Executive Summary and Information Paper

It's been a week since the end of my POPM, so I've been a bit of a slacker about writing about the end of it. Sorry. Overall, it was a really good rotation and taught me a lot about the necessary steps in making policy (it's not a short nor simple process).

Most of my work during the rotation involved reading memos and proposed regulations and comparing them to current regulations to see how they fit (and that was an oversimplification of the whole thing). I also researched current issues that were coming in to POPM (things that people from outside the Office of the Surgeon General thought needed attention) and tried to make a decision about how important it would be. One of those issues was a report of twelve cases of swine flu (a different swine flu, not H1N1) in five states. After doing research, which mostly consisted of reading what the CDC has to say about it, I wrote an executive summary and information paper. Also easier said than done.

An executive summary is a short and concise summary of an issue, and there are very specific formatting rules for it, from the font and size to the fact that it has to be fewer than fifteen lines of information. Here's my EXSUM (we like acronyms):

(U) 12 HUMAN CASES OF INFLUENZA A(H3N2)v IN THE US.  (U) (DASG-PPM-NC)  Since August 2011, the Centers for Disease Control and Prevention (CDC) reported 12 human cases in five states of swine-origin influenza A (H3N2)v.  No cases have been reported among DoD beneficiaries.  Severity of illness is similar to seasonal influenza with three hospitalizations and no deaths.  The majority of cases occurred in children who have had contact with swine, with evidence of limited human-to-human transmission.  CDC provides interim guidance to clinical and laboratory personnel for surveillance and testing.  MEDCOM provided guidance to Army medical treatment facility laboratories on 13 Jan 2012 regarding typing and subtyping of specimens. Preventive medicine personnel will report all confirmed, probable, or suspected influenza A(H3N2)v cases in Disease Reporting System Internet and to local public health authorities.  Healthcare personnel should encourage beneficiaries to be immunized against seasonal influenza, as this may confer partial protection against influenza A(H3N2)v virus.     

If, after reading an EXSUM, someone wants more information, they request it and are provided an information paper, which, as it sounds, contains more information. It's supposed to be less than one page (again, very specific formatting rules), but can be longer. Mine was about a paragraph onto the second page, and I won't subject you to that.

So now that I'm done with POPM, I'm spending a little bit of time hanging out at WRAIR on what we refer to as "research downtime". Unfortunately, my research project happens to be at that exact place where there is nothing I can do to accelerate it, which makes my research downtime more of just, well, downtime. It's given me the opportunity to work out during the lunch hour, which is quite enjoyable, and get my poster ready to present at the ACPM conference in a couple of weeks. And get caught up on sleep, which after the commute I had to go down to Falls Church, was a bit lacking.

Pandemic Influenza Table Top Exercise

On Thursday and Friday (I'm only a couple of days behind, go me), I participated in a table top exercise about pandemic influenza preparedness. It had a tendency to drag on and get into the weeds at time, but was overall fairly educational.

One thing I didn't know before going into this is that we have definitions of pandemic severity, based on the case fatality ratio (below). In terms of pandemic influenza, the H1N1 (or swine flu) from 2009 was a category 1 pandemic (I feel like I need to back-up for a second and define 'pandemic'. It doesn't mean 'bad disease'; it means a disease outbreak that is spread around the world. An epidemic, on the other hand, is an outbreak that is in one area or part of the world. So H1N1 is a pandemic, because it's found everywhere, but obesity is an epidemic, because it isn't). Anyway, back to what I was saying: H1N1 is a category 1, because while there were a lot of cases, there weren't a lot of deaths. The 1918 flu, on the other hand, was a category 5 pandemic, and was the only category 5 influenza pandemic in history.

For the table top exercise, we were using a pandemic influenza modeling tool developed by the Innova Group, where you can enter in the severity of the pandemic (from 1-5), duration (typically 6-12 weeks for influenza, depending on the size of the geographic area you're talking about), the population size and age distributions, and expected attack rate by age (for example, children tend to have higher attack rates for influenza than adults). You enter in all that stuff, and then it spits out a bunch of reports about how many healthcare workers you need, how many gloves, the amount of storage space required for everything you're going to need, etc, etc. 

For this exercise, they modeled the Northern Region Medical Command, which is all the Army treatment facilities from the Canadian border through North Carolina, and a category 3 pandemic. The people running the table top were logisticians, not epidemiologists, so they didn't know all the right terminology of influenza surveillance or epidemiology and some of the things just didn't make sense. For example, based on the scenario, we knew there was a pandemic coming before the first cases hit the United States, which isn't the situation. With H1N1, it had been going on in Mexico for a couple of months before anybody typed the virus in San Diego and realized that it was a new influenza. So a little unrealistic, at least at the beginning of the outbreak, but it still generated a lot of good discussion about what we can do to prepare and how individual treatment facilities have to respond.

Overall, I don't know how much it taught me about policy (which is what I'm supposed to be learning on this rotation), but still educational overall.

Periodic Health Assessment

Today was a meeting of the Joint Preventive Medicine Policy Group (another acronym: JPMPG, pronounced jip-em-pig), which is a group of preventive medicine people from all of the services (Army, Navy, Air Force, Coast Guard, sometimes foreign militaries, etc), and the topic of the meeting was the periodic health assessment.

The periodic health assessment is done by each of the services, but each one is different, which in today's fairly integrated military, makes things a bit difficult. There's an online portion that each service member completes on his/her own time, and then there's a face-to-face with a medical provider (doc, PA, NP, etc). The problem comes in for the face-to-face... if a sailor goes to an Army clinic to do the PHA, there's no guarantee that that Army doc knows how to do a Navy PHA (or even knows which computer program to use). For the record, I don't know how to do Navy or Air Force PHAs, nor do I know what programs they use. As you can figure, that creates some problems on joint bases.

