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 ~ 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. “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

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 @ 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