Originally Broadcast November 8, 2008

Washington, DC

Mr. Morales: Good morning. I'm Albert Morales, your host, and managing partner of The IBM Center for The Business of Government.

The provision of health services is a critical and significant mission within each branch of the U.S. military. The U.S. Department of the Navy's Bureau of Medicine and Surgery has a long and cherished tradition of serving and safeguarding the health of U.S. Navy and Marine Corps personnel. The Bureau plays a central role in the most effective joint casualty care and management system in military history, a system that has saved thousands of lives that otherwise would have been lost on the battlefield.

With us this morning to discuss his role is Vice Admiral Adam Robinson, U.S. Navy surgeon general and chief of the Navy's Bureau of Medicine and Surgery.

Good morning, Admiral.

VADM Robinson: Good morning.

Mr. Morales: Also joining us in our conversation is Tom Romeo, IBM's general government industry leader.

Good morning, Tom.

Mr. Romeo: Good morning, Al.

Mr. Morales: Admiral, although many of our listeners are familiar with the U.S. Navy, they may not be familiar with the U.S. Navy Bureau of Medicine and Surgery, also known as "Navy Medicine." Would you share some history with us? When was the Bureau of Medicine and Surgery created? Tell us a little bit about its mission, and how does it support the overall mission of the DoD?

VADM Robinson: Al, thanks very much for having me this morning. The Bureau of Medicine and Surgery, affectionately known as BUMED, has existed since 1842, when Congress established the chief of the Bureau of Medicine and Surgery. And the surgeon general's title has existed since approximately 1871, when Congress took the Navy commissioners, which originally were set up to administer medicine and engineering and navigation, and actually made bureaus. So in fact, BUMED has existed from 1842, and the title of surgeon general has existed since the 1871/'72 timeframe, which then goes to this point: I am the 36th surgeon general of the Navy, but I'm the 40th chief of the Bureau of Medicine and Surgery. And that discrepancy accounts for the time differences that Congress chose in order to establish what we now know as the Bureau of Medicine and Surgery

The mission of the Bureau of Medicine and Surgery -- and thank you very much for understanding that BUMED and Navy doctors and all of Navy medicine supports not only our Navy, but also our Marine Corps. And in that effort, force health protection is what our mission is. Force health protection includes a fit and ready force, deploying with the warfighters, supporting the warfighter no matter what that support may be, and then taking care of eligible family members and those who have worn the cloth of the nation, our retirees.

Additionally, we have a new strategic imperative, which has come about since the initiation of the 21st century maritime strategy, and that is humanitarian assistance and disaster relief, which has become a major portion of what we in Navy Medicine do and what we in Navy and even Marine Corps do. So that is, in a capsule format, the mission of Navy Medicine.

Mr. Morales: Well, that's a wonderful long and very broad history and mission. Could you give us then a sense of the scale of operations that we're talking about here? Perhaps you can talk a little bit more specifically about your office, how you have it organized, your budget, size of your staff, and perhaps a sense of how you're geographically dispersed around the globe.

VADM Robinson: I think of my office as being corporate headquarters for Navy Medicine. The Bureau of Medicine and Surgery -- again, BUMED -- has approximately 1,000 people on Potomac Annex, which is exactly -- which is the hill on which we reside across from the State Department. Navy Medicine encompasses approximately 59,000 people. Of that number, 25,000 enlisted -- I think approximately 12,000 officers. We have a number of GS employees and also contractors, which make up that 59,000 total.

We have a budget of approximately $3 billion a year. And we encompass the entire world in terms of where we go. We are involved in every aspect of naval operations, as we say "from the blue side," which means from the Navy ships, Seabees, and wherever sailors may be; and also the green side, which is the Marine side, so in Afghanistan, in Iraq. Anywhere that our Marine Corps is, Navy Medicine is also present. So it is a worldwide operation.

We have research facilities located around the world: South America, Egypt, Indonesia. We have facilities throughout the United States, which include medical centers, family practice, teaching hospitals, and different hospitals and clinics. And we also have overseas hospitals in Europe and in Asia. So truly, the Bureau of Medicine and Surgery, BUMED, is a worldwide operation. We go 24 hours a day, 7 days a week because that's the nature of medical care.

Mr. Morales: Right, great.

Mr. Romeo: Well, Admiral, now that you've given us a view of the global operation, maybe you could tell us a little bit more about your specific responsibilities as the U.S. Navy surgeon general and the chief of the Navy's BUMED.

