The education mission of the 

army medical department

October – December 2010 

Commander’s Introduction 1 

MG David A. Rubenstein 

How Science and Technology Will Enhance Medical Education and 4 

Training by the Year 2039 

COL Randall G. Anderson 

Effects of Using Human Patient Simulator Versus a CD-ROM on 9 

Learning the Management of Patients Exposed to Chemical Agents 

Don Johnson, PhD; Amanda Flagg, PhD; Theresa L. Dremsa, PhD 

Training Forward Surgical Teams: Do Military-Civilian Collaborations Work? 17 

Carl I. Schulman, MD; Jill Graygo, MA; Katherine Wilson, PhD; 

LTC Donald Robinson; LTC George Garcia; Jeffrey Augenstein, MD 

Veterinary Surveillance Laboratories: Developing the Training Program 22 

Staci L Mitchell; SSG Katasha T. McCline; LTC Margery M. Hanfelt 

Leveraging Affective Learning for Developing Future Airmen 25 

Col Donald Tharp, USAF; Anthony Gould, PhD; Col (Ret) Robert Potter, USAF 

Problem-Based Learning Preparation for Physician Assistant Faculty 39 

MAJ George S. Midla; Joellen E. Coryell, PhD 

Critical Thinking Skills: Do We Have Any? 48 

Carol F. Hobaugh, PhD 

Assessment-Based Instruction 63 

Stephanie Hamilton, MEd 

If You Want to Know Why Students Fail, Just Ask Them 65 

Carita DeVilbiss, PhD; Valerie J. Rice, PhD; Linda Laws; Petra Alfred 

Understanding the Leadership and Cultural Dimensions of 73 

Strategic Healthcare Policy-Making in Iraq 

LTC Thomas S. Bundt 

The School for Advanced Military Studies: An Untapped Resource for the 78 

Army Medical Department 

MAJ Jon E. Baker; MAJ Jason R. Sepanic 
LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 

October – December 2010 The Army Medical Department Center & School PB 8-10-10/11/12 

Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1 

A Professional Publication 

of the AMEDD Community 

The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for 

The Surgeon General by the US Army Medical Department Center & School, ATTN 

MCCS-HT, 2419 Hood St STE C, Fort Sam Houston, TX 78234-7584. 

Articles published in The Army Medical Department Journal are listed and indexed in 

MEDLINE, the National Library of Medicine’s premier bibliographic database of life 

sciences and biomedical information. As such, the Journal’s articles are readily 

accessible to researchers and scholars throughout the global scientific and academic 

communities. 

CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive 

copies, and unit address changes or deletions should be sent to the Journal at the 

above address. Telephone: (210) 221-6301, DSN 471-6301 

DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional 

information to expand knowledge of domestic & international military medical issues 

and technological advances; promote collaborative partnerships among Services, 

components, Corps, and specialties; convey clinical and health service support 

information; and provide a peer-reviewed, high quality, print medium to encourage 

dialogue concerning healthcare initiatives. 

Appearance or use of a commercial product name in an article published in the 

AMEDD Journal does not imply endorsement by the US Government. 

Views expressed are those of the author(s) and do not necessarily reflect official US 

Army or US Army Medical Department positions, nor does the content change or 

supersede information in other Army Publications. The AMEDD Journal reserves the 

right to edit all material submitted for publication (see inside back cover). 

CONTENT: Content of this publication is not copyright protected. Material may be 

reprinted if credit is given to the author(s). 

OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical 

Department units and organizations, and other members of the medical community 

worldwide. 

By Order of the Secretary of the Army: 

Official: 

1027802 

GEORGE W. CASEY, JR 

General, United States Army 

Chief of Staff

DISTRIBUTION: Special 

Administrative Assistant to the 

Secretary of the Army 

JOYCE E. MORROW 
 October – December 2010 1

Perspectives Perspectives

The Army Medical Department Center and School is, 

first and foremost, an educational institution. For many 

years it has been charged with imparting the knowledge 

and skills necessary to ensure our country’s Warriors 

receive the finest medical care possible, wherever and 

whenever it is needed. That mission is currently expanding dramatically as the facilities morph into the allservice Medical Education and Training Campus, 

centralizing all basic and most specialized enlisted 

military medical education at one location at Fort Sam 

Houston, Texas. It is, therefore, both appropriate and 

timely to publish an issue of the AMEDD Journal highlighting various aspects of the education responsibilities 

and functions within the Army Medical Department. 

Definitions of the verb “educate” vary somewhat from 

source to source, but such variations are largely in style. 

Consolidating the kernels of those definitions, one finds 

that educate means: 

To provide with training or knowledge, especially 

via formal schooling. 

To provide with training for a specific purpose, as 

a vocation. 

To provide with information. 

To stimulate or develop the mental or moral growth. 

The AMEDD Center and School (AMEDDC&S) fulfills 

every element of that definition in the education of all of 

its students. Indeed, as with all military service schools, 

students must attend classes in leadership, responsibility, 

ethics, and morality, in addition to professional skill 

knowledge, something that is rare today in many civilian 

learning environments. We are proud of the military 

healthcare professionals that leave our school to join 

America’s Warriors throughout the world. 

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 

EDITORS’ PERSPECTIVE

COL Randall Anderson opens this issue of the AMEDD 

Journal with an overview of one area of a collaborative 

“brainstorming” effort by a large group of AMEDD 

subject matter experts to project AMEDD’s operating environment 30 years in the future. COL Anderson focuses 

on their ideas with regard to how AMEDD will educate 

and train medical personnel, based on trends in education, 

healthcare, and the military. The ideas are at once 

intriguing, exciting, and obviously challenging, because 

major adjustments to design and delivery of academic 

material would be forthcoming, along with a greater 

emphasis on the individual student’s ability to accept, 

process, and learn the necessary information. Further, 

students’ aptitudes, skills, and mental capabilities would 

be matched to a suitable occupational specialty to ensure 

their education optimizes their contributions to the health 

and well-being of our military personnel. This article 

provides excellent insight, not only into where we should 

be going, but also where we are, in that all the ideas are 

based on present technical and educational initiatives and 

trends. A good read which should encourage all military 

medical professionals to obtain and read The AMEDD 

Futures 2039 Project: Phase 2 Final Report. 

An excellent example of the rapid advances in the 

capability and sophistication of technology in medical 

education is the expanding use of human patient simulation in many venues. Dr Don Johnson and his coauthors 

compared the efficacy of the simulation against self-paced 

instruction using a CD-ROM based syllabus in a very 

specific circumstance—management of patients exposed 

to chemical agents. During their preparatory search of the 

extensive literature on simulation use in medical 

education, they found no rigorously designed studies that 

had made such comparisons. Therefore, their study is apparently the first to apply scientific rigor in the collection 

of data on which to base comparative conclusions. Their 

article presents a detailed description of the carefully 

designed and executed study which used Army and Air 

Force nurses as the sample population to investigate 

teaching this specialized element of trauma care. Absent a 

major accident or natural disaster involving release of 

chemical agents, the occurrence of patients with such 

injuries is rare, so healthcare providers have been largely 

limited to printed and computer-based courses and 

exercises to obtain their expertise in this area. Effective 

simulation provides the interactive environment with the 

benefit of actual feedback to the actions of the student. 

Intuitively it would seem obvious that the student obtains 

the greater benefit from the simulation scenario. 

However, the considerable expense of purchasing and 

maintaining the simulators dictate that their value must be 

justified by performance data. The study by Dr Johnson et 

al is an important component in planning the future 

course of the education of healthcare professionals. 

In an effort to ensure healthcare providers experience the 

most effective training possible in preparation for combat 

deployment, in 2001 the Department of Defense initiated 

the establishment of several joint trauma training programs in existing civilian trauma centers. The centers are 

located in areas with a high occurrence of combat-like 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Perspectives 

trauma injuries, thus allowing military medical providers 

exposure to such actual injuries prior to deployment into 

the combat environment. On the surface, the program 

would seem to be an excellent idea, but do actual experiences of participants support the commitment of time and 

resources? Dr Carl Schulman and his team at the Army 

Trauma Training Center in Miami, Florida, conducted a 

scientific survey of participants following their return 

from combat deployments to gather their opinions as to 

the value of the training, and suggestions on improving 

the training experience. The survey sample represented 

over 2 years of training participants. The excellent article 

contributed by Dr Schulman et al provides an overview of 

the joint training effort, and presents the results of their 

study. Again, validation of a concept is a valuable 

contribution to planning for the future commitment of 

resources to our medical training efforts. 

Army medical professionals have never hesitated to aggressively pursue solutions to better protect the health of 

our military. The safety of food and water is a paramount 

concern to commanders as their units deploy and operate 

in areas that usually have no capabilities or resources in 

that regard. Army Veterinary Service operates 4 food testing laboratories worldwide, but the delays between sample submissions from the field and receipt of results can 

delay necessary local actions in support of combat operations. To mitigate this problem, AMEDD developed and 

fielded 2 laboratory veterinary equipment sets designed to 

allow food and water testing capabilities to be located in 

close proximity to operating units. Staci Mitchell and her 

coauthors have contributed an article describing the 

process by which the AMEDDC&S Department of 

Veterinary Science identified the training requirements for 

the new equipment, designated the specialties who required training, designed and constructed the training syllabi, and implemented the training. The resulting fielding 

of equipment with trained operators has quickly placed 

testing capabilities in all major theaters of operations, 

markedly improving the health and safety of our deployed 

Warfighters. This article is an excellent example of how 

those responsible to create and provide training react 

quickly and effectively in response to a critical need. 

We are pleased that this issue of the AMEDD Journal

includes the report of a recent, major Air Force study to 

investigate the learning process, identify the components 

of how we learn and the factors affecting that process, and 

relate that information into the world of today, 

particularly from the military perspective in the design 

and delivery of training and education. The study was 

conducted by the Air Force Research Institute of the Air 

University. The resulting report, published in November 

2009, is a collection of invaluable information for those 

responsible for any aspect of planning, courseware development and design, training delivery, and evaluation of 

training effectiveness. 

One approach to developing specialized skills which will 

be used in a team environment is called problem-based 

learning (PBL). Students are presented with a problem 

which they explore while working in groups. From a 

medical education perspective, this approach mirrors the 

course of patient care which is performed in a clinical 

setting. The triservice physician assistant program at Fort 

Sam Houston is restructuring its curriculum, and implementation of PBL for portions of the course is planned. 

The various elements to create a PBL program are complex and challenging. MAJ George Midla and Dr Joellen 

Coryell investigated one of those components, the 

preparation requirements for instructors in a physician assistant program which uses PBL. They identified universities that used PBL in physician assistant education, and 

interviewed experienced instructors in the programs. The 

interviews followed standardized formats with openended questions, and responses were transcribed and 

analyzed to develop categories and identify recurrent 

themes. Following a rigorous process, MAJ Midla and Dr 

Coryell extracted extensive information about the instructor/facilitator experiences which are unique to the PBL 

approach, the important differences in preparation and 

attitude from the standard classroom structure, the 

opinions of those experienced instructors as to the value 

of PBL, and many other factors to be considered in the 

selection and preparation of staff personnel. Their study 

results should be an important consideration in courseware design and staff planning for the restructured 

physician assistant curriculum.

As our understanding of the learning process has evolved, 

it has become clear that the static model of rote 

memorization and recitation of arcane facts is of little 

value in the development of an educated person. The 

concept of critical thinking has become prominent as one 

of the most important factors in effective learning—in its 

simplest terms, the idea of interpretation, analysis, 

evaluation, and application of information. This capability 

is extremely important for many professions, but none 

more so than healthcare. Further, since the education 

process depends on the quality and capabilities of the 

faculty, it is obvious that their critical thinking skills are 

very important as they must develop those skills among 

their students. In her extensive, detailed study, Dr Carol 

Hobaugh explored the critical thinking skills among the 

instructors of the AMEDDC&S Academy of Health 

Sciences. Her project examined the sample population 

with regard to a number of factors, including rank, level 

of education, occupational specialty, military experience, 

and others. Her article describes the complexities 

involved in a study of this extent, presents the design and 
 October – December 2010 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

process of this project, and details the results after careful 

data reduction and analysis. Her results offer some surprises, answer questions, and generate more opportunities for inquiry into the factors supporting and 

detracting from the development of critical thinking skills 

among military professionals. Dr Hobaugh’s study is a 

textbook example of classic scientific inquiry, and the 

results should stimulate further interest in this very 

important aspect of the learning process. 

The next 2 articles continue the discussion of the 

changing nature of teaching and the learning process. In 

the first article, Stephanie Hamilton challenges the 

traditional method of information presentation, 

memorization, and summary examinations as markedly 

inferior to a multiple assessment protocol. Known as 

assessment-based instruction, students are evaluated 

throughout the course with multiple types of assessment 

tools to determine the level of cognitive understanding of 

material. Over the last 2 decades, this technique has 

demonstrated that it makes students active participants in 

the learning process rather than audience members, 

generates a collaborative learning environment, and 

allows students to more directly relate the course to realworld applications. It also generates measurable 

improvements in retention and proficiency. Such results 

are perfectly suited for the requirements of military 

training. Assessment-based instruction is the future, and 

should be strongly considered for incorporation into the 

curriculum of military medical education. 

Dr Carita DeVilbiss and her coauthors investigated student failures in one of the enlisted medical training programs from a different perspective: they asked the students. Their team designed a research project to identify 

potential reasons why students fail (or succeed) using 

questionnaires and interviews, exploring several aspects 

of the learning environment (ie, class size, teaching 

methods, support systems) in addition to the individual 

participant characteristics, backgrounds, and experience. 

They also asked the students’ battle buddies or close 

friends (with the student’s permission) to complete questionnaires related to their assessment of the student. After 

examining the data, Dr DeVilbiss et al conclude that the 

majority of student responses are truthful, so the results 

should be valid indicators of what may be wrong, and 

right, in areas of the training program. Their article 

presents the data and the researchers’ interpretations, and 

offers a list of recommendations based on the results. This 

study should be closely examined by curriculum planners 

and courseware developers for indicators as to how to improve the success rate in our military training programs. 

To this point, the articles in this issue of the AMEDD 

Journal have dealt with the process of education—the 

tools used, current methodologies, and research focused 

on how people learn, and how to teach. The last 2 articles 

deal with broadening the scope of education for military 

medical professionals beyond that necessary for their 

primary healthcare responsibilities. As with virtually 

every military career path, those in military medicine 

often take Soldiers from their primary occupational fields 

into (usually) related, albeit unfamiliar responsibilities. 

The learning curve may be difficult, and the individual’s 

effectiveness may suffer for an extended period. There are 

also assignments for which a targeted educational 

preparation should be required, because the 

responsibilities may be situational, depending on shifting, 

external circumstances beyond the direct control of the 

military. In his article, LTC Thomas Bundt describes one 

such environment in which lack of background and 

understanding of under-lying factors seriously hamper 

efforts to develop and apply strategic healthcare policies 

in Iraq. He describes a number of situations for which the 

lack of under-standing of historical, cultural, political, and 

religious factors seriously hampered efforts by US 

planners and policy-makers to assist Iraqis with their 

national health-care policy development. Unfortunately, 

some of these problems were generated by nonmilitary 

US government agencies with major roles in the 

development of Iraq’s infrastructure, but LTC Bundt 

points out that military staff members must be in a 

position to deflect such uninformed, counterproductive 

actions. Such intervention must come from a sound 

position of knowledge and confidence. Sources for such 

training should be identified for the military as a whole, 

because the critical gaps in knowledge are not limited to 

medical issues and policy development. 

MAJ Jon Baker and MAJ Jason Sepanic close this issue 

of the AMEDD Journal with a thought-provoking article 

describing a resource for higher level, professional military education that they contend is notably underutilized 

by the AMEDD, to the detriment of AMEDD representation on high-level staffs throughout the military command structure. The Army’s School for Advanced Military Studies (SAMS) provides an intense curriculum on 

the complex operational problems of warfare, and provides the knowledge and insight to address them. The 

authors point out that AMEDD officers may be at a 

disadvantage when serving in high-level staff positions 

because they might not share the same background perspectives as their non-AMEDD contemporaries. 

Consequently, medically related policy matters and 

decisions may be developed without equivalent level 

participation from the medical staff representative. 

AMEDD officer personnel managers should examine this 

situation with a view towards broadening the eligibility 

for attending SAMS, and actively encourage AMEDD 

officers to apply. 
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

In the fall of 2008, the Army Medical Department 

(AMEDD) began work with the Institute for 

Alternative Futures* on an initiative to develop leaders 

with a capacity for futures thinking and to examine 

major trends that may impact the AMEDD. Bringing 

together a large group of subject matter experts from 

across the command, this project, titled “AMEDD 

Futures 2039,” was designed to envision the operating 

environment 30 years in the future.1

 An important 

element of this forecasting included looking at 

advances that may impact how we train and educate 

our medical personnel. 

After examining current trends in healthcare and the 

military, it appears likely that new advances in medical 

science and educational technology will continue to 

drive the evolution of the techniques and products used 

to prepare personnel for their medical missions. Two 

primary themes stand out in this area: 

 personalized medical education and training for 

each individual; 

 a continuum of life-long medical education that 

begins before arriving at the school and continues 

throughout the service member’s career. 

In the broadest definition of terms, “education” is the 

process of gaining knowledge, while “training” is the 

process of learning a skill. We can expect the military 

to continue to focus on the importance of essential 

medical skills built upon a strong scientific base of 

knowledge. By 2039, the preponderance of medical 

education will be tailored to the individual learner and 

less structured to a core curriculum delivered 

uniformly to classrooms of students. Students will be 

trained to learn through mental skill development. 

Interaction between written instruction, hands-on 

practical training, and proficiency testing will become 

virtually seamless, enhanced by adaptive products that 

sense and respond to individual aptitudes (strengths) 

for learning. 

Avatars tailored to an individual’s specific learning 

style will assist them beyond the initial training and 

provide a continuum of education throughout their 

career. New information on medical issues and 

emerging scientific discoveries will be integrated realtime to the teaching products, removing the delay 

experienced by cycle times to develop and update 

curriculum and textbooks. Based on these basic 

assumptions, the following forecasts for medical 

education and training appear viable between now and 

2039. 

ACADEMIC TRAINING ENVIRONMENT

The future academic institution is less focused on 

general (core) curriculum delivered in a standardized, 

physical classroom. Instead, military personnel benefit 

from tailored instruction, delivered in the style that is 

optimal for each student. Data-rich educational records 

for new service members will better match their 

aptitude, skills, and mental capacity to their 

occupational specialty and selection for advanced 

training. Before any medical instruction begins, 

students are trained on mental skill development to 

enhance their reading comprehension, critical thinking 

strategies, and time management skills.2

 Through braincomputer interfaces using dynamic, learning 

biofeedback, resilience is instilled to achieve 

maximum results in courses. Competency-based, 

patient outcome-oriented skills evaluation will replace 

the preponderance of written examinations that are 

limited in value to test only the retention of facts. This 

How Science and Technology Will 

 Enhance Medical Education and 

 Training by the Year 2039 

COL Randall G. Anderson, MS, USA 

* The Institute for Alternative Futures is a nonprofit research and educational organization founded in 1977, located at 100 North 

Pitt Street, Suite 235, Alexandria, Virginia. It works with clients to create forecasts, scenarios, goals and strategies that are the 

essential tools for transforming organizations to succeed in times of rapid change. Information available at: http://

www.altfutures.com/.
 October – December 2010 5

evaluation of skills is accomplished through motion 

tracking, sensor data capture, and built-in sensing 

systems that provide unbiased error-tracking and 

feedback assessments for all students.3

Many of the courses are taught through a virtual 

campus, providing a seamless continuity of training 

and counseling by a mix of human and computer 

academic instructors and advisors. With access to a 

constantly evolving knowledge base, educators and 

researchers will have a better understanding of the 

third- and fourth-order effects of the medical 

techniques taught and the effectiveness of their 

outcomes.4

 Linkage between the large medical centers 

and the classroom through synchronous learning 

modality provides students with real-time case reviews 

and the ability to train as staff of a hospital while still 

in school. 

Much of the curriculum and programs of instruction 

are created and maintained through hybrid-wikis. This 

tool for subject matter expert collaboration allows 

medical professionals around the globe, even those on 

the battlefield, to assist in shaping the instruction with 

the latest lessons learned.5

 The hybrid form of the 

wiki* retains limited access, permission-based editing, 

and is moderated by school faculty. 

CAREER-LONG AVATAR ASSISTED LEARNING

To assist service members in their continuum of 

education and training, a personalized avatar is 

assigned to them when they first join the military. This 

avatar guides the new recruit to prepare for the next 

level of training as they progress through their basic 

training and advanced studies. The education avatar 

learns the cognitive traits of the individual and uses the 

military’s extensive training databases to continuously 

review and evaluate previously learned skills and 

critical knowledge sets. True benefits are realized as 

medical professionals arrive for specialized training 

and education. The personal education avatar assesses 

each new medical course for which an individual is 

scheduled, and systematically sequences previously 

unlearned lessons for maximized precourse 

development. 

Once the medical professional leaves the school, the 

education avatar remains engaged with them 

throughout their career, updating them on new medical 

findings and ensuring they are aware of the latest 

information appropriate to their profession. The careerlong avatar has the ability of contacting its “owner” 

through all electronic means of communication when 

medical emergencies occur (ie, a pandemic outbreak) 

and advises them on appropriate actions. 

ENHANCED LEARNING DEVICES

Development will enable a personal learning device to 

serve as a single “textbook” for all courses, able to 

wirelessly download text, audio, video, and reference 

materials for the most updated curriculum and 

instruction.6

 The dynamic curriculum will enhance the 

military applicability of the education by making 

battlefield lessons-learned readily available to those 

training for war. 

All new medical equipment and techniques are 

designed and integrated to require minimal training. 

Standardization of common components in all 

equipment reduces the amount of time and effort 

required to adapt new tools. Medical instruction will 

be augmented with animated, digital holograms, 

providing 3-dimensional diagrams of the entire human 

anatomy. Interactive holograms will allow realistic 

visualization of the anatomy under study, with the 

ability to manipulate the parts for a better 

understanding, often unavailable with static training 

models.7

Some learning is accomplished through devices that 

affect cultured neural networks. This interface between 

computers and the brain is made possible by advances 

in biocompatible materials, noninvasive sensory leads 

to the brain, and computational technology that relays 

data to enhance the learning capability of students. 

Students will gain medical knowledge through this 

brain-computer connectivity, often outside of the 

classroom and through portable, personal devices that 

provide education reinforcement of highly complex 

medical subjects.8

MEDICAL SIMULATION IN THE “CLASSROOM” 

Advances in simulation will continue to enhance the 

environment for learning in the classroom. More 

responsive, situational-aware models will improve the 

* A wiki is a web site that allows visitors to make changes, contributions, or corrections. Source: Merriam-Webster’s Collegiate 

Dictionary. 12th Edition. Springfield, MA: Merriam-Webster, Inc; 2008. 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

realism of the increased human-computer interaction 

resulting in more effective training and reduced mental 

barriers to that experienced working with programmed 

machines.9 New advances in simulated tissues and 

multitexture human systems will allow realistic 

training in near-live tissue training. Human and animal 

mannequins not only replicate flesh-like tissues, but 

also fluids, sounds, and smells of real patients, 

incorporating greatly enhanced feedback sensors that 

respond to treatment and communication from the 

provider. 

To add to the realism of the education, most classroom 

equipment and instructional methods are greatly 

adaptive to changes in the curriculum and 

interoperable with multiple scenarios of training. The 

physical layout of the “classrooms” morphs, through 

multisensory projection, to the desired environment 

that matches the simulated location.10 Virtual walls 

and virtual medical attendants in the classroom 

respond to sensors to assist in the education process 

and add realism. Telementoring and online classroom 

projection makes the virtual classroom available to 

anyone world-wide, even deployed personnel 

undergoing skills training in a combat zone.11

EMPOWERMENT OF ALL SERVICE MEMBERS, CIVILIANS, 

AND FAMILY MEMBERS TO HAVE A ROLE IN MEDICAL

EDUCATION

The military has long recognized the benefits of the 

promotion of disease prevention instead of treatment. 

Emerging technologies will allow the empowerment of 

all individuals involved in the military mission, 

including civilians and family members, to maintain 

their individual health network. A focus on prevention, 

with the most current recommendations, is tailored to 

the personal style of each individual, emphasizing their 

most effective behavior modification characteristics to 

achieve optimum health. This adaptation of truly 

personalized health education will accelerate the 

reduction of many preventable diseases and increase 

the medical readiness of the military forces. 

Through integrated medical databases and personal 

avatars, each person will enjoy personalized health 

advice with the sound backing of the most recent 

medical science. Health interaction “kiosks” provide 

remote health professional and computer-assisted 

testing, diagnosis, and advice.12 The empowerment of 

all personnel is achieved when the kiosk becomes a 

dynamic, learning platform that provides relevant, 

sound medical education targeted at promotion of 

disease prevention. 

ALTERNATIVE FORECAST

Futurists must also examine the possibility that the 

future they envision may not come to fruition based on 

certain predictable and unpredictable conditions. These 

are called alternative forecasts. An alternative forecast 

for medical education and training in 2039 may 

include hampered synchronization of efforts required 

to bring the virtual classroom to its maximum capacity 

due to budget constraints and conflicting priorities.13

Academic resistance to collaborative development of 

curriculum could continue to propagate outdated 

instruction, lacking the advantages of lessons learned 

from daily practice.14 Without proper consideration of 

ethical and legal implications of new science and 

technology introduced in medical training, medical 

professionals could find themselves in the middle of 

controversial practices and suffer a regression in 

accepted advances in this area. Without the focus on 

tailored medical education to the individual learner 

and the establishment of mental skill development 

training, AMEDD personnel may experience course 

attrition from essential medical specialties and 

experience delays through reclassification processes at 

greater rates than experienced today. 

RECOMMENDATIONS FOR THE ARMY MEDICAL

DEPARTMENT

What can we do to help shape the outcomes of the 

future? Analysis of the forecasts presented in AMEDD 

Futures 2039 provides 5 recommendations for the 

enterprise. They include: 

1. Continue to support ongoing education research 

into outcomes and competency-based training. 

Embrace international collaboration, effective 

scientific exchanges with academia, and 

focusing education research on advancing 

outcome-based training. Ensure civilian and 

military academia research efforts are 

coordinated to gain the best results. 

2. Focus efforts and resources on technologies that 

meet the strategic goal of clearly superior trained 

individuals, following a well-coordinated 

roadmap to ensure that funded projects support 

the overall objective and are not duplicative. 

How Science and Technology Will Enhance Medical Education and Training by the Year 2039 
 October – December 2010 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

Some funding will be required to support 

bridging technology to reach this future 

education and training capability. 

3. Increase the information technology training and 

development for all medical professionals, 

including those that develop curriculum and 

provide instruction in the classroom. Posture the 

AMEDD training environment to be a developer 

(and leader within academia) of new 

technologies and techniques to enhance 

education throughout the continuum of learning. 

4. Consider ethical and legal implications and 

cascading effects of all new science and 

technology introduced in the training and 

education of medical professionals. Make sure 

there are clearly understood processes to review 

their impact. 

5. Increase public relation campaigns to articulate 

the AMEDD’s achievements in advanced 

technologies and research and development to 

recruit higher quality medical academic 

personnel. Continuously evaluate the 

requirement for new subject matter expertise, 

especially in areas such as genomics, molecular 

imagery, nanotechnology, and medical 

simulation robotics. 

CONCLUSION

In 1919, Lincoln Steffens stated “I have seen the 

future, and it works.”15 While none of us can truly 

“see” the future, we can use all tools available to 

forecast the environment we expect and establish a 

framework to achieve the best future possible. By 

synchronizing our efforts to achieve this strategic plan, 

we can maximize resources by reducing redundancies 

and waste. By embracing the benefits of science and 

technology, we can overcome barriers to change. The 

AMEDD Futures 2039 Report16 can serve as the 

launching point for this framework to enhance medical 

education and training. Then, leaders at all levels must 

realize their mission to develop skills as futurists to 

facilitate a positive change environment. 

REFERENCES

1. AMEDD Futures 2039. Institute for Alternative 

Futures Web site. Available at: http://altfutures.org/

amedd-futures-2039-overview. Accessed August 27, 

2010. 

2. Fact Sheet. US Army Center for Enhanced 

Performance. West Point, New York: US Military 

Academy; April 2009. 

3. Kania K. Virtual reality moves into the medical 

mainstream. Med Device Diagn Ind. May 2000. 

Available at: http://www.mddionline.com/article/

virtual-reality-moves-medical-mainstream. Accessed 

August 27, 2010. 

4. Kim S. The future of 3-learning in medical education: 

current trend and future opportunity. J Educ Eval for 

Health Prof. 2006;3:3. 

5. University of Delaware IT-User Services. Wikis in 

higher education. Ver 1.2. University of Delaware 

Web site. May 23, 2008. Available at: http://

www.udel.edu/sakai/training/printable/wiki/

Wikis_in_Higher_Education_UD.pdf. Accessed 

April 15, 2009. 

6. Shah S. The pulse of health care is wireless: the 

future medical enterprise. Mobile Comput News

[serial online]. December 16, 2003. Available at: 

http://searchmobilecomputing.techtarget.com/

news/941579/The-pulse-of-health-care-is-wirelessThe-future-medical-enterprise/. Accessed March 24, 

2009. 

7. Tactical Digital Holograms Fact Sheet. Aberdeen 

Proving Ground, MD: US Army Research, Development, and Engineering Command; March 2009. 

8. Sandhana L. This is a computer on your brain. Wired

[serial online]. July 12, 2006. Available at: http://

www.wired.com/medtech/health/

news/2006/07/71364. Accessed April 14, 2009. 

9. US Army Telemedicine & Advanced Technology 

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MD: US Army Medical Research & Materiel Command; 2008. Available at: http://www.tatrc.org/docs/

TATRC_report_2008.pdf. Accessed April 20, 2009. 

10. Bimber B, Almeroth K, Patton R, Chun D, Flanagin 

A, Liu A. The Future of Technology and the 

University. Santa Barbara, CA: University of 

California, Santa Barbara Center for Information 

Technology and Society; March 1, 2002. CITS White 

Paper. Available at: http://escholarship.org/uc/

item/21t7g1q1#page-1. Accessed March 26, 2009. 

11. Armstrong J, Franklin T. A Review of Current and 

Developing International Practice in the Use of 

Social Networking (Web 2.0) in Higher Education. 

York, United Kingdom: Tom Franklin Consulting 

Ltd; September 2008:105-112. Available at: http://

franklin-http://franklin-consulting.co.uk/

Reports.html#International_Web20. Accessed August 

31, 2010. 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

12. Kozek A. GE Healthcare’s health kiosks enable easy 

“ATM style” access to electronic medical records. 

GE Healthcare Web site. February 14, 2005. 

Available at: http://www.gehealthcare.com/company/

pressroom/releases/pr_release_10220.html. Accessed 

April 12, 2009. 

13. Cohen R. 10 problems with technology: why some 

military systems get used and others collect dust. 

Armed Forces J. April 2009:32-34. Available at: 

http://www.afji.com/2009/04/3939965/. Accessed 

August 31, 2010. 

14. Smith LG. The Future of Medical Training: Back to 

Basics in a New World. J Fam Pract. 2008;57(suppl 

10A):S14-S16. Available at: http://www.jfponline 

.com/pages.asp?id=6830. Accessed August 31, 2010. 

15. Oxford Dictionary of Quotations. Oxford, UK: 

Oxford University Press; 1979:518. 

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Futures 2039 Project: Phase 2 Final Report. 

Alexandria, VA: Institute for Alternative Futures; 

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p u b s / g o v t / A M E D D _ F u t u r e s _ 2 0 3 9 

_Project_072909.pdf. Accessed February 10, 2010. 

AUTHOR 

COL Anderson is the Director, Medical Capabilities 

Integration Center, AMEDD Center & School, Fort 

Sam Houston, Texas. 

How Science and Technology Will Enhance Medical Education and Training by the Year 2039 
 October – December 2010 9

INTRODUCTION

Never has chemical warfare presented such a real 

threat as it does today. The threat of terrorism is that an 

attack can happen anytime, anywhere in both civilian 

and military sectors. In situations where individuals 

are exposed to chemical warfare such as in combat or 

terrorist attacks, nurses may be the first or the only 

responders. Nurses, particularly those in the military, 

may have to extend beyond their usual scope of practice in providing care to individuals exposed to chemical warfare. Because war and terrorism continue to be 

constant threats to the United States, former President 

Bush’s address to the nation after September 11, 2001, 

is still very timely, “I have a message to the military—

be ready!” Readiness for all military nurses consists 

not only of a thorough knowledge base, but the ability 

to assess, intervene, and evaluate care given to patients 

exposed to chemical agents. Military nurses are 

challenged as never before to have these skills. There 

have been no studies that have investigated the most 

effective method of teaching skills necessary for the 

care of patients exposed to chemical agents. 

PURPOSE AND RESEARCH QUESTION

The purpose of this study was to evaluate whether the 

Human Patient Simulator (HPS) (METI, Sarasota, 

Florida) or an interactive CD-ROM was more effective 

in teaching the care of patients exposed to chemical 

Effects of Using Human Patient Simulator 

 Versus a CD-ROM on Learning the 

 Management of Patients Exposed to 

 Chemical Agents 

Don Johnson, PhD 

Amanda Flagg, PhD 

Theresa L. Dremsa, PhD 

ABSTRACT

Introduction: Very little prospective, randomized, experimental research exists on the use of simulation as a 

teaching method, and no studies have compared the effects of 2 strategies of using the Human Patient Simulator 

(HPS) and a CD-ROM on the management of patients exposed to chemical agents. 

Methods: A prospective, pretest-posttest experimental, mixed design (within and between) was used to 

determine if there were statistically significant differences between educational strategies using HPS, CD-ROM, 

and a control group in the care of patients exposed to chemical agents. Care was operationally defined as the 

score on the Management of Chemical Warfare Patients Performance (MCWPP) instrument. Participants 

included active duty and reserve military nurses (n = 92). They were randomly assigned to one of 3 teaching 

groups: HPS (n = 30), CD-ROM (n = 31), or a control group (n = 31). 

Results: Analysis of variance and a Tukey post-hoc test were used to analyze the data. The means on MCWPP 

instrument were as follows: HPS (pretest: mean =65.13, SD ±8.9; posttest mean =73.0, SD± 8.6); CD-ROM 

(pretest: mean =67.74, SD±11.18, posttest mean =65.67, SD ±10.82); control (pretest: mean =68.51 SD ±8.5; 

posttest mean=62.6, SD ±8.6). There were no significant differences between the groups on the pretest (P=.363), 

but there were significant differences on the posttest (P=.001). Post-hoc analyses indicated the HPS group 

performed better than the CD-ROM group (P=.017) and the control group (P=.000). There was no significant 

difference between the CD-ROM and control groups (P=.485). 

Conclusion: Based on the results of this study, the HPS is more effective than the CD-ROM in teaching nurses 

about the care of patients exposed to chemical agents. 
10 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

warfare. Care was operationally defined as the score 

on the Management of Chemical Warfare Patients 

Performance (MCWPP) instrument and could range 

from 0 to 100 percentage points. The research question 

that guided the study: 

Is there a statistically significant difference in 

educational strategies using HPS versus CD-ROM, 

and a control group relative to scores on the MCWPP 

instrument? 

BACKGROUND

Simulation is defined as a realistic representation 

(model) of the dynamics or processes with which the 

participant interacts with the environment, applies 

previously learned knowledge into the decision 

making process, and responds with definitive decisions 

and actions to deal with a problem or situation. 

