Military Pediatrics: Everything You Were Afraid to ask

1
Military Pediatrics Everything You Were Afraid
to ask

• Gregory S Blaschke, MD, MPH, FAAP
• Captain, Medical Corps, United States Navy
• Associate Professor of Pediatrics
• Uniformed Services University of the Health
  Sciences
• Naval Medical Center San Diego Pediatrics

2
Department of Defense Disclaimer

• The opinions or assertions contained in this
  presentation are the private views of the
  presenter and are not to be construed as official
  or as reflecting the views of the
• Department of Defense (DOD)
• Navy, Army or Air Force (USN, USA, USAF)
• Uniformed Services University of the Health
  Sciences (USU or USUHS)
• Naval Medical Center San Diego (NMCSD)
• I could go on

3
Context

• USN x 19 years so some Navy examples
• Info from all 3 services but each is slightly
  different
• Uniformed Services Section of AAP 700
• Military Chapter East and Chapter West
• Chose to stay
• Children, Families and Communities
• Training, Leadership Opportunities

4
Recruitment

• I am NOT a recruiter
• I am
• Well trained
• An adventurer, a travelor
• A leader
• Not in debt
• Opportunity may exist for students, residents,
  fellows and staff

5
Alphabet Soup

• Pediatrics SGA, LGA, AGA, PDA
• Education AAP, APA, FOPO, COMSEP, CORNET, PROS,
  PRIS, AMA, ACGME, RRC, ABP, ABMS
• Navy DOD, DON, USN, DOS

6
Perspective

• Residency at small program
• 15 residents
• Naval Hospital Oakland
• Fellowship at large program
• 450 fellows
• 145 residents
• Childrens Hospital Boston
• Ideal 1-2 years at small and large

7
Practice

• 5 States, 8 Countries, 7 medical schools and
  visited 20 programs
• FP and Peds training (students to fellows)
• Community to quaternary care hospitals and
  clinics
• Newborn, Inpatient, Outpatient General and DBP
• International work
• MPH

8
Disclosures

• Minimum of 50 clinical practice for past 8 years
• Bright Futures
• Community Pediatric Training Initiative
• Caring for children, their families and our
  communities

9
Military Pediatrics

• Clinical Care and Service Delivery
• It takes a village
• Internal and external advocacy
• Education, Training Research
• Quantity, Quality
• Students to Fellows and beyond
• Military Medicine
• Operational Medicine
• Humanitarian Security Assistance
• Homeland Defense and Disaster Preparedness
• Opportunities, Threats Collaboration

10
Military Pediatrics

• Clinical Care and Service Delivery
• It takes a village
• Isolated and austere
• Internal and external advocacy
• AAP Book About Children
• Some inaccuracies
• Stereotypes misconceptions

11
The Military Culture

• Fortress A metaphor for military culture
• Represents enclosure, exclusion, and apartness,
  as well as the warrior mission that is its reason
  for existence
• Has systems of symbols, values, beliefs, dress,
  jargon

12
The Military Not your typical culture

• Undefined racially, ethnically, religiously,
  geographically, and linguistically
• Most members not military-born
• Membership impermanent
• Most join for advancement, education
• Cross section of America (with some exceptions)
• Medical, Military and Military Medical Cultures

13
History of the Military and Families

• Ancient and not so ancient history
• Enlisted men of lowest rank forbidden to marry
• After WWII, global responsibilities led to
  expansion of peacetime military
• If the Marine Corps had wanted you to have a
  family, it would have issued you one.
• Wives and children often treated as bothersome
  complications and potential threats to readiness

14
A Growing Role for Families

• 1973 all volunteer force created
• Families essential to an all-volunteer military
• Restrictions on marriage of junior enlisted
  dropped
• 1979, 1st Family Support Center opened by Navy
• Family discontent principal reason to leave
• Family Centered Care!
• Recruiting/Retention during current GWOT conflicts

15
State Populations of Military and Civilian
Personnel in U.S. Military Installations, 1999
Source Statistical Abstract of the United
States 2001
16
Military Demographics

