United States General Accounting Office

GAO Report to the Congressional Requesters

September 1995 MILITARY

PHYSICIANS

DOD’s Medical School

and Scholarship

Program

GAO/HEHS-95-244

GAO United States

General Accounting Office

Washington, D.C. 20548

Health, Education, and

Human Services Division

B-265758 

September 29, 1995

The Honorable Strom Thurmond

Chairman

The Honorable Sam Nunn

Ranking Minority Member

Committee on Armed Services

United States Senate

The Honorable Floyd D. Spence

Chairman

The Honorable Ronald V. Dellums

Ranking Minority Member

Committee on National Security

House of Representatives

Enclosed is our report, Military Physicians: DOD’s Medical School and Scholarship Program

(GAO/HEHS-95-244), which was mandated by the National Defense Authorization Act for Fiscal Year

1995. This report provides information on the Department of Defense’s Uniformed Services

University of the Health Sciences and the Health Profession Scholarship Program. Among other

things, the report addresses the costs of obtaining physicians through each of these sources and

how physicians obtained through each are prepared to meet the special needs of military

medicine.

We are sending copies of this report to the Chairman and Ranking Minority Member of the

Senate Committee on Armed Services’ Subcommittee on Personnel, Senator Russell D.

Feingold, other appropriate congressional committees, the Secretary of Defense, and other

interested parties. We also will make copies available to others on request. If you have any

questions about this report, please call George F. Poindexter, Assistant Director, at

(202) 512-7213. Other major contributors to this report are Lawrence L. Moore, William A.

Schechterly, Michael C. Williams, and Mona M. Zadjura.

David P. Baine

Director, Health Care Delivery

 and Quality Issues
Executive Summary

Purpose In the 2 decades since its legislative establishment, proposals have been

made to close the Uniformed Services University of the Health Sciences,

the Department of Defense’s (DOD) medical school in Bethesda, Maryland.

Those who propose closing the University assert that DOD’s need for

physicians can be met at a lower cost using physicians educated at civilian

medical schools. Those who propose retaining the University assert that it

is needed to provide a stable cadre of physicians trained to meet the

unique demands of military medicine.

Following proposals in 1994 to close the University, the Congress

mandated that GAO review issues related to the University and the other

means through which DOD obtains physicians.1

 Among other things, GAO

was directed to examine (1) the cost of obtaining military physicians from

all sources, (2) the quality of the medical education provided at the

University, (3) how physicians are trained to meet the needs of military

medicine, and (4) retention rate patterns among the accession programs.

GAO reviewed prior studies; analyzed data from DOD, the services, and the

University; and held discussions with military and civilian officials to

respond to these issues.

Background In 1972, Public Law 92-426 established two complementary physician

accession sources: the Health Profession Scholarship Program and the

University. Under the scholarship program, DOD pays tuition and fees, plus

a monthly stipend for students enrolled in civilian medical schools. In

return, the students incur an obligation to serve a year of active duty

service for each year of benefits received, with a 2-year minimum

obligation. Upon graduation, most scholarship program participants

(regular program participants) go on active duty and begin graduate

medical education (GME) in military hospitals. Other scholarship program

participants (deferred program participants) are granted deferments while

they pursue civilian GME. In 1994, 987 scholarship program participants

graduated from medical school.

Students at the University enter active military service as medical

students, receive the pay and benefits of an officer at the O-1 level, and

incur a 7-year service obligation. In 1994, 155 medical students graduated

from the University.

1

The National Defense Authorization Act for Fiscal Year 1995, (P.L. No. 103-337, §922(c)(1)(4)).

Page 2 GAO/HEHS-95-244 Military Physicians
Executive Summary

The primary responsibilities of military physicians (regardless of accession

source) are to provide medical support to the forces who carry out DOD’s

operational missions and other active duty personnel. They also provide

health care to nonactive duty beneficiaries. To prepare physicians for the

practice of military medicine, the University augments the traditional

4-year medical school education with readiness training; scholarship

program graduates attend training courses offered by the services.

In 1990, the DOD Inspector General reported on the adequacy of the

University’s management oversight and control of its diverse operations.

The Inspector General’s report recommended corrective actions in six

categories of those operations and closed the inspection in October 1994

based on the University’s corrective actions. Appendix IV contains a

detailed discussion of the Inspector General’s findings and the University’s

actions.

Results in Brief Determining the most cost effective way to educate and retain military

physicians depends on the cost elements included and the unit of analysis

used to measure cost. By most measures, the University is a more costly

way to educate and retain military physicians. For example, on a per

graduate basis, GAO’s analysis shows that the University is the most

expensive source for educating and retaining military physicians when

considering DOD and total federal costs. When costs are distributed over

the expected years of military physicians’ service, the University remains

more costly when DOD costs are considered. However, when all federal

costs are considered, the University is nearly equal to the cost of the

regular scholarship program and lower than the cost of the deferred

scholarship program. This difference occurs because University graduates

are expected to have much longer military careers and the University

receives much less non-DOD federal support than civilian medical schools.

GAO’s analysis shows that the University provides a medical education that

compares well with that of other U.S. medical schools. Traditional

measures of quality place the University within the midrange of medical

schools nationwide and its graduates at or above other military physicians.

In addition, to help meet standards required for accreditation as an

academic institution, the University provides education and training for

other health care and related professions and engages in research,

consultation, and archival activities. These activities, which do not directly

contribute to the education of military physicians, involve University

faculty and staff. University officials believe that DOD would continue to

Page 3 GAO/HEHS-95-244 Military Physicians
Executive Summary

conduct these activities even if the University is closed and estimated their

value to be about $18.6 million—a figure which GAO did not validate.

University graduates begin their military medical careers with more

readiness training than their peers, but the significance of the additional

training is unclear. The commanders of military medical units that GAO

contacted believe that University graduates are, at least initially, better

prepared than other physicians to address the special needs of military

medicine. However, due to the absence of objective measures, no

conclusive evidence exists that University graduates are better prepared to

meet the needs of military medicine than their civilian-educated peers. The

services have not assessed the impact of readiness training and a thorough

assessment is needed to determine the type and amount of such training

that military physicians need.

GAO’s review of DOD retention data suggests that University graduates are

likely to provide DOD with a cadre of experienced physician career officers.

Scholarship program physicians, who comprise the majority of new

physician accessions, are retained in the military for shorter periods, on

average, than University graduates.

However, given the changes in operational scenarios and DOD’s approach

for delivering peacetime health care, new assessments of the military’s

physician needs and the means to acquire and retain such physicians are

in order. For example, if DOD continues to need a cadre of experienced

career physicians, alternative strategies such as an additional scholarship

option with a longer service obligation could be considered as a

potentially less expensive way to increase the length of selected military

physicians’ careers.

As the Congress makes decisions regarding both physician accession

programs, it will need information not only about the programs’ relative

costs but also about their effects on the short- and long-term requirements

for military physicians and the value of the other University activities.

Page 4 GAO/HEHS-95-244 Military Physicians
Executive Summary

Principal Findings

The University Is the

Costliest Physician Source

on a Per Graduate Basis

GAO’s analysis shows that on a per graduate basis, the University is the

most expensive source of military physicians when considering DOD costs

and total federal costs. With DOD education and retention costs of about

$3.3 million, the cost of a University graduate is more than 2 times greater

than the $1.5 million cost for a regular scholarship program graduate and

about 5 times greater than the $659,000 cost for a deferred scholarship

program graduate. When all federal costs are considered, the cost of a

University graduate is about $3.4 million, about 1.9 times more costly than

regular scholarship program graduates ($1.8 million) and more than 2.7

times more costly than deferred scholarship program graduates

($1.2 million). Figure 1 depicts these relationships.

Page 5 GAO/HEHS-95-244 Military Physicians
Executive Summary

Figure 1: Per Graduate Costs for

University and Scholarship Program

Participants

 Dollars in millions

0

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

3.35

1.77

1.22

Other federal costs

DoD costs

University

Regular Scholarship

Deferred Scholarship

.66

1.46

3.25

Page 6 GAO/HEHS-95-244 Military Physicians
Executive Summary

University Costs Are

Comparable to Scholarship

Costs Based on Expected

Years of Service and All

Federal Costs

The difference in costs between the University and the scholarship

program narrows when costs are amortized over the expected years of

military service for each group because University graduates are expected

to serve nearly twice as long as their regular scholarship program peers

and more than three times as long as deferred scholarship program

physicians.2

 On an expected years of service basis, DOD’s cost to educate

and retain a University graduate is about $176,000 compared with about

$150,000 for the regular scholarship program and about $125,000 for the

deferred scholarship program. However, when total federal costs are

amortized over the expected years of military service, the costs of

University graduates are more comparable to scholarship program

physicians because the University receives less non-DOD federal support

than civilian medical schools. University graduates are expected to serve

for about 18.5 years, on average, resulting in a per year federal cost of

about $182,000. Regular scholarship program physicians, expected to

serve for 9.8 years, on average, have an annual federal cost of about

$181,000, and deferred scholarship program physicians, expected to serve

for 5.3 years, on average, have an annual federal cost of about $232,000.

Figure 2 shows DOD and federal costs for physicians from each source

based on expected years of military service.

2

Expected years of service is a calculation based on DOD retention estimates for physicians from each

program multiplied by the number of graduates from each program in 1994. DOD’s retention estimates

are projections based on historical retention data for each program and the experience of all military

physicians. Actual years of service for physicians from each accession source may be greater or less

than these projections.

Page 7 GAO/HEHS-95-244 Military Physicians
Executive Summary

Figure 2: Per Expected Year Costs of

Service for University and Scholarship

Program Participants

 Dollars in thousands

0

50

100

150

200

250

182

181

232

Other federal costs

DoD costs

University

Regular Scholarship

Deferred Scholarship

176 150

125

Page 8 GAO/HEHS-95-244 Military Physicians
Executive Summary

The University Provides

Quality Education and

Other Benefits to DOD

The University’s School of Medicine is fully accredited and its students

have undergraduate grade point averages and admission test scores that

fall within the middle of the ranges for such statistics for all medical

schools. Post-graduate measures, such as pass rates for the medical

license examination and graduates’ performance in their first year of GME,

indicate that the results for University graduates are equivalent or slightly

better than those of other military physicians.

To help meet accreditation standards and to advance the practice of

military medicine, the University engages in several activities in addition

to operating its School of Medicine. These activities include providing

overseas medical personnel required continuing medical education,

serving as the academic affiliate for several military graduate medical

education programs, and offering graduate education programs for allied

health professionals. The University has established research and archival

programs in such areas as casualty care, preventive medicine, and

psychiatric responses to trauma and disaster. University officials point out

that if the University were not performing these roles, other DOD

components would have to be tasked to carry them out.

University Students

Receive Extensive

Medical Readiness

Training, but Its

Impact Is Unclear

The University provides training in the special needs of military medicine

as an integral part of its medical school curriculum. By the time University

students graduate and begin active duty, they have received at least 784

hours of medical readiness training. Other new military physicians take

specific medical readiness training courses once they are on active duty;

however, the initial training they receive is less extensive than that

provided to University graduates.

Even though graduates of the University begin their military medical

careers with more initial readiness training than other new military

physicians, the significance of the additional training is unclear. While the

commanders of military medical units that GAO contacted perceive that

physicians from the University are at least initially better prepared than

their civilian educated peers for military medicine, objective measures of

the effects of the University or other approaches to medical readiness

training are not available. DOD has not compared the effectiveness of the

University approach with other initial readiness training offered by the

services. Recent deployments have not comprehensively tested the

individual readiness capabilities of military physicians, and such

capabilities are not routinely assessed in peacetime.

Page 9 GAO/HEHS-95-244 Military Physicians
Executive Summary

Retention Rate

Patterns for

Graduates Consistent

With Program

Objectives

DOD’s need for physicians has changed as a result of the end of Cold War

scenarios, the emergence of regional threats, and the overall downsizing of

the military in response to budget deficits. In addition, DOD has

dramatically changed its approach to delivering medical care to military

beneficiaries during peacetime by relying more heavily on civilian

providers to deliver much of that care. Although the Department is

currently reevaluating its future need for physicians, it has not reached

final conclusions about the number of physicians needed nor the optimal

length of time that physicians should serve.

GAO’s analysis of DOD retention data shows that University graduates are

likely to meet DOD’s needs for an experienced cadre of military physicians

while scholarship program graduates generally have shorter careers.

Factors such as age, marital status, compensation, nonphysician duties,

and working conditions have been associated with physician retention. A

key factor in the longer retention of University graduates, however,

appears to be their longer pay-back obligation. If the University were

closed, the scholarship program might need to be revised to encourage or

require some scholarship students to stay longer in the military. For

example, one approach might be a scholarship option with a longer

service obligation, including enhanced military readiness training and,

perhaps, additional benefits.

Matter for

Congressional

Consideration

The Administration’s National Performance Review has proposed that the

University be closed. This proposal has presented the Congress with

difficult policy decisions regarding the need for a cadre of physicians who

are likely to become career military officers and the most appropriate

means of retaining those physicians.

As the Congress makes those decisions, it may wish to consider requiring

DOD to justify both the University and the scholarship program in the

context of DOD’s specific short- and long-term requirements for military

physicians, the role of the University and the scholarship program in

satisfying those requirements, and their relative costs.

Agency Comments On September 15, 1995, GAO met with the Assistant Secretary of Defense,

Health Affairs, and other DOD officials and with the President of the

University and his top staff to obtain their comments on a draft of this

report.

Page 10 GAO/HEHS-95-244 Military Physicians
Executive Summary

The Assistant Secretary stated that the report presents a great deal of

relevant, factual data and reflects a significant research effort. In response

to GAO’s matter for congressional consideration, however, the Assistant

Secretary stated that the Department does not believe that additional

justification is needed for the University and scholarship program. Both

the Assistant Secretary and University officials expressed concerns

regarding several presentational issues, such as the use of cost per

graduate as a unit of analysis as well as GAO’s treatment of the University’s

cost-avoidance activities and contributions to the training and education

of physicians for the unique demands of military medicine. GAO believes

that its findings are presented in a balanced and objective way. These

issues are discussed in more detail on page 60. As a result of these

comments and technical suggestions, GAO has revised the report as

appropriate.

Page 11 GAO/HEHS-95-244 Military Physicians
Contents

Executive Summary 2

Chapter 1 

Introduction

16

Current Physician Accession Programs 16

The Special Needs of Military Medicine 19

Objectives, Scope, and Methodology 21

Chapter 2 

Analysis of University

and Scholarship

Program Costs

23

Key Factors Considered in Our Analysis 23

Results of Our Analysis 27

Career Compensation Is Higher for University Graduates Than

for Scholarship Participants

30

Non-DOD Federal Dollars for Medical Education and GME

Increase Overall Costs

31

Chapter 3 

The University

Provides Medical

Education

Comparable to

Civilian Schools and

Emphasizes the

Special Needs of

Military Medicine

34

Quality of Medical Education at the University Compares

Favorably With That Provided by Other Sources

34

University Students Receive Extensive Medical Readiness

Training, but Its Impact Is Unclear

40

Chapter 4 

Other Activities of the

University

47

Education and Training Activities 47

Research, Consultation, and Archival Activities 49

Chapter 5 

DOD’s Retention

Needs Are Unknown

51

University and Scholarship Program Retention Patterns 51

DOD Is Evaluating Its Overall Need for Physicians 53

Factors Influencing Physician Retention 55

Page 12 GAO/HEHS-95-244 Military Physicians
Contents

Chapter 6 

Conclusions

59

Matter for Congressional Consideration 60

Agency Comments 60

Appendixes Appendix I: Objectives, Scope, and Methodology 64

Appendix II: Comparison of Hours Spent in Initial Medical

Readiness Training

73

Appendix III: Studies of Factors Affecting Retention of Military

Physicians

75

Appendix IV: Responses of the Uniformed Services University of

the Health Sciences to the Inspector General’s Recommendations

78

Tables Table 1.1: Physician Accessions by Source 17

Table 2.1: Expected Years of Service From Each Accession

Source

25

Table 2.2: Educational Costs for University and Scholarship

Graduates

29

Table 2.3: Projected Costs of GME for University and Scholarship

Graduates

29

Table 2.4: Costs of Military Training for University and

Scholarship Graduates

30

Table 2.5: Costs of Salary and Bonuses for University and

Scholarship Graduates

30

Table 2.6: Retirement Benefits for University and Scholarship

Graduates

31

Table 2.7: DOD Costs for Education and Career Compensation of

University and Scholarship Graduates

31

Table 2.8: Federal Support Allocable to University and

Scholarship Graduates

32

Table 2.9: Total Federal Costs for Education and Career

Compensation of University and Scholarship Graduates

33

Table 3.1: Results of USMLE Taken by the University’s 1993

Graduating Class

38

Table 3.2: Results of USMLE Taken by the University’s 1994 and

1995 Graduating Classes

38

Table 3.3: Intern Evaluations for 1994 39

Table 4.1: Number of Graduate Nursing Students Entering in

Fiscal Years 1993-96

49

Table 5.1: Active Duty Physician Requirements as Portrayed in

the 733 Study

53

Page 13 GAO/HEHS-95-244 Military Physicians
Contents

Table I.1: Yearly Tracking of Cohort Group Members at the

University

65

Table I.2: Yearly Tracking of Size of Cohort Group, Navy

Scholarship Program

66

 Table II.1: Comparison of Hours Spent in Initial Medical

Readiness Training

74

Figures Figure 1: Per Graduate Costs for University and Scholarship

Program Participants

6

Figure 2: Per Expected Year Costs of Service for University and

Scholarship Program Participants

8

Figure 3.1: MCAT Scores for University and Other Students

Entering Medical School in 1994

36

Figure 3.2: Undergraduate GPAs for University and Other

Students Entering Medical School in 1994

37

Figure 3.3: Comparison of Initial Readiness Training by Training

Source

42

Abbreviations

AAMC Association of American Medical Colleges

CHAMPUS Civilian Health and Medical Program of the Uniformed

Services

C4 Combat Casualty Care Course

DOD Department of Defense

CBO Congressional Budget Office

EEO equal employment opportunity

GME graduate medical education

GPA grade point average

HEHS Health, Education, and Human Services Division

HPSP Health Profession Scholarship Program

IG inspector general

LCME Liaison Committee on Medical Education

MCAT Medical College Admissions Test

NIH National Institutes of Health

NPR National Performance Review

NSIAD National Security and International Affairs Division

OMB Office of Management and Budget

OSD Office of the Secretary of Defense

PA&E Program Analysis and Evaluation

ROTC Reserve Officer Training Corps

USMLE United States Medical Licensing Examination

USU Uniformed Services University of the Health Sciences

Page 14 GAO/HEHS-95-244 Military Physicians
Page 15 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

The Department of Defense (DOD) has about 13,700 active duty physicians,

nearly 1,300 of whom entered military service in fiscal year 1994.3

 About

93 percent of these new physicians entered the military through the Health

Profession Scholarship Program (HPSP) or through DOD’s medical

school—the Uniformed Services University of the Health Sciences

(USU)—which were authorized as complementary programs under the

Uniformed Services Health Profession Revitalization Act of 1972 (P.L.

