Lt. Gen. Eric B. Schoomaker was sworn in as the 42nd Army Surgeon General on Dec. 11, 2007, and assumed command of the U.S. Army Medical Command on Dec. 13, 2007. Schoomaker, who comes from a military family, previously served as the commanding general, Walter Reed Army Medical Center, the North Atlantic Regional Medical Command, and U.S. Army Medical Research and Materiel Command, among a wide variety of Army Medicine posts.
The Year in Veterans Affairs and Military Medicine: What actually led you into medicine as a part of your dual profession of being both soldier and doctor?
Lt. Gen. Eric B. Schoomaker: My first and foremost interest was in medicine initially, and I came into medical school with a whole array of interests that I derived from being an undergraduate. But as I got into medical school and began to do more classroom work I really got interested in the research side of things. How does knowledge develop? How does a single insight from the laboratory or in the clinic get generalized over a large population of patients to influence and change the whole way and the whole direction to relieve human suffering on a grand scale. Human genetics at the time was an area that I had worked in with one of my professors, a fellow named George Brewer at the University of Michigan. It also seemed to me that genetics could be the quintessential form of preventive medicine: to have insight into one’s own predisposition to disease and illness, and to be able to modify one’s environment to either move away from, or prevent the illnesses and conditions associated with that predisposition. In those days pioneers in genetics were talking about even maybe changing the genetic constitution of human beings – that once we got greater insights into how the genetic code operated we could prevent certain diseases altogether. I was working with a group of patients who suffered from a genetic form of anemia that led me into the field of blood disorders, and that was the launch of my medical career.
So what were some of the standout assignments you had along the way?
One of the really remarkable things about a career in uniform, especially in medicine and nursing, is the agility that one can demonstrate in pursuing different interests. I was an educator of young physicians and medical students at one point in my career, and I came back to that several times. I ran whole departments, organized care for entire communities, and eventually became a hospital commander. Being able to do these things in one span of a three-decade career is remarkable, and the Army provided me those opportunities.
The standout assignments for me involved education in general, along with fostering and developing the next generation of military medical practitioners. I was the “Top Doc”, what we call the deputy commander for clinical services at the Landstuhl Regional Medical Center in Germany just prior to the first Gulf War in 1990. I saw how a military medical organization on that scale could rapidly change its missions, its roles and even its structure, to meet what we anticipated to be a very dramatic load of patients. I began to see on a much larger scale what we could do – as I said earlier about the pursuit of human genetics – and what could be achieved through good organizational planning and coordination and synchronization of effort. And I saw how we could really make a difference in people’s lives.
These experiences extended into command surgeon roles at FORSCOM and the Fifth Corps. Few experiences rival the command of a medical brigade like the 30th Medical Brigade in the Fifth Corps in Germany: humanitarian missions in West Africa; medical logistical support in Kuwait; partnership with NATO partners; support of the Balkans War; and preparations for the wars in Afghanistan and Iraq. Perhaps only the experience of overseeing biomedical research and development – to assist in the development of vaccines against malaria and HIV/AIDS; to respond to bioterrorist and natural pandemic threats against the nation; to witness what our people are doing in Kenyan labs and throughout Asia through our partnership with the Royal Thai Army and Thai Ministry of Health. Or commanding Walter Reed Army Medical Center during some of her darkest and most brilliant hours …
The whole “process” part of the medical business?
Absolutely. As a former clinician and educator I began to realize that, just as a line officer who spends his or her career doing things at the tactical level, if you bring that experience into the operational and strategic levels, the organization benefits from that experience. And so those became defining career high points for me.
When I re-entered the academic field, I realized that without some organizational construct we could not have the kind of impact we wanted. But I didn’t want to just be somebody who studied how things got done, I wanted to be a “doer.”
As we sit here today, you’re Surgeon General of the Army and commander of the Army Medical Command. What are your responsibilities? What’s the job description? You know, somewhere out there is someone who’s going to get your job in about three months …
For the first time in 236 years, a non-physician, and a woman. Maj. Gen. (Promotable), Patricia D. “Patty” Horoho will be the Army Surgeon General and commander of the Army Medical Command. She’s been confirmed by the Senate, and she’s in Afghanistan right now. Patty has been deployed for three months in Afghanistan working on a health services support program and on standardization of the TBI [traumatic brain injury] protocols and behavioral and women’s health. She’s a remarkable leader, a remarkable soldier-medic, a remarkable person.
As you literally walk out the door and hand her the stethoscope, as it were, what’s her job description going to be? If she’s going to have your jobs, what are her job descriptions?
