Surgical readiness in the Military Health Service is fraying fast. A nine-month U.S. News investigation has uncovered mounting evidence that military medical leaders are squandering a valuable wartime asset: the surgeons and surgical teams that save lives on the battlefield and back home.

The investigation is the latest chapter in a continuing U.S. News probe of military health care . Interviews with more than two dozen active-duty and retired military surgeons and a confidential survey of Army surgeons and Pentagon records obtained by U.S. News have found:

Severe shortages of skilled surgeons, especially trauma surgeons, on active duty and in the reserves.

Army field hospitals that "are not staffed with appropriate specialty capabilities for a combat theater."

An active-duty patient population that rarely needs surgery, with the end result that in the majority of the nation's 48 military hospitals, surgeons struggle to practice their craft. Many moonlight in civilian hospitals to keep their skills from eroding.

Lengthening deployments that keep surgeons out of the operating room for months at a time, sapping hard-earned and highly perishable surgical skills.

The documents reveal that members of the military's Joint Trauma System and other military medical leaders repeatedly warned Pentagon officials, including former Surgeon General Nadja West, about the crisis in surgical care. West could not be reached for comment.

West retired in December according to the Army and her deputy, Maj. Gen. R. Scott Dingle, was appointed in July to replace her. The Senate confirmed his appointment in September. Unlike previous surgeons general, Dingle is an administrator with no medical degree or clinical experience. He is out on emergency family leave and could not be reached for comment, Army public affairs officer Maura Fitch said.

Each year, the Military Health System invests $50 billion annually in a network of hospitals and clinics to serve the routine health care needs of healthy, young, active-duty personnel, their families and some retirees.

The military justifies the expense of funding the MHS by asserting it provides a training ground for military health personnel to hone their skills until they're needed on the battlefield.

The U.S. News investigation indicates that the reality is often the opposite of what is intended: military hospitals sap surgeons' skills because most surgeons spend so little time in the operating room.

Civilian surgeons at busy medical centers may perform as many as 500 operations per year; military surgeons perform one fifth of that number, and, in many cases, even fewer, according to published studies of surgeons' case logs.

The situation is so dire that many surgeons view the military hospitals where they're assigned as a form of confinement where they watch their training – which costs taxpayers approximately $500,000 per surgeon – atrophy. Deployments , months spent in austere conditions often doing little or no surgery, are even worse.

Congress has accepted the Pentagon's assurances that military hospitals can keep surgeons' skills fresh. House Armed Services Committee staff, briefed on the U.S. News findings, did not respond to a U.S. News request to interview the group's chairman, Rep. Adam Smith (D-Wash), or other committee members. Smith did not respond to a request for an interview conveyed to him via his Twitter account.

Surgeons and other trauma care specialists are among the harshest critics of the current system and its failure to ensure that military medical teams are prepared to care for wounded warriors. A military that is ill-prepared and ill-equipped to perform surgery, they say, can't fulfill its solemn promise to provide life- and limb-saving care to those who are injured serving their country.

So many Army surgeons have become disenchanted with their military careers that "a surgeon insurgency is building," one says in an email obtained by U.S. News. To gather information firsthand, U.S. News reached out confidentially to approximately 140 U.S. Army surgeons.

Almost two dozen responded, providing detailed information on their surgical caseloads and experiences. The respondents answered a set of standard questions and most agreed to be interviewed. They spoke to U.S. News on condition of anonymity, asking that their identities be withheld to guard against retaliation from superiors.

In frank comments, surgeons shared serious concerns about the state of military surgery, about the complacency of commanders, and about the lack of awareness among young combatants who believe that, if they're wounded, they'll be well cared for.

"Parents who send their kids to war should be worried about the care they'll get if they're wounded," says one Army surgeon who has cared for scores of injured combatants. "I would be."

"These 20-year-old kids think they're getting top-notch care," says another. "They're not. And it's nobody's fault but the Army's."

The Surgeon Pipeline Is Running Dry

At latest count, of the 4,500 physicians in the Army, just two dozen are trauma surgeons. (Joe Raedle/Getty Images)

The U.S. military fields 1.3 million active duty troops, with another 865,000 in reserve. Surgeons, and the teams they lead, are combatants' best hope of surviving catastrophic injuries.

Combat casualty care depends on expert surgery performed hundreds of miles from sterile, high-tech operating rooms. Military surgeons operate in small teams under challenging conditions, often in tents or hovels without running water or bright light.

Skilled surgeons are essential for high-quality trauma care. They can definitively treat severe injuries – stop the bleeding, cut away damaged or infected tissue, extract bullets or bomb fragments, manage complex wounds and debride burns, especially in such critical areas as the head, neck and torso. Military surgeons are famed for improvising new procedures in challenging settings that revolutionize civilian medicine.

