[Senate Hearing 109-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2007

                              ----------                              


                         WEDNESDAY, MAY 3, 2006

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:05 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Ted Stevens (chairman) presiding.
    Present: Senator Stevens, Inouye, and Mikulski.

                         DEPARTMENT OF DEFENSE

                        Medical Health Programs

STATEMENT OF LIEUTENANT GENERAL KEVIN C. KILEY, M.D., 
            SURGEON GENERAL, DEPARTMENT OF THE ARMY

                OPENING STATEMENT OF SENATOR TED STEVENS

    Senator Stevens. Thank you very much for your appearance.
    We want to welcome you to this hearing as we seek to review 
the Department of Defense medical programs. There are two 
panels scheduled today. First we will hear from the surgeon 
generals, followed by the chiefs of the nursing corps. Today, 
joining us from the Army, we have Lieutenant General Kevin 
Kiley, Vice Admiral Donald Arthur, from the Navy, and 
Lieutenant General Peach Taylor, representing the Air Force. 
It's nice to have you all back with us again.
    The President's fiscal year 2007 request for the defense 
health program is $21 billion, an increase over the fiscal year 
2006 request. The request provides for healthcare for 9.2 
million beneficiaries and for the maintenance and operation of 
70 inpatient facilities and 1,085 clinics.
    Our subcommittee recognizes that the continuing efforts 
overseas in support of the global war on terror and the 
national disaster relief, along with rising costs for 
prescription drugs and related medical costs, will continue to 
strain the financial resources that are contained in the 
request of this year's budget, will place an increased demand 
on our medical service providers, both here and those deployed 
in combat. The subcommittee also understands that the 
Department of Defense request to implement several initiatives 
to help mitigate this growing cost are here before us, and we 
plan to work with the Department to find the best means 
possible to medicate this rapid growth in regard to the 
financial burdens that you face.
    Senator Inouye and I are personally familiar with the value 
of military medicine. We're committed to working with you to 
address the many challenges you face. We certainly applaud your 
efforts, military medical people and the nurses that are 
deployed in harm's way. These men and women in uniform risk 
their lives in support of our Nation in the global war on 
terror, and also here at home, through the devastations such as 
Hurricane Katrina. They support the warfighter and this country 
in all aspects of the fight, and we certainly commend them for 
their leadership, compassion, and bravery.
    I'm pleased to yield to my co-chairman.

                 STATEMENT OF SENATOR DANIEL K. INOUYE

    Senator Inouye. Well, thank you very much, Mr. Chairman. I 
want to join you in welcoming our witnesses. They're all 
veterans here, and it's always reassuring to have them back.
    Our military healthcare system has been transforming in a 
wide array of areas during the past few years. These changes 
not only affect the military treatment facilities and private-
sector care, but extend to the battlefield, as well. And we 
have seen considerable growth in the benefits provided to our 
servicemembers and their families. At the same time, the 
private sector and the military treatment facilities are 
altering their management practices and patient resources due 
to new TRICARE contracts. We continue to see high patient 
volume, which requires seamless coordination between in-theater 
treatment, military treatment facilities, private-sector care, 
family support and counseling. And let's not forget the 
Veterans Administration.
    Continued improvement in battlefield protection and combat 
casualty care have enabled us to save thousands of lives.
    We're also transforming our approach to treatment at home. 
The direction of care is changing from focusing on individual 
servicemembers to focusing on the individual and his or her 
family from the moment orders are received to the time 
treatment is no longer needed. While we are engaged in this 
transformation, the Department has also initiated budget cuts 
and personnel changes that could have longstanding implications 
in our ability to care for our servicemembers and their 
families. These changes and fiscal constraints are compounded 
by the chronic recruiting and retention challenges faced by 
each service. Shortfalls reside in various specialties, but of 
most concern are those critically important to our 
servicemembers serving in harm's way, and their families, who 
rely upon the quality of homecare.
    We look forward to discussing these and many issues crucial 
to the military medical system.
    Once again, I'd like to thank the chairman for continuing 
to hold these hearings on issues which are so important to our 
military and their families. And I thank you very much.
    Senator Stevens. Thank you very much.
    Our first witness will be Lieutenant General Kiley. We're 
going to place your full statements in the record as though 
read, and we'd like to hear the comments you wish us to hear.
    General Kiley. Mr. Chairman, Senator Inouye, and 
distinguished members of the subcommittee, thank you for the 
opportunity to discuss the current posture of the Army Medical 
Department with you today.
    During combat operations in Afghanistan and Iraq, we've 
recorded the highest casualty survivability rate in modern 
history. More than 90 percent of those wounded survive, and 
many return to the Army fully fit for continued service. Our 
investments in medical training, equipment, facilities, and 
research, which you have strongly supported, have paid 
tremendous dividends in terms of safeguarding soldiers from the 
medical threats of the modern battlefield, restoring their 
health and functionality to the maximum extent possible, and 
reassuring them that the health of their families is also 
secure. Military medicine is essential to Army readiness and an 
important quality-of-life program.
    On any given day, more than 12,000 Army medics are deployed 
around the world supporting our Army in combat, participating 
in humanitarian assistance missions, and training not only at 
our centers throughout the world, but in Africa, South and 
Central America, and Eastern Europe.
    In the past year, Army medics have cared for more than 
6,000 soldiers evacuated from Iraq and Afghanistan, deployed in 
support of gulf coast hurricane relief operations, and deployed 
the Army's last mobile surgical hospital, the 212th, to support 
earthquake relief operations in Pakistan.
    Over the past 3 years, more than half the Army medical, 
dental, and nurse corps officers have deployed at least once to 
Iraq or Afghanistan. Many of our critical wartime specialists 
have deployed multiple times. Every active component field 
hospital and forward surgical team has deployed multiple times. 
Our Reserve components, which comprise more than half the 
Army's medical force structure, have experienced similar 
operational tempo.
    All of this is happening while we transform and reset the 
Army. 2005 base realignment and closure decisions, Army modular 
force decisions, and the integrated global positioning base 
strategy--basing strategy have presented us with a significant 
challenge and a significant opportunity to improve the way we 
care for patients in the battlefield and at our camps, posts, 
and stations around the world. This process is complicated by 
the long lead time necessary to plan and execute military 
construction and by the low thresholds for military 
construction projects.
    In the short term, we continue to maintain high states of 
medical readiness and high service levels to families and 
retirees by increasing internal efficiencies, leveraging 
modular building technology, and relying on TRICARE networks, 
where necessary. Lean Six Sigma techniques are used throughout 
our planning process to develop expeditious, affordable 
solutions that ensure no decline in the accessibility or 
quality of the care provided to Army beneficiaries.
    Much of the healthcare we provide to wounded soldiers is 
funded through supplemental appropriations. The military 
amputee care programs, centered at Walter Reed Army Medical 
Center and Brooke Army Medical Center, has cared for nearly 
4,000--400--excuse me--amputees over the past 3 years. I want 
to thank Congress and the subcommittee for your continued 
support of this program. We're leading the Nation in improving 
amputee care and improving the field of prosthetics technology. 
Working jointly with the Department of Veterans Affairs and the 
civilian industry, we're sharing lessons learned and raising 
the standards of amputee care across our country. Due to your 
support and advances in the care of amputees, many of these 
soldiers will be able to remain on active duty, and many will 
return to combat units fully capable of performing their 
duties.
    Medical research, development, testing, and evaluation are 
critical to our ongoing success both on the battlefield and in 
our hospitals around the country. Over the past year, we've 
pulled 12 medical products out of the research, development, 
test and evaluation (RDT&E) process and fielded them to 
deploying forces because of their demonstrated efficacy and 
safety in improving patient care and force protection on the 
battlefield.
    Despite all of our advances in battlefield medicine, 
hemorrhage continues to be the major cause of death on the 
battlefield, and we continue to develop and test blood 
substitutes and hemostatic agents to mitigate blood loss in our 
combat casualties.
    Today, every soldier in Iraq and Afghanistan deploys with a 
hemostatic bandage and a tourniquet. Evacuation assets quickly 
move casualties from the battlefield to the forward surgical 
teams and combat support hospital within minutes of injury. 
These advances in equipment, training, and doctoring are saving 
lives every day in Iraq and Afghanistan.
    To support homeland security, Fort Detrick, Maryland, is 
working to become the home of the National Interagency 
Biodefense Campus. This interagency initiative co-locates 
researchers from the Department of Defense, the Centers for 
Disease Control and Prevention (CDC), Department of 
Agriculture, Department of Homeland Security, and the National 
Institute of Allergy and Infectious Diseases to achieve 
productive, efficient, interagency cooperation in support of 
our Nation's biodefense.
    Military health benefit has gained critical attention this 
year due to the Department's proposal to initiate control over 
the long-term costs and sustain this important benefit for our 
current and future retirees. This truly outstanding health 
benefit is important for accessions, retentions, and military 
readiness. Each service has taken action over the past few 
years to improve efficiencies and control healthcare costs. 
However, these actions alone will not stem the rising costs in 
the military health benefit.
    I am concerned that delaying action will put even greater 
financial pressure on our hospitals and clinics, when we are 
still trying to care for combat casualties and continue to 
deploy Active and Reserve component soldiers.
    The President's budget request adequately funds the defense 
health program to meet our military medical readiness 
requirements if the sustaining benefits proposals are enacted. 
However, the medical budgets of the three services have little 
flexibility to absorb additional efficiencies to sustain our 
medical readiness mission if no action is taken in this 
important issue.
    In closing, let me emphasize that the service and sacrifice 
of our soldiers and their families cannot be measured with 
dollars and cents. The truth is, we owe far more than we can 
ever pay to those who have been wounded and to those who have 
suffered loss. Thanks to your support, we've been very 
successful in developing a healthcare delivery system that 
honors the commitment of our soldiers, retirees, and their 
families that have been made to our Nation by providing them 
with world-class medical care and peerless military force 
protection.

                           PREPARED STATEMENT

    Thank you, again, for inviting me to participate in the 
discussions today, and I look forward to answering your 
questions.
    Senator Stevens. Thank you, General.
    [The statement follows:]

     Prepared Statement of Lieutenant General Kevin C. Kiley, M.D.

    Mr. Chairman, Senator Inouye, and distinguished members of the 
subcommittee, thank you for the opportunity to discuss the current 
posture of the Army Medical Department and our requirements for fiscal 
year 2007. During the past five years, military medicine has constantly 
exceeded any measure of success we could establish. During combat 
operations in Afghanistan and Iraq, we have recorded the highest 
casualty survivability rate in modern history. More than 90 percent of 
those wounded survive and many return to the Army fully fit for 
continued service. Our investments in medical training, equipment, 
facilities, and research, which you have strongly supported, have paid 
tremendous dividends in terms of safeguarding Soldiers from the medical 
threats of the modern battlefield, restoring their health and 
functionality to the maximum extent possible, reassuring them that the 
health of their families is also secure. Military medicine is essential 
to Army readiness and an important quality of life program.
    On any given day more than 11,000 Army medics--physicians, 
dentists, veterinarians, nurses, allied health professionals, 
administrators, and combat medics--are deployed around the world 
supporting our Army in combat, participating in humanitarian assistance 
missions, and training not only at our training centers throughout the 
world but in Africa, South and Central America, and Eastern Europe. In 
the past year, Army medics have cared for more than 6,000 Soldiers 
evacuated from Iraq and Afghanistan; deployed a combat support 
hospital, a medical logistics company, and several preventive medicine 
and veterinary teams in support of Gulf Coast hurricane relief 
operations; and deployed the Army's 212th Mobile Army Surgical Hospital 
(MASH) to support earthquake relief operations in Pakistan.
    The story of the 212th MASH illustrates the dedication, 
flexibility, and adaptability of Army Medicine. On September 23, 2005, 
the 212th returned to Germany after a 3-week training and humanitarian 
assistance mission in Angola. Within days of the devastating earthquake 
that struck Pakistan on October 8, the 212th MASH was on its way to 
provide surgical and medical care to survivors. When the Pakistani 
mission became apparent, the 212th was the only Department of Defense 
unit that could fill the requirement. It was close to Pakistan, mobile 
enough that it could be put in position quickly, and completely self-
contained with the capability to house and feed its staff without 
additional assistance from support units or the host nation. The 212th 
returned to Germany in late-February and has begun training with new 
equipment for an upcoming deployment to Iraq.
    It is this dedication, flexibility, and adaptability that has 
allowed us to provide superb medical care for more than 24,000 sick or 
injured Soldiers from Iraq and Afghanistan over the past three years. 
Army Medicine is an integrated system of healthcare designed, first and 
foremost, to protect and treat the warfighter. Let me explain how we 
accomplish this and several new initiatives underway to improve how we 
work.

                        RECRUITING AND RETENTION

    Success begins with recruiting, training, and retaining quality 
healthcare professionals. Fiscal year 2005 presented recruitment 
challenges for healthcare providers. We made 99 percent of our goal for 
Medical Corps recruitment (goal of 419 with 416 achieved) and 84 
percent of our Dental Corps goal (goal of 125 with 105 achieved). 
However, the Army fell short of its goals for awarding Health 
Professions Scholarships in both the Medical Corps (77 percent of 
available scholarships awarded) and Dental Corps (89 percent of 
scholarships awarded). These scholarships are by far the major source 
of accessions for physicians and dentists. This presents a long-term 
recruiting challenge beginning in fiscal year 2009. It is too early to 
tell if this is a one-year anomaly or the beginning of a long-term 
trend, but we are working hard to ensure every available scholarship is 
awarded this year. In conjunction with United States Army Recruiting 
Command (USAREC) we have initiated several new outreach programs to 
improve awareness of these programs and to increase interest in a 
career in Army Medicine. I also ask for your support of legislation 
just submitted by DOD establishing a 2-year pilot program for an 
increased recruitment incentive bonus in up to five critical medical 
specialties. We hope this will attract more interest in our critical 
medical specialties.
    In January I sent letters to the Deans of every U.S. medical 
school, asking for opportunities for Army physicians and Army 
recruiters to meet with medical students and discuss opportunities to 
serve in the Army. Response to date has been strong and positive. We 
will use the same tactic with dental and nursing schools this year.
    I am encouraged by a recent analysis of retention among active duty 
Medical Corps officers in fiscal year 2005. More than 50 percent of 
physicians who completed their initial active duty service obligation 
last year agreed to stay for at least one more year. This analysis 
challenges the myth that increased operations tempo leads to lower 
retention. We continue to monitor this trend carefully and will be 
expanding the analysis to include dentists and nurses in the next year.
    The Reserve Officer Training Corps (ROTC) is a primary source for 
our Nurse Corps Force. In recent years, ROTC has had challenges in 
meeting the required number of Nurse Corps accessions and as a 
consequence, USAREC has been asked to recruit a larger number of direct 
accession nurses to fill the gap. This has been difficult in an 
extremely competitive market. In fiscal year 2005, USAREC achieved 83 
percent of its Nurse Corps mission. We have recently raised the dollar 
amount that we offer individuals who enter our Army Nurse Candidate 
Program to $5,000 per year for max of two years with a $1,000 per month 
stipend. Last year we increased the multi-year bonuses we offer to 
Certified Registered Nurse Anesthetists with emphasis on incentives for 
multi-year agreements. A year's worth of experience indicates that this 
increased bonus, 180-day deployments, and a revamped Professional 
Filler system to improve deployment equity is helping to retain CRNAs.
    Reserve Component Accessions and Retention continue to be a 
challenge. In fiscal year 2005 we expanded accessions bonuses to field 
surgeons, social workers, clinical psychologists, all company grade 
nurses and veterinarians in the Army National Guard and Army Reserve. 
We also expanded the Health Professions Loan Repayment Program and the 
Specialized Training Assistance Program for these specialties. In 
February 2006, we introduced a Baccalaureate of Science in Nursing 
(BSN) stipend program to assist non-BSN nurses complete their four-year 
degree in nursing. This will be an effective accessions and retention 
tool for Reserve Component Nurses who have only completed a two-year 
associates degree in nursing. Working with the Chief of the Army 
Reserve and the Director of the Army National Guard, we continue to 
explore ways to improve Reserve Component accessions and retention for 
this important group. The Reserve Components provide over fifty percent 
of Army Medicine's force structure and we have relied heavily on these 
citizen Soldiers during the last three years. They have performed 
superbly.

                     INSTALLATIONS AS OUR FLAGSHIPS

    Army healthcare providers train and maintain their clinical skills 
in hospitals and clinics at Army installations around the world 
everyday. Our medical treatment facilities are the centerpiece of 
medical readiness. These facilities provide day-to-day healthcare for 
Soldiers to ensure they are ready to deploy; allow providers to train 
and maintain clinical competency with a diverse patient population that 
includes Soldiers, retirees, and families; serve as medical force 
projection platforms, and provide resuscitative and recuperative 
healthcare for ill or injured Soldiers. In order to do this 
successfully, we must sustain appropriate workload and patient case-mix 
in our facilities and have a supportive network of civilian providers 
for the healthcare services we cannot effectively or efficiently 
provide.
    The combination of Base Realignment and Closure (BRAC) decisions, 
Army Modular Force decisions, and the Integrated Global Positioning and 
Basing Strategy have presented us with a significant challenge and a 
significant opportunity to improve the way we care for patients at 
affected installations. This is complicated by the long-lead time 
necessary to plan and execute military construction and by low 
thresholds for military construction projects.
    Two important proposals coming forward from the Quadrennial Defense 
Review will enhance our flexibility to rapidly implement military 
construction projects in response to the challenges of Army 
restationing initiatives. One increases the Operations & Maintenance 
threshold for military construction from the current cap of $750,000 to 
$3,000,000. The second proposal increases the unspecified minor 
military construction threshold from $1,500,000 to $7,000,000--the same 
authority the Department of Veterans Affairs has. The Army fully 
supports these proposals. We need to have authority comparable to the 
Department of Veterans Affairs in order to reset our medical force in 
support of these restationing decisions.
    Much of the healthcare we provide to wounded Soldiers is funded 
through supplemental appropriations. The Military Amputee Care Program, 
centered at Walter Reed Army Medical Center and Brooke Army Medical 
Center, has cared for nearly 400 amputees over the past three years. I 
want to thank the Congress and the subcommittee for your continued 
support. This program is leading the nation in improving amputee care 
and improving the field of prosthetics technology. They are working 
jointly with the Department of Veterans Affairs and civilian industry 
to share lessons learned and raise the standard of amputee care across 
our country. Due to your support and advances in the care of amputees, 
many of these Soldiers will be able to remain on active duty and many 
will return to combat units fully capable of performing their duties.

                        RESEARCH AND DEVELOPMENT

    Medical Research, Development, Testing, and Evaluation are critical 
to our ongoing success both on the battlefield and in our hospitals 
around the country. Over the past year we have pulled 12 medical 
products out of the RDT&E process and fielded them to deployed forces 
because their demonstrated efficacy and safety in improving patient 
care and force protection on the battlefield. Despite all of our 
advances in battlefield medicine, hemorrhage continues to be the major 
cause of death on the battlefield. We continue to develop and test 
blood substitutes and hemostatic agents to mitigate blood loss in our 
combat casualties. Today, every Soldier in Iraq and Afghanistan deploys 
with a hemostatic bandage and a tourniquet. Evacuation assets quickly 
move casualties from the battlefield to Forward Surgical Teams and 
Combat Support Hospitals within minutes of injury. These advances in 
equipment, training, and doctrine are saving lives every day in Iraq 
and Afghanistan.
    Army scientists continue their work in research and development of 
new vaccines, including adenovirus vaccine, malaria vaccine, and plague 
vaccine. These vaccines are needed to protect against microbes that 
threaten Soldiers in basic training, in tropical locations, or as 
bioweapons. To support Homeland Security, Fort Detrick, Maryland has 
become the home for a National Interagency Biodefense Campus (NIBC). 
This interagency initiative collocates researchers from Department of 
Defense, Centers for Disease Control, Department of Agriculture, 
Department of Homeland Security and the National Institutes for Allergy 
and Infectious Diseases to achieve productive and efficient interagency 
cooperation in support of our Nation's biodefense.
    A key component of protecting Soldiers on the battlefield and 
citizens at home from the threat of chemical and biological agents is 
research and development of medical countermeasures against such 
agents. The infrastructure and expertise to do this resides within the 
U.S. Army Medical Research and Materiel Command (USAMRMC) at Fort 
Detrick, Maryland. The U.S. Army Medical Research Institute for 
Infectious Diseases (USAMRIID) at Fort Detrick, and the U.S. Army 
Medical Research Institute for Chemical Defense (USAMRICD) at Aberdeen 
Proving Ground, Maryland, represent critical national capabilities 
that, in addition to National Defense, support the entire spectrum of 
Homeland Security.
    USAMRIID provides basic and applied research on biological threats 
resulting in medical solutions to protect the War Fighter and offers a 
comprehensive ability to respond to biological threats. USAMRIID 
scientists have more than 34 years of experience safely handling the 
world's deadliest pathogens in biocontainment. USAMRICD is charged with 
the development, testing, and evaluation of medical treatments and 
materiel to prevent and treat casualties of chemical warfare agents. In 
addition to research, USMRICD, in partnership with USAMRIID, educates 
health care providers in the medical management of chemical and 
biological agent casualties. Simply put the Nation's experts in 
chemical and biological weapons work at USAMRIID and USAMRICD.

                          SUSTAIN THE BENEFIT

    The Army requires a robust military medical system to meet the 
medical readiness needs of active duty service members in both war and 
peace, and to train and sustain the skills of our uniformed physicians, 
nurses, and combat medics as they care for family members, retirees, 
and retiree family members. Therefore we share the Department of 
Defense's (DOD) concern that the explosive growth in our healthcare 
costs jeopardizes our resources, not only to the military health system 
but in other operational areas as well.
    Expansion of TRICARE to the Selected Reserve in the fiscal year 
2005 and fiscal year 2006 National Defense Authorization Act highlights 
the challenge presented to DOD by expanding benefits with limited 
resources. We are very concerned by the projections of cost growth in 
the Defense Health Program over the next ten years. Without addressing 
the issues, our healthcare costs will total approximately 12 percent of 
the DOD budget by 2015. This growth forces us to look for additional 
efficiencies in our direct care system and threatens quality of life, 
readiness, and modernization programs.
    The Army and Army Medical Command fully support the Sustaining the 
Benefit proposals for working age retirees, as it represents a 
reasonable approach to meeting the challenge of providing for our 
Soldiers and the future of our force. After the proposal is fully 
implemented, TRICARE will still remain a very affordable option for our 
military retirees under the age of 65, with out-of-pocket costs for 
retirees still projected to be little more than half of the costs for 
members of the Federal Employee Health Benefits Program. The change 
merely begins to bring the cost share for working age military retirees 
in line with the same proportion it was when Congress created TRICARE.
    The Department of Defense continues to explore other opportunities 
to help control costs within the Defense Health Program and in many of 
initiatives the Army leads the Department in implementation and 
innovation. This year, I implemented a performance-based budget 
adjustment model throughout the Army Medical Command. This model 
accounts for provider availability, proper coding of medical records, 
and use of Clinical Practice Guidelines to adjust hospital and clinic 
funding levels to reflect the cost of actual healthcare delivered. The 
Southeast Regional Medical Command implemented this system in 2005 
where it increased staff awareness on properly documenting workload and 
staff availability. This model increases command attention to the 
business of delivering healthcare. It is an Internet-based model so 
commanders at all levels receive fast feedback on their organization's 
performance. Finally, use of Clinical Practice Guidelines encourages 
efficiency by using nationally accepted models for disease management. 
These adjustments provide my regional commanders the flexibility needed 
to move funds within their region to the facilities that are 
demonstrating improved performance and the ability to absorb more care 
from TRICARE networks.
    The Army is also leading the Department's implementation of an 
electronic medical record. The armed forces health longitudinal 
technology application (AHLTA) will help to significantly reduce the 
number of negative medical outcomes and errors compared to paper 
methods of documenting treatment and ordering drugs. Eighty-three 
percent of Army hospitals are using AHLTA today and every Army hospital 
will be using AHLTA by the end of August 2006. Nearly two-thirds of 
Army hospitals have fully implemented AHLTA and the Army leads DOD in 
the number of healthcare providers using AHLTA. For the past 3 years, 
Army providers deployed in Iraq and Afghanistan have been using the 
Theater Medical Information Program so each Soldier's treatment data is 
available to providers at Landstuhl, Walter Reed, or other Army medical 
treatment facilities when that Soldier-patient comes home. The Army 
Medical Department now captures over 200,000 patient encounters a week 
in this 21st century medical record.
    The 2005 Base Realignment and Closure decisions demonstrate actions 
to improve the joint delivery of healthcare in both the National 
Capital Area and San Antonio, Texas. Recommendations to collocate 
medical training for all three Services at Fort Sam Houston, Texas and 
to collocate a number of medical research and development activities at 
Fort Detrick allows for enhanced synergy, collaboration and cost 
effectiveness. The next step is to move beyond a collocation of these 
activities to implementation of a business plan that realizes a true 
integration of DOD's medical training and research activities.
    The Army continues to support the development of a Unified Medical 
Command and is working closely with our sister Services and the Joint 
Staff to realize the full potential of this initiative. A fully 
functional unified command represents an opportunity to reduce multiple 
management layers within DOD's medical structure, inspire collaboration 
in medical training and research, and gain true efficiencies in 
healthcare delivery. These changes need to be made in conjunction with 
actions to Sustain the Benefit.
    In closing let me emphasize that the service and sacrifice of our 
Soldiers--and their families--cannot be measured with dollars and 
cents. The truth is that we owe far more than we can ever pay to those 
who have been wounded and to those who have suffered loss. Thanks to 
your support, we have been very successful in developing a healthcare 
delivery system that honors the commitment of our Soldiers, retirees, 
and their families made to our Nation by providing them with world-
class medical care and peerless military force protection.
    Thank you again for inviting me to participate in this discussion 
today. I look forward to answering your questions.

    Senator Stevens. Admiral Arthur.

STATEMENT OF VICE ADMIRAL DONALD C. ARTHUR, M.D., 
            SURGEON GENERAL, DEPARTMENT OF THE NAVY
    Admiral Arthur. Good morning, Chairman Stevens and Ranking 
Member Inouye. Thank you very much for the opportunity to 
address the subcommittee.
    In this age of interoperability of the three services, I 
dare say that each of the surgeons could have given the same 
opening comments. And, in that spirit, I echo what General 
Kiley has said in his opening remarks, they equally apply to 
Navy medicine.
    We also have thousands of people deployed to Operation 
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF), where 
we're very proud of the greater than 90 percent survival rate 
for combat injuries, the lowest disease and nonbattle injury 
rate in history, and the rapid rate at which combat casualties 
can be taken from the field, resuscitated, brought to Landstuhl 
and then for further care at Walter Reed, Bethesda, Malcolm 
Grow, and other great facilities throughout the country.
    We believe in family-centered care for these casualties, 
and we've continued the policy of having family members meet 
the casualties as they are received in our continental United 
States (CONUS) facilities. Most of the casualty care that we 
have delivered has been on the east coast, and we're proud to 
announce that this summer we'll open up a Comprehensive Combat 
Casualty Care Center in San Diego, where we will offer the full 
spectrum of rehabilitative services. I have asked that each 
member of the rehabilitate team have specific training in 
combat stress and the psychological effects of combat. I've 
also asked that this center be staffed by as many combat 
veterans, and especially combat-wounded sailors as possible to 
provide that degree of empathy for the combat-wounded.
    We are also reshaping our force for future events, 
especially humanitarian assistance, stability operations, 
homeland defense, and disaster relief, which is not currently 
part of our planning for combat casualty care injuries. I think 
the important thing is that we need to have the flexibility to 
accomplish all of the missions that we might be tasked to join. 
A good example of our flexibility is the U.S.N.S. Mercy, which 
launched recently on a humanitarian assistance mission to 
Southeast Asia, where it will, in collaboration with 
nongovernmental organizations (NGO), deliver humanitarian 
services to many people who have been unreached by the United 
States in any other way. And I think that that will provide us 
with a great deal of diplomacy in those areas.
    We are having challenges in recruiting and retention. I 
know that Senator Mikulski is interested in how we have used 
the loan repayment program. We are very proud that we have made 
some inroads in our recruiting efforts with these programs.
    One of the issues which is most challenging for us is the 
operational tempo, as General Kiley talked about. We have some 
specialities, especially those that are combat intensive--
surgeons, nurse anesthetists, operating room (OR) technicians--
who have deployed at least once, and sometimes two times, per 
year over the last 3 years.
    The administration's proposals to manage cost growth and 
sustain this valuable TRICARE benefit encourages beneficiaries 
to elect medically appropriate, cost-effective healthcare 
options. The Navy supports the words of the Joint Chiefs, 
Chairman Pace and Secretary Rumsfeld, and wants to work closely 
with the distinguished members of this subcommittee and all of 
Congress to sustain this great health benefit.
    I would like to mention one guest that we have with us 
today. That is Captain Catherine Wilson, who just returned from 
Kuwait as the commanding officer of the expeditionary medical 
force, so she's a nurse corps officer who is en route to Naval 
Hospital Bremerton, where she will be the commanding officer. 
And she's our officer with the most recent combat support 
experience. And she's with us today. I'm glad to have her here.
    Senator Stevens. Catherine, why don't you stand up so we 
can recognize you?
    Admiral Arthur. Cathy.
    Senator Stevens. Thank you very much.
    Admiral Arthur. One of the things that we have decided to 
do recently is to re-code all of our leadership billets to be 
corps-nonspecific, so that it could be--all leadership billets 
can be occupied by any corps in the Navy. And Captain Wilson is 
a good example, as a nurse corps officer, who went there and 
did an outstanding job in combat support.

                           PREPARED STATEMENT

    Mr. Chairman, thank you very much for allowing me to give 
you some opening comments. And I look forward to all of your 
questions.
    Thank you.
    Senator Stevens. Thank you very much.
    [The statement follows:]

          Prepared Statement of Vice Admiral Donald C. Arthur

                              INTRODUCTION

    Chairman Stevens, Ranking Member Inouye, thank you for the 
opportunity to testify before you today about the state of Navy 
Medicine and our plans for the upcoming year.
    Navy Medicine is an integral part of the Navy and Marine Corps team 
and plays a key role in our ever expanding and more diverse missions 
that continue to evolve as we fight the global war on terrorism. 
Against new enemies whose arsenals include catastrophic medical 
threats, Navy Medicine is a critical defensive weapon for the Navy and 
Marine Corps team. Consider just a few of these efforts: Navy Medicine 
provides surveillance for biological attacks, immunizes personnel to 
reduce the impact of bioterrorism events, assesses potential health 
threats in the operational environment, and provides expert clinical 
consultation to operational commanders, all while providing combat 
casualty care far-forward and exceptional care for our heroes and their 
families here at home.

                        FORCE HEALTH PROTECTION

    The primary focus of Navy Medicine is Force Health Protection. Navy 
Medicine is preparing a healthy and fit force that can go anywhere and 
accomplish any mission that the defense of the nation requires. 
Further, Navy Medicine goes with them, to protect the men and women in 
uniform from the hazards of the battlefield. But as hard as we try, all 
this preparation does not fully prevent the physical and psychological 
impact of combat service.

                          COMBAT CASUALTY CARE

    As you know, more seriously injured warfighters are surviving their 
wounds--more than in any other conflict in history. These low mortality 
rates can be attributed to improved trauma and combat casualty care of 
our medical personnel, advances in medical technology, better body 
armor, and improved training of our medical personnel; however, one of 
the most important contributors to saving lives on the battlefield has 
always been, and remains Navy corpsmen--Navy Medicine's first 
responders on the battlefield. The platoon corpsmen are supported by a 
team of field surgeons, nurses, medical technicians and support 
personnel in theater, who are supported by medical evacuation teams and 
overseas Military Treatment Facilities (MTF) working together with MTFs 
in the United States--this is the Navy Medicine continuum of care.
    Navy Medicine's commitment to the warfighter is clearly seen in the 
combat casualty care provided to injured and ill Marines and Sailors 
engaged in Operations IRAQI FREEDOM and ENDURING FREEDOM since the 
beginning of the Global War on Terror. Combat casualty care is a 
``continuum-of-care,'' which begins with corpsmen in the field with the 
Marines; progresses to forward resuscitative care; on to theater level 
care; and culminates in care provided in route during patient 
evacuation to a military hospital. Medical care is being provided in 
Iraq and Afghanistan by organic Marine Corps health services units 
which include battalion aid stations, shock trauma platoons, surgical 
companies, and Forward Resuscitative Surgical Systems.
    During current operations, Navy Medicine has made significant 
advances in the health care provided by first responders and in access 
to resuscitative surgical care during the critical ``golden hour.'' A 
badly injured Marine who receives advanced medical care within an hour 
of injury is highly likely to be saved.
    Navy Medicine is also deployed worldwide with Naval air, surface 
and subsurface forces, providing daily health service support, force 
health protection, and medical intelligence and planning for the Navy's 
many traditional and nontraditional missions.
    Our operationally-focused research efforts in areas such as disease 
surveillance, bioweapon detection, protection and countermeasures, 
emerging illnesses, field medical gear, and advanced aviation and 
diving physiology facilitates the warfighter's efforts to do his or her 
job more safely and effectively.
    As our engagement in Iraq and Afghanistan continues, the number of 
injured service members who return in need of critical medical services 
will increase. As a result, and due to the severity and complexity of 
their injuries, increased cooperation and collaboration with our 
federal health care partners is essential to providing quality care. As 
an extension of Navy Medicine's ability to care for patients, 
partnerships with Veterans Affairs (VA) medical facilities continue to 
grow and develop into a mutually beneficial association. In 2003, the 
VA created the Seamless Transition Program to address the logistic and 
administrative barriers for active duty service members transitioning 
from military to VA-centered care. This program is working well and 
continues to improve as new lessons are learned. Recently-wounded 
Sailors and Marines differ from the VA's traditional rehabilitation 
patient in age, extent and complexity of injury, and family 
involvement; therefore, we are actively engaged at all levels to ensure 
that quality care is being provided throughout both systems.

          PARTNERSHIP WITH THE DEPARTMENT OF VETERANS AFFAIRS

    Navy Medicine and the Department of Veterans Affairs continue to 
pursue enhancements to information management and technology 
initiatives to significantly improve the secure sharing of appropriate 
health information. Several efforts are underway that will enable us to 
share real-time patient information and to improve system 
interoperability. We also continue to support the pursuit of increased 
sharing and are currently managing medical and dental agreements across 
the country.
    In addition, our joint effort to create a hybrid organization based 
on new paradigms and practices continues to move forward. The Federal 
Health Care Facility at the site of Naval Hospital Great Lakes and the 
North Chicago Veterans Affairs Medical Center will operate under a 
single line of authority, overseen by a Board of Directors. All 
services currently being offered at both facilities will remain 
available, but will be delivered more efficiently within a seamless 
patient care and support environment.
    Finally, in the area of military construction Navy Medicine is 
pursuing a variety of joint ventures that include a Consolidated 
Medical Clinic aboard the Naval Weapons Station in Charleston, SC; a VA 
clinic to be built to replace the Naval Clinic at Corry Station in 
Pensacola, FL; and planned replacement hospitals at Beaufort and Guam, 
each of which will include a VA presence. We are also pursuing Joint 
Incentive Fund Projects, as directed by the fiscal year 2003 National 
Defense Authorization Act, across the enterprise.

