NAVY MEDICINE Vol. 84, No.6 November-December 1993

36 Pages·1993·11 MB·English

by  U.S. Navy. Bureau of Medicine and Surgery

NAVY MEDICINE
November-December 1993
Surgeon General of the Navy NAVY MEDICINE
Chief, BUMED
VADM Donald F. Hagen, MC, USN Vol. 84, No.6
November-December 1993
Deputy Surgeon General
Deputy Chief, BUMED
Chief, Medical Corps Department Rounds
RADM Richard I. Ridenour, MC, USN 1 Putting Out the Smoking Lamp
CDR B.K. Bohnker, MC, USN
CAPT J. Fraser, MC, USN
Editor
LT S. Shappell, MSC, USN
Jan Kenneth Herman
CAPTS. Hart, MC,USN
Assktant Editor
Forum
Virginia M. Novinski
4 Charting a New Course for Navy Medical Education
CAPTD.G. Kemp, MC, USN
Editorial Assistant
Nancy R. Keesee Features
6 Innovations in Alcoholism Treatment
NAVY MEDICINE, Vol. 84, No. 6, (ISSN 089S-8211 CDR D.S. Derrer, MSC, USNR
USPS 316-070) is published bimondlty by the Deparlmellt
of the Navy, Bureau of Medicine and SuraerY (BUMED
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14 Patient Encounter Skills Development
ciM care Navy Public:alionsand Forms Dira:ronte, AT T'N:
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18 The Innocent Flame of Ignorance
DeparllliCDI persoJmel and COIUins professional informa
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sciences. Opioioos e~pmsed are 1bose oftbe autbon and
do not necessarily represau lbe oflicial poaition of tbe
Depanmeol of lhe Navy, lhe Bureau of Medicine and 21 Chronology-World War II: Navy Medicine November-December 1943
Suraery. or any otber aovemmenlal departmelll or aaeocy. J. Mitchum
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30 INDEX Vol. 84, Nos. 1-6, January-December 1993
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NAVMED P-5088
Department Rounds
Putting Out the
Smoking Lamp
CDR Bruce K. Bohnker, MC, USN
CAPT James Fraser, MC, USN
LT Scott Shappell, MSC, USN
CAPT Steven Hart, MC, USN
NAVY VESSELS HAVE LONG As the medical hazards associated prevent smokers from exposing others
passed the word that "the smoking with tobacco have become more ap to the harmful effects oft obacco smoke.
lamp is out" to protect the health and parent, the elimination of smoking in A number of ships took on long
safety of ship and crew. This call was the Navy was entertained. The Secre term goals to become tobacco-free,
primarily made because of the risk tary of the Navy and Chief of Naval with the commanding officer of USS
from exposed flame and smoke dur Operations established guidance on Theodore Roosevelt (CVN-71) setting
ing evolutions such as refueling. Simi smoking prevention and cessation pro a course in 1989 to end smoking by the
larly, smoking has routinely been grams.(J-3) In response, Commander 1Oth anniversary oft he ship's commis
prohibited on various parts of ships Naval Air Force, U.S. Atlantic Fleet sioning, or 25 Oct 1996. That ship had
due to risk of fire, such as the flight (COMNAV AIRLANT) provided ad long prohibited chewing tobacco on
deck and hangar deck. Even where ditional guidance on smoking cessa board due to shipboard sanitation and
permitted, smoking has posed a fire tion programs to all claimancies, in cleanliness problems. Recently, the
hazard on ships. For instance, the cluding Atlantic Fleet Aircraft Environmental Protective Agency clas
only significant fire on board one carriers.(4) Smoking was permitted sified environmental tobacco smoke
aircraft carrier in a recent 18-month only to the extent that it did not endan (ETS) as a human lung carcinogen,
period was caused by a cigarette ger life or property, or risk impairing meaning that exposure to secondary
thrown into a wastebasket. nonsmoker's health. The intent was to smoke is a health risk.(5) This action
November·December 1993 1
...,I ...... -
USS Theodore Roosevelt (CVN-71)
changed the status ofs moking on board (bathrooms) which vented directly continually added to the shipboard
Navy ships, since the mere exposure overboard for smoking. Those heads population. It became obvious that the
to ETS is a health risk for nonsmokers. quickly became so choked with smoke gradual process would not result in a
On board Theodore Roosevelt, sev that they were no longer fit even for tobacco-free ship.
