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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

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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


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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…


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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


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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


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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…


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Perspective

  • Residency at small program

    ~ 15 residents

    ~ Naval Hospital Oakland+

  • Fellowship at large program

    ~ 450 fellows

    ~ 145 residents

    ~ Children’s Hospital Boston

  • Ideal: 1-2 years at small and large


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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


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Disclosures

  • Minimum of 50% clinical practice for past 8 years

  • Bright Futures

  • Community Pediatric Training Initiative

  • Caring for children, their families and our communities…


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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


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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


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“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


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“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


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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


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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


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State Populations of Military and Civilian Personnel in U.S. Military Installations, 1999

Source: Statistical Abstract of the United States 2001


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Military Demographics Military Installations, 1999

  • 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


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Number of Active Duty Military Installations, 1999by Service Branch

September 2005


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Military Families Military Installations, 1999

  • 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


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Age of minor dependents Military Installations, 1999of Active Duty

N = 1,177,190


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Junior Enlisted Military Installations, 1999

  • 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


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Women in the Military Military Installations, 1999

  • 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


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Children and the Military Military Installations, 1999

  • 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


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Number of U.S. Military Personnel by Installation Location, 2003

Source: Department of Defense 2003


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Military Life 2003

  • 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


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Challenges 2003

  • 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


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Community Challenges 2003

  • 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


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Challenges 2003

  • 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


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Positive Attributes of Military Children 2003

  • 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?


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Military Health Care 2003

  • 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


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Military Health Care 2003

  • 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


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Clinical Practice 2003

  • “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


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American Academy of Pediatrics – March 2007 ALF Resolution 2003

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


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Video Resources 2003

  • 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


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Other Important Resources 2003

  • 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


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No matter what you think… 2003

“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


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Education & Training Implications 2003

  • 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


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Advocacy 2003

  • 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


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Discussion 2003

  • 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


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Military Pediatrics 2003

  • Education, Training & Research

    • Quantity, Quality

    • Students to fellows and beyond


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USUHS 2003

  • 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


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Health Professional Scholarship Program (HPSP) 2003

  • 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


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The Price 2003

  • 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


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Navy GME Training Pathways 2003

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


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Inservice GME 2003

  • Largest of training pathways

  • Navy: 60 programs @ 9 institutions

  • Navy:

    ~ 1000 in-service

    ~ 400 additional deferred

  • Air Force: ~ same total but more deferred

  • Army: ~ twice the size

    Total about 5800



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General Medical Officers (GMO) 2003

  • 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


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GMO Tour 2003

  • 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


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GMO Tour 2003

  • Frequently seen as a negative by students

  • Students are focused on completion of training

  • Army and Air Force do operational medicine after residency


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GMO Positives 2003

  • 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


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General Pediatrics: 2003

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

Military Pediatric Residencies & Fellowships


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Quality of DOD GME? 2003

  • 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%)


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Navy GME Quality 2003

  • 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%)


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NAVY 2003vs. National Rates


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Research & CME 2003

  • USAMRID

  • ID Research Labs

  • Fellowships and Research

  • Publications & Grants at all teaching centers

  • Uniformed Services Pediatric Seminar


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Outstanding Training 2003Graduate 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


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Individual ‘Downside’ of Military GME 2003

  • 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)


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Education & Training Summary 2003

  • 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


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Military Pediatric Residents: 2003

  • “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


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Military Unique Curriculum 2003

  • Comprehensive Generalist

  • Decision making, resuscitation stabilization

  • Neonatology

  • Critical Care

  • Subspecialty

  • Child Protection

  • Military specific roles


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Military Medicine 2003

  • Military Medicine

    • Operational roles

    • Humanitarian & Security Assistance

    • Homeland Defense and Disaster Preparedness


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Military Medicine 2003A 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


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Military Pediatrics 2003

~ 700 in Uniformed Service Section of AAP

  • 150 Navy

  • 150 AF (64 sites with pediatricians)

  • 300 Army

    ~25% additional in training


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Military Pediatrics 2003

  • 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)


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Military Providers 2003

  • 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


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Operational Tours 2003

  • Generally 24-months

    • USMC, USA, USN, USAF

    • Kuwait, Iraq, Afghanistan

    • All global sites


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Pediatrics in Military / War 2003

  • 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


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Humanitarian Curriculum 2003

  • Cultural Competent Care

  • Medical Content

    • Humanitarian Assistance (MMHAC)

    • Disaster Preparedness (ATLS, etc)

  • Practical Experiences

    • International

  • Military Unique Curriculum (MUC)


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MMHAC 2003

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



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USNS MERCY USNS COMFORT 2003

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


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USS PELELIU Pacific Partnership 2003

  • 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


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Pacific Partnership 2003

  • 30,000 patients seen, > 300 surgeries

  • Approximately 40% Pediatric Age

  • Visited 8 nations & worked with 10 partner nation’s medical personnel

    • Da Nang General NICU Viet Nam

    • Kar Kar Hospital Papua New Guinea


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Security Assistance 2003

  • DOD HIV/AIDS Prevention Program (DHAPP)

  • President’s 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


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DHAPP 2003

  • 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


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PEPFAR 2003

  • 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


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Military Pediatrics 2003

  • 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


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Military Pediatrics 2003

  • 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


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Summary 2003

  • Challenges:

    • Recruitment and Retention

    • Military Unique Curriculum

    • DOD Commitment to Families/Children as well as wounded warriors

    • Collaboration internally/externally advocacy

    • Research/Academia


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Discussion / Conclusion 2003

  • 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



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Naval Medical Center San Diego 2003

The Pride of Navy Medicine

ﴀReadiness Optimization Integration Alignment Covenant Leadership


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