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Patient Care and Related Activities

Annual Report of the Surgeon General United States Army Fiscal Year 1961

Hospital Clinic Care

As was indicated in the Annual Report of The Surgeon General for the fiscal year 1960, there has been an ever-increasing shift of emphasis, during the past several years, from inpatient care to the treatment of patients on a clinic or outpatient basis. The year just concluded has served to reemphasize the permanency of this change in the type of patient seen at AMEDS (Army Medical Service) treatment facilities. During this past year, AMEDS personnel saw more than 15 million outpatients at its installations worldwide and treated approximately one-half million inpatients during the same period. The trend was most marked in CONUS (continental United States) where the outpatient load was the highest for the past 5 years, with a daily average of 31,936 clinic visits. This figure was 4.2 percent higher than in fiscal year 1957.

The Army Medical Service has continued to be acutely aware of the fact that such a shift in the type of patient seen requires a new and different concept in the type of care to be rendered, and in the type of facility in which this care and treatment is to be given. Basically, the problem is being met by the inauguration of a health facility concept (p. 71) which is aimed at the maintenance of the highest standards of professional care, the most efficient use of personnel and equipment, and the continued improvement in doctor-patient relations. This, to be achieved, requires facilities which permit maximum utilization of available space, improve communications, streamline the flow of traffic, and, in general, further the rendering of the best possible medical service in the most appealing atmosphere.

Professional Consultant Activities

A review of the mission of the Directorate of Professional Service, OTSG (Office of The Surgeon General), of which the Consultant Division is a part, best illustrates the rationale behind the activities of the professional consultants. The mission is as follows: "To establish and define professional policies, standards, and practices for preventive and curative medicine, seeks to develop and adapt to the needs of the


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Army the best information available in professional specialties and supporting activities to insure the highest type of professional care." To this last phrase should be added that the information sought, developed, or adapted is also transmitted to personnel at Army medical treatment facilities with all possible speed.

One of the major, and most effective, activities of the professional consultants in the fulfillment of their mission is the visit which is made each year to each CONUS hospital and, at least once every other year, to all oversea medical facilities. For all concerned, these visits have proved most advantageous in that the consultants can not only teach, but can also learn from, the professional staffs of the installations visited.

In addition to the military personnel serving as professional consultants in the Consultant Division, there are military medical specialists in every professional field who are assigned to duty with various medical facilities and who, concurrently and on a part-time basis, serve as consultants. This arrangement is highly satisfactory, especially in oversea areas, as it makes available, with a minimum loss of time, highly trained and experienced specialists for consultation in most any part of the world where U.S. troops are stationed. Additionally too, The Surgeon General, with the cooperation of the American medical profession, utilizes the services of civilian professional consultants, in all the specialties, for periodic visits to medical treatment facilities.

General Medicine

During fiscal year 1961, significant improvement was made in the staffing of the departments of medicine of Army medical treatment facilities. Recognizing the importance of having a medical officer experienced in the administration of the professional program of the hospital, a continuing effort has been exerted to assign field grade board-certified or board-qualified internists as chiefs of the departments of medicine. As of the end of this fiscal year, all CONUS hospitals, except 2, having a bed capacity of 26 or more, will have a Regular Army officer or career reservist serving in this capacity and with these qualifications.

In class I teaching hospitals, and at the larger station hospitals which do not have intern training programs, Regular Army officers now fill the second, third, fourth, or even the fifth space on the medical service. This has significantly improved the quality and continuity of the teaching programs and the medical care. It has also been possible


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to assign internists with additional training in cardiology and gastroenterology to all class I teaching facilities.

The situation in respect to the assignment of pediatricians and dermatologists also has improved, and by August 1961, all dermatology spaces will be filled by Regular Army officers.

In class II teaching facilities, the most significant improvement in staffing has occurred because of the increased flexibility now present in assignment planning. This planning is being done from 1 to 3 years in advance and thus permits the best qualified men to be placed in these teaching positions. It has been possible, through careful planning and assignment, to provide a number of these hospitals with highly competent personnel trained in such specialties as hematology, endocrinology, and biochemistry.

With the improved situation in the number and training of Regular Army officers as internists and specialists in fields allied thereto, career planning has become much more effective and practical. Opportunities for training qualified medical officers in military schools and returning them to professional assignments are becoming a reality.

Significant progress also is being made in providing a tour of duty in a research position for medical officers not specifically desiring to follow a career in this field but wanting a good background in research design and methods. Increasing numbers of medical officers are being so assigned.

Pulmonary function laboratories with research facilities have been established at certain class II hospitals. All class II and class I teaching hospitals have full facilities to perform clinical pulmonary function studies. A number of other class I hospitals have established clinical pulmonary function laboratories.

TB MED (technical medical bulletin) 206, "Viral Hepatitis," was fully revised and was published during March 1961. TB MED 231, "Prevention of Spread of Tuberculosis in Armed Forces Hospitals," was submitted to The Adjutant General for publication.

TB MED 97, "Rheumatic Fever," and TB MED 202, "Allergy," were rescinded because no special military need for these two publications exists.

During the past year, closer liaison with the Directorate of Medical Research, U.S. Army Chemical Research and Development Laboratories, Army Chemical Center, Md., has resulted in increased knowledge of problems and progress in the medical defense against chemical weapons by members of the Professional Directorate. Such liaison has aided this Directorate in handling staff problems within OTSG and with AMEDS units in the field.


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Surgery

The Army Medical Service has continued to improve its surgical services by the assignment thereto of an ever-increasing number of trained and experienced surgeons of all the surgical specialties. At the present time, there is no shortage of trained surgeons assigned to AMEDS treatment facilities, except in the specialty of otolaryngology. Here, a marked shortage does exist, and several otolaryngology positions are filled by physicians with only a few months' on-the-job training. It is not anticipated that this situation will be alleviated during the coming years.

