The Department of Defense (DOD) has about 13,700 active duty physicians, nearly 1,300 of whom entered military service in fiscal year 1994. 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) 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. 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.Table 1.1 shows the number of physicians entering each military service from each accession program for fiscal years 1992 to 1994. The scholarship program is the largest source for military physicians. 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. 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. 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 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. 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. 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. 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 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. 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.) 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. 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). 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.