92-426.)

To acquire physicians through these two programs, DOD incurs either the

costs of providing the participants a medical education plus student

stipends for scholarship participants or military salaries and benefits for

students at the University. After the participants graduate from medical

school, DOD incurs the costs of physician ownership—providing graduate

medical education (GME)4

 and other training; salaries, bonuses, and

benefits; and retirement pay for those physicians who remain on active

duty for at least 20 years.

Military physicians are needed to support operational forces during war or

other military operations and to maintain the well-being of the forces

during nonoperational periods. Military physicians also provide health

care services to nonactive duty beneficiaries.

Current Physician

Accession Programs

With the end of the draft in 1972, the military services needed new means

of obtaining active duty physicians. To address this need, Public Law

92-426 established two complementary accession sources—the

scholarship program and the University. In addition to these sources, the

services continue to attract physicians directly from the private sector.5

Table 1.1 shows the number of physicians entering each military service

from each accession program for fiscal years 1992 to 1994.

3

The services also have about 6,500 physicians in the reserves. However, except where indicated, this

report addresses issues related to active duty physician accession programs (the University and the

scholarship program).

4

During their fourth year of medical school, students formally elect the medical specialty area they

intend to pursue. The medical specialty training programs, which generally take 3 to 7 years to

complete, are referred to as graduate medical education (GME). During this time, physicians are

generally referred to as interns or residents.

5

In 1994, about 7 percent of physicians came through programs such as the Financial Assistance

Program, which pays incentives to medical school graduates specializing in medical disciplines critical

for wartime needs, and through direct recruitment of civilian physicians. Because of the small

numbers involved, they were not included in the analyses for this report.

Page 16 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

Table 1.1: Physician Accessions by Source (Fiscal Years 1992-94) 

1992 1993 1994

Source Army Navy Air Force Total Army Navy Air Force Total Army Navy Air Force Total

HPSPa 351 363 380 1,094 313 373 306 992 313 344 393 1,050

USUb 69 56 47 172 56 46 48 150 56 48 43 147

Other 49 53 182 284 46 32 102 180 22 45 21 88

Total 469 472 609 1,550 415 451 456 1,322 391 437 457 1,285

aScholarship accessions include current-year graduates and graduates from previous years who

deferred their active-duty service to participate in civilian GME programs.

bSome students take longer than 4 years to complete medical school, while others drop out for

various reasons; hence, the total number of graduates differs from the average number of

students enrolled in each class (about 160). In addition, during this same period, 19 University

graduates entered the Public Health Service: 6 in 1992, 5 in 1993, and 8 in 1994.

Health Profession

Scholarship Program

The scholarship program is the largest source for military physicians.6 The

legislative history of Public Law 92-426 indicates that the scholarship

program was intended to provide the services with the majority of their

physicians, most of whom would not be expected to make the military a

lifetime career. Under the scholarship program, the services pay medical

school tuition and fees as well as stipends for civilian medical school

students. In return, after graduation, program participants must serve 1

year of active duty military service for each year that they receive benefits

with a 2-year minimum obligation. Scholarship program participants also

incur an obligation to serve in the reserves for a period of time, which

varies depending upon the number of years of benefits received. The total

obligation of active and reserve duty is 8 years for all scholarship program

participants (not including time spent in GME).

Upon graduation, most scholarship program participants enter active duty

at the O-3 pay grade (that is, as captains in the Army and Air Force and as

lieutenants in the Navy) and begin their first year of GME in military

medical facilities. Licensure typically occurs at the end of that year. At that

point, depending upon the needs of the service, a scholarship program

participant may continue GME or begin serving as a general medical officer.

Time spent in GME does not satisfy the commitment incurred as a

participant in the scholarship program; however, such time is credited for

retirement purposes.

6

The scholarship program also sponsors students of dentistry, optometry, and nursing.

Page 17 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

Although most scholarship program participants enter active duty upon

graduation from medical school, others are granted a deferment so that

they may pursue GME in the civilian sector. Upon completion of their GME,

deferred scholarship program participants serve their active duty

obligations, entering active service at the pay grade they would have

attained had they not deferred their military service. Of the 987

scholarship program participants who graduated in fiscal year 1994, 283

were deferred. Scholarship program participants who participate in

military GME programs are referred to as regular scholarship program

participants. In fiscal year 1994, 704 regular scholarship program

participants entered the military.

For DOD, the educational costs of acquiring physicians through the

scholarship program include medical school tuition and fees, student

stipends, active duty pay for a 45-day period each year, and program

administration costs. After graduation, the costs that DOD incurs to employ

these physicians include those for GME (for those graduates who

participate in military GME programs); initial medical readiness training

(including basic officer training); salary, bonuses, and benefits; and

retirement pay for those physicians who remain on active duty for at least

20 years.

Uniformed Services

University of the Health

Sciences

The University also authorized by Public Law 92-426, is DOD’s medical

school in Bethesda, Maryland. According to the legislative history, the

University is intended to provide DOD a group of military physicians likely

to make the military a career.

When students enter the University’s School of Medicine, they begin active

military service with the pay grade of O-1 (that is, as second lieutenants in

the Army and Air Force or ensigns in the Navy) and receive all benefits

associated with active military service. Upon graduation, University

students are promoted to the grade of O-3 and begin serving a 7-year

obligation. They might also incur a reserve obligation of 2 to 6 years (not

including time spent in GME).

On average, the University has enrolled about 160 students each year since

1981. Most graduates go into the Army, Navy, or Air Force; however, a

limited number of students each year are sponsored by the Public Health

Service. For example, of the 155 graduates in 1994, 8 were sponsored by

the Public Health Service. Since its first class graduated in 1980, the

Page 18 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

University has produced 2,064 physicians for the three services and 84 for

the Public Health Service.

For DOD, the educational costs of acquiring physicians through the

University include the costs of student and faculty salaries and benefits,

facility operations and maintenance, and basic officer training. After

students graduate, DOD incurs the costs of their GME, salary and benefits,

and retirement pay for those who serve at least 20 years.

The Special Needs of

Military Medicine

Military medicine is not a recognized medical specialty; however, medical

literature we reviewed as well as military and civilian officials with whom

we spoke identified a number of factors that differentiate the practice of

military medicine from the practice of medicine in civilian settings.

According to these sources, the primary factors that contribute to the

special needs of military medicine are the objectives of the combat

medical care system, the circumstances and environments in which care is

provided, and the need to understand military operations and procedures.

However, no consensus exists in DOD or the services regarding the amount

or types of education and training physicians need—in addition to

traditional medical education—to meet the special needs of military

medicine. Chapter 3 discusses how University and scholarship program

graduates are prepared for the special needs of military medicine.

Military Medicine

Emphasizes Keeping

Troops Fit for Duty

Practitioners of military medicine concentrate their attention on

preventing and treating illnesses and injuries more commonly experienced

in operational or combat settings. While similar or related illnesses,

injuries, or health concerns exist in civilian settings, military medical

literature and practitioners state that some illnesses and injuries lack

parallels in civilian settings; thus special training is necessary to practice

medicine in operational settings in support of combat and noncombat

missions.7

Military medical literature notes that the objectives of the combat medical

care system are different from civilian objectives. In civilian

circumstances, the physician’s objective is to ensure the welfare of the

individual patient. In contrast, the objective of the military physician is to

“conserve the fighting strength” in order to ensure the success of the

7

For further discussion about military medicine see International Military and Defense Encyclopedia

(Washington, D.C.: Brassey’s, Inc., 1993); Public Health & Preventive Medicine 13th ed. (East Norwalk,

Conn: Appleton & Lange, 1992); and The Oxford Companion to Medicine, (Oxford: Oxford University

Press, 1986).

Page 19 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

military mission. To minimize troop losses to disease and injury both

before and during deployment, the military physician is responsible for

identifying the health threats to which troops are exposed and developing

plans to minimize their impact. Such preventive medicine programs

include immunization, sanitation, and safety awareness.

The Provision of Care in

Combat Settings

When troops become ill or are injured in combat, the objective of military

physicians is to provide treatment that will permit the patient’s return to

duty, if possible, or removal of the patient to a location where additional

care may be provided. To accomplish this objective, the combat medical

system is organized into echelons, or different levels of medical support

for combat troops. Echelon 1, the most far-forward and mobile level of

medical support, is necessarily the most austerely staffed and equipped. At

this level, minimally injured personnel are treated and returned to combat.

More serious casualties are evacuated to higher echelons. Each echelon, 2

through 5, has all the capabilities of the lower echelons, plus increasingly

sophisticated capabilities.

An essential element of the combat medical system is the practice of

triage, or sorting, which is based on the principle of accomplishing the

greatest good for the greatest number under the circumstances. Triage is

the process of establishing the priorities for treatment and evacuation and

is necessary in the case of mass casualties in order to avoid overwhelming

the medical resources available. In such instances, before providing

treatment, medical personnel are required to place casualties in categories

ranging from urgent (those injuries requiring immediate intervention to

prevent death) to expectant (wounds so severe that survival would be

unlikely even if all medical resources were applied.)

Medical Staff Advise Line

Commanders

In operational settings, the military physician serves as medical staff

advisor to the commander. In so doing, the physician participates in the

development of command plans and policies, advises the commander on

relevant medical issues, and works with other staff officers to ensure

medical support of military operations. Given these responsibilities,

military physicians need an understanding of military operations, staff

planning and administration processes, the various work environments,

and the natural and manmade hazards that personnel may encounter.

Page 20 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

Objectives, Scope,

and Methodology

Even before its first class enrolled in 1976, the University was

controversial. Several earlier studies have concluded that the University is

the most costly source of obtaining military physicians. Consequently,

proposals have been made to close the University, including one that

resulted from the work of the National Performance Review (NPR).8

The National Defense Authorization Act for Fiscal Year 1995 specifically

prohibited the closure of the University and directed us to report on issues

related to the University and other sources of military physicians. The act

directed us to report on various aspects of physician accession programs

including costs, retention rate patterns, quality of medical education, and

preparation for the special needs of military medicine. The act also

directed us to report on actions taken by the University in response to

recommendations made in 1990 by DOD’s Inspector General concerning

internal controls and other issues.

To respond to these issues, we collected information (through interviews

and documentation) from the following organizations and officials:

• the Office of the Assistant Secretary of Defense (Health Affairs);

• the Uniformed Services University of the Health Sciences;

• the Joint Staff;

• the Offices of the Surgeons General of the Army, Navy, and Air Force;

• medical readiness training representatives for each service;

• major medical units throughout DOD;

• the Office of Management and Budget;

• NPR;

• the Congressional Budget Office;

• the American Medical Association;

• the Association of American Medical Colleges; and

• various other organizations within and outside of DOD.

A detailed discussion of our methodology is presented in appendix I.

The results of our cost analysis are presented in chapter 2. Chapter 3

discusses the quality of medical education obtained by military physicians

and how physicians from each accession source are prepared to meet the

special needs of military medicine. Chapter 4 provides information on the

activities conducted at the University in addition to its School of Medicine.

Chapter 5 provides information on issues related to the retention of

8

NPR, led by Vice President Gore, was an Administration effort to identify opportunities to streamline

government operations. In September 1993, NPR recommended closing the University.

Page 21 GAO/HEHS-95-244 Military Physicians
Chapter 1 

Introduction

physicians. Chapter 6 presents overall conclusions about military

physician accession programs and related issues. Appendix IV discusses

the responses to the 1990 recommendations of DOD’s Inspector General.

Our work was conducted between September 1994 and August 1995 in

accordance with generally accepted government auditing standards.

Page 22 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

Our review of the costs of obtaining and retaining physicians for the

military focused on the historical educational costs for the graduating

class of 1994 and the projected postgraduation costs for additional training

(including GME and initial medical readiness training), salary, and

retirement costs. We analyzed prior studies and held discussions with

military and civilian officials to identify the factors to include in our

analysis. Our analysis showed that when considering DOD costs, the

University is the most expensive source of military physicians. In a

supplemental analysis, which includes an estimate of additional federal

support for medical education, the University is the most expensive on a

per graduate basis but comparable in cost to other accession sources

when physician costs are distributed over the expected lengths of their

military careers.

Key Factors

Considered in Our

Analysis

In developing our analysis of University and scholarship program costs,

we made decisions regarding the following key factors:

• the appropriate year to use as the base year for analytical purposes,

• the appropriate units of analysis against which to compare the estimated

costs for each program,

• the use of retention rate data in the cost equations, and

• the appropriate methods of treating various components of each

program’s costs.

Each factor is discussed below with particular reference to the differences

in approaches used by the Office of the Assistant Secretary of Defense,

Program Analysis and Evaluation (PA&E), and the University9

 in their

analyses of the costs of obtaining physicians for the military. The

University’s study, which responds to the issues that we were asked to

address in the National Defense Authorization Act for Fiscal Year 1995,

concluded that the scholarship program (as a combined program) is

almost 2 times more costly than the University. The DOD study concluded

that the University was 20 to 27 percent more costly than the regular

scholarship program and 39 to 63 percent more costly than the deferred

scholarship program, depending on medical specialty.

Base Year for Analysis Our review focused on the historical educational costs for the graduating

class of 1994 and the projected costs for additional training and career

9

The University “Working Copy” for the Senate Armed Services Committee Directed USUHS Review,

March 1995, Physician Retention and the Cost-Effectiveness of the Uniformed Services University of

the Health Sciences, DOD/Office of the Assistant Secretary of Defense (PA&E), July 1991.

Page 23 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

compensation as expressed in 1994 constant dollars. Our focus on a

specific graduating class represents a snapshot of the cost factors as they

existed at the time of our analysis and can provide a benchmark for later

analyses. The University’s analysis is also based on the 1994 graduating

class; however, the PA&E analysis was performed in 1991 using 1989 data.

Unit of Analysis PA&E used the number of expected years of service for the graduates of

each program as the measure of benefit and the estimated cost per

expected year of service as its unit of analysis. The University used the

number of years of obligation for the graduates of each program as the

measure of benefit and the cost per year of obligation as its unit of

analysis.10

We used the PA&E unit of measurement and analysis (expected years of

service)11 and the costs per graduate from each program as an interim unit

of analysis. We believe that the University’s focus on the minimum

obligation period understates each program’s contribution to military

medicine because some graduates from all accession programs are

retained longer than the minimum obligation period, including some who

stay to retirement.

For example, under the University model, the 155 graduates from its class

of 1994 are expected to provide 1,085 staff years of service based on a

7-year obligation. For the scholarship program, the University model uses

a 4-year obligation, which results in 2,816 expected staff years of service

for the regular scholarship program and 1,132 for the deferred scholarship

program.

Table 2.1 shows our calculation of expected years of service for 1994

graduates of the University and the scholarship program using DOD

physician retention projections.

10The scholarship program obligation of 4 years is an estimate based upon experience, whereas the

University obligation of 7 years is supported by the statute.

11The University developed this measure in 1975 because it expected its environment would cause a

larger percentage of its graduates to choose the military as a career.

Page 24 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

Table 2.1: Expected Years of Service

From Each Accession Source

Accession source

Graduates

in 1994

Expected

years of

service per

graduate

Expected

years of

service

from 1994

graduates

USU 155 18.45 2,860

HPSP (regular) 704 9.75 6,865

HPSP (deferred) 283 5.29 1,497

Retention Rates The selection of the expected years of service as our unit of analysis

required that we use physician retention data in our calculations. Since

1981, DOD has maintained an electronic database on the rates at which

physicians leave or stay in the military. The retention database identifies

the program through which physicians are obtained, the military

department, and the percentage of physicians remaining each year. DOD

makes projections about (1) the average years of service that may be

anticipated from physicians and (2) the percentage of physicians expected

to stay in the military to retirement from each accession source. DOD’s

projections are based on historical retention data for each program and

the experience of all military physicians.

DOD officials acknowledged that their retention database has not been

updated since 1993. However, DOD and service officials agreed that DOD’s

projections using this database are the best DOD-wide information available

on the retention of military physicians. We used DOD’s retention

projections to calculate the expected staff years of service for each

accession source by multiplying the actual number of graduates from each

program by the expected years of service for graduates from each

program. We also calculated projected career compensation (salary and

bonuses) and retirement costs using the DOD physician retention data.

Treatment of Program

Costs and Uncertainties

PA&E examined the costs of procuring and retaining physicians from

medical school through retirement. PA&E’s cost elements included the

University’s budget, educational costs for the scholarship program,

military GME costs, salary and bonuses during a physician’s career, and

estimates of physician retirement benefits. The University’s methodology

focused on its operational budget and scholarship program educational

costs, but excluded the other DOD costs associated with training and

retaining physicians used in the PA&E model.

Page 25 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

We used the PA&E cost elements when considering DOD’s costs. DOD incurs

costs for military physicians after they graduate from medical

school—including the University—because of medical and military

training requirements and to pay salaries and benefits during the military

physician’s career. Under our calculation, educational costs represent

about 9 percent of DOD’s total costs for the regular scholarship program,

about 17 percent for the University, and about 19 percent for the deferred

scholarship program.

Treatment of Some

University Costs

The total University budget in any year includes funding for activities that

do not directly contribute to the education of a medical student. For

example, in fiscal year 1994, the University budget included $28.5 million

for projects, such as research on head and neck injuries, and the Armed

Forces Radiobiological Research Institute. DOD and University officials

agreed that these costs should not be included because they are not

associated with the education of physicians. However, the University

excluded an additional $18.6 million from its analysis for cost-avoidance

activities. These are largely faculty and staff activities that the University

believes DOD would continue to procure even if the University is closed,

but at potentially higher costs.

We have not included the University’s reductions for cost avoidance

because our methodology focused on the actual outlays for the

educational costs of the University and the scholarship program.

Moreover, we were unable to validate the details in the University’s cost

avoidance estimates.

Additional Federal Dollars

to Civilian Medical

Education

The University included additional federal contributions to civilian

medical education (and by extension to the scholarship program) in its

analysis, while the PA&E study did not. Considerable debate exists about

whether other (non-DOD) federal support for medical education should be

considered in the cost of obtaining military physicians. Authors of

previous cost studies have argued that inclusion of these funds is

inappropriate because this funding is made to civilian schools for reasons

totally unrelated to the scholarship program. Counterarguments suggest

that other federal support should be attributed to the scholarship program

because civilian medical schools require this federal support to continue

their operations.

