Good morning. We are going to present a plaque today. Dr. Klatka is going is the our first speaker and she's going to speak on MEPS exam. She graduated from Ohio University College of Osteopathic Medicine in 1989. She served for 22 years in the United States Army, initially in the practice of neurology. After completing a residency in preventive medicine in 2003, her focus shifted to general preventive medicine, public health, and occupational medicine. Since retiring from the Army, she has worked as a Department of Defense contract physician performing medical screening examinations for the Cleveland, Ohio Military Entrance Processing Station, MEPS. Dr. Klatka is a past president and a fellow of the American Osteopathic College of Occupational and Preventive Medicine. She has nothing to disclose. It is my pleasure, she is the recipient of the Brent V. Lovejoy Memorial Lecture. The Brent V. Lovejoy Memorial Lecture is given in honor of Brent V. Lovejoy, DO and fellow of our college, a founding member of the Division of Disability and Impairment Evaluation. Dr. Lovejoy served the AOCOPM as a tireless worker. He was the first to seek recognition in this field of medicine in the osteopathic profession and developed the first formal course of study for the college. He was most interested in continuing medical education and was a frequent lecturer. Dr. Lovejoy was a fellow of the American College of Osteopathic Occupational and Preventive Medicine and was designated posthumously a full professor under the faculty status for the college. Dr. Lovejoy served on a number of committees and held all offices of the college, including president-elect. Due to illness, he was unable to serve as president but was designated an honorary assistant to the president prior to his death in 1997. Established in 1998, this prestigious lecture is presented to an individual member or non-member who has demonstrated proficiency in the area of disability and impairment evaluations and a desire to promote this area of medicine for the public good. It is my pleasure to present that award to Dr. Plattka. Thank you. I'm just going to get set up real quick and see if I have a pointer. Where's the pointer on here? Right in the middle. Middle top. The middle one right here in the middle. Great. Just in case. All right. Can everybody hear me okay? Are we good? Push this down so your face is trying to ease. Is that good? Okay. Good. Is that good? Is your little face in the middle? Sit down here. I see you're on. Hopefully. There you go. I think that'll... Anyway, I'll put you... Yeah, we'll check that out. Good morning. Thank you, everybody. Thank you, Dr. Esten, for the invitation. I am residency trained in preventive medicine, but did a lot of occupational medicine. As you probably know, in the military, there's a lot of overlap. I am in now, of course, I've been working for MAPS for about four years after retiring from the Army. It's all pre-employment, occupational-related, and I'm enjoying it very much. I'm going to talk a little bit about what I do and why. I have... Let's see. Our objectives are... We're going to talk a little bit about, again, about what I do, why it's important, what are some of the qualifications for entry into the armed forces of the US, and why those qualifications and disqualifications are important. Lastly, for our audience in the public, providers, physicians, and other providers, what do we need from them? Sometimes we do have applicants that we send back to their doctor clarification or for follow-ups, and the information we get back from them can be very helpful, or sometimes it's not very helpful. I'm going to go over a little bit on what we would like to see back from those physicians that are helpful to everybody, to us, and ultimately to the applicant, to hopefully succeed and pass there and be qualified for entry into military. I have no disclosures whatsoever. The views presented are my views, and not necessarily represent those of the Department of Defense. Importantly, we don't, under any circumstances, photograph any applicants, so I will have some interesting cases at the end. I'm using only stock photographs, no photographs of any actual applicants. So every year, about 200,000 men and women enter active in reserve or guard components of the US. Most of those are with the Army. You can see some of the other breakdown there. Marine Corps, Navy, Air Force, Space Force now too, although we don't have those numbers really broken out yet, they're still under the, kind of under the umbrella of the Air Force and Coast Guard applicants. So when an applicant is interested in joining the Armed Forces, of course, they will first meet with a recruiter. There are some non-medical things they do, aptitude testing, all kinds of background checks, fingerprinting, verification of education, et cetera, interviews as to job interests, and so forth. Those are done generally with the recruiter and liaisons at our MEPS station. Every MEPS station has, there's a medical section, but there are also administrative and service-specific liaison offices also. So it's not just medical, and many of those functions are done by the recruiter and the liaison. So I'm going to focus here, of course, on the medical examination, and it begins with a pre-screen, and I know this is meant to, not meant to be read in detail, but some of you have gone through MEPS, have probably seen something like this, medications, allergies, and