Simulation as a teaching method allows an interactive 

experience to reflect or parallel patient scenarios.1

Performance feedback can be provided without 

concern regarding real-life consequences.2

 Simulation 

is a method of translating didactic knowledge into a 

safe learning environment. Further, Jeffries et al3

emphasize that simulation is a teaching strategy that 

can be used to facilitate connections between and 

among concepts through a process that actively 

engages students in learning. Such a strategy facilitates 

learning skills and knowledge. 

The development of competency-based approach to 

education of healthcare professions has moved the 

focus away from recall of facts or knowledge to more 

complex clinical activities such as data gathering, 

prioritization, implementation of care, and evaluation. 

Simulation as a teaching strategy can provide both 

educational opportunities to learn those skills and the 

ability to evaluate whether the learner has acquired 

those skills. Maran and Glavin4

 emphasize that the 

traditional systems of assessment such as multiplechoice examination questions cannot distinguish 

between clinicians with adequate versus inadequate 

skills or performance. Good5

 emphasizes that 

simulation allows for real world experience that occur 

infrequently and can be used not only for effective 

education but for effective evaluation of the learner’s 

ability to perform correctly. 

Very little prospective, randomized, experimental 

research exists on the use of simulation as a teaching 

method, and no studies have compared the use of the 

HPS and a CD-ROM relative to caring for patients 

exposed to chemical agents. However, a wealth of 

literature addresses the value of using simulation as a 

teaching method but fails to use a rigorous research 

design.6-10 For example, McIndoe11 surveyed participants and found that the majority preferred problembased simulation to lecture, rounds, or tutorial teaching 

formats, but he did not investigate the effectiveness of 

such an approach. Korndorffer et al12 studied the 

development of performance-based laparoscopic 

suturing content using simulators and to test the 

effectiveness of the teaching strategy. They found that 

simulation showed a significant improvement in 

overall scores from baseline. However, they did not 

compare simulation to any other teaching method. 

Rauen13 found that simulation as a method of teaching 

allows learners to apply theory to practice in an 

integrated manner. Furthermore, she found that a 

simulator has the capacity to demonstrate more than a 

single event or parameter at a time, which allows 

participants to identify relationships essential and 

common to clinical practice. She found that the 

evaluation of the simulation sessions were universally 

positive. As a result of the use of simulation, students 

became confident and were able to demonstrate skills 

learned. However, Rauen did not compare the simulation approach to any other method or to a control 

group. Hall et al14 compared the success rate of 

endotracheal intubation among paramedic students 

trained on a human patient simulator group or on 

human subjects in the operating room. They found that 

human patient simulator training was as effective as 

students who were trained on human subjects. 

Steadman et al15 investigated whether full-scale simulation was superior to interactive problem-based learning for teaching medical students acute care assessment and management skills. They used a pretestposttest design and determined that simulation-based 

learning was superior to problem-based learning for 

the acquisition of critical assessment and management 

skills. Wayne et al16 conducted a retrospective study of 

cardiac arrest team responses and compared them to a 

simulator trained group and a control group to 

determine if simulation improved the quality of 

advanced cardiac life support care provided. They 

found that simulator-trained residents showed significantly higher adherence to standards versus traditionally trained students. Gordon et al17 surveyed both students and educators about their opinions about simulation as a teaching tool. Both groups thought that the 

Effects of Using Human Patient Simulator Versus a CD-ROM on Learning 

the Management of Patients Exposed to Chemical Agents 
 October – December 2010 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

advantage of using the stimulator outweighed the disadvantage of the cost of the simulator. Eaves and 

Flagg18 created a 10-bed simulated medical unit as part 

of a new graduate nurse orientation. The program 

received outstanding evaluations from the new graduates, the educators, and preceptors in the clinical 

setting where the new graduates practiced. However, 

the study did not compare the simulation with any 

other methods. Cioffi et al19 investigated the effectiveness of simulation on clinical decision making of 

midwifery students; however, the study used a posttest 

design with no mention of score reliability or instrument validity. Results showed that the students who 

received the simulation strategy collected more clinical 

information, had higher confidence levels, and reached 

a final decision more quickly than the lecture group. 

Dieckmann et al20 introduced concepts into medical 

simulation that help to clarify potential problems during simulation and foster its goal-oriented use. Their 

introduction of these concepts allow for improved 

matching of simulation realism with desired outcomes. 

Johnson et al21 investigated the use of the HPS compared to a CD-ROM group in teaching care of patients 

exposed to chemical warfare agents relative to cognition and critical thinking. They found that there were 

no significant differences in lower-level cognition 

between the 2 approaches, but HPS was more effective 

relative to higher-level cognition and critical thinking. 

Bearnson and Wiker22 stress that there are limited 

rigorously designed pretest-posttest studies of simulation and a need exists for investigations that compare 

the simulation approach to other educational methods. 

METHOD

The protocol was approved by the local military 

Institutional Review Committee. A prospective, pretestposttest experimental, mixed design (within and between) was used to determine if there were statistically 

significant differences in HPS and CD-ROM educational strategies compared to a control group. 

Setting 

The study was conducted at the Air Force War Skills 

Simulation Laboratory located at the Wilford Hall 

Medical Center, Lackland Air Force Base, Texas. The 

laboratory is a fixed facility configured to represent a 

typical wartime medical care environment. For example, the walls were covered with camouflage netting 

and reinforced with sandbags. Bruce lights (field 

lights) provided the lighting. Equipment included field 

gear used to transport equipment and supplies, and 

only the equipment that is available in a deployed environment such as a PT LOX (equipment used to produce field oxygen), field ventilator, Lifepak 12 Defibrillator/Monitor (Medtronic Inc, Minneapolis, MN), 

and a transport intravenous pump. A stereo system 

provided helicopter, artillery fire, and bomb blast 

sounds in the background. The centerpiece of the simulation laboratory was the HPS. Also, a room adjacent 

to the laboratory was equipped with video recording 

equipment and a monitoring system . 

Sample 

A convenience sample was used for this study which 

consisted of 103 active duty and reserve Air Force and 

Army nurses from south Texas. All had a minimum of 

a baccalaureate degree in nursing; five had master’s 

degrees, and one had a PhD. The age ranged from 22 

to 47 years. The rank was from 1st lieutenant to 

lieutenant colonel. The years of experience in the 

military ranged from 2 to 28 years (mean =10 years, 

SD±3.4). Fifteen had been deployed to Iraq, and the 

remainder expected to be deployed within the next 

year. Potential participants were informed of the 

purpose of the study and were assured that their 

participation was voluntary. They were also told that 

their performance would be videotaped to be used for 

evaluation purposes. All of the participants agreed to 

participate and signed a consent form. Eleven 

individuals elected to withdraw from the study, leaving 

a total of 92 participants, 51 female and 41 male, who 

completed all aspects of the study. 

Content Development 

The investigators reviewed the literature to develop the 

essential content to be taught in both the HPS and CDROM groups. The content was reviewed by an expert 

panel consisting of 2 certified critical care registered 

nurses, one emergency department nurse, 2 trauma 

physicians, and one chemical warfare educator. The 

content was revised until there was 100% agreement 

that the material presented for both approaches was the 

same, comprehensive, and accurate. To make sure that 

each individual received the same instruction in the 

HPS group, a script was used by the instructor for each 

session. To prevent an experimenter effect, the same 

instructor taught all participants in the HPS group. 
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Process for All Groups 

The participants were randomly assigned to one of 3 

groups: HPS, CD-ROM, or control group. All of the 

participants completed the demographic data sheet, 

and each individual’s performance was videotaped 

while caring for 3 simulated patients exposed to 

chemical agents. The HPS was programmed for 3 

patient scenarios. The investigators used the MCWPP 

instrument for the evaluation for both the pretest and 

posttest. After their initial performances were 

videotaped, those participants in the HPS received 

instruction using the HPS as a teaching strategy, and 

those in the CD-ROM group used specially developed 

software covering the same content. Those in the 

control group received no instruction. One month after 

the pretest data were collected, the participants 

returned and had their performances videotaped for the 

posttest. At this time, the same scenarios were used, 

and the MCWPP instrument was used again for 

evaluation. So that individuals in the control group did 

not have the perception that they did not benefit for 

participation, they were able to select either the HPS or 

the CD-ROM for teaching after they completed both 

the pretests and posttests. 

Numerous researchers have investigated the effects of 

simulation by evaluating the group’s performance 

rather than the individual’s performance. The disadvantage of such an approach is that some individuals 

may know the appropriate care and some individuals 

may not, but all receive the same score. To avoid this 

limitation, the investigators evaluated each participant 

individually for both the pretest and posttest. 

Human Patient Simulator Group 

The HPS consisted of a computerized, full-body 

mannequin that was capable of providing real-time 

physiological and pharmacological responses to various health condition and pharmacological interventions. The complete HPS system included the 

mannequin, computer software, monitors and gases 

required to operate the system. A cordless speaker 

located in the mannequin’s head was used to simulate 

the “patient’s voice.” Participants were able to ask the 

mannequin questions, and the operator was able to 

respond by transmitting his voice through the mannequin. The operator was in an adjacent room, and observation was possible from a separate room through a 

closed circuit television monitor. Participants were 

able to assess all physiologic parameters including 

normal and abnormal heart and lung sounds; to palpate 

pulses, check pupil response, and obtain vital signs; to 

monitor rhythms, pulse oximetry, blood pressure, and 

respiratory rates; and assess bowel sounds. 

The HPS was used as a teaching strategy and was 

programmed with 3 patient scenarios: one exposed to a 

nerve agent with an abdominal wound and subsequent 

hypovolemic shock; one exposed to a nerve agent 

only; and one exposed to a mustard gas. The HPS was 

programmed to manifest signs and symptoms relative 

to nerve agent exposure that included pinpoint pupils, 

copious secretions from the nose and mouth, tearing, 

lung crackles, rhonchi, perspiration, hypotension, hyperactive bowel sounds, and pulse changes. Participants were able to obtain a manual blood pressure and 

palpate pulses. A HPS was attached to a cardiac monitor, the Life Pak 12, so that blood pressure, pulse, and 

cardiac rhythms could be assessed by observing the 

monitor. In the hypovolemic scenario, the monitor 

demonstrated that the patient had hypotension with 

tachycardia. In this scenario, radial and brachial pulses 

were absent but carotid pulses were present. HPS provided participants with the ability to assess, make a 

diagnosis, intervene, and evaluate the intervention. 

Appropriate physiological responses to pharmacological interventions such as administration of fluids or 

atropine were immediately demonstrated by the HPS. 

For example, in the hypovolemic model, fluid administration resulted in a decrease in pulse and an increase 

in blood pressure. After an adequate amount of fluid 

was administered, radial and brachial pulses were palpable. The administration of oxygen resulted in an 

increased saturation as monitored by pulse oximetry. 

The administration of atropine resulted in a reduction 

in secretions, crackles, rhonchi, perspiration, and increase in pupil size. The HPS allowed programming of 

2 complex problems to be manifested simultaneously 

in the same patient scenario: exposure to chemical 

agent and hypovolemic shock. To prevent an experimenter effect, the same investigator served as an 

instructor and used the HPS as she guided the participant through each scenario. 

Chemical Warfare CD-ROM 

A chemical warfare CD-ROM was developed for this 

study that allowed participants to view PowerPoint 

slides that covered the pathophysiology of chemical 

agent exposure and hypovolemic shock. In addition, 3 

Effects of Using Human Patient Simulator Versus a CD-ROM on Learning 

the Management of Patients Exposed to Chemical Agents 
 October – December 2010 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

scenarios were developed for the HPS. With each 

scenario, participants were able to assess each patient 

by clicking a selection of choices. The choices 

included assessment parameters such as vital signs, 

auscultation of the chest, and visual inspection of an 

abdominal wound as examples. After the choice was 

made, the CD-ROM provided the appropriate 

information that was queried. For example, if breath 

sounds were clicked, the participant would hear 

crackles and rhonchi. After collecting data, the 

participant made a diagnosis and intervened by 

clicking on a selection of choices. The participants 

were also able to click on various treatment options 

such as administration of oxygen, intravenous fluids, 

administration of atropine, and other treatment 

modalities needed to stabilize the patient. The 

participant could evaluate the treatment by clicking on 

assessment parameters such as vital signs, pulse 

oximetry, etc. After completion of each of the 

scenarios, the CD-ROM program provided feedback 

on each decision and evaluated each participant’s 

performance. Each of the scenarios for both the HPS 

and CD-ROM groups took approximately 30 minutes 

to complete for a total of 90 minutes. The same expert 

panel as described above reviewed the CD-ROM to 

make sure the same content was presented as the HPS. 

There was a 100% agreement that the content was the 

same as the content developed for the HPS, accurate, 

and comprehensive. 

MCWPP Instrument Development 

The investigators reviewed the literature on chemical 

warfare to develop the criteria needed for evaluation of 

care given to the simulated patients. One hundred 

fifteen criteria were developed for the instrument. 

Each criterion was followed by a 1 or 0 (did or did not 

meet the criterion). The instrument was given to 6 

experts in education and chemical warfare as described 

above. The experts individually rated each criterion as 

very relevant, relevant, not relevant, or not at all 

relevant. The items that all of the experts rated as 

either not relevant or not at all relevant were excluded 

from the instrument. The experts were also asked to 

include additional criteria that they believed to be 

relevant. The revised instrument had 105 criteria and 

was reevaluated individually by the same experts. The 

total number of agreements divided by the sum of 

agreements plus disagreements provided the percent 

agreement. The revised instrument had 98% agreement 

relative to the comprehensiveness and the relevancy of 

the items. 

Test-retest reliability was determined by evaluating 30 

military nurses and reevaluating the same participants 

in 30 days. Pearson r was used to determine the 

correlation between the 2 sessions (r=0.97, P<.01) 

indicating that the instrument was stable over time. 

Using the MCWPP instrument, 3 investigators independently evaluated the performance of 3 participants 

who had been videotaped giving care to the simulated 

patients. The Pearson r was used to determine 

interrater reliability (r=0.92, P=.01). In a group 

session, the investigators discussed why they had or 

had not given credit for individual criterion until there 

was 100% consensus in evaluating the performance of 

the 3 participants. They evaluated an additional 3 

subjects who had been videotaped. The interrater 

reliability was increased (r=0.98, P=.01). 

An evaluation specialist was hired and educated in 

relation to evaluation of the participants. To maintain 

consistency, she evaluated all of the participants on 

both the pretests and posttests. Pearson r was used to 

determine the interrater reliability between the investigators and specialist (r=0.98, P=.01). Ten percent of 

the participants who were evaluated by the specialist 

were also evaluated independently by the investigators. The interrater reliability was maintained (r=0.98, 

P=.01). All of the investigators and the specialists 

were able to rewind the videotape if there were questions as to whether a participant did or did not meet a 

particular criterion. The specialists and investigators 

did not know to which group the participant was 

assigned, nor whether it was the pretest or posttest. 

Power Analysis 

The number of participants needed for this study was 

calculated by using an alpha of 0.05, moderate effect 

size of 0.5, and power of 80% which yielded 90 

participants (30 in each group). The medium effect 

size was calculated from data from a pilot study 

implemented by the investigators. 

RESULTS

An alpha of 0.05 was used for all analyses. Means and 

standard deviations (SD) were calculated for each 

group. The means on the MCWPP instrument were as 

follows: 
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

HPS: (pretest mean =65.13, SD±8.9; posttest 

mean =73.0, SD±8.6) 

CD-ROM: (pretest mean =67.74, SD±11.18, 

posttest mean =65.67, SD±10.82) 

Control: (pretest mean =68.51, SD±8.5; posttest 

mean =62.6, SD±8.6) 

A repeated analysis of variance was used to analyze 

the data. There were no significant differences 

between the groups on the pretest (P=.363) indicating 

that the groups were equivalent. There were significant 

differences on the posttest (P=.001); therefore, a 

Tukey post-hoc analyses was used to determine where 

there were significant differences. The HPS group 

performed better than the CD-ROM group (P=.017) 

and the control group (P=.000). There 

was no significant difference between 

the CD-ROM and control groups 

(P=.485). The data are summarized in 

the Table. 

COMMENT

Based on the results of this study, the 

choice of teaching strategies is the HPS 

as compared to the use of a CD-ROM. 

Perhaps the reason is that the use of the HPS provides 

more of an opportunity for learners to apply principles, 

concepts, laws, and theory than other strategies. 

Specifically, the approach may foster critical thinking. 

May et al23 summarize the definition of critical 

thinking from various authorities and conclude that it 

is a process, a composite of knowledge, attitudes and 

application of skills. They reasoned that such thinking 

involves the examination of ideas, inferences, 

assumptions, principles, arguments, conclusions, 

issues, and actions. Specifically, critical thinking is the 

ability to assess, diagnose, intervene, and evaluate 

accurately. These are the same processes inherit in 

clinical decision making. 

The HPS allowed participants to use the cognitive 

skills of assessment, treatment, and evaluation in a 

realistic simulated environment. Specifically, in this 

study, participants were able to collect data relative to 

the signs and symptoms portrayed by the HPS, make a 

diagnosis, intervene, and evaluate the effectiveness of 

the treatment in a very realistic environment. This 

supports the findings of Cioffi and colleagues who 

found that simulation education increased clinical 

decision making.19,24 The current findings also support 

the findings of Johnson et al21 who found that that the 

use of HPS did not make a difference in increasing 

lower-level cognition, specifically knowledge and 

comprehension. This may be related to the fact that 

knowledge is a function of remembering facts, and 

comprehension is the ability to grasp the meaning of 

information. These levels of cognition represent the 

lowest level of learning outcomes. Johnson did find 

that the use of HPS compared to a CD-ROM made a 

statistically significant difference in outcome for 

higher-level cognition and critical thinking cognition 

as measured by a multiple-choice examination. We 

theorize that the higher-level cognition and critical 

thinking are prerequisites for effective performance as 

defined in the current study. 

The effectiveness of such a strategy stems from the 

theory of situated cognition, which states that 

individuals best learn “what to do” and “how to do” in 

a real world environment.21 Accordingly, situated 

cognition asserts that critical thinking and ability to 

perform has to occur within the context of the 

situation. Knowing what to do and how to do it are 

essential components of appropriate care of chemical 

warfare casualties. This concept has to be developed 

within specific subject matter and is best taught under 

realistic simulated conditions that best represents the 

desired patient care conditions. 

SUMMARY

This was the first study that investigated the use of 

HPS compared to a CD-ROM in the performance abilities relative to management of care of patients exposed 

to chemical agents. The study used a pretest-posttest 3-

group prospective, randomized design. The groups did 

not differ on the pretests scores indicating that the 

groups were equivalent. The posttest scores indicated a 

significant difference between the HPS and control 

groups and the HPS and CD-ROM groups, but there 

Effects of Using Human Patient Simulator Versus a CD-ROM on Learning 

the Management of Patients Exposed to Chemical Agents 

Summary of data results. 

*Mean difference is significant at the 0.05 level. 

Mean 

Scores HPS 

Group 

Mean Test 

Scores 

CD-ROM 

Group 

Mean Test 

Scores 

Control Group 

Post-Hoc Analyses 

Pretest 65.13 ± 8.9 67.74 ± 1.18 68.15 ± 8.50 HPS vs 

CD-ROM 

P = .017* 

HPS vs 

control 

Posttest 73.00 ± 8.6 65.67 ± 0.82 62.60 ± 8.60 P = .000* 

CD-ROM 

vs control 

P = .485 
 October – December 2010 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

was not a significant difference between the CD-ROM 

and control groups. Perhaps the reason the CD-ROM 

group was no more effective than the control group 

was that the approach was not as realistic as the HPS 

and provided choices for the participant to click. The 

HPS provided real world scenarios where participants 

could practice collecting relevant data, clustering the 

data, making a diagnosis, intervening, and evaluating 

the effectiveness of the approach without a list of options. Such an approach provided by the HPS provides 

the opportunity to develop higher level cognition and 

critical thinking that are necessary for the ability to 

perform and manage patient care. The disadvantage of 

using HPS is that it is expensive to purchase and maintain. The HPS was reliable, but on 2 occasions the 

investigators had to cancel participation until it was 

repaired. Also, the system requires at least 2 individuals: one to teach and one to operate the system. 

Limitations of the study include the use of a convenience sample which may restrict the ability to generalize findings. Some participants worked the night shift 

before participating in the study and could be an 

external threat to validity in terms of fatigue. However, 

the same number of participants who worked the night 

shift before participation was in each group. 

Recommendations for future research include using 

the same framework for different content and 

investigating the effects of simulation on performance 

with other scenarios and comparing HPS to traditional 

classroom presentations. 

ACKNOWLEDGEMENT

The authors gratefully acknowledge the 59th Clinical 

Research Squadron, Wilford Hall Medical Center, 

Lackland Air Force Base, Texas, for their support of this 

protocol. This study was funded by the TriService 

Nursing Research Program of the Uniformed Services 

University of the Health Sciences, Bethesda, Maryland. 

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2. Jeffries PR. A framework for designing, 

implementing, and evaluating simulations used as 

teaching strategies in nursing. Nurs Educ Perspect. 

2005;26(2):96-103. 

3. Jeffries PR, Bambini D, Hensel D, Moorman M, 

Washburn J. Constructing maternal-child learning 

experiences using clinical simulations. J Obstet 

Gynecol Neonatal Nurs. 2009;38(5):613-623. 

4. Maran NJ, Glavin RJ. Low- to high-fidelity 

simulation - a continuum of medical education? Med 

Educ. Nov 2003;37(suppl 1):22-28. 

5. Good ML. Patient simulation for training basic and 

advanced clinical skills. Med Educ. Nov 2003;37

(suppl 1):14-21. 

6. Landeen J, Jeffries PR. Simulation. J Nurs Educ. 

2008;47(11):487-488. 

7. Harder BN. Use of Simulation in Teaching and 

Learning in Health Sciences: A Systematic Review. J 

Nurs Educ. Sep 7 2009:1-6. 

8. Kaakinen J, Arwood E. Systematic review of nursing 

simulation literature for use of learning theory. Int J 

Nurs Educ Scholarsh [serial online]. 2009;6

(1):Article 16. Available at: http://www.bepress.com/

ijnes/vol6/iss1/art16/. Accessed August 23, 2010. 

9. Valli K, Revonsuo A. The threat simulation theory in 

light of recent empirical evidence: a review. Am J 

Psychol. 2009;122(1):17-38. 

10. Huang YM, Pliego JF, Henrichs B, et al. 2007 

Simulation education summit. Simul Healthc. 2008;3

(3):186-191. 

11. McIndoe A. The future face of medical training: shipshape and Bristol fashion. Br J Theatre Nurs. Nov 

1998;8(8):5, 8-10. 

12. Korndorffer JR Jr, Dunne JB, Sierra R, Stefanidis D, 

Touchard CL, Scott DJ. Simulator training for 

laparoscopic suturing using performance goals 

translates to the operating room. J Am Coll Surg. 

2005;201(1):23-29. 

13. Rauen CA. Using simulation to teach critical thinking 

skills. You can’t just throw the book at them. Crit 

Care Nurs Clin North Am. 2001;13(1):93-103. 

14. Hall RE, Plant JR, Bands CJ, Wall AR, Kang J, Hall 

CA. Human patient simulation is effective for 

teaching paramedic students endotracheal intubation. 

Acad Emerg Med. 2005;12(9):850-855. 

15. Steadman RH, Coates WC, Huang YM, et al. 

Simulation-based training is superior to problembased learning for the acquisition of critical 

assessment and management skills. Crit Care Med. 

2006;34(1):151-157. 
16 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

16. Wayne DB, Didwania A, Feinglass J, Fudala MJ, 

Barsuk JH, McGaghie WC. Simulation-based 

education improves quality of care during cardiac 

arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61. 

17. Gordon JA, Wilkerson WM, Shaffer DW, Armstrong 

EG. “Practicing” medicine without risk: students’ and 

educators’ responses to high-fidelity patient 

simulation. Acad Med. 2001;76(5):469-472. 

18. Eaves RH, Flagg AJ. The U.S. Air Force pilot 

simulated medical unit: a teaching strategy with 

multiple applications. J Nurs Educ. 2001;40(3):110-

115. 

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investigate the effect of a simulation strategy on the 

clinical decision making of midwifery students. J 

Nurs Educ. 2005;44(3):131-134. 

20. Dieckmann P, Gaba D, Rall M. Deepening the 

theoretical foundations of patient simulation as social 

practice. Simul Healthc. 2007;2(3):183-193. 

21. Johnson D, Flagg A, Dremsa T. The effects of using 

human patient simulator vs CD-ROM on cognition 

and critical thinking. Med Educ Online [serial 

online]. 2008;13:1. Available at: http://

www.ncbi.nlm.nih.gov/pmc/articles/PMC2779609/

pdf/MEO-13-0118.pdf. Accessed August 23, 2010. 

22. Bearnson CS, Wiker KM. Human patient simulators: 

a new face in baccalaureate nursing education at 

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(9):421-425. 

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Womens Health. 2009;54(1):65-72 e63. 

AUTHORS

Dr Johnson is a Professor at Northeastern University, 

and is Director of Research in the US Army Graduate 

Program in Anesthesia Nursing, Fort Sam Houston, 

Texas. He is a retired Colonel of the US Air Force 

(Reserves) Nurse Corps. 

Dr Flagg is an Assistant Professor-Clinical in the 

School of Nursing, University of Texas Health Science 

Center, San Antonio, Texas. She is a retired Major of 

the US Air Force Nurse Corps. 

Dr Dremsa is a retired Lieutenant Colonel of the US Air 

Force Nurse Corps, last stationed at the Wilford Hall 

Medical Center, Lackland Air Force Base, Texas. 

Effects of Using Human Patient Simulator Versus a CD-ROM on Learning 

the Management of Patients Exposed to Chemical Agents 

Photo courtesy of the authors. 
 October – December 2010 17

INTRODUCTION

Military-civilian collaborations in healthcare have 

existed for decades. Each community relies on the 

other to gain information and experience that would 

otherwise not be obtainable on their own. The US 

Army and the Ryder Trauma Center (Jackson 

Memorial Hospital, Miami, FL) teamed up to provide 

a training environment (ie, the Army Trauma Training 

Center) in which forward surgical teams can attend to 

gain critical teamwork and trauma technical skills to 

prepare for deployment to Iraq or Afghanistan. This 

paper discusses trainees’ reactions to the militarycivilian collaboration provided at the Army Trauma 

Training Center. 

BACKGROUND

Warfighters on today’s battlefield endure almost 

insurmountable threats. However, despite this, it is 

estimated that 90% of those injured on the battlefield 

survive their injuries.1

 Simulation-based training has 

often been the strategy chosen to train medical 

providers in both the civilian and military 

communities. After all, simulations offer a safe, 

nonconsequential, cost-effective environment in which 

Training Forward Surgical Teams: 

 Do Military-Civilian Collaborations Work? 

Carl I. Schulman, MD, MSPH 

Jill Graygo, MA, MPH 

Katherine Wilson, PhD 

LTC Donald Robinson, MC, USA 

LTC George Garcia, MC, USA 

Jeffrey Augenstein, MD, PhD

ABSTRACT

The US Army and the Ryder Trauma Center (Jackson Memorial Hospital, Miami, Florida) teamed up to provide a 

training environment (ie, the Army Trauma Training Center) in which forward surgical teams can attend to gain critical 

teamwork and trauma technical skills to prepare for deployment to Iraq or Afghanistan. The purpose of this study was 

to gather trainee reactions to the military-civilian collaboration provided at ATTC after deployment to Iraq or 

Afghanistan. 

Methods: Survey respondents were 135 US Army personnel (an approximately 50% response rate) who participated in 

the ATTC 2-week team training program between January 2005 and June 2007. The survey asked questions pertaining 

to their experience in the resuscitation unit and patient contact at the trauma center. 

Results: Over 90% of participants agreed or strongly agreed that training in the resuscitation area was beneficial. A 

majority of participants also agreed or strongly agreed that the patient contact experience was sufficient (78.5%), was a 

good learning opportunity (90%), and that the experience was a good opportunity to apply what they had learned in 

their classroom training (over 80%). 

Areas of suggested improvement included the importance of clarifying roles between the ATTC trainees and the Ryder 

Trauma Center residents and interns. Trainees would have preferred an extension of the training as a whole, as they felt 

it was rushed in order to fit all training opportunities into the 2 weeks that they were in Miami. Finally, trainees noted 

the lack of injuries admitted to the trauma center which replicate injuries caused by blasts (ie, improvised explosive 

devices). 

Conclusions: The results of our efforts indicate that military-civilian collaborations do in fact work and are beneficial 

to both military and civilian medical providers. The opportunity to perform as a team in their respective roles, to 

respond to a variety of actual trauma patients, and access to civilian medical providers were beneficial. As  mentioned,

such collaborations are not without limitations. The good news is that most of the identified limitations will be 

corrected to ensure trainees get the best possible experience possible. 
18 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

to practice the application of one’s knowledge and 

skills. However, simulation-based training can only 

take medical personnel so far. 

A General Accounting Office (GAO) report published 

in 1998 shed light on the lack of military medical 

preparedness during the Gulf War (1991).2

 For 

example, at the time, only 2 of 16 surgeons stationed 

on one Navy ship had recent trauma experience. 

Furthermore, surgical support teams operating in the 

battlefield in fact had no actual surgeons on the team. 

This led to a number of initiatives to improve predeployment training for US Army medical personnel. 

These initiatives focused on providing surgical teams 

with not only classroom and simulation training, but 

also hands-on training with actual trauma patients. 

The severity of injuries seen on today’s battlefield is 

nothing like those previously encountered by these 

medical teams. Many of these injuries, resulting from 

improvised explosive devices, gunshot wounds, or 

other blunt and penetrating trauma, require immediate 

care and stabilization before Soldiers can be transported from the war zone. Therefore, forward surgical 

teams must be able to respond rapidly and effectively 

to save lives during the “golden hour.” It is within 

these first 60 minutes after a trauma occurs that care is 

required to significantly improve a trauma victim’s 

chance of survival. 

To address the concern over a lack of preparedness, 

efforts stemming from the 1998 GAO report2

 focused 

on exposing military medical providers to combat-like 

injuries in civilian trauma centers. As a result, 7 joint 

trauma training centers were opened,3

 including the 

US Army Trauma Training Center (ATTC). In 

existence since 2001, ATTCin is located within the 

Ryder Trauma Center at the University of Miami/

Jackson Memorial Medical Center in Miami, Florida. 

The Ryder Trauma Center, a standalone, level 1 

trauma facility, was chosen based on its close 

replication of the battlefield trauma system. The Ryder 

Trauma Center sees approximately 4,400 trauma cases 

each year. In addition, as a standalone trauma center, 

Ryder was chosen to minimize the “competition for 

action” between trainees and civilian staff employed 

by the trauma center (a concern at other hospitals 

where trauma cases are few and far between). 

While previously unable to gain expertise on 

battlefield-type injuries prior to deployment, ATTC 

offers a 2-week intensive team training program which 

combines classroom, simulation, and actual clinical 

experiences. The culmination of their training is a 

grueling, 24-hour exercise in which the forward 

surgical team essentially takes over the resuscitation 

unit at the Ryder Trauma Center. It is here that the 

knowledge and skills learned are put to the test; their 

last opportunity to apply what they know before being 

deployed. 

Although initial reactions data is currently collected 

during the 2-week training course, also important is 

long-term reactions to the training program 

postdeployment. Therefore, the purpose of this effort 

was to gather trainee reactions to the military-civilian 

collaboration provided at ATTC after deployment to 

Iraq or Afghanistan. With this information, strengths 

of the program can be highlighted and improvements 

made in areas where necessary. 

METHOD

Procedure 

Surveys were conducted online. A link to the survey 

was distributed via email to all US Army forward 

surgical team personnel who attended training at 

ATTC between 2005 and 2007. The survey was 

developed using Key Survey (WorldApp, Braintree, 

MA) and asked questions pertaining to their 

experience in the resuscitation unit and patient contact 

at the trauma center. Questions were both quantitative 

(using a 5-point Likert rating scale) and qualitative, 

focused on trainees’ reactions to the training. 

Participants 

Survey respondents were 135 US Army personnel (an 

approximately 50% response rate) who participated in 

the ATTC 2-week team training program between 

January 2005 and June 2007. Participants were a mix 

of surgeons (15.2%), nurses (registered nurses: 19%, 

nurse anesthetists: 10.5%, vocational nurses: 16.2%), 

operating room techs (15.2%), emergency medical 

transporters (12.4%), administrators (2.9%) and other 

(8.6%). 

RESULTS

Quantitative Responses 

Questions were broken down around two areas, 

reactions to experiences in the resuscitation unit 

Training Forward Surgical Teams: Do Military-Civilian Collaborations Work?
 October – December 2010 19

THE ARMY MEDICAL DEPARTMENT JOURNAL

(Resus) and reactions to amount of patient 

contact. Overall, the quantitative responses were 

extremely positive. 

Resuscitation Experience. When asked about 

trainees’ experience in the resuscitation unit of 

the Ryder Trauma Center, over 90% of 

participants agreed or strongly agreed that 

training in Resus was beneficial. A majority of 

participants also agreed or strongly agreed that 

the clinical experience gained in Resus was 

related to the trauma curriculum and were given 

feedback after a case. Finally, approximately 

90% of respondents agreed that Ryder Trauma 

Center faculty/physicians were available to 

answer questions and less that 40% would have 

liked greater access to Ryder staff. Table 1 presents the response distribution. 

Patient Contact Experience. The next set of questions focused on trainees’ reactions to the 

patient contact experience during their 2-week 

training program. Similar to their resuscitation 

experience, a majority of trainees agreed or 

strongly agreed that the patient contact experience was sufficient (78.5%). In addition, almost 

90% agreed or strongly agreed that the patient 

contact experience was a good learning opportunity, and over 80% felt that the experience 

was a good opportunity to apply what they had 

learned in their classroom training. Table 2 presents the response distribution. 

Qualitative Responses 

In addition to quantitative questions, survey 

respondents were also asked open-ended questions 

about their experience during the 24-hour capstone 

event, as well as what they thought could be improved. 

Overall, positive responses outweighed negative 

response with approximately 60% of respondents 

providing positive feedback. A number of trainees felt 

that overall the experience was excellent, especially 

for nurses and medics. Others commented that the 

opportunity to work as a team and be “in charge of the 

whole operation” was beneficial. Finally, one 

respondent stated “My team is 6 months into 

deployment and I am grateful that I got to ATTC prior 

to shipping.” These comments and the other positive 

comments, such as those in Table 3, highlight the 

importance of the military-civilian collaboration when 

training forward surgical teams. 

Question SA A N D SD 

Cases that came into Ryder Trauma 

Center were applicable to the 

trauma curriculum. 

53.7 41.8 3.7 0 0 

I feel that the clinical training 

experience in Resus was a good 

opportunity to work in the role and 

function I perform/am assigned. 

45.2 38.5 4.4 5.9 3.0 

After a case in Resus, I was given 

feedback on my performance. 42.2 40.7 5.9 3.7 3.7 

After a case in Resus, we discussed 

the scenario and actions taken 

within the team. 

45.2 45.2 4.4 2.2 0.7 

I had access to Ryder Trauma 

Center faculty/physicians to ask 

questions regarding a specific topic. 

48.5 41.0 8.2 0.7 0.7 

I would have liked to have had 

better access to Ryder Trauma 

Center faculty/physicians to ask 

questions and gain information. 

