Modern peer combat has blown apart the myth of protected combat medical units. On the battlefields of Ukraine, scores of medical personnel, shielded in theory by both international law and historic norms, now lie dead. To survive in this environment while rescuing others, medics ranging from junior enlisted caregivers to senior physicians need tactical experience under fire. Skipping this training leaves them vulnerable and turns them into a security risk — a losing formula in modern combat.
Throughout the past four years, Russia has targeted Ukrainian aid stations, evacuation routes, and trauma teams. These attacks offer a grim triple advantage: killing or wounding medics that serve as force multipliers, eliminating wounded soldiers who might return to the fight, and demoralizing troops and the public. These threats require a new paradigm for frontline combat medical teams that combines tactical proficiency and medical expertise.
This model harkens back to the earliest recorded combat medics described in Homer’s Iliad. These military surgeons served as both battlefield healers and stalwart commanders — a model that meets the demands of modern warfare. Yet today, the U.S. military health system is not designed to produce combat-savvy medical teams and medical leaders at a scale required for modern conflict. The harsh realities of today’s battlespace demand a fundamental redesign of how the U.S. armed forces train military medical teams, how we select and promote their leaders, and how we deliver combat casualty care.
Ancient Combat Medics Worth a Battalion
To avenge the abduction of Helen — wife of Menelaus, King of Sparta — his brother Agamemnon assembled a large Achaean (Greek) coalition. Among its leaders were Machaon and Podalirius — physicians and sons of Asclepius — who sailed thirty ships of men to Troy where they served as both battlefield surgeons and commanders. In the following passage from Stanley Lombardo’s translation of the Iliad, Machaon treats King Menelaus, wounded by a Trojan arrow:
Machaon’s heart was pounding as he made his way
This compact narrative reveals the essence of a warrior medic: a surgeon on the front lines, ready to fight or intervene medically, as the situation demands. His presence reassures Menelaus’ men. His decisive action turns a potentially fatal blow into a manageable wound.
Later, Machaon himself is wounded by a triple-barbed arrow from the bow of Paris, the Prince of Troy and abductor of Helen. A fellow Greek comes to his aid and quickly calls for help:
Nestor, son of Neleus, mount your chariot
It is hard to find a plainer statement of medical value as a force multiplier. Machaon not only commands his men in the fight, but his healing skills enable many others to fight again. Accordingly, the Greeks act quickly to rescue him by shifting resources to evacuate him to safety.
The same book also describes “buddy care” rendered under fire — what today we’d call tactical combat casualty care — by an ancient combat lifesaver. Patroclus, best friend of Achilles, is no surgeon, but he knows enough to save a teammate:
Patroclus had him lie down, and with a knife
Long before the 75th Ranger Regiment, the ancient Greeks distributed lifesaving skills across the formation. These combat lifesavers started the chain of survival and bought time for definitive help to arrive. This contrasts sharply with the Trojans who fought with limited medical support.
In sum, the Greeks fought on thanks to the critical advantage afforded by their medics and other warriors trained to render immediate care. Three millennia later, this principle still holds true: Pushing life-saving trauma care far forward to support teams in contact boosts confidence and preserves the fighting force before even the stiffest opposition.
Are Medics and Warriors Intrinsically Incompatible?
From the Iliad, we see battlefield medical expertise at its peak — some ten years into the siege of Troy. These surgeons and combat lifesavers treated enough combat wounded to sustain their skills in combat casualty care even while they commanded their troops. Centuries later, though, there is a sharp divide between military medics and warriors. This divide places both communities at risk. In 1952, Dr. Frank Berry, famed thoracic surgeon and World War II veteran, noted that Machaon, “forsook his primary calling and was wounded while joining his fellows in arms to repel a particularly fierce assault by the Trojans” (emphasis added). This statement portrays the perceived tension between healer and warrior and raises the question of whether these roles are intrinsically incompatible in modern times.
This perceived incompatibility has two primary origins: one principled and another practical. First, on principle, the U.S. military treats medics as a protected class rather than operational assets. This designation harkens back to the first Geneva Convention of 1864. Like civilians and journalists in a combat zone, medical personnel — so long as they are not operating in a combatant role — are considered non-combatants by international law. Yet, scores of examples in the decades since — including accidental collateral damage and deliberate strikes — demonstrate the hazards of relying solely on legal and normative protection during war.
