Introduction: The narrative feedback medical students receive during their clerkships plays a critical role in developing clinical skills and professional identity. Most existing research on feedback focuses on undergraduate medical education within the civilian sector. The Uniformed Services University (USU) School of Medicine provides a unique environment for training uniformed service members, necessitating the integration of clinical skill development with the professional standards and cultural norms inherent within military medicine. This study aims to examine themes and characteristics in written feedback that military medical students receive during their pediatric clerkship within the Military Health System.
Materials and methods: This is a qualitative, retrospective analysis of written feedback comments (N = 953) provided to military medical students during their pediatric clerkship. An online survey tool prompted preceptors to comment on performance in line with the domains of Professionalism, Reporting, Interpreting, Managing, and Educating (PRIME) and provide one area for growth. De-identified comments underwent thematic and summary content analysis.
Results: Five themes were identified: (1) Evaluating the student as a learner, (2) Evaluating the student as an emerging physician, (3) Cultivating professional characteristics and identity, (4) Praise and encouragement, (5) Scope of evaluation. Comments on performance were longer (mean = 1,013 characters) and more frequently used third person (68.21%). Comments on growth were shorter (mean = 167 characters) and more frequently omitted the subject (62.33%). Only 26.65% of comments applied the PRIME schema.
Conclusions: The language within the feedback comments showed partial alignment to best practices for feedback, particularly with a focus on observable physician and learner behaviors. In addition to the professional characteristics, knowledge, and skills all doctors must develop, this study's themes also suggested a process of expected acculturation to the military system and ethos. Less productive comments regarding personal traits, general praise, and depersonalized critical feedback were still prevalent. The apparent ineffectiveness of current strategies suggests exploration of novel approaches, such as artificial intelligence (AI), to enhance the language used in feedback.
Wartime conditions present major challenges to the timely diagnosis and management of severe aplastic anemia (SAA). We describe 3 previously healthy military service members who developed idiopathic SAA during active duty. In all 3 patients, no chronic illnesses were documented in the medical records, and no specific toxin exposures or prior hepatitis were recorded. All experienced a gradual onset of cytopenias accompanied by hemorrhagic symptoms, initial misclassification as immune thrombocytopenia or myelodysplastic syndrome, and war-related delays to definitive therapy. Each required prolonged transfusion support and broad-spectrum antibiotics for neutropenic complications. Two patients received immunosuppressive therapy (antithymocyte globulin plus cyclosporine A) four to 5 months after diagnosis, while the youngest underwent urgent allogeneic bone marrow transplantation. Despite severe logistical constraints, all survived the acute phase but remained transfusion-dependent at discharge. These cases underscore the need to strengthen medical logistics and ensure early access to specialized hematologic care to improve SAA outcomes during wartime.
Introduction: Fire suppression can result in injury and death, with cardiac events being the leading cause of death of on-duty structural firefighters. Few data, however, are available regarding the physiologic responses to shipboard fires. Therefore, the purpose of this report was to determine physiologic responses of simulated shipboard firefighting tasks.
Materials and methods: Nineteen subjects (age: 24 ± 5 y, V˙O2peak: 44.9 ± 7.2 mL · kg-1 · min-1) performed firefighting tasks in protective garments and breathing apparatus. After completing each task, heart rate (HR), core temperature (TC), ratings of perceived exertion (RPE), and physiological strain index (PhSI) were measured. The tasks began with walking 80 m followed by carrying two 20 kg buckets up and down a flight of stairs. Subjects then completed circuits of lifting, striking, and pulling tasks in an environmental chamber heated to 40 °C, 41% relative humidity. The circuit was repeated until volitional fatigue, or if a stopping criterion was met.
Results: Subjects were in the simulated shipboard firefighting protocol for 1432 ± 516 seconds. All measured variables increased over time (P ≤ .01) and HR, RPE, and TC were different from baseline at all timepoints (P ≤ .04). PhSI was different from baseline starting at circuit 2 (P < .01). Baseline HR was 85 ± 13 bpm and increased to 188 ± 10 bpm at peak exertion (P < .01). Similar changes were seen for TC (baseline: 36.8 ± 0.2 °C, peak: 37.9 ± 0.5 °C, P < .01), RPE (baseline: 1 ± 1, peak: 9 ± 1, P < .01), and PhSI (baseline: 4.0 ± 0.9, peak: 7.2 ± 1.2, P < .01).