do you have or have you ever had, importantly, have you ever had, ever, and that means ever, even if you outgrew it, even if you don't think it's important, even if the recruiter doesn't think it's important. So they should answer yes if they have ever had any of these conditions. I'm going to jump down real quick, and I'll jump back up, but just a little blog, for example, very specific questions, undersystems, lungs, have you ever, asthma, inhalers, pneumonia, et cetera. I won't read the whole thing to you, but you get the idea of how in-depth this questionnaire is, 112 questions. And then if they answer yes to any of these questions, they should, generally there's a process in which they may gather some medical information, submit it up to our office, it's reviewed, there may be some back and forth before the person is, for the applicant is permitted to actually come in for the examination. The goal being we don't want the applicant to be going back and forth and back and forth. We want to have all the information we need to make a qualification when they come in one time. It doesn't always happen, of course, for a variety of reasons. Now it doesn't mean if they're invited to come in and continue their exam process, they may have a known disqualifying condition. So it doesn't, sometimes they think I'm good to go, not necessarily. They may have, we know they have asthma beyond the date, beyond the age at which it's disqualifying, they'll still come in, we'll do the exam, they'll be disqualified, hopefully nothing else will pop up, and then they go forward to pursue a waiver. But they can't do that until they've had their exam. So we gather the information. Once we have the information, then they are permitted to come and get their examination. So why is this so important? Well, we want to make sure, of course, basically we want to make sure the applicants are not going to be a danger to anybody, to themselves, to their other service members, to the mission. And frankly, financially also, there's a financial consideration. It costs about, they say it costs about $25,000 to recruit somebody. For every recruit that comes in, that's advertising, personnel costs from recruiting, lodging, transportation to MEPS and back, meals. And so there's a lot of costs in there. So there's a fiscal consideration too. But most importantly, we want to make sure they're safe, that they can complete their term of service, that they can adapt to a variety of environmental conditions. They may, as we've obvious, I'm sure you know, may be exposed to heat, cold, dust, altitude, et cetera, austere conditions where medical, tertiary medical care is not immediately available. We want to make sure they are medically capable for forming the duties without aggravating an existing condition, free from contagious diseases that may endanger other personnel and free from conditions that may impair. We're looking more at the mission here. Extended time may require extended time from military service or result in early separation. And it is a problem. High attrition rates have been a problem for, if you follow the timeline here, 06 and even before then, it's been known. We're not doing very well in improving those numbers. So it's up to, it's about 15% at 72 months. The highest rate is in the first six months. So first 180 days is considered an early separation. It's about 5%. We'll separate during that time. So it's a big problem. These are just some, if you're interested in further reading, it's been studied many times or ran studies and GAO investigations of why this is and what we can do about it. I'll just point out here, I think the dates here, I think it's 97 and 07, I think, or 17, sorry. So you can, yes, question. Real quick question. I know our recruiting is way behind in all our service. So I'm fortunate that I'm surrounded by some of our soldiers out there recruiting new soldiers coming in. And I know personally, they highly encourage them not to fully, honestly answer their screening. Like, you know, my son was this big. You got to be active, be a leader. You want to come in the army. That's me advising my son. I know those recruiters are doing exactly that. And then that first six months, obviously, it could manifest very easily. Yeah, correct. And I'll recap briefly that the comment is that there's a great deal of pressure, especially now with recruiting being down to for applicants to not be entirely truthful on that 112 question form. And yes, that is, a matter of fact, I think the most common when they look at, these are just kind of categories of reasons for separation, everything from unqualified. There's a lot of overlap with these unqualified fraudulent entry, which is kind of alluding to what you're saying. So people intentionally not disclosing known medical conditions and then being qualified when they should not be qualified. And when you look at when they have looked at those reasons, that's about probably half of the cases of early separation. Next in line would be maybe a condition that just wasn't known, that propped up that supposedly they did not know or was never diagnosed. But yes, intentionally not disclosing information is the number one reason here. I'll kind of comment on what we're doing about that. But yes, go ahead. When does the military buy the condition? I know there's a point where... 180 days. The question is, when does it become kind of the property or responsibility of the government? 