• Today uniformed personnel outnumbered by
  dependents
• 3.5 million total military personnel
• 1.4 mil active duty (with 1.9 million
  dependents)
• 1.1 mil reserve and national guard
• 800,000 DoD civilians
• Military force is 32 smaller than 1990

17
Number of Active Duty by Service Branch
September 2005
18
Military Families

• Total of family members of AD 1,865,058
• 54.6 active duty are married (59.4 in Army)
• 51.2 of spouses are less than 30 years old
• Average number of children is 2
• ½ of military were between 20-25 years of age
  when first child born
• 5.4 are single parents (overall, US Census is
  11.4)
• Total of family members of R/NG 1,141,735
• 53.8 reservists are married
• 26.8 of spouses are less than 30
• Average number of kids is 2

19
Age of minor dependents of Active Duty
N 1,177,190
20
Junior Enlisted

• 46 of military is junior enlisted (E1-E4)
• Majority single (71)
• 24 Married to civilians
• 63 Spouses work to make ends meet
• 21 Young children

21
Women in the Military

• 14 of military population
• Ratio Officers Enlisted
• 20 in joint service marriage (4 of men)
• 75 of joint service marriage E1-E6 ranks
• Family care plans

22
Children and the Military

• Membership is not a choice
• Military is powerful, shaping culture
• May lack hometowns and may not have easy access
  to extended families
• Mobility affects continuity
• Legacy members choose to give back to community

23
Number of U.S. Military Personnel by Installation
Location, 2003
Source Department of Defense 2003
24
Military Life

• Much absence from family life by the parent(s) in
  uniform
• Extreme mobility
• Separateness, and maybe alienation, from the
  civilian community
• Constant preparation for war

25
Challenges

• Loss Cycle of Deployment
• Resiliency
• Military families move on average every 2.9 years
• Children attend 5 to 7 schools in 12 yrs
• Threat of parental loss in the line of duty looms
• Highest quality daycare in Nation, but not
  meeting 100 of need

26
Community Challenges

• Reluctance to use available resources
• Most bases have centers that provide advice,
  counseling, and education for military families
• Services underused because sometimes perceived as
  a career risk
• Services delivered in a military way
• Some choose civilian services

27
Challenges

• Financial stress
• Financial difficulty is one of the principal
  quality-of-life reasons members leave
• Military pay is about 6 below civilian pay for
  comparable work
• Military behavior extending inside the family
• Authoritarian
• Can contribute to stress, family violence and
  child insecurity

28
Positive Attributes of Military Children

• Often emerge with qualities that serve them
  extraordinarily well for the rest of their lives
• Resilience in the face of change
• An anti-racist attitude
• Idealism
• Decreased disparities
• Community?
• Access?
• Single Party Payer?

29
Military Health Care

• Single party payer health care system
• MHS Military Health System
• Direct care in military
• HMO, PPO, FFS
• Employer and health care provider employed by
  same system
• Staff Model HMO
• Occupational Health

30
Military Health Care

• Continental US (CONUS)
• Tertiary Care (Peds categorical training)
• Community Care (FP with Peds staff)
• Isolated small rural hospitals and clinics
• OCONUS
• Global practice ranging from solo to tertiary
  care
• Mostly 1 to 4/6
• Comprehensive Generalists

31
Clinical Practice

• It takes a village
• About AND not OR
• Military and Civilian Pediatricians care for
  children of military
• Semi-closed system of care
• Mix is community dependent

32
(No Transcript)
33
American Academy of Pediatrics March 2007 ALF
Resolution

• Critical Action to Support the Children and
  Adolescents of American Military Families

34
Video Resources

• Talk, Listen, Connect Helping Families During
  Military Deployment (Preschool Age)
• Mr. Poe and Friends Discuss Reunion after
  Deployment (Elementary Age)
• Military Youth Coping with Separation When
  Family Members Deploy (Older Children and
  Adolescents)
• TriWest Deployment Video Support Video - Getting
  Home - All the Way Home, and On the Homefront

