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Commander's introduction.

The Army Medical Department Center and School is, first and foremost, an educational institution. For many years it has been charged with imparting the knowledge and skills necessary to ensure our country's Warriors receive the finest medical care possible, wherever and whenever it is needed. That mission is currently expanding dramatically as the facilities morph into the all-service Medical Education and Training Campus, centralizing all basic and most specialized enlisted military medical education at one location at Fort Sam Houston, Texas. It is, therefore, both appropriate and timely to publish an issue of the AMEDD Journal highlighting various aspects of the education responsibilities and functions within the Army Medical Department.

Definitions of the verb "educate" vary somewhat from source to source, but such variations are largely in style.

Consolidating the kernels of those definitions, one finds that educate means:

* To provide with training or knowledge, especially via formal schooling.

* To provide with training for a specific purpose, as a vocation.

* To provide with information.

* To stimulate or develop the mental or moral growth.

The AMEDD Center and School (AMEDDC&S) fulfills every element of that definition in the education of all of its students. Indeed, as with all military service schools, students must attend classes in leadership, responsibility, ethics, and morality, in addition to professional skill knowledge, something that is rare today in many civilian learning environments. We are proud of the military healthcare professionals that leave our school to join America's Warriors throughout the world.


COL Randall Anderson opens this issue of the AMEDD Journal with an overview of one area of a collaborative "brainstorming" effort by a large group of AMEDD subject matter experts to project AMEDD's operating environment 30 years in the future. COL Anderson focuses on their ideas with regard to how AMEDD will educate and train medical personnel, based on trends in education, healthcare, and the military. The ideas are at once intriguing, exciting, and obviously challenging, because major adjustments to design and delivery of academic material would be forthcoming, along with a greater emphasis on the individual student's ability to accept, process, and learn the necessary information. Further, students' aptitudes, skills, and mental capabilities would be matched to a suitable occupational specialty to ensure their education optimizes their contributions to the health and well-being of our military personnel. This article provides excellent insight, not only into where we should be going, but also where we are, in that all the ideas are based on present technical and educational initiatives and trends. A good read which should encourage all military medical professionals to obtain and read The AMEDD Futures 2039 Project: Phase 2 Final Report.

An excellent example of the rapid advances in the capability and sophistication of technology in medical education is the expanding use of human patient simulation in many venues. Dr Don Johnson and his coauthors compared the efficacy of the simulation against self-paced instruction using a CD-ROM based syllabus in a very specific circumstance--management of patients exposed to chemical agents. During their preparatory search of the extensive literature on simulation use in medical education, they found no rigorously designed studies that had made such comparisons. Therefore, their study is apparently the first to apply scientific rigor in the collection of data on which to base comparative conclusions. Their article presents a detailed description of the carefully designed and executed study which used Army and Air Force nurses as the sample population to investigate teaching this specialized element of trauma care. Absent a major accident or natural disaster involving release of chemical agents, the occurrence of patients with such injuries is rare, so healthcare providers have been largely limited to printed and computer-based courses and exercises to obtain their expertise in this area. Effective simulation provides the interactive environment with the benefit of actual feedback to the actions of the student. Intuitively it would seem obvious that the student obtains the greater benefit from the simulation scenario. However, the considerable expense of purchasing and maintaining the simulators dictate that their value must be justified by performance data. The study by Dr Johnson et al is an important component in planning the future course of the education of healthcare professionals.

In an effort to ensure healthcare providers experience the most effective training possible in preparation for combat deployment, in 2001 the Department of Defense initiated the establishment of several joint trauma training programs in existing civilian trauma centers. The centers are located in areas with a high occurrence of combat-like trauma injuries, thus allowing military medical providers exposure to such actual injuries prior to deployment into the combat environment. On the surface, the program would seem to be an excellent idea, but do actual experiences of participants support the commitment of time and resources? Dr Carl Schulman and his team at the Army Trauma Training Center in Miami, Florida, conducted a scientific survey of participants following their return from combat deployments to gather their opinions as to the value of the training, and suggestions on improving the training experience. The survey sample represented over 2 years of training participants. The excellent article contributed by Dr Schulman et al provides an overview of the joint training effort, and presents the results of their study. Again, validation of a concept is a valuable contribution to planning for the future commitment of resources to our medical training efforts.

