Survey of Current Simulation Based Training in the US Military Health System.

INTRODUCTION: Simulation-based medical training has been shown to be effective and is widely used in civilian hospitals; however, it is unclear how widely and how effectively simulation is utilized in the U.S. Military Health System (MHS). The current operational state of medical simulation in the MHS is unknown, and there remains a need for a system-wide assessment of whether and how the advances in simulation-based medical training are employed to meet the evolving needs of the present-day warfighter. Understanding the types of skills and methods used within simulation programs across the enterprise is important data for leaders as they plan for the future in terms of curriculum development and the investment of resources. The aim of the present study is to survey MHS simulation programs in order to determine the prevalence of skills taught, the types of learners served, and the most common methodologies employed in this worldwide health care system. MATERIALS AND METHODS: A cross-sectional survey of simulation activities was distributed to the medical directors of all 93 simulation programs in the MHS. The survey was developed by the authors based on lists of critical wartime skills published by the medical departments of the US Army, Navy, and Air Force. Respondents were asked to indicate the types of learners trained at their program, which of the 82 unique skills included in the survey are trained at their site, and for each skill the modalities of simulation used, i.e., mannequin, standardized patients, part task trainers, augmented/virtual reality tools, or cadaver/live tissue. RESULTS: Complete survey responses were obtained from 75 of the 93 (80%) MHS medical simulation training programs. Across all skills included in the survey, those most commonly taught belonged predominantly to the categories of medic skills and nursing skills. Across all sites, the most common category of learner was the medic/corpsman (95% of sites), followed by nurses (87%), physicians (83%), non-medical combat lifesavers (59%), and others (28%) that included on-base first responders, law enforcement, fire fighters, and civilians. The skills training offered by programs included most commonly the tasks associated with medics/corpsmen (97%) followed by nursing (81%), advanced provider (77%), and General Medical Officer (GMO) skills (47%). CONCLUSION: The survey demonstrated that the most common skills taught were all related to point of injury combat casualty care and addressed the most common causes of death on the battlefield. The availability of training in medic skills, nursing skills, and advanced provider skills were similar in small, medium, and large programs. However, medium and small programs were less likely to deliver training for advanced providers and GMOs compared to larger programs. Overall, this study found that simulation-based medical training in the MHS is focused on medic and nursing skills, and that large programs are more likely to offer training for advanced providers and GMOs. Potential gaps in the availability of existing training are identified as over 50% of skills included in the nursing, advanced provider, and GMO skill categories are not covered by at least 80% of sites serving those learners.

Mastering multicasualty trauma care with the Trauma Non-technical Skills Scale.

BACKGROUND: Multicasualty events present complex medical challenges. This is the first study to investigate the role of nontechnical skills in prehospital multicasualty trauma care. We assessed the feasibility of using the Trauma Nontechnical Skills Scale (T-NOTECHS) instrument, which has not yet been investigated to evaluate these scenarios. METHODS: We conducted an observational study involving military medical teams with Israel Defense Forces Military Trauma Life Support training to assess the T-NOTECHS' utility in predicting prehospital medical team performance during multicasualty event simulations. These teams were selected from a pool of qualified military Advanced Life Support providers. Simulations were conducted in a dedicated facility resembling a field setting, with video recordings to ensure data accuracy. Teams faced a single multicasualty scenario, assessed by two instructors, and were evaluated using a 37-item checklist. The T-NOTECHS scores were analyzed using regression models to predict simulation performance. RESULTS: We included 27 teams for analysis, led by 28% physicians and 72% paramedics. Interrater reliability for simulation performance and T-NOTECHS scores showed good agreement. Overall T-NOTECHS scores were positively correlated with simulation performance scores ( R = 0.546, p < 0.001). Each T-NOTECHS domain correlated with simulation performance. The Communication and Interaction domain explained a unique part of the variance ( ß = 0.406, p = 0.047). Assessment and Decision Making had the highest correlation ( R = 0.535, p < 0.001). These domains significantly predicted specific items on the simulation performance checklist. Cooperation and Resource Management showed the least correlation with checklist items. CONCLUSION: This study confirms the T-NOTECHS' reliability in predicting prehospital trauma team performance during multicasualty scenarios. Key nontechnical skills, especially Communication and Interaction, and Assessment and Decision Making, play vital roles. These findings underscore the importance of training in these skills to enhance trauma care in such scenarios, offering valuable insights for medical team preparation. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level III.

Perceptions of general surgery residents at military treatment facilities: Excellent training with crisis of confidence.

