“A Great Day to Be an Airman”

February 18, 2010

Afghan National Army Air Corps Graduates First Flight Surgeon Class

                A couple weeks ago, the Afghan National Army (ANA) Medical Command graduated its first class of medical logisticians.  To mark that monumental day, Mike Brown, the course director, said, “It is a great day to be a Soldier.”  Two days ago, it was the ANA Air Corps’ (ANAAC) turn to have a great day when they graduated their first class of Flight Surgeons.  The significance of this ANAAC event was recognized by the distinguished visitors who marked the event, including LTG Darwan (ANAAC Commander), MG Yaftali (ANA Surgeon General), MG Azimi (MOD Spokesman and MoD Deputy for Parlimentary Affairs), BG Barat (Kabul Wing Commander), and Brig Gen Boera (Combined Air Power Transition Force and 438th Air Expeditionary Wing Commander).  As a USAF Flight Surgeon, that event was my turn to say proudly “It is a great day to be an Airman.”

                This Flight Surgeon graduation was the culmination of months of effort by COL Rasoul (ANAAC Surgeon), Col Diane Ritter (previous ANAAC Surgeon Advisor), Lt Col Jeanine Czech (course director), and many other Afghan Airmen and advisors.  During their nine month course, the six newly-winged Flight Surgeons learned the evidence-based principles of aerospace physiology, spatial disorientation, flight safety, and physical standards.  With their newfound knowledge, these six Airmen form the nucleus of future ANAAC Aerospace Medicine cadre.  The result is that, for the first time, the ANA has doctors with knowledge and skill required to advocate for the health and welfare of the flying mission. 

                Aerospace Medicine is not just primary care medicine for aircrew and their families.  Aerospace Medicine is all about prevention and health promotion that improve flying safety and mission accomplishment.  Flight surgeons are required to participate actively in their unit’s flying mission in order to gain first-hand appreciation for the human challenges of aviation.  Flying as crew members also helps flight surgeons gain the trust and confidence of their patients.  It is said that the flight surgeon is the only doctor who routinely puts his life in the hands of his patients.  With the expertise these new flight surgeons have received, they and the mission will be in even better hands.

                 But their training is not over yet.  Like any great medical education program director, Lt Col Czech, proud Mom that she is, is already planning the next phase of their Aerospace Medicine training:  These six flight surgeons will remain in Kabul a while longer to continue their training and gain experience.  Their growing expertise will allow them to become teachers themselves: teachers of other flight surgeons, teachers of other Airmen, teachers of other fishermen.  THAT is building enduring capacity in the Afghan healthcare system.  It was and is a great day to be an Airman.

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Building Enduring Healthcare Systems in the Afghan National Security Forces – Part 3

February 13, 2010

“Eminence-Based Medicine” versus “Evidence-Based Medicine”

Speaking of improving medical practice, COL (Dr, Ret) Gary Davis, my predecessor four times removed, has an apt description of Afghan medical practice in previous years:  “eminence-based medicine” versus “evidence-based medicine”.  When we ask some of the ANA physicians why they may have, for example, prescribed five antibiotics for a cold, the answer is usually “That is how my teacher did it.”  The younger physicians are much more interested in reviewing journal articles in order to practice more evidence-based medicine.  That is very encouraging.  What is also encouraging is that ANA medical leadership is actually asking for advice in providing more structure to hospital staff practice.  To that end, we are in the process of updating and fleshing out the 2006 Ministry of Public Health hospital standards of care.  Specifically, we are developing standards for nursing, medical records, and internal medicine.  The best thing about this effort is that these will be true Afghan standards of care.  In case you missed my previous comments about Afghans holding themselves accountable, these standards will also come with requirements for Inspector General HSI-like assessments that will start with ANSF MTFs and spread to MoPH facilities.  They are not quite ready for Joint Commission standards, but this project will set them on their own quality improvement odyssey.

