https://orcid.org/0000-0002-9562-0821
The practice of medicine has always put the physician in a role that bears witness to extreme suffering, inequities, and death—a context that continues to evolve. No longer do physicians stand by helplessly as patients succumb to bacterial illness; even cancer is morphing into a chronic disease with limited suffering. However, the suffering, inequity, and death that our future physicians will bear witness to will look much different than they do to those of us who are training them. Health effects from climate change will not only include, for example, masses suffering heat-related complications from a city, dependent on air conditioning, that experiences a power outage, but may also include novel diseases and ramifications of conflict because of competition for dwindling natural resources such as water, oil, and even clean air. Current education and training have focused on preparing trainees to care for individual patients who suffer from an illness created by an organism or dysregulation of the physiologic process. How can we expand medical education to prepare trainees to provide patient care in the wake of climate-enhanced disasters and climate change–induced crises? How can we better prepare them to provide care in the 21st century and beyond?
One of the challenges of responding to climate-related illness is that often multiple patients are affected at once, creating multiple casualty events. These events often not only affect patients but also upend the structure of the organizations built to care for them and their capacity to mobilize and respond. A recent survey of experts who have participated in multiple casualty incidents highlights a need for “education on specific injuries, revising future plans and preparatory exercises.”1 Moreover, Skryabina and colleagues identified a lack of immediately available clinical protocols to deal with unique and specific injuries due to widespread catastrophic incidents as a major area of vulnerability in current training practices.2 Compounded with the growing trend of physician and surgeon subspecialization, the expertise and competencies required to attend, and respond to, large or small climate change–related events may require more interprofessional and transdisciplinary education and training, as well as the ability to pivot from everyday practices. Currently, competencies put forth by the Accreditation Council for Graduate Medical Education (ACGME) for residents do not specifically target these growing needs, and it is unclear how, if at all, undergraduate and graduate medical education are addressing this evolving landscape of patient care. Thus, we propose shifting our gaze to how physicians are educated and trained in military medicine as an early scaffold to begin this endeavor.
Operational Readiness in Military GME Training
The military has been training physicians since the 20th century with a focus on preparing them to respond to crisis situations in austere, resource-constrained environments. Often referred to as “operational readiness,” this type of training has not been done without significant preparation. For example, to optimize training protocols on how to care for climate-related illnesses, significant research has been done to define not only the illnesses, their natural history, and risk factors, but also the processes needed to care for those suffering from these illnesses.3-5 This research guides recommendations on how to modify work in the heat and to mitigate factors, such as clinical conditions or medications, that may increase risk of morbidity. From here the military implements these guidelines through multiple avenues, including the education of military physicians trained to ensure the health of our nation’s military. Notably, Parsons and colleagues found that practicing military physicians deployed in austere environments had retained knowledge and training related to climate- and heat-related illness, long after completing their military medical training.3
In addition to the research, knowledge, and skills that are required to care for patients with climate-related illness, there is additional complexity. During climate-related disasters such as flooding, blackouts, or other events, the environment may be chaotic and resource-limited as well. These environments often require decisions under stress.6,7 Military residents explicitly train for stressful situations, such as in the Combat Casualty Care Course, which all military trainees complete. This 8-day training is designed to enhance the operational medical readiness and predeployment trauma training skills of incoming medical officers.8 Included in this program are medical scenario simulations revolving around mass casualty events, tactical field and evacuation care, and roles of care, as well as an Advanced Trauma Life Support course.9 These types of experiences improve the skills, as well as organization, needed to manage multiple trauma patients.10
Graduate medical education (GME) in military medicine has continued this line of training and has demonstrated the impact of military unique curricula. For example, annual capstone programs occur in the last month of military GME training and consist of 3 to 4 days of hands-on training. During this time, residents rotate through multiple simulations, including response to mass trauma, field medicine, triage exercises, and evacuations. Beyond these end-of-year experiences, elective and fellowship opportunities (also called programs or schools in military training) are available to military residents to prepare them for medical practice in different environments. Examples include the Army Flight Surgeon Course, the Expert Field Medical Badge, and the Jungle Operations Training Course, as well as wilderness medicine and dive medicine courses.11,12 These courses not only focus on medical and survival issues, but also strongly emphasize the leadership skills needed in austere, acute settings.
