Introduction
In the 2020s, large-scale military conflicts, such as the Russia–Ukraine War, have intensified globally. Given South Korea’s unique geopolitical posture and persistent high risk of conflict, maintaining robust clinical readiness is a primary national security objective. However, military medicine in Korea has progressed slowly over more than 70 years of peacetime since the armistice, increasingly lagging behind the civilian sector. To bridge this gap, the Korean Army established the Armed Forces Trauma Center (AFTC) in 2022. However, the low peacetime military accident rate, combined with the efficient operation of 17 civilian regional trauma centers (RTCs) nationwide, has resulted in a low patient volume at the AFTC. Consequently, military surgeons face significant challenges in maintaining adequate surgical volume and exposure to complex trauma cases.
Maintaining case volume outside active combat is a well-documented global issue for military medical readiness. Reference Hight, Salcedo and Martin1–Reference Hall, Davis and Vasquez2 To address this during peacetime, the United States military has implemented Military-Civilian Partnership (MCP) programs, guided by strategic frameworks developed jointly by the Department of Defense and the American College of Surgeons.Reference Knudson, Elster and Hoyt 3 Similarly, NATO member states (e.g., the UK, Germany, and the Netherlands) operate integrated trauma-civilian networks to sustain clinical readiness.Reference Grushka, Bradley and Klein 4 Studies have confirmed that these partnerships can successfully sustain the clinical competence of military trauma specialists.Reference Grabo, Gurney and Parascandola 5
To enhance clinical readiness, the Korean military initiated its first MCP pilot program in 2024, sponsored by the Korean Society of Traumatology and the Ministry of National Defense. This brief report evaluates the inaugural clinical experiences of a military surgeon embedded in a civilian RTC through this program, thereby assessing its viability and potential impact on enhancing military clinical readiness within the Korean health care context.
Methods
Study Setting and MCP Work Arrangement
Long-term, continuous deployments of military surgeons, which are common in the United States MCP model, were deemed unfeasible in Korea because of a severe shortage of military trauma surgeons. Therefore, a context-specific, intermittent trauma shift model was designed to maximize educational exposure at a civilian RTC without disrupting existing health care delivery at military hospitals. Under this framework, the participating military surgeon maintained regular duties at the military facility while performing 3-4 trauma shifts per month at the civilian RTC. To avoid clinical disruptions, these shifts were restricted to Fridays or Saturdays. Each shift was defined as a continuous duty period of 24 hours. Patient care followed a team-based approach; patients admitted by the military surgeon during a shift were comanaged with the civilian host faculty. Throughout the 1-year study period, the surgeon completed 65 shifts at the AFTC and 41 shifts at the civilian RTC, averaging 5.4 and 3.4 shifts per month, respectively.
Characteristics and Roles of the MCP Military Surgeon
The participating military surgeon was an active-duty lieutenant colonel with 10 years of clinical experience, holding board certifications in both general and trauma surgery. At the military hospital and AFTC, he operated as an acute care surgeon managing trauma, critical care, and emergency general surgery. At the civilian RTC, he was granted full clinical privileges as a clinical professor, conducting unsupervised trauma surgeries, managing patients in the trauma intensive care unit (TICU), and serving as the attending trauma surgeon on call. Additionally, he supervised trauma fellows and residents, served as the primary surgeon during helicopter emergency medical service (EMS) activations, and provided trauma education for regional EMS personnel and medical students.
Eligibility Criteria and Data Collection
Data from all trauma patients treated by the military surgeon at both centers between September 2024 and August 2025 were retrospectively reviewed. Patient demographics included age, sex, active-duty soldier status, and injury mechanisms. Injury severity was stratified using the Injury Severity Score (ISS), with cutoffs of >9 and >15. To compare procedural exposure, 5 invasive bedside procedures conducted at both centers were analyzed: central line insertion, endotracheal intubation, percutaneous dilatational tracheostomy, bronchoscopy, and chest tube insertion. Trauma surgeries included only those performed under general anesthesia to focus on severe injuries. Additionally, the surgeon’s elective and emergency nontrauma general surgeries conducted at the military hospital were quantified to assess overall surgical activity.