Lastly, how do we know if we are making the system improvements we intend?  You guessed it:  metrics.  In November, each ANSF hospital started documenting patient encounters on standardized forms that become a permanent part of the patient record.  That in itself is a paradigm shift.  Many providers had gotten away with only documenting a general diagnosis, if even that.  Clerks then transfer key information from the form to a patient database.  At the end of each month, we will have actionable data that ANA senior leadership can use to allocate personnel and supply resources to meet demand as well as focus future preventive medicine and medical education efforts to more common conditions.  It is not quite AHLTA and P2R2, but they are well on their way to having the tools they need to provide adequate command and control over their medical system.  Eighteen months from now, those systems will provide the proof of our successes.

This has been an incredibly challenging and rewarding year for me.  I have worked with some amazing US, Coalition, NATO, and Afghan personnel.  Many times, it feels like we are not making much progress.  I am confident, though, that the systems we have put in place, especially in medical education, will be the tipping point that carries the government of Afghanistan to provide self-sustaining security for its people.

Building Enduring Healthcare Systems in the Afghan National Security Forces Part 2

February 11, 2010

It has been said that it is better for the Afghans to do it “good enough” to an Afghan standard than for us to do it for them.  Some Afghans seem very happy to have us buy them their fish, clean it, cook it, and even take care of the dishes.  We are here to teach them to fish.  And teach them we will.  In fact, the best way for us to teach them to fish is for us to teach them to teach others to fish.  That is the point behind what may be our most gratifying efforts.  On the Coalition and ISAF medical mentor/advisor side, we recently published a 150-page medical mentor handbook, containing everything we wish someone had taught us in predeployment training.  It is a living document that will be translated from English into French for distribution to any one of the other 40-plus NATO nations who may participate in the NTM-A medical mission in the future.  On the ANSF side, we have now trained over 100 Afghan medical personnel in faculty development, teaching Afghans how to teach medicine to other Afghans.  That will be the key to sustainability.  In the coming year, in cooperation with USUHS, University of Nebraska Medical School, and the Nebraska National Guard, we will be starting true Graduate Medical Education, focusing first on warfighter services like trauma surgery, intensive care medicine and nursing, preventive medicine, and rehabilitative medicine.

The Afghans have already shown a remarkable ability to practice to their own standards.  The crown jewel of our efforts has been the creation of a real ICU at the National Military Hospital with a series of US Navy medical ETTs showing the way.  In a little over a year since starting the ICU, the Afghan-US partnership has equipped and staffed ten ICU beds and decreased initial ICU mortality from 30% to now 5% while the number of occupied ICU beds has more than doubled.  Not bad, but how are we doing outside the Afghan capital and the flagship hospital of the ANA?  A recent blog by a news network not necessarily friendly to our efforts made a comment that being sent to the ANA’s Kandahar Regional Military Hospital (KRMH) was tantamount to a death sentence.  That followed several comments made by some of our Coalition medical partners in southern Afghanistan that the mortality of patients transferred from those coalition MTFs to KRMH was 98%.  That seemed a bit high, so I asked the ETT on the ground.  Maj (Dr) Herman Ellemberger, Emergency Medicine advisor at KRMH, summarized the data he had so wisely already been collecting:  From July to December 2009, the overall KRMH mortality was only 4%!  That is hardly a death sentence.  In fact, many a developing nation in an asymmetric insurgent war would be quite proud to perform to such a level.

What else are we doing to develop ANSF healthcare?  Several months ago, CSTC-A initiated a medical special pays program that significantly increases the pays of physicians, nurses, and even Combat Medics.  But as we started looking very closely at actual hospital staffing to increase capability in hottest combat areas (Kandahar), we realized that we could not easily confirm that the physicians in the physician slots really were physicians.  There are many medical personnel who may have been working years in physician slots who have never actually been to medical school.  In January 2010, we will start a formal credentialing process.   Pending ANA and ANP SGs approval, we will interview each person in a hospital physician slot to document their training history.  We fully expect that a few individuals in physician slots will say “The Taliban ate my medical school diploma.”  For some physicians, that may be true.  Then all physicians will be required to take a knowledge assessment test, probably the same test required on graduation from Kabul Medical University.  If they “pass” to the Afghan standard, we will continue to endorse their physician special pay.  If they do not pass but want to continue to receive physician special pay, we will require they take extensive CME and retake the test 6-12 months later.  We expect resistance to this program, especially from older personnel.  The end product should be medical personnel who are motivated to improve their medical knowledge and practice.

