Faculty and Student Perceptions of Unauthorized Collaborations in the Preclinical Curriculum: Student or System Failure?

PURPOSE: Unauthorized collaboration among medical students, including the unauthorized provision of assistance and sharing of curricular and assessment materials, is a reported problem. While many faculty view such sharing as academic dishonesty, students do not always perceive these behaviors as problematic. With the trend toward more small-group and team-based learning and the proliferation of resource-sharing and online study aids, collaboration and sharing may have become a student norm. This multi-institutional, qualitative study examined faculty and student perceptions of and student motivations for unauthorized collaboration. METHOD: Using a constructivist approach, the authors conducted scenario-prompted semistructured interviews with faculty and students in the preclinical curriculum. Participants were asked to reflect on scenarios of unauthorized collaboration and discuss their perceptions of student motivation and the influence of personal or environmental factors. The authors performed inductive thematic analysis of the interview transcripts using open and axial coding followed by abstraction and synthesis of themes. RESULTS: Twenty-one faculty and 16 students across 3 institutions were interviewed in 2021. There was variation in perceptions among faculty and among students, but little variation between faculty and students. Both participant groups identified the same 3 areas of tension/themes: faculty/curriculum goals vs student goals, inherent character traits vs modifiable behavioral states, and student relationships with their peer group vs their relationships with the medical education system. Student behaviors were perceived to be influenced by their environment and motivated by the desire to help peers. Participants suggested cultivating trust between students and the education system, environmental interventions, and educating students about acceptable and unacceptable behaviors to prevent unauthorized collaboration. CONCLUSIONS: Given the various tensions and positive motivations behind unauthorized collaborations, institutions should consider explicitly preparing students to make thoughtful decisions when faced with competing priorities in addition to developing mitigation strategies that address the environment and its interactions with students.

Women's Clinical Preventive Services: Closing the Gaps and Implementing in Practice.

Evidence-based clinical preventive services have the potential to reduce morbidity and mortality and optimize health. The Affordable Care Act mandates coverage without cost-sharing for several clinical preventive services. The Women's Preventive Services Initiative (WPSI) has worked to and continues to identify gaps in recommended preventive services for women. The WPSI Well-Woman Chart and the accompanying Clinical Summary Tables can be used at the point of care to ensure women are offered and receive all the preventive services recommended for their age and circumstance.

Physical Health and Well-being: Updates and the Way Ahead.

INTRODUCTION: The Women in Combat Summit 2021 "Forging the Future: How Women Enhance the Fighting Force" took place during February 9-11, 2021, via a virtual conference platform. The third and final day of the Summit regarded the physical health and well-being of military women and included the topics of urogenital health, nutrition and iron-deficiency anemia, unintended pregnancy and contraception, and traumatic brain injury. MATERIALS AND METHODS: After presentations on the topics earlier, interested conference attendees were invited to participate in focus groups to discuss and review policy recommendations for physical health and well-being in military women. Discussions centered around the topics discussed during the presentations, and suggestions for future Women in Combat Summits were noted. Specifics of the methods of the Summit are presented elsewhere in this supplement. RESULTS: We formulated research and policy recommendations for urogenital health, nutrition and iron-deficiency anemia, contraception and unintended pregnancy, and traumatic brain injury. CONCLUSIONS: In order to continue to develop the future health of military women, health care providers, researchers, and policymakers should consider the recommendations made in this supplement as they continue to build on the state of the science and forge the future.

Shorter and Stronger: Revision of a Resident Performance Evaluation Survey.

