COMMENTARIES MILITARY MEDICINE, 178, 11:1154, 2013
Military Graduate Medical Education: Are the King's Clothes Tattered? Col Woodson S. Jones, USAF MC (Ret.)
Military Graduate Medical Education (GME) has long been considered a cornerstone of the Military Health System (MHS) and comprises 3% of the nation's GME positions. In these times of fiscal uncertainty, the $9.5 billion the federal govemment annually contributes to teaching hospitals through Medicare is under significant scrutiny.' With MHS consuming 10% of the Department of Defense (DoD) budget, the cost-benefit of military GME is likely to be questioned yet again. As early as 2006, an Office of the Secretary of Defense, Health Affair's sponsored report stated we must be willing to "admit the rhetoric of needing GME to maintain the force structure as it relates to quality, recruitment, and cost effectiveness may not be true."'^ This report concluded, "A critical re-look at DoD-sponsored GME is needed today. The King may not be naked—but his clothing is tattered." As I pondered whether the allure of military GME was more rhetoric than reality, a question crossed my mind. "Why do a number of cost-conscience, quality health care delivery institutions such as Kaiser Permanente (KP), Geisinger Health System, and Intermountain Healthcare engage and value GME?" The President of KP Southem California, after noting a lack of financial incentive, stated their health care system should become even more involved in GME.^ Are there insights into the value of GME the MHS might gain from health care systems like KP? Further, any significant changes in military GME should be considered in the context of growing challenges in meeting the health care needs of the country, the shining accreditation emphasis on patient safety
Office of the Dean, Graduate Medical Education, San Antonio Uniformed Services Health Education Con.sortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234^504. This article was presented at the Department of Pediatrics Grand Rounds. Uniformed Services University, Bethesda. MD, April 11, 2013. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Air Force, Department of the Army. Department of Defense, or the U.S. Govemment. This work was prepared as pan of their official duties and, as such, there is no copyright to be transferred. doi: 10.7205/MILMED-D-13-00283
1154
and quality improvement, and the impact of residency training on future practice. Senior leaders at KP reported several reasons for being engaged in GME for over 60 years: grounding residents in their culture; growing future leaders; positive impact on faculty recruitment, quality, satisfaction, and retention; workforce contribution; research; and enhancing the image of the organization."* They assert "grounding of trainees in the fundamentals of Permanente Medicine virtually ensures a cultural fit." Given the unique nature of military medicine, the value of MHS acculturation during training should not be underestimated. A military physician's career may result in movement among five different cultures: academic, clinical, research, administrative, and military-unique operations. During the last decade of conflict, military GME teaching faculty, nurses, support staff, and patients have lived the "raison d'être," as the operational culture has been described. They bring this back to the classroom, the health care team, and the bedside. Like KP, we breed our future health care leaders in this training culture."* Our military treatment facilities (MTFs) contain key ingredients described by a Nobel Laureate, Robert Fogel, found in a flourishing culture: a common sense of community, purpose, general discipline, and a strong work ethic." Given challenges with military life (deployments, moves, lower career pay), incentives are needed to retain top physicians, who, in tum, recruit our future DoD physicians. Yet recruitment, satisfaction, and retention of highly qualified providers remain vexing problems for the MHS, with 15% to 30% annual turnover. Tumover is expensive, costing one college of medicine with an annual 6.7% tumover an estimated 45 million dollars over 5 years.^' A significant proportion of the cost was due to orienting to the new practice setting. Perhaps this further explains why KP is willing to finance GME. KP hires 30% of their former residents, who make up 15% of their faculty workforce.'^ The Department of Veterans Affairs (VA), with an annual tumover of 9%, found residents are twice as likely to consider a VA career after their rotations.^
MILITARY MEDICINE, Vol. 178, November 2013
Commentary
Teaching residents was the second highest reason to remain military internal medicine providers.^ In this survey, nearly two-thirds of Uniformed Services University graduates and half of service academy graduates were considering remaining on active duty after their obligation, significantly more likely than those without these backgrounds. A survey of over 1000 military physicians found higher faculty satisfaction at MTFs with GME compared to those without GME.' KP believes faculty are kept "at the cutting edge of their specialty practice" by the "energy and openness to new ideas" residents and "teaching responsibilities" brings to their health care system."* This may be more than rhetoric given that teaching hospitals perform better than nonteaching hospitals in most patient safety and quality metrics.'*' KP also believes residents are force multipliers and net contributors to their workforce.