Building Enduring Healthcare Systems in the Afghan National Security Forces Part 1

February 9, 2010

     So, how do you build an enduring military healthcare system in one of the poorest countries in the world?  How do you do that in the face of an active insurgency?  How do you do that in less than ten years when it has taken the US a couple hundred years to do it?  Where do you even start?  What are the priorities?

    Our #1 challenge is recruiting, training, and retaining an adequate number of qualified medical personnel.  We still need to train 3700 more front-line medics, plus 130 more nurses and 380 more physicians to support an Afghan National Security Force (ANSF) of about 190,000.  As the ANSF grows, we will need to double or even triple the number of trained medical personnel.  Our current projections are that we will have sufficient numbers of medics by 2014, nurses by 2016, and physicians by 2020 respectively…more than ten years from now.  This year, we started a military medical and a nursing school, regionalized Combat Medic training, and expanded the Allied Health Professions Institute for laboratory, radiology, and ultrasound technicians to include preventive medicine technicians.  I have to say that one of my proudest moments this year has been attending the graduation of our first nursing school class.  There we recognized the five graduates who had scored higher than 95% of the Afghan civilian medical school graduates who had rotated through the intern program at Bagram Craig Joint Theater Hospital.  There is great hope for a bright Afghan future.

     Compared to the daunting task of producing sufficient numbers of well-trained medical personnel, buying them “stuff” is the easy part.  This year, we have been building 50-bed expansions to the five 50-bed ANA regional hospitals.  Those are in addition to the 50-bed ANP Hospital and 400-bed National Military Hospital, considered by many to be the premier medical facility in Afghanistan, both in Kabul.  With over $50 million available to us for construction and equipment, we are well supported.  The challenge is that we must always balance what we can acquire for the Afghans with what we should acquire for them.  For example, there are nearly constant requests from some of the regional hospitals for CT scanners, a very reasonable request considering the volume of trauma some of them treat.  However, does it make sense to install such equipment when they do not have “clean”, reliable power?  Do they have a radiologist trained to read CT scans?  How about a CT technician to run the machine?  The answer to all of these questions happens to be “no” for now, so now is not the time to acquire these machines….maybe later when all those other prerequisites are in place.

     If buying them “stuff” is the easy part, getting the Afghans to change their behavior is the tough part.  The former Soviet command and control (C2) systems and attitudes are still very much ingrained in many of the ANSF leadership.  Three of my biggest mentoring challenges are getting leaders to take initiative, delegate responsibility, and hold themselves accountable.  It is common for a principal (an individual whom we are mentoring) to verbalize understanding and agreement that a certain task needs to be accomplished, yet refuse to act until a superior gives them a written order to do so.  It was a happy day when the ANA SG proudly showed me the daily report his staff had initiated to summarize management level information from their five hospitals and eleven 20-bed clinics.  Yet delegation is not something that comes easily to a culture where control of “stuff” is tantamount to power and a hedge against logistical famine.  We are slowly making progress in teaching that the reason for having that “stuff” is to ensure that it actually gets used to the appropriate benefit of patients and the unit mission.  And if someone makes a mistake, even if it is an elder or a fellow tribesman whom you respect, the correct response is to hold them accountable and teach them how to improve the situation for next time.  We are not here to build a US standard of healthcare.  We are here to build the best possible Afghan standard of healthcare.  It may take ten to twenty years to get there, but we are helping them get there.

“A Great Day To Be a Soldier”

February 6, 2010

               On 4 February 2010, the Afghan National Army (ANA) Armed Forces Academy of Medical Sciences (AFAMS) graduated its first Medical Logistician course.  The twelve graduates had completed a 3 week course of instruction on the ground of the ANA’s National Military Hospital in Kabul, Afghanistan.  Their training included fundamentals in receipt, classification, and storage of all medical supply items.  In addition, the students received training on CoreIMS, the electronic inventory management system that will allow these future medical logisticians to manage warehouses effectively using First In/First Out principles.  Most importantly for the medical system will be their ability to distribute medical supplies and equipment based on real-time customer needs.  From here, the graduates will return to their home units around Afghanistan where they will manage all aspects of the ANA medical logistics system from acquisition of pharmaceutical to biomedical equipment repair.

