Neuskabich, Neuskabich, Neuskabich, that's a tough name to pronounce, but I apologize for that. But I practiced it earlier and completely forgot how to pronounce it. But I'm also joined by Lieutenant Colonel Hiram Bronson from the Air Force. And they're gonna talk about their experiences and their roles when they come up and talk their individual pieces. So initially what we're gonna do is just give a little bit of an overview what the Department of Defense looks like for Army, Navy, and Air Force all together. And then we'll break out into our individual reports and then we'll wrap it up, give opportunities at the end for questions. So I'll ask that you hold your questions to the end just so we can maximize time in presentation and in question and answer sessions. Again, our disclosures, as you may know, that we're military and we have nothing to disclose because we work for the military. All right, our workforce, this actually is a slide that's been reproduced from last year. It's difficult to come up with accurate numbers that represent the force strength across all the services. So again, just a reminder of what the force strength looks like. Active duty, we're at about 1.36 million uniformed individuals. And Compost 2 and 3 National Guard and Reserves are around 800, 826,000 or so. We have a large population of DOD civilians, somewhere around 730,000. We see, thanks. Oh, good. Now I can really hear my echo. But across the DOD civilian workforce, which is about 730,000, there's quite a few occupations that we as uniformed and non-uniformed providers ensure the proper surveillance activities and safe conduct of their workplaces and their jobs are not harming them. You can imagine that it's a tall challenge. Lots of skill sets, including engineers and scientists. We have technicians, we have mechanics, lots of folks working in different types of materials, whether it's tangible or intangible, that cause us to have surveillance activities to ensure their safety in their workplace. The civilian workforce by size, and these again are appropriated funds, meaning that they are employed by the Department of Defense. They're not hired as non-appropriated funds, which they have to generate their own funds for their pay. But the appropriated fund population is, as you see there, the Army has quite a few at 265,000, Navy and Marine Corps is around 227, Air Force has 185,000, and Secretary of Defense actually has a population about 113,000. I would tell you that those numbers have dramatically changed in the last year or two because of the standup of the Defense Health Agency and the congressional mandate for us to transition the majority of our, actually all of our civilian provider force over to the Defense Health Agency. So those numbers are wildly inaccurate at this moment because DHA has assumed authority, direction, and control of the military medical mission, and with that, the population of providers. We'll just move on to the next slide. Just globally, you're probably very much well aware, and especially if you work in the environment of the Department of Defense, Occupational Environmental Medicine, we're global. We have clinics all over the world, and some of them have considerations like SOFA agreements and other types of host nation considerations to ensure that not only are our DOD United States civilians that work there are functioning in a safe place, but the host nation support that the host nation provides is operating in a safe environment, but also recognizing that there are programs that the host nations in many locations provide in order to ensure the safe work conditions of their employees. Again, just a few bullets there. We cooperate with other governmental agencies, and we really, I think in occupational medicine, we really don't have a lot of boundaries that allow us to coordinate and share information as long as it's secure and not secret, but we really do work with other agencies across the DOD and across U.S. government to share best practices and ensure that our clinics are functioning optimally. And again, this is a repeat slide from previous years just to show that we do have commonalities with other occupational medicine programs out there in that it's a constantly evolving system. We are integrated with our industrial hygienists and our occupational health nurses to ensure the safe operation and the constant updating of any types of surveillance activities due to new or change in materials that we're working with. So, I apologize for the small text there, but just understand that we are very much similar to other programs that are constantly evolving and adapting to the threats that are out there in the occupational environment. And with that, I'm gonna move on to the Army update. And again, Colonel Ben Palmer, work at the Army Office of the Surgeon General. I'm currently the Director of Public Health for U.S. Army Medical Command and the Army Office of the Surgeon General, but I also wear the hat as the Occupational Environmental Health Consultant, directly advising Army medicine senior leaders on all things occupational health. Uniformed personnel, again, just talking some numbers, we're approximately around 460,000 individual active duty personnel. And again, that's a mixture of officers and enlisted and warrant officers and cadets. So, through the entire spectrum of duty, of service members in the Army, you can see there that we have quite a few, just a little shy of a half a million people. The National Guard for the Army is about 323,000 and the Reserves is a little smaller at 175,000. And I would note here that something that has come up in the last few months as I've gone to the Consultant Symposium for the Army is about half of the Army's medical support structure is in the Reserves. So, the active force actually has a very tall order as it manages the majority of the active duty population and the civilian population, but about 50% of all medical forces reside in the Reserve component. And what we look like across the world as far as the medical command structure, we're divided across four medical readiness commands, each commanded by a one-star general officer. And the majority of those locations, the one-star general officer is also dual-hatted as a network director for the Defense Health Agency. So, they're very, very much employed and maybe stressed to their capacity to function in both areas to support Army Medical Command as well as the Defense Health Agency. You can see there, the little blips there, how many hospitals and clinics we have across the country and you can see also across Europe and the Pacific Rim. We have providers in all those locations and those locations vary in their mission sets, whether it's bread-and-butter occupational medicine supporting industrial bases or it could be an Occupational Environmental Medicine Clinic and an MTF that supports the hospital