Page 26 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

If other federal expenditures for the education of scholarship program

students are included in the analysis, only a portion of these costs should

be viewed as related to their careers as military physicians. For example,

deferred scholarship program graduates serve about 5.29 years in the

military on average and many more in the private sector. Nonetheless,

because of the interest in some quarters for inclusion of other federal

costs, we developed a supplemental analysis including, as a subsidy to the

scholarship program, Department of Health and Human Services funding

to civilian medical schools for research and GME programs (commensurate

with the rate of scholarship program participation in civilian

undergraduate and graduate medical education programs).

In an effort to ensure comparability between the cost elements in the

programs, we also included other federal dollars to the University in the

form of research grants and support for its graduates who participated in

civilian GME programs.

Additional details about our cost methodology are in appendix I.

Results of Our

Analysis

Our analysis of DOD’s costs to educate and retain a military physician

showed that the University is more costly than the scholarship program on

a per graduate and an expected year of service basis. To illustrate:

• DOD’s educational costs per graduate were $566,506 for the University and

$125,946 for the scholarship program;12

• DOD’s educational costs per expected year of service were $30,697 for the

University, $12,916 for the regular scholarship program, and $23,825 for

the deferred scholarship program;

• DOD’s total per graduate costs were $3.3 million for the University,

$1.5 million for the regular scholarship program, and $0.7 million for the

deferred scholarship program; and

• DOD’s total costs per expected year of service were $176,236 for the

University, $149,969 for the regular scholarship program, and $124,801 for

the deferred scholarship program.

Our supplemental analysis showed that when an estimate of additional

federal dollars that support civilian medical education is included in the

analysis, the University is more costly on a per graduate basis, but on an

expected year of service basis, the University is nearly equal the cost of

12Educational costs are the same on a per graduate basis for the deferred and regular scholarship

programs.

Page 27 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

the regular scholarship program and less costly than the deferred

scholarship program. To illustrate:

• the total cost per graduate, when all federal costs are included, was

$3.4 million for the University, $1.8 million for the regular scholarship

program, and $1.2 million for the deferred scholarship program; and

• the total cost per expected year of service, when all federal costs are

included, was $181,575 for the University, $181,169 for the regular

scholarship program, and $231,501 for the deferred scholarship program.

DOD Educational Costs

Are Higher for the

University Than for the

Scholarship Program

The medical educational costs associated with the University include

facility operations and maintenance, research and development,

procurement, construction, and military and PHS salaries for faculty and

students. Educational costs associated with the scholarship program

include medical school tuition and fees, stipends and salaries for students,

summer training, and program administration.

The DOD cost to educate the 1994 graduates of the University was $566,506

per graduate—4-1/2 times as great as the cost to educate a medical student

through the scholarship program ($125,946).

University Costs Are

Amortized Over a Longer

Period of Time

The difference in cost between the University and the scholarship program

narrows when education costs are amortized over the expected length of

service for each group. DOD estimates show that physicians from the

University are expected to serve nearly twice as long as their regular

scholarship program peers and more than three times as long as deferred

scholarship program physicians. Using DOD estimates that, on average,

physicians from the University will serve 18.45 years; regular scholarship

program physicians 9.75 years; and deferred scholarship program

physicians 5.29 years, our calculation of the educational cost per expected

year of service for University graduates was $30,697. Costs per expected

year of service for University graduates are more than twice those for

regular scholarship program participants ($12,916) who begin active

military service immediately after graduation and 29 percent higher than

the per expected year of service cost for scholarship program participants

($23,825) who defer their military service to attend GME in civilian

institutions. Table 2.2 compares DOD’s educational costs for University and

scholarship program physicians who graduated in 1994 on a per graduate

and per expected year of service basis.

Page 28 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

Table 2.2: Educational Costs for

University and Scholarship Graduates

USU

HPSP

(regular)

HPSP

(deferred)

Per graduate $566,506 $125,946 $125,946

Per year of service 30,697 12,916 23,825

GME and Medical

Readiness Training

Regular scholarship program participants and most University graduates

receive additional medical training through GME programs primarily in

DOD’s medical treatment facilities. DOD’s most current study of its military

GME costs (based on 1992 data) estimated the annual GME cost per

participant at $168,777, including resident salaries.13 Assuming an average

of 4 years of GME for each participant, the GME per participant cost is

$521,048, after adjusting for inflation. (Military GME costs do not apply to

deferred scholarship program or University graduates who participate in

civilian GME programs.) While the GME costs on a per participant basis are

identical for the University and the regular scholarship program, the per

graduate costs differ because the University costs are spread over all its

graduates (155), even though 6 University graduates participate in civilian

GME programs. GME costs for those 6 University graduates and all deferred

scholarship participants are included in “non-DOD federal dollars”, as

discussed on page 31. Table 2.3 shows our projections of DOD’s GME costs

for University and regular scholarship program physicians who graduated

in 1994.

Table 2.3: Projected Costs of GME for

University and Scholarship Graduates

USU

HPSP

(regular)

Per graduate $500,879 $521,048

Per year of service 27,141 53,433

In addition to their graduate medical education, military physicians are

required to have basic officer training, regardless of their accession

source. In general, new scholarship program physicians also attend the

Combat Casualty Care Course to acquire basic field medical skills.

(University graduates generally do not attend the Combat Casualty Care

Course.) Our projected costs (based on DOD estimates) of these training

courses for the physicians who graduated in 1994 are shown in table 2.4.

13Cost Analysis of the Military Medical Care System Institute for Defense Analysis, September 1994.

Page 29 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

Table 2.4: Costs of Military Training for

University and Scholarship Graduates

USU

HPSP

(regular)

HPSP

(deferred)

Per graduate $5,776 $10,970 $10,970

Per year of service 313 1,125 2,075

Career Compensation

Is Higher for

University Graduates

Than for Scholarship

Participants

In addition to the cost of medical education, DOD bears physician retention

costs, including career salary and bonuses, as well as retirement benefits.

Compensation costs are estimated to be highest for graduates of the

University because, on average, they are expected to remain in the service

longer and to earn retirement benefits at a rate higher than either their

deferred or regular scholarship program peers.

Salary and Bonuses Are

Highest for University

Graduates

Active duty compensation for physicians includes regular pay and

allowances as well as special pay and bonuses that vary depending upon

board certification status, length of service, and other factors. Because

University graduates will be compensated over a greater number of years

than their scholarship program peers, the per graduate compensation

costs are estimated to be the highest for University graduates. Deferred

scholarship program graduates earn nearly as much on an expected year

of service basis because they enter active duty service after becoming fully

trained in a medical specialty and, thus, receive higher compensation for

the fewer years they serve. University and regular scholarship program

graduates receive lower salaries while in military GME programs than they

earn after their GME training, which reduces their average career earnings

on an expected year of service basis. Table 2.5 shows the estimated costs

of salary and bonuses for the University and scholarship program

physicians who graduated in 1994.

Table 2.5: Costs of Salary and

Bonuses for University and

Scholarship Graduates USU

HPSP

(regular)

HPSP

(deferred)

Per graduate $1,739,626 $723,257 $497,302

Per year of service 94,265 74,169 94,075

Retirement Costs Are

Higher for University

Graduates Than for

Scholarship Participants

Military physicians are eligible for retirement benefits after 20 years of

active military service. Because the University graduated its first class only

15 years ago, actual retirement data are not available. However, based on

experience with other military physicians, DOD estimates that about

Page 30 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

50 percent of the 1994 University graduates will remain on active duty

through retirement, compared with 3 percent for deferred scholarship

program graduates and 11 percent for regular graduates. Because the

expected retirement rate for University graduates is higher than their

scholarship program peers, projected retirement costs for physicians who

graduated in 1994 are correspondingly higher for the University, as shown

in table 2.6.

Table 2.6: Retirement Benefits for

University and Scholarship Graduatesa

USU

HPSP

(regular)

HPSP

(deferred)

Per graduate $439,575 $81,186 25,506

Per year of service 23,819 8,326 4,825

aRetirement benefits do not include DOD contributions to Social Security or other retirement

plans.

Table 2.7 summarizes DOD costs for educating and retaining military

physicians.

Table 2.7: DOD Costs for Education and Career Compensation of University and Scholarship Graduates

Costs per graduate Costs per year of service

Cost element USU

HPSP

(regular)

HPSP

(deferred) USU

HPSP

(regular)

HPSP

(deferred)

Education $566,506 $125,946 $125,946 $30,697 $12,916 $23,825

Pay 1,739,626 723,257 497,302 94,265 74,169 94,075

Retirement 439,575 81,186 25,506 23,819 8,326 4,825

GME 500,879 521,048 a 27,141 53,433 a

Military

training 5,776 10,970 10,970 313 1,125 2,075

Total DOD costsb $3,252,362 $1,462,408 $659,724 $176,236 $149,969 $124,801

aNot applicable; deferred scholarship students do not participate in military GME programs.

bTotals may not add due to rounding.

Non-DOD Federal

Dollars for Medical

Education and GME

Increase Overall Costs

Beyond the costs to DOD, a portion of the federal dollars that support

undergraduate and graduate medical education may be considered as part

of the overall cost of educating military physicians. For example, one form

of federal support for undergraduate medical education is research

funding through the National Institutes of Health ($5.7 billion in 1994) and

Page 31 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

other federal agencies. Similarly, a portion of the federal dollars that

support civilian GME through the Medicare program ($6.2 billion in

1994) may be considered relevant to the overall cost of educating

physicians from the deferred scholarship program and the University (six

Public Health Service graduates from the University’s class of 1994 are

participating in civilian GME programs). Table 2.8 shows our estimate of

these costs.

Table 2.8: Federal Support Allocable to

University and Scholarship Graduates

USU

HPSP

(regular)

HPSP

(deferred)

Per graduate $98,522 $304,248 $564,038a

Per year of service 5,339 31,200 106,700

aThe deferred scholarship program includes federal support for undergraduate ($304,248) and

graduate medical education ($259,790).

When all federal costs are included on a per graduate basis, our analysis

shows that at a cost of $3.4 million, the University is about 1.9 times more

expensive than the regular scholarship program ($1.8 million) and more

than 2.7 times more expensive than the deferred scholarship program

($1.2 million). However, when total federal costs are spread over the

expected life of a physician’s military career, the University is more

comparable in cost to the other accession sources at $181,575 per

expected year of service. The deferred scholarship program is the most

expensive source using this approach at $231,501, while total federal costs

for the regular scholarship program total $181,169 on an expected years of

service basis. Table 2.9 summarizes total federal costs for obtaining and

retaining military physicians.

Page 32 GAO/HEHS-95-244 Military Physicians
Chapter 2 

Analysis of University and Scholarship

Program Costs

Table 2.9: Total Federal Costs for Education and Career Compensation of University and Scholarship Graduates

Costs per graduate Costs per year of service

USU

HPSP

(regular)

HPSP

(deferred) USU

HPSP

(regular)

HPSP

(deferred)

Education $566,506 $125,946 $125,946 $30,697 $12,916 $23,825

Pay 1,739,626 723,257 497,302 94,265 74,169 94,075

Retirement 439,575 81,186 25,506 23,819 8,326 4,825

GME 500,879 521,048 a 27,141 53,433 a

Military

training 5,776 10,970 10,970 313 1,125 2,075

Total DOD costsb $3,252,362 $1,462,408 $659,724 $176,236 $149,969 $124,801

Other federal support $98,522 $304,248 $564,038c $5,339 $31,200 $106,700

Total federal costsb $3,350,883 $1,766,656 $1,223,762 $181,575 $181,169 $231,501

aNot applicable. GME costs for deferred scholarship program participants are included in other

federal support.

bTotals may not add due to rounding.

cThe deferred scholarship program includes federal support for undergraduate ($304,248) and

graduate medical education ($259,790).

Page 33 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

Our analysis shows that the University’s School of Medicine provides a

traditional medical education that compares well with other U.S. medical

schools and combines that education with coverage of topics more

specifically related to the practice of military medicine. Traditional

measures of quality place the University’s program within the midrange of

medical schools nationwide and its graduates at or above other military

physicians. The commanders of military medical treatment facilities that

we contacted regard physicians who are graduates of the University as at

least as well-prepared as their civilian-educated colleagues for the practice

of medicine in the clinical setting. Our analysis shows that the University

also provides students more exposure to the special needs of military

medicine. Also, the medical commanders believe that the University’s

approach produces physicians who at least initially are better prepared

than their civilian-educated peers to meet the demands of military

medicine. However, no conclusive evidence exists to show that University

graduates are better prepared to meet DOD’s operational needs.

Quality of Medical

Education at the

University Compares

Favorably With That

Provided by Other

Sources

Indicators generally accepted in the medical community show that the

University provides the military services with physicians whose medical

education is equivalent in quality to the education received by other

military physicians. The University’s School of Medicine is fully accredited

and its students have undergraduate grade point averages and admission

test scores that fall within the midranges for such statistics for all medical

schools. Postgraduate measures such as pass rates for the medical license

examination and graduates’ performance in their first year of GME indicate

that University graduates are equivalent to or slightly better than other

military physicians.

The University Has Earned

Full Accreditation

Most medical schools in the United States are accredited by the Liaison

Committee on Medical Education (LCME), a joint activity of the Association

of American Medical Colleges (AAMC) and the Council on Medical

Education of the American Medical Association.14 In April 1993, LCME

awarded the University full accreditation for 7 years, the standard length

of time. LCME also identified areas for improvement during the

14LCME accredits the University’s School of Medicine and the other 125 allopathic medical schools in

the United States. U.S. schools of osteopathic medicine are accredited by the American Osteopathic

Association.

Page 34 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

accreditation process, including an overly dense curriculum15 (particularly

for students’ first 2 years) and vacancies in several department chairs.

In February, 1995, LCME notified the University of its satisfaction with the

University’s progress in making improvements in these areas. For

example, in response to the concerns raised about the density of its

curriculum, modifications were made to the curriculum of the basic

sciences to allow an afternoon of self-study in most weeks for first and

second year students. In addition, four of the five vacant faculty chairs

were filled. However, in June 1995, the position of the Dean of the School

of Medicine became vacant and, as of September 1995, the School was

seeking a permanent Dean.

In addition to LCME’s accreditation of the School of Medicine, the

University, as a whole, has been accredited by the Commission on Higher

Education of the Middle States Association of Colleges and Schools, an

organization that accredits institutions of higher learning.

Characteristics of Students

Entering the University

In the medical community, the academic credentials of the students that a

medical school attracts are considered to be a reflection of the school’s

quality. Two widely used measures of academic achievement among

medical school applicants are undergraduate grade point averages (GPA)

and scores on the Medical College Admissions Test (MCAT).

Compared with their peers nationwide, students who entered the

University in the fall of 1994 had above average MCAT scores. In addition,

the MCAT scores of students at the University were higher than those for

the Army and Navy scholarship program participants who entered in 1994.

Figure 3.1 shows these averages.

15A curriculum that includes a very high percentage of classroom instruction, leaving little time for

independent study.

Page 35 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

Figure 3.1: MCAT Scores for University

and Other Students Entering Medical

School in 1994

Average Score

8.00

8.20

8.40

8.60

8.80

9.00

9.20

9.40

9.60

9.80

10.00

USUHS Students

National Average (all schools)

Army HPSP

Navy HPSP

9.8

9.5

8.7

9.7

Note: GPA is computed on a 4-point scale. The Air Force was not able to provide similar data.

In contrast, Figure 3.2 shows that University students had average

undergraduate GPAs that were slightly below the national average, higher

than Army scholarship program entrants, and equivalent to Navy

scholarship program entrants.

Page 36 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

Figure 3.2: Undergraduate GPAs for

University and Other Students

Entering Medical School in 1994

Grade Point Average

3.0

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9

4.0

USUHS Students

National Average(all schools)

Army HPSP

Navy HPSP

3.4

3.5

3.3

3.4

Note: MCAT is graded on a 15-point scale. The Air Force was not able to provide similar data.

Achievements of

University Graduates

University graduates compare favorably with other medical school

graduates in their performance on the United States Medical Licensing

Examination (USMLE) and in their evaluations from internships at military

medical treatment facilities. Military medical commanders believe that

University graduates perform as well or better clinically than other

military physicians. DOD data indicate that University graduates are cited

for fewer adverse clinical privileging actions than other military

physicians.

University Students

Perform Well on USMLE

All students seeking medical licensure take the three steps of the USMLE,

administered by the National Board of Medical Examiners. Part 1 tests the

student’s ability to apply knowledge of the basic biomedical sciences, part

2 assesses the student’s application of clinical capabilities under

supervision, and part 3 measures the candidate’s use of medical

knowledge deemed appropriate for the unsupervised practice of general

Page 37 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

medicine. The most recent University class to have completed all three

parts of the USMLE is the class that graduated in 1993. Those students took

parts 1 and 2 while at the University and part 3 during their internship,

scoring near the national average for all medical students and achieving

pass rates that were equal to or better than the pass rates for all medical

students, as shown in table 3.1.

Table 3.1: Results of USMLE Taken by

the University’s 1993 Graduating Class Part 1 Part 2 Part 3

USU average 199a 195b 497c

National averaged 200 200 480

USU pass rate 92% 94% 97%

National pass rate 88% 94% 96%

aScores are reported on an open-ended scale, with the mean usually about 200; passing score

was 176.

bScores are reported on an open-ended scale, with the mean usually about 200; passing score

was 167.

cScores are reported on an open-ended scale, with the mean usually about 500; passing score

was 310.

dIncludes graduates of Canadian medical schools.

The classes that graduated in 1994 and 1995 had completed only parts 1

and 2 of the examination at the time of our review. The results of those

tests are shown in table 3.2.

Table 3.2: Results of USMLE Taken by

the University’s 1994 and 1995

Graduating Classes

1994 1995

Part 1 Part 2 Part 1 Part 2

USU average 201 197 203 198

National average 200 200 203 198

USU pass rate 96% 95% 97% 96%

National pass rate 89% 93% 91% 92%

University Graduates

Perform Well During

Internship

The three military services operate GME programs. During the internship

(the first year of GME), physicians are evaluated 13 times. We reviewed the

evaluations for all interns at the Air Force’s Malcolm Grow Medical

Center, the Walter Reed Army Medical Center, and the Bethesda National

Page 38 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

Naval Medical Center for the academic year 1993-94.16 On average, for the

sample we reviewed, interns who graduated from the University received

similar or higher evaluations than interns who graduated from other

medical schools, as shown in table 3.3.

