Soldiers' Experiences with Military Health Care - UNC School of Nursing

MILITARY MEDICINE, 170, 12:999, 2005

Soldiers' Experiences with Military Health Care Guarantor; COL Bonnie M. Jennings, AN USA (Ret.) Cotitributors: COL Bonnie M. Jennings, AN USA (Ret.)*; Lori A. Loan, PhD RNCf; Stacy L. Heiner, RN BSN*; COL Eileen A. Hemman, AN USA (Ret.)*; Kristen M. Swanson, RN PhD FAAN| Patient satisfaction can be enhanced by narrowing gaps between what health care consumers experience and what they expect. A study was therefore conducted to better understand health care experiences and expectations among Army beneficiaries. Data collected using focus groups were analyzed by using qualitative research methods. A concept was identified and labeled "Soldier Care." It involves first-line care delivered at the unit level as well as the interface between first-line care and military treatment facilities. There are four features of Soldier Care, i.e., provider competence, the sick call cycle, getting appointments, and unit leadership. Together, these features affect soldiers' time from injury to recovery. Insights about Soldier Care can provide decision-makers with direction for initiating changes that may contribute to improved soldier satisfaction with health care.

study was conducted to better understand satisfaction among Army health care beneficiaries.'' The study was guided by three broad questions. Quite separate from those questions, and not expected by the investigators, was the identification of a concept labeled "Soldier Care." The findings about Soldier Care are reported here. Methods

Study Design The study was conducted using descriptive phenomenological methods based on the assumption that health care is a process with deep personal meaning.'^"'^ Inherent to this method is the requirement that the researchers bracket or suspend their personal beliefs and biases. Neutrality on the part of the investigaIntroduction tors is essential to accurately poilray experiences as they are hroughout the United States, health care is in turmoil. Part described by study participants. Focus groups are well suited to collecting qualitative research of the turmoil is created by the tension between infinite health care needs and finite health care resources. The tension data."^ They are also becoming a common means for gathering involves difficult tradeoffs among cost, quality, and access.' The input from health care consumers to improve quality.^'^ Focus military health system (MHS) is not immune from this turmoil. group interviews are conducted in a methodologically rigorous Just as the rising cost of health care was the catalyst for change way by a skilled moderator, who keeps the discussion moving in civilian health systems, increasing health care costs within and consistent with the topic. These guided group discussions the Department of Defense prompted a move to a military man- are a rich source of data about participants' experiences and aged care system known as TRICARE. The MHS has a mandate beliefs.'^'^ Focus groups were used in this study to gather data to provide comprehensive health coverage to >8 million benefi- from consumer beneficiaries and health care personnel (HCP) in ciaries worldvidde.^ The shift to TRICARE thus created a pro- two geographically distinct TRICARE regions. found change for a large beneficiary population. The focus group moderator must set the tone for the session Although the MHS strives for excellence, quantitative assess- and skillfully guide the discussion.'^'^ In this study, the same ments of TRICARE suggest that beneficiaries are not satisfied moderator conducted all of the focus groups. The moderator was with certain aspects of their care.^"^ Moreover, compared with all a MHS civilian rather than a uniformed service member. This other beneficiaries, active duty (AD) personnel report the least ensured that the moderator was sufficiently familiar with the nuances of the military to appropriately guide the discussion overall satisfaction with the health care system.**'^ while avoiding the perception of coercion. The moderator was Satisfaction, which is a key component of health care quality and an important health care outcome, is related to differences trained by an expert in qualitative research and focus groups. between patients' experiences and their expectations.^"'" Logical This expert vertfied the moderator's skills in conducting focus steps to enhance military patient satisfaction are to examine groups before the initiation of data collection. MHS beneficiary experiences and what beneficiaries expect and then to take action to reduce the gaps. Therefore, a qualitative Sample Although stratified random sampling is unusual in qualitative *The Geneva Foundation, Tacoma, WA 98405. studies, it was used to recruit soldiers and family members (i.e., tMadigan Army Medical Center, Tacoma, WA 98431, health care consumers) by considering region, site where care IDepartment of Family and Child Nursing. University of Washington, Seattle. WA was given, rank, gender, and ethnicity. In addition, purposive 98915, Preliminary fmdings were presented at the Phyllis J, Verhonick Nursing Research sampling was used to recruit a variety of HCP ranging from Conferences, April 29 to May 3, 2002, and April 26-29, 2004, San Antonio, TX, providers to administrators.

