgery	1	6
Pediatric surgery	1	8
Residents
Total	24	62
Interns	13	11
General surgery: categorical	8	44
Integrated vascular surgery	4	4
Integrated cardiothoracic surgery	1	3

Since 2007, UCD has graduated 72 general surgery residents, including 11 USAF surgeons. Between 2007 and 2016, there was no difference in average case volumes between military and civilian residents (1020 vs 970 cases; P = .26). Currently, 8 active duty military surgeons have volunteer faculty appointments at UCD in trauma (n = 6), thoracic (n = 1), vascular (n = 1, combined vascular/trauma surgeon), and pediatric (n = 1) surgery (Table 1). While most military faculty members work full-time at UCD, some split their time at DGMC.

During the 2014-2015 academic year, military faculty performed a comparable average caseload (Table 2). Military surgeons published fewer journal articles on average between 2013 and 2016, but grant funding was variable (Table 2).

Table 2. Faculty Contribution to Academic Efforts and Patient Care^a.

Contribution	Trauma and Acute Care Surgery			Cardiothoracic Surgeryb
	Military (n = 3)	Civilian (n = 8)	P Value	Military (n = 2)	Civilian (n = 3)	P Value
Academic Efforts
Average No. of peer-reviewed articles per faculty member, 2013-2016	2.7	10.8	.31	6.5	11.6	.14
Total research grant funding/average funding per faculty member for 2013-2016, $c	958 000/319 000	470 000/59 000d	.07	43 000/21 000	1 189 000/396 000	.43
Patient Care
Operative case ratio for 2014-2015 average military faculty cases to average civilian faculty cases	0.96	1 [Reference]	.51	0.86	1 [Reference]	.51

^aNumber of faculty members differs from those in Table 1 owing to staffing changes. Vascular and pediatric surgery are not included as these surgeons have recent appointments at the University of California, Davis, and were deployed for a significant time.

^bDuring this period, both a cardiac and thoracic military surgeon were working at the University of California, Davis.

^cAmounts are rounded to the nearest $1000.

^dA total of 33.5% of civilian funding went to projects in which there was collaboration with military faculty.

All active duty military surgeons at UCD (residents and faculty) are employed by the USAF. This, combined with the fact that military faculty may have sudden or prolonged service obligations, ensures that military faculty do not take civilian faculty positions, but are considered adjunct faculty members. Military surgeons report to their command at DGMC and have a volunteer faculty appointment at UCD.

Discussion

Trauma surgery continues to be an obvious area of collaboration between military and civilian surgeons. With only 1 level I US military trauma center (San Antonio Military Medical Center), working at civilian trauma centers helps ensure readiness for military surgeons. Through research and combat experience, civilian trauma care is also enhanced.

Integrating the residencies has ensured adequate case volumes for military residents and has allowed for educational resources to be shared. It has also enabled military surgeons to participate in academic endeavors, which supports military research and personal career advancement. The opportunity for academic engagement arguably attracts USAF surgeons to seek assignments at Travis Air Force Base and may encourage surgeons to remain in the military after their service obligations. Challenges to this partnership include ongoing adjustments to meet the changing needs of each institution and managing logistics, especially scheduling around military commitments, which can sometimes be sudden and unexpected.

Although ongoing preparedness in trauma surgery is necessary for today’s military surgeon, a military-civilian partnership beyond trauma care is mutually beneficial. The military faculty supports UCD’s mission in clinical care and research, while UCD helps train the next generation of military surgeons and provides a busy clinical and academic environment for sustainment of readiness and professional enhancement. This model could be expanded to other specialties as well as midlevel health care professionals, nurses, and operating room technicians.