                             MENTAL HEALTH

    The issue of mental health has been receiving much deserved 
attention since the beginning of OEF/OIF. I would like to take this 
opportunity to share with you some of the things that the Department of 
the Navy is doing to help the Navy and Marine Corps team cope with the 
stresses of combat.
    Anyone exposed to the extremely stressful environment of combat is 
affected by those events, with the effects varying with each individual 
service members. Although most cope with no significant or lasting 
impact, a small percentage will need assistance in dealing with their 
experiences, and some of them may ultimately be diagnosed and treated 
for Post Traumatic Stress Disease or other mental health conditions.
    Marines and Sailors are prepared for the psychological rigors of 
combat by being run through a realistic recreation of combat during 
pre-deployment training. Health screenings are conduced via the multi-
tiered deployment health assessment process, prior to deployment, 
immediately upon return from theater, and most recently at the 3-6 
month post deployment mark. In theater, Sailors and Marines have prompt 
access to chaplains, medical officers, and other mental health 
providers embedded with the operation forces through the Operational 
Stress Control and Readiness (OSCAR) Program. All aircraft carriers 
have a psychologist attached to the medical department aboard ship, and 
many of our new expeditionary strike groups also deploy with 
psychologists or psychiatrists onboard. In addition, since 
reunifications can sometimes be difficult, Sailors and Marines 
returning home are prepared to reunite with their families and 
communities through the ``Warrior Transition'' and ``Return and 
Reunion'' programs.

                    DEPLOYMENTS AND QUALITY OF CARE

    On an average day in 2005, Navy Medicine had over 3,500 medical 
personnel from the active and reserve components deployed in support of 
Operations, Exercises or Training around the world. Our missions vary 
and include humanitarian assistance abroad and at home; environmental 
risk assessments around the world; and combat casualty care.
    Navy Medicine is continuously monitoring the impact deployments of 
medical personnel have on our ability to provide quality health care at 
home. Together with the network of TRICARE providers who support local 
Military Treatment Facilities (MTFs), beneficiaries have been able to 
continue accessing primary and specialty care providers. We closely 
monitor the access standards at our facilities using tools like the 
peer review process, to evaluate primary and specialty care access 
relative to the Department of Defense's standard.
    Another means used to ensure quality is our robust quality 
assurance and risk management programs that promote, identify, and 
correct process or system issues and address provider and system 
competency issues in real time. Our program promotes a patient safety 
culture that complies with nationally established patient safety goals. 
These goals include training in the area of medical team management to 
improve communication processes as well as implementation of the Bureau 
of Medicine and Surgery (BUMED) advisory boards' recommendations in 
critical patient safety and quality areas, such as perinatal care.
    We have established evidence-based medicine initiatives and 
currently measure diabetes, asthma and women's breast health. Soon, we 
will add dental health and obesity.
    Navy Medicine also promotes healthy lifestyles through a variety of 
programs. These programs include: alcohol and drug abuse prevention, 
hypertension identification and control, tobacco use prevention and 
cessation, and nutrition and weight management. Partnering with other 
community services and line leadership enhances their effectiveness and 
avoids duplication.

                        CHANGES IN NAVY MEDICINE

    Since I testified before you nearly a year ago, Navy Medicine has 
gone through several changes to meet the evolving needs of the Navy and 
Marine Corps team. Last summer, we implemented a focused enterprise 
wide realignment effort to better direct our assets to maintain 
readiness and deliver the highest quality care in the most cost 
effective manner. This effort included standing up four regional 
commands--Navy Medicine West, Navy Medicine East, Navy Medicine 
National Capital Area and Navy Medicine Support Command--to provide a 
centralized and standardized structure of command and control. The 
regional commands have flexibility in supporting operational 
requirements while improving health care access and logistic support 
for all beneficiaries. Also, Navy Medicine's ten reserve medical units, 
Operational Health Support Units (OHSU), are aligned with the regional 
commands to gain operating efficiencies and maximizes the utilization 
of reserve assets. Furthermore, Reserve dental units have also been 
consolidated into the OHSUs to mirror changes implemented by Navy 
Medicine's active component.

                           EMERGING MISSIONS

    Pandemics of influenza have occurred in the past and will likely 
occur again in the future. For the first time, however, the United 
States along with the global community have an opportunity to 
cooperatively plan and prepare for a potential influenza pandemic. The 
operational and medical leaders of the Navy are working together to 
develop operational tactics, public health techniques, and clinical 
capabilities to protect our active duty members, their families and our 
civilian workforce against this threat. Navy Medicine's efforts will be 
a key component of the larger plan being developed by the Defense 
Department.
    Navy Medicine has proven to be an asset in providing humanitarian 
relief overseas and at home. Two significant examples are Operation 
Unified Assistance in the Indian Ocean and Hurricane Katrina relief in 
the Gulf of Mexico. Our most visible support in these disasters was the 
deployment of both hospital ships, USNS MERCY (T-AH 19) and USNS 
COMFORT (T-AH 20). The hospital ships have inpatient capabilities 
comparable to major medical facilities ashore. They each have fully-
equipped operating rooms, inpatient beds, radiological services, a 
medical laboratory, a pharmacy, an optometry laboratory, a CT-scanner 
and two oxygen producing plants. Both have flight decks capable of 
landing large military helicopters evacuating casualties.
    For six months after the December 2004 Indonesian earthquake and 
tsunami, teams of Navy medical personnel and health care providers from 
the nongovernmental organization (NGO) Project HOPE conducted daily 
humanitarian assistance operations on board USNS MERCY. Operating off 
the coast of Banda Aceh, MERCY's medical staff treated more than 9,500 
patients ashore and afloat, and performed nearly 20,000 medical 
procedures, including more than 285 surgical and operating room cases. 
During a stop in Alor, Indonesia, MERCY's team cared for more than 
6,200 patients, and during a visit to East Timor, they saw more than 
8,000 residents.
    On August 29, 2005, Hurricane Katrina struck the coastal areas of 
Louisiana, Alabama and Mississippi, causing many deaths, displacing a 
large civilian population, damaging infrastructure including health 
care and public health systems, disrupting communications, and 
generating devastating flooding. Navy Medicine deployed over 800 health 
care professionals in support of Hurricane Katrina relief efforts and, 
with the help of Project Hope volunteers, treated over 14,500 people. 
Our personnel deployed with USS BATAAN, USS IWO JIMA, USNS COMFORT, the 
Joint Task Force Katrina Surgeon's cell, Forward Deployed Preventive 
Medicine Units, mental health response teams, Navy Construction 
Battalion Units, as well as in direct support of Navy clinics in 
Mississippi and Louisiana. Navy Medicine coordinated supporting relief 
efforts with medical staff and supplies from Navy medical facilities 
across the country.
    Earlier this year, U.S. military field hospitals in Shinkiari and 
Muzaffarabad provided the earthquake-stricken people of Pakistan with 
medical assistance. Navy Medicine's Forward Deployed Preventive 
Medicine Units and the Marine Corps' Combined Medical Relief Team 3 
were located in Shinkiari while the U.S. Army's hospital was set up in 
the city of Muzaffarabad. Between these units, U.S. forces brought to 
bear medical capabilities including operating rooms, x-ray equipment, 
pharmacies, laboratories, and many other assets all in an effort to 
supplement organic Pakistani medical facilities which were hit hardest 
by the earthquake. Surgeons, general medical officers, nurses, and 
dentists were joined by other support Marines and Sailors in treating 
victims of this natural disaster.

                           MEDICAL RECRUITING

    Although our missions continue to evolve, we, like the other 
services and the private sector, are struggling to meet all of our 
recruitment, retention and end strength goals in health care 
professions. The need for skilled doctors and nurses has been 
demonstrated time and again throughout the global war on terror; 
however, the number of medical school applicants and graduates in this 
country is declining. The Navy, together with Navy Medicine, is working 
to improve recruiting and retention of doctors and nurses so we can 
meet our deployment requirements. Some of the efforts being considered 
include: improving compensation parity with the private sector; 
studying incentive programs that better meet the needs of the current 
student population; and offering an accession bonus and medical 
insurance coverage for student programs.

                SUSTAINING THE BENEFIT/HEALTH CARE COSTS

    Navy Medicine has a dual mission. While meeting the operational 
medical needs of our warfighters as illustrated above, Navy Medicine 
continues to provide the finest, cost-effective health care to 
America's heroes and their families at home and overseas.
    The Navy is proud of the exceptional health benefit and health care 
delivery system that Congress and the Defense Department have built, 
expanded upon and improved over the years. In the last ten years, both 
congressional and departmental initiatives have addressed gaps in 
program coverage and improved access to care for millions of military 
beneficiaries. These new benefits have made a positive contribution to 
our recruitment and retention efforts, and we wish to sustain them for 
the long-term.
    In order for the Department to sustain the benefits that so many 
have come to expect, the long-term costs of the program must be 
contained for the program to remain viable in the future. TRICARE 
benefits have been expanded and implemented; however, there have been 
no changes in beneficiary cost shares since 1995. The Department 
proposes to restructure beneficiary contributions to proportions 
similar to when TRICARE was established in 1995. These changes will 
ensure we will be able to continue providing the same high level of 
access and quality care enjoyed by our beneficiaries today. As Chairman 
Pace testified before you earlier this year, the Joint Chiefs have 
unanimously recommended that we renorm the cost sharing for the health 
care benefit.
    As overall health care costs have grown for both the Department and 
the private sector, the expanding disparity in out-of-pocket costs 
between TRICARE and civilian health plans has led to a significant 
increase in the number of retired beneficiaries under the age of 65 who 
are now using TRICARE as their primary health insurance. This has 
resulted in an increase in the costs borne by the Department of 
Defense. The increased utilization, especially among this group of 
retirees, together with the expansion of benefits and healthcare 
inflation, have created a perfect storm. Costs have doubled in five 
years from $19 billion in fiscal year 2001 to $38 billion in fiscal 
year 2006. Analysts at Health Affairs project these costs will reach 
$64 billion by 2015, about 12 percent of the Department's budget (vs. 
4.5 percent in 1990). This current rate of medical cost growth is 
unsustainable and internal efficiencies are not, and will not, be 
sufficient to stem the tide of rising health care costs.
    The Navy honors the service and sacrifice of our active duty and 
reserve members and retirees, as well as their families. Because of 
their service and sacrifice the Navy continually strives to provide a 
truly outstanding health benefit for them. The Administration's 
proposals to manage cost growth and sustain this valuable benefit 
encourage beneficiaries to elect medically appropriate cost-effective 
healthcare options. A very important point of the proposals is that the 
changes in cost sharing will not impact active duty troops or retirees 
over age 65. In addition, catastrophic protections would remain intact 
for retiree families--at $3,000 per year.
    The Navy strongly supports the words of Joint Chiefs' Chairman Pace 
and Secretary Rumsfeld and wants to work closely with the distinguished 
members of this committee and all of Congress to sustain this great 
health benefit for the men and women of our Armed Forces and their 
families. Together, we will sustain the vital needs of the military to 
recruit, train, equip and protect our Service members who daily support 
our National Security responsibilities throughout the world, keeping 
our nation strong.

                               CONCLUSION

    Mr. Chairman, Navy Medicine has risen to the challenge of providing 
a comprehensive range of services to manage the physical and mental 
health challenges of our brave Sailors and Marines, and their families 
who have given so much in the service of our nation. We have 
opportunities for continued excellence and improvement, both in the 
business of preserving health and in the mission of supporting our 
deployed forces.
    I thank you for your tremendous support to Navy Medicine and look 
forward to our continued shared mission of providing the finest health 
services in the world to America's heroes and their families--those who 
currently serve, those who have served and the family members who 
support them.

    Senator Stevens. General Taylor.

STATEMENT OF LIEUTENANT GENERAL GEORGE PEACH TAYLOR, 
            JR., M.D., SURGEON GENERAL, DEPARTMENT OF 
            THE AIR FORCE
    General Taylor. Mr. Chairman, Senator Inouye, and members 
of the subcommittee, it's a pleasure and privilege to be here 
today. Your Air Force Medical Service continues to serve 
America proudly, whether in caring for our wounded in the Balad 
theater hospital, in flying them safely home, in treating 
thousands of Hurricane Katrina victims or in providing quality 
healthcare to our home-station troops and their families.
    During the gulf coast disaster, a Federal Emergency 
Management Agency (FEMA) physician told me that one of the most 
impressive things about our people is that they treated every 
patient during that chaotic, crowded, and terrible time, as if 
they were family, as if the person on the stretcher was their 
own father, mother, sister, brother, or child pulled from 
harm's way. I would add that this is true, from my experience, 
for all patients treated by Air Force medics, to include 
coalition forces, the Iraqis, and even the occasional 
insurgent.
    To maintain this level of quality, ability, and esprit de 
corps throughout our Air Force, we are focusing on the three 
major challenges our Chief of Staff, General Moseley, has 
outlined--fighting the global war on terrorism, taking care of 
our people, and recapitalizing our valuable assets.
    What we are accomplishing in Operations Enduring Freedom 
and Iraqi Freedom is phenomenal. If you had the opportunity to 
see the USA Today article and video published on March 27, you 
saw firsthand what incredible work our medics are doing across 
the services. The reporter, Greg Zororya said, quote, ``To save 
lives in the battlefield, medical innovations are born in days 
rather than in years. And as with wars past, the new ways of 
treating the injured and sick in Iraq and Afghanistan have 
benefits beyond the battlefield,'' close quotes. He was 
absolutely correct. Through our in-theater experience, we are 
exploring uncharted territory in blood products and medical 
surveillance, telehealth, trauma response, and many more areas 
of cutting-edge medicine.
    Our commitment to joint operations cannot be 
overemphasized. As part of the joint team, we have more than 
600 ground medics in 10 deployed locations. In 2005, we treated 
more than 12,000 patients in Balad alone. Our Balad chief of 
intensive care, Colonel Ty Putnam, said, ``The caseload rivals 
any major trauma center in the USA.'' That level of experience 
has resulted in unsurpassed survival rates. As a former Balad 
medical group commander said, ``If you arrive here alive, you 
have about a 95-96 percent chance of leaving here alive.''
    The other crucial piece of our ability is to aeromedical 
evacuate our patients out quickly, getting them from point of 
injury to the States usually within 72 hours. The Air Force 
Medical Service was honored by the USO recently for the lives 
we've saved through our ``critical care in the air'' 
capability.
    The value of the care we provide in theater with our sister 
services has been recognized in recent months by many grateful 
patients, among them Members of the U.S. Congress. The same 
capability to stabilize patients and quickly move them to 
higher levels of care was on clear display last summer on the 
gulf coast. I'm very proud of the role the Air Force total 
force team played in working with other Federal, State, and 
local agencies in moving over 3,000 sick or infirmed Americans 
from the devastated coast to shelters throughout the country, 
in addition to treating 7,600 people on the ground. But taking 
care of our people, General Moseley's second challenge is, and 
always has been, critical to the Air Force Medical Service. We 
continue to put great emphasis on deployment health 
surveillance of our troops. You know we are particularly 
concerned about them--you are particularly concerned about 
their mental health, as are we. Currently, Air Force post-
deployment health assessments show only 1 to 2 percent of our 
redeploying airmen are experiencing--or expressing mental 
health concerns.
    We recently rolled out the post-deployment health 
reassessment program, and we've received over 2,000 so far. Of 
those, 38 percent report some health concern, and about 5 
percent report at least one mental health concern. While this 
may indicate that we are identifying additional problems, it's 
a little too early in the data collection to draw conclusions. 
We are watching this very carefully.
    We are excited about the composite occupational health 
operational risk tracking, or COHORT, initiative which will 
assist us in tracking the health of our personnel, as it will 
provide occupational and medical surveillance data on every 
member, from the time an airman joins the Air Force until 
retirement or separation, opening up enormous fields of data 
never before available to us.
    Our third challenge of recapitalizing our assets has become 
increasingly significant for the Air Force Medical Service. Six 
percent of our current facility inventory is more than 50 years 
old. By 2025, that could grow to 35 percent. With an annual 
military construction budget of $60 million, we find we have to 
phase any major construction out over several years. In fact, 
this $60 million, relatively flat for the past decade, now buys 
one-sixth the amount of construction it did 10 years ago.

                      BASE REALIGNMENT AND CLOSURE

    We believe the BRAC process will help us relieve this 
situation as we combine facilities, close small, underutilized 
hospitals, or convert them to ambulatory surgery clinics. We 
also continue to seek ways to strengthen our partnerships in 
the civilian sector and with the Department of Veterans 
Affairs.
    Finally, on behalf of our military families, I pledge my 
support to you and my fellow surgeons to work together to 
preserve the superb healthcare benefit that we offer. It is 
second to none, and so greatly earned and deserved by our 
military heroes and their families.
    Finally, as this hearing began, the Chief of Staff 
announced my retirement, effective this year. I'd like to say 
what a privilege it is to have served the Nation for the last 
27\1/2\ years, half of that serving an Air Force that's been in 
combat. The Air Force has been flying combat operations since 
1991.
    I've been part of an Air Force Medical Service that's made 
a difference. We've re-engineered our field hospitals, we've 
re-engineered our mirror medical evacuation system to allow 
people to move from foxhole to Bethesda in 36 hours. We've 
integrated into ground operations. A large portion of the 
ground-force support is done by airmen today.
    A few things to think about. One is, I ask for us all to 
watch the BRAC implementation. There--as the head of the 
Medical Joint Cross-Service Group, working with the Base 
Realignment and Closure Commission, there are fairly innovative 
recommendations that need to be implemented, in terms of 
facility structure and combining facilities, and we just need 
to make sure that as we do this, it's not just the finances, 
but it is the change in the way we practice medicine, and 
changing the infrastructure, that the BRAC recommendations 
gives us a chance to rebalance. And so, we all need to pay 
attention over the next 5 years as we implement the 
recommendations that came through BRAC.
    Second, I think we need to continue in areas where we're 
challenged with funds to watch for centralization. There is a 
lure of saving money with centralizing assets. The Air Force 
Medical Service is a highly decentralized operation, and that 
drives innovation very close to mission, innovation in field 
medicine, innovation in aeromedical evacuation, innovation in 
local healthcare. And I'd just say that we need to watch very 
carefully about centralization.

                           PREPARED STATEMENT

    Finally, it's been my privilege to serve with a team of 
healthcare professionals throughout my career that I can only 
describe with one word, and that word is ``magnificent,'' a 
magnificent group of people in a magnificent mission in a 
magnificent service, part of a magnificent Department, in the 
best country on the planet.
    Thank you very much.
    [The statement follows:]

Prepared Statement of Lieutenant General (Dr.) George Peach Taylor, Jr.

    Mr. Chairman and members of the committee, it is a pleasure to be 
here today to share with you stories of the Air Force Medical Service's 
success both on the battlefront and the home front.
    The Air Force Medical Service (AFMS) continues to provide world-
class health care and health service support anywhere in the world at 
anytime. This includes ensuring that active duty and Reserve component 
personnel of all Services are healthy and fit before they deploy, while 
deployed, and when they return home. It also includes providing the 
same quality of care--and access to care--for our 1.2 million TRICARE 
enrollees.
    This year, our well-honed capabilities were important national 
assets in the medical response and evacuation of thousands of fellow 
Americans who were victims of Hurricanes Katrina and Rita. Our Total 
Force Airmen medics converged on the ravaged region twice in one month 
to work with Federal Emergency Management Agency (FEMA) medical teams 
to care for and transport thousands of ill patients. Overall, our Total 
Force medics provided health care for 7,600 people. Another 3,000, many 
of whom were critically ill, were safely aeromedically evacuated from 
the region.
    During our response to these natural disasters, a senior physician 
in FEMA's disaster medical assistance team told me that one of the most 
impressive things about our people is that they treated every patient 
during that chaotic, crowded, and terrible time as if they were family, 
as if the person on the stretcher were their own father, mother, 
sister, brother, or child pulled from harm's way.
    This catastrophic event, though, is something for which we are 
uniquely trained and equipped to perform. Obviously, the positive 
attitudes of our people and their collective competence go a long way 
toward ensuring that the AFMS successfully responds to and overcomes 
any disaster--natural, domestic or foreign.
    To ensure we maintain these abilities and attitudes, Air Force 
Chief of Staff, General T. Michael Moseley, has outlined three major 
challenges for leadership to focus upon: fighting the Global War on 
Terrorism; preserving our culture of excellence through the training 
and development of our people, and breaking the vicious cycle of 
operating the oldest inventory in the history of the United States Air 
Force through recapitalization.

                        GLOBAL WAR ON TERRORISM

    The Global War on Terrorism will be with us for years to come. 
Among the Air Force's most critical components in successfully fighting 
this war both overseas and here at home is considering how we plan for 
our long-term requirements.
    Key in accomplishing this is reinforcing that the Air Force is one 
organization--not active-duty, Guard and Reserve ``tribes.'' This 
philosophy necessarily extends to interoperating with all of our sister 
Services, a method of warfighting that has taken--and will continue to 
take--growing importance unmatched at any other time in our nation's 
history.
    Most certainly, our light, lean and mobile expeditionary medical 
support--or EMEDS--is the linchpin of our ground mission. As 
importantly, the Air Force Medical Service makes its unique 
contribution to the Total Force and joint operational environment 
through our aeromedical evacuation and en route care mission.
    Significant as these two components are, we must also continually 
refine the Air Expeditionary Force deployment system; ensure the pre- 
and post-deployment health and fitness of our troops; and diligently 
work to maintain the technological edge over our enemies--overseas and 
in the United States--through the development of bio-surveillance and 
medical treatment capabilities.

                                 EMEDS

    EMEDS, especially at the Air Force Theater Hospital at Balad Air 
Base in Iraq, has validated the ``golden hour'' concept--the importance 
of delivering care in first 60 minutes after injury. This life-saving 
capability has proved its effectiveness, and no one illustrates the 
importance of its capability better than the joint troops who make it 
happen.
    ``If a patient requires surgery to survive, it will be done here,'' 
said Staff Sergeant Jalkennen Joseph, an emergency room medic. The 
reality and benefit of having a robust surgical capability forward has 
been key to the lowest casualty rate in the history of combat. Colonel 
(Dr.) Elisha Powell, former 332nd Expeditionary Medical Group (EMDG) 
Commander in Balad, supports this fact that ``If you arrive here alive, 
you have about a 96 percent chance of leaving here alive.''
    We are proud of the teamwork between Air Force flight medics and 
the Army and Air Force medics on the ground in the patient 
administration office of our theater hospital as they prepare for the 
arrival of casualties. ``I give all the credit in the world to flight 
medics . . . they do things you only see in movies or read about in 
books. They do it on a daily basis and they do it well.'' said Staff 
Sergeant Joseph. Moreover, although the Theater Hospital at Balad is 
largely staffed by the Air Force, the symphony of teamwork is its 
cornerstone. Joseph continues, ``We have all really clicked together . 
. . we run this place smooth, doing the same mission. We live by the 
hospital motto `One team. One mission.' ''
    In this light, we foresee a continued need for this important 
capability to provide health care anywhere, and we will continue to 
refine this to meet joint warfighting medical requirements.
    Our commitment to Joint operations cannot be overemphasized. As 
part of a joint team, we now have more than 600 ground medics in 10 
deployed locations. In addition to Balad, we also operate two smaller 
hospitals in Iraq--one in Kirkuk and another at the Baghdad 
International Airport. Every day, Air Force medics in these theater 
hospitals are saving the lives of Soldiers, Sailors, Marines, Airmen, 
civilians, coalition and Iraqi forces, friend and foe alike. We treated 
over 12,000 patients in 2005 at Balad alone. These included U.S. 
forces, Iraqi Security Forces, U.S. and Iraqi civilians, as well as a 
combination of coalition forces, third country nationals and detainees.
    Because our medical teams are operating closer to the front lines 
than ever before, patients are getting advanced medical care within 
hours, not days or weeks as they had in the past. However, as our 
experience in the past four years has shown us, as important as beds 
and forward deployed health care is, equally important is the ability 
to quickly move patients from the field to higher levels of care.

                         AEROMEDICAL EVACUATION

    Aeromedical Evacuation (AE) crewmembers perform many of the same 
life-saving activities their peers accomplish in hospitals, but in the 
back of an aircraft at over 30,000 feet. The conditions are sometimes 
challenging as crewmembers work under the noise of the engines or when 
flying through turbulence--but there is no place else they would rather 
be.
    ``It is a great feeling of responsibility and a privilege to care 
for these patients,'' says Colonel (Dr.) Peter Muskat, director of 
clinical training at the Cincinnati Center for Sustainment and Trauma 
Readiness Skills (C-STARS), who has flown 15 missions from Balad. 
Without a shadow of doubt, casualties aboard AE flights are entrusted 
to warrior medics well trained to effectively perform under these 
conditions. Colonel Muskat: ``From the point of injury in theater to 
the time the injured person is medevac'd to the states, most times 
within 72 hours, they receive care from medics who have been exposed to 
every potential problem a trauma patient may face on the ground and 
during that flight.''
    It is crucial to emphasize that of our approximately 400 AE 
personnel deployed today, the majority of them--almost 90 percent--are 
Guard and Reserve. A better example of fighting together in the Global 
War on Terrorism simply escapes me--the Reserve Component contribution 
to AE operations represents an undeniable hallmark of Total Force.
    Occasionally, our AE crews transport patients who are so ill or 
injured that they require constant and intensive care. When that 
happens, our AE medical capability is supplemented by Critical Care Air 
Transport Teams, or CCATTs. These are like medical SWAT teams that fly 
anywhere on a moment's notice to treat and extract the most seriously 
injured troops.
    Team members carry special gear that can turn almost any airframe 
into a flying intensive care unit within minutes. An in-theater EMEDS 
commander told me that CCATTs are a good news/bad news entity. He said, 
``The bad news is, if you see the CCATT team jumping on a plane, you 
know someone out there is hurt bad. The good news is, if you see the 
CCATT jumping on a plane, you know that someone will soon be in the 
miraculous hands of some of the best trained medics in existence.''
    No where in recent AE operations was this capability highlighted 
better than when three members of a CCATT, Major (Dr.) Linda Boyd, an 
emergency medicine physician, Major Denise Irizarry, a nurse, and 
Master Sergeant Jeffrey Wahler, a respiratory therapist, were aboard a 
C-17 Globemaster III from Ramstein Air Base, Germany, to Andrews Air 
Force Base, Maryland. They treated 30 casualties including ABC 
anchorman Bob Woodruff and cameraman Doug Vogt. Major Boyd said, ``It 
was awesome--we did intubations and ventriculostomies--a procedure 
where a device is place into the ventricles of the brain when needed to 
drain spinal fluid and relieve pressure.'' On a regular basis, our AE 
warrior medics leverage superior training, commitment to excellence, 
and talent to uphold our requirements to support America's heroes who 
defend our great nation.
    Overall, partnering with our critical care air transport teams, our 
aeromedical evacuation system has made it possible to move seriously 
injured patients in an astonishingly quick time, as short as 72 hours 
from the battleground to stateside medical care--unheard of even a 
decade ago.

                              DEPLOYMENTS

    When I joined the Air Force in the 1970s, we planned, trained, and 
equipped our medics on the basis of the threats faced in two major 
operational plans of short duration. That construct is no longer valid, 
as can clearly be seen with the Global War on Terrorism.
    Today's Air Expeditionary Force structure was created, in part, in 
response to this new construct. The AFMS needed to restructure itself, 
too, so that it could face multiple commitments overseas of both short 
and long duration. Our nation requires that medics field combat support 
capabilities that are very capable, rapidly deployable, and sustainable 
over long periods.
    Medics must be placed at locations where they can maintain the 
skills they need for their combat medicine mission. It is also vital 
that these locations allow the medics to deploy easily without 
significantly interrupting the care they provide the base or TRICARE 
beneficiaries, especially at those locations with sustained medical 
education training programs.
    This challenge is straightforward: create expeditionary medics who 
are focused on developing the skills for the field and eager to deploy 
for four of every twenty months. Currently, we assign medics at large 
facilities into groups of five so that one team can be deployed at any 
one time while the other four remain to work and train at home station. 
We also actively work the ratio of active-to-Reserve component medics 
to determine the proper mix of active duty and Reserve component to 
ensure the best balance between the ability to deploy quickly and the 
capability to surge forces when necessary.
    We are also actively reviewing the total size of the AFMS to make 
sure that over the next few decades we can successfully fulfill our 
wartime mission while still providing the peacetime benefit to our 
members, retirees, and their families.
    Finally, a vital part of our preparation is state-of-the-art 
training, such as our Coalition for Sustainment of Trauma and Readiness 
Skills, or C-STARS, where we partner with renowned civilian medical 
centers in Baltimore, St. Louis, and Cincinnati to allow our medics to 
receive trauma training. While our medics--300 in 2005--receive 
training that is unavailable in most of our stateside hospitals, we 
provide a service to the people of those cities--a mutually beneficial 
relationship that enhances preparedness both at home and abroad. Many 
students laud C-STARS as the best medical training they have received 
to prepare them for deployment.

                           DEPLOYMENT HEALTH

    Collaborative arrangements among the medical, chaplain and family 
support communities support our claim the Air Force has personnel and 
processes in place to monitor and address health concerns before, 
during and after deployments.
    Deployment Health Surveillance is a continuous process of Force 
Health Protection. From accession, through service, and into separation 
and retirement, the Air Force Medical Service is dedicated to ensuring 
the health of our Airmen. We maintain a robust Individual Medical 
Readiness program to ensure each Airman, active and reserve component, 
is assessed for deployability and mission capability. At the point of 
deployment, we conduct a tailored deployment health assessment to 
include appropriate immunizations, medications, and health 
communication of known threats in the deployment area. In OIF/OEF, 
these activities combined with continuous health support in theater 
have resulted in the lowest disease/non battle injury rate ever 
experienced in combat operations.
    Although some of these efforts are strictly medical in nature, 
others focus on specific and increasing needs such as mental health. To 
address the mental health needs of deployed airmen, the Air Force 
deploys two types of mental health teams: a rapid response team and an 
augmentation team. Mental health rapid response teams consist of one 
psychologist, one social worker and one mental health technician. Our 
mental health augmentation teams are staffed with one psychiatrist, 
three psychiatric nurses and two mental health technicians. Deployed 
mental health teams use combat stress control principles to provide 
consultation to leaders and prevention and intervention to deployed 
airmen.
    I was involved in the medical combat service support laydown for 
Operations ENDURING FREEDOM and IRAQI FREEDOM, and one of my highest 
priorities was to ensure that the Air Force fielded mental health 
professionals early and as far forward as possible to not only treat 
casualties, but to put in place strong prevention and outreach 
programs. Today, the Air Force has 49 mental health personnel deployed 
for current operations, 36 of whom are supporting joint service 
requirements. We also position psychiatric nurses at our aeromedical 
staging facilities to better address emerging psychological issues for 
all troops being medically evacuated out of the combat theater.
    The Air Force and the Department of Defense have enhanced efforts 
to monitor and address the health concerns of deploying service 
members. Airmen complete the post-deployment health assessment (PDHA) 
at the end of a deployment, and are now being assessed again 90-180 
days after return from deployment via the post-deployment health 
reassessment (PDHRA). These instruments provide an overall health 
assessment of our Airmen, with an emphasis on mental health.
    A recent study published in the Journal of the American Medical 
Association examined the mental health problems reported by Army and 
Marine combat troops following deployments. We have examined the same 
data sets for Air Force personnel, and found that Airmen report 
significantly less mental health concerns following deployments than 
Army and Marine combat units. According to the report, while over 19 
percent of Army and Marine personnel reported at least one mental 
health symptom after an OIF deployment, only 4.7 percent of Air Force 
OIF deployers reported at least one mental health symptom. Only about 1 
percent of Air Force deployers were referred for mental health care 
following a post-deployment health assessment. The lower incidences of 
mental health problems for our Airmen are most likely attributable to 
both the type and length of Air Force missions. That said, we are 
closely scrutinizing deploying Airmen who may be at greater risk for 
mental health concerns, such as convoy personnel and medics.
    The Air Force is also standardizing existing redeployment and 
reintegration programs to help Airmen and family members readjust 
following deployments. These programs are collaborative among the 
medical, chaplain and family support communities. Airmen and their 
families can also take advantage of The Air Force Readiness Edge, a 
comprehensive guide to deployment-related programs and services, as 
well as Air Force OneSource, a contractor-operated program that 
provides personal consultation via the web, telephone or in-person 
contacts, on matters that range from severely injured service member 
family impact to dealing with grief and loss to a myriad of other 
family related matters. Air Force OneSource is available 24 hours a 
day, and can be accessed from any location.

                           TECHNOLOGICAL EDGE

    Terrorism confronts us all with the prospect of chemical, 
biological, and radiological attacks. Of those, one of the most 
disconcerting to me are the biological weapons. Nightmare scenarios 
include rapidly spreading illnesses so vicious that if we cannot detect 
and treat the afflicted quickly, there would be an exponential 
onslaught of casualties.
    Medics have the capability to find, track, target, engage and 
defeat such biological threats, whether they are naturally occurring, 
like Severe Acute Respiratory Syndrome (SARS) and influenza, or man-
made, like weaponized smallpox.
    The rapidly advancing biogenetics field may provide the technology 
that allows us to identify and defeat these threats. Many consider the 
coupling of gene chip technology with advanced informatics and alerting 
systems as the most critical new health surveillance technology to 
explore--and we are doing it now in the Air Force.
    In 2005, an Epidemic Outbreak Surveillance project, an Air Force 
initiative, was successfully tested during a real-world exercise in 
Washington, DC, that began shortly before the 2005 inauguration and 
ended after the State of the Union Address.
    During the exercise, medical teams around the National Capital 
Region collected samples from patients who had fever and flu-like 
illnesses. The samples were transported to a central lab equipped with 
small, advanced biological identification units--a ``gene chip''--that 
tested for common or dangerous bacteria and viruses. These results were 
known within 24 hours, not the days or weeks normally required. A web-
based program then tracked outbreak patterns, providing an additional 
mechanism to automatically alert medics and officials of potential 
epidemics or biological attacks. We continue to work with this 
technology to create better diagnostics for our normal clinical work as 
well as for early detection of a new disease, whether it be avian flu 
or a biological attack.
    We are seeking techniques to convert common tap or surface water 
into safe intravenous solutions in the field. We are also developing 
the ability to generate medical oxygen in the field rather than 
shipping oxygen in its heavy containers into the field.
    Telehealth is another fascinating technology that enhances the 
capabilities of our medics. It allows providers in Iraq to send 
diagnostic images such as X-rays through the Internet back to 
specialists located anywhere in the world for a near real-time consult. 
This ensures that each Soldier, Sailor, Airman or Marine in the field 
has access to one of our outstanding specialists almost anytime and 
anywhere.
    In 2006, we expect to start transitioning another advancement--our 
ability to create an unlimited number of cohorts of our beneficiaries 
using the Composite Occupational Health and Operational Risk Tracking 
(COHORT) initiative. This will provide occupational and medical 
surveillance from the time they join the Air Force until retirement or 
separation, regardless of where they serve or what job they perform. We 
will finally be able to tie together medical conditions, exposure data, 
duty locations, control groups, and demographic databases to globally 
provide individual and force protection and intervention, reducing 
disease and disability. These tools will work in near real time, and 
eventually will be automated to work continuously in the background, 
always searching for key sentinel events.
    We are also proud of our collaborative efforts and pursuit of 
technological advances that extend beyond threats of biological or 
epidemic concerns, to also include advancements in more common diseases 
such as diabetes.
    In collaboration with the University of Pittsburgh Medical Center, 
the USAF is actively engaged in diabetes research. The emphasis of this 
research is on primary prevention, education, and lifestyle 
modifications. The ``test bed'' includes both urban and rural western 
Pennsylvania, the USAF's Wilford Hall Medical Center in San Antonio, 
Texas, and rural Texas. The ultimate goal is to develop a template for 
the development of Diabetes Centers of Excellence that can be utilized 
across America to include the military community and civilian resources 
for poor under-privileged regions. This research continuum and 
partnership will also add significantly to the development of a 
Diabetes Outreach Clinic at the Wilford Hall Medical Center that will 
ultimately serve the over 65-year old civilian community as well.
    The program utilizes state-of-the-art educational principles and 
tools as well as groundbreaking technology. Telemedicine applications, 
videos, specialized retinal cameras (to demonstrate pathology) are some 
of the high-tech educational tools. A computerized Comprehensive 
Diabetes Management Program designed to promote self-management will be 
tested as well. These educational efforts target both adults with Type 
II diabetes as well as at-risk children. Biochemical research involving 
platelet derived growth factors as related to wound healing (for 
diabetes related wounds) are also under study.
    Diabetes has become a major healthcare crisis in the United States. 
Currently, over 20 million Americans have diabetes and that number is 
growing at 8 percent a year. In an effort to halt this unhealthy trend, 
this program will develop the Premier National Model for diabetes 
education and treatment. The program is well underway and remarkably, 
beneficiaries are seeing fruits of this labor already.