To mitigate this risk, the U.S. military services have settled on a compromise. Military surgeons, nurses, and other support personnel receive training in combat fundamentals focused on self-protection and protection of one’s patients. Typically led by other medical personnel, these predeployment courses often lack the realism and seriousness that characterize most operational training. When cloistered well behind the front lines in their medical bubble, combat medical teams can get by with these elementary skills. But if the need arises to relocate the medical facility or to care for casualties outside the wire, these combat neophytes represent a security liability rather than an asset.
What’s more, today’s large-scale military exercises typically neglect any medical elements or allow medics to opt out of these drills. This is a mistake. Medical teams need to learn how to function in an operational environment, ensure their equipment works, and confirm hypothetical plans function as expected, especially in contested environments. Likewise, operational commanders benefit from interfacing with their medical teams before real bullets start to fly. Familiarity breeds trust, and trust breeds confidence.
At the same time, medics should continue to adhere to international law. Masquerading as a healer while actively participating in offensive attacks constitutes the crime of perfidy. Weapons like handguns and even an M-4 or M-16 are allowed and should be used expertly in self-defense and to defend one’s patients. Offensive weapons like hand grenades, however, should remain off limits.
Want to Lead? Give Up Patient Care
The practical origins of the warrior-medic divide stem from the explosion in medical knowledge over the past century, the long medical training pipeline, and increased medical specialization. Surgical training today requires well over a decade: four years of premedical studies, four years of medical school, and five to seven years of surgical residency. Research and specialty training tack on more time to this already lengthy process. Then, to practice clinically, board certification and continuous professional education require near constant upkeep.
This rigorous clinical training leaves little time for military operational studies in our current system. What’s more, no modern clinical practice encompasses the corpus of battlefield medicine — from disease prevention to trauma surgery. Dr. Edward Churchill, Allied Chief Surgical Consultant in the Mediterranean and North African theater of World War II, observed: “Military surgery is a subspecialty of surgery, but a discontinuous one.” It’s as if the entire field must be reinvented every time the U.S. goes to war. Eighty years later, the super-specialization across all of medicine has made this discontinuity even worse.
Recreating a system of combat casualty care at the beginning of each conflict costs lives. This recognition has motivated the development of a dedicated military training pipeline in “expeditionary surgery.” This novel approach ensures that the U.S. military always has at least a few combat casualty care experts. It emphasizes expertise in trauma and burns, emergency conditions, and mass casualty events. Large medical centers across the United States — including Brooke Army Medical Center and many civilian trauma centers — consistently manage enough patients with these conditions to offer deployment-relevant training. Once war breaks out and the demand for combat medical teams surges, these experts can supervise or train others with adjacent or adaptable skills.
Even after acquiring these skills, however, those who aspire to lead as warrior medics face one more stumbling block: Modern senior medical leaders often don’t manage patients. The usual military medical career progression starts with building a clinical practice using the skills developed during training while serving in local leadership roles. However, once physicians reach the O-6 (colonel/Navy captain) level — and nurses even earlier — they typically must choose either clinical practice or leadership advancement. Faced with this decision, most take the third option of separation or retirement.
Framing senior military medical leadership and clinical experience as a binary choice deprives the U.S. military health system of many highly skilled clinicians with superb leadership skills. In civilian medicine, the best senior leaders often maintain a clinical practice. This better informs their strategic decision-making, and for operating surgeons, allows them to sustain their clinical relevance.
Modern Combat Medics Modeled After the Ancient Greeks
In the face of an ongoing conflict with Iran and a peer threat in China, how can the United States best restructure its current approach to prepare for modern combat? In short, I believe it needs to train and advance true warrior medics in the mold of Machaon.
At the operational level, grooming tactically skilled medics with trauma expertise has recently gained recognition. Austere resuscitative and surgical care teams meet the highest standards of far-forward trauma care while also achieving a high level of tactical proficiency. These medics embed with operational units and undergo intensive fitness, weapons, and team-based training. On the medical side, they learn to transfuse blood, staunch hemorrhage, and perform life-saving surgery close to the forward edge of battle.