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The information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred from, the TriSerWce Nursing Research Program, Uniformed Services University of the Health Sciences, the Army Medical Department, the Department of the Army, the Department of Defense, or the U,S, government. This manuscript was received for review in August 2004, The revised manuscript was accepted for publication in December 2004,

Procedure

After acquiring approval from appropriate Institutional Review Boards, lists of potential participants were created based on data in the MHS data repository. These lists were compiled to

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Soldiers' Experiences with Military Health Care

ensure that individuals meeting the inclusion criteria would be given the opportunity to participate. Therefore, the lists were based on region, site of care, rank, gender, and ethnicity. The names on the lists were sorted with a random number generator and supplied to the research assistants (RAs) in increments of 100 names. The RAs used the lists to contact potential participants, with the goal of locating 20 individuals who verbally agreed to participate in the focus group being recruited. A standard script was used to inform individuals about the study. Those who agreed to participate were sent a letter restating information discussed during the telephone conversation. Additionally, a few days before each focus group meeting, the RAs called each person who had agreed to participate, to remind them about the focus group. Before the start of each focus group, vmtten informed consent was obtained. The moderator used a scripted dialogue at the beginning and end of each focus group. A list of possible probes was available to stimulate the discussion, but the probes were not used. The groups were eager to talk based on two general queries posed by the moderator, as follows. (1) What do you expect from the MHS? (2) Give me some ideas of what happens to you when you go to get health care. The moderator was diligent in soliciting both positive and negative experiences from the participants. All focus groups were recorded verbatim by a court reporter and converted into Word (Microsoft, Redmond, Washington) documents. The transcripts were assessed by all members ofthe research team using the iterative analytic process described by Colaizzi.'^"'^ Specifically, each transcript was read by each investigator independently. As a group, the investigators extracted phrases pertinent to the questions being investigated. These phrases were the unit of analysis in this study. The phrases were then formulated into categories and themes. The rigor of the analysis was maintained by attending to tenets of trustworthiness applicable to qualitative research.^" The fmdings reported here are based on 564 pages of transcripts from which the Soldier Care concept emerged. Results Sample Characteristics AD Army personnel (n = 15) and AD family members (n= 11) ranged in age from 21 to 55 years. The AD consumers included eight commissioned officers, three warrant officers, and four enlisted soldiers. All enlisted participants were men. All family members were women; 4 of the 11 AD officers were also women. The group included 13 Caucasian participants, 6 African American participants, 4 Hispanic participants, and 1 each of Pacific Islander, Asian, and other participants. Participants discussed their experiences with care at both military treatment facilities (MTFs) and troop medical clinics (TMCs). TMCs are medical clinics designed for sick call. They also provide limited treatment, immunization services, medical examinations, physical profiling, and limited pharmacy dispensing sendees,^' HCP ranged in age f^rom 29 to 56 years based on data for the 27 individuals for whom age data were available. Of the 31 HCP, 14 were men and 17 were women. Most ofthe HCP participants were AD commissioned officers (n = 23), seven were MHS civilian workers, and one was an enlisted member. There were 12


physician participants (39%), 8 registered nurses (26%), 4 physician assistants (PAs) (13%), 4 physical therapists (13%), 1 administrator, 1 social worker, and llicensed practical nurse. Although medics were invited to the focus groups, none attended. Therefore, the perspective of the medic is absent from these data. Ethnically, 25 HCP were Caucasian, 3 were African American, 2 were Asian, and 1 was Hispanic, HCP practiced in both MTFs and TMCs. All of the HCP were also MHS beneficiaries and therefore could address care from both consumer and provider perspectives. Features of Soldier Care