In the area of residency training, significant advancements have been made with the starting of a hand surgery residency at Walter Reed General Hospital, Washington, D.C.-this is a 1-year program with an input of one resident each 6 months-and a thoracic surgery residency at Brooke General Hospital, Fort Sam Houston, Tex. The latter residency, which will start on 1 September 1961, is of the usual 2 years' duration and will accommodate one resident starting each year. A program has been instituted, also, whereby those surgeons finishing a general surgery residency are assigned to one of the AMEDS large class I hospitals for a period of 1 year. This practice will enable these physicians to gain experience from the large number of trauma cases which are present at those hospitals.

The importance of consultant visits is best illustrated by the fact that surgical consultants for the Professional Directorate visited a total of 33 CONUS hospitals during the year, as well as the Army hospitals in Japan, Korea, Okinawa, and Hawaii. In addition to these visits, civilian surgical consultants in the specialties of general surgery, obstetrics and gynecology, orthopedic surgery, and urology made visits to Army medical facilities in Europe and the Far East.

The Surgeon General's chief surgical consultant, or his representative, attended and participated in several interservice meetings during the year. Additionally, the American College of Surgeons' Clinical Congress in San Francisco, Calif., was attended, in October 1960, at which the chief surgical consultant was made a Governor of the College.

Psychiatry and Neurology

During fiscal year 1961, the Army psychiatry program continued its efforts in preventive psychiatry, increasing the quantity and quality of mental hygiene consultation services; endeavored to improve the care of inpatients undergoing psychiatric and neurologic treatment; and further, coordinated psychiatric activities with commanders, the


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The Surgeon General, visiting a children's ward of the 121st Evacuation Hospital, during an inspection tour of U.S. Army medical units in Korea



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Provost Marshal General, the Judge Advocate General, and members of other pertinent agencies so as to deal more effectively with disciplinary and other abnormal behavioral manifestations of noneffective military personnel. Hospital admission rates for psychiatric disorders for the calendar year 1960 were maintained at the previous low of 7 per 1,000 per annum which had been established in 1959. Average bed occupancy for psychiatric patients in CONUS also continued at approximately the same level (457 per month) as that of the previous year (452). Outpatient treatment rates for neuropsychiatric conditions were increased approximately 10 percent over that of the previous year, demonstrating that the increasing demand for psychiatric evaluation and treatment for both military personnel and their dependents was being accomplished with little or no rise in the utilization of inpatient facilities. Post mental hygiene consultation facilities and divisional mental health services expanded their operational capabilities particularly in initiating and implementing so-called field programs. Particular emphasis has been placed upon the utilization of enlisted specialists in social work and psychology, and an effort will be made in the forthcoming fiscal year to initiate an advanced long course at the Medical Field Service School, Fort Sam Houston, Tex., which will enhance the attractiveness of the psychology and social work specialist career pattern.

For inpatients, the use of milieu therapy in special wards at Walter Reed General Hospital and at Valley Forge General Hospital, Phoenixville, Pa., has been continued. It is planned that the milieu therapy method will be utilized for cases of alcohol addiction in career military personnel in an effort to determine if such individuals with special skills can be salvaged both for themselves and for the military service. In addition, it is planned to expand this milieu therapy method to include the neuropsychiatric treatment center at Fitzsimons General Hospital, Denver, Colo., and the addition of more milieu wards at Walter Reed General Hospital.

Professional training has been maintained at the previous high level of quantity and quality. Approximately 33 residents are in training in psychiatry at Walter Reed General Hospital and at Letterman General Hospital, San Francisco, Calif. In addition, seven residents are in training in neurology at these institutions. The child psychiatry training program which was initiated in fiscal year 1960 has been expanded until now there are four residents in training. Additional training included many short courses, both military and civilian, which were utilized by medical officers in the specialties of psychiatry and


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neurology. The American Board of Psychiatry and Neurology certified four Regular Army officers-three in psychiatry and one in neurology.

During the fiscal year, approximately 160 psychiatrists, 28 neurologists, 120 social work officers, and 81 psychology officers were on active duty, exclusive of those in residency or other training status. Each

year, there has been an increased proportion of career officers occupying these positions. At the end of this fiscal year, approximately 45 percent of the psychiatrists on active duty were members of the Regular Army. Reserve officers on active duty have in a large part been graduates of the Berry plan (Armed Forces Reserve Medical Officer Commissioning and Residency Consideration Program), and relatively few medical officers assigned to psychiatric positions have had less than 3 full years of approved psychiatric training. The foregoing improvement of the capabilities of the professional personnel has resulted in raising the standard of psychiatric care both in hospitals and in mental hygiene consultation services.

In regard to the work of mental hygiene personnel with disciplinary disorders, there has been a combined effort with the Office of the Provost Marshal General to enhance the correctional atmosphere of stockades and to improve techniques of early recognition and management of behavioral problems. During the calendar year 1960, the decrease of punitive-type discharges has continued, although there has been a slight increase in the number of individuals given general discharges because of unsuitability. Major efforts are being made to aid commanders in the evaluation of problem soldiers so that recruits found early in the course of their career to be unsuitable for service will be eliminated before they become chronic disciplinary problems.

Scientific papers on Army psychiatry were presented at the 117th annual meeting of the American Psychiatric Association. One concerned a followup study on schizophrenic patients treated in Army hospitals and returned to duty. It was demonstrated that approximately 50 percent of these were able to perform average or better military service over a 2-year period.