Conclusion: Simulated shipboard firefighting tasks caused considerable tachycardia and hyperthermia among subjects completing multiple rounds of work. Future research should consider appropriate work to rest ratios to ensure firefighter safety.
Introduction: Demand for reproductive endocrinology and infertility (REI) specialists has increased with rising utilization of assisted reproductive technology. As a reflection of societal trends, the military medical system has noted increased call for infertility services and specialty-trained expertise. Recent Department of Defense Amendments to the Assisted Reproductive Services Policy reflect an increased utilization of fertility care within our active duty population. Obstetrics and gynecology (OB/GYN) resident physicians are required to complete training in REI, but many report a lack of formalized education while on their REI rotations, and medical students have endorsed decreased interest in the subspecialty with a smaller proportion of represented research. We aimed to develop a case-based REI curriculum for resident physicians and medical students that fulfills national, standardized objectives and assess if the curriculum increases confidence in managing REI conditions.
Materials and methods: After receiving exemption from our institution's IRB (protocol number DBS.2023.598, reference 964364), we developed a curriculum using a needs assessment completed by OB/GYN residents in March 2023 who had previously rotated on REI at our institution. A panel of experts wrote the curriculum, which used clinical cases to convey national recommendations and fulfilled learning objectives per the Council on Resident Education. We implemented the curriculum from July 2023 to July 2024 and compared learners' confidence in diagnosing and managing commonly tested REI conditions using the Wilcoxon signed-rank test. We compared needs assessment responses to post-curriculum responses using the Mann-Whitney U test.
Results: Fourteen prior learners completed the needs assessment (response rate 73.6%), all 15 new learners completed the pre-curriculum survey, and 13 of the 15 completed the post-curriculum survey (response rate 86.7%). The curriculum improved the reliability of weekly structured didactics (28.5%-100%) and increased interest in REI grew (28.5%-53.8%). Following curriculum implementation, participants who felt "fairly confident" diagnosing and treating every tested REI condition increased, including amenorrhea (13.3%-84.6%, P < .01), androgen excess (0.0%-69.2%, P < .01), recurrent pregnancy loss (6.67%-76.9%, P < .01), infertility (13.3%-69.2%, P < .01), premenstrual dysphoric disorder (20.0%-53.8%, P = .03), primary ovarian insufficiency (6.67%-53.8%, P < .01), and Mullerian anomalies (6.67%-23.1%, P = .01).
Conclusions: A case-based curriculum improved learners' confidence in diagnosing and managing REI conditions. This curriculum fulfills national learning objectives and can be implemented at medical programs without an REI division. Meeting the rising demand for REIs starts with robust education.
Introduction: Discharged military medics and corpsmen historically have not had well-defined avenues to use their skills within the civilian licensed healthcare sector, although the Defense Health Agency (DHA), the Veteran Administration (VA), as well as most states, face significant shortages of registered nurses (RNs). Highly trained military medics and corpsmen with health care and leadership skills are ideal candidates to become professional nurses. Innovative Veteran to Bachelor of Science (VBSN) programs are available and critically important to increasing the pool of diverse nursing applicants.
Materials and methods: Faculty, with 2 successful university VBSN programs for over 10 years, retrospectively provide information about their medic and corpsmen students, presenting creative curricular strategies, unique challenges, and specific entry and exit data. For this Brief, university and faculty records, including student anecdotal remarks were reported.
Results: In 10 years, 348 medics have graduated with first-attempt NCLEX (91.5%) and overall NCLEX (99.7%) pass rates exceeding national levels. Approximately one-third of all graduates have completed or are pursing graduate education, as well as similar numbers have returned as commissioned officers in their respective nurse corps branches to further their military service, demonstrating a yield to an initial military investment.