The investigators were not aware of the features of Soldier Care, as explained here, before this study. However, early in the analysis it became clear that health care for soldiers was quite different from health care for family members. This led the investigators to identify the Soldier Care concept. Soldier Care can be defined as a spectrum of health care that starts with unit-level care, spans the interface between unit and MTF care, and continues until injured soldiers are fully recovered and able to return to duty. In the Army, soldiers are initially treated at battalion aid stations and TMCs, This care is provided by flight surgeons and other physicians, as well as field medics and PAs. Overall, participants were not impressed with their initial treatment. There are four features of Soldier Care that may increase the time from injury to recovery, thereby exerting an effect on units' readiness posture. These features include gaps between what soldiers expect and what they experience regarding health care provider competencies, sick call cycle inefficiencies, appointment challenges, and lack of support from unit leaders. The features of Soldier Care, the experiences that render them problematic, and the expectations that provide direction for improvements are listed in Table I, Provider Competence

The importance of accurately and swiftly diagnosing problems is illustrated by a 24-year-old enlisted soldier who had a foot problem. They [the medics] kept pretty much blowing me off at the aid station, telling me it was something totally different. , . , When I went to (the MTF] . ., the podiatry section , . , told me , . . "If you had come here to begin with, we could have taken care of this 5 or 6 months ago, instead of you continuing to be on profile and not getting well." This soldier's recommendation for improving care was to place more qualified providers in the aid stations. He was not confident in the skills of medics who were "looking into books" for the answers. Female soldiers expressed some gender-specific concerns about provider competence. A 34-year-old female warrant officer summarizes these concerns. All the guys in the aid station are guys. And females go in there . . . complaining of a headache or stomachache, first thing they do is they give you a pregnancy test. Provider competence, however, has less to do with degrees than it does with understanding soldiering. Being a superb


1001 TABLE I FEATURES OF SOLDIER CARE

Features Provider competence

The sick call cycle Depersonalized Diagnosis

Profiles

Recovery Getting appointments

Unit leadership

Experiences Too often providers fall to take Into account the full nature of the specific physical requirements of a soldier's Job.

Expectations Soldier care is enhanced when providers have a solid grasp of how the military works and what soldiers do in their jobs.

Sick call operates in a very depersonalized way; it is "see 'em and street 'em" medicine.

Soldiers expect to be treated with courtesy and respect; they expect to be believed and not have their concerns "blown off." Shorten the time soldiers spend in the Motrin/ profile cycle and facilitate them getting into the direct care system sooner.

It takes too long to get an accurate diagnosis; too heavy a reliance on Motrin as the treatment of choice and repeated temporary profiles prolong reaching a definitive diagnosis. Medical profiles are too vague; they are written without knowledge of what soldiers'jobs entail. and they do not address what soldiers can do along with what they cannot do. It takes too long for soldiers to go from injury to full recovery. The current appointment system does not consider the length of soldiers' duty days or training activities that pull them away from garrison. Unit leaders view soldier health care as a necessary nuisance; creates tension between needing soldiers at their duty stations and allowing soldiers to keep appointments or comply with injury profiles.

Protect soldiers from making their injuries worse; profiles should be specific and tailored to the soldiers' jobs. Keep soldiers fit tofight;expedite the time from injury to recovery. The MHS should accommodate military life; soldiers must be able to get appointments in a timely manner. Instill good communication between unit leaders and health care providers to improve unit compliance with profiles and increase the chance of soldiers keeping appointments and getting the care they need.