                                 PEOPLE

    Almost half the people currently serving in the United States Air 
Force joined after September 11, 2001. They knew what they were getting 
into, and there's no question that the military's medical personnel are 
a critical component of the Global War On Terrorism. As such, one of 
the Chief of Staff Air Force's (CSAF) key priorities--get the right 
number of Airmen into the right jobs--takes on added significance.
    The Air Force must have a balanced force of officer and enlisted 
Airmen. Force shaping is necessary to maintain the effectiveness of the 
Air Force and to maximize career opportunity for all Airmen.
    Even so, the Air Force Medical Service (AFMS) continues to face 
significant challenges in recruiting and retaining physicians, 
dentists, and nurses--the people whom we depend upon to provide care to 
our beneficiaries. The special pays, loan repayment programs, and 
bonuses to our active and Reserve component medics are helpful in 
retaining people. In fact, nearly 85 percent of nurses entering the Air 
Force say they joined in large part because of these incentives.
    The need to retain and recruit health care providers and 
specialists will grow as the military remains involved in the Global 
War on Terrorism for years to come.
    As Assistant Secretary of Defense for Health Affairs Dr. William 
Winkenwerder, Jr., has said that the military medical community today 
is engaged ``in a mission that, perhaps, has never before been so 
complex, challenging, or far-reaching as we find today.''
    Still, I am heartened by the caliber of the folks we continue to 
attract. One such person is Capt. (Dr.) An Duong, who, gave up her 
family medicine practice in Florida and came on active duty at Keesler 
Air Force Base, Mississippi, this year.
    Doctor Duong was born in Saigon, South Vietnam, in 1971 and 
emigrated to the United States from the communist-held country at age 
14 with her mother and two siblings. Now an American citizen, she said 
that part of the reason she joined was because of her early upbringing 
in a communist country. She said: ``America adopted me and raised me. I 
owe her a lot.''
    She also said she was not fearful--but willing--to serve in a war 
zone. ``I'm not intimidated about war. I was born into war--a child of 
war.''
    As we work to balance the force with the right combination of 
active duty, reserve component, civilian and contract staff, we must 
keep in mind that we deploy people, not our hospitals and clinics. We 
take care of the nation's heroes, past and present, and it takes the 
finest of medical staffs to care for this country's finest.

                            RECAPITALIZATION

    We recognize the importance of maintaining a modern and effective 
infrastructure in our military treatment facilities, from clinics to 
medical centers. This is essential as we consider how the Air Force 
plans for its long-term requirements. The atmosphere in which our 
medics work is as important as any other retention factor. Our patients 
deserve not only the most brilliant medical and dental minds, but also 
first class equipment and facilities.
    Though the TRICARE contracts create a strong civilian support 
system to augment the care we provide in our direct care medical 
treatment facilities. We continue to work to improve the quality of 
military health care with to investments and modernization of key 
medical facilities, replacing aging infrastructure, and to improvements 
in health care delivery efficiency.
    When General Moseley recently stated that the Air Force is 
operating with the oldest inventory in the history of the Air Force, he 
was largely referring to our aircraft inventory. But that assessment 
also applies to medical facilities with the AFMS.
    As an example, six percent of our current inventory is more than 50 
years old; by 2025, it could grow to 35 percent. We've spent $30 
million in less than two years to fix structure failure at our 46-year-
old facility at Tinker AFB, Oklahoma. We've fixed safety code 
violations in five facilities, which ranged in age from 30 to 48 years.
    This kind of budgetary pressure has changed the way we think about 
healthcare facilities. One initiative we are proud of is our clinic 
replacement at MacDill AFB, Florida. This 236,000 square foot new 
clinic will include a drive-through satellite pharmacy, which will 
consolidate 20 buildings and reduce our medical footprint by 25,000 
square feet. Phase one of this project will cost $55 million in fiscal 
year 2007. When completed, we will have replaced the oldest AFMS 
hospital in the United States; and we will provide $4 million annual 
savings to the Military Health System. But what is important to 
understand is that the specialists at MacDill will actually perform 
their inpatient work at the civilian medical center in Tampa.
    As part of the recent Base Realignment and Closure (BRAC) process, 
DOD will operate on a more rational, modernized footprint. Through the 
combination of facilities, the closure of small hospitals, and the 
combination of similar educational and research activities, we will be 
able to take advantage of new partnerships, both inter-service and with 
our civilian and Department of Veterans Affairs partners. These BRAC 
decisions support strategies of reducing excess capacity and locating 
military personnel in activities where the workload is more diverse, 
providing them with enhanced opportunities to maintain their medical 
currency to meet combatant commander requirements. I strongly support 
the BRAC law and am fully committed to its complete implementation. It 
is right for military medicine and, as importantly, it is right for our 
patients and our staff.
    We strive every day to ensure that the Military Health System is 
the best health care system for the dedicated men and women in uniform 
who sacrifice so much.

                                TRICARE

    Across the services, we believe TRICARE is great health benefit and 
a superior program that supports the warfighter and the family at home. 
On behalf of the Department, General Granger, deputy director and 
program executive officer of the TRICARE Management Activity says, ``We 
know we have a nation that is at war, and were going to continue to 
make sure that we maintain those superb benefits that we need to 
support this long and drawn out global war on terrorism.''
    The military health benefit has gained critical attention recently 
due to the Department's proposed initiative to sustain this important 
benefit for the future. Understand that we honor the service and 
sacrifice of our active duty members and retirees as well as their 
families. Because of their service and sacrifice the Department 
continually strives to provide a truly outstanding health benefit for 
them.
    We must sustain this health benefit into the future; to do so, we 
have implemented management actions over the past few years and these 
continue. However, and this is critically important, these actions 
alone will not stem the rising costs of the military health benefit. 
Costs have doubled in five years from $19 billion in fiscal year 2001 
to $38 billion in fiscal year 2006. Our analysts project these costs 
will reach $64 billion by 2015, over 12 percent of the Department's 
budget (vs. 4.5 percent in 1990).
    Several factors contribute to this cost spiral: expansion of 
benefits, increased beneficiary usage, especially among retirees, 
healthcare inflation, and no increase in beneficiary cost-sharing since 
the TRICARE program began eleven years ago.
    Our proposals to manage cost growth and sustain this valuable 
benefit encourage beneficiaries to elect medically appropriate cost-
effective healthcare options. Significantly, our proposals, which seek 
to, as the Chairman of the Joint Chiefs of Staff put it, ``re-norm'' 
contributions to approach those when TRICARE was established in 1995, 
will continue the high level of access to care and quality enjoyed by 
our beneficiaries today. We are also recognizing differences in cost-
sharing to be expected from retired officers versus enlisted personnel.
    We fully support these proposed changes and believe together we 
will be able to sustain this great health benefit for the men and women 
of our Armed Forces. It is critically important to place the health 
benefit program on a sound fiscal foundation for the long term.
    In so doing, together, we will also sustain the vital needs of the 
military to recruit, train, equip and protect our Service members who 
daily support our National Security responsibilities throughout the 
world, and keep our nation strong.

                                SUMMARY

    As we enter the fifth year of the Global War on Terrorism, we are 
engaged in combat and in humanitarian operations overseas and at home. 
From the Gulf of Mexico to the Persian Gulf, well-trained, dedicated, 
and compassionate medics from every service are making a difference in 
the lives of thousands of warriors and civilians. This blending of 
increasingly interoperable talent and equipment has made the miracles 
of today's battlefield medicine possible.
    In conclusion, a recent comment by General Moseley, perfectly 
describes our future and the challenges we face. ``When someone asks 
you what the Air Force will be doing in the future, tell them this: We 
will do what we have always done. We will stand on the shoulders of 
giants. We will take care of each other and every member of this great 
fighting force. We will innovate. And . . . we will fly . . . we will 
fight . . . and we will win.''

    Senator Stevens. Thank you all very much.
    You know, as we go to visit the hospitals at Walter Reed or 
Bethesda, we note the extremely high morale of your forces in 
the medical-care area. It's just astounding, and it's reflected 
in the type of care that these wounded service people are 
getting, and their attitudes. I have said before--I think 
Senator Inouye has experienced it, too--I have yet to talk to 
one of those wounded people that didn't ask me to sort of bend 
down and listen to them. And the comment's been, ``They're 
treating me fine, but when can I get back to my unit?'' The 
morale of this generation is just staggering for us. So, we 
thank you all for your service and what you're doing.
    We are a little worried. For instance, I am worried, when I 
hear that the health professional scholarship program (HPSP)--
that the Army and Navy were unable to fill the slots that were 
allocated to young people who are seeking those scholarships. 
There weren't enough seeking the scholarships. What's the 
reason for that? Is there not enough publicity or lack of 
interest of the new--coming generation in such education? What 
do you think, Admiral?
    Admiral Arthur. Well, I think there is a combination of 
factors. Certainly, there is less interest in military service. 
And a lot of those people coming into medical schools don't 
know about the health professional scholarship program. And I 
think it would behoove us to do a better job of publicizing the 
scholarship, but also publicizing the kind of experience that 
they get in the military health system. If they knew that we 
never asked any of our patients how sick they can afford to be, 
I think that would change their opinion of whether to practice 
medicine in the military. If they knew that all of our patients 
are patriots, and they're all insured, and we don't have to 
worry about those kinds of issues, it would change their 
opinion. I think if they were given an opportunity to come into 
any of the services hospitals and see the camaraderie, the 
morale, and the quality of care that's given, they would be 
more apt to come in.
    What we have done is work with our recruiting command, and 
we're now going to have physicians recruiting physicians, 
nurses recruiting nurses, instead of leaving that to the 
recruiting professionals. I think it's much better to have a 
young physician or a young nurse recruiting people who would 
want to come into the profession. We will select people who 
have been out in the operational theater, who have had some 
experience in the Navy, either in the Navy or the Marine Corps, 
and can tell the young people in medical school that this is a 
truly rich, professional atmosphere, as well as one that has 
other elements of service that are not found in the civilian 
sector. We're also increasing the amount of pay that we will 
give them. And you know that Senator Mikulski has supported 
legislation that has given us the ability to do health 
professions loan repayments. And we are doing that for nurses, 
podiatrists, psychologists, and other health professionals.
    So, I think it's going to get better. We are also going to 
be sending more physicians to meetings where part of their 
meeting obligation is not just to attend and get education, but 
also to be part of the recruiting booth, and to just be there 
to talk with people who would come up and ask them about their 
professions.
    Senator Stevens. Do you have any comment about that, 
General Kiley?
    General Kiley. Yes, sir. Yes, Senator. I actually agree 
completely with Admiral Arthur. I'd say there are some other 
forces at work in our schools--medical and dental schools. I 
think there are other opportunities for students to get 
scholarships and to have stipends. The military is not the only 
way that students get through school.
    I think there is a perception that they get of the 
military, particularly military medicine, based on what they 
see on the television and hear in the reports. And, as Admiral 
Arthur articulated, they don't understand the full depth and 
breadth of opportunities for all doctors, dentists, nurses, 
physicians assistants (PAs). We're doing exactly the same thing 
as the Navy. We recognize this. Army has been recruiting HPSP 
through recruiting command, but it's much more effective to 
have doctors recruiting doctors and nurses recruiting nurses.
    We've developed a new DVD. I've personally communicated 
with the deans of every medical school and osteopathy school in 
the Nation and asked for access, and have been very pleasantly 
surprised and pleased with the very positive responses. We've 
actually identified a group of physicians who have stepped up 
and said, ``I'd like to help with recruiting.'' Just like with 
the Navy, we're sending them to professional conferences, the 
American College of Obstetricians and Gynecologists meets next 
week, and we're going to have a booth there, with doctors in 
uniform, to talk to people that might be interested in it.
    And, of course, it's not just about the students, it's 
about their parents, it's about spouses, and the perceptions.
    So, I think we're paying a lot more attention than we were. 
I am concerned that we've--we have fallen short with dental and 
medical HPSP. We may not see the impact of that for another 4 
to 7 years down the road, but we're getting very aggressive, in 
terms of offering these scholarships, both for the Active and 
Reserve. And I think we'll see that turn around. And I--we've 
had some very good data and information on retention that goes 
with this--with the sessions. Started a new process where we 
look at our doctors who were finishing their obligation in 
2005, at the end of the fiscal year. And we looked at what they 
did. There were about 283, I think is the number.
    My fear was, 15 to 20 percent of them would sign up for 
further obligation, either through training or bonuses. Close 
to 55 percent signed up for more obligation, which is very 
heartening. And we're going to do this for our nurses and 
dental officers, so that we have the data to track this in the 
Active. Our Reserve forces are more of a concern for us, and 
we're getting more aggressive with recruiting in the Reserve 
forces, also.
    Senator Stevens. Thank you. We'd be pleased to work with 
the Ad Council with your services to try to get them to 
emphasize the availability of these scholarships and advantages 
to young high school graduates and to college students.
    General Taylor, you remarked about your service's care, 
particularly the critical care in the evacuation process. Are 
you concerned about the level of funding that you have 
available for 2007 as we continue this process now?
    General Taylor. I think the President's budget allocates 
money to the direct-care system that appears to be adequate for 
fiscal year 2007 to cover our needs for peacetime work, as well 
as what's in the supplemental request, to cover the warfighting 
request. I think we have the right staff right now. We have 
some areas of shortage, in terms of personnel; less so in the 
warfighting specialties, except in the nursing area. And I 
think General Rank will talk about that. The budget for 2007, 
appears to be a well-balanced budget for the direct-care 
system.
    Senator Stevens. Well, staff tells me that, overall, you've 
got a 10-year low in retention of professionals in the Air 
Force. Do you have any suggestions what we might be able to do 
to help you on that?
    General Taylor. Sir, I think there are a couple of things 
that we've been working with the staffs, in terms of changing 
the environment of care. And one of the things I've talked 
about is making the practice attractive for folks to stay in. 
And part of that is making sure that we have facilities and 
equipment and supplies and a range of practice that appears 
adequate for them.
    In terms of pay and fees and those sort of things, we need 
to make sure that we're exploiting, as best we can, all of the 
availability of pay options and loan repayments for our folks, 
for them to be able to stay in longer.
    The near-term problem we have is in recruiting 
replacements. We filled our health professions scholarship 
program last year, plus 21; we appear to be filling the program 
fine today. We've been working with the Uniformed Services 
University of the Health Sciences (USUHS) to expand their 
medical student throughput. The problem with all of this is, 
those pay off 8 to 10 years in the future.
    In the near term, we have holes in certain specialty types 
across physicians and dentists and nurses and other types that 
we need to make sure we have the right authorities that we can 
attract people into the system. One of our toughest problems is 
to get people into the system, particularly the fully trained 
providers.
    Senator Stevens. I don't have much time----
    Admiral Arthur. With regard to----
    Senator Stevens. Pardon me.
    Admiral Arthur. Yes, sir. Yes, sir.
    Senator Stevens. I don't have much time left, but I've been 
concerned about the articles and the conversations I've had 
about the monitoring and treatment of those who are at risk for 
post-traumatic stress disorder. And I wonder if we're doing 
enough to interview and to deal with military people as they 
come out of the theater immediately. It seems that the longer 
that that is ignored, the more it increases. Am I wrong? 
Admiral Arthur?
    Admiral Arthur. Yes, sir. We're doing quite a bit. We are 
embedding psychologists and other healthcare professionals into 
the units so that they don't have to go somewhere else to get 
the counseling or to get some kind of a social service referral 
service. So, the counselors and trained professionals are in 
the units. And as they come back, they work with them. They 
work with them, both in the combat theater, in transit, and 
when they get back home.
    It is really the Reserve component and those who get out of 
the military right after they come back from combat with which 
I am most concerned. And we've worked with the Veterans 
Administration (VA) and extended the TRICARE benefits to be 
able to take care of them.
    Now, these signs are very subtle. And so, we want to be 
sure that we detect them in the units and have people there who 
can talk with them and get to know the individuals. I think 
that's the best way to do it. It's worse if you let it go, and 
you see it in the families or in the employment venue. I think 
we've got a lot of energy into this, because we realize that 
everyone who goes into combat is significantly affected by it.
    Senator Stevens. Well, thank you very much.
    Senator Inouye.
    Senator Inouye. Thank you very much.
    I'd like to continue the line of questioning. Whenever I've 
had the pleasure of visiting troops on a carrier or on an 
airbase or an Army training post, I always set aside an hour to 
meet with enlisted personnel without the presence of officers. 
And it never fails, the first subject brought up is healthcare, 
about their dependents.
    Using that as a background, I've been advised that the Army 
is below its required end strength. For example, psychologists 
are staffed at 88 percent of its required end strength; family 
practice physicians, 81 percent; surgeons, at 65 percent; 
emergency medicine specialists, 70 percent; pediatricians, 65 
percent; social workers, 75 percent. And these are just some of 
the shortages.
    When one considers that we've been operating with these 
shortages, and yet we are able to maintain the morale we have, 
as our chairman described, and the efficiency and the quality 
of service, your effort is almost heroic, but you can't keep it 
up that way. Now, what is the Army going to do to address this 
retention and recruiting problem?
    General Kiley. Senator, as you know, that's a critical 
question for us. You've articulated some of the very worst 
data. I've alluded to some of the things we've started, with 
our peer-to-peer program, where we're going out to talk to 
pediatricians, to talk to psychologists, to talk to 
neurosurgeons, to talk to general surgeons, about service in 
the Army. In some cases, for example, with certified nurse 
anesthetists, we were able to begin to give them a retention 
bonus, which has helped. And we have just recently been 
approved, although we haven't funded, a retention bonus for our 
physicians assistants, who are critical providers, particularly 
on the battlefield.
    We've been able to maintain a high quality of healthcare 
for our soldiers and their families, and particularly manage 
casualty receiving and, frankly, mobilization and deployment, 
because our commanders have had the support of Congress and the 
support of the Department in allowing the local commander to 
not only use uniformed providers, but to have the flexibility 
to hire civilian and contract providers. It's a more expensive 
way to do business, in some respects, but it does help us in 
areas where we've got a fairly robust healthcare system.
    I'm confident that with some of the scholarship and loan 
repayment programs that we've got in place, plus the focus that 
we've been placing, and not only for physicians, but for 
doctors, and particularly for the nurse corps, led by General 
Pollock, I think we're going to turn this thing around. I don't 
know that I'm going to have absolutely as many neurosurgeons as 
I need.
    I think we've also got to address retention, because the 
more physicians and others that we can retain--and, frankly, 
many of these providers have articulated that their service in 
combat--in the combat zone, and their service in caring for 
soldiers, and the families of soldiers that have been in 
combat, has actually given them a new vision as to why they're 
in military medicine. It really comes home to them. And, as I 
alluded to, when I thought we were only going to retain 15 to 
20 percent of our physicians in fiscal year 2005, we retained 
over 50 percent.
    I think we're--I'd like to think we're at a nadir in some 
of these issues. But I think we need to continue to work at 
looking again at bonus levels. We've just now started to feel 
the impact of the increased bonuses that you all provided us in 
the 2003-2004 timeframe. So, I think we probably--with God's 
help, we'll be back here next year telling you that we've 
started to turn this around.
    Senator Inouye. Well, is there anything we can do, here? Is 
it money?
    General Kiley. Sir, I don't--from my perspective, I don't 
think it's money. I think we've got a package of bonuses and 
opportunities for loan repayment. We've just started some of 
these new things in the last 3 to 4 months. I, frankly, have, 
in the future, a couple of other strategies, if these don't 
work. I might consider taking Army Medical Department (AMEDD) 
recruiting and asking the chief to pass that back to me, as the 
surgeon general, where it was back in the 1970s and 1980s, 
before U.S. Army Recruiting Command did it. But I think right 
now our best strategy is to work with them. And, frankly, 
recruiting command has been absolutely superb, even from a 
financial perspective, in assisting us in our efforts to get to 
medical schools, to get doctors to medical schools, nurses to 
nursing schools. I think General Pollock may talk to you a 
little bit about her efforts coming up this weekend.
    So, for right now, the Congress has been so good to us on 
these that I'm not ready to come back and ask. I do think 
there's a financial issue. I mean, dentists are living in 
private practice, fairly robust salaries. We compete with that. 
Despite the fact that physicians in some areas of the country 
are working hard, or having trouble with--or issues with 
medical malpractice premiums, et cetera, there's a perception 
in some that, you know, it's better on the outside. I think we 
have shifted that a little bit with the care that our providers 
are providing to injured soldiers and their families. So, I 
think we're on the cusp of that right now. I think how things 
go in current operations over the next 12 to 18 months may also 
give us an indicator of our retention.
    Senator Inouye. Admiral, in fiscal year 2005 the Navy was 
required to convert 1,772 medical professionals from military 
to civilian.
    Admiral Arthur. Yes, sir.
    Senator Inouye. And you are 74 percent successful. Now, 
you're discussing the possibility of converting 10,000 medical 
professionals into civilians?
    Admiral Arthur. Well, sir, actually, we were asked to 
convert those 1,700. We have decided only to convert 1,100 of 
those. And the balance are people that we've saved as we 
consolidated some functions, some medical and dental functions. 
So, the 74 percent is actually 74 percent of 1,100. We've found 
it very challenging to get the quality of healthcare 
professional--whether it's doctor, nurse, physician assistant, 
or podiatrist, social worker--that would meet the Navy's high 
standards for the salary that we're able to pay. So, we're 
finding it a challenge, especially in some isolated locations, 
to find healthcare providers who will come and work there full 
time. We can get locum tenens, people who come in for 2 weeks 
or 1 month at a time, but that's not the kind of continuity 
that we really want for our beneficiaries.
    The additional conversions are conversations that we're 
having within the Pentagon as part of the Quadrennial Defense 
Review and its derivative, the Medical Readiness Requirements 
Review. And we're looking at the requirements for all kinds of 
combat service support, stability operations, humanitarian 
assistance, the full spectrum of military mission. There is 
thought that we should only staff for the combat casualty care 
portion of that, and to staff many of our overseas and isolated 
continental U.S. facilities with civilians, rather than U.S. 
military.
    We are participating in those discussions, and I think that 
the number will be far less than 10,000, but it will still 
present a significant challenge to us, especially overseas, 
where the education may be good, but the interface with our 
American servicemembers may not be the best. And we have 
promised American-standard care for all of our soldiers, 
sailors, airmen, and marines, wherever they are, overseas or in 
the continental United States.
    Senator Inouye. General, you have served us well, and 
you're just about ready to retire. And so, maybe you can speak 
with a little more objectivity. There's been a lot of 
discussion on a joint medical service command. What do you 
think about that?
    General Taylor. This is a work in progress within the 
Department to look at the joint activities. If you look at a 
marine who goes down in Fallujah, he can arrive in Bethesda 36 
to 48 hours later, going through eight care teams, pretty 
remarkable bit of work, with a high survival rate. We focus on 
that. We also focus on the unique missions that each of the 
services have.
    So, as we look to build some sort of joint or unified 
command, we have to be very careful that we retain not only the 
capability to make joint activities, like moving that marine 
from Fallujah to Bethesda, work well, but also the unique 
missions that the services have.
    So, I think it's a work in progress. The Department's 
looking at various options in a more jointly run medical set of 
services. And I think we need to let that play out. The Air 
Force Chief of Staff's position on that has been, ``Let us see 
what the alternatives are, and see what the impact is,'' 
particularly on the Air Force. As I said, we don't run an Air 
Force medical command. We run a decentralized system. And so, 
it's a much larger leap for us to move to some sort of unified 
command than it would be for the other services.
    Senator Inouye. I've got 7 seconds. Do you agree that it 
should be a joint command?
    Admiral Arthur. Yes, sir. I think there's great advantage 
to doing single common training, acquisition of supplies and 
equipment, have a single mission, singly financed, singly 
measured, but I also agree with General Taylor that every 
service has specific missions--care in the air; we have 
submarine medicine; the Army has other types of medical support 
to their combat forces. And we need to ensure that we meet the 
service's needs. And this is not to meet the medical system's 
needs, but to meet the service's needs for combat service 
support.
    General Kiley. Yes, sir. We have ``care in the dirt.'' They 
have ``care in the air.'' We have ``care in the dirt''--I very 
strongly support unified medical command.
    Senator Inouye. Thank you very much, Mr. Chairman.
    Senator Stevens. Senator Mikulski.
    Senator Mikulski. Well, good morning, Admiral, Generals.
    First of all, know that it's really an honor to be the 
Senator from Maryland, because we, in many ways, feel we're the 
home of military medicine, from the Bethesda Naval Hospital, to 
having the Uniformed Services University of the Health Sciences 
(USUHS), to having Fort Detrick, and even the hospital ship 
Comfort is in our State.
    I also just want to say to you, and to our nurse corps 
leadership and to all of the people who serve, just how proud 
we are of you. What you all are sustaining is enormous, and in 
the midst of a war. Amidst these tremendous battlefield 
casualties and taking care of dependents, along comes something 
called Katrina that you had to respond to, along comes a 
pandemic that we have to be getting ready for. And I know 
you're planning for that. So, we just want you to know, we're 
very proud of you. And, as my two colleagues have said, you 
can't talk to a soldier that's come back who just wasn't proud 
to serve his country, but expresses the gratitude to the 
medical care, even for the infections. You know, we hear about 
the battlefield trauma, but it's the urinary tract infection 
that the young female soldier has, and it's the fungus 
infection, the foot infection that the young marine or 
infantryman has. So, it's all that usual and customary. So, 
we're just very impressed.
    Let me go to the battlefield aspects of medicine, just for 
a minute, and to General Taylor. I understand that these 
evacuations, the golden hour from battlefield to Walter Reed, 
are an amazing and stunning accomplishment with, obviously, 
lower morbidity and mortality. Can you sustain that on the 
basis of the National Guard and Reserve? Because I understand 
that the majority of how that occurs comes from the National 
Guard and the Reserve. They provide the air infrastructure, and 
then you provide the staff, shall we say, in the hospital room 
in the sky. Am I correct in that?
    General Taylor. It's a little bit of both. We have teams 
that are in the air, in the back of the airplane, and they are 
a mixture of Guard and Reserve and Active. The most impressive 
part is, by and large, we do this with volunteers. The people 
that are in the air--the thousands of men and women that are in 
the aeromedical evacuation community, both Active, Guard, and 
Reserves, are a highly motivated, well-trained group with a 
fairly substantial depth, because we had to plan to move as 
many as 300 or 400 casualties a day, in the opening days of the 
war. And so, moving 10s and 20s a day is well within the realm 
of our aeromedical evacuation capability.
    Senator Mikulski. Yes, but are you able to sustain this?
    General Taylor. Yes, ma'am. We're doing it with volunteers 
today, and very little mobilization, and we see that we're able 
to do that for the foreseeable future.
    If I could just add one thing to your list of----
    Senator Mikulski. Yes.
    General Taylor. In addition to Bethesda Naval Hospital and 
other places, I'm also very proud of the Baltimore Shock Trauma 
Center. As you know, we have military surgeons and nurses and 
technicians working in the Baltimore Shock Trauma Center every 
day. We rotate surgeons and nurses and technicians and other 
folks through there for training, and large numbers of people 
that you see working in the air or on the ground in Balad are 
graduates, recent graduates, of the shock trauma orientation 
course, where they go and take care of people.
    Senator Mikulski. Yes, well, in my time, in 10 minutes----
    General Taylor. Yes, ma'am.
    Senator Mikulski. I'm aware of that.
    General Taylor. I just wanted to add one more comment.
    Senator Mikulski. Yes, I'm aware of that. And we're proud 
of that--which takes me to the recruitment issue. I'll be 
talking a lot with the nurse corps about their particular 
issues, but when we talk about the medical corps and the 
variety of very sophisticated specialties, General, are you 
looking at how you can get to the medical students while 
they're medical students with these kinds of partnerships 
between military medicine and perhaps a local civilian medical 
school? In other words, where you have a big military presence, 
like we have in Maryland--it could be Oklahoma, it could be 
South Carolina--where there you are, there's the military, and 
there's the civilian medical system, where there is exposure, a 
lot of these kids don't know about the military. Their fathers 
don't know about the military, or their moms, because, again, 
we don't have a draft. They just don't know. And decisions are 
made at the medical student level, not where they're going to 
do their residency and find it enormously exciting to be, for 
example, what General Taylor talked about.
    General Kiley. Yes, ma'am. We are--we're very interested. 
In fact, part of this thrust for the digital video disc (DVD), 
which we've developed, which is part of a presentation by Army 
physicians who go to medical schools, to the large classes, 
particularly freshman and sophomore, and show them the DVD and 
give them an opportunity to talk about all the options, 
possibilities, either research, clinical care, academics and 
teaching, and then operational medicine. What we've changed, in 
an effort to address your concern, is to focus recruiting 
efforts and the tools that we use, focusing them on physicians, 
specifically. I think, in the past, one of our shortfalls has 
been, we've had this Army Medical Department recruiting effort, 
writ large. And if you're a doctor, you don't see enough in 
there to identify with. If you're a nurse, you don't see enough 
in there to identify, to help you understand. So, that's one 
thing.
    We've also began to look at pre-med classes, the 
universities where the medical students are, before they go to 
medical school, because we'd like to get to them while they're 
still juniors and seniors in college, thinking about going to 
medical school.
    Senator Mikulski. Well, is one of these obstacles to 
recruitment the money? Or is it the lack of knowledge and 
awareness about these career opportunities?
    General Kiley. Off the top of my head, ma'am, I think the 
answer would be captured in an article that was in Military 
Medicine a few years ago, ``Canvassing Medical Students in 
Medical School: Don't Know, Don't Care.'' I'm not so sure they 
don't care anymore, because of our global war on terror 
efforts, but they still don't know. I think it's less about 
that than it is about money. There are, as I alluded to a 
little bit earlier--as I understand it, there are potentially 
other competing interests for repaying loans and giving 
individual stipends in medical school. I think, mostly, it's 
education. And, frankly, we've got a tremendous cadre of young 
enlisted recruiters. But when the doctor--when a medical 
student wants to know, you know, can they be a pediatrician, or 
are they going to have to be a this----
    Senator Mikulski. They don't have the answers. Well, this 
is why I think, through, again, the pre-med level is excellent, 
but I think it requires creative outreach. And I think, you're 
exactly right, where you think you're going to be is who you 
want to talk to----
    General Kiley. Right.
    Senator Mikulski [continuing]. Whether it's in allied 
health, not only are we going to talk about nurses, I know 
there is a shortage of pharmacists, x-ray technicians. We could 
go the cadre, because of what we see in the civilian 
population. So, we want to be able to help you be able to do 
that. So, that's one thing.
    General Kiley. Right.
    Senator Mikulski. Second thing is, while we're talking 
about the battlefield, I'm also concerned about some other 
threats, like the Katrina-like natural disaster, to be ready in 
our own country, should there be a predatory attack and local 
government collapses, or if a pandemic hits and your doctors 
and your nurses and your own institutions could go down, just 
like in Katrina, where you had nurses and doctors carrying 
people eight flights of stairs to get them out. What is the 
thought and the planning there? And are we stretched so thin 
now that we would have limited resources to deal with a 
catastrophe within the homeland, regardless of whether it's 
natural or predatory? For any of our panelists.
    General Taylor. I'll be glad to--I'll say a few things, and 
then maybe Kevin can kick in afterward.
    The medical services within the Air National Guard have 
been tasked by General Blum to begin moving toward a homeland 
security defense. So, they are organizing their capabilities, 
along with the FEMA regions. They're building response 
capabilities, and they're organizing and practicing for a 
national disaster, not only because the Guard's immediately 
available, but with State-to-State agreements, there is also 
rapidly available without having to wait for the Do loop 
through the Federal Government.
    And so, I'm very excited about that. There was a recent 
exercise last week, called Coyote Express, in Scottsdale, 
Arizona, where they practiced. How would you respond to a major 
casualty event? I think you have it right, that people think 
about first responders in any sort of national disaster, 
without thinking about----
    Senator Mikulski. They, themselves----
    General Taylor [continuing]. First----
    Senator Mikulski [continuing]. Could go down.
    General Taylor [continuing]. The first receivers. Is there 
going----
    Senator Mikulski. What about the----
    General Taylor [continuing]. To be anybody at the end of 
the----
    Senator Mikulski. What about the pandemic? My time is----
    General Kiley. Yes, ma'am. Actually, U.S. Army Medical 
Command just finished a three-part CPX/headquarters exercise 
with all of my regional commands, walking through a what-if 
scenario. If the Army was asked, in this case, to help the 
local civilian communities--you've identified an area that 
concerns us. I mean, it has the potential to be a very 
significant impact on the Nation. I think all three services 
are concerned about that. I think we would be simply waiting 
for direction from the Department to begin to execute that. And 
I know that my commanders, at places from Fort Lewis to Walter 
Reed, are talking with----
    Senator Mikulski. You're waiting for the direction from 
who, General?
    General Kiley. Well, I mean, in the event of a pandemic, 
we--you know, we would--we would expect the Department or the 
President to give us direction to begin to execute mission 
support outside the fences of our camps, posts, and stations. 
What we're not waiting for is getting to know who in the 
communities, both medical and civilian leadership in the 
communities, has accountability and responsibility in a 
Seattle/Tacoma or in Fairfax, Virginia, as it relates to how a 
community would react to and support the medical demands for a 
pandemic in an area. And they would be very significant. And 
our analysis, as we've worked our way through this, the last 
couple of months, is, it would be a very significant problem, 
everything from the health of our providers to the logistics of 
taking care of a community.
    So, we share your concern. We are training now, as I 
guess----
    Senator Mikulski. Well, again, I think this is just 
something that we'll be talking about, because it really has a 
real national security impact. In the event of an emergency 
like a pandemic, it's very likely that the very people who have 
to treat could, themselves, be sick, in the local community. 
The second thing is, the massive treatment, the massive 
inoculation, and then the need to maintain civil order and 
possibly even a quarantine, and the only place that we can turn 
to with the backup reserves, even under the doctrine of mutual 
aid with first responders, is our United States military. And 
you're stretched--and you are--you're doing a fantastic job, 
but I believe you're stretched. And so----
    General Kiley. I----
    Senator Mikulski [continuing]. We'll look forward to 
further discussion on this.
    General Kiley. Yes, ma'am.
    Senator Mikulski. Thank you.
    General Kiley. We agree with you.
    Senator Stevens. Well, thank you very much.
    We thank you, General Taylor, for your service, and wish 
you well.
    Senator Mikulski. Yes, I wanted to say that, too.
    Senator Stevens. Admiral, I'm interested in your answers to 
Senator Inouye's question about integration. I think we'd be 
very pleased to see if some of you would take the initiative to 
get your groups together and some of your predecessors, see if 
we could have a meeting with the eight Members of Congress who 
really lead the four defense committees. It may be time for a 
defense military corps with some type of training that would 
be--would specialize in the necessities for the marines, the 
Army, the Air Force, the Navy, whatever it might be. But, very 
clearly, it appears that the integration of the medical 
services could have a substantial benefit, and could raise the 
level of awareness of the corps and what it means to the 
country. So, I think that the two of us would be very pleased 
to work with you on that, if--when some of these current 
travails are over here, sometime this fall.
    Admiral Arthur. Yes, sir.
    Senator Stevens. We'll give you a call.
    Admiral Arthur. Yes, sir.
    Senator Stevens. Let me thank you all for your service, 
and----
    Senator Inouye. May I also----
    Senator Stevens. Yes, Senator.
    Senator Inouye. Before we dismiss the panel, I just wanted 
to make a footnote. According to my studies, a military 
radiologist receives $150,000 a year. One on the outside, a 
civilian radiologist, with similar skills and experience, would 
get at least $450,000.
    Admiral Arthur. Yes, sir.
    Senator Inouye. You've got a job ahead of you.
    Admiral Arthur. And if we asked them to work side by side 
in military/civilian conversion, it's an incredibly 
demoralizing situation. When one works nights, weekends, and 
deploys, and the other does not, but gets three times the 
salary--yes, sir.
    Senator Inouye. I hope Americans realize the bargain 
they're getting on our military personnel.
    Admiral Arthur. Yes, sir.
    General Kiley. Yes, sir.
    Senator Stevens. Some of my former assistants here in town 
are making $1 million right now. We don't want to do some 
comparisons.
    Thank you all very much for your service.
    Senator Stevens. We look forward to working with you on 
this subject. We'll turn to the next panel.
    We're going to hear now from the chiefs of the service 
nursing corps. This subcommittee has always believed in the 
value of the nursing corps. It is vital to the success of our 
military medical system, and absolutely necessary in periods 
such as we're going through right now.
    We want to thank all of you involved in the leadership of 
the nursing corps for your service, and look forward to your 
statement of your accomplishments and the challenges you face. 
We will be hearing today now from General Gale Pollock, the 
Chief of the Army Nursing Corps; Admiral Christine Bruzek-
Kohler of the Navy Nurse Corps; and General Melissa Rank, the 
Assistant Surgeon General for Nursing Services for the Air 
Force.
    We welcome you here, want to hear your testimony, and we do 
have some question.
    I turn to my friend, Senator Inouye, to see if he has any 
opening comment.
    Senator Inouye. Well, I'd like to join you in welcoming 
these chiefs, but I'd also like to congratulate General 
Pollock. She did a great job at Tripler. And now you're going 
to be chief of staff of the Army Medical Command. That's quite 
an accomplishment. Is this the first time a lady has been in 
charge?
    General Pollock. Yes, sir. And the actual job title is--
I'll be the deputy surgeon general, sir, not the chief of 
staff.
    Senator Inouye. That means we're ready for three stars now.
    General Pollock. I'm not sure the rest of the world's ready 
for that, sir.
    Senator Inouye. Thank you, Mr. Chairman.
    Senator Stevens. Senator Mikulski, do you have any open 
comment for the nurses?
    Senator Mikulski. Well, we're just glad to see you. You 
know, in every war that America's fought, you've been there, in 
one way or the other, and we want to make sure that we continue 
to provide that service. So, we look forward to hearing from 
you and your ideas and recommendations.
    Senator Stevens. Yes, thank you very much.
    General Pollock, we'll hear from you first.