Army medical professionals have never hesitated to aggressively pursue solutions to better protect the health of our military. The safety of food and water is a paramount concern to commanders as their units deploy and operate in areas that usually have no capabilities or resources in that regard. Army Veterinary Service operates 4 food testing laboratories worldwide, but the delays between sample submissions from the field and receipt of results can delay necessary local actions in support of combat operations. To mitigate this problem, AMEDD developed and fielded 2 laboratory veterinary equipment sets designed to allow food and water testing capabilities to be located in close proximity to operating units. Staci Mitchell and her coauthors have contributed an article describing the process by which the AMEDDC&S Department of Veterinary Science identified the training requirements for the new equipment, designated the specialties who required training, designed and constructed the training syllabi, and implemented the training. The resulting fielding of equipment with trained operators has quickly placed testing capabilities in all major theaters of operations, markedly improving the health and safety of our deployed Warfighters. This article is an excellent example of how those responsible to create and provide training react quickly and effectively in response to a critical need.

We are pleased that this issue of the AMEDD Journal includes the report of a recent, major Air Force study to investigate the learning process, identify the components of how we learn and the factors affecting that process, and relate that information into the world of today, particularly from the military perspective in the design and delivery of training and education. The study was conducted by the Air Force Research Institute of the Air University. The resulting report, published in November 2009, is a collection of invaluable information for those responsible for any aspect of planning, courseware development and design, training delivery, and evaluation of training effectiveness.

One approach to developing specialized skills which will be used in a team environment is called problem-based learning (PBL). Students are presented with a problem which they explore while working in groups. From a medical education perspective, this approach mirrors the course of patient care which is performed in a clinical setting. The triservice physician assistant program at Fort Sam Houston is restructuring its curriculum, and implementation of PBL for portions of the course is planned. The various elements to create a PBL program are complex and challenging. MAJ George Midla and Dr Joellen Coryell investigated one of those components, the preparation requirements for instructors in a physician assistant program which uses PBL. They identified universities that used PBL in physician assistant education, and interviewed experienced instructors in the programs. The interviews followed standardized formats with open-ended questions, and responses were transcribed and analyzed to develop categories and identify recurrent themes. Following a rigorous process, MAJ Midla and Dr Coryell extracted extensive information about the instructor/facilitator experiences which are unique to the PBL approach, the important differences in preparation and attitude from the standard classroom structure, the opinions of those experienced instructors as to the value of PBL, and many other factors to be considered in the selection and preparation of staff personnel. Their study results should be an important consideration in courseware design and staff planning for the restructured physician assistant curriculum.

As our understanding of the learning process has evolved, it has become clear that the static model of rote memorization and recitation of arcane facts is of little value in the development of an educated person. The concept of critical thinking has become prominent as one of the most important factors in effective learning--in its simplest terms, the idea of interpretation, analysis, evaluation, and application of information. This capability is extremely important for many professions, but none more so than healthcare. Further, since the education process depends on the quality and capabilities of the faculty, it is obvious that their critical thinking skills are very important as they must develop those skills among their students. In her extensive, detailed study, Dr Carol Hobaugh explored the critical thinking skills among the instructors of the AMEDDC&S Academy of Health Sciences. Her project examined the sample population with regard to a number of factors, including rank, level of education, occupational specialty, military experience, and others. Her article describes the complexities involved in a study of this extent, presents the design and process of this project, and details the results after careful data reduction and analysis. Her results offer some surprises, answer questions, and generate more opportunities for inquiry into the factors supporting and detracting from the development of critical thinking skills among military professionals. Dr Hobaugh's study is a textbook example of classic scientific inquiry, and the results should stimulate further interest in this very important aspect of the learning process.