as well as installation employment activities. In the next slide, again, this is a bread-and-butter slide of what our technical Army depot and industrial base looks like. In those locations, it's a variety of occupational medicine ranging from surety medicine, which ensures that employees are in the right state of existence to handle materials and handle information. It's very much like anyone that works at USAMRID or works with biomedical or biohazards or nuclear materials that they have oversight medically to ensure that any changes in medicine or any changes in their physical condition doesn't result in their inability to handle the material or to do their job. So again, a lot of variety out there in the depots, Tobyhanna in Pennsylvania and Letterkenny, lots of material handling out there, lots of industrial processes of welding and handling materials that are potentially hazardous to an individual employee. As far as the uniformed physicians, we have about 34 uniformed physicians that are in practice today across the force and then augmenting them are about 35 civilian occupational medicine physicians. So in total, around 70 physicians are in the workforce for the Army that are scattered across these hospitals and depots to cover down on the mission. We have one rising third year resident and unfortunately, we didn't have any selects for the residency to start next year. That again, feeds a challenge of the Army's educating the medical students and general medical officers that are out there in the force. What we have done to try to offset this is we have pre-selects that the Army has agreed to put out there for medical students that'll be pre-selected to an internship that will then immediately transition to a PGY-2 status in our program. And that we hope will give visibility to medical students because they'll say, hey, what is this program other than waiting for somebody to try to spoon feed it to them. But anyway, it's a challenge and that's probably our biggest challenge is recruiting into our residency program. And we hope to try to turn that around soon. We're losing about six military personnel due to training or to retirements or other resignations. And ultimately what that means is we have a net loss of about zero because some of those physicians that are retiring are senior officers that have been holding positions that are not specific to occupational medicine. We have six individuals that are transitioning this summer and some will be moving to just different clinics within the structure. But we'll continue to do outstanding service for the Army. Just in general, we have about 34 positions that we try to fill at any one given time. And you can figure about a quarter to a third of those positions transition every year. And then again, we transition about every three years or so. As I mentioned, recruitment and retention is one of our biggest challenges. And civilian hiring is, again, one of our biggest challenges. And I think even the last day or so, I've had and my colleagues have had conversations with some of you about what you're seeing in your clinics about how difficult it is to hire a civilian provider into these positions. There's a lot of hiring actions that are open and they just unfortunately take a very long time. I do want to note here that Fort Novosell Residency in Aerospace Medicine, they have a sequential program that produces Occupational Medicine residents or physicians as well. And I would say that we have a very good relationship between the core Occupational Medicine Residency at Uniformed Services University and the Fort Novosell program. As we generate pure Occupational Medicine residents right out the bat, the Novosell program is generating Aerospace Medicine residents that fill key critical combat aviation brigade and like positions in the tactical and operational sense. But then as they kind of develop into senior Occ Med physicians, they come over and assume some of our positions in the strategic level that Occ Med physicians usually fill. So we have a great relationship with that community now. It's always been good and I think we just always make it better. And I'll kind of jump through any requirements and competencies. We have our own internal skill sets called the Individual Critical Tasks that Brigadier General Murray, who's the Medical Corps Chief, is ensuring that we make sure that we maintain as individuals to ensure competency across our skill sets. I'll just jump on over to my last slide. The concerns that we have, the relevance for Occupational Environmental Medicine just continue to exist every day. And obviously the relationship that we have between our uniformed providers and our civilian ununiformed providers is very critical and hopefully is seamless wherever you may see them be. Unfortunately, through the preventive medicine specialties, Occ Med and Prev Med, we're seeing a decline in our population. So it means it's a challenge for us to fill assignments that are out there. In many places, we are only one deep, depending on what the location is. Other challenge that we have, you may have gone to the PFAS talk that was prior to this discussion. You know, we're testing firefighters across the Department of Defense for PFAS in their blood. That's been going on for a few years now. That's an ongoing program that continues to evolve. And I would just note here, the final comment here is that blast overpressure and biosurveillance are two topics that are very, very much front and center of Congress's mind. And they directly communicate through the Office of the Secretary of Defense to the services about blast overpressure and blast injuries that occur in soldiers and sailors and Marines and airmen that are just out there doing normal range activities. So we're very, very much involved with that effort across the Department of Defense to help mitigate and identify blast overpressure and explosives. And with that, I'll pass it over to Rob, who's going to give you an overview on the Navy OCMED. So thank you very much. Thank you, Colonel Palmer. Good morning, everybody. I'm Captain Rob Unaskevich. I'm the Special Leader for Occupational Medicine for the Navy. We're not consultants. We're special. We're in the Navy, so I'm Specialty Leader, a little different. I'm currently stationed at NORAD US NORTHCOM in Colorado Springs, Colorado. You're saying, what is a Navy guy doing in Colorado Springs? I don't know. I'm actually filling a preventive medicine billet. I miss the water tremendously. The mountains are beautiful. And I track Santa Claus every December. So if your kids wanna know where he is, I'll be able to find him for you. Now, I wanna give you an update here on where we are from Navy OEM perspective. So obviously we focus on occupational health care to our civilian workforce and our shore-based active duty folks. We also do quite a bit of environmental