AAP HP 2010 Mental Health Chapter grant
35
Other Important Resources

• www.MilitaryOneSource.com
• www.ZeroToThree.org
• Coming Together Around Military Families
• www.NMFA.org
• National Military Family Association Operation
  Purple Camps
• www.MilitaryHomeFront.DOD.mil

36
No matter what you think

• If you want to honor a member of the military
  for their service and sacrifice, take
  exceptionally good care of their legacy their
  children, while they are away doing the necessary
  work of the nation.
• COL Elisabeth M. Stafford, MD, FAAP
• -- Congressional Testimony

37
Education Training Implications

• Military is cross section of America
• Care occurs within semi-closed system that cannot
  care for all (by choice to allow choice)
• Training occurs within a semi-closed system
  (Diversity important)
• Military Unique Curriculum (MUC) necessary and
  required by Congress
• Military internal and collaborative external
  advocacy

38
Advocacy

• Care of children in university-like system
• Collaborate and connect to civilian systems
• San Diego, CA or Minot, ND
• Anywhere, USA
• DOD commitment to military children, families,
  retirees, reservists
• DOD commitment to training to meet unique needs

39
Discussion

• Are we (PEDIATRICS) doing enough to train all
  pediatricians about caring for these children,
  their families and our military community?
• Avoid the tyranny of OR
• Military AND Civilians care for children
  families
• Our obligation
• Need Military and Civilian training and education

40
Military Pediatrics

• Education, Training Research
• Quantity, Quality
• Students to fellows and beyond

41
USUHS

• Only federally funded medical school
• Army, Air Force, Navy, US Public Health Service
• Graduate Nursing School
• School of Public Health
• About 25 of students
• Full military officers while in training

42
Health Professional Scholarship Program (HPSP)

• Largest accessioning program for Navy Medical
  Corps officers (75)
• Training at US civilian medical schools (MD DO)
• 4-, 3-, 2-, and l-year scholarships available
• Tuition, books, fees covered, plus monthly
  stipend
• Paid 6-week active duty training time each year
  while on scholarship

43
The Price

• Contractual obligation
• Year-for-year payback
• Minimum 3-year payback
• Active Duty Internship/Residency does not count
  for payback, but counts for time-in-service for
  pay and retirement purposes
• Internship counts for payback for 1- and 2-yr
  HPSP recipients

44
Navy GME Training Pathways

• Similar in all services
• Fulltime Inservice (FTIS)
• Other Federal Institution (OFI)
• Fulltime Outservice (FTOS/DUINS)
• Navy Active Duty Delay for Specialists (NADDS)
• Full deferred civilian training
• Financial Assistance Program (FAP)
• Residency and Fellowships

45
Inservice GME

• Largest of training pathways
• Navy 60 programs _at_ 9 institutions
• Navy
• 1000 in-service
• 400 additional deferred
• Air Force same total but more deferred
• Army twice the size
• Total about 5800

46
(No Transcript)
47
Navy MC Officers in GME
48
General Medical Officers (GMO)

• Must have completed internship successfully
• Practice as a primary care physician
• Must obtain a license
• Assigned
• Fleet Marines (usually 1-2 years)
• Overseas Clinics (usually 2-3 years)
• Ships (2 years)
• Undersea Medical Officer
• Flight Surgeon

49
GMO Tour

• Navy Medicine is working to convert GMO billets
  to Primary Care Operational positions
• Moving towards an all board eligible force
• By 2011 GMO/FS/UMO positions will be drastically
  reduced
• This will increase the opportunities for straight
  through training
• Army and Air Force physicians are battalion
  surgeons after residency

50
GMO Tour

• Frequently seen as a negative by students
• Students are focused on completion of training
• Army and Air Force do operational medicine after
  residency

51
GMO Positives

• Allows break after years of intense education
  training
• Maturation decision making clinical skills
• Leadership opportunity early in career
• Lifestyle and overall maturity
• Certainty of specialty choice, career
• Opportunities to travel around the globe
• Participate in events that shape history
• No comparable experience in civilian world
• Increased pay

