AIR UNIVERSITY

AIR WAR COLLEGE

Achieving Medical Currency via Selected Staff 

Integration in Civilian and Veterans 

Administration Medical Facilities

THOMAS W. HARRELL

Colonel, USAF, MC, SFS

Air War College

Maxwell Paper No. 68

Maxwell Air Force Base, Alabama

October 2012
2

Disclaimer

Opinions, conclusions, and recommendations expressed or implied within are 

solely those of the author and do not necessarily represent the views of Air 

University, the United States Air Force, the Department of Defense, or any other 

US government agency. Cleared for public release: distribution unlimited.

The Maxwell Papers are available electronically at the Air 

University Press website at http://aupress.au.af.mil.
3

Achieving Medical Currency via Selected Staff Integration 

in Civilian and Veterans Administration Medical Facilities

Col Thomas W. Harrell, USAF, MC, SFS

During Operations Enduring Freedom (OEF) and Iraqi Freedom, 

the Air Force Medical Service (AFMS) contributed to the lowest “died of 

wounds rate” in the history of warfare (less than 10 percent).1 Cuttingedge medical care on the battlefield and revolutionary methods of 

transporting critically wounded patients, once miraculous, are now 

considered routine.2 Simultaneously, while fielded medical forces are 

performing in a heroic manner, garrisoned AFMS providers, particularly 

surgeons and some medical specialists, are struggling to maintain their 

required wartime skills. Relying on just-in-time training and brief ingarrison dwell times coupled with multiple deployments, medical service 

personnel work to sustain skill sets needed for meeting both the active 

duty force’s health needs and the wartime mission.

But when this war is over, how can the AFMS remain medically 

prepared for the next conflict? This contradiction in preparedness and 

performance resulted from two decades of changes in AFMS structure as 

well as the AFMS mission’s duality. How did the AFMS get here? How 

can the system change to sustain skills, provide robust health care to all 

beneficiaries, and retain the expert staff needed for the mission? The 

story stretches back two decades, and a resolution may require looking 

outside the Department of Defense (DOD) to civilian and Veterans Affairs
4

(VA) medical systems where currency-sustaining cases are more 

plentiful. Exploring this avenue may allow the restructuring of the 

current manpower lay down to meet these ends and continue efficient 

beneficiary care.

Setting the Stage

During the Cold War, the DOD maintained a robust medical 

service in preparation for casualties associated with Soviet aggression in 

Europe. Each service sustained significant medical footprints both inside

the continental United States (CONUS) and overseas (OCONUS). To keep 

its aeromedical evacuation (AE) skills honed and maximize the use of its 

massive capacity, the AFMS utilized a highly developed medical air 

transport system to move patients to appropriate military treatment 

facilities (MTF) where they received specialty care if it was unavailable

locally. In 1990 the AE system moved around 70,000 patients a year.3

Near the end of the 1980s, the Soviet Union’s demise flattened the 

defense budget.4 However, health-care costs in both the civilian sector 

and the military health system (MHS) began to rise, driving the industry 

toward managed care. The MHS’s rising costs began to take an 

increasing bite out of defense appropriations—a trend continuing to this 

day. The MHS budget accounts for $50 billion of the DOD fiscal year (FY) 

2011 appropriations. This is a near quadrupling of the FY 1988 MHS 

budget ($14.6 billion), and costs continue to rise at 12 percent/year.5
5

The Soviet Union’s collapse also made it attractive for the United 

States to draw down military power and its budgets. Consequently, the 

AFMS reduced its footprint worldwide which, coupled with base 

realignment and closure recommendations, drove the AFMS from 108 

MTFs (1983) to 75 MTFs (2010), consisting of four medical centers, 10 

hospitals, and 61 clinics.6

Adapting to the New Order Has Consequences

To address costs and maintain health care quality and access for

DOD beneficiaries, the DOD directed a civilian health and medical 

program of the uniformed services (CHAMPUS) reform initiative pilot 

project in 1987 to assess the effectiveness of outsourced health care.7

The law mandates health care for DOD personnel and permits space 

available care for retirees and dependents.8 The pilot proved successful,

and TRICARE was born in the FY 1994 Defense Appropriations Act.9

TRICARE shifted eligible beneficiary care (primarily retirees and 

dependents) to available civilian medical providers in a manner more cost 

effective than the direct care costs incurred by the MTFs. In some 

locales, active duty would also be referred to the network if MTF care was 

not available. TRICARE also allowed the available MTF staff to focus on 

active duty care and the required medical readiness mission. An obedient 

retiree population reluctantly adopted this new way of doing business,

and dependent care started shifting to the civilian sector. An unintended 

consequence of creating TRICARE, downsizing the AFMS, and 
6

conducting base realignments was the dramatic reduction in DOD

physicians’ exposure to complex patients requiring specialty care.