medicine consultation. I personally have worked very closely with the Force Health Protection Center, now it's called, to do risk communication around the world for various environmental boo-boos that have come up from all kinds of sources. So to include Red Hill water contamination fuel to Camp Lejeune, I've been to Singapore. We've dealt with PFAS, PFOA, and in Virginia Beach. And so we have a lot of experience with trying to explain in a form similar to this, adverse health effects for potential exposures, and then a way forward. So risk communication is a large part of what I've done in my career, and still remains an opportunity for a lot of folks who are wearing the uniform to do that kind of work in the future. And I'm happy to talk about those at a later date. We're responsible, obviously, for surveillance, certification, and prevention of those injuries and illnesses in the workforce, not just clinical services. We get out there, we do our worksite visits, we sit in on supervisor meetings, safety meetings, much like the other services. This is a challenge, and I'll speak to this in a little bit for us, because as we get compared to other clinical specialties in terms of what our productivity is, it's often very difficult to try to explain to other folks our relevance, our necessity to be at those tables and at those meetings, and how come we're not just churning patients. I know everyone in this room probably has had that kind of conversation with somebody along the way. We are still having those fights. So I want to highlight our bread and butter, our naval shipyards. We have weapons stations, we work in the MTS, but our naval shipyards are bread and butter occupational health that we do for the Navy. Norfolk Naval Shipyard, our oldest shipyard. It is, we service, the clinic there services about 10,500 civilian workers, not including the tenant commands like CNIC, NAVFAC, security forces, that sort of thing. There they maintain and modernize ships and subs for the Atlantic Fleet. Pearl Harbor, located in Oahu, maintains Pacific Fleet ships and submarines, and that clinic takes care of about 6,000 employees. Portsmouth Naval Shipyard up in Kittery, Maine, maintains nuclear submarines. It was an OSHA VPP site since 2005, and they have about 8,500 employees that they care for there. In Puget Sound up in Bremerton, largest shipyards, about 16,000 employees that they're responsible for at the clinic. They decommission nuclear submarines. They also do maintenance and upgrades for the Pacific Fleet. So Navy OEM manning is part of my job as specialty leader is help manage the manning with the detailer and also working with DHA and BUMED to make sure that those critical spots are filled so that we're meeting the mission and we're supporting the operational units as we're tasked to do. So part of that involves civilian providers and our OHNs. Real push to try to hire more civilians, GS employees as we talked about. If we can, the problem is the hiring process is, I'm sure most people in this room know, is not an easy or short process at all. Trying to incentivize those positions, we lose out a lot, competition, quite frankly, to the civilian sector. So trying to find other ways to incentivize people to take critical positions that we have. Sometimes it's very difficult and, you know, a lot of our Navy positions are in very pretty places, San Diego, Bremerton, Washington, Kittery, Maine, but some are in more challenging locations that require more incentivization to get people to go to those locations, both that wear the uniform and don't wear the uniform. And so that's part of the process that we work through, too. We have about 36, 37 active duty OEM physicians at any given time. We have 10 residents currently in the PGY-2 in three years, including full-time out-service individuals, and we'll have four incoming residents to the Uniformed Services University to start this July. We still are expecting about two to four departures, so it'll be a push by the end of this year. That being said, I'm working with BUMED currently and also with DHA to try to get additional billets or reallocated billets from other specialties that may have been gapped for prolonged periods of time to fill more critical fill areas. For example, Norfolk Naval Shipyard, we're looking to try to get a billet there, trying to expand our operational presence and support of the fleet. That is a challenge, it's a tug of war. Some years ago, as everyone may already know, there were a lot of cuts, preliminary cuts made to the Medical Corps, and we are reaping back some of those. I think they realize we've overcut, but now it's kind of a free-for-all for where those billets are gonna land. And so part of my job working with the folks at BUMED and with DHA is to make sure that we account and we don't miss an opportunity to open up new spots where right now, either due to civilian physician shortages or because of increased workload to support the fleet, that we are able to have a presence there. There's approximately 10 to 12 of our individuals, our physicians, are cross-boarded, so we also share slash steal from preventive medicine, aerospace medicine, we're very interchangeable with those specialties and we work very closely with their specialty leaders as well. I'm a good example. I'm in a PrevMed bill currently in Colorado Springs. So we do that as an interchange program. I do think personally that that's a benefit for our community because it opens up our experience and we get to see how other specialties operate. We get to see jobs that we wouldn't necessarily see ordinarily if we just stay to our within our own specialty. That being said, it's my job to make sure that our specialty, our critical specialty bills are filled when the time of need comes. Obviously, we recruit heavily from the operational medical officers, GMOs, flight surgeons, UMOs, that community. That's where we get a bulk of our residents. We are working towards expanding our pipelines for training as Colonel Palmer mentioned. We want to, we're also getting a pre-select from UCIS for the start of next academic year, not the one upcoming. And that's important, right? One of the big things for the longest time is do OEM. It's great hours, right? It's got no call. It's great lifestyle. And that's all well and good. It depends on your job, I would expect. I didn't always have the same, especially during COVID, the same luxury of saying I wasn't working long hours, that's for sure. But it's a very satisfactory field. You know, it's very satisfying, professionally satisfying field as you all know in this room. I don't have to convince you guys. But I think recruiting for the specialty is all of our efforts, right? I think we want to recruit the best and brightest. I think we need to focus our energies at UCIS, at the medical schools where people are ambitious and want to make a