Command of military medical units: grounding the paradigm.

Proper command of medical units is central to their effectiveness. For many years the majority of commands have been available only to physicians. This paper suggests a concept for structuring the way in which individuals are considered suitable for command assignments. In this regard, there is an ongoing process within the Army Medical Department working toward delinking command from specific corps and substituting branch immaterial commands. Some ideas are presented to clarify this issue and contribute toward the resolution of a crucial and potentially divisive area.

Medical exercises by the National Guard for underserved Americans.

The National Guard has begun a series of medical exercises designed to bring health-related services to underserved Americans. This paper reviews the origins of the program, its philosophy, organization, goals, and procedures. With an increasing emphasis on the use of the military in support of the civilian sector for the rebuilding of America, this program would appear to be only the first of many such endeavors.

Medical triage in the post-Cold War era.

Military medicine is caught at the confluence of two major currents of change. The Department of Defense and the American system of health care are both undergoing major revisions. Triage was a key operational concept for patient care during the Cold War era. With the changed world situation, the author suggests new operational concepts including the relegation of triage to a marginal role in wartime care. The author argues that increasing the ratio of medical personnel to combat troops is consistent with a changed national perspective on wartime casualties.

Against medical advice: Part I, A review of the literature.

As a preliminary step to studying the Army's experience with against medical advice (AMA) discharges, the literature was reviewed. Fifty-one articles were found through a computer program search. These articles reported widely varying rates depending upon the type of patient, primary diagnosis, and type of setting. Patients with drug and/or alcohol abuse problems are at significantly higher risk for AMA. No civilian studies have been identified which evaluate long-term trends.

Against medical advice: Part II, The Army experience 1971-1988.

The Army experience with discharges against medical advice (AMA) from 1971 to 1988 is analyzed. AMA discharges have declined in a statistically significant manner in both medical centers and community hospitals. Discharges have decreased among men but increased among women. AMA discharges have decreased for both blacks and whites. Among clinical services, only obstetrics and gynecology demonstrated statistically significant increases. Among patient categories, only family members showed an increase. The possible sources of these various changes are discussed.

The National Practitioner Data Bank: an introduction.

The National Practitioner Data Bank, mandated by law, has created a great deal of anxiety in the medical community. The author describes the origin, development, and operation of the bank. Army implementation procedures emphasize safeguards for practitioners and are also felt to be fully consistent with patient protection. Potential problems and areas for further research are described. Linking practitioner entry to standard of care or setting a dollar cut-off for entries are two possible solutions.

Quality assurance and quality improvement: the 1990s and beyond.

Quality assurance and quality improvement are two highly visible indicators of the significant forces that are remolding the American healthcare delivery system. Edward K. Jeffer reviews the current status of these disciplines and makes projections on how they will affect the structure and practice of healthcare in the next century. Some speculations are presented as to why the future appears so bleak to so many healthcare providers. A more optimistic outlook is suggested, and the key role of quality assurance professionals is emphasized.

Total quality management and the Army health care system.

Total quality management (TQM) is the newest in a long line of magic formulas which have been touted as saviors for American industry and medicine. The author discusses the basic concepts of TQM and notes that much of it resembles philosophical beliefs long held by the medical community. TQM does offer many opportunities to refine old concepts and further those goals of quality care to which health care providers have always aspired. If, however, it becomes simply another codified bureaucracy, then a great deal of time and money will be invested for very little gain.

Medical units: who should command?

In the military nothing is more crucial for mission accomplishment than the leadership of an organization or unit. The author argues that physicians by their education and training are uniquely fitted to Command units that have the mission of providing medical care. A systematic exposition is provided that utilizes a large number of categories.

Civilian external peer review: lessons learned.

Since 1986, the Department of Defense has contracted with an outside agency for Civilian External Peer Review (CEPR). From January, 1986 to December, 1988, records indicate that approximately 350,000 discharges from Army hospitals have been included in the study. Initially, the small number of positive findings prevented generalizations; as the total number of cases screened has increased, several valuable lessons have been learned suggesting avenues for improving care. Additionally, a great deal has been elucidated concerning the process of large-scale clinical peer review.

Drug abuse, the U.S. Army Europe: women and substance abuse.

Although numerous statistics on drug and alcohol abuse are kept by the U.S. Army Europe, several areas have not been studied. The authors obtained information on both current and past drug and alcohol use patterns from 96 female soldiers stationed at several locations in Germany. Results were compared to studies in the literature citing female use. Female soldiers showed use rates that were comparable or lower than those of civilian populations except for a slightly higher percentage who had "ever used" narcotics. Several explanations for the marked differences in relative male and female use in the military are discussed, with suggestions for future research.

Deterrence of methaqualone abuse through mass urinalysis.

A temporary court-ordered cessation of urine testing in Europe and the widespread abuse of a detectable methaqualone-containing drug provided an opportunity with the resumption of testing for the evaluation of the possible effects of urinalysis on usage patterns. Evidence is presented suggesting that in this instance urinalysis acted to deter usage of this particular drug.

Problems of organizational consultation in the Army.

Psychiatrists in the U. S. Army have received official sanction as organizational consultants. In common with other bureaucratic organizations, several obstacles impede their full effectiveness in this role. These include communication breakdowns and negative attitudes toward change. These attitudes are divided into four subgroups: Conspiracy of Silence, Fear of Innovation, Cult of Personality, and "Good Old Common Sense." While these obstacles are not inconsiderable, the possibility for effective consultation still exists.