Burn the Ships

Last month, more than 2,600 military health professionals gathered in Dallas for the annual Military Health System Worldwide Conference. "Our mission is readiness," declared Assistant Secretary of Defense for Health Affairs Keith Bass. "We have a no-fail mission." He also warned against the "Walker Dip" named for Admiral Alasdair Walker, former British Surgeon General, who aptly observed that throughout history, military medical teams repeatedly fail to maintain "steady state readiness." The diagnosis is exactly right, and the prescription was laid out before the Senate Armed Services Committee in March 2025. Now we must find the institutional will to act.

The next major conflict will barely resemble past experience. Future large-scale combat operations against peer adversaries will produce casualty volumes and injury complexity on the scale of World War II — approximately 1,000 casualties per day for 100 consecutive days or longer. Evacuation timelines will stretch well beyond the golden hour in a contested battlespace. Blood product collection and storage will prove nearly impossible. Surgical teams will move underground to avoid becoming targets.

Yet our current MHS is not designed to meet these harsh demands. Most military treatment facilities (MTFs) do not manage sufficient trauma volume to sustain wartime proficiency. Today, fewer than 10% of military general surgeons meet even a minimal clinical readiness threshold, and the MHS cannot bridge this gap through low-volume practice or episodic training rotations. Expertise in modern combat casualty care demands full immersion, not intermittent exposure.

This readiness gap has created a demoralized workforce and significant talent attrition. A 2024 RAND Corporation study found that physicians leave after their service obligations primarily because of pay disparity, administrative burden, and clinical skill degradation. The Department of Defense's Inspector General verified this systemic failure, reporting that the military services routinely assign critical wartime specialists to low-volume locations without any regard for their clinical readiness requirements. Thus, it’s hardly surprising that the first question military physicians often ask each other is not “What drives you to serve” but rather "When do you get out?"

To enable decisive transformation, we present a three-part solution.

First, aggressively embed active-duty critical wartime specialties into America’s busiest civilian trauma systems. Military partnerships with high-volume civilian trauma centers must become the gold standard of deployment readiness. Military clinicians should belong to these centers operationally, contributing daily to high-acuity patient care while maintaining their deployable identity and command integration.

Second, optimize the domestic MTF footprint. Most MTFs should be refocused toward what they do best — beneficiary care, pre- and post-deployment health, rehabilitation, and force health maintenance. Simultaneously, a select number of strategically designated flagship MTFs should be fully resourced as national trauma readiness hubs. A recent GAO report noted the MHS maintains only Level I trauma center among the 725 MHS facilities, Brooke Army Medical Center. Additional sites — like Madigan and Walter Reed — must grow into their full potential by managing civilian trauma in high volumes.

Third, rebuild the reserve workforce through a modern Volunteer Medical Service Corps. Looking to history once again, when the United States entered World War I, the active Army had just 491 doctors. To scale the force, military and political leaders partnered with the American College of Surgeons and the American Medical Association to mobilize more than 30,000 physicians into uniform. Today, Congress must act with similar resolve to establish a modernized framework that allows regular reserve and individual mobilization augmentees to sustain wartime proficiency through daily practice at high-volume civilian trauma centers, backed by defined mobilization obligations and viable financial incentives. This will cost money; not acting now will cost lives.

Critics will note that military families depend on MTFs for healthcare, and they are right. Nothing in this proposal ends that access. Rather, it is a rejection of a status quo that is failing military medicine's core moral obligation: to safeguard the lives of our service members and bring America's sons and daughters home alive. To maintain our military medical edge in the current threat environment, Congress must mandate that the Pentagon embed its deployable teams where the trauma volume exists, expand its flagship military hubs to meet the mission, and bolster the reserve workforce.

It's time to burn the ships.

John M. Ruggero, DO is a trauma surgeon at Cook County Hospital in Chicago, IL where he serves as the Section Chief of Joint Combat Education and Training and surgeon champion for the U.S. Navy/Cook County Health Military Civilian Partnership. He served a combat tour during Operation Inherent Resolve and separated from active duty in the U.S. Navy in 2025 after 16 years of service.

Jeremy W. Cannon, MD, SM is a trauma surgeon and professor of surgery at the University of Pennsylvania, a member of the American College of Surgeons Committee on Trauma, and Chair of the Strategic Advisory Committee of RESPOND-US. He served multiple combat tours during the Global War on Terror and retired from the U.S. Air Force Reserve in 2023.