BACKGROUND: The declining operative volume at Military Treatment Facilities (MTFs) has resulted in Program Directors finding alternate civilian sites for resident rotations. The continued shift away from MTFs for surgical training is likely to have unintended negative consequences. METHODS: An anonymous survey was generated and sent to the program directors of military general surgery training programs for distribution to their residents. RESULTS: A total of 42 residents responded (response rate 21%) with adequate representation from all PGY years. Ninety-five percent of residents believed that their programs provided the training needed to be a competent general surgeon. However, when asked about career choices, only 30.9% reported being likely/extremely likely to remain in the military beyond their initial service obligation, while 54.7% reported that it was unlikely/extremely unlikely and 19% reported uncertainty. Eighty-eight percent reported that decreasing MTF surgical volume directly influenced their decision to stay in the military, and half of respondents regretted joining the military. When asked to assess their confidence in the military to provide opportunities for skill sustainment as a staff surgeon, 90.4% were not confident or were neutral. CONCLUSION: Although military surgical residents have a generally positive perception of their surgical training, they also lack confidence in their future military surgical careers. Our findings suggest that declining MTF surgical volume will likely negatively impact long-term retention of military surgeons and may negatively impact force generation for Operational Commander. LEVEL OF EVIDENCE: Prognostic and Epidemiological, Level IV.

'Delivering effective Defence Healthcare Engagement during Short-Term Training Team deployments: Guidance from on-the-ground Practitioners'.

Defence Engagement (DE) has grown to become one of the key operational outputs of UK Defence. Defence Engagement (Health) (DE(H)) is a subcategory of DE, in which Defence Medical Services (DMS) personnel and assets are used to achieve influence and promote the UK's national interests. For most DMS personnel, their involvement in DE(H) will be as part of a Short-Term Training Team (STTT). STTTs are deployed to Host Nations (HNs) to work alongside a Partner Force, training, mentoring and supporting them to enhance their own capabilities. This article aims to guide junior members of the DMS in how they might approach an STTT from a DE(H) perspective. The article will draw primarily on the recent operational experiences of the authors across multiple STTTs in a variety of HNs.

Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study.

BACKGROUND: Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS: Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS: We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION: The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.

The impact of simulation-based training on medical students' whole blood transfusion abilities.

BACKGROUND: Whole blood transfusion has been found to increase the likelihood of patient survival within both military and civilian medicine contexts. However, no whole blood transfusion training curriculum currently exists within undergraduate or graduate medical education in the United States. The purpose of our study was to: (1) determine the impact of simulation-based training on medical students' abilities to conduct whole blood transfusions; and (2) determine the impact of simulation-based training on medical students' confidence in conducting whole blood transfusions. STUDY DESIGN AND METHODS: We assessed 157 third-year military medical students' ability to conduct whole blood transfusion before and after Operation Gunpowder, a 2-day high-fidelity prolonged casualty care simulation. We conducted a paired samples t-test to compare the students' pre- and post-simulation performance scores as well as self-reported confidence and stress ratings. RESULTS: There was a significant difference in students' scores at the beginning of the course (M = 20.469, SD 6.40675) compared to their scores at the end of the course (M = 30.361, SD = 2.10053); t(155) = -18.833, p < .001. The effect size for this analysis (d = 6.56) was large. There was a significant difference (p < .001) between the pre- and post-ratings for all self-reported confidence and stress survey items. DISCUSSION: Our results suggest that simulation-based training is an effective means of training medical students to conduct whole blood transfusiontraining in a limited resource simulated environment where blood inventories may be limited.

Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams.

BACKGROUND: Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. METHODS: The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools. RESULTS: A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.

Defining capabilities in deployed UK military prehospital emergency care.

The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.