The need for a quick disposition so that soldiers can get back to work contributes to sick call being regarded as depersonalized. More importantly, sick call often sets in motion a repetitious sequence involving profiles and Motrin (ibuprofen, McNeil I don't want to say doctors do not believe people, but know- Consumer & Specialty Pharmaceuticals, Fort Washington, ing what certain jobs require . . . that maybe somebody is Pennsylvania), Profiles provide an index of functional capacity; coming in [whose job has them] wearing a heavy pack, they are governed by Army Regulation 40-501.^^ Medical permaybe three times a week or for a couple weeks at a time, sonnel issue profiles to inform unit leaders and individual soljumping out of airplanes, jumping off vehicles, and maybe diers about physical limitations resulting from illness or injury. Profiles are used to modify physical activity for a specified time understanding these injuries. by limiting soldiers' participation in physical training or certain Special Forces medics, in contrast, were viewed as being quite aspects of their jobs (e.g., jumping out of airplanes). competent. Because they train with other soldiers, they have a Soldiers expect quick initiation of appropriate treatment to good grasp of how injuries happen as well as how to treat them. expedite their return to duty. Instead, providers rely heavily on A 26-year-old AD officer recounted how Special Forces medics expedited his care for a nontraumatic problem during a field Motrin, which the soldiers and family members call "Ranger training exercise. The soldier moved from the field to the TMC Candy," "Vitamin M," or "Sweet Tarts," Using Motrin as the and on to the MTF, where he had surgery, all in 1 day. Such swift initial treatment is sometimes the right thing to do. Other times, it delays definitive diagnosis and treatment. Officers, enlisted intervention was the exception. soldiers, and family members objected to the repeated use of Motrin. The sentiment was conveyed by a 26-year-old male The Sick Call Cycle enlisted soldier. Sick call is the means by which most soldiers initially access care. Both HCP and soldiers see sick call similarly, referring to it If you have an injury, ibuprofen is the solution, .. , If you as "cattle call medicine" because of the large volume of patients come in there with an inflamed joint, they'll give you rapidly triaged. A 39-year-old civilian PA conveyed a common Motrin, If you come in there with a tooth that's falling out, sentiment, i.e., that sick call was about moving the numbers. you're getting Motrin, I guess it's the common cure for everything. I don't think soldiers feel that they were actually listened to or cared for as much as if you were able to spend a little bit Profiles are also a source of concern among both soldiers and more time with them. HCP, Remarks were highly consistent between the HCP and surgeon is not enough. Participants expected HCP to understand soldiers' jobs and to initiate treatment that is more specific to their jobs and their injuries. This expectation was well stated by a 30-year-old male officer,


1002 soldiers regarding the expectation that profiles should be written and used to protect soldiers from further injury. Several of the HCP were aware of the need to tailor profiles specific to the individual's job and the injury. However, the HCP also observed that frequently this specificity was not achieved, as noted in remarks by a 44-year-old, male, civilian PA. Most docs at our clinic don't know to ask what the person's job is. So they're [the soldiers] going to get a generic answer [profilel whether they're a finance clerk or an infantryman. The Appointment Obstacle Course

When unit-level care fails to retum soldiers to a healthy status so they are "fit to fight," soldiers need to access care at the MTF. Although other beneficiaries face challenges in getting appointments, these challenges are compounded for soldiers because of their training schedules. This may initiate the appointment obstacle course, i.e., telephone calls, no appointments available, and then out for training, which may repeat itself for several months before a soldier succeeds in scheduling an appointment. The experience of a 30-year-old male officer who tried to coordinate an appointment with his unit's training schedule typifies the situation. I would call for an appointment with the MRI (magnetic resonance imaging] folks. And they're, like,... "I have one appointment available a month from now." "Okay, well, I'm deployed [then]. I can't take that one. Can you . . . put me in 2 months from now?" "Well, we don't book out that far." So then I get back from the deployment [and] call again. "No, we're all booked up but you can have this date." "Well, I'm gone again, and I get back on this date." "Well, we can't book out that far." It was j u s t . . . it was infuriating, absolutely infuriating. So I think the appointment system they have is designed for like we work 9-to-5 jobs, and we don't.