Compared with most Air Force support missions, the AFMS is 

unique in that it has dual readiness and peacetime missions, which have 

almost coequal priority due to the powerful incentive of the health care 

benefit on military recruitment and retention efforts.10 When the AFMS 

maintained a robust inpatient capacity and manpower pool, servicing the 

health care benefit also provided the professional staff with most of their 

medical currency needs. This currency need was used to justify a large 

MHS footprint since the medical providers were fulfilling a dual purpose 

by preparing for war while caring for dependents and retirees, therefore 

producing a marginal cost savings.11 With the aforementioned draw 

downs, this is no longer possible.

In addition to the numerical losses, the medical force mix 

requirements to meet both the healthcare benefit and the readiness 

mission pose challenges. The peacetime AFMS mission emphasizes 

primary care. Primary care needs are best met by a staff heavily weighted 

in family practitioners, pediatricians, and obstetrician/gynecologists. 

This type of health care is delivered chiefly in the ambulatory patient 

care setting. Primary care providers require access to specialized medical 

and surgical care to fully provide for their patients, but a large referral 

population is needed to generate a secondary case load for the 

consultant surgical and medical specialists to maintain viable skills. 
7

With TRICARE and the outsourcing of patient care into the civilian 

network, this referral population has dwindled.

The war readiness mission depends heavily on surgical specialties, 

particularly general and orthopedic surgeons as well as trauma and 

critical care related specialists. These medical/surgical specialties 

depend significantly on an inpatient population with complex medical 

problems.12 The shift in AFMS structure after the Cold War led to a 

reduction in both the number of military hospitals and inpatient bed 

capacity. In 1984 the AFMS inpatient bed capacity was 6,000. In 2006 it 

drifted below 1,000 and is lower today.13

These programmatic shifts pose significant training and currency 

problems for surgical and medical specialists. The current AFMS patient 

caseload and complexity mix falls significantly short in several areas of 

providing the types and volume of cases recommended by medical 

professional and self-generated AFMS standards to maintain the required 

staff medical skills sets. The AFMS-assigned medical staff struggles to 

maintain their respective wartime skills. A large body of literature 

indicates the volume of experience and exposure to complex cases has a 

significant impact on the outcomes of surgical and medical care.14 One

study in particular demonstrated a reduction from 60 to 25 percent

mortality for patients in shock from penetrating abdominal trauma 

(predominantly gunshot wounds) when seen in high-volume trauma 

centers when compared to lower volume facilities.15
8

Additional experience also improves outcomes during subsequent 

periods of lower patient care volume.16 As early as 1985, analysis showed 

that only a few Air Force surgeons were regularly exposed to wartime 

relevant cases. Peacetime procedure rates were also only a fraction of the 

rate needed to maintain wartime skills.17 Surveys of general surgeons in 

1985 showed more than 20 percent of surgeons were not comfortable 

with a range of combat type procedures such as anastomosis of 

peripheral vessels, lobectomy of the lung, liver resection, and urinary 

bladder repair believing they would need to “brush-up” before going to 

war.18 Notably, this information was known before the bulk of TRICARE

patient shifts and reductions had taken full effect.

More recently in 1995, the Congressional Budget Office concluded 

the MTF-furnished care during peacetime bore little resemblance to the 

care required by wartime. Most military physicians had limited

opportunities for wartime mission preparation.19 To illustrate this, a 

comparison of the current prevalent medical and surgical diagnoses and 

procedures between in-garrison MTFs and OEF are listed in figure 1.
9

Figure 1. Medical and surgical diagnoses/procedures in-garrison vs. 

OEF (Adapted from Joint Theater Trauma System, August 2010, and Air 

Force Medical Operations Agency, Medical Services Directorate, May 

2010).

There is little similarity between the in-garrison MTF and OEF case 

loads. The striking difference is exactly why alternative avenues to 

sustain relevant medical and surgical currency are needed. Presently, Air 

Force surgeons and physicians are spending considerable time in theater 

operating on a large volume of patients. This wartime exposure sustains

their skills while rotating back to lower volume in-garrison care. When 

this higher paced wartime exposure subsides, mechanisms are needed to

continue providing adequate exposure to complex caseloads that are 

currently lacking in most MTFs.

The Challenge

Notwithstanding the currency difficulties, the readiness mission 

requires specialized physicians, particularly surgeons and medical 
10

subspecialists and their support staff, be maintained to face war as well 

as humanitarian missions. How can the AFMS maintain both the 

appropriate numbers and skill sets of this medical staff within a system 

that currently cannot support the required currency needs? Although the 

last two years have seen great strides with enhanced surgical currency 

by optimizing operating room efficiencies, increasing patient throughput, 

and bringing more complex cases into selected MTFs, the required 

clinical volumes remain lacking as seen in figure 2.