INTRODUCTION: In order to evaluate the outcomes of a USU School of Medicine (SOM) education, a program director (PD) evaluation survey was developed in 2005 and is completed annually by PDs regarding trainees who graduated from USU and are in their first post-graduate training year (PGY-1) and their third post-graduate training year (PGY-3). The survey was last reviewed and revised in 2010 to better align with the competencies established by the Accreditation Council for Graduate Medical Education but has not been further evaluated or revised. The objective of the study was to utilize 12 years of aggregated data to improve the psychometric properties of the survey, with an emphasis on shortening the survey. A secondary objective was to refine the verbiage of the existing questions and add new items to assess health systems science competencies. METHODS: The survey was sent out to PDs who supervised USU SOM graduates in the classes of 2008 to 2019 (n = 1,958) with 997 responses for the PGY-1 PD survey and 706 responses to the PGY-3 PD survey. Exploratory factor analysis (EFA) was conducted on 334 complete responses of the PGY-1 survey and 327 responses of the PGY-3 survey. A working group of PDs, USU Deans, and health professions education scholars reviewed the results from the EFA and from a survey of experienced PDs and, in an iterative process, developed a proposed revised survey. RESULTS: The EFA for both the PGY-1 data and the PGY-3 data yielded three factors, and a total of 17 items were identified with cross-loading across the factors in the PGY-1 and/or PGY-3 surveys. Items without clean loadings or that were determined to be unclear, redundant, or difficult to assess by PDs were revised or removed. Items were revised or added to address needs within the SOM curriculum, including the new health systems science competencies. The proposed revised survey had 36 items in place of the original 55 items and contained at least four items for each of the six competency domains (patient care, communication and interpersonal skills, medical knowledge, professionalism, system-based practice and practice-based learning and improvement, and military-unique practice, deployment, and humanitarian missions). CONCLUSIONS: The USU SOM has benefited from over 15 years of results from the PD surveys. We identified those questions that performed well, and these were refined and augmented in order to optimize the performance of the survey and fill gaps in our knowledge of graduates' performance. To determine how well the revised set of questions performs, efforts will be made to increase the response rate and completion of 100% of items on the survey, and the EFA should be repeated after about 2-4 years. Furthermore, the USU graduates should continue to be tracked longitudinally past residency to determine if PGY-1 and PGY-3 survey measures predict long-term performance and patient outcomes.

Assuring TRICARE Coverage of Preventive Health Services for Women Beneficiaries of the Military Health System.

WHY DEFENSE HEALTH HORIZONS PERFORMED THIS STUDY: The primary role of the Military Health System is to assure readiness by protecting the health of the force by providing expert care to wounded, ill, and injured service members. In addition to this mission, the Military Health System (both directly through its own personnel and indirectly, through TRICARE) provides health services to millions of military family members, retirees, and their dependents. Women's preventive health services are an important part of comprehensive health care to reduce rates of disease and premature death and were included in the 2010 Patient Protection and Affordable Care Act's (ACA) expanded coverage of women's preventive health services, based on the best available evidence and guidelines. These guidelines were updated by the Health Resources and Services Administrations and the American College of Obstetrics and Gynecology in 2016. However, TRICARE is not subject to the ACA, and therefore, TRICARE's provisions or the access of TRICARE's female beneficiaries to women's preventive health services was not directly changed by the ACA. This report compares women's reproductive health care coverage under TRICARE with coverage available to women enrolled in civilian health insurance plans subject to the 2010 ACA. WHAT DEFENSE HEALTH HORIZONS RECOMMENDS: Three recommendations are proposed to ensure that women who are TRICARE beneficiaries have access to and receive preventive reproductive health services that are consistent with Health Resources and Services Administration recommendations as implemented in the ACA. Each recommendation has strengths and weaknesses that are described in detail in the body of this paper. WHAT DEFENSE HEALTH HORIZONS FOUND: In covering contraceptive drugs and devices, TRICARE appears to reflect the scope of coverage found in ACA-compliant plans but, by not incorporating the term "all FDA-approved methods" of contraception, TRICARE leaves open the possibility that a narrower definition could be adopted at a future date. There are important differences in how TRICARE and ACA-compliant plans address reproductive counseling and health screening, including TRICARE's more restrictive counseling benefit and some limits to preventive screening. By not aligning with policies related to the provision of clinical preventive services established under the ACA, TRICARE allows health care providers in purchased care to diverge from evidence-based guidelines. Although the ACA respects medical judgment when providing women's preventive services, standards restrict the extent to which health care systems and providers can depart from evidence-based screening and prevention guidelines essential to optimizing quality, cost, and patient outcomes.

Improving the Health and Readiness of Military Women.

