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VADM Donald Hagen,
Navy Surgeon General
Admiral Hagen became the 31st Surgeon General of the Navy on 28 June 1991, shortly after the end of Gulf War hostilities. Now he is leading Navy medicine into a new era of triservice cooperation, focusing on quality of life issues for all Navy personnel.
Proceedings. What do you think is the major concern within the fleet, as far as Navy medicine goes?
Hagen: Generally, the fleet is very pleased with Navy medicine. The reports from Desert Storm were superb in every aspect. We did a super job, did it faster, and did it better than the other services. We delivered every doctor who was required for the Marine Corps to the Marine Corps in a timely fashion. We deployed the fleet hospitals. The things we don’t think we did right we are learning how to fix, but the fleet is satisfied that we are on top of it. The professionals in our service also recognize that we were able to take care of their families while they were gone, and that is important.
Now the fleet is focusing on some of the basic problems of peacetime health care delivery- access to care, getting patients into the system, and maintaining the quality of care. They want timely access to quality care for all their people, and they want an equal benefit, regardless of whether they are on the East Coast, the West Coast, or overseas.
Quality-of-life issues are very important to our people. If the Navy wants to retain quality people, we are going to have to provide a quality environment where they can do what they are trained to do, and we have to see that their families are taken care of. In that is health care. We want quality health care for our people so they will stay.
Proceedings: Aren’t these fairly divergent demands— preparing for combat casualty care and peacetime beneficiary care. How do you balance the two?
Hagen: The most important wartime asset we have is being clinically proficient in our skills in peacetime. There very few things that are really different, in terms of dical education and experience. The principles of uijti care are the same, many of the principles^f^realth
care are the same, and much of what you do in peacetirtf can be transferred to wartime.
You could say, why do you need pediatricians i*1: wartime? Why don’t you contract those out? Pediatrician* are experts in infectious diseases, which can be a majdi problem in wartime. If you get involved in chemical wan fare or radiation warfare—where you see exposure to toxi£ agents and what they do to your blood cells and bone mat' row depressions—how do you find doctors with expertis£ in rejuvenation? Hemotologists and oncologists. They af£ dealing with how cancer affects the bone marrow. The) work on suppressing, radiation, bone marrow transplants-' all these things directly related to wartime requirements There are many bridges to the clinical side that peopl£ do not consider when they talk about divergent response bilities. It is not divergent at all; it’s complementary.
Proceedings-. Are there things about your Desert Storfl1 performance that you would change?
Hagen: There are a lot of things that we will do differ' ently next time. We are learning about communication an<> medical evacuation—maybe different modes of patiefl1
____ transportation, because thing*
moved so fast, the helicopter could not keep up. We need t° give consideration to fixed-win) dedicated aircraft for patien1 evacuation.
Everything is triservice no"1 We’ve got to look at Arm)1' Navy, and Air Force people ad® hospitals, and at simplifying sys" terns there. We need better track' ing systems for patients as the) come back to the United States from the farthest distances of th£ globe. But as far as doing wh®1 we were supposed to do, we di® it better than we have ever dod® it. We did a very good job cod' sidering everything, and I thi^ there is just some polishing that we need to do. Esse®' tially, we would do it the same if we were at the sad*6 point in time. But we are not at the same point in time' we are learning, so we are going to do it differently. s^i are going to do it better.
Proceedings: Do you think fleet hospitals could be °f should be a reserve mission?
Hagen: They should be both. If they were a solely reseA® mission, we could not have supported Saudi Arabia. Peop'® think the hospital ships got there first. They did not. Flee* Hospital Five was there first, staffed by active-duty per sonnel from Portsmouth Naval Hospital and other hospital' and was ready to go right after the invasionfcf Kuwa£t;
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pitals staffed by active duty to be able to respond at a moment’s notice.
And then there have to be some that are reserves that can follow on. It is a combination mission.
Proceedings: In light of the current downsizing, are there any plans to use medical assets for other than nhlitary purposes?
Hagen: Using the military for other missions—such as teaching in the •nner cities and providing medical support and inoculations for underprivileged children—is a very notable and noble thing. But it is important to keep in mind what is happening to the military medical system in terms of resources. As People retire from the military—and even more are retiring early as a result of the downsizing—they and their families remain in the military health care system. In fact, after they retire, these beneficiaries get elder and often require more med- lcal care. As a result, we will not see a downturn in requirements for medical support in our facilities uutil the late 1990s, when the number of people actually using the services will decrease.
Ultimately, these outside missions could happen, but with the high demand on medicine and with us struggling t° meet the services’ needs now, I would say it’s going to be a while.