^ The VA found variability in the contribution net the cost of supervision to the workload in its system. Surgical and medicine residents had a lai-ge to moderate contribution, respectively, while psychiatry residents had a net negative contribution.^ The VA also started the GME enhancement initiative in 2006 to add an additional 2000 GME training positions." Hospitals, in general, do not bill directly for resident services because they receive federal funding for GME. Yet, residents generate workload. Over a 10-year period, surgical residents contributed over a million dollars a year in "neglected" relative value units (RVUs) in unbillable "minor procedures" done without faculty supervision.'" If first assistant billing (16% RVU) for residents were allowed, one health care system reported the potential for over $20,000 annually per resident.'^ In internal medicine, one program noted RVUs more than tripled when faculty precepted residents' continuity clinics compared to RVUs generated in their faculty clinics.'"^ The break-even point for covering pédiatrie faculty salaries was about 3.5 residents in clinic per staff preceptor.'^ The MHS's approach of using an early educational investment (i.e.. Uniformed Services University attendance) coupled with structured salary during a time of service obligation was cited as a model the civilian sector shotild consider to address the nation's health care cost.'^ Finally, the BowlesSimpson commission recommended lowering indirect GME payments to teaching hospitals to 42% of the current rate reportedly to better refiect actual cost, a further indication GME may not be as costly as generally perceived.' KP believes its health care image is enhanced by being a teaching center.^ The Accreditation Council for Graduate Medical Education (ACGME) common requirements states; "Faculty must establish and maintain an environment of inquiiy and scholarship with an active research component."'^ Like KP, our military teachers are not daunted by the "publish or perish" mentality of some academic centers. Yet, our programs must have clinical researchers to move military medicine forward in care delivery, institutional reputation, and to ensure accreditation. Therefore, MHS must continue to fund and support processes that enhance the educational and clinical scholarship necessary for academic MTFs to be "academic."
MILITARY MEDICINE, Vol. 178, November 2013
Given a primary objective of the Defense Health Agency is to recapture purchased care, losing the prestige, and lure associated with academic medical centers seems counterproductive. As a Program Director, I would scramble to provide "justin-time" training to ensure our residents were aware of The Joint Commission (TJC) standards. The ACGME Next Accreditation System focus presents a challenging opportunity to fully embrace institutional and TJC patient safety and quality improvement endeavors in GME. Its Clinical Leaming Environment Review Program institutional visits will use a TJC "walk-about" model to ensure our programs and MTFs are championing resident education and engagement, and can demonstrate impact on patient safety and quality improvement initiatives. Residents are the "tip of the spear" when it comes to physician care delivery in our GME MTFs. Recognizing this, the VA hires Chief Residents of quality and patient safety to facilitate greater integration." Likewise, MHS efforts to improve patient safety or quality are unlikely to succeed without resident engagement in planning and implementation. Because we hire all of our graduates to take care of our own, another compelling reason to ensure military GME occurs in high-quality, safety-focused MTFs is the "imprinting" associated with where a resident trains. Graduates of residency programs with lower obstetric complication rates continued to show lower rates themselves for 20 years when compared with graduates from programs with higher complication rates.'* Therefore, military GME has a moral imperative to lead the way for acculturation of interprofessional teams delivering safe, efficient, and effective care. The result will benefit all of our MTFs and our patients for years to come. Finally, the U.S. health care system faces a significant shortage of physicians in the coming years. The growth of U.S. medical schools is significandy outpacing the current growth of GME training positions, which will lead to the number of U.S. graduates exceeding GME positions.' The closing of 3% of the nation's GME positions in MTFs would further impact the crisis. In this environment, the MTF would need to hire physicians and mid-level providers to replace the lost GME productivity or lose even more patients to the purchased care sector. If the MHS chose to fund salaries and benefits for military residents in civilian teaching hospitals, either for recruitment or to ensure training positions in quality centers, the potential for fiscal gains from stopping or downsizing military GME would be significantly reduced while simultaneously losing the myriad of benefits outlined above. In this time of fiscal uncertainty, looming physician shortages, and evidence supporting the benefits of GME, the MHS should focus on policies that foster synergy between military GME and MTFs. Policies that enhance recapturing patients currendy in the purchased care sector into quality, safety-focused military academic centers are good for the MHS, our patients, and for our future. The King's clothes are not tattered, though maybe a bit soiled. The MHS needs to continue to value and operate military GME more than ever, even in this time of fiscal challenges.
