This column was originally published in AMA eVoice on May 22, 2008. Dr. Davis is president of the American Medical Association.
With Memorial Day being observed on Monday, May 26, I'd like to acknowledge all—wherever they are and whenever they served—who have put themselves in harm's way to protect our freedom, this country, and a way of life that embraces peace and friendship among all people. That includes the many physicians who have worked, or now work, in uniformed services.
The United States has seven uniformed services that commission officers, five of which make up the Armed Forces—four under the Department of Defense (Army, Navy, Air Force, and Marine Corps) and one under the Department of Homeland Security (Coast Guard). Two noncombatant uniformed services are the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps (under the Department of Commerce) and the U.S. Public Health Service (PHS) Commissioned Corps (under the Department of Health and Human Services).
While the NOAA and PHS Commissioned Corps are "noncombatant," their members often put themselves in harm's way, whether flying "hurricane hunter" aircraft into storms in research and reconnaissance missions or investigating outbreaks of Ebola virus or Severe Acute Respiratory Syndrome (SARS).
I look back on my seven years at the Centers for Disease Control and Prevention (CDC), as part of the PHS Commissioned Corps, as one of the most enriching periods of my career. In his book Plagues and Politics: The Story of the United States Public Health Service, Fitzhugh Mullen, MD, wrote, "For many, the Service was a culture, a way of life that entailed work, frequent moves, a far-flung camaraderie with other officers, and a quiet, perennial commitment to national service."
Despite ongoing budget constraints, the Commissioned Corps continues to provide vital services in health care and public health—locally, nationally, and globally—through many PHS agencies including the CDC, National Institutes of Health, Food and Drug Administration, Agency for Healthcare Research and Quality, Indian Health Service, Health Resources and Services Administration, and Substance Abuse and Mental Health Services Administration. As of March 2004, the Corps employed 1,185 physicians (PPT, 962KB) among its 5,965 officers.
Military physicians—and I use that term broadly here to refer to physicians who work in any uniformed service—are faced with all of the challenges that confront their civilian counterparts, plus the unique area of "operational medicine" (medicine performed in the field) in Iraq, Afghanistan, and closer to home for the victims of natural disasters (such as hurricanes Katrina and Rita in 2005). The practice and skills of these men and women reach inspirational levels.
Military physicians are changing the way we practice medicine. For example, their work over the past few years has completely revolutionized trauma care—with the application of quick clot products, battlefield triage and stabilization, rapid advanced care near the front lines, and prompt transport for specialized care.
That expertise was on display two years ago for AMA Immediate Past President William G. Plested III, MD, and former AMA President J. Edward Hill, MD, when they traveled to Germany to visit Ramstein Air Base, Landstuhl Regional Medical Center, and Spangdahlem Air Base. While en route to Landstuhl Regional Medical Center, Drs. Plested and Hill were aboard an air evacuation flight with multiple critically injured patients from the Middle East combat arena. Dr. Plested wrote about his observations and experiences in a 2007 column in American Medical News (AMNews).
And earlier this year, AMA Board Chair Edward L. Langston, MD, had an opportunity to learn about the mission and operation of the Air Mobility Command, which handles all of the air evacuation of wounded soldiers around the world. As Dr. Langston wrote in an AMNews column, the experience showed "the extent, quality, and depth of medical care" our nation's armed services provide for our wounded soldiers across the globe.
That care is resulting in a markedly increased survival and recovery rate for our military combat injuries. If an injured patient can reach one of our deployed medical facilities alive, the patient has a greater than 95 percent chance of survival. And the military conflicts in Afghanistan and Iraq have resulted in the lowest lethality rates—9 percent—than in any previous war. By contrast, that figure was 24 percent during the Vietnam War and 30 percent during World War II.
In addition, we're seeing the lowest disease nonbattle injury rates in recent recorded conflict. The Gulf War resulted in 65 injuries per 1,000 military personnel per week. Operation Iraqi Freedom generated 52 injuries per 1,000 during the war phase, and the stabilization phase has produced 40 injuries per 1,000.
These numbers illustrate that military medicine is at the forefront of some of the amazing advances we're seeing. AMA member and Boston surgeon Atul Gawande, MD, made this exact point during the Presidents' Forum at this year's AMA National Advocacy Conference. Some of his comments are reflected in his recent book Better: A Surgeon's Notes on Performance, and in an article he wrote for the Dec. 9, 2004, issue of the New England Journal of Medicine.
With military physicians making such a strong contribution to medicine and public health, it's important to note that the AMA has a strong history of support and involvement by our nation's uniformed services and veterans. The Air Force, Army, Navy, and PHS all are represented in the AMA House of Delegates, as is the U.S. Department of Veterans Affairs, the Association of Military Surgeons of the U.S., and the Society of Medical Consultants to the Armed Forces.
The AMA has a number of policies involving military physicians, including requests for flexible policies for active and reserve physicians, and support for graduate medical education programs in the military, physician participation in armed forces medical reserve programs, and continuation of the PHS Commissioned Corps.
Those returning from the front lines are faced with a challenging transition. As physicians, we'll be dealing for years to come with highly visible physical injuries suffered by service members returning from Iraq and Afghanistan, and also post-traumatic stress disorders and other emotional wounds that afflict our returning troops. Let's be ready for them—they deserve it.
And this Memorial Day, let's remember those physicians who are not only treating these men and women but are on the front lines themselves. They especially deserve our gratitude.
The lighter side
I have many fond memories of my years in the PHS Commissioned Corps. During my first two years in the PHS, I was an officer in the CDC's Epidemic Intelligence Service (EIS), working on the national measles elimination campaign. EIS officers lead many of the CDC's investigations of disease outbreaks, and my first opportunity to do so was in the fall of 1984, when I led a small team sent to investigate a large measles outbreak in Puerto Rico.
Soon after arriving in San Juan, where most of the reported cases had occurred, I asked local health officials to show me one of the children who was ill with measles. In my EIS training, I had learned that one of the early steps in investigating an outbreak is to verify the diagnosis. I inspected the child's maculopapular rash and found Koplik spots in the mouth, which are considered pathognomonic for measles. I indicated that I was satisfied with the diagnosis of measles.
Truth be told, this was the first case of measles that I had seen, since there were no patients with measles during my six-week rotation in pediatrics in medical school. But from that point on, I could claim that yes, of course, this CDC "measles expert" had seen the disease.
"See one, do one, teach one" is a well-known part of medical training (although that approach is being replaced more and more by simulation programs and other new teaching methods). In my EIS experience, the method of learning how to investigate an outbreak could have been described as "do several in the classroom and then do one in real life" (with telephone back-up from supervisors at the CDC).
Please send comments, questions, and replies to amaprez@ama-assn.org.
Content provided by: Ronald M. Davis, MD