Soldiers' Experiences with Military Health Care Unit leaders, for the most part, were portrayed as having a low tolerance for soldiers who are not fully functional. Soldiers quickly leam they may need to "suck it up," or carry on with their mission despite health problems. A 44-year-old PA summarized the situation by noting, I have more problems with commanders and supervisors . . . they push the troops until they are broken and figure, "I'll just get a new one," . . . rather than give the person time to get better. . . . They want them to get in formation and just mn until they drop out. Both soldiers and HCP were well aware of the stigma of being labeled a "broken soldier." An AD physician who was married to a soldier noted, "Anything medical is a sign of weakness." Similarly, the will of the commander with respect to appointments was illustrated by a 30-year-old female physician. Some commanders sort of think [soldiers'] personal health care time is before 0900 and after 1700, so they won't let [soldiers] go for physical therapy or occupational therapy. I've had [soldiers] miss CT [computed tomography] scans, MRI [magnetic resonance imaging] scans, consults to consultants who are really hard to get appointments with . .. and it's just the commanders thinking that's not important. This perspective was consistent with the view of AD soldiers and family members. In the words of a 26-year-old male officer. For me to be able to get an hour out of my time to go down there [to the MTF], I think the hardest part is going through the u n i t . . . trying to get the time or trying to be able to do it.

Other unit leaders may also create obstacles to getting care. Platoon sergeants and squad, team, or platoon leaders may decide who gets to leave work to get care. A 37-year-old female physician thought the age of the leader was an important factor. The incompatibility of the current health care appointment Younger leaders are still leaming their jobs and might view structure with soldiers' work schedules was mentioned fre- health care as a nuisance because it interferes with work and quently. The essence of the problem is illustrated in the words of training of the troops. Conversely, efficiently delivered health a 39-year-old male officer. care could be seen as supporting the mission because it keeps I've got to go in for orthopedic surgery because I've been soldiers fit to fight. Soldier Care is enhanced when solid relationships are estabputting it off for about a year now, just because of the nature of my lovingjob. I couldn't go in the daytime.... My lished between HCP and unit leaders. Good two-way communijob, you know, starts at 0600, and I did not normally get cation creates a strong bridge between the unit and the health care system. When unit leaders know the HCP, it is possible to out until approximately 1930. negotiate times for soldiers to get care that fit best into the unit's schedule. Additionally, as commanders grow to tmst the HCP, The Role of Unit Leadership in Soldier Care they are more likely to initiate calls to the HCP regarding soldiers The interface between the soldier's unit (its leadership and whose health coneems them. philosophy regarding health care) and the health care system was threaded throughout the data. Commanders regulate soldiers' whereabouts, including whether they are released from It's a Long Road from Injury to Recoveiy duty for medical appointments. They also have the final say in Soldiers experience a long road from injury to recovery, in part whether the parameters of a profile are followed. The power of because of the features of Soldier Care. All too often, the recovthe command structure in supporting or thwarting health care ery process is prolonged because of issues such as those dewas recognized by soldiers, family members, and HCP. As noted scribed by a 26-year-old enlisted participant. by a 51-year-old PA, We've got a soldier . .. [who[ got hurt in May, and they The commander can do whatever he wants to do. If I put finally got notice it was going to be like October before he somebody on quarters [but] the commander says, "No, gets in there to get the surgery. And then he's going to be you're going to work today," you work. out. And to the Army, that's almost a whole year . . . beMilitaiy Medicine, Vol. 170, December 2005

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Soldiers' Experiences with Military Health Care cause he's got to go through all the rehab from it, and that's another 6 months. . . . So we've pretty much lost a soldier for a whole year there. The consequences of delays in recovery are experienced by soldiers, their military units, and the Army. Morale may be diminished among injured soldiers who feel stigmatized and unchallenged when assigned to administrative duties in lieu of their usual jobs. These become quality of life and retention issues, as reflected in the comments of a 30-year-old male officer. Health care has an enormous impact upon morale, and that just cascades down into so many other things: productivity, reenlistment, retention. It plays a huge role. Unit cohesion may be reduced when injured soldiers cannot perform mission-related training. This creates vacancies that may jeopardize units' readiness status. A 26-year-old male enlisted soldier noted. They [soldiers on profile] are held on our battle rosters. And they take up a space, so we can't get a fully functional soldier in because he's there.

