Editor in Chief

“You can design and create, and build the most wonderful place in the world. But it takes people to make the dream a reality.” —Walt Disney (1901-1966)

by Chester Buckenmaier III, MD COL (ret), MC, USA

April 8, 2019

A friend recently texted me a Military.com article by columnist Tom Philpott entitled, “More than 17,000 Uniformed Medical Jobs Eyed for Elimination.” I read the item with no small amount of trepidation and concern, since I have some experience with military medicine. The past 18 years of continuous war is unprecedented in this nation’s history. The blood and treasure invested by this country in the prosecution of these wars is sobering, and I will not debate the political concerns that have resulted in the nations’ longest conflict. I prefer Gen. George Patton’s position on the topic, “I am a soldier, I fight where I am told, and I win where I fight.”

Yes, the military medical response to these conflicts has been a solid win for this nation. The services built the premier trauma system on the planet, literally on the fly and with worldwide influence, in the middle of armed conflict. The scope and reach of this response are truly epic, and every federal medicine provider involved can take justifiable pride in the accomplishment. If one requires more evidence concerning the veracity of my statements, please refer to the book “Out of the Crucible: How the US Military Transformed Combat Casualty Care in Iraq and Afghanistan” (ISBN: 9780160941672). If anything positive can be said of war, it is the advances in medicine that resulted from armed human conflict and the lessons learned from this nation’s longest war that will positively influence medicine in this country for decades.

The success of our military medical forces in response to this conflict and the wars in our past is neither fluke nor accident. It represents a military medical tradition, beginning with the birth of our nation during the Revolutionary War and spanning the nation’s history in its entirety. Through war, natural disaster and public health crises, the nation’s federal medical system has been available to care for those who defend and protect us from enemies of our Constitution and way of life. This capability is not something you can purchase only when needed or conjure on a whim from the raw materials of medical practice. The institution of federal medicine is a national asset that contains the collective knowledge and experience, passed from generation to generation of federal medicine providers, that is medically ready to support the servicemembers who defend our nation.

Obviously, this institution requires investment and nurturing in those times when it is not relied upon for it to be ready and available in the event of national emergency. I think, if the incredible response of our nation’s federal medicine professionals during the past 18 years is any measure, that the nation’s investment in federal medicine has paid handsome dividends. I am not stating our system is perfect, alas far from it, since any endeavor involving the health and idiosyncrasies of humans is necessarily fraught with imperfection. I am saying that federal medicine in this country has achieved a level of excellence in the prosecution of the recent conflicts not matched by any other system in history.

With this solid narrative of success so poignant in our recent past, I am confused by calls from many politicians and military leaders to dismantle or, at the very least, severely degrade the institution that made these successes possible. The arguments for disassembling federal medicine are not new, and they have been voiced throughout my 30-plus year career in federal medicine. The laments of federal medicine detractors are surprisingly consistent and tend to be loudest after the battle is done and the nation is relatively free from danger. The complaints from politicians and line generals tend to focus on the expense to train and maintain the system, particularly when the country enjoys a perfectly capable health system supported by a vast network of medical education institutions. I have had discussions with purveyors of this position who basically state, “Why can’t we just invite doctors and nurses from our civilian system to the next conflict, and they will do their medical thing.” Other arguments suggest we should only focus on “wartime” medical specialties to save money. I imagine to those leaders who have never practiced or observed medical care in an austere environment, like Iraq or Afghanistan, this idea has real merit. I am sure the ability to move investment in federal medicine to other priorities is exceptionally appealing to these leaders. Unfortunately, the basic premise that backs these ideas, the contention that medicine is medicine, regardless of where and when it is practiced, is fundamentally flawed.

Like so many other federal providers, I have spent a career understanding the vast differences and complexities involved in providing medical care anywhere, anytime and under any conditions. I know the limitations of medical supply in wartime or disaster conditions, and I know how to function and provide quality care despite these limitations. In short, I am a military medicine provider, with expertise and an approach to patient care that is not commonly encouraged or understood by the providers in your local hospital.

To those neophytes suggesting we need only train in military- specific specialties, I would remind them that the military fights as a team and that team includes the family that supports the servicemember. That’s not to mention the fact that specialties such as pediatrics, specifically commented in the article with the suggestion that we have “more trauma surgeons, fewer pediatricians for example,” tended to be a much-needed asset in the combat-support hospitals I worked where wounded children were common. The article was particularly critical of personnel bloat within the system leading to stagnation in medical skill sets. I think this situation, where it exists, might be handled through federal/private medical partnerships where federal providers can work in civilian institutions and civilians in military facilities, enhancing the medical experiences of both.

As I have stated, these arguments have been raging throughout my career and likely will continue. It is my hope, as has occurred in the past, that the tremendous value of our federal medicine system and its potential for supporting our country in future wars and disasters, will effectively counter those myopic viewpoints who hunger for quick fixes to their budgetary dilemmas. The strength and primary asset of the federal medicine institution, so vital to our nation’s defense and safety, is in its people. Walt Disney understood this fact when he built his entertainment empire; our leaders should realize this fact as they consider dismantling federal medicine.



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