This article reviews the background, scope, equipment, and organization of MM&S, placing particular emphasis on the evolving relationship between Readiness-oriented and Clinical Benefit-oriented training.
The history of medical modeling and simulation is relatively contemporary, but has roots in antiquity. The Greek physician Galen, in the 1st Century, used a monkey model as the basis for his teachings on anatomy and physiology. His teachings were radically transformed when Vesalius, a Flemish physician in the 16th Century, studied human cadaveric models. Moulage, the simulation of wounds, has similarly been used since the early 18th Century, first as wax models. In the late 1950s, the Norwegian toymaker Laerdal first began creating moulage, then shortly after, a life-sized manikin. A proliferation of manikins of varying fidelity has followed from the 1990s to present day. But, in modern medical training, simulation is more than just manikins.
A variety of simulation technologies or platforms are in use currently. Partial task trainers are purpose-specific devices typically used to teach one or a few skills. An example would be a simulated hand for practicing the placement of intravenous (IV) lines. Full-body manikins range in sophistication from plastic and latex shells to highly interactive, computer-driven devices with built in physiology engines that respond to treatment interventions. Standardized patients, scripted actors presenting role-based scenarios, are commonly used in graduate medical education, are the professional counterpart to the untrained soldier-actors in field exercises who are instructed “go crazy when the Doc touches you.” Screen-based simulators range from defibrillators that project a cardiac rhythm to ultrasound training systems to Augmented Reality-driven applied (“serious”) medical games. Even larger systems (and systems of systems), analogous to the command and control simulations used by the Line are being developed. The Joint Evacuation and Transport Simulation system (JETS) is one example in which participants who may be geographically separated may (synchronously or asynchronously) play a role in the medical care, hand-offs, and transportation of a casualty from a battlefield point of injury to a stateside military treatment facility.
Simulation is just one piece of a holistic approach to developing a Ready Medical Force. Real life patient care remains the gold standard for mastery of medical procedural skills, but it is nearly impossible to fully standardize and training errors can bring negative medical consequences to real people. Simulation overcomes these challenges, so MM&S has an increasing role in education and training. Just as the aviation community may desire that the first flight is a perfect flight for a trainee, the medical trainee is expected to “get it right” the first time, ideally every time. Simulation is excellent for first exposure to new skills, for learning the steps in complex procedures, practicing team skills, and learning or refreshing skills on uncommon or rare medical procedures.
Medical modeling and simulation are used in several other contexts, as well. In pharmacy formulary management, modeling is frequently employed to estimate cost: benefit or return-on-investment through Monte Carlo simulations. Additionally, medical operational planners employ modeling of anticipated future battle scenarios based on a myriad of medical and non-medical intelligence sources. Anatomic modeling is used in surgical preparation for medical and dental procedures. These illustrative applications are acknowledged but will not be further discussed in this essay.
Medical modeling and simulation as an education and training modality within Navy Medicine (Budget Submitting Office (BSO)-18, aka BUMED) is currently overseen and supported by a central program office, guided by a Central Simulation Committee. Validated and resourced training requirements may come from a variety of sources (e.g. Fleet Forces, the Surgeon General, etc.) and are intended to drive program development—an application of the Navy Education and Training Command End-to-End process. However, validation and resourcing of requirements often lag behind the practical need for training, so training programs and curricula are developed and launched prior to validated requirements or resources. This reality often promotes a “Tyranny of the Urgent”-type priority system and places systematic program development and standardization at risk (with apologies to Oswalt Chambers).
Conceptually, there are four broad categories of training for which military medical simulation may be a useful training modality—initial technical training; clinical skills sustainment; resuscitation training; and Readiness (or Operational) training. Initial technical training involves the acquisition of new skills—basic Hospital Corps School; C School training; Internship, Residency, or Fellowship; or targeted training for a new discipline-specific procedural skill (e.g. placing a newly-marketed contraceptive device under the skin). Sustainment training involves the refresh and demonstration of currency in skills previously acquired. For example, hospital-based nursing staff must demonstrate proficiency in a series of clinical tasks on an annual basis. Resuscitation training encompasses a blend of initial and sustainment training and includes courses like Basic and Advanced Life Support (BLS, ACLS, respectively). Readiness-training for Navy Medicine includes a series of training evolutions analogous to the Basic Phase of the Optimized Fleet Response Plan (OFRP) for sea-going sailors.
Drilling down further, simulation may be used not only to train, but also to evaluate individuals, teams, or large groups within those categories. Skills Validation for individuals involves the individuals proving that they are capable of meeting the demands of the particular job which they are being assigned. For example, a pharmacy technician filling a Hospital Corpsman 3rd Class (HM3) billet would need to demonstrate the skills involved in dispensing medications safely and managing a deployment pharmacy’s inventory. There is no analogous step in the OFRP, but because of the highly technical and often unique nature of each position on a life-saving medical team, Skills Validation may be instituted in Navy Medicine. Operational Readiness Exercises for deployment platforms are unit level evaluations ranging from small teams (e.g. Role Two Light Maneuverable (R2LM) teams; formerly called Expeditionary Resuscitative Surgical Squads) to large organizations (e.g. Expeditionary Medical Facility-150s; formerly called Fleet Hospitals). For example, an R2LM team might demonstrate proficiency as a team in dealing with a mass casualty event in a simulated environment similar to the locale in which they are set to deploy, analogous to the Fast Cruise of READ-E 4 of the OFRP.
