Sherri L. Rudinsky

Introduction: Military medicine in armed conflict presents unique ethical challenges, especially under the resource constraints and extended evacuation timelines anticipated in future large-scale combat operations. Currently, there is no standardized military medical ethics (MME) curriculum within U.S. military Graduate Medical Education (GME) programs, leaving a significant portion of the medical force unprepared for high-intensity conflicts and at increased risk of moral injury, thereby compromising operational readiness. The purpose of this study was to characterize the current landscape of MME training within U.S. military GME, identify critical educational gaps, and establish an expert-driven consensus framework to inform the development of standardized curricula. Materials and Methods: This study utilized a sequential, multi-method design incorporating an exploratory survey and a modified Nominal Group Technique (mNGT). First, a convenience sample of military GME Program Directors across the Military Health System (MHS) completed an online survey evaluating current MME training. Second, an mNGT session was conducted virtually with a purposively selected panel of 9 current and former Program Directors representing seven medical specialties. The mNGT addressed three focus questions prioritizing core topics, teaching methods, and implementation barriers. Quantitative ranking data were analyzed using the Borda Count technique, and inter-rater agreement was assessed using Kendall’s Coefficient of Concordance (W). Qualitative data from transcripts were analyzed using thematic analysis. Results: The exploratory survey (n = 41) revealed that 39% of respondents’ programs lack a formal MME curriculum, and existing instruction relies heavily on passive lectures, frequently omitting military-specific topics such as dual loyalty and Medical Rules of Eligibility. For curriculum content, the mNGT panel achieved significant consensus (W = 0.63, P < .001), ranking principlism and dual loyalty as top priorities. Qualitative themes highlighted dual loyalty as the defining overarching construct of MME. For pedagogy, the strongest consensus was observed (W = 0.76, P < .001), decisively favoring active, blended strategies like small group case discussions and simulation-based learning over passive instruction. Regarding implementation obstacles (W = 0.33, P = .02), a lack of faculty expertise in MME and a scarcity of curated resources were identified as primary barriers, compounded by an apprehension surrounding sensitive operational topics. Conclusions: The operational realities of contemporary warfare demand that military healthcare professionals possess ethical readiness before deployment. This study presents a framework for integrating ethical competence as a core operational readiness capability longitudinally throughout military residency and fellowship training. Key implications suggest that structuring curricula around ethical reasoning and dual loyalty will better prepare providers to navigate extreme operational environments. To operationalize these findings, future initiatives should focus on creating a centralized, peer-reviewed repository of operationally relevant case materials, executing deliberate faculty development programs, and cultivating a psychologically safe learning climate to eliminate the culture of apprehension. Future research must evaluate how these curricular strategies influence longitudinal outcomes, such as ethical reasoning performance, decision-making confidence, and moral resilience, while exploring how frameworks adapt across diverse specialties and interprofessional teams.

Introduction: As military operations increasingly rely on coalition partnerships, interoperability has become a core competency for medical readiness. Traditionally emphasised in postgraduate or deployment settings, earlier integration of interoperability-focused training in undergraduate medical education (UME) may better prepare physicians for coalition environments. Simulation-based education (SBE) offers an effective platform for developing shared understanding, communication, and trust within multinational teams, with multinational faculty informing best practices in programme design and implementation. Methods: We conducted a qualitative phenomenological study exploring faculty perspectives on multinational SBE during a large-scale, high-fidelity military training exercise. Faculty from multiple North Atlantic Treaty Organization partner nations participated in semistructured interviews and focus groups conducted during or shortly after the exercise. Transcripts were analysed using inductive thematic analysis to identify patterns related to learning outcomes, interoperability and coalition readiness. Results: Four themes emerged: enhanced cultural competence, development of a common operating picture, increased interoperability and a positive outlook on international collaboration. Multinational SBE promoted shared professional identity, reduced cultural and communication barriers and supported development of non-technical skills, including communication, situational awareness and decision-making under pressure. Interoperability was described as extending beyond equipment compatibility to include procedural alignment, shared cognition and mutual trust. International faculty were essential for modelling best practices, identifying operational frictions and supporting curricular transfer across institutions. Conclusions: Multinational SBE is a key enabler of military medical training, fostering competencies required for effective coalition performance. Early integration of interoperability-focused training in UME, supported by international faculty engagement, may strengthen readiness, reduce operational friction and enhance global health security.