change. They want to have a significant impact to what we're doing in the public health sector. We got to strike when the iron is hot. We just went through a pandemic and there's still a lot of focus on public health. We have a lot of value. Installation commanders listen to us if we put ourselves in those rooms. And so I think that's important for us to keep doing, keep pushing. This is not just where you go to take it easy after another residency. Perhaps you bring those skills from that other residency to enhance what we do here as a skill set. And I think that's what we need to do. That's the direction we need to go to really promote what we do as a specialty. So I asked our good regional occupational health nurses to help me with the clinical manning data for where we are. As you can see, from an active duty physician standpoint, we are pretty well filling those positions, plus or minus one or two. And like I said, we want to grow those important positions, have a few extra so that we can really focus our efforts on supporting the fleet. Civilian physicians, we're about 44 percent vacant. That's a real problem for us. Same with our civilian OHNs and OHTs. About a quarter of those are vacant. And so there's a real push to say, hey, how do we recruit to those positions as I alluded to earlier? One of the things, I'm working with BU Med and DHA to, how do we fill these gaps? How do we meet the demand? Well, one of the options is to, like a lot of our partners in civilian world, is change some of those AHRQ health boarded physician billets, civilians, and focus more on mid-levels, nurse practitioners, PAs, having broaden our ability to recruit and then having the uniformed, trained OEM physician work as more of a clinic lead so that they can see it's more challenging cases, they can oversee the clinical work that's going on as a whole within their clinic, and then they can be that interaction between the line and the operational unit that we're supporting, help improve that communication. So there's a real push and a recommendation to DHA to focus their efforts on trying to realign what some of those billets look like. Major, who here is from DHA? You can go raise your hands. It's all right. We're not going to attack. It's not DHA bashing. Not DHA bashing. The truth is, if you wear the uniform and you work in public health, we're all DHA. And for the longest time, you know, services, mine is one, I'll put it out there, we really dug our heels in and said we're not going to do this. Well, it's here. We are all defense health agencies. We are a combat support agency. Now, being at NORTHCOM, now that's really important to me just in what I do. I know it's important to our four star. Combat support agency is an important thing to really show our support to the fleet. Now, what we need to do, what I need to do, is really work with the DHA leadership to explain why they need occupational health and why now that it's under DHA and not aligned with the services, what makes us special, right? What makes us unique and what makes us a vital asset for the warfighter and for the operational units that we support and why DHA needs to be interested in that. We're only going to do that if we work together, not oppose one another. It's a challenge, as we've all talked about. Trying to align the three services in an occupational health environment is not without its challenges. Sometimes it feels like putting a square peg in a round hole, but we're going to get there. I think the more people we have who are passionate and involved in those conversations, the better the product will look like at the end of the day. It's not going away and we definitely need to embrace it and see how to make it our own. We can kind of steer the ship, so to speak. Sorry for the Navy metaphor, but we need to take ownership of that and really do that. Recruiting is another big thing, like we talked about alternate pipelines for training opportunities. We have three applicants for a single spot available at USIS from the Navy's perspective. That's good. We want to be competitive. We want to select the cream of the crop who's coming through our specialty. We want people who are serious about this kind of work and are going to do the best going forward. We have to keep showing our value and we can only do that with good, strong people. Civilian manning, as I talked about, and then, like I already mentioned, challenges with DHA and policy. The other problem with DHA and policy, I'll just say, since they own a lot of the bodies and the hiring actions, it does become a challenge, I'll speak for the Navy, but it's really across the services, in what we can control and how much of a gap we're able to fill for DHA sometimes when they have unmanned positions and they're not hiring civilians at the rate that we need them to. A lot of that then ends up falling to us and finding, I know a number of people wearing the uniform in the room have filled in at various locations, TDY as a stop gap. I don't see that going away immediately because the hiring fixes don't happen overnight, but that's where we kind of have to carry the water, so to speak, and work together with DHA. I, as a specials leader, I'm trying to, for those of you that work at various commands at the tactical level, I'm trying to push formal processes for requests for support. If you're in a location where you're gapped and you're having trouble meeting the mission, reach out to me. We're going to work with the regions and we're going to make sure that it gets codified. You know, the drug deals, so to speak, being able to help behind the scenes, that's all well and good, but if we're not able to capture in an objective way the kind of support and where the demands really are, then it makes it really challenging when we're sitting at the board or for our partners at BUMED talking with Admiral Vai to say, look, we need more positions, we need more spots, we need more training spots. Here's why. We're not meeting the mission at various shipyards, like I mentioned, or other locations around the globe. Here are our activity OEM billets. As you can see, we're scattered across 11 states, also Europe and Asia, as well as Guam or Asia. We have the luxury of having some beautiful locations. Some places are with their challenges, isolation, and so we have to, we work closely as a tight-knit community to be able to help one another out, especially those in far-off locations. I will say that almost without exception, people who get sent to these far-off place lands, almost without exception, come back with nothing wonderful to say about their experiences. It's really been a highlight of their career, whether it's because they've been there on their own and they had to figure out problems for themselves, or even though being far away from home, they got to experience another culture, and so we try to harness that as much