As the Surgeon General she’s a staff officer on the Army staff, and she’s the principal health advisor and health care advisor to the leadership of the Army.
To the Chief of Staff and secretary of the Army?
To the secretary and Chief, and she’ll work most closely with the Vice Chief of Staff of the Army, who is responsible for the care of all our soldiers.
So, you and Gen. Peter Chiarelli have spent a lot of quality time together these past few years?
We have. We are joined at the hip. He is a great proponent for medical programs and for health and healing of soldiers and families. There are very few more passionate people than Gen. Pete Chiarelli, there’s no question. But back to Gen. Horoho: she will be one of several senior leaders on the Army staff who are both staff officers and commanders: the Army Surgeon General and commander of the Medical Command is one. The Assistant Chief of Staff for Installation Management and Commander of the Installation Management Command, Lt. Gen. Rick Lynch, is another officer who has both a staff responsibility role and a command responsibility. So, she will be an advisor, as I am an advisor, to the senior leadership of the Army, in health and health care matters. Additionally she will be – as I am – the commander of all garrison based, non-deployable, medical, dental and veterinary laboratory units throughout the Army. My command is about 75,000-strong. It is made up of 60 percent civilians, and is comprised of over 400 different medical units. That includes clinics and health centers, community hospitals, medical centers, and also our laboratories for biomedical research and product development, commands and agencies for medical materiel and intermediate supply chain management for devices, drugs and vaccines and the like. In fact the headquarters of my entire command, the Army Medical Command, is in San Antonio, Texas, where we also have our schoolhouse, the Army Medical Department Center and School (AMEDDC&S). We have the U.S. Army Public Health Command in Aberdeen, Md., along with the Army Medical Research and Materiel Command that does biomedical research and advance development and intermediate supply chain management in Fort Detrick, Md. We have a Dental Command also headquartered in San Antonio. Additionally we have five regional medical commands, one in Europe, another in the Pacific and three in the continental United States. These all work closely with the managed care support contractors and other services to deliver care and promote health, which is why I separate “health” from “health care.” One is about promoting health, improving health, sustaining health, and preventing injury and illness, and the other is about providing after-the-fact healthcare in the event of ill health, wounds or injuries.
Does your command train and package deployable forces for the COCOMs (Combatant Commanders)?
We have a responsibility for formulating what that force structure looks like, as well as looking over the horizon as to what the next generation of deployable medical systems needs with regard to how they’ll need to look, how they’ll need to be equipped, and what soldier medics will be needed to be a part of that. And my Medical Research and Materiel Command (MRMC) is responsible for the equipment sets and the packaging that goes into that force structure. However, the actual units themselves belong to FORSCOM and other commands.
So, in other words, you are more or less the medical TRADOC (Army Training and Doctrine Command) to FORSCOM’s actual packaging and training function to get them out to the COCOMs?
Exactly right. We are the force provider. At the same time, about 15 percent of all of the doctors, medics, nurses, administrators, everyone that can be assigned to a deployable hospital or unit, comes directly out of our clinics and hospitals. That’s the way we maintain their skills, and the way that we provide a medical force with the least overall burden in structure to the Army by leveraging the institutional or generating force as part of the deployable or operational force.
As the Army’s top doctor, can you lay out what your biggest challenges have been during the time you’ve had this job? What have been the elephants in your tent for these past few years?
I think, first and foremost, has been the challenge of keeping abreast of health threats and health care demands on the force and their families during a very challenging time of war. And not a single war, but this applies to all the wars that our Army has fought.
Also important has been being adaptive and agile to recognize emerging threats, to stay ahead of them, to respond not only to battlefield wounds and psychological injuries, but also to things that may occur or only become apparent back in home station, in garrison To do that, we’ve used a variety of tools, such as the Mental Health Advisory Teams that we’ve sent out every year to Afghanistan and Iraq, to assess the behavioral health challenges of deployed soldiers and to see what combat exposure and the impact of combat exposure and combat injuries such as concussive injuries does to our soldiers.
One of the key metrics we watch is the impact of the BOG vs. dwell – the time spent “boots on ground” versus the time spent back home, which we call “dwell time.” We’ve looked at the very short “dwells” that soldiers have had before they’ve been re-deployed. We’ve looked at this and many other factors to see what impact they’ve had upon the physical and psychological health of our soldiers, and the support network that they need back home.
