Q&A: Brigadier General David A. Rubenstein
Sustainment Proponent
Providing for the Needs and Requirements of Deployed Army Health Care
.jpg)
Brigadier General David A. Rubenstein
Assistant Surgeon General
for Force Sustainment
Brigadier General David Rubenstein is the assistant surgeon general for force sustainment, assigned to U.S. Army Medical Command, Fort Sam Houston, Texas. Prior to this assignment he commanded the 30th Medical Brigade and was the V U.S. Army Corps Command Surgeon, Heidelberg, Germany. He has previously commanded Landstuhl Regional Medical Center, Landstuhl, Germany, 21st Combat Support Hospital, Fort Hood, Texas, Task Force Med Eagle, Bosnia & Herzegovina, 18th Surgical Hospital (MASH), Fort Lewis, Wash., and Headquarters Company, 307th Medical Battalion (Airborne), 82nd Airborne Division, Fort Bragg, N.C. Other assignments have been with the 3rd Medical Battalion, 7th Infantry Regiment, Eisenhower, Madigan and Beaumont Army Medical Centers, DeWitt Army Community Hospital, the Office of The Surgeon General, Europe Regional Medical Command and the Academy of Health Sciences.
Rubenstein is a graduate of Texas A&M University and the Army War College. He has earned a master’s degree in health administration from Baylor University and a master’s degree in military art and science from the Army’s Command and General Staff College.
Among his awards and decorations are the Department of Defense Legion of Merit, Army Meritorious Service Medal, Army Commendation Medal, Army Achievement Medal, Armed Forces Expeditionary Medal, Humanitarian Service Medal, NATO Medal, Overseas Ribbon, Military Outstanding Volunteer Service Medal, Army Superior Unit Award and German Proficiency Badge (Gold).
He has earned the Expert Field Medical Badge, Master and Canadian Parachutist Badges, Ranger Tab, German Marksmanship Badge, Army Staff Identification Badge, The Surgeon General’s “A” professional proficiency designator and German Sports Badge. Among his honors are the U.S. Army-Baylor University Alumni Club Distinguished Alumni Award, Order of Military Medical Merit, Federal Excellence in Healthcare Leadership Award, Regent’s Healthcare Executive Award from the American College of Healthcare Executives, and the Medical Service Corps Chief’s Award of Excellence. He is listed in four Who’s Who publications and has been included in Modern Healthcare’s 2003 and 2004 lists of the 100 most influential people in health care.
Rubenstein is a board-certified health care executive and has attained Fellow status in the 30,000 member American College of Healthcare Executives. He is a governor on the college’s board of governors and sits on a national committee. He served as the health care administration consultant to the Army Surgeon General from 2003 to 2005. His other professional memberships include the Association of the United States Army, Association of Military Surgeons of the United States, American Hospital Association, and Veterans of Foreign Wars of the United States.
Interviewed by MMT editor Jeff McKaughan
Q: The Army Medical Department has been supporting warriors on the battlefield since combat operations in Afghanistan began in late 2003. What are some of the AMEDD’s critical successes and lessons?
A: First and foremost, the money, time, effort and focus to improve training, equipment, facilities and research have led to tremendous outcomes for the wounded warrior. Chief among these outcomes is the fact that 90 percent of all warriors wounded in Iraq and Afghanistan survive their injuries. Advancements in combat health support that have contributed to this survivability include the superbly trained 91W Combat Medic, development of an easier to use and individually issued self-use tourniquet, groundbreaking research that resulted in a hemostatic bandage that is issued to every soldier, and the deployment of almost 11,000 medical personnel into the Iraq and Afghanistan area of responsibility. And the amazing care provided to our wounded is captured on electronic medical records using the Theater Medical Information Program. Instead of documenting care on sheets of paper exposed to the weather and loss, every step in the care of these warriors is recorded on an electronic record that is immediately available to health care providers as the wounded arrive at Landstuhl in Germany, Walter Reed and Bethesda medical centers in Washington, and at the patient’s final military destination when they arrive home for continued care.
The AMEDD has been there to treat and evacuate more than 25,000 sick or injured patients since the start of operations in Southwest Asia. The AMEDD has also been there to prevent disease, preserve health and protect warriors in order to ensure as low a casualty rate as possible. These advancements and results demonstrate time and again that our military health services are critical to readiness of individual soldiers and their organizations.