Figure 2. General surgeon (Adapted from “Operating Room Assessment 

and Process Improvement Project: Phase 1 of the Surgical Services 

Continuous Improvement Project” [briefing to AF/SG, Washington DC, 

24 August 2010]).
11

This single AFMS MTF example suggests the number of cases 

required for physician currency is severely below the recognized

standard. Despite optimization efforts, no self-sufficient AFMS surgical 

program currently meets the need. AFMS medical center surgical and 

medical specialists are faring better than their colleagues at smaller 

MTFs, but they often moonlight in civilian medical institutions near their 

MTF to increase their complex case exposure. It is probable when these 

military physicians rotate to smaller regional hospitals for a two to three 

year rotation, their skill sets diminish, and if not rotated back to a higher 

volume facility, a vicious spiral of skill diminution can begin.

To help manage this issue, the AFMS requires surgeons and 

medical specialists to attend predeployment “just-in-time training” at a 

center for sustainment of trauma and readiness skills location in 

Baltimore, St. Louis, or Cincinnati. It provides a two to three week 

immersion in wartime skill sets. Another avenue, the sustainment of 

trauma and resuscitation skills program (STARS-P), provides short

rotations in civilian trauma centers or high-volume hospitals near an 

MTF. The current STARS-Ps are at the following locations: San Antonio 

Military Medical Center, Texas; Nellis AFB, Nevada; Wright-Patterson 

AFB, Ohio; Travis AFB, California; and Luke AFB, Arizona. The first four 

serve also as AFMS medical centers.20 The AFMS surgical consultant also 

secured the ability to waive time-on-station requirements for selected 

surgical and medical specialists to allow their relocation back to a larger 
12

MTF after as little as two years when they have been assigned at a low 

volume, low acuity hospital setting.21

A Concept and Recommendations

Although improving operating room efficiencies, providing just-intime training, and setting up intermittent rotations are all positive steps 

in shoring up the needed medical skill sets, a more durable solution 

needs consideration. Medical currency needs could be maintained by 

integrating segments of the health profession staff into existing large 

volume civilian and VA medical facilities through a deliberate, multi-year 

rotational plan that expands the Center for Sustainment of Trauma and 

Readiness Skills (C-STARS)/STARS-P concepts. Physicians would enter a 

cycle of rotating into a civilian center, then moving back to the AFMS at a 

higher volume location before finally shifting to a smaller facility. The 

integration of doctors, nurses, and technicians into this cycle is

desirable, but existing professional certification requirements, labor 

union concerns, and scope of practice differences involving the nursing 

and technician fields make it easier to focus only on the physicians first.

This model would not jeopardize the AFMS health care benefit as 

currently envisioned. In locations where robust civilian network care 

exists, beneficiaries would receive care from civilian providers as they do 

now. Integration into civilian and VA medical centers for currency could 

also provide an avenue for realignment of select primary care and 

specialty services at underserved CONUS locations where the civilian 
13

care network is sparse and OCONUS installations where host-nation 

health care can prove problematic due to language, standard of care, and 

cultural differences. Finally, opportunities provided by this integration 

model would decrease the dissatisfaction of many current AFMS 

providers as it relates to their inability to consistently employ the

procedures for which they were trained and are expected to deliver to the 

battle wounded. This would likely lead to higher physician job 

satisfaction, retention, and recruitment. Although this integration 

concept might be new for the American MHS, it isn’t without successful 

precedent.

A Proven Integration Model

In the 1990s, the United Kingdom (UK) integrated its MHS into its 

civilian health care system.22 The UK’s decision was made in an 

environment similar to the current US MHS—rising health care costs and 

redundancies between the services’ medical branches and the civilian 

community. Prior to 1994, the British Defence Medical Service 

maintained a network of hospitals and outpatient clinics analogous to 

the US MHS. Today, they continue to employ a few primary care 

focused—mostly aviation medicine related—outpatient MTFs, but their 

specialized medical officers practice full time in civilian hospitals or as 

part of imbedded Ministry of Defence (MoD) hospital units (MDHU) until 

required for deployed military duty.23 Military inpatients are treated in 
14

the civilian sector or in one of six MDHUs located within civilian facilities 

as opposed to maintaining stand alone hospitals.24

For over 10 years, this stable construct has undergone favorable 

annual reviews as directed by the MoD and British law. It is suggested 

that the combined military/civilian system has reduced the MoD’s health

care budget by cutting operations and facilities maintenance costs as the 

MoD no longer maintains large facilities with mostly empty wards. Also, 

medical treatment capabilities are not duplicated as a result of individual 

service desires but are instead apportioned based on actual demand in 

MDHUs, which can also be used to treat civilian patients when the 

military beneficiary patient census drops. The Royal Medical Service 

(RMS) medical specialist officers (surgeons, anesthetists, and medical 

subspecialists) enjoy a practice that produces reliable patient volume, 

complexity, and acuity since they function within civilian centers and 

treat both military and civilian patients. In this way, even if the military 

beneficiary demand decreases, they still regularly apply their skill sets. 

