Army Medical Department continuum of medical education.

The F. Edward Hebert Armed Forces Health Professions Scholarship Program (HPSP) may very well be the starting point for many of our Army health care professionals. As a first step for college graduates desiring a medical degree, HPSP is the beginning phase for the Army's Graduate Medical Education (GME) and Continuing Medical Education (CME) programs. The Army's scholarship program currently sponsors over 1,500 students seeking various health care degrees and provides over 77 per cent of the active duty Army physicians. It is one of the most generous and comprehensive scholarships offered for students seeking to be Physicians, as well as Dentists, Veterinarians, Optometrists. Clinical Psychologists, or Nurse Anesthetists desiring to serve their country in a military medical career. Applications are made through the U.S. Army Recruiting Command, which also conducts competitive selection boards. If qualified and selected, full-tuition scholarships plus a monthly allowance (stipend) is provided and recipients must agree to a period of military service.

To qualify for participation in the HPSP, an individual must:

* Be a U.S. citizen;

* Be enrolled in or accepted for admission to an accredited course of study in the United States or Puerto Rico:

* Sign a service agreement,

* Qualify for appointment as a commissioned officer in die U.S. Army Reserve;

Once accepted. The Army HPSP will pay for required expenses, fees and tuition for up to 4 years, plus a monthly stipend (currently $1,235.00 per month). An HPSP recipient is commissioned as a Second Lieutenant in the Army Reserve and required to serve 6 weeks (45 days) each year on active duty for training (ADT). Recipients are also required to attend the Army Medical Department (AMEDD) Basic Officer Leadership Course when attendance dots not compromise their studies. In most cases, the active dirty time is spent in an Army military medical facility where the opportunity to learn and work with top Army health care professionals is a special bonus that is long remembered in a medical career. During their exposure to Army medicine, a scholarship participant will learn about Army health care first-hand and get practical experience in various disciplines while earning 45 days of military pay as an Army officer.

The 6-week period of annual ADT is an important and integral part of an Army officer's professional military education and development. During ADT, the scholarship participant could be assigned to work in an Army facility near the school or in one of the Amy's world-renowned health care facilities. In any case, the future Army health care officer is exposed to a medical education system that excels at training people for rewarding careers in health care, offers immediate hands-on experience, and unique specialized training and assignment opportunities that are not normally found any where else. In addition, if qualified, there may be additional incentive and special pay depending on the specific specialty area chosen for their professional career.

After graduation, the Army health care professional will become a member of the most comprehensive and dynamic health care organizations in the world--the Army Health Care Team. Its mission is to support America's Army at home and abroad. The Army Health Care Team is comprised of sit corps: die Medical Corps (MC). The Medical Service Corps, Medical Specialists Corps, the Dental Corps, die Nurse Corps, and the Veterinary Corps. Together, these Corps offer more diversity and learning experiences than can be found in any other health care system.

The AMEDD Health Care Team is fully focused and committed to supporting the effort of die Army's medical education programs. From the scholarship participant at the medical treatment facility or installation to die resident or fellow, die training of our health care professional Soldier is a transitional and seamless process that can only be improved through dedication and commitment from all that are involved in the process of developing the best AMEDD Soldier possible.

The GME is defined as that education beyond completion of medical school which qualifies the physician for the independent practice of medicine, generally in a specialty. Since it is a prerequisite for licensure and practice privileges, GME must be viewed as a mandatory, rather than an elective, experience for all physicians. Additionally, since 95% of graduating medical students pursue specialty training, GME participation is clearly a national standard with which compliance is expected.

The Army GME program is directly tied to two mandates: (l) The need to provide a supply of qualified physicians to serve in medical units during mobilization for war (readiness mission) and (2) the need to provide high quality, cost-effective health care to military beneficiaries during peacetime (health care benefits delivery mission). The AMEDD considers GME to be absolutely critical to the maintenance of quality health care. The standards, scope of practice, arid professionalism required by the teaching program accreditation bodies and supporting clinical investigations activities, directly contribute to the high quality of health care provided in the Army. Vigorous GME programs ensure state of the art care for combat casualties and are key to the recruitment and retention of quality physicians and to the survival of national medical assets such as the Army Burn and Trauma Center at Fort Sam Houston.

As was demonstrated during Operations Desert Shield/ Storm and now during Operations Iraqi Freedom and Enduring Freedom, time physician graduates of our GME programs have proven themselves to be trained, competent providers, able to function anywhere operationally or within time peacetime mission. Their in-theater performance combined with the support of staff physicians, faculty, and trainees at our casualty receiving hospitals gives the AMEDD a continuous chain of combat casualty care that has resulted in medical successes that have been unparalleled in previous endeavors. With additional incorporation of telemedicine, state of the art care can be further projected from our academic Medical Centers to front line casualties as has been previously demonstrated in Bosnia and Somalia as well as current operations. Maintaining such critical wartime skills during peacetime is particularly challenging. State of the art Medical Centers (MEDCENs) with a variety of training programs and a diverse patient population, to include retired beneficiaries and their families, are absolutely essential if clinicians are to acquire and maintain skills crucial to combat casualty in wartime.