Statistical Analysis
Continuous outcome variables are expressed as the mean ± standard deviation. Student’s t test and the chi-squared test were used to compare continuous and categorical variables between outcomes, respectively. Statistical significance was set at P < 0.05 (2-sided). All statistical analyses were performed using IBM SPSS Statistics, version 21.0 (IBM Corp., Armonk, NY, USA).
Results
Patient Demographics
Over the 1-year study period, the military surgeon managed 103 and 193 patients at the AFTC and civilian RTC, respectively (Table 1). Patients at the civilian RTC were significantly older than those at the AFTC (50.8 ± 20.2 vs 44.5 ± 20.8 years, P = 0.010). Conversely, the proportions of active-duty soldiers (16% vs 1%, P < 0.001) and burn injuries (6% vs 1%, P = 0.008) were significantly higher at the AFTC. Crucially, the civilian RTC presented a substantially higher burden of severe trauma, with significantly more patients presenting with ISS >9 (49% vs 35%, P = 0.023) and ISS >15 (35% vs 23%, P = 0.035). However, sex and general injury mechanisms did not differ significantly between centers, although gunshot and blast injuries occurred exclusively at the AFTC.
Demographic characteristics of patients with trauma treated at both centers
Table 1. Long description
The table consists of four columns: Characteristics, A F T C (n equals 103), Civilian R T C (n equals 193), and P-value.
* Active-duty soldiers: A F T C has 16 (16 percent), Civilian R T C has 1 (1 percent), P less than 0.001.
* Age, years: A F T C is 44.5 plus or minus 20.8, Civilian R T C is 50.8 plus or minus 20.2, P equals 0.010.
* Sex (Male): A F T C has 84 (82 percent), Civilian R T C has 140 (73 percent), P equals 0.085.
* Mechanism of injury:
- Blunt: A F T C 89 (86 percent), Civilian R T C 180 (93 percent), P equals 0.051.
- Penetrating: A F T C 6 (6 percent), Civilian R T C 12 (6 percent), P equals 0.893.
- Stab: A F T C 5 (5 percent), Civilian R T C 9 (5 percent), P equals 0.941.
- Gunshot: A F T C 1 (1 percent), Civilian R T C 0, P equals 0.348.
- Cut: A F T C 0, Civilian R T C 3 (2 percent), P equals 0.554.
- Burn: A F T C 6 (6 percent), Civilian R T C 1 (1 percent), P equals 0.008.
- Blast: A F T C 2 (2 percent), Civilian R T C 0, P equals 0.120.
* I S S greater than 9: A F T C 36 (35 percent), Civilian R T C 94 (49 percent), P equals 0.023.
* I S S greater than 15: A F T C 24 (23 percent), Civilian R T C 68 (35 percent), P equals 0.035.
Abbreviations: A F T C stands for Armed Forces Trauma Center; R T C stands for regional trauma center; I S S stands for Injury Severity Score.
AFTC, Armed Forces Trauma Center; RTC, regional trauma center.
Procedures and Surgeries
The surgeon performed 23 invasive procedures at the AFTC and 141 at the civilian RTC (Table 2). Central line insertion was the most common procedure at both facilities, while chest tube insertions were more common at the civilian RTC. Although the overall procedural volume was significantly higher at the civilian RTC, the relative distribution of procedure types did not differ significantly between the 2 centers.
Details and frequencies of trauma procedure/surgery
Table 2. Long description
The first table lists five trauma procedures with columns for A F T C (n = 23), Civilian R T C (n = 141), and P-value.
* Endotracheal intubation: A F T C 5 (22), Civilian R T C 30 (21), P 0.947.
* P D T: A F T C 1 (4), Civilian R T C 5 (4), P 1.000.
* Chest tube insertion: A F T C 2 (9), Civilian R T C 35 (25), P 0.109.
* Bronchoscopy: A F T C 1 (4), Civilian R T C 5 (4), P 1.000.
* Central line insertion: A F T C 14 (61), Civilian R T C 66 (46), P 0.200.
The second table lists trauma surgeries for A F T C (n = 19) and Civilian R T C (n = 33).
* Primary repair of the bladder: A F T C 1, Civilian R T C 1.