WHY THE DEFENSE HEALTH HORIZONS DID THIS STUDY: Women comprise approximately one-fifth of the total force in the U.S. Military. Gynecologic and reproductive health issues not only affect the health and wellness of individual servicewomen but may also impact the mission of the DoD. Unintended pregnancies can result in adverse maternal and infant outcomes and can negatively impact the careers of military women and mission readiness. Gynecologic conditions such as abnormal uterine bleeding, fibroids, and endometriosis can also limit women's optimal health and performance, and a significant proportion of military women have indicated their desire to manage and/or suppress menstrual cycles, especially when deployed. Access to the full range of contraceptive methods is an important strategy to allow women to achieve their reproductive goals and address other health concerns. This report reviews rates of unintended pregnancy and contraceptive utilization among servicewomen and examines factors that influence these measures of health. WHAT DEFENSE HEALTH HORIZONS FOUND: Overall rates of unintended pregnancy are higher among servicewomen than the general population and rates of contraceptive use among servicewomen are lower than the general population. Congress mandates that servicewomen have access to contraceptive options, but the DoD has not established target measures for contraceptive access and use, unlike that present for the civilian population. WHAT DEFENSE HEALTH HORIZONS RECOMMENDS: Four potential courses of action are proposed to improve the health and readiness of military women.Recommendation 1: The Military Health System (MHS) should develop and maintain reliable sources of data to assess the gynecologic health of servicewomen, including rates of unintended pregnancy.Recommendation 2: When menstrual suppression, treatment for a medical condition, or contraception is desired, servicewomen should have ready access to the information they need to select the option that is best suited for their personal preferences and situation.Recommendation 3: In order to ensure that servicewomen have optimal access to the full range of contraceptive methods, the MHS should determine true access at all their facilities and identify actions to address any barriers.Recommendation 4: The MHS should establish service delivery targets for use of women's preventive health services, particularly contraception, to prevent unintended pregnancies.

Unintended pregnancy among U.S. military active duty servicemembers: Estimates for 2018 and trends since 2005.

OBJECTIVES: To evaluate the prevalence of and factors associated with unintended pregnancy in the past 12 months among women and men in the United States (U.S.) military in 2018, as well as trends in unintended pregnancy between 2005 and 2018. STUDY DESIGN: This was a cross-sectional study using the 2018 Department of Defense Health Related Behaviors Survey of active duty servicemembers. We selected a stratified random sample from members of all military service branches and used weighted logistic regression models to identify associated independent factors. A 9.6% weighted response rate to the online survey resulted in 16,806 active duty servicemembers analyzed; 4993 women aged 17 to 44 years and 11,813 men aged 17 to 45+ years. We used data from five independent surveys: 2005, 2008, 2011, 2015, and 2018 to examine trends over time. RESULTS: A total of 5.6% (95% CI: 4.5%-6.7%) of servicewomen reported unintended pregnancy and 2.4% (95% CI: 1.9%-2.9%) of servicemen reported to have caused unintended pregnancy. Unintended pregnancy was associated with contraception nonuse, younger age, and being either married or cohabiting. CONCLUSION: The decrease in prevalence of unintended pregnancy among U.S. servicemembers since 2005 mirrors the general U.S. POPULATION: Differing contraception policies during basic training across military services may influence rates of unintended pregnancy. Unintended pregnancies place a large burden on the military healthcare system, as the majority of women serving in the military are of reproductive age, and thus require care before, during, and for years after giving birth. IMPLICATIONS: Unintended pregnancy among U.S. military servicewomen relatively mirrors that seen in the U.S. POPULATION: Contraceptive policies affect unintended pregnancy throughout servicemembers' duration of service. As they are more likely to live in states which restrict access to abortion services, servicewomen with unintended pregnancy may face increased obstacles to care.

Influence of "Decide + Be Ready" Contraceptive Decision Aid on Pre-deployment Health Decisions.

INTRODUCTION: The number of active duty servicewomen and the career opportunities available to them continue to increase. Of the approximately 350,000 women in uniform, 97% are estimated to be of reproductive age, underscoring the importance of reproductive health care. This study aimed to explore the influence of the Decide + Be Ready (DABR) contraceptive decision aid on providing contraceptive knowledge, facilitating a servicewoman's contraceptive choice before and during deployment, and enabling understanding of individual preferences around contraception in a population of active duty women most at risk for unintended pregnancy. MATERIALS AND METHODS: We conducted a qualitative study, recruiting active duty women between the ages of 17 and 24 with at least one prior deployment who were stationed at Naval Station Norfolk and presented for evaluation at a primary care clinic. Participants downloaded and reviewed the DABR application. A semi-structured interview was conducted and audio-recorded. Interviews were transcribed and underwent thematic analysis. RESULTS: Twenty women participated in the study over 2 weeks. Analysis revealed three overarching themes: perceived utility of and attitudes toward DABR, knowledge of and comfort with contraceptive options, and challenges specific to active duty women. In total, eight subthemes were also identified and explored. CONCLUSIONS: The DABR app provided study participants with new information about contraception. Participants reported improved knowledge of gynecologic and reproductive health options available during deployment. Other findings raise interest for future studies exploring incorporation of peer validation in counseling and decision-making tools, challenges with the deployed environment for obstetric/gynecologic health, and medical support on naval deployments.

Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative.

DESCRIPTION: The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation. METHODS: The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported. RECOMMENDATION: The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

Risk Factors for Postpartum Depression in Active Duty Women.

INTRODUCTION: Postpartum depression (PPD) is a common perinatal complication. Risk factors previously found to correlate with PPD in civilians include prenatal depression, childcare stress, limited social support, difficult infant temperament, and maternity blues. Previously identified risk factors in military spouses include spouse deployment/redeployment cycles. It is unclear if these previously identified risk factors are also a risk factor for AD women or if the additional stressors associated with being on active duty (AD) are risk factors for PPD. The purpose of this review is to determine if civilian risk factors have been found to put AD women at risk for PPD and to identify unique risk factors for PPD in AD women. MATERIALS AND METHODS: A scoping literature review was performed using PubMed, Defense Technical Information Center, and PsychINFO. The searches were conducted using relevant medical subject headings and keywords. The inclusion criteria included articles published since 1948 (the year women were legally allowed to join the military) that reference risk factors for postpartum/peripartum depression in AD women serving in the U.S. military. The following exclusion criteria were also applied: in a language other than English, opinion papers, and/or not published in a peer-reviewed journal. Articles meeting criteria were evaluated and mapped to stressors previously identified in the literature for civilian and military spouses with PPD with novel stressors identified as mapping outside this framework. RESULTS: Only two articles met the inclusion criteria. The first study included 87 AD women. The second study, a cohort study between 2001 and 2008, included 1660 AD women. Unique risk factors identified in AD women include previous deployments, serving in the Army, smoking status, alcohol use, and low self-esteem. CONCLUSIONS: Few studies have investigated the risk factors for PPD in AD women. It appears that AD women share many risk factors, or variants of those risk factors, for PPD as their civilian and AD spouse counterparts, but there are also unique risks to consider. More work is needed to improve screening and prevention efforts.

Seeing Complexity: Cultural Historical Activity Theory (CHAT) As a Lens for Shared Decision Making.

Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.

Decide + Be Ready: A Contraceptive Decision-Making Mobile Application for Servicewomen.

Women in the military have a high rate of unintended pregnancies, which is an issue both personally and with respect to the warfighting mission. One strategy to help servicewomen achieve family planning goals includes increasing education about and access to contraception. Research suggests that preference-sensitive decisions about contraceptives benefit from shared decision-making, and decision aids have been shown to facilitate this patient-centered approach. In this article, we describe the process by which we enhanced an existing evidence-based tool to meet the needs of military servicewomen and created Decide + Be Ready, a contraceptive decision-making mobile application. After extensive research into challenges faced by servicewomen with respect to contraceptive knowledge and access, we developed content for the decision aid and determined that a mobile app format would provide the privacy and convenience needed. Our team developed a prototype that, in collaboration with the Defense Health Agency Connected Health Branch, was tested with servicewomen and providers. User feedback shaped the final version, which can be accessed free from the App Store and Google Play. Early implementation has demonstrated patient and provider satisfaction. Obstacles to full implementation of Decide + Be Ready remain within the Military Health System. We lay out a roadmap for dissemination, implementation, and evaluation and explore the applications of the decision aid for health professions education in the realm of shared decision-making. Finally, we recommend consideration of decision aids for other health care decisions as a way to achieve patient-centered care, improve health outcomes, and potentially reduce costs.

The Impact of Mammography Screening Guideline Changes in a Universally Insured Population.

Background: The U.S. Preventive Services Task Force (USPSTF) modified breast cancer screening guidelines in November 2009. The impact has been studied among privately and Medicare insured populations, but not among universally insured women. Materials and Methods: This study compared the proportion of TRICARE beneficiaries aged 40-64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis to determine the impact of the 2009 USPSTF guideline changes. Stratified analyses evaluated differences by age (ages 40-49, 50-64), race, care setting, beneficiary type, and military status. Results: The proportion of women receiving mammograms increased from October 2005 through September 2009. A small, but significant decrease of 65-66 fewer women screened per 10,000 occurred in the first quarter of 2010 (October 1 to December 31) following the screening guideline update publication. The proportion screened then remained unchanged through 2015. Comparative analysis revealed no differences in impact between age groups, blacks and whites, or military dependents and active-duty/retirees. Conclusions: This study determined that the USPSTF guideline updates had a small, but immediate and lasting impact that was not different across age groups, beneficiary type, or race. No racial disparities in the proportion screened or in the impact of the guideline change were noted in our universally insured population.