So the purpose of the meeting (which extends into tomorrow, but I won't be going to, because I'll be at WRAIR for didactics), is to figure out 1) what the purpose of the PHA is (that's an entirely different conversation, which I won't get into); 2) if the multiple different PHAs can be standardized into one form; and 3) what that might look like.

Easier said than done. There's a lot more to policy than meets the eye.

Proponency Office for Preventive Medicine at the Office of the Surgeon General

That's where I'm rotating now (today was the first day). Or, because the military likes acronyms the way normal people like breathing, POPM/OTSG (which we just call POPM, pronounced pop-'em).

To put it (very) simply, POPM is where medical policy in the Army comes from. Whenever there's a question about the way things are done in the Army medical department (AMEDD, back to the acronym thing), it goes to POPM, they check the research and what the civilian side and other services are doing and get the opinions of subject matter experts, and then make policy. Yes, that was very simplified.

Today I spent the morning doing the standard for a new rotation: in-processing. Fortunately, every Army prev med resident as rotated through POPM since 2008, so they know what they're doing (which is impressive; usually when someone should know better, they act as if it's never been done before and the wheel needs to be reinvented). Then the afternoon was taken by a teleconference about the new regulation for the Army program, which mostly turned into public health nurses bashing just about everyone else (including prev med docs). That took over three hours, and when it was done, they sent me home, because the snow was falling pretty heavily (not sticking, but still falling). Unfortunately, people around here become idiots on the road when there's weather involved (and I mean any weather... snow, rain, sunshine, hurricane, earthquake...). It's a little more than 15 miles from work to home, and it took me almost two and a half hours. I was not happy with that commute.

First day at Madigan

Today I began the fun and exciting adventure that is a 4th year HPSP student on Army rotations. For the first time ever, I put on my ACU (Army Combat Uniform) in its entirety (when I went through Officer Basic Course, we were still in the old BDU, or Battle Dress Uniform). Of course, I had a brief panic attack thinking that I had the flag on the wrong arm, but it was all good.

I left really early from Ann and Norm's to give myself enough time to get a visitor's pass and get through the gate... that was a mistake. After more than half an hour at the main gate, they finally called my number and I handed over my proof of sale and proof of insurance for the car. The lady at the counter looked at it, and then told me that if I have temporary tags, I don't need a pass, I can just show my ID and get in. That would have been helpful half an hour before! So, I ended up being five minutes late for in-processing. What a great first impression.

Fortunately, I in-process with the Graduate Medical Education people, not the Preventive Medicine people, so they'll never know. There were three of us who are doing the rotation without orders (called non-ADT, or non-Active Duty Training), so we filled out our papers pretty quickly and then were done, so we went and got our hospital ID badges and white coats. I won't wear my coat (they don't wear them in Preventive Medicine), but it was an interesting novelty to check out a long white coat, instead of the short med student coat that I've been using for the last three years (we aren't allowed to wear the coats from our schools while on rotations in Army hospitals). Anyway, after that, it was back into the car to drive to the Madigan Annex, where the PM department is located (it's in the old hospital, not the main hospital).

Since I haven't been trained on the computers yet (that's tomorrow, all day), there wasn't a whole lot for me to do, so they gave me a tour of the place and introduced me to the interns, one of whom I met last February at the American College of Preventive Medicine conference, and then I started researching my project for the month (picking a recommendation from the US Preventive Services Task Force and describing the recommendation and the evidence behind it; I think I'm going to do scoliosis screening for adolescents, which is actually NOT recommended by the USPSTF). I also met some of the third year residents, one of whom is an OSU grad--go Bucks! I did have the misfortune of informing him that Dr. Stang, one of our former associate deans, passed away about two months ago, which was hard for him to hear. Dr. Stang was a mentor to him, as he was to many OSU grads.

After a longish day of not doing much, I decided my boots weren't all that comfortable, so I went to the uniform shop and bought myself a new pair of boots, which are very nice. I think I've had more uncomfortable tennis shoes. Anyway, tomorrow is eight hours of computer training through the Graduate Medical Education office, and then we'll see what PM has in store for me after that. I think it's going to be a good month.

Half-marathon and beginning rotations

Kit and I ran a half-marathon (13.1 miles) in Camas this morning. It wasn't too big of an event--only a couple of hundred people, as opposed to some of the other races I've done, with 10,000+ runners. Not too bad, although it did rain for the first six miles or so, and there was a massively huge hill at mile 12 (I walked up it--I'm a wimp, and was a tired one at that). In the end, I came in at 2:02, which is about nine minutes slower than my best, and Kit came in at 2:23. Not bad for a first half.
He was less than thrilled with me, as I'm sure you can tell.

How I'm able to smile after this is beyond me.

Anyway, that was pretty much all I've done the last few days. The parents went to Spokane for LeMaster and Daniels 100th year anniversary, and Alex left for Seattle on the 23rd (to get ready for the Olympics), so I had the house to myself until Kit showed up Saturday morning. I did a lot of reading, and that's about it.

Well, all lazy vacations come to an end, unfortunately. After dinner tonight I headed up to Tacoma (University Place, technically), where I'm staying with Ann and Norm for the month while doing a rotation in preventive medicine at Madigan. I in-process at 7:30 tomorrow, which means I need to leave here by 6:30 so I can be sure to get to Ft. Lewis, get through the gate, drive to Madigan, park, and get to the medical education office by 7:30. Fun, fun.