as we can as a recruiting tool as well. I think that's my last slide. I'll pass it over to Lieutenant Colonel Bronson, and it'll be available for questions at the end. Okay, good morning everybody. I'm Lieutenant Colonel Hiram Bronson. I want to thank both of my counterparts here for the words that they've shared, and a lot of the similar challenges that we're facing is what they have already talked about, so that shortens my part up a little bit, but I wanted to give you an overview of where we're at with the Air Force Occupational Medicine program. A little bit about me. I'm stationed at Warner Robins Air Force Base. I'm an occupational medicine physician there at the Air Logistics Complex. I'm in the process of going up to Wright-Patterson to be the deputy consultant up there. That spot actually is kind of a field consultant, because we only have a few occupational medicine physicians throughout the Air Force, but I guess you could say our main force are all the flight surgeons that are stationed around the world, and when they have occupational medicine questions, they reach back to Wright-Patterson Air Force Base to get that additional aid and help as they haven't had any real experience or exposure doc met, and then they're doing all the shop visits and the evaluations and all the exams, and they're like, I've never heard of cadmium. What's cadmium? So there's a lot of instruction, a lot of help that goes along with that. I do want to excuse Colonel Everson. He is our consultant. He's out on some sick leave right now, so we miss him here today, and I'll do my best to cover for him. So we do have... I just wanted to run over our three main depot sites that is kind of our gem for occupational medicine. Our largest one is at Tinker Air Force Base. You can see by the numbers there, there's a lot of folks there that are working at that air logistics complex. There's the one in Oklahoma, there's one in Georgia, and there's the one just north of Salt Lake City, and these are the hubs where we're doing all the repair work and taking care of our airplanes or missiles to make sure that they're good to go and get them back out to the light side to keep protecting the force. Here's the amount of civilians that are working there, the financial impact that that has and the infrastructure that we have in Oklahoma. Additionally, here's where I'm working at in Georgia, the air logistics complex there. We got 54 mission partners there on the base, five different major commands. There's a lot of business that goes on there. We employ, you can see, around 7,700 civilians, 97 military and some contractors. Again, just like our other services, those don't include some of the active duty members, the security forces, people that we help screen and take care of and take care of their health and occupational exposures. You can see the budget and infrastructure that we work on there. And then in Utah, like I mentioned, there's a big facility there, big infrastructure, big budget that we have at that location as well and keeps a good workforce there in just north of Salt Lake City. We do have our dedicated OM spots across the Air Force as well, up in Alaska, California, Arizona, Texas, Ohio, Florida, and also in New Jersey, and these are just where we have a dedicated occupational medicine physician at these locations. We do have about a dozen contractors out there at other Air Force bases as well, and then, like I said, in addition, all of our flight surgeons that are handling all the occupational medicine exposures at the rest of the Air Force bases throughout the Air Force to assist and help them. Similar to my Navy and Army counterparts, our recruitment and retention is one of our challenges as well. We do have a high turnover with, specifically this year, we had six individuals retire this year, and so there's a big changeover with that. Residency opportunities, we have our four civilian-sponsored positions every year and one USHAS position each year, and thankfully we've been able to keep those filled, so at least the pipeline keeps coming in, keeping at least our baseline at least steady for our occupational medicine billets that we have, and just as you guys all know, it's a unique career field, and there's a lot of specialties that's involved with that. For our residency program, there's the specific spots that we have there, and then we also have just some things that we're trying to figure out with DHA and some reductions and trying to figure out where our billets are going to be at these next few years. Those are some potential challenges that we're facing in the future and things that we're trying to understand and figure out, and that is, so I'm not going to go into some of the same things that they already talked about, so we'll skip over some of those slides, and that's just kind of a quick Air Force update from that standpoint, so we did want to leave some time for questions for our audience and to see how we can help answer those. Thank you. I don't think we have any microphones set up, so we'll just, if you have any questions or concerns, comments, just, we'll have you project. We'll repeat them if you need, but we want to give plenty of opportunity and not just turn into a DHA bashing session either, so, but. Yes, no. No, no, I'm there with you. So, so there has been some backpedaling on that. We're trying to, we're still waiting to see where that is falling, but they realized, hey, that was a little excessive, so, so those numbers we're still trying to figure out. We're still getting the final result. We should be getting some of those back, but we haven't been told exactly how many yet. No specific guidance on that. I'm sure Colonel Everson would have a little bit more info on that, but he did say specifically that when I asked him before we came here. I was like, I know this is going to come up. I mean, I tried to skip over it quickly, but he's like, it has been delayed a little bit. We should be getting some of those numbers back. The specifics, we don't have that yet, but they are realizing that that was, that was too excessive for that. So, so just from the Army, the Navy's perspective, you know, 9,000, across the DOD, something like 9,000 medical court bills were cut. On the Navy side, I've been told that this summer we're going to see a good number of them come back. I suspect that'll be the case across all three services, but then it's going to be up to us collectively to fight for those billets back perspective. It's not like if they took three from Ock Health 10 years ago or five years ago that those three are coming back. No, they just go back to the big pool, and so now it's, it's kind of a pickup game where we have to kind of fight and justify why we need that, and that's, like I mentioned, one of our challenges is how do you speak in a language that people who run hospitals understand, right, but at