Implication Statement Augmented reality (AR) telementoring offers a novel approach to delivering real-time procedural instruction to learners in remote and austere environments. By enabling faculty to annotate a learner’s field of view, overlay visual guides, and provide live audio coaching, AR can extend the reach of procedural training without requiring in-person presence. In this pilot, we demonstrate the feasibility of AR telementoring for visually guided, tactile procedures such as escharotomy, while highlighting important challenges for complex, image-dependent tasks such as ultrasound-guided central venous access. With intentional alignment between procedure type and technological capabilities, AR telementoring may help reduce instructional inequities across geographically dispersed medical education sites.

Introduction: Peer role-playing, in which medical students alternate between provider and patient roles, is a core component of peer-assisted learning. While the educational value of playing the provider is well established, the extent to which students gain medical knowledge through acting as patients remains unclear. Methods: In this quantitative study with qualitative components, 178 first-year medical students portrayed patients during a high-fidelity prehospital simulation. Medical knowledge was assessed with a 21-item multiple-choice test after simulation (162 responses; 91.0% response rate). An open-ended reflection prompt captured students' perceived learning. Chi-square analyses compared knowledge performance between students who portrayed a given scenario (“Actors”) and those who did not (“nonactors”). Qualitative data were analyzed using reflexive thematic analysis. Results: Quantitative analysis revealed no statistically significant differences in performance between actors and nonactors across test items ( P = 0.17–0.99). However, 160 students (89.9%) reported perceived gains in medical knowledge. Thematic analysis identified 3 primary learning mechanisms: observational learning, experiential learning, and direct instruction. Conclusions: Although knowledge gains specific to patient roles were not captured through multiple-choice testing, students perceived substantial learning through peer role-play. The student-as-patient role may be intentionally designed to support cognitive as well as affective learning in simulation-based medical education.

Ensuring proficiency in responding to, evaluating, and treating chemical, biological, radiological, and nuclear (CBRN) casualties is a critical component of military medical student education. To meet this objective, we developed a case-based CBRN curriculum that can serve as a model to address potential curricular gaps for civilian prehospital, UME, and GME programs. The curriculum was administered in two sessions, 1 month apart, each with individual student preparation, including an optional asynchronous online module and a review of clinical practice guidelines. Session one consisted of a 2-hour introductory lecture, followed by a student reflection. Session two consisted of a 1-hour small-group case study, designed as a multimodal exercise with a corresponding computer-based worksheet and knowledge check. Forty-five teams consisting of three to four second-year medical students (N = 170) completed the sessions and course survey. Sixty-four percent of student teams were extremely or quite satisfied with what they learned, 62% found the materials very or quite relevant to their needs, and 69% rated the instructional materials as extremely or quite understandable. Student feedback included designating additional time for worksheet completion. A case-based training on CBRN patient care earned positive ratings for the clarity of instruction, the impact on students as learners, and the feasibility of the training. Future training evolutions could track student completion of prework, extend the allotted time for activity completion, and evaluate curricular effectiveness through pre-post measurement of students' confidence in their ability to care for a CBRN patient.

