Compassionate Care in Practice: Illness Experience and Post-Traumatic Recovery
Eric B. Schoomaker, MD, PhD Uniformed Services University of the Health Sciences
Bethesda, MD
“Department of Defense: Integrative Strategies for Recovery”
Principal Topics
• How can institutions innovatively respond to the
overwhelming needs of veterans returning from war: The
Walter Reed Army Medical Center experience.
• How can we develop innovative models of care: The
Warrior Transition Unit experience.
• How can we incorporate compassion and innovation in
healthcare leadership: The USUHS experience.
There are no financial conflicts of interest.
The opinions expressed represent solely the
views of the presenter and do not reflect official
policy of the DoD or USUHS.
"Americans should not expect one
battle, but a lengthy campaign,
unlike any other we have ever
seen.” President George W. Bush
Address to a Joint Session of Congress September 20, 2001
“…the long war” GEN John Abizaid
* May 2008 DoD Data **3 June 2010 DoD Data
% Su
rvivability O
ver Tim
e
[Wounds Not Mortal / (Battle Deaths + Wounds Not Mortal)] * 100
69.7% 75.4%
86.5% 89.9%
Improved Survival Over Time
Improvements in
Warrior Care
• Improvements on the battlefield
– Better trained medics
– Improved equipment
– Far forward emergency & surgical care
• Improvements in evacuation
• Improvements in recovery &
rehabilitation
Rising Musculoskeletal & Mental
Disorders—Ambulatory Visits
OIF Mental Health Advisory
Team:
Dwell-Time is Critical
Page 7
Rising Hospitalizations for
Mental Disorders
(JAN-SEP ONLY)
Increasing Combat TBI Cases
2000
9000
10000 10,963
20,199 27,507
20000
6,282
(27%)
7,135
(26%)
4,133
(20%)
2007 2008 2009 DoD Baseline DoD OIF/OEF DoD OIF/OEF DoD OIF/OEF
DoD Total
Data Source: AFHSC
Deployed Forces
23,002
OVERALL TBI CASES HAVE MORE THAN
DOUBLED
PTSD
N=232
68.2% 2.9% 16.5%
42.1%
6.8%
5.3%
10.3%
12.6%
TBI
N=227
66.8%
Chronic Pain
N=277
81.5%
The intersection of mind & body
Lew, Otis, Tun et al., (2009). Prevalence of Chronic Pain, Post-traumatic Stress Disorder and Post-concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. JRRD.
Slide 10
Prevalence of Chronic Pain, PTSD and TBI in
a sample of 340 OEF/OIF veterans with
polytrauma
Trauma Spectrum Response
Depression
Somatic dysfunction
(sleep, appetite, sex,
energy)
Anxiety
Pain
TBI
PTSD
Substance dependence,
abuse and tolerance
TRAUMA SPECTRUM DISORDER
“Forty Days of Winter:
Walter Reed, the Wounded and
the Washington Post” February - March 2007
February 15, 2007 – Washington Post
reporters met with the WRAMC Commanding
General and Staff
February 18, 2007 - Sunday
First Washington Post Article
Changes in leadership…
March 5 - Monday
House Committee on Oversight and Government Reform
Hearings at Walter Reed
My Personal Low Point
North Atlantic Regional Medical Command
At Walter Reed: The Perfect Storm
Combined effects of:
• Unprecedented Battlefield Survival
• Medical Regulating Challenges
• Limited Primary Care Capacity
• BRAC
• A-76 Workforce Privatization
• Long-standing PDES concerns
• Fragmented wounded warrior C2
• Others…
“To stay a Soldier…”
Commanding General’s Intent
•Walter Reed provides a continuum of integrated care and services
• from point of injury to return to duty or
• transition to active citizenship.
•Warriors and their Families should receive a quality of care and services that is
commensurate with the sacrifice they provide to the Nation.
End State:
•Warrior Transition Units are established with the Triad of support consisting of:
• primary care manager (PCM),
• case manager (CM)
• squad leader (SL)
•Streamline the issues affecting Family care and disposition.
•Soldier and Family Assistance Centers are established at our supported
installations as entry points for Warriors in Transition.
•The Army & American people have a restored sense of confidence in the Army
Medical Department.
4
“I am a Warrior in Transition. My job is to heal as I transition back to duty
or continue serving the nation as a Veteran in my community. This is not a status, but a mission.
I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG.”