18.7 18.7 32.8 22.4 5.2 

I feel that we had a sufficient 

amount of time in Resus. 33.3 44.7 11.4 6.8 2.3 

Training in Resus was beneficial. 51.5 41.8 3.7 1.5 0.7 

I would have like to have spent 

more time in Resus. 34.8 21.5 28.1 13.3 1.5 

Note: All response values are stated as percentages. 

Response Keys 

SA - strongly agree: A - agree: N - neutral: D - disagree: SD - strongly disagree 

Table 1. Questions and responses related to experience in the 

resuscitation (Resus) unit. 

Table 2. Questions and responses related to patient contact 

Question SA A N D SD 

I believe I had sufficient 

patient contact hours at 

Ryder Trauma Center. 

38.5 40.0 9.6 8.1 3.0 

I feel that my patient 

contact hours were a good 

learning opportunity. 

48.1 41.5 4.4 2.2 3.0 

I feel that my patient 

contact hours were a good 

opportunity to apply what I 

had learned in the 

classroom setting. 

43.7 40.0 11.1 2.2 2.2 

Note: All response values are stated as percentages. 

Response Keys 

SA - strongly agree: A - agree: N - neutral: D - disagree 

SD - strongly disagree 
20 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Training Forward Surgical Teams: Do Military-Civilian Collaborations Work?

Survey respondents were also asked to provide 

suggestions as to how the resuscitation experience 

could be improved. Table 4 contains a small sample of 

the comments. Areas of improvement revolved around 

4 common themes. First, a number of respondents 

discussed the importance of clarifying roles between 

the ATTC trainees and the Ryder Trauma Center 

residents and interns. While fewer problems were 

identified with the permanent Ryder staff, there were 

several instances of military and civilian trainees 

competing for patient time. Second, some trainees 

commented that the number of patients admitted to 

Resus during their capstone experience was limited, as 

well as the time they were able to spend in the 

operating room. Next, trainees would have preferred 

an extension of the training as a whole, as they felt it 

was rushed in order to fit all training opportunities into 

the 2 weeks that they were in Miami. Finally, trainees 

noted the lack of injuries admitted to the trauma center 

which replicate injuries caused by blasts (ie, 

improvised explosive devices). 

COMMENT

The military-civilian collaboration occurring between 

the US Army and the Ryder Trauma Center has been 

in existence since 2001. The purpose of this survey 

study was to determine reactions to this collaboration 

by forward surgical teams who attended the 2-week 

training program offered by ATTC. Overall, reactions 

are positive; the opportunity to perform as a team in 

their respective roles, to respond to a variety of actual 

trauma patients, and access to civilian medical 

providers were beneficial. 

The ability to operate in such an environment, 

however, is not without its limitations. For example, it 

is not possible to predict the number of patients that 

will be admitted to the trauma center or the injuries 

which victims will present for treatment. While the 

injuries observed at Ryder Trauma Center may not be 

entirely representative of the injuries presented in Iraq 

and Afghanistan (for example, injuries resulting from 

improvised explosive devices do not frequently occur 

in the civilian environment), the forward surgical 

teams nonetheless are provided with the opportunity to 

operate as a team in “as close to the real” environment 

as possible. 

The feedback received from trainees has also shed 

light on areas within the program in need of 

improvement, namely interactions between military 

and civilian (ie, residents and interns) trainees and the 

need for additional training. First, it is no surprise that 

residents and interns at Ryder Trauma Center are eager 

to have “face time” with trauma victims admitted to 

the center. Thankfully, the clarification of roles 

between residents and interns on-call and forward 

surgical team trainees is a simple fix that can be 

implemented within the program. 

A larger effort is underway to address concerns over 

the availability of training time, as well as the desire to 

attend training closer to the time of deployment. 

Forward surgical teams attending ATTC typically 

deploy as an intact team within 6 months of training. 

Because the deployment of a team cannot specifically 

be predicted, and to minimize the amount of time that 

the teams are away from their families, ATTC is 

exploring the use of portable technologies (eg, iPod 

Touch (Apple Inc, Cupertino, CA)) to provide 

procedural animations/videos and other educational 

Table 3. Sample of comments related to strengths 

of training program. 

Having gone through 2 rotations, I still learn something 

new and would enjoy the chance to come back again. 

All in all, I believe this was the very best medical 

training experience ever received. 

It was scary but the presence of the Ryder staff gave 

me confidence to deal with my cases. 

Physically and mentally demanding. 

We saw a variety of patients. 

Overall a good tool for assessing strengths and 

weakness of team members. 

Table 4. Sample of comments related to areas in 

need of improvement. 

More collaboration instead of collision with the interns 

and nursing staff. 

More shifts even if you have to go to 3 weeks. 

Good for nurses and medics, not so good for MDs. 

More exposure to the operating room. 

More time, more patients. 

It would have been better closer to our deployment 

time. 
 October – December 2010 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

materials to teams that can be viewed prior to 

deployment. The advantage of the use of such portable 

devices is that educational materials, serving as a 

refresher course, can be stored on the device and 

viewed at any time by trainees (eg, in transport, during 

downtime) and as often as one would like. 

CONCLUSIONS

Military-civilian collaborations have existed for 

decades. The question posed by this research is do 

these collaborations work? The results of our efforts 

indicate that they do in fact work and are beneficial to 

both military and civilian medical providers. As 

mentioned, such collaborations are not without 

limitations. The good news is that most of the 

identified limitations will be corrected to ensure 

trainees get the best possible experience possible. 

ACKNOWLEDGEMENTS

This work was supported by funding from the 

Department of Defense Telemedicine and Advanced 

Technology Research Center (Award Number 

W81XWH-05-1-0372). All opinions expressed in this 

paper are those of the authors and do not necessarily 

reflect the official opinion or position of the University 

of Miami or the Department of Defense. 

REFERENCES

1. Clark C. 90 percent now survive battlefield injuries. 

San Diego Union-Tribune. February 15, 2007. 

Available at: http://www.signonsandiego.com/news/

military/20070215-9999-6m15ortho.html. Accessed 

January 23, 2008 

2. US General Accounting Office. Medical Readiness: 

Efforts are Underway for DOD Training in Civilian 

Trauma Centers. Washington, DC: US General 

Accounting Office; April 1, 1998. Report GAO/

NSIAD-98-75. 

3. Moore EE, Knudson MM, Schwab CW, Trunkey 

DD, Johannigman JA, Holcomb JB. Military-civilian 

collaboration in trauma care and the senior visiting 

surgeon program. N Engl J Med. 2007;357(26):2723-

2727. 

AUTHORS

Dr Schulman is an Associate Professor of Surgery, 

DeWitt Daughtry Family Department of Surgery, and 

Director of Clinical Research, William Lehman Injury 

Research Center, University of Miami Miller School of 

Medicine, Miami, Florida. 

Ms Graygo is Research Manager, William Lehman 

Injury Research Center, University of Miami Miller 

School of Medicine, Miami, Florida. 

Dr Wilson is the former human factors 

psychologist at the William Lehman Injury 

Research Center, University of Miami Miller 

School of Medicine, Miami, Florida. 

LTC Robinson is the former director of the 

Army Trauma Training Center, Miami Florida. 

LTC Garcia is the Director of the Army 

Trauma Training Center, and an Assistant 

Professor of Surgery, DeWitt Daughtry Family 

Department of Surgery, University of Miami 

Miller School of Medicine, Miami, Florida. 

Dr Augenstein is a Professor of Surgery, 

DeWitt Daughtry Family Department of 

Surgery, and Director of the William Lehman 

Injury Research Center, University of Miami 

Miller School of Medicine, Miami Florida. 

An Army Forward Surgical Team at work in the Ryder Trauma Center during their 

predeployment training at the Army Trauma Training Center, Miami, Florida. 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

BACKGROUND

Veterinary Services has 2 accredited reference food 

testing laboratories; the Department of Defense (DoD) 

Veterinary Food Analysis and Diagnostic Laboratory 

(FADL) at Ft Sam Houston, Texas, and the Veterinary 

Laboratory Europe at Landstuhl, Germany.1

 The laboratories, complemented by regional surveillance laboratories in Korea and Hawaii, encompassed the food 

laboratory support to the field. Despite the exemplary 

performance of these laboratories, the delays between 

sample submissions to receipt of results due to time 

and distance factors can adversely impact local missions. Thus, immediate local command support has 

relied on the Veterinary Service food inspection subject matter expertise, thermometers, and organoleptic 

testing for the inspection of food and bottled water for 

wholesomeness, safety, and defense. Striving to overcome this technology gap, 2 new laboratory veterinary 

equipment sets were developed and fielded. Assay 

training methodologies, originally developed at the 

Veterinary Laboratory Europe, were exported to the 

Army Medical Department Center and School 

(AMEDDC&S) Department of Veterinary Science 

(DVS) as a Professional Postgraduate Short Course 

Program course in early 2007. This initial, basic oneweek familiarization course was fully developed and 

expanded into 2 separate DVS functional courses. As a 

result, “surveillance food laboratories” is the new term 

for the successful deployment of these training initiatives. 

SURVEILLANCE FOOD LABORATORY VETERINARY

EQUIPMENT SETS

To meet the need for increased rapid, portable, onsite 

testing of food and bottled water to complement current programs established by reference laboratories, 2 

veterinary equipment sets (VES) were developed and 

fielded to test for indicators of microbiological and 

chemical agents: 

 The Field Microbiology VES primarily incorporates capabilities for microbiology testing of food, 

water, and equipment surfaces for indicators of 

microorganisms. This VES also includes bioluminescent swab tests. 

 The Food Testing VES incorporates additional 

food chemistry screening tests. 

Together, these equipment sets provide the Veterinary 

Service commander the opportunity to maintain surveillance food laboratories at critical sites within the 

command and the ability to “scout” local sites/vendors 

for potential food safety and defense issues. 

Veterinary Surveillance Laboratories: 

 Developing the Training Program 

Staci L. Mitchell 

SSG Katasha T. McCline, USA 

LTC Margery M. Hanfelt, VC, USA 

ABSTRACT

The increased need and demand for onsite, frequent, rapid, and portable food and bottled water testing for indicators of 

microbiological and chemical agents led to the deployment of 2 laboratory veterinary equipment sets. A Surveillance 

Food Laboratory Program (SFLP) was developed to allow Veterinary Corps commanders to establish targeted testing 

programs to enhance food safety and wholesomeness, along with faster responses to food defense, suspected foodborne 

illness, and food/water risk assessment missions. To support the deployment of the veterinary equipment sets and the 

SFLP, 2 new functional courses were developed by the Department of Veterinary Science. The Surveillance Food 

Laboratory Technician Course teaches essential technical skills that include sample processing, assay methodologies, 

results review, and interpretation of results produced by these laboratories. The Surveillance Food Laboratory Manager 

Course, developed for designated managers of the laboratories and laboratory programs, teaches the skills critical to 

ensuring proper surveillance laboratory oversight, testing, evaluation of results, risk communication, and response to 

presumptive positive results produced by the laboratories. Together, the courses allowed for the successful deployment 

of the unique veterinary equipment sets, resulting in development of fully operational surveillance laboratories in 

support of food protection missions in every major theater of operations.
 October – December 2010 23

SURVEILLANCE FOOD LABORATORY PROGRAM

DEVELOPMENT

To provide guidance to Veterinary Service commanders on the deployment and use of the laboratory veterinary equipment sets, the Surveillance Food Laboratory Program Guide2

 was developed by DVS in coordination with the FADL, and signed into implementation by the DoD Veterinary Service Activity. The purpose of developing surveillance laboratories within 

unit/district commands is to achieve multiple food 

safety and defense goals. While not all inclusive, these 

goals provide unit/district commanders and the military community they support with a greatly expanded 

and improved food safety program: 

Increased surveillance allows increased opportunities to identify potential problems before they are 

manifested and provide guidance to local commands in areas or situations where the military 

mission necessitates a direct response. 

Increased surveillance allows targeted testing of 

potentially hazardous food products of increased 

concern that are specific to a region or locality. 

SURVEILLANCE FOOD LABORATORY PROGRAM

TRAINING INITIATIVES

As an AMEDDC&S training department, the Department of Veterinary Science is responsible for training 

Soldiers and Department of the Army civilians on the 

proper use and follow-up actions necessary to deploy 

and operate the laboratory veterinary equipment sets to 

their full potential. This responsibility was met with 

the development of the 2 new functional courses, the 

Surveillance Food Laboratory Technician and Manager Courses, which are taught by designated DVS 

laboratory training personnel complemented with 

FADL subject matter experts. Additionally, DVS dispatches a Veterinary Training Assistance Team 

(VTAT) to conduct an offsite version of these courses 

at the unit’s location when requested by the unit commander. However, successful completion of this training is only the first step. Certification as a Surveillance 

Food Laboratory Technician is a 2-part process; successful completion of the DVS functional course or 

targeted VTAT as determined by the Chief, DVS; and 

acceptable proficiency results as determined by the 

FADL Director. This certification must be renewed 

annually. 

The Surveillance Food Laboratory Technician Course 

(321-F18), developed for Veterinary Food Inspection 

Specialists (military occupational specialty 68R) and 

designated civilians, is an intensive, fast paced, 80-

hour course; where students learn microbiological and 

chemistry indicator assay methodologies and procedures. The first week of the course is the “crawl/walk” 

phase, as students are walked through topics that include basic laboratory procedures, laboratory safety 

and HAZMAT requirements, laboratory environmental 

surveillance, testing methods, laboratory worksheets, 

laboratory equipment and supplies, and interpretation 

and significance of their testing results. Week two is 

the “walk/run” phase where students are required to 

individually perform a variety of tests on samples of 4 

different commodities, properly document all phases 

of testing and results, and conduct an oral briefing to 

explain the significance of those results. There are 

quizzes, practical exercises, and preparation time allotted throughout. Students are required to maintain an 

overall academic average of 75%, as well as receive 

first-time “GOs” on all graded practical exercises, in 

order to receive an AMEDDC&S Certificate of Training. Demonstration of this Certificate of Training for 

the residence course, or a DVS issued training certificate for VTATs, is required for the Soldier to request 

proficiency testing samples from the FADL in pursuit 

of certification as a Surveillance Food Laboratory 

Technician 

Recognizing the need to train Veterinary Food Inspection noncommissioned officers, Veterinary Corps Food 

Safety Officers (Area of Concentration 640A), Veterinary Corps Officers (Area of Concentration 64A), and 

designated civilians as managers of the laboratories 

and laboratory programs, the Surveillance Food Laboratory Manager Course (6G-F15/321-F17) was created. Commanders must have confidence that only 

actionable results are produced by the surveillance 

food laboratories, and the training in this course directly contributes to providing that confidence. Building on the food safety and defense expertise already in 

their military occupation skill set, students are quickly 

immersed in a fast-paced, one-week course (including 

nightly homework and morning quizzes) that teaches 

concepts and skills critical to the surveillance laboratory operation, including laboratory rollout plans, laboratory oversight, testing, documentation verification, 

evaluation of results, risk communication, response to 

presumptive positive results, and auditing surveillance 

laboratories. The week culminates in a 6-hour, graded, 

practical exercise consisting of testing stations of the 

key concepts as taught. As with the technician course, 

students must achieve an overall 75% and all GOs to 
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Veterinary Surveillance Laboratories: Developing the Training Program 

receive an AMEDDC&S Certificate of Training as 

determined by the DVS Chief. In addition, each student receiving an overall average of 90% and all GOs 

will have passed the surveillance laboratory manager 

proficiency requirement, as determined by the FADL 

Director, and will receive the Surveillance Laboratory 

Manager certificate. This training by DVS and certification by the FADL will also be conducted offsite for 

Veterinary Service units as needed and requested. 

THE RESULT

As a result of these aggressive training initiatives by 

DVS, complemented by the FADL, 100 technicians 

and 48 managers have been trained to date. In turn, 

they have established 5 fully functional surveillance 

laboratories, with several more in varying stages of 

development. Locations include all major theaters of 

operations; and the units include both TOE* and TDA†

units, Active Army and Reserve Veterinary Service 

units. These surveillance laboratories have successfully supported destination monitoring, Department of 

the Army special events, food and water risk assessment, food safety objectives, and similar food protection missions worldwide. 

THE FUTURE

Upgraded versions of the 2 veterinary equipment sets 

are being fielded, with an associated shift in the surveillance laboratory concept and purpose. The VES 

913B (Surveillance Lab Basic), will incorporate the 

methodologies, equipment, and supplies currently 

taught; but will include additional capabilities, including basic animal disease surveillance. This additional 

capability is not designed to support a veterinary treatment facility, but rather the disease surveillance within 

a local animal population or area of concern within a 

theater of operations. The VES 914B (Surveillance 

Lab Augmentation) is the next level of testing capabilities, with the dual purpose of both food protection 

and animal disease surveillance missions, with an emphasis on specialty and advanced assays. To train the 

VES 914B, an Advanced Veterinary Surveillance 

Laboratory Course for certified technicians and managers is under development for implementation during 

Fiscal Year 2011. This course will train the new methodologies, with an emphasis on the dual purpose laboratory mission. All the DVS laboratory courses will 

reflect this shift from the Surveillance Food to the 

dual use Veterinary Surveillance Laboratory. 

CONCLUSION

The Department of Veterinary Science, in conjunction 

with the DoD Veterinary Food Analysis and Diagnostic Laboratory, continues to successfully meet the challenge of developing new training initiatives to fulfill 

the field requirement for onsite deployment of the 

laboratory veterinary equipment sets and establishment 

of local veterinary surveillance laboratories. The result 

has been the establishment of multiple surveillance 

laboratories supporting food protection missions 

worldwide. 

REFERENCES

1. Lab Sample Submission Guide. Fort Sam Houston, 

Texas: Department of Defense Veterinary Food 

Analysis and Diagnostic Laboratory; January 2009:3. 

Available at: http://www.vetlab.army.mil/documents/

LABguide2009.pdf. 

2. US Army Surveillance Food Laboratory Program 

Guide. Fort Sam Houston, Texas: Department of Veterinary Science, Army Medical Department Center 

and School; August 2008. 

AUTHORS

Ms Mitchell is the Project Officer for surveillance 

laboratory training courses at the AMEDDC&S, Fort 

Sam Houston, Texas. 

SSG McCline is the Surveillance Laboratory Training 

Noncommissioned Officer, Department of Veterinary 

Science, AMEDDC&S, Fort Sam Houston, Texas. 

LTC Hanfelt is Commander, Japan District Veterinary 

Command, Camp Zama, Japan. 

*Table of Organization and Equipment: Defines the structure 

and equipment for a military organization or unit. 

†Table of Distribution and Allowances: Prescribes the 

organizational structure, personnel and equipment 

authorizations, and requirements of a military unit to perform a 

specific mission for which there is no appropriate table of 

organization and equipment. 
 October – December 2010 25

The mission of Air Education and Training Command 

(AETC) is to empower our nation’s Airmen to fly, fight, 

and win by “delivering unrivaled air, space, and 

cyberspace education and training.” However, realizing 

this vision in today’s highly interactive, informationsaturated, and global environment is tougher than ever. 

Mission success requires knowledge-enabled Airmen who 

understand, appreciate, trust, and internalize the tactics, 

techniques, processes, and procedures necessary to 

succeed in any number of complex situations. 

As leaders at all levels, our Airmen must be able to 

anticipate and appropriately respond to a complicated and 

fluid national security environment. Developing such 

Airmen will require stronger commitments to education 

and training on the part of the learner to the point where 

learning never stops. Fostering this highly favorable 

attitude toward learning is possible only if Air Force 

education and training programs address learners’ goals, 

motivations, social interactions, and individual learning 

styles. This means the Air Force needs a stronger focus 

on affective learning during the instructional design (ID) 

process for education and training. 

The ability to handle complex problems across a wide 

spectrum of missions is not acquired through traditional 

rote-learning practices that merely assess an individual’s 

ability to memorize facts in the short term. Air Force 

learning processes must facilitate intuitive understanding 

and personal internalization of often conflicting concepts, 

applications, and decision-making models. Effective 

education and training methods must recognize the filters 

and perceptions individuals will employ to frame a 

solution to any number of problem sets. Relying solely 

on a cognitive learning approach for leadership 

development is quickly being eclipsed by a drive to 

understand and employ affective methods to enhance 

learning and internalize decision-making skills.1

Recognizing the evolutionary changes in the information 

environment, AETC published a white paper entitled On 

Learning: The Future of Air Force Education and 

Training,

2

 which stipulates that successful education and 

training in today’s complex environment require a new 

learning culture. This includes instant and unfettered 

access to information through knowledge management, 

nonstop learning opportunities to provide continuous 

learning, and the right information at the right time that 

leads into precision learning. However, in addition to 

flexible and timely access to information, an effective Air 

Force learning environment must also instill in every 

Airman a strong desire to learn continuously. 

More than just the opportunity and means to learn, 

effective education and training also require engendering 

students’ desire to improve continuously.3

 This should be 

directed at improving abilities and knowledge to 

accomplish the mission more effectively. A large 

percentage of the academic failure rate in our nation’s 

schools is not because of limited facilities or incompetent 

teachers. Rather, many students fall behind because they 

do not feel that learning is important to them.4

 To ensure 

mission success, the Air Force must have education and 

training programs that consider not only cognitive goals, 

but also learners, attitudes, and motivations. This should 

be carried out through the use of expert ID and 

innovative technology applications that inspire students 

to put forth their best effort. 

Because of the fast-changing, technology-driven 

environment in which we operate, a true warrior ethos 

must be dominated by a desire to learn.2

 This paper 

addresses the importance of instilling that desire through 

Air Force education and training, and it examines various 

ways that technology can help. The opening portions of 

this paper review general learning theory, including the 

cognitive and affective aspects of learning. The next 

section considers the impact of ID on cognitive and 

affective learning. Good ID is the primary means to 

engage the affective domain. The paper then considers 

how technology can facilitate cognitive and affective 

learning processes. Recent advances in technology 

Leveraging Affective Learning for 

 Developing Future Airmen 

Col Donald Tharp, USAF 

Anthony Gould, PhD 

Col (Ret) Robert Potter, USAF 

This article is a reprint of the research study report of the same title which was released in November 2009 by the Air Force 

Research Institute, Air University, Maxwell Air Force Base, Alabama. 
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

provide increased social networking and adaptive 

learning applications that cater to affective needs. The 

remaining sections discuss how to apply these concepts 

with regard to advanced technologies, leadership, and 

future research. 

LEARNING DOMAINS

Learning can be viewed as both a product and a process. 

Standard definitions of learning from the educational 

psychology textbooks of 40 years ago generally defined 

learning as a “change in behavior as a result of 

experiences.”5

 This behaviorist approach assessed 

learning as an outcome that resulted in some external 

behavioral activity; however, not all learning leads to 

overt behavior. Consequently, many theorists later refined 

the definition of learning to consider changes in the way 

people “understand, or experience, or conceptualize the 

world around them.”6

 So learning is an increase in 

information, but it also involves interpreting and 

comprehending. Different learners filter information in 

different ways, based on perspective. Individuals then 

restructure information to create personal knowledge.6

 In 

other words, learning is a multidomain process involving 

intellect, emotion, and physical skills. Further, these 

domains are connected, and the condition of one 

influences the others. 

Historically, educators have recognized and accepted the 

notion of separate domains for addressing different types 

of learning objectives. Bloom7

 and his group’s 

foundational effort established three categories or 

domains of educational objectives and identified them as 

cognitive, psychomotor, and affective. The theory and 

accompanying research for the cognitive (thinking) and 

psychomotor (physical) categories are fairly well defined 

and commonly accepted. The definition and theoretical 

framework of the affective category has been more 

problematic and difficult to establish. This lack of clarity 

exists because the affective domain concerns human 

cultural beliefs, behaviors, attitudes, motivations, 

feelings, perceptions, and emotions that are very fuzzy 

and lead to ill-defined characterizations. Each of the three 

domains requires specific considerations, based on the 

intended learning objectives.8

COGNITIVE DOMAIN

Processes involving the development of intellectual skills 

characterize the cognitive domain. According to Bloom,7

the cognitive domain is best described by six categories 

that typify successive levels of thought complexity. 

Knowledge, comprehension, application, analysis, 

synthesis, and evaluation designate progressive stages 

ranging from recalling simple information to making 

judgments about the value of ideas or concepts. 

Collectively, the theoretical range of the cognitive 

domain connects the thought processes necessary to 

acquire, process, and interpret information. This linkage 

to information processing makes computers and 

associated information technology applicable, facilitating 

cognitive objectives.9

The most effective educational processes in the cognitive 

domain challenge and support the learner’s ability to 

grasp new information and concepts. They focus on 

knowledge, reasoning, and performance that underpin the 

categories in Bloom’s taxonomy.10 Assessment processes 

in the cognitive domain determine the level of 

understanding achieved and provide feedback on learning 

outcomes. Educators design lessons intended to 

maximize the transfer of information and provide valid 

learning-assessment tools. Most educational programs 

focus almost exclusively on these processes during ID.11

PSYCHOMOTOR DOMAIN

The psychomotor domain involves physical movement, 

coordination, and the use of motor skills and is generally 

associated with training. Physical skills, developed 

through training or practice, are measured in terms of 

accuracy, speed, precision, distance, or technique. There 

are several taxonomies describing psychomotor skills, 

and each includes increasing levels of physical dexterity 

and ability to adapt new movements when necessary. 

This domain is considered well defined as the results 

from empirical research generally agree with theories 

concerning psychomotor learning.7

 Pilot, vehicle driver, 

weapons operator, and maintainer training are examples 

of psychomotor instruction. 

AFFECTIVE DOMAIN

Processes involving our needs and emotions characterize 

the affective domain. Affective filtering of life’s 

circumstances creates an individual’s disposition, 

enthusiasm, motivation, attitude, attention, value, and 

emotion regarding another individual, object, fact, 

concept, process, and/or belief. Sinclair12 refers to affect

as a term used to describe the feeling or emotional aspect 

of experience, associated with 

 the motivation of behavior, 

 the maintenance and enhancement of self-esteem in 

the educational setting, 

 anxiety and achievement motivation, 

Leveraging Affective Learning for Developing Future Airmen 
 October – December 2010 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

 development of curiosity and a need to know and 

understand, and 

 social motives, such as a need for praise, recognition, 

and attention. 

Although affective learning is difficult to define, anyone 

who has taught for very long recognizes its crucial role. 

In any given lesson, some students seem driven to absorb 

new concepts and ideas while others seem disinterested. 

This situation can lead to the often-heard phrase “what is 

taught is not the same as what students learn.”13 This 

highlights the strong influence exerted by affective 

processes on cognitive learning. Though theoretically 

incomplete, empirical evidence suggests that the absence 

of affective internalization of a concept attenuates longterm learning.14 Restated more simply, students who have 

little desire or interest to learn will learn little. 

Unfortunately, due to the indistinct nature of the affective 

domain noted above, there is not a good theoretical 

model for predicting the precise impact of affect on 

learning. A systematic approach for detecting level of 

affect is needed to assist teachers as they try to motivate and 

involve their students. 

Several schemas have been proposed to describe the 

processes of the affective domain. Krathwohl10 proposed 

the most widely cited taxonomy with five major 

categories describing levels of affect. These categories, 

listed below in order from lowest to highest affect, 

provide a rough framework to assess and compare: 

1. Receiving—Passive attention to phenomena (eg, 

listens attentively, asks, sits erect, and identifies). 

2. Responding—Active participation in and reaction 

to phenomena (eg, participates, discusses, and 

helps others). 

3. Valuing—Attachment of worth to phenomena (eg, 

explains, proposes, shares, and differentiates). 

4. Organizing—Construction of value system that 

compares and relates phenomena (eg, generalizes, 

integrates, and synthesizes). 

5. Characterizing by value—Application of consistent value system to control characteristic 

behavior (eg, works independently). 

This taxonomy and its full description provide enough 

detail to create learning objectives that address the 

affective domain. The following is an example of an 

affective learning objective used many years ago by the 

Air Force Academic Instructor School: 

The objective of this lesson is for each student to 

respond positively to using reflective teaching 

techniques to improve teaching ability. 

Forty years ago, educators placed nearly as much 

emphasis on affective objectives as they did on cognitive 

objectives.10 Since that time, the share of affective 

objectives in ID has slowly declined to the point that few 

schools today include affective objectives in their 

lessons. 

A student’s affective state influences his or her learning 

predisposition, and educators should consider this when 

designing and developing education and training courses. 

Students use affect as a filter to assist them in developing 

attitudes about the course, the instructor, their peers, and 

the topic that in turn contributes to students’ overall 

success in the learning process.15 When it comes to 

mastering skills, it is essential for students to exercise 

cognitive processes, but effective cognitive retention is 

marginalized if the affective domain is ignored. If one 

feels threatened, sad, bored, stressed, or preoccupied, the 

learning process can break down.16 Instructional theories 

and design models focus on the cognitive and 

psychomotor domains. Research generally makes the 

obligatory mention of the affective domain, but in 

practice affect is largely ignored as an area of scientific 

study in the instructional-technology field. 

There are numerous reasons proposed to explain why 

affective objectives are seldom included in the 

curriculum of most schools10,17: 

1. Affective results are long range and intangible. 

2. People fear the perception of brainwashing 

(blurring of education and indoctrination). 

3. Outcomes can be “faked.” 

4. Assessment is subjective (self-reported observations). 

5. Absence of behaviors is as important as 

presence. 

6. Some persuasive communication methods cause 

uneasiness. 

7. Definition and understanding of affect are 

imprecise. 

8. People disagree about affective behavior outcomes. 

9. Using computers to teach attitude seems 

Orwellian. 

10. The goal is efficiency, so affect is easily excluded. 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Each of these factors has contributed to the limited use of 

affective learning objectives. However, another factor 

that may have played a role was the growing influence of 

technology on education.18 During the past half century, 

technology has grown ever-more present in the 

educational process. Computers, networks, multimedia, 

the Internet, online communication, and all forms of 

digitized information are commonly termed educational 

technology (Ed Tech) when employed for learning. Ed 

Tech has revolutionized the educational environment, and 

few classrooms are without some level of Ed Tech in 

place. 

IMPACT OF TECHNOLOGY

Technology has routinely influenced educational theories, 

and some models of thinking reference the human mind 

in terms similar to a computer.19 The senses are seen as 

input devices, memory as a database, and the brain as 

some type of microprocessor. This may be a useful 

construct when considering presentation and recall of 

information, but one of the drawbacks to this type of 

model is that it neglects many other human processes 

such as interest, attention, emotion, beliefs, and 

motivation. Consequently, the impact of these factors on 

learning, which are frequently referred to as affective 

qualities, has often been ignored. 

Advances in Ed Tech generally mirror advances in the 

broader technological realm, which has been dominated 

by software and hardware focused on efficiently 

delivering and transferring information. Over the past 40 

years, educators have focused on the efficiencies that 

technological advances afforded educational processes.4

Computer-based instruction, Internet access, electronic 

testing, distance-learning applications, television, and 

content-management systems allow educators to transfer 

information to students and assess that transfer on a 

grand scale.20 The combined effect of these initiatives 

reduced the influence of human emotions on learning. 

Predominantly, educators ignored the student’s need for 

connection and personal involvement, both of which are 

necessary for effective learning. This situation created a 

bias toward cognitive objectives, which has only lately 

begun to subside.16 Recent developments in technology 

may help restore some balance between information 

processing and human involvement. 

Paradoxically, technology that in the past may have led to 

a bias in favor of cognitive objectives may now be used 

to foster and scaffold affective objectives.21 Improved 

networking technologies promise new mechanisms for 

social interaction, and advances in human/computer 

interaction are on the threshold of allowing computers to 

recognize user affect and respond accordingly. The latest 

social and communication technologies have led to 

applications that promote collaboration and student 

interaction. Educators now recognize that social learning 

(collaboration) tools have the potential to create 

opportunities to meet both cognitive and affective 

learning objectives. These tools include discussion 

forums, blogs, wikis, virtual worlds, and personal Web 

pages. However, the key to employing technology to 

support affective objectives is proper ID, which blends 

Ed Tech into the learning process. 

MEASURING AFFECT

Assessing progress in meeting affective learning goals 

requires more effort than evaluation for cognitive 

objectives. “Difficulty with measuring affective goals is 

cited in the literature as one of the major reasons for 

neglecting the affective domain in instructional design 

models.”8

 Perhaps the most important factor in this 

regard is the protracted period required to cultivate 

complex affective behaviors. Most instructional periods 

are relatively short. Influencing a learner’s value system 

generally requires instruction over a prolonged period. In 

addition, some affective objectives such as attention 

usually require periodic reinforcement. Main8

 points to 

advertising or public relations campaigns as examples 

that address lower-level affective objectives over an 

extended period. 

There are several basic methods for assessing affect. 

Direct behavioral observation is considered the most 

reliable but may not be possible for a large number of 

students or for dispersed learning activity. The ability to 

discern the affective state of students is a vital skill for 

effective teaching. One-on-one conversations or an 

interview is another method available to query a learner’s 

affective state. However, workload and personnel 

constraints frequently impede such time-intensive 

assessment methodologies. 

Self-reporting is another means to determine a learner’s 

affective state. Surveys or questionnaires are generally 

used to query attitude or other affective characteristics, 

but there can be problems with reliability. Some students 

may give the answers they believe more suitable rather 

than express their true emotional state or attitude. 

Another means to measure overall affective state is an 

implicit questionnaire designed to reveal affect without 

bias from the student.22 These instruments probe affective 

characteristics through a series of highly formatted, 

previously validated questions to register affect reliably. 

Leveraging Affective Learning for Developing Future Airmen 
 October – December 2010 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

Writing assignments are commonly used as a valid 

assessment of affect. Essays can provide evidence of a 

learner’s attitude toward a particular subject. However, 

analyses of essays can be somewhat subjective and may 

require a rubric and trained evaluators.22

INSTRUCTIONAL DESIGN PROCESS

So how do we bridge the gap and develop linkage 

between cognitive and affective instruction as we develop 

lifelong learners? The key is to use an integrated ID 

process that targets both the affective and cognitive 

domains. According to Smith and Ragan,23 ID refers to 

the “systematic and reflective process of translating 

principles of learning and instruction into plans for 

instructional materials, activities, information resources, 

and evaluation.” Good ID produces effective lessons 

based on sound educational principles. To be effective, 

lessons must both engage the learner and provide 

instruction in a clear and an efficient manner. 

Engaging learners requires instructional designers to 

focus on incorporating the affective domain along with 

the cognitive domain during the ID process. The problem 

resides with the prevalent tendency to use ID models 

centered on instruction for cognitive objectives.8

However, the more instructional designers know about 

both the cognitive and affective processes involved in 

learning, the more competent and confident they are with 

regard to designing effective learning.24 Expert ID of 

affective objectives can lead to greater motivation on a 

particular lesson and to successful cognitive and affective 

outcomes. 

According to Pierre and Oughton,11 instructional 

designers should not limit efforts in the affective domain 

to just motivating students to learn. Rather, they should 

consider how to engage students in deeper learning 

through the use of affective learning with appropriate 

pedagogy and evaluation methods. ID needs to become 

more effects based by creating instruction that addresses 

teaching strategies and learning outcomes that span the 

various levels of Bloom’s taxonomy. In effects-based 

design, the designer considers holistic effects and the 

interrelated and interdependent nature of the learning 

domains. Main8

 stated that integrating the affective 

instructional component into, or alongside, the ID model 

or process ensures that domain objectives are covered in 

every lesson. 

