Lieutenant General Nadja Y. West is the 44th Surgeon General of the U.S. Army and Commanding General of the U.S. Army Medical Command. General West is the highest-ranking female graduate of the U.S. Military Academy, and she is the first African-American and second woman to serve as Surgeon General of the U.S. Army.
She completed her internship and residency in family medicine at Martin Army Hospital at Fort Benning, Ga. During that assignment, she deployed to Operation Desert Shield with the 197th Infantry Brigade. General West completed a second residency in dermatology at Fitzsimons Army Medical Center and University of Colorado Medical Center in Denver.
General West served as chief of the Department of Medicine and Dermatology Service at 121st General Hospital in Seoul, Republic of Korea. Her most recent assignment prior to appointment as Surgeon General was Joint Staff Surgeon at the Pentagon, serving as chief medical advisor to the chairman of the Joint Chiefs of Staff and coordinating all health services issues related to operational medicine, force health protection, and readiness within the U.S. military.
When Anthony E. Johnson, MD, was chief of orthopaedics in the Department of Specialty Care at Fort Eustis, General West was the commander at McDonald Army Community Hospital. Dr. Johnson spoke with General West to get her insights on leadership and military medicine career opportunities.
Dr. Johnson: How did you choose to go into dermatology?
General West: Medical school afforded me the opportunity to experience different medical specialties. Although I enjoyed surgery, I developed an interest in dermatology through Carmen Myrie Williams, MD, but initial concerns on the limited scope of dermatology resulted in selecting family practice as my first area of concentration. Family practice allowed a broad medical exposure to complex medical cases.
As my career progressed as a family practice physician, I gained a greater appreciation for dermatology through a clinical rotation with a dermatologist. This opportunity allayed my concerns. I was amazed at the range and scope of relationships developed with patients with chronic skin diseases and the full spectrum of dermatology with surgery, immunodermatology, pediatric dermatology, and dermatopathology. I also enjoyed the discipline of dermatology and was grateful to have the background in family medicine, as there are many skin manifestations of internal disease. This prior training gave me a good basis for dermatology.
Dr. Johnson: When I was at Fort Eustis, my five-year-old daughter told me that one of the teachers told her she didn’t need to know math because she was beautiful. This prompted me to instill in my daughter that looks have nothing to do with learning. Professionally, that prompted me to serve on committees such as the Women’s Health Issues Advisory Board for AAOS, the Diversity Advisory Board for the American College of Healthcare Executives, and the American Medical Women’s Association. The percentage of women going into medical school is currently quite representative of the general population—about 55 percent female. In terms of women entering into medicine, diversity efforts appear to have worked.
But post-medical school, that distribution is not representative. Dermatology seems to be much more welcoming than other specialties (about 46 percent women). Orthopaedics has not been successful in attracting women—the number of practicing female orthopaedic surgeons is around 6 percent. What are your thoughts on strategies for attracting more women to various medical specialties, especially ones that are struggling, such as orthopaedics?
General West: Many occupational specialties do not allow a “one answer fits all” approach. Early exposure to STEM (science, technology, engineering, and mathematics) programs will attract not only women but also minorities and individuals with diverse backgrounds to occupations such as orthopaedics.
Diversity in educational environments is also important. We must ensure that professors in college and medical school are comprised of individuals with diverse gender and cultural backgrounds. Diversity enables students to have the opportunity to see themselves in any type of organization. Seeing others similar to them gives them hope.
Diversity and mentorship lead to effective messaging. There must be a concerted effort in publicizing diversity to attract students. For example, in medical school, professors can tell students the factors that led to choosing their specialty. I would also recommend using a survey of medical school graduates to assess the factors that led them to choose their field of specialty.
There are also lifestyle issues to consider. Are there things prohibiting individuals from choosing specific specialties because of incompatibility in and out of medicine?
Dr. Johnson: At one point, 15 percent of the residency program at San Antonio Military Medical Center was women. One of the selling points was that being a military physician gave the chance to hone your leadership skills early. Because you are at the tip of the spear, do you have any recommendations for junior physicians—military or not—on developing leadership skills during practice?
General West: Army physicians must first acknowledge their leadership roles and responsibilities. I am disheartened to hear other branches of the Army say, “Medical folks do not have the opportunity to practice leadership.” I challenge our line colleagues by saying, “What we do with our patients and healthcare teams every day is a leadership opportunity.” Army medicine influences others to accomplish a mission. Our mission is ensuring the health and wellness of our patients. Military providers must hone leadership skills by taking advantage of leadership opportunities and courses that are available.
During my tenure as Surgeon General, I directed the U.S. Army Medical Command’s talent-management team to develop a list of all the available leadership positions for the various medical occupational specialties. This allows every officer and enlisted soldier to know the available opportunities, triggers interest, and allows an individual to identify and declare goals early. Quite often, we falsely assume that people know what opportunities are available, but it starts with organizations identifying available opportunities.
I would also encourage finding role models and choosing several mentors from diverse backgrounds.
Dr. Johnson: What are your thoughts on the ways that professional organizations, especially AAOS, can help build military-civilian collaboration?
General West: Military-civilian collaboration is very important to the future of military medicine. Along with ensuring skills sustainment of military medical personnel, military-civilian collaboration facilitates a “cross-pollination” of ideas.
Army Futures Command (AFC) is the newest four-star Army command. Located in Austin, Texas, AFC enables the Army to partner with academic institutions and the U.S. industrial base. Army senior leaders expect to increase innovation through collaboration with academic institutions and the industrial base.
Army medicine partners with various academic institutions and civilian healthcare organizations to establish and maintain innovative relationships. These relationships enable Army medicine to maintain the currency of our individual providers and medical teams.
