Page 126 - Journal of Special Operations Medicine - Spring 2017

Two notable exceptions include undersea/hyperbaric cornerstone of ACGME accreditation. 16,17 The previous
medicine and sports medicine, though arguably the clin- widespread potential for local variations in fellowship
ical aspects of those subspecialties still largely involve curriculum, often driven by specific institutional capabil-
patient care occurring in predominantly conventional ities or opportunities, has functionally been eliminated
settings. A major advance in the recognition of opera- for the merits of standardization. Under the auspices of
tional medicine occurred in September of 2010, when the ACGME, regardless of the potential for expanded
the American Board of Emergency Medicine (ABEM) or advanced institutional opportunities within a given
recognized professional practice in emergency medical academic program, core EMS fellowship training must
services (EMS) as eligible for subspecialty certification. be completed within one academic year. The time often
required for fellowship trainees to develop personalized
This decision by ABEM followed an Institute of Medicine roles or advance expertise in sub-areas of specific inter-
report in 2006, Emergency Medical Services at the Cross- est within EMS is significantly curtailed. Finally, main-
roads, which included recommendation for the creation tenance of accreditation requires intensive reporting of
of subspecialty certification in EMS. While recognizing detailed compliance metrics and evaluative performance
15
established clinical practice in this arena, a standardized milestones within a strict framework of an EMS cur-
educational pathway towards EMS subspecialty board riculum that effectively minimize opportunities for
certification was next to be defined. Previous to this, fel- supplemental or advanced experiences, including those
lowship training in EMS across the country represented surrounding tactical medicine.
widely varying curricula providing education in diverse
areas of prehospital care and often with focus on par- Strictly considered in the context of developing physi-
ticular content areas based on local expertise. cian expertise in tactical medicine within the educa-
tional rubric of EMS fellowships, the advent of ACGME
The next milestone occurred in February 2013, when accreditation has presented a new and unforeseen chal-
the first EMS fellowships were accredited by the Accred- lenge. Moving forward, EMS fellowship programs with
itation Council for Graduate Medical Education (AC- a historical emphasis on tactical medicine may soon find
GME). Today, EMS fellowship programs accredited by themselves at a philosophical and logistical crossroads.
the ACGME achieve the highest recognition available While a fundamental understanding of EMS principles
for physician subspecialty graduate medical education. is essential to a tactical physician, the field of tactical
For academic institutions that have demonstrated the medicine may necessarily be considered an independent
longitudinal commitment to this level of physician edu- but overlapping practice from EMS. For those who do
cation, ACGME accreditation represents a prestigious not specifically seek EMS subspecialty training, a stand-
accomplishment. alone tactical medicine fellowship model that includes
only select EMS content may be the most appropriate
educational pathway.
Impact of ACGME Accreditation
Aside from the accreditation process, which can itself be Tactical Medicine Fellowships
a monumental task requiring substantial commitment of
individual institutional resources, ACGME recognition Beyond satisfying the training requirements to foster
has not come without an unanticipated cost to tactical safe and effective individual physician practices in tacti-
medicine education. Previously, formal physician sub- cal medicine, the academic educational mission main-
specialty education in tactical medicine had occurred tains a broader perspective. Graduate medical education
most often under the auspices of EMS fellowships. With considers the sustainability of the subspecialty as an ob-
a few notable exceptions academic institutions have jective of equal magnitude. Fellowship programs seek
not possessed the faculty expertise, available field op- to develop not only individual practitioners but rather
erational experiences and formal affiliations with law future educators, mentors, and leaders. Tactical medi-
enforcement agencies sufficient to sustain dedicated fel- cine finds itself in such familiar territory now. With the
lowships in tactical medicine. Further, centers with long- newly identified limitations within EMS fellowship pro-
standing EMS fellowships more often had the requisite grams for meaningful physician education in tactical
educational resources and academic infrastructure suf- medicine, other options must be actively identified and
ficient to develop and integrate emerging tactical medi- encouraged to develop appropriate training programs.
cine content if desired.
Dedicated tactical medicine fellowships would ap-
Programmatic accreditation by the ACGME has changed pear to represent a logical solution and have started to
the landscape for those premier EMS fellowships that emerge. 18,19 However, as already described, for poten-
have achieved this laudable recognition. Fastidious ad- tial tactical medicine fellowships the essential admin-
herence to standardized EMS educational content is the istrative, educational, and operational elements can be

102 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017