Efficiency
A well-created curriculum that meets objectives will require more than an assigned rotation and a few lectures. The most successful ones in the literature review were the ones that were deliberately planned and longitudinal, such as the ones at USU that combined a mixture of classroom and field exercises over the course of 4 years.4,8 In that way, the curriculum may not be considered time efficient, but if integrated well into the already existing medical training, the production of military physicians who are mission ready upon graduation—ready to serve as military medical leaders and deploy—will be invaluable.
Cost Comparison
Due to the associated overhead of running a training platform and the additional hours of operational training, military GME is more expensive initially compared with civilian outsourcing. In USU, for example, there is an additional 700 hours of operational curriculum alone. This cost difference more than doubles the cost of a USU education vs a Health Professional Scholarship Program (HPSP) scholarship at a civilian medical school. However, a causal analysis performed by the IDA to determine value basis noted that USU graduates deploy almost 3 times as much and serve 6 years longer on active duty.3
After graduating medical school through either accession source, physicians complete specialization training in a GME program. The IDA study noted an average $12,000 increased cost of military GME compared with civilian programs. The analysis included resident compensation and overhead costs of running the program as well as the net cost, which also accounted for resident productivity and workload by training in a military facility.3 Calculations due to mandated budget cuts estimated cost savings of closing the military medical school at < $100 million while significantly impacting the military physician pipeline and operational research output.3
Duplication of Effort
There are already established training programs such as Tactical Combat Casualty Care (TCCC) that could be incorporated into the curriculum to avoid expending additional resources to recreate the wheel. USU has a validated operational training curriculum and may be able to make opportunities available for outside trainees to participate in some of its military-unique training and leadership exercises. Other ways to decrease duplication of effort and improve cost efficiency include focusing on the creation of an academic health system (AHS) and consolidating similar programs to conserve resources. Increasing existing military program sizes will not only ensure the continuation of the military medicine pipeline, but will spread overhead costs over a larger cohort, decrease costs of civilian outsourcing, and ensure the less tangible benefits of military cultural exposure early in trainees’ careers. For example, increasing the class size of USU by 30 students actually reduces the cost per student to $239,000 per year from $253,000, while decreasing the need for HPSP accessions training in civilian programs, making the endeavor overall cost neutral.3
Program Portability
The operational medicine residency has proved that an operational curriculum can be remotely managed and reproduced at a variety of residency specialties.12 Remote education could be developed and distributed throughout the MHS, such as the proposed USU course Military Medicine and Leadership course.3 Centralized training programs like Global Medicine and C-STARS could be scheduled TDYs during the medical training calendar.
Retention
The military medical school, USU, is the largest military medicine accession source. An IDA report notes that retention of USU graduates is 15.2 years compared with 9.2 years served by civilian trainees. Due to the longevity in service, USU graduates also make up more than 25% of military medical leadership.4 The long-term outcome study that looked at the past 40 years of USU graduates observed that over 70% of graduates served until retirement eligibility and are overrepresented in special operations units.3,13 While some of this longevity may be attributed to the longer USU service contracts, military GME graduates were still noted to be 4 times more likely to commit to a multiyear service contract.14 A RAND study on the retention of military physicians in the Army, Air Force, and Navy noted that overall retention increased throughout all the services for physicians who went through the military GME pipeline.15 Conversely, civilian GME training was associated with a 45% chance in leaving active duty.16
It is theorized that early military acculturation during training increases the likelihood of instilling a sense of mission. Being involved in military GME on the teaching side also showed increased retention rates for 63% of survey respondents.17 Reduced burnout and increased work satisfaction for those involved in military GME was noted on another faculty satisfaction survey.17