The ID process ensures that learning does not occur in a 

haphazard manner but is guided using a process with 

specific, measurable outcomes. The responsibility of the 

instructional designer is to create an instructional 

experience which ensures that learners will achieve the 

desired learning outcomes. ID has the appearance of a 

linear system; however, it is best viewed as an interactive 

process in which sequencing and fine-tuning of 

objectives are possible. There are no prohibitions against 

incorporating affective events or making changes to 

instruction. Teachers can adapt instruction based on 

evaluations and flow changes back through the process. 

Using ID as a working template can create the right 

learning program or process and justify necessary 

resources.25

The ID process considered for the purpose of this study is 

the Military Instructional System Development (ISD) 

Model. 2 6 Analysis, Design, Development, 

Implementation, and Evaluation—generically known as 

ADDIE—is widely accepted as an industry standard for 

ID of educational media.27 The ADDIE model brings a 

generic, systematic approach based on foundations-oflearning principles and standard system theory to the ID 

process.28 The ADDIE process provides a framework that 

instructional designers can use to optimize the 

effectiveness of instructional products and the 

efficiencies of creative processes.29

Each phase of the ADDIE model is a decision-making 

process that needs to ensure the effectiveness of the 

instructional experience23: 

 Analysis: The instructional problem is clarified, the 

goals and objectives are established, and the learning 

environment and learner characteristics are 

identified. 

 Design: The instructional strategies are designed, the 

media choices are made, and the objectives and tasks 

that will show student mastery are created. 

 Development: Materials are produced according to 

the instructional process. 

 Implementation: Instruction is tested using prototypes (with the targeted audience). Flaws are 

corrected or revised before the product goes into 

production, and learners and instructors are trained 

on product use. Flexibility is the key element during 

the implementation phase. 

 Evaluation: Feedback is gathered to help determine 

instructional effectiveness. Many consider this the 

most important stage, and it should be an ongoing 

process. 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

AFFECTIVE OR MOTIVATIONAL DESIGN

Motivational design is a systematic process that results in 

the preparation of learning programs that predictably 

influence the learner’s behavior. Consequently, 

motivational design is concerned with connecting 

instruction to learner goals, providing stimulation and 

appropriate levels of challenge, and influencing how 

learners will feel following success or failure of goal 

accomplishment. Every educator understands the 

challenge of stimulating and sustaining learner 

motivation and the difficulty of finding reliable and valid 

methods for motivating learners. 

One approach to motivational design is provided by 

Keller’s Attention, Relevance, Confidence, and Satisfaction (ARCS) model of motivation.30-33 The ARCS model 

is based on a synthesis of motivational concepts and 

characteristics that provide guidance for analyzing the 

motivational characteristics of a group of learners and 

then designing motivational strategies to fit the learners.33

The four conditions that comprise ARCS must be met to 

motivate learners. 

There are two major parts to the model. The first is a set 

of foundational factors representing the components of 

motivation, based on research into human motivation. 

The instructional designer should use them as guidelines 

during lesson-development activities: 

 Attention strategy relates to stimulating and maintaining the learner’s attention by initiating an instructional event with some sort of sensory stimuli 

and/or varying the kinds of activities or media. 

 Relevance strategy communicates to the learner how 

the activity or event relates to personal needs, 

interests, or motives. 

 Confidence strategy relates to the learner’s 

expectancy to feel it is worth the effort to participate 

in the activity. 

 Satisfaction strategy provides extrinsic and intrinsic 

reinforcement from the learning experience. 

The second part of the ARCS model is a systematic 

design process that assists in creating motivational 

strategies appropriate for a given set of learners. The 

synthesis allows educators to identify the various 

elements of student motivation; the design process helps 

profile students’ motivational characteristics in a given 

learning environment and then design appropriate 

motivational tactics.32 Keller further breaks down each 

ARCS strategy into three psychological concepts that 

assist designers by providing a theoretical foundation for 

each component: 

 Attention – perceptual arousal, inquiry arousal, and 

variability 

 Relevance – goal orientation, motive matching, and 

familiarity 

 Confidence – learning requirements, success opportunities, and personal control 

 Satisfaction – intrinsic reinforcement, extrinsic rewards, and equity 

COMBINED INSTRUCTIONAL AND MOTIVATION DESIGN

Keller never intended that the ARCS model stand apart as 

a separate system for ID; rather, it should be incorporated 

with instructional models.34 Additionally, history and 

research have revealed that no one theoretical foundation 

for ID practices is suitable for all applications.35 Both 

affective and cognitive ID approaches account for 

meaningful learning and realistic contexts for application 

knowledge and skills.36 Both recognize the importance of 

learner motivation and prior experience.37

Keller’s ARCS model attempted to correct discrepancies 

that marginalized the efficacy of most educational 

theories.8 That is to say, while a learner may be motivated toward learning, there is no assurance that a person 

is motivated to learn what the instructional event 

delivers. Additionally, instructional designers cannot assume they understand student motivation. During analysis, designers must attempt to understand how best to 

encourage students to reach the same conclusions regarding the values, interests, motivation, and content intended 

by the lesson’s learning objectives.38 The goal should be 

a combined ID model that includes a structured process 

incorporating both cognitive and affective concerns. 

Main8

 suggested integrating the ADDIE and ARCS models using a matrix to address the two domains in a systematic manner. Integrated ID (Figure 1) is an essential 

component for building an effective learning program. 

The design process has become more complex as 

advanced communication technologies have made social 

networking, information retrieval, and knowledge 

management available 24/7 worldwide. To bridge the gap 

and engage students in deeper, meaningful learning, 

instructional designers need to incorporate the affective 

domain during the design process. They must also follow 

the fundamental principles that apply to all pedagogy, 

including the external conditions that support learning 

and performance.24

Leveraging Affective Learning for Developing Future Airmen 
 October – December 2010 31

THE ARMY MEDICAL DEPARTMENT JOURNAL

A large number of instructional strategies and models are 

available for designers to help facilitate learner 

engagement and the learning process. It is important for 

instructional designers to have a solid understanding of 

the theory and the design process though they need not be 

subject-matter experts in a particular discipline. This 

paradox makes it important for instructional designers to 

keep sight of what Sugrue24 calls the five fundamental 

learning and performance principles: 

1. Learning is not performance: Align learning 

objectives with required performance objectives 

entwined with adequate incentives for applying the 

new skill and knowledge. 

2. Medium is not the method: Design to maximize 

strengths of the medium, but don’t expect the 

medium itself to influence content effectiveness. 

3. External and internal conditions should match: 

Ensure that flexible instructional methods are 

compatible with the cognitive processes of 

acquisition, knowledge storage, and retrieval while 

motivating learners to engage in their own 

learning. 

4. Authentic practice makes perfect: Design as 

contextually realistic as possible, matching goals 

of instruction for deepening knowledge. 

5. One size does not fit all: Accommodate individual 

differences by monitoring performance; diagnosing 

weaknesses; and adjusting feedback, information, 

and practice activities to meet group and/or 

individual goals. 

Instructional designers well grounded in affective and 

cognitive learning and motivation processes are better 

equipped to design effective learning products. 

LEARNING WITH TECHNOLOGY

Ed Techs are evolving daily, and the use of advanced Ed 

Techs in the classroom is now the rule rather than the 

exception. Higher education in the United States has 

given priority to integrating technology into the 

curriculum. The primary benefits of technology 

integration include efficiency in accessing information, 

distribution and presentation of course materials, 

applications to calculate and record, flexibility to adapt to 

individual learning differences, and meeting real-world 

technological skill requirements. Even the simplest use of 

technology (eg, spreadsheets, presentations, word 

processing, downloading information) appeals to faculty 

and learners. 

Today, advanced communication technologies have 

enabled instant delivery of massive amounts of information in a variety of formats and user-defined levels. 

Some posit that the instantaneous availability of massive 

amounts of unstructured data leads to problem-solving 

errors.39 Others take the opposing view, suggesting that 

“digital natives” have adapted their learning skills to 

accommodate the technology40 and have acquired a selfregulating ability to organize the data necessary to 

resolve decision-making conflicts.41,42 Further research is 

required on the subject, but advanced communication 

technologies are alluring to the educator because they 

provide the power to reach more students at a variety of 

learning levels.21 Additionally, such technologies afford a 

multisensory approach to gaining and maintaining 

student cognitive and affective interest as long as such 

approaches are based on sound pedagogical principles.18 

The quandary facing researchers and faculty members 

alike is the question of whether or not advanced 

communication technologies actually improve learning. 

The literature on the subject is varied, but a majority of 

people writing on Ed Tech have found that technology 

alone does not necessarily enhance the learning process 

over traditional methods.24,43 Rather, research has shown 

that technology can aid the learning process but only if 

applied correctly. Therefore, we can assert that although 

learning is not technology dependent, technology as an 

enabling tool has potential to improve the level of 

learning when properly applied. 

One advantage of integrating technology into ID is its 

ability to present or provide access efficiently and 

effectively to a variety of information. However, it is 

imperative that educators shift the paradigm from where 

students learn from technology to where students use 

technology as a cognitive tool or learning enabler. The 

real power of Ed Tech comes not from automating 

information transmission but from enabling student 

Figure 1. Combining ISD and affective-design models 
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

education while engaging their desires to continue 

lifelong learning. 

Cognitive tools allow students to interact with information to acquire, synthesize, create, and share new 

knowledge. Technology allows students to use cognitive 

tools to seek and present information while organizing 

and integrating knowledge.19 Technology facilitates this 

process by enabling the learner to access and retrieve 

information beyond the limits of memory, which enables 

the student to return to previous information, engaging it 

throughout the learning process.19

Cognitive tools are distinct in their implications of 

technology. Jonassen and Carr9 distinguish the impact of 

learning from technology and that of learning with 

technology. Simply stated, when students work with 

technology, instead of being controlled by it, they enhance the technology’s capabilities, and the technology 

enhances their thinking and learning. This interaction 

empowers learners to become active and responsible 

filters of information who engage in directing their 

mental processes. Cognitive tools should allow students 

to “activate metacognitive learning strategies.”9

Metacognitive learning strategies are used when students 

encounter new information, connect it to their prior 

knowledge, and then construct and revise their 

schemata.44 The effective use of cognitive tools should 

enable learners to undertake this process and assist them 

in experiencing cognitive processes that would be 

impossible without such tools.45

TECHNOLOGY TO PROMOTE AFFECTIVE LEARNING

Research has proven that learners who are not engaged 

and motivated are not learning as effectively as their 

peers who are engaged and motivated. According to Rose 

and Meyer,14 educators engage and motivate by providing 

a choice of content (print, audio, information, video, 

simulation, and instruction), adjustable levels of 

challenge, and choice of learning context since learners 

are unique, like fingerprints. Technology enables 

designers to embed video, pictures, sounds, and story 

lines while providing links to additional information and 

social networks that learners can access. In multimedia 

learning, the student engages in three cognitive 

processes: selecting, organizing, and integrating based on 

dual coding theory.46 Additionally, the affective domain is 

engaged through an emotional story, an evocative image, 

a video, or mood-provoking music. 

By properly designing and integrating with correct 

technology, the educator can emphasize the desired effect 

to engage the learner to promote knowledge construction 

and problem solving.47 For example, consider an online 

instruction consisting of text explaining that one should 

avoid filling a gas can in the bed of a truck. Now 

consider the same learning goal using video showing an 

individual at the gas station as gas fumes—ignited by 

static electricity—explode, and flames engulf the truck. 

Such poignant examples, delivered by means of 

technology, are designed to engage emotions while 

making people think about potential consequences. 

Another proven influence on affect is socialization and 

personal interaction with others, including students and 

faculty. Social interaction can lead learners to make 

strong internalizations and can affect their reasoning and 

beliefs. Learners’ comprehension or retention of 

knowledge (cognitive learning) as well as their feelings 

about, attitudes toward, behavior during, and satisfaction 

with the course (affective learning) may also be 

influenced. Social presence has emerged as an important 

social factor in the field of education. To understand the 

concept of social presence, one must understand what 

socialization and presence entail.48 According to 

Kandwar and Swenson,49 socialization refers to the 

“process by which people learn the characteristics of their 

group and the attitudes, values, and actions thought 

appropriate for them.” Presence—important in social 

learning to reach learning goals—is reported to have 

positive effects on student perceptions of the course’s 

communications and relevance.50

The recent advance of several new Ed Techs such as 

online learning environments, social networking, mobile 

devices, and intelligent agents is reshaping the nature of 

Ed Tech. These technologies allow asynchronous and 

synchronous communication that facilitates socialization 

and social presence. Technology can facilitate 

communication across barriers of time and distance while 

enabling virtual communities with affective and social 

support that fosters deeper shifts in education practices.51

Educators are using these advances to meet affective 

learning objectives. The following Ed Techs focus on 

current and ongoing capabilities, thus facilitating the 

affective educational processes. 

ONLINE LEARNING ENVIRONMENTS

Online learning environments encompass a variety of 

types and styles, providing different capabilities such as 

content management, discussion, assessments, and 

messaging. If properly designed and employed, these 

environments can facilitate affective and social 

interactions. The key is providing social, learning, and 

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THE ARMY MEDICAL DEPARTMENT JOURNAL

technology support in the learning environment.52 All 

three areas impact affective learner characteristics. 

Successful learning environments must facilitate a variety 

of learners and educators across the spectrum of affective 

and cognitive knowledge levels. Successfully providing 

such support requires instructional designers to consider 

the ID process for the learner and to plan for costs, 

logistics, and faculty support in all three areas. 

SOCIAL NETWORKS

Social networks and social learning are coming of age as 

technology grows and the Internet expands across the 

world. Social learning can take place in discussion 

forums, chats, blogs, wikis, and virtual worlds. Social 

theory provides insight into why social networks need to 

be part of the learning process. According to sociallearning theory, human behavior is based on continuous 

reciprocal interaction among individuals in terms of 

cognitive, behavioral, and environmental influences.41,53

Preece45 emphasizes that, if online communities wish to 

be successful, developers and designers need to pay 

attention to social as well as technical issues while 

infusing sociability in communities that depend on trust, 

collaboration, and appropriate styles of communication. 

Online-learning communities normally congregate 

around formally organized learning activities. Wenger’s55

concept of communities of practice (CoP) has gained 

acceptance across the education domain, enabled by new 

technologies that permit the development of virtual CoPs. 

Air University’s Commander’s Connection is one of 

those communities that has proven successful in allowing 

new and current squadron commanders to get together 

virtually and educate, assist, and update each other. CoPs 

have provided motivation and emotional support while 

allowing peers to operate in real-world contexts.53

Technology not only has the capability to engage students 

by enriching the learning environment, but also can assist 

the faculty. Professional networking can link educators as 

a community of peers to help establish best practices and 

pedagogical strategies. Such online communities also 

assist faculty engaging in research and provide a means 

for them to compare cognitive and affective strategies. 

Distance-learning technology also enables teachers to 

reach more students than face-to-face meetings would 

allow. An experienced teacher in the role of subjectmatter expert may participate in the design, development, 

and implementation of both an online class and 

pedagogical techniques focused on cognitive or affective 

strategies that can aid novice educators; such a teacher 

could also act as a mentor.56

The most common method for social interaction in CoPs 

and other online venues is the discussion forum. The 

creation of a discussion forum to encourage social 

interaction among individuals while they undertake 

online studies has become a common practice as increasingly sophisticated learning-management systems 

pervade education. Pilkington and Walker57 assert that 

effective teaching and learning is predicated on the 

forum’s capacity to facilitate collaborative and critical 

discussion to “develop student ability to reason” for both 

cognitive and affective learning. As Roberts58 suggested, it is 

not just about participating but about how this 

participation can enrich student-learning experiences. 

CoPs, discussion forums, or online chats are all ways to 

integrate social learning and networking with the 

educational process. Learners are able to extend their 

range of learning opportunities by collaborating with 

others to achieve goals and complete assignments not 

otherwise possible. According to Woods and Ebersole,59 a 

properly designed social-learning network facilitates 

interconnectedness and shared responsibility for learning 

outcomes, allowing cognitive and affective aspects of 

online learning to produce optimal results. Technology 

has facilitated social learning and brought it to a higher 

level of educational awareness. Further research is 

necessary to determine the best means to exploit it for 

optimized learning. 

VIRTUAL WORLDS

Perhaps we are reaching the next stage of social presence 

through the use of virtual worlds, which are gaining 

acceptance as a viable teaching and learning tool. Virtual 

worlds can provide an immersive environment that 

facilitates a strong social presence. They allow simulated 

experiences not possible in school settings, increase 

learner engagement by visually immersing students, 

support new forms of interaction and collaboration with 

the potential to increase students’ knowledge and skills, 

and build self-efficacy.60

Virtual experiences can have a more profound influence 

on affective outcomes than other pedagogy because 

multiple senses (visual, auditory, and tactile) are 

involved. Additionally, learning in virtual environments 

can be tailored to individual needs. Rather than learning 

by listening to lectures or reading, students will be able to 

access information, work collaboratively, and evaluate 

knowledge using virtual simulations. Although virtual 

worlds in education and training are still in their infancy, 

they show potential. 
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

MASSACHUSETTS INSTITUTE OF TECHNOLOGY AFFECTIVE

COMPUTING: HUMAN/COMPUTER INTERFACE

As discussed earlier, it is problematic to assess short-term 

affective status, and it is even more difficult to measure 

long-term affective learning outcomes. However, 

advanced technology is promising new means to provide 

affective feedback. The Massachusetts Institute of 

Technology (MIT) is actively researching ways to 

measure the affective state of learners via technology. 

One aspect of MIT’s research is the affect-sensitive 

AutoTutor, which aspires to keep students engaged, boost 

self-confidence, and maximize learning by narrowing the 

communicative gap between the highly emotional human 

and the emotionally challenged computer.61 AutoTutor is 

intended to be responsive to learners’ affective and 

cognitive states. Whether or not the affect-sensitive 

AutoTutor positively influences learning and engagement 

awaits further development and empirical testing.61

AutoTutor represents just one of a handful of related 

efforts currently being researched. Technology that 

senses or measures human affect will need to be 

considered as we design our future educational and 

training courses. 

AFFECTIVE-REASONING AGENTS

Affective-reasoning agents are similar to an expert tutor 

who uses artificial intelligence to respond to a learner’s 

cognitive needs. These agents parse learner responses for 

affective content and respond realistically with correct 

emotional expressions to the human user. Similar to 

affective computing, they have the potential not only to 

provide social-learning contexts intertwined with 

affective reasoning, but also to provide a way to reach 

learners with inspiring, affective presentations and 

realistic experiences. If properly designed and executed, 

affective-reasoning agents can also offer powerful 

affective feedback, which can take the form of natural 

conversation, gestures, or verbal clues, allowing the 

learner better insight into and connectivity to the 

educational outcome the designer intended.62 Like the 

work at MIT, affective reasoning is in its infancy, and 

more research is needed to find the proper mix of 

technology and design. 

MOBILE LEARNING

Technology also enriches learning by extending 

education and training away from normal education sites. 

Learners can take learning on the road, using laptops, 

mobile-learning devices (m-learning), and wireless or 

wired networks. Learners can then tie into web sites, 

social networks, or e-learning sites (eg, Blackboard), 

where they can engage in research, communicate with 

students or faculty, write papers, do homework, take 

tests, read required articles, or even catch the lecture they 

might have missed. Mobility allows formal and lifelong 

learners to control the learning experience in a number of 

dimensions.63

Mobile technology allows learners to tailor education to 

their lifestyles. Learners can stay connected with other 

students, faculty, and instructional resources. The result is 

that learners feel more comfortable with the educational 

process and are more likely to internalize what they are 

studying and sharing.40 Further, some learners are tied to 

their friends and business activities through their mobile 

devices, and the trend of using the devices may be 

culturally ingrained. The combination of convenience and 

connectivity can increase the level of social presence, 

which can improve the level of affect toward learning. 

The use of mobile devices requires active interest and 

precludes the passive process found in some traditional 

learning environments.64 Businesses are starting to look 

at ways to take advantage of mobile and m-learning 

capability, including learning-content systems, 

assignment reminders, and learning aids. According to 

the eLearning Guild, over 30 percent of organizations 

surveyed currently deliver some amount of learning 

content through mobile platforms (eg, iPod, Blackberry, 

or other smartphones). 

LEADERSHIP

The affective domain is vital to overall learning, but it 

holds special interest to leaders and those individuals 

who develop tomorrow’s leaders. Leadership requires 

influencing people’s attitudes, motivations, and goals, 

which correlates directly with the factors comprising the 

affective domain. All leaders must be able to address 

problems and make decisions, but truly effective leaders 

must be able to create positive affect in themselves and 

their followers to motivate everyone toward a common 

goal. This synergy between leadership and affect makes 

affective learning a vital concern to the Air Force. The 

most likely means to develop motivated leaders who can 

motivate others is to cultivate them through substantive 

affective learning in Air Force education and training 

programs. 

One approach to acquiring leadership skills involves 

studying the philosophy, habits, and methods of one or 

more highly successful leaders and then trying to develop 

a personal leadership style based on a single leader or a 

composite of several.65 This method relies on inspiration 

Leveraging Affective Learning for Developing Future Airmen 
 October – December 2010 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

to create affect in the learners toward leadership. A welldesigned leadership course should provide a wide variety 

of leadership examples and highlight key achievements 

and methodologies that reinforce desired philosophy and 

traits. Ed Tech’s integration of video, audio, or other 

multimedia to grab learners’ attention by introducing 

relevant, informative, and inspirational leader aspects 

provides essential learner ownership.31 Additionally, 

designers need to provide learners with opportunities to 

conduct discussions, engage in authentic practice, and 

build confidence as they apply and synthesize the desired 

philosophy and traits. 

Recently, practitioners of leadership and business 

development have become increasingly interested in the 

formation of leadership networks as a way to strengthen 

relationships among leaders. Within groups, peer 

members build relationships with each other, based on 

cooperation rather than a chain of command.55 Group 

members converse about their experiences as part of a 

shared social/cultural community, or perhaps just as 

people who share similar values.54 Learners participate in 

exercises virtually, online in games, or through authentic 

role-playing opportunities to build the confidence vital to 

leaders. Designers can use the advantage of technology to 

allow the learner to replay scenarios, discuss issues with 

peers, or try out a different leadership philosophy. These 

activities can occur whether learners are collocated or 

geographically separated. A related process entails 

developing future leaders through mentoring, which also 

relies on social relationships but involves interactions not 

only among peers, but also among senior leaders and 

younger protégés. The desired end state still requires the 

creation of positive affect in future leaders and their 

followers to motivate everyone toward a common goal. 

RECOMMENDATIONS

The results of this study give rise to several 

recommendations that could help Air Force education 

and training develop knowledge-enabled Airmen and 

foster leadership. The first suggestion is to 

institutionalize affective learning throughout all aspects 

of Air Force education and training: 

 Integrate affective objectives into the ID process. 

 Develop and adopt a combined ID methodology that 

merges cognitive and affective concerns. 

 Develop Air Force faculty who are sensitive to the 

student’s affective states, and devise empirically 

validated methods to positively impact affect. 

 Promote policies that encourage affective-learning 

tactics, techniques, and procedures throughout Air 

Force education and training programs. 

 Implement experienced Ed Tech manning positions 

at higher headquarters along with a similar institution 

at Air University. 

Significant integration of affective learning will be 

possible only with the buy-in of Air Force leadership. 

Senior leaders must recognize the importance of affective 

learning and work to institute policies that promote its 

use in all Air Force education and training programs. 

A second suggestion is that the Air Force actively 

develop and apply social networking and other 

technologies described in this study to achieve affectivelearning goals. This may be problematic due to current 

limitations imposed by network security. Discussion 

boards, CoPs, streaming videos, chats, blogs, and other 

applications enabling social interactions are encumbered 

with security policies on military networks. 

Consequently, educational networks may be necessary 

before social networking technologies can be employed 

throughout the Air Force. However, it is important for the 

Air Force to cultivate lifelong learners by encouraging 

engagement and social interchange during the learning 

process. Social networking is being exploited in civilian 

education and promises to change the face of learning 

from directed information exchange to a more learnercentered approach. 

A third recommendation is to conduct further studies on 

affective learning to address questions regarding its use 

in and impact on Air Force education and training: 

 How can cognitive and affective-design methods be 

combined to create a more effective overall 

curriculum-development process? 

 What assessment or survey methods provide the best 

measurement of a learner’s affective state and 

success in meeting learning objectives? 

 How does the learner’s affect influence cognitive 

learning? 

 Which methods and technologies are most effective 

in building positive attitudes, motivation, leadership, 

and confidence? 

CONCLUSION

This study is intended to help Air Force leadership and 

educators better understand the importance of affective 
36 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

learning in the development of Airmen as lifelong 

learners. Affective learning concerns learners’ attitudes, 

motivations, beliefs, and emotions. Unfortunately, the 

affective domain has been a neglected area because its 

characteristics are neither directly observable nor easily 

measured. Consequently, most educational systems 

evaluate student performance against cognitive 

proficiency rather than against affective measures. 

However, it is important to realize that affect is critical to 

the overall learning process since cognitive learning 

depends on attitude, motivation, and other affective 

factors. 

It is necessary to include a learner’s emotional/cognitive 

state in the ID process to assist the learner in 

understanding the efficiency and satisfaction of the 

learning process. ID that merges affective and cognitive 

objectives is even more critical as more instruction is 

conducted through distance learning without a facilitator 

present. An important Air Force goal should be to partner 

technology with the affective and cognitive domains to 

provide distance students with an experience similar to 

that of in-residence students. 

Technology offers the opportunity to promote affective 

learning through multimedia, social networking, mobile 

learning, and more. Additional study is needed to assist 

short- and long-term affective gains using technology. 

Social networks and learning are having successes and 

failures; further research is needed to gain more 

understanding of affective and cognitive linkages in 

social-learning environments. It is imperative that 

technology support education and not the other way 

around. 

There is a great deal of overlap and synergy between the 

concepts of affect and leadership. Successful leaders 

must be able to motivate themselves and those they lead 

toward a common goal. How we encourage today’s 

learners impacts how they develop into tomorrow’s 

leaders. To be successful, affective learning must be 

institutionalized into Air Force culture, including strong 

support from senior leaders. 

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56. Wepner S. Tao L. From master teacher to master 

novice: shifting responsibilities in technologyinfested classrooms. Read Teach. 2002;55(7);642-

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57. Pilkington R, Walker S. Facilitating debate in 

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58. Roberts AG. Beyond a participation focus. In: 

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International Conference. Cambridge, MA: Media in 

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detects and responds to learners affective and 

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Leveraging Affective Learning for Developing Future Airmen 
 October – December 2010 39

INTRODUCTION

Medicine has evolved greatly over the last century, but 

the way in which many institutions are educating those 

studying this discipline have not. The standard 

continues to be “chalk and talk” and “death by 

PowerPoint” as a way of depositing information into 

those seeking knowledge in the medical field. Many 

lecturers continue to deliver their neatly wrapped 

presentations. Unfortunately, it has been noted that students become mentally detached within the first 10 to 

20 minutes of lectures. Learners are then left with the 

options of either attempting to extract the information 

from texts, or possibly questioning others who have 

taken the same instruction for exam outlines.1

 The 

issues related to lecture-type teaching are longstanding. Although the banking model2

 still exists in 

adult education, a variety of options have been explored as possible substitutes for this type of learning. 

A search has begun by some to find alternate ways of 

presenting practitioner-based information. In pursuit of 

this goal, medical programs have reviewed the way in 

which this community conducts its business, and have 

attempted to mirror that in the way students are taught. 

In reality, practitioners are first presented with a 

problem. That problem could be a complaint of a 

headache or abdominal pain. The caregivers then 

investigate using multiple tools to come to some type 

of conclusion. Medicine has also incorporated a strong 

team approach to curing the ill. This team mentality 

can be observed, whether in an outpatient clinic or in a 

surgery suite. The ability for a group of individuals to 

communicate well and work together towards an 

objective results in positive patient experiences and a 

happy staff. An educational approach that supports 

learner development with a strong team mentality, 

clear critical reasoning skills, and complex medical 

knowledge and decision-making would be invaluable. 

Problem-based learning (PBL) has been considered as 

a possible educational tool to support this needed 

evolution.3

 PBL education begins with a problem. 

Students then explore the problem while working in 

groups. The learners are required to take a team 

approach in analyzing the situation and applying 

critical reasoning skills to ultimately evaluate and 

formulate solutions. Simply stated, this teaching 

strategy mimics the course of patient care as seen in a 

clinical practice. This technique is vastly different 

from traditional medical education. In this latter form 

of pedagogy, students are first required to memorize 

packaged presented material in a lecture format. Later 

the student is required to retrieve these abstract ideas 

and apply them to a clinical problem. 

Learning through problems has had its origins from 

before the time humans walked upright. To be first 

challenged with a problem, then have to resolve it has 

been the standard for our development. More recently, 

this method of education was resurrected and studied. 

To date, this form of teaching has been adopted by 

multiple disciplines in a variety of pedagogical roles. 

Although some scientific and medical programs have 

adopted PBL formats, physician assistant (PA) 

programs have been slow to implement it. Shared 

Problem-Based Learning Preparation for 

 Physician Assistant Faculty 

MAJ George S. Midla, SP, USA 

Joellen E. Coryell, PhD 

ABSTRACT

This study explores facilitator preparation for a physician assistant problem-based learning (PBL) program. A 

qualitative study approach was used to investigate the experiences of 7 faculty members from 2 separate physician 

assistant PBL programs within the United States. Data was collected through interviews using open-ended questions 

that were recorded and analyzed. The results revealed important themes related to topics that addressed the faculty 

participants’ personal experiences when first beginning this method of teaching. Issues addressed included the 

facilitator’s outlook towards PBL, previous experiences which helped to make a smoother transition into their teaching 

position, approaches that assisted in preparing faculty and students to teach and learn in a PBL program, academic 

resources referenced by faculty members, and the use of nonclinical tutors in a physician assistant PBL program. 
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

knowledge concerning this particular group and PBL 

in the form of studies and published literature is 

limited. Also, some universities have had a difficult 

time convincing their staffs that the revamping of their 

educational practices is a wise endeavor. Shifting the 

curricula and teaching methodology of a program is 

time-consuming and requires a philosophical buy-in 

from faculty and administration. These types of 

changes can often create friction within a program if 

individuals are unwilling or uninterested in working 

toward the success of the new approach.4

A study designed to examine a skilled way in which to 

implement a PBL PA program, although important, 

would be an immense endeavor. Some of the elements 

that would need to be addressed include logistical support, teaching topics, time, student preparation, and 

grading systems. Of these possible issues the preparation of a teacher who is not familiar with this particular 

mode of instruction would also be invaluable. 

The teacher takes on the role of facilitator in a PBL 

format. The facilitator helps to guide students through 

the curriculum while promoting reasoning skills and 

self-directed learning. In addition, facilitators offer information in a capacity designed to cultivate enthusiasm and intellect. Students involved in a PBL curriculum then use critical thinking, teamwork, and research 

to address the topics needed to complete the course requirements. We find that the facilitator’s job is multifaceted. In addition to guiding students, a balance 

between individual and group work must be achieved. 

The time allotted for student exploration must be managed. In addition, references and resources that fulfill 

the goals of a course must be identified. Student group 

dysfunction is also a possibility. The way that this is 

managed is as equally important as the presentation of 

rules as to how the groups will conduct themselves. If 

a new facilitator has a strong background in lecture 

based education, the change away from a teacher 

centered classroom to one that is student centered can 

also be a difficult task. This transition should be well 

thought-out and executed correctly for this style of 

instruction to be well received, and learning 

expectation outcomes to be achieved. 

STATEMENT OF THE PROBLEM

Instructors involved with a PBL program must be able 

to manage both their knowledge of the subject matter 

and their facilitator skills. Knowledge of the subject 

matter includes their use of expertise, cognitive 

congruence, and test orientation. The facilitator skills 

to be managed are authority, role congruence, and 

cooperation orientation.5

A facilitator must be able to gauge how much of their 

knowledge of the subject matter should be shared with 

the students. For some tutors, it may be easy to fall 

back on previous teaching skills and start lecturing 

about the material instead of fostering additional 

research and inquiry. Cognitive congruence as related 

to how well the facilitator can communicate with the 

students, at their current level of understanding, must 

also be managed. Test orientation refers to how well 

the instructor directs students to what should be 

learned for the successful completion of the course 

requirements. 

Facilitator skills needed by the teacher begin with the 

amount of authority used to steer student learning. 

Constant interruptions by the instructor can be 

detrimental to the PBL process. Role congruence, or 

the amount of understanding of the student’s situations 

and perspectives, is also required. Finally, cooperation 

orientation refers to the ability of the facilitator in the 

management of group dynamics. Cooperation 

orientation will vary from relieving any frictions 

identified within the class to help in building positive 

relationships. 

Therefore, the topic of this study was to determine 

what types of preparation might be needed for an 

instructor of a physician assistant program to be 

successful in the adoption of a teaching style that 

includes problem-based learning facilitation. In 

addition, the triservice physician assistant program 

located at Fort Sam Houston, Texas, is currently 

restructuring its curriculum. The changes that are 

planned for this program include portions of the course 

to be taught in PBL fashion. This study will also 

directly help with this planned transition of the Army 

Medical Department. 

METHOD

The purpose of this study was to identify what types of 

preparation would benefit a facilitator who would 

assume a new teaching role in a PBL program for 

physician assistants. The research questions were: 

1. In what ways have PA instructors been prepared 

to conduct PBL in a PA program? 

Problem-Based Learning Preparation for Physician Assistant Faculty 
 October – December 2010 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. In what ways have PA programs prepared the curricula, students, and logistical issues which directly 

or indirectly support PBL instructor readiness? 

A qualitative approach in data gathering was used to 

address the research questions. This method was chosen because the study conducted was exploratory in 

nature. An open-ended approach to data gathering was 

essential in finding a descriptive interpretation of the 

phenomena. Open-ended questions were used to gain 

insight into PBL facilitator preparation. During interviews, individuals clearly translated their issues to 

provide a coherent understanding of what they felt was 

needed for such a transformation. The use of a qualitative approach provided additional insight related to the 

respondents’ attitudes, beliefs, and motives.6

SAMPLE

A web search was conducted to locate universities that 

had physician assistant programs which use problembased learning in their curriculum. Two American 

universities were identified and approached for 

respondents to take part in this study. One institution is 

located in the midwest and the other in the southwest. 

A total of 7 PBL facilitators from these programs were 

interviewed. Six of those participating were certified 

physician assistants. The last was a practicing family 

medicine doctor. The average amount of time these 

individuals had been working as a facilitator in a PA 

program was 3.3 years, and the average amount of 

hours per month they were in an active PBL setting 

was 48.8. Five of the respondents were female, two 

were male. All of the respondents were currently 

licensed to practice medicine and were working parttime as providers in local practices in addition to their 

full time teaching duties. Five of the participants 

answered “all topics” when asked about the topics of 

instruction for which they were responsible. Of the last 

2 facilitators questioned on teaching responsibilities 

the first answered electrocardiograms, evidence based 

medicine, advanced cardiac life support, basic medical 

procedures, and antibiotics. The last instructor said he 

was responsible for facilitating physiology, 

pharmacology, clinical procedures, gastroenterology, 

and cardiology. The teaching and medical experience 

and demographic data are presented in the Table. 

DATA COLLECTION

In this study, the semistructured interview was used as 

a data gathering technique. This approach allowed the 

informants to discuss their experiences in ways that 

made sense to them, yet was focused enough to 

connect with the research questions. One to 2 hours of 

time were allotted for face-to-face meetings. Locations 

that were both quiet and void of possible interruptions 

were chosen for these encounters. Anonymity was 

achieved by hiding the participant’s identities through 

number coding; all the participants were given a number code so that no links could be made between their 

remarks and them. In addition, no information collected during the interviews was shared within the departments at which those interviewed were employed. 

