Don't know, don't care: revisited

OBJECTIVES: This study re-evaluates the awareness and attitudes of medical students concerning military programs, which can provide financial support for medical student education. An original study, 10 years ago, demonstrated a minimal awareness of these programs. With medical school tuitions rising dramatically in the intervening years, as well as the resultant student indebtedness increasing significantly, it is appropriate to readdress this knowledge of attitude toward financial options through military programs for medical students. Reassessment was undertaken using the same evaluation instrument. In the decade in which these four assessments were made, attitudes toward amelioration of medical student tuitional indebtedness, through programs sponsored by the Department of Defense, have worsened. This phenomenon jeopardizes military medicine and, in so doing, negatively impacts readiness of our Armed Forces.     

Strategic National Stockpile program: implications for military medicine

The Strategic National Stockpile (SNS) program, managed by the Centers for Disease Control and Prevention, Department of Health and Human Services, is designed to deliver critical medical resources to the site of a national emergency. A recent interagency agreement between the Department of Defense and the Department of Health and Human Services indicates that military medical treatment facility commanders should be actively engaged in cooperative planning with local and state public health officials, so that reception, storage, distribution, and dispensing of SNS materials as a consequence of an actual event could occur without disruption or delay. This article describes the SNS program and discusses issues of relevance to medical treatment facility commanders and Department of Defense medical planners and logisticians.     

Worksite health promotion: rationale for military implementation.

Health promotion programs are being offered in many segments of U.S. society. Corporations find offering health promotion programs at the worksite effective and cost-efficient. The U.S. military, following a 1986 Department of Defense directive, has also developed health promotion programs. At present, not all components of military health promotion programs are being offered at the worksite. Improved employee health and lower health care costs are objectives sought by both the military and major corporations. Therefore, full worksite implementation of all health promotion program components will assist the military services in reaching their health goals.     

Improving the Emergency Whole Blood Program

The military has used the Emergency Whole Blood Program (EWBP) to treat combat casualties since World War I and it remains important in modern military campaigns. Despite frequent use, military medical providers receive little to no training on EWBP operations. The authors sought to improve the efficiency of the EWBP at a Forward Operating Base in southern Afghanistan during Operation Enduring Freedom 10-11 through the development of a prescreening program. A prescreened donor pool and registry were established by confirming blood type, rapid communicable disease testing, and completion and review of Defense Department (DD) form 572 before an emergency blood drive, during which prescreened donors were moved to the front of the line. Using prescreened donors, the mean time from EWBP activation to blood delivery to the operating room decreased from 43.3 (SD 4.4) to 26.7 minutes (SD 3.1) (p < 0.0004). The EWBP can be conducted more efficiently without compromising patient safety by implementing a robust prescreening program. Other improvements should include education of health care providers and commanders on prescreening and the EWBP. The use of fresh whole blood continues to be an important lifesaving resource in military medicine, and the Department of Defense should allocate resources to provide EWBP training and in-theater prescreening programs.     

A comparison of the military entrance processing station screening audiogram with the Defense Occupational and Environmental Health Readiness System reference audiogram at Fort Sill, Oklahoma, in 2000