Introduct ion: The demands of future large-scale combat operations may require medics and corpsmen to increasingly perform expectant casualty care (ECC). However, no detailed guidelines currently exist for providing ECC within military medicine. To guide the development of education and training guidelines and advance team training of both medics and non-medics, an in-depth understanding is first needed regarding caregivers’ experiences providing ECC in recent conflicts as well as perceived training gaps. Therefore, this study explored the experiences of medics and physicians providing ECC and investigated their perceptions of training needs in this area for future conflicts characterized by large-scale combat operations and prolonged casualty care operational settings. Materials and Methods: We conducted an engaged qualitative phenomenological study to explore ECC training needs for future conflicts. We interviewed 9 senior health care professionals (medics and physicians) who had extensive combat and deployment experiences and served primarily in the Role 1 environment. The interviews averaged 45 min each and were conducted via phone. To analyze this interview data, we reviewed the interview transcripts and then noted terms, phrases, and concepts within the interview transcripts that we found to be salient to answering the research question. Our team then met to review these codes and grouped them into categories. These categories served as the themes of this study that illustrated the participants’ perceptions and experiences. Results: Five themes emerged from our data: (1) There is a current gap in ECC training for enlisted Role 1 caregivers throughout the military; (2) ECC training is needed to shift organizational culture; (3) ECC training should be comprehensive; (4) ECC training should be deliberate; and (5) Time is the greatest challenge to implementing ECC training. Our participants noted that developing guidelines and filling training gaps is not only critical for preparing Role 1 providers for effective and ethical military medical decision-making but also for addressing death and dying on the battlefield and building moral resilience across the medical corps. Conclusion: Our results provide direction for development of ECC clinical guidance and collective team training recommendations. Following these guidelines may increase life-saving capabilities on the far-forward battlefield and equip medical directors and medics to provide ethical and compassionate care to those who cannot be saved in the setting of limited resources and evacuation opportunities.

Introduction: A successful working relationship between the Military Medical Officer (MMO) and Commanding Officer (CO) is critical for mission success. However, there is a gap in the professional literature outlining evidence-based practices for teaching early career MMOs how to strategically develop this relationship. The purpose of this study, therefore, was to explore our participants’ perceptions of how MMOs can foster a positive and productive working relationship with the CO. Materials and Methods: We leveraged interpretive phenomenological design to interview 16 seasoned military physicians with extensive operational experience. We transcribed and coded each interview. Our research team determined how to organize these codes into major categories, which served as our study’s themes. Results: The participants described three key elements for developing a good working relationship between the CO and MMO: (1) mission-focused communication; (2) active and physical presence; and (3) expert/advisor role fulfillment. The MMO should communicate with the CO in an understandable and mission-focused manner. The MMO should likewise be present within day-to-day operations and should establish their officership during mission planning. The MMO should fulfill their role as a subject matter expert, yet advisor, to the CO. Conclusions: Communication, presence, and role fulfillment are essential elements for optimizing the MMO–CO working relationship. Learning these roles during medical school may enhance early career physicians’ mission readiness.

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.

Introduction: Mentorship is essential for professional development and advancement within the military. In civilian medicine, the intersection between gender and mentorship holds important implications for research opportunities, academic success, and career progression. However, the intersection of gender and mentorship has not yet been explored within the field of military medicine. The purpose of this study, therefore, was to investigate the role of gender in mentorship within the field of military medicine. Materials and Methods: We investigated gender and mentorship within military medicine by developing and distributing a 16-item Likert survey to active-duty military physicians. We used the Chi-squared test of independence and the independent samples t-test to examine the role of gender in mentorship among the 16 questions. Results: The male respondents reported more same-gender mentors than females (male [M]: 61.9% vs. female [F]: 33.0%), whereas the female respondents had significantly more mentors of the opposite gender than males (M: 12.4% vs. F: 47.3%). A higher proportion of males indicated no preference compared to females. Conversely, a significant preference for a same-sex mentor was expressed by female respondents compared to male respondents (M: 5.2% vs. F: 30.1%). In contrast, female respondents considered having a mentor more important than their male counterparts (t(206) = −2.26, P = .012, F: 3.86 vs. M: 3.57). Both male and female respondents had significantly more female mentees ($\chi _{\left( 1 \right)}^2$ = 12.92, P < .001, Cramer’s V = 0.254). Conclusions: While the female participants in our study preferred female mentors, the male participants had more same-gender mentors than the female participants. In addition, more females reported that they did not have the time to be mentored. Our results, therefore, suggest that training males to be better mentors to females and providing accessible mentorship training to females may promote equitable career development within military medicine.