                The ceremony was officiated by Major General Ahmad Zia Yaftali, the ANA Surgeon General.  Also in attendance were the Afghan National Police Surgeon General Brigadier General Qandahar Shinwari, AFAMS commanding general Lieutenant General Ahmadi, and several other ANA Medical Command general officers.  MG Yaftali noted that this course represents a new phase in ANA training, the first time that the ANA will have officers specifically trained in this field, allowing doctors to dedicate their time to taking care of patients.  He reminded the graduates that their work will be absolutely critical to current growth of the Afghan National Security Forces that will secure Afghanistan for the Afghan people.

                Mike Brown, Medical Logistics course director and retired US Army Sergeant Major of the US Army Medical Command Center and School, started his comments as he says he used to start similar graduations in the US:  “It is a great day to be a soldier.”  Mr. Brown congratulated the graduates on their achievement by telling them they would be key in ensuring that the ANSF medical system has everything it needs to take care of Afghan patients.

                AFAMS is the ANA’s center of medical education.  Its four schools include the Military Medical Institute, the Allied Health Professions Institute, the Nursing School, and the Medical School.  It trains over 2000 students per year with over 500 students enrolled in courses at any given time.  These courses range from front line Combat Medic and Preventive Medicine technician to radiology and lab technician to clinical nursing to physician residency programs.  We now welcome the Medical Logistics course to this list of successful programs.  The NATO Training Mission and Combined Security Transition Command – Afghanistan Medical Training Advisory Group is proud to support the Afghan National Security Forces in developing enduring medical training capacity for the people of Afghanistan.

Take My Hand – Part II

February 5, 2010

                Let me continue from Part I with an extension of a familiar aquatic theme.  (After all, half of our Medical Training Advisory Group (MTAG) team is US Navy.)  “If you give a man a fish, he eats for a day.  If you teach a man to fish, he eats for a lifetime.”  We are here to take that proverb to the next level.  Our development with the Afghans of the Afghan National Army’s Armed Forces Academy of Medical Sciences (AFAMS) is the first step in teaching the Afghans how to teach other Afghans how to fish.  Some of the schools and courses within AFAMS are the Combat Medic (and Trauma Assistance Personnel for the Afghan National Police), Medical Logistics, and Patient Administration courses, as well as Nursing and Medical schools.  But the enduring piece, teaching the Afghans how to teach other Afghans how to fish, is found in our recent faculty development courses and the start of real graduate medical education programs.  In the very near future, we will expand this effort with faculty, residency, and nursing education development partnerships involving the University of Nebraska Medical School and the Uniformed Services University of the Health Sciences (USUHS) as well as the Nebraska Army National Guard.  The graduates of these programs will be the foundation of future Afghan medical education, the teachers of fishermen.

                Switching gears (or nets, as it were), there are three other foundational efforts we are helping the Afghans put into place.  A patient-centered electronic encounter form will greatly increase the quality of the patient care data that is maintained in patient records.  In addition, this data will feed a central database which will give actionable information senior leaders from clinic/hospital commanders to the Surgeons General which they can use to apportion their scarce resources more effectively.   Second, credentialing will give the Afghans a way to assess and track the clinical competency of their physicians for the first time. Third, we are developing much more robust hospital standards for the ANA and ANP which we expect to be adapted by the Ministry of Public Health, thereby becoming the national hospital standard of care for all of Afghanistan. 

               Several months ago, we recognized the need to do a better job of teaching ourselves to be the teachers of the teachers of those fishermen.  A huge team of contributors put together a 150-page tome called the Medical Mentor Manual.  Its intent was to be almost everything you would want to know about medical advising in Afghanistan, but just did not realize you needed to ask.  In addition, we are working with Joint Staff and First Army to pare down pre-deployment medical mentor training to make it shorter and more appropriate in content to better prepare future medical advisors for their mission here.  At the end of this effort, we envision that Afghan will say to Afghan, “Take my hand.  Follow me.”