Conclusions: Valuable information from 2 universities with innovative civilian academic nursing programs for military medics and corpsmen, reveals the laudable amount of VBSN students' success to becoming RNs. Encouragement and guidance from military healthcare leadership is both needed and important when counseling medics and corpsmen seeking enrollment within these Veteran-specific nursing programs.
Introduction: The United States Air Force's (USAF's) Critical Care Air Transport (CCAT) capability has faced significant readiness challenges due to declining operational experience from decreasing global deployments since 2010. This experience erosion-the "Walker Dip"-is compounded by the loss of subject matter experts needed to lead unit sustainment training, further heightening the risk of patient morbidity and mortality in future large-scale conflicts. To bridge this readiness gap, we aimed to identify and synthesize best practices of the train-the-trainer (TTT) model from the literature to inform the development of a CCAT educator course.
Materials and methods: We conducted a narrative review of the literature on TTT programs, querying PubMed and CINAHL for articles published from 2001 through January 2025, using the terms "skills and train-the-trainer," with a focus on content relevant to CCAT training and skills sustainment. Guided by the research question of current best practices, we reviewed and synthesized data from 37 relevant articles, including 4 systematic reviews. Thematic analysis was employed iteratively to identify and refine best practices.
Results: The review identified 29 best practices organized across seven core themes: Program Development, Implementation, Learning Competencies, Instructional Methods, Evaluation, Educator Toolkit, and Community of Practice (CoP).
Conclusion: Our synthesis offers an evidence-informed cohesive framework spanning the life cycle of a TTT program, from design through longitudinal implementation, addressing sustainability concerns. Key elements for success included stakeholder support, learning competencies, experiential hands-on practice, educator toolkit, and CoP. Future studies should compare program components, evaluate the optimal blend of methods, explore virtual options, and assess long-term system impact. By applying best practices to developing a CCAT educator course, we aim to empower local units to deliver critical sustainment training and close the operational readiness gap across the USAF enterprise, saving lives and bringing heroes home.
Introduction: The limb symmetry index (LSI) is a common tool for evaluating functional performance across a variety of populations. An LSI of ≥90% is a common, generally accepted clinical threshold for patients with musculoskeletal injuries to achieve before returning to activity. This study's aims were to: (1) describe normative symmetry characteristics and evaluate the influence of sex and limb dominance during functional tasks in healthy, entry-level U.S. Marines, and (2) describe the relationship between symmetry performance across all functional tasks.
Materials and methods: This was a cross-sectional study including 651 active duty U.S. Marines with no current injuries (187F/464M, 19.9 ± 2.4 years, limb dominance 59L/592R, 4.8 ± 3.2 months of service). Limb dominance was defined as the preferred limb to kick a soccer ball. Participants completed 5 repetitions of bodyweight bilateral squats and maximal effort vertical jumps using a natural arm swing. Peak eccentric and concentric force (N) were recorded bilaterally on dual force plates for the squat and jump. Participants completed an isometric midthigh pull (IMTP) by standing atop force plates with their knees and hips flexed at approximately 40-50° and 35°, respectively. A fixed bar was positioned at the midpoint between the hips and knees. Participants pulled up as hard and as fast as possible and held a maximal effort for 3-5 seconds for 3 repetitions. Peak vertical force (N) was recorded bilaterally. Force values were normalized to participants' body mass (N/kg). Limb symmetry index was calculated as nondominant limb/dominant limb*100%. Independent sample t-tests determined significant differences in LSI force variables and sexes. Paired t-tests evaluated significant differences in loading between dominant and nondominant limbs. Effect sizes were evaluated via Cohen's d values. Pearson correlations coefficients (r) described the relationship between all dependent variables across all tasks.
Results: Across all tasks and variables, there were no differences in LSI values across sexes (P > .05). Regardless of sex, participants loaded more of their body mass on their dominant limb compared to their nondominant limb with weak-to-small effect sizes (d: 0.22-0.34). Squat LSI had a weak-to-moderate positive relationship with LSI during the vertical jump (r: 0.13-0.69). No other significant relationships were observed (P > .05).