52
Military Pediatric Residencies Fellowships

• General Pediatrics
• NMCSD 22
• NMCP 28
• NCC 33
• SAMPC 24
• WP Dayton 24
• MAMC 18
• TAMC 18
• Total 167

• Fellowships
• NCC/USU
• Neo, GI, ID, HO
• SAMPC
• Adol, Neo
• TAMC
• Neo
• MAMC
• DBP

53
Quality of DOD GME?

• Majority of GME sites with maximum institutional
  accreditation
• Over 85 of individual programs have maximum or
  near maximum program accreditation
• Excellent 1st time Board pass rate in all
  specialties (95)

54
Navy GME Quality

• 25 of Medical Officers
• 1,000 trainees at Navy internship (23), residency
  (43), and fellowship (14) programs
• 400 in deferred civilian training status
• Superb Programs
• 99 of programs fully accredited by ACGME
• First time pass rate of 94 for board
  certification exams (several at 100)

55
NAVY vs. National Rates
56
Research CME

• USAMRID
• ID Research Labs
• Fellowships and Research
• Publications Grants at all teaching centers
• Uniformed Services Pediatric Seminar

57
Outstanding Training Graduate Medical Education
(GME)

• Highest quality education training
• Young enthusiastic faculty
• Adventure travel
• Leadership opportunities
• Service to your country
• Tremendously appreciative patients
• Universal single party payer 1 plan
• Higher pay and little if any debt

58
Individual Downside of Military GME

• The needs of the Navy, Army AF
• Choice of training site
• Timeline
• Subspecialty choice may not be available
• Academic tracks may be limited
• Possibility of interrupted training (GMO) and/or
  operational role (PCO)

59
Education Training Summary

• Only federal medical school 25 of physicians
• Scholarship students generally 75 of physicians
• Draft and Selective Service Law
• Semi-closed GME to support MUC
• GME at generalist and specialists level both
  internal and external (Diversity)
• Direct acquisition financial assistance

60
Military Pediatric Residents

• Show up on time
• Know what they need to learn
• Understand common need to know what to do for
  children in Guam and Minot, ND
• Think of the World as their Community
• -Vivian Reznik, UCSD Co-PI CPTI

61
Military Unique Curriculum

• Comprehensive Generalist
• Decision making, resuscitation stabilization
• Neonatology
• Critical Care
• Subspecialty
• Child Protection
• Military specific roles

62
Military Medicine

• Military Medicine
• Operational roles
• Humanitarian Security Assistance
• Homeland Defense and Disaster Preparedness

63
Military MedicineA Global Enterprise

• Health care for
• Active duty (avg age on ship 19)
• All eligible family members (enrolled to 23)
• Retiree and family members
• Tertiary Care, Community Hospitals and Clinics
  in U.S. around the globe

64
Military Pediatrics

• 700 in Uniformed Service Section of AAP
• 150 Navy
• 150 AF (64 sites with pediatricians)
• 300 Army
• 25 additional in training

65
Military Pediatrics

• Peace time benefit to eligible population
• Homeland Defense/Disaster Preparedness
• Humanitarian opportunities
• USNS MERCY (Tsunami, SE Asia)
• USNS COMFORT (Latin America)
• USS PELELIU (SE Asia and Oceania)
• Operational Roles
• Iraq, Kuwait, Afghanistan
• Security Assistance
• Presidents Emergency Project for HIV/AIDS Relief
  (PEPFAR)

66
Military Providers

• Majority will get the opportunity to do something
  besides specialty
• Navy shifting toward Army Air Force model
• Proportional to services role in war
• Army Pediatrics 50 Iraq, Kuwait, Afghanistan
  (75 GP, 40 Subs)
• Navy Pediatrics (Marines)
• Air Force Pediatrics

67
Operational Tours

• Generally 24-months
• USMC, USA, USN, USAF
• Kuwait, Iraq, Afghanistan
• All global sites