The same can be said for the importance of our deployable health system to other situations. For instance, many Active and Reserve component Army medical units deployed to New Orleans and the Gulf Coast in response to domestic health care issues following hurricanes Katrina and Rita.
Another example shows with stark reality the AMEDD’s ability to, on short-notice, apply dedicated personnel, The 212th Mobile Army Surgical Hospital—MASH returned to Germany from an extensive month-long training and humanitarian assistance mission in Angola, on the Southwestern coast of Africa. Three weeks later, with only a few days notice, the 212th deployed a hospital task force to Pakistan to provide surgical, medical and preventive care to the victims of the devastating 8 October earthquake. For four months the hospital and subordinate units provided quality health care to thousands of victims and those needing preventive health care and immunizations. Then the staff trained counterparts from the Pakistani 62nd Medical Battalion in preparation for turning the entire 84-bed hospital over to the 62nd.
Q: What is your responsibility as the Army’s Assistant Surgeon General for Force Sustainment?
A: My assigned portfolio has four specific areas of responsibility that apply to Army health care—medical, dental, veterinary, education and training, preventive medicine, research and development— around the world, whether in brick and mortar facilities in garrison settings or under tentage and in deployed facilities in combat settings. The organizations responsible for executing the ASG-FS portfolio are the Army Medical Command’s [MEDCOM] Directorate for Medical Logistics, Directorate for Information Management and Information Technology, Directorate for Installations, Environment, and Facilities Management, and the Health Care Acquisition Agency.
The ASG-FS portfolio includes: 1. being accountable to provide medical and combatant commanders with medical logistics policies and programs for current operations while reengineering for future demands, 2. providing oversight and direction for AMEDD garrison and tactical information management and technology operations and advancements, 3. ensuring sustainment and modernization of 32-million square feet of AMEDD facilities and development of construction projects to meet future needs, and 4. serving as head of contracting activities responsible for over $1 billion in health care contracts annually. In addition to numerous delegated duties, the ASG-FS serves as the deputy commanding general of the Army’s 3rd Medical Command in Atlanta, Georgia.
Q: One of the focus areas of the Army and Department of Defense is joint force health protection [JFHP]. How is this area supported and how does medical logistics fit into the concept?
A: The Under Secretary of Defense for Health Affairs has organized the management of this joint focus area under his Assistant Secretary of Defense for Force Health Protection and Readiness, Ms. Ellen Embrey. This alignment at the Department level facilitates health protection through improved medical capabilities and solutions to the warfighter with the assist of each of the service’s surgeon general. With this alignment and approach force health protection issues and requirements are best able to be addressed jointly to minimize duplication of effort.
Medical logistics, as one of the Army’s 10 medical battlefield operating systems in our integrated combat health system, supports JFHP and the other nine medical systems in the delivery of health care by providing acquisition, materiel management and distribution, optical fabrication, blood storage and distribution and health facilities management. In essence, medical logistics supports every aspect of the continuum of care, which includes the health protection of our forces.
Another recent improvement to JFHP is the establishment of governance under the Joint Force Health Protection Council. Joint medical logistics initiatives, policy and business processes are formally worked among the Services within the Medical Logistics Proponent Committee of the Council. Although this committee has existed independently among the logisticians for years, it recently was formally aligned to report directly to the JFHP Council to better facilitate medical logistics support to JFHP.
Q: To improve the integration of medical supply sustainment support among the services, the Deputy Secretary of Defense appointed a department-level executive agent for medical materiel. Please explain some of the benefits of that directive and what it means for both the services and the warfighter?
A: The deputy secretary announced this appointment in DODD3101.9 last year. The director, Defense Logistics Agency [DLA] was named as the DoD Executive Agent for Medical Materiel. In that role the director acts as the single DoD point of contact to establish the strategic and operational relationships among the services and the medical industry in order to promote effective and efficient medical supply chain support.
The primary aspects of this directive are the establishment of joint business processes, the development of a joint requirements tool to effect better programming medical materiel sustainment requirements to support combatant commanders, the establishment of a defense funding framework and automation to improve medical materiel acquisition for the services and overall sustainment support to the warfighter. Although each of the services remain responsible under Title 10 for initial outfitting of forces, this directive provides an opportunity to the services to consolidate medical materiel requirements to industry, improve future funding levels for sustainment materiel [D+60 to D+180], and utilize the Defense Working Capital Fund to initially procure and capitalize inventories to support combatant commanders earlier in the development of a joint area of operations.