We’ve also been highly adaptive in leaning forward with the whole joint force – Army, Navy, Marines, and Air Force, in responding to injuries and wounds on the battlefield in a way that keeps abreast of a highly adaptive enemy and what they employ such as IEDs [improvised explosive devices] and other weapons used against our soldiers.
A particularly challenging combination of circumstances has been the transition of a strategic Reserve to an operational Reserve coupled with the all-volunteer force. We have been challenged to assist the Reserve Components – U.S. Army Reserve and Army National Guard – in maintaining their medical readiness to deploy and to restore that medical and dental readiness once they return and while they have returned to their lives as citizen-soldiers, as civilians. This is accompanied by the importance of maintaining the health and fitness of all of our all-volunteer force. Our soldiers are the premier tactical athletes who – like any professional athlete – must be fit in mind, body and spirit, not unprepared for the stresses associated with service nor trained and physically conditioned by techniques or methods which unnecessarily or avoidably injure them.
Finally, we have restored a focus on healing, rehabilitating and reintegrating these great soldiers should they develop major illnesses, be injured or be wounded in combat. We want our wounded, ill and injured warriors given every possibility for returning to service in uniform or to return to as full a civilian life as is possible through our program of Warrior Care & Transition.
Part of this challenge has been grappling with an outdated, adversarial, overly bureaucratic system of disability adjudication in partnership with the Veterans Administration. We need fundamental reform of our 60+ year system of Physical Disability Evaluation, and in the absence of reform, we have labored to make the present system as adaptive, timely and soldier and family-friendly as possible. Our soldiers deserve no less.
So, you’ve been working with the offices of the other Surgeons General?
Absolutely. One joint program that comes to mind is the Joint Theater Trauma System, or JTTS, which employs a data base/registry of all traumatic wounds that occur in the theater of war, in real time to look at how wounds are treated, and what the outcomes of those treatments are to improve care for the next patient. The JTTS is organized around gathering very clear evidence as to what makes a difference in the survival and long-term care and rehabilitation of every casualty. Another focus area is to link injuries, wounds – survivable and non-survivable – back to the protective armor, the vehicle, or the aircraft that the soldier, sailor, airman, Marine, or Coast Guardsman may have been in when they were wounded or killed. This way we can design the next generation of systems to be more protective and more effective, in keeping that service member from being wounded or killed. This program is the Joint Trauma Analysis for Protection of Injuries in Combat (JTAPIC) program. It is another joint effort that links materiel developers with the medics to look at how can we prevent that next wound by closing gaps in vulnerabilities in protective body armor, goggles, or vehicles.
We are working closely with our service medical partners in refining an electronic health record to provide a comprehensive picture of the health of our patients and beneficiaries. Ideally, this EHR should be interoperable with the VA for a single record of health of all soldiers while on active duty and as veterans. We are working very hard to achieve this ambition.
What has your office been doing to help those veterans with long-term care situations and long-term illnesses that are going to require maybe even lifetime care? And what are you doing to help dovetail your efforts with the VA?
Well, this goes back to one of the major challenges that we have faced, and to an earlier question that you asked. And that was to reverse a trend that began in the eighties and nineties that created a kind of artificial boundary zone between what we call inpatient medicine – around surgery and hospitalized care – and outpatient medicine with highly functional ambulatory patients, people who can walk into a clinic and take medication on their own. We rediscovered what we learned after the Civil War, the First and Second World Wars, Korea, and Vietnam, which is that warfare carries with it a burden and responsibility to care for soldiers across the entire continuum of their recovery, rehabilitation, and reintegration into a full life.
What Abraham Lincoln said…
Exactly. We have worked very hard with the Veterans Administration and civilian partners to create a continuum and a very warm hand-off between these different communities to ensure that soldiers and other warriors who are severely injured or combat-wounded will have this continuum, and will have the best shot at fully re-embracing and recovering as much of their full potential as possible. But I say also, what we’re working hardest to do, quite frankly, is to prevent the problem in the first place. Prevention has always got to be the primary focus, and it’s always been the focus of every Surgeon General in every Army, to keep the force strong in the first place.
One of the most significant changes that we’ve instituted is managing concussions at the point of injury on the battlefield. We have begun management of a concussion at the moment it occurs, or as close as possible within the circumstances of battle, so that there aren’t recurrent concussions and lingering physical and psychological problems that can burden a soldier for a lifetime. And I again credit Gen. Chiarelli with his leadership, and people like Brig. Gen. (Promotable) Richard “Tom” Thomas, our Assistant Surgeon General, with those initiatives. I think that has been one of the real achievements of the last several years – to teach soldiers and their leaders that we need to do whatever we can to prevent multiple concussions and then manage and treat them aggressively from the moment that they first occur. I believe that’s going to reduce some of the burden that we’ve seen from warfare, the “shell shock” and the “battle fatigue” and the mixture of concussive injuries and psychological wounds that soldiers have suffered in war after war after war. Concussions occur in battle, as they have since the beginning of this war, and certainly since the invention of the rock and the spear or gunpowder. We know now that the long-term effects of concussions have burdened soldiers from the dawn of explosive warfare.