The determination of the number of trainees, mix of specialties, and number of trainees within those specialties' GME programs is a complex process that addresses force structure considerations first, then regional needs and cost-effectiveness considerations, in conjunction with accreditation, licensure, and similar professional requirements. Currently, there are 130 GME programs in the Army--6-transitional internships, 71 residencies (3 combined, 22 joint), and 53 fellowships (22 joint). Not counting the 17 programs still awaiting final accreditation decisions from site visits conducted in 2004, 55% of Army GME programs have received full accreditation status for the maximum period of 5 years, 23% full accreditation status for a period of 4 years, 15 per cent percent full accreditation status for a period of 3 years, and 3% full accreditation for a period of 2 years or less. There has recently been concern expressed by program directors that accreditation cycle length may be shortening over the past few years. However, a review of accreditation decisions rendered over the past 2 years demonstrates that the percentage of programs receiving either the maximal accreditation of 5 years or 3 years, full accreditation has not changed. There has been a slight decrease in the percentage of programs being awarded full accreditation for 4 years with a proportional increase in the percentage of programs receiving full accreditation for a period of 2 years or less. But until all the 17 pending decisions are received, it is difficult to say anything more definitive.

Army GME offers MC Officers the opportunity for their professional satisfaction, career advancement, and retention. At the current time, a total of 1,369 MC Of beets are in training in 11 Armory teaching hospitals or other Service facilities, and 88 are in Army sponsored civilian training. An additional 226 trainees are in civilian training programs in a nonfunded (delay) status. Army GME training is available in 25 residency specialties, while over 100 subspecialty choices are available at the fellowship level. The determination each year of die exact number of available positions and locations is determined by a GME school year plan approved by the Army Surgeon General. The school year plan is disseminated in mid July for GME training to begin the following July. The application process for GME is submitted via a web-base program. When beginning the application process, applicable policies and established deadlines are provided to the potential applicant via time GME website: http://www.mods.army.mil/medicalEdueation/. By logging on, one can access a wealth of information concerning Army GME that expands the summary information presented here.

There has never been a time when Army GME has not faced challenges, but it has always been equal to the task; the future will be no different. The only certainty is that the training environment and its demands will not remain static, but will continue to change. Developing the flexibility to respond to such changes, even if unanticipated, will be the best strategy for ensuring continued longevity and excellence for Army GME. This past year has seen a deliberate proactive change initiated to deal with HPSP obligors who have encountered academic challenges which, without immediate intervention, could compromise their future ability to contribute to the AMEDD. Such individuals, when identified, have preferentially been selected for training in military programs so that any academic difficulties can be remediated as expeditiously as possible. This policy has resulted in a slightly larger intern class and increased demands on training program faculty, but in the long run, is the absolute right thing to do. There has also been considerable effort expended to develop a policy for limited deployment of program directors (PDs) which will allow Accreditation Council on Graduate Medical Education (ACGME) standards to still be met by training programs, but allow PDs to both participate in operational mission requirements similar to those of their specialty colleagues and bring back clinical and operational lessons learned which can then be incorporated into training curriculums. The ACGMF feedback to a draft policy has been supportive and a formal incorporation of such a policy into the current deployment policy is being finalized. Finally, the ability to incorporate the distance learning modules of the revised MC AMEDD Captains' Career Course into the curriculum of all Army GME residency training programs is currently under discussion. The goal is to incorporate standardized military unique curriculum requirements with standardized transition to practice requirements and determine what remaining requirements would be necessary, to round out the Advanced Course Curriculum in a distance learning format so that the follow on in-residence portion of the course could be markedly reduced. Such changes could consolidate training, reduce duplication/repetition, and enhance career advancement.

Army GME has enjoyed protracted success as evidenced by the 96% first time pass rate of its graduates on specialty certification board examinations. Given the talent of our applicant pool, the expertise and dedication of our faculty and program directors, and the support of our leadership, there is every expectation for such success to continue.

Following completion of GME, the next crucial stage in physician development is CME. The purpose of CME is to facilitate self-assessment and lifelong learning by physicians so that their practices may reflect the best medical can; for their patients. Optimal patient outcomes are linked to developing competent physicians, so the goal of CME is to help physicians improve their performance in practice. The responsibility for fulfilling this goal lies with all of us involved in CME--U.S. Army Medical Command (MEDCOM) as the accredited provider, MEDCEN/Medical Department Activity (MEDDAC) CME directors and planners as the activity/ meeting planners, faculty and speakers, educators, supporters, and the physician learners themselves.