We do some inner city work now—for instance, the hlavy Kids program and the Personal Excellence program, ^ethesda has adopted a school downtown and is tutoring children in math and science, helping them learn better study habits and different behavior patterns. We also have teams of surgeons who work downtown at Washington hospital Center, so they can get experience taking care of baurna casualties. It helps the city and it helps us. We are doing these mutually supportive kinds of things, and there ls Probably a lot more we can do later on to make it even better.
Proceedings: What about using the hospital ships for these Purposes?
Hagen: The Mercy (T-AH-19) did go to the Pacific, early on when President Ronald Reagan sent her out for a humanitarian mission. That can be done, but it is very Apensive. There are the operating costs for the ship, which are significant, and there are the people you have to take ^ay from the hospitals here in the states to do that kind of work.
The ships are not designed for general practice; they Signed for combat casualties and surgical functions.
rffective way to use them in a humanitarian ’ sending people to the distressed country t^ igs / October 1992
a lot of the preliminary screening and work in health care before the ship even arrives. They then refer to the ship only those patients who require the specific surgical functions the ship can provide. That makes it much more complex but much more efficient. They did that in the islands during the humanitarian mission of the Mercy, and it worked.
And, oftentimes, more important than health care delivery is basic preventive medicine. Wood, nails, hammers, and plumbing to build houses and screens to keep the insects away—public health things—probably are more important for the health of the people than the tertiary care of a hospital ship, which sooner or later goes home. They need a bootstraps kind of program instead, to train their people.
Proceedings: How is the Bureau of Medicine affected by the downsizing? Are you losing a lot of billets? Hagen: Not yet. A couple of years ago, Congress imposed a floor level of 12,510 officers within the Navy medical department. They did the same with the enlisted people, and they have been watching our numbers very closely. The only way we can cut back is if we can document that there is no wartime requirement and that it is cheaper to not have them in the military. So, if you could purchase a service outside cheaper than it is having this person on active duty, you have to go through a process and get approval to cut that billet.
Should the mandated level stay? My opinion is no, ultimately not. If the force is going to be smaller, then we have to look at these forces, how they are going to be used, what kind of medical support they will need, and how many people we will need to provide it, and then the medical active-duty and reserve components should be derived. But for now, with the predictions of stable demand for the next seven or eight years, we certainly need to maintain our current level.
In terms of dollars, medicine has always had a problem in the military because it has had to program and achieve resources based on defense inflation factors. Defense is programming 3.5%-4%, while medical inflation consistently has been double digit. So when we are straight-lined or have a slight increase in growth, we really are losing ground because our purchasing dollars are not going as far. But the perception, when everyone else is being cut, is that we are growing in terms of relative cost for the defense department. So they watch us very carefully, re have been teo many charges lately in qp
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year part of our money has come from a Navy appropriation and part from a Defense appropriation, and there are a lot of uncertainties about how to execute a budget like this. What do you do if there is not enough, and who do you go to? We are being impacted in many ways financially, and I fear our people in the hospitals are getting caught in a bind right now.
Proceedings: You mentioned contracting services, such as emergency room and obstetrics. Is this more cost effective? Is it the wave of the future in a smaller service? Hagen: We could not have survived without contracting. Standards in the United States changed in terms of staffing and education and certification requirements for people working in emergency rooms. We did not have the resources to staff the emergency rooms to the new standard, so contracting was the only way we could do it right.
We had to regroup. Emergency room work is critically related to war preparation, and it is very important that our people get this kind of training, but we could not do it all. So we retained emergency room training programs in San Diego and are starting one in Portsmouth to train more of our own people in these skills. Gradually, as we train them, we will go back and bring a number of emergency room services back into the Navy. But I do not foresee taking them all back. It is a heavy requirement, and we have so many hospitals.
We also probably will continue to contract some nursing. We will not be able to have enough nurses in the Navy to do everything that is required of us, nor will we have enough authorizations for civilian positions to augment the Navy nurses.
The most important thing is that the person assigned to the job is the person most qualified. If we can be open- minded enough to recognize the skills people have—regardless of whether they are active duty, reserve, civilian, or contract—and put them in positions where they are needed and teach them to work together, then the system works very well, and that is what I’m trying to achieve.
Proceedings-. Do you think contracting affects morale, especially if contract doctors are earning more than their active-duty counterparts?
Hagen: Most of the people we contract with are not doctors. In general, you contract for the entire emergency room operation. Let’s use the hospital here in Bethesda as an example. The staff are contract; the people rotating through are the Navy interns and residents who are learning. They are rotating through and the contract people are teaching. There is not a Navy doctor and an emergency room doctor working together as equals in the emergency room at Bethesda. So there’s not a parity issue there.