STATEMENT OF MAJOR GENERAL GALE POLLOCK, CHIEF, ARMY 
            NURSE CORPS, DEPARTMENT OF THE ARMY
    General Pollock. Thank you.
    Mr. Chairman and distinguished members of the subcommittee, 
it's indeed, an honor and great privilege to speak before you 
on behalf of the nearly 10,000 officers of the Army Nurse 
Corps.
    Army nurses continue making impressive contributions 
throughout the world. In addition to excellent nursing care of 
combat casualties, we've provided training for physician and 
nursing leaders in Afghanistan, served as advisors to the Iraqi 
armed forces surgeon general, and led discussions to raise the 
quality of military and civilian nursing in the Republic of 
Vietnam.
    Here at home, Army Nurse Corps officers are key to the 
medical holdover program. Soldiers report high satisfaction and 
prefer to have Army nurses manage their healthcare. I'm 
committed to developing a world-class nurse case-management 
model within the framework of the AMEDD. We expanded the scope 
of practice for operating room nurses through registered nurse 
first assist training. This change optimizes the utilization of 
surgeons, enhancing capabilities in theater and in fixed 
facilities. Psychiatric advanced-practice nurses are proven 
force multipliers. I directed that these nurses enroll in 
psychiatric nurse practitioner programs to clarify the issue of 
prescriptive authority and provide the Army Medical Department 
(U.S. Army) (AMEDD) additional flexibility to better support 
the mental health mission.
    Caring for our combat wounded is one of the most demanding 
services we provide, and we consistently do it well. However, I 
remain concerned about the toll that caring for these trauma 
patients exacts over time. The effects of post-traumatic stress 
disorder and compassion fatigue on our clinicians cannot be 
underestimated. If left unchecked, it leads to a variety of 
long-lasting personal and professional problems. It must remain 
a high-priority issue.
    We continue staffing the theater trauma system. Nursing 
documentation of serious outcomes due to hypothermia resulted 
in a major change to care on the battlefield and is saving 
lives.
    Army nurse researchers and our doctoral students focus 
their efforts on military-relevant issues. Recently they 
examined the physical effects of body armor and loadbearing 
personal protective equipment, and methods to improve walking 
performance in amputees. Due to your generous support of the 
tri-service nursing research program, there is both monetary 
and educational support for these studies which encourage 
collaboration and advance the science of nursing practice.
    The use of simulators improves the critical thinking and 
technical skills required of healthcare personnel. The Nursing 
Science Division of the Army Medical Department (AMEDD) Center 
and School uses adult and pediatric simulators to augment the 
training of anesthesia students. The U.S. Army graduate program 
in anesthesia nursing is the second-ranked program in our 
Nation, but I remain concerned about the retention of our 
certified registered nurse anesthetists (CNA).
    The need for nurses outpaces the number of new graduates. 
Baccalaureate programs turn away qualified applicants each year 
due to faculty shortages. We are encouraging our retiring 
officers to select faculty positions as a second career.
    We learned from Recruiting Command that results were much 
improved when candidates spoke directly with Army nurses. In 
response, we launched the every nurse is a recruiter program. 
Now all nurses are actively engaged in identifying 
opportunities to recruit and advocate for the highest quality 
of nursing personnel.
    We've received inquiries each year from line officers 
interested in becoming Army nurses. We're developing a program 
similar to the Judge Advocate General's funded legal education 
program to allow them to complete their baccalaureate 
educations and join us.
    In all Army medical treatment facilities, we face 
significant shortages of civilian nurses, particularly in 
critical care, postoperative, perioperative, and obstetrics and 
gynecology (OB/GYN) nursing. The delay of National Student 
Personnel System (NSPS) renewed our concerns that Office of 
Personnel Management (OPM) regulations insisting that new 
college graduates begin their Government service as a GS-5 
thwarts our ability to recruit a civilian nursing workforce.
    We must be the employer of choice for all professional 
nurses. Diversified accession and retention incentives for both 
military and civilian nurses are essential. We will sustain our 
focus on readiness, clinical competency, and sound educational 
preparation to serve those who defend our Nation.

                           PREPARED STATEMENT

    I appreciate this opportunity to highlight our 
accomplishments, and look forward to your questions.
    Senator Stevens. Thank you very much.
    [The statement follows:]

          Prepared Statement of Major General Gale S. Pollock

    Mr. Chairman and distinguished members of the committee, it 
is indeed an honor and great privilege to speak before you on 
behalf of the nearly 10,000 officers of the Army Nurse Corps. 
Your unwavering support has enabled Army Nurses, as part of the 
larger Army Medical Department (AMEDD) team, to provide the 
highest quality care for our Soldiers and their family members.
    I regret that I was unable to be here last year. It was 
during this time that I co-hosted the 15th Annual Asia Pacific 
Military Medicine Conference in Hanoi, Vietnam as the U.S. Army 
Pacific Surgeon, the first international military conference 
held in Vietnam since the Reunification of Vietnam in the 70's. 
This forum provides an important cultural exchange for military 
medical professionals from 27 nations to develop relationships 
critical to ensuring cooperation and security in the Asia-
Pacific region. Several Army Nurse Corps officers from Tripler 
Army Medical Center also attended, participating in a cultural 
exchange with Vietnamese military nurses. It is commonly 
asserted that the unprecedented regional cooperation and 
response to the devastating tsunami that hit in December 2004 
occurred as a result of the relationships previously built at 
these conferences.
    The Army Nurse Corps remains fully engaged in our Nation's 
defense and in support of its strategic goals. Our vision of 
advancing professional nursing and maintaining leadership in 
research, education, and the innovative delivery of healthcare 
is at the forefront of all we do. Army Nurses provide expert 
healthcare in every setting in support of the AMEDD mission and 
the military health system at home and abroad. There are 
currently almost 400 Army Nurse Corps officers from all three 
Components deployed in support of operations in 16 countries 
around the world. From April 2005 to March 2006, we deployed 
over 500 Army Nurses and mobilized an additional 779 Army 
Reserve Nurses in support of the total AMEDD mission. They 
serve in clinical and leadership roles in medical treatment 
facilities in the United States and abroad, in combat 
divisions, forward surgical teams, combat stress teams, civil 
affairs teams, combat support hospitals (CSHs), and coalition 
headquarters. Today, the 10th CSH from Fort Carson, CO; the 
47th CSH from Fort Lewis, WA; and the Army Reserve's 344th CSH 
from New York are deployed to Iraq. The 14th CSH from Fort 
Benning, GA is deployed to Afghanistan. The 21st CSH from Fort 
Hood, TX is expected to arrive in theater by early May to 
replace the 344th CSH.
    The AMEDD team provides the same outstanding care to all, 
U.S. service members, Iraqi security forces, and civilians of 
all nationalities. The statistics are astonishing. For example, 
since November, the 10th CSH has had over 3,500 emergency room 
visits. Over a quarter were multi-trauma resulting in almost 
1,900 admissions, but only one in five were U.S. forces. On the 
eve of parliamentary elections in Iraq, nurses from the 10th 
CSH helped deliver the first ``democracy baby,'' a little girl, 
by cesarean section. LTC Steven Drennan, Chief Nurse of the 
10th CSH, recounted several stories of caring for severely 
wounded Iraqi children as if they were their own. In summation, 
he said, ``Imagine one of your children in similar 
circumstances. You'd be overjoyed to know that he was cared for 
by a staff as concerned, competent, and caring as the Soldiers 
of the 10th CSH.'' This is but one unit, one example of our 
AMEDD team's consistently outstanding performance.
    In the wake of Hurricane Katrina, 97 Army Nurses deployed 
in support of relief operations. The 14th CSH and the 756th 
Medical Detachment arrived in New Orleans on September 5, 2005. 
Their initial mission was providing medical relief for those 
displaced by the storm, but after arrival it changed to 
providing care for personnel assigned to Joint Task Force (JTF) 
Katrina. Two of the Army Nurses assigned to the 14th CSH, 1LT 
Warren Gambino and 1LT Manual Galaviz, had family living in the 
New Orleans area, making the mission more personal not only for 
them, but for the entire unit as well. During the deployment, 
Lieutenant Gambino was promoted from second to first lieutenant 
in the New Orleans Convention Center. Wearing the only clothes 
they had, his family was there to witness the event. In mid-
October, in preparation for their follow-on deployment to 
Afghanistan, the 14th CSH transferred authority to the 21st 
CSH.
    The 2005 hurricane season had a huge impact on military 
installations and personnel across the Gulf Region. Nurses and 
medics from the 4010th Field Hospital from New Orleans who were 
serving as backfill at Fort Polk lost family members, homes, 
and civilian jobs. As part of the Federal Coordinating Center 
of the National Defense Medical System, William Beaumont Army 
Medical Center received 65 evacuees from hospitals and nursing 
homes in Beaumont, TX. At Walter Reed Army Medical Center, the 
Uniformed Services University of the Health Sciences (USUHS) 
nurse anesthesia program welcomed Air Force Capt James Goode 
into their program. Capt Goode, a second year nurse anesthesia 
student stationed at Keesler Air Force Base, was only months 
from graduation when the storm hit and he already had orders 
for Andrews Air Force Base. We worked with the Air Force to get 
him to Walter Reed where he was able to finish his requirements 
and graduate on time.
    On October 8, 2005, a massive earthquake struck in northern 
Pakistan. The 212th Mobile Army Surgical Hospital (MASH) was 
just completing a multinational humanitarian operation in 
Angola where they treated more than 3,700 patients, performed 
191 surgeries, and completed mass casualty, humanitarian 
assistance, and national disaster response training. By October 
25th, the 160th Forward Surgical Team and the 212th MASH, 
augmented with 11 Army Nurses from the 67th CSH arrived in 
Pakistan to provide medical relief in the stricken region. 
During its four months in Pakistan, the 212th MASH, which 
included 31 Army Nurse Corps officers and 39 enlisted medics, 
treated over 20,000 outpatients and 838 inpatients, performed 
426 surgeries, and responded to 105 life-threatening 
emergencies--many of which were infants and children. Nurses 
also accompanied patients on over 250 medical evacuation 
missions. In February, the 212th, the last remaining MASH in 
the Army's inventory, turned over the hospital to the Pakistani 
government. The 212th MASH will be redesignated a combat 
support hospital in October.
    Army Nurses continue making contributions toward building 
sustainable medical infrastructure throughout the world. Army 
Nurses assigned to the 14th CSH worked with Afghan officials to 
spearhead an education outreach program with Afghan nurses. A 
team, including LTC Susan Anderson and MAJ Brian Benham, 
provided training for senior Afghan military medical leaders. 
As part of an effort to improve emergency healthcare in 
Lebanon, another team led by LTC Kimberly Armstrong conducted 
basic emergency medical technical training for members of the 
Lebanese Armed Forces. Eleven Army Reserve Nurses led by COL 
Cheryl Adams and then COL Gloria Maser were deployed to serve 
as advisors to the Iraqi Armed Forces Surgeon General. Their 
efforts resulted in a compendium of basic medical training 
materials and courses in Arabic, a standardized policy and 
procedures manual for Iraqi Army medical clinics, and a medical 
logistics distribution system. They also validated sites and 
monitored the building progress of 11 medical clinics and a 
medical supply warehouse. In addition, we sent a team of Army 
and Air Force nurses to Vietnam to exchange information about 
military and civilian nursing with representatives from the 
Republic of Vietnam.
    Since 2003, over 20,000 mobilized Army Reserve Soldiers 
have entered the Army's Medical Holdover Program with injuries 
and illness due to deployment. With so many Soldiers returning 
home from theater requiring intensive medical management, there 
is a tremendous need to assist veterans and their families as 
they navigate the healthcare system. There are currently 229 
mobilized Reserve Army Nurses assigned as case managers 
throughout the country serving at military medical treatment 
facilities, mobilization sites, and at eight regional 
Community-Based Healthcare Organizations. Reports indicated 
that case managers are effectively and efficiently coordinating 
appropriate and quality healthcare for this population of ill 
and injured Soldiers. Soldiers report high satisfaction 
regarding their case managers and prefer to have Army Nurses 
manage their healthcare. I am committed to developing a world-
class nurse case management model within the framework of the 
AMEDD managed care system. Through the efforts of COL Rebecca 
Baker, we have established authorizations for nurse case 
managers within Army Reserve medical support units along with 
the curriculum and qualifications to ensure Reserve nurses who 
are placed in the case management positions obtain the 
necessary skills and competencies to manage the healthcare of 
medical holdover Soldiers.
    I am proud of the Army Nurses and our colleagues who have 
cared for our combat-wounded along the entire medical 
evacuation pipeline. This is some of the most demanding 
healthcare anywhere in the world and these wonderful 
professionals do it consistently well. However, I remain 
steadfast in my concern about the toll that caring for the 
traumatically wounded exacts over long periods of time. The 
effects of post-traumatic stress disorder (PTSD) on clinicians 
cannot be underestimated. If left unchecked, they can lead to a 
variety of long-lasting personal and professional problems. The 
transition to home for healthcare personnel must be as 
supportive and successful as possible. Facilities have 
established support groups to assist returning veterans during 
this critical reintegration time. They have also established 
programs specifically for clinical staff caring for the combat-
wounded to address the issue. These are high-priority issues 
for us all. We continue searching for new ways to improve the 
mental health care we provide not only to our returning combat 
veterans, but also the clinical staff caring for them.
    Military medical ethics continues to be a subject of 
interest for Army Nurses. All professional nurses in the United 
States abide by the ANA's code of Ethics for Nurses, which 
clearly states, ``The nurse's primary commitment is to the 
health, well-being, and safety of patients across the life-span 
and in all settings in which health care needs are addressed.'' 
Army Nurses everywhere provide ethical, compassionate, expert 
nursing care. They receive training in the Geneva Conventions, 
the Laws of Armed Conflict, and Army Regulations related to the 
care of detainees. I included deployment ethics in continuing 
education programs sponsored by the Army Nurse Corps.
    As the Army works to rebalance its forces, we are also 
working to adapt to the circumstances of this long global war 
on terrorism. We are rapidly applying lessons learned to ensure 
the best care is provided on the battlefield and across the 
healthcare spectrum. At the AMEDD Center and School, the 
Department of Nursing Science has incorporated those lessons 
into all courses offered to Army Nurses, LPNs, and combat 
medics. We have had a number of other successes in both ongoing 
and new initiatives that I would like to share with you.
    In wars past, nursing personnel received trauma training 
on-the-job. Today, we know that the ability to train as 
interdisciplinary teams under real-world conditions improves 
patient outcomes. The U.S. Army Trauma Training Center (ATTC) 
in association with the Ryder Trauma Center, University of 
Miami/Jackson Memorial Hospital provides our forward surgical 
teams and slices of CSHs an invaluable opportunity to 
experience realistic best-practice total team trauma training 
prior to deployment. We have four Army Nurses and three LPNs on 
faculty at ATTC. This past year, they trained seven units, 
including 33 Army Nurses and 19 LPNs to provide state-of-the-
art trauma care on the battlefield.
    In the absence of real-world training, simulators improve 
the critical thinking and technical skills required for 
healthcare personnel. Today, we are not only caring for more 
patients with lower extremity injuries, but also large numbers 
of children. To meet that demand, the AMEDD Center and School 
purchased adult lower body and pediatric simulators to augment 
the training of nurse anesthesia students learning to employ 
regional block anesthetics. They also purchased simulators that 
have true-to-life intravenous access, vital signs, and other 
capabilities to improve the training medics receive. At the 
Joint Readiness Training Center, LTC Richard Evans led the 
effort to incorporate combat trauma simulators into mission 
rehearsal exercises for CSHs. Using realistic simulators 
increases the fidelity of pre-deployment training and allows 
healthcare teams to expertly respond to a combination of live, 
virtual, and constructive scenarios over time, mirroring 
military healthcare on the battlefield.
    From the beginning of combat operations in Iraq, nurses 
transported severely wounded patients by air within theater. 
They performed superbly, but most had no training in aviation 
medicine. To address this, the U.S. Army School of Aviation 
Medicine developed the Joint Enroute Care Course to improve 
medical evacuation care, policy, and coordination. In 2005, the 
228th CSH hosted the first iteration in Iraq. Today, with over 
40 nurses from all three Services trained, there are fewer 
issues with patient transports, including accidental line 
removal and equipment malfunctions. This collaborative joint 
effort has improved patient care.
    The first year of nursing practice sets the foundation for 
a successful career. We are committed to ensuring that our 
nurses receive the training and maintain clinical competencies 
essential in all operational environments. Feedback indicated a 
need to assist our new nurses in building a firm foundation of 
clinical competency in critical wartime skills. To address this 
need, we added the Trauma Nursing Core Course (TNCC) to the 
Officer Basic Leaders Course in May 2005. Completion of TNCC 
helps develop core trauma knowledge and critical thinking 
skills while also establishing a firm foundation in the 
stabilization of trauma patients. One hundred and thirty three 
nursing officers successfully completed TNCC in December. This 
course was coordinated by MAJ Anthony Bohlin with the 
assistance of Ms. Susan Douglas of the San Antonio Chapter of 
the Emergency Nurses Association. This was the largest class 
ever to complete TNCC at one time.
    Once new nurses arrive at their first duty station, their 
initial orientation is critical to proper skill development. We 
are working towards the creation of an enhanced new graduate 
internship program. In the meantime, some facilities have re-
looked at how they orient new graduates. An example is from 
Tripler Army Medical Center where they provide new nurses 
opportunities to develop basic competencies in the variety of 
clinical areas they will experience in a deployed environment 
rather than focusing on a single competency area.
    The Department of Nursing Science at the AMEDD Center and 
School broke ground for a new general instruction building this 
past November. The building will be named in honor of Brigadier 
General Lillian Dunlap, 14th Chief of the Army Nurse Corps, 
will house all Department of Nursing Science offices, 
classrooms, and practical exercise areas. We expect it to open 
in 2007.
    The Registered Nurse First Assist (RNFA) is a subspecialty 
of perioperative nursing offering an expanded scope of practice 
in the operating room setting. The RNFA practice model expands 
the scope of practice for perioperative RNs to function as 
first assists to the surgeons in the operating room and 
optimizes the utilization of general surgeons. It is also 
enhances the capabilities of the forward surgical team, the 
CSH, and fixed facilities. A pilot project at Fort Drum yielded 
a cost savings of $190,000 by eliminating a costly contract and 
provided Army Nurses practical experience enhancing wartime 
capability. Incorporating RNFAs into our structure also 
enhances our ability to recruit and retain perioperative 
nurses. Historically, these nurses otherwise looked for 
advanced training and education in roles unrelated to 
perioperative nursing within or outside of the Army. In concert 
with our perioperative nursing consultant, COL Linda Wanzer, 
USUHS is working to incorporate this training into the 
curriculum for perioperative clinical nurse specialists. To 
date, we have trained eight RNFAs and deployed five in support 
of contingency operations.
    Clinical competency is another key concern. We completed a 
major revision of how our officers who specialize in critical 
care, emergency, and OB/GYN nursing demonstrate clinical 
competency. Our goal is to standardize the way in which we 
confirm and maintain competency for all of our nurses. These 
revisions clarify guidance on how to achieve this and are 
particularly important for Army Reserve Nurses who may not 
practice their military clinical specialty in their civilian 
employment.
    Facilities located on installations with a large number of 
medical personnel assigned to field units are reestablishing 
programs to help them maintain clinical competency. We have 
also begun a number of initiatives in this area with our sister 
Services. William Beaumont Army Medical Center established a 
partnership with the medical clinic at Holloman Air Force Base 
to provide inpatient refresher training for its medical 
personnel. In the first iteration of a joint critical care 
nursing course at Fort Sam Houston, we trained eight Air Force 
critical care nurses. We expect five more to graduate this 
summer and hope to have five Air Force nurses in the next 
Emergency Nursing Course. During their deployment in support of 
JTF-Katrina, members of the 21st CSH completed TNCC, the Combat 
Lifesaver Course, and the Advanced Cardiac Life Support Course. 
In Afghanistan, Army Nurses spearheaded an effort that resulted 
in the 14th CSH's designation as an official provider for the 
Emergency Medical Technician-Basic (EMT-B) Refresher Course, as 
well as the Combat Medic Advanced Skills Training Course. Their 
efforts have helped dozens of combat medics deployed in support 
of Operation Enduring Freedom sustain critical skills.
    Our collaborative efforts also include our colleagues at 
the Department of Veterans Affairs (VA) and surrounding 
civilian facilities. Dwight David Eisehower Army Medical Center 
and the Augusta VA Medical Center established a joint training 
and staffing initiative which includes a critical care nursing 
internship program and a staffing pool. Eisenhower, as our lead 
facility in the Southeast Medical Region, also coordinated with 
Augusta's Doctors Hospital to provide burn training for 
deploying staff and those caring for wounded patients. To date, 
50 military and civilian nurses have completed this training.
    Many of our smaller facilities serve as clinical training 
sites for our enlisted medics, such as those in the surgical 
technologist program. At some of these sites, the caseload was 
too limited to provide the appropriate clinical experience for 
our Soldiers. In 2005, we closed 10 sites and shifted our 
training mission to facilities with larger volumes of diverse 
surgical cases. This improved the quality of the training 
students received and better prepared them for deployment.
    In June 2005, the family nurse practitioner (FNP) was 
approved as an authorized substitution for a family physician 
in CSHs and for physician assistants in division-level units. 
Deploying FNPs now complete advanced trauma training at the 
AMEDD Center and School to ensure they are prepared for 
deployment. We are also collecting lessons learned and actively 
working with the AMEDD Center and School and USUHS to determine 
potential opportunities for curriculum changes at each site.
    Psychiatric advanced practice nurses are proven force 
multipliers as authorized substitutions for psychologists on 
combat stress teams. I am directing officers pursuing graduate 
education in psychiatric nursing to enroll in psychiatric nurse 
practitioner (PNP) programs to clarify the issue of 
prescriptive authority and provide the AMEDD additional 
flexibility to better support the mental health mission.
    Army public health nurses are perfectly suited to meet 
essential public health demands at home and abroad. As experts 
in wellness promotion and in building healthy communities, they 
provide valuable services in a deployed environment and play a 
key role in the pre- and post-deployment health assessment 
process. In 2005, we redirected our services toward public 
health in response to the needs of Soldiers and their families. 
We realigned the practice of our public health nurses and 
broadened their roles to include homeland defense, 
epidemiology, occupational health, and support for national 
disasters and detainee operations. These changes better 
position us to meet public health demands in support of our 
Nation's defense.
    The AMEDD's Theater Trauma System Initiative standardizes 
treatment, evaluates processes, and provides training for 
clinicians to improve patient survivability in theater. As part 
of this system, the Joint Theater Trauma Registry 
systematically collects, stores, and analyzes medical data. We 
have deployed 12 Army Nurses since 2004 in support of this 
initiative. The work they do directly improves patient 
outcomes. For instance, the rate of hypothermia and resulting 
mortality decreased thanks to the education these nurses 
provided to first responders and the hypothermia prevention 
kits they distributed.
    Evidenced-based nursing is the process by which nurses 
utilize research to make clinical decisions and provide state-
of-the-art patient care. Army Nurse researchers, in 
collaboration with their Navy and Air Force colleagues, are 
heavily vested in the TriService Nursing Research Programs' 
Center of Excellence in Evidenced-Based Nursing Practice. 
Projects to bring research findings to the bedside are underway 
at Walter Reed, Brooke, Madigan, and Tripler Army Medical 
Centers. These projects are part of a larger effort to improve 
patient outcomes and reduce costs by standardizing care. They 
teach nurses how to critique research and incorporate the 
relevant findings into patient care. Nurses involved in these 
projects increase their knowledge, become motivated to further 
their education, and are becoming involved in research 
projects, much earlier in their careers.
    Army Nurse Researchers and our doctoral students focus 
their efforts on military relevant issues. They are conducting 
a number of studies that foster excellence and improve the 
nursing care we provide. They are researching issues including 
recruit health; clinical knowledge development; the provision 
of care for the traumatically injured; objectively measuring 
nursing workload; and the impact of deployments on service 
members and their families. At USUHS, COL Richard Riccairdi is 
completing his doctoral dissertation on mitigating the physical 
effects of body armor and other load-bearing personal 
protective equipment and LTC Lisa Latendresse is examining how 
to improve gait and walking performance in amputees.
    The Military Nursing Outcomes Database (MilNOD) program of 
research provides military nurse managers the ability to 
analyze the effects of staffing patterns on patient safety and 
outcomes to improve all levels of nursing care. This work 
builds upon that done by the California Nursing Outcomes 
Coalition and the Veteran's Administration. Using this 
framework, nurse managers at the 14 military sites are 
analyzing workload and staffing data as it relates to patient 
events and make more informed management decisions. Through 
your generous support of the TriService Nursing Research 
Program, there is both monetary and educational support for 
these studies, which encourage collaboration and advance the 
science of nursing practice. On behalf of the Army Nurse Corps 
and the patients whom we serve, thank you.
    The U.S. Army Graduate Program in Anesthesia Nursing once 
again ranks second in the nation. We are equally proud of the 
USUHS Registered Nurse Anesthesia Program. Our students are 
actively involved in research studying airway management, 
hypothermia, herbal remedies, and nurse retention, thus 
furthering the science of nursing. At Walter Reed, anesthesia 
students have the additional opportunity to deploy on a two-
week humanitarian mission with experienced faculty to obtain 
field anesthesia experience. Our students are consistently 
battle ready upon graduation, beginning with board 
certification. We are proud to say that again this year they 
had a 100 percent pass rate. Both anesthesia programs produce 
exceptional graduates who serve our Army and sister Services 
extremely well.
    We acknowledge and appreciate the faculty and staff of the 
USUHS Graduate School of Nursing for all they do to prepare 
advanced practice nurses to serve America's Army. They train 
advanced practice nurses in a multidisciplinary military-unique 
curriculum that is especially relevant given the current 
operational environment. Our students are actively engaged in 
research and the dissemination of nursing knowledge through the 
publication of journal articles, scientific posters, and 
national presentations. Of special note, I wish to acknowledge 
our perioperative clinical nurse specialist students for their 
contributions to a national white paper on medication errors.
    Despite an upswing in enrollments in baccalaureate nursing 
programs for the fifth straight year, the need for nurses 
continues to outpace the number of new graduates. Baccalaureate 
programs continue to turn away tens of thousands of qualified 
applicants each year, many due to faculty shortages. We remain 
committed to partnering with the civilian sector to address 
this and other issues contributing to the worldwide shortage of 
professional nurses. We are currently researching ways to 
encourage our retired officers to consider faculty positions as 
viable second career choices.
    The Virtual Clinical Practicum is another example of our 
efforts to combat the nursing shortage. We first told you about 
this last year when nurses at Walter Reed Army Medical Center 
partnered with a rural nursing school to provide their students 
an effective clinical experience through telehealth technology. 
Last fall, approximately 180 students from this school 
participated in the second phase of this study with staff and 
one enthusiastic patient from the U.S. Army Burn Center in San 
Antonio. Planning is ongoing for a third practicum. This 
innovative research initiative is providing tertiary level 
learning opportunities for students who otherwise would not 
have that experience.
    We have been successful in establishing working 
relationships with local communities. In Korea, the 18th 
Medical Command established an exchange for professional 
nursing with the Korean Ministry of Health. Under this program, 
four Army Nurses, MAJ Michael Hawkins, MAJ Thomas Cahill, MAJ 
Dana Munari, and LTC (Ret) Priscilla Quackenbush, were 
appointed Clinical Professors at Yonsei University where so far 
they have precepted 26 Korean advanced practice nursing 
students. At West Point, LTC Diane Scherr is serving as adjunct 
faculty at Mount Saint Mary's College. Efforts such as these 
are contributing to a steady supply of basic and advanced 
practice nurses for the future.
    The nursing shortage and current operational conditions 
continue to make recruitment and retention challenging for all. 
It is projected that the need for nurses will continue to 
outpace the supply. The Active Component Army Nurse Corps is 
short 320 officers. This results in under-filled year groups. 
Every year since 1999, we have accessed an average of 16 
percent fewer officers than required and the projected 
shortfall for this year is 27 percent. We are also seeing a 
decline in our retention rates for the first time in many 
years.
    While the Army Reserve is at 100 percent of its 
authorizations for nurses, each year since 2003, we have 
accessed an average of 21 percent fewer Army Reserve nurses 
than required and half of those who were accessed possessed an 
Associate Degree in Nursing (ADN) or a Diploma in Nursing. 
However, we still cannot fill crucial company-grade ranks, 
despite concentrated efforts at recruiting ADN-prepared nurses. 
This is evidence that simply recruiting more nurses with ADNs 
is not the answer to solving our shortages in the Reserve 
Component.
    In order to mitigate the current situation, ensure 
competitive advantage, and build an Army Nurse Corps for the 
future, we must be the employer of choice for professional 
nurses. Diversified accession and retention incentives that are 
attractive to nurses in each sector of the available market are 
essential. For those sectors which we currently have no 
recruitment programs, we are collaborating with the U.S. Army 
Accessions Command to develop relevant recruitment programs 
that will attract Bachelor of Science prepared nurses to serve 
in either the Active or Reserve Component. Army Nurses at all 
levels are actively engaged in the several nurse recruitment 
and retention programs at our disposal.
    We have 47 Army Nurses assigned to recruiting duty. While 
their efforts are invaluable, we consistently hear that 
applicants want to talk to Army Nurses directly involved in 
patient care. In response to this need, we have launched the 
``Every Nurse is a Recruiter Program'' to provide 
encouragement, opportunities, and recognition for nurses at all 
levels to become actively engaged in not only the recruitment 
of Army Nurses, but also the sustainment of professional 
nursing.
    To attract nursing students into the Reserve Officer 
Training Corps (ROTC), there has to be sufficient financial 
benefit. We thank the U.S. Army Cadet Command for providing 
full scholarships and a variety of tools and improved processes 
to ensure cadets successfully access into the Army Nurse Corps. 
We also thank Congress for ratifying a limited bonus for ROTC 
nurse cadets and increasing the cap on ROTC scholarships 
offered to cadets interested in Reserve Forces duty.
    Our AMEDD Enlisted Commissioning Program continues to be 
extremely successful. This provides Active Component Soldiers 
$10,000 per year for up to 24 months to complete their BSN 
while remaining on active duty. We currently start 65 Soldiers 
per year and hope to expand that in 2007.
    We appreciate the efforts of the U.S. Army Recruiting 
Command (USAREC) to provide the balance of professional nurses 
we require for the Active Component and all of the nurses for 
the Army Reserve. They are on the front lines competing with 
organizations that can often offer more flexible and attractive 
compensation packages. To help meet our requirements, they have 
a variety of tools available to help them attract the best-
qualified nurses.
    For the Active Component, we offer an accession bonus of up 
to $20,000 and the Health Professional Loan Repayment Program 
(HPLRP) for up to $30,651. USAREC is able to utilize these 
tools in various combinations with service obligations to 
tailor packages to suit individual applicants. This flexibility 
has proven to be invaluable in today's highly competitive 
market. Last year, 19 percent of eligible applicants chose the 
bonus, 27 percent chose loan repayment, and 52 percent opted 
for a reduced bonus of $8,000 in combination with loan 
repayment for a six-year obligation. USAREC estimates that 
without loan repayment, we would have recruited 69 fewer new 
officers.
    In 2005, we reinstated the Army Nurse Candidate Program 
(ANCP) to target nursing students ineligible to participate in 
ROTC. ANCP provides a $10,000 bonus and a monthly stipend of 
$1,000 per month for up to 24 months to full-time students 
pursing a BSN. To date, we have 12 students enrolled in the 
program and expect two to access onto active duty this summer.
    We receive numerous inquiries from the field each year from 
Army officers interested in becoming nurses and looking for a 
program to assist them. In response, we are collaborating with 
the Office of the Surgeon General and U.S. Army Accessions 
Command to develop a program that allows them to complete their 
BSN and convert to Army Nurses, similar to the Judge Advocate 
General's Funded Legal Education Program for Army lawyers.
    For the Army Reserve, USAREC offers an accession bonus up 
to $30,000 and HPLRP up to $50,000 for selected specialties. 
Critical care, operating room, psychiatric, and medical-
surgical nurses without a BSN can receive an accession bonus of 
up to $15,000. All Army Reserve accession incentives require a 
three-year service obligation in the Selected Reserve.
    The Specialized Training and Assistance Program for BSN 
completion (BSN-STRAP) is also now available for both new 
accessions and existing Army Reserve nurses without a BSN. This 
stipend program is for those who can complete their BSN in 24 
months or less. This is a good start, and I am hopeful that 
programs to attract BSN-prepared nurses to serve in the Army 
Reserve will be expanded in the years ahead.
    Retention of nurses is of utmost importance. Initial 
research shows that nurses stay on active duty for the 
educational opportunities, job satisfaction and retirement 
benefits. We are proud of the educational benefits we offer our 
officers. Our graduate-level specialty courses, fully-funded 
graduate and doctoral education programs, and post-graduate 
courses are second to none. However, we have five years of data 
from departing officers that consistently indicates that middle 
management, lengths of deployment, and the absence of specialty 
pay are the main reasons they leave. To address this, we are 
working to refine our retention strategy. In one research 
effort, we looked at the effect middle managers have on junior 
staff. The results of this study are being incorporated into 
our Head Nurse Leadership Course to better educate middle 
managers on the development of strong and healthy teams.
    I am particularly concerned about the retention of our 
certified registered nurse anesthetists (CRNAs). Our inventory 
of CRNAs is currently at 73 percent. The restructuring of the 
incentive special pay program for CRNAs last year, as well as 
the 180-day deployment rotation policy were good first steps in 
stemming the loss of these highly trained providers. We are 
working closely with the Surgeon General's staff to closely 
evaluate and adjust rates and policies where needed.
    We face significant shortages of civilian RNs and LPNs, 
particularly in critical care, perioperative, and OB/GYN 
nursing. We increased utilization of contract support and are 
currently working on a civilian nurse recruitment and retention 
program for Walter Reed Army Medical Center and Fort Hood. The 
AMEDD also recently approved the limited application of a 
student loan repayment program for current and new civilian 
nurse recruits.
    One promise of the National Security Personnel System 
(NSPS) is to attract and retain talented and motivated 
employees. I remain optimistic that NSPS will address the 
issues that make civil service a disincentive for new and 
practicing nurses. We have worked with the Navy and Air Force 
to standardize duty titles throughout the system. This will 
ease local marketing and facilitate the development of tiers 
for advanced practice nurses, similar to those for physicians 
and dentists. However, the delay in implementation of NSPS 
because of legal challenges by Unions renews our concerns.
    The Sustaining Base Leadership and Management Program is a 
centrally funded leader development program in support of the 
Army Civilian Training, Education, and Development System 
(ACTEDS) preparing Army civilian and military members for 
leadership positions. We actively encourage our civilian staff 
to take advantage of this training.
    The positive impact Army Nurses make on patient care is 
found throughout the military health system. At Landstuhl 
Regional Medical Center, CPT Travis Hawksley improved the 
overall management of burn patients by developing a tool to 
accurately track fluid resuscitation throughout the evacuation 
system. Others, such as LTC Sharon Steele and LTC Kris 
Palaschak provide clinical expertise in the design and 
construction of new facilities. Our nurse informatacists work 
to deploy and upgrade electronic clinical systems used to 
document the delivery of inpatient care, provide objective data 
related to patient workload, and electronically capture, 
automate, and analyze patient safety data.
    Each year, the Daughters of the American Revolution honor 
one Active Component Army Nurse who epitomizes professional and 
military nursing excellence with the presentation of the Dr. 
Anita Newcomb McGee Award. Last year's recipient was COL Norma 
Garrett. COL Garret also received the Clinical Nursing 
Excellence Award from the Association of Military Surgeons of 
the United States for recognition of her many research 
accomplishments and contributions to clinical education.
    More than ever, the Army Nurse Corps is focused on 
providing service members and their families the absolute 
highest quality care they need and deserve. We continue 
adapting to the new realities of this long war, but remain firm 
on providing the leadership and scholarship required to advance 
the practice of professional nursing. We will maintain our 
focus on sustaining readiness, clinical competency, and sound 
educational preparation with the same commitment to serve those 
Service members who defend our Nation that we have demonstrated 
for the past 105 years. I appreciate this opportunity to 
highlight our accomplishments and discuss the issues we face. 
Thank you for your support of the Army Nurse Corps.
                                ------                                