eral smoking strategies were imple smokers to use. Carbon monoxide The commanding officer published
mented to prevent the exposure of levels measured in those heads would a Commanding Officer's Memoran
nonsmokers to environmental tobacco preclude personnel from entering the dum of20 Jan 1993 which accelerated
smoke while allowing smoking on space without an independent source the smoking cessation program. As a
board. These included reduced smok of oxygen. Maintaining sanitation of former smoker, he was well aware of
ing days, specific smoking hours, and those heads became impossible, with the difficulties associated with smok
fmally limitation of smoking to a few walls acquiring a thick yellow-brown ing cessation, but he planned for a
spaces. None of these were deemed covering of tobacco smoke residue. It smoke-free environment for the health
sufficiently effective to adequately was impossible to prevent smoke from of his crew. His actions were fully
protect nonsmokers. intruding into nearby smoke-free supported by the commander of the
Smoking was permitted only in spaces and affecting nonsmokers. Fur embarked Carrier Airwing Eight, an
spaces without shared ventilation, lead ther, one third of the crew transferred other former smoker. The ship's store
ing to the designation of 10 heads every year, thus new smokers were stopped selling tobacco products ef-
2 NAVY MEDICINE
fective 1 March 1993. Meanwhile,
Theodore Roosevelt's medical depart
ment continued to provide smoking
cessation clinics and made nicotine
transdermal patches available.
Theodore Roosevelt put out the
smoking lamp on 4 July 1993. After
the date, all tobacco products were
considered contraband, the possession
of which was subject to nonjudicial
punishment (NJP). First offenders were
offered voluntary enrollment in a medi
cal department smoking cessation
course. Second offenders were or
dered to attend the smoking cessation
course while third offenders received
NJP. The commanding officer directed
that NJP records would be expunged
for offenders with no further UCMJ
violations after 90 days; his intentions
in the measures were to reform mem
bers and not ruin careers.
While not all the crew has been Navy Smoking Cessation Logo
overjoyeu wilh Lhis action, the re-
sponse has been favorable. Many
crewmembers expressed appreciation
for the assistance with smoking cessa
tion provided on board. They verbally
reported that these measures allowed
them to quit where multiple previous
attempts had failed. smoking cessation programs with their 6. Ward D. Carrier to kick smoking habit July
Theodore Roosevelt has received a medical departments providing smok 4. Navy Times. March 8, 1993:22.
7. Burlage 1. USS Roosevelt snuffs smoking
great deal of attention now that it is a ing cessation counseling, nicotine lamp after all. Navy Times. August 2, 1993:5.
smoke-free ship. The Navy Times fea transdermal patches, and other medi 8. Gunby P. Despite tensions of monitoring
tured the ship in March and Au cal assistance. The San Diego-based world trouble spot, aircraft carrier becomes first
to ban tobacco. lAMA. 1993;269:2960.
gust. ( 6, 7) A supporting article noted Navy Health Research Center, in co 9. Bureau of Medicine and Surgery Annual
several other smaller ships have al operation with COMNA V AIRLANT, Quality Assurance Report of 1992. Washington,
DC:GPO;l992:13. 0
ready gone smoke-free. The Journal has implemented a shipboard study of
of American Medical Association smoking, smoking cessation efforts,
(JAMA) also spotlighted smoking ces and the impact on ship personnel. Dr. Bohnker is acting Force Medical
sation efforts on board Theodore Results from this study will benefit the Officer, Force Medical Office, Commander
Roosevelt. (8 ) entire fleet. Naval Air Force, U.S. Atlantic Fleet
(COMNAV A IRLANT), Norfolk, VA. Dr.
The smoking cessation program has
Fraser is former senior medical officer aboard
since grown with other aircraft carri References Theodore Roosevelt. He is currently Force
ers in the Atlantic Fleet working to 1. SECNAVINST 5300.13A. Medical Officer, COMNAVAIRLANT. LT
2. OPNAVINST 6100.2.
eliminate on board smoking. The Navy Shappell is an aerospace medical safety offi
3. OPNAVINST 5100.19B.
cer-aerospace experimental psychologist and
Surgeon General has made smoking 4. COMNAVAIRLANTINST 5100.2.
5. Environmental Protective Agency Respira smoking cessation coordinator. Dr. Hart is
cessation his highest promotion prior
tory Health Effects of Passive Smoking: Lung Can Medical Director, Naval Medical Center,
ity.(9) Commands have established cer and Other Disorders. EPA/600/6-90/006F. Portsmouth, VA.