VADM Robinson: My job is threefold, I think. We can talk about it in many different ways, but programs, that's money; personnel, that's people; and policy. As the surgeon general, I am the chief medical advisor to the chief of Naval Operations. I am also the person that vets the medical policies, whatever they may be, throughout Navy Medicine, and that includes both the operational forces, the active forces, and also those eligible family members -- what we used to call "dependents" -- and also retirees. So working with OpNav, working with TMA -- TRICARE Management Activity -- we deliver a worldwide health benefit to those men and women who are both active, retired, and who are eligible family members, to make sure that they can get the force health protection I've talked about, and also the medical care that they deserve.

Mr. Romeo: Great. And within your responsibilities, what would you say are the top three challenges that you face in your position? And how have you addressed those challenges?

VADM Robinson: Well, the top three challenges are personnel, programs, and policy. Now, within the personnel point of view, I think that we have some major challenges with making sure that we have the right people doing the right job at the right time. I'll give you a fast example: mental health professionals.

We need more psychiatrists, psychologists, social workers, occupational therapists, and psychiatric nurse practitioners as well as our psychiatric techs. We are now competing with the Department of Veterans Affairs, Air Force, Army, and the civilian population is a universal need my major issues with personnel is just to compete for scarce resources in a world that needs the same professionals. That would be number one.

I'm very happy to tell you that for the first time in the last five years, we have made our goal for health professionals in our HPSP, Health Profession Scholarship Program. We have to grow our people, and the pipeline for growth is actually 10 to 15 years. We're making those goals now. Now the onus of responsibility is on us to make sure that we can retain these qualified people and that we can train them.

So the third thing is graduate medical education, which also includes research, which is the cornerstone and the bedrock of what I have to do from a Navy Medicine perspective in order to make my men and women who are in Navy Medicine understand that we care about them and that they have a worthwhile career path.

Mr. Morales: Admiral, one can say that you've heeded two sets of callings: one is as a medical professional, and the other one is as an officer in the U.S. Navy. I'm always curious, what brought you to service as both a physician and an officer within the U.S. Navy? How did you get started?

VADM Robinson: Well, I got started because I was in the first class of HPSP, Health Profession Scholarship, students. In 1972, when I finished Indiana University and was on my way to medical school, I needed to have a way to pay for medical school, and that's when the HPSP program came around to my campus.

I think it's as much a view of the country in the '60s, a view of President Kennedy, a view of his assassination, a view of him being brought back to the National Naval Medical Center -- indelibly printed on my mind. And it always gave me -- it always made me feel that I would like to be a part of that organization called the United States Navy. There was no one in my family in the Navy before. My father was a physician -- no military service.

What has kept me in the military is the fact that I have served with the greatest group of professionals and greatest group of people that I could have ever been with. I haven't wanted to leave this organization because of the people that I'm with.

Mr. Morales: That's great. That's fantastic. Admiral, as you sort of reflect upon all of these experiences, and I understand that you've held several commands during your career, how have these experiences prepared you for your current role as surgeon general and chief of the bureau?

VADM Robinson: As a general surgeon, as a colon and rectal surgeon, I've spent most of my years on active duty as a practicing surgeon and as an educator, teaching and training residents and actually preparing the next generation of surgeons -- the first thing is to become professionally competent, and I certainly was able to do that.

The second thing is the lifetime education that you have to commit to in medicine also means that you need to commit to those things that are not clinical but are still executive-oriented; All medical care is local. Medical care ends up being between a provider and a patient -- that's what the nature of medicine is all about.

So I've learned and been able to have a professionally rewarding career in clinical surgery. There are very few opportunities in corporate America or in the private sector that can afford you the breadth and the depth of the experiences that I've been fortunate to have.

Mr. Morales: Great.

What about the significant advances in combat casualty care? We will ask Vice Admiral Adam Robinson, surgeon general of the U.S. Navy, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Vice Admiral Adam Robinson, surgeon general of the U.S. Navy.

Also joining us in our conversation from IBM is Tom Romeo.

Admiral, would you explain for us the joint doctrine on force health protection? What are its key components, and what are the benefits from following this doctrine, and what makes it different from perhaps other operational approaches?