The medical commodity, called Class VIII, is the first of five supply classes to be consolidated under the leadership of DLA. Our senior medical logisticians are working aggressively to realize the benefits of this alignment in order to improve overall sustainment of forces once deployed.
Q: You’ve discussed the DoD executive agent directive and its benefits. What are some of the new joint medical logistics concepts required to affect improved support to the combat commanders?
A: Two come to mind and are currently being formalized through extraordinary efforts by our senior medical logisticians. First, the implementation of the Executive Agent for Medical Materiel [MMEA] is being formally developed by a joint integrated process team cochaired by the J-3, Defense Logistics Agency and the commanding general, Defense Supply Center, Philadelphia. Medical logistics leaders from all services are among the members, to include the Army, Navy and Air Force medical logistics chiefs.
One of the first concepts and objectives for the MMEA is to appoint theater lead agents. These lead agents will be held responsible for improving the distribution of medical materiel to combatant commanders. Theater lead agents are service organizations which act on behalf of the MMEA to provide medical materiel distribution and supply chain management in support of combatant commands. On February 13, 2006, the chairman of the joint chiefs of staff approved the appointment of the first three theater lead agents for medical materiel [TLAMM].
The three initial TLAMMs approved by the chairman are: U.S. Army Medical Materiel Center-Europe for support to European Command; U.S. Army Medical Materiel Center, Southwest Asia, for support to Central Command; and the 16th Medical Logistics Battalion for support to Pacific Command and United States Forces-Korea. Each of these organizations is now responsible to support all joint health services support, as outlined in Joint Publication 4.02, within a designated combatant command.
The second concept is the development of a new joint medical logistics automated system to provide support at the theater level. This new system is called the Theater Enterprise Wide Logistics System [TEWLS]. Initial system development is underway at Fort Detrick, Md., and is expected to be fielded to all combatant commands by early FY2008. This enterprise approach will be incorporated into the joint medical logistics automated program called Defense Medical Logistics Standard Support System [DMLSS] in FY2007 as a sustained portfolio capability.
DMLSS is currently utilized by each of the services in all institutional medical treatment facilities across the DoD. The incorporation of TEWLS enables the DMLSS system to provide the same improved business practices to combatant commands and deployed medical forces. Some of the expected benefits include much better management of assets and complete medical assemblage production, a single master catalog of products, increased asset visibility across all service health systems, faster medical product sourcing, and improved medical supply and equipment delivery to deployed forces.
Q: Radio frequency identification [RFID] has been under study for sometime. What conclusions has MEDOCOM reached for application within the Army?
A: The DMLSS automated system will be utilized by all services to manage medical logistics functions and interface with the nation’s medical supply industry. MEDCOM has been involved for the last two years as a member of the DMLSS Joint Medical Logistics Functional Development Center at Fort Detrick to examine the maturation of current RFID technology and its applicability for medical materiel.
The initial application concept for medical logistics is being finalized within the DMLSS Program Office and the Joint Medical Logistics Functional Development Center for use by all services. The Medical Logistics Proponent Committee, as the DoD’s policy body for all medical logistics initiatives, expects to rule on the initial implementation policy and concept by the end of this fiscal year. Once approved, the medical materiel applications of RFID for the services will be briefed to the Defense Logistics Agency as the DoD’s executive agency for medical materiel. The medical supply industry will be notified formally of DoD’s application intent and technology selection by DLA’s contract administration officials.
Applications within DMLSS are designed to support both peace and war requirements as part of the DoD’s integrated and commercially- based medical supply chain. Expanded use of RFID will start during calendar year 2007.
Q: What effect does Army transformation have on health care facilities management?
A: The Army has identified a number of locations in the continental United States where Army transformation will take place. As directed by the Secretary of Defense, brigade combat teams and other units will be organized and personnel will be restationed to support the Army’s transformation to a modular force. Additional sites have been identified that will support the Army’s integrated global presence and basing strategy moves from units currently overseas to new locations in the States. The final piece of Army transformation related specifically to locations are the actions assigned by the Base Realignment and Closure Commission report [BRAC] that established a variety of centers of excellence and joint operations sites. The BRAC results also combined medical training sites to maximize utilization of resources and allow the services to gain training and other synergies working together.