Unfortunately, the number of casualties austere resuscitative and surgical care teams can manage is small — one to two emergent surgical patients at a time. Thus, this model offers exquisite care but in limited quantities. Building a robust survival chain in advance of a large-scale conflict with a peer enemy will require expertise at scale from point of injury through recovery. Recent efforts to implement pre-hospital tactical combat casualty care training using a four-tiered model across all services within five years reveals the level of commitment required for success. Declaring combat casualty care as mission critical felt like a great win. However, insufficient resources and inconsistent enforcement led to disappointing initial results. These trends have recently reversed, suggesting a renewed commitment to maximizing battlefield survival. Extending this same scaling approach to full trauma teams will require a robust training investment from both civilian and military medicine, starting with medical and nursing schools and extending through specialty training.
Wiggle room for adding military-specific clinical and tactical training already exists. Take, for example, the Health Professions Scholarship Program, the U.S. military’s scholarship for studying at a civilian medical school. During the required but mostly unstructured 180 days of military service, learning tactical combat casualty care and expeditionary surgery would represent a far better use of precious time than learning to read electrocardiograms in a military hospital. The former is unique to a military career while the latter can be learned anywhere.
At the leadership level, recent efforts to modernize the military health system led to the creation of the Defense Health Agency. The Defense Health Agency serves as a combat support agency tasked with operating all military hospitals and health clinics while also supporting medical readiness. But each service retains command and control over its personnel. This division of labor holds the promise of improved efficiency for the health system. In practice, though, military medical readiness has suffered: Only 10 percent of the general surgeons on active duty qualify as combat ready — a bellwether of the whole system. Fixing this egregious gap requires urgent attention at multiple levels.
First, the Defense Health Agency’s mission needs clarification, and its structure requires further refinement. The in-garrison and forward-deployed missions are largely divergent, making it impossible for the Defense Health Agency to serve both. Going forward, the Defense Health Agency should focus exclusively on the in-garrison noncombat mission while learning from the other federal healthcare system — the Veterans Health Administration — and from excellent civilian healthcare systems. These systems benefit from consistent civilian executive-level leadership focused on a singular mission of delivering effective and efficient care in the United States. Appointing a senior civilian healthcare administrator to direct all domestic military medical healthcare for servicemembers, their families, and beneficiaries — and holding that leader accountable for performance — would allow the Defense Health Agency to excel at this singular mission.
Second, the armed services should own the combat casualty care mission under a joint unified medical command. This would elevate forward-deployed care — the one mission that only the military health system can perform — to its rightful place of primacy. Holding the commander of a joint unified medical command accountable for both medical and tactical readiness among all combat medics would serve operational units well in modern conflicts. For clinical currency, the commander of the joint unified medical command should embed these warrior medics in select Defense Health Agency facilities or civilian trauma centers that offer large volumes of combat-relevant clinical training. The commander should also coordinate operational training and large scale exercises with line commanders to ensure its teams are truly combat ready. Finally, establishing a clinician-commander leadership track — one in which senior leaders maintain their patient care skills — within this joint unified medical command would ensure our nation maintains a pipeline of truly exceptional warrior medics.
For decades, the armed services have resisted a unified medical command. Scandalously inadequate readiness suggests the historic service-centric approach has failed. In this light, can the armed services finally be coaxed into a new paradigm? The admonition of Odysseus in rallying the troops rings true: “We Achaeans cannot all be kings here. Too many kings can ruin an army — mob rule! Let there be one commander, one master only.” The brutal realities of the conflict in Ukraine and the prospect of an imminent peer conflict with China lend urgency to these reforms. Now more than ever, the U.S. military needs operationally savvy, clinically excellent warrior medics and medical leaders — like those who fought on the plains of ancient Troy.
Jeremy W. Cannon, M.D.-S.M., is a trauma surgeon and professor of surgery at the University of Pennsylvania. He served multiple combat tours during the “Global War on Terror” and retired from the U.S. Air Force Reserve in 2023. He recently coedited Edward D. Churchill’s Surgeon to Soldiers, 2024 Edition with Modern Commentary. From 2024 to 2025, he was a veteran fellow in the Bochnowski Family Veteran Fellowship Program at the Hoover Institution, Stanford University.
Image: Sgt. Caitlinn Belcher via Wikimedia Commons
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