VADM Robinson: The military health system -- Army, Navy, and Air Force -- we're all after the same thing: force health protection. Force health protection has several components, and those components are to make sure that, number one, we're practicing the best in preventive care and that we're keeping fit ourselves, both from a physical point of view, but also an emotional and even a spiritual point of view.

The second thing is to make sure that we can provide whatever capability that the warfighter may need. Make sure that we are providing for the line -- to perform their function. The third thing is to make sure that we can provide the comprehensive look, medical care that we need. We need to be able to provide that medical care. We have to make sure that it gets there.

And lastly, we have to make sure that we take care of our families. This is being very Navy-centric. We practice patient and family-centered care because we recruit individuals, but we retain families. We take care of all members of the family. We have to make sure that we provide that comprehensive medical care.

And last, but not least, are those who in fact have served. That's our retired population. As I say, those who've worn the cloth of the nation, we have to make sure that we are there for them. So we have a medical system that's force health protection that literally goes from cradle to grave.

Mr. Morales: So it's very, very comprehensive, great. Could you paint for us a picture of Navy Medicine's battlefield operations? Specifically, could you give us some examples of your forward-deployed assets that may act as the first oasis of care for warfighters who may be seriously wounded? And what have been some of the challenges and perhaps some of the lessons that you've learned over the past couple of years?

VADM Robinson: Well, the first oasis of care is actually our corpsmen. Who are embedded with, for example, our Marines who are teaching our Marines, exactly what to do in terms of injury, exactly how to apply the new tourniquets that we have. In fact, how do you care for one another on the battlefield, because the first person to you may not be that corpsmen, it may be your buddy. So buddy care becomes very important, and it's the onus of responsibility of Navy Medicine vis-�-vis our 8404 Corpsmen, corpsmen with the Marine Corps, to do that.

The second thing is that we can get comprehensive care for the individual in the right amount of time. We always speak of the golden hour, from wounding to definitive care. It's essential that we have a system that will allow us to do that. So we've done that looking at the Forward Resuscitative Surgical Units, the FRSSs. This is a way of getting surgeons anesthesiologists, corpsmen, our OR techs, and our nurses forward with the forces so that when they are wounded, we can get them -- it's resuscitative surgical care. Resuscitative surgical care means that we do life and limb salvage surgery, and then with en route care, place them at a higher level of surgical or medical capability so that we can do definitive care.

In our present operations in Iraq, utilizing the approach that I'm describing to you, we have had our highest level of care with the lowest mortality rate and highest survivability rate of any conflict.

The en route care system is a method of actually getting you from one level of care to another. In other words, you're in the field. You're then heloed to a Level 3 facility somewhere in Iraq, for example, and then you are then airlifted, usually by C-17, from that Level 3 care to Landstuhl; often from Landstuhl back to either Bethesda or Walter Reed. The key here: wounding occurs; usually within 72 to 96 hours, you may be at the definitive care site. So this is truly a phenomenal system that has incorporated Army, Navy, Air Force physicians, nurses, medical service corps, corpsmen, airmen, medics together to build a system that will allow for the best in trauma care.

Mr. Morales: Admiral, when I think of health care, in my mind I always think of very tangible bricks-and-mortar heavy equipment, things that don't transport very well. Could you tell us a bit more about the Navy fleet hospital transformation? Specifically, how has the Navy Medicine contributed to redesigning the U.S. expeditionary medical capabilities into much lighter, modular, and mobile theater equipment?

VADM Robinson: Well, the fleet hospital construct, for lack of a better word, is one that included, as you said, a very heavy equipment module, and then thousands of people to recreate a Level 3 or a Level 4 medical facility. Have all of the specialties that you would have at any hospital in most of the United States.

The key is that as we did this in the first Gulf conflict. There weren't many casualties. It took many months to actually set that hospital up, and we had literally thousands of people who were standing by in order to take care of casualties. We didn't have many casualties.

Irregular warfare has different magnitudes of scale and emphasis is much more mobile and is much more elusive, as it were, we need to make sure that we can keep up with that. We don't need to send in large, heavy facilities that are people-laden. We need to send in the right number of people with the right specialty mix with the right amount of equipment and the right amount of gear, so that we can do very fast, mobile, and flexible care.

Mr. Morales: Great.

Mr. Romeo: Admiral, you talked quite a bit about some significant advances in combat casualty care and moving patients to care facilities very quickly. Could you elaborate a little bit on how Navy Medicine and other services disseminate the advances that they find in medical trauma management to non-military and civilian health care practitioners?

