Stinner DJ

When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.

Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.

At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.

Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.

A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.

All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.

We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

See Dr. Guillamondegui's commentary here.

When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.

Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.

At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.

Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.

A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.

All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.

We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

See Dr. Guillamondegui's commentary here.

When taking care of the polytrauma patient, coordinated care between services has been demonstrated to lead to improved outcomes on various levels. However, most trauma centers function in a constant state of chaos, where communication between services is sporadic and haphazard. It is in this environment that communication between services is paramount, not just to improve the flow of information between services, but to improve overall patient care.

Each of the authors come from different residency training programs and in each, there was very limited coordination between the general surgery and orthopedic trauma services. In most cases, discussions about the daily care of patients would be between junior residents and interns, who may not recognize the big picture in the polytrauma patient. This can lead to inadequately resuscitated patients going to the operating room, or unanticipated intra-operative needs slowing down treatment including inadequate lines/monitoring and blood available. In addition, poor communication in the postoperative period can lead to inaccurate weight-bearing status and physical therapy plans being initiated, as well as incorrect information being relayed to the patients’ family members.

At Vanderbilt University Medical Center, the orthopedic trauma fellows meet with the general surgery trauma team every morning during the trauma conference to review the plan for all orthopedic trauma patients on the general surgery trauma service. We briefly review old patients but primarily focus on new patients to discuss optimal timing for the operating room (OR) and anticipated intra- and postoperative needs. We also focus on ensuring appropriate postoperative plans have been established to facilitate patient disposition in the postoperative period. These meetings occur at 7 am every morning—even on weekends and holidays—and last anywhere from 5 to 20 minutes. During these meetings, the general surgeons may highlight aspects of a patient’s physiologic status that we, orthopaedic surgeons, had not recognized and recommend that we postpone surgery a few hours while they optimize the patient for the OR. In other cases, we discuss anticipated length of time in the OR, patient positioning, which can sometimes be an area of concern, and blood loss. These discussions may lead both the general surgeons and orthopedic trauma surgeons to change their current approach to better meet the needs of the patient by looking at the bigger picture.

Through this coordinated approach, our services operate very well with one another, which equates, in our opinion, to better overall patient care. The following is one case example highlighting the collegial relationship between the two services.

A middle-aged male was shot with a high-powered rifle resulting in a comminuted femur fracture and dysvascular extremity. The vascular surgery team felt that the leg could not be revascularized and recommended immediate amputation. After discussing it with orthopedic trauma, it was felt that an amputation might be necessary, but that it did not need to occur that night and that an attempt at limb salvage was possible. Following this discussion, the patient underwent external fixation by the orthopedic trauma service and the general surgeon performed leg fasciotomies. While this is a relatively common scenario at many trauma centers across the country, we want to highlight that communication between services not only lead to improved patient care by attempting to salvage the limb, but also improved communication with the family. The family and the patient were then able to have time to adjust to the possibility of an amputation should limb salvage not be successful.

All too often our trauma services operate independently of one another. While the case presented here is a relatively common scenario in one form or another at many trauma centers, we would venture to guess that many of the orthopedic trauma and general surgeons may never even be found in the operating room at the same time. Due to our frequent daily interactions, our two services have developed a camaraderie with one another that facilitates an open collegial relationship that makes interservice communication easy, which we feel leads to better overall patient care.

We sought to share the experience we have had as fellows in orthopedic trauma and surgical critical care and acute care surgery as well as to highlight the effectiveness of daily communication. It requires a commitment from both services to reserve the same 15 or 20 minutes every day to meet. But once these daily exchanges become the norm, it leads to a change in culture. And rather than surviving in a state of chaos in the busy trauma centers, we can thrive in a culture of coordinated patient care.

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

See Dr. Guillamondegui's commentary here.

Being part of a team means being part of something bigger than yourself—it is one of the most basic life-lessons. If your work is gratify­ing, you put forth a bit more effort than you would otherwise, and devel­op a sense of pride in both your team and your teammates. All of this applies to the military. We are a team and we share a common goal: providing the best possible care to our service members and their families. Our job as orthopedic residents within the military is to make sure we are well trained to succeed in this aim.