Do You See What I See? A Comparison of CCC and Self-Assigned Milestones Across Military Medical Specialties.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to complete competency-based assessments of medical trainees based on nationally established Milestones. Previous research demonstrates a strong correlation between CCC and resident scores on the Milestones in surgery, but little is known if this is true between specialties. In this study, we investigated a variety of specialties and sought to determine what factors affect self-assessment of milestones. In addition, a post-hoc analysis was completed on the COVID-19 pandemic effects on self-evaluation. METHODS: This is an IRB approved observational study on prospectively collected self-evaluation milestone data that is used within each ACGME program's Clinical Competency Committees. Medical trainees within the San Antonio Uniformed Services Health Education Consortium were approached for possible participation in this study with permission from program directors. RESULTS: There was no significant difference between self-assessments and CCC-assessments based on self-identified gender or residency type (surgical versus nonsurgical) for any milestone domain. Within the postgraduate year (PGY) groups, the PGY5 and PGY6 tended to rate themselves higher than CCC. Chiefs (Internal Medicine PGY2/3, and General Surgery PGY5/6) tended to be more accurate in scoring themselves than the interns (PGY1) within the milestone of Interpersonal Skills and Communication (chiefs 0.5 vs. interns 0.62, p = 0.03). On post hoc analysis of self-rating, during the first wave of the COVID 19 pandemic, Post-Covid residents were more likely to underrate themselves in Systems-Based Practice compared to the Pre-Covid cohort (-0.49 vs 0.10; p = 0.007) and more likely to rate themselves higher in Professionalism (-0.54 vs. -0.10, p = 0.012). CONCLUSION: Unique to this study and our institution, there was no gender difference found in self vs CCC evaluations. With the change in learning environment from COVID, there was also a change in ability for some learners to self-assess accurately. As medical educators, we should understand the importance of both encouraging learners to practice self-assessment as well as give feedback to trainees on their progress. We also need to educate our faculty on the use of milestones for assessment to create a true gold standard in the CCC.

Evaluation of the Pedagogical Impact of "Traum'Cast" Podcast: A Pilot Study Based on Metacognition.

INTRODUCTION: With the evolution of educational tools, the French Military medical service has created a podcast program, Traum'Cast, about the principles of war medicine, accessible online for free. METHOD: Our objective was to measure the learning effect of the Traum'Cast program's first episode. A non-randomized pilot trial between July and December 2021 included 80 health care providers: 40 in the video podcast group compared to 40 in a group reading a pdf file providing the same information. Using a 10 MCQs, we evaluated knowledge acquisition before, just after, and 2 weeks after the intervention. It was measured using metacognition tools based on confidence marking (number of correct answers, score weighted by certainty level, and realism). RESULTS: Knowledge acquisition was better in the podcast group than in the pdf file group immediately after the intervention (correct answers: 9.0 [9.0-10.0] vs 9.0 [7.8-9.0], P = 0.015; weighted score: 177.0 [159.0-198.0] vs 160.0 [129.5-176.5], P = 0.020). This difference was persistent 2 weeks after (weighted score: 127.5 [101.8-145.2] vs 105.5 [74.2-128.5], P = 0.023). CONCLUSION: This podcast is an innovative teaching tool which has proven to strengthen the knowledge of the principles of war medicine.

European military surgical teams in combat theater: A survey study on deployment preparation and experience.

INTRODUCTION: Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training. METHODS: A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations. RESULTS: The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]). CONCLUSIONS: Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.

French Military Neurosurgery: At Home and Abroad.

The origins of military neurosurgery are closely linked to those of neurosurgery in France and more particularly in Paris. The history of the field starts with its origins by 2 men, Thierry de Martel and Clovis Vincent. The first note about the creation of military neurosurgery was in 1942, when Marcel David was reassigned from the Sainte Anne Hospital to practice at the Val-de-Grâce Military Hospital. David trained the first military neurosurgeon. The field of military neurosurgery was subsequently developed at the Val-de-Grâce Military Hospital, at Sainte Anne Military Teaching Hospital in Toulon in 1990 and then at Percy Military Teaching Hospital in 1996. Over 29 military neurosurgeons were trained in these institutions. Since 2000, French military neurosurgeons have been deployed from France in the Mobile Neurosurgical Unit. This Mobile Neurosurgical Unit represents 12% of all medical evacuation of casualties categorized as the high dependency level. Neurosurgeons were able to adapt to asymmetrical wars, such as in the Afghanistan campaign where they were deployed in the Role 3 medical treatment facility, and more recently in sub-Saharan conflicts where they were deployed in forward surgical roles. To manage the increasing craniocerebral war casualties in the forward surgical team, the French Military Health Service Academy established a training course referred to as the "Advanced Course for Deployment Surgery" providing neurosurgical damage control skills to general surgeons. Finally, military neurosurgery is reinventing itself to adapt to future conflicts through the enhancement of surgical practices via the addition of head, face, and neck surgeons.

Leading Graduate Medical Education in the Face of Uncertainty.

Leading through uncertainty poses significant challenges. The COVID-19 pandemic, the Afghanistan withdrawal, and the implementation of a new electronic medical records system led to massive shortages of health care workers throughout the Military Health System (MHS). This case describes the leadership challenges of a surgical residency program director during uncertain times.