The civilian centers benefit because they avoid paying the RMS medical 

officer’s salary. As for medical liability, it is a far simpler issue in the UK 

as compared to the United States in that there is nationalized health care 

in the form of the National Health Service (NHS). Physician credentialing 

is also simplified by the presence of a single, national licensing and 

accrediting body, the General Medical Council (GMC). Both these issues 

would be more complex to negotiate within the United States, but 
15

solutions are possible, albeit a full discussion is outside the scope of this 

paper. However, utilizing the VA system as an initial integration site may 

prove a workable first step and smooth the way forward while not directly 

addressing these two issues.

Hurdles—Systems Issues

Like the British, the US MHS is reluctant to move toward 

enterprise-wide civilian integration. To this point, individual MTFs 

engage in mutually beneficial relationships based mainly on the local 

leadership team’s strength and vision but have often seen good working 

agreements fall by the wayside with the inevitable staff rotation. The 

hesitancy to move toward an integrated system is understandable as the 

US MHS must contend with several challenges that were either not 

factors in the UK or were easier to overcome.

The most obvious impediment to integration is the lack of a 

national unified health care system. The existence of a UK federalized 

health care system made the integration far easier. The NHS regulatory 

practices are similar to the MoD; all physicians practicing in the MoD are 

required to meet national professional standards and licensure 

established by the NHS and the overarching regulatory body, the GMC.25

Within the United States, though national professional organizations 

such as the American College of Surgeons and the American College of 

Cardiology exist, their established standards are nonbinding. Instead, 

each state maintains a board of medical examiners, which establishes 
16

that state’s medical practice criteria. Even though there are significant 

similarities between the states’ boards, licensure reciprocity similar to 

driver’s licenses is nonexistent. The mobility of military physicians has 

been accommodated by allowing portability of a medical license as long 

as care is delivered in a military facility.26

Hurdles—Liability

Medical malpractice also presents a formidable challenge. In the 

UK, all liability fall under the NHS and the GMC regardless of the 

practice venue. Thus MoD physicians are covered regardless of where 

they deliver their care.27 Within the United States, the responsibility for 

liability coverage rests with the individual practitioner or the facility 

where the medical practice occurs. Military physicians receive their 

liability protection from the federal government and are afforded 

protection under the Feres Doctrine, arising from the Federal Tort Claims 

Act (FTCA). The FTCA makes the United States liable for injuries caused 

by the negligent or wrongful act or omission of any federal employee 

acting within the scope of his/her employment, in accordance with state 

law where the act or omission occurred.28 In case law stemming from 

Feres v. United States, 340 US 135 (1950), the Supreme Court and lower 

courts have held that suit cannot be brought against military medical 

personnel due to the federal nature of the relationship between the 

government and military personnel, and the Veterans’ Benefits Act 

compensation scheme, which substitutes for tort liability, a statutory “no 
17

fault” compensation scheme providing generous pensions to injured 

servicemen without regard to any negligence attributable to the 

government.29

If a US military physician practiced on behalf of the MHS in a 

civilian facility on civilian patients, this indemnification would no longer 

exist. The remedy would be to construct agreements that account for this 

circumstance. Another more immediate solution would be to pursue 

currency patient care within the VA medical centers. The US MHS 

relationship with VA medical centers is analogous with the MoD and the 

NHS in several respects. If suit was brought against an Air Force 

physician, the VA would work the case along with the US attorney's 

general office as opposed to the Air Force judge advocate general.30 The 

AFMS will also have to determine which specialties are best suited for 

integration and which medical services could undergo reorganization to 

make integration feasible, effective, and efficient.

Hurdles—Defining the Need

Integrating AFMS physicians into the civilian or VA health care 

system would provide a sustainable avenue for wartime skill set

maintenance. The first step is identifying the specialties of greatest need 

whose requisite procedural numbers cannot be obtained. Using existing 

battle injury data, the greatest demand in the surgical arena is for

orthopedic and general surgeons. More highly specialized neurosurgeons 

and vascular surgeons are also required, but this cohort group’s size is 
18

measured in single digits, and as a result, their currency training is 

easier to achieve in existing large MTFs and other mechanisms.