Table 3.3: Intern Evaluations for 1994

Air Force Army Navy

Average evaluation for USU graduatesa 5.63

(15)b

87.53

(9)

3.86

(25)

Average evaluation for other interns 5.26

(6)

86.02

(49)

3.81

(37)

aAir Force interns were evaluated on a 7-point scale, the Army interns on a 100-point scale, and

the Navy interns on a 4-point scale.

bThe number of interns evaluated is in parentheses.

Military Medical

Commanders View

University Graduates and

Other Military Physicians

as Comparable Clinicians

We contacted 24 commanders of the largest military hospitals, most of

whom believe that University graduates equal their civilian-educated

colleagues in terms of overall clinical capabilities. Typical was the remark

made by the commander of an Army hospital:

“The graduates of [the University] demonstrate the same spectrum of abilities and clinical

aptitude as the graduates from any of our best civilian medical institutions. I have seen no

difference in intellect or performance.”

Others noted less variation in the quality of University graduates. For

example, the commander of an Army medical center said

“The [University] graduates are of a more consistent level of quality [compared with] a

spectrum of abilities that come from the variety of civilian medical school sources.”

Adverse Actions Among

University Graduates Are

Few

DOD tracks adverse clinical privileging actions as an indicator of the

performance of military physicians. Adverse clinical privileging actions

can involve a range of activities such as malpractice, drug abuse, or

unprofessional conduct. Based upon our analysis of data maintained by

the Armed Forces Institute of Pathology, physicians who graduated from

the University have had fewer reported adverse clinical privileging actions

than military physicians from other sources. From 1982 to 1994, University

graduates had 19 reported actions, or 1.48 actions per 1,000 physician staff

16These programs, all in the Washington, D.C., area, represent only a small portion of the military’s

internship programs. We cannot project the results of our analysis to other military internship

programs or to other years of the three programs in our analysis.

Page 39 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

years. During that same period, physicians from the scholarship program

had 234 actions, or 3.06 actions per 1,000 physician staff years.

University Students

Receive Extensive

Medical Readiness

Training, but Its

Impact Is Unclear

Preparing physicians for the special needs of military medicine involves

education, training, and experience beyond that of a traditional medical

education. This additional preparation is broadly referred to as medical

readiness training.17 Our analysis shows that the medical readiness

training provided to University medical students is more extensive than

that initially given to other military physicians in terms of the amount of

time involved and the nature of the training. Leaders in military medicine

that we contacted consider University graduates to be better prepared for

military medicine, at least during the early years of their careers. However,

University and DOD officials do not know of any objective evidence that

shows that the extensive readiness training at the University produces

physicians who are better prepared than their peers to meet the special

needs of military medicine.

Readiness Training at the

University Is More

Extensive Than That Given

to Other New Physicians

Military physicians currently receive their initial readiness training

through one of two means: University medical school students receive

medical readiness training as part of their 4-year medical education;

graduates of civilian medical schools receive it by attending medical

readiness training courses that the services offer individually or jointly.

The medical readiness training given to University medical students is

more extensive in volume and breadth than the initial medical readiness

training for other physicians.

University Students

Receive More Hours of

Initial Readiness Training

Than Other New Military

Physicians

According to University officials, the University’s curriculum is intended to

provide the medical and military knowledge and capabilities that the

curriculum developers felt was necessary to prepare a physician to

function in a leadership role in a range of operational assignments and

environments. At our request, University officials identified the hours of its

curriculum devoted to medical readiness topics. According to those

officials, University medical students receive an estimated 734 hours of

readiness training (including both classroom and field exercises). They

also receive at least 50 hours of medical readiness training during the

officer basic training that they are required to attend before beginning

17As used in this report, medical readiness training refers to any education or training (including basic

officer training) designed to enhance the knowledge and skills of health care personnel in concepts of

military medicine.

Page 40 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

their first year at the University.18 Thus, by the time they graduate,

University medical students have received between 784 and 889 hours of

readiness training, depending upon the service branch involved.

Service training officials and guidance indicate that the objectives of the

initial readiness training usually provided to other military physicians are

to teach physicians the fundamentals of military officership and the basic

skills needed to treat combat casualties on the forward points of the

battlefield. New military physicians who are graduates of civilian medical

schools typically receive less initial readiness training than that provided

to University students. For example, Air Force physicians who attend only

the required basic officer training receive 50 hours of readiness training. If

they were to also attend the optional Combat Casualty Care Course (C4),

the total number of hours would increase to about 132 hours.19 Figure 3.3

compares the total number of hours of initial readiness training depending

upon the source or sources through which the training was acquired.

18Some University students, such as those with prior commissioned service, may not be required to

attend basic officer training.

19Regardless of the source of their initial readiness training, all military physicians can take additional

readiness training courses to sustain and enhance their knowledge and skills. In the past, however,

physicians have not always attended even required readiness training.

Page 41 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

Figure 3.3: Comparison of Initial

Readiness Training by Training Source Training hours

0

100

200

300

400

500

600

700

800

900

Air Force Navy Army

USUHS Military-Unique Courses

Combat Casualty Care Course

Basic Officer Training

Some Readiness Topics

Covered at the University

Are Not Covered by Initial

Readiness Training for

Other New Physicians

The portions of the University’s curriculum related to military medicine

cover 17 broad areas, some of which are primarily medical in nature, some

of which are primarily military. With less total time spent on initial

readiness training, the amount of time spent on any individual topic

generally is less for other physicians than for students at the University.

However, some of the topics that the University program covers receive no

coverage in the initial training given to other physicians (either in basic

officer training or C4.) For example, the two areas that receive the most

coverage in the military portion of the University’s curriculum are tropical

medicine (66 classroom hours) and weapons effects (59 classroom hours.)

Tropical medicine is not covered by the initial readiness training for other

physicians in any service. Air Force physicians receive 30 minutes of

coverage on weapons effects as part of their initial training; Army and

Navy physicians receive none. Appendix II compares the hours of training

provided by each source.

University and other DOD officials view the difference between the

University’s program and the medical readiness training provided to other

Page 42 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

military physicians to be more than a matter of extent and content. These

officials point out that the information the University provides concerning

military medicine is interwoven throughout all of its classes, including the

basic sciences—not merely in the classes dedicated to military medicine.

They view the University’s program as fundamentally different from

readiness training in that it is a complete program of education.

Commanders View

University Graduates as

Better Prepared for

Military Medicine

We obtained the perspectives of 44 commanders of major military medical

units about the relative capabilities of University graduates and their

civilian-educated peers. The responses received were narrative in nature

and did not lend themselves to tabulation. However, the overall tenor of

the comments was favorable to the University, even though most of the

respondents were graduates of other accession programs.20

According to nearly all the medical commanders that we contacted,

University graduates are at least initially better prepared for military

medicine when compared with their peers. Only one commander viewed

University graduates as no better prepared than their peers for the

practice of military medicine. The remainder perceived, among other

things, that physicians from the University have a greater overall

understanding of the military, greater commitment to the military, better

preparation for operational assignments, and better preparation for

leadership roles. Some commanders noted that the advantage of the

University medical education diminishes over time. Others expressed the

view that the University and civilian medical schools should be regarded

as complementary accession sources.

Commanders Believe

University Graduates Have

a Greater Understanding of

the Military and Their Role

in It

Many of the medical commanders believe that, compared with other

military physicians, University graduates have a better understanding of

the military mission, organization, and customs. They also said that they

perceive that University graduates have a better appreciation of and

greater satisfaction with the physician’s role within the military. Others

remarked that because of their greater overall knowledge about the

military, University graduates are more easily assimilated into it. Some

noted that this better understanding of the military mission and related

matters gives University graduates greater credibility with the nonmedical

personnel whose needs they serve. Commanders said that they view

University graduates as more committed to the military and to a military

20Respondents were asked to describe their military experience and background. Some respondents

identified their accession source in their written comments.

Page 43 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

career. This commitment was sometimes attributed to the longer pay-back

requirement associated with the University. Typical of such observations

is the following from the commander of an Army deployable medical unit:

“[The University] produces physicians that are not only technically competent, but are also

able to quickly function as . . . military officer[s]. They are already familiar with the military

corporate culture, which enhances their credibility and allows them to progress more

rapidly into leadership positions. Civilian graduates are less equipped to do so and, in many

cases, have no interest in doing so.”

Further, the commanders generally stated that they value the University

graduates, as a group, because they view them as a cadre that provides a

source of stability and continuity in military medicine. University

graduates were generally perceived as possessing more of the technical

knowledge and skills needed in operational assignments. The commander

of an Army deployable medical unit remarked that

“[University] graduates. . . seem to adjust better to field conditions when deployed for

operations or exercises. Having had some experiences with field medicine during their

training, they know what to expect when they are called to a battalion aid station to

provide support. The civilian school physician is often shocked by . . . [the] first encounter

with field medicine in terms of the austerity and the age of the equipment and

pharmaceuticals he is expected to use. In a combat or [other operational] scenario, that

initial shock can be disastrous for the patients unless the physician adjusts quickly and

learns to make do with what is at hand.”

Commanders Perceive

University Graduates to Be

Better Prepared to Assume

Leadership Roles

The commanders generally viewed University graduates as better prepared

than their peers for leadership roles. They also saw them as better team

players. In their roles as leaders and team players, commanders noted the

willingness of University graduates to share their knowledge in military

medicine with their peers. Because the University graduates are willing to

share their knowledge, the commanders said that their presence enhances

overall readiness among civilian-educated physicians and other health

care providers. Some commented on the importance of the acculturation

process, which they believe occurs during the 4 years of medical

education at the University. Several commanders expressed the view that

the advantages of a medical education from the University would diminish

over time as the civilian-educated physicians acquired additional training

and experience. The commander of an Army deployable medical unit

commented that

Page 44 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

“[University graduates] generally seem better prepared for field duty during the first few

years of service. . . . [University] students are taught military bearing and know how to act

around soldiers. As time passes, the advantages of being schooled in a military

environment become less apparent and do not appear to play a role after the two or three

years that civilian graduates take to become accustomed to their Service requirements.”

Finally, several respondents said that the University and scholarship

programs should not be viewed as competing; rather, they viewed them as

both necessary and complementary. As expressed by the command

surgeon of a unified command:

“[The University] is necessary to provide a corps of physicians who have the knowledge

base and experience to practice medicine in a military environment. This will provide a

substantial amount of tomorrow’s leaders. But I don’t want to underemphasize the

importance of the civilian-trained physicians. They bring in a wealth of diverse training that

ensures the services will have personnel experienced in the latest procedures and

techniques of civilian medicine.”

Objective Information Is

Lacking About the

Effectiveness of the

University and Other

Readiness Training

Objective evidence is lacking concerning the relative effectiveness of the

University and traditional readiness training programs. Neither University

officials nor others we contacted within DOD were aware of any specific

studies done for the purpose of comparing the effectiveness of the two

approaches for providing readiness training. They were also not aware of

databases that track information that would permit such an analysis.

University officials said that they do not have a formal process in place to

assure themselves that the military portions of their curriculum are

appropriate to meet the needs of their customers. They do not seek an

official endorsement of their curriculum by the services or DOD (although

the Board of Regents includes the Surgeons General and a representative

from the Office of the Assistant Secretary of Defense, Health Affairs.) The

validity of other medical readiness training is uncertain as well. For

example, the Chief of the Joint Medical Readiness Training Center (which

administers C4) said that C4 has remained essentially unchanged since its

start in 1980.

The ultimate measure of a physician’s medical readiness is performance in

an actual military deployment. We and others have reported that

physicians were not adequately qualified for immediate deployment to

Operation Desert Shield/Desert Storm because they lacked the required

Page 45 GAO/HEHS-95-244 Military Physicians
Chapter 3 

The University Provides Medical Education

Comparable to Civilian Schools and

Emphasizes the Special Needs of Military

Medicine

readiness training.21 For those physicians who were deployed, readiness

skills were not comprehensively tested because the military suffered few

casualties. Likewise, other recent deployments have not fully tested

physician readiness capabilities to the extent that could be expected in a

major conflict. In peacetime, the services have not routinely assessed the

readiness capabilities of their physicians. Thus, neither recent actual

deployments nor peacetime simulations have provided a basis to compare

the performance of University graduates with their civilian-educated

peers.

DOD and the services lack agreement concerning the medical readiness

knowledge and capabilities that physicians need. The services offer

training courses to enhance and sustain the medical readiness capabilities

of physicians; however, only one course—officer basic training—is

explicitly required for all military physicians. Without agreed upon

standards, the validity and effectiveness of University and other readiness

training programs cannot be readily assessed. While University graduates

have more readiness training than their contemporaries, the value of that

training to DOD and the services cannot be objectively assessed from a

requirements standpoint.

In March 1995, DOD recognized the need for improvements in medical

readiness training and set out to develop and establish medical readiness

requirements and standards.22 Only against such standards can the validity

of the current program at the University and of the training provided by

the services be fully assessed.

21Operation Desert Storm: Full Army Medical Capability Not Achieved (GAO/NSIAD-92-175, Aug. 18,

1992); Operation Desert Storm: Problems with Air Force Medical Readiness (GAO/NSIAD-94-58, Dec.

30, 1993); and Operation Desert Storm: Improvements Required in the Navy’s Wartime Medical Care

Program (GAO/NSIAD-93-189, July 28, 1993).

22Medical Readiness Strategic Plan 1995-2001, Office of the Assistant Secretary of Defense, Health

Affairs (Washington, D.C.: 1995). DOD has a draft instruction that is intended to set standards

regarding military medical readiness skills training.

Page 46 GAO/HEHS-95-244 Military Physicians
Chapter 4 

Other Activities of the University

To help meet LCME standards required for accreditation as an academic

institution, the University engages in several activities in addition to

operating its School of Medicine. These fall generally into two major

categories: (1) education and training activities and (2) research,

consultation, and archival activities. Financial support for these activities,

mostly the salaries and benefits of the University’s faculty and staff, is

provided through the University’s general budget process. Although these

are included in our computation of the cost to educate University medical

students, we did not evaluate these activities in detail.

In response to advances in science and medicine, medical schools have

assumed responsibility for or participated in other programs in medicine

and related fields that complement their programs leading to the Medical

Doctor degree. LCME believes that the education of medical students is best

conducted in such enriched environments. Our review of University

documents and discussions with University officials showed that the

University conducts several activities that correspond to LCME standards.

Currently, the University is the only military organization conducting some

of these functions, such as providing overseas physicians with required

continuing medical education and maintaining a database on casualty

wound treatment cases. University officials stated that if the University

was not performing these roles, DOD would need to identify other

providers.

Education and

Training Activities

The University provides medical education beyond that provided by the

School of Medicine and also conducts training and education for other

health care and related professions. This mission is consistent with the

LCME standards that medical schools should include programs for

postdoctoral fellowships, graduate education in the basic medical

sciences, continuing education for physicians, and education in other

health professions and allied fields.

Office of Continuing

Health Professional

Education

Health professionals, particularly physicians, must acquire certain levels of

continuing education to maintain their licenses. In fiscal year 1994,

according to a University report to the Office of the Secretary of Defense,

the University’s Office of Continuing Health Professional Education

conducted about 600 continuing educational programs, attended by about

11,000 individuals, mostly military physicians. The largest programs are

provided for physicians in Europe, East Asia, and the Pacific, thereby

Page 47 GAO/HEHS-95-244 Military Physicians
Chapter 4 

Other Activities of the University

avoiding the costs of these physicians traveling to U.S. facilities for

training. Examples of the courses provided include video endoscopy,

obstetrics ultrasound, and laparoscopic cholecystectomy.23 The University

is also developing the use of videoconferencing and computer networking

to present its training. The University also provides certification for those

trained in cardiac resuscitation courses.

Graduate Medical

Education

LCME accreditation standards also encourage medical schools to provide or

be affiliated with institutions that provide programs in GME. (As mentioned

in chapter 1, GME programs, which are usually 3 to 7 years in duration,

provide physicians training in their chosen specialty.)

The University is the academic affiliate for several military GME programs,

including three in the Washington, D.C., area, providing faculty

development, research, curriculum enhancement, and patient care. In

addition, the University’s Office of Graduate Medical Education conducts

DOD-wide consultation and oversight for 11 GME programs sponsored or

co-sponsored by the University. DOD plans to assign the University with

other responsibilities to ensure that military GME programs maintain their

standards of quality for a smaller military force.

Graduate Education in

Basic Sciences

In addition to its continuing education offerings, the University offers

master’s and Doctor of Philosophy (Ph. D.) programs in anatomy,

biochemistry, pharmacology, and other sciences. Between 1977, when the

first students were admitted, and 1994, the University awarded 128 Ph.D.

and 238 master’s degrees. These graduates form a pool of researchers and

potential instructors at the University or other institutions. The University

also conducts smaller, more specialized programs, such as a Ph.D.

program in clinical psychology for selected military officers.

Graduate School of

Nursing

The 1993 Defense Appropriations Act directed the University to implement

a training program for nurse practitioners. Currently, the University

operates accredited masters’ nurse programs for family nurse practitioners

and for nurse anesthetists. The students are military officers who incur 4

additional years of obligated service for the 2-year course. The number of

students entering the program are shown in the following table.

23Endoscopy is the inspection of the inside of a hollow organ or cavity using an endoscope—a device

consisting of a tube and an optical system. Laparoscopic cholecystectomy is gall bladder surgery using

endoscopic procedures.

Page 48 GAO/HEHS-95-244 Military Physicians
Chapter 4 

Other Activities of the University

Table 4.1: Number of Graduate Nursing

Students Entering in Fiscal Years

1993-96 Fiscal year

Family nurse

practitioners

Nurse

anesthetists

1993 3 0

1994 12 9

1995 12 12

1996 (estimate) 12 20

Research,

Consultation, and

Archival Activities

The University conducts several research and archival activities both to

meet its accreditation requirements and to advance the practice of military

medicine. The research, consultation, and archival activities are conducted

by faculty and staff in many departments of the University, including

special centers for (1) casualty care research, (2) traumatic stress studies,

and (3) preventive medicine and public health. The activities of each of

these centers are summarized below.

Casualty Care Research Center: This center researches and investigates

issues related to injury control, casualty care, and disaster medicine. The

center employs medical and graduate students and full-time staff to

conduct its research, maintain a database of casualty care cases, and

provide consultation to other federal, state, and local government

agencies.

A key activity of the Casualty Care Research Center is the Counter

Narcotics Tactical Operations Medical Support program—a week-long

course for emergency medical technicians and paramedics who operate as

part of tactical law enforcement teams. Among other topics, this course

covers medical care while under fire, hostage survival, effects of ballistic

wounds, and evidence preservation. The staff also provides consultation to

law enforcement agencies.