There are many differences between Army and civilian residency programs. One of the most drastic differences is the fellowship. While nearly 90% of graduat­ing residents go on to a fellowship in the civilian sector, only approximately one-third of graduating Army residents do so. One reason is the limited number of fel­lowship positions available for graduating Army residents each year. The available positions change yearly and are based on military needs at that particular time. For example, if you are a 4thyear resident interested in total joint arthroplasty, but there are no openings at major military medical centers (MEDCENs) for a fellowship trained total joint surgeon, there will likely not be a fellowship position available that year. Even if there are fellowship spots available, an Army resident has to go through a rigorous application process in order to secure a fellowship position. The first step is to complete an Army fellowship application, which consists of similar components as a civilian fellowship application including letters of recommenda­tions and a CV. The application is typically completed by mid October in the 4th year of residency and the selection is announced in mid December. The next step is applying for fellowship match. In the meantime, many of us have already started the civilian fellowship application process before we even know whether we were accepted for the Army fellowship.

The decision to complete an Army fellowship also means that, in most cases, you incur an additional 2 years of service obligation. While this may not affect the ability of applicants to get or complete a fellowship, a graduating resident whose service obligation is only 4 years, may not want the extra commitment. They may decide instead to complete a civilian fellowship after gaining invaluable experience as a gen­eralist in the Army. For the graduating resident whose service obligation is only 4 years, they may decide to serve their time and complete a fellowship after gaining invaluable experience as a generalist within the Army.

Regardless of whether an Army resi­dent completes a fellowship, most will be deployed to a combat environment within the first 2 years after graduation. Even if you are a sports medicine fellow­ship trained surgeon, you are considered an Army orthopedic surgeon first and will be deployed as such. Many military orthopedic surgeons have said that their deployments are some of the best expe­riences of their lives, both professionally and personally. While we have not had the opportunity to deploy—because as residents we have a non-deployable sta­tus—we look forward to having a simi­lar opportunity to care for our wounded service members overseas.

Graduating Army residents have multiple opportunities for placement. Whereas most Army medical facilities act like smaller community hospitals and are typically staffed by generalists and a hand or sports medicine orthope­dist if needed, most of the MEDCENs function as large, civilian academic cen­ters and are staffed by fellowship trained specialists. Some of these facilities are quite remote (eg, Landstuhl, Germany), while others are in large metropolitan areas (eg, Washington, DC). During our final year of residency or fellowship, we submit a rank list based on the openings at these different centers worldwide. Then, in February or March, we find out where we will be heading after gradua­tion. This process is very similar to any match process in medicine. Depending on your training, career goals, and type of practice you desire, the Army will try to align your personal goals with its needs. Therefore, everyone can be in the optimal position for success. For those physicians who only owe 4 or 5 years of military ser­vice, the locations they serve after gradu­ation will likely be their last in the Army.

Being an orthopedic resident in the Army also provides us with the oppor­tunity to be part of many multi-center research projects. Some of these are strict­ly within the military (eg, the Society of Military Orthopaedic Surgeons [SOMOS] and Research Collaborative “Innovative Methods to Preserve Articular Cartilage after Trauma”), whereas others are in collaboration with multiple civilian pro­grams (eg, the Major Extremity Trauma Research Consortium and Fluid Lavage of Open Wounds). SOMOS is also begin­ning to put together lessons the military has learned from our research and experi­ences while deployed into a formalized package. This past December marked the first of what should be many Disaster Response Courses. This course, hosted in part by SOMOS, with collaboration from the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS), and gave military and civilian orthopedic surgeons alike, the ability to learn some of the les­sons the military has learned during its most recent conflicts, and the recent disas­ters experienced by the civilian world by natural disasters and terrorist acts.

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.

These are just a few of the many dif­ferent and unique facets of completing a military residency. Like any other institu­tion or residency program, the military is not perfect. However, it is an honor to treat and interact with our Wounded Warriors and we look forward to continu­ing to provide the best care possible for our soldiers.

Author's Disclosure Statement. The authors report no actual or potential conflict of interest in relation to this article.

Being part of a team means being part of something bigger than yourself—it is one of the most basic life-lessons. If your work is gratify­ing, you put forth a bit more effort than you would otherwise, and devel­op a sense of pride in both your team and your teammates. All of this applies to the military. We are a team and we share a common goal: providing the best possible care to our service members and their families. Our job as orthopedic residents within the military is to make sure we are well trained to succeed in this aim.