Conclusions: Our study provides stakeholders (e.g., military personnel, clinicians, researchers, etc.) normative ranges of LSI performance values during a bodyweight bilateral squat, vertical jump, and IMTP tasks in a large healthy active duty population. Sex does not appear to influence LSI performance; however, limb dominance may influence loading patterns during these specific functional tasks. Given the similarities between the squat and vertical jump performance, future work sh
Introduction: Insomnia is a significant yet underrecognized concern among U.S. service members (SMs), with broad implications for health, performance, and operational readiness. Prior prevalence estimates of insomnia vary widely, often because of inconsistent definitions, measurements, and study designs, which limits clear interpretation in the absence of pooled estimates. Sex-specific prevalence has also been reported in primary studies; however, findings remain mixed and inconclusive without pooled estimates. Branch-specific data are even more limited and can therefore only be synthesized descriptively. Unlike previous reviews, no meta-analysis has estimated insomnia prevalence solely on U.S. SMs and disaggregated by sex, leaving a critical gap in understanding within the military. Therefore, this systematic review and meta-analysis aimed to estimate the overall and sex-specific prevalence of insomnia in SMs and describe available data by service branch.
Materials and methods: This review followed PRISMA 2020 guidelines. PubMed, EMBASE, APA PsycINFO, and CINAHL were systematically searched for studies published between January 2016 and October 2024. Eligible studies reported insomnia prevalence in U.S. military populations. Meta-analyses were conducted in R using a random-effects model to account for between-study heterogeneity.
Results: Eight studies met inclusion criteria, comprising 3 cohort and 5 cross-sectional designs, with insomnia sample sizes from 49 to 66,869 participants. The pooled prevalence of insomnia was 18% (95% CI, 0.11-0.29, P < .001, I2 = 99.9%). Sensitivity analysis yielded a slightly higher prevalence of 23% (95% CI, 0.18-0.29, P < .001, I2 = 99.9%). Sex-specific subgroup analysis revealed female SMs had higher odds of insomnia than males (OR = 2.05, 95% CI, 1.12-3.76, P < .001, I2 = 98.7%), supported by sensitivity analysis (OR = 1.44, 95% CI, 1.36-1.54, P = .91, I2 = 0%). Branch-specific meta-analysis was not feasible because of limited data.
Conclusions: This review begins to address the gap by providing prevalence estimates of insomnia among SMs by narrowing wide-ranging prevalence estimates to a pooled range of 18-23% and demonstrating higher odds among females compared to males. Findings provide a more precise epidemiologic estimate and highlight the need for standardized insomnia measurement tools, expanded and consistent sex- and branch-specific research, and the incorporation of occupational and contextual factors. Addressing these gaps is critical to inform health planning and to support future sex- and branch-specific efforts to optimize readiness across the U.S. military.
Fungal and amoebic keratitis are rare but serious infections that can lead to significant vision loss and are often difficult to diagnose promptly, particularly in resource-limited environments. Although conventional cultures and PCR have notable diagnostic limitations, in vivo confocal microscopy (IVCM) offers rapid and accurate pathogen detection. This retrospective case series examines four cases of infectious keratitis in deployed military personnel, highlighting the diagnostic and clinical utility of IVCM. All patients were young males, with a mean age of 29.75 years. Half had a history of improper contact lens use, although the others sustained ocular trauma from plant material. Corneal cultures performed in the field were uniformly negative, underscoring the limitations of traditional diagnostics in austere settings. In contrast, IVCM performed after the patients were repatriated enabled timely identification of filamentous fungi and amoebic cysts, allowing for targeted antimicrobial therapy. Patients experienced prolonged hospitalizations (mean: 2 months) and extended treatment courses (up to 9 months), with three undergoing amniotic membrane transplantation. Early diagnosis using IVCM contributed to the prevention of severe complications such as corneal perforation and endophthalmitis. These findings support the role of IVCM as a critical diagnostic modality in managing complex corneal infections when conventional microbiological tools are unavailable or insufficient.
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