There are some cases where we hire a service and pay a significant amount more than we would pay a Navy person. Usually those are functions that we are unable provide. Again, there’s no parity issue; in general, we try not to put two people together who are contract and active luty performing the same function.
We do have partnership arrangements, through the |MPUS program, where civilian doctors coripe in a
military hospital and work side-by-side with an active duty person. For example, at Bethesda, we had more people trying to get into the urology clinic than we had the capability to handle, so we added partnership arrangements. The civilian doctors augment the existing staff and increase the clinic’s ability to handle routine urology. Patients who are diagnosed with more complicated problems are referred to the Bethesda Navy staff, who then can use those cases to teach residents and expand the scope of their practice. And it’s complementary, not competitive.
Proceedings: The Navy trains most of its own doctors through graduate medical education [GME], which requires a lot of resources to maintain civilian accreditation’ Is it worth the expense?
Hagen: If we don’t, we won’t have Navy medicine. Without graduate medical education you cannot attract doctors and you can’t keep them. The scholarship programs and the training programs are the real hooks that attract people. After World War II, all the specialists left the mili' tary services. They had no educational programs of sig' nificance. The country got together and said, “Wait a minute.” So the American Medical Association, the American College of Surgeons, and key leaders of the-U.S. medical system formed the Society for Medical Consultants of the Armed Forces, became actively involved in creating these graduate medical education programs, and built them up. Now, they are of the highest quality, and that is how we attract the finest people.
People do not want to practice medicine without having the full scope of practice around them. You cannot have all experts in trauma/surgery without anything else- Nobody’s going to join the military to take care of 18-21 year old men and women in peacetime. You have to offer a balance of clinical practice, education, and research-
Critics like to attack graduate medical education, citing cost. They equate it to being away from practice and in3 classroom environment, and that is not the way it is. The majority of the work in these big four teaching hospitals is done by the house staff, the residents, and the interns- The teachers are teaching the students—the residents-' and the residents are doing volumes and volumes of work, plus they are getting excellent quality educational experience. So they are not out of circulation, they are actually producing and providing care. The benefit is great-' attracting and retaining people and maintaining the sys' tern and balances—so I reject the argument that GW costs too much.
What we do have to do is look at graduate medical education in terms of a triservice approach, whenever poS' sible sharing resources with the Army, Air Force, the Veterans Administration, and the public health service, so tha1 we are working “smart,” training the specialties we need- I cannot promise our physicians they can be super sub' specialists and put them out for training in the civilian efl' vironment, then bring them back in and not have a sys' tern where they can work, with the right kinds of suppo'1. We have to constantly look at what types df specialist re need to make sure we arjp training people to a relent that (xi
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active duty and with the number of women of childbearing age in the dependent population. We have been trying hard to do something special, to improve the environment, so we can retain more people and deliver better services. The midwife program at Camp Lejuene is one of those programs. It gives us a better scope of practice than we have had. I would do it across the board immediately if I had the resources, but it takes time.
We also are pleased with other hospitals where they have tried to incorporate the doctor/nurse team into the delivery of health care. In fact, some of the efforts are triservice—Public Health,
Air Force, and Navy doctors working together with mid-
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I have established a graduate medical education policy council to examine these issues and determine what changes need to be made in GME and how they should he implemented. And that is from the field—from Portsmouth, San Diego, Bethesda, Oakland, and the family practice teaching hospitals.
Proceedings: Are you excited about Coordinated Care and TriCare?
Hagen: Oh, yes. Coordinated care starts with the premise that we will use our defense facilities to their optimum, keeping as much as we can within our own facilities because it’s cheaper and better for people and they want to come to us. It starts with that nucleus, saying let’s share °ur Army, Navy, and Air Force facilities and our people, working closely together in °rder to take care of as ’fiany people as possible.
And then, if for some rea- s°n we cannot get everyone ln this facility, we have another option for them 1° bridge into the civilian community—through an arrangement in which networked civilians provide Quality care at reduced c°sts. The third option is standard CHAMPUS.
Hut we do not believe in *°ckouts. We believe you should be able to go back a°d forth, or be able to have ^ost of your family with us and still be able to take a child or other beneficiary With a special need to that social doctor out there.
’°u pay more for that child, but you can do it and jjhll have the rest of your
tamily here, or you can move back and forth. We are very e*cited about this.
. There are service centers being set up, so when you call 'n you are told right away where you can go and who you are going to see, and then it’s coordinated within the series. You might be going to an Army, Navy, or Air Force Physician, but you will know where you are going right aWay. Phones are answered right away; paperwork is filled °at for you so you don’t have to file the CHAMPUS bairns. It is very positive. We’re expanding the Coordinated Care program from Charleston to Tidewater and SUdually worldwide.