the same time talk about the work that we do to support the line, and sometimes that runs counter to the end, the bottom line or the final goals of maybe what DHA looks at or what the MTF is responsible for, and so that, that's where we kind of are stuck right now. It's an opportunity, okay. It's a challenge, but it's an opportunity, but I think across the services we're going to be getting a good number of those billets back. This is short. So, I'm coming from the NCR region where we've got 28 different branch occupational health clinics by all three services with variable levels of staffing, and when I hear each of y'all talk, it's about the Army, the Navy, the Air Force aspect, but in our region, it really is short because of the short quality path and low back and forth. And what I've seen is a disparate impact where the Army, Navy, and Air Force stake out their historic positions and undercut the DHA, and the DHA lacks the organizational structure of the headquarters to address the region. It counts in the marketplace doing it, but there's no organizational structure of a region to execute that, and we don't allow it. So, how do we work to realign the organizational structure, because the only way we'll succeed is to be joined to these environments because we are all so short, and that's where it's gone already. And the drug deals we have have undercut positions. I mean, we need legacy sites that should be local, but those aren't closed to consolidate our efforts and get what we really need. How do we work to get that organizational model? What does it look like instead of showing three separate service models? One of the things that we just talked about this morning is how this military OEM brief should really have a DHA representative sitting on this panel as well to answer stuff like that. Sorry. So, you're right. We have to work together. I think there's a lot of tradition steeped in the services that only I can do what I can do because I'm wearing the Navy uniform. Well, I'll tell you, in my prior life when I was a family physician and I was stationed aboard the USS Harry S. Truman, I had zero experience of what it meant to be a doctor on an aircraft carrier, and I would imagine that an Air Force physician or an Army physician would be able to adapt just like I did, and so I think that's the place where we're going. There's going to be still pockets of specializations within the services, and I think we just need to hold on to those, and if they make practical sense to do so, we do that. I will say that at the headquarters levels, and I won't speak for Colonel Palmer here, but it does seem like there is, for the first time in a few years, a significant attempt to try to work collectively in a joint space. But the amount of work, and to your point about the lack of infrastructure and the ability for DHA to just come over the top and do that, it's going to take time. And there's a lot of input that needs to come from the services. When we're talking about standardizing policies that have been separate across the services for forever, even just basic clinical practices, some of the best practices or use of tools in order to do clinical care are wildly different. The way we view how we code, just a lot of things are so different that the challenge, which is an opportunity, is real. And I think it's going to take some time. In the meantime, what I'm trying to do as a Navy specialty leader is be a forcing function to make sure we use established procedures that are in place, like I said about the drug deals and things like that, making sure that we are adequately making formal requests. Once, this is just a little soapbox for a second, once military medicine starts acting like it's actually in the military and following the same procedures that the line does to get the things that they need, then I think we'll have a better voice. And the line will understand that if we speak their language. And so that's what I can do within my sphere of influence. And I don't know if you have anything more you want to say. Just to kind of put things in perspective from the Army standpoint, we moved from an Army medical command of 65,000 plus individuals to 6,400. And other services experienced a similar transition. Change that has happened in military medicine hasn't been the Army, the military hasn't experienced this since the establishment of the Air Force. And if you really think about that, how much of a strategic move this has been for military medicine, it's astronomical. DHA has responsibilities, and the service surgeons general are coordinating with the director, Lieutenant General Crosland, to ensure that DHA is going to succeed. What that looks like is going to be something in between where we were as completely separate service medical functions to where DHA assumed authority, direction, control of the majority of medical operations. So we're going to be somewhere in the middle. Structure wise, I think there is some negotiation, at least in the Army, there's some negotiation to kind of establish more structure within the regions, because we realize there's a need to have more structure in the regions. There needs to be that mid-level coordinating effort to ensure that the strategic level, whatever policy is established, is interpreted appropriately and followed appropriately at the tactical level. So those things will happen, it's just going to take time. And as we're continuing to move, DHA is realizing how much work this is. And they're having to build their team. So it just takes time. And I would just encourage you to be patient, continue to communicate to your leadership of your concerns, but also make sure that the mission at the tactical level continues so that our employees are protected in their workplaces. So Hiram, I don't know if you want to add anything to that, but we're all kind of beating the same drum here. But we are very much synchronizing much more closely than we ever did in the past. And becoming a purple force, so to speak, I mean, we're going to get there. We appreciate your patience and understanding. It probably won't happen in some of our generations, that things are going to work smoothly. But we're going to do our best to get it there. So appreciate your patience. But Hiram, if you want to throw out any comments? Exactly what they're saying. And there are steps being made right now on different levels. Like Navy, they have their Navy Matrix. If you ever use that, it's phenomenal for AUCMET, OK? That's not something that we have, right? So we're trying to transition with that. Air Force has a really amazing ASIMs, Occupational Health Tracking Program. We're trying to expand that for all three services. So we are taking best practices. How can we unify? How can we join up together and use our best abilities to strengthen each other? So there are processes in place, but it might take a