Another mission of this center is maintaining the Wound Data and

Munitions Effectiveness Team, which contains information on the tactical

engagement, weapons employed, resulting injuries, and treatment of

approximately 8,000 Vietnam combat casualties. Its collection of

photographs, X rays, recovered bullets, and other data is the only one of

its kind.

Center for Traumatic Stress Studies: This center conducts research,

maintains archives of medical literature, and provides consultation for

psychiatric responses to trauma and disasters. Staff also collect on-site

Page 49 GAO/HEHS-95-244 Military Physicians
Chapter 4 

Other Activities of the University

data to facilitate longitudinal follow-up on disasters and traumatic events.

To illustrate, in 1992 a University psychiatrist traveled to Florida within 48

hours of Hurricane Andrew to provide emotional assistance to base

personnel and evacuees from Homestead Air Base. To increase its

knowledge in helping future victims, the University has surveyed

participants in military engagements (such as the Gulf War) and natural

disasters (such as Hurricane Andrew) to identify their emotional problems

and how to help them.

Centers for Preventive Medicine and Public Health: These centers develop

databases and analytic methodologies, and prepare curricula for and

evaluate processes and outcomes in clinical practice. They serve program

managers and policymakers in DOD, other federal agencies, local

governments, and private organizations concerned with health policies

and services. These centers address topics that receive little attention in

many civilian medical schools but are critical to the practice of military

medicine, such as foreign area medical studies, landscape epidemiology,

and health in extreme environments.

Page 50 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

DOD’s need for physicians has changed as a result of the emergence of

smaller regional threats at the end of the Cold War and the overall

downsizing of the military in response to large budget deficits. Our review

of DOD retention data shows that University graduates have the longest

expected retention among physicians from the various accession sources.

Because a higher percentage of University graduates are expected to reach

retirement (20 years), they contribute to DOD’s long-term need for

physicians and for medical specialists considered critical for wartime

needs. Scholarship program graduates, who are the largest source of

military physicians, generally have shorter careers.

Although DOD is reevaluating its future need for physicians, it has not

reached conclusions about the number of physicians needed or the

optimal length of time that physicians should serve. While the longer

pay-back obligation of University graduates is a key factor in their

retention, factors such as age, marital status, compensation, nonphysician

duties, and working conditions have also been associated with physician

retention. If DOD continues to need a cadre of experienced career

physicians, alternative strategies such as an enriched scholarship

component could be considered as a potentially more cost effective way to

meet DOD’s long-term need for physicians.

University and

Scholarship Program

Retention Patterns

In 1972, when the University and the scholarship program were

authorized, the University was expected to supply DOD’s long-term needs

for military physicians, while the scholarship program would supply the

majority of physicians for short-term needs. Early graduates of both

accession programs are still several years from retirement eligibility. Our

efforts to determine whether graduates of both programs had satisfied

their pay-back obligations were hampered by incomplete information on

other service commitments created by factors such as prior service,

academy attendance, or extended GME training. We reviewed DOD’s

retention databases to obtain estimates of the expected retention patterns

for University graduates and scholarship program physicians. These

databases incorporate information from retention experiences to date for

University and scholarship program physicians and projections of their

future retention based on historical experiences of physicians from other

accession programs.

Retention Rates for

Scholarship Program

Physicians

DOD has offered scholarships since 1973, but few scholarship program

graduates have served for 20 years to qualify for retirement. Our review of

DOD retention data shows that regular scholarship program graduates on

Page 51 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

average are expected to provide 9.8 years of service, while deferred

scholarship program graduates serve 5.3 years on average. Further, using

DOD retention data, we project that 11 percent of the regular scholarship

program and 3 percent of deferred scholarship program physicians from

the class of 1994 will reach retirement.

Retention Rates for

University Graduates

DOD’s retention experience with University graduates is also limited

because the first class graduated in 1980. As a result, the most senior

alumni have only 15 years of service.24 The DOD retention databases show

University graduates are expected to provide about 18.5 years of service,

and about 50 percent of University graduates are expected to stay on

active duty service for 20 years or longer. The longer expected retention of

University graduates is consistent with the legislative intent of providing

long-term military medical officers. In addition, our analysis of DOD

retention data shows that University graduates are retained at a higher

rate in the medical specialties considered critical for the wartime mission.

University Graduates Will

Likely Comprise Large

Portion of Peacetime

Medical Cadre

University graduates are expected to comprise a significant portion of the

medical cadre needed for long-term leadership. For example, although

University graduates were about 14 percent of the physicians who

graduated in fiscal year 1994 (the remaining 86 percent being scholarship

program participants), they are expected to comprise 47 percent of the

members from this class who stay 20 years or longer.

University Graduates Have

Greater Retention in the

Critical Medical Specialties

University graduates also have greater retention in those medical

specialties considered critical for war. Current readiness planning

considers the medical specialties of anesthesiology, orthopedic surgery,

and general surgery to be critical for the wartime need. However,

physicians in these specialties historically leave the military at faster rates

than those in other specialties. For example, Navy officials estimate that,

each year, the Navy loses about 22 percent of physicians in these

specialties, compared with an annual 11 percent loss for all physicians. A

review of Army data shows that a larger percentage of University

graduates are retained in these critical specialties than are graduates of

the scholarship program.25 The Army data show that, on average,

31 percent of University graduates in the three critical medical specialties

24Data maintained by the University show that 81 percent of its physicians who graduated between

1980 and 1985 have remained on active duty.

25Neither the University nor the scholarship program train graduates to be medical specialists.

Page 52 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

will stay 20 years, compared with 12 percent from the regular scholarship

program and 2 percent of deferred scholarship program graduates.26

DOD Is Evaluating Its

Overall Need for

Physicians

DOD’s ability to adapt to the changing nature of operational scenarios and

the challenges of providing cost-effective peacetime health care will be

key factors in determining physician needs for the military. Although

recent DOD studies suggest that large reductions have occurred in the

overall number of physicians, these studies do not indicate the optimal

retention needed for physicians from the various accession programs.

DOD Study Suggests

Lower Active Duty Need

DOD’s evaluations of its future physician needs have not led to conclusions

about the number of physicians required or optimal retention patterns.

The catalyst for these evaluations was section 733 of the National Defense

Authorization Act for fiscal years 1992 and 1993, which required DOD to

conduct a study to, among other things, determine (1) the size and

composition of the military medical system needed to support U.S. forces

during a war or other conflict and (2) the adjustments needed for

cost-effective delivery of medical care to covered beneficiaries during

peacetime. DOD’s study (referred to as the 733 study) estimated that DOD

has as many as 3 times the number of physicians it needs during peacetime

to meet projected wartime requirements, as shown in table 5.1.

Table 5.1: Active Duty Physician

Requirements as Portrayed in the 733

Study

Programmed for

fiscal year 1999

733 study

base case

733 study

augmented

during

peacetime

Active duty physicians 12,600 4,000 6,300

Percent difference from 1999

program

Not applicable –68% –50%

The base case in DOD’s study represents a 68 percent lower requirement

than DOD’s fiscal year 1999 program plan suggests, but refers only to those

active duty physicians needed to administer care to wartime casualties. It

excludes the additional numbers of physicians needed for readiness during

peacetime (the augmented case). In the augmented case, the study

concludes that the number of active duty physicians could be lower by

50 percent.

26DOD-wide data were not available.

Page 53 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

The 733 study results immediately prompted a review by the services of

their physician needs. Although the services have not disagreed with the

733 study results, their individual efforts produced higher estimates of

physician needs, primarily because their reviews were based on different

assumptions than were used in DOD’s study. Our review of the 733 study

and the service’s responses27 found that even if the services’ assumptions

are correct, the resulting requirements for military physicians would be

less than are currently planned for in 1999. The 733 study did not present a

precise estimate of DOD’s needs or a precise guide for deciding which

medical personnel, units, and capabilities are no longer required. Issues

such as these must be resolved before DOD can make decisions about its

retention needs.

Some Downsizing Has

Occurred

Since 1991, the total active duty physician force has dropped about

4 percent, from about 14,200 in 1991 to about 13,700 in 1994. Further

reductions to about 12,600 are scheduled by 1999 (11 percent overall).

However, according to service officials in the Offices of the Surgeon

General, most of the reductions between 1991 and 1994 were due to the

normal attrition of physicians through retirement, resignations, and

administrative leave. Navy officials also said some physicians were

allowed to transfer from active duty to reserve status, mostly as a result of

base closures.

These reductions in active duty physicians are slight when compared with

reductions in the entire force over the same period. Between 1991 and

1994, total military endstrength dropped about 20 percent, from 2.O

million to 1.6 million, and is expected to drop to 1.45 million by 1999

(about 28 percent). Service officials cited congressionally imposed limits

with respect to reductions of health care personnel and DOD’s continuing

responsibility to provide care to beneficiaries of DOD’s health care system

as reasons why greater reductions have not occurred in the physician

force.

DOD Required to Certify

Excess Need

Section 711 of the National Defense Authorization Act for fiscal year 1991

prohibits reductions in military (and civilian) health care personnel below

the number of such personnel serving on September 30, 1989, unless DOD

certifies to the Congress that (1) the number of personnel being reduced is

in excess of current and projected needs and (2) that the reduction will

27Wartime Medical Care: Aligning Sound Requirements With New Combat Care Approaches Is Key to

Restructuring Force (GAO/T-NSIAD-95-129, Mar. 30, 1995).

Page 54 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

not increase costs in the $3.6 billion DOD-administered health insurance

program for beneficiaries—the Civilian Health and Medical Program of the

Uniformed Services (CHAMPUS). DOD is also prohibited from reducing the

number of Navy active duty medical officers to fewer than 12,510

(including nonphysicians) unless DOD certification is accomplished.

Our review of the DOD certification documentation for fiscal years 1991 to

1995 indicated that the Army has led in the reduction of its physician

force. In fiscal year 1995, the Army was given authority to reduce its

physician force by 553 physicians after certifying this number was in

excess of their requirements and would not result in increased CHAMPUS

expenses. The Assistant Secretary of Defense for Health Affairs, as part of

the fiscal year 1995 DOD certification, requested the repeal of all legislative

provisions that prohibit medical staff reductions.28 Officials in the Navy

and Air Force stated that they have not sought to reduce the number of

physicians because they have not been able to obtain and retain the

targeted number of physicians they believe they need.

Tricare May Affect

Peacetime Needs

For several years, DOD has been testing alternative approaches to

delivering health care that increasingly incorporate managed health care

techniques. In this regard, DOD recently established its TRICARE program as

an alternative to the traditional CHAMPUS fee-for-service health insurance

plan covering beneficiaries of active duty members. TRICARE is intended to

provide an economical source of medical care for all DOD beneficiaries

even as medical service endstrength is reduced. A key component of

TRICARE involves contracting with civilian health care providers for

beneficiary health services. If TRICARE is successful, it could result in a

reduced need for active duty physicians as more care is provided by

civilian contractors. Progress made in the implementation of TRICARE was

one of the reasons mentioned by the Assistant Secretary of Defense for

Health Affairs for the proposed repeal of legislative provisions that

prohibit medical staff reductions.

Factors Influencing

Physician Retention

University graduates are retained in the military at higher rates than other

accession sources largely because of their longer pay-back obligations.

Also, some University students, such as those who graduate from the

military academies and the Reserved Officer Training Corps (ROTC)

programs, have existing obligations before becoming University students.

28DOD officials said that the repeal was not granted for fiscal year 1995, but is currently being

discussed by the Congress.

Page 55 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

Overall, many factors are associated with the decision to make the military

a career, including demographic and personal concerns such as age and

family considerations, compensation, and nonphysician activities.

Longer Pay-Back

Requirements Contribute

to Higher Retention of

University Graduates

Although DOD’s retention data indicate a relationship between retention

and accession source,29 the data do not indicate the reasons why these

patterns occur. However, the longer obligation pay-back requirement is a

key factor in the longer retention of University graduates. University

graduates are expected to serve for about 11 years after graduation,

including GME training, before they are first able to leave military service;

compared to about 8 years for the regular scholarship program and 4 years

for deferred scholarship program graduates. This longer pay-back

obligation period is expected to lead many University graduates to decide

to serve another 9 years until they are able to retire. University officials

said the longer retention may be partially due to their recruitment criteria,

under which they specifically attempt to select people who express an

interest in making the military a career. Hence, the longer retention is

consistent with students’ stated intentions.

Prior military obligation on the part of some of its students may also

influence University retention. Two 1994 military studies30 identified

military academy backgrounds, prior military experience, University

attendance, and fellowship training31 as predictive factors in the retention

of physicians in certain specialties. About 21 percent of all students at the

University have attended the military academies or participated in ROTC

programs. We previously reported that retention of these officers,

regardless of profession, is high.32 Another 25 percent of all University

students had prior military experience in that they were either currently

on active duty at the time they enrolled or they had prior active duty or

reserve experience.

29Retention rates also vary by service and medical specialty.

30“Retention Rates and Retention Predictors Among Graduates of Army Family Practice Residency

Programs,” Steinweg, Kenneth K., Journal of Military Medicine, Vol. 159 (July 1994), pp. 516-519), and

“Retention of Internal Medicine Physicians in the U.S. Army, Zaloznik, Arlene J., Journal of Military

Medicine, Vol. 159 (July 1994), pp. 520-523.

31Fellowship training is advanced GME that prepares a physician for a medical or surgical

subspecialty.

32Officer Commissioning Programs: More Oversight and Coordination Needed (GAO/NSIAD-93-37,

Nov. 6, 1992).

Page 56 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

Many of these predictive factors could apply to scholarship program

graduates as well. For example, Army scholarship program officials

suggested that the retention experience of ROTC and military academy

graduates in the scholarship program is similar to that of University

graduates from the same sources. Moreover, scholarship program

recruiters also look for people who are interested in making the military a

career. Lower retention among deferred scholarship program graduates

has been attributed to the fact that they are better able to network in the

civilian sector during their civilian GME programs and create private sector

opportunities for themselves. One DOD official who has contributed to a

number of DOD retention studies believed the retention patterns for all

physicians who stay 12 years is about the same, regardless of accession

source.

Other Factors Affecting

Decisions About a Military

Career

Many other factors influence physicians’ decisions to stay in or leave the

military. For example, personal characteristics, such as age and sex, family

considerations, and working conditions have all been found to influence

physicians’ decisions. More often than not, financial considerations have

been identified as a significant factor in retention. For example, in 1990,

we conducted a survey of 1,500 military physicians to determine the

factors that most influence their decisions to leave the military.33 Time

spent on nonphysician tasks and gaps between military and civilian

compensation were the most significant factors identified. Physicians also

reported dissatisfaction with other aspects of military service, such as

poor hospital equipment, the inability to provide continuity of care to

patients, excessive amounts of quality assurance tasks, and limited

opportunities to attend professional meetings and training.

Although many factors affect retention, a key DOD official involved in DOD

retention studies said that the options available to DOD to change retention

patterns are limited. For example, there may be little that can be done

about dissatisfaction with quality assurance procedures because these are

needed for hospital accreditation. The official also said that even in those

areas where DOD might have some control, such as physician

compensation, there are limits on the amounts that DOD can pay.

Moreover, he believes that for some medical specialties, DOD could not

match the compensation that these physicians could earn in the private

sector.

33Defense Health Care: Military Physicians’ Views on Military Medicine (GAO/HRD-90-1 Mar. 22, 1990).

Page 57 GAO/HEHS-95-244 Military Physicians
Chapter 5 

DOD’s Retention Needs Are Unknown

Other studies that examined why physicians stay in the military identified

the following reasons: the availability of teaching assignments and clinical

research opportunities; lack of worry about malpractice and office

management problems; more control over working hours; the collegial

atmosphere of military medicine; and the opportunity to travel.

Alternative Strategies to

Meet DOD’s Long-Term

Physician Needs

Proponents of the University note that the University meets DOD’s need for

a small cadre of experienced military officers and leaders who, in their

opinion, are better prepared for the special needs of military medicine. If

the University is closed and DOD continues to need experienced career

military physicians, DOD will need to find alternative ways to extend the

careers of some military physicians while enhancing their exposure to

military readiness training.

One approach could involve an enriched component to the scholarship

program which would require a longer pay-back obligation for selected

students in return for additional benefits, training, and military career

opportunities.34 Additional readiness training could be provided through a

post graduate period specifically designed to enhance the physician’s

preparation for the special needs of military medicine. Through this type

of two-tiered scholarship approach, DOD could address its short- and

long-term requirements for military physicians.

34GAO did not determine if scholarship students would have been willing to accept scholarships if their

service obligation periods were longer. Under this alternative strategy, the current elements of the

scholarship program, including the service obligation requirements, would not need to be changed for

the majority of scholarship applicants. The change in service obligation requirements could apply to a

small subset of scholarship applicants who would be specifically recruited for longer military careers.

Page 58 GAO/HEHS-95-244 Military Physicians
Chapter 6 

Conclusions

When the University and the scholarship program were authorized by the

Congress in 1972, following the end of the military draft, they were

intended to be complementary physician accession programs.

• The University was established to meet the need for a small cadre of

physicians who would be likely to become career military officers and

leaders.

• The scholarship program was authorized to provide a continuing and

larger supply of military physicians who would, for the most part, not be

expected to serve until their retirement.

Notwithstanding the intended complementary nature of the two physician

accession programs, the comparative cost-benefit and cost-effectiveness

of the programs have been the subject of debate ever since their

authorization.

Our prior work, this report, and several studies by other groups over time

show that by most measures the University program is a more costly

physician accession program than the scholarship program. Nevertheless,

those who advocate the continuation of the University make strong

arguments that the need for a cadre of military physician career officers

and leaders remains, and that the University fulfills that need well.

University supporters also note that in addition to providing a high quality

medical education, the University provides other benefits such as medical

research and archival programs, required continuing medical education for

overseas medical personnel, and graduate education programs for allied

health professionals. University officials stated that if the University were

not performing these tasks, other DOD components would have to be

tasked to carry them out.

The early retention history for University graduates indicates that the

majority of them are still in the military and fulfilling their service

obligations. Also, our review of DOD’s retention analyses shows that the

University would likely continue to meet DOD’s needs for a cadre of

military physician career officers. However, based on our review of

available information, we believe that if the University were closed, these

needs could be fulfilled by alternative strategies, such as adjusting the

pay-back requirements of scholarship students, revising the training

approach for those students to incorporate additional military unique

training sessions, or doing both.