          Biographical Sketch of Major General Gale S. Pollock

    MG Gale S. Pollock was born in Kearny, New Jersey, but 
calls Texas home. She holds a Bachelor of Science degree in 
nursing from the University of Maryland and is a 1979 graduate 
of the U.S. Army Nurse Anesthesia Program. She earned a Master 
of Business Administration from Boston University; a Master in 
Healthcare Administration from Baylor University; and a Master 
in National Security and Strategy from the National Defense 
University. Her military education includes completion of the 
General Officer Joint CAPSTONE program; Senior Service College 
at the Industrial College of the Armed Forces; the U.S. Air 
Force War College; the Interagency Institute for Federal Health 
Care Executives; the Military Health System CAPSTONE program; 
the Principles of Advanced Nurse Administrators; and the NATO 
Staff Officer Course.
    In addition to her responsibilities as the 22nd Chief of 
the Army Nurse Corps, MG Pollock is currently the Commander of 
Tripler Army Medical Center and the Pacific Region, U.S. Army 
Pacific Surgeon and the Multi Market manager under the regional 
TRICARE program. Her past military assignments include Special 
Assistant to the Surgeon General for Information Management and 
Health Policy; Commander, Martin Army Community Hospital, Fort 
Benning, GA; Commander, U.S. Army Medical Department Activity, 
Fort Drum, NY; Staff Officer, Strategic Initiatives Command 
Group for the Army Surgeon General; Department of Defense (DOD) 
Healthcare Advisor to the Congressional Commission on Service 
Members and Veterans Transition Assistance; Health Fitness 
Advisor at the National Defense University; Senior Policy 
Analyst in DOD Health Affairs; and Chief, Anesthesia Nursing 
Service at Walter Reed Army Medical Center, Washington, DC.
    MG Pollock's awards and decorations include the Legion of 
Merit (with two Oak Leaf Clusters), the Defense Meritorious 
Service Medal, the Meritorious Service Medal (with three Oak 
Leaf Clusters), the Joint Service Commendation Medal, the Army 
Commendation Medal, and the Army Achievement Medal. She proudly 
earned the Expert Field Medic Badge and the Parachutist Badge. 
She received the Army Staff Identification Badge for her work 
at the Pentagon. In addition, she earned the German Armed 
Forces Military Efficiency Badge, ``Leistungsabzeichen'', in 
gold.

    Senator Stevens. Admiral, we'd be pleased to have your 
statement.

STATEMENT OF REAR ADMIRAL CHRISTINE M. BRUZEK-KOHLER, 
            DIRECTOR, NAVY NURSE CORPS, DEPARTMENT OF 
            THE NAVY
    Admiral Bruzek-Kohler. Thank you.
    Good morning, Chairman Stevens, Senator Inouye, and 
distinguished members of the subcommittee.
    I am Rear Admiral Christine Bruzek-Kohler, the 21st 
Director of the Navy Nurse Corps and the Navy Medical Inspector 
General. It is an honor and a privilege to speak before you 
about our outstanding 4,500 Active and Reserve Navy nurses and 
their contributions in operational, humanitarian, and 
traditional missions at the home front and abroad.
    My written statement has already been submitted for the 
record, and I would like to highlight a few key issues.
    In this time of increased deployments, our Navy nurses are 
utilizing their specialized training in critical wartime 
specialties everywhere in the continuum of care, from the 
battlefield, with our forward-deployed troops, to our military 
treatment facilities, for restorative and rehabilitative care.
    In the last year, they have served with distinction in a 
variety of locations--Kuwait, Iraq, Djibouti, Afghanistan, 
Bahrain, Qatar, Thailand, Indonesia, Sri Lanka, New Guinea, 
Pakistan, Guantanamo Bay, Cuba, and along our own gulf coast to 
provide assistance to Hurricanes Katrina and Rita victims. As 
part of the Marine Corps team, our perioperative critical care 
and anesthesia nurses in the forward resuscitative surgical 
system, shock trauma platoons, and en route care system are 
influencing the survivability of our battlefield casualties. 
With the prevalence of combat and operational stress, mental 
health nurses are part of the collaborative treatment team 
providing immediate interventions at the front and post-
deployment.
    At Naval Medical Center San Diego, one of our nurse leaders 
is spearheading a multidisciplinary team to establish the 
Comprehensive Combat Casualty Care Center. This is a patient- 
and family-centered cooperative program with the San Diego VA 
Medical Center to provide the full spectrum of care to our 
returning casualties and their families.
    During 2005, our hospital ships, U.S.N.S. Mercy and 
U.S.N.S. Comfort, were providing care for natural disaster 
victims overseas and along the gulf coast. Both of our hospital 
ships recently deployed, last week. While the U.S.N.S. Comfort 
is involved in a joint exercise with the Canadian Government, 
our nurses are optimizing this training opportunity to enhance 
their clinical skills in response to regional and domestic 
emergencies. Simultaneously, the U.S.N.S. Mercy is partnering 
with volunteer nurses from nongovernmental organizations and 
host nations in a transcultural nursing effort to share 
clinical skills while providing quality care during 
humanitarian missions in Southeast Asia.
    This increased operating tempo (OPTEMPO) underscores the 
necessity for clinical skills sustainment through operational 
and joint training programs such as the Defense Medical 
Readiness Training Institute for burn and trauma care and the 
Army enroute care course at Fort Rucker, Alabama, for medical 
evacuation. Through written agreements, we have also 
collaborated with civilian medical communities for training in 
intensive care, emergency, and other specialty areas.
    In the face of a national nursing shortage and the 
challenges we have had in recruiting over the past 2 years, we 
have implemented several initiatives to attain our recruiting 
goal this year. We have seen more applications as a result of 
the tiered-rate increase of our nurse corps accession bonus at 
$15,000 for a 3-year and $20,000 for a 4-year obligation. For 
the first time, we offered the health professions loan 
repayment program, up to $30,000 for school loans, with all 
positions filled. We have also increased the accession bonus 
from $5,000 to $10,000, and stipend from $500 to $1,000, for 
the nurse corps candidate program, as well as increasing our 
recruitment goals for this program by 20 nursing students, for 
a total of 75.
    Retention of Active duty nurse corps officers has posed a 
greater challenge. Our present manning end strength is at 92 
percent in the Active component. As a retention tool, the 
health professions loan repayment program was also offered for 
all eligible Navy nurses. The certified register nurse 
anesthesia incentive special pay was increased along tiered 
levels from $20,000 to $40,000, with a 1-to-4-year obligation. 
In addition, we are exploring other incentives to retain our 
junior nurse corps officers after 4 years of service.
    In the Reserve component, our critical wartime specialties 
in mental health nursing, perioperative nursing, and nurse 
anesthesia pose recruitment challenges. For that reason, fiscal 
year 2006 nurse accession bonuses are targeted toward these 
specialties. With our increased rate of mobilization to Kuwait 
and to our military treatment facilities, it is imperative that 
we meet our nursing specialty requirements and explore all 
options to support our recruitment and retention efforts.
    Civil Service nurses are the backbone of professional 
nursing practice in our military treatment facilities. To 
remain competitive during this national nursing shortage, we 
implemented the special salary pay rates granted under title 38 
at five military treatment facilities. We also implemented the 
accelerated promotion program at Naval Medical Center San Diego 
to recruit recent nursing school graduates. Our robust 
graduation--our graduate education program is one of our top 
retention initiatives. On an annual basis, we select our most 
talented nurse leaders to attend accredited universities around 
the country. They attain their master's and doctorate degrees 
in our required specialties to meet our mission.
    Our focus on military nursing research is key to successful 
patient outcomes and quality care, and we do appreciate the 
support of the tri-service nursing research program in this 
effort. As a result, we have been able to incorporate 
evidenced-based clinical-practice guidelines and multisite 
protocols. Some examples are programs in pain and wound 
management, falls precaution, and prevention of nosocomial 
infections. Our innovative practices and research findings 
involving care from the battlefield to our military treatment 
facilities are cited in numerous professional publications and 
textbooks. Navy nurses have also shared their expertise, their 
presentations at national and international healthcare forums.

                           PREPARED STATEMENT

    In summary, from World War I to the present global war on 
terrorism, Active and Reserve Navy nurses have answered the 
call of a grateful Nation and created a legacy for all of us. 
In the tradition of nursing excellence, our nurses are 
providing the finest care worldwide, making a positive and 
meaningful difference in the lives of our sailors, marines, 
their dependents, and our retired heroes. I appreciate the 
opportunity of sharing the accomplishments and issues that face 
Navy nursing. I look forward very much to working with you 
during my tenure as director of the Navy Nurse Corps.
    Thank you.
    Senator Stevens. Thank you very much.
    [The statement follows:]

     Prepared Statement of Rear Admiral Christine M. Bruzek-Kohler

    Good morning, Chairman Stevens, Senator Inouye and distinguished 
members of the Committee. I am Rear Admiral Christine Bruzek-Kohler, 
the 21st Director of the Navy Nurse Corps and the Naval Medical 
Inspector General. It is an honor and privilege to speak before you 
about our outstanding 4,500 Active and Reserve Navy Nurses and their 
contributions in operational, humanitarian and traditional missions at 
the home front and abroad. We have had many challenges facing us over 
the past year including the continuing War in Iraq, the Global War on 
Terrorism and the recent devastation of Hurricanes Katrina and Rita. 
Based on the magnificent performance of our Navy Nurses answering the 
call to duty at a moment's notice and the support of our outstanding 
Civil Service and contract nurses, I am confident that we successfully 
meet all challenges with commitment and dedication while providing hope 
and comfort to all those in need.
    The future success of the Navy Nurse Corps depends on our ability 
to clearly articulate our military relevance and alignment with the 
goals of the Navy and Navy Medicine. To accomplish this, our nurse 
leaders recently met to review our strategic goals and objectives in 
2005 and determine where we need to be in 2006 and beyond. The outcome 
of this meeting resulted in the establishment of five priorities for 
Navy Nursing, specifically aligned with the vision and goals of the 
Chief of Naval Operations and our Surgeon General. To chart our course 
and navigate our achievements into the future, these five priorities 
include: emphasis on clinical proficiency to sustain our readiness; 
validation of Nurse Corps requirements and force shaping; review of the 
processes to match educational opportunities to requirements; improved 
management and leadership development for mid-level Nurse Corps 
officers; and a formalized leadership continuum for senior Nurse Corps 
officers entering executive level positions. Addressing each category, 
I will highlight our achievements and issues of concern.

                   READINESS AND CLINICAL PROFICIENCY

    Throughout the career continuum, all Navy Nurses must be 
responsive, capable and continually ready to maintain mission 
essentiality. We must be clinically proficient to quickly deploy, 
arrive on the scene whether it is New Orleans or Baghdad, and deliver 
the finest nursing care. Solid clinical competencies ranging from the 
fundamentals to specific wartime specialties serve as the foundation to 
enhance the depth and quality of nursing care in all environments. To 
meet these challenges, we remain on the cutting edge of clinical 
nursing to provide the finest care to our Sailors and Marines, while 
welcoming opportunities to participate in a joint service environment.
    During the past year, Navy Nurses from both active and reserve 
components were deployed throughout the world as members of joint, 
multi-national, Marine Corps and Navy missions, recording over 60,000 
days in support of and training for our missions. Operational units 
were located in Kuwait, Iraq, Djibouti, Afghanistan, Bahrain, Qatar, 
Thailand, Indonesia, Sri Lanka, New Guinea, Pakistan, Guantanamo Bay, 
Cuba and along our own Gulf Coast to provide assistance to Hurricanes 
Katrina and Rita victims. Nursing care services for both operational 
and humanitarian missions were delivered by Surgical Teams, U.S. Marine 
Corps Surgical Companies, Shock Trauma Platoons, and the Forward 
Resuscitative Surgical Systems, including the Enroute Care System Teams 
for casualty evacuation. In addition, care was provided in 
Expeditionary Medical Facilities; on Navy and Hospital ships including 
aircraft carriers; and at our military treatment facilities.
    Ultimately supporting warfighting capability, Navy Nurses are at 
the front, developing and implementing numerous health care programs to 
assist active duty personnel and their families. With the prevalence of 
combat and operational stress, mental health nurses are providing 
immediate interventions at the front, assisting our troops to cope; 
through humanitarian missions, providing aid to natural disaster 
victims; and to our military treatment facilities, enhancing access to 
care for our military personnel and their families. Through the Medical 
Rehabilitation Platoon Program at Camp Geiger, North Carolina, nurses 
have closely coordinated the medical care of our Marines, decreasing 
their length of stay in the program and increasing their timely return 
to full duty for training. As active participants in Operation Special 
Delivery at Twenty-Nine Palms, California, nurses received Honorable 
Mention through the Admiral Thompson Awards Program for Community 
Relations. As trained doulas, they provide physical, emotional and 
information support to women with deployed spouses before, during and 
after childbirth. Partnering with volunteer Project Hope nurses, our 
Navy Nurses of all specialties assisted devastated Americans along the 
Gulf Coast and onboard the Hospital Ship Comfort, providing the best 
quality of care with pride. The most noteworthy accomplishments 
included providing emergency trauma care, completing over 900 
screenings for trauma indicators and crisis management; implementing 
preventive mental health interventions for local relief workers; and 
establishing a Mother Baby Unit.
    Our nurses continuously seek specialized training to enhance their 
critical wartime nursing specialties to safely administer immediate and 
emergent care in any situation. To provide comprehensive care for our 
trauma casualties, Navy Nurses have maximized available training 
opportunities through the Navy Trauma Training Course at the Los 
Angeles County/University of Southern California Medical Center with 
their operational platform team members; the Tri-service Combat 
Casualty Course in San Antonio, Texas for all nurses; and the Military 
Contingency Medicine/Bushmaster Course for our students at the 
Uniformed Services University Graduate School of Nursing in Bethesda, 
Maryland.
    Joint training opportunities in critical wartime nursing 
specialties in both military and civilian medical communities are 
essential to enhance our mission-ready capabilities. Navy Nurses in 
Guam, Marianas Island have rendered assistance to Air Force nurses in 
maintaining their critical readiness skills. In return, our nurses have 
attended the Air Force Critical Care Air Transport Team Training in San 
Antonio, Texas to optimize medical evacuation efforts. Coordinating 
with Landstuhl Regional Medical Center in Germany, our nurses from 
Naples, Italy have been able to enhance their clinical skills in 
emergency room, critical care, advanced medical-surgical and 
complicated obstetrics. Our nurses in Yokosuka, Japan have invited the 
Japanese Self Defense Force nurses to their Trauma Nurse Core Courses, 
fostering goodwill relationships. Supporting the concept of 
interoperability, Navy Nurses in the reserve component have worked 
seamlessly with the Defense Medical Readiness Training Institute, 
sponsoring and teaching three professional programs pertaining to 
trauma. A total of 50 courses in Advanced Burn Life Support, Combat 
Trauma Nurse Curriculum and Pre-Hospital Trauma Life Support were 
conducted on-site at San Antonio, Texas and exported to several 
regional training sites to maximize participation, such as in Camp 
Pendleton, California; Great Lakes, Illinois; Dallas, Texas; and Fort 
Gordon, Georgia.
    Within and across our military treatment facilities, we optimize 
all cross-training opportunities to maintain clinical proficiency for 
our operational assignments. We continue with robust Nurse Internship 
Programs at our three Medical Centers at Bethesda, Maryland; 
Portsmouth, Virginia; and San Diego, California. With the return of 
Sailors and Marines from Iraq with complicated trauma wounds, we have 
focused more intensive training to become certified wound care 
specialists. Aligned with professional standards of practice, we have 
adopted the Essentials of Critical Care Orientation by the American 
Association of Critical Care Nurses as our primary didactic critical 
care training curriculum, augmented with on-site clinical rotations at 
our larger military treatment facilities. The successful Post 
Anesthesia Care Course at Bethesda, Maryland has included a total of 30 
Army and Air Force nurses and medics in addition to Navy personnel in 
the past year, and has been exported to other Navy military treatment 
facilities due to its strong clinical content and application.
    Collaborating with our civilian medical communities, our nurses in 
Jacksonville, Florida maintain an agreement with Shands Medical Center 
to train in their intensive care unit, emergency room and neonatal 
ward. In addition, at the Medical University of South Carolina, our 
nurses in Charleston participate in a two-week trauma orientation to 
sustain their clinical readiness. In our outreach support of community 
education, we have provided clinical experiences and preceptors to 
nursing programs throughout the United States. We have also 
participated in collaborative training groups, such as the Greater 
Washington Area Consortium for Critical Care Nursing Education. These 
examples are only a few of the many courses and training sessions 
taking place on a regular basis to maintain clinical proficiency and 
optimize operational readiness.

                     REQUIREMENTS AND FORCE SHAPING

    Maintaining the right force structure is essential in meeting Navy 
Medicine's overall mission through validated nursing specialty 
requirements, utilizing the talent and clinical expertise of our 
uniformed and civilian nurses. Focused on our operational missions, our 
wartime specialties include nurse anesthesia, critical care, emergency, 
mental health, medical-surgical and perioperative nursing.
    The national nursing shortage, compounded by competition with 
civilian institutions as well as other federal sectors, has resulted in 
direct accession recruiting shortfalls over the last two years. For 
that reason, we continue to closely monitor the status of our pipeline 
scholarship programs, which include the Nurse Candidate Program, the 
Medical Enlisted Commission Program, the Naval Reserve Officer Training 
Corps Program, and the Seaman to Admiral Program. Rate increases were 
applied this fiscal year to our Nurse Corps Accession Bonus to attract 
new applicants to the naval service. In addition to increasing the 
accession bonus and stipend for the Nurse Candidate Program, we have 
recently increased our recruitment goals for this program by 20 nursing 
students.
    Retention of active duty Nurse Corps officers has posed a bigger 
challenge, with retention rates after the first four years of 
commissioned service ranging from 54 to 72 percent for all accession 
categories and decreasing further beyond 4 to 7 years of service. At 
the end of calendar year 2005, our manning end strength decreased to 94 
percent in the active component, with a deficit of 175 Navy Nurses. 
Within our wartime specialties, shortfalls have been identified in 
critical care with an end strength of 57 percent, nurse anesthesia at 
84 percent and perioperative nursing at 90 percent. To counter these 
deficiencies, the Health Professions Loan Repayment Program was 
recently implemented for recruitment and retention purposes. In 
addition, the Certified Registered Nurse Anesthesia Incentive Special 
Pay was increased. We will continue to closely monitor our end strength 
through the year, evaluate newly initiated programs and explore other 
options to retain our talent at the 4 to 10 years of service level.
    In the reserve component, our critical wartime specialties also 
pose a recruitment and retention challenge in mental health nursing, 
perioperative nursing and nurse anesthesia. For that reason, fiscal 
year 2006 Nurse Accession Bonuses are focused on these specialties. We 
had a record of success during the past fiscal year with the Nurse 
Accession Bonus when it was offered for the first time to professional 
nurses with less than one year of experience. Since there is a national 
nursing shortage of perioperative nurses, our six-week perioperative 
nursing training programs in Jacksonville, Florida and Camp Pendleton, 
California now include our reserve nurses. As a pipeline program, our 
Hospital Corpsman to Bachelor of Science in Nursing Program has 
resulted in three Nurse Corps Officers entering the reserves since its 
inception two years ago, with twenty-three participants who will 
graduate within the next one to two years. With our increased rate of 
mobilization to Kuwait and to our military treatment facilities, it is 
imperative that we meet our nursing specialty requirements and explore 
all options to support our recruitment and retention efforts.
    Civil Service nurses are the backbone of professional nursing 
practice in our military treatment facilities as the frequency of 
deployment schedules increases for our uniformed personnel. We continue 
to encourage the use of authorized compensation packages to retain our 
talented nurses through recruitment, retention and/or relocation 
bonuses to meet staffing requirements. Last year, we implemented 
Special Salary Pay rates granted under Title 38 at five military 
treatment facilities in San Diego, California; Camp Pendleton, 
California; Twenty-Nine Palms, California; Great Lakes, Illinois; and 
Bethesda, Maryland to compensate for on-call, weekend, holiday, and 
shift differential duty, resulting in satisfaction to staff members and 
leadership. In addition, we have recently implemented the Accelerated 
Promotion Program in San Diego, California to recruit novice nurses 
with less than one year of experience, who have been integrated into 
their Nurse Internship Program to develop solid clinical skills.
    Our success in meeting the mission in all care environments 
requires that we continuously reassess our measures of effectiveness, 
adjust personnel assignments, transfer authorized billets, and revise 
training plans. To maximize our performance, it is imperative that we 
pursue funding to recruit and retain our exceptionally talented nurses 
to meet our staffing requirements. We will also closely monitor the 
national nursing shortage projections and the civilian and federal 
compensation packages to determine the best course for us to take in 
this competitive market.

                    EDUCATION PROGRAMS AND POLICIES

    The Navy Nurse Corps provides state-of-the-art nursing care around 
the world, 365 days a year by continually adapting to the ever-changing 
healthcare environment. We accomplish this by maintaining our 
competitive edge beyond the status quo through a variety of 
initiatives. On an annual basis, we shape our graduate education 
training plan based on our health care and operational support 
requirements. We select our most talented nurse leaders to attend 
accredited universities around the country to attain their masters and 
doctorate degrees, which has also proven to be an invaluable retention 
tool. In addition, a plethora of continuing education courses and 
specialized training opportunities are available to further enhance 
solid clinical skills.
    The success of our graduate education and specialized training is 
exemplified through the remarkable impact of our professional 
achievements in Navy Medicine and across the Department of Defense. Our 
advance practice nurses lead the way in building upon our reputation of 
outstanding patient care by incorporating evidence-based clinical 
practice guidelines and multi-site protocols to improve patient 
outcomes. Through the Evidence-Based Consortium developed by nurses 
from Bethesda, Maryland, and Portsmouth, Virginia with Walter Reed Army 
Medical Center, team training has resulted in a focus on primary 
surgical wound dressings, alcohol withdrawal assessment and peripheral 
intravenous therapy. In collaboration with the Washington State 
Hospital Association as part of Institute for Health Care Improvement 
initiatives, our nurses in Bremerton, Washington have participated in 
the implementation of three clinical practice guideline protocols: 
elimination of nosocomial infections, prevention of ventilator 
associated pneumonia and prevention of central line infections. Each 
protocol consists of a group of interventions resulting in better 
outcomes, a reduction in mortality, and cost containment. Nurses at 
Bethesda, Maryland are involved in a TRI-STATE initiative implementing 
similar protocols, in addition to the Critical Care clinical practice 
guideline. Through the Pain Management Clinic at Jacksonville, Florida, 
civilian referrals have been reduced and patient satisfaction 
increased, resulting in significant cost avoidance.
    The focus on military nursing research is essential to successful 
patient outcomes and quality care. Sponsored by the TriService Nursing 
Research Program, the collaborative multi-phase Evidence Based Practice 
Improvement Project between National Naval Medical Center and Walter 
Reed Army Medical Center plans to implement six nursing practice 
guidelines at each site. Our Navy Nurses have developed guidelines for 
pain management, falls prevention and neonatal tactile stimulation and 
thermoregulation. A sample of funded research studies includes: 
Retention of Recalled Navy Nurse Reservists Following Operation Iraqi 
Freedom; Oxidative Stress and Pulmonary Injury in U.S. Navy Divers; 
Coping Interventions for Children of Deployed Parents; and Focused 
Integrative Coping Strategies for Sailors, a Follow-Up Intervention 
Study.
    There have been numerous publications attesting to the expertise of 
our Navy Nurses, such as in Advances of Neonatal Care, Archives of 
Psychiatric Nursing, Association of Operating Room Nurses Magazine, 
Journal of Cardiac Failure and professional textbooks. In addition, 
Navy Nurses have been invited to present innovative practice and 
research findings at Sigma Theta Tau Nursing Honor Society's 
International Nursing Research Congress; the Annual Meeting of the 
Association of Military Surgeons of the United States; the 18th Annual 
Pacific Research Conference, and many more. Of prestigious note, two of 
our Navy Nurses were invited to coordinate and present a symposium 
entitled ``Military Nursing Care: Land, on the Sea and in the Air'' 
with Army and Air Force colleagues at the Biennium Conference for Sigma 
Theta Tau International focusing on burn care, quality of life and 
nursing care delivered in austere environments.
    It is this personal dedication to the highest clinical proficiency 
and continuing education that makes us proud members of the military 
healthcare system today and tomorrow. As the scope and practice of 
nursing continues to grow, we must make sure that we continue to be 
closely aligned with Navy Medicine and the Line community.

           MID-LEVEL LEADERSHIP/SENIOR LEADERSHIP DEVELOPMENT

    The last two priorities consist of improving management and 
leadership development for mid-level Nurse Corps officers and 
formalizing the leadership continuum for senior Nurse Corps officers 
entering executive level positions. Leadership development begins the 
day our nurses take the commissioning oath as Naval Officers and is 
continuously refined throughout an individual's career with increased 
scope of responsibilities, upward mobility, and pivotal leadership 
roles within the field of nursing and health care in general. Our Navy 
Nurses are proven strategic leaders in the field of education, 
research, clinical performance, and health care executive management. 
To insure we continue this legacy of nursing excellence, it is critical 
that we identify those leadership characteristics and associated 
knowledge, skills and abilities that are directly linked to successful 
executives in Navy Medicine. This information will provide the basis 
for ongoing leadership development of our mid-grade officers as they 
advance in their leadership and management positions and experiences.
    To meet today's challenges, nurse leaders must be visionary, 
innovative and actively engaged across joint service and interagency 
levels to maximize our medical capabilities and achieve new heights of 
excellence. As one of many examples, a Navy Nurse recently assumed 
command of the Expeditionary Military Facility at Kuwait, which is 
comprised of personnel from 22 Navy Medical Commands. Navy Medicine 
Emergency Management Program nurses are developing a comprehensive 
strategy to guide our efforts to prevent or deter health consequences 
of natural or international attacks. Navy Nurses are involved in the 
multi-faceted development of a Federal Health Care Facility as part of 
the Veterans Affairs/Department of Defense partnering project. Within 
the Reserve Component, our dedicated Navy Nurses are in key leadership 
positions in their units, as well as in their civilian organizations, 
professional associations and local communities. Of particular note, 
our nurse leaders in the Navy Reserve Operational Health Support Unit 
at Jacksonville, Florida attended training at the Air National Guard's 
Mentoring Conference, prior to developing and coordinating the Navy's 
Mentoring Initiative. Effective partnerships have resulted in positive 
mentoring experiences between junior and senior officers, promotions, 
advancement to leadership positions, and professional development.

                            CLOSING REMARKS

    From World War I to the present War on Terrorism, active and 
reserve Navy Nurses have answered the call of a grateful nation and 
created a legacy for all of us. As we near the 100th anniversary of the 
Navy Nurse Corps, we are most proud of being integral members of the 
One Navy Medicine Team through an outstanding record of partnering with 
civilian and military health care teams, ensuring a better tomorrow for 
all. Our nurses provide the finest care worldwide and make a positive 
and meaningful difference in the lives of our Sailors, Marines, their 
dependents and our retired heroes. The basis of our future requires 
that we align with the mission of our armed forces while adapting to 
the advances in professional nursing practice. The uniqueness of 
military nursing is our dynamic ability to seamlessly integrate the 
critical nursing specialties into the personal needs of the troops on 
the field and at sea. Indeed, we will continue the exemplary tradition 
of Navy Nursing Excellence by focusing on interoperability and working 
side by side with colleagues from each service with personal pride.
    I appreciate the opportunity of sharing the accomplishments and 
issues that face Navy Nursing. I look forward to working with you 
during my tenure as Director of the Navy Nurse Corps.

    Senator Stevens. General Rank.