BACKGROUND: The Department of Defense Hearing Conservation Program requires that a reference audiogram be performed at initial entry training (IET), before noise exposure. In the Army, only Fort Sill, home of the field artillery, and Fort Benning, home of the infantry, are in compliance. All military applicants receive a screening audiogram at a military entrance processing station (MEPS) to qualify for service. This audiogram does not meet the Defense Occupational and Environmental Health Readiness System-Hearing Conservation (DOEHRS-HC) standard. Nevertheless, it has been proposed that the MEPS screen be used as the reference because of limited resources and time during IET medical in-processing. METHODS: A total of 11,816 individual reference audiograms performed at Fort Sill 95th Adjutant General Recruit Reception Center in 2000 were identified in the DOEHRS-HC database. Results of the MEPS screening audiograms were found for 11,311 (96%) of these individuals. The two audiograms were compared by frequency and ear and by using the two Department of Defense criteria for threshold shift. RESULTS: A total of 14.49% (95% confidence interval, 14.48-14.50%) of audiograms using the three-frequency average difference and 23.19% (95% confidence interval, 23.18-23.20%) using the four-frequency difference in either ear demonstrated a threshold shift. The mean difference in intensity between the two audiograms ranged from 5 to 12 dB and varied by frequency and ear, with the greatest differences being seen at 500 and 6,000 kHz and in the left ear, compared with the right ear. The mean threshold level was higher for each frequency in the DOEHRS-HC audiogram, compared with the MEPS audiogram. CONCLUSIONS: Approximately 15% of soldiers at Fort Sill in 2000 showed a clinically significant threshold difference between their MEPS screening and the DOEHRS-HC baseline audiogram. Methodological variations in testing and interval noise-induced hearing loss could account for these differences. The results do not support the use of the MEPS screening audiogram as the reference audiogram. Compliance with the Hearing Conservation Program in the Army would require either improving MEPS testing to DOEHRS-HC standards or performing baseline audiograms at all five IET sites.     

Military nursing research by students at the Graduate School of Nursing Uniformed Services University of the Health Sciences

Military nursing research has had a long and productive history. Today, much of this research is conducted under two programs, the TriService Nursing Research Program and the Graduate School of Nursing (GSN), both located at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. This article will discuss the 150 military nursing research projects carried out by students at the GSN since its founding in 1992. Although most projects have been small in scope, they have obtained useful results. Some projects have served as the basis for larger-scale research studies, receiving funding from the TriService Nursing Research Program. Reports of all projects are available in an online database and some have been published in professional journals. This review concludes that the research produced by GSN students has been beneficial to students and to the military health system.     

Human performance optimization: an evolving charge to the Department of Defense

Uniformed Services University of the Health Sciences hosted a conference in June 2006 entitled "Human Performance Optimization in the Department of Defense: Charting a Course for the Future" with the goal of developing a strategic plan for human performance optimization (HPO) within the Department of Defense (DoD). The conference identified key issues: (1) advocating for HPO at all DoD levels, (2) defining HPO specific to DoD requirements, (3) developing valid and standardized metrics for HPO, (4) translating HPO research into the operational community, and (5) establishing effective communication and coordination across military services and within the medical, research and operational communities. The program objectives should enhance mental and physical resilience of the war fighter; accelerate recovery; reduce injury and illness; provide seamless knowledge transfer from laboratory to line; improve the human system contribution to mission success; and allow the U.S. to remain in the lead in this area.     

The Recruit assessment Program: a program to collect comprehensive baseline health data from U.S. military personnel.

Pilot testing has begun on the Recruit Assessment Program (RAP). The RAP is a proposed Department of Defense (DoD) program for the routine collection of baseline demographic, medical, psychosocial, occupational, and health risk factor data from all U.S. military personnel at entry into the armed forces. The RAP currently uses an optically scannable paper questionnaire, which will provide data for the first building block of an electronic medical record within the DoD and the Department of Veterans Affairs. The RAP will serve several important functions, including automating enrollment into the military health care system, improving patient care and preventive medicine efforts, and providing critical data for investigations of health problems among military personnel and veterans. If the feasibility of the RAP is demonstrated and the program is fully implemented throughout the DoD, it could provide a substantial improvement in health care delivery. For the first time, DoD and Department of Veterans Affairs physicians, public health officers, and researchers will have access to comprehensive baseline health status data.     

Force health protection: 10 years of lessons learned by the Department of Defense

The Department of Defense has applied lessons learned since the Persian Gulf War to develop the force health protection (FHP) strategy. The goal of this new, unified strategy is to protect the health of military members from medical and environmental hazards associated with military service to the maximum extent possible. FHP is an evolving strategy that seeks to balance the military health system's responsibilities to promote and sustain health and wellness throughout each person's military service; prevent acute and chronic illnesses and injuries during training and deployment; and rapidly stabilize, treat, and evacuate casualties. In addition, FHP demands a continuous assessment of the current and future health of military members through medical surveillance, longitudinal health studies, adequate medical record documentation, and clinical follow-up. Effective communication with military members, leaders, veterans, families, and the public regarding military members' health status and the health risks of military service is a key element of the FHP strategy.     