Page 59 GAO/HEHS-95-244 Military Physicians
Chapter 6 

Conclusions

In our view, issues relating to the changed need for military physicians in

war and peacetime settings are important factors to be considered as

decisionmakers debate the future of both the University and scholarship

programs. The changed wartime scenarios, which point to a reduction in

the number of physicians needed to meet contingency requirements

should, in our opinion, be taken into account as the future existence and

the possible size of the accession programs are determined. Moreover,

DOD’s attempt to meet its peacetime care obligations to military

beneficiaries through increased reliance on its TRICARE managed care

program will also affect the number and type of physicians that DOD needs.

Matter for

Congressional

Consideration

The Administration’s National Performance Review has proposed that the

University be closed. This proposal has presented the Congress with

difficult policy decisions regarding the need for a cadre of physicians who

are likely to become career military officers and the most appropriate

means of retaining those physicians.

As Congress makes those decisions, it may wish to consider requiring DOD

to justify both the University and the scholarship program in the context

of DOD’s specific short- and long-term requirements for military physicians,

the role of the University and the scholarship program in satisfying those

requirements, and their relative costs.

Agency Comments We obtained comments on a draft of this report on September 15, 1995,

from the Assistant Secretary of Defense, Health Affairs, and his staff and

from the University’s President and other top University officials.

The Assistant Secretary stated that the report presents a great deal of

factual data and reflects a significant research effort in its collection and

compilation. Both the Assistant Secretary and University officials were

concerned, however, about several presentational issues including what

they viewed as

• a focus in our comparative cost analysis on the cost per graduate of each

program, rather than on the total cost to the taxpayer per staff year of DOD

service, which they believe is the appropriate measure of cost;

• a lack of emphasis on the activities of the University, which results in

cost-avoidance for other DOD components; and

• a lack of emphasis on the University’s unique contribution to providing

military physicians schooled in militarily unique medical subjects and our

Page 60 GAO/HEHS-95-244 Military Physicians
Chapter 6 

Conclusions

failure to acknowledge the “acculturation process” provided by the

University in meeting the needs of military medicine.

In response to our matter for congressional consideration, the Assistant

Secretary stated that, although the position of the Administration and the

Department is that the University should be closed, the Department noted

our recognition of the different goals of the two programs and their

complementary nature. He also stated that the Department does not

believe additional justification is needed for the University and scholarship

program and that the need for a long-term experienced cadre of military

physicians produced by the University and short-term physicians will

continue.

Regarding the first concern of DOD and the University, we recognized that

there can be and, in fact, have been several units of measurement used to

compare the relative costs of DOD’s physician accession programs. Rather

than offering one unit of measurement, we have presented, in an iterative

way, several units of measurement that we believe present a complete

comparative analysis of the programs.

We have revised the report to further emphasize the cost-avoidance

activities of the University but, as stated earlier, we did not validate the

University’s estimates of cost-avoidance.

The Assistant Secretary and University officials were concerned that we

had not appropriately emphasized the University’s unique contribution to

military medicine. In response, we have revised the report to reflect the

University’s approach to providing a complete education in military

medicine and made minor adjustments to the draft report. These

adjustments were designed to attribute statements about the unique needs

of military medicine and the University’s contributions without appearing

to question the credibility of our sources. However, we believe that

judgments regarding the relative emphasis placed on various issues

discussed in the report must be based on the evidence at hand. In this

case, the evidence was based primarily on our review of military medical

literature and discussions with military medical personnel who provided

their opinions regarding the uniqueness of military medicine.

Finally, in developing the matter for congressional consideration, we did

not envision that DOD would have to provide additional justification for the

accession programs. Rather, we believe that the two programs need to be

discussed in the context of DOD’s specific short- and long-term

Page 61 GAO/HEHS-95-244 Military Physicians
Chapter 6 

Conclusions

requirements for military physicians so that decisions regarding the

continued need for the programs and their relative sizes can be made with

confidence that the requirements will be adequately met.

Department and University officials offered several technical comments

on our draft report that we incorporated into the final report as

appropriate.

Page 62 GAO/HEHS-95-244 Military Physicians
Page 63 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

The National Defense Authorization Act for fiscal year 1995 directed us to

submit a detailed report to the Congress on the University. More

specifically, the report was to include the following:

• a comparison of the cost of obtaining physicians for the Armed Forces

from the University with the cost of obtaining physicians from other

sources;

• an assessment of the retention rate needs of the Armed Forces for

physicians in relation to the respective retention rates of physicians

obtained from the University and physicians obtained from other sources

and the factors that contribute to retention rates among military

physicians obtained from all sources;

• a review of the quality of the medical education provided at the University

with that provided by other sources of military physicians;

• a review of the overall issue of the special needs of military medicine and

how these special needs are being met by physicians obtained from the

University and physicians obtained from other sources;

• an assessment of the extent to which the University has responded to the

1990 report of DOD’s Inspector General including recommendations for

resolution of any continuing issues relating to management and internal

fiscal controls of the University, including issues relating to the Henry M.

Jackson Foundation for the Advancement of Military Medicine identified

in the 1990 report; and

• any other recommendations that the Comptroller General considers

appropriate.

The methodology for our review is discussed below.

Cost of Obtaining

Physicians

Our review of the costs of obtaining physicians for the military focused on

the historical educational costs for the graduating class of 1994 and the

projected postgraduation costs for additional training (including GME and

initial medical readiness training), salary, and retirement costs. In a

supplemental analysis, we included a proportional amount of (non-DOD)

federal funds provided to civilian medical schools and the University for

research and GME programs. We reviewed studies conducted by DOD, the

University, GAO, and others on various aspects of medical education costs,

including civilian undergraduate and graduate medical education. We held

discussions with officials of DOD, the University, and the Association of

American Medical Colleges on the relevant cost elements to be included.

We included elements that contribute to the cost of obtaining and

Page 64 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

retaining physicians and we attempted to ensure comparability between

cost elements in the programs.

Detailed Discussion of

Cost Methodology

Having determined our base year, unit of analysis, and cost elements, we

determined (1) the total cohort associated with the graduating class of

1994 and (2) the percentage of yearly costs to be applied to the cohort.

Tracking the 1994 Cohort The total cohort included:

• the original members of the class of 1994 that entered in 1991;

• extended matriculations from prior years (5- or 6-year students who were

scheduled to graduate with past classes, but who graduated in 1994); and

• student attrition (students who were scheduled to graduate in 1994, but

who dropped out of medical school).

We did not include the original members of the graduating class of 1994

who, at the time of our analysis, were expected to graduate in a

subsequent class. Under our methodology, the cost of these students

would be included in the costs of the class in which they graduate.

The University was able to provide all data needed to determine the total

cohort, while the scholarship program officials in the services had varying

success. Scholarship program officials were not able to provide useful

data on the extended matriculations in the graduating class of 1994.

However, they also said that they did not provide additional years of

scholarship for 5- or 6-year students. Army officials were not able to

provide attrition data by year. Navy officials did not provide any attrition

data. We averaged the attrition from the Army and Air Force programs and

applied it to the Navy. Table I.1 illustrates the tracking of the 1994 cohort

for the University.

Table I.1: Yearly Tracking of Cohort

Group Members at the University

(Fiscal Years 1989-94) Starting year 1989 1990 1991 1992 1993 1994

1994

graduates

1989 (6) 1 1 1 1 1 1 1

1990 (5) • 15 15 15 15 15 15

1991 (4) • • 149 142 142 139 139

Yearly 1994 cohort 1 16 165 158 158 155 155

Total students 660 667 673 648 658 671 •

Page 65 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

The table shows that the 1994 graduating class at the University had 16

extended matriculations from previous years. Also, 13 members from the

original freshman class (162) were excluded because, at the time of our

analysis, they were scheduled to graduate in subsequent years. As a result,

the start year 1991 shows 149 students instead of 162 students. There were

10 students from the original class of 1994 (start year 1991) who dropped

out of medical school altogether. Seven dropped out after the first year

and 3 dropped out after the third year.

Scholarship Program

Cohort Tracking

Because scholarship program officials were not able to provide

meaningful data on the number of 5- or 6-year students who graduated in

1994, the size of the yearly scholarship program cohort was largely

determined by the length of the scholarship. Table I.2 illustrates how we

tracked the scholarship program cohorts, using the Navy as an example.

Table I.2: Yearly Tracking of Size of

Cohort Group, Navy Scholarship

Program (Fiscal Years 1991-94) Award year 1991 1992 1993 1994

1994

graduates

1991 (4) 187 175 175 175 175

1992 (3) • 149 149 149 149

1993 (2) • • 14 14 14

1994 (1) • • • 1 1

Total cohort 187 324 338 339 339

Total scholarships 1,350 1,206 1,273 1,348 •

The table shows that the Navy provided scholarships of 4, 3, 2, and 1 years.

For example, a 4-year scholarship started in 1991, while a 3-year

scholarship started in 1992. Regardless, these start years led to a 1994

graduating date. We assumed that the Navy scholarship program

experienced all of its attrition after the first year.

Yearly Costs to the Cohort Having determined the size of the cohort in any year that a cohort member

was present, we then determined allocation factors to be used to

apportion a percentage of each program’s yearly educational costs to the

cohort. The allocation factors represent the yearly percentage of cohort

members to the total number of scholarships or students at the University

in any given year. For example, using the Navy table above, 187 members

of the 1994 cohort were among the 1,350 scholarships in 1991. The

percentage of the Navy’s fiscal year 1991 costs applied to the 1994 cohort

is represented by the fraction 187/1,350. In fiscal year 1992, the cohort lost

Page 66 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

12 students, but gained 149 3-year scholarships. Hence, the percentage of

1992 costs applied to the 1994 cohort is represented by the fraction

324/1,206. We calculated these percentages for each year that a member of

the cohort was present in the scholarship program and at the University.

Allocating Cost to the

Deferred Program

We allocated the educational and initial readiness training costs to the

deferred and regular scholarship programs using a four-step process. We

first calculated the individual service’s educational and initial readiness

training cost for the scholarship program as a unified program. We totaled

the service costs and multiplied the total by the ratio of deferred to total

scholarship program students and the ratio of regular scholarship program

participants to total. This same process was used to determine the initial

readiness training costs to be applied to each program, because there was

no difference in costs for this training.

Additional Federal Costs to

the Scholarship Program

A portion of federal expenditures that support civilian medical education

may be incurred to augment the supply of military physicians.

Identification of those expenditures, however, is problematic.

The federal government supports civilian medical education in two

primary ways. Medicare provides direct and indirect payments to teaching

hospitals to defray the costs of resident training. These amounts totaled

about $6.2 billion in 1994. The National Institutes of Health (NIH) and other

federal agencies provide funding for biomedical research, largely at the

undergraduate level. In 1994, NIH provided about $5.7 billion to support

research in medical schools. Officials at the AAMC suggested that these

monies could be applied directly to medical school programs for the

purpose of this analysis.

An apportionment of Medicare GME monies to reflect the funds incurred to

augment the supply of military physicians should reflect the fraction of

these scholarship students’ expected practice lives that will be spent in the

military versus the civilian sector. Estimates of the expected length of

civilian practice for military physicians is not easily obtainable, especially

for University graduates. However, the expected length of military practice

is about 5.3 years for deferred scholarship students, 9.8 years for regular

scholarship students, and 18.45 years for University students. Lacking the

data on expected civilian practice duration, we apportioned Medicare GME

monies based on the number of deferred scholarship residents and

University graduates who attended civilian GME programs relative to the

Page 67 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

total, and on the expected length of their military careers. This

apportionment, thus, overstates the Medicare GME expenditures that

should be attributed to DOD for preparation of medical students for military

service.35

Apportionment of the research funding received by medical schools

should reflect the expected length of military versus civilian practice.

Further, the apportionment should only include those research funds that

are directly or indirectly essential to maintaining an effective

undergraduate medical education program. Again due to the absence of

data on expected practice lives and on the portion of research funds

essential to maintaining schools’ medical educational program, we

apportioned the research monies based on the total number of scholarship

students compared with the total number of medical school students for

each year from 1991 to 1994, and on the expected length of their military

careers. This apportionment also likely overstates the research funding

that should be attributed to DOD for preparation of scholarship students for

military service.

DOD’s Retention Rate

Needs

To understand DOD’s need for physicians, we interviewed and obtained

documentation from the Office of the Assistant Secretary of Defense,

Health Affairs, and the Offices of the Surgeons General for each service in

order to understand (1) their processes for determining the number and

types of physicians required to fulfill their missions and (2) the impact of

DOD’s downsizing on the physician force levels. As part of this effort, we

held additional discussions with officials who were examining some of

these issues in PA&E and members of the DOD Roles and Missions

Commissions.

To assess how well physicians from the various accession sources served

the needs of DOD, we supplemented our discussions with the medical

planners in the Offices of the Surgeons General with interviews and data

gathered in the Office of the Assistant Secretary of Defense, Health Affairs,

and the Defense Data Manpower Center pertaining to the historical

retention of physicians by accession source, military service, and medical

specialty. The Office of the Assistant Secretary of Defense, Health Affairs,

also provided copies of several published and unpublished studies and

provided data pertaining to the retention of physicians. The service level

35Similarly, in this context, the costs to DOD for preparing University students is overstated, given the

fact that University graduates can be expected to spend a portion of their medical careers in civilian

practice.

Page 68 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

officials that we contacted all agreed that we should use these numbers to

discuss the historical and projected retention patterns of DOD physicians.

To examine the factors that influence physicians’ decisions to remain in or

leave the military, we obtained and reviewed studies from numerous

sources dating back to the 1970s. Appendix III is a listing of these studies.

Quality of Medical

Education

To determine how the quality of medical education provided by the

University compares with that obtained by other military physicians, we

identified generally accepted measures of medical education quality

through a review of the literature. We also held discussions with and

reviewed documentation provided by representatives of the University as

well as the accrediting body for U.S. schools of allopathic

medicine—LCME—which is a joint activity of the AAMC and the Council on

Medical Education of the American Medical Association. We discussed the

identified measures with representatives of the Surgeons General of each

military service and the Office of the Assistant Secretary of Defense,

Health Affairs. Among the measures identified, we assessed the following:

the accreditation status of the school, the academic credentials of the

students that the school admits, performance on standardized tests,

performance upon graduation, and negative indicators of quality.

We also examined documentation provided by the University concerning

its accreditation by LCME as well as the Middle States Association of

Colleges and Schools, which accredits institutions of higher learning. We

met with a representative of LCME to discuss the significance of concerns

raised during its most recent accreditation review of the University’s

School of Medicine and the response of the University to these concerns.

Representatives from the University and LCME said that the academic

credentials of the students that a medical school attracts are considered

an indirect reflection of the medical school’s quality. Two widely used

objective measures of academic achievement among medical school

applicants are undergraduate GPAs and scores on MCAT. The University

provided average MCAT scores and GPAs for University students and for

medical students nationwide (access to nationwide records is available to

the University as a result of its membership in AAMC). The Army and Navy

provided these averages for scholarship program participants, but the Air

Force was unable to do so.

Page 69 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

We used scores on the USMLE, a standardized test used by all 50 states as

part of the physician licensing process, as a basis for comparison of

medical education across all U.S. medical schools. The University

provided average scores and pass rates for its students and for medical

students nationwide for each of the three parts of the test.

To compare how well University graduates and scholarship program

graduates perform at the beginning of their medical careers, we examined

a sample of performance evaluations completed by supervisors of interns

from the University and other schools in military GME programs at the Air

Force’s Malcolm Grow Medical Center at Andrews Air Force Base,

Maryland; the Walter Reed Army Medical Center in Washington, D.C.; and

the National Naval Medical Center in Bethesda, Maryland. Because intern

performance evaluation procedures vary from program to program, we

were not able to examine the performance of interns beyond these three

hospitals. The results of our analysis cannot be projected to any other

group of interns. We also contacted the commanders of 33 of the largest

military medical treatment facilities to obtain their perceptions about the

relative clinical performance of University graduates and other military

physicians.

Finally, the Armed Forces Institute of Pathology provided information

concerning the number of adverse clinical privileging actions occurring

among graduates of the University and graduates of other medical schools.

The Institute provided the absolute number of actions for each group for

the period 1982 through 1994. We combined that information with data

about the number of physicians on active duty during that period to

determine the number of actions per 1,000 physician staff years.

The officials with whom we met suggested certain other indicators of

medical education quality that we did not include in our analysis. For

example, University officials suggested that we consider the rate at which

University graduates get their first choice among the service’s GME

programs—a measure favorable to the University whose graduates have a

very high first-choice rate. While the Army and Air Force also track this

measure, its usefulness is limited in that University graduates receive

counseling in choosing a GME program, with the result that they are less

likely to make inappropriate choices (that is, to select a GME program for

which they are not competitive). Scholarship program participants would

not routinely have access to such counseling. Another measure suggested

but not included in our analysis is board certification status of University

graduates compared with graduates of other medical schools. Although

Page 70 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

this measure is important to the services, it may be more reflective of the

GME program, rather than the undergraduate program that the physician

attends.

Special Needs of

Military Medicine

We used several techniques to identify the ways in which military

medicine differs from the practice of medicine in a peacetime setting and

how military physicians are prepared for these unique aspects of military

medicine. We collected information through a literature search and

through contacts with and documentation provided by officials throughout

DOD including the Office of the Assistant Secretary of Defense, Health

Affairs; the Joint Staff; the University; the offices of the Surgeons General

for each military service; the DOD Inspector General; training activities

throughout DOD; and commanders of some of the largest military medical

treatment facilities and selected deployable medical units.

Through discussions with DOD officials, we identified the training required

for new military physicians (basic officer training) and the training that

most new military physicians initially receive after coming onto active

duty (the Combat Casualty Care Course or similar training). Then, working

with University officials and representatives of each of these training

courses, we compared the medical readiness content of the training that

University medical students receive during medical school with that which

civilian-educated physicians would have after they complete basic officer

training and the Combat Casualty Care Course.

We asked DOD officials to identify measures that would indicate the

relative effectiveness of the University program to the approach used to

provide medical readiness training to military physicians who are

graduates of civilian medical schools. Officials suggested that in the

absence of specific measures of physicians’ preparedness to meet the

special needs of military medicine we consider other indicators such as

physician promotion rates, types of assignments held, awards received,

and levels of professional military education attained.

We examined but, for several reasons, rejected using these measures in

our report. For example, in examining a selection of records, we found

that they contained many inaccuracies. In addition, information about the

type of assignment held was often ambiguous; thus, it was not clear if a

physician was serving in a capacity that was primarily clinical or primarily

operational in nature. Using the number of awards received or levels of

professional military education attained could unfairly favor University

Page 71 GAO/HEHS-95-244 Military Physicians
Appendix I 

Objectives, Scope, and Methodology

graduates because many served in the military before they attended the

University. Finally, promotion data did not exist in a format that would

permit meaningful comparisons.