A set of verbal questions to determine demographics 

was first presented (Figure 1). The demographic questions enabled the researcher to better understand both 

the teaching and medical experiences of each participant. The interviews were then conducted immediately 

after the demographic questions were answered. 

Twelve questions were asked to each participant in the 

order presented in Figure 2. All interviews were conducted by the investigator and were captured using a 

digital recorder. 

The questions developed for this study were designed 

to promote open discussion. By supporting this type of 

dialogue through an open format, valuable insight was 

gained into the issues under investigation. There was 

no cost to those participating in these dialogues, nor 

were there any incentives offered. 

DATA ANALYSIS

All interviews were transcribed. The initial 

information collected was viewed as raw data. This 

material was then analyzed using the process described 

by Hitchcock and Hughes.7

 The first goal was to 

become well acquainted with the interviews. This 

included multiple reviews of the audio files and 

transcribed discussions.8

 The texts were then 

condensed by eliminating information which did not 

pertain to the study questions. After this had been 

accomplished, a second approach was initiated. 

The data were then examined for repeating words and 

phrases that might be used to code the information into 

logical segments. For this technique, the codes were 

applied in order to develop multiple categories which 

were originated from the interviews. Grouping and 

examination of the information further resulted in 

recurrent themes. In using the collected material to 

develop concrete meaning, the results were 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

“grounded” in the data.9

 The grounded method for 

analyzing data was used so the examiner was not as 

likely to impose his own biases and preconceived 

perspectives on the information. 

The themes derived from the identified codes were 

then annotated. The themes were used as a basis for 

interpretation of the information that was initially 

collected. These summaries captured the essence of 

what the respondents felt was important or might have 

been lacking in their experiences when beginning their 

new roles as PBL facilitators. In the identification of 

recurrent themes, many of the respondents supported 

each others’ perspectives on PBL facilitator 

preparation. Because of this agreement, second 

interviews to clarify the respondent’s viewpoints were 

not requested.10

FINDINGS

The questions posed to the interviewees exposed large 

amounts of information concerning PBL facilitator 

preparation. There were 2 goals of this study: to 

identify in what ways PA instructors have prepared to 

conduct PBL in a PA program, and to identify ways in 

which PA programs prepared the curricula, students, 

and logistics issues which directly or indirectly 

supported instructor readiness. 

The first question presented to each of the respondents 

required them to share personal thoughts on their 

definition of PBL. The most common remarks made 

were that PBL was based on problem solving and was 

student-centered. It was also mentioned that PBL 

developed both critical thinking skills and life-long 

learners. All of these comments were congruent with 

definitions identified in current PBL literature.11

I would like to ask you some demographic questions. Your 

participation in answering them will help in this study. The data 

collected from demographics may uncover information specific 

to certain groups of individuals, which can later function in the 

designing of a PBL program that caters to these differences. 

1. What is your ethnicity? 

2. What is your age? 

3. How long have you been teaching physician assistants? 

4. How long have you been teaching in your current 

position? 

5. How long have you been a facilitator for PBL? 

6. Did you ever teach at a PA program where you used a 

lecture based format? 

7. How many hours per month do you work as a facilitator 

for PBL? 

8. What topics of instruction are you responsible for as a 

facilitator? 

Figure 1. Format of interview questions to determine the 

demographic makeup of study participants. 

Gender Female Female Female Female Female Male Male 

Age 52 43 41 55 39 54 38 

Ethnicity White White White White White White White 

Years teaching in 

PA programs 6 7 1.8 9 1.5 1.5 1.5 

Years in current 

position 6 7 1 9 1.5 1.5 1.5 

Years teaching 

with PBL 6 13 1 9 1.5 1.5 1.5 

Years teaching in 

lecture format 0 0 0.8 3 1 0 0 

PBL hours per 

month 90 60 12 12 80 12 80 

Topics of PA 

instruction 

All All All All All Physiology 

Pharmacy 

Clinical 

procedures 

Gastrointestinal 

Cardiology 

Electrocardiogram 

Evidence-based 

medicine 

Advanced Cardiac 

Life Support 

Basic procedures 

Antibiotics 

Profiles of study participants by demographics and medical and teaching experience. 

Problem-Based Learning Preparation for Physician Assistant Faculty 
 October – December 2010 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

Four major themes related to these questions were 

produced from the data. The themes identified include 

attitudinal factors and previous experiences that support instructor transitions, insights into new instructor 

professional development, and the importance of 

preparing students to learn in PBL programs. 

ATTITUDINAL FACTORS AND PREVIOUS EXPERIENCES

THAT SUPPORT INSTRUCTOR TRANSITIONS TO PBL 

Facilitator Support for PBL 

All of those interviewed felt very strongly that PBL 

was a good approach for the instruction of physician 

assistants. Common responses from the subjects 

interviewed included phrases such as: 

I think the program is very effective. 

I think it’s terrific. 

I think it is an excellent way for teaching PAs and in 

teaching medicine in general. 

This support felt by staff members was not without 

reasons. Interviewees felt that the method supported 

authentic clinical medicine practices: 

So my feelings are very strongly positive, because we 

learn in the way that we need to know it as a clinician. 

PBL is structured so that it closely mimics what 

students will ultimately face once in practice. 

This argument has been observed in the past in other 

cited literature.11,12 PBL supports clinical medicine in a 

unique way by mirroring actual medical practice. 

Previous Experience 

A strong buy-in for this educational forum, although 

important, was not the only consideration discussed in 

helping with the transition to PBL facilitation. Staff 

members were quick to identify their thoughts 

concerning what previous experiences might support a 

smooth transition into such a teaching position. All 

faculty members arrived at their current position 

through different routes. The variations included 

previous clinical experiences, educational 

backgrounds, and for some, other teaching jobs. These 

differences had an impact on thoughts concerning 

what previous experiences might cause a new PBL 

physician assistant instructor to have a smoother time 

adjusting to this new method of instruction. 

Comments were made concerning the need for a 

generalist’s background. It was thought that since they 

were teaching a variety of medical disciplines, being a 

specialist in one given field might restrict a facilitator’s ability to manage the variety of material that must 

be addressed. For example, one participant remarked: 

I think that general practice or family practice would be 

helpful just because it depends on what you tutor. Our 

program is set up and our units are on specific 

disciplines, so if you’re an expert on that topic it will be 

very easy for you. If you get stuck teaching neurology 

and you are not experienced in it, then it will be more 

difficult for you. 

The wide range of medical topics presented in these 

programs and the level of experience students may 

The following questions I am going to ask you have been 

designed so that knowledge can be gathered to help answer 2 

broader issues concerning problem-based learning (PBL). These 

issues are: 

▪ In what ways do current physician assistant instructors 

specifically prepare themselves to implement problem-based 

learning in their program? 

▪ What are the perceptions of current physician assistant 

facilitators in terms of their programs preparing the curricula 

and logistical issues of making a change to problem-based 

learning, which directly or indirectly support instructor 

transition? 

1. PBL education can mean a variety of things to people. 

Can you explain your definition of PBL? 

2. Could you tell me about your feelings regarding PBL 

and its effectiveness in instructing PAs? 

3. Could you tell me about your feelings regarding PBL 

and its effectiveness in instructing PAs? 

4. Were there facilitator preparation topics you wish you 

had more insight into that could have better prepared 

you for your new teaching role? 

5. What should a preparation program for new 

facilitators look like? 

6. We already discussed some of the possible topics that 

would have better prepared you for this new teaching 

role, but do you have any other comments on topics 

that might help other instructors? 

7. How do you now plan/prepare for an upcoming 

course or class? 

8. Have you identified any academic resources that are 

needed for a facilitator? If so, please explain. 

9. How do you prepare your students for their role in a 

problem-based learning group? 

10. How is time managed in your classes? 

11. How do you achieve a proper balance between 

individual and group work? 

12. What other insights have we not discussed that you 

can offer future PA facilitators using PBL? 

Figure 2. Format of interview questions to determine the 

teaching and medical experiences of study participants.
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

have will often lead to a variety of differential diagnoses presented by a group. Having a broad range of 

clinical experience, although important, is not the only 

criterion concerning facilitator transition that emerged. 

Having been exposed to PBL while undergoing initial 

PA training was another possibility discussed. It 

should not be surprising that those who attended a 

PBL program while first becoming a PA felt their 

experiences gave them greater insight into this method 

from the start of their new teaching position: 

In our opinion, someone who has been through PBL 

adjusts to it more smoothly than those who only have 

previous work experience. Graduates who come back to 

our program or they have had some PBL previously and 

at least understand what it is usually adapt easily. However, someone who comes from a background of primarily receiving lectures usually they fall back into that 

teaching mode. In PBL that is not done; we must hold 

ourselves back and let the students do self learning. 

These remarks offer a clearer picture of a new facilitator who would be expected to have the easiest transition into the teaching role. Participants agreed that 

prior PBL exposure in addition to a broad clinical 

background may significantly support PBL instructor 

transitions. 

Nonclinical Facilitators 

A final subtheme regarding previous experience and 

transition to PBL instruction addressed the negative 

feelings about the use of nonclinical tutors as facilitators. The interviewees did not support the idea of 

nonclinical tutors, although they did recognize that this 

teaching practice has been described in the literature: 

The typical program states that anyone is capable of 

doing PBL, so I think you need to eradicate that form of 

program and be more practical. 

Physician assistant programs do not have the luxury of 

time. They are required to produce a competent 

clinician in a very small span of time. Using a 

nonclinical tutor as a facilitator could cost a program 

valuable time in educating their students: 

The group would correct themselves if we were in there 

for 20 hours, but that is not possible. So the main thing 

for facilitators is to not fool themselves. They must be 

clinicians to be effective tutors in PA education. 

Students often relate well to teachers who can offer 

real-life experiences while working in the field of 

study under examination. The faculty from the 2 

programs stressed this and described sharing their 

personal trials of being a clinician, which was accepted 

warmly by their students. Having a nonclinical 

facilitator negates this important venue when 

attempting to educate a group. In addition to having 

previous clinical experience as a prerequisite to 

applying this method, additional professional 

development was also identified as critical. 

NEW INSTRUCTOR PROFESSIONAL DEVELOPMENT

Faculty preparation upon coming to a PBL program 

was discussed in depth. Two common themes arose 

from the interviews. A short preparation course that 

included some mock PBL sessions and a mentorship 

shadowing program were identified as critical 

preparation elements: 

We do a very nice job. We do role playing, which I 

think is the best thing to do besides being dumped in as 

a tutor and see what happens. 

Five of the 7 participants interviewed supported the 

opportunity to attend a one- or 2-day mock PBL 

session. Participants of this training used role play to 

prepare themselves through instructional scenarios. 

New staff members became the students as a senior 

member took on the role of a facilitator. The role 

players would take breaks at specific times to review 

what had transpired and what individuals could have 

done to maximize the outcome for those involved. 

Immersion in a training exercise that closely mimicked 

typical group behavior was the reason this experience 

was so highly valued. 

Finally, a mentorship program was identified as the 

most important aspect of facilitator preparation. One 

participant suggested: 

I think the biggest thing is mentoring. The other thing 

we do is once we get a new person who comes in we 

have someone go in with them at least the first few 

times they are tutoring. 

The ability to identify and access a trusted advisor was 

instrumental in this professional change. These 

relationships included new faculty first observing their 

assigned mentors in an actual tutorial group. As they 

became more comfortable, they would assume 

stronger roles as assistants. Finally, their mentors 

would observe the new facilitators’ work and offer 

critique until a comfortable level and institutional 

Problem-Based Learning Preparation for Physician Assistant Faculty 
 October – December 2010 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

standard was reached. New faculty arrivals were also 

expected to review and study the course work so that 

they would be prepared to address instructional topics 

in addition to the outlined professional development. 

Preparing to Teach for the First Time 

Preparations for the first teaching experience was 

consistent across the data set. In preparation for 

leading an upcoming group session, the staff liked to 

review the case, the students’ text books, and MD 

Consult* for any recent changes to the material. This 

allowed them to have an updated foundation of the 

course work. One individual made what they called a 

“word target list” after reviewing these resources. This 

list was used by presenting the words or phrases 

compiled at specific times during a session, which 

were then used by the students as hints to guide them 

through the material. In addition, the “word target list” 

was used as a listening tool for the facilitator which 

helped her gauge the amount of progress that was 

being attained in the classroom. She offered:

I review the learning issues sheet and then go to 

resources to review for the case even if I have taught it 

before. Then I go back to the learning issues sheet and 

make notes like little word targets that I’m going to look 

for and hopefully they [the students] will bring me back 

through their learning issues. I will then spring off of 

that learning issue and point some of those out, to track 

them and puzzle weave them into the learning issues. 

The review of current medical literature for an 

upcoming tutorial is crucial and common in PA 

education practices. The medical field is constantly 

undergoing reforms based on published current studies 

with the development of new pharmaceuticals, 

instruments, and techniques. Although the 

identification of facilitator preparation topics was the 

main goal of this study, the participants stressed that a 

continuously updated PBL knowledge base for the 

students was also critical for a facilitator. 

Preparing the Students 

The discussions for the participants changed as we 

began to explore what their programs had done in 

preparation of such things as the curricula, students, 

and logistical issues that directly or indirectly helped 

with instructor transition: 

When they [the students] interview, we do a mock PBL 

so they already have an idea. Our website talks about 

PBL but we encourage them all to be aware of PBL 

before they ever come to the program. 

Students are encouraged to read about PBL on their 

own. In addition they are given the opportunity to 

observe an actual tutor group. Once they begin the 

course work, time is set aside to identify ground rules 

for the groups. The class determines consequences for 

tardiness, how it makes the group feel, why it is 

important to start on time, how to give and take 

criticism, when breaks will be taken, and for how long 

they will be. Some of the faculty also stated that 

physical exams should be taught early in the program 

to support the clinical philosophy of PBL. 

One of the interview questions addressed the 

achievement of a proper balance between individual 

and group work. The participants in this study 

suggested this was not a concern in their facilitation 

experiences. It was stated that all students are 

responsible for their own individual learning, and, if 

they do not succeed in their personal tasks, the group 

fails. It becomes obvious to the group and the 

instructor if one of the participants is not prepared. A 

participant also mentioned that the learners are so busy 

with keeping up with the course work, they do not 

have time to complete another colleague’s assigned 

tasks. The demanding obligations imposed on each 

learner ensures individual work will be performed. In 

addition to extending the time allotted for early group 

work, student and facilitator preparation defined what 

was needed for a new facilitator to transition well. 

COMMENT

The open-ended questions posed to the interviewees 

exposed insight into useful concepts regarding 

facilitator preparation for a physician assistant PBL 

teaching position. The information collected on the 

demographics of the participants (Table 1) did not 

provide the study any additional data which was 

identified as having an effect on the findings. The first 

theme presented suggested strong support for the 

instructional approach for PA education. Not only did 

those questioned endorse this method, they were 

excited about being a part of their respective programs. 

During each of the interviews, every participant used 

very strong positive verbiage in describing their 

support for using PBL in PA education. Their 

commitment to PBL rested heavily in the belief that 

the method allowed learners to practice, with support, *http://www.mdconsult.com/php/217887812-2/homepage 
46 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

what they would ultimately face clinically in a realworld setting. Others felt that it also proved effective 

in student preparation for written exams, and that their 

pass rates on the Physician Assistant National 

Certification Exam were very competitive with 

traditional programs.13

Past work and educational exposures were also found 

to be important factors. When they discussed previous 

experiences that might help a facilitator transition into 

this new teaching role, many felt that past participation 

in PBL training would be helpful. They thought that 

PAs who were initially trained in a PBL program 

transitioned to PBL instructor roles more easily. It was 

also suggested by some that generalists might be more 

suited to teach in this format because of the wide range 

of medical exposure they have had. This experience 

would help them with the broad range of differential 

diagnoses that are discussed during a case study. Many 

interviewed also felt that a physician assistant, rather 

than another type of medical provider (to include 

medical doctors) would be the best suited for this 

teaching position. It was pointed out that a PA has a 

better understanding of the student’s clinical role after 

graduation. The students in these programs were being 

trained for a primary care setting and not a specialty 

clinic. This awareness was felt to be important in 

recognizing when a PA would refer a patient out of 

their clinic due to the complexity of the case. For a 

primary care PA, the initial diagnosis and treatment 

plan of a case study concerning colon cancer is much 

different from the same patient’s situation at an oncology or general surgery clinic. Becoming too in-depth 

in a case study might result in the use of extra time 

when these types of programs do not have this luxury. 

The last theme related to previous experiences was the 

use of nonclinical tutors in a physician assistant PBL 

program. The traditional PBL model suggests that a 

facilitator need not be well versed in the subject 

studied. As Woods14 explains: 

Staff may feel uncertain about facilitating a PBL 

tutorial for a subject in which they do not themselves 

specialise. Subjectspecialists may, however, be poor 

PBL facilitators as they aremore likely to interrupt the 

process and revert to lecturing. 

He further advises that eventually students will selfcorrect and develop the right answers without a 

clinical expert present. The findings of this study suggest otherwise. All respondents agreed that this might 

be true in theory, but they did not feel that it was plausible in the PA education context. PA programs are 

under great time constraints to cover large amounts of 

critical material. Without a facilitator with a clinical 

background, it was believed that increased lengths of 

time for the students to adequately address all the 

learning issues would be needed. Having an experienced clinician as a facilitator helps refocus the group 

when it gets too far from the required learning topics. 

Learning topics are designed into the curriculum at 

specific levels within the course work. Students may 

begin to address material that is designed for exploration at a later date in the program. Refocusing group 

work saves time and supports curriculum sequencing. 

In addition, an experienced clinician is better apt to 

question incorrect information presented in the group. 

Facilitators without a medical background would not 

be in a position to identify incorrect data. Having clinical experience would better support efficient learning. 

A preparation course for new facilitators was offered 

at both institutions that took part in this study. 

Although, each institution felt that their training 

program was important, those interviewed also felt that 

it should be limited to one or 2 days, if possible. A 

training program designed around role playing or a 

mock PBL session was recommended. In addition, a 

mentorship program was stressed. It was felt that a 

new facilitator would benefit greatly by observing and 

team-teaching in an actual PBL class for a period of 

time and then having a seasoned tutor observe their 

first few classes. This experience allowed constructive 

criticism to be offered on tutor session management. 

Insight into facilitator techniques was gained through 

this process as well. A mentoring program was 

considered vital in the preparation of new faculty. 

Part of ensuring facilitator success is a program that 

prepares learners for their role in this setting. A tutorial 

group aware of how problem-based learning is 

constructed helps ensure that these gatherings will 

attain the goals set by the curriculum. Student 

preparation in PBL was conducted through a 

multifaceted approach. It was pointed out that it is 

important for students to recognize if such an 

independent educational venue is right for them. 

Interviewees stressed the requirement for additional 

time allotted for early PBL group work. This increase 

is required for students during their adjustment phase 

to PBL. In addition to the new educational process, 

Problem-Based Learning Preparation for Physician Assistant Faculty 
 October – December 2010 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

achieving a grasp of both complex medical concepts 

and related vocabulary is another considerations for 

planning more time. Also, the faculty stated the 

importance of becoming involved with guiding the 

students early in the program. It was presented that if 

these measures were not taken, extended time would 

be required in their initial PBL group work. With 

additional time already factored into a new class, 

having students extend an already long day might lead 

to both student and faculty fatigue. Preparation of the 

students for their new educational role lays a supported 

foundation for success for both learners and new 

faculty members. 

In the preparation for an upcoming group session, all 7 

facilitators approached the task in the same manner. 

They reviewed material that coincided with the subject 

taught by reviewing text books, up-to-date web sites 

(MD Consult was the favorite), and other references. 

In addition to these resources, one facilitator used a 

word-target-list which she synthesized from the same 

web sites. 

There is a lack of published information concerning 

physician assistant PBL programs. This study sought to 

resolve some specific issues centered on facilitator 

preparation in these programs. The data gathered resulted in themes related to facilitator’s outlook towards 

PBL, experiences which helped faculty better transition 

into their teaching position, and identification of various resources that assisted in preparing faculty and 

students. 

REFERENCES

1. Marzano RJ, Pickering DJ, Pollock JE. Classroom 

Instruction that Works: Research-based Strategies 

for Increasing Student Achievement. Alexandria, VA: 

Association for Supervision and Curriculum 

Development. 2001. 

2. Freire P. Pedagogy of the Oppressed. 3rd ed. New 

York, NY: Continuum Publishing Company; 1994. 

3. Leung W. Why is evidence from ethnographic and 

discourse research needed in medical education: the 

case of problem-based learning. Med Teach. 2002;24

(2):169-172. 

4. Azer SA. Problem-based learning challenges barriers 

and outcome issues. Saudi Med J. 2001;22(5):389-

397. 

5. Groves M, Régo P, O'RourkeP. Tutoring in problembased learning medical curricula: the influence of 

tutor background and style on effectiveness. BMC 

Med Educ. 2005;5:20. 

6. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative 

Research: Reading, Analysis, and Interpretation. 

Thousand Oaks, CA: Sage Publications; 1998. 

7. Hitchcock G, Hughes D. Research and the Teacher: 

A Qualitative Introduction to School-Based Research. 

92nd ed. New York, NY: Routledge; 1995.

8. Creswell JW. Research Design: Qualitative, 

Quantitative, and Mixed Methods Approaches. 2nd 

ed. Thousand Oaks, California: Sage Publishing; 

2003:150. 

9. Strauss AL, Corbin J. Basics of Qualitative Research: 

Grounded Theory Procedures and Techniques.

London: Sage; 1990. 

10. Fontana A, Frey JH. Interviewing: the art of science. 

In: Denzin D, Lincoln Y, eds. Handbook of 

Qualitative Research. Thousand Oaks, California: 

Sage Publishing; 1994:361-376. 

11. Duch BJ, Groh SE, Allen DE. Why problem based 

learning? A case study of institutional change in 

undergraduate education. In: Duch BJ, Groh SE, 

Allen DE, eds. The Power of Problem-Based 

Learning. Sterling, Virginia: Stylus Publishing, LLC; 

2001:3-11. 

12. Blessing JD. Introduction to problem-based learning. 

In: Blessing JD, ed. Clinical Problem Solving for 

Physician Assistants. Philadelphia, PA: F.A. Davis 

Company; 2002:1-6. 

13. Van Rhee JA, Wardley S, Hutchinson CA, Applegate 

B, Vangsnes EH, Meyer JM, Grinwis BA, Fenn WH. 

Problem-based learning in physician assistant education: establishing a basis for a comparative study. 

Perspect Physician Assist Educ. 2003;14(4):242-248. 

14. Wood DF. ABC of learning and teaching in 

medicine: problem based learning. Br Med J. 

2003;326(7384):328-333. 

AUTHORS

MAJ Midla is a physician assistant at the Brooke Army 

Medical Center and an adjunct professor at the 

Interservice Physician Assistant Program, Army 

Medical Department Center and School, Fort Sam 

Houston, Texas. 

Dr Coryell is an Assistant Professor of Adult Learning 

and Teaching at the University of Texas San Antonio. 
48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Countless course introductions and administrative 

announcements include the phrase, “in this course we 

will not teach you what to think; rather you will be 

taught how to think.” It may be declared so often as to 

become cliché, however, that goal is not necessarily 

realized for any number of reasons. Two major issues 

related to the definition and to the teaching of critical 

thinking were addressed in 2 important studies that 

informed my own doctoral research*: 

 Expert Consensus on Critical Thinking: The American 

Philosophical Association (APA) Delphi Report (1990). 

In this landmark study, a panel of 46 well-known 

scholars and experts in the field collaborated over a 

period of 20 months to articulate an international 

expert consensus definition of critical thinking: 

We understand critical thinking to be purposeful, selfregulatory judgment that results in interpretation, 

analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, 

criteriological, or contextual considerations upon which 

that judgment is based.1(p3)

 California Teacher Preparation for Instruction in Critical 

Thinking (1997): The compelling study, commissioned 

by the California Commission on Teacher 

Credentialing, determined that faculty subjects were 

indeed confident that they understood the critical 

thinking concepts and were also successful in teaching. 

Paul states unequivocally that they were also wrong; 

fewer than 10% of the teachers actually taught critical 

thinking, could enumerate critical thinking criteria or 

standards required of students, or provide clear 

conceptions of critical thinking.2(p3)

There are many regulatory mandates and professional 

guidelines establishing requirements for critical 

thinking, particularly with a focus on healthcare. 

Among those are requirements for nursing, physical 

therapy, respiratory therapy, dentistry, pharmacy 

laboratory specialties, social work, and clinical 

psychology. The Pew Health Professions Commission 

also stipulated critical thinking, reflection, and 

problem-solving skills among their set of 

competencies for the 21st century.3

In addition to Army training guidance reiterating the 

necessity for self-aware and adaptive problem-solvers, 

there emerged a compelling requirement for instructors 

who not only have relevant experience and skills 

necessary for training students, but also the ability and 

expertise to teach critical thinking.4,5

Therein lay a problem. Instructors at the US Army 

Medical Department (AMEDD) Center and School 

(AMEDDC&S) have been selected for their expertise 

in the particular subject matter they are to teach. 

However, they do not generally have a background or 

training in education. Nor have they necessarily been 

specifically trained in critical thinking skills. This is 

not unlike any number of situations facing many other 

teachers. Duldt succinctly describes this quandary: 

We, the faculty, are to teach critical thinking throughout 

the curriculum to all health care professional students 

so that new practitioners will be able to function 

effectively and creatively in the changing arena of 

health care. Somehow or other, in a manner and by a 

method not stated or clearly understood, we, the faculty, 

are to do this. However, we, the faculty, are the very 

ones, to a significant degree, who are alumni of an 

educational system which historically has omitted the 

very things we are now to teach.6

It was from the Pew Commission’s broad based 

educational perspective that my doctoral study was 

conceived, and it was situated in the context of the 

AMEDD. My study measured the critical thinking 

abilities of instructors with divergent training 

backgrounds and experience. All instructors assigned 

to the Academy of Health Sciences were encouraged 

to participate in the study. The population was 730 

potential subjects. The Noncommissioned Officers 

Academy was not included in this study. 

Critical Thinking Skills: Do We Have Any? 

Critical Thinking Skills of Faculty Teaching Medical Subjects 

 in a Military Environment 

Carol F. Hobaugh, PhD 

*Dr Hobaugh’s dissertation, the basis for this article, was completed in October 2005. 
 October – December 2010 49

Because this research involved the use of a cognitive 

test, it was exempt from full institutional review board 

(IRB) review and continuous monitoring. All protocols 

associated with this research were submitted to the 

University of the Incarnate Word (San Antonio, Texas) 

IRB to determine its status. It was understood that personally identifiable information would remain confidential throughout the research and thereafter. Signed 

informed consent statements were obtained from each 

participant at the beginning of each testing session. 

Participation in this study was voluntary, and at all 

times subjects retained the option to refuse to 

participate and withdraw from the study. Results of the 

study were reported in the aggregate to protect the 

identity of individual subjects. 

In addition to permission sought from the University 

of Incarnate Word IRB, letters seeking permission and 

approval for this study were secured from the AMEDD 

Clinical Investigation Regulatory Office, the Judge 

Advocate General, the Fort Sam Houston Army 

Garrison, the AMEDDC&S Chief of Staff, and the 

Dean/Commandant of the Academy of Health 

Sciences, AMEDDC&S. 

INSTRUMENTATION

California Critical Thinking Skills Test (CCTST). Developed 

by Facione and associates specifically to assess the 

skills dimension of critical thinking as defined by the 

APA Delphi Report, the CCTST measured critical 

thinking characterized as the 

...process of purposeful, self-regulatory judgment. This 

process gives reasoned consideration to evidence, 

contexts, conceptualizations, methods, and criteria.”7(p2)

The test consisted of 34 multiple-choice questions 

which were intended to be free of critical thinking 

jargon and technical vocabulary. No discipline-specific 

content knowledge was presumed, and although it was 

designed primarily for post-secondary level 

assessment, the CCTST had been used successfully 

across a wide range of subjects from 10th grade to 

graduate and professional school students.

The CCTST yielded 6 scores: an individual’s overall 

score as well as scores on 5 subscales. The subscales 

were analysis, evaluation, inference, deductive 

reasoning, and inductive reasoning. Facione et al noted 

that these cognitive skills operate interdependently and 

interactively rather than as isolated factors; therefore, 

scores on the subscales were intended primarily as 

gross indicators of strengths and weaknesses.7(p13) The 

maximum scores for the overall CCTST and each of 

the subscales were as follows: overall=34, analysis=7, 

inference=15, evaluation=12. The last 2 subscales 

were reclassified and captured as induction=17, and 

deduction=17. Validation studies of the CCTST Form 

2000 produced internal consistency estimates of 

KR20* equal to 0.80 and 0.78. Because more than one 

critical thinking skill was being tested with a single 

instrument, reliability ratings of 0.65 to 0.75 should be 

considered sufficient.7(p15) Having been developed as 

conceptually consistent with the Delphi expert consensus definition, the CCTST was assumed to have 

both content and construct validity. Criterion validity 

was substantiated with correlations to college grade 

point average, Scholastic Aptitude Test (The College 

Board, New York, New York) verbal and math scores, 

and the Nelson-Denny Reading Test (Riverside Publishing Company, Rolling Meadows, Illinois) scores. 

A demographic questionnaire was researcherdeveloped and included requests for information 

regarding gender, age, ethnicity, rank, military medical 

specialty designator (military occupational specialty or 

area of concentration), education level, teaching 

assignment, assignment experience, deployment 

experience, and years of service. 

Answer sheets were sent to the publisher, Insight 

Assessment (California Academic Press, Millbrae, 

California), to be scored. Insight Assessment returned 

individual test-takers’ overall scores as well as scores 

on each of the subscales. The demographics data were 

tabulated by the researcher using SPSS and coordinated with CCTST results as they were returned from 

the publisher. The data were not used to report critical 

thinking skills of individual instructors. All results 

were reported in the aggregate to insure anonymity. 

The following hypothesis and ancillary hypotheses 

drove the study. 

H1: Instructors of military students have the necessary 

skills to teach critical thinking skills. 

*The Kuder-Richardson Formula 20 (KR20), first published in 1937, is a measure of internal consistency reliability for an overall 

test consisting of several individual items, each measuring some construct. Source: Nova Southeastern University Center for Psychological Studies (http://www.cps.nova.edu/~cpphelp/class/psy0507/consistency.html). 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Ancillary hypotheses 

H2: There are differences in the level of critical 

thinking skills of officer and enlisted instructors. 

H3: There are differences in the level of critical 

thinking skills of instructors teaching leadership 

courses and those who teach a technical medical 

specialty. 

H4: There are the differences in levels of critical 

thinking skills among instructors teaching in the 

various medical military occupational specialties. 

H5: There are differences in the level of critical 

thinking skills of instructors with a field TOE 

background, those who have primarily a TDA 

background, and those who have experience in 

both types of assignments. 

H6: There are differences in the level of critical 

thinking skills of instructors who have combat 

experience, humanitarian deployment experience, 

those who have both, and those who have neither 

type of experience. 

Because this study was supported by the leadership of 

the AMEDDC&S, a great deal of data covering a wide 

range of variables was collected with a view toward 

supporting future studies or projects across 

departments. Data collected specifically for those 

second and third or ancillary purposes were considered 

to be tangential to this study. In terms of what is 

germane, only data specifically relevant to this study 

were reported. The demographic data, descriptive of 

the sample, was presented first. Inferential statistics 

that addressed each of the research hypotheses followed. An alpha (α) level of .05 was used for all 

statistical tests. 

After a review of the Table of Distribution and 

Allowances,* it was estimated that there were 730 

instructors in the sample population at the 

AMEDDC&S at the time of the study. Three hundred 

fifty-five (49%) individuals actually participated. Nine 

response sheets were not usable. All remaining 346 

participants were instructors at the AMEDDC&S. The 

sample included 51 officers and 248 noncommissioned 

officers (NCOs) as well as 34 civil service instructors 

(Department of the Army employees), and 13 other 

civilians hired under contract to provide instruction in 

basic medical skills. The numbers represented a lower 

percentage of both officer and civilian instructors in 

the sample and were not necessarily representative of 

the general AMEDDC&S instructor population. On 

the other hand, NCO instructors comprised 71% of the 

sample of 346 subjects, a percentage that is much 

higher than the actual 38% reflected in the 

AMEDDC&S population of 730 instructors, and 

suggested that results were entirely representative. 

Age was a demographic of great interest because it 

represented a developmental or natural maturation 

process. Therefore it was examined in terms of 

possible influence on critical thinking skills using a 

one-way analysis of variance (ANOVA) procedure. 

While the majority of military instructors at the 

AMEDDC&S are generally assigned in midcareer, the 

ages of the instructors in the sample ranged from 26 to 

over 56 years. The sample was disaggregated into 7 

subsets, shown in Table 1. There were no significant 

differences indicated for the overall CCTST score and 

the analysis, inference, inductive thinking and 

deductive thinking subscores. However, the level of 

significance for the evaluation subscore was 0.035 

which was less than the level of 0.05. A subsequent 

Scheffe post hoc analysis revealed the statistically 

significant difference occurred between the subset 46-

50 years with the lowest mean score of 3.41, and the 

subset 41-45 years with the highest mean score of 

5.03. There were no significant differences among the 

other subsets. 

A series of statements on the demographics survey 

addressed participants’ attitudes and opinions 

regarding critical thinking skills and established the 

focus for the study. Table 2 presents the frequencies of 

responses to indicate participants’ levels of agreement, 

ambivalence, and/or disagreement with the statements. 

The sample population was segregated into 3 naturally 

occurring groups: officer, NCO, and civilian instructors. Data analysis was accomplished by using a chisquare (χ

2

) procedure to test the association among the 

3 subsets. There were statistically significant differences in responses of the 3 groups for items 3 and 6, 

however, the source of the differences was not found. 

*Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform

a specific mission for which there is no appropriate table of organization and equipment (the document that defines the 

structure and equipment for a military organization or unit).

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 51

THE ARMY MEDICAL DEPARTMENT JOURNAL

The preliminary research question for this study asked, 

“what are the critical thinking skills of instructors at 

the AMEDDC&S?” The results of the 6 ancillary 

hypotheses derived from this question are presented in 

the following sections. Where comparisons with a 

norm group were indicated, results were analyzed by 

using independent samples t tests to determine 

significant difference between 2 sample means. The t

tests were also used to analyze data generated for 

Hypothesis 3. Otherwise, an ANOVA procedure was 

used to analyze results of hypotheses involving 

multiple groups and CCTST scores, reported by the 

publisher as an overall score plus 5 subscores 

reflecting critical thinking skills of analysis, inference, 

evaluation, inductive thinking, and deductive thinking. 

It is important to note that a cut score 

of n=10 was applied throughout this 

data analysis. According to Isaac and 

Michael: 

...in exploratory research, samples of this 

size are large enough to test the null 

hypothesis...[and] remain educationally 

significant.8

Statistically significant results were 

demonstrated in 4 of the 6 hypotheses: 

H1, H2, H4, and H6. 

Hypothesis 1: Instructors of military 

students have the necessary skills to 

teach critical thinking skills. 