November-December 1993 3
Forum
Charting a New Course for
Navy Medical Education
CAPT David G. Kemp, MC, USN
AVIATORS HAVE A SAYING WHEN FACED WITH the applicability oft he skills and knowledge gained to a long
a crisis that "There's nothing more useless than the runway range plan for individual career development, which, in
behind you or the altitude above you." In that spirit, I want turn, is tied to operational requirements. In short, we do not
to focus on where we are going, rather than what is behind carefully manage skills and knowledge as a resource at a
us, for there is no reverse gear on time. I see a real need to time when resource management is vital to our survival.
more clearly defme an overarching philosophy for educa Point 2: The Navy requires an educated work force,
tion and training inNa vy medicine, for rational policy must but the responsibility for education is shared between
be derived from core values, expressed as doctrine. the student and the system. A bachelor's level degree is
TheNa vy has modified its core doctrine to face the future a basic "condition of employment" for most officer com
with reduced resources and a significant change in antici missions. Significant variation exists in this philosophy,
pated mission requirements. This new philosophy is clearly however. For example, corpsmen seeking commissions in
articulated in a document entitled "From the Sea." The men the Medical Service Corps must obtain the bachelor's
and women of HSETC (Health Sciences Education and degree on their own time while receiving partial financial
Training Command) must take the lead in developing the support, while the same corpsman seeking a nursing degree
education portion of Navy medicine's new philosophy for receives a relatively greater level ofs upport through a more
health services delivery in the 1990's. This doctrine will comprehensive program.
indeed be unique in that Navy medical philosophy will be The current philosophy is really one of "supply and
developed as a congruent element of DOD philosophy, as demand." This is most clearly demonstrated through the
articulated by the Assistant Secretary ofD efense for Health Health Professions Scholarship Program (our most expen
Affairs. sive education program at over $20 million per year) which
I will emphasize six points which I believe important to provides over 85 percent of our new physicians. Policy
consider in developing doctrine. Some may be very tough regarding the level of support provided has varied widely
pills to swallow, but we need to "break out of the box" to during my career, based on relative supply and demand. I
get the job done as resources rapidly downsize and our do not propose any change in the basic tenets, but believe
beneficiary population attrites at a much slower rate. there is room for improvement in fine tuning the present
Point 1: In the Navy Medical Department, education system to achieve greater value for dollar invested.
and training are support functions. Unlike a university Point 3: Navy training programs are conducted
where education is the principal mission, we train to satisfy mostly in Navy schools, with Navy developed curricula,
a system need. Navy medical education and training must at Navy expense. It is in these schools, focused on teaching
be geared to provide the right number of men and women, specific skills to specific work requirements, where we
trained with the necessary skills and knowledge, at the right need to think outside our current paradigm. ITRO, the
time in their personal career tracks. Too often, we have Interservice Training Review Organization, an acronym I
sponsored both courses and individuals without ensuring didn't even know when I began my tour, has assumed
4 NAVY MEDICINE
increasing importance in consolidating enlisted training When we have surveyed supervisors regarding the
programs among Army, Navy, and Air Force. Now, it is quality of our newly graduate technicians, they routinely
hampered by different training philosophies existing among complain that the techs do not possess the needed skills to
the three services. We in the Navy intuitively believe that "hit the deck running." Yet, for many of our physicians,
we train to a better standard than our sister services and so the opportunity to participate in residency training (truly
state, but I know of no data to prove that belief. I believe on-the-job training) is the primary incentive Navy medicine
we must back our beliefs with data in every case where our offers for retention. Why the difference in attitude? Teach
programs are longer and more expensive. This is really a ing is part of the "physician paradigm"; the Hippocratic
variant on outcomes research, the new paradigm for oath pledges every physician to teach others what has been
assessing quality in health care services, and one in which taught to him. Is it possible to infect every member of the
Navy medicine needs to invest. Medical Department with this same enthusiasm for teach
Point 4: Doctrine must be developed regarding free ing? I believe that we must attempt this as a future education
dom of choice in education and training. In an ideal and training philosophy on a far broader scale than it now
world, every man and woman would have the opportunity occurs. To be effective, this philosophy must extend
to "be all he/she can be." In a system not governed by the beyond the staff education and training departments of our
rules of the marketplace, some policy must exist to educate hospitals and clinics down to the level of each ward nurse,
and train members of the force to the needs of the system. administrator, senior laboratory, and X-ray technician,
We assign recruits to corps school, even when they might etc.