U.S. military service members' perceptions of the Anthrax Vaccine Immunization Program

This research identifies the perceptions of U.S. military service members regarding the Department of Defense Anthrax Vaccine Immunization Program (AVIP). The service members' perceptions were addressed in the dimensions of ethics, effectiveness, and safety, as well as the overall perceptions of the AVIP. The study, conducted in October 2004, randomly selected active duty service members from the uniformed services assigned to a Caribbean military base who participated in the AVIP during the period of 1998 to 2000. Their perceptions were measured with a survey instrument with 14 closed-ended, Likert-scale questions. The research demonstrated that a substantial number of service members disagreed with issues regarding the ethics, safety, and efficacy of the AVIP. We recommend enhanced training and education to increase understanding of the benefits of the AVIP.     

Utilization management affects health care practices at Walter Reed Army Medical Center: analytical methods applied to decrease length of stay and assign appropriate level of care

The Department of Defense has embraced utilization management (UM) as an important tool to control and possibly decrease medical costs. Budgetary withholds have been taken by the Office of the Assistant Secretary of Defense (Health Affairs) to encourage the military services to implement UM programs. In response, Walter Reed Army Medical Center implemented a UM program along with other initiatives to effect changes in the delivery of inpatient care. This paper describes this UM program and other organizational initiatives, such as the introduction of new levels of care in an attempt to effect reductions in length of stay and unnecessary admissions. We demonstrate the use of a diversity of databases and analytical methods to quantify improved utilization and management of resources. The initiatives described significantly reduced hospital length of stay and inappropriate inpatient days. Without solid command and clinical leadership support and empowerment of the professional staffs, these significant changes and improvements could not have occurred.     

Measuring cultural climate in a uniformed services medical center

The purpose of this study was to determine the employee perceptions of the cultural climate at a large uniformed service medical center in the mid-Atlantic region of the United States. The analyses are based on the responses of 1,751 medical center employees, whose demographic characteristics were representative of the medical center population. Analyses indicate the existence of systematic perceptual differences between: (1) the medical center and Department of Defense personnel, and (2) the following cultural groups: (a) male and female personnel, (b) military and civilian personnel, and (c) majority and minority personnel. Recommendations are provided for future areas of research that need to be conducted with respect to the phenomenon of cultural diversity and the development of positive cultural climates within both the military and civilian medical settings.     

The evolution of a health hazard assessment database management system for military weapons, equipment, and materiel

During the 1970s, the Army health hazard assessment (HHA) process developed as a medical program to minimize hazards in military materiel during the development process. The HHA Program characterizes health hazards that soldiers and civilians may encounter as they interact with military weapons and equipment. Thus, it is a resource for medical planners and advisors to use that can identify and estimate potential hazards that soldiers may encounter as they train and conduct missions. The U.S. Army Center for Health Promotion and Preventive Medicine administers the program, which is integrated with the Army's Manpower and Personnel Integration program. As the HHA Program has matured, an electronic database has been developed to record and monitor the health hazards associated with military equipment and systems. The current database tracks the results of HHAs and provides reporting designed to assist the HHA Program manager in daily activities.     