There are many differences between Army and civilian residency programs. One of the most drastic differences is the fellowship. While nearly 90% of graduat­ing residents go on to a fellowship in the civilian sector, only approximately one-third of graduating Army residents do so. One reason is the limited number of fel­lowship positions available for graduating Army residents each year. The available positions change yearly and are based on military needs at that particular time. For example, if you are a 4thyear resident interested in total joint arthroplasty, but there are no openings at major military medical centers (MEDCENs) for a fellowship trained total joint surgeon, there will likely not be a fellowship position available that year. Even if there are fellowship spots available, an Army resident has to go through a rigorous application process in order to secure a fellowship position. The first step is to complete an Army fellowship application, which consists of similar components as a civilian fellowship application including letters of recommenda­tions and a CV. The application is typically completed by mid October in the 4th year of residency and the selection is announced in mid December. The next step is applying for fellowship match. In the meantime, many of us have already started the civilian fellowship application process before we even know whether we were accepted for the Army fellowship.

The decision to complete an Army fellowship also means that, in most cases, you incur an additional 2 years of service obligation. While this may not affect the ability of applicants to get or complete a fellowship, a graduating resident whose service obligation is only 4 years, may not want the extra commitment. They may decide instead to complete a civilian fellowship after gaining invaluable experience as a gen­eralist in the Army. For the graduating resident whose service obligation is only 4 years, they may decide to serve their time and complete a fellowship after gaining invaluable experience as a generalist within the Army.

Regardless of whether an Army resi­dent completes a fellowship, most will be deployed to a combat environment within the first 2 years after graduation. Even if you are a sports medicine fellow­ship trained surgeon, you are considered an Army orthopedic surgeon first and will be deployed as such. Many military orthopedic surgeons have said that their deployments are some of the best expe­riences of their lives, both professionally and personally. While we have not had the opportunity to deploy—because as residents we have a non-deployable sta­tus—we look forward to having a simi­lar opportunity to care for our wounded service members overseas.

Graduating Army residents have multiple opportunities for placement. Whereas most Army medical facilities act like smaller community hospitals and are typically staffed by generalists and a hand or sports medicine orthope­dist if needed, most of the MEDCENs function as large, civilian academic cen­ters and are staffed by fellowship trained specialists. Some of these facilities are quite remote (eg, Landstuhl, Germany), while others are in large metropolitan areas (eg, Washington, DC). During our final year of residency or fellowship, we submit a rank list based on the openings at these different centers worldwide. Then, in February or March, we find out where we will be heading after gradua­tion. This process is very similar to any match process in medicine. Depending on your training, career goals, and type of practice you desire, the Army will try to align your personal goals with its needs. Therefore, everyone can be in the optimal position for success. For those physicians who only owe 4 or 5 years of military ser­vice, the locations they serve after gradu­ation will likely be their last in the Army.

Being an orthopedic resident in the Army also provides us with the oppor­tunity to be part of many multi-center research projects. Some of these are strict­ly within the military (eg, the Society of Military Orthopaedic Surgeons [SOMOS] and Research Collaborative “Innovative Methods to Preserve Articular Cartilage after Trauma”), whereas others are in collaboration with multiple civilian pro­grams (eg, the Major Extremity Trauma Research Consortium and Fluid Lavage of Open Wounds). SOMOS is also begin­ning to put together lessons the military has learned from our research and experi­ences while deployed into a formalized package. This past December marked the first of what should be many Disaster Response Courses. This course, hosted in part by SOMOS, with collaboration from the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS), and gave military and civilian orthopedic surgeons alike, the ability to learn some of the les­sons the military has learned during its most recent conflicts, and the recent disas­ters experienced by the civilian world by natural disasters and terrorist acts.

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.

These are just a few of the many dif­ferent and unique facets of completing a military residency. Like any other institu­tion or residency program, the military is not perfect. However, it is an honor to treat and interact with our Wounded Warriors and we look forward to continu­ing to provide the best care possible for our soldiers.

Author's Disclosure Statement. The authors report no actual or potential conflict of interest in relation to this article.

Being part of a team means being part of something bigger than yourself—it is one of the most basic life-lessons. If your work is gratify­ing, you put forth a bit more effort than you would otherwise, and devel­op a sense of pride in both your team and your teammates. All of this applies to the military. We are a team and we share a common goal: providing the best possible care to our service members and their families. Our job as orthopedic residents within the military is to make sure we are well trained to succeed in this aim.