prefer to be an electronics technician or a language Point 6: We must instill core values as an element of
specialist. In the more recent past, we have begun to assign every curriculum. At the beginning of my tour, I stated:
corpsmen to "C" schools to be trained as technicians in "If we fail to teach the same values and standards in training
fields not of their choosing, in response to our inability to that we will require during practice, we cannot expect our
fill critical needs. former students to remain loyal to the system they enter
The more difficult challenge now occurs in the training upon graduation." The lessons of Tailhook have driven
of officers, particularly physicians. We have a crisis in home an even greater need to emphasize core values, and
primary care, which will only worsen as we move to a we have responded. This is not a task to be confmed to the
managed care environment. To date, our policy has been classroom, but a requirement that every member of the
confined to limiting specialty training to established re education community live through personal example a life
quirements and the result, unfortunately, has been more reflecting our core philosophy. The student should experi
physicians leaving the Navy to pursue postgraduate train ence this lifestyle beyond the classroom. He/she should
ing in the civilian sector after their obligated service has adopt it in the chow hall, in the barracks, everywhere. We
been completed. Our present system off inancial incentives must teach more than rules, we must educate students in the
continues to favor specialty training as does the career moral and ethical foundation which makes this the right
development pattern. Mandated training in a specialty is behavior.
not a possibility, for the civilian certifying agencies dis These are my thoughts as I bring my tour to a close. They
avow such policies. We clearly need new ideas. may seem too businesslike and not academic enough to suit
Point 5: A new alliance must be forged between many.But we are now in a competitive environment. We
formal (classroom) training and on-the-job (OTJ ) train compete with Army, Air Force, and civilian educational
ing. For most of my tour I have been opposed to "on-the institutions for training contracts. Navy medicine may soon
job training," because of the variation inherent in multiple, be in competition with "accountable health care plans" for
uncontrolled training environments. I continue to believe health services delivery for dependents and retired person
that OTJ is largely uncontrolled as it exists today, but nel. We must not be content with quality alone; we must
understand that it can, and must, become searnlessly seek value, which relates quality to dollars invested. 0
integrated with the classroom. To quote Dr. W. Edwards
Deming: "Assembling people in a classroom and giving
them lectures can be at best only one-third or one-fourth of
This article is based on a speech delivered at the change of Command
the total educational process. A superior must educate his
upon Dr. Kemp's completion .of his assignment as Commanding
subordinate on a one-to-one basis through actual work.
Officer of the Health Sciences Education and Training Command
Once the subordinate is educated in this manner, delegate
(HSETC). Dr. Kemp is now Specialty Advisor to the Surgeon General
authority to him and let him have the freedom to do his job." for Internal Medicine.
November-December 1993 5
Features
Innovations in
Alcoholism Treatment
CDR DouglasS. Derrer, MSC, USNR
ON GUAM, "WHERE AMERICA'S DAY BEGINS," have developing a true sense of" community," specifically,
the Alcohol Rehabilitation Department (ARD) has been a therapeutic community. Usually, the treatment groups
experimenting with some innovative treatment strategies are constantly preoccupied with issues of trust, openness,
since mid-1990. ARD Guam is a small facility (15 beds, and self-disclosure, seldom progressing much beyond
although we have treated up to 20 patients at times) with these initial concerns.
limited resources in an isolated area with most of the At ARD Guam, admitting and discharging patients each
treatment, supply, and administrative problems inherent in week gave the staff too little control over the composition
those conditions. The ARD believed that traditional and size of the patient community and the treatment groups.
treatment strategies had not undergone much progress in Ward census and group size fluctuated too much, depen
recent years and were in need of change in order to better dent as it was on demand for services and availability of
serve the patient population. clients. Demand and availability were often at the mercy
Before mid-1990, like most Navy ARDs and ARCs oft he operational commitments of the commands served or
(Alcohol Rehabilitation Centers) the program ran continu of ship deployments. At times there were too many patients
ously with patients entering treatment each week for 6 so that the ARD's modest bed capacity was exceeded, or
weeks of rehabilitation and patients graduating every week too few which weakened the program. As group size
who had completed the program (unless they were dis fluctuated between these extremes so did therapeutic
charged early for treatment failure). This is called an "open effectiveness. A "critical mass" of at least six patients per
group" format because the composition of the treatment treatment group is necessary for the maintenance of group
groups changes constantly with the regular, weekly admis progress. We found that number very hard to maintain.