Overview of overseas humanitarian, disaster, and civic aid programs

The U.S. Department of Defense (DoD) conducts humanitarian assistance missions under the Overseas Humanitarian Disaster and Civic Aid program for the statutory purposes of training military personnel, serving the political interests of the host nation and United States, and providing humanitarian relief to foreign civilians. These purposes are undertaken via the humanitarian assistance (HA), humanitarian and civic assistance, and excess property donation programs. DoD conducts over 200 such projects annually at a direct cost of approximately 27 million dollars in fiscal year 2001. Although varying by year and command, as many as one-half of these projects involve aspects of health care. These range from short-term patient care to donation of medical supplies and equipment excess to the needs of the DoD. Despite the considerable resources invested and importance of international actions, there is presently no formal evaluation system for these HA projects. Current administrative staffing of these programs by military personnel is often by individuals with many other duties and responsibilities. As a result, humanitarian projects are often inadequately coordinated with nongovernmental organizations, private volunteer organizations, or host-nation officials. Nonmedical military personnel sometimes plan health-related projects with little or no coordination with medical experts, military or civilian. After action reports (AARs) on these humanitarian projects are often subjective, lack quantitative details, and are devoid of measures of effectiveness. AARs are sometimes inconsistently completed, and there is no central repository of information for analysis of lessons learned. (The approximate 100 AARs used in the conduct of these studies are available for official use in the Learning Resources Center, Uniformed Services University of Health Sciences.) Feedback from past humanitarian projects is rare and with few exceptions; DoD-centric projects of a similar design are often repeated. Critical reviews to determine whether other kinds of projects might be more effective are rarely conducted. Recommendations for improving the effectiveness of DoD HA under Overseas Humanitarian Disaster and Civic Aid programs include: ensuring adequate staffing to meet the complex, dynamic nature of humanitarian missions and measuring the effectiveness of each project in mandatory, standardized AARs. For medical HA projects, application of public health strategies would compliment the patient care approach of the majority of medical projects to date. This offers possibilities for enhancing host nation infrastructure, allowing improvements beyond the short period of most military humanitarian projects.     

Performance of military-trained physician assistants on the physician assistant national certification examination

Although the first physician assistant (PA) program was born at a civilian academic institution, the impact of the military was immediately obvious as evidenced by the entire first class of PA students being Vietnam veteran Navy Corpsmen. Following initiation of the PA profession, the armed services established their own PA training programs that were eventually consolidated into a single interservice program in 1996. The mission of the Interservice PA Program is to produce high-quality PAs prepared to provide medical care in not only the traditional clinical arena but in the more unique situations seen in both peacetime and wartime military settings. PAs must complete an approved formal training program encompassing didactic and clinical training and pass a national certification examination to be licensed to practice. Pass rates are a key measure of the quality of a training program. We compared the national certification examination pass rates for our program with those of accredited civilian programs. Graduates of our program had a significantly higher pass rate and higher average scores than their civilian counterparts. These results are due to the strength of the program and faculty as well as the considerable hard work and dedication of the students who are drawn from a community that is, in many ways, non-traditional compared with other PA programs. These results demonstrate that the military training of PAs continues to provide high-quality health care providers who perform above their civilian-trained counterparts.     

Accession standards for attention-deficit/hyperactivity disorder: a survival analysis of military recruits, 1995-2000

A retrospective cohort study was conducted to evaluate the Department of Defense practice of allowing some individuals with a history of attention-deficit/hyperactivity disorder (ADHD) to enter military service (waiving for ADHD). Enlisted recruits who entered active duty with a waiver for academic problems related to ADHD were compared with control subjects who did not reveal health problems before entry, in terms of retention, promotion, and mental health-related outcomes. A total of 539 recruits with a history of ADHD were retained at the same rate as 1,617 control subjects, with no differences in promotion rates, comorbid diagnoses, or mental health-related discharges. On the basis of these findings, the Department of Defense medical accession standards have been changed to allow applicants who reveal a history of ADHD but did not require medication to finish high school or to hold a job for at least 1 year the opportunity to enter active duty without going through the current waiver process.     

The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system

In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties. In the past 2 years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, Soldiers and DoD civilian medical personnel. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization and provides an example of centralized support and oversight of simulation-based medical education.     

Contracting out military health care

The military health care system is currently facing a critical provider supply versus patient demand imbalance. Contracting out health care through the Civilian Health and Medical Program of the Uniformed Services and the Primary Medical Care for the Uniformed Services programs is one approach that Army Medical Department leaders have taken to correct the problem. This article critically analyzes the success of this approach using data from an Army hospital in the eastern United States. The article concludes with three suggestions aimed at improving the current situation.