All of these actions have resulted in population shifts— increases and decreases—that have generated new or additional demands on the Army’s health care system as it supports the health care needs of our soldiers and their family members.
The MEDCOM currently has 52 interim projects either completed, in progress, or planned to be accomplished by 2007. These are interim solutions which consist of internal renovations, reopening buildings of opportunity, and building modular facilities to serve as clinics and administrative areas of operations. Interim solutions were required in conjunction with extended hours of operations until permanent construction is authorized, funded and obtained to support these increased needs.
We currently have plans to start permanent construction at many of these installations starting in FY2007, with projects continuing through FY2013. Our superb facility management staff is working around the clock to ensure we have solutions in place to meet the health care needs of our soldiers and their family members.
Q: With regards to creating the future AMEDD facility infrastructure, what challenges and opportunities do you foresee?
A: These are truly exciting and challenging times for the AMEDD. At the same time that our military facility planners are improving our medical facilities in Afghanistan and Iraq in support of OIF/ OEF, planning is underway for almost $5 billion in new medical facilities proposed for construction around the world over the next 5 years to support Army transformation. This is almost 10 times the normal investment rate of our military construction [MILCON] program, so the obvious challenge will be the proper management and oversight of project development and execution. Across CONUS, the Health Facility Planning Agency is working closely with the Army Corps of Engineers to develop responsive acquisition and design methodologies that will expedite the normal MILCON process. In the National Capital Area and San Antonio, where the major medical BRAC initiatives will occur, facility planners from all three services are already working together to establish joint project offices to work closely with the multi-service market offices. Similarly, in Korea and Germany, Army and Air Force medical planners are developing integrated health facility solutions that optimize the medical infrastructure of those unique health care environments.
The less obvious challenge, however, will be the impact on the rest of the AMEDD. The volume, and speed, at which these facilities are proposed to come on line will require engagement by the entire MEDCOM. Health care policy, personnel movements, contract support and equipment and IMIT systems acquisition processes, to say the least, must be carefully planned, resourced and synchronized to deliver new facilities with the greatest capabilities for our beneficiaries. Although this will be a truly challenging time for an AMEDD at war, 10 years from now, our infrastructure, and our health care delivery, will be far different than today, and we will all look back with pride at our accomplishment.
This is a unique opportunity to reset our Army Medical Department with creative solutions. These large investments will require us to make sure that we are doing smart business—not just in the process of creating these facilities—but also in the health care that they will deliver. New capital decision investment models, and facility acquisition approaches, will change the way we recapitalize our buildings. Privatization models, similar to the Army’s Residential Community Initiative, are being looked at throughout the Army, and our MEDCOM will be no exception. Although we are uncertain as to how they may be applied, the analytical process will require us to think differently about our infrastructure. Each new facility also presents an opportunity to integrate the latest medical equipment and IMIT solution—to deliver a truly integrated health care solution.
But as broad a change as is proposed for our many medical treatment facilities, this change is not limited to our health care delivery platforms. Medical research, force health protection and training will be fundamentally changed, and vastly improved. In support of the global war on terrorism, both the U.S. Army Medical Research Institutes of Infectious Diseases, Fort Detrick, and Chemical Defense, Aberdeen Proving Grounds, Md., have been proposed for replacement, as have critical parts of the Center for Health Promotion and Preventive Medicine, Aberdeen Proving Grounds. As a result of these investments, opportunities for new federal partnerships have presented themselves, most notably at Fort Detrick, where the National Integrated Bio-defense Campus includes partners, and new facilities, from the NIH, the Department of Homeland Security and the Department of Agriculture. Not only will we be challenged to find new ways to work together within DoD; we will increasingly be working closer in partnerships across our government.
Q: There has been a lot of publicity surrounding the Center for the Intrepid [CFI], please tell us a little about it.
A: The CFI Advanced Training Skills facility is a state-of-the-art building incorporating the latest medical technology and innovation to support the rehabilitation of our wounded warriors.
Ironically, a driving force behind the need for a rehabilitation center has been the Army and the Army Medical Department’s success at reducing casualties on the battlefields. The Army has greatly improved soldier survival rates, to the point that 90 percent of wounded warriors survive their injuries. This is a dramatic success when compared to Vietnam and Desert Storm. In those wars, about one-fourth of all soldiers wounded did not. However, this survival rate improvement has some critical consequences, such as the need for rehabilitative care. Historically, about three percent of wounded soldiers suffered amputations. Unfortunately, in the violent world we face, that figure has doubled. Six percent of our wounded warriors are suffering amputations.