* Diagnostic laparoscopy: A F T C 1, Civilian R T C 1.
* Diagnostic laparotomy: A F T C 2, Civilian R T C 0.
* Small bowel resection and anastomosis: A F T C 2, Civilian R T C 0.
* Preperitoneal pelvic packing: A F T C 3, Civilian R T C 4.
* Vessel ligation: A F T C 3, Civilian R T C 3.
* Thrombectomy: A F T C 1, Civilian R T C 1.
* Vessel anastomosis: A F T C 3, Civilian R T C 0.
* External fixation: A F T C 1, Civilian R T C 0.
* Primary repair of lacerations: A F T C 2, Civilian R T C 0.
* Other surgeries (trachea, mesentery, stomach, diaphragm, laparoscopic repairs, rectum, splenectomy, renorrhaphy, liver suture, neck exploration, venorrhaphy) show 0 for A F T C and counts of 1 or 2 for Civilian R T C.
AFTC, Armed Forces Trauma Center; PDT, percutaneous dilatational tracheostomy; RTC, regional trauma center.
The surgeon conducted 19 trauma surgeries at the AFTC and 33 at the civilian RTC (Table 2). Overlapping surgical cases included primary bladder repair, diagnostic laparoscopy, preperitoneal pelvic packing, vessel ligation, and thrombectomy. Surgeries performed exclusively at the civilian RTC included complex visceral and structural repairs, such as primary repairs of the trachea, mesentery, stomach, and diaphragm; therapeutic laparoscopy for small bowel, bladder, and rectal injuries; splenectomy; renorrhaphy; liver suture; and lateral venorrhaphy of the external iliac vein. Conversely, surgeries performed only at the AFTC included diagnostic laparotomy, small bowel resection and anastomosis, peripheral vessel anastomosis (brachial and radial arteries), external fixation (tibia), and primary repair of lacerations (buttock and neck). In addition to trauma cases, the surgeon performed 101 general surgeries at the military hospital (Table S1). The most frequent procedures included laparoscopic appendectomy (n = 53), hemorrhoidectomy (n = 20), and left internal lateral sphincterotomy (n = 11). Other general surgeries comprised low anterior resection, laparoscopic right hemicolectomy, laparoscopic herniorrhaphy, small bowel resection and anastomosis, and low-rectum bleeding control. For trauma surgeries, the proportions of laparoscopic approaches were 5% and 21% at the AFTC and civilian RTC, respectively.
Discussion
The inaugural Korean MCP pilot program was launched in 2024 to counteract the clinical readiness deficits imposed by peacetime constraints. By quantifying a single surgeon’s dual-center activities, this study demonstrated that the MCP successfully provided extensive exposure to complex trauma care. Despite working fewer shifts at the civilian RTC, the surgeon encountered a higher volume of invasive procedures, complex trauma surgeries, and severely injured patients (ISS >15). These findings align with the global literature, showing that civilian embedding helps military surgeons to maintain essential trauma skills.Reference Grabo, Gurney and Parascandola 5
Distinctively, this pilot highlighted complementary benefits between the military facility and the civilian center. While the civilian RTC provided sheer volume and physiological complexity, the AFTC exposed the surgeon to military-specific injury mechanisms (such as gunshots, blasts, and military burns) that are exceptionally rare in the Korean civilian sector. This dual exposure creates a comprehensive training environment. Furthermore, the surgeon’s continuous general surgery practice at the military hospital preserved baseline operative dexterity. In Korea, the Ministry of Health and Welfare regulations restrict civilian RTC surgeons strictly to conducting trauma surgeries, preventing them from performing elective or emergency general surgeries within their specialties. This restriction commonly limits overall surgical volume and erodes broader technical proficiency.Reference Lee, Lee and Lee 6 However, because the MCP surgeon operated under the Ministry of National Defense, he was exempt from these civilian constraints, thereby allowing him to maintain superior surgical proficiency through conducting routine general surgery. This military environment further fostered cross-specialty collaboration, enabling the surgeon to perform emergency external fixations under orthopedic guidance.