Educational services and consultation to other Government agencies.-Members of the Psychiatry and Neurology Consultant Branch, Professional Directorate, OTSG, served on the National Advisory Council for Mental Health and the Behavioral Science and Experimental Psychology Study Sections at the National Institute of Mental Health; the Medical Education for National Defense Committee, Committees on National Defense and Disaster and Civil Defense of the American Psychiatric Association; the Group for the Advancement of Psychiatry Committee for Cooperation Among Governmental Agencies;


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and the Committee on the Mentally Handicapped of the President's Committee for the Employment of the Physically Handicapped. The chief psychiatry and neurology consultant served on the examining board of the American Board of Psychiatry and Neurology, and participated in meetings of the Peace Corps to discuss criteria for selection of members. Lectures were given at USMA (U.S. Military Academy); the Armed Forces Staff College; the Army Management School; the Walter Reed Army Institute of Research; the Judge Advocate General School; the Intelligence School at Fort Holabird, Md.; the Nuclear Weapons Medical Symposium at Sandia Base, N. Mex.; the Command and General Staff College; the Forensic Science Symposium; the Nuclear Weapons Medical Symposium for Canada; the American National Red Cross; various agencies of the U.S. Public Health Service; the regional meeting of the Office of Civil and Defense Mobilization; the Institute of Correctional Administration at American University, Washington, D.C.; and the American Psychiatric Association convention.

The two significant trends in Army social work practice during fiscal year 1961 were, first, the extension of the field approach in mental hygiene consultation service through more disciplined use of social science concepts; and second, more active participation in the teaching programs of other professional groups. The first was given marked impetus by a short course conducted at WRAIR (Walter Reed Army Institute of Research), Walter Reed Army Medical Center, Washington, D.C., 14-19 November 1960. The second was the theme of the 11th annual Army Social Work Conference held in conjunction with the National Conference of Social Welfare at Minneapolis, Minn., 12-14 May 1961. Informal regional meetings of Army social workers, the first of which was held at Fort Belvoir, Va., for social work officers assigned to the Second U.S. Army, as well as attendance at short courses given by civilian institutions have assisted in the furthering of these trends.

During the past year, there was a total of 81 commissioned psychologists in the Army Medical Service. This number included clinical and experimental psychologists and participants in the Graduate Psychology Student Program and amounted to about a 10-percent increase over the previous year, indicating increased effectiveness of procurement.

A career progression pattern embracing a broader application of psychology in the Army Medical Service was developed. This pattern placed emphasis on the following areas in professional psychology:

(1)  Consultation, (2) research, (3) the modification of behavior, (4)


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training (participation in teaching programs), and (5) psychological assessment.

Approximately 25 scientific papers and addresses were presented to international, national, and regional professional conferences. An extensive liaison program with the departments of psychology in American universities and colleges was carried out by the psychology consultant who also served with an interagency committee working with the American Psychological Association. An exhibit portraying the activities of psychologists in the Army Medical Service and the opportunities for a military career for psychologists was displayed at several conferences.

Internship training in clinical psychology at Letterman and Walter Reed General Hospitals was improved by training visits to the field to observe programs carried out respectively in the mental hygiene consultation services at Fort Ord, Calif., and at Fort Belvoir, Va.

Pathology and Laboratory Activities

Pathologists.-An average of 143 pathologists were on active duty during the fiscal year, of which 87 were Regular Army officers. Twenty-five percent of the pathologists were on duty overseas, some of whom had special assignments in such areas as Egypt, Thailand, Malaya, and Lebanon. Research and development activities throughout the world required about 20 percent of the qualified pathologists. The utilization of pathologists showed a changing development along two lines-one was to increase pathology support in number and quality in the class I hospitals because of an increased requirement from assigned board-certified physicians who required and should have such service; the other was the greater utilization and development of pathologists in the subspecialties of forensic pathology, aviation pathology, wound ballistics, infectious diseases, geographic pathology, virology, and immunology, particularly in research. Losses to the Army Medical Service comprised 5 Regular Army officers, 4 through retirement and 1 through resignation, and 12 Army Reserves through category expiration of obligatory service.

There was an increased interest in board certification resulting in 12 pathologists becoming board certified. Of the 61 Regular Army officers who have completed training for board certification, 92 percent are now board certified. Of all the pathologists on duty with the Army, Regular Army and Reserve, over 50 percent are board certified.

The residency program consisted of a 4-year training period in both clinical and anatomic pathology. During the past fiscal year, 32 pathology residents received all their training in Army hospitals.


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The award of the prefix "A" was given by The Surgeon General to three pathologists in recognition of their outstanding qualifications in their specialties.

Army laboratories.-On 31 March 1961, ground-breaking ceremonies were held for the construction of a new Second U.S. Army medical laboratory. Plans for a new Fourth U.S. Army medical laboratory have also been initiated, and a priority has been established for its construction by the DA (Department of the Army).

During the year, provisions were made for the establishment of a sanitary engineering division within all U.S. Army medical laboratories. This was done in conjunction with the Preventive Medicine Division, OTSG, and will provide consultation service to the field on radiation and industrial hygiene problems.

Training.-Of the laboratory science officers on duty, 51 hold a master's degree and 18 have been awarded the Ph. D. degree. The remainder of the officers hold the B.S. degree and are certified as medical technologists or the equivalent. At the present time, nine officers are attending postgraduate training leading to the Ph. D. degree, and two officers are studying for their M.S. degree. The overall requirement for officer personnel with advanced degrees in the laboratory science specialties is 86 Ph. D.'s and 94 M.S.'s, respectively.

Five pathologists and five laboratory science officers completed the AMEDS Officer Career Course 8-A-C22 given at the Medical Field Service School. One pathologist completed the Military Medicine and Allied Science Course 8-A-F6 given at WRAIR, and one attended the Associate Course at the Command and General Staff College, Fort Leavenworth, Kans.

Outstanding among the many short courses attended by the pathologists and medical laboratory personnel were the following: "Aspects of Missile Operations," Patrick Air Force Base, Fla.; "Technic of Using Radioisotopes," Oak Ridge Institute, Oak Ridge, Tenn.; "Current Trends in Laboratory Activities," WRAIR; "Forensic Pathology," the "Annual Armed Forces Institute of Pathology Lectures," "Forensic Science Symposiums," and the "Application of Histochemistry," at the Armed Forces Institute of Pathology; and the "Second Postgraduate Course for Pathologists in Clinical Cytopathology," at The Johns Hopkins University, Baltimore, Md.