68
Pediatrics in Military / War

• 2.0 Million military children, families who are
  stressed
• Deployed worry most about those behind
• Peds deployed as Primary Care / Triage
• Sick Call
• Triage
• Psych, Derm, Prev Med, Ortho, Infectious Disease
• Mid to late adolescents

69
Humanitarian Curriculum

• Cultural Competent Care
• Medical Content
• Humanitarian Assistance (MMHAC)
• Disaster Preparedness (ATLS, etc)
• Practical Experiences
• International
• Military Unique Curriculum (MUC)

70
MMHAC

• Military Medical Humanitarian Assistance Course
• 2 Day Course similar to PALS
• Designed for Providers
• Overview, NGOs, Surveillance, Public Health and
  Ethical Dilemmas
• D/D, Infectious Diseases, Malnutrition

71
Preventing War
72
USNS MERCY USNS COMFORT

• Tsunami, Earthquakes Hurricane Katrina
• Project HOPE (Civilians)
• All services and Partner Nation Military
  providers
• MMHAC Faculty and NGOs
• 1-3 Staff Peds
• Resident rotations 28d-6wks internal medicine and
  peds

73
USS PELELIU Pacific Partnership

• 4 month deployment
• 12 pediatricians (85 medical providers)
• 5 US Navy 2 GP 1 Neo, 2 Residents
• 1 Partner Nation India GP
• 6 Civilian NGOs 3 GP, 1 PICU, 1 Chief Res, 1 ED
• 5 FPs 1 USN, 1 NZ, 1 Australian, 2 Canadian

74
Pacific Partnership

• 30,000 patients seen, 300 surgeries
• Approximately 40 Pediatric Age
• Visited 8 nations worked with 10 partner
  nations medical personnel
• Da Nang General NICU Viet Nam
• Kar Kar Hospital Papua New Guinea

75
Security Assistance

• DOD HIV/AIDS Prevention Program (DHAPP)
• Presidents Emergency Project for AIDS Relief
  (PEPFAR)
• Partners include NMCSD, SD Public Health, UCSD,
  SDSU, NHRC
• 1 resident three 2-week trips to South Africa
• 1 resident two 2-week trips to SA
• 2 residents two 2-week trips to Zambia
• 3 Peds Faculty have gone to Zambia, South Africa
• 3 Peds Residents on Ships for HA missions

76
DHAPP

• Twinning between African and San Diego HIV
  programs
• Observe antiretroviral care Observe untreated
• Multidisciplinary, Multispecialty approach to
  annual exams
• Interact with ID, Internal Med, Peds
• Ongoing since 1999

77
PEPFAR

• 15 BILLIION
• 17 NATIONS
• DOD/DOS project for all US HIV/AIDS
• 500K to NHRC for twinning with NMCSD and country
  militaries
• South Africa, Zambia
• Russia, Thailand

78
Military Pediatrics

• 100 of our graduates become our partners and
  care for our children
• High standards
• Mentor, remediation termination
• About 75 do primary care pediatrics first
• 100 take the ABP Exam
• 100 NMCSD 1st time taker ABP pass x 6 years
• 100 NMCSD graduates are ABP certified

79
Military Pediatrics

• Utilization tours to isolated CONUS and OCONUS
• Train for resuscitation/stabilization x 48 hrs
• Strong primary care and subspecialty experience
• Child, Family and Community Pediatrics
  perspective
• The Comprehensive Generalist approach

80
Summary

• Challenges
• Recruitment and Retention
• Military Unique Curriculum
• DOD Commitment to Families/Children as well as
  wounded warriors
• Collaboration internally/externally advocacy
• Research/Academia

81
Discussion / Conclusion

• Are WE meeting the educational needs of learners
  and providers to care for military children,
  families and communities during war?
• Military education and training have many
  military pediatric unique needs (similar to
  rural)
• Both training systems are necessary and need
  support
• Military Pediatricians are performing competently
  in all roles
• Advocacy within MHS and on behalf of military
  children, families, communities and GME are at
  times necessary

82
QUESTIONS?
83
Naval Medical Center San Diego The Pride of Navy
Medicine
?Readiness Optimization Integration Alignment
Covenant Leadership