It may be generally accepted that 

instructors, by virtue of the fact that 

they are instructors, have subject 

knowledge, skills, and abilities that 

exceed those of their students. As such, 

it is often assumed that their critical thinking skills 

exceed those of their students as well. A means of 

verifying this assumption would be to assess the 

critical thinking skills of both groups and compare 

them. However, there had been no other critical 

thinking skills CCTST testing of instructors or 

students at the AMEDDC&S. Therefore, Hypothesis 1 

was answered in 3 ways: (a) self-reporting by 

responding to questions on the demographic survey, 

(b) completing the CCTST and achieving a score, and 

(c) by comparing overall CCTST scores and subscores 

to normed scores. 

The previously noted χ

2

 test indicated no significant 

differences among responses to the demographics 

Table 2. Frequency data for participants’ responses to statements on critical thinking skills. 

Survey Item Strongly 

Agree 

Agree Neither 

Agree nor 

Disagree 

Disagree Strongly 

Disagree 

Missing 

 n % n % n % n % n %

CT skills are essential for the military 162 (46.8) 127 (36.7) 36 (10.4) 2 (0.6) 2 (0.6) 17

Necessary to teach my class CT skills 76 (22) 161 (46.5) 72 (20.8) 15 (4.3) 4 (1.2) 18

CT already included in my instruction 26 (7.5) 123 (35.5) 111 (32.1) 54 (15.6) 9 (2.6) 23

I have sufficient CT skills to teach CT 32 (9.2) 130 (37.6) 127 (36.7) 34 (9.8) 4 (1.2) 19

My CT skills developed from experience 76 (22) 179 (51.7) 61 (17.6) 3 (0.9) 0 0 27

My CT skills developed from education 13 (3.8) 91 (26.3) 155 (44.8) 54 (15.6) 3 (0.9) 30

CT indicates Critical Thinking. 

Sample Subsets 

Officer NCO Civilian Totals 

Instructor Status (missing = 0) 51 248 47 346 

Gender 

(missing=20) 

Male 34 176 27 237 

Female 15 59 15 89 

Ethnicity 

(missing=56) 

African American 3 64 8 75 

Anglo American, Caucasian 39 89 22 150 

Asian American 0 7 0 7 

Hispanic, Mexican American, Latino 2 33 6 41 

Native American 1 3 1 5 

Other 0 11 1 12 

Age 

(missing=3) 

26-30 years 2 11 2 15 

31-35 years 5 98 4 107 

36-40 years 12 87 1 100 

41-45 years 15 39 5 59 

46-50 years 7 10 9 26 

51-55 years 4 2 12 18 

Over 56 4 1 13 18 

Table 1. Demographic data for the study participants. 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

survey statement “I have the skills 

sufficient to teach critical 

thinking.” However, it was 

interesting that the actual mean 

overall CCTST scores and 

subscores of those who disagreed 

or strongly disagreed were slightly 

higher than the mean scores of the 

participants in the other subsets. It 

may be that those who disagreed 

or strongly disagreed underestimated their own critical thinking 

abilities or simply wanted to allow 

themselves some cushion in 

anticipation of what their actual 

test results might be. It is possible that those participants who strongly disagreed or disagreed with the 

question of having sufficient critical thinking skills to 

teach did so because they did not feel that they would 

perform well. Conversely, it may be that those who 

disagreed or strongly disagreed actually had a better 

understanding of the concept of critical thinking which 

enabled them to think more globally, to see the larger 

picture, and to realize what might actually be involved 

in teaching critical thinking. 

What of those participants whose self-report indicated 

agreement or strong agreement that they had essential 

critical thinking skills, only to produce lower actual 

CCTST scores? It is possible that, because critical 

thinking is not necessarily well understood, 

participants may have had a limited view of the skills 

involved, overestimated their abilities, and believed 

themselves to be good performers. This interpretation 

would find support in the aforementioned study 

conducted for the California Commission on Teacher 

Credentialing, which explored teachers’ perceptions 

and practices related to critical thinking. Paul et al concluded, “it appears likely that we are now training 

teachers who not only have little understanding of 

critical thinking nor how to teach for it but also 

wrongly and confidently think they do.”2(p32)

The self-reported responses to the demographics 

survey were but one of the ways the critical thinking 

skills of AMEDDC&S instructors were addressed. The 

actual CCTST scores and subscores achieved provided 

a primary measure and were analyzed using normreferenced interpretation. The sample was disaggregated by education level for comparison with normed 

scores. Table 3 presents the distribution based on the 

highest level of education. 

There was no single norm group 

against which to compare the 

CCTST scores of the participants 

in the study of AMEDDC&S 

instructors. Instead, Insight 

Assessment, the publisher and 

vendor of the California Critical 

Thinking Skills Test, provided 2 

separate sets of norm scores based 

on highest level of education: one 

was a 2-year college group based 

on scores of 729 students, and the 

other was a 4-year college group 

developed from scores of 2677 

students. There were no norm 

scores available for graduate levels or advanced 

degrees at either the masters or doctoral levels. 

Because the education levels of the subjects in this 

study ranged from high school to post-doctorate, the 

data were recoded into 4 subsets for analysis. Level 

one included scores originally designated high school, 

some college, and associates degree, and it was coded 

Some College. Level two, coded Baccalaureate, 

was unchanged. Level three, coded Masters, included 

both masters and post-masters, and level four, coded 

Doctorate, included both doctorate and postdoctorate. This allowed for the CCTST mean scores of 

those in this study with education levels equal to or 

less than an associates degree to be compared to the 

mean scores of the 2-year norm group. The CCTST 

mean scores of those holding a baccalaureate degree 

were compared to the scores of the 4-year norm group. 

Comparison with 2-year norm group. Two hundred ten 

(61%) of the participants in the AMEDDC&S 

instructor sample reported an education level equal to 

or less than 2 years of college. Mean scores of the 2 

groups were very similar and t tests revealed no 

significant differences between the mean scores of the 

sample population and the mean scores of the norm 

group (Table 4). Therefore, one may infer that the 

critical thinking skills of the AMEDDC&S instructors 

with some college equal to or less than a 2-year 

associates degree and the skills of the 2-year college 

students were the same. 

Comparison with 4-year norm group. Sixty-nine (20%) 

of the AMEDDC&S instructor sample reported their 

highest level of education as the baccalaureate degree. 

Their scores were compared with norm scores of 2,677 

 Frequency Percent 

High School 3 0.9 

Some College 116 33.5 

Associates Degree 91 26.3 

Baccalaureate Degree 69 19.9 

Masters Degree 34 9.8 

Post-Masters 4 1.2 

Doctorate 22 6.4 

Post-Doctorate 5 1.4 

Missing 2 0.6 

Total 346 100.0 

Table 3. Distribution of sample based on 

education level. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

4-year college students (Table 5). Again, because there 

were no instructor norms available, the 4-year college 

group was considered to be representative of a peer 

group. In this case, the t tests revealed statistically 

significant differences in critical thinking skill levels 

in the areas of inference and deductive thinking. Further, in all areas, the 4-year college students had higher 

mean scores than the mean scores of the AMEDDC&S 

instructor sample in the Baccalaureate group. 

One might reasonably ask why it is that college 

students demonstrated significantly higher levels of 

certain critical thinking skills than military instructors 

with equal numbers of educational credits in addition 

to several years of military experience. The answer 

may lie in the instructors’ own military training backgrounds. It may be that in a structured military training 

environment, a focus on discreet tasks and technical 

content framed within specialty areas actually becomes 

a limiting factor with regard to critical thinking. 

Both Kegan9

 and Brookfield10 asserted that 

transformative learning through critical thinking/

reflection is not necessarily a goal for all instruction, 

and that all reflection is not necessarily critical or 

transformative. Kegan acknowledged differences 

between transformational and informational learning. 

Because it deepens or adds to understanding, 

informational learning may be appropriate for the 

theory, concepts, principles, and procedures associated 

with the specificity of military tasks and training. 

Finally, with regard to the norm-referenced 

interpretation of the mean CCTST scores of the Some 

College and Baccalaureate subsets, it may be 

important to note that all mean scores of the 

Baccalaureate subset were higher than the mean 

scores of the Some College subset (Table 6). This 

might suggest that there was evidence of some 

increased cognitive development for those 2 additional 

years of higher education. This finding is similar to 

Table 4. Descriptive statistics of overall CCTST scores and subscores comparison to the 2-year college 

norm group (n=20). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Sample 210 14.71 4.452 4.03 1.470 6.77 2.337 14.71 4.452 8.84 2.611 5.87 2.565 

Norm Group 729 14.75 4.922 4.13 1.491 6.80 2.632 14.75 4.922 8.60 2.787 6.14 2.837 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Table 5. Descriptive statistics of overall CCTST scores and subscores comparison to the 4-year norm 

group (n=69). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Subjects 69 15.65 5.387 4.38 1.446 7.10 2.739 4.17 2.242 9.20 2.978 6.45 3.183 

Norm Group 2677 16.80 5.062 4.44 1.408 7.85 2.684 4.52 2.143 9.53 2.821 7.27 2.889 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Table 6. Descriptive statistics of overall CCTST scores and subscores of instructors compared by education levels 

(n=346). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Some College 210 14.71 4.452 4.03 1.470 6.77 2.337 3.91 1.877 8.84 2.611 5.87 2.565 

Baccalaureate 69 15.65 5.387 4.38 1.446 7.10 2.739 4.17 2.242 9.20 2.978 6.45 3.183 

Masters 38 17.55 5.411 4.61 1.443 8.16 2.805 4.79 2.642 10.24 2.889 7.32 2.960 

Doctoral 27 23.22 3.876 5.59 0.844 10.41 2.454 7.22 1.672 12.67 1.732 10.56 2.819 

Missing 2 

Totals 346 15.88 5.247 4.28 1.483 7.27 2.673 4.32 2.214 9.37 2.856 6.51 3.029 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 
54 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

that of Pascarella11 who reported modest gains in 

critical thinking abilities for students attending college 

over students who did not. 

Although there were no norm group scores available 

for those participants in the study who hold advanced 

degrees, the mean overall CCTST scores and 

subscores of AMEDDC&S instructors were compared 

by education levels among and within the 4 subsets, 

with some surprising results (Table 6). While one 

might intuitively expect that increasingly higher levels 

of educational experience would yield higher levels of 

critical thinking skills, the results of a one-way 

ANOVA related to the masters degree indicated only 

one area of significant difference. The means of the 

overall CCTST scores of those with masters’ degrees 

were significantly higher than were the means of the 

overall scores of those in the 2-year subset. However, 

with regard to a comparison of the means of all the 

CCTST subscores, there were no significant 

differences among those instructors reporting a 

master’s degree as their highest level of education, 

those with some college, or those with a baccalaureate 

degree. Perhaps not so surprising, those with 

doctorates as their highest level of education had 

statistically significant higher CCTST scores and all 

subscores than any of the other participants across all 4 

education level subsets. 

Given the challenges and academic rigor associated 

with advanced doctoral level programs, these results 

are not unexpected. There is an expectation that those 

who have earned advanced degrees in a discipline have 

learned the skills of critical thinking in the process.12

Onwuegbuzie13 compared masters and doctoral-level 

students using the CCTST which revealed significantly 

higher critical thinking scores for doctoral students. 

Nonetheless, doctoral level results aside, the critical 

thinking skill comparison of those in the Masters

subset as indicated by their overall CCTST scores and 

subscores and those in the Some College and 

Baccalaureate subsets do raise some questions 

regarding the nature of their graduate degrees. 

Through the Defense Activity for Nontraditional 

Education Support and the Service members 

Opportunity Colleges Army Degree (SOCAD) 

program, military personnel may be given college 

credit for their military training and/or experience. The 

Military Evaluation Program, under the auspices of the 

American Council of Education (ACE), also evaluates 

military occupational training and publishes credit 

recommendations in the Guide to the Evaluation of 

Educational Experiences in the Armed Services (ACE 

Guide, available at http://militaryguides.acenet.edu/) 

which serves as a reference to over 3,000 colleges and 

universities in addition to the SOCAD network.14

There were no data collected to indicate the source of 

academic degrees held by the AMEDDC&S 

instructors, and, while the comparisons of the 

participants in the study sample with the norm groups 

were considered to be appropriate, it was not assumed 

that credit awarded for military or life-experience 

represents the same academic experience as that of 

matriculated students at a college or university. In the 

former cases there is, in effect, the equivalent of a 

“training avoidance” not unlike a cost avoidance that 

occurs when the requirement for an expenditure is 

eliminated. When individuals are given credit for 

training they have already had, they do not accrue any 

benefits that would be derived from additional learning 

or development. There are also many distance-learning 

opportunities afforded to the military through 

programs like eArmyU* for example. Because courses 

are offered by a number of institutions, there may not 

be a consistent philosophy or program of 

developmental progression which one might expect to 

find in a traditional 4-year program. Rather, degree 

plans and programs may be cobbled together out of 

disparate experiences and training that satisfy 

administrative requirements, but may not serve to 

enhance critical thinking skills. 

Ironically, civilian educational institutions have also 

been confronted with issues similar to those noted 

above: 

In the absence of shared learning goals and clear 

expectations, a college degree more frequently certifies 

completion of disconnected fragments than [that] of a 

coherent plan for student accomplishment.15

Weingartner observed that ends and means are often 

confused, and courses, rather than the learning, are 

considered to be the goal: 

We require what we believe students need, what they 

cannot do without; fulfilling requirements, however, 

soon becomes the whole of education.16

*eArmyU is an Army online learning portal which provides access for Soldiers to over 100 degree plans at regionally-accredited colleges 

and universities. Information available at https://www.goarmyed.com/public/public_earmyu-about_earmyu.aspx. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

With regard to the value of the baccalaureate degree, 

the Council for Higher Accreditation (among others) 

reaffirms the importance of a liberal education in 

assuring that students are developing the capacity to 

think and obtaining knowledge necessary to prepare 

for the future. Indeed, an impetus for this study 

emerged as a result of the increasing emphasis on 

critical thinking skills as a component of military 

education. 

Hypothesis 2: There are differences in the level of 

critical thinking skills of officer and noncommissioned officer instructors. 

Because the sample population was naturally segregated into 3 distinct groups of participants, null Hypothesis 2 investigated the critical thinking skill levels 

not only of instructors who were officers and those who 

were NCOs, but also of those who were civilians, using 

an ANOVA procedure (Table 7). The levels of 

significance for the mean overall CCTST scores and all 

subscores were 0.000. The Scheffe post hoc analysis 

indicated the officer instructor group was significantly 

different from the others and had higher levels of 

critical thinking scores than did both the NCO and 

civilian instructors. There was no significant difference 

between the scores of the civilian and NCO instructors. 

In light of the literature which addressed the 

dominance of the professional officer subculture, 

perhaps these results are not surprising.17 Further, the 

Center for Strategic and International Study Group on 

Professional Military Education, which focused 

exclusively on officer education, emphasized 

increasing intellectual demands. 1 8 Their 

recommendations for increased academic education 

and advanced degrees, particularly in civilian 

institutions, would be supported by the results of this 

study. Based on the previous discussion of education 

levels, the number of advanced degrees held by the 

officer subset of AMEDDC&S instructors must 

certainly be regarded as one explanation for the 

differences. Officer instructors held 43% of the 

masters’ degrees and 92% of the doctorates 

represented in this study. Conversely, the NCO (87%) 

and civilian (12%) instructors represented nearly the 

entirety of those instructors who populated the Some 

College subset. 

The majority of the instructors at the AMEDDC&S are 

NCOs. Because the results of this study indicated 

significant differences between the mean CCTST 

scores and subscores of officers and NCOs, the 

training and education of NCOs should be considered. 

It may be that a focus on the training of individual 

tasks to established standards either limits or precludes 

the critical reflection necessary for integrated 

transformative learning. In many respects, NCO 

training has been conducted from a fairly linear 

approach, characterized by performance checklists and 

algorithms and is usually taught in a step-by-step 

format described as “crawl, walk, run.” It may be that 

these training processes are entirely appropriate, given 

the ever-increasing demands for the initial training of 

both warrior skills and medical skills and reactions for 

the contemporary operational environment.* It may be 

desirable that these medical Soldiers first develop their 

skills to the level of automaticity. Subsequently, 

however, it is possible that with increasing 

implementation of scenario-based training, more 

explicit training for critical thinking will be realized. 

Hypothesis 3: There are differences in the level of 

critical thinking skills of instructors teaching leadership courses and those who teach a technical 

medical specialty. 

The comparison of mean overall CCTST scores and 

subscores of those who taught leadership courses and 

those of medical specialty instructors yielded no 

significant results (Table 8). It should be noted that 

mean scores of officer, NCO, and civilian instructors 

were all included in this comparison. Because officers 

were often responsible for curriculum development, 

served as course directors, and, in fact, taught some of 

the military occupational specialty (MOS) courses, 

their scores were included in the data analysis. The 

scores of civilian instructors were also included 

because they also have teaching responsibilities along 

with those NCO instructors who hold the MOS. 

Of note is the fact that the leadership subset was 

populated by only 13 subjects. A future study having 

greater participation of leadership instructors from 

both the Officer Education System and the 

Noncommissioned Officer Education System would 

obviously provide more valuable results. 

*The operational environment that exists today and for the clearly foreseeable future. An operational environment is defined in 

DoD Joint Publication 1-02 19 as “a composite of the conditions, circumstances, and influences that affect the employment of 

military forces and bear on the decisions of the unit commander.” 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Hypothesis 4: There are differences in levels of critical 

thinking skills among instructors teaching in the 

various medical military occupational specialties. 

Statistically significant differences were found in only 

2 instances when the mean overall CCTST scores and 

subscores of instructors in 9 medical military occupational specialties were compared (Table 9). In one 

case, overall CCTST scores of radiology specialists 

were higher than those of the practical nurses, while 

the mean scores of the other MOSs resulted in no 

difference. In the second case, the mean CCTST 

induction subscores of the veterinary food inspection 

specialists were higher than those of the practical 

nurses, while the mean scores of the remaining MOSs 

indicated they were statistically the same. 

One possible explanation for the differences may be 

that 25% of the radiology specialists had highest 

education levels equal to or higher than a 

baccalaureate degree, whereas the highest education 

levels of the veterinary food inspectors and practical 

nurses equal to or higher than a baccalaureate degree 

were 10% and 6% respectively. Preliminary 

qualifications for military occupational specialties are 

determined by scores on the Armed Forces Vocational 

Aptitude Battery (ASVAB) which is the official 

mental testing battery used by all US armed services. 

Groups of ASVAB subtest scores are combined into 

composite line scores, the most important of which for 

the majority of the medical enlisted specialties is the 

Skilled Technical (ST) score, a composite of subtests 

of general science, word knowledge, paragraph comprehension, mechanical comprehension, and mathematics knowledge. The ST requirements for the radiology specialist (MOS 91P), the veterinary food 

inspection specialist (MOS 91R), and the practical 

nurse (MOS 91WM6) are 110, 100, and 101 respectively. If the skilled technical score were indicative of 

actual critical thinking skills, the results of this 

comparison might have been anticipated, although a 

review of the literature indicated that critical thinking 

is not the same as intelligence, in that critical thinking 

involves specific skills and disposition.1,20-22 

Therefore, although the ST scores may be an 

indication of the mental abilities or cognitive skills 

required for each MOS, a more complete explanation 

for differences in critical thinking skill levels may be 

realized only after further study to examine the 

differences among the course content and the training 

processes for all 3 groups. Both the radiology 

specialists and the veterinary food specialists reported 

having a great deal of ownership and responsibility for 

the curriculum and development of their courses. Their 

branches are fairly small, and content in their courses 

is challenging and well integrated. 

Table 7. Descriptive Statistics of Overall CCTST Scores and Subscores Compared by Instructor Status: Officer, NCO, 

and Civilian (n=346). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Officer 51 20.53 5.201 5.06 1.318 9.45 2.633 6.02 2.396 11.43 2.594 9.10 3.195 

NCO 248 15.18 4.613 4.13 1.454 7.01 2.378 4.04 1.998 9.06 2.630 6.12 2.717 

Civilian 47 14.45 5.785 4.28 1.542 6.26 2.967 3.91 2.283 8.74 3.287 5.70 3.035 

Total 346 15.87 5.239 4.29 1.479 7.27 2.668 4.32 2.211 9.37 2.849 6.50 3.031 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Table 8. Descriptive Statistics for the Overall CCTST Scores and Subscores of Instructors of Leadership and of 

Medical Skills (n=346) 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Leadership 13 17.38 5.331 4.38 2.022 8.38 2.599 4.62 2.022 10.38 1.938 7.00 3.786 

Medical Skills 323 15.84 5.219 4.27 1.457 7.25 2.659 4.32 2.216 9.34 2.849 6.50 3.016 

Missing 10 

Total 346 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

On the other hand, it should be noted that the practical 

nurses participating in this study were among nearly 

300 instructors responsible for training of the 

healthcare specialists (MOS 91W) in the Department 

of Combat Medic Training. Instruction is modularized, 

and instructors do not necessarily have responsibility 

for curriculum development. This situation may be like 

those which gave rise to observations regarding undeveloped intellectual capital within an organization 

when individuals do not have responsibility for either 

training development or decisions related to the intellectual development of their students.23,24 There may 

not be opportunity for intellectual development or 

challenge for instructors as well. It may also be that 

the differences in numbers of instructors in small versus large departments impact the culture of their teaching organization and further influences perceptions of 

individual intellectual investment. Theirs may 

necessarily be a function of “instructor as messenger” 

rather than that of instructor/training developer.25

The AMEDDC&S is organized into teaching 

departments based on specialty areas which include 

the related MOSs. Therefore, another measure of 

instructor skills in specialty areas involved a 

comparison of overall mean CCTST scores and 

subscores across all departments, and included officer, 

civilian, and NCO instructors. Only departments 

having 10 or more participants were included in this 

comparison. Statistically significant differences were 

found in all instances when the mean overall CCTST 

scores and subscores of instructors in 9 teaching 

departments were compared using a one-way ANOVA 

(Table 10). The instructors of the Department of 

Veterinary Sciences (DVS) scored higher overall 

CCTST scores and inference subscores than did the 

instructors in both the Department of Health Services 

Administration (DHSA) and the Department of 

Combat Medic Training (DCMT). In addition, the 

DVS instructors had higher analysis and deductive 

thinking subscores than did the DCMT instructors, as 

well as higher evaluation and inductive thinking 

subscores than did the instructors in the DHSA. 

Based on the earlier discussions of Hypotheses 1 and 2 

which found significant differences between overall 

CCTST scores and subscores of officer and enlisted 

instructors as well as significant differences associated 

with advanced degrees at the doctoral level, the differences of critical thinking skill levels within departments might simply be explained by the fact that 36% 

of the DVS participants were officers, compared with 

10% and 5.4% officer representation for DHSA and 

DCMT respectively. Additionally, the highest level of 

education equal to or greater than the doctoral level 

were held by 24% of the subjects representing the 

DVS, by 5% of the subjects from the DHSA, and 0% 

from the DCMT. Therefore, the differences in overall 

CCTST scores and subscores among instructors in the 

AMEDDC&S teaching departments could be attributed to their rank and their highest levels of education. 

Table 9. Descriptive statistics for Overall CCTST scores and subscores comparisons of instructors by MOS (n=346) 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Radiology Specialist 12 16.92 3.554 4.75 0.965 8.25 2.137 3.92 1.975 9.83 2.209 7.08 2.539 

Veterinary Food 

Inspection Specialist 10 16.90 4.725 4.70 1.494 7.80 1.989 4.40 2.459 9.90 2.514 7.00 2.828 

Medical Laboratory 

Specialist 52 16.73 4.703 4.25 1.440 7.60 2.345 4.88 1.957 9.87 2.552 6.87 2.822 

Preventive Medicine 

Specialist 13 16.31 4.270 4.46 1.391 7.62 1.981 4.23 2.488 9.77 1.787 6.54 2.847 

Mental Health 

Specialist 19 15.47 4.683 4.47 1.349 6.89 2.536 4.11 2.052 9.42 3.288 6.05 2.345 

Preventive Dentistry 

Specialist 13 14.54 4.075 3.62 1.557 7.15 2.703 3.77 1.641 9.38 2.181 5.15 2.444 

Health Care Specialist 58 13.88 4.967 3.81 1.561 6.50 2.515 3.57 2.010 8.22 2.740 5.66 2.911 

Hospital Food Service 

Specialist 10 13.30 3.713 4.00 0.667 5.90 2.234 3.40 1.776 8.00 2.211 5.30 2.359 

Practical Nurse 16 13.06 3.435 3.38 1.628 6.25 1.770 3.44 1.590 7.69 1.922 5.38 2.500 

Totals 203 15.19 4.671 4.09 1.466 7.05 2.390 4.05 2.032 9.05 2.633 6.14 2.756 

CCTST indicates California Critical Thinking Skills Test. MOS indicates military occupational specialty. 

M indicates mean. SD indicates standard deviation. 
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

On the other hand, those who, like McPeck26 and 

Gardner,20 espouse a domain-specific paradigm of 

critical thinking, would argue that an analysis of 

professional knowledge, skill sets, and competencies 

required for the specialties within each department 

might better inform an interpretation of the results. 

Military Experience. The last 2 hypotheses in this study 

were addressed by 3 different examinations involving 

participants’ military assignment background, military 

deployment experience, and years of service. These 

examinations provided surprisingly similar results. No 

statistically significant differences were found in 

comparisons of mean CCTST scores and subscores of 

instructors by ranges of years of total military service; 

nor were there differences when types of assignments 

were compared. Types of military assignment 

backgrounds were categorized as: (a) primarily Table 

of Distribution and Allowances (TDA) – to 

organizations characterized as primarily 

“institutional,” because they are defined by TDAs; (b) 

primarily Table of Organization and Equipment 

(TOE) – to organizations characterized as 

“operational,” because they are defined by TOEs; and 

(c) “both” – background which included TOE as well 

as TDA assignments. The data is presented in Tables 

11 and 12. Finally, in a comparison of types of 

deployment experience, there were no significant 

differences found except in the means of CCTST 

analysis subscores of officers (Tables 13 and 14). 

Hypothesis 5: There are differences in the level of 

critical thinking skills of instructors with a TOE 

background, those who have primarily a TDA 

background, and those who have experience in both 

types of assignments. 

The results of the ANOVA indicated no significant 

difference found. However, it was interesting to note 

that in both the officer and NCO subsets, actual mean 

overall CCTST scores and subscores were highest for 

those instructors having had only TDA assignments. It 

is possible that the nature of unit training requirements 

and exercises in an operational TOE environment may 

somehow limit an individual’s range of decisionmaking or problem-solving requirements. This may be 

especially true when compared with the AMEDD 

institutional TDA environment in terms of the broad 

scope of research and medical treatment practiced in 

Army Medical Centers and teaching hospitals. The 

potential for more numerous opportunities for further 

training and continuing education afforded in a TDA 

assignment should also not be discounted. 

Hypothesis 6: There are differences in the level of 

critical thinking skills of instructors who have combat 

experience, humanitarian deployment experience, 

those who have both, and those who have had 

neither type of experience.

When comparisons of critical thinking skill levels 

were based on instructors’ deployment experience, the 

only statistically significant difference indicated that 

the mean CCTST analysis subscores were highest for 

Table 10. Descriptive statistics of overall CCTST scores and subscore comparisons of instructors by teaching departments (n=346). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Combat Medic Training 75 13.31 4.832 3.72 1.547 6.03 2.371 3.56 2.015 7.96 2.778 5.35 2.658 

Clinical Support 

Services 83 16.94 4.516 4.45 1.373 7.78 2.353 4.71 2.027 10.02 2.434 6.92 2.786 

Dental Sciences 26 15.50 4.752 4.27 1.687 6.85 2.679 4.38 1.899 9.88 2.215 5.62 3.021 

Health Services 

Administration 21 13.29 5.159 4.00 1.378 6.19 2.822 3.10 2.143 7.76 3.254 5.52 2.502 

Medical Science 52 15.90 4.860 4.31 1.229 7.35 2.504 4.25 2.239 9.06 2.697 6.85 2.933 

Preventive Health 

Services 39 17.46 5.481 4.62 1.350 8.00 2.734 4.85 2.477 10.33 2.950 7.13 3.189 

Veterinary Services 25 19.68 5.505 5.04 1.274 9.12 2.818 5.52 2.400 10.96 2.638 8.72 3.348 

Leader Training Center 13 17.38 5.331 4.38 2.022 8.38 2.599 4.62 2.022 10.38 1.938 7.00 3.789 

Other 10 15.00 5.944 4.80 1.476 6.30 2.830 3.90 2.424 9.10 3.755 5.90 2.601 

Missing 2 

Totals 346 15.88 5.252 4.30 1.473 7.27 2.676 4.31 2.217 9.37 2.855 6.51 3.029 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

those officers who had neither combat nor humanitarian deployment experience. In all other instances, 

the overall CCTST scores and subscores for both 

officer and NCO instructors, when compared within 

their respective subsets, were statistically the same 

regardless of their deployment experience. The actual 

mean overall CCTST scores and subscores for both 

officers and NCOs followed similar patterns, with the 

instructors who have had neither combat nor humanitarian deployment experience having the highest 

scores in a majority of cases. These results were not 

inconsistent with the comparisons of TOE and TDA 

background experience since combat and humanitarian 

or peacekeeping deployments may be most closely 

associated with TOE assignments, ie, the operational 

Army. Likewise, it was not unreasonable to associate 

those instructors having had no deployment experience 

with TDA assignments, ie, the institutional Army. 

With regard to the issue of combat experience, it 

should be noted that those in this study of 

AMEDDC&S instructors who indicated having 

combat experience were for the most part referring to 

Desert Shield/Desert Storm of 1991. Since then, and 

particularly beginning in 2000 with the Army Training 

and Leader Development Panels, there has been 

significant study of the Army profession. There has 

also been considerable study of the differences in the 

nature of current combat experience in Afghanistan 

and Iraq from previous combat and the development of 

expert knowledge. Snider pointed to the number of 

rotations of soldiers to the Middle East with the 

observation that “...students at Leavenworth now 

know more than their faculty.”27 In his study of 

combat experience of junior officers in Afghanistan 

and Iraq, Wong describes a cohort of “innovative, 

confident, and adaptable” lieutenants and captains who 

have learned to “...actually lead and make decisions 

rather than merely to execute the orders of higher 

commands.”28(p13) It is important to consider whether 

those lessons learned reflected enhanced critical 

thinking abilities. It may be that critical thinking skills 

of AMEDDC&S instructors more recently returned 

from combat deployment would differ from those who 

participated in this study. Only further research could 

determine if such is the case. 

While it was not possible to compare results of this 

study to other specific research of military medical 

instructors’ critical thinking skills, the effects of 

education on the development of critical thinking 

abilities could be corroborated. In a 1997 study 

conducted at the Center for Creative Leadership in 

Greensboro, NC, Duchesne examined “how 

Table 11. Descriptive statistics of overall score and subscore comparison of officer instructors by assignment 

background (n=51). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

TDA 14 22.36 3.319 5.36 7.45 10.21 2.259 6.79 2.045 12.21 1.672 10.14 2.214 

Both 34 19.65 5.645 4.94 1.455 9.15 2.743 5.56 2.452 11.03 2.876 8.62 3.438 

Missing 3 

Total 48 20.44 5.194 5.06 1.295 9.46 2.633 5.92 2.386 11.38 2.623 9.06 3.185 

M indicates mean. SD indicates standard deviation. 

Table 12. Descriptive statistics of overall CCTST score and subscore comparisons of NCO instructors by assignment 

background (n=248). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

TDA 26 16.85 4.211 4.62 1.444 7.38 2.368 4.85 1.826 9.88 2.142 6.96 2.891 

TOE 14 15.36 5.183 3.71 1.069 7.29 2.758 4.36 2.023 9.14 2.983 6.21 2.833 

Both 204 15.01 4.577 4.09 1.468 6.99 2.339 3.93 1.991 8.99 2.628 6.02 2.693 

Missing 4 

Totals 244 15.23 4.591 4.13 1.453 7.05 2.361 4.05 1.990 9.09 2.606 6.13 2.726 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

developmental learning, and adaptive flexibility relate 

to the level of critical thinking in sample of 

organizational leaders.”29(p1) Duchesne identified the 

following variables that had been associated with 

critical thinking in previous research: intelligence, age, 

years of education, and years of experience. To this 

list, he added adaptive flexibility and hypothesized 

there would be no combination of factors that predict 

the level of critical thinking. An analysis of the data 

generated by the Watson-Glaser Critical Thinking 

Appraisal (Pearson Assessment Inc, San Antonio, 

Texas), the Background Section of the McCauley Job 

Challenge Profile,30 and Kolb’s Adaptive Style 

Inventory (Experienced Based Learning Systems, 

Cleveland, Ohio) indicated “years of education beyond 

high school” to be the only significant predictor of 

critical thinking score ....”29(p3) From another 

perspective, Pascarella concluded that apart from any 

specific experience, it was the total integration of 

intellectual or cognitive development [in college] that 

positively influenced the development of critical 

thinking ability.11(p7) 

As noted in the literature, critical thinking is not 

innate; it must be learned. It must be learned in a way 

that is intentional and conative,31 and it must be 

supported by a culture that values critical thinking. 

There are no established standards of sufficiency with 

regard to levels of critical thinking skills required of 

instructors other than an understanding that instructor 

skills should be higher than those of their students. 

Certainly, the CCTST could be administered to sample 

populations of various groups of AMEDDC&S 

students to facilitate comparisons of critical thinking 

skill levels with those of instructors and, where 

appropriate, the norm groups as well. If it is accepted 

that instructor scores should be higher than student 

scores, then efforts towards increasing instructor 

critical thinking skills levels should logically follow. 

It is important that critical thinking be understood to 

involve the quality of one’s thinking as opposed to 

being more narrowly defined as decision-making, 

problem-solving, creative thinking, intuition, 

brainstorming, or “thinking outside the box.” Major 

General Maggart made a particularly cogent 

recommendation at the opening of a 2001 Army 

Research Institute Critical Thinking Workshop 

conducted at Ft Leavenworth: 

...the Army is basically a process driven organization, 

more interested in standardization of thought than in 

divergent thought. Critical thinking requires divergent 

Table 13. Descriptive statistics of overall CCTST score and subscore comparisons of officer instructors by deployment experience (n=51). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Humanitarian 19 22.00 3.496 5.32 .749 10.21 1.932 6.47 1.867 12.16 1.708 9.84 2.387 

Both 11 19.09 5.558 4.27 1.618 8.82 2.960 6.00 2.191 11.00 2.324 8.09 3.700 

Neither 14 21.79 4.492 5.64 0.929 9.64 2.818 6.50 2.139 11.86 2.413 9.93 2.947 

Missing 14 

Totals 51 21.20 4.465 5.16 1.180 9.68 2.513 6.36 2.001 11.77 2.112 9.43 2.968 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Table 14. Descriptive statistics of overall CCTST score and subscore comparison of NCO instructors by deployment 

experience (n=248). 