Plans were formulated to supplement the advanced training given at the Medical Field Service School for medical laboratory technicians (931.2) by utilizing Brooke, Letterman, and Walter Reed General Hospitals, and the Armed Forces Institute of Pathology. A total of


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80 enlisted personnel will be trained annually, compared to the present output of 40 for the 52-week course.

Current trends.-To meet the increased demands of scientific developments in the technical aspects of laboratory sciences, the total number of MSC (Medical Service Corps) laboratory science officers required during the next 5 years will increase 50 percent. Likewise, the demand for pathologists will be increased 25 percent.

With the present emphasis on infectious disease and nuclear energy in the global mobile army of today, there is a need for specialized training in microbiology, virology, and nuclear medical science to enable early definitive detection of biological and radiological warfare agents.

The demand for the utilization of ultramicro laboratory techniques, the logistic advantages of equipment involved, and the complexities of laboratory medicine today require that maximum use be made of miniaturization and automation.

A total of 167 laboratory science officers were on duty-48 bacteriologists (MOS 3307), 44 biochemists (MOS 3309), 10 parasitologists (MOS 3310), 13 immunologists (MOS 311), and 52 clinical laboratory officers (MOS 3314). Of these officers, 14 percent were assigned to class I hospitals, 13 percent to U.S. Army medical laboratories, 8 percent to class II hospitals, 23 percent to the U.S. Army Medical Research and Development Command, and approximately 8 percent in civilian and military training. Approximately 24 percent of the laboratory officers are in service in oversea commands.

Publications.-TM (technical manual) 8-227, "Methods for Laboratory Techniques," has been revised and will appear in a new loose-leaf format and be known as the 8-227 series. The first one of these manuals, DA TM 8-227-1, "Laboratory Procedures in Clinical Serology," has been published and is available through normal distribution channels. TM 8-227-2, "Laboratory Procedures in Parasitology," is now being published and will be available for distribution at an early date. It is planned that the series will consist of eight manuals covering the laboratory science specialties of serology, parasitology, chemistry, blood banking, immunohematology, bacteriology, mycology, and hematology. The series will be completed during the coming fiscal year.

Army Regulations No. 40-440, "Army Medical Laboratories," is now being revised. All Army regulations relative to the Army medical laboratories will be incorporated in one regulation.


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Pharmacy

Increased prescription workloads together with a recurring shortage of pharmacy personnel contributed to the problem of staffing pharmacies in fiscal year 1961. The shortage resulted from reduction in the draft quotas, the participation by draft-eligible pharmacists in the 6-month active-duty-for-training program, and the low retention rate of enlisted pharmacists. In an effort to minimize the shortage, assignment procedures for enlisted pharmacy personnel were refined, and increased emphasis was placed on the acquisition and the use of labor­saving devices. A further trend toward full utilization of the pharmacy officer in his professional capacity was evidenced during the year.

Emphasis continued on the training of commissioned pharmacists in the specialty of hospital pharmacy. Two officers completed a year's academic training in hospital pharmacy, in August 1960, and were placed in 1-year residencies at Brooke General Hospital and Walter Reed General Hospital in September 1960, and two have been selected to begin in September 1961. One officer possessing a master's degree in hospital pharmacy was obtained by direct commissioning in the Regular Army, bringing the total with this qualification up to 10.

The first Postgraduate Professional Short Course in Army Pharmaceutical Service Management was conducted at WRAIR, 22-26 May 1961. Twenty commissioned pharmacists attended, in addition to those assigned to the Washington area. This course met the need for discussion of major problems confronting the commissioned pharmacists, exchange of ideas, and a receipt of progressive professional guidance. Enhancement of services rendered by pharmacists within the Army Medical Service is expected from this course.

Nursing Service

As in the years past, continued emphasis is being placed on improved nursing care. This is implemented by according selected ANC (Army Nurse Corps) officers advanced preparation in clinical specialties at civilian colleges and inservice programs planned at the local levels. Increased medical specialization in medical care and treatment has required advances in nursing care; for example, a course in cardiac nursing has been instituted at Fitzsimons General Hospital. Four classes of four officers each were programed for the fiscal year. Already established courses in other clinical areas have been continued.

Proper utilization of all levels of nursing service personnel is being stressed by every medium. Maximum effectiveness of all personnel


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is necessary to increase both quantity and quality of patient care with continually dwindling professional resources.

Training programs for nonprofessional nursing service personnel in medical installations and STRAC-STRAF (U.S. Strategic Army Corps-U.S. Strategic Army Forces) units, as well as in AMEDS programmed courses, have been supported and emphasized in every possible way to strengthen effectiveness in day-to-day operations and to increase the potential if an emergency should arise. Approximately 95 ANC officers are assigned to units or courses as full-time instructors. Of the total number assigned, 87 were assigned to these positions for most of this fiscal year. The other eight officers were recently assigned in preparation for the opening of the two additional courses to prepare enlisted personnel for duty in MOS (military occupational specialty) 911.3. This total number does not include those officers who devote part time or nearly full time to instructing enlisted personnel at medical installations.

Research in clinical nursing is continuing. This has been a developing program and is noted with interest by civilian nursing. Requests have been received for participation on panels before large nursing and allied groups and for papers for publication.

Two ANC officers have continued to be assigned to MAAG's (military assistance advisory groups), one in Korea and one in Formosa. They serve as instructors and advisers to the military nurse corps of the respective countries. Information received indicates that the assistance rendered is well accepted and of high caliber. On the international scope, as well as through official programs, informal reports reflect person-to-person relationship, recognition and assistance both tangible and intangible.

In relation to this international aspect, one of the most tangible results has come from the training of professional nurses from foreign countries. During the past 2˝ years, a total of 53 such nurses, coming

from 11 countries, as widely separated as Great Britain and Thailand, have undergone nurse's training in AMEDS facilities. Some of these nurses have taen the advanced military nursing course at the Brooke Army Medical Center, while others have studied clinical specialties of their choice at Brooke, Walter Reed, William Beaumont, and Letterman General Hospitals.