little bit more time. Follow-up question on that? I guess what I'm saying is that when you look at a support command or something like AUCMET, I always look at it when they're doing a support command and training equipment. All the things we're talking about, usually like the medical matrix, I would look at it as an equipment. Training is just a training pipeline. Planning, we're trying to figure out the documents. The thing we talk the least about is the organizational aspect. First priority, and it's about an appropriate change of command responsibility and authority at the regional level for HOP, HOD, LOC, AUCMET forces. We cannot achieve it with those other elements. We have not addressed the organizational component first. So what efforts do we have? And this is the most critical gap. Yes. So perhaps I'm preaching to the choir of y'all here, but when I was on active, we were told you're a soldier first, an officer second, and somewhere down the line you're a doctor, I guess. So I say that because it took me over a year to get credentialed when I was active in a non-clinical role. And it took me having my buildings commander reach out to a MEDAC commander and a MEDAC DCS. So there's retention issues with that there. Then, as a civilian trying to hire mid-levels, the credentials process was a nightmare. So I guess my tangible question is, is there something being done to help streamline the credentials process in each service or between the services? I don't think there's anything between the services, as DHA sort of owns that process now. We all know that credentialing is challenging because it's so disconnected at the clinic level. Discussion about a centralized credentialing process has been ongoing for years. And that's something I believe DHA is probably discussing internally. Even just talking in our small group here, it's like, we all want to be guest providers at an MTF to maintain our skill sets because some of us sit in almost 100% administrative positions, but we owe it to the community to be physicians also. That's something that I think if we all continue to impress upon our own leadership about credentialing and the challenges with one common voice, if that gets up there, then it'll start making motions forward. But I can't speak specifically to across the services. I just know that it's very disconnected at the clinic level for credentialing. And it's still a work in progress. Do you guys have any updates for that? Personal experience, Navy guy on a Space Force base in the middle of Colorado. I want to see clinic. It took eight months for my credentials, my ICTB to go through from fleet forces. And it ended up falling flat trying to work at the Army clinic. So then the Air Force clinic then took me in. And so I've been seeing clinic a few days a month just to keep my skill set up. I help them. They help me. It all works out. But I'm an 06 in the Navy, Special Leader of Oc Health. And it took me eight months just to get that. And it's really only because of my persistence, they finally said, all right, stop being a pain in the neck. All right, we'll work it out. It's very easy to, the default is not to be that way. And I think to Colonel's point is if we can be a forcing function as much as we can, it trickles up. I know the conversations are there. I just, I haven't seen action yet. I'm with the Navy Colonel O'Hara with the Bantam Corps. I'm the Commander of the Chief of Oc Manpower. Can everybody hear me? Woo! OK. OK, guys. OK, anyway. I'm actually going to end with that question. So we have another issue with hiring specifically civilians, specifically oc vet docs. I've confronted this head on. And it's a problem. So right now, I have, let's just say, it looks like I have a doc that's OM residency training. Our residency includes intern years, three years. OPM, Office of Protocol Management, says we need four. I can't hire this residency training doctor because OPM won't put her on the list so that I can see her to click, I need to hire her. So I feel like we need an exception of policy or something. My question is, are y'all seeing this as well when trying to hire a civilian doc? I've seen that exact issue. When I was at Bremerton, we had the exact same thing. We had to work through the HR department to get an exception of policy and explain to them. But that worked one time, and then it goes off into the ether. There is no, yeah. And if you want to fix OPM issues, you're talking to the wrong group. So yes, I can commiserate. But no, I don't know if there's an actionable thing happening to correct that. Hey, I have no complaints or questions. Thank you. So more from the operational end, right, Ryland? I think you mentioned that the DHA thing was going for a while, and all of a sudden it's here, right? One of the things that I think is missed by our community is, at the same time, right back in 2018, that's where I think it is more. The counter-insurgency will no longer hold priority. And I think for years and years and years, we sort of put that aside up in DHA, and that is also here. So my comment, and my point is, if you guys start looking at billets coming back in to DOD because we feel like there's deficiencies, there's a very strong argument, right, to say, hey, look, the previous 20 years of us doing the same six-month deployments in my world with the counter-insurgency, we're going to shift the point with no combat, no concerns. That is shifting. And I think that, historically, emergency medicine docs, young medicine docs, like everyone I work with in my world is one of those guys. There's a real reason to make the argument that augmented effects were taking over the issue of coming back and having to legalize things like contaminated environments, right? CBER is a real thing in a peer-adversary environment. So my point is, right now, we're in a preventative medicine situation, right? I mean, there's a rocking environment, but not yet an ad environment. So our ability to look at the risk assessment at these tables, you guys are making arguments to get certain tables. I'm doing the same thing in the operation. I forget if you all are. It's really just a comment between you guys and choosing to look at trying to maintain billets. That is a huge argument to make. I have no argument with what you're saying. I think, honestly, what gives us more power to our argument, talking with medical folks, is when line leadership then echoes that. So if you're in an operational unit, or if you're working closely with the supported line units from your occupational health clinic, you sit at those leadership meetings. They need to understand the value that you give to their organization. And if they can then put it up their chains, I think that voice is even louder. So what Colonel Palmer talked about, right now, biodefense is the thing, right? So it is a thing, I'll say, but it is a big thing. And so