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. DODO

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 ~ Children�s 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. 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 �The Military: Not your typical culture�

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

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

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 � 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

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. 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 Children and the Military

24. 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 Military Life

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. 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 Community Challenges

27. 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 Challenges

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

33. American Academy of Pediatrics � March 2007 ALF Resolution �Critical Action to Support the Children and Adolescents of American Military Families� Be it resolved �that the Academy create a policy statement that addresses the emotional needs and stress challenges of family on the well being of children and adolescents in military families experiencing separation, injury or death, and that the Academy educate pediatricians and youth-serving professionals about the unique culture and needs of children and adolescents in military families.� Military pediatricians and the American Academy of Pediatrics (AAP) are leading an effort to be stronger and more vocal advocates for military youth The AAP has been and continues to be one of the most important voices in getting this message out to pediatricians and the larger national communityBe it resolved �that the Academy create a policy statement that addresses the emotional needs and stress challenges of family on the well being of children and adolescents in military families experiencing separation, injury or death, and that the Academy educate pediatricians and youth-serving professionals about the unique culture and needs of children and adolescents in military families.� Military pediatricians and the American Academy of Pediatrics (AAP) are leading an effort to be stronger and more vocal advocates for military youth The AAP has been and continues to be one of the most important voices in getting this message out to pediatricians and the larger national community

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 New Sesame Street VideoNew Sesame Street Video

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 @ 9 institutions Navy: ~ 1000 in-service ~ 400 additional deferred Air Force: ~ same total but more deferred Army: ~ twice the size Total about 5800

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

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 nation�s medical personnel Da Nang General NICU Viet Nam Kar Kar Hospital Papua New Guinea

75. 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

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