1155
Commentary
REFERENCES 1. Inglehart JK: The uncertain future of medicare and graduate medical education. N Engl J Med 2011; 365(14): 1340-5. 2. National Defense Industrial Association, Health Affairs Division. Military graduate medical education: A 21st century look. "A pro bono study." Arlington, VA, National Defense Industrial Association, 2006. Sponsored by the Office of the Secretary of Defense for Health Affairs and the Surgeons Generals of the Armed Forces. 3. Rasgón S, Hará JH. Blumberg B: The importance of graduate medical education for Permanente physicians. Kaiser Permanente, and American medicine [editorial]. Perm J 2007 Fall; 11(4): 79-87. 4. Dong T, Duming SJ, Gilliland WR. et al: Leadership success and the Uniformed Services University: perspectives of flag officer alumni. Mil Med 2012; 177:61-7. 5. Fogel RW: The Fourth Great Awakening and the Future of Egalitarianism. Chicago, IL, University of Chicago Press, 2000. 6. Schloss EP, Flanagan DM, Culler CL, Wright AL: Some hidden costs of faculty turnover in clinical departments in one academic medical center. Acad Med 2009; 84(1): 32-6. 7. Kashner MT, Chang BK; VA Residents Improve Access and Financial Value, AAMC Fall Meeting November 5. 2011. Available at https:// members.aatTic.org/eweb/upload/Kashner%20%20Chang%20ANN 11 -229 .pdf; accessed May 2013. 8. Salerno S, Ca.sh B, Cranston M, Schoonmaker E: Perceptions of current and recent military internal medicine residents on operational medicine, managed care, graduate medical education, and continued military service. Mil Med 1998; 163: 392-7.
9. Kravitz R, Thomas N, Sloss E, Hosek S: Satisfaction and dissatisfaction in institutional practice: results from a survey of U.S. military physicians. Mil Med 1993: 158: 41-50. 10. Shahian DM. Nordberg MS, Meyer GS, et al: Contemporary perfonnance of U.S. teaching and nonteaching hospitals. Acad Med 2012; 87: 701-8. 11. Chang BK: GME enhancement: expansion and educational innovation in VA residency programs. Acad Intern Med Insight 2009; 7: 6-13. Available at http://www.im.org/Publications/Insight/Archives/2009/ InsightV7I2/Pages/va.aspx; accessed May 2013. 12. Feinstein AJ. Deckelbaum DL, Madan AK, McKenney MG: Unsupervised procedures by surgical trainees: a windfall for private insurance at the expense of graduate tnedical education. J Trauma 2011; 70(1): 136-9. 13. Madan AK. Fabian TC, Tichansky DS: Potential financial impact of first assistant billing by surgical residents. Amer Surg 2007; 73: 652-7. 14. Albritton TA, Miller MD, Johnson MH, Rahn DW: Using relative value units to measure faculty clinical productivity. J Gen Intern Med 1997; 12: 715-7. 15. Ng M, Lawless ST: What if pédiatrie residents could bill for their outpatient services? Pediatrics 2001; 108: 827-34. 16. Cronin WA, Morgan JA. Weeks WB: The cost of pursuing a medical career in the military: a tale of five specialties. Acad Med 2010; 85: 1316-20. 17. Accreditation Council for Graduate Medical Education. Common Program Requirements. Effective July 1, 2011. Available at http://www .acgme.org/acgmeweb/; accessed May 2013. 18. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ: Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302: 1277-83.
GET THE POWER TO HELP THE BEST GET BETTER When America's best get injured, you can help them come back faster with the Game Ready® System.
For acute musctiloskeletal injury and post-operative recovery. Game Ready® is the new standard of care. Game Ready's innovative ACCEL'" Technology (Active Compression and Cold Exchange Loop)
To learn more about accelerated recovery, please visit vwvw.gameready.com or cali us toll-free at 1.888.426.3732.
synergistically combines pneumatic compression and cold therapies like never before - enabling you to help your wounded to heal
G A M E
R E A D Y »
faster. Get Game Ready and get the power to accelerate recovery. ©2013 Cool&ysleras. he. All ligfiSs reseated. vm,l¡ 'Û5/13
1156
MILITARY MEDICINE, Vol. 178, Novetnber 2013
Copyright of Military Medicine is the property of Association of Military Surgeons of the United States and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Military Graduate Medical Education: Are the King's Clothes Tattered? Col Woodson S. Jones, USAF MC (Ret.)