Dental Service

The dental health of the U.S. Army is satisfactory and continues to be so, maintained by the use of improved dental materials, equipment, and treatment methods. Nevertheless, the capabilities of the


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Dental Corps have been inadequate to reduce the man-hour losses among military personnel for dental reasons-a traditionally significant military problem-through corrective and reparative treatment means alone. Now, however, new preventive dentistry measures, developed within recent years, particularly those for the prevention of dental caries and periodontal diseases, together with time-proved preventive measures, offer hope for a solution to the dental health problem-this being primarily the need to reduce the number of manhours military personnel spend undergoing dental care and treatment.

Preventive dentistry.-In November 1960, the Army started a vigorous preventive dentistry program. This effort represents the first organized and positive action of this magnitude to implement prevention by a major segment of the dental profession.

Early major aspects of the new preventive program include Armywide dental health education for troops, military dependents, dental personnel, and troop commanders; oral hygiene instruction for individual patients; promotion of the program of fluoridation of post water supplies; and adoption of a procedure of patient care in which clinical preventive treatment procedures are given early and priority consideration.

Preventive dentistry officers have been appointed, preventive dentistry teams and clinics have been organized at the local installation level to coordinate and execute various aspects of the program, and a 5-day course in preventive dentistry has been instituted at WRAIR. Members of the first class attending the preventive dentistry course conducted at WRAIR, 5-9 June 1961, included senior DC (Dental Corps) officers representing Army-wide commands.

One aspect of the program which has caused concern is that, although the relative value of preventive measures is not questioned, time devoted to them by dental officers detracts from the amount of corrective treatment they can give. Actually, many of the features of the preventive program, including certain clinical procedures, can be accomplished by appropriately trained enlisted personnel and dental hygienists working under dental officer supervision. Presently authorized numbers of such auxiliary personnel are inadequate to make more than a token contribution, however. Future planning includes measures to obtain increases in such personnel within the dental service.

Central dental laboratories.-In January 1961, a study was undertaken to determine the feasibility of redesignating all central dental laboratories as class II activities under the command jurisdiction of The Surgeon General. This was accomplished by Department of the Army General Orders No. 18, 2 June 1961.


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Redesignation of central dental laboratories as class II activities has resulted in the following:

1.  Greater flexibility in assignment of missions.

2.  Establishment of standardized operational policies.

3.  Increased training and educational possibilities.

4.  Standardized fiscal procedures.

Because of advantages just listed, the evaluation of operations at central dental laboratories has been greatly enhanced.

Hospital Food Service

The Dietitian Section of the Office of the Chief, Army Medical Specialist Corps, OTSG, initiated a study on equipment and space utilization in kitchens of AMEDS hospitals of the future. The centralized service of food trays, for example, is a step toward increased automation. The transfer to this system in operating hospitals will demand alterations in space utilization, changes in personnel management, and certain new equipment. The study includes an assessment of multipurpose equipment with emphasis upon automation and other timesaving devices and controls. Additionally, product flow, from receipt of raw foods to actual service of trays, is incorporated in the study.

In coordination with the U.S. Army Subsistence Center, Chicago, Ill., the chief of the Dietitian Section is working on a hospital supplement to the standard B-ration to be stocked for inplace reserves. It is planned that this supplement can be used as an independent "hospital" ration with cycle menus for a minimum number of types of diets, for example, liquid, soft, and dental soft, in the event troops are not issued standard B-rations.

For several years, the Army Medical Service has been experimenting with various methods of improving its food service, especially the service which is rendered to the patient confined to a ward. The introduction of a central tray service food cart, designed with thermostatically controlled heated sections and mechanically refrigerated sections, into the Army hospital system has resulted in an improved food service for the patient. This method permits the conveyance of attractive-looking and properly heated or chilled foods directly to the bedside, and the serving of this food in portions consistent with the desires of the patient. An additional, and not inconsiderable, byproduct of this system is a considerable reduction in food wastage with a resultant savings to the Government.


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Care of Tuberculous Alien Dependents

The revision of AR 40-124, "Admission to the United States of Alien Dependents Afflicted With Tuberculosis," 2 September 1960, effected a major change in the procedure for processing applications by tuberculous alien dependents for admission to an Army hospital in the United States. Formerly, applications were forwarded through command channels to OTSG for approval and designation of a receiving hospital. Under the new procedure, applications are processed and approved by the major oversea commander, who obtains a hospital designation from ASMRO (Armed Services Medical Regulating Office). The new procedure has substantially reduced the time required for processing these applications.

Statutory authority for issuance of visas to turberculous alien dependents for admission to the United States is provided by temporary legislation which expires on 30 June 1961. Legislation to extend this authority has been introduced in the Congress, but its enactment into law before expiration of the present authority appears doubtful. Because of this, Changes No. 1 to AR 40-124 are to be published in July 1961 to provide instructions for processing applications of tuberculous alien dependents pending enactment of new legislative authority for issuance of visas to this category of dependent patients.

Armed Services Medical Regulating Activities

The overall total of armed services patients reported to ASMRO for movement from oversea areas and between specialty hospitals within CONUS for fiscal year 1961 was 20,587. This was 1,250 fewer than the total of 21,837 patients moved during fiscal year 1960. Army requests for patient movements increased 455 during the period with a total of 7,172 hospital designations as compared to 6,717 during fiscal year 1960.

Included in the total movement authorized by ASMRO were 10,014 oversea patients from debarkation medical facilities to Armed Forces and USPHS (U.S. Public Health Service) hospitals in CONUS, 9,316 patients between CONUS Armed Forces hospitals, and 1,257 active military patients from CONUS Armed Forces hospitals to VA (Veterans' Administration) hospitals. Table 1 shows how the movement of Army patients compared with those of the other services.