“Take My Hand” Part I

February 3, 2010


It has been almost a year since I took the position of CSTC-A Command Surgeon.  In the past year, we have seen tremendous change and impact of our efforts.  CSTC-A is now NATO Training Mission – Afghanistan/Combined Security Transition Command – Afghanistan (NTM-A/CSTC-A).  The following vignette is adapted from a story by Dr Gary Davis, who was sitting in my “seat” as then-Combined Forces Afghanistan Command Surgeon a few years ago.  It has tremendous applicability to our medical advisory mission here in Afghanistan.

A man fell into a river and was obviously struggling to stay afloat.  Another man came upon him and tried to offer his assistance.  “Give me your hand!” the first man said to the drowning man.  No response.  The drowning man continued to struggle even though he was less than an arm’s length away from his rescuer on shore.  A local leader came upon the scene and instantly recognized the issue.  “Take his hand!” said the local leader.  The drowning man was immediately rescued.  The next day, the same man fell in the river again.  This time there was no one to rescue him.

                What is the lesson for us advisors?  If you read my last blog a few days ago, you might recognize the following “tip for success”.

If at first you don’t succeed…change your approach. This is slightly different from what we heard as children: “…try, try again.” One definition of insanity is doing the same thing over and over again expecting to get a different result. If your first attempt to get a [counterpart] to do what you think needs to be done does not work, try a different approach, seeking to understand and address their underlying motivations and concerns.

I can tell you that I have changed my approach in advising the ANA and ANP Surgeons General over the past year.  Soon after I arrived, I recognized that it is easy to give the Afghans “stuff”.  That is why previous teams have done a wonderful job of developing physical infrastructure for the ANA and ANP.  It is much harder, though, to get someone to change their behavior especially when it requires effort on the individual’s part.  The change in approach has been one, honestly, of tough love.  What the Afghans have the ability to do for themselves, we need to require that they do themselves.  It is not comfortable to watch someone fail in an activity, especially if they are a family member, someone you love.  If the Afghans are capable of acquiring and distributing specific pharmaceuticals using their funds and processes, then we need to have them do that.  We as advisors must resist the temptation to rescue the Afghans at every turn.  In not rescuing them, we teach them confidence in their processes and that they must make them work.  If they do not like their processes, it is up to them to change them.  We cannot do that for them.  We can develop and even model different processes for them, but in the end the processes must be Afghan processes.  The Afghans must own them.  They must embrace them.  They must use them…. or they will drown

Building Healthcare Systems in Afghanistan – Tips for Success

February 2, 2010

Greetings again from Kabul! Our advising mission of the Afghan National Army (ANA) and Afghan National Police (ANP) continues to progress steadily. Every day has new challenges and opportunities to excel. It can be long, tedious, and even frustrating work; but the investment of your work here makes small, incremental progress in building sustainable ANSF health care capability and capacity that will pay huge benefits over time in a stable government for the Afghan people.

As I have settled in, I have become more aware how subtle differences in how an approach to a situation can mean the difference between small but satisfying successes or crushing, frustrating failures. In my introductory message to you in March, I gave several “tips for success.” Here are a few more borne of my experiences in Afghanistan:

  • Use “nice persistence.” This is the follow-up corollary to “Play well with others.” In other words, do not bludgeon someone the first time if they do not get you what you want on your timeline unless it really matters. Appreciate everyone’s honest hard work.
  • If at first you don’t succeed…change your approach. This is slightly different from what we heard as children: “…try, try again.” One definition of insanity is doing the same thing over and over again expecting to get a different result. If your first attempt to get a mentee to do what you think needs to be done does not work, try a different approach, seeking to understand and address their underlying motivations and concerns.
  • Check facts rather than succumbing to rumor and innuendo. Definitely do not participate in negative speculation about a mentee’s motives. Ask yourself, “Is this illegal, immoral, truly unjust…or just different?” If your mentee’s thoughts and actions are just different from your own, that is what you will need to work with.
  • Understand limitations of systems (Afghan and Coalition) and personalities. Just because your counterpart says that they agree with your ideas does not mean that your mentee will be able to implement your ideas. If possible, help your mentee figure out how they can change their system in their way for improvement of their system.

