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
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…
Context
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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
Recruitment
• I am NOT a recruiter
• I am:
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Well trained
An adventurer, a travelor
A leader
Not in debt
• Opportunity may exist for students, residents,
fellows and staff
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…
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
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
Disclosures
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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
• 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 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”
 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”
 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
 “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
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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
 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
Number of Active Duty
by Service Branch
500,000
450,000
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
ARMY
NAVY
AIR FORCE
MARINE
CORPS
September 2005
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
Age of minor dependents
of Active Duty
3.9%
24.4%
39.8%
31.9%
N = 1,177,190
age 0-5
age 6-11
age 12-18
age19-23
Junior Enlisted
• 46% of military is junior enlisted (E1-E4)
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Majority single (71%)
24% Married to civilians
63% Spouses work to make ends meet
21% Young children
Women in the Military
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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
 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
Number of U.S. Military Personnel by Installation Location, 2003
Source: Department of Defense 2003
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
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
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
Challenges
 Financial stress
 Financial difficulty is one of the principal qualityof-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
 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
• 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 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
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
“Critical Action to Support the
Children and Adolescents of
American Military Families”
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
• 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
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
• 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
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
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
Military Pediatrics
• Education, Training & Research
– Quantity, Quality
– Students to fellows and beyond
USUHS
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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)
• 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
• 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
Similar in all services:
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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
• 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
Navy MC Officers in GME
NAVY SPONSORED GME TRAINEES
1100
1000
900
800
700
600
500
400
300
200
100
0
1996
1997
1998
1999
2000
2001
2002
ACADEMIC YEAR
2003
2004
2005
2006
General Medical Officers
(GMO)
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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
• 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 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
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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:
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
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
• 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 vs. National Rates
2004 Board Certification Pass Rates
First Time Examinees
Navy-vs-National Averages
100%
90%
80%
70%
60%
50%
Navy Pass Rate
Nat'l Pass Rate
40%
30%
20%
10%
0%
Specialty
Research & CME
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USAMRID
ID Research Labs
Fellowships and Research
Publications & Grants at all teaching centers
• Uniformed Services Pediatric Seminar
Outstanding Training
Graduate Medical Education (GME)
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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
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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
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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:
• “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
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Comprehensive Generalist
Decision making, resuscitation stabilization
Neonatology
Critical Care
Subspecialty
Child Protection
Military specific roles
Military Medicine
• Military Medicine
– Operational roles
– Humanitarian & Security Assistance
– Homeland Defense and Disaster
Preparedness
Military Medicine
A 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 Pediatrics
~ 700 in Uniformed Service Section of AAP
• 150 Navy
• 150 AF (64 sites with pediatricians)
• 300 Army
~25% additional in training
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
• 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
• Generally 24-months
– USMC, USA, USN, USAF
– Kuwait, Iraq, Afghanistan
– All global sites
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
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Sick Call
Triage
Psych, Derm, Prev Med, Ortho, Infectious Disease
Mid to late adolescents
Humanitarian Curriculum
• Cultural Competent Care
• Medical Content
– Humanitarian Assistance (MMHAC)
– Disaster Preparedness (ATLS, etc)
• Practical Experiences
– International
• Military Unique Curriculum (MUC)
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
Preventing War
USNS MERCY USNS COMFORT
Tsunami, Earthquakes & Hurricane Katrina
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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
• 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
• 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
• DOD HIV/AIDS Prevention Program (DHAPP)
• President’s Emergency Project for AIDS Relief (PEPFAR)
• Partners include: NMCSD, SD Public Health, UCSD,
SDSU, NHRC
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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
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
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
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 Pediatrics
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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
Summary
• 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
• 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
QUESTIONS?
Naval Medical Center San Diego
The Pride of Navy Medicine
‫ﴀ‬Readiness Optimization Integration Alignment Covenant Leadership