STATEMENT OF MAJOR GENERAL MELISSA A. RANK, ASSISTANT 
            SURGEON GENERAL FOR NURSING SERVICES, 
            DEPARTMENT OF THE AIR FORCE
    General Rank. Mr. Chairman and distinguished Members of the 
subcommittee, it is truly my honor to represent the Active 
duty, Guard, Reserve, and civilian nurses and medical 
technicians of the United States Air Force total nursing force. 
This diverse group of professionals partner with the Air Force 
Medical Service to ensure a fit and healthy force, prevent 
casualties, restore health, and enhance human performance.
    I have personally contacted every Active duty chief nurse 
and senior medical technician and asked them, ``What keeps you 
up at night?'' Their predominant concerns validated my vision 
to strengthen operational currency and clinical expertise. 
Today, I will share with you our successes and challenges in 
expeditionary nursing, clinical skills sustainment, recruiting 
and retention, research, and future initiatives.
    Over the past year, our responsiveness was put to the test 
and was highly successful in the U.S. Central Command's Area of 
Responsibility and at home station. We are trained, current, 
and mobile. Our primary contributions to expeditionary 
operations are lifesaving medical/surgery and critical-care 
skills, and aeromedical evacuation. Even greater strides have 
been made ramping up from home station to war front. We credit 
this to our current inpatient experiences and continuous 
improvements in predeployment training. We deploy 2,369 total 
force nursing service personnel to five aeromedical evacuation 
locations, 10 expeditionary medical support units, and two 
contingency aeromedical staging facilities (CASF). Total 
patients evacuated from theater in support of Operation 
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were 
33,615 from October 10, 2001 to April 14, 2006. Of that total, 
over 6,200 were due to battle injuries. Key in the clinical 
transformation of our aeromedical evacuation system was the 
shift from transporting stable patients to rapidly moving 
patients requiring continuous in-flight stabilization, putting 
critical care nurses in very high demand. Our highly 
specialized critical care air-transport teams moved 711 
critically ill patients last year.
    The expeditionary medical group at Balad is currently home 
to 69 nurses and 97 medical technicians from our total force, 
the Army, and multinational forces. Nine different surgical 
specialties are on hand to provide state-of-the-art treatment, 
including care of massive trauma.
    The CASF at Ramstein Air Base safely moved over 15,000 
patients to Landstuhl Regional Medical Center. Time and again, 
the heroic efforts of the integrated healthcare team at 
Landstuhl came together to save the lives of wounded Americans, 
coalition forces, DOD contractors, and members of the press 
corps.
    The best way for nurses to maintain currency and be 
effective in deployed settings is to have recent hands-on 
experience as inpatient nurses. Recently, I released a policy 
mandating that nurses working in outpatient and nonclinical 
roles will complete a minimum of 168 hours on inpatient units 
annually. Bringing seasoned clinicians back to the bedside will 
provide a robust, technically ready force and mentorship to the 
less experienced.
    Due to unique deployment missions, we are increasingly 
using the Center for Sustainment of Trauma and Readiness Skills 
Training Platform (C-STARS). C-STARS produces medics ready to 
respond to peacetime or wartime contingencies through intense 
clinical immersion. The USUHS Graduate School of Nursing 
incorporated ``go to war'' skillsets into the curriculum for 
advanced practice nurses.
    At home, Hurricanes Katrina and Rita uniquely challenged 
our total force. Aeromedical evacuation crews and Expeditionary 
Medical Support (EMEDS) teams from Active duty, Guard, and 
Reserve safely moved over 2,600 patients after Katrina, and 
over 1,200 patients before Rita made landfall. Keesler Medical 
Center was greatly impacted by Katrina. Their staff saved 
130,000 medical records, erected an EMEDs, accounted for 
personnel, built new staffing requirements, and reopened 
limited primary care services in less than 1 month after the 
hurricane.
    Nursing is globally engaged, at stateside and overseas 
locations. Independent-duty medical technicians, Technical 
Sergeant Steven Yates and Technical Sergeant John Strothenke, 
from Alaska, deployed in support of the Joint Prisoners of War/
Missing in Action (POW/MIA) Account Command Mission, which 
recovered the remains of 19 service members in last calendar 
year.
    Through the international health specialist program, we 
gained access to countries that are otherwise inaccessible. 
Major Stephanie Buffet, currently working for the U.S. Central 
Command (CENTCOM) surgeon, played a pivotal role in the Air 
Force's response to medical issues in the ongoing Pakistan 
earthquake relief efforts.
    Continuous global engagement is making recruiting and 
retaining nurses one of our top priorities, especially with the 
national nursing shortage. Our accession sources include direct 
accession, Reserve Officers' Training Corps (ROTC) scholarship, 
health profession scholarship program, and enlisted to Bachelor 
of Science in Nursing (BSN) programs. In fiscal year 2005, we 
assessed 69 percent of our total recruiting goal of 357. Direct 
accessions, accounting for 82 percent took advantage of the 
recruiting bonus or the loan repayment program, and will 
increase for fiscal year 2006. And we thank you.
    We are investigating a robust nurse enlisted commissioning 
program, mirroring the Navy's success, to produce 50 officers 
from our enlisted force, allowing them to attend accredited 
bachelor's or entry-level master's programs. In fiscal year 
2005, our nurse corps inventory was at 90 percent of authorized 
positions. Currently, our inventory is a concerning 87 percent.
    We continue to monitor our attrition rates, particularly 
those at the first decision point at the completion of initial 
obligated service--4 years of commissioned service. To ensure 
we retain those experienced nurses, we plan to offer a critical 
skills retention bonus near the end of their initial 
commitment. We are also partnering with our sister services and 
Veterans Administration (VA) counterparts to expand training 
platforms.
    In addition to financial and training incentives, the 
quality of our medical treatment facilities is clearly of 
importance to recruiting and retaining top professionals. 
Sustaining state-of-the-art infrastructure is a top priority 
for maximizing clinical and operational effectiveness and 
promoting a safe environment for both staff and patients.
    Air Force nurses continue to remain at the forefront of 
operational research. Crucial areas being examined include 
deployment health, sustaining competencies, military practice 
outcomes, recruitment, and retention. None of this would be 
possible without the enormous support from the tri-service 
nursing research program, that will have far-reaching 
implications for our military forces.
    Several major events continue to shape our future. The Air 
Force transitioned to an expeditionary mission, and now 
deliberately prepares airmen through aggressive force 
development policies and programs. Through a comprehensive 
review of the medical group structure, we developed a new 
flight path to guide our organizational structure and the 
development of our clinical discipline. The flight path guides 
more deliberate development, placing the member in the right 
job at the right time, setting them up for career success and 
personal satisfaction, while maintaining expertise at the front 
lines of patient care.
    Nursing is already preparing for the many BRAC-related 
challenges by finding alternative inpatient platforms to train 
and sustain personnel, and by determining the right composition 
of Active duty ``blue suit'', requirements. We continue to 
evaluate our deployment-drive requirements and use market 
availability, along with cost data, to recommend appropriate 
civilian conversions. We plan to target company-grade 
outpatient and maternal childcare positions, while maintaining 
Active duty nurses for inpatient platforms. Along these lines, 
the results of the 2001 Air Force Surgeon General directed 
Nurse Corps Topdown Grade Review continues to guide our 
actions, and we strive to balance our company- and field-grade 
authorizations. We remain optimistic that our course of action 
will help improve overall promotion opportunity; therefore, 
increasing retention of experienced nurses. We've successfully 
increased field-grade requirements for deployment positions and 
are taking steps to lay in more senior clinicians at home 
station.
    Mr. Chairman and distinguished members of the subcommittee, 
it is an honor and a privilege to lead the men and women of our 
Active, Reserve, and Guard nursing services. My objective for 
this presentation was to provide you a glimpse of the 
extraordinary men and women that make up nursing services and 
the exceptional work they are doing daily in the service of 
their country. I look to the future optimistically and desire 
your continued support during these exciting times ahead for 
nursing and our Air Force.

                           PREPARED STATEMENT

    Thank you for inviting me and allowing me to tell our 
story.
    [The statement follows:]

          Prepared Statement of Major General Melissa A. Rank

    Mr. Chairman and distinguished members of the committee, it is 
truly an honor for me to be here for the first time representing Air 
Force Nursing Services. We employ a diverse group of professionals to 
ensure a fit and healthy force, prevent casualties, restore health, and 
enhance human performance.
    The vision for my tenure is to strengthen operational nursing 
currency and clinical expertise. The Air Force Nurse Corps will focus 
on our continued development as a clinical discipline to sustain nurses 
and aerospace medical technicians in an ever-changing, joint 
interoperable environment.

                         EXPEDITIONARY NURSING

    Our expeditionary medical capability has been proven and Air Force 
Nursing Services remains in the forefront supporting the war fighter. 
Globally since the year 2000, we supported 202 worldwide missions and 
exercises, treated 1.47 million patients, assisted with 2,700 
surgeries, and helped train 4,200 foreign medics. Just this past year, 
we deployed 2,369 nursing service personnel in support of Operations 
ENDURING FREEDOM and IRAQI FREEDOM (OEF/OIF). These Total Nursing Force 
members from the Active Duty (AD), Air National Guard (ANG), and Air 
Force Reserve Command (AFRC) deployed in support of 5 Aeromedical 
Evacuation (AE) locations, 10 Expeditionary Medical Support Units 
(EMEDS), and 2 Contingency Aeromedical Staging Facilities (CASF). We 
are trained, current and mobile.
    Survival rates have improved from 75 percent during Vietnam, DESERT 
SHIELD and DESERT STORM to 90 percent in OEF/OIF in large part due to 
forward deployed surgical teams and rapid AE. Total patients evacuated 
from theater in support of OIF and OEF were 33,615 (October 10, 2001 to 
April 14, 2006). Of that total, 6,243 were due to battle injuries. Key 
in the clinical transformation of our AE system is the shift from 
transporting stable patients to rapidly moving patients requiring 
continuous in-flight stabilization, putting critical care nurses in 
high demand. Our highly specialized Critical Care Air Transport Teams 
(CCATT) moved 711 critically ill patients last year.
    The 332nd Expeditionary Medical Group in Balad is currently home to 
69 nurses and 97 aerospace medical technicians from the Air Force Total 
Nursing Force, the Army, and multinational auxiliaries. Nine different 
surgical specialties are on hand to rapidly provide state-of-the-art 
treatment including care of massive trauma. These teams have responded 
to numerous mass casualty surges and have many incredible stories to 
tell.
    One story comes from Senior Airman Timothy Woodall, a reservist 
from the 349th Medical Squadron at Travis AFB California, serving at 
Balad. One of his most memorable patients is a three-year-old boy who 
was part of a tragedy that took his mother's life and left him with 30 
percent burns to the right side of his body. SrA Woodall, as one of his 
primary caregivers, delivered some of his medications, assisted with 
his routine tube feedings, and had the arduous task of changing his 
bandages. For SrA Woodall, being at Balad has been an enlightening 
experience, using more of his clinical skills in two months than he has 
in the past two years. We are delighted to report that the boy has 
healed very well and gone home.
    Gathering wounded service members and transporting them to higher 
echelons of care are scheduled missions like the ones flown by a Royal 
Australian Air Force C-130 aircrew with a U.S. Air Force medical team. 
``The patients we carry on these missions were injured in some way, 
down range,'' reports Captain Kristie Harlow, 379th Expeditionary 
Aeromedical Evacuation Squadron flight nurse. ``Our job is to get them 
where they need to go for treatment, while providing them the care they 
need.'' Litters are stacked, bunk-bed style, in the cargo aircraft. The 
crew and medics wear body armor and Kevlar helmets for most of the 15-
hour mission days, even while tending to patients. All on board agree 
that the Australian hosts, part of the Australian Defense Force's Joint 
Task Force 633, provide first class accommodations for the patients and 
the Airmen who care for them.
    Some of our personnel have also risked their own lives to save 
others. Capt. Kevin Polk received the Bronze Star for saving an injured 
Airman while deployed as a CCATT nurse with the 379th Expeditionary 
Aeromedical Evacuation Squadron. He had only been in Iraq a couple of 
days, when the base came under direct mortar attack. Despite being 
exposed to enemy fire, Captain Polk searched the living quarters for 
potential victims, where he found an Airman with life-threatening 
injuries. He stabilized the Airman's condition and assisted with the 
medical transport of the Airman to a hospital for emergency surgery. 
The Airman sustained permanent disabilities, but Captain Polk's heroic 
response was credited with saving his life.
    A typical day at the CASF in Balad consists of recovering two to 
three aerovac missions from the AOR with patients ranging from routine 
to critical. In addition, approximately 125 patients are prepared 
weekly for aerovac missions that transport patients from the CASF to 
Ramstein Air Base Germany, and then back to the United States. Patient 
support pallets and additional C-17 litter stanchions have increased 
the number of planes available for AE. The CASF at the 435th Medical 
Group, Ramstein Air Base, Germany, continued its high operational 
tempo, safely moving 15,093 patients between January 1, 2005 and 
December 31, 2005 to Landstuhl Regional Medical Center (LRMC) for 
admission and treatment until they are scheduled to travel stateside. 
Time and again the heroic efforts of the integrated healthcare team at 
LRMC come together to save the lives of the wounded Soldiers, Marines, 
Sailors, Airmen, coalition forces, DOD contractors, and members of the 
Press Corps. In fact, one Marine said, ``I knew that if I got to 
Landstuhl, I would make it.'' Countless others share this sentiment.
    A talented, multiservice nursing leadership team keeps this smooth 
running engine moving forward, always poised for the next potential 
wartime patient surge. Senior Air Force nurses are in leadership roles 
at LRMC. Col Sherry Cox is the imbedded Air Force Chief Nurse, 
providing guidance and direction to a team of outstanding nurses in 
various roles in both inpatient and outpatient roles. Her team found 
that there is a compelling impact on those who care for wounded 
Americans, allies, and even the enemy. As a consequence of prolonged 
exposure to caring for those traumatically injured, healthcare workers 
are at risk for burnout including feelings of detachment, loss of 
compassion, significant physiological stress symptoms and reduced 
morale. LRMC has established a formal program to support the staff and 
encourage the use of healthy stress coping methods. The major aim of 
the program is to increase awareness at all levels to the potential 
risk posed by repeated exposure to combat trauma with early 
identification and intervention.
    The Theater Patient Movement Requirements Center (TPMRC) is the 
pivotal ``behind the scenes'' agency facilitating the AE of combat 
injured troops. As part of the TPMRC team, the Senior Flight Nurse 
Clinical Coordinator, expedited the transfer of six critically burned 
service members after an Improvised Explosive Devise (IED) struck their 
Bradley Fighting Vehicle. Working around-the-clock with the Joint 
Patient Movement Requirements Center (JPMRC) and multiple European 
agencies, the TPMRC expeditiously synchronized the transport of these 
severely wounded troops by a specialized burn team from Brooke Army 
Medical Center (BAMC), Texas. In less than 48 hours from the time our 
heroes landed at Ramstein AB Germany, they were receiving definitive 
treatment at the Military's ``Center of Excellence'' for burns, BAMC in 
San Antonio, Texas.

                      HURRICANES KATRINA AND RITA

    The hurricane evacuations of 2005 uniquely challenged our 
aeromedical evacuation crewmembers (AECMs). AE units and EMEDS from Air 
Force Total Nursing Force supported the evacuations from Hurricanes 
Katrina and Rita while MAJCOM-level staff worked around the clock to 
coordinate and execute the missions. The ANG represented 25 percent of 
all military medical personnel deployed to the disaster areas with 901 
medics for both hurricanes. Despite complex challenges, the teams 
ensured the safe evacuation of 2,609 Hurricane Katrina patients. On 
September 3, 2005, the teams moved 580 litters and 300 ambulatory 
patients, the largest single day of transports since WWII. Over 1,200 
patients were moved in 24 hours before Hurricane Rita made landfall. A 
tremendous amount of orchestration was required between our AE mission 
coordinators and civilian counterparts to ensure the needs of a massive 
number of displaced people were met. AECMs worked extraordinarily long 
hours and loaded patients until they could practically no longer 
physically carry a litter.
    There are many heroes from Hurricane Katrina and the staff of the 
81st Medical Group, Keesler AFB is among them. Lt Col Maureen Koch, 
Flight Commander of the ICU, and her family were among the thousand or 
so military, family members, and patients who sheltered in the 81 MDG 
during Hurricane Katrina. Lt Col Koch's focus was on caring for two 
ICU's ventilator patients and a pregnant woman requiring an emergency 
caesarean section. Personnel quickly converted one ICU room into a 
makeshift operating room and the baby was delivered safely. In 
addition, the medics accomplished many other unprecedented actions. 
They saved 130,000 medical records, erected a portable bedded facility, 
accounted for thousands of personnel after the disaster, built new 
staffing requirements, and re-opened limited primary care services in 
less than one month after the hurricane.
    ANG personnel assisted with the setup of an EMEDS at Charity 
Hospital in New Orleans and training of the civilian staff. 
Additionally, medical professionals from the Mississippi, Alabama, 
Kansas and Delaware Air National Guards erected an EMEDS in Hancock 
County, MS. Forty-nine percent of the patients treated were from 
military organizations (AD, Reserve, Guard) and 56 percent were Non-DOD 
personnel. The ANG provided 68 percent of all immunizations given in 
the surrounding area.
    Hurricane Rita operations, staged out of Beaumont, Texas were 
confronted with preparing and transporting a large number of elderly 
patients with a Category five storm scheduled to make land-fall in less 
than 24 hours. Chief Master Sergeant Rodney Christa, a reservist, from 
the 433 AES, Lackland AFB TX, was appointed to the on-scene Command 
Element for both hurricane evacuations. Chief Christa stated, 
``Although the number of patients we had to transport was greater for 
Hurricane Katrina, Hurricane Rita was more stressful because the storm 
was bearing down upon us. Time was critical. Hospitals, nursing homes 
and private citizens were literally driving up by the busload to our 
doorstep. We had no idea what to expect; we received patients on 
ventilators, those needing dialysis and newborns. All needed medical 
care. At one point, I thought we were going to have to leave medics 
behind to remain with patients and ride out the hurricane. The patients 
were arriving faster than we could airlift them to safety. With 
teamwork, we were able to get everyone on the last aircraft available 
before the winds were too strong to allow us to take-off.''
    On September 22, 2005, an ANG crew from the 167th AES led by flight 
nurse, Major Jay Sandy, from Andrews AFB, MD, launched a C-5 Galaxy to 
Beaumont, Texas, to evacuate 117 incapacitated nursing home and 
hospitalized patients. During the flight to Dobbins AFB, they 
experienced several medical emergencies that were rapidly stabilized 
in-flight due to the highly experienced medical team. The Georgia Civil 
Defense Team of 100 volunteer physicians, nurses, and other personnel 
assisted with the offload and management of the evacuees. This mission 
was successful due to the superior leadership, professionalism, 
teamwork, and medical expertise of all involved.

                           CLINICAL SUCCESSES

    Air Force Nursing Services is globally engaged, at stateside and 
overseas locations, in the enhancement of patient care outcomes through 
outstanding initiatives. In fiscal year 2005, we supported 1.2 million 
TRICARE Prime enrollees and over 66,000 TRICARE Plus enrollees 
throughout the world. Currently, we have 19 Air Force hospitals and 
medical centers and 56 clinics. We would like to share some of our home 
station clinical successes.
    As you well know, the Family Advocacy Program's purpose is to 
prevent and treat family maltreatment. Mrs. Mary Fran Williamson, a 
civilian Family Advocacy Nurse at Offutt AFB, led the development of 
nursing practice guidelines to use for the care of family maltreatment 
cases and in the prevention of abuse. These guidelines recommend 
appropriate nursing interventions and were incorporated into the Air 
Force Parent Support Program, accessible via the internet-based Family 
Advocacy website.
    Our partners in the Reserves spearheaded the first-ever DOD-wide 
video teleconference on Sexual Assault Answer. Lt Col Susan Hanshaw, a 
Reserve nurse assigned to the Armed Forces Institute of Pathology 
(AFIP), serves as the consultant to the Assistant Secretary of Defense 
for Health Affairs. In this role, she co-authored the DOD policy for 
sexual assault and directed the AFIP-sponsored Sexual Assault Response 
Team (SART) Training Program.
    In one of our overseas locations, at Kaiserslautern Military 
Community (KMC), Germany, they are overhauling their primary care 
services. A unique feature of this endeavor is the establishment of a 
Women's Health Center, spearheaded by a Women's Health Nurse 
Practitioner, Major Elizabeth Decker. The goal of the Center is to 
improve access to care for women throughout the KMC, including active 
duty, dependents, DOD's teachers and civilian contractors. One 
highlight will be a specially designed ``Comfort Room'', specifically 
to support sexually assaulted victims. It will provide a soothing 
environment away from the emergency room for privacy and counseling.
    On another continent, Independent Duty Medical Technicians (IDMTs), 
TSgt Steven Yates and TSgt John Strothenke from Eielson AFB, Alaska 
deployed in support of the Joint POW/MIA Account Command (JPAC) 
mission, which recovered the remains of 19 service members in the last 
calendar year. In addition, IDMTs supported forward-stationed 
detachments in Laos, Vietnam, Thailand and Cambodia by providing 
influenza vaccines, conducting Self Aid and Buddy Care classes, and 
giving Avian Flu awareness briefings. JPAC IDMTs assisted active duty 
physicians in Laos and Cambodia in conducting Medical Civic Action 
Programs (MEDCAP) for local villagers assessing and treating a wide 
variety of jungle ailments.
    As the Department of Defense expanded its global reach, it became 
evident that understanding other cultures and languages is paramount. 
For several years, the Air Force Nurse Corps supported the development 
of cultural awareness and linguistic expertise through various 
humanitarian relief and military operations. Through the International 
Health Specialist (IHS) Program we gained access to countries that are 
otherwise somewhat inaccessible. Major Stephanie Buffet, an IHS nurse, 
currently working for the CENTCOM Surgeon General, played a pivotal 
role in the Air Force's response to medical issues in the ongoing 
Pakistan earthquake relief efforts. She advised the Task Force 
commanders on building healthcare capacity with the Pakistan medical 
system and served as a liaison with the civilian and host nation 
response agencies.
    A1C Stella Bernard, a medical technician in the Pediatric Clinic, 
from the 9th Medical Operations Squadron, Beale AFB CA, was a member of 
a 13-person medical team sent to Asuncion, Paraguay. She served as a 
Spanish interpreter as well as a medic. During their 10-day mission 
over 7,800 Paraguayans were treated with medical, dental, and 
preventive health services. A1C Bernard described this experience as 
``priceless''.
    Lt Col Diep Duong, a graduate of an AF-sponsored doctorate degree, 
directly supported multiple international medical missions. She 
established personal and professional relationships with senior medical 
leaders and U.S. defense attaches in Vietnam, Cambodia, and Laos. She 
led a 5-member multi-service medical team to Phnom Penh, Cambodia. Team 
members screened and treated 1,205 patients, delivered six babies, 
completed 263 prenatal visits, filled 2,378 prescriptions and 
distributed over 2,000 bed nets. An important component of this mission 
was collaboration between the United States, Cambodian and Cham Muslim 
health care providers to ensure appropriate and culturally sensitive 
delivery of health services to local women and children.
    Air Force Nursing Services made an impact at the national-level as 
well. In May 2005, the American Association of Critical Care Nurses 
(AACN) recognized the CCATT nurses at the 59th Medical Wing for 
Excellence in Clinical Practice, Non-Traditional Setting. This award 
reflects the contributions of the entire team from the field medic to 
the tertiary care centers. In March 2006, the American Academy of 
Ambulatory Care Nurses presented national level awards to two AF nurses 
at their annual conference. Major Christine Taylor, from Dyess AFB won 
the Outstanding Nurse/Clinical Excellence Award and Lt Col Carol 
Andrews, from Randolph AFB won the Outstanding Nurse/Administrative 
Excellence Award. The Air Force Affiliate of the National Nursing Staff 
Development Organization (NNSDO) was awarded the prestigious NNSDO 2005 
Affiliate Excellence in Quality Program and competed as a finalist for 
the Chief of Staff Team Excellence Award.
    Our influence is also evident at the state level. A clinical nurse, 
Captain James Gabriel, received the Governor's Alaska Council on 
Emergency Medical Service (EMS) Award/Melissa Ann Peters Memorial 
Award. He orchestrated a benchmark Emergency Medical Technician (EMT) 
training program, which is now a model for the Interior Alaska Region 
Emergency Medical Council. Lt Col Roseanne Warner, a Family Nurse 
Practitioner from Cannon AFB, was the recipient of the American Academy 
of Nurse Practitioners New Mexico State Award for Excellence.

                        RECRUITING AND RETENTION

    As you can see, Air Force Nursing Services is globally engaged, 
making recruiting and retaining nurses one of our top priorities 
especially with the national nursing shortage. On the civilian-nursing 
front, the Bureau of Labor Statistics reports that jobs for registered 
nurses will grow 23 percent by 2008. Nurses are entering the workforce 
at an older age with new graduates averaging 31 years old.

                           SKILL SUSTAINMENT

    Col Florence Valley, Chief Nurse at the 332nd Expeditionary Medical 
Group, Balad AB, Iraq, stated, ``when the Air Force Nurse Corps goes to 
war it brings inpatient nursing and aeromedical evacuation skills. 
These are our primary contributions to the war fighter.'' Great strides 
have been made to ease the transition from home station to warfront 
nursing care. For example, Wilford Hall Medical Center (WHMC) and the 
Air Force Theater Hospital (AFTH) in Balad have similar nursing 
requirements, which minimizes spin-up time. We credit this to the 
nurses' current inpatient care experience and to the continuous 
improvement of pre-deployment training.
    I agree that the best way for nurses to maintain currency and to be 
effective in deployed settings is to have recent hands-on experience as 
inpatient clinical nurses. Maintaining our basic technical skills while 
working in areas where the skills are not used regularly, led to an 
updated policy on nurse utilization. Recently, I released a policy 
mandating that nurses working in outpatient and non-clinical roles will 
be required to complete a minimum of 168 hours annually on the 
inpatient units annually to maintain their skills. We believe that 
bringing seasoned clinicians back to the bedside will not only provide 
a more robust technically-ready force, but will also provide a setting 
of mentorship for our less experienced nurses.
    Our senior leaders are already engaged, emphasizing clinical 
operational currency and expertise. Numerous VA Training Affiliation 
Agreements (TAAs) allow nurses to rotate to inpatient wards, 
maintaining their clinical skills. According to Lt Col Martha Johnston, 
Chief Nurse at the 377 MDG at Kirtland AFB, ``The nurses love it!'' The 
377 MDG plans to expand the program to include the aerospace medical 
technicians.
    Due to the unique missions at Balad, WHMC added the Defense Medical 
Readiness Training Institute's (DMRTI) Emergency War Surgery Course to 
their pre-deployment training to familiarize nurses with Balad-specific 
surgical procedures and care. Additionally, the nursing staff attends 
the Emergency Nurse's Association's Trauma Nurse Core Course (TNCC), 
which standardizes the approach to patient assessments. Finally, WHMC 
nurses attend a burn management course at BAMC.
    The criticality of patients seen in deployed areas significantly 
changed our definition of skills sustainment training requirements. To 
meet the needs of our deploying nurses, we are increasingly using the 
Center for Sustainment of Trauma and Readiness Skills (C-STARS) 
training platform. The goal of C-STARS is to produce medics ready to 
respond to any peacetime or wartime contingency through intense 
clinical immersion. Training is augmented by participation in trauma 
scenarios based on actual wartime medical missions using high-tech 
human patient simulators programmed to respond realistically to medical 
care. Not surprisingly, nurses who attend advanced training platforms 
such as C-STARS report an easier transition to the deployed 
environment. One of our deployed nurse anesthetists, Major Brent 
Mitchell believed that without C-STARS training, he wouldn't have been 
nearly as effective.
    The Uniformed Services University of the Health Sciences (USUHS) 
Graduate School of Nursing (GSN) Master Programs developed academic 
initiatives for the enhancement of ``Go-to-War'' Skill Sets of Advanced 
Practice Nurse. Some of these courses include Advanced Trauma Care for 
Nurses (ATCN), preparing students to function in operational 
environments and a Registered Nurse Surgical First Assistant, 
optimizing surgical outcomes.
    The GSN Masters Program 2005 fall enrollment was at an all time 
high of 140 students. Over the past twelve years, Air Force nurses 
comprised 41 percent of the overall enrollment and specifically 
contributed to 43 percent of the Peri-Operative Clinical Nurse 
Specialist track. Since 1996, 62 percent of the CRNAs were Air Force 
graduates and we are proud that our Nurse Anesthetists once again had a 
100 percent pass rate on the National Certification Exam. The three Air 
Force Doctoral Studies students are currently preparing for qualifying 
exams and grant proposals. Colonel Lela Holden, a part time doctoral 
student, is also moving into the dissertation phase of her program.

                                RESEARCH

    Air Force nurses continue to remain at the forefront of operational 
research. Their work expands the state of nursing science for military 
clinical practice and infuses research into evidence-based practice. Lt 
Col Laurie McMullan, a nurse anesthetist forward deployed with the 447 
EMEDS, employed the findings of a Navy research article on the ``Effect 
of Needle Size on Success of Transarterial Block''. She performed this 
short-needle regional anesthetic block on five Army soldiers requiring 
upper extremity surgical procedures, offering alternative anesthesia 
with a successful post-operative pain relief. We thank the Navy for 
their research, which allowed this Air Force nurse anesthetist to 
provide outstanding combat anesthesia to Army soldiers.
    Other crucial areas of research being examined by Air Force nurses 
include Deployment Health, Sustaining Competencies, Military Practice 
Outcomes and Recruitment & Retention. Lieutenant Colonel Theresa 
Dremsa, a nurse at WHMC, is one of the Air Force's leading operational 
researchers and her current focus is to measure CCATT nurses' 
preparation for deployment. Her study examines the experiential 
knowledge of CCATT nurses in the care of critically ill or injured 
patients in a high-risk deployed setting. The results will be used to 
guide clinical practice in the future.
    As large numbers of deployed members return home we must remain 
adequately prepared to help these veterans and their families with 
reintegration. Though return from deployment can be a happy occasion, 
homecoming can turn into a stressful event for troops and their 
families who are not alert to the impact of changes that occurred 
during separation. Unidentified and untreated PTSD puts them at higher 
danger for maladaptive responses to stress such as alcoholism and 
domestic violence. Colonel Deborah Messecar, from the Portland ANG, is 
conducting a study to explore the experiences of ANG military families 
with reintegration and identify resources and strategies to assist 
them.
    Disasters around the world over the past year have also emphasized 
the need to find ways to help affected military families. Research by 
Colonel John Murray, Consultant to the Air Force Surgeon General for 
Nursing Research, helped explain the consequences of disasters on 
children and provided the field with a framework to guide further 
research and clinical practice.

                             OUR WAY AHEAD

    Several major events continue to shape our future. The Air Force 
transitioned to an expeditionary mission and now deliberately prepares 
our Airmen through aggressive Force Development policies and programs. 
In his 2004 letter ``Developing Expeditionary Medics--A Flight Path,'' 
former CSAF, Gen John Jumper tasked the AF SG to ``complete a 
comprehensive review of the medical group structure for our garrisoned 
and expeditionary medical groups.'' We have since developed a new 
Flight Path to guide our organizational structure and the development 
of our clinical discipline. The Flight Path guides more deliberate 
development for Nursing Services, placing the member in the right job 
at the right time, setting them up for career success and personal 
satisfaction while maintaining expertise at the frontlines of patient 
care.
    The results of the BRAC mark a dramatic shift in DOD and Air Force 
healthcare capitalizing on multi-service markets, joint and interagency 
facility use, and civilian healthcare agreements. Air Force Nursing 
Services is already preparing for the many BRAC-related challenges by 
finding alternate inpatient platforms to train and sustain nursing 
personnel and by determining the right composition of active duty 
``blue suit'' nursing requirements. We continue to evaluate our bottom-
line deployment-driven Critical Operational Readiness Requirements 
(CORR) and use market availability along with cost data to recommend 
appropriate civilian conversions. The Nurse Corps plans to target 
company grade outpatient and maternal-child care positions for 
potential conversion while maintaining active duty nurses for inpatient 
platforms and other key career development positions.
    Along these lines, the results of the 2001 Air Force Surgeon 
General-directed Nurse Corps Top Down Grade Review (TDGR) continue to 
guide our actions as we strive to balance our company grade and field 
grade authorizations. We remain optimistic that our course of action 
will help improve overall promotion opportunity therefore increasing 
the retention of our experienced nurses. We've successfully increased 
field grade requirements for deploying nurses and are taking steps to 
lay-in more senior clinicians at home station.
    Mister Chairman and distinguished members of the Committee, it is 
an honor and a privilege to lead the men and women of our active, 
reserve and guard Nursing Services. My objective for this presentation 
was to provide you with a glimpse of the extraordinary men and women 
that make up Nursing Services and the exceptional work they are doing 
daily in the service of their country. I look to the future 
optimistically and desire your continued support during the exciting 
times ahead for nursing and our Air Force. Thank you for inviting me to 
tell our story.