VADM Robinson: You name the specialty and we have that particular hook-up with our civilian surgical specialty counterpart. So the first thing is that we write papers and we deliver and actually go to those organizational meetings yearly and provide data on the things that we're doing around the world.

I'll give you a quick example. If you look at military medicine, for example, en route care, en route care is something that is no more than having a helo available to transport a patient. Today, in most urban settings, we have helos that are out taking victims from crash sites or other trauma events to medical centers and to trauma centers. This is a direct reflection of what happened in both World War II and particularly Korea. So there's a lot of translation that occurs between the medical world on the military side and what we do in civilian.

Some other quick ones. Resuscitation of trauma patients: This is directly a result of a multitude of Navy Medical Research Institute, Navy Medical Research Command, Walter Reed Army Research Command. A lot of military researchers have done tremendous amounts of work in all sorts of different traumatic events. What we do on the battlefield can be translated to the city -- there's really a direct result.

And I think a lot of effort is placed on the military side to remain current, and talk to our civilian organizations.

Mr. Romeo: Great. Admiral, could you tell us about the Navy Medicine's Comprehensive Combat Casualty Care Center, or C5, as it's known? And specifically, how does it facilitate the crucial participation of families in the total healing process of wounded warriors?

VADM Robinson: C5 is in Balboa Navy Medical Center, San Diego. The concept of comprehensive care occurs there and also at the National Naval Medical Center in this regard: We have found that in order to fully leverage all aspects of the care that a patient needs, we need to have a team approach to that care, a trauma surgeon that directs the care, orthopedists, ear, nose, and throat surgeons, chaplains, mental health professionals, social workers. We need all of those people to make sure that we, in fact, coordinate care properly, and that we communicate with patients and with patients' families properly.

We'll have people who have devastating injuries return to National Naval Medical Center. They will require multiple operations. We bring the patient into a comprehensive care setting in which one person coordinates care. We then coordinate the surgeons and the professionals around that patient. So during one anesthetic procedure, which may last many, many hours, we will have all of the surgeons in and perform that surgery on Monday, so that we can feed and rehabilitate the patient Tuesday, Wednesday, Thursday, and Friday.

Now I have to go to the second part, and this is the Balboa, the C5. We not only are caring for the patient's immediate needs, but that we're caring for the needs, for example, of the patient that's lost a limb to make sure that they have the proper physical therapy, that they're fitted appropriately for the prosthesis learn how to use the prosthesis get the greatest value from the prosthesis. Additionally, we have to educate the family. We have to educate the community. We have to educate the patient. And often we have to educate our own staff as to how the needs of the patient and the family have to be addressed in non-war settings.

The key here is that we need to be very flexible and agile from the trauma perspective it is our highest honor and it's the most important thing that we can do in terms of caring for our injured patients to make sure that they have the care that they need and that their families have the care for a lifetime.

So the center, the C5 center in Balboa, has been the West Coast approach to doing the same thing that both National Naval Medical Center and Walter Reed have done in the Washington area.

Mr. Morales: So it really goes well beyond healing just the immediate injury. It's really about rehabilitating the whole individual and everyone around that individual.

VADM Robinson: Correct. It also means that we need to become involved with the systematic rehabilitative care. And that systematic rehabilitative care model is usually a Department of Veterans Affairs model. DVA is still there with us, but it means that we need to partner with DVA, with the VA facilities, with the polytrauma centers around the country.

Mr. Morales: Admiral, we only have about another minute left, but I do want to switch gears here quickly. I understand that the new maritime strategy calls for Navy Medicine to be globally engaged with allies as well as supporting humanitarian missions and responding to disasters. Could you elaborate for a moment on Navy Medicine's involvement in some of these relief efforts, and to what extent do such engagements represent an extension of U.S. soft power in the form of medical diplomacy?

VADM Robinson: The U.S. is beyond peer in terms of hard power. We also have to become good at winning the peace. Winning the peace means that we need to have soft power projection, and probably one of the most significant and best ways to do that is via humanitarian assistance. A disaster relief also comes into play as we think of the tsunami in Indonesia as an example.

The humanitarian assistance/disaster relief piece centers around two basic platforms. It centers around medical and engineering platforms. The things that people in the developing worlds and people who have been in disasters and who need humanitarian assistance, what they need first is they need superb medical care, not necessarily trauma. We're particularly good because we're expeditionary and we have platforms that have built-in infrastructure. So when the USNS Mercy or Comfort arrive, we have fresh water, we have electricity, we have the capability to do the surgery, we have the medical equipment, and we don't have to depend on anything in the particular area that we're going into to deliver that particular material.