biodefense, biosurveillance, we live in that realm. But we also have the luxury, admittedly, to step out if we want to focus in different areas or really dive into that. I think the areas where we see the most impact when it comes to a manning argument or our need, our importance, our value, are the people that jump into that world because they're speaking directly to line leadership and they hear us. And so that's where, you know, the complaint, I'll speak for the Navy, where the complaint from CNIC or someplace goes to Admiral Vai. Now, all of a sudden, we've got traction in BUMED from a manning perspective. And that's where we can get better at that and in that communication. I've had the pleasure. I'm Dr. Hill. I work at the Las Vegas VA. And I'm an occupational medicine physician. But I've had the pleasure in the Army of being both a general medical officer and occupational medicine physician. So we see the tail end of the active-duty soldiers that have disabilities. One of the things I noticed looking at records is the discharge physicals have little or no heat with regards to specific injury. You know, knee pain, chronic pain. The point I'm making is I retired from the military a number of years ago and we had the same problem retaining and including enough octocs. But one of the things that might be of assistance is some type of a training program a mini-training program for our general medical officers so we can have better coverage at least a little more education in terms of when we discharge our military soldiers that they put more details in the exams which in turn helps us do the disability exams so we can give our veterans our disabled veterans a better evaluation and give them the coverage they need. And what I'm saying is we can do that right here is make up some type of educational especially in the military tell them this is what we gotta do and the general medical officers have a mini-course TDY take them somewhere and at least educate them on toxicology or whatever that instead of trying to run up the hill and try to recruit all these people we can't, we're competing with the outside world and people have other lives and they want to retire or discharge so I'm just throwing that out So two quick points on that I don't know if you want to talk about the fundamentals of OEM course that we offer but there are courses that are developed service specific I know the Air Force has one as well we talked today about how do we merge that to make it a joint endeavor to do just what you're saying train those providers who are being asked to do Ock Health work who are not formally trained in Ock Health it's a fine line a lot of times it can be used as a recruiting tool because they're sent to this course and they say ok this is what Ock Health is now I want to do the residency so that's a positive we also want to show the value of the residency though in and of itself it's still, there's still value in going to the residency and getting formally trained it can't simply be supplanted because you took a one week TDY course that's why it's going to be made to improve the things that you're talking about another thing that my predecessor Max Clark was working on was trying to transform the PEB, the physical evaluation board billet that we have in the Navy at least to an Ock Health billet who better trained to do a billet like that and work in disability world than someone who's been trained in occupational medicine I think as we go forward particularly if we have limited people in uniform to do with the Ock Health services we need to be more strategic and we'll replace those people and how do we train the other people who are asked to do that job so they're at least doing it good enough to get maybe a C grade to get to where you're talking about where it's actually beneficial for the sailor, airman, or soldier when they retire I don't know if you had any points I would also just comment on the electronic medical record keeping system that presents. When you talk to primary care physicians that are trying to just accomplish their daily encounter workload they're spending hours in the evening trying to get caught up on their notes it forces them to maybe produce sub-optimal documentation so that may be a result also of the record keeping system that we have so there's improvements across many avenues to help that in-state service member transition to the VA with a great package so that assessments can be done and accurately done. There's multiple ways to get this to work better but I think the EMR the DOD or at least active duty, all the forces transition to the MHS Genesis platform and it has lots of room to improve including occupational medicine which I think does not still have a module yet but maybe working on it. We're down to just a handful of minutes. We're going to take one more so we have room for one more question, a burning question from the back yes sir I'm here for Section 82. In recent years, we've seen an explosion, an exponential growth of embedded medical physicians in my units. There's a forecast of losing OEM physicians. Have the policies having to be talked, created, embedded OEM physicians to alleviate this shortage Yeah, I think just availability of providers is going to prohibit something like that. We all talk about embedded occupational medicine within the formations and in the importance, especially in a large-scale combat operations scenario, because we're going to have conflicts that are going to run across industrial sites. We see this happening now. Who better then to interpret, you know, those exposure risks of TICs and TIMs than an OCDoc? We're just strapped for individuals to put there. Line funded, so operational funded. Yeah. You all have probably the best model of the three of us that Air Force has the line unit, OCMED. For us, for Army, we basically would just embed a preventive medicine or an occupational medicine physician at the division level and then work through down trace, skilled preventive medicine detachments for those types of operations. And then also educate our battalion and brigade surgeons to ensure that those types of surveillance activities occur. So it's definitely challenging. We have to think about those things given the world today. We certainly do. I appreciate that comment. Are we at time? We are at time. So ladies and gentlemen, thanks for your attendance today. Enjoy your lunch. And we'll see you next time. I'll just put, as we commented earlier, next year we'll change this format to include a Department of Defense occupational medicine update, not just the service-specific consultants. So we'll change that.

Military officers

Occupational and Environmental Medicine

Manpower challenges

Recruiting and retention

Credentialing processes

Joint approach

Training programs

Embedded OEM physicians

Electronic medical record-keeping systems

Policy changes