Because objective evidence is lacking concerning the relative effectiveness

of the University approach and other readiness training in preparing

physicians for the special needs of military medicine, we sought the

perspectives of leaders in military medicine. Through the Joint Staff and

the offices of the Surgeons General of each service, we posed questions to

the Command Surgeons of each of the unified commands, the

commanders of 33 of the largest military medical treatment facilities, and

the commanders of 18 of the Army’s deployable medical units. In total, we

queried 61 commanders, 44 of whom provided their opinions about the

University and other military physicians regarding their overall clinical

capabilities and their preparedness for the special needs of military

medicine.

Responses to

Inspector General

Recommendations

To determine the progress that the University has made in addressing the

recommendations made in 1990 by the DOD Inspector General, we

discussed the report, its recommendations, and corrective actions with

representatives of the University, the Henry M. Jackson Foundation, and

the Inspector General. We also reviewed corrective action documentation

that they provided and discussed with representatives of the Inspector

General plans for followup to their 1990 report.

Other Contributions

of the University

To identify functions of the University other than the medical education it

provides its students, we reviewed documentation provided by the

University, including correspondence, program descriptions, year-end

reports, and other documents. We also interviewed officials at the

University, including its President, the Dean of the School of Medicine,

department chairs, research office representatives, and various other

program officials. We also observed portions of its training program for

emergency medical technicians as well as a continuing medical education

seminar for physicians. Finally, we sought the opinions of commanders of

major military medical units regarding any benefits that they believe derive

from the University beyond the medical education it provides.

To identify school functions that are important for educating medical

students, we interviewed an official from LCME and reviewed its standards

for accreditation.

Page 72 GAO/HEHS-95-244 Military Physicians
Appendix II 

Comparison of Hours Spent in Initial

Medical Readiness Training

As part of its 4-year medical school curriculum, the University provides

coverage of many topics related to the special needs of military medicine.

Physicians who are graduates of civilian medical school receive such

training in basic officer training or the Combat Casualty Care Course (C4).

The following table shows the number of classroom hours spent in each

area by initial readiness training source. The subjects are grouped into

those that are primarily medical and those that are primarily military.

Within each of those groupings, the subjects are arranged in descending

order according to the amount of coverage that the University provides. As

mentioned previously, University students are required to attend the basic

officer training for their service branch. Thus, in addition to the amount of

coverage that the University provides, for example, 26 hours in

medico-legal issues, an Army physician who graduates from the University

will receive additional training (12 hours, in this case) by attending basic

officer training. (Field training hours for C4 are included within the other

subjects shown in the table.)

Page 73 GAO/HEHS-95-244 Military Physicians
Appendix II 

Comparison of Hours Spent in Initial

Medical Readiness Training

Table II.1: Comparison of Hours Spent

in Initial Medical Readiness Training

Medical subjects USU Army basic Navy basic

Air force

basic C4

Tropical medicine 66.0 0.0 0.0 0.0 0.0

Weapons effects 59.0 0.0 0.0 0.5 0.0

Combat medical skills 41.5 2.0 0.0 7.0 18.5

Nuclear, biological,

and chemical warfare 30.0 15.0 0.0 5.5 12.5

Military preventive

medicine 26.5 3.0 0.0 0.5 4.5

Advanced trauma life

support 26.0 0.0 0.0 0.0 20.0

Military psychiatry 22.5 8.0 2.0 1.0 1.5

Environmental threats 21.5 0.0 0.0 0.0 0.0

Advanced cardiac life

support 20.0 0.0 0.0 0.0 0.0

Military disease and

injury 18.5 0.0 0.0 0.0 1.5

Special infectious

diseases 15.0 0.0 0.0 0.0 0.0

Subtotal 346.5 28.0 2.0 14.5 58.5

Military subjects

Field training exercise 240.0 81.0 0.0 8.0 0.0

Defense studies and

military operations 42.5 11.0 23.0 2.5 1.5

Military field studies 35.0 12.0 0.0 0.0 11.5

Military organization

and administration 27.0 10.0 36.0 23.0 10.0

Medico-legal issues 26.0 12.0 10.0 1.0 0.0

History of military

operations 17.0 1.0 2.0 1.0 0.0

Subtotal 387.5 127.0 71.0 35.5 23.0

Total 734.0 155.0 73.0 50.0 81.5

Page 74 GAO/HEHS-95-244 Military Physicians
Appendix III 

Studies of Factors Affecting Retention of

Military Physicians

Cost Effectiveness Analysis of Two Military Physician Procurement

Programs: The Scholarship Program and the University Program

(GAO/MWD-76-122, May 5, 1976).

Federal Cost of the HPSP Program (GAO/HRD-76-140, June 15, 1976).

Physician Retention and the Cost-Effectiveness of the Uniformed Services

University of the Health Sciences; DOD/Office of the Assistant Secretary of

Health (Program Analysis and Evaluation) (July 1991).

The Cost of Physicians Accessions; Bircher, J. and Redman, R; Health

Studies Task Force, Office of the Assistant Secretary of Defense, Health

Affairs (Oct. 1987).

The Cost of Physicians Accessions; Prepared for the Senate Armed

Services Committee; Bircher, John; Office of the Assistant Secretary of

Defense, Health Affairs (Jan. 1988),

Physician and Dentist Retention; Bircher, John; Health Studies Task Force;

Office of the Assistant Secretary of Defense, Health Affairs (Dec. 1986).

Cost Analysis of the Military Medical Care System: Final Report; Institute

for Defense Analysis (Sept. 1994).

Military Health Services System Strategic Plan for Graduate Medical

Education; Office of the Assistant Secretary of Defense, Health Affairs

(Mar. 1994).

Graduate Medical Education Literature Abstracts; GME: A Review of the

Literature, Vector Research Inc. (Jan. 3, 1995).

Savings and Costs from Using the “Air Force Model” of GME, Carey, Neal,

Center for Naval Analysis (Feb. 8, 1995).

The Cost of Graduate Medical Education, Bircher J., and Ziskind B.; Office

of the Assistant Secretary of Health, Health Affairs, Health Studies Task

Force (1986).

Graduate Medical Education and Military Medicine, Institute of Medicine

(July 1981).

Page 75 GAO/HEHS-95-244 Military Physicians
Appendix III 

Studies of Factors Affecting Retention of

Military Physicians

Plan For Improving and Consolidating GME, Office of the Assistant

Secretary of Defense, Health Affairs (May 1992).

A Comparison of USUHS School of Medicine Graduate and the Health

Profession Scholarship Program Graduate in their First Year of GME: A

Descriptive Study, Chagallis, George, dissertation, (Feb. 20, 1984).

Military GME Under Stress: A White Paper, Society of Medical Consultants

to the Armed Forces (Oct. 1987).

Fourth Report of the Council on Graduate Medical Education to the

Congress and the Secretary, Department of Health and Human Services,

Council on Graduate Medical Education (Jan. 1994).

Measuring the Impact of the Navy’s Downsizing on Medical Officers Billets

Levy, R., and Carey, N.; Center for Naval Analyses (Nov. 18, 1993).

Defense Health Care: Military Physicians Views on Factors Which

Influence Their Career Decisions (GAO/T-HRD-89-10, Mar. 16, 1989).

Defense Health Care: Military Physicians’ Views on Military Medicine

(GAO/HRD-90-1, Mar. 22, 1990).

Retention Rates and Retention Predictors Among Graduates of Army

Family Residency Programs; Steinweg, Kenneth K.; “ Journal of Military

Medicine,” Vol. 159 (July 1994), pp. 516-519.

Retention of Internal Medicine Physicians in the U.S. Army; Zaloznik,

Arlene; “Journal of Military Medicine,” Vol. 159 (July 1994), pp. 520-523).

An Analysis of Factors Affecting The Retention of Medical Officers in the

United States Navy, Whalen, William P.; Naval Postgraduate School,

(master’s thesis) (Dec. 1986)

Correlations of Physician Retention at Tripler Army Medical Center,

Thomas, Brennand; U.S. Army War College, master’s thesis (Dec. 1991).

Socioeconomic and Personal Variables Effecting Retention of Medical

Officers; Cain, Russell L.; Naval Post-Graduate School, master’s thesis

(Dec. 1986).

Page 76 GAO/HEHS-95-244 Military Physicians
Appendix III 

Studies of Factors Affecting Retention of

Military Physicians

Medical Manpower Shortages and the Retention of Navy Physicians; May,

L., Graham, A., and Dolfini, J; Center for Naval Analyses (Mar. 1989).

The Impact of the All-Volunteer Force on Physician Procurement and

Retention in the Army Medical Department, 1973-1978; Brooke, Paul, U.S.

Army War College, master’s thesis (June 8, 1979).

Retention of Volunteer Physicians in the U.S. Air Force; Daubert, Victoria

L.; RAND Corporation (Feb. 1985).

A Turnover Analysis for Department of Defense Physicians; Gaffney,

James K.; Naval Post-Graduate School, master’s thesis (Dec. 1986).

A Retention Model for Navy Physicians; McMahon, J.; Center for Naval

Analyses (June 1989).

A Multivariate Analysis of Navy Physician Retention; Franco, Richard P.;

Naval Post-Graduate School, master’s thesis (Dec. 1989).

Retention of Navy Physicians, FY 1984-1988; May, L. and Graham, A.;

Center for Naval Analyses (June 1989).

U.S. Air Force Physician Retention; Rodgers, Lee P.; Air War College,

master’s thesis (Apr. 1990).

Recommendations for Improving the Bureau of Medicine Information

System May, L., Graham, A.; and McMahon, J.; Center for Naval Analyses

(June 1989).

Procurement and Retention of Navy Physicians Divine, Eugene J.; Center

for Naval Analyses (Nov. 1973).

Page 77 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

The DOD Inspector General (IG) reviewed the University in June and July

1989 to evaluate the adequacy of the University’s planning and program

execution and to assess the effectiveness of its oversight and management

controls. In its April 1990 report, the IG recommended corrective actions in

six categories: (1) management and organizational oversight, (2) finance,

(3) personnel, (4) acquisition, (5) information resources, and

(6) laboratory animal medicine. In October 1994, the IG closed the

inspection based on the University’s corrective actions reported over a

4-year period. A summary of the IG findings and the response from the

University follows.

Management and

Organizational

Oversight

The IG’s report made nine recommendations dealing with the University’s

management and organizational oversight. These recommendations

covered issues involving (1) the need for improvements in internal

controls; (2) participation in operational and research projects in foreign

countries without formal, written agreements; (3) failure to implement an

effective drug testing program; and (4) failure to use commercial entities

for services whenever appropriate, in accordance with the Office of

Management and Budget’s (OMB) Circular A-76.

Internal Controls The legislation authorizing the University allows the Board of Regents to

enter into contracts with the Henry M. Jackson Foundation, a

congressionally established not-for-profit organization for the

advancement of military medicine. The legislation allows the Board to

furnish the services of professional, technical, or clerical personnel and to

make University facilities, equipment, space, and support services

available to the Jackson Foundation. The IG found that the University had

assigned personnel to perform the same work for the Jackson Foundation

as they did for the University. By doing so, the University created an

appearance of a conflict of interest and eliminated essential internal

controls governing the separation of authority, duty, and responsibility.

For example, the president of the University, at the time of the IG

inspection, was a director and served as the secretary and treasurer of the

Jackson Foundation. As the University president, he had the responsibility

and authority to manage and control all University resources, including

research programs, and to oversee the administrative functions. At the

Jackson Foundation, he directed the day-to-day business and entered into

contracts, leases, and cooperative agreements.

Page 78 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

According to the IG, the University is subject to DOD’s internal management

control program, which is designed to provide necessary controls over the

accountability and utilization of DOD resources to prevent instances of

fraud, waste, and abuse. The University was required to evaluate its

internal controls and rate identified assessable units from high- to low-risk

vulnerability. In the assessment done in 1986, the University found no

weaknesses, and all units were rated low-risk. This occurred again in 1988,

shortly before the IG’s inspection. The IG could find no documentation to

indicate that the internal management control systems were tested in

several critical functional areas, such as logistics; contracting; the care,

treatment, and security of animals used in training and research; and

pharmaceutical management.

In December 1990, DOD issued a policy statement on the support and

resources shared between the University and the Jackson Foundation. In

1991, a general operating agreement and several subagreements between

the University and the Jackson Foundation were signed. However, support

provided by the University to the Foundation or by the Foundation to the

University in the same functional area require separate subagreements.

Billing schedules are quarterly and are paid in full. Additionally, 34

Jackson Foundation administration positions were reviewed and 7

converted to federal civil service.

The Naval Academy’s internal control system was used to shape a similar

system for the University, an internal control plan for implementation of

the Federal Manager’s Financial Integrity Act was established, and midand long-range plans were developed.

International Agreements Under Public Law 92-426 as amended, the Board may enter into

agreements with foreign military medical schools for reciprocal education

programs. The procedures to establish an agreement for student exchange

or a joint research program begin with informal discussions between the

University and foreign country representatives. A formal agreement is

prepared by the University’s General Counsel and is approved by the

Board. The agreement is then coordinated through the Deputy Director for

International Affairs; the Office of the Assistant Secretary of Defense,

Health Affairs; and DOD’s General Counsel. The Secretary of Defense signs

the agreement after completion of the coordination.

The IG found that the University was actively engaged in research projects

in countries that had no existing DOD-approved agreements. Agreements

Page 79 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

with Belize, Pakistan, and the People’s Republic of China had been in the

coordination phase at the Office of the Secretary of Defense for up to 2

years at the time of the IG inspection. University medical researchers

regarded these delays as a reason to begin work on their projects without

waiting for approval. They were managing these projects based solely on

informal arrangements. The President of the University approved and

supported these projects with DOD resources. The Board had the

responsibility to consider the ramifications of conducting operations in a

foreign country without a formal agreement.

The University subsequently established procedures to comply with DOD

requirements. The new procedures provide that no government resources

be committed until an approved agreement is signed. The approval

process requires the University’s General Counsel to collect and assemble

the agreement package and provide simultaneous copies to the Office of

the Assistant Secretary of Defense, Health Affairs, and DOD’s General

Counsel. The University’s Board of Regents requires that all proposed

international agreements be provided to the Board before the start of

negotiations and again once negotiations have been completed, but before

implementation.

The University also entered into memoranda of understanding with the

governments of Belize and Pakistan. The University determined that its

activities in Zambia were adequately covered by specific contracts. No

agreement was concluded with China and no operations or resources were

committed there. According to a University official, the University

currently has agreements with Canada, Denmark, Pakistan, the United

Kingdom, and Israel.

Drug Testing Programs to ensure a drug-free work place are required by DOD for the

safety, health, and productivity of its employees and the public they serve.

The Secretary of Defense directed each of the services to develop drug

abuse prevention and control programs.

The University, as part of the DOD medical community, should place

special emphasis on drug programs. The IG, however, found that an

inadequate number of military personnel assigned to the University had

been tested for drugs. As a result, the University updated its procedures

for the drug testing of all military personnel assigned to it, with the goal of

testing 100 percent of the military personnel at least once a year. The

implemented instructions contain internal control provisions that assure

Page 80 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

appropriate action is taken by the University or the military services when

a drug test proves positive.

In April 1990, the University also implemented procedures for the drug

testing of certain civilian employees (Chairman, Board of Regents

members, all persons with top secret security clearances, motor vehicle

operators, and faculty members who handle or manage controlled drugs).

Currently, 194 civilians are subject to drug testing out of an employee

work force of approximately 800.

OMB Circular A-76 OMB Circular A-76 requires reliance on commercially available sources to

provide products and services that the government needs. DOD supports

the policy through its commercial activities program. DOD components

have been directed to implement the program, designate a program office,

complete an inventory of all commercial functions, and report program

data to the Under Secretary of Defense for Acquisition.

The IG found, however, that the University’s inventory of commercial

activities included data on activities such as medical and dental

equipment; research and development support; data processing services;

training support; and the maintenance, repair and alteration of real

property, but excluded other functions such as printing and reproduction,

audiovisual, and library services. Further, the University did not have a

special program office to ensure that the program was carried out.

In response to the IG’s finding, the University implemented commercial

activities program procedures and contacted the A-76 representative for

the National Naval Medical Center to coordinate all program matters. The

University updated its inventory of commercial functions and added

printing and reproduction, audiovisual, and library services. In compliance

with DOD instructions, the commercial activities inventory report has been

submitted to the Assistant Secretary of Defense, Production and Logistics.

The report included a schedule for cost analysis of those functions subject

to the program.

Finance Three federal appropriations are the major sources of funding for the

University: operation and maintenance; research, development, testing,

and evaluation; and procurement. The University also receives

reimbursements for research projects in the form of grants or contracts.

The IG’s review found that the University did not have an organizational

Page 81 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

master plan that describes the University’s methodology for achieving its

mid- and long-range mission objectives and requirements. The purpose of

such a master plan is to establish a logical path toward accomplishing the

mission, set mission priorities, and provide reasonable justification for

resources.

The IG’s review showed that the University’s budget proposals were

generally straight-lined from one year to the next. The only notable

changes were the effects of inflation. Because no master plan existed,

University department heads independently determined the requirements

needed for their operations and projects and submitted them to the

financial management directorate. The submissions were approved by the

Board and provided to DOD’s Comptroller for inclusion in the DOD budget.

The IG’s review also showed that the University had not validated

personnel requirements with DOD. DOD requires its components to manage,

provide resources, and evaluate activities based on output performance

requirements and standards documented in performance statements. The

University’s 1989 budget request identified $24.8 million for civilian

personnel or 67 percent of the University’s annual appropriated budget.

(Military personnel were included in the respective service budgets.) No

personnel baseline was identified from which to establish resource

requirements, nor could changes in work load be tracked. Personnel

requirements were based on comparisons with civilian medical schools or

general functional duties instead of performance requirements or work

load analysis of actual duties.

The IG found that University funds are allocated based on judgments of

what programs were considered important at the moment rather than on

an established plan. For example, the then University president decided to

divert funds to increase support to the Jackson Foundation to prevent the

financial ruin of the Foundation. The IG found that the amount of the

diversion was not determined analytically based on accurate cost data,

and no complete, accurate analysis of the impact of the transfer of funds

was made.

Other than quarterly meetings of the University Board, the IG found no

established budget review procedures. The IG concluded that the Board

did not conduct in-depth reviews of mission performance or budget

execution. The University had no systematic measurement of progress to

ensure that resources were being applied to mission requirements, as

requested in original budget proposals.