In addition, military-civilian collaboration allows Army medicine to get the word out about the need for and desire to engage in collaborative partnerships. I’ve often said that the outpouring of support from our academic institutions is really heartwarming.
Dr. Johnson: I was fortunate enough—if you can say that—to be deployed during Operations Enduring Freedom and Iraqi Freedom, where the high-volume caseload was very important for developing my skills. But as the theater of operations expands and active hostilities have decreased, what are your thoughts on how surgeons deployed to low-surgical-volume/low-
operational-tempo (OPTEMPO) areas can maintain their skills?
General West: This goes back to the previous question about the partnerships. When military treatment facilities do not have the caseload needed to maintain medical competency, we must ensure we have access to high-volume civilian medical institutions. Army medicine must also have a retraining period for medical personnel returning from low-OPTEMPO institutions to train at high-OPTEMPO civilian institutions.
The idea of retraining at a high-OPTEMPO civilian medical treatment facility was started years ago by two former surgeons. This idea needs to be critically reviewed and operationalized. Army medicine also maintains continuing medical education (CME) presentations. Although not hands-on, CME presentations provide current clinical best practices.
Army medicine also uses simulators to maintain clinical proficiency. Simulations must be as realistic as possible to enable surgeons to remain current on the latest techniques and have the repetition needed to save lives on the modern battlefield. Army medicine continues to work with civilian partners to develop realistic simulators.
Dr. Johnson: A major concern for military residents and recent graduates who are very junior in their careers is that current stateside personnel-management programs with deployments are getting longer—11 to 12 months of not operating. What is your stance on MAP (modification table of organization and equipment assigned personnel) and its effects on orthopaedic surgeons’ maintenance of operative skills during those longer deployments?
General West: MAP, MEDCOM Assigned Personnel is an initiative to ensure our providers are connected to the units with which they will deploy. In the past, these soldiers often would not meet their chain of command until a few days—sometimes hours—before deploying. MAP allows us to foster a closer relationship that develops trust early and allows our medical soldiers to become a part of the organization.
We closely monitor clinical operations of our surgeons and other medical specialties, both in our stateside medical treatment facilities and while they are deployed. We are committed to ensuring that our providers always maintain a high level of proficiency in their clinical skills. During longer deployments, we will continue to pursue opportunities to ensure readiness—be it through the use of synthetic training environments deployed to support unit training, the rotation of providers into areas with increased requirements, and possibly rotating providers to host nation facilities to not only sustain their own skills but to build capabilities with our allies and partners.
The MAP initiative does not remove providers from the hospital. They remain in their current duty assignments providing health care to our beneficiaries. Additionally, many will have the opportunity to conduct a clinical rotation through a civilian facility that may provide more complex, higher-repetition opportunities to sustain their skills. The patch on their uniform may change, but their mission does not.
Dr. Johnson: Due to MAP, many orthopaedic surgeons in the Army are now planning to get out after their active-duty service obligations instead of staying 20 years for retirement. Do you have any thoughts on that or what we can do to improve retention?
General West: While visiting Emory University, I was informed that millennials now usually spend 1.5 years in a job. This is not because millennials are unhappy or had a bad experience but rather have a sense of, “What else is out there for me?” The long 20-year career may not be the paradigm everyone wants when deciding to join the military.
Some people think a five-year commitment is more appropriate and realistic. People do not necessarily want to commit to a long-term career and feel they might lose the opportunity to experience other things. The Army, in general, is looking at different ways of recruiting and offering various career paths. One option is to join the Army for a couple of years, leave, and then return.
There has to be some sort of incentive. Balance and predictability are important factors in people joining the military. Unfortunately, the high demand and multiple deployments of certain specialties are a source of dissatisfaction. We continue to try to even out deployments.
Dr. Johnson: If we go to a model where military physicians are on short-term active duty, will there be a readiness issue?
General West: There may be, but lack of capability is a bigger readiness issue. We need to try to find a way to make service more palatable. It’s all about tradeoffs.
Dr. Johnson: What are options for physicians after the U.S. Army Medical Command?
General West: Army medicine has a talent-management system that informs physicians of all opportunities available, such as working in the Office of the Chief Legislative Liaison. An Army physician has opportunities with legislative affairs, medical education, government agencies (such as Veterans Affairs, the Centers for Disease Control and Prevention, or the Food and Drug Administration), or think tanks.
Army medicine also has the flexibility to create fellowships. The Defense Health Agency offers opportunities for leadership division positions or roles.
Army medicine also has two astronauts assigned to NASA. Who would have thought that you can be in an Army position and then be part of the astronaut program?
Dr. Johnson: If a surgeon deployed to a low-OPTEMPO environment does not have 100 cases in the past 12 months, what will happen?
General West: Issues such as this are being addressed by the Joint Force and all of the services. One hundred annual cases may not be the best measure, but it is an attempt to verify clinical competency. More is always better, but a finite number is not the end-all-be-all for clinical competency. There must be a waiver process or other way of measuring competency. Ultimately, someone like the clinic/service/department chief has to verify the competency of that individual.
Dr. Johnson: Do you have any future plans for your career?
General West: I’m getting toward the end of the line here. By definition, the surgeon general is the highest point I can go, so I will be turning the reins over to the next generation of great young leaders. I hope to continue to serve in some capacity once I hang up the uniform.
Anthony E. Johnson, MD, is with the Department of Surgery and Perioperative Care at the Dell Medical School at the University of Texas at Austin. He is also a member of the AAOS Diversity Advisory Board and the AAOS Now Diversity Content Workgroup.