Inquiries

Inquiries which are received within OTSG relating to medical treatment and hospitalization, physical standards, and a variety of other


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TABLE 1-Movement of Patients authorized by Armed Services Medical Regulating Office

Service From debarkation hospitals Between CONUS hospitals To VA hospitals Total
Army 3,795 3,010 367 7,172
Navy 2,660 2,206 583 5,449
Air Force 1,776 4,078 307 6,161
Others1 1,783 22 0 1,805
     Total 10,014 9,316 1,257 20,587

1Includes civilians, merchant marines, and foreign nationals.

subjects allied to the total activity of the Army Medical Service play a major role in the daily activity of personnel assigned to the Office of The Surgeon General. Since, as can be appreciated, the majority of these inquiries concern medical treatment and hospitalization, the preparation of all responses to such inquiries is centralized with the Professional Inquiries Branch of the Directorate of Professional Service. These inquiries, which number several thousand during the year, are received from the Executive Office of the President, Members of Congress, Department of Defense, the three military services, other Federal Government agencies, and the general public.

It should be stated that all inquiries received are not complaints, and when consideration is given to the fact that several million patients are treated in outpatient clinics and hospitals during the year, it is gratifying to report that the number of dissatisfied patients represent a small fraction of one percent of the total number treated. Equally true is that many complaints, upon investigation, are found to be unjustified or the result of misunderstanding. All inquiries, however, are investigated and fully reported to the complainant or the inquirer, within the limits imposed by the directives restricting the release of information from individual medical records.

The most common complaint during this fiscal year, as in the past many years, related to the inductee entering the military service for the first time with a history of some illness or disability which he, his

parents, or his wife considered to have rendered him physically disqualified for induction. In the usual instance, investigation revealed that the inductee was physically qualified for induction and was physically qualified for retention on active duty. In a few cases, however, it was found that the inductees were not physically qualified, and appropriate action was taken to separate them from the Army as soon


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as possible. These cases were brought to the attention of the medical personnel assigned to the AFES's (Armed Forces examining stations) concerned so that deficiencies in medical examination procedures could be corrected.

Complaints regarding inpatient hospital care were varied. The number received from civilian dependents of active duty and retired military personnel showed a marked increase. Many were inconsequential and were representative of persons who are chronic complainers. Some, though few in number, were justified and some were of a serious nature. Investigative reports received from medical treatment facilities regarding these cases were very carefully reviewed and analyzed for corrective action to be taken where indicated. Analysis of all reports regarding hospital care indicated that all such complaints had one thing in common-faulty relationship between patients and their attending physicians. It is recognized that a mutually advantageous doctor-patient relationship is sometimes difficult to achieve under the not unusual conditions of overcrowded facilities and busy professional personnel. Yet, even under these circumstances, some explanation by the attending physician to his patient may eliminate many hours of investigative action in conjunction with a letter of complaint.

Dependents' Medical Care Program

Effects of Medicare upon morale.-From an overall standpoint, Medicare (Dependents' Medical Care) has continued to contribute greatly to the creation and maintenance of a high degree of morale among military members of all grades, in all branches of the uniformed services. The assured availability of necessary medical care is an important consideration among individuals in their decisions on enlistment or reenlistment. Recent surveys among Army reenlistments, for example, indicate that more than 60 percent placed availability of dependents' medical care in the forefront of those facts leading toward a continuation of a military career. The importance of the benefits derived from Medicare upon these decisions is readily apparent when the fact that the percentage of married men within the Armed Forces has steadily risen over the past several years-from 42 percent in 1956 to 54 percent in 1961-is taken into consideration.

Concurrent with the increased marriage rate has been the increase in the size of the average service family. This has risen from 13 children per 10 families in 1956 to 19 children per 10 families in 1961. As a matter of emphasis, it is significant to note that the number of dependents of active-duty personnel of the uniformed services was 2,772,800 in 1956 and rose to 3,611,200 by the spring of 1961.


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As was fully reported in the Annual Report of The Surgeon General, fiscal year 1960, a restoration of certain types of medical care, previously not authorized during fiscal year 1958 and fiscal year 1959, was directed in January 1960. This reintroduction of a wider range of medical care, albeit carefully controlled, was another factor which contributed to the satisfaction of beneficiaries of Medicare and aided

morale.

Inequities in the medical care program seemingly existed in certain geographic areas where dependents resided at some distance from large uniformed services medical facilities and, thus, were unable to obtain needed care not authorized from civilian sources. This was especially noted in regard to outpatient care, the purchase of drugs, and some instances in which dependents, ordered overseas to join sponsors, were obliged to pay for required immunization from personal funds because of the great distance of their place of residence from a military medical facility.

Impact of changes upon Medicare program.-Surveys which have been taken to assist in the evaluation of the impact which the restoration of a wider range of medical care has had upon the program as a whole indicate that following the restoration, and subject to the use of the nonavailability statement, there was an increase in the total number of hospital admissions. This total level, however, has not returned to the plateau reached before the introduction of the restrictions, and consequently, there has been no deleterious effect upon the patient levels in service hospitals, despite the increase in the number of patients admitted to civilian hospitals under the program. Additionally, total costs are reasonably well stabilized, and dependents are receiving needed medical care in substantial numbers. Expressed in percentage terms, tabulated data reveal that admissions to civilian hospitals increased 11.8 percent (calendar year 1959 to calendar year 1960) under the restored program in 1960, over the level of admissions during the previously restricted period, and preliminary figures available for fiscal year 1961 indicate a further percentage increase over fiscal year 1960, which functioned under the restricted program for one-half of the fiscal year. The ever-increasing number of dependents of uniformed services personnel also contribute to the increased admission rate.

Administration of Medicare program.-The Medicare program is administered under a single year's appropriated funds. Before May 1960, expenditures by contractors for authorized medical care were charged to the appropriation current in the fiscal year during which the payment was made by the contractor.


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Effective on 1 May 1960, a new method of recording obligations and expenditures under Medicare was begun. Obligations of appropriated funds and expenditures of these obligated funds are now based upon the date of the completion of the care and not upon the date the contractor made payment to the civilian source of care, as was formerly the case. The effect of this change in administrative procedure is that appropriated funds obligated during a fiscal year reflect the estimated amount of care completed during that particular fiscal year. Because of the timelag in submission of claims to contractors and subsequent reimbursement action to the contractors by Army finance officers, disbursements of these obligated funds will continue over several fiscal years. Every practical opportunity is taken by the Office for Dependents' Medical Care, OTSG, to gain the cooperation of all concerned in reducing the timelag in the submission of claims to Medicare contractors.