sion and discharge of patients. The open group format has Counselors were experiencing burnout. They had no
been used for many years in alcohol rehabilitation and other visible boundaries governing the number of patients they
kinds of inpatient psychological treatment. Eighteen of the treated nor the length of time they worked in a treatment
19 Navy ARDs currently operate using the open group capacity. Counselors perceived patients as an endless
model(1) and this format is similarly ubiquitous in the queue-a discouraging and disheartening perspective. While
civilian sector. (2) However, there are many problems ARD Guam attempted to rotate its three counselors among
inherent in this model. two treatment groups and a program administrator posi
Problems with the open group fonnat. The most tion, this was difficult to do in practice. Since groups ran
significant problem is the great difficulty patients and staff continuously, there was no optimum time to plan for and
6 NAVY MEDICINE
effect such rotations. Switching counselors in a group to Concern has been expressed about having no senior
give one of them a break from treatment always meant patients available at the beginning of each treatment cycle
disrupting some important therapeutic relationships with to help initiate new patients into the program. Our past
patients. experience with open group showed this to be a mixed
Why ARD Guam adopted the "closed group" for blessing. Senior patients could be effective if they were
mat. Initially, it was to gain more control over a number well engaged in treatment and working with the program.
of treatment variables. The main reasons for the closed But we have also seen poorly functioning senior patients
group format were to obtain better control over the have a toxic effect on new patients that ran counter to
vicissitudes of patient census and to reduce counselor therapeutic goals. In a small treatment setting, the effect of
burnout. In the 2 years ARD Guam used closed groups one or two patients, for good or ill, can be powerful.
during my tenure as Department Head, we learned much With the closed group system, we have found that the
about their efficacy and advantages. establishment of group norms, the development of a
Closed group format simply means admitting all the therapeutic ward milieu, and the socialization of patients
patients for a particular rehabilitation treatment cycle at the into the expectations of the program take place rapidly and
same time. All patients enter, go through the program at most effectively when conditions are controlled by the
the same rate, and graduate on the same day. The program staff. Detailed rules, regulations, assignments, and pro
then "stands down" for 1 to 2 weeks. gram requirements are provided to patients on the first day
During stand-down time preadmission activities for the of treatment. A marathon large group with all patients and
next treatment cycle take place such as patient screenings, staff on the second day of treatment helps to demonstrate
histories and physicals, biopsychosocial assessments, and what group therapy is about, how it works, and what is
team meetings. This enables the new patients to be com expected of patients. This "one-two punch" provides a
prehensively evaluated by the counselors, nurse, medical uniform introduction to the ARD program for all patients,
officer, psychiatrist, and psychologist. The stand-down sets clear standards and norms for the remainder of the
period enables staff to complete assessments, clinical treatment cycle, and begins to build a sense of community
fonnulations, and individual rehabilitation plans for all and mutual concern among a diverse collection of strang
patients within the first week of treatment. Doing all ers. Not unlike the indoctrination of boot camp, the staff
workups at the same time gives staff a much better sense of is better able to establish and maintain group norms from
the composition of the patient community than when a few the outset.
new patients trickled in each week. These are some ad Furthermore, the closed group format consistently pro
vantages of the closed group; there are many others. duces definable stages of group development and predict
Advantages of the closed group format. The effects able issues of group process. As our experience with and
of a stable community for a specified period are consider observations of closed group grew over the months, we
able. When the composition of the patient community is not realized these were highly important and powerful aspects
constantly changing, the establishment and maintenance of of this format. Group process issues went well beyond
a therapeutic milieu is much more effective. Large group chronic concern with trust and openness. Soon it also
and community issues take on greater importance and became apparent that the therapy groups moved through
meaning. They seem to have greater therapeutic impact well-defmed developmental stages, reflecting a deepening
when the community is stable. involvement with personal problems and a better engage
Clear boundaries are advantageous to patients and staff ment with the program. The developmental stages that we
alike. Specific beginning and end points of each treatment have identified together with their associated process
cycle reduce staff and patient confusion and uncertainty. issues, defense mechanisms, and affects are tabulated
Counselors are less stressed when they have defmite breaks below with an approximate timetable of when they occur
in the "endless stream" of patients. Staff rotations into or during treatment. It should be noted, however, that ARD
out of treatment can be planned in advance, are logical, and treatment groups do not progress steadily through these
do not disrupt counselor-patient relationships. stages but often move back and forth among them. Devel
The stable composition of the community and its several opmental stages are as follows.
treatment groups helps patients to build trust rapidly • First week: childhood stage-"needy and fearful;
leading to more open communication, self-disclosure, and resentful." Basic trust and open communication, depen
willingness to reveal and work on problems in group dency, denial. Staff often seen as "punitive parents."
therapy. • First to second weeks: adolescent stage-anger,
November-December 1993 7
defiance, rule bending and breaking, "storming." Author months (rather than a few patients weekly) allowed a
ity issues, limit testing, staff splitting, "us and them" reasonable patient census to build up for admission to each
conflicts, projection of blame, beginnings of family issues. treatment cycle, thus, greatly modulating and soothing
Staff usually seen as "controlling parents." patient census fluctuations.