Speaking of improving systems, there is a maxim which says “That which is measured improves.” CJ-Surgeon staff is developing metrics and measures of effectiveness which we hope will guide us in our efforts to fulfill the ANA and ANP Surgeons General’s mission, vision, and goals. Our five goals address high quality healthcare systems, efficient use of resources, access to high quality healthcare, healthcare training, and expansion of healthcare services provided. These five goals are in prioritized order of ANA and ANP medical leadership. We will start small and simple in our metrics collection, analysis, reporting, and actions. First, to develop metrics proficiency among advisors and partners. alike, we are comparing hospital staffing patterns to bed occupancy rates. We are already using this information to advise and assist the ANA Surgeon General to move new and experienced MEDCOM staff to the regional hospitals where they are so clearly needed. In the future, we will add metrics like antibiotic usage rates in primary settings to improve clinical practice patterns. Ultimately, we will use these metrics to improve ANSF healthcare systems as they promote the security and safety of Afghanistan.

As we enter the next rotation cycle of NTM-A/CSTC-A advisors, let me say welcome to all our new medical advisors and bid a fond adieu to those of you who have completed their tour of service. Your efforts, challenging as they undoubtedly have been, are collectively deeply appreciated by the people of Afghanistan. Thank you as you continue your service to the United States back at home station.

Think Differently

January 31, 2010

Greetings from NATO Training Mission – Afghanistan/Combined Security Transition Command – Afghanistan (NTM-A/CSTC-A) Command Surgeon Combat Medics. Let me begin by saying what an honor and privilege it has been for me to serve as NTM-A/CSTC-A Command Surgeon. In almost one year here, I have been inspired by the fabulous work of many hardworking, highly motivated, and creative individuals. I look forward to completing my assignment here building on the many successes this unit has had in recent years.

As we have moved forward, we focused on a couple conceptual items. First, everything that we do should be with the intent of developing enduring Afghan capability of their healthcare system. To that end, I encourage all Medical Training Advisory Group (MTAG) personnel to think differently about how we approach our projects and day-to-day efforts. Specifically, when planning your efforts, think in terms of outcomes rather than activities. Activities are things like teaching X number of classes, acquiring $X million of equipment and supplies, etc., which are all absolutely necessary for our training mission success. Those things make us feel good and look good on a performance report, but often do not translate into sustained changes in behavior. We must focus instead on enduring positive outcomes (e.g., decreasing died of wounds rates, decreasing nosocomial infection rates, increasing quality life expectancy, etc) that are final measures of benefit to patients. That is why we are military medics, to enhance the health of the fighting force and society as a whole. And in the end, remember that success for us will be defined as maintenance of those improved systems and outcome measures years AFTER each of us leaves this country.Second, consider this pearl of wisdom: It is better to understand that be understood. When you are frustrated because a mentoring interaction or services encounter is not going your way, try to understand the encounter from the other party’s perspective: What motivates them? What are their capabilities and limitations? Why should the other person care at all about what matters to me? How are they receiving my message? Is there any way I could change my approach such that they might see my position (assuming I have a reasonable, unselfish position) as being in their best interest as well. My experience is that this approach will almost always result in my changing my approach before the other individual changes theirs….yet we can both come to an arrangement that benefits us both. One might call this approach “enlightened self-interest.” Think about it.

I look forward to blogging with you all. Our mission is to develop enduring Afghan-led and owned healthcare systems that improve the health of all their beneficiaries. Any constructive dialogue that supports that effort will be greatly appreciated. Tashakoor!

Building Healthcare Systems in Afghanistan

January 28, 2010

Greetings from Kabul,  Afghanistan.  In this blog, I will record my experiences in developing the healthcare systems specifically of the Afghan National Army and the Afghan National Police.  I hope you find it informative and even entertaining.

Please understand that the views, commentary, and images on this blog in no way represent the views of NATO Training Mission – Afghanistan, Combined Security Transition Command – Afghanistan, the U.S. Air Force, the Department of Defense, or the United States Government.