180 days before that, they'll call it existed prior to service. Yeah. So like what John was just talking about too, we're constantly getting bombarded with requests to recruit, to act as recruiters. So that the reservist staff might be encouraged to reach out to as many people as possible to get them in. And they're also, like John was mentioning, they're pretty goosey-goosey on disclosing a lot of information. I was going to ask you about the height and weight requirements. I know there seems to be, there's a big problem with that in the service regard. It seems like everybody has to be tested, maybe over 70%. So is there an issue with that as well as someone who's otherwise qualified? So the question is, is height and weight or failure to make weight, that's actually, yeah, I believe that's one of the failure to meet height, weight, and body fat standards is definitely one of those. And that's a big issue as somebody we were discussing earlier. I think that something like 70% of youth aren't qualified either because of fitness, overweight, mental health, a variety of issues. So yes, height and weight is still an issue. I think some of the services are trying to be proactive with that. And you can come in, height, weight actually used to be a medical, like they'd be medically disqualified for weight. It's not medical anymore. It's been taken out of medical, which is kind of good for us. It's service specific, but yes, they still have to make weight. Yeah. But it's just handled by the service now. Talk about the pre-boot camp deal that they're doing. Yes. Yeah. Question is about the, this is about the pre-boot camp. Yeah. There are some incentives. I'm not intimately involved with them, but I believe there are some programs now they'll bring people in and get them to try to get them in shape. And so that they'll be, then meet the standards. The way it works, you can do there up to 12 weeks if you didn't quite qualify in height, weight, or asthma. So it's basically a pre-boot camp remediation course. And every week they test you either on the PT test or on the asthma. And if you agree with me, then you're off to the next class of boot camp. So you're there anywhere from a week, 12 weeks. If you don't do it in 12 weeks, then you're out. I'm not sure if you heard that, but yeah, these pre-boot camp, boot camp kind of things for about the 12 weeks. That's where they are. There's so few of our names in the world. And we have one more question and then we'll move on to the question. To work at a basic training post on my first student station. Oh, and I used to say, oh man, 60 minutes, get ahold of this. I'm telling you, it was not unusual. So I did the SIP call and it was not unusual. That guy said, oh, my recruiter told me not to say this. Yeah. And comment again, very, very common feedback from some applicants or early entries that, oh, my recruiter told me, basically told me to not disclose this. No, those are just like Lee or me. So let me real quick say, because of those studies that, you know, there were again, over 20 years, GAO has been saying, well, we need to do this and this and this. And, you know, one of the things, some of the things, things like track, why are people, why is the early attrition rate and overall attrition rate so high? What can we do about it? For years and years been recommended to get electronic medical records. And a year ago, we did just that. So the fallout from that has been interesting. It did put us, it's part of that process was that we had access. We now do have access to civilian electronic medical records. It's about, it's not a hundred percent. Some don't participate. Obviously not every doctor facility participates, but it's pretty good. Downside is it's been, it's increased our workload tremendously. So we are somewhat just catching up with that. I don't know that there's any feedback, follow up as far as what that's going to do to these rates. We would assume they would hopefully go down as we pick up more undisclosed information from applicants. Applicants don't like it and recruiters don't like it. But we are, we definitely do pick up things in the record that were not disclosed. So we'll see. We don't know yet, but we'll see what. Yes. Yes, sir. It's MHS Genesis, but it's through, yes, with Cerner. You can pull information retroactively from SureScripts too. So even in the practice was these electronic records that you were prescribing? Yes, that probably is where some of it comes in. We had this very brief period of time where they were looking only at pharmacy records and actually it was really fruitful because they would say no, and then they'd have five pages of Prozac and Tab, Ritalin and whatnot. So yeah, that may be where they pull the pharmacy records. I'm not sure. So let me move on. So we don't run out of time. I'd like to get some of these cases. Briefly, our command is MEPCOM, United States Military Entrance Processing Command, Joint Service Command. Again, it serves as a link between the recruiters and the basic training. There are 67 locations in the U.S. In 21 overall, among all the stations, we did 915,000 visits, 255,000 medical exams, and you see the number of contracts, and 102,000 people shipped to basic training. So what's a day like at the MIPS? The recruiters, of course, met with the recruiter, completed all the background screening and all that, and the medical screening form has been reviewed by