To achieve those gains, the military needs a reliable pipeline of skilled surgeons, technicians and nurses. But, in the all-volunteer military, surgeons are in short supply – and caught in a tug of war between military hospitals that need their services stateside and combat commanders who need them to care for troops who fight wars.

Vice Admiral Raquel Bono, who retired in August as director of the Defense Health Agency, which governs military hospitals, told U.S. News that the military's surgical crisis is exacerbated by a private-sector surgeon shortage that will make it difficult, if not impossible, to fill gaps by recruiting civilian surgeons. "We're very much a microcosm of what's happening in the rest of the health sector in the United States," Bono says.

"These 20-year-old kids think they're getting top-notch care. They're not. And it's nobody's fault but the Army's."

It has also proven difficult to entice qualified applicants to enlist and train at the military's medical school, the Uniformed Services University of the Health Sciences, despite the rich rewards of enlistment, which include free medical school tuition while earning a modest military salary; specialty training either in a military or civilian hospital; and the promise of a generous pension.

At latest count, of the 45,000 members of the Army's medical force, just two dozen are trauma surgeons. Some are eligible to retire in the coming months, according to the latest count by the Army’s surgical consultant to the surgeon general, Department of Defense sources said. There are fewer than 150 general surgeons, only 75 of whom are available for deployment.

In an effort to bolster the ranks, the Army has shunted 23 general surgeons into trauma-training fellowships at Brooke Army Medical Center, the military’s level one trauma center, and other hospitals, including University of Texas Health Sciences Center, Vanderbilt School of Medicine, University of Minnesota Medical School and the University of California, San Diego, Medical School.

When they complete their training, a handful will likely be assigned to Brooke, where they will continue to perform trauma surgery. Many others will be assigned to combat units, where they will do very little surgery, says a battle-tested surgeon, who asked that his identity be withheld to avoid retribution from superiors. Wherever they land, he says, “They’re all going to be young and inexperienced.”

There will also most likely be a shortage of senior surgeons to guide them, according to data published last year in the Journal of the American College of Surgeons. By the end of the year, the active-duty military is likely to lose half the current corps of senior surgeons to retirement and separation of service. Surgeons say their number one reason for leaving the military is their "loss of operative skills" and their concern that they won't be able to maintain their "surgical competence," the authors note.

Bono, recently retired from DHA, acknowledged that the surgeons' criticisms are valid. "I share the concerns the surgeons have shared with you," Bono says. "In their current configuration, military treatment facilities don't lend themselves...to giving surgeons the volume, diversity and breadth (of experience) that surgeons are looking for."

The shrinking pool of surgeons means that those that remain will shoulder a heavy deployment load. At any given time, half of all Army surgeons are deployed, says Dr. Matthew Martin, a trauma surgeon at Scripps Mercy Hospital in San Diego. Martin retired from the Army in October 2018 after a decade as medical director and chief of surgical research at Madigan Army Medical Center near Tacoma, Washington.

"There are fewer than 100 deployable surgeons in the Army now, and we have (fewer than) 50 deployment slots," he says. "That's a higher deployment pace than at the peak of the wars in Afghanistan and Iraq."

All three ranking surgeons in the military's Joint Trauma System have become so concerned with the Army's failure to address the surgeon shortage that they documented their assessment in a "memorandum of record" obtained by U.S. News.

"There are currently not enough general or trauma surgeons in the U.S. Army to support global contingency missions," according to the memo signed in June 2018 by Army Col. Jennifer M. Gurney, Air Force Col. Stacy A. Shackelford and Navy Capt. Zsolt T. Stockinger.

Why don't more surgeons leap at the opportunity to obtain a no-cost medical education and repay their debt by serving their country?

Col. Jason Hiles, MD, general surgery consultant to the Army Surgeon General, offered this explanation in a Feb. 19, 2019 update on coming changes to Army surgery for his fellow surgeons:

"I cannot get a single [surgeon] to assist recruitment command in recruiting general surgeons. Nor can I make myself do it," Hiles wrote in the memo obtained by U.S. News. "How can you recruit people to not operate and deploy where they will not operate?

"Surgeons who have operative experiences," he continued, are "rare as unicorns."

Hiles did not respond to requests for comment.

The surgeon shortage has already manifested during wartime.

During Operation Iraqi Freedom, U.S. Army Gen. Peter Chiarelli found himself waging a separate and unexpected battle to stop the Army from recalling one of two U.S. neurosurgeons in Iraq. It was July 2004, and the battle for Sadr City was raging.

Chiarelli's men were suffering devastating head injuries from the enemy's latest weapon of choice, improvised explosive devices. Soldiers with traumatic brain injuries need expert care that only neurosurgeons can provide. But the Army had other priorities.