Military Graduate Medical Education (GME) has long been considered a cornerstone of the Military Health System (MHS) and comprises 3% of the nation's GME positions. In these times of fiscal uncertainty, the $9.5 billion the federal govemment annually contributes to teaching hospitals through Medicare is under significant scrutiny.' With MHS consuming 10% of the Department of Defense (DoD) budget, the cost-benefit of military GME is likely to be questioned yet again. As early as 2006, an Office of the Secretary of Defense, Health Affair's sponsored report stated we must be willing to "admit the rhetoric of needing GME to maintain the force structure as it relates to quality, recruitment, and cost effectiveness may not be true."'^ This report concluded, "A critical re-look at DoD-sponsored GME is needed today. The King may not be naked—but his clothing is tattered." As I pondered whether the allure of military GME was more rhetoric than reality, a question crossed my mind. "Why do a number of cost-conscience, quality health care delivery institutions such as Kaiser Permanente (KP), Geisinger Health System, and Intermountain Healthcare engage and value GME?" The President of KP Southem California, after noting a lack of financial incentive, stated their health care system should become even more involved in GME.^ Are there insights into the value of GME the MHS might gain from health care systems like KP? Further, any significant changes in military GME should be considered in the context of growing challenges in meeting the health care needs of the country, the shining accreditation emphasis on patient safety
Office of the Dean, Graduate Medical Education, San Antonio Uniformed Services Health Education Con.sortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234^504. This article was presented at the Department of Pediatrics Grand Rounds. Uniformed Services University, Bethesda. MD, April 11, 2013. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Air Force, Department of the Army. Department of Defense, or the U.S. Govemment. This work was prepared as pan of their official duties and, as such, there is no copyright to be transferred. doi: 10.7205/MILMED-D-13-00283
1154
and quality improvement, and the impact of residency training on future practice. Senior leaders at KP reported several reasons for being engaged in GME for over 60 years: grounding residents in their culture; growing future leaders; positive impact on faculty recruitment, quality, satisfaction, and retention; workforce contribution; research; and enhancing the image of the organization."* They assert "grounding of trainees in the fundamentals of Permanente Medicine virtually ensures a cultural fit." Given the unique nature of military medicine, the value of MHS acculturation during training should not be underestimated. A military physician's career may result in movement among five different cultures: academic, clinical, research, administrative, and military-unique operations. During the last decade of conflict, military GME teaching faculty, nurses, support staff, and patients have lived the "raison d'être," as the operational culture has been described. They bring this back to the classroom, the health care team, and the bedside. Like KP, we breed our future health care leaders in this training culture."* Our military treatment facilities (MTFs) contain key ingredients described by a Nobel Laureate, Robert Fogel, found in a flourishing culture: a common sense of community, purpose, general discipline, and a strong work ethic." Given challenges with military life (deployments, moves, lower career pay), incentives are needed to retain top physicians, who, in tum, recruit our future DoD physicians. Yet recruitment, satisfaction, and retention of highly qualified providers remain vexing problems for the MHS, with 15% to 30% annual turnover. Tumover is expensive, costing one college of medicine with an annual 6.7% tumover an estimated 45 million dollars over 5 years.^' A significant proportion of the cost was due to orienting to the new practice setting. Perhaps this further explains why KP is willing to finance GME. KP hires 30% of their former residents, who make up 15% of their faculty workforce.'^ The Department of Veterans Affairs (VA), with an annual tumover of 9%, found residents are twice as likely to consider a VA career after their rotations.^
MILITARY MEDICINE, Vol. 178, November 2013
Commentary
Teaching residents was the second highest reason to remain military internal medicine providers.^ In this survey, nearly two-thirds of Uniformed Services University graduates and half of service academy graduates were considering remaining on active duty after their obligation, significantly more likely than those without these backgrounds. A survey of over 1000 military physicians found higher faculty satisfaction at MTFs with GME compared to those without GME.' KP believes faculty are kept "at the cutting edge of their specialty practice" by the "energy and openness to new ideas" residents and "teaching responsibilities" brings to their health care system."* This may be more than rhetoric given that teaching hospitals perform better than nonteaching hospitals in most patient safety and quality metrics.'*' KP also believes residents are force multipliers and net contributors to their workforce.^ The VA found variability in the contribution net the cost of supervision to the workload in its system. Surgical and medicine residents had a lai-ge to moderate contribution, respectively, while psychiatry residents had a net negative contribution.