Discussion Although AD soldiers are covered by the preferred TRICARE option (Prime), their initial access to care remains outside the TRICARE system itself. These data provide a view of factors, collectively referred to as Soldier Care, that may contribute to dissatisfaction with care among AD soldiers. Along with lengthening the time from injury to recovery. Soldier Care issues may have an impact on readiness. Concerns about provider competence suggest that training for all individuals providing care to soldiers needs to address the military culture. Being a good surgeon, for instance, is necessary but not sufficient. Taking good care of soldiers requires that HCP understand what each soldier's job entails, the role of unit leadership, and the military culture. Despite sick call being a longstanding military tradition, it may be overdue for a major overhaul. The dissatisfaction with sick call was confirmed in findings from a separate study." Along with improving interactions so that soldiers feel respected and valued, the seemingly automatic reliance on Motrin and profiles needs to be carefully examined. Possible strategies to improve profiles can be found in the regulation governing them, namely. Army Regulation 40-501.^^ Profiling officers, who are to be designated by MTF commanders, are expected to be thoroughly familiar with the contents of the regulation. Educating providers about how to tailor profiles to soldiers'jobs and monitoring the thoroughness of profiles could enhance satisfaction among AD personnel. This education needs to be ongoing, because individuals in the early stages of their medical training are likely to be more focused on acquiring technical proficiency and less focused on militaiy aspects of care. Although a goal of TRICARE is to improve access,* evidence from this study suggests that the goal is not being met for AD soldiers. For example, appointment times do not occur when soldiers can easily access the system. Although extended hours would put additional stress on clinical systems that may be underresourced,^"* soldiers greatly appreciated after-hours clin-

ics. Additionally, altering the appointment system to allow scheduling into the future would better accommodate soldiers as well as other MHS consumers. Finally, the tension between training and getting care was strongly conveyed in these data. The soldiers are caught in a tug-of-war. They expressed a fierce loyalty to their units, a strong desire to be kept fit to do their jobs, and a struggle to get the care they need. Unit leaders need to develop a better appreciation of how health care sustains soldiers' fitness and directly supports readiness. There is an interesting irony in the "mission first" norm within the military culture. Soldiers are essential to doing the mission, so which ought to come first, the mission or the "men"? The discrepancies between what soldiers experience and what they expect indicate possible sources of dissatisfaction with military health care. These sources of dissatisfaction represent opportunities for improvement. They are also dimensions of care not typically assessed by satisfaction surveys. Therefore, they represent a set of factors that may be pivotal to soldier satisfaction. With intervention to better align experiences and expectations, AD satisfaction with Soldier Care might be improved. Acknowledgment This research was sponsored by the TriService Nursing Research Program (grant NOO-023), Uniformed Services University of the Health Sciences.