    Senator Stevens. I thank you very much for your statements. 
I'm a little bit hesitant to ask questions, in view that I'm 
sitting here with the father and mother of the nursing corps of 
the Department of Defense. So they really have put in a lot of 
time, and, I must admit, a great deal more than I have. I do 
want to ask a couple of questions, though. I'm told the Army is 
short about 320 nurses. And you've heard, I believe, the 
conversation we had with the prior panel about the possibility 
that we might consider unification. Would unification help your 
corps at all? Would you tell me, General, and then Admiral and 
General?
    General Pollock. Yes, I think that a joint unified command 
would help us. It provides more opportunities for the nurse 
corps officers because of the different platforms that we do 
have across the services. And it will also, I believe, be a 
retention tool, because there are times during our career that 
there are issues with our other families, our nonmilitary 
families, our families of origin, our siblings, where we feel a 
need to be closer to those families. By expanding the 
assignment locations, we would be able to offer them more 
variety across the Nation for locations, and then also retain 
them.
    Senator Stevens. I know some women that I've talked to in 
the past don't like to fly. Others would not want to serve on a 
ship. Would unification give you problems with regard to the 
platforms that they might have to work on?
    General Pollock. If I were in charge of planning it? No, 
sir. Because I think that we've chosen a particular uniform. 
And that would be our first emotional obligation, was to the 
organization that we had started with. But by giving people 
some flexibility, our younger staff are often very curious, and 
they're looking for new experiences in new locations. And 
having that as an option, not a mandate, would help us.
    Senator Stevens. Admiral.
    Admiral Bruzek-Kohler. Thank you, sir. Yes, I think nurses, 
historically, have been able to informally make sure that the 
kinds of training and the kinds of experiences they need across 
the services and with our other agencies--in particular, with 
the VA and the public health--have always helped us to sustain, 
maintain, and grow. Having a unified medical command brings 
down the walls that help us to do that in a more effective and 
efficient way. I often say that the best retention tool I could 
have would be offering orders to Tripler to my Navy nurses.
    I'm the first one in line to get a set of those orders.
    So, absolutely, I think the possibilities for us, as corps 
chiefs and for all of our nurses, would be greatly enhanced by 
a unified medical command.
    Senator Stevens. General Rank.
    General Rank. Sir, I mentioned in my testimony that there 
are already opportunities where we are side by side together. 
We are at Landstuhl with the Army. They are in Balad with us. 
And we have continued to offer, where they are short; and they 
have offered to us, where we are short, to work side by side in 
our inpatient platforms where we are critically manned.
    We are on an Air Expeditionary Force (AEF) cycle of 120 
days, where we go to the U.S. Central Command Area of 
Responsibility. I, like my sister from the Navy, would love to 
be able to keep our unit type code (UTC) together, but find 
platforms in the Army and the Navy that keep us current. I 
would love to lay nurses into places like Balboa and into 
Tripler. We are working, already, on that endeavor, with Walter 
Reed. And, as I mentioned before, we already have laid in staff 
for Landstuhl, with an Air Force chief nurse working side by 
side with the Army.
    We are doctrinally different, and we train for care in the 
air, and we train for contingency air medical staging flight 
support. The Navy and the Army also are doctrinally different. 
But I think that we can work through all of our clinical 
platforms side by side, green, black, and blue together, and 
know what our heritage was, and work together with our heritage 
still blue, black, and green.
    Senator Stevens. I hesitate to ask this--I'm the father of 
three sons and three daughters, so I would ask it advisedly--
has there been any reluctance on the part of nurses to be 
deployed into the war zone?
    General.
    General Pollock. I think there's reluctance always to have 
new experience. And certainly that is one that they know is 
very intense. I think that they're more concerned about the 
length of time that they're deployed, sir, because what they do 
is different than what the infantry and the armor and the other 
military members do, because each day that the nurses and 
medics and physicians are serving in those combat hospitals, 
every day they're dealing with an injured soldier or marine or 
airman or sailor. They don't have any relief from that. And as 
they express it to me, ``Ma'am, we're willing to go. We know 
they need our help, and we want to be there. But a year is just 
wearing us down.'' So, I don't think that it's their--that 
they're afraid to go, because once they're there, they 
understand how valued they are by that community and how their 
loving and touching hands make a huge difference, but the 
duration of time that we're asking them to go now is really 
very, very hard on them.
    Senator Stevens. Have there been more deployments from any 
one of the services, as opposed to the other, into the war 
zone? Which of your services have sent more nurses into the war 
zone?
    General Pollock. Sir, I would say that the Army has--we--
we're the primary ground force. It's been a ground operation. 
We have had some support from both the Air Force and the Navy, 
but the majority of work is being done by the Army nurses.
    Senator Stevens. Here again, unification might give you a 
larger reservoir of people to rotate, correct?
    General Pollock. I would be very grateful if we were able 
to balance the rotations among all of the specialists that are 
required, so that people did not need to deploy a second time, 
until they knew that their colleagues that had the same 
competency and same skills had also deployed.
    Senator Stevens. Admiral----
    General Pollock. That would be a huge morale booster.
    Senator Stevens. Pardon me. Admiral, what's your feeling?
    Admiral Bruzek-Kohler. Well, I'd like to agree that the 
Army has given us the largest volume of nurses in the 
battlefield. Navy nurses have--however, if you recall, are with 
the marines, as well as with our fleet, so our--although not 
always in war, they are with our sailors and marines throughout 
the year in many short-term deployments, as well. I'd like to 
illustrate it simply with a phone call that I made about 2 
weeks ago. I was told that one of our Navy nurses is in Iraq 
and was injured by some shrapnel, not seriously, thank the 
Lord. When I talked to her, via telephone in Iraq, she was able 
to convey to me how important it was that she be where she was. 
She's the mother of five children, and a husband who's Active 
duty, as well. She had been offered, immediately after her 
treatment, and was offered by myself, to come home, and she 
said, without quivering, ``Absolutely not.''
    I will tell you that everywhere I go, our Navy nurses want 
desperately to serve with our marines and with our sailors. 
That's why we put the uniform on, that's why we are here. Do we 
like being away from our families for a year? Absolutely not. 
Do we understand why that is an important thing that we do? 
Absolutely.
    Senator Stevens. General.
    General Rank. As our personnel get ready to deploy, there 
is trepidation. It's trepidation about leaving the known, 
trepidation about what--how safe they'll be while they're 
there, trepidation about leaving their family behind. But there 
hasn't been a single nurse or medical technician that hasn't 
returned and provided an account to me in our Nightingale News 
every week when we put out our updates to what's happening in 
the nursing services that when we ask anyone, ``What was the 
highlight of your career?'' they tell us, ``It was when we 
deployed. It was when we were far forward. It was taking care 
of the injured.'' So, they do return rejuvenated and--with what 
they've just done, and it is their most memorable experience.
    In 2003, 407 of our nurses deployed; in 2004, 261; and in 
2005, it was 394. Our inventory is 3,675. Only 11 percent of 
our nurses have been able to go to the U.S. Central Command 
Area of Responsibility. Granted, some of these skills are high-
demand, low-density, but there is not a nurse, as I move 
through the Medical Treatment Facility (MTF), that doesn't say 
to me, ``I want to deploy, and I'm ready to deploy.'' And we 
have laid in, in our UTCs, as I mentioned in the testimony, 
more seniority, so that it's not just our captains going, over 
and over again; now our majors can go, and now our lieutenant 
colonels can go.
    And I would say of our relationship together, give us a 
mission, give us one of your missions, like we are doing in 
Balad, and we will do that mission, and stand proud to do that 
total mission.
    Senator Stevens. Well, thank you all very much. I have 
another appointment. I'm going to ask the co-chairman if he 
will continue this hearing.
    Thank you very much.
    Senator Inouye [presiding]. Thank you very much.
    All of the services have not been able to meet their 
recruiting goals. And I think that's understandable, because 
the nursing shortage is a national problem. I just read the 
report of the American Association of Colleges and Nursing that 
reported last year there was an increase in enrollment for 
entry-level baccalaureate programs in nursing, by 14 percent; 
however, at the same time, they turned away 32,000 qualified 
applicants. With that, we won't be able to solve the problem. 
Do you have any suggestions as to anything we, in the Congress, 
can do to work on this national shortage?
    General Pollock.
    Admiral Bruzek-Kohler. I think that one of the most 
important things that we all need to recognize is the 
importance of the role of the nurse. We need to market the 
expertise, the care at the bedside, the care of family that is 
unique to the profession of nursing. You do not see that in 
other types of care. I think they need to be incentivized to be 
able to make that a profession, as well as a part of a 
lifestyle for those wanting to raise a family or to get an 
education and further their careers.
    This year, in the Navy, we have instituted as many of the 
opportunities afforded to us with our loan repayment programs, 
but, most importantly, we have pipeline programs within the 
Navy, so that we give an opportunity to our enlisted staff to 
become nurses, and we are depending more and more on that 
population for the health and the breadth of the Navy Nurse 
Corps. I believe that our direct accessions in the future need 
to be more pointed toward those with specialties, as opposed to 
our new graduates. Again, when you look at the wartime skill 
sets, we don't train enough critical care nurses, we don't 
train enough perioperative nurses. I need to bring them in, I 
need to get them hitting the deck, and I need to get them 
providing that kind of care as quickly as possible. So, we need 
to be able to incentivize bringing in nurses with more 
seniority in the civilian practice, rather than those who are 
looking at this as a future, as a new graduate.
    Senator Inouye. General Pollock.
    General Pollock. Thank you, sir.
    I think that the profession of nursing continues to 
struggle, because they've not completed a transition that was 
started in the early 1970s. Other professions are recognized 
for their college entry into that profession. And until nursing 
across the Nation completes that transition, which it started 
then, we will continue to not be well recognized as 
professionals. And with the opportunity that men and women have 
now, they're selecting professions that will provide a better 
lifestyle and a better income for their families. So, dealing 
with the lack of respect that nurses have in the Nation is an 
integral step to solving the nursing shortage.
    Another piece is the low salary and high demands that are 
placed on the faculty members at the universities, because when 
people have an option of being a faculty member or working in 
another facility as a nursing executive, because they're 
master's or Ph.D. prepared, very few are opting to take that 
lower salary, that lower respect afford in the academic 
community. They're selecting where they can lead and mentor 
nurses in other areas.
    Those issues must be addressed nationwide in order for us 
to be successful in the future as nurses.
    Senator Inouye. General Rank.
    General Rank. General Pollock and Admiral Bruzek-Kohler 
just said everything I was about to say. I would ask, Senator, 
if there is any way for us to establish more publicity for 
healthcare careers at the health affairs and congressional 
levels. That would certainly help, beyond a recruiting effort, 
to bring some of the nurses to us. But I ditto what my 
colleagues have said about the nursing shortage, in that it's 
pervasive and carries over into our services.
    General Pollock. Sir, I'd like to make one more comment 
about that and the need that we will have for those educated 
nurses with entry at a baccalaureate and proceeding on for a 
master's and Ph.D. work. The research over the last 5 years 
strongly indicates that patient safety and patient outcomes are 
far better the higher the education level of that nurse that's 
caring for them. So, as we look at the needs and the complexity 
of the patients that are presenting now, it becomes even more 
critical that we address the failure of the universities to be 
able to bring in the faculty that they need so that we can care 
for the citizens of our country.
    Senator Inouye. I've always contended that pay plays an 
important role in recruiting. It's a fact of life. And there's 
another factor, in this case, where the nursing profession 
appears to be female-dominated. And this is a man's world, 
unfortunately. And the male gets a better pay scale than the 
woman. Now, in the civilian nursing community, there are not 
too many men working as nurses. What is the proportion, in the 
Army, of men?
    General Pollock. Sir, the Army Nurse Corps is 32 percent 
male, compared to less than 5 percent in the civilian 
community.
    Senator Inouye. And for the Navy?
    Admiral Bruzek-Kohler. Thirty-seven percent, sir.
    General Rank. Twenty-five percent male, sir.
    Senator Inouye. What can we do to encourage more male 
participants in the nursing programs? Because then the pay 
scale will go up?
    Those are the facts.
    General Pollock. I think that some of the public-service 
announcements that have been done by Johnson&Johnson in their 
nursing advertisements across the Nation have been focusing on 
males. It's been relatively easy inside our organizations, 
because our enlisted soldiers, again, are primarily male. They 
see what military nurses do, and they make that commitment to 
then complete their education and be a member of one of our 
corps. So, getting more of the men out, which all of us are 
doing through our recruiting efforts, helps to let the other 
men in the communities know that may have been concerned, 
``Gee, I'll only be such a small portion of the percentage of 
nurses,'' that there really are organizations in which they 
have a large place.
    Senator Inouye. Thank you.
    Senator Mikulski.
    Senator Mikulski. Thank you, Mr. Chairman--or Mr. Acting 
Chairman. I don't know if that's a battlefield promotion you 
just got here today.
    You can see, from Senator Inouye's questions, why we just 
so admire him and the chair who's serving with him.
    Senator Inouye, you should know that not only is Maryland 
the home of medical medicine, but two of our generals graduated 
from the University of Maryland School of Nursing. And----
    Senator Inouye. Oh, really?
    Senator Mikulski. General Kohler, I guess we have to give 
you an honorary something-or-other.
    And General Rank actually was born in Frostburg, Maryland, 
Garrett County, the Switzerland of Maryland. So, there is 
something----
    General Rank. Allegheny.
    Senator Mikulski [continuing]. Excuse me--Allegheny--there 
is something that's a magnet here.
    I'd like to pick up on the nurse education issue that 
Senator Inouye raised. And the point that he made, all of the 
issues about attracting people to the career of nursing are 
right--respect, pay, et cetera. But I have a little advisory 
board of the nine deans of nursing of the 4-year programs in 
Maryland, the dean of the University of Maryland and Johns 
Hopkins, and then other 4-year programs. And what they, of 
course, tell me is, they are now turning away--the issue of not 
being interested is no longer so--they're now turning away 
people who want to come to nursing. They identify the lack of 
graduate faculty and the lack of clinical training 
opportunities, the hands-on that, of course, is the hallmark of 
the field.
    And I think this is a national crisis. We have the civilian 
crisis, which would transfer to your ability, because you're in 
a war for talent, in addition to the global war on terrorism, 
so you're going to the same pool, so it's magnified for all of 
the stresses that you've just said. So, my question is: What is 
the role of the military? Because when we want to do an intense 
program, we tend to do it. What is it we could do? Do you think 
we could be looking at focusing on training, getting ready for 
some special accelerated or expanded program to get people to 
go to graduate school, with the understanding that they would 
go into nursing education? Should we use USUHS? Should that be 
the military academy for nursing educators to then train 
nurses? Should we expand the USUHS model? Should--you know, we 
graduate about 1,000 midshipmen; how do we graduate 300 to 500 
nurses a year? And is USUHS one of the ways of doing this? And 
also to take out of, as you said, the pipeline, some of your 
really talented people who want to make not only military a 
career, but as they transit, say, from battlefield or TRICARE, 
they would love to be nursing educators. What's your thoughts 
on that? Is USUHS something, or are there other linkages that 
the military could have with our civilian sector for nursing 
education? And should our military bases and military medicine 
be the source of clinical opportunities for people? So--you 
tend to go with what you know--so, if your clinical is at 
Maryland or Mercy Hospital, you tend to stay there, almost like 
the so-called 3-year girls. You remember that. And--but if they 
were in the military, that would also be part of your 
attraction, the way General Taylor and others talked about 
recruiting. What do you think? Or am I off the wall here?
    General Pollock. In the past, ma'am, the Army Nurse Corps 
had run a full baccalaureate program. That program was closed 
in 1978. That was the Walter Reed Army Institute of Nursing 
Program. At current strengths, I would not be able to manage 
that mission and do the other missions that we have, both at 
home and around the world.
    Until we're able to figure out where we can draw the 
faculty from, even if USUHS was willing----
    Senator Mikulski. What I'm asking you----
    General Pollock [continuing]. We wouldn't be able----
    Senator Mikulski [continuing]. Where could we play a role 
in developing the faculty to then expand it, where we keep--
unless we crack the faculty problem, both in the civilian and 
in the military sector--and I'm looking at cracking it from the 
military standpoint, that the military would have its own 
faculty cadre----
    General Pollock. Ma'am, I've had a Strategic Issues Working 
Group working on the education piece for me. What I'd like to 
do is provide you a written response of----
    Senator Mikulski. Good, why don't we do that.
    General Pollock [continuing]. Recommendation----
    [The information follows:]

    Each year, thousands are denied entry into baccalaureate nursing 
programs due to faculty shortages. The fiscal year 2005 National 
Defense Authorization Act recommended the creation of a Nurse Officers 
to Educators Program to address this issue. A complicating factor 
related to this issue is a concomitant national shortage of nursing 
faculty. A 2005 American Association of Colleges of Nursing survey 
reported 817 faculty vacancies nationwide, with 77 percent of those 
positions requiring both classroom and clinical teaching. The study 
also reported that many schools are not hiring against these vacancies 
due to budget problems. The Army recommends that the three military 
Nurse Corps serve as members of a working group to identify solutions 
to this national crisis.

    Senator Mikulski. Do the other Generals have a comment on 
this? And I'm trying to think out of the box, but I don't want 
to get myself into a new box----
    Admiral Bruzek-Kohler. Yes, ma'am.
    Senator Mikulski [continuing]. You know.
    Admiral Bruzek-Kohler. I think there are--there are many 
innovative ways to approach exactly what you're asking for. And 
I agree with General Pollock that we need an opportunity to sit 
together and provide you some background on the pros and cons 
to many of those. But you did mention the clinical rotations, 
and that is one of the major factors. I've spoken with the dean 
of Marymount not too long ago, and that was one of her biggest 
concerns, that she was not able to get enough faculty--clinical 
faculty working in an institution to train her graduate 
students. So, I think one of the things that we need to work 
more on, along with our sister service and the VA, is to 
determine ways that we can better link up our clinical 
institutions with the surrounding schools of nursing to make 
sure that we're giving them enough opportunity. Because 
sometimes it's just a matter of not knowing the need. We have 
nurse practitioners in most of our ambulatory care clinics. I 
know for a fact that my nurse practitioners would love to be a 
mentor to a graduate student who was going on to become a nurse 
practitioner.
    So, I think if we have the opportunity to provide you with 
some more information, we may come up with some good activities 
for you.
    [The information follows:]

    On an annual basis, the Navy Nurse Corps shapes our 
graduate education training plan based on our health care and 
operational mission support requirements. Approximately 50 
Nurse Corps officers graduate with a Master of Science degree 
in Nursing from accredited universities each year. On average, 
one to two Nurse Corps Officers graduates each year with 
Doctoral Degrees. These Nurse Corps Officers are eligible to 
serve as faculty in our universities and Schools of Nursing 
while on Active Duty, and upon retirement. Eighty-eight percent 
of our Active Duty Nurse Corps Officers with Doctoral degrees 
serve as faculty after normal working hours. Currently 100 
percent of our most recently retired Nurse Corps Officers with 
Doctoral degrees fill faculty positions in national 
universities. The majority of Nurse Corps officers with a 
Master of Science degree in Nursing do not pursue faculty roles 
in Nursing Education for a variety of reasons. These reasons 
are in alignment with current literature related to nursing 
faculty shortages. Navy Medicine currently has a Nurse Corps 
Leader who serves as the military liaison to the Maryland 
Statewide Commission on the Crisis in Nursing.
    Other opportunities to promote and encourage our nurses to 
become involved in faculty roles are available in our Military 
Treatment Facilities (MTF). The Nursing Internship Programs 
utilize our Bachelor's and Master's degree Nurse Corps Officers 
as clinical instructors to orient recent graduates and 
Registered Nurses with minimal clinical experience to the 
profession of nursing. A large percentage of our MTFs and staff 
are involved with undergraduate and graduate Schools of Nursing 
as preceptors and clinical consultants to grow the next 
generation of nurses.
    Many of our Nurse Corps Officers are members and elected 
officials of Sigma Theta Tau International Honor Society of 
Nursing in affiliation with their local chapters in support of 
leadership and scholarship practice. Members are provided 
resources which encourage advanced practice, academia, 
administration and research.
    At the Uniformed Services University of Health Sciences 
(USU) in Bethesda, Maryland, several of our Navy Nurse Corps 
Officers serve as faculty in the graduate programs for 
perioperative nursing, family nurse practitioner and certified 
registered nurse anesthetists. USU is experiencing faculty 
shortages in light of meeting our primary mission involving the 
Global War on Terrorism. Presently, the civilian schools of 
nursing meet our quotas for undergraduate accessions and 
graduate and post graduate programs. Navy Medicine recommends 
expanding the Army's Strategic Issues Working Group into a Tri-
Service working group as a subcommittee of the Federal Nursing 
Services Council. It's mission would include opportunities for 
the services to collaborate with civilian schools of nursing to 
positively impact the issue of the national nursing faculty 
shortage.
    The issues involving the national nursing faculty shortage 
are very complex and multi-layered such as aging faculty, 
faculty salaries and mentoring programs for new faculty. The 
Navy Nurse Corps is committed to continuing to explore 
opportunities that would maximize the use of existing resources 
along with our sister Services and Federal agencies to map the 
future for the nursing profession.

    Senator Mikulski. And one of the things that sometimes 
happens in a clinical situation is, the person who is the 
clinical supervisor, in addition, say, you know, at Mercy 
Hospital with Marymount, or Mercy Hospital with Maryland, they 
can have an adjunct faculty status.
    Admiral Bruzek-Kohler. Yes.
    Senator Mikulski. They like that.
    Admiral Bruzek-Kohler. Absolutely.
    Senator Mikulski. They just like it. It's part of the 
attraction, as you said, and it's part of that family, ``Well, 
you know, we're military nurses,'' and, ``Mom does this,'' and, 
``Mom's on the faculty,'' or, ``Dad's on the faculty.''
    The other is the promotion within--not the promotion, but 
the recruitment within, the corpsman who might want to go to 
nursing school. Like Senator Inouye said, the guys getting into 
nursing. Are there ways that we could enhance it? In other 
words, they've signed up for the military. They've signed up 
for the military lifestyle, and so has their family. So, 
there's nothing new here. But the opportunity to move within, 
is this something that we should look at, enhance, expand, help 
you have other tools----
    Admiral Bruzek-Kohler. Yes, to----
    Senator Mikulski [continuing]. Financial resources?
    Admiral Bruzek-Kohler [continuing]. All the above. Yes, to 
all the above. It is the lifeblood of our nursing services for 
the Navy. We have the Reserve Officer Training Corps (ROTC)--
Navy ROTC program, the STA-21, which is seaman to admiral 
program, the Medical Enlisted Commissioning Program (MECP) 
enlisted program. And without those programs, we would never 
meet our accession goals. They really give us the strength and 
breadth of our nurses for the future. And these are people who 
are committed to the Navy. They are not always our corpsmen, 
they are, across the board, our best and brightest, who want to 
become a nurse, and go through these programs, and then commit 
to a long term in the corps. So, we are looking at increasing, 
in all of those programs, the number of available seats for 
next year. We hope that we can continue to increase those 
numbers.
    Senator Mikulski. You mean, somebody right now who might be 
working as a medical librarian or in another area in the 
military wants to come into nursing.
    Admiral Bruzek-Kohler. Someone maybe on a ship right as a 
cyto----
    Senator Mikulski. Cytologist?
    Admiral Bruzek-Kohler [continuing]. A cryptotech--a 
cryptotech, nonmedically related at all, but had a desire all 
along to be a Navy nurse, applies to the program, meets the 
requirements, and is selected, and will become a Navy nurse.
    Senator Mikulski. General Rank, did you want to say 
anything?
    General Rank. Ma'am, in preparing for testimony, I found an 
interesting fact about our enlisted corps: 24 percent of our 
nurses in the Air Force were prior enlisted; 8 percent came 
from the Air Force and 16 percent from the Army and the Navy.
    Senator Mikulski. See? They're there. They're there in the 
military, and they've embraced it. You know, there is a saying, 
``Mine where there is gold,'' ``Drill where there is oil, as 
long as it's not off the coast of Ocean City.''
    And----
    General Pollock. Ma'am?
    Senator Mikulski. I just think that this offers 
opportunities, but they still have to go somewhere to school. 
And see what we can do about that. I'd like to have further 
conversations or written materials on it.
    The last thing is, has the debt repayment programs made a 
difference? The reason I like debt repayment is, it means 
you've already got yourself through school--you know, you start 
nursing, it might not be for you. So, it means you've not only 
finished it, but you've passed the boards, you know, you're 
ready to go. Has this worked?
    General Pollock. Yes, ma'am.
    Admiral Bruzek-Kohler. Yes.
    Senator Mikulski. Do you like it better than scholarships, 
or you need a mix?
    General Pollock. I'd like both. We have a population that 
likes options and wants alternatives. So, knowing that we can 
offer some--it's almost a cafeteria plan, some of this and some 
of this--is really helpful.
    Ma'am, I'd like to provide one other piece of information 
about our enlisted commissioning program. This year, we funded 
75 soldiers to complete their baccalaureate degree. So, in 2 
years, they'll be available for us. We had 125 applicants, and 
122 of them met all criteria. So, as----
    Senator Mikulski. And why did you only do 75? Is that all 
the money you had?
    General Pollock. Yes, sir--yes, ma'am.
    Senator Mikulski. Well, Senator Inouye, this might be where 
our biggest pool is for recruitment. And we should look at what 
the levels are there and welcome thoughts about how maybe----
    General Pollock. General Kiley----
    Senator Mikulski [continuing]. This is----
    General Pollock [continuing]. Has been assisting us----
    Senator Mikulski [continuing]. An existing pipeline.
    General Pollock [continuing]. In that----
    Senator Mikulski. Excuse me?
    General Pollock. Sorry. General Kiley has been assisting us 
to obtain more money for that, because he knew that we had 
those additional candidates ready to go.
    Senator Mikulski. But I bet we could go to each service, 
and that would be the case. Am I right, that you have now more 
than you can fund? But if we fund them, it's a pretty good bet 
that they'll finish----
    General Pollock. Oh, yes, ma'am.
    Senator Mikulski [continuing]. And stay.
    General Pollock. Yes, ma'am.
    Admiral Bruzek-Kohler. Uh-huh.
    Senator Mikulski. Just one last thing. If, then, after they 
do that, are they still treated like a GS-5, or would they get 
an accelerated promotion?
    General Pollock. No, they're treated like officers, and 
they begin as second lieutenants, the way that the other new 
graduate nurses are begun.
    Admiral Bruzek-Kohler. And it's very interesting, when you 
talk with them. The transition is there, clearly. And the 
longer you've been an enlisted person, the more of a 
transition. But once you become a nurse and you're practicing 
in the field that you've wanted to practice for a very long 
time, they are a Navy nurse. What is important is that 
experience as an enlisted--previously enlisted person is what 
we use then to help teach our other enlisted people, ``This is 
where I came from. This is what you can become.'' So, they 
become, again, a very good recruiting tool, as well as educator 
and mentor for our organization.
    General Rank. Ma'am, the other things I would add is the 
debt repayment program. We love it in the Air Force Nurse 
Corps, because it's a graduated nurse who has a license in her 
hand, and she can go right to work immediately. So, we really 
love that program. And I'm looking at my statistic, that we 
have 25 percent males, and 24 percent of our enlisted corps is 
enlisted. So, I'll have to look at those two to see if it's 
predominantly a male force that came up through the enlisted 
ranks and now is in our nurse corps.
    Senator Mikulski. Well, and, of course, then I hope that 
out of those that are already military nurses, we can think 
about how to help them become faculty, either in the academic 
sense of that word or in some way offer the clinical 
opportunities. And I'll bet it's going to be a bonanza for 
everybody.
    So, let's work together on it, but I think we can make a 
difference. You already are making a difference. And thank you 
very much.
    Senator Inouye. This has been a very interesting 
discussion. And while listening to all of you, I couldn't help 
but recall that a few years ago we decided that cancer was a 
major scourge. And, as a result, the Government and the 
Congress established special subsidy programs for medical 
schools to set up cancer centers for special studies. Now, I 
think the time has come to declare that the nursing shortage is 
a national crisis. And, if that's the case, we can do a lot of 
things that you have suggested, with proper funding from the 
Congress of the United States. It's just as much an emergency 
as we find in anything else. So, I thank you very much for your 
contribution.
    And, if I may, I'll use this for a personal note. Since 
April 1945, nurses have played important roles in my life. And 
I thank them for giving me the hope and the picture of the 
future, the good life. And I'm certain there are thousands, if 
not millions, of others who have spent time in hospitals who 
feel the same way.
    Admiral Bruzek-Kohler. Thank you, sir.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Inouye. Well, thank you all for your testimony.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]

        Questions Submitted to Lieutenant General Kevin C. Kiley
               Questions Submitted by Senator Ted Stevens

    Question. Have you modified the training you provide your Army 
medics and Navy Corpsmen and other military emergency care providers 
since hostilities began? What is your assessment of emergency care on 
the battlefield?
    Answer. The Army Medical Department has changed the training of 
Army medics based on lessons learned from Operation Enduring Freedom 
and Operation Iraqi Freedom. We have incorporated these changes into 
the Army's Initial Combat Medic training at Fort Sam Houston, Texas and 
at new Medical Simulation Training Centers at major Army installations. 
We have also used these lessons to train deploying physicians, 
physician assistants and nurses.
    Some examples of these changes including improving the medic's 
training in managing patients with hypothermia; the use of tourniquets 
and hemostatic agents as the primary means of controlling bleeding; the 
use of endotracheal intubation and nasopharyngeal airway for airway 
management; and training in medical support to detainee operations.
    Feedback on the quality and effectiveness of battlefield emergency 
care from returning units is very positive. The statistics of 
battlefield mortality are the lowest in any previous conflict in which 
our country has been involved. The major causes of death on the 
battlefield have remained unchanged since the Civil War. These are: 
penetrating head trauma, massive torso trauma, blast trauma, hemorrhage 
from extremity wounds, tension pneumothorax, and airway difficulty. Of 
these injuries, Combat Medics significantly impact extremity 
hemorrhage, tension pneumothorax, and airway difficulty. Based on data 
from Vietnam and trauma data from Operation Iraqi Freedom/Operation 
Enduring Freedom, we employed new training methods that encompass the 
types of wounds and the danger of the combat environment.
    In addition to Soldier Medic training, the Army's Self-Aid/Buddy-
Aid skills training for every Soldier has also been revised, also 
focusing on the preventable causes of death on the battlefield. A new 
Combat Lifesaver Course incorporates many of the principles used in 
training Combat Medics. The combination of these training programs 
allows more medical skills to be available on the battlefield to save 
Soldiers' lives.
    Question. How successful were you in meeting your mission 
recruiting goals for this past year? Are there any specialties that 
have seen a drastic decline in retention?
    Answer. The Army Medical Department and United States Army 
Recruiting Command (USAREC) had varying degrees of success in meeting 
our recruiting goals for fiscal year 2005. We achieved 99 percent of 
our Medical Corps goal, 84 percent of our Dental Corps goal, 100 
percent of our Medical Service Corps goal, 83 percent of our Army Nurse 
Corps goal, 110 percent of our Veterinary Corps and 151 percent of the 
Specialist Corps goal for individuals entering on to active duty. For 
the first time, we experienced difficulty in recruiting to 100 percent 
of our Health Professions Scholarship Program (HPSP) allocations. 
USAREC is working hard to ensure that this is not the start of a trend.
    Retention of our fully trained force is a priority. While increases 
in incentives have helped, we still have retention challenges. 
Specifically, we are closely monitoring Anesthesiology, Pediatrics, 
Family Practice and Emergency Medicine. We have also seen a decline in 
Physician Assistants and all Nurse specialties.
    Question. What are you as a service doing to try and address these 
critical shortfalls? How do you carry out the medical mission at home 
and abroad with a decline in recruiting and retention of specialty 
medical personnel?
    Answer. The National Defense Authorization Act for Fiscal Year 2006 
granted temporary Recruiting Incentives Authority for up to four new 
programs that should assist with the Army recruiting mission. One of 
these programs, the Recruiter Incentive Pay (RIP), will provide 
monetary incentives for AMEDD recruiters to exceed their missions. RIP 
has been approved and is expected to begin in June 2006, after the 
mandated 45-day waiting period.
    Another new program under review is the Officer Accession Bonus, 
which includes an additional monetary incentive for AMEDD applicants. 
This bonus would offer an immediate show of good faith and expedite the 
acceptance process. This program is expected to begin this summer or at 
the beginning of fiscal year 2007.
    Additionally, we are pursuing a critical skills retention bonus for 
the physician assistants. We are pursuing incentive special pay for 
certain nurse specialties. We increased the incentive special pay for 
nurse anesthetists. We are increasing the nurse accession bonus for 
fiscal year 2007. We are exploring the increase of special pays for 
dentists. We utilize professional officer filler information system 
(PROFIS) personnel to fill shortages/vacancies within deploying units. 
The TRICARE network as well as temporary contracts are then used to 
meet the beneficiary mission.
    Question. There is growing concern with how the Department monitors 
and addresses the emotional and mental health of each returning 
soldier, sailor, airman and Marine from combat. Can you each tell us 
how you are monitoring and treating those that are at risk for Post 
Traumatic Stress Disorder?
    Answer. The Army Deputy Chief of Staff for Personnel (DCSPER) and 
the Army Surgeon General (TSG) share responsibility for the prevention 
and screening for Post Traumatic Stress Disorder (PTSD) for both active 
and reserve component Soldiers serving in the Global War on Terrorism 
(GWOT). The DCSPER is responsible for the Deployment Cycle Support 
Program (DCSP) aimed at Soldiers and family members and TSG has 
oversight of the Combat and Operational Stress Control (COSC) program 
aimed at Soldiers serving in GWOT. TSG also exercises command and 
control over behavioral health services at Army medical centers around 
the world providing treatment for Soldiers with PTSD.
    During pre-deployment, the DCSP provides extensive training to 
Soldiers and family members on the operational and combat stressors and 
ways and means to lessen the impact of deployment and traumatic events. 
DCSP resources available to Soldiers include buddy aid, leadership 
support, chaplaincy services, primary care and behavioral health 
services. Family members are instructed on their roles, 
responsibilities and ways and means by which they may cope more 
effectively, support their deploying Soldier and seek and receive 
support and professional assistance. Soldiers are also introduced to 
COSC concepts and resources to prepare for combat and operational 
stress. Medical and behavioral health personnel are positioned in 
theater for forward prevention and care, to do assessments of unit and 
Soldiers' behavioral health needs, to teach techniques for prevention 
or reduction of acute stress reactions and to help conserve the 
fighting strength of the force by providing short term problem focused 
behavioral healthcare.
    Prior to deployment Soldiers receive a pre-deployment assessment 
which includes a question about mental health. If Soldiers have a 
positive response to the mental health question, they receive a further 
evaluation by a clinician. The final recommendation is based on 
clinical judgment and commander input, which considers the geographical 
area in which the Soldier will be assigned and the potential 
environmental/austere conditions.
    A face-to-face post-deployment health assessment (PDHA) by trained 
healthcare provider during the re-deployment process has been in place 
for several years aimed at identifying and referring Soldiers with PTSD 
symptoms needing professional assistance. Referrals of these Soldiers 
for behavioral healthcare have routinely taken place and early 
intervention to lessen the impact of traumatic experiences has been 
emphasized.
    Beginning in 2006, all active and reserve component Soldiers are 
receiving a face-to-face post-deployment total health re-assessment 
(PDHRA) at three to six months post-redeployment. Specific questions on 
the PDHRA screening aim at measuring the presence and impact of PTSD 
symptoms. Behavioral healthcare providers will be utilized to further 
assess the needs of Soldiers and ensure care is offered. If following 
the re-assessment there are identified healthcare needs, Soldiers will 
be offered care through by military medical treatment facilities, by 
Department of Veterans Affairs' medical centers or VET centers, by 
private healthcare providers through TRICARE, or through community-
based healthcare organizations established by the Army.
    If a Soldier has post-traumatic stress disorder or other 
psychological difficulties, they will be further evaluated and treated 
using well-recognized treatment guidelines. These include psychotherapy 
and pharmacotherapy. They may be delivered in a variety of venues, to 
include in theater and garrison, an outpatient or inpatient setting, 
and individually or in a group.
    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. The Army uses multiple screening processes to ensure all 
Soldiers who deploy are capable of performing their duties and do not 
pose a risk to themselves or other members of their unit.
    Prior to deployment Soldiers receive a pre-deployment assessment 
which includes questions about mental health. If Soldiers have a 
positive response to the mental health questions they receive further 
evaluation by a clinician. If the Soldier has symptoms of PTSD on the 
pre-deployment assessment, the symptoms are evaluated and treated by a 
mental health practitioner. A fitness for duty assessment is ordered if 
necessary. The final recommendation on deployment is based on clinical 
judgment of the treating provider and input from the unit commander.
    Research shows that all Soldiers are affected by combat experiences 
and the most seriously affected are those exposed to frequent direct 
combat or the injuries sustained in combat. It is likely that multiple 
deployments will lead to increased symptoms of PTSD. Soldiers with PTSD 
are identified in multiple ways. They may self-identify, be identified 
by the post-deployment health assessment, the post-deployment health 
re-assessment, or be referred by a family member or command. If a 
Soldier has PTSD or other psychological difficulties, they are further 
evaluated and treated using well-recognized treatment guidelines. These 
include psychotherapy and pharmacotherapy. They are delivered in a 
variety of venues, in theater and garrison, an outpatient or inpatient 
setting, and individually or in a group.
                                 ______
                                 
          Questions Submitted to Vice Admiral Donald C. Arthur
               Questions Submitted by Senator Ted Stevens

    Question. Have you modified the training you provide your Army 
medics and Navy Corpsmen and other military emergency care providers 
since hostilities began?
    Answer. Yes, the Navy has integrated emergency/trauma training 
throughout the educational continuum and in a variety of training 
centers. Please note the examples below:
    Naval Hospital Corps School, Great Lakes, IL (NHCS).--This is the 
first school in the career of a Corpsman. Since 2002, many changes have 
been made in response to regular communication between Field Medical 
Service School (FMSS) and NHCS. A variety of lessons and content have 
been added to the Tactical Combat Casualty Care and Care of the Patient 
with exposure to Nuclear Explosives courses. The courses have 
transitioned from group-paced lectures into a 100 percent blended 
learning environment.
    Independent Duty Corpsmen (IDC) Training at Naval School of Health 
Sciences (NSHS) San Diego, CA.--The IDC program has adjusted its 
curriculum to enhance the training for medical personnel who perform in 
an operational/remote environment, often without a medical officer. In 
the last two years students now attend the Operational and Emergency 
Medical Skills (OEMS) course which provides training to care for 
casualties using the principles taught in Advanced Trauma Life Support 
(ATLS) and addresses the mission of special medical care: prolonged 
transport times, unique military wounds and the pre-hospital 
environment. Additionally, the IDC program trauma unit has been revised 
to incorporate the principles/curriculum of TCCC.
    Tactical Combat Casualty Care (TCCC).--Corpsmen and Medics are 
trained in TCCC in response to evidence based practice used on the 
battlefield. The USMC has published a Marine Corps Order that all 8404s 
will now receive TCCC training. The Naval Expeditionary Combat Command 
(NECC) has adopted the same requirements for their Corpsmen. To help 
support the NECC and USMC Individual Augmentee (IA) deployment TCCC 
training, the Naval Medical Education and Training Command (NMETC) has 
instructed the Naval Operational Medicine Institute (NOMI) to institute 
a TCCC ``Train the Trainer'' program. The first training sessions will 
take place the first week of June 2006 with multiple courses to follow.
    Naval Expeditionary Medical Training Institute located at Camp 
Pendleton, CA (NEMTI).--NEMTI is instructing and updating Fleet 
Hospital (FH), Expeditionary Medical Facility (EMF) and Battle Skills 
standards based on requirement-driven training. These training 
standards are built upon several items: Subject Matter Expert Review, 
current AOR After Action Reports, Medical Lessons Learned and 
requirements based upon specific COCOMs, OPLANS, and AOR's. This is 
also aligned with the Naval Audit Report (2003).
    Joint Special Operations Medical Training Center in Fort Bragg, NC 
(JSOMTC).--Curriculum changes were made to move the Combat Trauma 
Management module to the Special Operations Combat Medic (SOCM) course 
to provide the Army Rangers, 96th Civil Affairs Medics, SEAL Corpsman, 
Recon Corpsman, and Special Warfare Combat Crewman additional trauma 
training before going to their units. The total curriculum remains the 
same with minor changes to curriculum information and updates to 
support feedback and after action reports from the field. The length 
has remained the same; the frequency of the training has increased from 
four classes per year to eight beginning this fiscal year.
    Marine Aircraft Wings (MAW) Training.--MAWs have instituted 
training of organic, Medical Augmentation Program (MAP) personnel and 
Individual Augmentees to serve as Casualty Evacuation Corpsmen. The 
training which includes trauma care, aviation physiology and aircraft 
orientation varies from 1-4 weeks. In addition Navy squadrons are 
augmenting the Army Air Ambulance Mission and have procured Search and 
Rescue (SAR) Corpsmen and provided them with 4 weeks of Army Flight 
Medic Training under the auspices of NAVAIRFOR.
    Navy Trauma Training Course located at Los Angeles County-USC 
Medical Center, Los Angeles, CA (NTTC).--This entire program for 
Corpsmen, Nurses and Physicians was started in the summer of 2002 in 
support of the increased operational tempo and the need for trauma 
training. Traditionally Naval Medical Facilities did not treat a 
sufficient number of trauma cases to provide adequate initial and 
sustainment training to achieve proficiency. NTTC incorporates a 
military specific Pre Hospital Trauma Life Support (PHTLS) training for 
Corpsmen as part of their curriculum.
    Question. What is your assessment of emergency care on the 
battlefield?
    Answer. ``Emergency care on the battlefield is much improved, so 
much so that the survival of our combat casualties is vastly better 
than it was in Viet Nam.'' This quote is from the Journal of Trauma, 
February 2006. (Holcomb JB, Stansbury LG, Champion HR, Wade C, Bellamy 
RF. Understanding combat casualty care statistics. J Trauma. 2006 
Feb;60(2):397-401.)