^ The VA also started the GME enhancement initiative in 2006 to add an additional 2000 GME training positions." Hospitals, in general, do not bill directly for resident services because they receive federal funding for GME. Yet, residents generate workload. Over a 10-year period, surgical residents contributed over a million dollars a year in "neglected" relative value units (RVUs) in unbillable "minor procedures" done without faculty supervision.'" If first assistant billing (16% RVU) for residents were allowed, one health care system reported the potential for over $20,000 annually per resident.'^ In internal medicine, one program noted RVUs more than tripled when faculty precepted residents' continuity clinics compared to RVUs generated in their faculty clinics.'"^ The break-even point for covering pédiatrie faculty salaries was about 3.5 residents in clinic per staff preceptor.'^ The MHS's approach of using an early educational investment (i.e.. Uniformed Services University attendance) coupled with structured salary during a time of service obligation was cited as a model the civilian sector shotild consider to address the nation's health care cost.'^ Finally, the BowlesSimpson commission recommended lowering indirect GME payments to teaching hospitals to 42% of the current rate reportedly to better refiect actual cost, a further indication GME may not be as costly as generally perceived.' KP believes its health care image is enhanced by being a teaching center.^ The Accreditation Council for Graduate Medical Education (ACGME) common requirements states; "Faculty must establish and maintain an environment of inquiiy and scholarship with an active research component."'^ Like KP, our military teachers are not daunted by the "publish or perish" mentality of some academic centers. Yet, our programs must have clinical researchers to move military medicine forward in care delivery, institutional reputation, and to ensure accreditation. Therefore, MHS must continue to fund and support processes that enhance the educational and clinical scholarship necessary for academic MTFs to be "academic."
MILITARY MEDICINE, Vol. 178, November 2013
Given a primary objective of the Defense Health Agency is to recapture purchased care, losing the prestige, and lure associated with academic medical centers seems counterproductive. As a Program Director, I would scramble to provide "justin-time" training to ensure our residents were aware of The Joint Commission (TJC) standards. The ACGME Next Accreditation System focus presents a challenging opportunity to fully embrace institutional and TJC patient safety and quality improvement endeavors in GME. Its Clinical Leaming Environment Review Program institutional visits will use a TJC "walk-about" model to ensure our programs and MTFs are championing resident education and engagement, and can demonstrate impact on patient safety and quality improvement initiatives. Residents are the "tip of the spear" when it comes to physician care delivery in our GME MTFs. Recognizing this, the VA hires Chief Residents of quality and patient safety to facilitate greater integration." Likewise, MHS efforts to improve patient safety or quality are unlikely to succeed without resident engagement in planning and implementation. Because we hire all of our graduates to take care of our own, another compelling reason to ensure military GME occurs in high-quality, safety-focused MTFs is the "imprinting" associated with where a resident trains. Graduates of residency programs with lower obstetric complication rates continued to show lower rates themselves for 20 years when compared with graduates from programs with higher complication rates.'* Therefore, military GME has a moral imperative to lead the way for acculturation of interprofessional teams delivering safe, efficient, and effective care. The result will benefit all of our MTFs and our patients for years to come. Finally, the U.S. health care system faces a significant shortage of physicians in the coming years. The growth of U.S. medical schools is significandy outpacing the current growth of GME training positions, which will lead to the number of U.S. graduates exceeding GME positions.' The closing of 3% of the nation's GME positions in MTFs would further impact the crisis. In this environment, the MTF would need to hire physicians and mid-level providers to replace the lost GME productivity or lose even more patients to the purchased care sector. If the MHS chose to fund salaries and benefits for military residents in civilian teaching hospitals, either for recruitment or to ensure training positions in quality centers, the potential for fiscal gains from stopping or downsizing military GME would be significantly reduced while simultaneously losing the myriad of benefits outlined above. In this time of fiscal uncertainty, looming physician shortages, and evidence supporting the benefits of GME, the MHS should focus on policies that foster synergy between military GME and MTFs. Policies that enhance recapturing patients currendy in the purchased care sector into quality, safety-focused military academic centers are good for the MHS, our patients, and for our future. The King's clothes are not tattered, though maybe a bit soiled. The MHS needs to continue to value and operate military GME more than ever, even in this time of fiscal challenges.