We do it are not only through our hospital ships, but also through our large-deck amphibious forces and through other vehicles that we have on the Navy side.

We've done a lot of humanitarian assistance, and I think that we are absolutely set to do more in the future.

Mr. Morales: That's fantastic. Thank you.

How is Navy Medicine treating traumatic brain injury? We will ask Vice Admiral Adam Robinson, surgeon general of the U.S. Navy, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Vice Admiral Adam Robinson, surgeon general of the U.S. Navy.

Also joining us in our conversation from IBM is Tom Romeo.

Admiral, it's been said that traumatic brain injury, or TBI, is considered the signature injury of the Iraq War. First, could you just take a moment and describe what constitutes TBI? And second, would you tell us about research in TBI prevention, assessment, and treatment, and how prevalent is it among your sailors and Marines?

VADM Robinson: TBI, traumatic brain injury, is an insult to the brain which is usually caused by a blast and a pressure gradient difference between the outside of the head and the inside of the head. There is a great deal of difference in the mechanism of injury and perhaps in how you diagnose and even how you treat those injuries.

Most of the data that we have is based on traumatic injuries that have occurred with what we call contrecoup injuries from hitting your head. And now we're having to deal with that pressure gradient and that actually blast effect has a different mechanism of injury in the brain itself.

Understanding how to diagnose traumatic brain injuries has really been very problematic we have thought that only people who are unconscious have traumatic brain injuries. We're finding is state of consciousness is not necessarily a determinant. Distance from the blast itself may not be a determinant. It may be a variety of different things that we have to take into question and to take into consideration as we make the diagnosis of traumatic brain injuries. Probably the best way of making the diagnosis is to do cognitive assessments of someone before they go into a conflict, and then do the same cognitive assessment of them after they have been introduced or been involved in a blast or been involved in some sort of injury. We're learning that there are numbers of people that have traumatic brain injuries that we've never listed before.

I'll give you the RAND study that says of the 1.6 million men and women who have been in combat theater operations, perhaps up to 20 percent of them may be involved with traumatic brain injuries

And the key here is that it is a rampant disorder that needs to be dealt with. And it's the type of disorder that can be very subtle and may be very difficult to detect. Usually, you're not going to be aware of it as much as perhaps a loved one that knows you well may be aware of it. So it's one of those insidious disorders that needs to be treated appropriately.

Mr. Morales: Along similar lines, Admiral, in some of the previous segments, we talked a little bit about psychological and mental health. Given operational tempo and the stress it places on service members, what is Navy Medicine doing in the area of mental health? Specifically, could you elaborate on the programs in place to diagnose, prevent, and treat service members in this area?

VADM Robinson: The combat operational stress care that we're doing now across the theater is very important. The first thing it's absolutely a leadership initiative. My leadership on the Navy side and my leadership on the Marine Corps side have taken full responsibility for caring for our sailors and Marines and trying to prevent operational stress. It starts from recruit camp and it goes all the way through war college.

Leadership is absolutely important in terms of talking to people, destigmatizing the need for mental health care, of letting people know that, as Heidi Kraft has stated so eloquently in her book Rule Number Two, rule number one is war hurts people. Rule number two is you have the invisible injuries of war, which are psychological, emotional, and I think spiritual injuries that have to be attended to also. Operational stress control is a formal method of trying to make sure that we remember rule number one, rule number two, and then we provide the care that people need: the mental health, the emotional health, and the spiritual health, which then means that we have our mental health professionals, our psychiatrists, our psychologists, our licensed clinical social workers. And we also have our chaplains who are there and who are talking and embedded with our men and women in their units on a day-to-day basis, so that they can have the mental health capability from the very first day and, if need be, they can be sent back to have further and more intense therapy.

Mr. Morales: So again, it goes back to this notion of a holistic approach to care.

VADM Robinson: A holistic approach to care and, again, you cannot divorce this from leadership responsibility. And I am talking now line leadership responsibility and care of our sailors and Marines. And our line has taken this on fully, both Marine Corps and Navy.

