Military leaders recognize the importance of maintaining their own academic medical facilities to support GME programs. Some of these are service specific, others are joint service training programs. Recently more emergency medicine residency training positions have developed in collaboration with local civilian emergency medicine residency programs to meet the growing demand to train more emergency physicians for the military's overseas contingency operations and to maintain currency platforms for faculty.
Military academic hospitals typically have multiple residency programs and thus broader scope of subspecialty care. The patient population at these hospitals includes more military retirees and is found in geographic locations with denser military beneficiary populations. In addition, many academic military EDs receive civilian emergencies by ambulance. All military emergency medicine residencies are accredited through Accreditation Council for Graduate Medical Education (ACGME) by review of the Residency Review Committee for Emergency Medicine. All graduates have eligibility to seek board certification through the American Board of Emergency Medicine and the military strongly promotes specialty certification and maintenance of certification.
Faculty positions are highly sought and competitive. Some of emergency physicians start an academic career right out of residency, while others perform an operational or clinical tour first. In addition, some faculty will move in and out of academic career path during their military service, thereby broadening their experience and clinical skills through operational or overseas tours or other career-broadening opportunities to include fellowship training. Program director positions are competitive and are seen as a pinnacle position in academic career path. Emergency medicine residency program director positions have become joint opportunities regardless of the service affiliation for that academic institution. This provides greater opportunities to select the most qualified applicant for the position from the 3 military branches. Services also recognize the importance of program director positions and will typically ensure the individual remains in place for at least 4 years regardless of how long they have been assigned at the institution.
Even if not formally integrated with a local civilian emergency medicine residency, most military emergency medicine residency programs have some degree of collaboration with civilian programs to help round out specialty training and provide diversity in patient populations. The Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Maryland has a School of Medicine and all students are required to perform a clerkship in emergency medicine with many rotating in military EDs. Students at USUHS also receive operational field training and basic combat medical skills early in their education affording several opportunities for military emergency physicians to serve as instructors. Academic emergency physicians also have opportunities for faculty appointments and educational opportunities at USUHS and civilian academic institutions through the previously discussed partnerships.
Research and scholarly activity are required in academic programs. Although departments do not have the “publish or perish” focus sometimes found in civilian programs. The past decade of combat has been both a curse and a blessing for research. The high deployment tempo for all emergency physicians, including academic emergency physicians, provided challenges to sustain research efforts. However, combat operations also drove the need for innovation, focused the military research agenda, increased military funding opportunities, and exploited the clinical strengths of emergency physicians. In addition, the military leaders identified ways to better manage deployments of key academic faculty such as program directors and lead researchers so as not to jeopardize residency accreditation or funded research programs.
The rapid and sustained growth of clinical research performed by military emergency physicians over the last 10 years has been due to several factors. Primarily, the chief consultants of emergency medicine of each military branch have emphasized subspecialty training, research funding support, and support of clinical researchers, and encouraged emergency physicians to participate in Joint military branch efforts and multispecialty research groups.
In addition, emergency physicians have clinical expertise innate to deployed and combat casualty care: disaster management, broad and acute medical and trauma management expertise, ultrasound proficiency at the bedside and in austere environments, medic and prehospital system knowledge, and expertise in chemical weapons, toxins, and venoms. Thus emergency physicians have led research efforts in these areas that have previously been without physician specialty leadership. Emergency physicians have been recruited to military research agenda committees, grant review panels, and editorial boards. These factors and the current encouragement of emergency care research have led to the integration of emergency care within the military. As new physicians are mentored and trained in the military environment, emergency care research will expand.
Specific examples include research conducted by emergency physicians who have specialized in medical toxicology. Some have led efforts to examine the effects of opioids, pain, chemical weapon toxicity, and venom effects. Ultrasound fellowship trained emergency physicians in the military have used ultrasound to evaluate trauma resuscitations, septic shock resuscitations, and care in rugged environments without the aid of radiography. Physicians trained in prehospital care have conducted research to revolutionize how the military trains, uses, and deploys combat medics and because of this work they now lead prehospital medic training for all branches. Recently, critical care trained emergency physicians have collaborated with intensivists and emergency physicians to systematically improve care between these care units and to improve care in critically ill patients transported by critical care air transport teams (CCATT) in combat and humanitarian operations.
Research funding is critical to sustain practice changing research. Overseas contingency operations and its resultant clinical care gaps over the last 10 years have led to sustainable and efficient efforts to provide intramural and extramural research funding. The military provides specific funding for GME resident-related research. Although the funding amounts are limited, the funds allow for execution of small, defined projects that address military clinical gaps. In addition, each military branch provides intramural funding for its own investigators. As an example, the AFMS provides funding for United States Air Force researchers to address specific USAF clinical problems related to peacetime and deployment. A large program of joint military funding is competitively awarded via grants to military and civilian investigators. The process is similar to the National Institute of Health (NIH) and other federal agencies that support research and awards multiyear research funding for important clinical problems the military needs addressed. This funding is highly competitive as it is divided by all branches, all specialties, and among military and civilian researchers. Nonetheless, the emergency physicians with specialty training have been successful in obtaining military research funds through all of the previously discussed sources.
