These are very interesting, perhaps even challenging, times for those who have dedicated their lives to public service. Donald J. Trump was elected our nation's 45th President; the oldest first-term President in our history. 2016 was the fifth time that the President-elect had lost the popular vote. Repealing Obamacare (ACA) was one of his signal campaign promises and this has clearly become a major political agenda for the new Republican Congress. Undoubtedly, "success" will ultimately be proclaimed. However, the details of this legislative effort will be critical for the 18 million Americans whom the non-partisan Congressional Budget Office (CBO) estimates may lose their health insurance unless a substantive replacement is adopted. The President's federal hiring freeze, at least initially, seems to significantly adversely impact the health and educational programs of the Departments of Defense (DoD) and Veterans Affairs (VA); for example, student training stipends. Will the momentum for integrated care and mental health parity be continued? With three physicians being appointed to the President's Cabinet, will health care continue to possess an appreciation at the highest policy level for the psychosocial-economic-cultural aspects of quality care or will it once again become predominately "medically" oriented with non-physicians relegated to paraprofessional status?
With unprecedented change always comes unanticipated opportunities. Arthur Evans has been selected as APA's newest CEO. Art has a distinguished public service career, most recently as Commissioner of Philadelphia's Department of Behavioral Health and Intellectual disability Service, responsible for providing the "safety net" for 1.5 million citizens of Philadelphia. Art's selection speaks very well for APA's collective interest on behalf of the public sector; perhaps even the Division's efforts to establish an office of Veterans Affairs. The new VA Secretary, Dr. David Shulkin, served as VA Undersecretary for Health under President Obama and was personally very supportive of Barbara Van Dahlen's Give an Hour efforts to effectively address the national tragedy of 20 Veterans committing suicide every day. Under his leadership, the VA adopted Full Practice Authority for its Advanced Practice Registered Nurses (APRNs). The final regulations authorize APRNs to provide services without the clinical oversight of a physician, regardless of State or local restrictions (i.e., federal preemption), when they are working within the scope of their VA employment. Restrictions unfortunately continue, however, for CRNAs; notwithstanding the overwhelming evidence of the quality of their care. Will the VA endorse prescriptive authority (RxP) for its psychologists?
The Fiscal Year 2017 National Defense Authorization Act (P.L. 114-328) also signals significant change for the military health care system. Traditionally, the various health professions (other than psychology) possessed statutorily mandated flag officer status for their service corps chiefs. For example, the dental and nursing corps leaders were designated at the two-star rank. Throughout the new law, title 10 of the United States Code was amended by "striking the second sentence," thus providing the Department with the flexibility to assign whatever rank was internally deemed appropriate given the administrative responsibilities involved. With the legislative pressure on DoD to significantly reduce the overall number of flag officers and also to demonstrate coordinated/integrated health care -- particularly with the newly provided "flexibility" regarding the traditional three-star Surgeon General status -- one must expect the corps leadership positions to be modified, once the incumbents retire. The law also calls for the development of Physician Assistant (PA) training initiatives in mental health for which the Uniformed Services University of the Health Sciences (USUHS) might take the lead.
Gary VandenBos and I co-edit the Division's journal Psychological Services. While teaching at USUHS, Gary became increasingly impressed by the wide-range of clinical opportunities that military psychologists and their nursing colleagues experience. Earlier this year, Eric Pauli of the Graduate School of Nursing (GSN) arranged for a tour of the aircraft carrier USS George H.W. Bush (CVN 77) [on which psychologist Navy Lieutenant Amanda Berg serves] for our health policy class. My son, who is a social worker at the Walter Reed National Military Medical Center substance abuse program, was able to join us.
Virginia Blackman (GSN) reflected on her role providing care on a Nuclear Aircraft Carrier. Integrated care was a particular theme: "The psychologist is one of the team; right alongside the family physician, physician assistant, independent duty corpsman, surgeon, certified nurse anesthetist, nurse, and senior medical officer (in my case, an internist). Also, we (the medical department) are inexorably integrated into the community at large – you will see your patients at meals, walking to the laundry, in the gym…. As the Ship's Nurse, I was selected for the job ("billet" in Navy parlance) based on my expertise and experience in critical care. Thankfully, in my nearly three years on the USS George H.W. Bush, those skills were rarely needed. Instead, I found that nearly everyone is comfortable talking to a nurse, and thus I spent a great deal of time focusing my energy towards health promotion. Often, these conversations came outside of the medical spaces, occurring while I was walking around the ship to plan locations for medical emergency drills, or providing CPR training to a team of sailors in return for their assistance with a medical training event. Conversations with officers, chiefs, and junior enlisted sailors provided me with an opportunity to explain the mental health resources available (we had a clinical psychologist and a psychology technician on board), and suggest or escort walk-in referrals, based upon my assessment of the patient's acuity.
"Another theme was: 'Turn the ship around' emergencies: Everyone on board has met the criteria the Navy has established for sea duty – no known issues that cannot be safely managed in this medically austere environment. However, the 5500 personnel on board (including air wing personnel) are predominately young people (approximately 80% are less than 25 years old), many of whom have poor or poorly developed coping mechanisms, and most of whom are having a totally new, stressful experience. In addition to the unique stresses of the work environment, they face the same challenges as many others such as balancing current job tasks with educational/career development aspirations and personal or professional relationship stressors. When medical emergencies arise, they are considered 'turn the ship around' (that is, change course/reduce mission capability) if there is a threat to life, limb or eyesight. Behavioral health emergencies are particularly challenging, based on limited staffing and the high-risk industrial environment. As the only registered nurse responsible for all inpatient care (in theory, up to 55 beds, including three intensive care) developing a plan for safe inpatient behavioral health care required team work with the psychologist and psychology tech, as well as the family physician and senior medical officer. Additionally, we needed to develop and execute training for the four 'general duty' hospital corpsmen who were assigned to rotating shifts on the inpatient ward, as only one of the four had any prior inpatient experience, and none had received formal training on behavioral health issues beyond a two hour lecture during their basic medical training.
"Challenges with implementing basic wellness like sleep hygiene abound on a carrier. Some sailors live in 120 person berthing areas with little control over lights/sounds (launching and recovering aircraft are rather loud), not to mention the snores of scores of fellow sailors and the noise disruptions of shift workers. There really are extraordinary opportunities for meaningful integration of behavioral health into the daily lives of our sailors and their families, but they require creativity, energy, and perseverance, as few are inspection requirements." Former US Army Surgeon General Patty Horoho constantly reminded her medical command that "the average annual amount of time spent with each patient is 100 minutes; this represents a very small fraction of one's life. It is in between the appointments – in the Lifespace – where health really happens and where we desire a different relationship with Soldiers, Families, and Retirees." "If it is in the right direction." Aloha,
Pat DeLeon, former APA President – Division 18 – February, 2017
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