Mr. Romeo: Thank you, Admiral. I'd like to shift gears a little bit. I know that the Navy is also very heavily involved in research, and research is at the heart of nearly every major medical and pharmaceutical treatment advancement. Could you tell us about Navy Medicine's research and development efforts? And specifically, what work is being done by the Naval Medical Research Centers, Biological Defense Research Directorate, and the Naval Health Research Center? Did those labs play in the worldwide monitoring of new emerging infectious diseases such as the avian influenza?

VADM Robinson: The Navy's research efforts, particularly in the form of infectious disease, is second to no one's. As a matter of fact, two particular vaccines which are now being tested -- and by the way, Army has played very heavily in these vaccines, also. The two are malaria and HIV. So both of those research vaccines, neither one has been approved, they're both in the research stage, but both of those have in fact come along, and that's with the diligent efforts of our researchers and our infectious disease experts.

We've partnered with the Indonesian government in particular and with other governments from the Asian community to look and to review samples of patients that are thought to have Asian influenza. And there's been a great deal of effort placed on trying to not only develop a screen for that particular disease, but also to develop a vaccine for that disease. Now, I'm going to shift on research and also tell you two things. The ability to have first-rate medical education in the military is dependent upon having medical research, the type of medical research that's being done at Walter Reed and at Navy Medical Research Commands. Actually a broad spectrum of bench research that's very critical to having a strong medical department. And the second is the clinical research that needs to get done from our medical centers.

The research community in the military and in the Navy has always been very heavily involved in both fundamental bench research and also the clinical research that we can translate into ways and methods to care for our patients on a daily basis.

Mr. Romeo: It would seem that collaboration with your federal health care partners is essential to providing quality care to returning wounded warriors. Would you tell us about your efforts to increase collaboration in resource sharing, new facility construction, and joint ventures with the U.S. Department of Veteran Affairs?

VADM Robinson: Presently, the Navy and the DVA, Department of Veterans Affairs, have open up a joint medical facility in North Chicago called the James Lovell Medical Clinic in North Chicago. It's a way of bringing together and partnering with Department of Veterans Affairs, which has a large veterans hospital there, the Navy, which has had a large naval hospital there.

It will be run by a Department of Veterans Affairs hospital administrator. The second in command will be a Navy chief operating officer. It will have both Department of Veterans Affairs and naval medical officers and dentists and health care professionals. And it will care for not only our recruit command, but also those individuals that are serving in the North Chicago area that may be eligible for care. So it's a way of partnering and sharing resources.

We have another facility at Pensacola, Florida; not nearly as far along in the development as in North Chicago, but still very promising. We also have another agreement in Guam between Department of Veterans Affairs and the naval hospital that we are -- the new naval hospital that we're building there.

The key to success for the future is to take our wounded warriors, who we will have a lifetime commitment to care for, to partner with the Department of Veterans Affairs to partner with DoD. Then to take those two great institutions and marry them together so that we can provide care for our wounded warriors that we will have to do in the future.

The reflection of how good we are and the reflection of how good our nation's promise is to our wounded warriors is how are they doing in long after this conflict is over.

Mr. Morales: That's great. Thank you.

Admiral, I only have about another minute, but I do want to get to a question around some of the challenges that perhaps you face around end-strength targets for medical personnel. What steps have you taken to address some staffing shortfalls and attract personnel staff? And what challenges still remain in this area?

VADM Robinson: Well, there are multiple challenges to shortfalls. The largest one we have today is mental health professionals. I need psychiatrists. I need psychologists. I need licensed clinical social workers. I need psychiatric nurse practitioners. I need psychiatric techs. I need occupational therapists.

The Navy made some decisions years ago. We thought that we didn't need as many uniformed social workers and as many uniformed psychologists as we now know that we do need. And we're trying to correct that by looking at our requirements.

And the way we do end strength in the military is you have to look at the requirements. We have to look way ahead, usually a five-year model. And we have to hope that we are correct because usually the decisions we made in 2009 and '10 often won't be reflected completely until 2015 or '16 in terms of where we are with end strength and where we are with capability.

All three services are competing with one another. The people who are at Health Affairs, are looking at policies to make that competition less and let us share more.

I think that end strength is going to be reflected in the fact that as the Marine Corps grows and the Marines go nowhere from an operational point of view without Navy Medicine, Navy.

I think is a reasonable medical end strength to make sure that we have the capability of delivering force health protection to you and to the commandant of the Marine Corps when you need it, where you need it, and how you need it.

Mr. Morales: Great.