The 60,000 square foot, four-story facility includes indoor tracks, a continuous wave-machine pool, a full size pool, a 30 foot climbing wall, a rappelling wall, and a fully equipped fitness area. It also includes an automobile simulator and a simulated apartment for soldiers to relearn essential life skills, as well as a weapons training simulator.
Some of the more high tech features of the facility include the uneven terrain modeler which allows health care providers to make adjustments to artificial limbs on the spot and helps the amputee relearn a basic human function, balance and walking. The modeler has the ability to create a myriad of simulated surfaces and terrains and includes a 300-degree projection screen to add realism to the environment. A high-tech gait lab will help rehabilitation specialists analyze the motions and assist veterans on their road to recovery. In addition to providing rehabilitative services, the CFI will have a prosthetic manufacturing center and a workshop to adjust and fine-tune prosthetic limbs as those changes are needed.
To help speed the rehabilitation and return these brave warriors to a normal life, the Intrepid Fallen Heroes Foundation, along with the Fisher House Foundation, joined with the government to build the CFI Rehabilitation Center and two 21-room Fisher Houses. The CFI is on the Brook Army Medical Center campus but physically separate from the hospital.
The entire focus of the CFI is the rehabilitation of our wounded warriors. It will also serve military personnel and veterans injured in other operations, combat and non-combat related. The oval shaped facility was designed so that patients and staff are in close proximity to each other, not separated by wings and floors. This type of healing environment will help the veteran by allowing for dependence on the care providers when needed, yet build their own independence during the rehabilitation process.
Next to the CFI, the Fisher Foundation is constructing two Fisher Houses for CFI and BAMC patients and their family members. This will bring to four the number of Fisher Houses at BAMC, and to 33 the number of critically important and much appreciated Fisher Houses worldwide. As we all know, having the family close to soldiers being treated for their wounds helps build their emotional stability which greatly improves their quality of life and speed of recovery.
Q: The war on terrorism places tremendous demands on Army health care. How will MEDCOM refine and transform contracting services in response?
A: The world today is markedly different from what it was before the 2001 events in the global war on terrorism. With those changes come new realities, such as recognition of the role of acquisition in responding to the need for battlefield information, mobility and speed. This new environment calls for innovation and new ways of contracting for medical supplies, equipment and services.
The demands for health care services, at a time when personnel are required to deploy to, or in support of, the combat zone, are growing at a rapid pace. In response, the professional team of contracting experts at the Army’s Health Care Acquisition Agency [HCAA] is continuing to refine the contracting process. HCAA is meeting these growing demands by developing and refining tools and procedures that reduce the time needed to contract for health care providers and ancillary services.
Using the flexibility of the Innovative Medical Acquisition Program the MEDCOM has a means to contract for both shortand long-term professional clinical staffing with performance at our medical treatment facilities. Additionally, the MEDCOM is constantly searching for resources and partnering opportunities to further enhance its capability.
Recently the MEDCOM also explored the use of the Department of Veteran Affairs National Acquisition Center’s Federal Supply Schedule. The Professional and Allied Healthcare Staffing Services Schedule, 621-I, is the first of its kind for professional clinical staffing. Instruments of this nature yield substantial administrative savings in resources, effort, and money. More importantly the time to procure services is significantly reduced and the instruments leverage the government’s collective purchasing power to get the best quality, prices and terms.
The traditional contracting process is complex and cumbersome. The contracting staff at HCAA and throughout MEDCOM is dedicated to continuing to streamline the process through innovation and listening to their customers.
Service contracting now accounts for approximately 52.9 percent of DoD contract expenditures. Last year HCAA obligated $1.1 billion of which over 75 percent were for services in support of the medical mission; a 23 percent increase in obligations over the previous year and nearly a 100 percent increase in obligations from FY03. A major portion of the increase is directly related to the Army Medical Department’s support of GWOT and the growing number of beneficiaries, to include soldiers from the Army’s Reserve and National Guard components and their family members. Contract services are becoming an increasingly integral part of our nation’s military health care system. I’m very proud how the staff in our various contract-support agencies and offices are meeting the challenge head-on.
Q: How does the transformation of contracting services impact the national policy to maximize use of small businesses whenever possible?
A: The MEDCOM has an outstanding reputation for supporting this national policy. Small businesses constitute the majority of the businesses in the United States and have proven to be very innovative and responsive in meeting our needs, particularly in providing health care services. We have been very successful promoting the use of small businesses where it makes good business sense to do so. Last year, with our record contracting volume, 70 percent of our contracts by dollar value went to small businesses.
By encouraging teaming arrangements and joint ventures to leverage the resources of multiple small businesses, we have helped small businesses realize they can compete for very large requirements. Our successes with mentor-protégé programs have also helped develop future small business resources to ensure continued performance.
Q: What do you see as the role of IM/IT in Army Medicine, now and in the future?
A: The Military Health System recognizes the need to incorporate clinical documentation, laboratory values, diagnostic imaging, medication records and other critical encounter data in a single integrated electronic medical record [EMR]. The need is two-fold: to support optimum medical care and to provide a longitudinal record for patient-specific health needs and population-level trends analysis. The key IM/IT strategies for the future will be focused on the joint force and integration efforts for patients whether in garrison, on the battlefield or in the Department of Veterans Affairs health system.
Complete integration and interoperability of disparate components of the current electronic record including AHLTA, Theater Medical Information Program, imaging systems, and National Guard and Reserve elements is the strategic target. Longitudinal data will be available on medical history, condition, status and medication allergies for each beneficiary. As the clinical data mart and clinical data warehouse become operational, population health issues will be addressed in a comprehensive manner that has never before been possible. Disease surveillance, prevention, wellness efforts, as well as pre- and post-health assessments will all take a quantum leap forward in quality and accessibility. As the execution of this project continues the MHS EMR will be interoperable with the VA’s electronic health record.
While the priority of our efforts is on direct support to health care, we also have initiatives involving capital returns, patient and workload accounting, sharing initiatives to maximize the use of federal facilities, and many others.
Leveraging current and future technologies for a single MHS solution just makes good business sense. It also concentrates our efforts as we coordinate efforts to meet the recent requirements of the BRAC decision. On a global scale, we are joining with the Navy and Air Force health care systems to integrate our health care information in order to create a truly unified effort by our medical forces and, thereby, enhancing capabilities and opportunities previously unrealized by any single service. As a result, the Army and DoD will have a solution that makes critical information available to our providers, anywhere, anytime, and for any patient.
Q: We began by talking about successes that have come from the AMEDD’s presence in and support to GWOT. Where do those advances lead us?
A: The short answer is that our successes lead us to new opportunities to save lives in our communities and around the world. Advances on the military medical front have, throughout history, found their way to the civilian health care community. Infection control, special surgical procedures, cutting-edge rehabilitation techniques, using helicopters to move the injured, and the development of emergency medical technicians are all examples of common health care expectations brought to the civilian community from America’s battles around the world.
From the ongoing global war on terrorism we already see advances in amputee rehabilitation techniques, hemostatic bandages, powders, and sponges that quickly control massive blood loss, the importance of forward surgical teams to provide immediate surgical intervention to stabilize patients for further evacuation, and the need for ever more complete and complex training for emergency medical technicians.
None of these advances, many of which will show up in civilian communities in some form or fashion, are at our finger tips by accident. The ongoing research, development, testing, and evaluation of innovative ideas to old problems is critical to being able to care of wounded, injured, and sick patients on today’s complex battlefields. Equally important, is the role of research and development to prevent illness and injury in the first place. Our ongoing malaria research is an example of this effort to meet a military preventive medicine problem that will have a clear-cut civilian application.
Q: Do you have a closing thought for us?
A: Two, one about the Army’s health care system and one about a very specific portfolio within that system.
First, America has every right to be extremely confident in the fact that its sons and daughters are receiving very good medicine in very bad places. The complex battlefield of today has introduced new enemy tactics, techniques, and weapons. The Army Medical Department has responded with the adaptability and flexibility that has been bred by over 230 years of experience in supporting the Army on battlefields around the world.
Second, the men and women who are responsible for providing expert support, policies and programs in the ASG-FS portfolio are superb. Though they do not touch patients, they are as responsible for the care provided as is the combat medic in an alley in Iraq or the sub-specialist clinician in a complex medical center. I am impressed with their dedication to the mission and their willingness to give that extra effort to support the MEDCOM community of commanders, staffs, patients and families. ♦