"I went crazy," says Chiarelli, now retired from the military and an adviser to the George W. Bush Presidential Center. "I fought to keep two neurosurgeons there. The day I left the country, they went down to one. That's when I realized we had a problem." Without another neurosurgeon, Chiarelli says, more men would die or risk suffering lasting brain damage.

Surgeon Shortage Grows as Threat of Conflict Rises

Iranian oil tanker Grace 1, which was seized by authorities leading to further tension between the U.S. and Iran, is seen off the coast of Gibraltar on July 6, 2019. (Jorge Guerro/AFP/Getty Images)

The erosion in military surgery comes at a perilous moment. Turkish forces, on Wednesday, attacked Kurdish troops. Tensions with Iran, Russia, China and North Korea are rising. The NATO Alliance is under unprecedented stress. Provocations like the recent drone strike on the Saudi oil field and missile attacks on tankers in the Gulf of Oman in June could quickly flare up into conflict and, then, conflagration. Sri Lanka's Easter church bombings, and countless other incidents, demonstrate that the war on terrorism is anything but won.

"Conflict with one of the great powers, Russia or China, would produce lots of casualties. Near their homelands they can challenge us quite severely," says Col. (Ret.) Mark F. Cancian, a 37-year Marine Corps veteran and national security adviser at the Center for Strategic and International Studies in Washington, D.C. "North Korea is also clearly very dangerous; (and) it would be very easy to imagine some incident sparking a confrontation with Iran."

Military planners say these conflicts could be far more savage than those experienced during the wars in Iraq and Afghanistan. They will likely also be fought on much more challenging terrain.

"The next battlefield is going to be unlike anything we've seen in the past 18 years," says Michael Heimall, a former Army officer who served as director of the Walter Reed National Military Medical Center in Bethesda, Md., from 2015 to 2017. "We've had the real luxury of taking the capabilities of places like Walter Reed and Landstuhl (Regional Medical Center in Germany) into large bases in Iraq and Afghanistan. We've brought the modern medical center to the battlefield.

"Because of air superiority, we've had the ability to fly wherever we want, whenever we want, to move people around rapidly on the battlefield and also out of theater," Heimall says. "A critically wounded patient could leave the battlefield and be back at Walter Reed Medical Center in 96 hours or less sometimes."

"We likely won't have that luxury on a battlefield in Eastern Europe, the Balkans, Africa, or the Pacific Rim, when near-peer competitors [such as China and Russia] are involved," he says.

With unrest escalating worldwide, experts say, the U.S. Military Health System must be ready to deal with the carnage that is likely to occur in even a limited conflict. The improvised explosive devices that were the terrorist's weapon-of-choice in Afghanistan and Iraq may cause catastrophic injuries, but their range is limited, affecting only those within the blast radius.

In contrast, high-tech weapons such as the thermobaric bombs deployed by Russia in Syria – which use oxygen as fuel and ignite the atmosphere – can devastate hundreds or thousands. A nuclear conflict with North Korea or Iran would produce unimaginable suffering and destruction, Cancian says.

"We're facing a level of threat and casualty generation that's orders of magnitude greater than anything the military dealt with in Iraq and Afghanistan," says one leading Pentagon expert, who, like most active-duty and Department of Defense personnel, agreed to speak on condition of anonymity.

Surgery as a Weapon of War

The uniform of a U.S. Army soldier lies on the floor of the trauma ward at Kandahar Air Field, Afghanistan in 2010. (Chris Hondros/Getty Images)

America's allies, including the NATO member nations, depend on the U.S. for a range of medical services essential for any military exercise, from providing medical infrastructure to evacuating and hospitalizing wounded combatants.

"Over 50% of the medical support for most NATO missions is provided by the U.S.," says Maj. Gen. Jean-Robert Bernier, M.D., who retired from the Royal Canadian Medical Service last year after chairing the NATO committee of chiefs of military medical services.

Knowing they'll receive world class care if they're injured is a critical morale builder for the troops, Bernier says.

"Any military leader who has been in combat knows that [the promise of prompt and high-quality medical care] has a massive impact on the morale of troops and their willingness to fight and take risks in combat," says Bernier, speaking on his own behalf and not that of the Canadian military or NATO.

Combatants might be less inclined to wade into the fight if they were aware of the surgeons' concerns about their own lack of readiness and atrophying skills.

"I could definitely use refresher training in trauma," one surgeon responded to the U.S. News survey. "It has now been eight years since I have really seen any volume of trauma patients. It is a skill-set that needs to be maintained."

Some surgeons fear that they do so little surgery that they will be unemployable when their service obligation ends.