The Korean MCP model naturally diverged from the United States framework owing to structural differences in health care systems. First, while US military surgeons embedded in civilian systems commonly manage general emergency surgeries, Korean civilian RTCs are legally restricted to pure trauma care, thus narrowing the embedding experience. Second, severe personnel shortages in the Korean military precluded the continuous deployments utilized by the United States, thus necessitating the intermittent, 24-hour shift model adopted here. Nevertheless, as seen in other resource-limited NATO states, such as Sweden and the Netherlands, MCP programs can be successfully tailored to match local health care regulations and military medical constraints.Reference Jensen, van Egmond and Ortenwall 7 The Korean MCP program currently lacks a formalized legal and financial foundation. In the United States, the National Defense Authorization Act (via the Joint Trauma System) explicitly mandates integrating military medical personnel into civilian systems, backed by federal grants from the Mission Zero Act. Conversely, Korea lacks explicit statutory provisions or dedicated budgets for war-preparedness medical embedding. Establishing joint legislation between the Ministry of National Defense and the Ministry of Health and Welfare will therefore be crucial to sustain the program.
Limitations and Strengths
To the best of our knowledge, although this is limited by its nature as a pilot study focusing on a single military surgeon, it holds significant value as the first proof-of-concept study outside of the United States to examine the objective clinical volume of an MCP program and directly compare it with military treatment facility data. Despite the clear strength of providing real-world validation, the present study has limitations. First, the findings are derived from a single surgeon at a single institution, thus limiting immediate generalizability. Future expansions must therefore scale this model across multiple surgeons and centers to standardize effectiveness metrics, such as the Knowledge, Skills, and Abilities (KSA) clinical readiness tracker. Second, while locoregional or spinal anesthesia is often the practical norm in austere battlefield settings to prevent general anesthesia-induced adverse effects such as the loss of airway reflexes and cardiorespiratory depression, the present study was conducted during peacetime, when resource constraints did not need to be considered. Accordingly, this study focused on surgical experiences with severe trauma patients who required general anesthesia. Third, while the substantial volume of laparoscopic surgeries performed at both the military hospital and civilian RTC was invaluable for maintaining the surgeon’s baseline technical dexterity during peacetime, the role of minimally invasive surgery (MIS) is severely limited or nonexistent in actual combat settings. Consequently, exposure to various abdominal trauma surgeries at the civilian RTC remains the primary pillar for maintaining clinical readiness, whereas peacetime laparoscopic surgery should be interpreted strictly as a supplementary means to preserve basic operative skills. Finally, wartime casualty care requires support from an integrated team. Future iterations must therefore expand the MCP beyond surgeons to include trauma nurses, anesthetists, and EMS personnel, matching the multidisciplinary “combat casualty care team” concepts applied globally.Reference Knudson, Elster and Hoyt 3
Conclusions
Overall, the present study indicates that a contextually tailored, intermittent MCP model effectively overcomes peacetime volume deficits by providing military surgeons with high-density trauma exposure. Combined with military-specific trauma care and unrestricted general surgery access, this framework offers a sustainable strategy for maintaining national military clinical readiness.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2026.10413.
Data availability statement
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.
Acknowledgments
The authors acknowledge the contributions of their colleagues at the Armed Forces Capital Hospital and Uijeongbu St. Mary’s Hospital.
Author contribution
Hojun Lee contributed to conceptualization and manuscript review and editing. Hangjoo Cho contributed to conceptualization, project administration, and manuscript review and editing. Yongwoong Lee was responsible for data curation, while Hoonsung Park and Dae-Sang Lee performed the formal analysis. Doo-Hun Kim contributed to the investigation and drafted the original manuscript. Tae Hwa Hong and Maru Kim participated in the investigation, with Maru Kim also contributing to the methodology. Sung Yub Jeong contributed to the methodology and drafting the original manuscript. All authors reviewed and approved the final manuscript.
Funding statement
Not applicable.
Competing interests
None.
Ethical standards
The study protocol was reviewed and approved by the Institutional Review Board of the Armed Forces Capital Hospital (approval no. 2025-12-005) and conformed to the principles of the Declaration of Helsinki (2024). The requirement for informed consent was waived owing to the retrospective nature of the study.