1155
Commentary
REFERENCES 1. Inglehart JK: The uncertain future of medicare and graduate medical education. N Engl J Med 2011; 365(14): 1340-5. 2. National Defense Industrial Association, Health Affairs Division. Military graduate medical education: A 21st century look. "A pro bono study." Arlington, VA, National Defense Industrial Association, 2006. Sponsored by the Office of the Secretary of Defense for Health Affairs and the Surgeons Generals of the Armed Forces. 3. Rasgón S, Hará JH. Blumberg B: The importance of graduate medical education for Permanente physicians. Kaiser Permanente, and American medicine [editorial]. Perm J 2007 Fall; 11(4): 79-87. 4. Dong T, Duming SJ, Gilliland WR. et al: Leadership success and the Uniformed Services University: perspectives of flag officer alumni. Mil Med 2012; 177:61-7. 5. Fogel RW: The Fourth Great Awakening and the Future of Egalitarianism. Chicago, IL, University of Chicago Press, 2000. 6. Schloss EP, Flanagan DM, Culler CL, Wright AL: Some hidden costs of faculty turnover in clinical departments in one academic medical center. Acad Med 2009; 84(1): 32-6. 7. Kashner MT, Chang BK; VA Residents Improve Access and Financial Value, AAMC Fall Meeting November 5. 2011. Available at https:// members.aatTic.org/eweb/upload/Kashner%20%20Chang%20ANN 11 -229 .pdf; accessed May 2013. 8. Salerno S, Ca.sh B, Cranston M, Schoonmaker E: Perceptions of current and recent military internal medicine residents on operational medicine, managed care, graduate medical education, and continued military service. Mil Med 1998; 163: 392-7.
9. Kravitz R, Thomas N, Sloss E, Hosek S: Satisfaction and dissatisfaction in institutional practice: results from a survey of U.S. military physicians. Mil Med 1993: 158: 41-50. 10. Shahian DM. Nordberg MS, Meyer GS, et al: Contemporary perfonnance of U.S. teaching and nonteaching hospitals. Acad Med 2012; 87: 701-8. 11. Chang BK: GME enhancement: expansion and educational innovation in VA residency programs. Acad Intern Med Insight 2009; 7: 6-13. Available at http://www.im.org/Publications/Insight/Archives/2009/ InsightV7I2/Pages/va.aspx; accessed May 2013. 12. Feinstein AJ. Deckelbaum DL, Madan AK, McKenney MG: Unsupervised procedures by surgical trainees: a windfall for private insurance at the expense of graduate tnedical education. J Trauma 2011; 70(1): 136-9. 13. Madan AK. Fabian TC, Tichansky DS: Potential financial impact of first assistant billing by surgical residents. Amer Surg 2007; 73: 652-7. 14. Albritton TA, Miller MD, Johnson MH, Rahn DW: Using relative value units to measure faculty clinical productivity. J Gen Intern Med 1997; 12: 715-7. 15. Ng M, Lawless ST: What if pédiatrie residents could bill for their outpatient services? Pediatrics 2001; 108: 827-34. 16. Cronin WA, Morgan JA. Weeks WB: The cost of pursuing a medical career in the military: a tale of five specialties. Acad Med 2010; 85: 1316-20. 17. Accreditation Council for Graduate Medical Education. Common Program Requirements. Effective July 1, 2011. Available at http://www .acgme.org/acgmeweb/; accessed May 2013. 18. Asch DA, Nicholson S, Srinivas S, Herrin J, Epstein AJ: Evaluating obstetrical residency programs using patient outcomes. JAMA 2009; 302: 1277-83.
GET THE POWER TO HELP THE BEST GET BETTER When America's best get injured, you can help them come back faster with the Game Ready® System.
For acute musctiloskeletal injury and post-operative recovery. Game Ready® is the new standard of care. Game Ready's innovative ACCEL'" Technology (Active Compression and Cold Exchange Loop)
To learn more about accelerated recovery, please visit vwvw.gameready.com or cali us toll-free at 1.888.426.3732.
synergistically combines pneumatic compression and cold therapies like never before - enabling you to help your wounded to heal
G A M E
R E A D Y »
faster. Get Game Ready and get the power to accelerate recovery. ©2013 Cool&ysleras. he. All ligfiSs reseated. vm,l¡ 'Û5/13
1156
MILITARY MEDICINE, Vol. 178, Novetnber 2013
Copyright of Military Medicine is the property of Association of Military Surgeons of the United States and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