• Second to third weeks: adult stage-focus on treat Advantages of stand-down time. Downtime has been
ment, internalization of affects, taking responsibility for criticized as time wasted since no active treatment is being
self. Family and generational issues in alcoholic behavior. conducted. In fact, the staff is often busier during
Staff seen as "understanding parents." downtime than during the active treatment cycle. Down
• Third to fifth weeks: mature (working) stage time has numerous benefits.
acceptance ofa nd working through issues, coming to terms • Provides regular treatment evaluation. Downtime
with alcoholism and other personal problems, responsibil gives counselors a periodic, planned opportunity to
ity for self and others. Staff seen as consultants. "regroup" and reflect on their work. It gives all staff
• Fifth to sixth weeks: termination stage-"a bandon regular, scheduled periods to evaluate each treatment
ment and loss; consolidation ofg ains." Separation anxiety cycle, conduct a "postmortem" of the treatment phase just
and reentry conflicts, fears and anticipations about return completed, and to make systematic changes for the upcom
ing to the "real world," reemergence of some issues ing cycle. Downtime enables staff to develop new pro
previously left incomplete; getting it together; facing life grams, lectures, workshops, contact guest speakers, and to
without alcohol. Staff seen ambivalently as "rejecting make adjustments in the treatment program in view of the
parents" and "welcoming friends." assessed needs of the new patient group.
• Post-treatment stage: aftercare and relapse preven • Reduces counselor burnout. While downtime does
tion; patient bonding continues (see discussion of patient give counselors a short break from active patient treatment,
cohort below). this in itself does not reduce burnout. Burnout often results
With this model, family therapy constructs and meta from counselors treating patients constantly and having
phors are useful ways to conceptualize and discuss patient little or no time to consider themselves, their own needs,
issues during treatment, which has been very helpful in and what they are doing therapeutically. Downtin1e
clinical supervision. Because of the predictability of these reduces counselor burnout because the nature of their jobs
stages and the issues regularly associated with them, the changes significantly during this phase. This procedure
counselors' understanding and use of group process has works especially well in small ARDs where staff and other
improved; yet another benefit of the closed group format. resources are limited and multiple demands are made on all
A strong cohort usually develops among the patients. staff.
Because all patients are admitted to treatment, move • Simplifies job rotation. The Department Head is able
through its stages at the same time, and graduate together, to rotate jobs among counselors more easily such as
they have a sense of "common fate" from the beginning program management, family therapy, screening new
which draws them closer together, forming a strong patient patients, facilitating groups, lecturing, etc. Rotating coun
cohort or "family." Patients quickly come to know each selors into or out of group work for the next treatment cycle
other's problems and weaknesses so that a sense of mutual becomes easy, logical, and never disrupts any therapeutic
caring develops. This improved bonding among patients relationships.
results in a greater sense of responsibility for each other's • Increases staff efficiency. Downtime makes admis
welfare. Patients offer each other mutual support during sion procedures and physical exams easier and more
treatment, but more importantly, the development of efficient by grouping the new patients together and seeing
stronger ties helps to prevent relapse after they have left the them all within a few days to a week. Physicians have
program. indicated this is a better use of their time by concentrating
Closed group format has worked well to stabilize the history-taking and physical exams into a short period with
treatment program. During the demands of Desert Shield/ a long break (during the treatment cycle) rather than having
Storm with ship deployments and rapid changes of orders to work up a few patients every week for admission. All
due to a large drawdown of military personnel from Guam, treatment staff make good use of downtime to preadmit
the patient census could have fluctuated wildly from week patients and to initiate team biopsychosocial assessments,
to week. This would have been quite disruptive to psychological testing, clinical formulations, and individual
community stability and the effectiveness of treatment. rehabilitation plans.
Having an entire group of patients admitted about every 2 • Improves staff awareness of community issues. In
8 NAVY MEDICINE