Military Orthopedic Residency: The Good, the Challenging, and the Different

Military orthopedics has also worked hard over recent years to increase its col­laboration with different orthopedic asso­ciations, such as the AAOS (ie, Extremity War Injuries Symposiums), Arthroscopy Association of North America (shoul­der and knee arthroscopy courses), and the OTA (Disaster Response Course) to name a few. These associations have yielded some extremely positive results for military residents in the form of dis­counted rates, specialized courses, and other unique opportunities for all military residents. For all of these organizations, and the personnel who have worked so hard to make these opportunities a reality, we owe a very special thank you.

In addition to the previously mentioned research initiatives, all of the MEDCENs where residents train—there are 6 total for the Army—provide residents with many research opportunities. Most of these projects are centered on the wounds and injuries that we are commonly exposed to as a result of the current conflicts. Very high-energy blast and penetrating trauma wounds from explosive devices sustained during combat are commonly seen. Due to these injuries, military resi­dents are frequently exposed to the prin­ciples of damage control orthopedics, deformity correction, limb salvage, ampu­tation, wound coverage, and infection prevention/management, among others. However, residents are also exposed to many athletic injuries in addition to the variety of orthopedic conditions sustained by the retirees (eg, degenerative arthritis) and dependents (eg, scoliosis) of the mili­tary. This all equates to, in our opinion, a well-rounded education that is compa­rable to civilian orthopedic programs.

The treatment of wounded warriors also includes a rather unique view of state-of-the-art rehabilitation practices. Our Center For the Intrepid in Fort Sam Houston, Texas, provides a centralized location for rehabilitating soldiers and provides resi­dents with a glimpse of what happens to these soldiers when their orthopedic treat­ment is ‘finished.’ Similar centers are also located in Bethesda, Maryland, and San Diego, California. Many new and, literally, life changing advances in rehabilitation (such as the Intrepid Dynamic Exoskeletal Orthosis brace) are being developed at this facility and being able to observe these rehabilitative efforts helps provide a more global picture of the patient’s treatment.

Many opportunities that arise from being a resident within Army orthope­dics are not anticipated when making the initial commitment to the program. This is especially true with professional and networking opportunities. The Army, and the military as a whole, is a very small and close-knit group. While staff turnover is quite frequent at many of the Army Treatment Facilities, it provides residents with an opportunity to interact with many orthopedic surgeons who go on to estab­lished practices and positions all over the world. The breadth of such a network can obviously assist a resident or staff member as they explore future career opportuni­ties. The experiences gained from Army residency also provide residents with the ability to shape their career in the way they see most fit. Some residents will stay within the military for life, some will go on to academic facilities, others to private practice, and a few will dabble in all of the above. Many resident opportunities are truly dependent on the individual’s aspira­tions or career goals. Some residents will take time off to complete a research fel­lowship, others to complete specific training to improve their leadership, and a few may opt to set-up their careers so that when residency is complete they can participate in more operational specific training (eg, Airborne school or being the commander of a Forward Surgical Team).

Of course, any program has its chal­lenges, and Army orthopedics is no dif­ferent. One weakness is that residents are not exposed to many of the economic barriers and constraints that guide most practices within the civilian world. While being shielded from such constraints can often feel like a blessing in the moment, many military residents and attendings do end up practicing outside of the military at some point in their career. Our system is setup so that there are no financial rewards for increased productivity and no financial penalties for lack thereof. As such, the lit­tle emphasis placed on maximizing patient encounters, figuring out how to increase our Relative Value Units, manage clinic throughput, or many other business les­sons that are necessary in order to practice medicine in the civilian world. Not being exposed to some of the guiding principles of civilian practice can make this transition difficult. If you look at many of the young practitioner forums at the AAOS annual meeting, you are likely to see our bosses, mixed amongst senior residents and junior attendings learning about business models, coding, and reimbursements, as they pre­pare for their time as a civilian practitioner.