Military medical studies support that hands-on experiences and high-fidelity simulations for stressful, complex, and urgent situations are feasible during residency. For example, a military internal medicine residency program developed a course aimed at building key knowledge and skills required for clinical care and leadership in a deployed environment. Practical, hands-on scenarios focused on assessment, stabilization, treatment, and evacuation during mass casualty events, with participants reporting an increase in knowledge of deployment medicine.13 An emergency medicine residency program at a naval medical center introduced a curriculum, a Joint Emergency Medicine Exercise. This 3-day event combined didactics, practical applications, and immersive simulation exercises. This curriculum improved perceived operational readiness among graduating emergency medicine residents.14 Another military internal medicine initiative in a large residency program developed an iterative point-of-care ultrasound (POCUS) curriculum focused on using the tool for triaging multiple casualty incidents.15
Applications for the Civilian Sector
While not all aspects of operational readiness training in GME have been studied, the ethos of preparing, and being ready for, conflict and crises is prevalent in military medical training. Thus, military GME curricula offer opportunities to the civilian sector. Many elements of military GME exercises will be relevant to health care during serious environmental events.
Whether through high-fidelity simulations, live exercises and field operations, or procedural training for austere, resource-constrained settings, nonmilitary trainees will need advanced preparation to provide patient care and leadership. The increasing prevalence of climate-enhanced disasters and climate change–induced crises requires moving beyond the classroom and traditional hospital settings so that trainees are capable in settings with reduced supports. Military medicine has created a myriad of curricular experiences intended to train physicians to meet these needs and be “operationally ready.” How can nonmilitary residency programs integrate or modify military training models into training and also capture the essential ethos of operational readiness?
First, there already exist opportunities for synergy between military and civilian GME. These include partnering with an established national network of GME training sites such as the Veterans Affairs (VA) health care system, with the potential also to be intentional about rotating residents at military training facilities. However, not all residency training programs are affiliated with or located near a VA or military training site. Here, high-fidelity virtual simulations, borrowing from military medicine existing protocols, could be implemented. These simulations allow residents to visualize and experience the effects of a climate change–induced event, while learning fundamental procedural responses, to minimize adverse patient and system outcomes.
Second, climate change effects vary according to geography, which will predict the type and severity of climate change–related events. Resident physicians may not practice after graduation where they train, so how do educators determine the content of simulations and other curricular elements? Again, based on military curricula, there are likely fundamental content and procedural approaches for each specialty. Equally important, what are the essential elements of an operational readiness curriculum that could be standardized across all ACGME training sites? These could be addressed by an operational readiness committee, similar to the Military Readiness Committee formed at the San Antonio Uniformed Services Health Education Consortium that has helped identify gaps in their GME readiness training to facilitate related program development.16
Conclusions
Most calls for stronger civilian-military partnerships have focused on utilizing the civilian sector as a resource for operational readiness.17,18 However, some have called for further exploration and possible integration of how military medical training and practice can be adapted for operational readiness in a civilian context.19-21 We amplify this call and highlight the potential for translation and adaptation of curricula across both civilian undergraduate and graduate medical education. As we determine how to respond to more climate change events affecting more people, we should look to military medicine for tested strategies and collaboration on the best training to care for anyone in harm’s way.
References
Author Notes
Disclaimer: The opinions and assertions expressed herein are those of the author(s) and do not reflect the official policy or position of the US Government, Department of Defense, Uniformed Services University of the Health Sciences, or the Henry M. Jackson Foundation.