References 1. Kissick WL: Medicine's Dilemma: Infinite Needs versus Finite Resources. New Haven. CT. Yale University Press. 1994. 2. SheltonH: Defense health care: the way ahead. Retired Off Mag 2001: 57: 53-8. 3. Jennings BM. Loan LA: Patient satisfaction and loyalty among military healthcare beneficiaries enrolled in a managed care program. J Nurs Admin 1999: 29(11|: 47-55. 4. Stoloff PH. Lurie PM. Goldberg L. Almendarez M: Evaluation of the TRICARE Program for FY 1999: Report to Congress. 2001. Washington. DC. 2001. 5. Jennings BM. Loan LA. Wilson S: A Survey of Access to Care in the TRICARE Environment: Final Report for Proposal N96-018. Bethesda. MD, TriService Nursing Research Program. 2001. 6. Bendall D. Powers TL: Cultivating loyal patients: even in managed care, service satisfaction is a critical success factor. J Health Care Mark 1995: 15: 50-2. 7. Cleary PD. Edgman-Levitan S: Health care quality: incorporating consumer perspectives. JAMA 1997: 278: 1608-12. 8. Conway T. Willcocks S: The role of expectations in the perception of health care quality: developing a conceptual model. Int J Health Care Qual Assur 1997: 10: 131-40. 9. Jones KR. Bumey RE. Christy B: Patient expectations for surgery: are they being met? Jt Comm J Qual Improv 2000: 26: 349-60. 10. Kravitz RL: Patients' expectations for medical care: an expanded formulation based on review of the literature. Med Care Res Rev 1996: 53: 3-27. 11. Jennings BM. Loan LA. Heiner SL. Hemman EA: Expectations of Military Health Care: An Inductive Analysis: Final Report for Proposal NOO-023. Bethesda. MD. TriService Nursing Research Program. 2004. 12. Colaizzi PF: Psychological research as the phenomenologist views it. In: Existential-Phenomenological Alternatives for Psychology, pp 48-71. Edited by Valle RS. King M. New York. NY. Oxford University Press. 1978. 13. Husserl E: Gibson WRB. trans: Ideas: General Introduction to Pure Phenomenology. London. United Kingdom. George Allen & Unwin. 1931. 14. Swanson-Kauffman K. Schonwald E: Phenomenology. In: Paths to Knowledge: Innovative Research Methods for Nursing, pp 97-105. Edited by Sarter B. New York. NY. National League for Nursing. 1988. 15. Valle RS. King M: An introduction to existential-phenomenological thought in psychology. In: Existential-PhenomenoIogical Alternatives for Psychology, pp 6-17. Edited by Valle RS. King M. New York. NY. Oxford University Press. 1978.

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16. Sofaer S: Qualitative methods: what are they and why use them? Health Serv Res 1999; 34: 1101-18. 17. Berwick DM: The total customer relationship in health care: broadening the bandwidth. Joint Comm J Qual Improv 1997; 23; 245-50. 18. Carey MA: The group effect in focus groups: planning, implementing, and interpreting focus group research. In: Critical Issues in Qualitative Research Methods, pp 225-41. Edited by Morse J. Thousand Oaks, CA. Sage, 1994. 19. Cote-Arsenault D, Morrison-Beedy D; Practical advice for planning and conducting focus groups. Nurs Res 1999; 48; 280-3. 20. Lincoln YS, Guba EG; Naturalistic Inquiry, pp 289-331. Beverly Hills, CA, Sage, 1985.

21. Headquarters, Department of the Army; Army Regulation 310-25: Dictionary of United States Army Terms, p 366. Washington, DC, Department of the Army. 1986. 22. Headquarters, Department ofthe Army: Army Regulation 40-501: Standards of Medical Fitness, pp 66-72. Washington, DC, Department of the Army, 2004. 23. Jennings BM, Loan LA, Yoder LH, Heiner SL, Bingham MO; Care Coordination for Active Duty Soldiers on Profile; Final Report for Proposal N02-017. Bethesda, MD, TriService Nursing Research Program, 2005. 24. Mulkey SL, Hassell LH, LaFrance KG; The implications of TRICARE on medical readiness. Milit Med 2004; 169; 16-22.

to tlje Cbitor including the spring/summer of 2003. The findings of this study were presented at the American Association for the Surgery of Trauma meeting in September 2003, andftiUmanuscript was submitted for publication on October 30, 2003. The dates of submission and acceptance are clearly mentioned in the published manuscript. Thus, the delivery date ofthe product matches the period of active experimentation, and was many months prior to the completion of this project. I am sure that FastAct is a wonderful product that works very well. The efficacy of any hemostatic dressing in a pre-clinical study depends upon a variety of factors such as; the animal size and species, source of bleeding, nature of injuries.

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rate and pressure of hemorrhage, resuscitation strategies, just to name a few. It is fairly common for a hemostatic agent to work well in certain models, but not in others. Unfortunately, in our animal model, FastAct failed to stop the bleeding. For full details please refer to the published data in the Journal of Trauma (56:974-983. 2004). I am very grateful that Mr. Wortham decided to help us with this study, which was designed to improve the care of our troops in the battlefield. Husan B. Alam, MD, FACS Div of Trauma, Emergency Stirgery Massachusetts General Hospital Boston, MA