Mission of the Warrior in
Transition: to Heal
15 AUG 07 24
Administrative Services
& Benefits
Clinical Services &
Leadership
Legend: SFAC: Soldier Family Assistance Center PCM: Primary Care Manager RNCM: Registered Nurse Case Manager SQD LDR: Squad Leader
WELCOME TO
RN
CM
• RTD
• VA
• Citizen
Total Continuum of Warrior Care
+ =
SFAC
“I am a Warrior in Transition. My job is to heal as I transition back to duty or continue serving the nation as a Veteran in my community. This is not a status, but a mission. I will succeed in this mission because I AM A WARRIOR AND I AM ARMY STRONG. “
Warriors in Transition Support Team
THE SOLDIER FAMILY
ASSISTANCE CENTER
Prescription Opioids
An Epidemic in Opioid Problems in the US
– Provide recommendations for a DoD
comprehensive pain management strategy that is
holistic, multidisciplinary, and multimodal in its
approach, utilizes state of the art/science modalities
and technologies, and provides optimal quality of life
for Soldiers and other patients with acute and
chronic pain. Army Pain Management Task Force Charter; signed 21 Aug 2009
Pain Management Task Force
– Relieving Pain in America: A Blueprint for
Transforming Prevention, Care, Education and
Research Institute of Medicine; June 2011
Comprehensive Pain Management
Evidence-Based Complementary and Alternative Therapeutic Modes
Acupuncture Biofeedback Yoga Meditation
Standardizes Pain Management Services at echelons of care across our Medical Treatment Facilities: Team-Based Provides optimal quality of life for Soldiers and patients with acute and chronic pain
Defense and Veterans Pain Rating Scale
(DVPRS)
• Goal: Standardized Pain Assessment Tool
• A common language DoD and VHA pain assessment
tool with visual cues and a common set of
measurement questions—linked to function.
PASTOR/PROMIS: Patient Reported Outcomes
• Center for Disease Control and Prevention: (Health People 2020 will include PROMIS Global Measure)
• Bravewell Collaborative Integrative Medicine Outcomes Study (PRIMIER)
• Defense & Veterans Center for Integrated Pain Management (DVCIPM) Research
– Pain Management
– Rx Med Abuse
– Interdisciplinary Care
RESEARCH * OUTCOMES REGISTRY * CLINICAL DECISION TOOL
Auricular Acupuncture or
“Battlefield Acupuncture”
Mind-Body Medicine with
Guided Imagery
Special Pain Medicine Supplement on Active Self-Care
Complementary & Integrative Therapies for Chronic Pain
Examples of Holistic Care Ready for
Integration
Stars and Stripes January, 2011
Mind-body stress
management
Nutrition for optimal human
performance
Integrated “Family and
Team Care” approaches
Individual and Enterprise
Total Fitness Metrics
Acupuncture, yoga, music
therapy and exercise for
the TSR
“Compassion is not a relationship between the healer
and the wounded. It's a relationship between equals. Only
when we know our own darkness well can we be present
with the darkness of others. Compassion becomes real
when we recognize our shared humanity.” Pema Chödrön, The Places That Scare You: A Guide to
Fearlessness in Difficult Times
USUHS Medical Education:
Compassion and Innovation in Leadership
• Experiential
• Self-reflective: behaviors, cognitions and
emotions
• Values-based: personal, professional and
cultural
• Context is essential: situational and
interpersonal
• 4-C’s:
• Character
• Competencies
• Context
• Communication
USAFA PITO Leadership Model
• Leadership Focus
Areas:
– Personal
– Interpersonal
– Teams
– Organization
Leadership Focus Levels
MEM 101 Pre-Clerkship
Fundamentals of Military Medical Practice
Clerkships
Emergency Medicine
MEM 201 BBB & Post-Clerkship Advanced Military Medical Practice
Organizational
Team
Interpersonal
Personal
Military and Emergency Medicine Leadership Curriculum
Military M
edical
Practice
Learnin
g A
ctivities
MFP
10
1
MFP
10
2
Sum
mer O
peratio
nal Exp
erience
Eme
rgen
cy Me
dicin
e
4th Ye
ar Cle
rkship
MFP
20
1
Lead
ersh
ip C
apsto
ne (O
ptio
nal)
MFP
20
2 “B
ush
maste
r”
Military C
on
tingen
cy Me
dicin
e
LEADERSHIP GROWTH AND DEVELOPMENT
An
tietam M
edical Staff W
alk
Eme
rgen
cy Me
dicin
e Se
lective
(Op
tion
al)
Use of Films
Teaching Our Own
Take Away Messages
• Maintaining and restoring the health of Warriors and their Families of
all eras is paramount for the military, the military health system and
the nation.
• It is team-based, multi-disciplinary and rests on honoring the service
and commitment of each Service Member.
• Lessons abound in how we can improve health & well-being and
restore health & function. Compassion is an essential element.
• Management of chronic pain is a complex, individual experience often
with comorbid elements for which care must be patient-centered and
individualized.
• Leadership in military health & healthcare is an inherent feature of
service in uniform and must be taught carefully and deliberately.
Thank you! Questions?