a physician at MIPS, projected for the visit. They may spend one or two days at MIPS because generally at medical, it's about four hours, but they may be doing other functions like testing. So most of them come from out of the area. You can see from the map, some of them are fairly spread out. So they'll generally spend a night in a hotel, supervised, of course, griefed on the MIPS process, provided lodging and meals at no charge to them, get on a bus in the morning, arrive at MIPS, have some briefings, and meet with their service liaison, and they come over to medical. So our medical processing, probably many of us, I think, have been through MIPS ourselves. Some things have changed. Some have not changed. There's a medical briefing, vital signs, vision, visual acuity. If they're 20-20, they're good. Near and far, 20-40 are better. If they're not, they get an auto-refraction, hearing tests, standard audiogram, lab blood draw, that's for HIV. And UA, I left one thing off accidentally. Everybody, of course, does get the directly observed urine drop test, men and women. The only point of care urine now we do is a pregnancy test for women. We don't dip the glucose and protein anymore. That was felt really not to be cost-effective, so we don't do that. We discontinued that a couple of years ago. And, of course, we'll get a height and weight. And then the doctor talks to the applicant, has a history interview, goes over that long form that I showed you earlier, does a closing interview. We ask them, again, those important questions face-to-face, even though they may have said no on the form. We ask them face-to-face, asthma, behavioral health, drug alcohol, accidents, injuries, broken bones. So kind of standard, common questions that we will ask them. So they have to, if they're going to deny it, so they're denying it a couple of times if they're, and sometimes they will come clean and either because they really didn't want to lie or because they, you know, they get that moment of truth, you know, that warning about fraudulent enlistment and all that. So sometimes things will come up in the interview that they didn't disclose, and we're nice to them when they do. We don't, we're not punitive to them. We just say, okay, write it down, and then we may have to, we'll always complete the physical, but, of course, we may need to put them on hold administratively until we get further information. So. So where we are now, yes or no, if they've said yes to anything, then it comes, the whole thing comes through for a pre-screen, pre-evaluation by the doctor, a doctor at MIPS. If they say no to everything, it doesn't. That's kind of a point of contention among us, because obviously if then they show up and then we open the electronic medical record and they've got a bunch of stuff, then we have to address it at that point. So, yeah, yes and no. We try to look at everything, whether or not, we're actually notified 48 hours ahead of time who's coming in. So we will use that time to preview it, even if it hasn't come up to us formally for a pre-screen. That makes sense. Yes. You mentioned a doctor would review. Do they also employ a nurse practitioner and physician assistant? To a very limited extent. Actually, most of the fee-based providers are physicians. There are a few, I'm not sure why that is, but there are some PAs and NPs, but they've tended to want to hire physicians as fee-based providers. So like all of ours, I think we are actually getting a PA down the road, but right now all our fee-based providers are physicians. You're a CMO, right? No, I'm not. Yeah, thanks for asking. So the hierarchy in any MEPs is there is a CMO, a chief medical officer, that's a salaried full-time position. A big MEPs may have another assistant CMO, another, so they are a federal employee. All the other providers are contractors. So I'm a contractor. I actually work for a company called Chenega Tri-Services. That's actually who handles that contract. So I'm an independent contractor. So I work part-time, about three days a week. So yeah, that's clarifying that. Thank you. Do you, as an examiner, get any feedback on somebody washing down early? No, that would be nice. So we don't. Now, there is general feedback on, again, all these studies that have looked at this problem as to why people wash out again. About 40% of the ones that are known, actually, probably more than where the cause is known, over half are that they intentionally didn't disclose something. And then another about 30% are maybe they had something, it just never got diagnosed because for whatever reason, they never went to the doctor. And a very small percentage, again, this is just MEPS overall, is a MEPS error. So we're kind of glad about that. In other words, maybe a physician should have disqualified, it should have been known, they should have been disqualified, and did not disqualify. So the number is fairly small. Do genome coercions on family history apply to military? That's a good question. I was thinking about that yesterday. We don't ever ask family history. We get these medical records that they do have family history on them. So I don't know. And I hadn't actually, to be honest, thought about that until the talk yesterday where that was discussed. We certainly never discuss family history. Our standard template on our electronic medical record has a family history box. I always just X it out so it's not even in the record blank or