There is no secret that right now the administration and Congress are looking for places to save money. Is there a danger that Army Medicine is going to suffer cuts to its funding base that could affect the quality of the care that we give to the soldiers who have served over the last ten years?
There’s always a risk when a nation faces the kind of financial strain that we’re currently facing. And as each one of the executive departments, be it the Veterans’ Administration or the Department of Defense, faces issues around the sustainability of costs associated with care and rehabilitation, risks to the quality of care are inevitable.
But I also think that the Congress and the people have been extraordinarily supportive of the soldiers and again, by extension, all warriors, and have done all within their power and their purse to keep their pledge to care for those soldiers for however long it takes. I think the obligation of leaders like me in military medicine, not just Army medicine but all of military medicine, is to look for efficiencies so we aren’t wasting precious dollars, and where we can focus those dollars on people who require the care. And I think that, just as in American medicine in general, there’s waste in non-evidence-based practices, and in unwarranted variation in practices.
We know we have a better way of doing something but are sometimes stuck in the old ways of doing it. We need to get rid of those old ways of performing our administrative and clinical tasks and adopt a more effective and efficient way. We have administrative variances that we need to trim and take out. We have organizational redundancies that we need to eliminate and take out. And we need to synchronize and integrate our care to the maximum extent that we can so we can create the sustainable system that we talked about. We owe it to soldiers and families to do that.
What new medical technologies do you see being leveraged in the future, to better deal with the emerging threats of America’s next wars?
One of the things I’ve really focused a lot on are enduring systems. I’ve just mentioned two of them, the JTTS and the JTAPIC programs, along with better materiel development to protect soldiers. I think we need to apply these tools in any theater we may find ourselves in the future, because, just as we’ve learned in this war and all wars before, we don’t know where the real threats lie until they start to emerge. And so we’ve got to have very responsive systems of surveillance, medical analytics, and rapid adaptations to our programs, in our technologies, and in applying technologies that work.
For example, the realm of infectious diseases has always been a major threat to a deployed force. We’ve got to have systems that are agile enough to detect emerging threats in the global economies we are working within, and rapidly respond to them as quickly as we possibly can. Those are about systems that are focused on surveillance and rapid response using good science and good evidence.
I think another thing that we’re going to see increasingly is the use of what we talked about earlier: the use of information that we have about our people: their genetics, their predisposition to injury or specific illnesses that they may acquire, and to use that in such a way that we arm people with the knowledge and the tools through behavior modification and other things that prevent illness and injury. Add to that heart disease and diabetes, which are some of the things that jump right out at you. But what we’re applying even to the training of soldiers is much more scientific methods that prevent a soldier from getting injured in the course of training so that they’re not knocked out of commission.
Falls and other orthopedic injuries?
As you well know, America suffers today from a shortage of trained medical professionals, and we have to import people from overseas. A big part of the problem is of course that medical training is expensive. Can you please tell us about the great deal the U. S. military offers for medical professional training?
As I said to you earlier I “squandered” my own personal fortune paying for an education that today the U. S. military will assume responsibility for, in exchange for service. And the important thing for young people to realize, whether they are nurses or psychologists or physicians in training, is that not only will they get a quality education, and relief from education-related debt, but also access to some of the most exciting medicine, nursing, laboratory science, and behavioral health initiatives that they will ever see by virtue of wearing the military uniform.
What are you going do now? What do you want to do now?
I want to sleep past 3:30 in the morning!
I want to spend time with my family. And I want to give some careful thought to this issue. You know, I still have a big interest in serving to some capacity, and I love developing that next generation of medical professionals, and working with organizations to make them more effective. To help them work their strategies, as we’ve tried to do so hard in Army medicine, so that every person in every role in an organization as complex as ours is, feels committed and aligned to the larger goals of the team. To help every person make a contribution – to realize their potential; to achieve meaning in their work. Like my parents and my extended family of citizen-soldiers and airmen, a yoga therapist wife and children who aspire to leave the world better than they found it. That’s the kind of work I hope to continue to perform.
This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.