**r°ceedings: What other health-care initiatives is your de- j^chnent taking that you are excited about?
Hagen: One of the major problems I have is keeping peo- j^e in |he ob/gyn specialty in the Navy. Now, the coun- rV is lacing a similar problem—we know that—but for *1 blcofces a bigger problem as more women comt
’roc<*dinls / October 1992
wives and nurse practitioners. It works very well.
I am very concerned about being able to augment and increase the ob community. Because malpractice insurance is so high on the outside, and doctors cannot join the Navy without paying off that huge malpractice insurance bill, they are kept from joining the Navy. We are working on that issue as well.
The shortage of internal medicine is also a nationwide problem. People are going through that specialty on to subspecialization, because subspecialization offers more money and more excitement. So we are trying to see what we can do to help them.
My personal agenda items that I preach everywhere I go again relate back to women’s health—the fact that we have some ships that will be 30% women, one that will be 50% women, perhaps in a few years. That means that
me I send to si issues. I 1 on worn
know they can go to a meeting of a process action team, r and they can sit down and be heard, because they are pad PS C
of the process. If there is something wrong at their level lQrnp they can voice it and get it changed. It is a totally different philosophy, and it is working. L"—
We now have a Navy Medical Quality Institute, and <ik< those people go out and teach the hospitals how to change lricr
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hospitals—people helping rehabilitate the old Portsmom
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duty issue that has to be taken on.
And then there is my major fight against tobacco. Tobacco is just crazy. If there is one thing we can do to help the health of this country, it is get rid of tobacco. People are finally starting to listen across the country; they are starting to listen in the Navy. We are trying to get smoking off the ships—at least not inside the ships—because
I am very concerned about the statistics on passive inhalation of smoke and what it does to your lungs and your heart. My slogan is, “You don’t have the right to squeeze my coronaries.”
And then we are looking at how we treat our sailors at sea, especially how we feed them. We are finding that we should be changing their dietary habits; we shouldn’t be focusing so much on cheeseburgers and hot dogs, hash browns and French fries. It appears in preliminary studies that, if sailors have a family history of heart disease or hypertension and they go to sea, they have a greater chance of having elevated cholesterol and lipids when they come back, because of something—the way we feed them, or the stress, or the lack of exercise. Our messmen are being trained on how to prepare food in a healthier way. Many people are interested in getting more physical fitness programs onto the ships.
Proceedings'. How is your department doing with the total quality leadership [TQL] initiative? Are you on board? Hagen: We have been really digging into total quality leadership for four or five years. People were looking at all these things that go on and asking, “Why is this happening, why do I have to do this, why do I have to fill form, what value is added by this process or that —and they were not being heard. So, we worked
hard to set up a Navy medical mission and vision and guiding principles and we said this is what Navy medicine should be; this is what we would love to have it b& And we came up with our strategic plan, and we have been educating people.
And gradually, as they start to learn, they become converts, and they start saying, “I can fix that.” People feel empowered to suggest changes in the institution, and they are not afraid to do it. In our hospitals, people,
their philosophies. When you see the spark, then all of3 sudden the hospital starts to change. Once they get a flo"' chart out that shows how a process works, then peopk start looking and start getting involved—saying that isn’1 necessary, that’s not the way it works, it’s this way—the" * they start to buy in. It becomes a way of life.
We have tackled one process here at the bureau just recently. We had a four-to-six week process for approving certain pay issues for civilian physicians. We looked the history, tracked who was involved in it, then went back and found out that in the last five years we had not disapproved any. We were adding four to six weeks of work for something we never turned down because the commanding officers were doing it fine at the local command' All we were doing was stalling, and, in some cases, losing applicants because they could not get their pay. The process action team recommended that we stop doing th"* here, that we let the commanders have the final approval' So now when the Inspector General comes out, he wm check to make sure the commands are doing it right. Tim1 frees up all those people here to do something else mof" important. Just one simple example of how TQL can work in an institution.
You have to know which direction you are going, an" your people cannot be afraid to speak out. And they have got to know not to throw rocks at people, but to attack processes. But once they get on board, it work5 very well. We have a long way to go, but it’s a good star"
Proceedings: Is there anything you wanted to address th"1 I didn’t ask?
Hagen: The only thing that I think we should stress is th"1 Navy medicine—Navy health—is not my program. ItlS the Navy’s program. That mind set is taking hold, and 11 is working very nicely. We have the line involved in °l'r
Naval Hospital. We have people helping at Camp Pendleton, in Puerto Rico, Guam, Spain, and Naples. And line is now helping fix their hospitals, that kind of thin?; I hear sailors say, “I want this to look better because m>' wife might deliver my child in this room.” That is the rig" attitude. That is what we are after. People need to cor" mit to their health care system, pie is a leadership