Advancing Readiness Through Military Programs: An Evidence-Based Practice Perspective.

INTRODUCTION: Military nurses comprise the largest percentage of military health care providers. In the current military health care system, they have two roles: (1) Patient care in military treatment facilities (MTFs) and (2) patient care during combat operations. Although in MTFs, the military nurse's roles are similar to those of their civilian counterpart, their roles are unique and varied in the combat operational environment. These combined roles lead to questions regarding readiness training to ensure that nurses are proficient in both MTFs and combat operational settings where treatment requirements may differ. The purpose of this paper is to (1) present the current state of educational readiness programs to maintain a ready medical force that entail formal teaching programs, military-civilian partnerships, and joint exercises of combat simulations, and (2) identify gaps as presented in an evidence-based practice educational panel. METHODS: On March 11, 2022, TriService Nursing Research Program hosted the virtual First Military Evidence-Based Practice Summit from the Uniformed Services University of the Health Sciences in Bethesda, MD. As part of the summit, an evidence-based practice education panel discussed the availability of current evidence-driven military medical readiness programs and identified gaps in the integration of military readiness for nursing personnel into the Defense Health Agency and Armed Services. RESULTS: The panel participants discussed the separate requirements for training within the MTFs and in combat operational settings. The available training programs identified by the panel were primarily those developed in local MTF settings to meet local needs. Although these programs support the MTFs' peacetime mission, competing roles, limited time, and limited funds contributed to limited preparation of nursing personnel in skills associated with combat-related injuries and illnesses. Prolonged casualty care has become an important focus for the Department of Defense as greater considerations are directed to wartime operations in austere expeditionary environments. Although there is some training available that is specific for prolonged casualty care, the focus has been the adaptation of combat casualty care during contingency operations. A keynote here was the concept that combat casualty care training must include both development of individual skills and integration of the team since maximal care can be achieved only when the individual and the team operate as a unit. A key point was the utility of central repositories for storing information related to training a ready medical force at individual and unit levels and that these repositories could also be used to collect and facilitate the accession of current evidence-based information. DISCUSSION: Optimal patient care at all levels of the military health system requires training that maximizes individual and unit skills specific to the environment at an MTF or in a combat operational setting. Training must be designed to incorporate evidence-driven knowledge in all military settings with guidance that is specific to the environment. CONCLUSION: Enhanced communication of evidence-based training and knowledge is an important component of maintaining a ready medical force for broader medical support of combat contingency operations.

A Comparison of HPSP and USU Graduates' Preparation for Residency.

INTRODUCTION: Military medical students enter residency through two main pathways: (1) The Uniformed Services University (USU) and (2) the Armed Services Health Professions Scholarship Program (HPSP). The purpose of this study was to compare how these two pathways prepare military medical students for residency. METHODS: We conducted semi-structured interviews with 18 experienced military residency program directors (PDs) in order to explore their perceptions of the preparedness of USU and HPSP graduates. We used a transcendental phenomenological qualitative research design to bracket our biases and guide our data analysis. Our research team coded each of the interview transcripts. We then organized these codes into themes, which served as the results of our study. RESULTS: Five themes emerged from our data regarding the residents' preparedness: (1) Ability to navigate the military culture, (2) understanding of the military's medical mission, (3) clinical preparation, (4) ability to navigate the Military Health System (MHS), and (5) teamwork. The PDs described how USU graduates better understand the military's medical mission and are more easily able to navigate the military culture and the MHS because of their lived experiences during military medical school. They also discussed the various levels of clinical preparation of HPSP graduates, in contrast to the USU graduates' more consistent skills and abilities. Finally, the PDs believed both groups to be strong team players. CONCLUSIONS: USU students were consistently prepared for a strong start to residency because of their military medical school training. HPSP students often experienced a steep learning curve because of the newness of the military culture and MHS.

Relationship Between Gender and Academic and Military Achievement Among USU Medical School Graduates.