There are many differences between Army and civilian residency programs. One of the most drastic differences is the fellowship. While nearly 90% of graduat­ing residents go on to a fellowship in the civilian sector, only approximately one-third of graduating Army residents do so. One reason is the limited number of fel­lowship positions available for graduating Army residents each year. The available positions change yearly and are based on military needs at that particular time. For example, if you are a 4thyear resident interested in total joint arthroplasty, but there are no openings at major military medical centers (MEDCENs) for a fellowship trained total joint surgeon, there will likely not be a fellowship position available that year. Even if there are fellowship spots available, an Army resident has to go through a rigorous application process in order to secure a fellowship position. The first step is to complete an Army fellowship application, which consists of similar components as a civilian fellowship application including letters of recommenda­tions and a CV. The application is typically completed by mid October in the 4th year of residency and the selection is announced in mid December. The next step is applying for fellowship match. In the meantime, many of us have already started the civilian fellowship application process before we even know whether we were accepted for the Army fellowship.

The decision to complete an Army fellowship also means that, in most cases, you incur an additional 2 years of service obligation. While this may not affect the ability of applicants to get or complete a fellowship, a graduating resident whose service obligation is only 4 years, may not want the extra commitment. They may decide instead to complete a civilian fellowship after gaining invaluable experience as a gen­eralist in the Army. For the graduating resident whose service obligation is only 4 years, they may decide to serve their time and complete a fellowship after gaining invaluable experience as a generalist within the Army.

Regardless of whether an Army resi­dent completes a fellowship, most will be deployed to a combat environment within the first 2 years after graduation. Even if you are a sports medicine fellow­ship trained surgeon, you are considered an Army orthopedic surgeon first and will be deployed as such. Many military orthopedic surgeons have said that their deployments are some of the best expe­riences of their lives, both professionally and personally. While we have not had the opportunity to deploy—because as residents we have a non-deployable sta­tus—we look forward to having a simi­lar opportunity to care for our wounded service members overseas.

Graduating Army residents have multiple opportunities for placement. Whereas most Army medical facilities act like smaller community hospitals and are typically staffed by generalists and a hand or sports medicine orthope­dist if needed, most of the MEDCENs function as large, civilian academic cen­ters and are staffed by fellowship trained specialists. Some of these facilities are quite remote (eg, Landstuhl, Germany), while others are in large metropolitan areas (eg, Washington, DC). During our final year of residency or fellowship, we submit a rank list based on the openings at these different centers worldwide. Then, in February or March, we find out where we will be heading after gradua­tion. This process is very similar to any match process in medicine. Depending on your training, career goals, and type of practice you desire, the Army will try to align your personal goals with its needs. Therefore, everyone can be in the optimal position for success. For those physicians who only owe 4 or 5 years of military ser­vice, the locations they serve after gradu­ation will likely be their last in the Army.

Being an orthopedic resident in the Army also provides us with the oppor­tunity to be part of many multi-center research projects. Some of these are strict­ly within the military (eg, the Society of Military Orthopaedic Surgeons [SOMOS] and Research Collaborative “Innovative Methods to Preserve Articular Cartilage after Trauma”), whereas others are in collaboration with multiple civilian pro­grams (eg, the Major Extremity Trauma Research Consortium and Fluid Lavage of Open Wounds). SOMOS is also begin­ning to put together lessons the military has learned from our research and experi­ences while deployed into a formalized package. This past December marked the first of what should be many Disaster Response Courses. This course, hosted in part by SOMOS, with collaboration from the Orthopaedic Trauma Association (OTA) and the American Academy of Orthopaedic Surgeons (AAOS), and gave military and civilian orthopedic surgeons alike, the ability to learn some of the les­sons the military has learned during its most recent conflicts, and the recent disas­ters experienced by the civilian world by natural disasters and terrorist acts.

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.

These are just a few of the many dif­ferent and unique facets of completing a military residency. Like any other institu­tion or residency program, the military is not perfect. However, it is an honor to treat and interact with our Wounded Warriors and we look forward to continu­ing to provide the best care possible for our soldiers.

Author's Disclosure Statement. The authors report no actual or potential conflict of interest in relation to this article.