Okay, everybody, let's go ahead and start the session. This is session 235, Military Occupational Update. So essentially these are all the consultants or the specialty leader for the Navy for all the services. We don't include the Coast Guard yet, but it's something we may include. So in the future, we'll start looking into that. But it's mainly the Army, the Air Force, and the Navy. So I'm gonna introduce myself and do the first part of the talk about DOD and then about the Army. Then we'll move over to the Navy and then over to the Air Force. No particular order, to be honest. Maybe by the age of the service, if anything. So I really appreciate, I know you have choices to go to other talks. So I really wanna borrow some of your time. My wife tells me to articulate a little bit more. And the reason why I say borrow is a good trick is if you have somebody at work that doesn't like you, a good trick is to go up to them and just borrow something simple. Can I borrow a pencil? Borrow a pen? And somehow it makes them like you better for some reason. So just try that. So I don't know if it'll work this time around, but it's an interesting tactic to try. So anyway, I have some notes in front of me that I'm gonna use a little bit just so I don't forget anything. Our sponsor is the Federal Military Section. So appreciate the Dr. Barrett and others from the Federal Military Section. They put on a nice breakfast the other day. And really today, we're gonna try to go through these pretty quickly so that we can answer questions at the end. I know a lot of people have questions about DHA that we'll try to address and tell you what we do know, at least at this time. Beyond that, again, we have disclosures. We're speaking, even though we're in uniform, the military's paying for us to be on TDY. But really, in the end, we're not speaking on behalf of the Army, the Navy, and the Air Force. Really, these are our own opinions despite us being in uniform. So just remember that. So beyond that, let's go on to the next slide. Again, my name is Colonel Joe Ortiz. I wear multiple hats. My hat right now is that I am the Chief of Occupational Medicine at Walter Reed. I just transitioned from being the APD at the USHERS Residency Program in John Downs. I think I saw John Downs as the current Residency Director. So we swapped around December. Associate Program Director, of course. But it was a great time to transition because that was just as all the cases were picking up with COVID and with the Omicron variant. So it was a really interesting time to take over for the service. But it was really great, great learning. And I actually went on leave in January, but we still survived and it was fine despite all that. Because we have a great team at Walter Reed is the bottom line. So beyond that, I'm also, again, the consultant for the Army. I've been the consultant for about four years now. And I hope to turn this over within the next maybe month or two. OTSG just wants to make sure that we have the adequate number of applications for that. So hopefully within the next month or two, I'll be turning that over to somebody else. So the first part of this presentation is just about DOD. And as you can see, the DOD is a large workforce. It's very diverse. Not only do we have active duty, but don't forget about the Guard and Reserve. And I have to say that because one of my prior jobs was being the Chief of Preventive Medicine for the Army National Guard. So again, we have lots of civilians, probably more than you even thought. Again, we have a very diverse types of individuals, engineers, scientists, but we also have a pretty large contingent of blue collar workers as well. And as you can see, the actual numbers, the Army is not that far, too far ahead of the Navy and Marine Corps and the other services. Even OSD, I was a little surprised to hear, to see that the workforce for OSD is 100,000 plus. And of course, don't forget about that we have foreign contractors, foreign nationals, as well as contractors across the world. So military occupational health. You know, it is a global health enterprise. Again, we're everywhere on all continents and we do this full spectrum of services. And we also work really closely with other agencies, whether we're deployed in Afghanistan, in Europe, in Africa, et cetera. And in addition, we have to contend with having joint operations with all the other services. And we also have to contend with host nation issues if you're in Germany, Italy, Japan, and whatnot. In terms of the process, really the process is the same, whether you're a civilian occupant provider in general or in the military. And our basic job is we either do medical surveillance or medical qualification. And really a lot of our exams is a combination of the two when you actually are in service and on the wards itself or in the occ health clinic. So it really doesn't change. It's really pretty much the same across the board, across each service. And really it should mirror what you do on the civilian side as well. So let's transition to the Army. This is really one of my favorite pictures of my experiences in the Army. And what you're seeing here are a before and after picture. These are 1,000 pound bombs that are produced in Oklahoma. So I became the command surgeon for the Joint Munitions Command around 2003. And that was just, of course, when the war was ramping up. And we had to produce more of these bunker-busting bombs in order to use in Afghanistan and other places in the world. And what was happening was that some of our employees at this plant were developing subclinical anemia. And we had to go, OK, why are they developing this anemia? So of course, we had to go through the hierarchy controls, what's going on. In the end, the bottom line is in the beginning, they were just wearing what you see on the right side, on the left side, actually, from your facing, these cotton overalls, et cetera. And we did everything from trying to engineer it out, substitute it, administrative controls. But in the end, what really worked was PPE. And as you can see on the right side, was what you saw. And it really solved the problem. But the next challenge was, even when we had the solution, the workers didn't want to get into this really hot gear that really was hard to work with as they were tamping this TNT in a hot environment. So sorry. So again, it was a matter of continuing the talk, work with the management, and continue to emphasize, this is what's protecting them. So it's kind of a reflection of what we do in general when it comes to hazardous exposures to our workers. So in terms of the Army demographics, it really hasn't changed. A lot of this data is a bit dated by two years. And we'll probably change it next year. But again, we're the largest service out of all the services. Again, don't forget about the reserves. And most of our people are enlisted on the enlisted side. So really, maybe one out of every five are actually officers. And a very small number are warrant officers, too. In terms of the civilian demographics, again, a large workforce, diversity, lots of educated. But also, don't forget there's a large portion that are blue collar workers as well. We have 11,000 medical workers, and with lots of specialties, as you know, just like any hospital, or as with the other services. And a lot of our workers are veterans. Our civilian workers are veterans as well. I just threw up this slide because to remind you that even though we're moving more towards, or we're actually, a lot of our clinics now belong to DHA, the Army still has this regional health model. And the reason why we have this model is because DHA is really supposed to take care of the clinical side. But we can't forget that there's a readiness side of the Army or the other armed services. And we're still trying to figure out of what parts of what we do not commit because we're really kind of in the middle of things. We do some clinical things. But we also work with the line side to keep the workforce healthy, particularly when we're supporting some of our logistical commands or our industrial commands as well. So this structure will continue. It's just that the regional health commands will get smaller, and a lot of the clinical aspects will go over the DHA. But we have to remember, how do we both support the line side and the operational side while also doing our clinical work as well? I'm sure that's where a lot of the questions will come in terms of this transition to DHA. I also threw up this slide to remind everybody about the Army Organic Industrial Base. And these are different sites across the country. The ones that are in green and blue are the ones where we actually have residents going to, or we have residents that are there already. So yeah, there is a direct line of support to these clinics there. But we also have all these other clinics. And for example, Water of Relief doesn't have an active duty physician there. But we do have an active physician. In fact, one of our residents is going to Fort Drum this summer that does support Water of Relief directly. So that's just an example of the support. And another thing to remember is that we have very few OCDocs in all the services. We have about 20, actually about 30, 30 plus in the military. And again, you think about the size of our workforce, that's all we have to support the entire civilian and active duty workforce. So really the thing that I would emphasize to our residents and everybody is that we have to have a way of being able to consult with other providers, whether they're primary care, about what we do in occupational medicine. And it's just something to think about. How do we do that? How do we get our names and what we do out there? And also educate our other providers across the services as well and in the Army. In terms of our uniforms, physicians, this is the numbers. And I will say that I did change this slide yesterday in order to add the aerospace medicine. And the difference between the occupational medicine residency at USU's is, number one, USU's is really tri-service. But usually we have Navy and Army. And we have a lot more residents as well. Whereas right now, I think each service has its own aerospace medicine residency. But the unique thing about the Army is that the Army is actually three years of training. And they dedicate one year of that training to occupational medicine training, whereas the other services don't do that. Although the other services do send residents out off service to, say, Harvard to do strictly an occupant residency too. But for example, the Navy does have a contingent of residents that come to USU's and some that go off service. Whereas the Army, all of our strictly occupant residents are going to USU's. But if they did go to the aerospace medicine residency, they will get one year of occupational medicine residency as part of their training. So I look at that as the occupant consultant as really a pool of providers that we could bring into OccMed. And we still do that. And I'll get into the billets. One thing I will say about the billets is that we don't have very few positions. We actually have a good number of residents that are going to be graduating this year and next year from the Army. So it may be challenging in terms of accommodating aerospace medicine graduates coming into OccMed. But I'm always happy to kind of work with them to try to get them into the billet. Because my idea or my thought is that I want to right fit everybody into an OccMed position, whether coming from aerospace or coming directly from USU. So that's what I've tried to do as a consultant. And so the only other thing I'm going to say about this slide is that typically assignments are three years. So we expect people to rotate after three years. And I think it should be the same with the other services. But there are exceptions where people have family issues or something else that may have people rotate early or later. So that's been my approach as a consultant. And finally, in terms of recruitment and retention, these are my last two slides. OEM is still a relatively unknown specialty in the Army, at least. So being the APD at USU has been very helpful to get involved with the medical students and also be involved with others from other medical schools, to be honest, to also look at OccMed as an alternative for training. And typically, the Army, we can accept up to four residents a year into USUs. But we've actually struggled to fill all those billets, certainly compared to the Navy. The Navy has many more applicants for their three or four positions. The Army, typically, we've had trouble. But I think we're improving in terms of doing that. And we're always going to have the private sector and the economy and other jobs to compete with us in terms of recruitment, as well as retention. But in general, I think the Armed Forces have done pretty well in terms of filling our billets and providing a pipeline for OccMed providers. Other unique things about the Army is that we've also developed these things called individual critical task lists. So what these are is that every specialty is supposed to have. These are the things you have to do to deploy as a radiologist, as a surgeon, et cetera. Obviously, OccMed is a bit different because we actually deploy as 60 Charlies or actually as preventive medicine providers. So I deployed into a preventive medicine billet with the 30th Med Brigade to Afghanistan. And that's really typical of our deployments. Whereas, aerospace medicine, they have their own billets in terms of operational assignments, whether they're deployed or assigned to a unit. So OccMed is typically not assigned to units like that. It's more common on the preventive medicine and aerospace medicine side. And I talked about that up there. I'm not going to talk too much about these other things. I will say that Dr. Jung's talk about the other day was pretty interesting, but also to point out that ACGME is actually moving towards separate specialties in terms of aerospace medicine, OccMed, and preventive medicine. Preventive medicine actually has a different name. So just something to think about when you talk about Dr. Jung's talk from the other day. And again, we have to remember that we're always going to support the operational force. And readiness is really primary in what we do in all the armed services. And this is my last slide. The main things I'm going to say about the DHA transition is, of course, COVID has helped to make us a bit more relevant. But what I really tell all the residents and others across the specialty is that we have to go back to we're supporting readiness, and part of the readiness is making sure there's compliance with the regulatory and statutory requirements. By the end, we want to make sure all our workers and service members are safe and healthy and continuing to support whatever the missions are across the armed services. One of the other challenges, I think, will be in terms of budget. I know on the Army side, what we've talked about in the past is we're fully funded. We're funded through bag three. My question is, what's going to happen with that kind of fenced money now that everything goes over to DHA? And I don't have an answer to that, but I think that's a big challenge, is how do we maintain, hey, we're mission-driven. We're not RVU-driven. And I guess that's one of the things we have to continue to talk to DHA about and to continue to make sure that we're supported by billets and by residency slots, et cetera. And I'm sure you all are going to maybe talk a little bit about that as well. And of course, the other big thing that you hear about from the VA and from deployments are exposures, exposures to PFAS, exposures to burn pits, et cetera. And I'll just throw out there, if you're not familiar with the EILER, I think all of us in the services need to learn about the EILER, learn how to use it. And it's not perfect, but we need to have a way of finding information about when there's questions about exposures. And we're really experts of exposure medicine in the military. And we need to really be the experts and know how to use the tools. Ultimately, we need to go find ways of doing real-time exposure and all the way to the point of being like Star Trek, where they can scan you and what are you exposed to? Is it actually being manifested in some kind of biological disease? But we're nowhere near that. I mean, that's really the holy grail if we can ever get to that point. But in the end, until we get to that point, there's always going to be questions about what are you exposed to and when was my disease due to exposure from deployments or from garrison? So that's all I have from the Army side. And I'm going to turn it over to Max Clark from the Navy. All right, quick mic check. OK, awesome. I'll just use this one. So we'll give you a variety. All the services are different, so I'll just sit up here. A couple quick caveats. The slides are going to look very familiar to last year, so I'm going to move pretty quickly. And I'm also presuming that you have a bit of a foundation in Navy occupational medicine. If for some reason I gloss over something that confuses you or just doesn't make sense, please feel free to ask a question or come up afterwards. I just want to move quickly, because I'm only going to bet the majority of people want to get to the Q&A. So anyhow, Commander Max Clark, I'm currently Camp Pendleton as a Department for Occupational Medicine, also currently the Specialty Leader. How long I'm going to do that I'll come back to at the end. So I'm very proud of the industrial base that we serve in the Navy. And I would say with great respect to my Army Air Force colleagues, that due to our industrial base, we're kind of the preferable big kids on the block, just due to the nature of our exposures. So obviously, these are mine. While being a uniformed military member, these are my opinions, and I'm not officially speaking for the Surgeon General or any part of the Department of Defense. So again, I'm going to go through these pretty quickly. Occupational health care, we have our civilian workforce and our shore-based activity. We also do environmental consulting. I would say personally in my career, I haven't done as much as this probably would like. And I think the Navy is under-utilizing us. There's certain environmental exposures that may have been in the news, where I think we could have been of value, and I wish we could have gotten ahead of that. We are responsible for the surveillance and prevention of injuries and illnesses in the workforce. And not just clinically, and I think the preventive aspect is often under-emphasized. And I hope as we go forward, that goal of prevention is further emphasized. And I'm willing to bet my colleagues up here would agree with me. Approximately 210,000 civilian personnel, about 325,000 active duty personnel. So while not as large as the Army, of course, certainly more than a few people that were responsible for taking care of. So our current manning situation, obviously we have civilian providers and occ health nurses. And I do just want to take a quick moment to say I love occ health nurses. They're the most important part of our programs. So any occ health nurses listening, just know that I am your biggest fan. We have, and hopefully this data is current, about 223 civilian provider positions and OHN positions, only about 80%. It wouldn't shock me if that's actually fallen a little bit. At a later slide, manning continues to be a challenge. Global presence, that'll be on another slide, so I'm going to skip that. A lot of our occ med is done by GMOs, general medical officers, flight surgeons, undersea medical officers, and then FPs and other fillers. The Navy is currently transitioning away from the general medical officer model to what they call the operational medical officer model, or OMO. And what an OMO is, is the Navy, kind of the last to do this, Army and Air Force have beaten us to it. They want people going straight through for training, then do their payback tour. And then if they want to promote, especially they expect them to do operational tours as flight surgeons or with the Marines or whatnot, surface warfare. And that's great, having a board certified internist or ophthalmologist, then being a flight surgeon. But I put my hand up during this talk and said, but they're going to be doing a lot of occ med, how is that going to work? Oh, yeah, that's a good point. So clearly some more development on that. I think it's going to increase utilization of the OEM fundamentals course that the Navy Marine Corps Public Health Center does. So I would expect to see increased demand and hopefully that syllabus can continue to mature. So we have about 10 to 12 occ med providers that are cross-boarded, either PrevMed, RAM. And then we have a few people who, family practice, internal medicine. so a few people who can live in two different worlds. Currently have 34 active duty physicians, not including nine residents, including PGY 2 and 3. And then we have five incoming residents starting in July. And I just want to say that I'm very, very impressed by the talent pool of people applying to Navy Acmed. I'm deeply impressed and humbled by the quality of applicants that we've been getting the past several years. And I also just want to say I'm really glad that I'm not trying to get a residency these days, because these guys are top notch. Oh, yeah, for anyone who doesn't know me, obviously I take this stuff very seriously, and I love to talk about it. But I'm also going to throw in some jokes. And I kind of have a deadpan delivery. So either A, I'm just not funny, which is what my wife tells me, or like I said, people are just confused. But yeah, I throw in some glib comments. So all right, let's keep moving. So while it's not as pretty as Joe's slide, again, we're all over the map, particularly the coasts, Pearl Harbor, Okinawa, Yokosuka, Sigonella. Is Marlon in here? All right, Marlon Tingzon, who's our Acmed doc in Sigonella, made it. Mike Parenteau from Naples, unfortunately, couldn't. And then Ross, yep, we got Yokosuka represented. Puccini, Anthony Puccini from Okinawa, unfortunately, couldn't make it. Hopefully, he's online. So obviously, we're the Navy. We're by the water. Who would have guessed? So that also makes it, I think, easier to sell the Navy because, hey, you want to be by the ocean, usually is a nice selling point. So we don't have too many bases that are too far inland. And I think OCONUS assignments are amazing. I'm biased. Three years in Okinawa was fantastic. So shipyards, usually the big thing people talk about in Navy occupational medicine, there are four shipyards owned and run by the Navy. Obviously, they're not the only shipyards in the United States, but these are the Navy shipyards. Norfolk Naval Shipyard, the big kid on the block, it's been around since 1767, really supports the fleet on the Atlantic, about 10,000 employees, very, very busy shipyard. Pearl Harbor, obviously, probably the most desirable one. And I say that with lots of bias because I was stationed there. So I have a lot of affection for it. It's an intermediate facility. So it doesn't do a lot of definitive stuff, say, like Puget Sound or Norfolk would, but still a big shipyard. And there's a lot of unique challenges out in Pearl Harbor in the sense that we often struggled with people who I think had poor understanding of their diabetes and hypertension. And I had more than one conversation of, sir, your systolic is 180. You have high blood pressure. What are you going to do about it? I'll surf more, brah. That's a direct quote. So there are lots of opportunities for education. But people at shipyards, we had people on 16, 17 different stressors. So very kind of complex exams. So Portsmouth Naval Shipyard. So this isn't Portsmouth, Virginia. This is Portsmouth, New Hampshire. Technically, it's in Kittery, Maine. I don't know why we always call it Portsmouth, New Hampshire. Maybe Pam Crawl in the back can explain it to me. So does some nuclear submarine work, is an OSHA VPP star status, a little smaller, 8,500 employees. And then Puget Sound up in the Pacific Northwest. Matt Case, are you here? Yep, there he is. He can talk a lot more about Puget Sound. All right. The slide that everyone wants to get to. Before I say anything, please secure your shoes. There's no shield in front of me. And I don't know how good my reflexes are. So if anything is thrown at me, I don't know if I'll duck in time. And some of these I've already alluded to before. The transition straight through GME. So with this last GME cycle, they created one slot for a medical student to apply. They would go directly into a transitionary internship at Walter Reed, and then directly into the USHERS residency. Unfortunately, we had zero applicants, which didn't surprise me or shock me. Disappointing for sure, but didn't shock me. And this ties into the larger Achmed issue of branding, marketing. And for all those of you in the audience, I would encourage you to go back to your alma maters and recruit. Use the ambassador program through ACOM. Talk to the Corps Chief's office, and I can make that connection if you'd like. Because there might, I won't promise, but there might be funding for you to go back and do some recruiting for Navy Achmed. And I think it behooves us to promote our field, and the Navy, of course, to the community so we can get more applicants. And even just in the Navy, if you know somebody who's a flight surgeon, a UMO, and I don't know what I want to do, or you just think they'd be a good fit, talk to them. Promote the field. And I'm going to go clockwise. Recruitment, I said I've already addressed that a little bit. We, the past couple of years, have had about a 3 to 1 applicant to spot ratio for GME. That's fantastic. Hopefully that continues. I think people are starting to realize, hey, at least the smart ones, starting to realize, hey, Achmed is a great field, and I want to be part of it. So hopefully that continues. DHA transition, I'm just going to do a big collective I don't know, because this is going to come up, I'm sure, in the question section. So I'm intentionally skipping over it. Needless to say, that is the 800-pound gorilla in the room. Should Navy have greater involvement with LIMDU and the PEB status? Yes and no. Yes, I think we should. No, we can't right now, because we don't have the manning. This is kind of my personal frustration of maybe the military in general, but at least the Navy. I think sometimes struggles with what is occupational medicine, what do we do. And a lot of, quote unquote, military medicine is occupational medicine. They just don't realize it's occupational medicine. So that's a challenge. But I'm not all doom and gloom. I know last year people came at me and said, oh my god, Max, the sky is falling. Like, I wasn't prepared for that. And I'm not trying to paint a gloomy picture at all. One of the pluses is in 2023, we're getting a permanent spot on the PEB at the Navy Yard. So I think that's very exciting to be working with senior people and contributing to the PEB board. Transition to MHS Genesis. I know some of the people in the room are on it already. Some of you are waiting to get it. It is not built for Oc Med. I'll leave it at that. And then the divestitures, or the 702, or whatever you want to call it, absolutely unknown if these are going to happen or not. I mean, it's still technically on their books. They're still saying it's going to happen. But I will be honest with you, I don't know if it's going to happen. But I will be quite candid with you that I've spoken to senior Navy people who are skeptical this is going to happen. They've been pushed back before. And they absolutely could happen. They absolutely could happen. They absolutely may not happen. I don't know. So it makes planning very difficult. And I've probably scared people enough to death. So I better turn over to Scott. All right. Got me on here? He's going to switch mics. Everything that was already said applies to the Air Force. Your ratio of civilian to active duty members is pretty much the same in the Air Force. Numbers of Oc Docs are the ratio. We are well under what the average Docs are. Who was at Sappington last night? Come on. All right. So this is my chance now to add on to what's already been said and to sell you on the sexiness of the Air Force jobs. When I call you for that mil-to-civ conversion. All right. So we are the newest on the block. We are now the Department of the Air Force. And I have this cool new logo to show you. Welcome Space Force. So they're modeling after the Marine Corps. We're still supplying their medical care at this time. Now, what does the Air Force do that is different? We have this wonderful structure called the Air Force Sustainment Center, under which we have our three depots. Welcome to Oklahoma City. This is home to the second and third largest DOD buildings. We roll these wonderful aircraft in, tear them apart at the beginning, put them back together, repaint, refurb, and they roll out the other door ready to go. How many people do we have there? This is what it looks like on the numbers. So building 3001, building 9001, those two buildings are the second and third largest in the DOD. You can see we have a hefty number of employees working at this installation. Who went on, we'll get to that one next, Warner Robins, Georgia. These are the aircraft we take care of there. The 130, the Galaxy, the Hercules, 13,000 employees. And here's some facts about this wonderful location. Who went on the tour today, or yesterday? Who went out to see Hill Air Force Base? This is what we're looking at at Hill Air Force Base, taking care of some fighters. Got some Navy throwing some aircraft in there for us to take care of as well. And what it looks like on paper. So a large number of a workforce doing a pretty diverse processes on aircraft from beginning to end. If you can imagine the nastiness, we've got some cool automatic exposures. Now, one other place. Sitting over at Tinker, every aircraft engine almost flows through there from all the branches. So as you can imagine, taking the engine apart, all the things that go along with that, and putting it back together, that's some of the cool stuff we do. What else do we do in the Air Force? We get our standard tactical Leo medicine. We've got cool firefighters. Everybody knows about AFFF. And all the things that are going on with PFOS, PFOA right now. We also have Wild Blades. Believe it or not, we have a lot of bases who have a base that's a little bit more who have to manage their wildlife and the greenery. So we come in and we do scheduled burns. We have rangers. We take care of them. Some of our locations where we have OCDOCS stationed. So what are some of the direct challenges of the Air Force? And I'm going to move through this quickly, because I want to get to, like we said, we want to do a back and forth with you and answer some questions. I'm sure there's lots of questions. So I want to point out, Pam Kroll, did I see her sneak in? This is a wonderful paper. If you have not read this yet, look it up in the journal. It's got a wonderful swat in here. And I've used this to speak with command and get a little more understanding, I say little, of what occupational medicine does and an outlook of what will happen if you shrink our force down. So I encourage you to take a look at this journal article. It is well worth the read. Our pipeline, we do one slot at USHU's. Everyone else is civilian sponsored. We put through about four people, four, I think we have four slots since last year, through the residency. We get some cool places to hang out. I'm going to say, I think the best one was probably Harvard. And Nate Jones went to his residency. Got a couple of residents back there. So the Air Force mirrors a lot of what you see in the Army and the Navy as far as our problems, our makeup in that. So DHA, the big guy in the room, what's it going to look like after DHA absorbs public health? I think we're still trying to form that. We don't exactly know. Does anyone have any questions about anything that we've talked about or wanted to bring up anything about operational or military occupational medicine? I think there's a microphone in the back. Yeah. We got folks online so they can hear you. Yeah. Yeah. Good afternoon, gentlemen. One question. When I was at the Bureau of Medicine and Surgery in Falls Church, one of the things that stayed the same was that occupational medicine, for all the services, remained a service-specific function while a lot of the other services, primary care, things like that, went to the DHA. Will occupational medicine remain a service-specific function? Or are there plans to have the DHA absorb occupational medicine? Who wants to jump on that grenade? So I can start on that. So the DHA split started two times. One was the benefit. Benefit went over. That's the family practice and all those good things over there. Now come back, they want public health function. That's where we sit underneath there with that. The Navy wants to keep their shipyards. Air Force wants to keep their depot locations that are very unique to our job. And we have very specific functions. And all of them are directly related to readiness. We are asking DHA to let us keep them. And again, I'm just going to speak not for the Air Force. These are just things that we're asking for. Currently, it's being argued back and forth through legal because it's an interpretation. Congress said, you will take over these functions. And they said it to DHA. DHA said, well, I want everything. So now it's the service's chance to talk back and say, these are the ones we want to keep. And this is why. So yes, our key locations we're trying to keep. You want to talk about the Navy, and I'll talk about the Army? And from the Navy side? Yeah, so I mean, largely what Scott said, I think he was spot on. The challenge with the NDA that was from 2017 is, in black and white, it says public health shall go to the DHA. Now, I mean, I have my personal strong opinion about how that was phrased, and why it was phrased, and et cetera. But that's what the law says. And clearly, we can't violate the law. OK, well, now the lawyers are involved. Well, what does public health mean? And what is defined as readiness? What is defined as public health? And that's why it's in the realm of the lawyers. And we're going to figure it out. I know what I would prefer. I know what I would like. But at this point, like I said, it's with the lawyers. So from the Army side of things, as far as I know, all the clinics are going over DHA. I don't think there's a question to that. But again, there's these regional medical commands that focus on readiness. So the question in my mind is, what functions will go over there? The clinic's going to go to DHA. And then, again, how do you support our big customers, being Army material command on the Army side? And the other services have their own version of material support commands and other line functions. So Ben Palmer is our point of contact at OTSG. So he might have more insights. I know he couldn't attend the meetings this week. But he might have some more insights. But again, that's all I know right now in terms of the clinics, clinical going over there. But we have to make sure our customers, the line side, the material, the logistics side, are well supported or else we will fail. So again, that's really the big conundrum or the big challenge as we transition to DHA is how do we make sure the medical side understands that we sit between medical and operational and we can bridge that. But they have to use us in the right way in order to help to make that bridge happen effectively. Just as a follow-up corollary, and I apologize because I've beaten this horse so many times, but for the Navy folks in the room, and I would even argue Air Force and Army, we're here for the line. We're not beneficiary care. We're for Title X, Title V, and active duty. So the most important person to persuade on our importance is your line commanders. Because at least in the Navy, they carry a much bigger stick than even the Navy SG. And I say it with great respect to Admiral Gillingham, but the head of Navy Reactors is a four star. CNIC, CNO, and they care about getting ships to sea. Commandant Marine Corps cares about Marines being qualified to drive tactical vehicles into combat. Well, who's doing that? It's us. So talk to your line leadership and press upon them the things that we can and should and are doing for them so that they know how important we are. And when RSGs are at a table, but with line leadership, line leadership can say, oh, by the way, I want my ACMED services protected. And again, this is not all doom and gloom. DHA taking over some of these functions gives us a chance to kind of hit the reset button on some of our occupational medicine and look at what we can do in the future, how we can deliver occupational medicine services. What are we gonna do with physician shortages on our side? How are we gonna extend the ability to see that? Everything from telemedicine and other things that we're looking at. The possibilities and options are there to kind of do what we want. We just have to get DHA on board and explain to them why. We have to sell it, and we need, from the field, we will need support as well, people to speak up. I agree, Joe, when I was looking at your map and I saw the Army, I think you build tanks in Lima, Ohio, and I was like, Lima, Ohio, that's like a 30-minute drive from Wright-Patt. Why isn't Wright-Patt able to support Lima and Navy bases by major Army installations and vice versa? So I think this is an opportunity for us to come closer together and realize so many things that we do have in common and can work better as a unified force. I mean, I think to anticipate one question about that is, I'm not aware of the, it's challenging to be truly a purple force because I think we're still stuck in the structures and our missions on the individual services, but I think if it can be worked out in terms of assignments, a Navy, OCDOT going to an Army, OCDOT, bill it, great, but I think the services still hold on to kind of that vestigial or, you know, traditionally, you know, Navy takes, yeah, so, so anyway, it's something I think in the future to consider, yeah. So, but I don't, I'm not aware of that happening yet. Not yet, that's, that's, so I would argue the DHA, and I say this respectfully, is in kind of the terrible twos, you know, it's birth, that's infancy and it's maturing. Well, you know, as you mature, you go through an evolution, so. Terrible teens, there we go, so. One other thing I did want to touch on because I have been asked over and over, make sure people know this, is the privileging issues that are going on with occupational medicine. The memo did come out that has been changed. What had happened, it was a black and white interpretation of the DHA privileging book that said, if you did not take a residency in what you're being privileged in, you could not practice in that area. They did not understand that there were alternative pathways within occupational medicine to become board certified without doing a specific residency. So there is a interim letter in place allowing hires to go through and privileging to happen, and we are actively working on the credentialing and privileging issues at the DHA level to come down. Maybe another question from the crowd, and then we'll check the online questions. Sure. Sir, wondering, I've heard that the Air Force, specifically, and I don't know what's going on with the Navy and the Army, but it's gonna cut down on the number of active duty billets over the next several years through a process of attrition, and they won't necessarily replace those billets with active duty occupational medicine physicians. So my question to you is, what are those of us that are active duty occupational physicians now, particularly in the early to mid parts of our career, what is the message to us? Should we be trying to switch over to flight medicine billets so that we can still stay in the Air Force and stay relevant and do a lot of occupational medicine with that slant towards flight medicine? Or are there ways, is DHA going to take over but still utilize active duty physicians within DHA billets instead of Air Force, Army, Navy billets? Has there been any discussion on that front? So the first part of your question relates back to the core, correct? COR reduction, the 702, correct? The six and six, is the yes. So again, this is what Congress has asked, that we reduce the force. That has not come through yet. Should you go into flight medicine? Do you have a passion for flight medicine? Is that something you want to do? Do you want to go into another specialty under preventive medicine? If that's a yes, I would say follow where you want to go. If you love occupational medicine more than flight medicine, I would stay where you're at. I would rather have a physician happy than doing something just to get promoted. I don't see them removing active duty physicians. It would all be by attrition over years. So your position now that you're in, me speaking, not DHA, not Air Force. I can't read the tea leaves. That isn't shared with me. But I would see through your career, you would probably be safe in occupational medicine. Yeah, on the Navy side, there might be fewer billets to go to. But I would say at any given year, there's 10% of our community that are out who have returned to senior flight surgeon or UMO jobs, executive medicine, med IG, war college, all sorts of stuff. So there's kind of off ramps, which might even be beneficial to your career promotion chances. So I would argue that I would encourage you, if you like OCMED, stay OCMED. There'll be plenty of opportunities. And in that vein, as I mentioned, there's going to be the new billet at the PEB coming out in 2023. And we're in the very early stages. I hope it happens. But we're trying to get a billet created at NAMRU Dayton to help with some of their research and stuff. So sunny Dayton, Ohio is hopefully the future of a Navy occupational medicine billet. All right, from online, Dr. Goodrich asks. Hey, Scott, can I just say one thing about the Army side? Just to kind of talk about what's going on with the Army, I also don't anticipate losing any billets or any positions. We actually have about 30 positions that we could fill. We don't fill them all. So theoretically, if we actually get a bigger pipeline, which would be a good problem to have, we could expand our billets. And once you lose a position that's active duty, it's so hard to get it back. I mean, I will fight. And I imagine my replacement will fight to keep those billets, because they're few as they are. And they're all very important. I could shift a billet from one area where I don't think it's a good fit for whatever reason to another. But again, that line commander has to say, I'm willing to give up a billet to give someplace else. And that's also very hard to do. But I know of one billet where I would consider that right now. So I don't anticipate any billets being lost on the Army side. Great. All right, real quick, Dr. Goodrich asks, from all three medical officers representing up at the table, what are the arguments for not including US Public Health Service Commission Corps as another branch of the military, particularly since we now receive DD-214s upon honorable discharge? I'm going to start with the very first line. You said medical officers. This is not, I would not venture on where this would fall in the future, because they are Homeland Security, correct? Yeah, DHS. They fall under Homeland Security, which is completely separate from the DOD, even though you're a uniformed service, wearing those beautiful Navy uniforms, and getting that 214. So I believe that. I know you're jealous, Scott. It's OK. No, actually, I want to wear one of those Space Force suits. Have you seen those? Next year, I'll wear Choker Whites. Really make them look bad. All right. Next question. Actually, I'm sorry to interrupt. Just apropos of nothing, something Joe had mentioned earlier. We had the good fortune of having the comptroller for DHA come through Camp Pendleton. And I got to sit around the table and ask some questions. And you can guess what my question was, which was, let's talk about bag three. And he seemed very earnest and straightforward in his answers, which was that he was a believer in that bag three had been chronically and almost criminally underfunded, and was absolutely going to fight to make sure that bag three was properly funded. So yeah, DHA is coming online. It could cause some change and some fits and starts there. But it felt very nice to hear the guy with the purse strings at DHA saying, I want to support bag three. So a bit of good news. So bags are budget allocation groups. And so you've got different bags. So one's for education, one's for travel, one's for hospital care. Bag three is public health. So everything that we do is bag three, unless you're putting in your voucher for your travel. And that's bag six, I think. Bag seven, I don't know. Bags for everything. All right. I've been waiting for one of these questions, and I knew this would come up. The next question has to do with Genesis and occupational medicine. Who in here has transitioned over to Genesis already? How do you like Genesis and occupational medicine? Has anyone got, huh? There's potential, right? You can use the mic, please. It's for the people online. The people online. That's all. Yes, we can absolutely hear you. So there's potential, right? Genesis has got the tools and everything else. The question that I ask you all is, what are we doing proactively to make it a one-stop shop? For example, where the ER departments have FirstNet in there, where that's what they use for their stuff. And the clinics and inpatient care uses PowerChart. Where's this thing called Aero? Why is it not in there? Things for medical readiness, if we're talking about the bean counters, subs, we got special people that are on nuclear orders and stuff that can be in there. What are we doing to optimize that, because bag three funds, so we're not using our money, to get it incorporated in Genesis as it rolls out across the force? All right, from the occupational medicine working group up top, we are communicating with the DHA div chief for public health and have expressed the fact that Genesis for occupational medicine is broke. Has potential, but is broke. So they are actively aware of the problem. The question is, what are they going to do about it? They are supposed to create an occupational medicine suite, a nice little suite, so we can practice occupational medicine, firewall off GINA information, firewall off everything that we're not supposed to see, and practice occupational medicine within this little suite. It's on hold. Why? Where's it going? I don't know that they are aware of the problem. You brought up EROS? I think EROS Sundown, correct? You mean on the aerospace medicine side, EROS? Is that what you're talking about? No, it's not. It's still functioning. It's still there? OK. The developers of Genesis are working to roll ILR into, it'll be right on the front of Genesis on the screen. Who in here is not familiar with ILR? ILR stands for Individual Longitudinal Exposure Record. It is everything that an active duty or civilian worker comes in contact with from cradle to grave, from the time they enter the military to the time we hand them to the VA. That is the goal with Cerner, making connected EHRs on both sides, is ILR will grab information from DMDC and other locations to show where that person was at that time and what exposures are there. It's going to go into DOORS IH. It's going to pull what exposures were known in that area. Combine that, look at ICD-10 codes, suggest things such as, right now, the burn pit registry. If a person comes in with recurrent sinusitis, they were in a location in Bagram, that Bagram did have a burn pit, it will suggest to the physician, hey, you might want to think about burn pit and burn pit registry and working them up for that. So that is going to be into the front page of Genesis and the occupational medicine, or not even occupational medicine. It's just going to be there for every physician to use. ILR is now live. Any physician can get access to ILR. You have to go on either JKO or another training platform, get your little certificate, and you can actually see ILR up and running. And you can see exposure data as your patient comes in. So I encourage all of you to get access to ILR. Look at it. Play with it. It is coming to Genesis soon. We're working with an informatics person to make it friendly. And they actually have an orthopedic surgeon along with the informatics person. So hopefully, it will be useful and not throw garbage at you. And everything that hopefully pops up is useful to you. I just want to say some really quick things about Genesis. I was at OTSG back in 2013. And maybe one or two years later, we started having conversations about Ock Health. And I just want to say that we did submit our requirements of Ock Med from the very beginning. The challenge is that with the big, huge requirements across MHS Genesis versus our requirements, I think they were able to include some things, like trying to firewall Ock Med versus the rest of the health record. But other than that, very limited what they could do, just based on the massive engine that MHS Genesis is. So that's just one perspective. I don't know if others have had experience actually using it. But Luke? Yeah. So I can speak to Genesis a little bit. I do have a question after this. So as a Genesis user, I think one huge pro, one thing that I really like about it, it has a powerful auto text feature. And it's pretty easy to share within the EMR. So you don't have to email or anything. You can find other people's auto text. So obviously, for a lot of the clinical stuff we do in Ock Med, where it's fairly templated, fairly consistent with each encounter, I think that's really high yield and really valuable. And if one person builds a really great template, it's really easy to grab that for anybody else. It obviously has the problem, as you mentioned, sir, of not being firewalled for GINA and other non-OH pertinent information. It's all kind of there in the pool. So huge issue there. I personally find it a little bit more clunky than I did Alta. Nothing to do about that. That just is what the system is. I think it is being developed. It also, I find that it is not super well integrated. And so you have to open different program, different way to look at someone's prior records previous to their, you basically have to open JLV on an internet window to look at anything prior their Genesis integration, which can be kind of a pain in the neck. But the one thing that I'd say is a real positive is the auto tech feature that's built in. You can share really easily. So the question I had is for you, Colonel Ortiz. And I apologize. This is really an Army specific question. But can you comment briefly on the evolution of the role of the consultant with regards to assignments as AIM 2 has developed and evolved? I can comment real quickly on what I know. What I do know is that, and I just sent an email out about this the other day, is that if you were part of the AIM process recently, it was a matter of you have applicants, the individual officer providing kind of their portfolio and kind of where they want to go, their requests. And you have the units trying to say, hey, we need certain individuals. And they want to do a one-to-one match. The problem is that trying to match individual officers where we want to go, their kind of desires versus the mission needs, and kind of what are the overall priorities, didn't really work very well. So I think we're transitioning now where the consultant, at least on the Army side, will have a better role in terms of where people go within the specialty. But particularly, I know within the GME side, I think there's going to be direct decisions from directly GME to what billets they go to. And you have everybody else in the AIM or assignments process. So that's the last thing I heard. The question is, the chicken and egg, what comes first? Or is it going to be in tandem? And I don't know the answer to that. I just know the consultant on the Army side is going to have more of a role, at least on the GME side, and probably more on even the other assignment side. I mean, our assignment billets are so small that, I mean, honestly, when I saw some of the matches at first, I'm