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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

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

department of defense disclaimer
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…
  • 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
  • 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
alphabet soup
Alphabet Soup
  • Pediatrics: SGA, LGA, AGA, PDA…
  • Navy: DOD, DON, USN, DOS…
  • 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
  • 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
  • Minimum of 50% clinical practice for past 8 years
  • Bright Futures
  • Community Pediatric Training Initiative
  • Caring for children, their families and our communities…
military pediatrics
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
military pediatrics10
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
the military culture
“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
the military not your typical culture
“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
history of the military and families
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
a growing role for families
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

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

Source: Statistical Abstract of the United States 2001

military demographics
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
military families
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
junior enlisted
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
women in the military
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
children and the military
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
military life
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
  • 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
community challenges
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
  • 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
positive attributes of military children
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?
military health care
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
military health care30
Military Health Care
  • Continental US (CONUS)
    • Tertiary Care (Peds+ categorical training)
    • Community Care (FP with Peds staff)
    • Isolated small rural hospitals and clinics
    • Global practice ranging from solo to tertiary care
    • Mostly 1 to 4/6
    • Comprehensive Generalists
clinical practice
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
american academy of pediatrics march 2007 alf resolution
American Academy of Pediatrics – March 2007 ALF Resolution

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

video resources
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

other important resources
Other Important Resources

– Coming Together Around Military Families

    • National Military Family Association –Operation Purple Camps
no matter what you think
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

education training implications
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
  • 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
  • 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
military pediatrics40
Military Pediatrics
  • Education, Training & Research
    • Quantity, Quality
    • Students to fellows and beyond
  • 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
health professional scholarship program hpsp
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
the price
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
navy gme training pathways
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
inservice gme
Inservice GME
  • 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

general medical officers gmo
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
gmo tour
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
gmo tour50
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
gmo positives
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
military pediatric residencies fellowships
General Pediatrics:


NMCP: 28

NCC: 33


WP Dayton: 24

MAMC: 18

TAMC: 18

Total: ~167



Neo, GI, ID, HO


Adol, Neo





Military Pediatric Residencies & Fellowships
quality of dod gme
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%)
navy gme quality
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%)
research cme
Research & CME
  • ID Research Labs
  • Fellowships and Research
  • Publications & Grants at all teaching centers
  • Uniformed Services Pediatric Seminar
outstanding training graduate medical education gme
Outstanding TrainingGraduate 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
individual downside of military gme
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)
education training summary
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
military pediatric residents
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

military unique curriculum
Military Unique Curriculum
  • Comprehensive Generalist
  • Decision making, resuscitation stabilization
  • Neonatology
  • Critical Care
  • Subspecialty
  • Child Protection
  • Military specific roles
military medicine
Military Medicine
  • Military Medicine
    • Operational roles
    • Humanitarian & Security Assistance
    • Homeland Defense and Disaster Preparedness
military medicine a global enterprise
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
military pediatrics64
Military Pediatrics

~ 700 in Uniformed Service Section of AAP

  • 150 Navy
  • 150 AF (64 sites with pediatricians)
  • 300 Army

~25% additional in training

military pediatrics65
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)
military providers
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
operational tours
Operational Tours
  • Generally 24-months
    • Kuwait, Iraq, Afghanistan
    • All global sites
pediatrics in military war
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
humanitarian curriculum
Humanitarian Curriculum
  • Cultural Competent Care
  • Medical Content
    • Humanitarian Assistance (MMHAC)
    • Disaster Preparedness (ATLS, etc)
  • Practical Experiences
    • International
  • Military Unique Curriculum (MUC)

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
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
uss peleliu pacific partnership
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
pacific partnership
Pacific Partnership
  • 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
security assistance
Security Assistance
  • 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
  • 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
  • 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
military pediatrics78
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
military pediatrics79
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

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

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The Pride of Navy Medicine

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