Payments to contractors.-As has been indicated earlier, the restoration of a wider range of medical care within the program brought with it an increase in the number of patients admitted to hospitals. Again, a correlated factor was the increase in the number of dependents eligible for care under the Medicare program. Final figures for fiscal year 1961 are not available; however, during fiscal year 1961, 237,899 hospital claims were paid, amounting to $32,782,351. This represented an average of $137.81 per hospital claim, or 3.3 percent more than that reported during fiscal year 1960. A contributing factor to this increase, however, is the general rising cost of hospital care throughout the United States.

On the other hand, 338,840 physician claims paid, during fiscal year 1961, totaled $26,089,238 and averaged $77 per claim, or 2.5 percent less than that experienced during fiscal year 1960. Investigation reveals that this decrease is basically attributable to a population shift among eligible personnel from those areas of high population density with concurrent high cost of living indexes to less populated areas with generally lower cost of living indexes.

Reimbursements processed by Army finance.-When an eligible dependent obtains authorized medical services at personal expense, and there is justifiable reason for not having submitted the claims for such services to the appropriate contractor, a procedure has been established for reimbursing the dependent or sponsor for the cost of such authorized care. For this reimbursement, the claim is submitted to the continental U.S. Army commander in the area concerned.

The number of such claims processed per year amounts to approximately 500. During fiscal year 1961, Army commanders processed 486


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claims amounting to $80,824. This was a reduction of 14 claims below those processed during the preceding fiscal year. This figure is negligible in comparison to the claims processed by contractors, and indicates the results of a concerted effort on the part of all commanders to acquaint their personnel with the latest available Medicare information and the benefits of the program to which they are entitled.

Medicare overseas.-The Dependents' Medical Care Act also provides that eligible dependents may obtain authorized medical care at Government expense in oversea areas. Administration of the program abroad is the responsibility of the oversea military commanders, and information concerning payment for civilian care is furnished The Surgeon General of the Army by the oversea commanders. These data are made available on a calendar year basis and by geographic area. During 1960, for example, a total of 4,047 oversea claims totaling $340,019 were paid. These claims represented medical care provided in 80 countries. Cambodia, Honduras, Iran, Jamaica, Japan, and the Virgin Islands reported only one case each. Of submitted claims, however, 74 percent came from only 12 countries-Canada, Italy, Greece, France, Belgium, Germany, Netherlands, Philippines, Spain, Thailand, Brazil, and Scotland-with by far the greater number, 1,415 claims totaling $117,987, being submitted from Canada. The Air Force continued to be the largest user abroad, as at home, followed in order by the U.S. Navy, the U.S. Army, and the U.S. Public Health Service.

Army Health Experience and Trends

The very favorable health experience of Army personnel continued and improved during fiscal year 1961 as reflected by the following indexes:

Admissions.-The admission rate to hospital, dispensary, and quarters for all causes among U.S. Army troops worldwide was about 7 percent lower than the rate for fiscal year 1960. This decrease was reflected in both the disease and the non-battle-injury components. Non-battle-injury rates in areas outside CONUS continued somewhat higher than those within the United States, while the disease admission rate was higher in CONUS. Worldwide admissions for all causes occurred at a rate of 321 per 1,000 average strength in fiscal year 1961 as compared to 344 in fiscal year 1960. Both the all causes and the disease admission rates for the fiscal year 1961 were the lowest reported since the outbreak of the Korean War.

The admission rates for Hawaii and Alaska went counter to the general trend. Non-battle-injury admission rates in Hawaii showed a sharp increase during fiscal year 1961 over the preceding year. The


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peak months in which the increase occurred were October 1960 and February 1961, when the rates were 77 and 78, respectively. In the latter month, this increase reflected an increase in injuries reported as "aircraft accidents." Table 2 shows non-battle-injury admission rates worldwide.

TABLE 2.-Nonbattle admission rates to hospital and quarters,1U.S. Army military personnel, fiscal years 1959, 1960, and 1961

[Rates expressed as admissions per 1,000 average strength per year]

Area All causes Disease Nonbattle injury
19612 1960 1959 19612 1960 1959 19612 1960 1959
Total Army 321 344 379 274 294 327 47 50 52
Total CONUS 316 340 389 274 295 340 42 45 49
Total outside                  
     CONUS 327 351 364 273 293 307 54 58 57
          Europe 331 353 372 272 292 310 59 61 62
          Japan-Korea-Ryukyus 313 383 382 273 330 334 40 53 48
          Alaska 273 255 339 219 203 282 54 52 57
          Hawaii3 346 290 271 293 246 231 53 44 40

1Admissions to all medical treatment facilities, Army and non-Army. Excludes carded-for-record-only cases reported on summary morbidity reports, largely venereal disease cases treated while individual is on duty status.
2Data for June 1961, partially estimated.

3Includes data for Hawaii and other Pacific areas.

Source:  Morbidity Report, DD Form 44a (RCS MED-78) and DA Form 8-268 (RCS MED-78(R1)).

Disease admission rates are shown by month in table 3 for each of the past 3 fiscal years. It is seen that, as in previous years, the peak was reached in February. This can be attributed mostly to common respiratory diseases and influenza. Monthly disease admission rates were generally lower in fiscal year 1961 than in fiscal year 1960. However, for each month, August through November 1960, these rates were higher.

Noneffectiveness.-Noneffective rates for all causes, disease and non-battle injuries, are shown in table 4. The average daily noneffective rate remained approximately the same in fiscal year 1961 as in fiscal year 1960-11.8 versus 11.7 per 1,000 average strength. The disease component was 9.5, slightly below the rate of 9.7 in fiscal year 1960, while the injury component showed a slight increase to 2.2 from 2.0 in


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fiscal year 1960. The increase in non-battle-injury noneffectiveness occurred primarily among troops in Hawaii. Noneffective rates for all nonbattle causes and nonbattle injuries were higher in CONUS during fiscal year 1961 as compared with fiscal year 1960.