        COMPARISON OF STATISTICS FOR BATTLE CASUALTIES, 1941-2005
------------------------------------------------------------------------
                                         World War
                                             II      Vietnam    OIF/OEF
------------------------------------------------------------------------
Percent KIA............................       23.7       21.3       12.5
------------------------------------------------------------------------

    Question. How successful were you in meeting your mission 
recruiting goals for this past year? Are there any specialties that 
have seen a drastic decline in retention?
    Answer. The Navy's Medical Department Recruiting did not meet 
recruiting goals in fiscal year 2005 for either the Active Component 
(AC) or Reserve Component (RC) and has had limited success this year to 
date. The Nurse Corps has been much more successful this year with its 
student programs and Direct Accessions thanks to the initiatives 
mentioned below. The Direct Accessions for the Medical Corps, Dental 
Corps and Medical Service Corps are falling short of the mission 
recruiting goal this year.
    The following specialties have had an increased loss rate over the 
past few years:
    Medical Corps--Preventive Medicine, Psychiatry, Family Medicine, 
and Occupational Medicine.
    Dental Corps--Endodontics, Orthodontics, and Periodontics.
    Medical Service Corps--Clinical Psychologists, Pharmacists, and 
Physician Assistants.
    Nurse Corps--Family Nurse Practitioners.
    Question. What are you as a service doing to try and address these 
critical shortfalls?
    Answer. Efforts to increase recruitment and retention of qualified 
health care professionals in Navy Medicine are underway in several 
directions. This year, the compensation for Health Services Collegiate 
Program (HSCP) students (used by Dental Corps and Medical Service 
Corps) increased from E3 to E6 pay, greatly improving the success of 
that program. Increases in the Dental Officer Multiyear Retention 
Bonuses were also realized for fiscal year 2005.
    The fiscal year 2006 NDAA recently authorized Incentive Special Pay 
(ISP) for Oral and Maxillofacial Surgeons.
    Funding has recently been increased for the Health Professions Loan 
Repayment Program (HPLRP) which was authorized in 1998. This offers 
over $30,000 per year to be paid directly toward loans incurred for 
healthcare training. This is used for both retention and recruitment 
across all medical communities.
    Nurse Corps recruiting continues to be impacted by the national 
shortage of nurses, resulting in strong competition for a finite pool 
of work force nurses and nursing school students. The primary 
strategies chosen to recruit and retain our Nurse Corps officers 
include the following:
  --The Nurse Corps Direct Accession Bonus was increased at two levels: 
        $15,000 (incurring a 3 year obligation) and $20,000 (with a 4 
        year obligation).
  --HPLRP was offered for the first time this year as both a recruiting 
        and retention tool.
  --The Nurse Candidate Program (NCP) accession bonus was increased 
        from $5,000 to $10,000, and the monthly stipend increased from 
        $500 to $1,000. In addition, NCP has been expanded by twenty 
        openings this year.
    Medical Service Corps' increases in HSCP compensation have improved 
interest. HPLRP awards were offered to an expanded number of clinical 
psychologists and podiatrists this year and are being used for 
accessions for the first time. One-year HSCP scholarships are being 
successfully used to recruit candidates already in training for some of 
the specialties.
    Question. How do you carry out the medical mission at home and 
abroad with a decline in recruiting and retention of specialty medical 
personnel?
    Answer. We have adopted several measures to respond to this 
challenging issue. One, we make every attempt to maximize the 
efficiency of our existing staff. This includes ensuring that our 
providers are focused on clinical rather than administrative services. 
Two, we focus the use of support and ancillary staff on the clinical 
mission. Third, where indicated, clinic hours have been adjusted to 
meet demand. Fourth, to address shortfalls and meet access standards, 
we engage in greater use of contract services and network referrals, 
while at the same time attempting to maintain training programs vital 
to operational medical readiness.
    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. We employ numerous methods for screening those at risk for 
development of PTSD and related conditions. Service members are 
screened prior to deployment, upon redeployment, and again periodically 
after returning from deployment. At any point if a service member 
presents symptoms that indicate the potential need for treatment, he or 
she is referred to an appropriate mental health or medical provider for 
complete evaluation and any treatment deemed necessary.
    Navy Medicine actively encourages Sailors and Marines to seek care 
for behavioral healthcare concerns from a variety of sources. 
Behavioral healthcare services are included on all deployment and 
redeployment briefs. Navy chaplains provide information on availability 
of counseling from pastoral and medical sources in Warrior Transition 
Briefs. Fleet and Family Service Centers and Marine Corps Community 
Services publish availability of non-medical counseling for behavioral 
issues.
    If after treatment a service member's condition is not judged to 
have improved such that he or she can be returned to full duty, they 
are placed in a limited duty status to ensure that they get whatever 
further treatment is necessary. At this time, we have no evidence that 
service members are, in general, being returned to a deployed 
environment too early.
                                 ______
                                 
   Questions Submitted to Lieutenant General George Peach Taylor, Jr.
               Questions Submitted by Senator Ted Stevens

                           MEDICAL RECRUITING

    Question. The Air Force plays a critical role in the medical 
evacuation of troops overseas. With recruiting and retention 
challenges, are you concerned that the Air Force will be unable to 
continue meeting the high optempo of meeting the needs of this mission 
overseas?
    Answer. The Air Force Personnel Center (AFPC) places high priority 
on ensuring critical authorizations for aeromedical evacuation (AE) 
assignments are filled. Information from AFPC shows all AE 
authorizations are currently filled and they continually plan ahead to 
fill projected vacancies. At this time, AE is a voluntary career 
option. Multiple avenues exist to showcase AE as a positive career 
broadening opportunity for AF medics. Many AE forces reside in the 
Reserve Component, and they are actively engaged in recruiting and 
retention initiatives to ensure continued success in this vital Total 
Air Force mission.

                     POST TRAUMATIC STRESS DISORDER

    Question. There is growing concern with how the Department monitors 
and addresses the emotional and mental health of each returning 
soldier, sailor, airman and Marine from combat. Can you each tell us 
how you are monitoring and treating those that are at risk for Post 
Traumatic Stress Disorder?
    Answer. The Air Force views the monitoring and addressing of Post 
Traumatic Stress Disorder (PTSD) and all deployment related issues as a 
shared community responsibility not just a medical issue. In August 
2005, the Air Force standardized this support by adding Chapter 8 
Redeployment Support Process to Air Force Instruction 10-403, 
Deployment Planning and Execution. This instruction outlines the 
responsibilities of both commanders and helping agencies in supporting 
deployment members and their families.
    Monitoring for PTSD begins with the post-deployment process. Thirty 
days before returning home, Airmen are given reintegration education by 
chaplain and mental health staff where reunion/reintegration issues are 
addressed, as well as mental health concerns that might occur and 
resources Airmen could pursue to address those concerns. Prior to 
returning home, the Area of Responsibility (AOR) commander is 
responsible for contacting the home station command for Airmen who 
could benefit from support due to personal loss, exposure to danger, or 
witnessing traumatic events.
    As our troops re-deploy, post-deployment assessments are conducted 
for all Airmen, mainly in-theater, just before they return home, or 
within five days of re-deploying. Commanders ensure all re-deploying 
Airmen have completed their post-deployment medical processing 
immediately upon return from deployment, prior to release for downtime, 
leave, or demobilization. These are stored in electronic fashion and 
are available through TRICARE Online to our provider staffs worldwide.
    During the post-deployment assessment, each Airman has a face-to-
face assessment with a health care provider. This discussion includes 
discussion of any health concerns raised in the Post-Deployment Health 
Assessment questionnaire, mental health or psychosocial issues, special 
medications taken during the deployment, and concerns about possible 
environmental and occupational exposures. Concerns are addressed using 
the appropriate Department of Defense (DOD) guidelines such as the 
Veterans Administration (VA)/DOD Post-Deployment Health Clinical 
Practice Guidelines and the VA/DOD Clinical Practice Guidelines for 
Post-Traumatic Stress.
    Within seven days of return to their home station, Airmen receive 
reintegration education by the installation helping agencies where 
issues that may develop are discussed and resources are identified. 
These briefings are mandatory for military members while family members 
are highly encouraged to attend.
    To better ensure early identification and treatment of emerging 
deployment related concerns, at every medical appointment Airmen are 
asked if their appointment is deployment related.
    Airmen complete another screening assessment, the Post-Deployment 
Health Re-Assessment (PDHRA), within three to six months of return from 
deployment. Appropriate referrals for care are made as indicated by 
their responses to the PDHRA questions.
    In addition, on an annual basis, every military member receives a 
Preventive Health Assessment to ensure the required clinical preventive 
services are received and they meet their individual medical readiness 
requirements.
    As evidenced above, early identification of PTSD and other 
deployment related concerns is accomplished by the active involvement 
of commanders and helping agencies who not only train themselves, but 
also the average Airman on how to recognize distress and match that 
distress with the appropriate resource. In 2004, the Air Force began to 
emphasize the concept of being a good Wingman, a person who actively 
assesses and responds to the needs of his or her fellow Airmen.
    Air Force psychologists, psychiatrists, and social workers treat 
Airmen for PTSD at our Life Skills Support Centers (LSSC). Every 
installation in the Air Force has a LSSC and military members have 
first priority for treatment. The frequency and length of treatment is 
extremely variable, depending upon the symptom intensity, impact on 
functionality, and a host of other clinical issues.

                            RECRUITING GOALS

    Question. How successful were you in meeting your mission 
recruiting goals for this past year? Are there any specialties that 
have seen a drastic decline in retention?
    Answer. For fiscal year 2005, the Air Force Medical Service 
experienced limited success in recruitment of health professionals. The 
overall recruiting of fully qualified health professionals was 46.12 
percent of goal (see chart 1). A fully qualified health professional is 
a trained practitioner, fully ready to begin work and with no prior 
obligation to the Air Force.

                                 CHART 1
------------------------------------------------------------------------
                                    Fiscal Year 2005 September 30, 2005
         Fully Qualified          --------------------------------------
                                       Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................          204           29        14.22
DC...............................          104           23        22.12
NC...............................          350  ...........        57.14
BSC..............................           81           70        86.42
MSC..............................           35           35       100.00
                                  --------------------------------------
      FQ Total...................          774          357        46.12
------------------------------------------------------------------------

    The Air Force Medical Service has been quite successful in 
recruiting of health care professionals through the Health Professions 
Scholarship Program (see chart 2). The Health Professions Scholarship 
and Financial Assistance Programs (HPSP/FAP) are valuable training and 
force sustainment pipelines, particularly for the Medical Corps and 
Dental Corps. The overall recruiting success for HPSP was 108.28 
percent of goal while the resident Financial Assistance Program (FAP) 
met 56.41 percent of goal (see chart 3).

                                 CHART 2
------------------------------------------------------------------------
       HPSP (Scholarships)             Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................          191          220       115.18
DC...............................          105          107       101.90
NC...............................            7            3        42.86
BSC..............................           23           23       100.00
MSC..............................  ...........  ...........  ...........
                                  --------------------------------------
      HPSP Total.................          326          353       108.28
------------------------------------------------------------------------


                                 CHART 3
------------------------------------------------------------------------
         FAP (Residents)               Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................           35           21        60.00
DC...............................            4            1        25.00
NC...............................  ...........  ...........  ...........
BSC..............................  ...........  ...........  ...........
MSC..............................  ...........  ...........  ...........
                                  --------------------------------------
      FAP Total..................           39           22        56.41
------------------------------------------------------------------------

    The Air Force Medical Service continues to struggle with retention 
and staffing of multiple required specialties. While retention rates 
have not declined dramatically in recent years, retention after 
completion of the initial active duty obligation remains low for many 
specialties.

                        RECRUITING AND RETENTION

    Question. What are you as a service doing to try and address these 
critical shortfalls? How do you carry out the medical mission at home 
and abroad with a decline in recruiting and retention of specialty 
medical personnel?
    Answer. The Air Force Medical Service (AFMS) continues to 
experience challenges in recruiting and retaining physicians, dentists 
and nurses. Our current monetary incentive strategy includes the Health 
Professions Scholarship Program (HPSP), accession bonuses, loan 
repayments, and special pays or bonuses for retention of required 
specialties. We are also addressing top non-monetary concerns affecting 
recruiting and retention, such as tour length, deployments, working 
conditions, and educational opportunities. The AFMS is working closely 
with Recruiting Service, the personnel community and the Secretary of 
the Air Force for Manpower and Reserve Affairs to improve our 
accessions processes and secure the funding needed to retain health 
care professionals.
    The AFMS optimizes the effectiveness of healthcare delivery via 
efficient management of well trained members and teams operating 
smaller, faster, mobile, and modular platforms. The AFMS carries out 
its medical mission by utilizing personnel resources based on their 
multiple skill sets and diverse training. Additionally, we develop 
mutually beneficial working relationships with our Sister Services, 
TRICARE affiliates and networks, and civilian contract providers.

                     POST TRAUMATIC STRESS DISORDER

    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. The decision as to when an Airman who has been receiving 
treatment for Post-Traumatic Stress Disorder (PTSD) is ready for 
deployment is a medical decision made between the Airman and their 
medical provider based on medical expertise and the clinical 
circumstances. Command and mission constraints do not interfere with 
this medical decision making process. Airmen are not returned to 
deployable status before their medical provider has determined they are 
ready to deploy. Air Force psychiatrists, psychologists, and social 
workers are highly trained in the assessment and treatment of PTSD, as 
well as military fitness for duty determinations. These providers are 
trained in world-class residency and internship programs at medical 
centers across the United States.
    Medical providers communicate medical fitness for duty to the 
personnel system through the use of medical profiles. Airmen receiving 
treatment for PTSD who the medical provider determines should not 
deploy are given a psychiatric S4 profile (nondeployable). Commanders 
cannot override the profile and Airmen cannot deploy until their 
medical provider changes this profile. Thus, the military cannot 
redeploy Airmen until their medical provider determines they are ready.
    Factors that influence medical determinations of deployability 
include the resolution of the member's symptoms, the likelihood of 
relapse, the risk of recurrence if the member were re-exposed to 
trauma, the presence or absence of ongoing functional impairment due to 
the disorder, and the provider's estimation of the member's ability to 
psychologically tolerate the rigors of deploying to austere and hostile 
environments. If and when the provider determines the member is again 
ready for worldwide duty, the profile is changed from S4 to S1, S2, or 
S3 (all deployable profiles), depending on the clinical circumstances.
                                 ______
                                 
          Questions Submitted to Major General Melissa A. Rank
               Questions Submitted by Senator Ted Stevens

                        RECRUITING AND RETENTION

    Question. How successful were you in meeting your mission 
recruiting goals for this past year? Are there any specialties that 
have seen a drastic decline in retention?
    Answer. For fiscal year 2005, the Air Force Medical Service 
experienced limited success in recruitment of health professionals. The 
overall recruiting of fully qualified health professionals was 46.12 
percent of goal (see chart 1). A fully qualified health professional is 
a trained practitioner, fully ready to begin work and with no prior 
obligation to the Air Force.

                                 CHART 1
------------------------------------------------------------------------
                                    Fiscal Year 2005 September 30, 2005
         Fully Qualified          --------------------------------------
                                       Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................          204           29        14.22
DC...............................          104           23        22.12
NC...............................          350  ...........        57.14
BSC..............................           81           70        86.42
MSC..............................           35           35       100.00
                                  --------------------------------------
      FQ Total...................          774          357        46.12
------------------------------------------------------------------------

    The Air Force Medical Service has been quite successful in 
recruiting of healthcare professionals through the Health Professions 
Scholarship Program (see chart 2). The Health Professions Scholarship 
and Financial Assistance Programs (HPSP/FAP) are valuable training and 
force sustainment pipelines, particularly for the Medical Corps and 
Dental Corps. The overall recruiting success for HPSP was 108.28 
percent of goal while the resident Financial Assistance Program (FAP) 
met 56.41 percent of goal (see chart 3).

                                 CHART 2
------------------------------------------------------------------------
       HPSP (Scholarships)             Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................          191          220       115.18
DC...............................          105          107       101.90
NC...............................            7            3        42.86
BSC..............................           23           23       100.00
MSC..............................  ...........  ...........  ...........
                                  --------------------------------------
      HPSP Total.................          326          353       108.28
------------------------------------------------------------------------


                                 CHART 3
------------------------------------------------------------------------
         FAP (Residents)               Req       Recruited   Req Percent
------------------------------------------------------------------------
MC...............................           35           21        60.00
DC...............................            4            1        25.00
NC...............................  ...........  ...........  ...........
BSC..............................  ...........  ...........  ...........
MSC..............................  ...........  ...........  ...........
                                  --------------------------------------
      FAP Total..................           39           22        56.41
------------------------------------------------------------------------

    The Air Force Medical Service continues to struggle with retention 
and staffing of multiple required specialties. While retention rates 
have not declined dramatically in recent years, retention after 
completion of the initial active duty obligation remains low for many 
specialties.
    Question. What are you as a service doing to try and address these 
critical shortfalls? How do you to carry out the medical mission at 
home and abroad with a decline in recruiting and retention of specialty 
medical personnel?
    Answer. The Air Force Medical Service (AFMS) continues to 
experience challenges in recruiting and retaining physicians, dentists 
and nurses. Our current monetary incentive strategy includes the Health 
Professions Scholarship Program (HPSP), accession bonuses, loan 
repayments, and special pays or bonuses for retention of required 
specialties. We are also addressing top non-monetary concerns affecting 
recruiting and retention, such as tour length, deployments, working 
conditions, and educational opportunities. The AFMS is working closely 
with Recruiting Service, the personnel community and our Secretary of 
the Air Force for Manpower and Reserve Affairs to improve our 
accessions processes and secure the funding needed to retain health 
care professionals.
    The AFMS optimizes the effectiveness of healthcare delivery via 
efficient management of well trained members and teams operating 
smaller, faster, mobile, and modular platforms. The AFMS carries out 
its medical mission by utilizing personnel resources based on their 
multiple skill sets and diverse training. Additionally, we develop 
mutually beneficial working relationships with our Sister Services, 
TRICARE affiliates and networks, and civilian contract providers.
    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. The decision as to when an Airman who has been receiving 
treatment for Post-Traumatic Stress Disorder (PTSD) is ready for 
deployment is a medical decision made between the Airman and their 
medical provider based on medical expertise and the clinical 
circumstances. Command and mission constraints do not interfere with 
this medical decision making process. Airmen are not returned to 
deployable status before their medical provider has determined they are 
ready to deploy. Air Force psychiatrists, psychologists, and social 
workers are highly trained in the assessment and treatment of PTSD, as 
well as military fitness for duty determinations. These providers are 
trained in world-class residency and internship programs at medical 
centers across the United States.
    Medical providers communicate medical fitness for duty to the 
personnel system through the use of medical profiles. Airmen receiving 
treatment for PTSD who the medical provider determines should not 
deploy are given a psychiatric S4 profile (nondeployable). Commanders 
cannot override the profile and Airmen cannot deploy until their 
medical provider changes this profile. Thus, the military cannot 
redeploy Airmen until their medical provider determines they are ready.
    Factors that influence medical determinations of deployability 
include the resolution of the member's symptoms, the likelihood of 
relapse, the risk of recurrence if the member were re-exposed to 
trauma, the presence or absence of ongoing functional impairment due to 
the disorder, and the provider's estimation of the member's ability to 
psychologically tolerate the rigors of deploying to austere and hostile 
environments. If and when the provider determines the member is again 
ready for worldwide duty, the profile is changed from S4 to S1, S2, or 
S3 (all deployable profiles), depending on the clinical circumstances.
                                 ______
                                 
          Questions Submitted to Major General Gale S. Pollock
               Questions Submitted by Senator Ted Stevens

    Question. How successful were you in meeting your mission 
recruiting goals for this past year? Are there any specialties that 
have seen a drastic decline in retention?
    Answer. Our efforts to achieve the Active Component nurse mission 
have not been successful since 1999. The U.S. Army Accessions Command 
(USAAC) achieved 83 percent of the required mission in fiscal year 
2005. Unfortunately, USAAC projects that they will only complete 73 
percent of mission in fiscal year 2006. As of April 30, 2006, the 
Active Component is 304 officers below authorized strength. Recruiting 
is essential as it is through new medical surgical nurse accessions 
that we then educate into specialties such as anesthesia, critical 
care, preoperative and OB/GYN nursing.
    In fiscal year 2005, the recruiting mission for the Reserve 
component was 485, only 66 percent of this goal was achieved. Since 
2003, accession into the Reserve is an average of 21 percent below 
mission. In addition, 50 percent of those nurses accessed are not 
baccalaureate prepared, and are not eligible to remain in the Reserves 
long-term.
    Our active duty retention rate has declined overall to 91 percent 
in fiscal year 2005. Unfortunately, when we look at the number of 
specialty nurses, retention failure has lowered their numbers such that 
operational tempo is significantly increased and data indicates this 
increased deployment rate is contributing to their exit from the 
military. This is a problem for preoperative, critical care and 
emergency room nursing staff as well as the nurse anesthetists.
    The Reserve Component retention rate is adversely affected by the 
failure to recruit BSN nurses and the mandatory release of those who 
are unwilling to complete their educational requirements to serve as a 
military officer.
    Question. What are you as a service doing to try and address these 
critical shortfalls? How do you to carry out the medical mission at 
home and abroad with a decline in recruiting and retention of specialty 
medical personnel?
    Answer. We are actively addressing both recruiting and retention to 
assess critical shortfalls. We recently implemented the ``Every Nurse 
is a Recruiter'' initiative to increase participation by all Army 
Nurses in nurse recruiting. Our AMEDD Enlisted Commissioning Program 
provides active duty Soldiers the opportunity to complete their BSN and 
receive an appointment as an Army Nurse. The Health Professions Loan 
Repayment Program is also available to our officers as both a 
recruiting and a retention incentive. Data suggests that retention of 
our officers is largely dependent on three main factors: job 
satisfaction, education and training, and retirement benefits. To 
better prepare our new graduates, we are developing an enhanced Nurse 
Internship Program. We also offer intense entry-level courses in a 
variety of nursing specialties and our nurse anesthesia program, ranked 
second in the nation, continues to serve us well. We fully fund many of 
our nurses to complete graduate or doctoral degrees in nursing or 
closely related fields. We recently implemented a pilot program to 
train Registered Nurse First Assistants. Finally, the U.S. Army Medical 
Command (MEDCOM) utilizes a system called the PROFIS Deployment System 
(PDS). The PDS helps to ensure equitability of deployments within each 
specialty of nursing by tracking both who has deployed and the duration 
of that deployment. All MEDCOM Soldiers are able to volunteer online 
for deployments, this ongoing opportunity provides an element of 
predictability for our officers. All of these programs are crucial to 
our accession and retention efforts.
    We utilize a combination of Reserve Component, civilian and 
contract nurses to augment our deploying staff, but they are often not 
available. Our retention rate is negatively affected by the increased 
demand at home station for the nurses who are not deployed in support 
of OEF/OIF. Whenever we are unable to hire civilian nurses in part due 
to the hiring constraints of OPM on college graduate nurses or are 
unable to fill contract positions, our military nurses must serve in 
their stead in addition to normal work demands. This constant pressure 
on our junior nurses contributes to their decision to leave the 
military. Finally, data suggest that increased lengths of deployment 
negatively impact retention rates. In addition to increasing their 
incentive pay in fiscal year 2005, implementation of a 180-day 
deployment rotation policy was a good initial step in stemming the loss 
of our certified registered nurse anesthetists.
    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. The Army uses multiple screening processes to ensure all 
Soldiers who deploy are capable of performing their duties and do not 
pose a risk to themselves or other members of their unit.
    Prior to deployment Soldiers receive a pre-deployment assessment 
which includes questions about mental health. If Soldiers have a 
positive response to the mental health questions they receive further 
evaluation by a clinician. If the Soldier has symptoms of PTSD on the 
pre-deployment assessment, the symptoms are evaluated and treated by a 
mental health practitioner. A fitness for duty assessment is ordered if 
necessary. The final recommendation on deployment is based on clinical 
judgment of the treating provider and input from the unit commander.
    Research shows that all Soldiers are affected by combat experiences 
and the most seriously affected are those exposed to frequent direct 
combat or the injuries sustained in combat. It is likely that multiple 
deployments will lead to increased symptoms of PTSD. Soldiers with PTSD 
are identified in multiple ways. They may self-identify, be identified 
by the post-deployment health assessment, the post-deployment health 
re-assessment, or be referred by a family member or command. If a 
Soldier has PTSD or other psychological difficulties, they are further 
evaluated and treated using well-recognized treatment guidelines. These 
include psychotherapy and pharmacotherapy. They are delivered in a 
variety of venues, in theater and garrison, an outpatient or inpatient 
setting, and individually or in a group.
                                 ______
                                 
     Questions Submitted to Rear Admiral Christine M. Bruzek-Kohler
               Questions Submitted by Senator Ted Stevens

                        MEDICAL RECRUITING GOALS

    Question. How successful were you in meeting your mission 
recruiting goals for this past year?
    Answer. Navy did not meet recruiting goals in medical programs in 
fiscal year 2005 for either the Active Component (AC) or Reserve 
Component (RC). Navy attainment by program was: Medical Corps--58 
percent AC, 60 percent RC; Dental Corps--76 percent AC, 39 percent RC; 
Medical Service Corps--82 percent AC, 60 percent RC; and Nurse Corps--
73 percent AC, 97 percent RC.
    Question. Are there any specialties that have seen a drastic 
decline in retention?
    Answer. Within our wartime specialties, shortfalls have been 
identified in critical care--64 percent manned, peri-operative 
nursing--89 percent manned, and nurse anesthesia--90 percent manned.

            ADDRESSING BILLET SHORTFALLS AND MEETING MISSION

    Question. What are you as a service doing to try and address these 
critical shortfalls?
    Answer. Navy is executing a Total Force plan to correct medical 
personnel shortages through a coordinated effort by the Chief of Naval 
Personnel, the Surgeon General of the Navy, Commander Navy Recruiting 
Command and Chief of the Navy Reserve.
    We have reemphasized recruiting in critical medical specialties 
through an expanded bonus program, education loan relief programs, and 
medical specialty pays. Specific measures we have implemented since 
fiscal year 2005 include increasing capacity in our most popular 
accession programs, implementing the Health Profession Loan Repayment 
Program, diversifying our accession sources, and increasing the 
following financial incentives: Nurse Corps Direct Accession Bonus, 
Nurse Candidate Program Accession Bonus, Nurse Candidate Program 
Monthly Stipend, and the Certified Registered Nurse Anesthesia 
Incentive Special Pay. We are continuously evaluating these newly 
initiated efforts while exploring other options to retain our talent at 
the 4-10 years of service level.
    To combat reserve shortfalls, we have implemented a mobilization 
deferment process whereby an Active Component (AC) officer 
transitioning to the Reserve Component (RC) may apply for deferment 
from mobilization for up to one year. This initiative is aimed at those 
separating AC officers who have recently deployed and may be hesitant 
to transition to the RC for fear of immediate re-deployment. 
Additionally, we are considering an option for Medical Professionals 
that would permit shorter, predictable mobilization periods to limit 
``time away from practice,'' a common reason for both medical attrition 
and shortages in accession.
    Question. How do you carry out the medical mission at home and 
abroad with a decline in recruiting and retention of specialty medical 
personnel?
    Answer. Our facilities abroad have priority status and are not 
affected by medical manning shortfalls.
    At home, we have a broad range of options, including contracting 
for care or referring care to the TRICARE Managed Care Support Contract 
Network. The TRICARE network is designed to support the military direct 
care system in times of sudden or major deployment of Military 
Treatment Facility staff. In addition, Reserve personnel in designated 
key specialties are utilized when required by Military Treatment 
Facilities at home.

                  POST TRAUMATIC STRESS RETURN TO DUTY

    Question. How do you determine when a service member who has been 
receiving treatment for PTSD is ready for deployment again? Are once-
deployed soldiers, sailors, airmen and Marines being sent back too 
early?
    Answer. Anyone exposed to the extremely stressful environment of 
combat is affected by those events. The majority of service members are 
able to cope with and integrate these events over time and experience 
no significant or lasting impact. However, a small percentage will need 
assistance in dealing with their experiences and may ultimately be 
diagnosed and treated for PTSD or other mental health conditions.
    Navy Medicine is committed to providing appropriate mental health 
care to our Sailors and Marines and to their families. In order to 
accomplish this mission several continuous programs of education, 
training, assessment, referral, and professional care have been 
implemented. These services are provided to service members and their 
families before, during, and after deployment to an operational 
theater.
    For Sailors and Marines preparing for a deployment, the Department 
of the Navy (DON) provides a comprehensive program of stress education, 
health surveillance, and forward identification and management of 
stress symptoms, including psychiatric conditions such as PTSD. A broad 
range of services are available to our Sailors and Marines while 
underway and while in port via our MTFs, psychologists aboard ships, 
and other non-medical assets such as Fleet and Family Service Centers 
and chaplains. The Marine Corps' Combat Operational Stress Control 
(COSC) Office, headed by a Navy psychiatrist with combat experience, is 
actively engaged in heightening awareness of combat and operation 
stress, ensuring quick access to care, and strengthening the coping 
skills of Marines and their families. In theater, members with stress 
problems receive prompt support from chaplains, medical officers, and 
mental health providers embedded with the operating forces through the 
Operational Stress Control and Readiness (OSCAR) program. Upon 
returning, service members are prepared for reintegration with their 
communities through the ``Warrior Transition'' and ``Return & Reunion'' 
programs.
    Navy Medicine actively encourages our Sailors and Marines to seek 
care for behavioral health concerns from a variety of sources. We 
include information on the availability of behavioral health care 
services on all deployment and redeployment briefs. Our Navy chaplains 
provide information on availability of counseling from pastoral and 
medical sources in Warrior Transition Briefs. Our Fleet and Family 
Services Centers and Marine Corps Community Services assets publish 
availability of non-medical counseling for behavioral issues.
    The stigma associated with seeking mental health care remains a 
significant issue, both in the military and in society in general. To 
overcome that barrier, the Navy and Marine Corps team realizes that to 
overcome that barrier time and education are essential; however, at 
heart it is a leadership issue. As a result, we educate and 
indoctrinate our leaders to be aware of potential behavioral health 
care concerns and of the availability of medical and non-medical assets 
to manage these concerns. Two new programs we offer are the ``Leader's 
Guide to Personnel in Distress'' with versions for both Navy and Marine 
Corps.
    We continually evaluate service members prior to and immediately 
following their deployments to determine whether they've suffered any 
adverse psychological or physical consequences of that deployment using 
the Pre and Post Deployment Assessment (PDHA) process. Three to six 
months following deployment, we are instituting screening of each 
service member with the Post Deployment Health Reassessment (PDHRA). 
Any service member who identifies emotional or physical concerns 
related to their deployment is referred for further evaluation and 
treatment as indicated. If a service member is deemed to have a 
deployment limiting condition in need of treatment, we would not 
redeploy that member until appropriate treatment had been rendered and 
the service member restored to a duty status.

                          SUBCOMMITTEE RECESS

    Senator Inouye. The subcommittee will reconvene on May 10 
at 10 a.m., in this room, SD-192, to review the missile defense 
program for fiscal year 2007.
    The subcommittee will now stand in recess. Thank you very 
much.
    [Whereupon, at 12:03 p.m., Wednesday, May 3, the 
subcommittee was recessed, to reconvene at 10 a.m., Wednesday, 
May 10.]
