Paddling permanent white water: managing within the paradigm shifts in military medicine

The challenges of managing military medicine over the last three decades have been complicated by rapidly changing priorities and redirections. Inspired by Kuhn's theory of "paradigm shifts," we can identify five distinct paradigms and four paradigm shifts that have dominated military medicine over the last 25 years. These shifts began in the early 1970s when military medicine was forced to make a transition from a focus on combat casualty care to the problems of becoming an all-volunteer force. These paradigm shifts continue in the form of the current challenges of simultaneously embracing new cost-conscious forms of health care delivery while downsizing the force. Each of the shifts has been characterized by a lack of anticipation and the onset of crisis. The present challenges faced by military medical leadership are not necessarily unprecedented; prescience in regard to inevitable future shifts could reduce turmoil and enhance adaptation.