Does Universal Coverage Mitigate Racial Disparities in Potentially Avoidable Maternal Complications?

OBJECTIVE: Potentially avoidable maternity complications (PAMCs) have been validated as an indicator of access to quality prenatal care. African-American mothers have exhibited a higher incidence of PAMCs, which has been attributed to unequal health coverage. The objective of this study was to assess if racial disparities in the incidence of PAMCs exist in a universally insured population. STUDY DESIGN: PAMCs in each racial group were compared relative to White mothers using multivariate logistic regression. Stratified subanalyses assessed for adjusted differences in the odds of PAMCs for each racial group within direct versus purchased care. RESULTS: A total of 675,553 deliveries were included. Among them, 428,320 (63%) mothers were White, 112,170 (17%) African-American, 37,151 (6%) Asian/Pacific Islanders, and 97,912 (15%) others. African-American women (adjusted odds ratio [aOR]: 1.05, 95% CI: 1.02-1.08) were more likely to have PAMCs compared with White women, and Asian women (aOR: 0.92, 95% CI: 0.89-0.95) were significantly less likely to have PAMCs compared with White women. On stratified analysis according to the system of care, equal odds of PAMCs among African-American women compared with White women were realized within direct care (aOR: 1.03, 95% CI: 1.00-1.07), whereas slightly higher odds among African-American persisted in purchased (aOR: 1.05, 95% CI: 1.01-1.10). CONCLUSION: Higher occurrence of PAMCs among minority women sponsored by a universal health coverage was mitigated compared with White women. Protocol-based care as in the direct care system may help overcome health disparities.

Early Childhood Outcomes Among Infants Born by Vaginal Birth After Cesarean and Repeat Cesarean Delivery in the Military Health System.

OBJECTIVE: This study examines whether children delivered by repeat cesarean section experience higher incidences of otitis media, respiratory infections, and allergic diseases than children delivered by vaginal birth after cesarean section (VBAC) in the Military Health System. STUDY DESIGN: This is a retrospective cohort study from the Military Health System Data Repository of women who underwent repeat cesarean section or VBAC between 2006 and 2012 and their offspring through 2014. RESULTS: About 11,659 infants with 2 years of follow-up were identified. Infants delivered by VBAC had lower odds of developing respiratory illness (P < .000), otitis media (P < .001), and allergies (P = .022) compared with infants born by repeat cesarean section. There were no differences in the development of food allergies. CONCLUSION: Emerging data regarding early childhood health are additional factors that can influence the mother's decision on mode of birth after a primary cesarean section.

Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience.

INTRODUCTION: The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation's only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. METHODS: This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. RESULTS: Six key "lessons learned" were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. CONCLUSIONS: Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

Situativity: a family of social cognitive theories for understanding clinical reasoning and diagnostic error.

The diagnostic error crisis suggests a shift in how we view clinical reasoning and may be vital for transforming how we view clinical encounters. Building upon the literature, we propose clinical reasoning and error are context-specific and proceed to advance a family of theories that represent a model outlining the complex interplay of physician, patient, and environmental factors driving clinical reasoning and error. These contemporary social cognitive theories (i.e. embedded cognition, ecological psychology, situated cognition, and distributed cognition) can emphasize the dynamic interactions occurring amongst participants in particular settings. The situational determinants that contribute to diagnostic error are also explored.

The Impact of Mammography Screening Guideline Changes Among Women Serving in the U.S. Military.

INTRODUCTION: The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access. MATERIALS AND METHODS: This study evaluated the impact of the 2009 guideline changes among the population of universally insured military servicewomen, comparing the proportion of active duty women aged 40 to 64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis. Stratified analyses evaluated differences by age (aged 40-49, 50-64), race, military branch, and rank. This research is considered exempt by the Uniformed Services University Institutional Review Board. RESULTS: The proportion of insured military servicewomen receiving mammograms increased from October 2005 through September 2009. A significant decrease occurred in the first quarter of 2010 following the publication of the screening guideline update. From this new baseline, the proportion of women screened increased again through September 2015. Comparative analyses showed more pronounced effects both immediately and over time among the women aged 50 to 64 compared to those aged 40 to 49 years and among older enlisted women compared with their officer counterparts. The patterns were near identical in all subgroups; however, no changes in rate were evident among Air Force and black servicewomen aged 50 to 64 and Army and Navy/Marine Corps servicewomen aged 40 to 49 years. No racial disparities in screening or impact were noted. CONCLUSIONS: The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses.