All right, let's get this kicked off since we're the last session of the day and I know folks want to get on with the rest of the evening. Can I just take a quick show of hands, who is non-military, meaning who's not been active duty guard or reserve? Do we have anybody? Great. Please feel free if something sounds weird or what the heck are you talking about, what is the name of that thing, what are those letters you threw out, please feel free to stop and ask questions. We really want this to be kind of interactive going back and forth. So, all right. Any talk that we have to give, let's start here. Everything that we are going to say, and I'll let them say their own statements later, is going to be our opinion, our opinion owned, we do not speak for the DOD, our military department, or our representative Surgeon General. Is there anybody from the Massachusetts Air National Guard here? Are you serious? Can I see your ID? I'll need your token back. Too soon? Too soon. All right. Well, welcome to our non-DOD folks and everyone else who is residents and coming in through the pipeline. Let's start at the top. Let's start at where the DOD hands each one of the MILDEPs a task to do through a DOTI or a DODM. So that's the instruction or manual that kind of tells us what we're doing and how we're going to do it. Each military department still gets the same instruction. We had the same output. We just developed ways of doing the same system a little bit differently. But we still accomplished the mission. Who is the mission? Who are we taking care of? A couple of numbers here up on the screen are all the folks that we do take care of throughout the DOD. We also have, when it says, this does not have it on you, but you can imagine any other three-letter agency, postal service, and other federal agencies that may require us to do a pre-hire exam, fitness for duty, and things like that. But these are our DOD workforces. You can see that's quite a large number. Where are we? Every MTF in the enterprise has some function of occupational and environmental medicine. We perform these functions downrange. We have bioenvironmental engineers, public health, and some of our new initiatives with EILER. Who in here has not heard of EILER before? Awesome. I'm glad to see lots of hands down over here. That is going to be our new longitudinal exposure record. So EILER, individual longitudinal exposure record. Once this system goes live, the thought behind it is multiple computer systems will talk to each other, meaning person was where, measurement of an exposure comes together, gives you the time, and it's applied to a personnel record and also to a medical record so that when you look them up in the future in the DOD or in the VA, it will show you what possible exposure the person had throughout time. Fingers crossed that we get it working. All right. So that is the very, very, very top level. So let's get into some military department specifics. I'll hand you off to the Army. Ignore that slide. All right. Good afternoon, everyone. Colonel Andrew and Dr. Ben Palmer, currently the consultant to the Army Surgeon General for Occupational Environmental Medicine. Thanks for the opportunity today, this afternoon. I know it's the last session of the day. There's not much standing between you and the door and whatever else is awaiting you this evening. But we're really glad that you're here and allowing us to share the information. We do have some updates as far as what the Defense Health Agency is up to. Some of you may be working with the Defense Health Agency. And I'll start off by saying that the migration and transition to the Defense Health Agency is being equated to military medicine moving to a DOD agency, the likes of which we haven't seen since the establishment of the United States Air Force. Major, major muscle movement as far as personnel and services, and it hasn't been without its bumps, but we are making good on what Congress has told us to do. So we'll just kind of start off with that. But anyway, the Army, uniformed personnel, the individual soldiers that are out fighting the fight and servicing those who are fighting, and then the back, you know, all the way, the seven individuals that support that infantryman out there, all those individuals are people that we support in the bottom line as far as support to the readiness activities that get those guys out there to do the mission. Our demographics, you can see that pie chart, about 372,000 active enlisted individuals. And then the blue pie chart, there's the officers. So those are the leaders of those soldiers. And then that green sliver are the warrant officers. And the warrant officers, if you're not familiar with what a warrant officer is, they're highly specified in a specific task. A lot of them are pilots. A lot of them are trained in special activities. We have warrant officers in logistics. We have warrant officers in health services, a lot of food support, and those types of activities. And then the very, very smallest sliver there are the cadets in between ROTC and United States Military Academy cadets. So that's the uniform population that we support. And we support those not necessarily directly, but it's indirect through the activities of our civilians that are working in depots and other facilities, security guard workers, firefighters that work on the installations and provide that installation support to all these individuals who do get assigned to missions. So as far as the civilian demographics, we have about 265,000 civilians in the Army that work directly under the Department of the Army, have a Department of the Army rating. And they are what we call appropriated funds. So the Army programs their wages and salaries. And then another 22,000 or so non-appropriated funds. And those are individuals that work on installations, that work on morale, welfare, and recreation facilities. They work in the restaurants. Actually, we have non-appropriated funds that work in our veterinary clinics. I just realized that because of where I work now. But we have an established number of mechanisms to pay wages, and we do provide support to both non-appropriated and appropriated funds civilians. As far as how many lines of work, they're involved with over 650 occupations across the Army from highly, highly skilled technicians all the way to other lesser skilled individuals that are just as important to get to accomplish that installation support mission. About 130,000 of those civilians have a four-year equivalent degree. And another 72,000 are considered blue-collar artisans, and they're working in the depots, whether it's turning turrets to a tank, assembling and retrofitting equipment. Because you know it's not like you can just go build a tank. You actually take an old tank, sandblast it, repaint it, put it together, upgrade it, and then put it back out on the line. So there's a lot of retrofitting activities that go through our depots that doesn't really go back to the initial stages of manufacturing processes. So about 72,000 of those individuals do those types of work. And across, actually this is kind of, this is an update to this slide, almost 11,000 medical professionals, well guess what? Those individuals are no longer part of the Department of the Army. They're part of the Defense Health Agency. So I have to update this slide to reflect that. About 25% of our civilians are veterans, and as you can imagine, a lot of individuals that do leave active duty, they turn right around and go back to what they know and environments that are familiar to them, and they become Department of the Army civilians. So as far as what we look like, the U.S. United States Army Medical Command, we are broken down into four distinct coordinating medical readiness commands. And you've probably seen this slide before with different vernacular. I updated it according to what the new medical command looks like. We no longer have military treatment facilities, medical treatment facilities assigned directly under the medical command, because all those hospitals and clinics have moved over to the Defense Health Agency. That's going to be the common theme you're going to hear in our discussion today, is that medical services are no longer aligned entirely within the services. They're under the Defense Health Agency as dictated by the Defense Authorization Act through multiple years of work. The four commands that we have, each commanded by a Brigadier General at this time, we have Europe, Pacific, and then East and West. If you can imagine, and some of you may be familiar with the old naming convention where we had a readiness command Pacific, a readiness command Central, readiness command Atlantic, and a Europe. So at this point, we're just at Europe, Pacific, East and West. Kind of simplifies things. In the reestablishment of the medical command, the medical readiness commands have gotten much smaller with a much smaller public health footprint. So any coordination that we and the medical command and offices of Surgeon General, we're directly coordinating with the operations folks and a few public health representatives that are within those medical readiness commands. So that's how we look today. And I would add that as far as checks and balances, you know, we do inspections. We do inspections at echelon. So we, as a strategic level, we'll inspect the operational level. Operational level inspects the tactical level. Kind of, you know, military jargon speak. But what happens is you get a high level management that inspects medium level and then down to the clinic level and hospital level. That's changing a little bit as far as how our structure looks as a medical command and having subordinate medical readiness commands. So what we're seeing is more of an influence of we as now receivers of the Defense Health Agency services have to ensure and integrate with installations to ensure that Army requirements are being met. So we're no longer in a position where we can authoritatively direct medical services within the Army. Now we have to ensure that coordination occurs between organizations that need medical support and the Defense Health Agency. So it's more like a big triangle now. And we all have an important piece of that triangle. It's complicated. A little more distinct in our Army and Organic Industrial Basin, you've probably seen this slide in the past where we just highlight the areas where the Army owns depots and arsenals and industrial bases. Again, where we're retrofitting and refitting equipment, managing certain types of ordinances and ensuring that the stockpiles are maintained and rotated appropriately and stored and appropriately ordered up and shipped out appropriately. Those activities happen at these locations. So Rock Island, Pine Bluff and Anniston, they're in green because we have uniformed individuals that are assigned there and actually Dugway as well. A lot of the other places are mostly civilian operated, commanded by a military individual, but the majority of the individuals that are employed by that facility are civilian. And you'll see in the next slide that we have about an equal number of ‑‑ I'll go ahead and move to the next slide ‑‑ about an equal number of civilian occupational medicine physicians and uniformed occupational medicine physicians. Currently we have 38 uniformed military occupational medicine physicians, including those that are in residency and training. So you can take a handful off the top of that. It takes you down to maybe 34, 33. And then of those 33, about 10 of those are serving in positions that are not occupational medicine related. So we have leaders of clinics, we have individuals that are serving in other administrative roles that aren't directly occupational medicine assigned. So down ‑‑ we're down to about 22, 23 individuals that are serving in bread and butter occupational medicine billets across the Army. Now, the 36 civilians that are out there practicing, they are practicing the bread and butter occupational medicine clinic management type functions that you would expect an occupational medicine physician to conduct. As far as our pipeline for production and inventory management, we have two residency graduates this year, as well as two fellows. And come July, August timeframe, they'll be graduating and moving to their Army billets and assuming commanding ‑‑ or not assuming command, but assuming positions of high authority and getting ready to do great things. We have three rising third‑year residents. And within the next year, they'll be preparing themselves for assignment in whatever ‑‑ whatever the cycle brings up for their assignments. And then we're actually bringing on board two residents in the coming year to begin their training with us, both of which have prior internship already on board and they have prior experience in the Army medicine program, the Army medicine enterprise before entering the residency. Losing or lost, again, these are individuals that are either in some kind of training pipeline or program or they're in other assignments. But we will gain four of those back in training at some point. The bottom line here is, it's not as cut and dry as you think as far as where people are assigned and how to visualize where they work. Because it's such a variety of locations where they can be, and the Army has specific professional training requirements of us. You have a captain's career course, you have an intermediate level education, and those aren't just like a couple weeks here and there, they're months at times. Specifically in residence, intermediate level education at Fort Leavenworth is a 12‑month program. And it results in a master's degree in some kind of strategic policy or whatever, but it takes physicians out of the clinics and then that's ‑‑ the Army expects us to do that in order to progress and be promoted and assume higher levels of position. This summer, six Army occupational medicine physicians will be rotating positions and they'll be moved to another job, either it's overseas or back here in the states. On average, in the bottom bullet there in the very last section says, you know, about every three years we rotate positions in Army medicine. You can stay a little bit longer if you want, four years is not unusual. If it's a high op‑tempo job, a high operational tempo job, sometimes we want to get them out at two years just so we don't burn them out and then get them to another assignment. So across the board we have about 34 uniform positions that we try to fill from year to year, and mostly rotates every three years, but by and large, we as consultants in Army medicine, we're asked every year to sort of list them in what they call a one‑to‑end list when we list out the assignments in priority of fill based on the hierarchy of what Army staffing guidance is. So based on what the mission is, we support the very high level, high op‑tempo units first. The forces command and those types of elements that absolutely are kind of the tip of the spear when it comes to operations, and then it actually trickles down to what you would think high level of priority of fill would be the medical command, but we actually reserve the medical command as sort of the lowest priority of fill because we have the ability to kind of cross level and share jobs and responsibilities within the medical command to accomplish that medical mission. So it's kind of backwards, but when you think about it, when the country needs a reactionary force to go face an adversary, it's those forces command that are highly volatile and highly maneuverable that need to be filled first, and that's who gets the priority of fill right off the bat. So Army occupational medicine areas of concern, you know, it's a common thread across medicine, not just occupational medicine, recruitment and retention. We are really, really trying hard to break into social media and other avenues of communication to get the word out about occupational medicine. You know, it is the best kept secret in medicine. People need to know that, and our medical students need to know that. You know, a lot of, we get washed out by a lot of family medicine, internal medicine, and the surgeries and a lot of other specialties. We get over, overspoken by a lot of other specialties that, you know, just basically go in and pick up gobs and gobs of medical students and pick them up into their whatever intern year is and then bring them right into their programs. So we have to continue to beat the drum about occupational environmental medicine, that it's a fantastic specialty. We all know this. We all have a part in recruiting and retention. Our program at the Uniform Services University can actually accept up to four residents a year in the Army side. The Navy has their number of billets, but it is a very, very productive program. It has a lot of opportunities there and rotations throughout the D.C. and Maryland area, whether it's clinical or administrative and policy, we usually generate a really nice complement of rotation sites for each resident, and I know Colonel John Downs and Captain Crawl, yeah, Pam Crawl. See, I'm all Army in my brain. Captain Pam Crawl do a really nice job ensuring that they get the best rotating sites as possible. We do compete with the Army private sector for the civilian jobs. It's difficult for us to list a position and move a position into the hiring process and then interview and then bring a selected physician on board. Those of you who are in the civilian medical Army position know this. It usually takes six, eight, nine or more months to onboard a physician. Well, what can a doctor do in about six to nine months? Can do pretty good. You know, there's a lot of productivity in nine months that you can accomplish while you wait for an Army decision to be made to bring you on board as one of our docs. It's something that we've worked with to try to refine that continues to be an administrative challenge to onboard our physicians. As far as uniformed individuals, we still have the individual critical task list, and that's something that our Surgeon General has basically set out and said, you know, specialists, AOCs, make sure you generate whatever the critical lists are for you to be able to deploy in your specialty. For us in occupational medicine, it's more of a preventive medicine flair, and if you look at an Army occupational medicine physician who has deployed, we have all deployed as a division preventive medicine or preventive medicine person, physician in a deployed setting. So that's how we don't normally deploy as occupational medicine physicians, even though there is a role out there, especially when you're dealing with urban conflicts that have industrial site involvement. We definitely have a role in that, but many of us who are dual trained in preventive medicine and occupational medicine, we really blend those two skill sets into one, and it fits the division preventive medicine role very nicely, and it's a great asset to complement that division surgeon cell, so it's very beneficial. A triangle of public health. So we have aerospace medicine, general public health and preventive medicine, and occupational environmental medicine. We are very, very tightly aligned within the Army as far as assignments. even now, this current assignment cycle, we're having occupational medicine physicians that are rotating into aerospace medicine physician positions and preventive medicine and vice versa. We are pretty much all interchangeable except for the fact that an aerospace medicine position would require a six-week training session for our occupational medicine physician to go and acquire those aerospace skills that's separate from the aerospace medicine residency. So we're definitely interchangeable and with a few extra bits of training, we could be totally interchangeable amongst all three if need be. And because our inventory continues to kind of draw down, we continue to explore those opportunities to get individuals trained and location, having to do with it, whatever skill sets they have and whatever they want to do or what their objectives are. We get those uniformed physicians into positions of whatever their wishes are. And of course, what the needs of the Army are, or the needs of the Army is. Okay, we'll move on to the next slide. Concerns, DHA transition, I've already kind of mentioned that. It's not been without its challenges, but it continues to move on. Our guidance from the consultancy out to Army personnel assigned to defense health agency clinics is that you continue to do what you do day in and day out. Your support to that supportive population is critical. And anything that we do at the strategic level should be transparent to what you do at the clinic level or what the clinic employees are doing. So we kind of, we really reiterate that. And I know there's kind of in the intermediates, there's transition with the leadership at some of the military and medical treatment facilities. But by and large, patient interaction is patient interaction when it comes to the military. The population you have served prior to the migration and transition to DHA is still the population you're serving today. And that's something that we'll continue to beat the drum about. And actually, the guidance from DHA is continue to serve and follow the service specific guidance. So continue to serve Army, Navy, and Air Force guidance until guidance has been written and published by the defense health agency. So that's current guidance that's out there. And in collaboration in health safety, okay, allied professionals, we still have the important requirement to integrate with our safety and our industrial hygienists to ensure that individuals are enrolled in the appropriate surveillance programs. So none of that has changed. It continues as needed. And I would say the perfluoroalkyl substances testing of blood for our firefighters, that was something that Congress told us to start doing a couple of years ago. And that has continued in earnest. Some of you may be in clinics that are actually continuing to draw these samples. And the Defense Centers for Public Health Portsmouth continues to analyze that preliminary set of data to see if they can draw any conclusions to it and see if there's any ways forward for the value of that data from a quasi-research perspective. But we were told to draw those blood samples to look for PFAS in order to document exposure to PFAS. So you can imagine that's been a challenging situation. But we've done that according to the direction of Congress and will continue to do that until told not to. That's the one thing about the Department of Defense. Congress can tell us exactly what to do. And because the Department of Defense directly has to follow the National Defense Authorization Act law, they can direct us to do certain things that kind of go sideways with what science tells us. And we have had that very intellectual conversation all the way up to the Department of Defense to say, why are we drawing PFAS? Because we don't have any concrete direct medical effects connected to PFAS exposure. And they say, yeah, we know that, but go ahead and draw it anyway and document. So we do that. But anyway, Lieutenant Colonel Leverson mentioned about the individual longitude and exposure record. That continues to be refined. That is actually a result of years and years and years of development that links an exposure in a deployed setting to a time and a place deployed into a potential exposure scenario that could be related to a disease. So it's a highly complicated record that links time, place, and exposure to a potential exposure. And this has potential PACT Act connections. If you have been following PACT Act, the VA is really, probably 99% of the effort is in the VA to assist those veterans that have medical effects, and they're trying to link that in a very meaningful and valid way to an exposure downrange. So hats off to those VA colleagues that are performing those duties. It's definitely a challenge that lies ahead. So with that, I'm going to hand it over to Commander Max Clark, who's going to talk about the Navy. And then we'll talk Air Force, and then we'll wrap it up with the questions at the end. So thank you very much for your time. Thank you, everybody. I'm Commander Max Clark, a proud graduate of the Uniformed Services Residency. So if you have the chance, I recommend it thoroughly. I'll probably go through my slides fairly quickly. But again, if you have a question, particularly if you're not used to DOD or Navy vernacular acronyms, please stick your hand up. Obviously, our goal is to educate, maybe entertain, but not confuse. So core mission, which hopefully should be pretty obvious. We have a very large civilian workforce, large industrial base in the Navy, our shipyards in particular, which I'll go into in greater detail in future slides. Mostly shore-based activity. We're not really chasing people around on ships as they're underway in the middle of the ocean. But we certainly want to protect their health at Marine Corps depots or Navy shipyards. We also get dragged into environmental health consultations. And in my, Max Clark's, opinion, I think we should do a better job of this. Unfortunately, the Navy and Marine Corps has been involved in far too many environmental health issues. Camp Lejeune drinking water, now Red Hill. I sincerely hope those are the last ones we'll ever see. But that just remains a hope, and I'll leave it at that. Obviously, responsible for the surveillance, certification, and prevention of occupational injuries and illnesses. You know, as alluded to in an earlier talk, Navy occupational medicine is a lot more structured and formalized than, as I, excuse me, as I understand Army and Air Force occupational medicine. I'm not saying anyone is better or worse, they're just done a little differently. So as much as I would love to rib my Army and Air Force colleagues, please remember I only tease the people and entities that I like. So it's okay to laugh. So where are we at with manning? We have a great deal of civilian providers in our health nurses. A large part of Navy occupational medicine is done by general medical officers, flight surgeons, undersea medical officers, who may or may not have any occupational medicine exposure. Credit to the Navy and Marine Corps Public Health Center for developing the OEM Fundamentals Course, which I think is a great primer into occupational medicine. I've also had the pleasure of being part of the Air Force Fundamentals Course, and I think after that exposure, we've had talk about, you know, how we tri-service can work to improve our fundamentals courses. We do have about 10 to 12 people cross-boarded, either aerospace or prep med, so sometimes you will see people jumping back and forth into those billets, preventive medicine, aerospace. We currently have 34 active duty occupational medicine physicians. Actually, I'm sorry, that's actually probably should be 10 residents, with four that are incoming this summer. So I am anticipating, although I haven't seen all the paperwork, eight to nine departures, whether that's retirements or resignations in fiscal year 23-24. So this is a lot of data. There will be a quiz at the end, so please memorize it. But what I really want to take away is, you know, just like the Army, and I'm only about the Air Force, you know, filling positions, retainment, particularly with civilian providers and staff, has been a challenge. Some of that, you know, the HR process has not gone as fast as we would like. We have some amazing billets in places along the coasts, in Hawaii, where people want to be. We also have some billets that have been challenging to hire. You know, the desert or other remote locations, which some people love, some people don't. But they bring challenges to hire. So we're sitting at about a 30% vacancy rate. So there's a lot of work that then gets transferred, and it has definitely been a challenge. So here we're going to kind of talk briefly about the shipyards, the big four. I do want to quickly give a shout-out to the Philadelphia Naval Shipyard. Go Philly. Where I had my very first dental appointment many years ago. It is not a Navy shipyard in terms of NAVSEA doesn't own and operate it, so that's why it's not listed here. But we do have Naval Occupational Medicine there, and I wanted to make sure that they were recognized for all their hard work. So Norfolk, our biggest, our oldest continuing shipyard. They definitely need more staff. Right now we have one uniformed billet in that area, and they're pulled between the shipyard and Naval Medical Center Portsmouth, which is a very large Navy hospital that creates a lot of challenges. We have Pearl Harbor Naval Shipyard, which is near and dear to my heart. I haven't been stationed there before. A little smaller, only 6,000 employees, but I can promise has lots of really fascinating exposures. There's some people who have to then go into the bilge tanks of submarines and had 16 separate exposures or certifications. So their exams were very lengthy, lots of labs. I would also have guys come in and their A1C would be 10.2, and they'd be like, oh, it went down. So you definitely have some challenges with the workforce, and it presented great opportunities for education because, much to my lament, surfing is probably not the most effective treatment for hypertension. We also have Portsmouth Naval Shipyard. Now this is not Portsmouth, Virginia. This is Portsmouth, New Hampshire. It's right on the New Hampshire main border, and then you also have Puget Sound up in the Pacific Northwest, a very large submarine base. So kind of our biggest challenges, the Navy has been kind of the last to adopt the transition of straight through GME. In the military, historically, you'd come in, you'd do your internship, and then you would go out and serve the fleet. You know, go to a ship, you'd be a flight surgeon, go to undersea, you'd do that. Then you'd come back into residency, and then Congress came back and said, no, we really want residency-trained folks being treating doctors. We don't want only internship-trained. Army and Air Force adopted that fairly quickly. The Navy's been much more of a challenge to adapt that. So we have people kind of returning from GMO tours, and then we also have people coming straight out of med school. And I'm certainly not opposed. Clearly, there's lots of talented medical students. The biggest challenge we face there, though, is we as a specialty need to do a much better job about advertising to medical students. And I'm going to specifically challenge Navy providers, Navy doc, med docs, who are closer to residency, closer to medical school, because no one wants to see me dance in TikTok videos. So you know, maybe, maybe, maybe. So there would be lots of occupational injuries if that happened. So yeah, we as a specialty need to advertise better. That sort of ties into recruitment. As I was just saying, I think the people who've gone out and served as flight surgeons, UMOs, et cetera, because you're doing occupational medicine, I mean, that was my path. That's what brought me to occupational medicine. I'm very grateful for it. But if you don't have that exposure, a lot of people are like, I didn't even know this existed. In the story that I like to beat to death, my father, retired Air Force physician, physician for... Not me. Not Scott. Scott's not my dad. A physician for 40 years. He still asked me, what is it you do again, son? I don't understand. So he has a failure of recruiting. The civilian manning, I already went over. He's an organization, DHA, Navy Medicine, needs to do a better job of filling those civilian billets. And then there's the DHA transition. I don't have specific bullets because this is an evolving challenge. I will share with you that the Navy has a request to keep occupational medicine with the Bureau of Medicine and Surgery and bring it back from the DHA. We are waiting from a very, very high level of the Department of Defense to make a ruling on that. I certainly have a way that I would like it to go. But regardless, I hope a decision is made quickly so then we can start moving out smartly in whatever direction we're going to go. So with that, Viva Air Force. All right. So I am Scott Everson. I am the Air Force consultant. I am not Max Clark's father, despite. I'm going to pause here on this slide real quick to do a little nomenclature change. Yes, we're still the Air Force. We picked up this neat little Star Trek thing over on the side, which means we had to change names a little bit. So we're still the United States Air Force. We're still the United States Space Force. And together we are now the Department of the Air Force, similar to the Department of the Navy. Nomenclature change as you see things coming forward. One of the coolest things I can think of is working on an airplane. Our depots service some of the best aircraft in the world. Some of the oldest aircraft in the world that are still flying. These wonderful pieces of machinery flow in through one door, completely disassembled, sandblasted, wiring out, avionics out. And we can't run down to Home Depot or the nearest Radio Shack, who remembers Radio Shack, and get some new avionics. A lot of the parts we have to actually go and physically create. Roll in a block of metal, let's hone it, let's machine it, let's do all these different things. We do all that stuff in-house. So just as the Navy shipyards, just as the Army depots, we create a lot of interesting industrial processes. We have the same workers, we have the same basically demographics and jobs that the other branches have. A little bit smaller. So we have the same challenges in that. So that's why I let the Army and Navy go first and go over their challenges. These ALCs, or Air Logistics Centers, we have three. My favorite, home, Tinker Air Force Base, OCALC. See some nice numbers there. If you take a look at how many civilian employees at one of our installations. Almost 9,000 civilian employees. Warner Robins, tucked away down in beautiful, sunny Georgia. And they now have a new Buc-ee's. So if you're ever going through there, make sure you stop at the Buc-ee's. Again, sitting around 8,000 civilian employees. Finally, Hill. Who's been through wonderful Hill country? It's a beautiful area up there. Again, you can see approximately 9,000 civilian employees. Much smaller, but still you can see a number of employees that we have to deal with, with industrial issues. Not only that, one thing we didn't discuss so far is our workforce is also an aging workforce. We're not getting the same younger folks in anymore. So that is complicating the way we're dealing with our workers. Where else does the Air Force sit for occupational and environmental medicine? Here are other dedicated locations where we have an OEM physician, at least one sitting. So similar to the Army and the Navy, we also have our pipeline coming in. I have four slots for students or for residencies going through. One through USHERS. One are two funded and one unfunded civilian occupational medicine residency. Over the last several years, I've been able to fill two of my four slots each year. We are sitting at approximately 60% manning, 62% manning in the Air Force for occupational medicine. So similar to Army, Navy, similar to this college is we're having a difficulty in keeping our specialty alive. Where are we getting our new residents? How are we advertising this in medical schools? So these are the same issues that we have. One thing I did want to point out is if you are ever in a clinic and you have a clinic administrator that will question, why are you doing something different than family practice, please, please, please take the time to speak up about your specialty. It is a misunderstood specialty. And now that the MILDEPs have handed over occupational medicine to DHA, who is now in turn handed over to the medicine side and not the public health side, take a moment to explain to any clinic administrator what is going on in your specialty, why you do things a little bit different, why you're not an RVU generating entity. It is always good to try to get that education out there a little bit. And our future training, we just went over that. So going back to, or going forward, we're going to go into how is this arranged throughout the DOD. We touched on doing the PFAS testing earlier. I did want to update on that as well. The PFAS testing, we are now expanding the panel of the PFAS chemicals. We're also going to match the NHANES methodology. So we'll actually have something to equate to. Other big accomplishment coming down through the DOD safety governance channels is we've gotten handed a new 605505. Who's read that yet? Awesome. Yes? Great. So this has realigned some of the exams that we do. We are now doing a little flavor of Leo medicine. We've stripped away the NFPA requirements out of it and retained the occupational side of it. The preventive health side is gone. Workers are now asked to self-certify. So make sure you talk to them about these things that are going through. So those are the big accomplishments that the DOD safety governance has done over the last year is push this out. And this is just a look at where does all of our guidance or who's in charge? Where does all of this stuff flow? And this is a little diagram from DSACA or Defense Safety Oversight Council. So we as the consultants sit together on the occupational medicine working group and we feed information and answer questions coming down from the Defense Safety Oversight Council. Sorry, too many letters. Some of the things we've done over the past year is, and it may have affected some people in here, is the exception to policy for board examinations in occupational medicine. And he's gone through any of the alternative pathways. Previously could not become privileged in an MTF, or a military treatment facility. That's one of the accomplishments, is we actually got DHA Health Affairs to listen to us. Future, we're gonna work on our scope and our privileges. We have quite a good portfolio of skills that we can do, but we have a narrow scope that we're practicing now. We're working with DHA Health Affairs to expand that. We're also looking at other providers who are not credentialed within occupational medicine, and how we can train them, bring them in, give them tiered privileges, and expand the role of occupational medicine, and help take care of these folks that we see in our clinics every day. We are asking for, but have not been funded yet, a capability assessment, or a CBA. Within this, we're gonna take a look at exactly what it takes to run an occupational medicine clinic. Army had did one in 90s, I believe, and we have some old historic data. And we're gonna re-up that so we can talk to DHA, who runs the program, who feeds us, and give them an idea of what to expect, what you should be asking these clinics to do, and what the output should be. Out of that, we're hoping to get a assessment of what IT needs we will need in the future. We wanna bring public health, bio-environmental, industrial hygiene, safety, and occupational medicine together into one IT system, so we can actually talk back and forth, so we can hopefully eliminate some of the siloing. What else is coming up? These are the current DOD instructions, and memos, and policy letters that we're gonna be working on over the next year for revamping. So expect some of these to be flowing out. And we purposely wanted to end this early so we can have a discussion with the group. We wanted this to be a back and forth. So I would like to open the floor to any questions, thoughts, concerns, comments. Yes, please, go right ahead, yes. Thank you. Hello, can everybody hear me? Yes, ma'am. Outdoor voice. My name's Christina Peterson. I'm a federal supervisory PA at Fort Hood, Texas. I am also an army commander captain on the reserve side. So I have a comment and then a question. Comment, I absolutely love the occupational environmental medicine guides from the Navy. They have been so very helpful. I save those websites, so no offense to the army side, but you guys have amazing guides out there, particularly for what we utilize not only for soldiers but civilians. On my question side, for the individual longitudinal exposure record, is that looking at potentially retrograde, adding things in, obviously our burn pits, exposures, et cetera. So I know that when we implement something, we usually from this moment forward, is there concern and thoughts about adding post-known exposures already? I know we do that a lot in our annual physicals. We're notating the burn pit stuff. We're asking our members to self-register, et cetera. Is that something that we're considering and looking at? Thank you. Yes, and I can give an example of that. Currently, the Air Force does not consider an airframe to be a workplace. We are changing that. Each airframe's gonna be assigned a shop. That shop is gonna get registered into DOORS. So the DOORS Industrial Hygiene Module will record the shop. DMDC, where you get your personnel data, and DEERS, the person itself. So you get DMDC that says where they are, who they are, where they work, all that gets plugged in. Now, we don't have exposure, so what you're talking about, like I say, downrange, battlefield, or even the burn pit right now. We don't know what some of these things are going on. Someone registers they were exposed to a burn pit. DMDC verifies that they were there and that they were a DOD employee. All of this comes together and sits within ILR. Theoretically, theoretically, once an exposure and a nexus get created, it will go into the system, the system will see that X person was there at this location, and retroactively put that exposure criteria, or exposure information retroactively to everyone who is in that location. So theoretically, it's gonna be a very, very good system. I know there'll be a lot of questions, you know, as the system rolls out, so it's, you know, me and my soldiers, kind of where we go and how we can. It is partially live now, and I encourage you to go ahead and register for it and get access to it. Again, they're still building it, it's a work in progress, but you can actually say, if you have a soldier come in, you can plug them in and just see what comes up for them. At some point in time, once it does go live, it'll also go live for the public. So it'll be a non-CAC enabled side that anyone can go into and look up their information. Yes. By the way, thank you very much for the kind comments. You know, we're very proud of the MedMatrix and the Marine Corps Public Health Center, which owns it and operates it, they've done a phenomenal job. Let me get a mic. Yeah, come on up here and talk. Oh, you don't have to, you don't get a mic, but it's just for Jeff. I'm too much. Yeah, like I said, we're very proud of our MedMatrix. I want you to know, I've asked the DHA straight up, and there's actually no movement to take the MedMatrix away, because that's been a fear of ours. It's our Bible, if you will. That being said, we've made concerted efforts to include our Army and Air Force colleagues, because I think what we have is a great tool to be made even better, to hopefully serve Army and Air Force needs as well. And there's a few areas that I personally would like to see updated. Some hobby horses of mine, but I won't belabor all that. But we are trying to make a great thing, and make it even better, so it's available for everyone to use, as long as you have common access card access. Just go to the AmeriCorps Public Health Center, MedMatrix. If you have struggle using it, please call me. I'll walk you through it, but it is very user-friendly. You just plug in the exposures and programs, baseline periodic termination, as applicable. It'll spit out a physical for you. A questionnaire, a physical, and all that in there. So it's a very good product. So if you have never used it, take a chance. Go home, look it up. Google Navy Medical Matrix, or MMO, Medical Matrix Online. It is well worth going through there, taking a look at the pre-populated exam that it creates for you. Yeah, and heaven forbid you look it over, and you're like, oh my God, they made a huge mistake. Like, let us know. Because like I said, we wanna make a great thing even better. I'll just jump in from the Army's perspective. We're not against using the Medical Matrix. But, it's got Navy on it. But, no, well it is. It's a good tool, and it's very effective. I mean, it works very well. In the Army, we have very, very deep connections to our human resources side. The position descriptions are what drive a lot of our surveillance programs. So we have to work around the position descriptions, or incorporate those types of factors into the Medical Matrix to make it work for the Army. From the Office of the Surgeon General, if you remember Dr. Faye Bresler, who just recently retired back in September, God bless her, she's enjoying the retired life. But, she and I had lots of long conversations about how we could use it in the Army. And she and I both agreed. It's not that we couldn't use it, it's just we have to have gateways that are able to accomplish that through our human resources. Because the position description for the Army is what drives our requirements for surveillance and assessment. So, I think VHA, now that they kinda rule the roost, they may, in time, adopt that as a purple solution. So, all service solution to occupational medicine. And when that happens, the powers that be, and under the right advisement, is that the Matrix will be rolled out across all services appropriately. So I think we're heading that direction. As you all can acknowledge, it's a good tool. It just needs to be adjusted and tweaked here and there to make sure it does effectively be applied across all services. So, just wanted to put that out there. Can you put on the to-do agenda, put some Army green on the opening page, splash some Army green on there? We'll make it all green, and then they'll think it's theirs. Okay, perfect. And then they'll be adopted. You can try. Gentlemen, wondering what the thoughts are and what the current plan is for the rollout of DOD 6055.05. Right now, it is a requirement that has not been resourced appropriately. We do not have the resources at my base, I know, to perform the additional exams for, say, the security forces of the EOD. And I know this is a common concern amongst my Air Force occupational medicine providers across many bases. And I'm wondering what, so two questions. One is, what's the plan as it's been laid out for actually being able to implement that? Is it going to be resourced? And then second would be on the NFPA side with the firefighters. I know that was, not to air out our dirty laundry, but it was a little bit of a fiasco when that was rolled out, and then we rolled back the NFPA, and then it came back, and now we're saying it's gonna be gone. So has that been pushed through the Air Force fire chief, and what's the response on that? And what can we tell our fire departments when we get back? So I'll handle the Air Force side, and if any of the other folks wanna bring up your problems with that. So 605505. Could you speak into the mic? Some of us have service-related hearing loss. For our service-related hearing loss folks, please look over here, and I'll have someone transcribe for you. So 605505, the new iteration, has us doing some Leo medicine, and it's a good thing. What it doesn't exactly tell you to do is how to do your exams, and that is good in a way, because every MTF, especially on the Air Force side, is staffed differently. You've got a standard manning document, and this is something that has to be handled outside of the clinic. You're gonna have to go to your EXCOMM meeting. This is a MTF commander type of thing that you're gonna have to solve, and not sit between squadron commanders and argue, well, I'm not giving you this resource, I'm not giving you that, but it has to be done the right way. Don't just go in there, kick the door down, and I want some more people, and I want them now. It's a good way to get it not handed to you, but yes, you need to figure out the pathways. I can't tell you how to do it, because every MTF has made different connections on how to do things. Some use public health texts, some use BOMC texts, some use different texts in different ways to make pathways. So I give you an input, you process it in each MTF's way of doing it, and spit out the appropriate output. If you need more resources in the middle, that is a discussion to have with the MTF commander. Where do you get more stuff if you need more stuff? That comes in a bundle of money that the MTF or the Air Force gets on the first day of the fiscal year, bag three money. Now it's gonna be blurred together with regular DHP or regular benefit funding, and they're gonna have to solve some of these problems. But if you are having a shortfall, you need to signal that up. It is not wrong to say, I can't do this pathway, I need help. If you're starting to miss OSHA exams, you darn well better list why. Communicate it, okay? I know it's not the perfect answer, and there was an SBAR that went out from the public health side to the general Air Force, followed up by a medical-specific SBAR that we wrote to kind of cut through the public health stuff, and that should be at your MAGCOM level and should be going out further from there. Second part, NFPA. Yes, you're right. We're doing it this week. This week we're not. Yes, this week we're doing it. There's a big fiasco on our level as well up top. But according to the new 60-5505, non-bargained entities don't use NFPA. Air Force bargains. Legal's still out on that, whether we'll bring it back or not. But what you don't do is you don't stop doing a contract. If you have a contract in place, the lawyers have to terminate that. The MTF must still do the standard exam that is bargained in until it's told otherwise. Does that make sense? So you're still doing some legal side over here, and I have to do it because I have a contract. Contract comes up for renegotiation. They can't have it. And they have to take that up with bigger Air Force or even the DOD. Has the Fire Chief known about this? Yes. Does he get a say in it? No, he was told, because it's the Department of Defense, Trump's Air Force. So currently, state of the status quo. Status quo, until it comes up time that you're base-wide contract, that's when all the players come to the table and all the different unions come to discuss something. At that time, the lawyers have to take that away. And usually that's handled by Air Force Material Command has the biggest negotiation side of it. And they know that this is out there looming. At right path, yeah. Sir, Lieutenant Commander Wallace from USU. So I think where that resourcing question comes to a problem here is when you start getting into the more joint marketplaces as we see in the capital area, whereas McCain once said, where you have joint responsibility, you have zero accountability because it's hard to have accountability jointly. And one of the problems that we see with this is that the agencies requesting the exams are not the funding agencies. And also there's no universal customer list for any of these chargebacks. So in our area, there's three to four at least different servicing clinics, all of whom seemingly Rochambeau for who will provide the service at any given time. And there's no responsibility for any one clinic to have it except from historical practices. So in that setting, how can we get a uniform customer list and a uniform paying organization so we can cross level these marketplaces? Go ahead. You know, to be honest, I don't have a good answer for you. I think partially because of the stylistic differences between the services. I mean, you heard how Army likes to approach their OCMED. Navy, the default answer is, well, what does the MedMatrix say? Just do that. You know, and Air Force has their approach as well. You know, and then think about all the things that we do like pre-employment exams from other federal agencies. You know, pre-DHA, I remember getting hit over the head from region all the time saying, you need to open up and do these more. And, you know, that's definitely been a challenge with the DHA because sometimes they wanna approach this as more of a traditional clinic and in a lot of ways we're the exact opposite of say like a family practice clinic. So, you know, as Colonel Everson already mentioned, you know, this is where you engage on a local level and trying to explain to administrators. And this is also engaging line leadership, particularly if you were at a shipyard or depot. You know, I, you know, the Navy Surgeon General is a powerful person, but doesn't swing a big of stick as the four star for naval reactors. So if you're at a shipyard and you're saying, hey, this is endangering your ionizing radiation program, well, the four star naval reactors is gonna have their ears perk up real fast. And I'm not trying to say you purposely drag them in, but NAVSEA cares a lot about their programs. They need to keep the shipyards open and running. That is essential line readiness. The Brigadier Generals who run Marine Corps installation commands need to keep their facilities running. So their base environmental, their firefighters, their cops, et cetera. So I urge you when you're out at those installations to be talking to those line leadership to say, in order for me to keep all that going, I need support because they're gonna bark up the chain and frankly have a bigger effect than a hospital commander. Not that the hospital commander doesn't care. I know they do, but they don't have a bigger voice. So have I sufficiently tap danced around your question? Kind of what I expected. I'm gonna add to it real quick. You also have to remember what is happening there. You are trying to get some butt in a seat to do a job, correct? That should be priority number one. You're gonna go and ask for more resources. What do you need in your pocket to ask for resources? You need to be able to show them that you need more resources. Every department screams, I need more bodies. I need more money. That'll solve everything. You're gonna have to have them do their dimmer's eye correctly, showing all these extra things that they're doing. Anytime that you have something come in for a decision that isn't face-to-face, they still need to chart it. They still need to code it. They still need to show their time that they're doing this. So accurate timekeeping, accurate charting, and account of how many of these things flow through. That's what you need to take to the market. You're NCR? So yeah, you've got one market leader for the whole market, and they need to understand this. There's a bunch of people there. Our job is to protect the dash show. If the dash show is unprotected, and we're not doing what we should be doing, that is the true line of where the money's gonna come from. Because it's still the service providing this. DHA doesn't have the MOU, MOA, and the money part of it for the public health product line. But your dash show is the one that you're protecting. You gotta get the workers in the job. So that has to keep going. But the DHA market and the dash show need to know where you're hitting problems, so that they can start talking at a higher level. There's nothing you can do at the market level. Even the market leader can't do anything. To change money, to change funding, to bring more people in, that is a big deal. But you have to show them why you need them and what's failing. Once you have that in hand, that's when you engage these other people. But it doesn't hurt also to talk to them now. Mission's failing, I need help. Well, can I pull resources from X and Y? Because they also have the other things that the benefit side is screaming at them that they must provide this, they must do that. And that's what they're hearing, is who's screaming the loudest, and that's where they're going. Is that, I know that doesn't solve. It seems more of like there's a dichotomy. So using Bethesda as an example, whenever you go joint, especially when there's a large concentration, more than one service, you essentially create three times the overhead for the same function you used to provide. So much less work being done. So you now have that troop support element from the Army. You now have the NMRTC, and then you've got the Air Force equivalent if there happens to be, except for the ICU at Bethesda, any Air Force equivalent. And then you have the hospital director, who is not any sort of command authority, has no title, what do you call it, no UCMJ authority. And so they're not actually a commander. They're a director. And all they care about is running their hospital. And your unit supplies bodies at that hospital. So they view you as a service to provide for that hospital. They don't view you as providing for Carderock. They don't view you as providing for the Navy Yard. They view you as making sure that their hepatitis B screenings are done for the hospital, and the hospital runs, it's like a facility services. So when you bring in those outside entities, they don't see it as that. And that direct connection between the NMRTC CO and the director of the hospital is more direct, where they're supplying you as a body, not seeing those outside guys. And if you do go to the line aspect, having seen that aspect, they're gonna ask where to point and who to send to. So do we turn around and tell them to go to the DHA head, who is on the lateral on the org chart next to the commissary? They're not in the line of it either. They have no reporting authority. So they're gonna go to health affairs, they're gonna go to OSD, so it's the four star blast OSD. The 24 star letter got nothing done. Right. So what is our advice for them when they come and say, I can't get this done? And ask, Doc, who do I need to yell at? Who do I tell them? That's a good question. That's a very good question, because you're running the same thing we're all running. There's a lot of leadership that can't do anything. And I don't have the perfect answer for you, but if you do get that information, that is something that... Because no matter who you get to, they're all gonna want that data, so. And I'll just kind of throw in that all of this is part of the transition challenges to defense health agency. So, everyone has a supervisor in a chain of command to report it up to. So, for us in the Army, we're coordinating through two chains of command. You have an installation support chain of command, and you have the Army medicine medical support chain of command. At some point, those will eventually come up and then cross over and hit. You've got to, you have a significant requirement to meet, to be met, and you don't have the services to be able to meet that requirement. So, at some point, and it does hit flag officer visibility, that comes across, and that's when the lightning strikes. So, what we're doing in the Army is we're raising up those signals to our Army medicine senior leaders, and then they're walking it down the hall to defense health agency senior leaders to make these things kind of connect for coordinating efforts. So, you're, where the rubber meets the road, we're, you know, we have folks that are experiencing these shortcomings that needs to be brought up the chain. And it's, unfortunately, it's the market structure for what DHA exists as currently. It just can, you just have to continue to beat that drum. And then we're trying to beat the drum over from the policy side to meet you halfway across at the senior leadership level so that priorities can be made to effectively get these, get these functions in place and appropriately funded. So, we're going to have a lot of challenges still as DHA continues to roll, you know, in existence. But you're bringing up a very good question, and it's a question we see at the policy strategic level, and we're all trying to work to figure out what the, you know, solution is. And unfortunately, it's still in progress. So. Thank you. Yeah. Thanks. Yeah. I can see Max's hands get sweaty when I grab a microphone, but. So, I just want to talk real, real quickly about recruitment. Okay. So, I think part of what keeps the Navy ahead of the services on this as far as applicants is we're still under the legacy construct of GMOs. You alluded to that. That will eventually end. One of the things I'm interested in is, is there a mechanism that we can start thinking about that's going to put medical students at work with me for a day, right? Because if you give me three or four med students for a month a year, I'll give you three or four applicants, 100%. We can do that. There's a bunch of people in this room that I've recruited doing that when they were GMOs. So, I guess the argument is how do we streamline the capability to take guys that are in operational jobs, give them whatever level of professorship we need at UCIS, right, and then reach out and make elective capability. And people will say you can't do it. You can do it. I've had residents approved to come to the command I was at. We lost one due to COVID, so it fell through. But, like, it can be done. The other thing is to look at the way we do mid-shipment on a summer cruise, right? We bring those guys out to operational units as Naval Academy students. We should be doing that with people on scholarships in medical schools. It's something to consider. I think we could crush that because we really do well in the operational community. You'd be hard-pressed to find better recruiters. We just need to get our hands on the students. So, just food for thought. Yeah, I completely agree. The GMO pipeline in the Navy I don't think is going to completely go away. So, I think there will be people who recognize, hey, Occ Med's a great field. And I had time to kind of discover it. I personally don't have a great answer for how we better get into medical schools. I know for uniformed services, there's, what's it called? A specialty night or specialty day. And, you know, they actively try and recruit and get in front of medical students. So, that might be a pretty good community. But, for example, my medical school back in Ohio, I called back saying, hey, you have, they don't have a residency but they have an MPH program. And I said, hey, I have an MPH, career in public health. I'd like to think I'm reasonably successful. I'd really love to come and talk to the students about public health. And the answer was, well, you know, we just went through the pandemic. So, they've already had quite a bit of exposure to public health. And, you know, I just wanted to slam my head against the wall because like, no, not really. But. I just think, so part of it is a lot of it becomes, I don't want to monopolize. I'll make one comment and I'll stop it. You know, when kids think public health in med school, they think biostatistics course and it's miserable, right? And they're all geared toward, I did a rotation. I was that guy, right? I was an ortho guy. That was all I was. If I didn't do orthopedics at med school, I was going to quit. Right? Like, that was the only thing I wanted to do. And then I got to be a GMO with the Marines. And I got that experience. So, the point is, I don't think doing a career day talk, I can show you a thousand cool picture slides that I've done. But it's not the same as coming to work with me for two weeks on an elective. So, I think if we can create the space for that, that changes the dynamic. Because until we can show people that this isn't just an exercise in the mathematics part of medical school that you skipped because it's not heavy on the boards, like, that's, we need to find a way to do that. I agree. I think both at the individual level and at the, you know, organization, ACOM slash DJ, BUMED, OTSG level. On the civilian side or residency side, we may have made one small accomplishment, is the National Registry Match Program will now list us on their website. We are now our own thing. We're no longer other. So, you will see occupational medicine. Previously, we were other, and people had to go to other down and keep looking for it. We are now on the National Registry Match Program. Just real quick, and I'll add on the Army side, our GME, individual in charge of GME is actually working to get occupational medicine dialogued across HPSP scholarship recipients. And it's somewhat being successful. We'll see what happens after the summer, because we do have three medical students that are rotating in the NCR with us in July and August, and I think one in October. So, there is some information that's getting out to medical students. In case you don't know, HPSP relies heavily on social media. So, you can skillfully, carefully take a look at what's out there on social media and Facebook, and maybe potentially engage in that venue cautiously. And I throw that out there very cautiously, because the social media realm is extremely vast. So, I think we can leverage that to some degree, because there are medical students that don't have a clue that occupational environmental medicine exists, and we have to kind of tap into that and kind of feed that little bit of curiosity. I tell medical students, in occupational medicine, you can do a lot of things that you want to do. If you like dermatology, you can do occupational-related dermatological illnesses. Lungs, heart, bones, skin, muscles, musculoskeletal. There's a lot of stuff you can do in occupational medicine that you wouldn't be able to do in other specialties. So, we have to be those points of entry to medical students, get into the HPSP programs. They're hungry for information. HPSP students struggle for basic information from the services about essential things, like how do I do ADT? You know, how do I do that 45-day of extra training and get to a hospital? You know, there's a lot of, they're very information-hungry. I'll just say that. And I think if we start kind of pollinating those venues for education, then we're going to start making efforts into getting it out there. So, but anyway. Go ahead, sir. Hi. I'm Dr. Michael Caldwell. I am from Meharry Medical College in Nashville, Tennessee. A 150-year-old, historically black school. The only HBCU occupational medicine residency. So, please, to my colleague there, call me, Michael Caldwell, 914-474-4034. Look me up on the app right now. We have 110 medical students per year. We have both a PreventMed and OccMed program. We just announced we are creating the first historically black school of global public health. We have everything that you want to partner with. So, we look forward to being here with you. Thank you. And also, poster 506, dry January, USA. Alcohol awareness, please. We know it is a problem throughout all of our armed forces and the civilians. We'd appreciate your support of that, as well. Appreciate it. Just real quick, do you know how many HBSP scholarship students you have? No. But you reach out to me and we have a lot of interest in working with you. Thank you. Yeah, thank you. And remember, our residents come with funding. I, I, didn't cross my mind. No, I didn't. I just also want to be an advocate for APPs. So, I think sometimes in, in a lot across the specialties, we forget a little bit about our PAs and nurse practitioners that are filling a lot of your gaps. So, as someone who went through the military IPAP program with my fellow colleagues, you know, I know that we're out there in the field and we also don't always advocate for occupational environmental medicine because we forget that all military providers are occupational and environmental medicine providers. So, we as PAs also need to advocate, but I think I need to plug in that all of our physicians and residents, et cetera, also need to be raising up their APPs to say, hey, have you thought about AHK Health? Bringing them over to the team, either on the civilian side, but also on the military side. I know as military providers, we are teams, right? The Army's really, really great about utilizing PAs. So, I just wanted to plug that in. PAs and nurse practitioners do a lot of work for our field as well. Absolutely. Absolutely. Can I put a reply in for that one? Because I think you are absolutely right. And we've also, on the military side and the Navy side, the Army calls it some difference. Air Force, it's IDMT's. Navy's, it's IDC's. I don't know what the Army equivalent is, 68-somethings. Yeah, whatever. It doesn't matter, yeah. But the thing I've learned from that is it comes down to a manpower issue and nobody wants to increase the top size of the military. We will waste the money and say it's cost savings to not order a new body to put it off on the civilian side. For a long time, I was trying to argue in a distributed maritime operation environment that we're never going to get all the docs we want, PAs or NPs, and that the IDC's, when we get them, as soon as they make IDC, they're up for cheap and we start losing them clinically. And we wanted to try and retain those. So, the Navy doesn't have an extensive warrant officer program going. I've made a pitch for years to convert IDC's to warrants to keep them clinically relevant on the smaller boys where we need them. But where it eventually loses out is that they want to keep those officer billets and manning from somewhere else. So, for me to even bring you on, I got, they ask me, well what doctors can I cut to get those IDC's as warrants? They want us to source it out of hide. So, it doesn't matter if I can get the PA or NP. If I can't increase the top line manning, I run into the same zero sum game. And I've seen that from inside the Pentagon and it's ridiculous. Yeah, I can just say really quickly, you know, we've been trying to expand the scope of AACMED. So, for example, this year we plan on sending somebody to NAMU Dayton to support, you know, aerospace research because I think it's an important component. We don't have a lot of research per se in Navy AACMED. I'd like to plus that up, make it a pipeline for our residents. You know, and I think it's just, I'm pro aerospace. I have my wings. So, I think it's an important thing to support. We also, next summer 24, we'll be filling a billet that's finally come to us at the PEB personnel evaluation board at the Navy Yard. And that's going to be important to fill because, frankly, we need to be more involved in LIMDU, medical boards, et cetera. I mean, that's what we do. And the Navy has kind of turned a blind eye to us. So, we kind of have to kick the door in. Commander Robbie Niskevich. Max, I know we talked about this briefly before. And first, I completely agree with Mike in terms of what we need to do for our medical students. Mine's also a recruitment statement. I think we oftentimes advertise our specialty in the military, not just in the military, but as a college in general. We usually lead with the things like best work-life satisfaction. Great hours, you know. No call, no weekends, that kind of stuff, which is great. Those are benefits to some positions. But I don't know about everyone else in the room, but during COVID, I was working a lot of hours. I didn't see a lot of the family. I think if we put more emphasis on the subject matter expertise it takes to do our specialty, where we find our uniqueness in terms of the way we can be consultants, particularly to the line for the military side, and the impact that we can have towards readiness, and why we need smart, intelligent, hardworking people to come into this field. You know, people go to medical school because they're motivated. And so, I think if we lead with the easy stuff, it almost undermines the hard work that everybody's doing with very short staffing. And so, I think if we focus more on what it takes to be a really good occupational medicine physician or environmental medicine physician, I think that might be more appealing to the right caliber of medical student that we want to attract to the specialty. Just my thoughts. Rob, I think that's very well spoken. And, you know, we were literally just talking about it earlier today. So, kind of off the cuff, you know, maybe a way to sell it is, you know, we're public health physicians. We have the ability to impact dozens, hundreds, hundreds of thousands of people. I mean, Scott and Ben at OTSG, you know, if they're affecting policy, that's hundreds of thousands of people. If you're at Bumed, hundreds of thousands of people could be affected by your policy. And that's an enormous power and responsibility. And maybe that's a better lead in to, hey, you want to help people be healthy, prevent injury, look at the impact you can have as an occupant doctor. So, you're generating your own line of communication to these young physicians. And you're right, it's a lot of young medical students, they want to be challenged, right? That's why we went to medical school. We want to be challenged. We're not looking for, I don't want to say we're not looking for an easy road, but we want to be challenged. Young student physicians that are preparing for internship and residency are looking for challenges. And this can be a specialty that can challenge them. So, we need to spin it that way. And at OTSG, we have residents that rotate through our service, and we challenge them. We challenge them to understand policy, to link policy with Army to DHA, where are the gaps? We challenge them. And hopefully, you don't make, I'm not lying to you, some of our residents are actually here in the room. They can tell you they have actively kind of seen the challenges that we present to them. So, we need to challenge medical students, challenge our residents, and maintain relevance, really. Hi, I'm Curtis Cummings, retired Navy Captain. And you guys don't need our help, but a couple of us old guys back there, older than any of these folks, were just agreeing. I didn't want weekends off and easy this and easy that. I wanted plenty in public health. As a Navy OCDOC, I actually got a much broader experience than I ever expected, including tropical med research. The word really needs to be spread, and I'm still saying so. And I don't need any acknowledgment, just we all, you know, we're all shipmates. Please carry on. We stand on the shoulders of giants like you, sir. Thanks. All right, so I want to remind everyone that we are here to help. Send us a line and email, you know. Can you, Colonel McDonald, can you stand up, please, sir? I'd like to introduce you to the Army Consultant for Occupational Environmental Medicine, taking. So he, let me just get us to where we are. Lieutenant Colonel MacDonald is the Occupational Medicine Staff Physician in the Office of the Surgeon General. So he actually took my old job, and I'm currently the Chief of Preventive Medicine for the Public Health Directorate. I'm, I cross streams, but I'm the consultant and communicate with the Surgeon General. Jason works directly with the policy pieces that flow across BUMED and USAF SAM and other Army entities. So we're very blended at OTSG MedCom. But we're all here to help. And actually, Jason is on the DOD Occupational Medicine. Working group. Working group. So, yeah. Do you need clinical and policy questions either to help? Yeah. If you're Army, that is. Just really quick kind of reminder. My terrible bloody reign is almost over as Specialty Leader. So if you think you want to apply for Navy Specialty Leader, accepting applications, send it to the Corps Chief's Office and myself. I believe 28th of April is the cutoff. If you have questions about it, please let me know. Also, I don't ever want to paint the picture of doom and gloom. Joe, I see you. Get to you in one second. We have some challenges ahead for sure. But I have the utmost faith in the long-term future of both military and especially Navy Occupational Medicine. Why? That is the people in this room, civilian and uniformed, who do an amazing job. And I've seen the qualifications of people coming out of residency, applying to residency. And all I can say is thank God I'm not trying to apply to residency because I wouldn't get in. So I think the future is bright. We just got to get through some heavy roles. Colonel? I just want to remind everybody about the social tomorrow. It's a combination of Metro Washington, D.C. components and the Fed Med section. So it's at the McGillans Old Hill Pub. It's about two to three blocks down the street. It's a combined social. So everything's paid for. About the first 72 people, I think that's what our budgets will allow. So even if you didn't show, if you didn't already reserve RSVP, just show up, please. I mean, it's, again, I think it's an opportunity to network and socialize between Fed, Mill, and really anybody who's interested in what we do in the DoD and also the federal sector. Afterwards, are we going to head over to the original location of Tun Tavern and celebrate the Marines? Sure. Okay. But it's, again, McGillans Old Hill Club. It's the oldest continuously serving pub, I think, in Philadelphia. So, again, tomorrow at 6.30, please show up. Everyone touch the pump handle. No, but still, I have one more question for you, too. This is for Colonel Everson. Can you just speak really quickly to the 16 down to 6 by 2028? Is it still an attrition plan for occupational environmental medicine physicians going from 16 down to 6? So, that is part of the core reduction. That is part of the 2017 NDAA. It is still, yes. Well, it went from 16 to 6 in 26. So, 16 to 6 in 28. Yes. So, it's all the specialties are taking a cut. The Air Force has chosen to go ahead and start downsizing by attrition. But this is not official policy. But what we are going to be doing, if we stay on the current trajectory, is we will only be able to fill depots and a couple of spaces. And so, but we'll still have the same recruiting pipeline bringing people in. I have not. Every time I'm asked, because it's a different person or a different office that gives me the pipeline question. So, I've kept the pipeline open as much as I can while the other side is trying to do attrition. Got it. Thanks, sir. But, yes, that is their goal. It's called core. And they want to reduce the forces because those numbers, again, everyone in here in the military, you have so many active duty billets. They're just playing shuffling game with the billets and pushing it back to the line. And they're taking it out of the Med Corps right now. Well, Colonel Everson was right. Air Force depots, thank you very much. You do take care of the finest aircraft in the world because Navy and Marine Corps aircraft also go through there. All, yes, all aircraft engines will go through an Air Force depot. So, all right, everybody, have a great evening. Thanks for coming out.

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