Group Overall Analysis Inference Evaluation Induction Deduction 

n M SD M SD M SD M SD M SD M SD 

Combat 31 13.77 4.417 3.68 1.681 6.55 2.188 3.55 1.670 8.35 2.374 5.42 2.826 

Humanitarian 84 15.48 4.419 4.14 1.381 7.21 2.298 4.12 2.008 9.30 2.592 6.18 2.580 

Both 54 15.19 4.589 4.02 1.236 7.20 2.358 3.96 2.282 9.04 2.642 6.15 2.818 

Neither 78 15.53 4.821 4.37 1.555 6.92 2.475 4.23 1.893 9.19 2.683 6.33 2.762 

Missing 1 

Totals 248 15.21 4.593 4.13 1.456 7.04 2.352 4.05 1.997 9.09 2.607 6.13 2.719 

CCTST indicates California Critical Thinking Skills Test. M indicates mean. SD indicates standard deviation. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

thought, so as you discuss critical thinking over the next 

2 days, please try to resist the urge to develop another 

military decision making process or a command and 

staff action process...If you describe critical thinking as 

an algorithm, that is what the Army will teach and 

students will learn...but unfortunately they will not 

learn how to think critically!32 

CONCLUSION

The purpose of this study was to measure critical 

thinking skills of instructors within the AMEDDC&S, 

in part, to establish a baseline or frame of reference for 

subsequent professional development and curriculum 

design and development, as well as other critical thinking initiatives. Many questions emerged: What will be 

the trends in critical thinking skill levels of instructors 

over the next 5 or 10 years? To what extent is the 

organizational culture supportive of critical thinking? 

What kinds of experiences impact instructor critical 

thinking skills? What kind of training or professional 

development will be required? Do enhanced critical 

thinking skills of instructors actually lead to greater 

student success? What are the characteristics of instructors of successful students? What kinds of successful student achievement data could be indicative of 

instructor critical thinking skills? There may not be 

easy answers, but it was hoped that the results of this 

study might provide a starting point for increased 

interest in collaborative efforts toward development of 

critical thinking skills as AMEDDC&S intellectual 

capital, professional development of instructors, and, 

ultimately, improved student performance. 

REFERENCES

1. Facione PA. Critical Thinking: A Statement of Expert 

Consensus for Purposes of Educational Assessment 

and Instruction. Millbrae, CA: California Academic 

Press; 1990: ERIC Doc No ED 315 423. Available 

at: http://www.eric.ed.gov/PDFS/ED315423.pdf. 

Accessed September 21, 2010. 

2. Paul R, Elder L, Bartell T. California Teacher 

Preparation for Instruction in Critical Thinking: 

Research Findings and Policy Recommendations. 

Sacramento, California: California Commission on 

Teacher Credentialing; 1997. Available at: http://

www.criticalthinking.org/store-page.cfm?P= 

products&ItemID=147&catalogID=214&cateID=132

. Accessed September 21, 2010. 

3. O’Neal EH. Recreating Health Professional Practice 

for a New Century: The Fourth Report of the Pew 

Health Professions Commission. San Francisco, CA: 

The Center for the Health Professions; 1998. 

4. Army Training and Leader Development Panel 

Officer Study: Report to the Army. Fort Leavenworth, 

Kansas: US Army Combined Arms Center; 2001. 

Available at: http://www.army.mil/features/ATLD/

report.pdf. Accessed September 21, 2010. 

5. Army Training and Leader Development Panel Noncommissioned Officer Study: Report to the Army. 

Fort Leavenworth, Kansas: US Army Combined 

Arms Center; 2002. Available at: http:/www.army. 

mil/features/atldpnco/nco_study_report.pdf. Accessed 

September 21, 2010. 

6. Duldt BW, Coaching winners: how to teach 

critical thinking. In: Duldt BW, Instructor’s 

Manual: SmartPrim, A Computer Assisted 

Instructional Program about Critical Thinking, 

Term Papers, and Speeches. Springfield, VA: 

Duldt & Associates Inc; 1999;39.

7. Facione PA, Facione NC, Blohm SW, Giancarlo CAF. 

The California Critical Thinking Skills Test Manual. 

Millbrae, CA: California Academic Press; 2002. 

8. Isaac S, Michael WB. Handbook in Research and 

Evaluation for Education and the Behavioral 

Sciences. 3rd ed. San Diego, California: Educational 

and Industrial Testing Services; 1997:101. 

9. Kegan R. What form transforms? A constructivedevelopmental approach to transformative learning. 

In: Mezirow J, ed. Learning as Transformation. 

Critical Perspectives on a Theory in Progress. San 

Francisco, CA: Jossey-Bass; 2000:35-70. 

10. Brookfield S. Transformative learning as ideology 

critique. In: Mezirow J, ed. Learning as 

Transformation. Critical Perspectives on a Theory in 

Progress. San Francisco, CA: Jossey-Bass; 2000:125-

150. 

11. Pascarella ET. The development of critical thinking: 

does college make a difference?. J Coll Student Dev. 

1989;30:19-26. 

12. Schafersman SD. An introduction to critical thinking. 

Scottsdale Community College Web site. January 

1991. Available at: http://smartcollegeplanning.org/

wp-content/uploads/2010/03/Critical-Thinking. 

Accessed September 21, 2010. 

13. Onwuegbuzie AJ. Critical thinking skills: a 

comparison of doctoral and master’s level students. 

Coll Stud J. September 2001. Available at: http://find 

articles.com/p/articles/mi_m0FCR/is_3_35/ai_80744 

661/?tag=content;col1. Accessed September 21, 2010 

14. Kime SF, Anderson CL. Contributions of the military to 

adult and continuing education. In: Wilson AL, Hayes 

ER, eds. Handbook of Adult and Continuing Education. 

New York: John Wiley and Sons; 2000:471-472. 
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15. Greater Expectations: A New Vision for Learning as 

a Nation Goes to College. Washington, DC: 

Association of American Colleges and Universities; 

2002:x. Available at: http://greaterexpectations.org/

pdf/GEX.FINAL.pdf. Accessed September 21, 2010. 

16. Weingartner RH. Undergraduate Education: Goals and 

Means. Phoenix, Arizona: The Oryx Press; 1992:3. 

17. Snider DM. An uninformed debate on military 

culture. In: Lehman JF, Sicherman H, eds. America 

the Vulnerable: Our Military Problems and How to 

Fix Them. Philadelphia, PA: Foreign Policy Research 

Institute; 2000:115-130. Available at: http://www. 

fpri.org/americavulnerable/BookAmericathe 

Vulnerable.pdf. Accessed September 21, 2010. 

18. Cheney RB, Taylor B, eds. Professional Military 

Education: An Asset for Peace and Progress: A 

Report of The Csis Study Group On Professional 

Military Education. Washington, DC: Center for 

Strategic & International Studies; 1997. 

19. Joint Publication 1-02: DoD Dictionary of Military 

and Associated Terms. Washington, DC: Joint Staff, 

US Dept of Defense; March 4, 2008. Available at: 

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20. Gardner H. Multiple Intelligences. New York: 

BasicBooks; 1993. 

21. Goleman D. Vital Lies, Simple Truths: The Psychology 

of Self Deception. New York: Simon & Schuster; 1985. 

22. Paul R, Elder L. Critical Thinking: Tools for Taking 

Charge of Your Learning and Your Life. Upper 

Saddle River, NJ: Prentice Hall; 2001. 

23. Robinson L. America’s secret armies: a swarm of 

private contractors bedevils the U.S. military. US 

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at: http://www.usnews.com/usnews/culture/

articles/021104/archive_023164.htm. Accessed 

September 21, 2010. 

24. Snider DM, Lira LL. The Future of the Army 

Profession Phase II. Paper presented at: Senior 

Leader Conference XLI; September/October 2004; 

West Point, NY. 

25. Slusarski SB. Learners’ perspectives of the train-thetrainer program in creating the role of classroom 

trainer. Proceedings of the Annual Adult Education 

And Research Conference; 1999. Available at: http://

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Accessed September 21, 2010. 

26. McPeck JE. Critical Thinking and Education. New 

York: St Martin’s Press; 1981. 

27. Snider DM. The multiple identities of the 

professional Army officers. In: Snider DM, Matthews 

LJ, eds. The Future of the Army Profession. New 

York: McGraw-Hill; 2005:142. 

28. Wong L. Developing Adaptive Leaders: The Crucible 

Experience of Operation Iraqi Freedom. Carlisle 

Barracks, PA: Strategic Studies Institute, US Army 

War College; 2004. Available at: http://www. 

strategicstudiesinstitute.army.mil/pubs/display.cfm?

PubID=411. Accessed September 21, 2010. 

29. Duchesne R. Critical thinking, developmental 

learning, and adaptive flexibility in organizational 

leaders. Proceedings of the Annual Adult Education 

And Research Conference; May 16-18, 1997. 

Available at: http://www.adulterc.org/

Proceedings/1997/97duchesne.htm. Accessed 

September 21, 2010. 

30. McCauley CD, Ohlott PJ, Ruderman MN. Job 

Challenge Profile: Learning from Work Experience. 

San Francisco, CA: Pfeiffer; 2010. 

31. Huitt W. Conation as an important factor of mind. 

Valdosta, GA: Valdosta State University; 1999. 

Available at: http://www.edpsycinteractive.org/topics/

regsys/conation.html. Accessed September 21, 2010. 

32. Riedel S. Training Critical thinking Skills for Battle 

Command. Fort Leavenworth, Kansas. Army Research Institute Newsletter. Spring 2001:7. Available 

at: http://www.au.af.mil/au/awc/awcgate/army/

ari_spr01_crit.pdf. Accessed September 21, 2010.

AUTHOR

Dr Hobaugh is Deputy Chief, Staff and Faculty Development Division, Army Medical Department Center and School, 

Fort Sam Houston, Texas. 

Critical Thinking Skills: Do We Have Any? 
 October – December 2010 63

There has long been discourse between teacher and 

student. What is the best way to effectively transfer 

data from teacher to student? More importantly, what 

is the best way to effectively analyze the retained data 

that has been transferred? In this paper, I attempt to 

analyze assessment-based instruction; define the key 

components, explore how different assessments can 

change instruction within the current classroom, and 

examine how assessments can improve curriculum and 

the implementation difficulties within the Academy of 

Health Sciences, US Army Medical Department 

Center and School. 

Herman et al2

 iterate the key components of 

assessment-based instruction: 

Note five recent trends in assessment. They are 

movements from (1) behavioral to cognitive views of 

learning and assessment, (2) paper-pencil activities to 

authentic assessment, (3) single-occasion assessment to 

samples over time (portfolios), (4) single-attribute to 

multidimensional assessments, and (5) near-exclusive 

emphasis on individual assessment to group assessment. 

Essentially, in the last 20 years there has been a shift 

from rote education to cognitive understanding. The 

desire for students who can regurgitate information 

learned in the course has diminished, and in its place is 

the desire for students who can incorporate 

information into real life competency. The movement 

from pencil and paper assessments to dioramas or 

portfolios have helped shift education into 

multidimensional, multitasking assessments that create 

students who not only understand, but fundamentally 

understand the concept. Assessment-based instruction, 

in its pure form, uses multiple assessment types 

throughout the course to effectively determine the 

level of cognitive understanding. Replacing a singular 

summative assessment with multiple forms teaches to 

the entire class, attacks the cognitive domain from all 

angles and helps students “see” the connection 

between what is on paper and how it applies within the 

student’s experience. 

Eldridge3

 describes a study conducted with English 

proficiency students in which 8 cohorts of students 

were assessed over a 4-semester period. Four of those 

cohorts used summative assessments, while the other 

four used formative (self-assessment, peer assessment, 

portfolios, and cooperative learning assignments). The 

results of the study were that the formative 

assessments “were found to be no less reliable than 

grades calculated using purely teacher-assessed 

summative tasks.”3

 Eldridge goes on to say: 

In terms of learning, the formative cohorts 

demonstrated a rate of growth in proficiency that was 

36% faster than the summative cohorts for listening and 

3.2% faster for reading.3

The language study emphasizes that the recent trend 

shift from an essentially rote form of learning to a more 

dynamic integration only serves to improve the level of 

cognitive retention in students, and the demonstrated 

benefits of formative assessments in the classroom. 

As seen in the language cohort study, the integration of 

multiple forms of assessment can improve learning 

markedly. The use of formative assessments such as 

self-evaluation, portfolios, and individual research 

questions creates an environment where the students 

feel more responsible for their learning. According to 

the Organization for Economic Cooperation and 

Development: 

Formative assessment builds students’ “learning to 

learn” skills by emphasizing the process of learning, 

and involving students as partners in that process. It 

also builds students’ skills at peer-assessment and selfassessment, and helps them develop a range of effective 

learning strategies.4

In so doing, it teaches students an understanding of 

how they learn, and why they learn in that way. The 

recent shift in teaching strategies, such as the 

incorporation of multiple formative assessments, 

brings the student into focus, creating an atmosphere 

of mutual learning, where in the past there was only a 

Assessment-Based Instruction 

Stephanie Hamilton, MEd 

Assessing accomplishment in the cognitive domain has occupied educational psychologists for most of 

this century.1
64 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Assessment-Based Instruction 

teacher oriented setting. The ultimate goal of educating 

students is to teach them how to learn, to explore and 

to understand their own cognitive processes — a very 

important step in a student’s education. By learning 

that early and developing a solid understanding of their 

own cognitive processes, students are being helped not 

only to learn, but to develop their own lifelong 

learning experiences. 

Implementing a formative focus into the Academy of 

Health Sciences will add a level of proficiency for our 

medically-related Soldiers. Many military occupational specialty courses use a combination of LXR 

tests (Logic Extension Resources Inc, Georgetown, 

South Carolina) and hands-on skills exams to show 

student proficiency, while other leadership courses use 

a combination of capstone exercises to demonstrate 

understanding. To date, one significant piece of technology being wholly underutilized is the BlackBoard 

(Bb) Enterprise System (Blackboard Inc, Washington, 

DC). LXR tests and Bb are both assisting instructors in 

course assessments, however, the collaborative 

environment is all but untouched. Within Bb, as with 

other learning managements systems, is the capability 

to ask and answer questions and to interact with 

instructors in an asynchronous environment. This 

asynchronous environment can give instructors an 

opportunity to view how well students are relating to 

the material being presented. Questions can be posed 

in a forum, promoting a collaborative learning environment that can aid the instructor in personalizing or 

redirecting instruction when necessary. 

CONCLUSION

The shift from summative assessment to the 

incorporation of more formative assessments over the 

last 20 years has improved curriculum overall. In study 

after study, it has been shown that the use of multiple 

assessment types has helped students become active 

stakeholders in their education, and makes them 

guardians of their own career progression. The key 

aspects to formative assessment and the integration of 

those key aspects has been the determinant of change 

in the educational world. Creating assessments that 

focus on cognitive interactions will create multidimensional students who can better integrate into an 

operational environment. As we develop new and 

better ways to teach, train, assess, and evaluate our 

students, we will continually improve the development 

of better students, and eventually a better workforce. 

REFERENCES

1. Angelo TA, Cross KP. Classroom Assessment 

Techniques: A Handbook for College Teachers. 2nd 

ed. San Francisco, CA: Jossey-Bass Inc; 1993:116. 

2. Herman JL, Aschbacher PR, Winters L. A Practical 

Guide to Alternative Assessment. Alexandria, VA: 

Association for Supervision and Curriculum Development; 1992. 

3. Eldridge G. Does formative assessment aid learning?. 

Int Educat. 2008;22(3):28. 

4. Organisation for Economic Cooperation and Development Website. Formative assessment: improving 

learning in secondary classrooms. Policy Brief. 

November 2005:2. Available at: http://www. 

oecd.org/dataoecd/19/31/35661078.pdf. Accessed 

August 10, 2008. 

AUTHOR

Ms Hamilton is Chief, Health Education and Training 

Branch Curriculum Development Division, US Army 

Medical Department Center and School, Fort Sam 

Houston, Texas. 
 October – December 2010 65

INTRODUCTION

Academic attrition is a challenge in all demanding 

education programs, regardless of the field. According 

to the US Army Accessions Command in 2004, 

academically demanding advanced individual training 

programs are experiencing high rates of academic 

attrition where many students must repeat courses or 

recycle into training programs. The Health Care 

Specialist (military occupational specialty 68W), 

commonly referred to as a combat medic, has been 

selected as the focus of this study. However, it is only 

one of the military occupational specialties that are 

experiencing high attrition and recycling. 

As the changing nature of warfare yields an 

increasingly dispersed battlefield, the combat medic 

(hereinafter referred to as 68W) can be required to 

function while physically separated from a medical 

support unit. That is, they could be the only health care 

provider available during critical situations. The 68W 

will have to make independent decisions and be 

proficient in complex medical evaluation and 

intervention techniques. All graduates from 68W 

training are expected to be capable of performing 

emergency medical and lifesaving trauma care 

techniques, including critical skills in trauma 

assessment, advanced airway and shock management, 

intravenous therapy, and administration of specific, 

limited medications. These specialists may be required 

to provide independent care for casualties for as long 

as 72 hours. 

To prepare for these stringent requirements, students 

attend an intensive 16-week advanced individual 

training program at Fort Sam Houston, Texas, in the 

Department of Combat Medic Training facility. The 

first 6 weeks focus on Emergency Medical Technician 

(EMT) training, followed by 10 weeks of combat 

medic training that includes classroom lecture, 

interactive computer training, and patient simulation. 

Between 2007 and 2009, the 68W attrition rate peaked 

as high as 45%, but on average was 31% during that 

period (average pass rate of 69%) (D. Whittaker and 

D. P. Parsons, unpublished data, January 2010). 

Toward the end of 2009, the attrition rate significantly 

If You Want to Know Why Students Fail, 

 Just Ask Them 

Self and Peer Assessments of Factors Affecting Academic Performance 

Carita DeVilbiss, PhD 

Valerie J. Rice, PhD 

Linda Laws 

Petra Alfred 

ABSTRACT

One method to discover possible reasons why individuals fail academic training is to ask them. However, self-report 

information can be difficult to trust, especially if students are perceived as having something to lose if they are honest. 

The purpose of this study was to identify potential reasons students fail (or do well) in their training as reported by 4 

groups: those who failed the program (F) (n=28) and a peer (F-P) (n=28); and those who passed with a grade of B or 

above (P) (n=101) and one of their peers (P-P) (n=32). Statistical analysis included chi-square (χ

2

) test statistics and t

tests with a P<.05. Only findings considered “external” to students are included here, including class structure and 

schedule, instructors and teaching, support systems, and sleep. Few differences were found between peer reports and self 

reports by students who passed or students who failed their program. On the positive side, both P and F students 

indicated they could get individual attention even with large classes, having good support systems, and bonding well 

with their unit. On the negative side, P and F students reported difficulty staying focused during long class hours, and F 

students felt teaching methods made it difficult to succeed and struggled with the fast pace of the course (P<.05). More 

than half of all students reported sleeping between 5 and 6 hours per night, but those who failed more often reported 

sleeping only 3 to 4 hours per night (P<.05). These findings highlight areas of organizational strength, as well as areas of 

difficulty for students, which will permit administrators to set goals and perhaps tailor their programs to reduce attrition. 
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

dropped to approximately 25% after some major 

process changes in the 68W program (R. Brooks, 

written communication, March 17, 2010). 

During initial focus group interviews, the 68W 

company commanders, drill sergeants, and academic 

instructors revealed their perception that approximately 50% of academic recycles are due to reasons 

internal to the student, including: life skills, motivation, cognitive ability, stress/resiliency/coping, inability to deal with failure, tendency to distraction, and 

symptoms of learning disorders. The other 50% were 

considered external to the student and included issues 

such the program of instruction (curriculum), scheduling, selection and training of instructors, and teaching proficiency (V. J. Rice, Y. Woods, and M. Bundy, 

unpublished data, 2004). An open question is whether 

students who were successful in the course differ significantly in either their personal “internal” dimensions, 

or their perceptions of “external” issues from students 

who were not successful. This paper addresses 4 areas 

considered external to the student: class structure and 

schedule, instructors, support systems, and sleep. 

Figure 1 shows the line of research conducted by the 

Army Research Laboratory Field Element and 

highlights the portion described in this paper. 

Peer evaluations are often used to evaluate current 

performance and to predict future success among 

educators, law enforcement professionals, managers, 

medical professionals, and students. Some studies have 

shown that peer evaluations are better predictors of 

career success than evaluations by trainers or 

instructors.1

 Although seen less often in studies with 

medical students, peer evaluations have been used to: 

...measure medical student achievement and predict 

future performance in terms of clinical competence, 

interpersonal skills, and professional behavior.2

Peer reviews of both clinical skills and social skills are 

related to later professional success in medicine (eg, 

referrals, hospital privileges).3

 

Focus Groups

Studentsupervisors,

Faculty

Interviews

Commander, Sergeant Major

Student categories: ≥ B avg;

Failed; Battle Buddy

Literature Review

Associate Degree Program

Bachelors Program

Health Care Program

Student Surveys

Existing course completion

surveysfor both passing

and failing students

Pilot Project

Respiratory therapy

Examine existing data

Decision Point

Examine “Internal” vs “External” Information?

Survey Students

Categories: ≥ B avg, Failed,

Battle Buddy

Results:Descriptive and

nonparametric statistics

Survey Students

All Levels

Results: Regressionmodelsfor

pass/fail and grade point average

Further Study and/or Interventions

Survey Tool 

• Provides feedback &

mitigation strategies

to students on their

strengths/weaknesses

• Derived from research

results

Neuropsychological

Timing Training

• Targets ability to

focus/concentrate

• Targetstiming/

sequencing

Audio-Photic

Stimulation

• Targets adaptive stress

management/anxiety

• Evaluate mood, cogni‐

tive performance,

and grades

In-Progress

Test & Evaluation

Phase

In-Progress

Testing Complete

In Final Development

In-Progress

Testing Complete

Writing Final Report

Analysis

Design

Test & 

Evaluation

Redesign as Necessary

Decision Focus first 

on “internal”

Figure 1. The Army Research Laboratory Field Element Attrition Line of Study. The highlighted section represents 

the focus of this study 

If You Want to Know Why Students Fail, Just Ask Them 
 October – December 2010 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

Within the 68W Advanced Individual Training (AIT) 

program, students are assigned a battle buddy* for the 

duration of the training program. During the first 72 

hours following arrival at Fort Sam Houston, drill 

sergeants assign one student to another based on 

gender and basic combat training post. The program is 

consistent with the established US Army Training and 

Doctrine Command policies for enlisted training 

systems that includes guidance for a battle buddy 

system that pairs new recruits into teams to provide 

mutual support and assistance; teach teamwork; 

develop a sense of responsibility and accountability; 

and improve safety during training.4

 Hence the 

existing battle buddy system can be employed to 

compare peer evaluations with self evaluations for 

both passing and failing students. 

RESEARCH OBJECTIVE

The purpose of this study was to identify potential 

reasons students fail (or do well) during 68W AIT, as 

reported by students who failed the course, passed 

with a B or above, or were a friend or battle buddy of 

either the failing or passing cohort. 

METHOD

Participants 

All participants were volunteers who were currently 

enrolled in a 16-week 68W training program at Fort 

Sam Houston. Volunteers were recruited in 3 

categories: (a) students who had failed the course 

twice, (b) students who were very successful in the 

course (average grade of at least a B or above), and (c) 

the battle buddy or friend of the unsuccessful and 

successful students to provide a peer evaluation. A 

total of 189 students (28 failing; 101 passing; and 60 

peers) volunteered to participate. 

Instrument 

A single questionnaire was developed and then broken 

into two formats. The first format addressed the 

student (either passing or failing). The second format 

was used for the peer evaluations where the battle 

buddies were asked to complete the questionnaire as 

they felt was most appropriate for their buddy, ie, 

either a passing or failing student. Both formats asked 

students how they felt on a number of topic areas, 

including motivation, sleeping patterns, study habits, 

stress perception, coping strategies, learning 

disabilities, health status, leadership abilities, unit 

cohesion, morale, indices of family status, 

demographics, and other situational and organizational 

factors that may contribute to attrition. The 

questionnaire included a number of statements that the 

students were asked to rate on a 5-point Likert scale 

(strongly agree, agree, neutral, disagree, and strongly 

disagree). Students were also asked to participate in an 

interview, but interview results are not included here. 

This paper reports only responses for the external 

factors, eg, class structure, teaching, support systems, 

sleep, etc. 

Procedure 

Students were briefed on the protocol and the 

voluntary nature of the study. If interested, they were 

asked to sign a volunteer consent form, after which 

they completed the questionnaire and an interview. 

Each student volunteer, whether passing or failing, 

was also asked to consent to the researchers giving a 

questionnaire to their battle buddy, or another trusted 

friend. The battle buddy or friend was instructed to 

complete the questionnaire as it applied to the 

volunteer, not themselves. All research complied with 

the human use guidelines of Army Regulation 70-25.

5

 

Analysis 

The first comparison was to contrast responses from 

failing students and passing students to 5-point Likert 

scale questions. Responses for each question were 

compressed into 3 categories (strongly agree and 

agree, neutral, strongly disagree and disagree). The 

resulting 2 by 3 matrix was analyzed with a χ2

 test. To 

analyze the peer evaluations, the questionnaires (35 for 

passing students and 25 for failing students) were 

matched (eg, the study volunteer and his/her battle 

buddy) and the difference between them analyzed with 

a t test to determine whether the difference varied 

significantly from zero. The Statistical Package for 

Social Sciences (SPSS Inc, Chicago, Illinois) was used 

for all analyses with a significance level of P=.05. 

RESULTS 

The results summarized here are for the external 

factors included in the extensive questionnaire. 

Positive results (strengths of the program) are 

presented first, followed by areas identified as 

difficulties. 
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Participants 

A total of 189 students volunteered to participate; 

28 failing and 101 passing students and 60 battle 

buddies (25 peers for the failing students and 35 for 

the passing students). The students were 

predominately Caucasian (78%), with the 

remainder comprised of 8% African American, 8% 

Hispanic, and 6% identified as other. The gender 

composition across groups was comparable, with 

male students comprising approximately threequarters of the students (79%, 72%, and 82% for 

failing, passing, and battle buddy, respectively). 

However, the female students were younger than 

the male students (average age 22.4 years (female), 

24.7 years (male)). The failing students were 

younger than passing students and the peers 

(average age 23.0 years, 24.7 years, and 23.8 years, 

respectively). Half of the students (50.0% of failing 

and 52.0% of passing) reported that they had studied at 

the college level, ie, they checked either “some 

college” or “college diploma” levels. However, more 

passing students reported having college diplomas than 

did failing students (16.0% and 7.1%, respectively). 

Class Structure and Schedule 

When asked whether the class sizes were too large to 

allow for individual attention, only one in 8 students 

(13% passing and 14% failing) agreed with that 

statement. Two-thirds of the students (66% passing 

and 61% failing) did not feel that class size prevented 

individual attention. Students also agreed (50% 

passing and 43% failing) that it is difficult to stay 

focused because the class days are too long. The 

students differed, not surprising, when asked whether 

they struggled with the fast pace of the course. 

Significantly more failing than passing students 

(57% and 19%, respectively) agreed that they 

struggled with the fast pace of the course (χ2

=16.48, P<.01). Although not significant, more 

failing students tended to agreed that there was not 

enough tutoring or mentoring available during the 

class (29% failing vs 20% passing students). The 

consolidated results are presented in the Table. 

Sleep Patterns 

There were no positive self-reports in regard to 

sleep. More than half of the students (57% of 

failing students, 67% of passing students) reported 

getting 5 to 6 hours of sleep each night (Figure 2). 

A larger difference was seen when 43% of the failing 

students reported they were getting only 3 to 4 hours 

of sleep each night, as compared with 23% of the 

passing students. 

However, when asked whether they get enough sleep, 

33% of the failing students and 17% of the passing 

students report that they “seldom” or “never” get 

enough sleep at night. Consistently, more failing 

students than passing students (29% vs 16%) report 

that they “always” or “often” stay up and study after 

“lights out.” Fifty-eight failing students and 37% of 

passing students report that they “always” or “often” 

have trouble staying awake in class (Figure 3). Battle 

buddies of passing students believed the passing 

students had less trouble staying awake in class (that 

is, they felt the passing students were able to stay 

Percentage of students (categorized by those either passing or 

failing coursework) who agreed with statements describing 

possible negative circumstances attributable to class structure 

and schedule conditions. 

Statement Failing 

Students 

Passing 

Students 

Class size too large 14% 13% 

Class size did not prevent individual 

attention 61% 66% 

Difficult to stay focused with long 

class days 43% 50% 

Had to struggle with the fast pace* 57% 19% 

Tutoring and mentoring inadequate 29% 20% 

*Significant at P<.01 

Figure 2. Student responses to the statement “Most nights I get ___ 

hours of sleep.” 

If You Want to Know Why Students Fail, Just Ask Them 
 October – December 2010 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

awake more easily than the passing students 

themselves believed) (P<.05). 

Instructors (including Drill Sergeants) and 

Teaching 

Two out of 5 students (46% passing and 43% 

failing) reported that instructors were easily 

understood and taught at the appropriate level. 

When asked to comment on the teaching methods, 

significantly more failing students than passing 

students (54% and 25%, respectively) agreed that 

the teaching methods made it difficult to succeed. 

In the peer evaluations for this question, there was 

a significant difference in the response from the 

passing student and the response of the individual’s 

battle buddy. The peer evaluations under estimated 

the difficulty that the passing students were having 

with the teaching methods. In fact, significantly 

more passing than failing students (37% vs 

21%) reported that adjusting to new instructors 

frequently (as they shifted between subject 

areas) had a negative impact on grades (χ2

=7.24, P<.05). When asked whether the drill 

sergeants affect a student’s performance, more 

passing students than failing students (56% and 

43%, respectively) agreed that drill sergeants 

affect academic performance, but this trend was 

not statistically significant (Figure 4). 

Support Systems: Unit 

There were no differences between the 

responses from the failing and passing students 

when asked whether they had bonded with their 

unit. More than half of the students (57% 

passing, 54% failing) reported that they had 

bonded well (Figure 5). More than half of the 

students (56% passing, 57% failing) reported 

that they felt their unit was “always” or “often” 

supportive of them. However, of note, a number 

of the students (25% failing and 14% passing) 

responded “N/A” to this question without 

further explanation. 

Support Systems: Family & Friends 

More than two-thirds of the students (68% 

passing, 71% failing) reported they had other 

people besides their battle buddy that they could 

turn to for support. Approximately 8 of 10 

students (87% passing, 79% failing) reported 

their family and friends were supportive and 

Figure 3. Student responses to the statement “I have trouble staying 

awake in class.” 

Figure 5. Student responses to the statement “My unit is supportive 

of me.” 

Figure 4. Student responses to the statement “The drill sergeants 

affect my performance.” Responses 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

were not pressuring them to find a way out of the 

course and out of the Army. However, 31% of 

passing students, compared with 11% of those 

failing, reported the wishes of their family affected 

their academic performance. 

Support Systems: Battle Buddy 

In addition to reporting support from their unit and 

the family and friends, the majority of the students 

report a positive relationship with their battle 

buddy. Three-fourths of the students (71% 

passing, 79% failing students) reported that felt 

they could approach their battle buddy to talk 

about personal matters or problems (Figure 6). 

More than 80% of all students (82% passing, 89% 

failing) agreed their battle buddy provides help 

and is supportive of them. Two-thirds of students 

(60% passing, 68% failing) reported they 

perceived they had a “close” relationship with 

their battle buddy. 

COMMENT

These results of the students’ assessments of external 

factors provide insight into the some of the issues 

surrounding academic performance of students 

attending combat medic training. They offer support 

for some organizational programs, dispel some myths, 

and identify some issues. 

Ask Students 

First, the results suggest that students are truthful in 

reporting their impressions. The assumption was that 

students who failed the program and will be assigned 

to attend alternate training in a different, nonmedical 

military occupational specialty might have something 

to lose (reputation, might receive less than fair 

treatment in regard to their new assignment) and 

therefore might be less truthful on a questionnaire. 

Their battle buddy would not have anything to lose 

and therefore might be expected to be more forthright 

with their responses. However, no differences were 

seen between failing student reports and the reports 

from their battle buddies. In fact, the peer evaluations 

did not differ significantly from the corresponding 

student responses except when battle buddies of 

passing students reported more positive responses than 

the individuals did themselves. For example, the battle 

buddies reported that passing students had less trouble 

staying awake in class than was reported by the 

passing students themselves. 

Class Size 

Second, class sizes have more than doubled since the 

onset of the war on terror from an average of 

approximately 200 to nearly 500. This data was 

collected approximately in the middle of that growth 

period, during which time the class sizes were 

approximately 350 per class. The growth in class size 

occurred without a commensurate increase in staff 

(instructors and supervisors). All are concerned about 

the affect this has on student learning and retention, as 

well as on burnout of instructors. Instructors have 

intensified their efforts to be available to students, set 

up study halls and review sessions, and deliver 

instruction in the best way possible. During late 2006 

and early 2007, students reported that they received 

individual attention in spite of the class size. However, 

a trend was noticed in the impressions of failing 

students that they did not receive the mentoring they 

needed. 

Teaching Methods 

Third, it is often stated anecdotally that the instruction 

in the 68W program is perhaps taught at too high a 

level. The findings that less than half of students 

reporting that instructors are easily understood and 

teaching at an appropriate level would appear to give 

credence to the anecdotal statements. In addition, 

teaching methods appear to be an issue for failing 

students. Given that the primary method of teaching is 

through lecture accompanied by PowerPoint slides and 

Figure 6. Student responses to the statement “I can approach my 

battle buddy to talk to him/her about personal matters and/or 

problems in my life .” Responses 

If You Want to Know Why Students Fail, Just Ask Them 
 October – December 2010 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

written outlines, this issue could easily be addressed to 

the benefit of the students. Combining information 

from this study with additional research results from 

this population could assist in guiding improvements 

in teaching and presentation techniques. For example, 

research with this population, and with operating room 

technicians, revealed visual learners performed better 

academically than auditory learners.6

 On the other 

hand, passing students felt adjusting to changing 

instructors was more of an issue than did failing 

students. It is not clear whether failing students did not 

see this as an issue, or were so focused on other issues 

of concern (such as the pace of the course) that 

adjusting to changing instructors was a lesser priority. 

Support Systems 

Fourth, support systems appear to be readily available 

to the majority of students, primarily through friends 

and relatives. Furthermore, the battle buddy system 

appears to be working despite the criticism that 

appointing a battle buddy will not guarantee friendship 

or support. All students reported feeling they could 

approach and talk with their battle buddies, and that 

battle buddies were supportive. This seems to occur 

even when the relationship is not described as close. 

Other information identified in this study is not new, 

but does substantiate items long thought to be issues. 

These issues include the long hours in the classroom 

(from 0900 until 1630) resulting in students having 

difficulty focusing on the subject matter, the fast pace 

of the course, and the perceived negative impact of 

drill instructors. Drill instructors are no longer used 

during 68W AIT, although supervising noncommissioned officers remain. 

Perhaps one of the most pertinent issues corroborated 

by these findings is the lack of sleep. Student grades 

have previously been associated with lack of sleep7

and abbreviated sleep times have been associated with 

classroom sleepiness and difficulties in concentration 

and focus.8

 Sleep is important for learning and 

consolidation of new memories,9

 which is the primary 

task for students attending AIT. While the 

recommended number of hours of sleep for young 

adults is approximately 8 to 9 hours per night, our 

students are getting 5 to 6 hours, and many failing 

students reported getting only 3 to 4 hours each night. 

It may be that the training program is effectively 

screening out students who require an average amount 

of sleep for their age. 

LIMITATIONS

The primary limitation to this study is the size of the 

population, especially the failing student population. 

Also, this is a unique population (students) who may 

not be representative of the general population. 

RECOMMENDATIONS

Use carefully constructed questionnaires and 

interviews to gather information on students and 

student perceptions of barriers to learning, as well 

as programs that assist learning. 

Reinvestigate the effect of class size on students, 

now that it has risen to approximately 450. 

Review the program of instruction, including 

individual lectures and presentations, for grade 

level. 