Conversely, general surgeons perform a wide scope of damage 

control and trauma related surgery, and as a result, it is critical they be 

exposed to a larger case volume of sufficient complexity to keep their 

skills both honed and diversified. In the AFMS today, as previously noted 

in figures 1 and 2, these surgeons do not approach the required case 

levels and in garrison, perform procedures that do little to prepare them 

for a war.

The same may be said for thoracic, trauma, and orthopedic 

surgeons. Further, within the medical specialties, critical care trained 

physicians are also in high demand. The level of in-theater surgical and 

critical care now equals or exceeds what can be found in US Level I 

trauma centers. It is now common for wounded warriors to get state-ofthe-art polytrauma critical care in theater. Pulmonologists and critical 

care trained internists also are essential to trauma care. Both medical 

specialties have suffered from a medical currency perspective as a result 

of the dwindling inpatient bed capacity and the loss of the retiree 

population, which often presents for medical care with complex, 

multiproblem disorders. Consequently, from a demand-driven 

perspective, these seven surgical and medical specialties represent the 

best starting place for integration outside the AFMS health care system.
19

Hurdles—Defining the Force Mix

The next issue is deciding how many civilian/VA positions would 

be appropriate for rotations outside of MTFs throughout the physician’s 

career cycle while providing the DOD required number of staff to support 

wartime deployments. Based on the existing deployment posture and 

anticipated combat and humanitarian mission sets, it is suggested that 

placing 20 percent of the seven aforementioned specialties into

civilian/VA employment for two to three year rotations is reasonable.31

Currently, 129 general, thoracic, and trauma trained surgeons serve the 

AFMS based at 25 Air Force and joint locations. Creating 25 integrated 

positions through which the surgeons would rotate would maintain 

currency and provide the required forces. For orthopedic surgeons, 

including traumatologists, the same calculation would yield 13 positions. 

Within the medicine specialties, 25 integrated internal medicine and two 

additional pulmonary/critical care positions would support the concept. 

These 65 manpower slots could be achieved within the existing end 

strength requirements and/or by reallocating existing MTF positions. 

This reallocation will be discussed later.

Solutions—System/Liability

As referenced earlier, the US MHS faces legal and procedural 

hurdles in developing this integrated model. These were not stumbling 

blocks for the MoD and UK. If the current move toward medical 

insurance reform continues, the United States could eventually realize a 
20

nationalized health system. Another possibility is the complete 

integration of the existing DOD and VA systems. This would consolidate 

the indemnification process, expand the patient pool for DOD providers, 

and create a robust manpower platform by combining the civilian and 

military staffs to simultaneously deliver in garrison care while

maintaining a deployment pool.

Regardless of the MHS’s and AFMS’s future state, integration is 

desirable. A 2008 RAND study explored the broad feasibility of military 

medicine to integrate into civilian institutions for the purpose of 

maintaining currency for its physicians. She found civilian institutions 

willing to embrace the concept.32

Solutions—Credentialing

If integration proceeded, physician licensure requirements would 

need addressing. A US national health system would most certainly 

increase license portability as it would likely federalize the accountability 

system. In lieu of a federalized licensing system, state medical boards 

might increase reciprocity agreements (even for a trial period and at least 

for the selected specialties) in a manner analogous to the interstate 

acceptance of a driver’s license. This would undoubtedly take some time.

In the proposed system of deliberate rotation for two to three years, 

the degree of predictability would facilitate applying for and receiving 

licensure in the appropriate state even though this may take several 

months. The fees for a medical license range from the low hundreds to 
21

several hundreds of dollars.33 AFMS or the civilian facility could bear the 

cost licensure, the latter option being made possible by the revenue 

generated by the Air Force physician practicing within the facility. In an 

experimental currency project based out of the RAF Lakenheath,

England MTF, inbound physicians were able to achieve licensure before 

or shortly after arrival. If this degree of cooperation is achievable with a 

foreign country’s regulatory structure, it seems the same could be 

achieved within the United States.

Liability for medical practice would be another major sticking 

point. As previously discussed, a vehicle filling the gap created by a 

military physician practicing outside the FCTA and Feres doctrine

umbrella needs development. In this case, civilian institutions are willing 

to provide the liability insurance coverage analogous to nonmilitary 

practitioners. A training affiliation agreement (TAA) can be constructed 

such that the civilian facility agrees to pay for the indemnification. The 

University of Pittsburgh Medical Center and the University of Alabama at 

Birmingham hospital have such a pilot project covering a handful of Air 

Force physicians. These facilities provided the indemnification contingent 

upon the Air Force physician’s continued good standing. This TAA 

arrangement is possible due to the financial advantage achieved by the 

civilian institution since employed physicians generate revenue without 

also generating a salary cost. One could envision a continuum of liability 

and salary negotiation providing a cost advantage to both the AFMS and 
22

the civilian institution. A TAA would allow a civilian medical facility to bill 

for all services provided by the AFMS physician, except in the case of 

DOD beneficiary treatment in which case all ancillary services would be 

billable. The physician’s fees would be exempted since a DOD physician 

would be caring for a DOD beneficiary.

Air Force physician credentialing and privileging are nearly 

identical to their civilian counterparts. All medical training is primary 

source verified. Previous practice patterns, as well as peer and supervisor 

evaluations, are reviewed in light of the requested practice capabilities. 

The civilian facility, just as a military one, would have the ability to 

refuse employing a military physician who doesn’t meet standards. 

Furthermore, a physician could be dismissed from the medical staff, just 

as their civilian counterpart, for substandard medical performance or 

inappropriate conduct.

Solutions—Integration of staff

Since AFMS physicians would provide augmentation of existing 

civilian staffs free of a payroll burden, civilian facilities would quite 

readily accept the loss of these physicians in the event of a national 

emergency requiring their deployment. In fact, the RAND survey report 

revealed civilian medical facilities were not overly concerned about the 

risk of deployment, and the impact on staffing though patient 

apportionment to the DOD staff physicians would have to be addressed 
23

to minimize patient care disruption should a DOD physician be 

unexpectedly pulled away for military duties.34

Solutions—Restructuring AFMS Manpower/Services

The deliberate two- to three-year rotation of selected specialties 

outside of the DOD into civilian/VA medical facilities for the maintenance 

of currency is possible and would likely result in greater skill 

sustainment compared to the RAND study’s suggested program,

consisting of shorter rotations and resembling the current STARS-P 

construct.35 To achieve the required numbers mentioned earlier without 

increasing end strength, it would be necessary to consolidate surgical 

and medical specialties in markets that could flourish within the AFMS. 

This process is already underway with the present surgical optimization 

program. Within the scope of this current optimization endeavor, market 

studies were performed indicating the best existing locations, depicted in 

figure 3, where currency could be captured.
24

Figure 3. AFMC currency platforms (Adapted from Air Force Medical 

Operations Agency/Medical Services Directorate, May 2010).

An enterprise-wide currency solution would require creating billets 

in the civilian institutions. If not achievable by consolidating and shifting 

of the specified specialty billets, it is proposed those billets be garnered 

from a selective reduction of MTF services in markets with robust 

network services. In those locations, MTF functions could be reduced to

offer only Air Force specific skill sets not available in the civilian 

community such as flight medicine, public health, and occupational 

health related functions. This kind of market may be found at Dover 

AFB, Delaware; Hanscom AFB, Massachusetts; Hickam AFB, Hawaii; 

and Little Rock AFB, Arkansas where a robust local network exists for 

pediatric, obstetrics/gynecology and selected non-Air Force mission 

essential services. The manpower authorizations gained in these selected 
25

locations could be utilized to create the estimated 65 positions needed to 

maintain currency across the most critical skills sets. More careful study 

would be required, but medical force rebalancing could provide the 

integration positions and maintain or bolster required AFMS support at 

locations where network care is nonexistent or too distant, such as 

Holloman AFB, New Mexico or in overseas locations where the ability to 

achieve host nation care is hampered by language barriers, or is not in 

keeping with the standard of care expected by US beneficiaries.

Solutions—Impact on Recruitment/Retention

In addition to increased proficiency, there may be a significant 

positive impact in another area: morale and retention. In AFMS surveys 

on physicians leaving the service conducted in 2009 and 2010, 

professional satisfaction ranked second only to administrative burdens 

and staffing concerns as the reason most influencing a decision to leave 

military medicine.36 The lack of professional satisfaction was closely 

linked to the limitations on the scope of practice. Though the survey 

results were not statistically significant, they do contend that the 

physician’s inability to practice their full range of procedures and 

maintain their critical skill sets is a huge retention disincentive. It is this 

same lack of the scope of practice that adversely impacts the surgeons’ 

maintenance of their wartime readiness that provides reason to explore 

alternatives to the existing system. Integration into the civilian/VA health
26

care system will provide a pool of physicians immediately capable of 

sustaining their battlefield medicine skill set.

Conclusion

The AFMS has always provided excellent health care to its 

beneficiaries in garrison. The health benefit remains one of the strongest 

attractants to military service in addition to the patriotism of the allvolunteer force. However, the 1990’s peace dividend and the resultant

AFMS restructuring placed the AFMS in a precarious position for 

sustainment of wartime skills. AFMS personnel have produced 

phenomenal results in caring for the wounded, but the consummately 

skilled staff we have currently is a fortunate but unintended outcome of 

our sustained high deployment rates. With diminished exposure to 

appropriate case volume and complexity in garrison, the staff has 

sustained this excellent performance almost by accident. The rapid 

rotational schedules with short in garrison dwell times have kept them 

operating at the front. We need to create a system that is self-sustaining 

without relying on a wartime pace. We need to fill the in garrison time 

with a more meaningful practice that provides predictable war skills 

training. Deliberate integration into existing civilian and/or VA systems 

featuring robust trauma and complex case loads would provide the 

needed predictable training opportunity. The potential hurdles of 

licensure, liability, credentialing, and privileging are all surmountable,
27

and even now, pilot TAAs have been generated to explore prospects for 

success.

A deliberate two- to three-year rotation would greatly sustain and 

enhance existing skill sets and rebuild those reduced by rotations to 

smaller facilities where AFMS care must be maintained to support the 

beneficiary population. A rotation from high volume civilian/VA medical 

facilities back to viable AFMS platforms would distribute skills to more 

junior staff and act as a positive motivation toward retention. The 

AFMS’s readiness depends on capable staff. They need to be positioned 

where they can achieve this status and, at the same time, continue their 

exceptional service to the beneficiary population.

Notes

1. Lt Gen Bruce Green, "Air Force Medical Service, Rebuilding Our 

Surgical Capabilities," (address, Society of Air Force Clinical Surgeons,

Biloxi, MS, 2010), slide 9.

2. Lt Gen Bruce Green, "Testimony before the House 

Appropriations Committee, Subcommittee of Defense," 111th Cong., 2nd

sess., 2010, 6–7.

3. Mark Diamond, "Global Security Military News," Global Security,

25 August 2003,

http://www.globalsecurity.org/military/library/news/2003/08/mil030825-amc02.htm (accessed 28 January 2011), 1.
28

4. Executive Secretary for the Secretary of Defense, "Annual Report 

1995," February 1995, 

http://www.dod.mil/execsec/adr95/budget_5.html (accessed 6 

December 2010), 1.

5. Robert F. Hale (under secretary of defense [comptroller] and 

chief financial officer), interview by author, Maxwell AFB, Alabama (31 

August 2010); Congressional Budget Office (CBO), "A CBO Study: Growth 

of Medical Spending by the Department of Defense," CBO, September 

2003, http://www.cbo.gov/ftpdocs/45xx/doc4520/09-09-

DoDMedical.pdf (accessed 6 October 2010), 1; and Don J. Jansen, 

"Military Medical Care: Questions and Answers," Federation of American 

Scientists, 14 May 2009, http://www.fas.org/sgp/crs/misc/RL33537.pdf 

(accessed 6 October 2010), 0, 4–5.

6. Susan D. Hosek, Joan L. Buchanan, and George A. Goldberg,

Reconciling Air Force Physicians' Peacetime and Wartime Capabilities: 

Demonstration of a Workforce Design Methodology, Office of the Secretary 

of Defense Analysis, National Defense Research Institute, and RAND 

Health, RAND Report R-3202-AF (Santa Monica, CA: RAND, August

1985), 1; and Air Force (AF)/Surgeon General (SG) Commanders Action 

Group, "U.S. Air Force Medical Service Snapshot," AF/SG, Washington 

DC, 2010, 1.
29

7. Robert F. Hale, "Champus Reform Initiative," CBO, 12 March

1987, http://www.cbo.gov/ftpdocs/94xx/doc9405/87doc80.pdf 

(accessed 18 January 2011), 2.

8. Congress of the United States, "Cornell University Law School 

U.S. Code 10 1074," 1 February 2010, 

http://www.law.cornell.edu/uscode/uscode10/usc_sec_10_00001074---

-000-.html (accessed 28 January 2011).

9. National Defense Authorization Act for Fiscal Year 1994, 103rd 

Cong., 1st sess., 5 January 1993, http://thomas.loc.gov/cgibin/query/F?c103:1:./temp/~c1039aWTI4:e447553: (accessed 6 

December 2010); and Lt Col Brian King, “Task Force on the Future of 

Military Healthcare” (briefing, secretary of defense, subcommittee of the 

defense health board, Washington, DC, 2007), 1.

10. William M. Hix and Susan Hosek, Elements of Change in 

Military Medical Force Structure: A White Paper, OSD Analysis (Santa 

Monica, CA: RAND, 1992), iv; and King, “Task Force on the Future of 

Military Healthcare,” 2.

11. Hix and Hosek, Elements of Change, vi-vii.

12. Ibid.

13. Lt Gen George Taylor, "Your AFMS: On the Right Flight Path" 

(briefing, 2006 Tricare Conference, Washington, DC, 2006), slide 62.