Finally, military emergency physicians have become incorporated in the military research agenda. Emergency physicians lead and develop research for prehospital care and training. They are researchers in the Army Institute of Surgical Research developing novel resuscitation techniques. Military EMS and ultrasound fellowship program directors collaborate with other specialties as coinvestigators and subject matter experts. The Enroute Care Research Center is led by an emergency physician. Military emergency physicians have been recruited to grant review committees, multispecialty joint research boards, combat casualty care steering committees, and local Institutional Research Boards (IRBs) and Institutional Animal Care and Use Committees (IACUCs). Annually, military emergency physicians present approximately 30 to 50 research abstracts at emergency care and other specialty meetings and are recruited to editorial boards, emergency medicine organizational boards, and civilian grant review panels. They receive funding from NIH for investigator-initiated investigations. They receive national research awards from military multispecialty organizations, emergency medicine societies such as the American College of Emergency Physicians and the Society of Academic Emergency Medicine, and civilian multispecialty associations such as the American Medical Association. Because of the growth of military emergency care research and specialty training of emergency medicine, emergency physicians are embedded into the corporate process of military medicine, combat casualty care, and critical care, and toxicologic research. Emergency physician will continue to be integral to military clinical research, collaborating with other specialties, all military branches, and with academic centers to address the gaps in military clinical emergency and combat casualty care.
Another opportunity to seek an academic path and develop an area of subspecialty competency is through fellowship training. Each service offers fellowship training opportunities annually through the Joint Service Graduate Medical Education Selection Board (JSGMESB) and opportunities vary each year by identified needs within each service. Some emergency physicians will pursue fellowship training immediately after residency, while others will apply later in their career. The expanded role of emergency physicians in the operational setting has driven even greater fellowship training opportunities and the development of military fellowship training programs in areas of EMS, ultrasound, and austere and wilderness medicine. For training positions not at military sites most often the fellow is civilian sponsored and thus continues to earn full military pay and benefits even though the training occurs at a civilian institution.
Medical Toxicology is a subspecialty which fills unique needs beyond support to academic programs. Each military branch has 2 to 4 fellow trained (2-year program) medical toxicologists. Most toxicologists are assigned to high-volume clinical hospitals which are also academic programs. Since there are no physician specialists in the military for toxicologic exposure, pharmacology, chemical agents, and envenomations, medical toxicologists provide clinical support as experts to outpatient clinics, hospitals, allied health professionals, disaster managers, and deployed providers.
Most military medical toxicologists support an inpatient consultative clinical service. As an example, at the San Antonio Military Medical Center and tertiary care referral center, the toxicology service is the busiest in the military and provides inpatient bedside consultation 24 hours a day treating overdoses, smoke inhalation (SAMMC is the only DoD-certified burn center), adverse drug events, occupational chemical exposures, envenomations, and other toxicologic emergencies. All of the DoD toxicologists also provide a telemedicine consult service which provides specialty consultation 24 hours a day to providers in deployed settings and smaller military facilities across the world. The toxicologists respond to consults usually within 1 hour of initial contact.
Military medical toxicologists also provide expert consultation when deployed acting as the theater consultant for the specialty to revised practice guidelines, modify response to potential threats, and treat critically ill patients with overdose, chemical exposures, and envenomations at the bedside in combat theater. Military toxicologists also provide opinion for medicolegal cases, quality care reviews, and military-wide approaches to mitigate substance abuse across all branches. Toxicologists provide speciality education to fulfill the curriculum needs for the local emergency medicine residencies, but have a larger educational demand from nonemergency medicine residencies to fill their gaps in the didactic curriculum. For example, the toxicologists at SAMMC annual lecture to internal medicine, psychiatry, pediatrics, trauma surgery, critical care, nephrology, and neurology departments. Finally, military toxicologists conduct preclinical and clinical research addressing gaps in military medicine. They conduct studies on chemical exposures, opioid toxicity, drugs of abuse, resuscitation, envenomations, and other related toxicologic emergencies.
Critical care fellowship opportunities have been new in the past 4 years resulting from operational needs for more critical care providers in deployed locations. Some emergency physicians with critical care training have been assigned to civilian trauma programs where they assist with the currency training of military staff who rotate through on a regular basis. In the Air Force, emergency medicine physicians have taken the lead in CCATT driving the desire for more critical care emergency medicine physicians to support the training and oversight of this program. In addition, critical care trained emergency augment hospital ICU staff and easily split time between ED and ICU strengthening each department.
In addition to physician training, the military has a long history of training physician assistants and is a role model for subspecialty training of emergency medicine physician assistants (EMPA) and their integration into the practice of emergency medicine. Each service branch offers general physician assistant training programs and specialty training for emergency medicine. EMPAs have a respected role in practice of emergency medicine in both EDs and in the deployed environment. The San Antonio Medical Center Department of Emergency Medicine sponsors one of the oldest EMPA training programs in the country.
In fact, the entire physician assistant movement grew out of the experience of Navy corpsmen returning from service in the Vietnam War era, trained with a high set of skills, but with no venue other than the military in which to utilize these skills. Doctor Eugene Stead, then Chair of Medicine at Duke University, recognized this situation and approached the Dean of the School of Medicine with a plan to create a new allied health specialty to use these highly trained and experienced people. The first class of physician assistants was comprised solely of former Navy corpsmen at Duke in 1965.
Finally, many military emergency physicians pursue an academic path whether they serve 4 years or 30 years in the military. The military offers leadership opportunities in combat and in stateside hospitals early in the career of emergency physicians. While many serve leading academic roles in the military, many also leave the service to enter civilian programs and mature into program directors, research directors, department chairs, Institutional Deans, and specialty organization leaders (eg, ACEP president).