What does the future hold for Navy Medicine? We will ask Vice Admiral Adam Robinson, surgeon general of the U.S. Navy, to share with us when the conversation about management continues on The Business of Government Hour.

(Intermission)

Mr. Morales: Welcome back to our final segment of The Business of Government Hour. I'm your host, Albert Morales, and this morning's conversation is with Vice Admiral Adam Robinson, surgeon general of the U.S. Navy.

Also joining us in our conversation from IBM is Tom Romeo.

Admiral, as we've discussed this morning, prompt and comprehensive medical treatment is a priority for service members suffering from an illness or an injury. Now, the National Naval Medical Center is the facility that has treated most returning casualties. As such, what are some of the critical lessons learned from NNMC which has led to improvements and enhancements to Navy Medicine's continuum of care?

VADM Robinson: The first is that we have to have a comprehensive care model, as I've already discussed, but that is absolutely crucial to the success in the future. You cannot segment care and you cannot in any way make care piecemeal. It has to be comprehensive and it has to include the physical, the emotional, the mental, and the spiritual well-being of the patient and -- this is critical -- and the family. The family has to be included in that model.

We have now developed a system whereby we have en route care, which is about as good as you can get considering that we can bring critically injured people from the battlefield to our medical center within virtually hours of wounding. And we have also developed a system where we will have our families who usually get there either simultaneously with the patient, very often a few hours before the patient. And we have to make sure that we care for them and care for their needs because they have become an integral part of the healing of that patient.

There is a concept of care that Navy Medicine has, which is patient and family-centered. This is not a slogan. This is a reality in terms of how we think about patients. We make sure that we bring all of our medical assets to the patient and to the family. We do not allow them to go out and search for those things. The onus of responsibility in care is on our shoulders, and we in fact, take that very, very seriously. It is important to make sure that we coordinate care for patients and for families. Their responsibility is to help in the healing process, not to coordinate their care.

Mr. Morales: Great.

Mr. Romeo: Admiral, would you tell us more about the key recommendations outlined in the President's Commission on the Care for America's Returning Wounded Warriors?

VADM Robinson: The key recommendations, I think that there are approximately six of them. And the key recommendations are going to be summed up in this regard: The first thing is that we have to have a comprehensive look at care and what we're doing for patients. We have to make sure that we take care of families. We have to make sure that we can deliver the care that patients need regarding the injuries that they are receiving. We have to make sure that we have both an acute model of care, which the military service does well, but we have to lash that up with the systematic rehabilitative model that the Department of Veterans Affairs also does. We have to make sure that we take care of patients in the immediate, but we also take care of them with the future in mind. And that we, no matter what care or what circumstances of care and treatment that we start, that we not only finish that care, but that it becomes a sustaining care model for the future.

Now, the six recommendations that were made are very specific recommendations. What I just told you are my interpretations coming out of those recommendations. That's what I think the Presidential Commission was trying to get at. And I think that in fact, we in Navy Medicine have taken that to heart. I actually think that the military health system -- Army, Navy, and Air Force medical -- have taken that to heart and are trying to provide that.

Speaking for Navy Medicine, I can assure you that we take this very seriously and that we are trying, in fact, to do what Secretary Gates has told us that we have to do. And that is there's no higher priority after the war itself than to take care of those men and women who have been wounded.

Mr. Romeo: Certainly in the programs and initiatives you discussed today, a lot of that comes through, so it sounds like you're well on your way to meeting those recommendations.

Admiral, I understand that you were a recent Banneker Institute Legacy Award winner. Congratulations.

VADM Robinson: Thank you very much.

Mr. Romeo: And could you tell us a little bit about the award and what the mission and vision of the Benjamin Banneker Institute is?

VADM Robinson: The mission and the vision of Banneker Institute is to shine the light on the African-American community and ostensibly on the minority community, and that is Asian Americans, Indian Americans, no matter what minority we are talking about

The Benjamin Banneker Institute and the award I received is simply a way of recognizing that there are not only individuals, but there are individuals committed to the success of minorities in science, technology, engineering, and mathematics.

Freeman Hrabowski, the president of University of Maryland, Baltimore campus, an African-American, has in fact one of the greatest science, technology, engineering, and mathematics programs that I have ever seen. He can show you firsthand that we can make the goal if we have real interest in trying to do that.