Page 82 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

Through a questionnaire distributed to its staff, the University conducted a

personnel study that was completed in January 1991, and validated by an

independent contractor. The survey justified 867 civilians, 309 uniformed

personnel, and 173 Jackson Foundation employees to work in direct

support of the University’s mission. A Table of Distribution and

Allowances was developed for each of 78 administrative work centers

identified in the study and its validation.

The Board of Regents formed a Planning Committee to administer the

development of mid- and long-range master plans. A strategic planning

group developed a strategic plan that was issued in December 1993, based

on the results of accreditation self-studies. This plan is to be updated as

conditions warrant.

The University requested DOD approval of the College and University

Finance System as the University’s accounting system. The Defense

Finance and Accounting System reviewed the system in February 1992,

and approved its use for reporting purposes under the Federal Managers

Financial Integrity Act.

Personnel

Management

The Inspector General’s report made seven recommendations dealing with

the University’s personnel system. These recommendations covered issues

involving (1) classification and position management, (2) merit promotion,

(3) equal employment opportunities, (4) training programs, and (5) federal

and state income tax.

Classification, Position

Management, and Merit

Promotion

Federal personnel law requires that in determining the rate of basic pay

the principle of equal pay for substantially equal work be followed. The

University published internal instructions to support federal personnel

law, directing each supervisor to certify the accuracy of positions on a

yearly basis and to prepare evaluation statements for supervisory

positions. The IG’s review found that the University was not complying

with either the intent of the federal law or its own instructions. For

example, the IG’s review included a random sample of 50 position

description and evaluation statement documents and found that there was

either no evaluation statement or the documentation did not properly

support the grade of supervisory positions. In two instances, an evaluation

statement that supported a lower grade was attached to a position

description as supporting documentation. In 17 other instances there was

no evaluation statement for positions in a mixed general schedule grade

Page 83 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

series. Without evaluation statements, there was no rationale to explain

how the grade levels were determined.

Seven of the 50 position descriptions that the IG examined had the same

duties and responsibilities but were classified at different grade levels.

Through comparison of University positions with the DOD Average Grade

Statistics, the IG concluded that misclassification of positions was a

systemic problem at the University. For example, the University had two

positions for GM-341, Administrative Officer, classified at the GS-14 level

that were comparable to the DOD average grade level of GS-11 for the same

position.

The IG also found that the University had failed to support and implement

basic merit promotion procedures for filling positions. According to the IG,

the practice of noncompetitive promotions was commonplace at the

University, with the following types of violations identified:

• adding duties to positions with known promotion potential and promoting

the incumbent without competition,

• noncompetitive promotion from one job series into a different series,

• managers preselecting individuals for promotion by memorandum or

notation on the personnel action form,

• reassignment of unqualified employees into key positions with promotion

potential, and

• failure to properly document promotion actions.

The Office of the Secretary of Defense and the Office of Management and

Budget conducted an evaluation of the University civilian personnel

program and, as a result, delegated the personnel appointing and position

classification authority to the Washington Headquarters Service which

developed a detailed plan of action for correcting the deficiencies. Data

pertaining to alleged prohibited personnel practices were collected by the

University and the Washington Headquarters Service. The IG determined

that the University took appropriate actions, which included replacing the

president, vice-president of operations, and civilian personnel officer. A

100-percent position reclassification or restructuring was conducted,

which resulted in savings of about $200,000.

The University implemented internal control procedures and established

standard operating procedures for civilian resource management. The

University also established instructions for the completion and approval of

Page 84 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

requests for personnel actions and for the merit promotion and placement

program .

Equal Employment

Opportunities

The IG identified three equal employment opportunity (EEO) violations at

the University:

• the EEO responsibilities were not included in position descriptions of

individuals assigned EEO responsibilities;

• of 80 University supervisors, 25 did not have EEO has a critical element in

their performance standards; and

• pictures of EEO representatives were not displayed on any public bulletin

board.

EEO responsibilities were incorporated in all appropriate position

descriptions when classification audits were done as part of the

100-percent reclassification review. An Equal Employment Officer began

work in July 1991, and a University EEO instruction was implemented in

May 1993.

Training Program In its review of the chief personnel officer’s activities, the IG found a lack

of oversight and improper management of the University’s training

program. Employees did not receive the training required to satisfactorily

perform their jobs, such as mandatory training for contracting officers.

Supervisors and managers were not fulfilling their obligations to manage

training dollars and improve the management of staff resources.

An experienced employee development specialist was appointed in

August 1991 and was charged with developing a functional program to

meet or exceed legal and regulatory requirements. The University now

requires an individual development plan for all employees in formal

training programs. All others must be supported by an individual

development plan or a written department or office training plan.

Federal and State Income

Tax

The IG found that the University had not established procedures to ensure

the collection of federal and state income taxes from foreign exchange

students and recommended that the University review all records

pertaining to the Exchange-Visitor program to correct tax withholding

discrepancies. The IG also recommended that the University develop

Page 85 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

written procedures and policies to ensure administrative controls and

oversight of the program.

A University standard operating procedure was finalized in February 1990.

All affected employees who were on board at the time of the IG’s review

were contacted and all required tax forms were completed.

Acquisition The IG focused its review on issues relating to the University’s

implementation of standard DOD logistics support methods and compliance

with the Federal Acquisition Regulations and the Defense Federal

Acquisition Regulation Supplement. The IG made nine recommendations

involving six issues: (1) contracting and auditing procedures, (2) logistical

support, (3) property management and accountability, (4) controlled items

and substances, (5) records management, and (6) cafeteria operations.

Contracting and Auditing

Procedures

The IG found that the University was awarding contracts without field

pricing. The purpose of field pricing is to give the contracting officer a

detailed analysis of a proposal for use in contract negotiations, such as

providing the basis for price determination. For example, an $8.9 million

contract was awarded on the last day of fiscal year 1988 but the contract

proposal was not received until November of 1988. The contract amount

on the proposal was $8.8 million. According to the IG, this contract was

awarded on the basis of available funds rather than on contracting

principles.

Another purpose for field pricing is to establish indirect cost rates for the

negotiation process. Without field pricing, the contracting officer had to

rely on previous indirect cost rates that were based on a lower volume of

sales by the contractor (the higher the sales volume, the lower the indirect

cost rate for a particular contract). The IG found that field pricing may

have saved the University over $200,000 on the $8.9 million contract.

Under the Office of Management and Budget guidelines for nonprofit

organizations doing business with federal agencies, the agency with the

largest dollar value of awards will be the cognizant audit agency for the

negotiation and approval of indirect cost rates. The assignment will not be

changed unless there is a major long-term shift in the dollar volume of the

federal awards to the organization. At the time of the IG’s review, the

cognizant audit agency for the Jackson Foundation was the Department of

Health and Human Services. However, a 1989 award from DOD had resulted

Page 86 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

in a major long-term shift in the dollar volume of Jackson awards from the

Department of Health and Human Services to DOD. According to the IG, the

University should have requested that DOD assume audit responsibility for

the Jackson Foundation but had not made such a request to DOD.

Since June 1990, the Contracting Division has experienced 100-percent

turnover in personnel. All new contract division personnel have been

made aware of the requirements of the Federal Acquisition Regulations,

with respect to field pricing support. The Contracts Division has

implemented DOD procedures for documenting contract negotiations for

awards exceeding $100,000. Contracts division personnel have received

mandatory training funded through the DOD Acquisition Enhancement

program.

Upon urging from the University, the Defense Contract Audit Agency

agreed to assume audit responsibility for the Jackson Foundation. In 1991,

the Defense Contract Audit Agency informed the Jackson Foundation that

it had full audit cognizance for contracts for fiscal year 1989 and forward.

Logistics Support According to the IG, the University had failed to use the Defense

Asynchronous Message Entry System for its procurements, which resulted

in duplicated efforts in the requisition process. The System permits the

University to submit machine-processible requisitions to the Defense

Automated Addressing System Office, which then transmits the

requisitions to the appropriate federal supply source. Instead, the

University relied on a manual system to requisition items stocked by the

Defense Logistics Agency or the General Services Administration. The

requisitions were mailed to those activities, where they were input into

automated logistics systems. According to the IG, if the University had

used the Defense Asynchronous Message Entry System only one

transaction would have been needed, and the margin of error would have

decreased because of built-in quality checks.

In November 1989, the Defense Asynchronous Message Entry System was

fully implemented by the University and is being used for placing all

Defense Logistics Agency and General Services Administration orders, as

well as receiving on-line status of requisitions.

Property Management and

Accountability

The University’s Logistics Division was responsible for administering and

directing the property management program. The program includes

Page 87 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

warehousing of all equipment and furniture assigned to the University and

receiving, identifying, delivering, and controlling all property entering or

leaving the University. The IG found that the University did not use

effective warehousing practices. Property was stored in a parking garage

and was vulnerable to waste, loss, unauthorized use, damage, and theft.

Property stored in this area was secured by a ceiling to floor chain-link

fence with two entries locked with standard padlocks.

In March 1989, an inventory of the University property identified about

$471,000 worth of property that was unaccounted for or lost. The

University’s vice-president of operations directed that all property items

valued at less than $500 and not accounted for be deleted from the records

without further investigation. This property was valued at about $138,000.

A new storage building was built and all accountable property moved into

it. The University has issued personal property reporting and disposal

procedures and developed an 83-element property management checklist.

The University also developed a property custodian guide and procedures

for accounting for lost, damaged, or destroyed property. All property

custodians were trained by January 1992. During biannual inventories, all

property custodians are briefed before beginning their inventory and new

custodians are given a property custodian briefing.

Controlled Items and

Substances

The University pharmacy is located in the Department of Laboratory

Animal Medicine and is responsible for the procurement and management

of controlled and noncontrolled pharmaceutical items required to support

the University’s teaching and research mission. The IG found that the

University violated security requirements for controlled items,

promulgated by DOD. One of the basic security measures required is a

limited access area defined by a barrier extending from floor to ceiling.

Hypodermic syringes and needles were stored on shelves and carts in the

back of the self-service store. All employees of the store had access to the

storage area.

The University supplements the DOD directives with standard operating

procedures including detailed security procedures for the pharmacy safe.

The IG found however that, with few exceptions, the security procedures

were not followed during a test period. Further, in 19 instances the same

person initialed opening, closing, and checking the safe.

Page 88 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

More specifically, the IG found that the pharmacy officer did not maintain a

complete and accurate inventory of all controlled substances as required

by University regulation. Further, the IG stated that the University’s failure

to adhere to established controls over the inventory resulted in inaccurate

inventory balances, loss of accountability, over- or underprocurement of

supplies, and the opportunity for theft or misuse.

In June 1991, the University issued procedures that implement previous

University and DOD instructions and federal regulations. Also,

unannounced reviews are made at least three times a month to ensure that

logs to record opening and closing of the pharmacy safe are completed

and that departments receive monthly controlled substance reports.

Records Management DOD has established a records management program that identifies

responsibility for the life cycle management of records from creation

through maintenance, use, and disposition. The IG found that the

University had no procedures for a centralized records management

system: each office kept its inactive files either with current files or in

storage areas that had not been designated as records holding areas. In

areas inspected, there were boxes of records that were undated, not

labeled, and opened with files in disarray; boxes were thrown together and

haphazardly stacked; and some had water damage while others were

crushed.

The University has implemented the DOD Records Management Program

and used the Records Management Division, Washington Headquarters

Services, to train University personnel in records management. Training

was completed in May 1991. IG followup found that all offices were in

compliance with University procedures. Schedules for scientific, research,

and educational records have been approved by the National Archives.

Cafeteria Operations The IG’s review of University food service personnel records showed that

the employees did not have certificates or documentation to indicate that

they had received the required initial and refresher training in food service

sanitation principles. Additionally, the IG found that only 5 of 30 required

bimonthly inspections had been conducted by the University from October

1987 to June 1989.

The IG requested to see the food handler cards of the cafeteria employees;

only 2 of the 11 employees could produce their cards. Further, 7 of the

Page 89 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

employees did not have physical examinations before their initial

assignment. One of these employees had tested positive for tuberculosis.

All current employees have been issued food handler cards by the

Occupational Health/Preventive Medicine Department, National Naval

Medical Center, and all new employees are required to obtain food handler

cards. All full-time employees also have completed food service training

sponsored by the Bureau of Medicine and Surgery.

Information

Resources

The information resources at the University consist of automated

information created and maintained for day-to-day operations and to meet

reporting requirements and information collected from and disseminated

to public sources. The University Computer Center is responsible for

implementing life-cycle management controls, approving hardware and

software purchases, and maintaining an accurate inventory and records of

accountability.

The IG found that the University had not followed DOD life-cycle

management procedures in the development, acquisition, and management

of automated data processing systems and resources. Specifically, the

University did not complete the definition and design phase for the

automated financial system, the College and University Finance and

Accounting System. The University had not defined the performance

factors necessary for the operation and assessment of the financial

system. System objectives such as performance, size and complexity of

transactions, response times, types and formats of reports, and internal

controls were not documented. Because the University did not establish

system objectives and performance factors, it had no means to accurately

evaluate the system’s efficiency, functional performance, and benefits to

the organization.

The IG found no written procedures to establish the University Computer

Center’s responsibility for reviewing and approving all automated data

processing procurements. The lack of written procedures prevented

enforcement of the University Computer Center’s responsibilities, which

resulted in circumvention of the life-cycle management process and

unapproved purchases. The University’s instructions covering automated

information systems were reviewed and found to provide adequate policy

guidance for most life-cycle management procedures. This policy

statement was rewritten in June 1993. Internal policies have been

implemented for the processing of systems development and maintenance

Page 90 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

requests. Acquisitions of all automated data processing equipment and

software are reviewed before purchasing and small system decision

papers are required for all microcomputer purchases.

An information resources management plan has been prepared with 5-year

costs and alternatives for all projected information resources management

initiatives. These initiatives have integrated the needs of the departments

with those of the University as a whole.

The University established the Air Force Accounting System as the

baseline to evaluate the College and University Financial System for

efficiency, functional performance, and benefits to the organization. A

Defense Finance and Accounting Service evaluation of the system found

that it is in compliance with GAO, Office of Management and Budget, and

DOD requirements. In April 1992, procedures were established and

implemented in the College and University Financial System to record all

transactions associated with the Jackson Foundation cooperative

agreements.

Laboratory and

Animal Medicine

The Laboratory Animal Medicine Department provides the University with

animals for teaching and research, develops and implements policy for

care of the animals, and maintains a professional and technical staff for

veterinary medical care. The IG found the University’s animal facilities

extremely clean and well ventilated and lighted. However, the IG found

some problems covering record keeping, security, and protocol reviews.

Animal Research Records The IG found that animal records were not adequately maintained and that

there was no system for quality control. The University has issued

directives that require documentation of all animal related activity,

including information on the general condition of the animals. The

purpose of this information is to provide a history of teaching and

research projects and documented evidence to validate the outcome of the

projects. The IG also found a breakdown in management controls over

recording transactions for controlled substances. Controlled substances

are used as anesthetic agents to prevent pain and suffering of the animals

during animal surgery and research analysis.

Corrective actions and a quality control system have been implemented to

ensure cage or animal numbers are included on the records. Procedures

have been implemented to ensure copies of the anesthesia records are

Page 91 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

filed in the appropriate animal’s health record. A quality assurance system

for animal records, consisting of an 89-item record audit checklist and 8 to

10 audits per month, has been implemented.

Laboratory Security The security of the facilities housing the animals that the University uses

in teaching and research programs is paramount to the safety of the

animals and the integrity of the research programs. The University’s

security system consists of a number of locked doors that can only be

opened by access cards. The cards are programmed to allow entry only

into certain areas and only during certain hours.

The IG found that 37 percent more cards had been issued than needed for

the number of people conducting research with animals. The University

did not have written guidelines for issuing the cards or an accurate

inventory of the access cards.

The University developed written instructions that were issued to each

individual when they were issued an access card. A random spot-check of

card holders entering the animal facility is conducted, then

cross-referenced against the issued card inventory. Should a discrepancy

be noted, it is investigated and resolved by the central animal facility

security officer. All excess cards that have not been issued are stored in a

combination safe with a current inventory list.

Animal Review Board The University established the Laboratory Animal Review Board to carry

out DOD requirements. The board reviews research and teaching protocols

using animals, recommends approval or disapproval, and conducts

periodic inspections of animal facilities. The IG found that the review

board had inadequately managed animal research protocol reviews.

The review board used a research protocol review request log to keep

track of the review and approval process. An IG comparison of the log with

the original research proposal showed that in 50 percent of the cases

examined the original proposal document did not have a signature to

match the reviewer shown on the log. Also, the IG found that none of the

original research documents examined was reviewed by all nine review

board members; at most four members had signed as reviewers. In one

instance, the chairman of the board was the originator of the proposal and

was the only member to approve the protocol.

Page 92 GAO/HEHS-95-244 Military Physicians
Appendix IV 

Responses of the Uniformed Services

University of the Health Sciences to the

Inspector General’s Recommendations

Procedures have been instituted requiring reviewers to submit signed

review sheets with their comments recommending approval or

disapproval. The final decision on proposals will be determined by a

quorum of members at the review committee meeting, and the chairman

will not be the signing authority for proposals on which he or she is the

principal or participating investigator.

(101462) Page 93 GAO/HEHS-95-244 Military Physicians
Ordering Information

The first copy of each GAO report and testimony is free.

Additional copies are $2 each. Orders should be sent to the

following address, accompanied by a check or money order

made out to the Superintendent of Documents, when

necessary. Orders for 100 or more copies to be mailed to a

single address are discounted 25 percent.

Orders by mail:

U.S. General Accounting Office

P.O. Box 6015

Gaithersburg, MD 20884-6015

or visit:

Room 1100

700 4th St. NW (corner of 4th and G Sts. NW)

U.S. General Accounting Office

Washington, DC

Orders may also be placed by calling (202) 512-6000 

or by using fax number (301) 258-4066, or TDD (301) 413-0006.

Each day, GAO issues a list of newly available reports and

testimony. To receive facsimile copies of the daily list or any

list from the past 30 days, please call (301) 258-4097 using a

touchtone phone. A recorded menu will provide information on

how to obtain these lists.

For information on how to access GAO reports on the INTERNET,

send an e-mail message with "info" in the body to:

info@www.gao.gov

PRINTED ON RECYCLED PAPER
United States

General Accounting Office

Washington, D.C. 20548-0001

Official Business

Penalty for Private Use $300

Address Correction Requested

Bulk Rate

Postage & Fees Paid

GAO

Permit No. G100
GAO/HEHS-95-244 Military Physicians