TABLE 3.-Disease admission rates to hospital and quarters,1 U.S. Army military personnel, by month, fiscal years 1959, 1960, and 19612

[Rates expressed as admissions per 1,000 average strength per year)

Period Total Army Total CONUS Total outside CONUS
19612 1960 1959 19612 1960 1959 19612 1960 1959
12-month period 274 294 327 274 295 340 273 293 307
     July 236 243 261 230 230 255 245 262 270
     August 261 246 274 259 241 267 263 253 285
     September 274 260 301 276 257 304 271 264 296
     October 286 272 337 289 256 343 281 296 328
     November 278 266 333 278 246 341 278 298 321
     December 252 253 313 240 235 331 271 281 284
     January 317 394 378 317 424 399 318 350 344
     February 325 445 437 352 487 477 285 380 376
     March 301 369 415 311 395 463 286 331 341
     April 268 279 345 272 273 370 262 287 307
     May 252 252 276 246 247 282 260 260 267
     June2 240 246 262 224 241 257 262 252 270

1Admissions to all medical treatment facilities, Army and non-Army. Excludes carded-for-record-only cases reported on summary morbidity reports, largely venereal disease cases treated while individual is on duty status.
2Data for June 1961, partially estimated.
Source: Morbidity Report, DD Form 442 (RCS MED-78) and DA Form 8-268 (RCS MED-78(R1)).

Hospitalization.-The rate of initial admission to hospitals in fiscal year 1961 was 191.9, as compared to 198.6 in fiscal year 1960 and 228.5 in fiscal year 1959. Table 5 gives data on admissions, dispositions, patient census, and average daily beds occupied for active-duty Army patients in terms of absolute numbers. When average daily bed occupancy is related to average strength, it shows that 0.85 percent active-duty Army personnel were occupying hospital beds on an average day in fiscal year 1961, which was slightly lower than 0.87 percent in fiscal year 1960 and 0.93 percent in fiscal year 1959.



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TABLE 4.-Average daily noneffective rates (hospital and quarters), U.S. Army military personnel, fiscal years 1959, 1960, and 1961

[Rates expressed as average daily number of patients remaining per 1,000 average strength]

Area All nonbattle causes Disease1 Nonbattle injury1
19612 1960 1959 19612 1960 1959 19612 1960 1959
Total Army 11.77 11.66 12.28 9.53 9.65 9.88 2.24 2.01 2.40
Total CONUS3 14.43 14.11 14.63 11.79 11.76 11.86 2.64 2.35 2.77
Total outside                  
     CONUS 7.95 8.00 8.62 6.28 6.50 6.80 1.67 1.50 1.82

1Days lost for disease and nonbattle injury, separately, were estimated.
2Data for June 1961, partially estimated.

3Includes evacuees from outside CONUS.

Source: Morbidity Report, DD Form 442 (RCS MED-78) and DA Form 8-268.

TABLE 5.-Hospital admissions, patient census, and final dispositions, U.S. Army military personnel in military hospitals, worldwide,1 fiscal years 1959, 1960, and 1961

[Figures in parentheses are subtotals]

Element of patient flow 19612 1960 1959
Patient census, beginning of fiscal year 8,481 8,434 8,744
Admissions (initial)3 166,035 171,193 200,908
Final dispositions4 166,087 171,146 210,218
     Returned to duty4 (160,187) (165,494) (195,001)
     Disability retirements (2,012) (1,960) (2,202)
     Disability separations (2,138) (2,075) (2,273)
     Other final dispositions (1,750) (1,617) (1,742)
Patient census, end of fiscal year 8,429 8,481 8,434
Daily average census 9,174 8,982 9,614
Daily average occupying beds 7,341 7,419 8,219

1Includes Army patients occupying beds in VA hospitals who are carried on the rolls of Army hospitals pending discharge for disability. Excludes transient patients; that is, patients remaining in military debarkation hospitals, patients remaining overnight in other military hospitals, and aeromedical-evacuee patients.

2Data for June 1961, partially estimated.

3Includes all direct admissions to hospital for bed care or observation, transfers from dispensary or sick-in-quarters status, readmissions for relapses or sequelae of previously treated conditions, readmission of patients AWOL for more than 10 days' duration, and admissions to ship sickbays while in passenger status at sea.

4Adjusted so that initial admissions plus beginning census equals final dispositions plus end census.

Source: Beds and Patients Report, DD Form 443 (RCS MED-79).


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Utilization of Army hospitals and dispensaries.-Approximately 439,300 patients of all categories were admitted to fixed Army hospitals, about 12,300 fewer than in the preceding year, representing a decrease of 3 percent.

A daily average of 12,741 beds were occupied by all patients in fixed Army hospitals as compared to 13,078 in fiscal year 1960. Army patients occupied 59 percent of the beds; dependents of military personnel, 28 percent; and the remaining 13 percent were occupied by all other patients authorized care in Army hospitals. It should be noted that data in table 6 relate to fixed hospitals only.

Table 7 shows data on outpatient visits by category of patient as reported by Army medical treatment facilities, worldwide, during the past 3 fiscal years. Total outpatient visits increased about 2 percent over those in fiscal year 1960. The average daily number of outpatient visits of Army personnel per 1,000 average strength was 17.2, as compared to 17.1 in fiscal year 1960 and 17.0 in fiscal year 1959.

About 36,200 daily average outpatient visits to facilities were made during fiscal year 1961 as against 35,500 in fiscal year 1960. Of the daily 36,200, approximately 14,900 were made by military personnel, 16,600 by dependents of military personnel, 1,300 by RFA (Reserve Forces Act) and other personnel on active duty for training, and 3,400 by all other persons authorized outpatient care at Army medical treatment facilities.

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