14. M. M. Chowdhury, H. Dagash, and A. Pierro, "Systematic 

Review of Impact of Volume of Surgery and Specialization on Patient 
30

Outcome," British Journal of Surgery 94, no. 2 (2007): 145–61; W. G.

Henderson et al., "Comparison of Risk-Adjusted 30-Day Postoperative 

Mortality and Morbidity in Department of Veterans Affairs Hospitals and 

Selected University Medical Centers: General Surgical Operations in 

Men," Journal American College Surgeons 204, no. 6 (June 2007): 1,103–

14; and Ethan A. Halm, Clara Lee, and Mark R. Chassin, "Is Volume 

Related to Outcome in Health Care? A Systematic Review and 

Methodolgical Critique of the Literature," Annals of Internal Medicine 137, 

no. 6 (September 2002).

15. Avery B. Nathans et al., “Relationship between Trauma Center 

Volume and Outcomes,” Journal of the American Medical Association, 7 

March 2001, http://jama.amaassn.org/content/285/9/1164.full.pdf+html (accessed 28 January 

2011), 1,167.

16. Hosek, Buchanan, and Goldberg, Reconciling Air Force 

Physicians' Peacetime, 58–61.

17.Ibid., 57.

18. Ibid., 7–10.

19. CBO, Restructuring Military Medical Care, Report to the House 

Committee on National Security (Washington, DC: CBO, 1995), xi.

20. AF/SG, Air Force Expeditionary Medical Skills Institute, 13 

September 2010,

http://airforcemedicine.afms.mil/idc/groups/public/documents/webco
31

ntent/knowledgejunction.hcst?functionalarea=CSustainmentTARS&doct

ype=subpage&docname=CTB_035119 (accessed 13 September 2010).

21. Lt Col Alan Murdock, Air Force medical service surgical 

consultant, San Antonio, Texas, interview by the author, 22 November 

2010.

22. House of Commons, "Defence Seventh Report Session 2007–

2008," 18 February 2008,

http://www.publications.parliament.uk/pa/cm200708/cmselect/cmdfe

nce/327/32704.htm#a3 (accessed 17 November 2010), 2.

23. Royal Air Force Britain, "Royal Air Force Medical Officer," 

December 2009, 

http://www.raf.mod.uk/careers/rafcms/mediafiles/70A687C4_5056_A3

18_A808EE691A4ED800.pdf (accessed 3 October 2010), 13.

24. Healthcare Commission, "Defence Medical Services: A Review 

of Clinical Governance of the Defence Medical Services of the UK and 

Overseas," NHS, UK, March 2009, 

http://www.nhs.uk/NHSEngland/Militaryhealthcare/Documents/Defen

ce_Medical_Services_review%5B1%5D.pdf (accessed 6 December 2010), 

6.

25. Ministry of Defence, “Ministry of Defence Special Recruitment,” 

28 January 2011, 

http://www.mod.uk/DefenceInternet/DefenceFor/Jobseekers/CivilianC

areers/SpecialistRecruitment.htm (accessed 28 January 2011).
32

26. Congress of the United States, “Cornell University Law School.”

27. General Medical Council, “Licensing,” 28 January 2011,

http://www.gmc-uk.org/doctors/licensing.asp (accessed 28 January 

2011); and House of Commons, “Use of Overseas Doctors in Providing 

Out-of-Hours Services,” para 6, 28 January 2011, 

http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhea

lth/441/441we06.htm (accessed 28 January 2011).

28. Henry Cohen and Venessa K. Burrows, "CRS Report for 

Congress 95-717," Federation of American Scientists, 11 December 2007,

http://www.fas.org/sgp/crs/misc/95-717.pdf (accessed 17 November 

2010), 1.

29. Ibid., 4–9, 12–16.

30. Hildegarde Conte Perlstein, attorney, interview by the author, 

30 November 2010.

31. Murdock interview, 22 November 2010.

32. Christine Eibner, "Maintaining Military Medical Skills during 

Peacetime Outlining and Assessing a New Approach," RAND, 2008,

http://www.rand.org/pubs/monographs/2007/RAND_MG638.pdf 

(accessed 15 September 2010), x.

33. Federation of State Medical Boards, “Federation Credentials 

Verification Service,” 12 December 2010, 

http://www.fsmb.org/fcvs_state_specific_req.html (accessed 12 

December 2010).
33

34. Eibner, “Maintaining Military Medical Skills,” xi.

35. Ibid., 5.

36. Erwin Gines, Air Force Medical Corps exit interview, AF/SG1M,

Air Force Medical Service, 2010.