Review teaching methods for those considered 

most effective for this age and subject matter. 

Consider matching teaching methods with learning 

styles of students. 

Provide information on positive impact of the 

battle buddy system to incoming instructors and 

students. Continue this program. 

Investigate teaching methods. Give students 

periodic breaks in the type and style of teaching/

learning throughout the day. Continue to provide 

study guides, outlines and other assistance to help 

counter the fast pace of the course. Consider 

lengthening the course or having at-risk students 

attend an early preparatory program before the 

course. 

Consider methods to decrease the need for 

students to continually adjust to changing 

instructors, such as increasing the uniformity of 

presentations or assigning instructors to remain 

with a class throughout their program. 

Investigate methods to increase time available to 

students so they can effectively study and learn 

their materiel, as well as get the needed amount of 

sleep. Educate administrators, educators, and 

students on the need for sleep and how adequate 

sleep enhances learning and memory. 
72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

ACKNOWLEDGEMENTS

This study was conducted under an approved ARLHRED Human Use Protocol (ARL- 20098-05031) 

entitled: Personal Factors Related to Student Performance and Retention Among 68W Health Care Specialists at Fort Sam Houston, Texas: Self and “BattleBuddy” Reports on Factors Affecting Academic Performance. It was funded by the US Army Research Laboratory, Human Research and Engineering Directorate. 

REFERENCES

1. Hofstede G. Predicting managers' career success in an 

international setting: the validity of ratings by 

training staff versus training peers. Manag Int Rev. 

1994;34:63-70. 

2. McCormack WT, Steven CB, Small PA. Simplifying 

medical student summative peer evaluation of clinical 

competence. Paper presented at: Annual Meeting, 

American Association of Medical Colleges Southern 

Group on Educational Affairs; 2002; Charleston, 

South Carolina. 

3. Wigen K, Holen A, Ellingsen O. Predicting academic 

success by group behavior in PBL. Med Teach. 

2003;25(1):32-33. 

4. TRADOC Regulation 350-6: Enlisted Initial Entry 

Training (IET) Policies and Administration. Fort 

Monroe, VA: US Dept of the Army, US Army 

Training and Doctrine Command; May 8, 2007:34. 

Available at: http://www.tradoc.army.mil/tpubs/regs/

r350-6.pdf. Accessed September 3, 2010. 

5. Army Regulation 70-25: Use of Volunteers as 

Subjects of Research. Washington, DC: US Dept of 

the Army; January 25, 1990. 

6. Alfred P, Rice V, Boykin G, Laws L. Auditory 

discrimination and academic performance. Paper 

presented at: Proceedings of the Applied Human 

Factors and Ergonomics Conference, Miami, FL, July 

17-20, 2010. 

7. Kelly WE, Kelly KE, Clanton RC. The relationship 

between sleep length and grade-point average among 

college students. Coll Student J. 2001;35(1). 

Available at: http://findarticles.com/p/articles/

mi_m0FCR/is_1_35/ai_74221510/?tag=content;col1. 

Accessed September 3, 2010. 

8. Sadeh A, Gruber R, Raviv A. The effects of sleep 

restriction and extension on school-age children: 

what a difference an hour makes. Child Dev. 2003;74, 

2:444-455. 

9. Ellenbogen JM, Hulbert JC, Stickgold R, Dinges DF, 

Thompson-Schill SL. Interfering with theories of 

sleep and memory: sleep, declarative memory, and 

associative interference. Curr Biol. 2006;16(13):1290-

1294. 

AUTHORS

Dr DeVilbiss is the owner and president of Dilemma 

Doc, a statistics and human factors consulting company. 

Dr Rice is Chief, Army Medical Department Field 

Element, Army Research Laboratory, Fort Sam 

Houston, Texas. 

Ms Laws is the Director of Medical Surgical Nursing at 

Methodist Stone Oak Hospital, San Antonio, Texas. 

When this article was written, she was a consultant with 

BearingPoint, Inc. 

Ms Alfred is a research psychologist, Army Medical 

Department Field Element, Army Research Laboratory, 

Fort Sam Houston, Texas. 

Logo of the US Army Research Laboratory 

If You Want to Know Why Students Fail, Just Ask Them 
 October – December 2010 73

To formulate policy that achieves our strategic ends in 

Iraq, we require an approach that embraces a more 

thorough understanding of the Middle East. More 

specifically, this includes an understanding of the 

differences in history, culture, leadership as core 

constructs that affect successful policy-making in this 

environment.1

 Speaking primarily through a medical 

lens, this paper includes commentary and discussion 

regarding strategic healthcare policy formulation and 

application in the Iraqi context. The end state of 

achieving an improved understanding of Middle 

Eastern systems and viable policy formulation then 

equates to a more effective transition in Iraq. 

One key stabilization phase tenet in a theater of 

operations is reestablishment of essential services to 

support basic social structure needs (ie, specifically 

health care in this case).2

 This can ease the suffering 

caused by disruption to healthcare services from 

conflict and likewise help to strengthen the legitimacy 

of the presiding government (democratic or 

otherwise).3(pp4,10,36,56) The follow-on transition to local 

authorities via a functional health policy assists in the 

sustainment of this perception. However, effective 

transition requires a synchronized approach between 

the United States Government (USG) and the 

Government of Iraq (GOI) leadership. Establishment 

of a functional health policy through leadership and 

cultural appreciation can lead to a more synchronized 

transition and promote the operation of the Iraqi 

healthcare system—by the Iraqis.4

The following discussion relays some examples and 

suggestions on how to achieve a more coordinated, 

and synchronous strategic healthcare policy. The 

discussion involves a review of certain healthcare 

system history as well as the leadership attributes and 

cultural awareness variables involved. Additionally, 

recommendations are provided for negotiating 

healthcare design through leadership and cultural 

appreciation mechanisms in future contexts. These 

elements enhance USG effectiveness in addressing 

policy operations in stabilization and transitional phase 

contexts currently and in the future.3(ppv,viii) 

History. The first requirement in a review of the 

strengths and weaknesses of previous attempts at 

functional policy formulation is a thorough examination of history. Several examples can be gleaned in the 

case of Iraq through their pre-invasion management 

systems. The Ministry of Health (MOH) for example, 

operated under a severely restricted budget that did not 

allow for many types of care common to Western 

nations. Although there is a temptation to change this 

paradigm on the part of medical planners, one should 

ask whether or not a change is relevant and/or 

sustainable. If USG planners and policy-makers do not 

consider historical systems in this case, then we make 

the error of providing a service or infrastructure that 

they cannot, or will not, fully sustain. 5

 If they cannot 

sustain it, the population could well look at this as a 

failure of the present regime, thereby damaging 

credibility and legitimacy.6

One current historical element under review is the 

interpretation of women’s health in Middle Eastern 

culture. Attitudes toward female centric medical 

requirements are religious, political and health related 

issues. Often without a thorough understanding of all 

these elements in this context, policy-makers and 

operators on the ground (healthcare administrators and 

physicians primarily) can make erroneous assumptions 

resulting in embarrassment to authorities and wasted 

efforts. While working in the Health Attachés Office 

in Baghdad, I encountered one such example which 

evolved through a request of a representative in the 

Understanding the Leadership and Cultural 

 Dimensions of Strategic Healthcare 

 Policy-Making in Iraq 

LTC Thomas S. Bundt, MS, USA 

We can't solve problems by using the same kind of thinking we used when we created them. 

 Albert Einstein 
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

USG who asked for the status of abortion clinics to be 

constructed in Iraq. This is not an acceptable 

consideration of Middle Eastern cultures. By the 

nature of the office (US Department of State) however, 

we were asked to include this in discussions with the 

local medical authorities.7 For effective policy making 

in this context, the role of the Department of State is 

not to dictate the types of issues and topics that Iraqi 

medical leadership should address, but to see what the 

Iraqis want through their own involvement and 

recommendations. Had the leadership on the ground 

not argued against this incorporation, the results of this 

inclusion would have degraded the success of the 

health policy mission and, indirectly, our national 

policy objectives. To avoid these shortfalls, it is 

critical to develop training in policy development and 

leadership on the ground, prior to any deployment. 

Leadership Training. As one might expect, disadvantages from lack of training, experience, and political 

acumen from USG elements hampered initial efforts to 

synch overall strategic healthcare policy operations.8

One example of lack of leadership training from the 

health policy perspective was during the initial 

introduction of provincial reconstruction teams 

(PRTs). The teams were at the operational, and, in 

some cases, strategic effects level of policy daily and 

have the potential to strengthen relationships and more 

seamlessly transition responsibility to local authority. 

However, due to their lack of initial orientation and 

health training, they did not understand the MOH 

strategic plan, the cultural sensitivity for specific 

medical concerns, and the makeup of the overall Iraqi 

healthcare system. Many of the healthcare 

representatives on the teams were not administrators 

and had little knowledge of health policy formulation 

or negotiations. Therefore, training of these USG key 

positions was initiated in-country in order to use those 

positions as a more effective catalyst to the overall 

government approach in policy formulation.9

Improvements continued to develop over time which 

allowed leadership involved in negotiations to 

understand the plurality of paths available in 

healthcare policy in international contexts. 

However the lack of initial training led to early 

ineffective policy development as USG agencies and 

MOH officials left negotiations with different 

understandings of each other’s positions, and thereby 

executed different agendas. One example was a 

meeting which occurred in Baghdad in Spring 2007 

between the Ministry of Defense (MOD), MOH, MultiNational Security Transition Command-Iraq, and the 

Health Attaché elements regarding the modeling, 

standardization, and implementation of a training 

program for Iraqi clinical staff at our military facilities 

in country. Although initially agreed upon in full to 

begin immediately, participation was nonexistent in 

the first attempt. Findings revealed that the Iraqis 

assumed we were to meet several more times and 

agree several more times until the implementation 

occurred. Different cultural norms came into play in 

this scenario, and agencies created to provide 

“seamless” coordination lost the initiative in early 

policy negotiations. We need to note this for future 

contexts and work to incorporate the lessons into our 

leadership training programs. 

As an added challenge, the MOH leadership does not 

maintain positive relationships with several other 

ministries, and are often at odds with the separate 

religious affiliations. These subtleties are relevant if 

we expect them to sustain any training and resources 

provided as the challenges inherent in this leadership 

culture impede forward progression.10 Part of the 

rejuvenation of essential services in a country which 

has suffered from deteriorating infrastructure and 

conflict requires a concerted effort toward the analysis 

of healthcare systems and needs for capacity 

development. If they fail in this endeavor, they could 

miss opportunities for deliberate funding from outside 

agencies, including the USG, to achieve true 

sustainment and legitimacy. The rationale for this from 

the historical perspective is this element of secularism 

and politics. When forming policy with institutions of 

this type—the secular nature of the government and 

the underlying religious dichotomy between religious 

sects (ie, a multilateral dynasty between Shiite, Sunni, 

and Kurd)—leadership needs to consider these factors 

in promoting certain ministerial and governmental 

systems. 

As an example of this secular and political impact, 

when the budget was laid out for MOH as late as 2007, 

the minister’s cabinet did not include 3 provinces of 

the 18 provinces throughout Iraq.11(p424) The 3 

provinces happened to be in Kurdish dominated 

territory (what the Iraqis commonly referred to as 

Kurdistan). The Shiite dominated MOH felt that the 

Kurds were already adequately funded by other 

systems (means) outside of their purview and did not 

require this funding stream.12(p224) Additionally, the 

Understanding the Leadership and Cultural Dimensions of Strategic Healthcare Policy Making in Iraq 
 October – December 2010 75

THE ARMY MEDICAL DEPARTMENT JOURNAL

other Arab sects also saw the Kurds as more interested 

in pursuing their own sovereignty and therefore did not 

wish to include them in “Iraq’s” foreign aid budget. 

USG planners were frustrated by this and tried to 

rectify the situation. Unfortunately, the USG 

leadership did not understand the Shiite and Sunni 

impression of the Kurds and failed to take that factor 

into account in their original negotiations with MOH 

on the equitable distribution of foreign aid funds. The 

MOH contended that they should alone manage the 

foreign aid fund distribution without any external 

interference. Any interjection into this process by the 

USG was then viewed as paternalistic and 

delegitimizing to their own systems of governance.11

(p426) In this case, ministerial capacity development for 

leadership and administrative elements was introduced 

but still reduced to one essential element of culture 

that is best characterized by Gray: “Iraq can be 

transformed only within its own complex cultural 

parameters, not in defiance of them, and then only by 

Iraqis.”13

Culture. The leadership element also correlates directly 

to these religious and cultural considerations. 

Reducing barriers to success by gaining a better 

understanding of the cultural differences in strategic 

healthcare planning is paramount. In this context, the 

Iraqis define healthcare (and democracy) differently 

than Western counterparts.14 As such, some aspects of 

Western-based systems had to be excluded in planning 

for Iraqi health policy. For example, certain managed 

care imperatives, insurance systems, and geriatric longterm care facilities, though all tenets of Western 

systems, are either vastly different or altogether 

nonexistent in Iraq. Even the conduct of negotiations 

with the Iraqis and the relevant parties should be 

exercised in tandem with their norms.11(p424) As Gray 

states, “such is the enduring significance of culture.”13

To appropriately educate our medical practitioners and 

policy-makers through orientations, we must remove 

our Western lens and evaluate their system through 

Iraqi lenses.15 Lastly, not only must we take local 

leadership and culture into consideration in 

synchronizing health policy planning, we also should 

review our own organizational culture to promote a 

singular strategic medical vision within the USG.15

Recommendation. Understanding the Iraqi health care 

environment requires particular attention to the 

leadership and cultural dimensions of their society. 

Many who deploy to Iraq, including me, had 

preconceived notions of healthcare delivery and other 

biases predicated on Western culture. Particular to 

healthcare, perhaps the simplest instructions should 

read, “please check your Western views at the door.”16

The essential element here is an appreciation of the 

subtle differences in healthcare on the international 

stage. USG leadership should accept Iraq’s definition 

and structure of a healthcare system.17 This includes an 

understanding of a hybrid socialized healthcare system 

(public in the day and private in the afternoon), no 

taxation system to pay for access to care, and funding 

through oil revenues, just to name a few.12(pp221-273) As 

such, we should enjoin host nation medical authorities 

into discussions on the intricacies of their system first, 

and then determine how best to address their shortfalls 

and thereby enable their successful approaches. 

Other themes emerge in the form of leadership and 

cultural strategies to enable future synchronization of 

healthcare policy. One element is an assessment of our 

current leadership competency in the healthcare 

context.18 This will ensure the most capable and 

culturally versed leadership is selected for healthcare 

policy-making positions in these environments. 

Another component is forming a strategic health 

policy in international contexts through Middle 

Eastern models, to include our own leadership training 

and cultural adaptation. 

Preparing now facilitates discussion and further 

introspection into these significant components of 

international health policy making.19 The future 

synchronization of health policies will then more 

effectively address the shortfalls of a disrupted 

healthcare system and could likely lead to a smoother 

transition to the Iraqis, as well as promote greater longterm sustainability.20 A primary course of action for a 

predeployment phase course would be the execution of 

this training and open-forum discussions with previous 

policy-makers and other Foreign Service assets in the 

leadership and cultural needs of these key postings.21

Agencies in Iraq, as well as those providing support 

from stateside and other international contributions, 

can then accomplish their mission with a more refined 

roadmap via improved leadership training and cultural 

appreciation within our own ranks.22

Although this article addresses only a few select 

segments of the training considerations for leadership 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

and cultural awareness, there are dozens of 

subcomponent categories that can only improve upon 

this intent. Future courses could easily incorporate the 

differing subjects into a readymade template to 

provide to participants for use in other theaters of 

current operations. While we continue similar missions 

in Afghanistan, we should take heed of these 

recommendations so as to avoid any parallel pitfalls or 

shortcomings for future operations. In his article on 

counterinsurgency, General Petraeus aptly quotes 

Lawrence: 

...try not to do too much with your own hands.... Better 

that the Arabs do it tolerably than that you do it 

perfectly.23

REFERENCES

1. Tyrrell MD. What To Know Before You Go: 10 

Questions to Ask Before, and During, a Mission. In: 

Kaufmann G, ed. Stability Operations and StateBuilding: Continuities and Contingencies. Carlisle 

Barracks, PA: Strategic Studies Institute, US Army 

War College; October 2008:129-130. Available at: 

http://www.strategicstudiesinstitute.army.mil/

pdffiles/pub879.pdf. Accessed September 13, 2010. 

2. Field Manual 3-07: Stability Operations.

Washington, DC: US Dept of the Army; October 6, 

2008:chap 3. 

3. Metz S. Learning from Iraq: Counterinsurgency in 

American Strategy. Carlisle Barracks, PA: Strategic 

Studies Institute, US Army War College; January 

2007:4,10,36,56. Available at: http://www. 

strategicstudiesinstitute.army.mil/pdffiles/

pub752.pdf. Accessed September 13, 2010. 

4. Force Health Protection and Readiness, Symposium 

Conveys Hope for Future of Health Services in Iraq. 

Available at: http://deploymentlink.osd.mil/new.jsp?

newsID=37. Accessed Oct 13, 2008. 

5. Health Capabilities in Stability Operations White 

Paper. Norfolk, VA: US Joint Forces Command; 

June 2006:3. 

6. Diamond L. Building democracy after conflict: lesson 

from Iraq. J Democr. 2005;16(1):9-23. 

7. Fallows J. Blind into Baghdad. Atl Mon. January/

February 2004:56. 

8. Shadid A. This is Baghdad: what could be worse?. 

Washington Post. October 29, 2006:B1. 

9. Major DW. Regional Initiatives: Eliminating the 

Causes of Terrorism [strategy research project]. 

Carlisle Barracks, PA: US Army War College; March 

15, 2008:4. Available at: http://www.dtic.mil/cgi-bin/

g e t t r d o c ? A D = A D A 4 8 0 1 6 2 & L o c a t i o n = U 2 

&doc=GetTRDoc.pdf. Accessed September 14, 2010. 

10. Hawail MJ. Guideline for Concise outlook for Health 

Approaches in Iraq: In Response to the Sixtieth Word 

[sic] Health Assembly Meeting. Paper presented at 

the 60th World Health Assembly; May 2007; 

Baghdad, Iraq. 

11. Lewis RD. When Cultures Collide: Leading Across 

Cultures. 3rd ed. Boston, MA: Nicholas Brealey 

International; 2006:424. 

12. Jones SG, Hilborne LH, Anthony CR, et al. Securing 

Health: Lessons from Nation-Building Missions. 

Santa Monica, CA: The RAND Corporation Center 

for Domestic and International Health Security; 2006. 

Available at: http://www.rand.org/pubs/

monographs/2006/RAND_MG321.pdf. Accessed 

September 14, 2010. 

13. Gray CS. After Iraq: The Search for a Sustainable 

National Security Strategy. Carlisle Barracks, PA: 

Strategic Studies Institute, US Army War College; 

January 2009:4. Available at: http://

www.strategicstudiesinstitute.army.mil/pdffiles/

PUB902.pdf. Accessed September 14, 2010. 

14. Bundt TS. Healthcare Policy Operations—A 

Formulary for Effective Transition in Iraq, Policy 

Paper for Health Attaché Operations. June 2007:4-5. 

15. Wagner M. The challenges of Iraq: putting US Army 

stability operations doctrine to the test. Small Wars 

and Insurgencies. 2008;19(4):484-509. 

16. Gerras SJ. Thinking Critically About Critical 

Thinking: A Fundamental Guide for Strategic 

Leaders. Carlisle Barracks, PA: US Army War 

College; June 2006. Available at: http://www.au. 

a f . m i l / a u / a w c / a w c g a t e / a r m y - u s a w c / c r i t _ 

thkg_gerras.pdf. Accessed September 14, 2010. 

17. Coffey R. Revisiting CORDS: the need for unity of 

effort to secure victory in Iraq. Mil Rev. 2006;86

(2):24-34. Available at: http://usacac.army.mil/

CAC2/MilitaryReview/Archives/English/

MilitaryReview_2006CR1031_art014.pdf. Accessed 

September 14, 2010. 

18. Field Manual 6-22: Army Leadership: Confident, 

Competent, and Agile. Washington, DC: US Dept of 

the Army; October 12, 2006:27. 

Understanding the Leadership and Cultural Dimensions of Strategic Healthcare Policy Making in Iraq 
 October – December 2010 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

19. Flavin W. Planning for conflict termination and postconflict success. Parameters. 2003;33(3):95-112. 

Available at: http://www.carlisle.army.mil/usawc/

parameters/Articles/03autumn/flavin.pdf. Accessed 

September 14, 2010. 

20. Natsios AS. The Nine Principles of Reconstruction 

and Development, Parameters 2005;35(3):4-20. 

21. Mori L, Meddings D, Bettcher D. Health, human 

security and the peace-building process. In: Conflict 

and Human Security: A Search for New Approaches 

of Peace-Building. Hiroshima, Japan: Institute for 

Peace Science Hiroshima University; 2004:176-196. 

English Research Report Series, No. 19. Available at: 

http://home.hiroshima-u.ac.jp/heiwa/Pub/E19/

Chap8.pdf. 

22. Metz S. Rethinking insurgency, (Carlisle, PA: U.S. 

Army War College, Strategic Studies Institute, June 

2007), 57. Carlisle Barracks, PA: Strategic Studies 

Institute, US Army War College; January 2007. 

Available at: http://www.strategicstudiesinstitute.ar 

myarmy.mil/pdffiles/pub790.pdf. Accessed September 14, 2010. 

23. Lawrence TE. Twenty-seven Articles. Arab Bulletin. 

August 20, 1917. Cited by: Petraeus DH. Learning 

counterinsurgency: observations from soldiering in 

Iraq, Mil Rev. 2006;86(1):2-12. Available at: http://

usacac.army.mil/CAC2/MilitaryReview/Archives/

English/MilitaryReview_2006CR1031_art010.pdf. 

Accessed September 14, 2010.

AUTHOR

LTC Bundt is Commander, 187th Medical Battalion, 32nd Medical Brigade, Army Medical Department Center and 

School, Fort Sam Houston, Texas. 

Articles  published  in  the  Army Medical Department Journal  are  indexed  in 

MEDLINE,  the  National  Library  of  Medicine’s  bibliographic  database  of  life 

sciences and biomedical information. Inclusion in the MEDLINE database ensures 

that  citations  to AMEDD Journal  content will  be identified  to  researchers  during 

searches for relevant information using any of several bibliographic search tools, 

including PubMed. 
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Although the Army’s School for Advanced Military 

Studies, better known as SAMS, has existed for 26 years, 

many within the Army Medical Department (AMEDD) 

do not have a full understanding of the school’s 

curriculum, nor what the Army expects of its graduates. 

More important, the lack of knowledge about the school 

and its graduates are defining any requirements that the 

AMEDD has for officers trained at the school. This is 

evidenced by both the lack of applicants and the lack of 

emphasis by AMEDD senior leaders for the department 

to build and maintain a bench of SAMS graduates. The 

situation became apparent several years ago in 

AMEDD’s response to the Army’s request for SAMS 

planners to develop the Warrior Transition Unit concept. 

When the requirement for a SAMS planner was 

announced, there were only 7 AMEDD officers who had 

graduated from SAMS, only one of which was available 

in the national capital region. As a result, a team of nonAMEDD SAMS graduates and students from Fort 

Leavenworth were sent to Walter Reed to begin the 

planning process. This article describes the school, the 

expectations of its graduates, and explains the importance 

of SAMS graduates to the Army Medical Department. 

SAMS is one of the professional military schools within 

the Command and General Staff College at Fort Leavenworth, Kansas. The mission of the school is to: 

...educate the future leaders of our Armed Forces, our 

Allies, and the Interagency at the graduate level to be 

agile and adaptive leaders who think critically at the 

strategic and operational levels to solve complex 

ambiguous problems.1

The school accomplishes this mission through 2 

programs: the Advanced Military Studies Program 

(AMSP) and the Advanced Operational Arts Fellowship 

Study Program (AOASF). 

The AMSP is typically attended as a follow-on school by 

majors upon completion of the Intermediate Level 

Education/Advance Operational Warfighter Course (ILE/

AOWC) at Fort Leavenworth. However, in 2007 this 

changed so that majors and junior lieutenant colonels 

who have completed ILE/AOWC may be accepted 

directly into the program from the field. Additionally, 

there has been a renewed emphasis on obtaining AMSP 

students from other US government agencies. Within the 

AMEDD, only Medical Service Corps officers with Area 

of Concentration (AOC) designations of either 70H 

(Health Services Plans, Operations, Intelligence, 

Security, Training Officer) or 70K (Health Services 

Materiel Officer) have been allowed to attend the AMSP. 

Whether officers with other AMEDD AOCs should 

attend AMSP should be an important topic of further 

discussion, but is not addressed within the scope and 

purpose of this paper. 

The AOASF program is a 2-year fellowship program 

attended by promotable lieutenant colonels and colonels 

as a senior service college program. The first year of the 

program is academically focused at the strategic level, 

transitioning to the second year as a seminar leader for 

the AMSP. 

The AMSP is the hallmark of the school and is what most 

officers understand to be SAMS. What some have 

perceived the AMSP to be—and what it definitely is 

not—is a year mastering the military decision-making 

process (MDMP). For those unfamiliar with MDMP, it is 

the Army’s planning process used primarily at the tactical 

level. In reality, the AMSP focuses on the development 

of officers to operate as staff officers and commanders at 

the operational level through the execution of battle 

command.* SAMS provides selected officers a 

comprehensive and rigorous 12-month curriculum on 

how to understand complex, adaptive problems at the 

operational level of war so that possible solutions, 

campaigns, or strategies can be generated. The AMSP 

accomplishes this by exposing its students to a wide 

variety of western and eastern lexicon, philosophy, 

The School for Advanced Military Studies: 

 An Untapped Resource for the 

 Army Medical Department 

MAJ Jon E. Baker, MS, USA 

MAJ Jason R. Sepanic, MS, USA 

* Battle Command is defined as the art and science of understanding, visualizing, describing, directing, leading, and assessing 

forces to impose the commander’s will on a hostile thinking and adaptive enemy. Battle Command applies leadership to translate 

decisions into actions – by synchronizing forces and warfighting functions in time, space, and purpose– to accomplish missions.2
 October – December 2010 79

military theory, joint and service military doctrine, and 

cultural studies. Finally, the SAMS curriculum 

emphasizes the necessity to synchronize the operational 

plan, both within interagency functions and across the 

elements of national power (diplomatic, information, 

military, and economic). The course then teaches 

students how to synthesize these various, and often 

divergent, ideas into a coherent executable combined, 

joint, and/or service specific operational plan to address 

identified problems at the operational level. These ideas 

are exemplified in the school’s stated outcomes of the 

program1

: 

 Innovative leaders, willing to accept risk and to 

experiment 

 Adaptive leaders who excel at the art of command 

 Leaders who anticipate the future operational 

environment 

 Leaders who apply critical and creative thinking 

skills in order to solve complex problems 

 Leaders who demonstrate mastery of operational 

art and doctrine 

 Leaders who synthesize the elements of US 

national power in joint, interagency, 

intergovernmental, and multinational operations 

 Leaders who demonstrate effective 

communications 

However, these outcomes are not realized through one 

year of academics alone. The follow-on utilization 

assignment, referred to as a “Tier One” assignment, is 

considered the final phase of an officer’s AMSP 

training .

3

 During the utilization assignment, an AMSP 

graduate generally serves as a planner within a corps or 

division general staff. As a result, the Army’s senior 

leaders expect officers that “are capable of serving as 

general staff officers dealing with complex adaptive 

military problems.”4

Due to the fact that the AMEDD has officers serving on 

general staffs at the operational level, and that the AMSP 

is the Army’s recognized operational planning program, 

the AMEDD has a need for AMSP trained officers. As 

mentioned in the introduction of this article, the AMEDD 

encounters complex problems. These problems often 

require critical thinking and problem solving skills that 

are not adequately cultivated within the established 

Officer Professional Military Development (OPMD) 

system. The AMSP builds on the established OPMD 

system by introducing new and cutting-edge ideas and 

theory which are not traditionally emphasized or taught. 

This statement is not meant to disparage the experience 

or professional training provided to AMEDD officers, but 

there is a void in how well AMEDD officers are 

developed to work at the operational level. This void is 

made apparent in the notes from the Combined Forces 

Land Component Command Surgeon’s Medical 

Conference in 2004,5

 and a command interview with the 

Multi-National Corps-Iraq Surgeon in 2008.6

 These notes 

reveal an assessment by AMEDD key leaders that 

AMEDD personnel are unprepared for duties at the 

operational and strategic levels. The comments noted in 

particular the inability of personnel to speak in common 

military terms rather than medical terms, as well as the 

difficulty experienced in getting personnel to the right 

training before filling positions at these levels. 

It is our opinion that the AMSP is an appropriate bridge 

to help fill the previously described void caused by 

AMEDD officers learning to work on the job at the 

operational level rather than arriving with the proper 

education and development experience. The AMSP not 

only gives AMEDD officers at the operational and 

strategic levels the tools to understand and craft possible 

solutions, it does so within a joint and combined setting. 

Thus, the AMSP-trained AMEDD officer gains 

knowledge and experience from foreign and sister service 

officers who attend the AMSP. The program provides the 

AMEDD student with the opportunity to understand how 

his or her medical knowledge fits within the overall 

operational or strategic plans. It also allows AMEDD 

AMSP graduates to gain insight into how they will go 

about achieving an understanding of the complex issues 

faced by operational and strategic level commanders. By 

sharing in the common AMSP experience, the AMEDD 

AMSP graduate develops a understanding with other 

operational level planners where a unique lexicon and 

procedures are used. Additionally, AMSP graduates 

establish a network of operational and strategic planners 

that facilitates coordination and synchronization across 

command and functional boundaries. 

Unfortunately, the traditional AMEDD OPMD system 

does not provide officers an equivalent forum in which to 

garner the previously mentioned skills or knowledge. 

Past experience has shown that on-the-job training or 

deployment experience also provides limited 

opportunities to gain such skills. Most officers would 

argue that the Intermediate Level Education (ILE) 

program taught at the Fort Leavenworth Command and 

General Staff College (CGSC), or ILE short-course 

programs taught at the various installations around the 

United States, are meant to provide this education for all 

field grade officers. The CGSC ILE is valuable for 

exposing field grade officers to the basics of the joint 

operation planning process and the military decision-
80 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The School for Advanced Military Studies: 

An Untapped Resource for the Army Medical Department 

making process, which in turn better prepares them for 

serving as a brigade or division staff officer. However, 

that school does not, nor was it ever meant to, teach the 

abstract skills necessary for understanding the complex 

issues found in the contemporary operating environment 

or future operating environment. SAMS is the premier 

forum where an AMEDD field grade officer can gain 

these skills and education. 

Some would even argue that the few AMEDD SAMStrained officers should serve in an AMEDD billet directly 

upon graduation in order to harness their skills for the 

AMEDD. This would be a mistake. As mentioned earlier, 

half of the value of the AMSP is the refinement of the 

academic experience during the follow-on utilization tour 

within a division or corps headquarters. The experience 

gained by implementing what the AMSP has taught 

within an operational division or corps headquarters 

would be essential to any AMEDD AMSP graduate’s 

development. The corporate AMEDD body reaps the 

final benefits by having a well-rounded officer who not 

only has a full understanding of the operational level of 

war, but is a competent practitioner of the Army’s 

operational planning processes. This argument was 

reinforced in an email message (January 7, 2009) to the 

authors from LTC Raymond “Scott” Dingle, the first 

AMEDD AMSP graduate, who performed his utilization 

tour as a 18th Airborne Corps G-3 Planner, responsible 

for provisional reconstruction teams in Afghanistan: 

During my two and a half years here on DA Staff 

(OTSG OPS)a

...I have been pulled to be lead planner 

on various projects for SECARMY,b

 TSG,c CSA/

VCSA,d and the SECDEFe

...they were major medical 

initiatives (Unified Medical Command, Army Medical 

Action Plan (WTUf

), JTF CapMED,g DCOE for TBI 

and PH,h

 and the MEDCOMi Reorganization) that best 

utilized...the SAMS experience and credentials. 

As the Army, including the AMEDD, evolves to meet the 

diverse and complex problems of the contemporary 

operating environments and future operating 

environments, it is imperative that the AMEDD seek to 

capitalize on what the AMSP can offer to the current and 

future development of its officers. This can only be 

achieved by encouraging AMEDD officers who have 

completed ILE, or are currently enrolled in ILE, to apply 

for the AMSP. The AMEDD can facilitate this by 

emphasizing the AMSP to its officers who will be 

serving in planning positions. This cannot be done solely 

by the outreach of AMEDD AMSP graduates to the field. 

There must be emphasis placed on the program by senior 

leaders within the AMEDD. If the AMEDD does not 

make the effort to educate its officers on the benefits of 

the AMSP, the AMEDD will continue to lag the rest of 

the Army by not having a core of officers that are skilled 

in the application of the operational arts. 

REFERENCES

1. US Army Command and General Staff College, 

School of Advanced Military Studies resource page. 

US Army Combined Arms Center Web site. Available at: http://usacac.army.mil/cac2/cgsc/sams/

about.asp. Accessed May 1, 2009. 

2. Field Manual 3-0: Operations. Washington, DC: US 

Dept of the Army; February 2008. 

3. Army Regulation 614-100: Officer Assignment and 

Assignment Policies, Details, and Transfers. Washington, DC: US Dept of the Army; January 10, 2006. 

4. Goble JJ. Wants and Needs: SAMS' Relationship with 

the Army [monograph]. Fort Leavenworth, Kansas: 

US Army Command and General Staff College, 

School of Advanced Military Studies; 2008. 

5. Initial Impressions Report, Operations Iraqi and 

Enduring Freedom, CFLCC Surgeon’s Medical 

Conference. US Army Center for Army Lessons 

Learned Web site. Report No. 05-4; December 2004. 

Available at https://call2.army.mil/docs/doc71/05-

4.pdf. Accessed August 30, 2010. 

6. Loughlin J. Interview, COL P. Joseph Caravahlho, 

MNF-I/MNC-I Surgeon. May 6, 2008. US Army 

Center for Lessons Learned Web site. Available at: 

https://call2.army.mil/toc.aspx?document=4965. 

Accessed August 30, 2010. 

AUTHORS

MAJ Baker is the Operations Officer, 1st Medical 

Brigade, Fort Hood, Texas. 

MAJ Sepanic is the Medical Plans and Logistics 

Officer, US Army Africa, Vicenza, Italy. 

At the time this article was written, MAJ Baker and 

MAJ Sepanic were students in the Advanced Military 

Studies Program at the School of Advanced Military 

Studies, Fort Leavenworth, Kansas. 

a. Department of the Army Staff (Office of the Surgeon 

General – Operations) 

b. Secretary of the Army 

c. The Surgeon General 

d. Chief of Staff/Vice Chief of Staff of the Army 

e. Secretary of Defense 

f. Warrior Transition Unit 

g. Joint Task Force – National Capital Region Medical 

h. Defense Center of Excellence for Psychological Health 

and Traumatic Brain Injury 
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GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Manuscripts  should  be  submitted  in  digital  format,  preferably  an  MS  Word  document,  either  as  an  email  attachment  (with 

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2. The  American Medical Association Manual of Style governs  formatting  in  the  preparation  of  text  and  references.  All  articles  should 

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3.  A complete list of references cited in  the article must be provided with  the manuscript. The  following is a synopsis of  the American 

Medical Association reference format: 

 Reference citations  of published articles must include  the authors’ surnames and initials, article  title, publication  title,  year  of 

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