Currently, throughout Navy MM&S, training is predominantly decentralized. Military treatment facilities are organized in a regional tiered-mentorship structure based on extent of graduate medical education offered at each site. However, the variety of simulated training, simulation equipment, and experienced simulation personnel (primarily simulation operators and educators) varies considerably from site-to-site based on the site’s unique mission-set. Funding is a blend of local, central, and grant-based. Further, funding is more typically urgency-based than programmed and predictable. Readiness training is delivered at MTF sites as well as dedicated training centers organized under the Naval Medical Operational Training Command. Finally, more than 60% of Navy medical personnel are aligned under organizations other than BUMED and their training is managed by their sponsoring organization. Much of this paradigm is changing with centralization and standardization of simulation centers’ personnel, curricula, equipment, and funding.
The National Defense Authorization Act of 2017 brought sweeping reorganization to military medicine. Most of the related provisions took effect on or before 01 Oct 2018. In broad strokes, the Defense Health Agency (DHA) was placed in charge of all services deemed related to the Clinical Benefit, including management of military treatment facilities. Additionally, DHA was charged with coordinating joint and shared-services. The Navy, as for the other Services, retained responsibility for service-unique Readiness related training. As part of this reorganization, a Defense Medical Modeling and Simulation Office (DMMSO) was created and aligned under the DHA Deputy Assistant Director/Education and Training (J7).
In August of 2018, DOD Instruction 6000.18 (Medical Modeling and Simulation Requirements Management) was signed with purposes of centralizing, coordinating, and consolidating MMS requirements; and eliminating unnecessary duplication of costs, among other things. DMMSO was charged with aligning MMS requirements processes with the Joint Capabilities Integration and Development System (JCIDS). A DHA Requirements Management System (RMS) was modified to specifically support medical simulation needs.
When a Service program office identifies a new simulation requirement, the need is entered into the RMS. It is categorized as Clinical Benefit, shared/joint service, or Service-unique. If submitted as Service-unique, the DMMSO gatekeeper compares it against known requirements to ensure that no solution already exists and to certify that it should not be a shared/joint requirement. If there is concurrence, the requirement returns to the Service and the requirement solution is funded through Service operating funds (rather than Defense Health Program) after it is passed through JCIDS. This “triage” should take less than a week, exclusive of JCIDS. If a previous solution is identified, the requirement is returned to the Service with a recommendation for the identified solution after it is passed through JCIDS. Should the Service reject the recommended solution, it may pursue development with its own operating funds, if desired. If a requirement is re-categorized as shared/joint, DMMSO consults the Senior Service Requirements Board (functionally, the Directors of each Service’s MMAST program), then routes the requirement based on the anticipated cost of the solution. For solutions with anticipated RDT&E needs below $10 million and Acquisitions needs below $40 million, an approval process internal to DHA J7 is followed after clearing JCIDS. This process takes a minimum of 14 weeks, plus dwell times at JCIDS. For initiatives above these thresholds, approval is sought through Senior Military Health System governance.
Previously validated or recurring requirements will be handled much as they have been prior to the creation of DMMSO, to a point. Simulation activities—whether military treatment facilities, operational training sites, or other organizations—draft requisition documents (e.g. NAVMED 6700/13, Expense Equipment Request, multiple vendor bids, etc.) and route them through their facilities approval chain. Rather than executing the purchase locally, the completed package is submitted through DMMSO. This is important to MTFs, in particular, because the discretionary local funds that have historically been used for a majority of simulation purchases will now be controlled by the DHA rather than the Service. DMMSO coordinates with the Service MMAST then funds are allocated from the appropriate Line of Accounting. This will be relatively straightforward for the Air Force which is coming from a strong centrally-funded paradigm, but more nebulous for the Navy and Army who have previously relied on multiple funding streams. Many of the procedural details have not yet been ironed-out, but a DHA Procedural Instruction is being drafted and will be challenged in the first year of transition when 8 MTFs of varying size and Service pilot the new organizational relationship.
Looking forward, the future is bright. There is already a great deal of cooperation as DMMSO and the Air Force and Navy MMAST programs are co-located and collegial. New collaborations are being developed between the medical and Line simulation communities. Partnerships with industry and academia are also being developed. These all share the goal of modernizing military medical education and training, focusing on the identification and prudent use of appropriate technology to improve acquisition and retention of life-saving skills. A Ready Medical Force will meet the needs and exceed the expectations of the Line that it serves.