INTRODUCTION: Despite increases in the number of female matriculants in medical school, civilian data demonstrate that women still struggle to reach parity in attainment of leadership positions. In military medicine, we have seen a major increase in the number of women graduating from the USU. Yet, we still know little about the representation of female military physicians in leadership positions. The aim of this study is to examine the relationship between gender and academic and military achievement among USU School of Medicine graduates. METHODS: Utilizing the USU alumni survey sent to graduates from the classes of 1980 to 2017, items of interest, such as highest military rank, leadership positions held, academic rank, and time in service, were used to evaluate the relationship between gender and academic and military achievement. Contingency table statistical analysis was conducted to compare the gender distribution on the survey items of interest. RESULTS: Pairwise comparison demonstrated significant differences between gender in the O-4 (P = .003) and O-6 (P = .0002) groups, with females having a higher-than-expected number of O-4 officers and males having a higher-than-expected number of O-6 officers. These differences persisted in a subsample analysis that excluded those who separated from active duty prior to 20 years of service. There was a significant association between gender and holding the position of commanding officer (χ2(1) = 6.61, P < .05) with fewer females than expected. In addition, there was a significant association between gender and the highest academic rank achieved (χ2(3) = 9.48, P < 0.05) with lower-than-expected number of females reaching the level of full professor, in contrast to males who exceed the expected number. CONCLUSIONS: This study suggests that female graduates of USU School of Medicine have not achieved promotion to the highest levels of rank, military, or academic leadership at the projected rate. Efforts to explore what barriers may impact military medicine's desire to have more equal representation of women in higher ranks and positions should be undertaken with specific attention to what drives retention versus separation of medical officers and if systematic changes are needed to help promote equity for women in military medicine.

Career Accomplishments of Uniformed Services University of the Health Sciences Medical Graduates: Classes 1980-2017.

BACKGROUND: The current study reports career accomplishments of Uniformed Services University (USU) graduates in four areas: (1) positions held over the course of their entire career, (2) military awards, decorations, and rank, (3) first residency completed, and (4) academic achievements. METHOD: Utilizing the responses to the alumni survey sent to USU graduates in the Class 1980 to 2017, we extracted relevant data and reported descriptive statistics. RESULTS: 1,848 out of 4,469 responded to the survey (41%). 86% (n = 1,574) of respondents indicated having served as a full-time clinician (seeing patients at least 70% of the time during a typical week), while many of them serve in leadership such as educational, operational, or command leadership roles. 87% (n = 1,579) of respondents are ranked from O-4 to O-6, and 64% (n = 1,169) of the respondents received a military award or medal. Family medicine, internal medicine, and pediatrics were the most chosen medical specialties, which is similar to the national patterns reported by AAMC. 45% (n = 781) held an academic appointment. CONCLUSION: USU graduates continue to make significant contributions to military medicine. USU graduates' medical specialty preferences are similar to the past, which calls for further investigation to identify driving factors on such preference.

Well-being at a Military Medical School and Implications for Military Retention.

INTRODUCTION: Physical and psychological well-being play a critical role in the academic and professional development of medical students and can alter the trajectory of a student's quality of personal and professional life. Military medical students, given their dual role as officer and student, experience unique stressors and issues that may play a role in their future intentions to continue military service, as well as practice medicine. As such, this study explores well-being across the 4 years of medical school at Uniformed Services University (USU) and how well-being relates to a student's likelihood to continue serving in the military and practicing medicine. METHODS: In September 2019, 678 USU medical students were invited to complete a survey consisting of three sections-the Medical Student Well-being Index (MSWBI), a single-item burnout measure, and six questions regarding their likelihood of staying in the military and medical practice. Survey responses were analyzed using descriptive statistics, analysis of variance (ANOVA), and contingency table analysis. Additionally, thematic analysis was conducted on open-ended responses included as part of the likelihood questions. RESULTS: Our MSWBI and burnout scores suggest that the overall state of well-being among medical students at USU is comparable to other studies of the medical student population. ANOVA revealed class differences among the four cohorts, highlighted by improved well-being scores as students transitioned from clerkships to their fourth-year curriculum. Fewer clinical students (MS3s and MS4s), compared to pre-clerkship students, indicated a desire to stay in the military. In contrast, a higher percentage of clinical students seemed to "reconsider" their medical career choice compared to their pre-clerkship student counterparts. "Medicine-oriented" likelihood questions were associated with four unique MSWBI items, whereas "military-oriented" likelihood questions were associated with one unique MSWBI item. CONCLUSION: The present study found that the overall state of well-being in USU medical students is satisfactory, but opportunities for improvement exist. Medical student well-being seemed to have a stronger association with medicine-oriented likelihood items than with military-oriented likelihood items. To obtain and refine best practices for strengthening engagement and commitment, future research should examine if and how military and medical contexts converge and diverge throughout training. This may enhance the medical school and training experience and, ultimately, reinforce, or strengthen, the desire and commitment to practice and serve in military medicine.