To the question, "Do you feel that you can maintain your skill set on active duty when you're not deployed?" one surgeon answered: "No. I only do one to three basic general surgery cases a week."

Asked, "Do you believe your surgical volumes will affect your ability to obtain civilian employment when you separate from service?" the surgeon responded, "Yes. As of now there's no way I could be employed outside the Army."

Combatants at Risk From Their Surgeons

A U.S. Army flight medic rushes into the dust out of a medevac helicopter in the Helmand Province of southern Afghanistan in 2011. (Kevin Frayer/AP)

The surgeon shortage also has profound implications for the way care is provided in conflict zones, by forcing the military to fill vacancies in Army Field Hospitals with OB-GYNs and other specialists with little training in combat trauma care.

Those vacancies have become all the more common, because the military now routinely deploys small teams of doctors, nurses and other personnel with special operations forces working in remote regions. The goal is to get wounded personnel into a surgeon's hands within an hour – the so-called "Golden Hour" – to improve survival.

In large conflicts, the military assembles modular 250-bed combat support hospitals near enough to the fighting to receive casualties from medics close to the front.

But as the nature of warfare changed, from clashing armies to targeted Special Forces engagements, the hospital units have been downsized as well, some of them to just 32 beds.

Standard 20-person forward surgical teams, with three or four surgeons, plus assorted anesthetists, nurses and operating-room technicians, have likewise been pared down. A typical configuration is a 32-bed field hospital staffed with four surgeons and an anesthetist.

Typically, two doctors are general surgeons and one is an orthopedic surgeon. Much to the trauma surgeons' chagrin, the team's fourth member can be an OB-GYN, capable of delivering babies and managing bleeding but ill-trained to save lives or salvage limbs.

"No OB-GYN takes trauma call at a level I trauma center. That's not what they do for a living," says Dr. John Holcomb, director of the Memorial Hermann Texas Trauma Institute and former head of the U.S. Army Institute for Surgical Research. "Why is that okay on the battlefield?"

The surgeons leading the Joint Trauma System contend that the Army Field Hospital staffing guidelines are ill-conceived. In 2016, they issued a formal Position Statement on the Specialty Capability of the Army Field Hospital.

"While OB-GYNs have a role in deployed field hospitals (primary care, female health)," the statement says, "it is not primarily in the management of combat injured requiring surgical care."

Orthopedic surgeons, in contrast, are "mission critical," the surgeons say, and they back their assertion with data. Between 2002 and 2014, surgeons performed 25,218 orthopedic procedures – including 8,347 amputations – at forward surgical facilities. More than 82% of casualties returning from Afghanistan and Iraq had an orthopedic injury.

"Here's the game they play," says one high-ranking Army combat care specialist. "A gynecologist counts as half a surgeon. Put two gynecologists together, and, in Army math, that makes a trauma surgeon. Who do you want operating on you when your spleen is broken – one surgeon or two gynecologists?"

Such substitutions are routine, says Martin, formerly of Madigan medical center. "They have to fill those slots, so they put other specialties in," he says. "It's a paper game."

In fast-moving special operations missions, forward surgical units are subdivided even more, to four- or five-person "austere surgical teams" made up of a surgeon, an anesthetist (often a trained, certified registered nurse), an OR nurse and another nurse or medic.

It takes a certain kind of surgeon to operate out of a backpack, solo. Experts say these surgeons should be highly experienced and accustomed to working in challenging settings."We take young graduates just out of training and they get the far-forward deployments," says the combat trauma care specialist. "They put you in a dugout with half the people and half the backup."

Military surgical leaders have also warned that downsized forward surgical teams often pair out-of-practice older surgeons with newly trained younger surgeons in situations where they may be required to juggle several soldiers with catastrophic injuries at once, without sufficient support.

In one published case report , an Army surgeon offers his own experience as a tragic lesson in what can go wrong. The surgeon had been assigned to a Forward Surgical Team a two-hour drive south of Baghdad with one other surgeon. Suddenly they found themselves caring for four soldiers with catastrophic wounds caused by an improvised explosive device.

"So here I am, three years out of residency, used to taking calls two to four times a month at a relatively slow, level II trauma center," the surgeon said. "In that time, I had performed maybe four or five blunt-trauma related operations…and only a few penetrating trauma cases from Afghanistan. Now I had to simultaneously care for four wounded, multi-system trauma patients with one other surgeon, who was less than a year out of residency."

Not realizing that the soldiers could have been transferred to a bigger hospital 17 minutes away by air for more definitive care, the surgeons did their best to repair the damage, according to the account in a 2016 report on "Essential Medical Capabilities and Medical Readiness" by the Institute for Defense Analysis.

Their decision, the surgeon says, cost precious time – and one patient a leg. Had the surgeons responded differently, amputation might have been avoided.