Mr. Morales: That's fantastic. I know the stem disciplines are vitally important to our nation. Admiral, I'd like to transition now to the future. What are some of the major opportunities and challenges that Navy Medicine may encounter in the future? And how do you envision your office will need to evolve over the next couple years to meet those challenges?

VADM Robinson: That's really a wonderful question. I sat all day, believe it or not, before I got here -- I shouldn't say all day, but for the last several weeks, talking about the future of Navy Medicine and what -- where do we need to be. I think that there are a number of areas that we need to be.

First of all, in terms of medical research, we certainly have to be involved in that: infectious diseases, emerging infections. But also, the research of military platforms, of military treatments, of quality -- of what is medical quality and how do you define it and how do you prove that you have actually gotten it.

And the other point is humanitarian assistance and disaster relief. We're really -- we're not at the beginning of it, but we're at the beginning of a strategic imperative by the entire Navy that has now incorporated that. And we need to have a methodology that not only shows what we do, but the effect of what we do. So the question is how do you know that this humanitarian assistance or this disaster relief operation was effective? We have polls now between countries. We liked the United States before. Well, we didn't. And then after the humanitarian assistance mission, we really liked them. But the key is there are other more precise mechanisms that we need to develop.

I think that we need to look at the medical infrastructure across the military health system. And we need to come to some conclusions as to how we're going to keep that strong and vibrant, particularly in the time of all-volunteer force. And I think we can do that, but I also think that we need to make sure we have the proper incentives, both from a monetary point of view and also from an educational and a career point of view, to make sure that we have commitment to that.

We need to make sure that America understands that the difference between military and non-military, in very many respects -- I didn't say military medicine, I said military and non-military is simply the word "service." Those of us in military have decided that we love the people that we're with, but we also are in love with the concept of service. We need to make sure that the American people realize that the strength of the nation is only the strength of all of the individuals that make up that nation, and that service is a way of giving back to the country a small fraction of what we have gotten from our great country. And we need to incorporate that in the future in how we in fact do our manpower and how we attract personnel to our Navy. And I think that that's something that we need to continually think about.

Mr. Morales: Well, on that note, Admiral, what advice would you give to a person who perhaps is out there thinking about a career in either medicine or public service or perhaps ideally both?

VADM Robinson: I think that one of the things that -- as I said, the service aspects are just tremendous. The collegiality and the people that you'll meet in the service are absolutely second to none. I have been very fortunate in my career to have received my education. And I tell people this and it's sort of funny. I have gotten nothing I asked for when I asked for it, but I've gotten everything I've asked for. And I think in very many respects the orders that I wanted to a different location or the orders or the commitment that I wanted for postgraduate education, none of it came when I wanted it, but it all came. I got every bit of it done. And I think that that is the way the Navy and the military works.

It's a fulfilling life. It's a life that is very exciting. And it's not duplicating -- it's not duplicatable anywhere but in the military. In other words, I can't go to the civilian sector and duplicate the life. And it's just -- it's very exhilarating and it's something that I certainly would do over again. After 31 years, I've enjoyed every day and I would do it again if I could.

Mr. Morales: That's fantastic and just a wonderful perspective. Thank you.

Unfortunately, we have run out of time. I want to thank you for fitting us into your busy schedule. But, more importantly, Tom and I would like to thank you for your dedicated service to our country and to our men and women in uniform, both as an officer and as a surgeon.

VADM Robinson: Al, Tom, thank you so much for having me here today. To be here as the representative of Navy Medicine is quite an honor. The men and women of Navy Medicine do a tremendous job day-in and day-out. The professionals that we have have kept in mind that we need three things in order to be great: we need to be professionally competent; we need to be personally committed to making sure that we take care of ourselves and our families; and we need to be spiritually active to know that we in fact are not the only ones that this is about, that we're only small parts of this, that it's about someone else and someone much greater than we are. That is what I think that military service and Navy Medicine has taught me, and that's what I think that I'd like to share with everyone in the audience today and actually everyone that ever comes around me.

Mr. Morales: That's great. Thank you, Admiral.

VADM Robinson: Thank you.

Mr. Morales: This has been The Business of Government Hour, featuring a conversation with Admiral Adam Robinson, surgeon general of the U.S. Navy and chief of the Navy Bureau of Medicine and Surgery.

My co-host has been Tom Romeo, IBM's general government industry leader.

As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who may not be able to hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.

For The Business of Government Hour, I'm Albert Morales. Thank you for listening.