like, what are they thinking? And then you have to go back to Human Resources and Command and fix it. And I think we're going back to the old system, where I think they rely more on the consultant. So does that answer your question, Luke? And you're always welcome on the Air Force side. Navy has better bases. Another question. Hey, John Downs. I think most people know me. The APD at USASNL. This may not be exactly a question, but pertinent to each one of you all, you mentioned these environmental exposures that an OM doc might be asked about or that we're getting integrated into ILR. And I just tell you, my experience with our community is, at large, is most of us overwhelmingly focus on the O, little e, and then big M. So I wonder if, perhaps, as we go through this DHA transition and we're thinking about where do we fall in clinical context or something, should we be thinking about what the VA has in terms of environmental centers or some places where we can, if we really want to have patients or active duty sent for an exposure assessment along those lines? I mean, it's easy for us to say, oh, we've got everybody at a med cent. Our Naval Medical Center at Portsmouth has an OM doc. And they should be able to do this. But I truly don't feel like our community is as comfortable with that as, perhaps, we make it out to be. I don't know if you all have comments for that. But just a thought as I was setting here, because we keep saying we get pulled into this. And I think a lot of us, I'm different in some sense. A lot of us then go, well, this isn't the standard surveillance exam that I want to do in clinic for five days a week. And now I'm a little uncomfortable. And who should I call? And who should I reach out to? And public health centers may or may not be able to engage in that, because they're not really there for direct interaction with those individuals. So just a thought. I need to make a comment. Go. I was making a comment. Go to the microphone. I'm Dr. Perez. I am not active duty. But some people know me here. And I'm glad about that. I have experience regarding to any kind of EMR system, because I have working. And you are talking about Dr. Scott. You have been talking about Genesis. I haven't been exposed yet to Genesis. But I have a point of reference, ALTA. So that is one. But I have been working so far with many EMR systems, out of the system and inside the system of the military. So it doesn't matter. My experience as working in medical field, oh my goodness, more than 30 years. I'm working in more than one country. I will say so far, how many? Three or four? I don't know. Don't ask me. I can say I am international as a joke, because we deserve to enjoy. Tonight we have a party, right? We have a party tonight. We need to enjoy that party. So it doesn't matter my opinion, my experience in the medical field. It doesn't matter what EMR system you use. The most important is you feel secure in the place where you are practicing medicine. In the military science, United States of America, we are the number one. We feel there. My goodness. I feel there. Secure, 100%. The problem is sometimes people around you don't cooperate with physicians sometimes, or with primary care physician, or with, I would say, mid-level provider or provider in general. If we work as a group and people cooperate, you be success in any kind of environment, you can use any kind of EMR system. That is my experience. I don't know if you are agree with that. I'm going to comment real quick. We're going to have to wrap this up real quick. But I think some of the talk about Aero, and I think alternatives to Genesis, I think we need to consider, continue to think about what we can do in terms of tailoring some type of OCMED record. Excuse me. Sorry for interrupt you. As an occupational medicine physician, sometimes we need resources out of the Genesis or out of the whatever to be success in order to treat a community or a patient. And we need to know to treat correctly the environment, because we are occupational medicine physicians. An environment is a population care. Sure. Let me comment on that. So real quick, go back to John's comment. I think Congress is going to force our hand on making that E a bigger E. POTUS's focus on exposures of concern. It was in a State of the Union address. It's been brought up over and over. Coming to a base near you very soon is going to be a look at how lead and hexachrome are used across the DOD. That's going to be the first push that I've seen coming out. So I think we're going to grow in our E, in our exposure. And then I want to springboard off what you said in the workplace security and feeling safe at where you work. And that's one of the things we need to consider. How do we keep retention? Our assets, our staff. How do we grow new people? How do we get people through a pipeline? How are we going to sell this specialty to a medical student? And we started talking about that a little last night. I think that all helps workplace security to keep people in and retention. And I'll just say, again, to finish up my thought from before, I think this is, in terms of the EMR, obviously we're going to be using Genesys in the future, and that's given. But again, I would urge everybody to consider what alternatives can we develop using Arrow, whatever systems are out there, to tailor the systems to meet our community needs. And again, I agree in terms of what John Downs says. In terms of the big E, how can we service in a consultative capacity? And I think a lot of that has to do with how can we educate others within the hospital, within your area of responsibility to say, we are the experts in that, and provide some of those services to support exposure needs. And I'm not sure if that's what you're getting at, John, but it's something we need to talk about more. Agree. So I apologize. I have to, I almost forgot one thing I wanted to add, so this is a complete segue. At some point between November of 22 and summer of 23, the Corps Chief has asked me to turn over for Specialty Leader. So I guess Admiral Hancock was having way too much fun with me. So if you're interested in applying to be the next Navy Occupational Medicine Specialty Leader, please connect with me so we can kind of talk about that process, and also try and figure out when that might be taking place, because those early discussions are starting. I actually think we're out of time. Are we out of time now? So again, I think we can continue these discussions offline. Throw your question out. We'll try to answer it quick. Throw it out. Super fast. On the east side, I had a patient who had gone to their flight surgeon, and they were participating in Operation Tamodachi. And when they saw their flight surgeon, the flight surgeon pushed their chair away from them and went to the office side of the exam room because they thought that they were radioactive. So with the longitudinal health exposure or the environmental exposure, it's going to be critical that we get out there. They were super lucky that somebody knew about AHCMED, and they came to see me. Their exposure was nil. But that is going to be huge, because if you have family practice, and OBGYN, and other folks that are opening this up and they don't know what they're looking at, your patient might really suffer. So. Thank you. Good comment. Thank you. All right. Thank you.

occupational medicine

military

challenges

potential changes

electronic medical records

integration

line commanders

support

environmental exposures

readiness