The MEDCOMs CME office is an integral part of the Medical Education Directorate and the final link in the medical education continuum from student to fully-trained physician to practicing professional. At its last survey review, the Army MEDCOM received "Accreditation with Commendation" by the Accreditation Council for Continuing Medical Education (ACCME) for a period of 6 years, from Jul 03 to Jul 09. As we move forward towards our next accreditation, we will be seeking out best solutions for important issues in the CME community, especially as they impact Army physicians. It is essential that CME be:

--Linked to Quality and Safety

--Effective in improving practice

--Independent of commercial interests

--Based on valid content

First and foremost, we will be updating our policies to conform to die ACCMEs 2004 updated Standards for Commercial Support of CME which will be implemented starting in May 2005. These standards reflect die belief of the ACCME that if the influence of commercial interests is eliminated from the planning and production of CME, then the CME will be free of commercial bias, and thereby ensure patient safety. This requires that Army MEDCEN/MEDDAC jointly sponsor with the responsibility for all aspects of the planning and implementation of CME activities. We will need to make fair and balanced decisions regarding content, faculty, and management of funds, and we will need to identify and resolve conflicts of interest whenever they arise during the planning of an activity.

Another goal of CME providers, aimed al linking CME to quality health care, is to develop CME that is based on valid content. When we put our accreditation statement on a CME activity, it should indicate that we are promoting recommendations that are either evidence-based or fall within the body of knowledge and skills generally recognized and accepted by the profession. The CME community intends to be accountable to the public and the medical profession to ensure we are not presenting activities that promote treatments that are known to be ineffective or that have risks that outweigh the benefits. Evidence-based medicine bases medical decision-making on concepts proven by reproducible, scientifically conducted studies. The American Academy of Family Physicians, an accredited CME provider, has taken the lead in promoting evidence-based CME by putting it in its own category of CME, allowing the participating physicians to be more educated consumers when selecting CME activities.

Performance Improvement (PI) initiatives have emerged as an important mechanism for physicians and other health care providers to systematically assess their practice, and identity areas where education can effect changes in clinical practice that result in improved patient cart and better patient outcomes. The CME is also committed to contributing to improvement in physician practice and performance, and can provide crucial support to PI initiatives by providing background information so that physicians understand the evidence behind the performance measures. The American Medical Association's (AMA) Division of Continuing Physician Professional Development conducted a PI Pilot Project over the last 3 years, which culminated in their approving new rules in Sep 04 governing how PI activities could be conducted for AMA Physician Recognition Award (PRA) category 1 credit Physicians may be awarded incremental AMA PRA category I credit for completing each successive stage of a performance improvement activity:

Stage A: Learning from current practice performance assessment (5 credits)

Stage B: Learning from the application of performance improvement to patient care (5 credits)

Stage C: Learning from the evaluation of the performance improvement effort (5 credits)

An additional 5 credits (fox a maximum of 20 credits) can be awarded for completing, in sequence, all three stages of a structured PI activity, as the best learning is associated with completing a well-designed PI activity. Further information on the AMA PRA Rules for PI activities is found at http:// www.ama-assn.org/ama/pub/category/13151.html.

Organizations in medical education such as the American Board of Medical Specialties, the ACGME, and the American Osteopathic Association are actively addressing issues of competency-based education, specialty-specific core curricula, maintenance of licensure, and maintenance of certification. As they work towards greater alignment of their goals, CME should continue to support these goals by providing quality, unbiased, educational activities based on sound medical evidence. Our CME programs are committed to providing Army physicians-in-training with a Military Unique Curriculum (MUC) in addition to their specialty-specific curricula. As we continue to serve a nation at war, we must adapt the MUC to meet the needs of our physicians deploying to various theatres of operation. Over the next couple of years, all Array physicians will complete an online clinician course on Chemical, Biological, Radiological, Nuclear and (High Yield) Explosives Emergency Medical Preparedness and Response. In the next few months, the MEDCOM CME office will report the results of the Deployed Physicians Needs Assessment (DPNA) which assessed the educational needs of deployed Army physicians for various clinical topics, most with an operational focus. The intent of the study is to share the information and feedback from deployed physicians with Army CME directors and planners, specialty consultants, and other Army medical educators who plan local and distance learning CME activities, Postgraduate Professional Short Course Programs, and the MUC. The results of the DPNA will hopefully enhance the development of relevant training and CME for Army physicians during active and future operational theatres.

For those who are interested in planning and conducting a CME activity in Army facilities, our office would be happy .A) assist in ensuring the activity conforms to MEDCOM and ACCME policies. It would be helpful to have identified the need for the topic, the target audience, and the learning objectives prior to contacting us. Our website is also a good resource for our policies and current CME offerings: https:// conus.mods.army.mil/emeweb/secured/. As history has shown, it will be the talent and creativity of our AMEDD staff that will inspire our medical education enterprise to meet the challenges of health care in the 21st century.

COL John M. Powers, MC, USA, Medical Corps, U.S. Army. Colonel Powers is assigned as Director, Medical Education, Office of the Surgeon General, Falls Church, VA.