The next 2 articles continue the discussion of the changing nature of teaching and the learning process. In the first article, Stephanie Hamilton challenges the traditional method of information presentation, memorization, and summary examinations as markedly inferior to a multiple assessment protocol. Known as assessment-based instruction, students are evaluated throughout the course with multiple types of assessment tools to determine the level of cognitive understanding of material. Over the last 2 decades, this technique has demonstrated that it makes students active participants in the learning process rather than audience members, generates a collaborative learning environment, and allows students to more directly relate the course to real-world applications. It also generates measurable improvements in retention and proficiency. Such results are perfectly suited for the requirements of military training. Assessment-based instruction is the future, and should be strongly considered for incorporation into the curriculum of military medical education.

Dr Carita DeVilbiss and her coauthors investigated student failures in one of the enlisted medical training programs from a different perspective: they asked the students. Their team designed a research project to identify potential reasons why students fail (or succeed) using questionnaires and interviews, exploring several aspects of the learning environment (ie, class size, teaching methods, support systems) in addition to the individual participant characteristics, backgrounds, and experience. They also asked the students' battle buddies or close friends (with the student's permission) to complete questionnaires related to their assessment of the student. After examining the data, Dr DeVilbiss et al conclude that the majority of student responses are truthful, so the results should be valid indicators of what may be wrong, and right, in areas of the training program. Their article presents the data and the researchers' interpretations, and offers a list of recommendations based on the results. This study should be closely examined by curriculum planners and courseware developers for indicators as to how to improve the success rate in our military training programs.

To this point, the articles in this issue of the AMEDD Journal have dealt with the process of education--the tools used, current methodologies, and research focused on how people learn, and how to teach. The last 2 articles deal with broadening the scope of education for military medical professionals beyond that necessary for their primary healthcare responsibilities. As with virtually every military career path, those in military medicine often take Soldiers from their primary occupational fields into (usually) related, albeit unfamiliar responsibilities. The learning curve may be difficult, and the individual's effectiveness may suffer for an extended period. There are also assignments for which a targeted educational preparation should be required, because the responsibilities may be situational, depending on shifting, external circumstances beyond the direct control of the military. In his article, LTC Thomas Bundt describes one such environment in which lack of background and understanding of under-lying factors seriously hamper efforts to develop and apply strategic healthcare policies in Iraq. He describes a number of situations for which the lack of under-standing of historical, cultural, political, and religious factors seriously hampered efforts by US planners and policy-makers to assist Iraqis with their national health-care policy development. Unfortunately, some of these problems were generated by nonmilitary US government agencies with major roles in the development of Iraq's infrastructure, but LTC Bundt points out that military staff members must be in a position to deflect such uninformed, counterproductive actions. Such intervention must come from a sound position of knowledge and confidence. Sources for such training should be identified for the military as a whole, because the critical gaps in knowledge are not limited to medical issues and policy development.

MAJ Jon Baker and MAJ Jason Sepanic close this issue of the AMEDD Journal with a thought-provoking article describing a resource for higher level, professional military education that they contend is notably underutilized by the AMEDD, to the detriment of AMEDD representation on high-level staffs throughout the military command structure. The Army's School for Advanced Military Studies (SAMS) provides an intense curriculum on the complex operational problems of warfare, and provides the knowledge and insight to address them. The authors point out that AMEDD officers may be at a disadvantage when serving in high-level staff positions because they might not share the same background perspectives as their non-AMEDD contemporaries. Consequently, medically related policy matters and decisions may be developed without equivalent level participation from the medical staff representative. AMEDD officer personnel managers should examine this situation with a view towards broadening the eligibility for attending SAMS, and actively encourage AMEDD officers to apply.

MG David A. Rubenstein
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Title Annotation:Perspectives
Author:Rubenstein, David A.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Oct 1, 2010
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