not. OK, let me move on a little bit because I do want to get some of these cases. So once we do the exam, there's a neuromuscular exam. That's the day in their females bra and underwear, males just in their tidy ways will do some maneuvers, the duck walk, look at their hands and feet, skin, check their back, so forth. And then the general physical exam, pretty brief exam, thorough but brief, eyes, ears, lungs, abdomen. Again, we like to look at their skin all over, look for scars. We actually don't do any more, much to everybody's delight, any breast exam, no pelvic exam, no digital rectal exam, occult blood, any of that anymore, even over 40s. There's no special over 40 exam anymore. That went away about a year ago. So it's thorough looking for what we need to look for, but not that thorough. So then we make a determination if they're qualified or not. We don't diagnose. This is where it gets a little iffy because we see something that maybe we know what it is. We don't say, oh, you have X, Y, Z. We'll kind of get into that later, but we don't treat anybody. We don't formally diagnose anybody. So then everybody gets a score. Many of you are familiar with a POLY score with a score from one to four among six body systems, physical, basically everything. That's not one of the remainder. Upper extremities, lower extremities, hearing and ears, eyes and vision, and psychiatric. Of course, a number is ranking between one and four. We actually only use one and three. So we don't worry about the nuances. They either pass and they're one or it's a disqualifying condition and there are three. Temporary or permanent. And then O for open, letter O. For open meaning, of course, that we need further information to make a determination. And P for permanent, T for temporary. Almost always it's permanent. Permanent doesn't mean permanent. It just means we don't know if or when they'll get better, so we can't put a time frame on it. T for temporary is used rarely. For example, pregnancy is disqualifying for six months. Well, somebody gave birth two months ago. We know, we will know if they otherwise qualify, it'll be four months. We can put a date on it. So we could use T, 3T for that, but it's not a big deal. It's, you know, as you know, profiles can always, they change. People get better, they get worse. New information becomes available. So we change, we just change the profile. So not a big deal there. And hopefully our applicants qualify, about half qualify first round with us. But, I mean, overall with MIPS, they'll sign a contract, take the date of, take the oath of enlistment. They'll go home, and depending on, they may be in high school, so it may be a year in delayed entry program, or they may be ready to go and come back in four weeks and ship. Nobody ships the same day. We don't do that, but they'll give a ship date, then they come back. Then they come back. We see them. We don't see them again until they ship. We do a brief history, and basically anything happened to you since we did your physical, specific questions. Very focused medical exam. We look at their skin. We don't do a whole exam again. And women will get another pregnancy test, and then they ship to basic training. And our standard is, we just call it a DOD, but it's a DOD instruction, 6130.03 Volume 1, which was just updated. It is public record. It's available. If anybody's interested in reading it or looking something up in it, it's available online. Make sure you look at the most recent publication and just kind of give you an idea. It's organized by systems, about 50-some pages long, and it is our standard. We refer to it all the time because it changes frequently. We don't necessarily have it memorized. Some of the common conditions, yes, but we will refer to this regularly. So any questions before I go on? I do want to—I'm just going to check the time. I've got plenty of time. We do want to go over some cases again for anybody that came in late. These are stock photos. No applicant photos are used in our presentation. Any questions before we go on? Okay, good. So I thought I might spend some time just going over some cases typical of what we might see at MIPS. One of the things when I—I have been there for four years. One of the things that I was surprised at was how much we see there, how interesting it is. I thought it was, you know, a lot of healthy people and just do exams, and we see everything, and it's very interesting. So it keeps—certainly keeps our day interesting. So here's an example. This male answered no to that long questionnaire. So he answered no to everything specifically. Question 75, skin rash such as atopic dermatitis, eczema, or psoriasis. And we do his exam, and his elbows look like this. So what do you think? It looks like psoriasis, and that's what I said. Well, it looks like it could be. Yeah, I thought it definitely looked like psoriasis. I didn't say, oh, you have psoriasis, but it was, well, you know, it looks like. And it asked, of course, at that point, when we're looking at them, we can, you know, ask, obviously, we'll ask more of the history. Well, have you ever seen a doctor for this? How long has it been there? Does it itch? We'll ask focused—focused additional questions, maybe do some focused exam. So what should we—well, first thing we'll do, we'll look at the book. And what does it say? Under Chapter 21, Skin and Soft Tissue Disorders, History of Psoriasis, Excluding Non-Recurrent Childhood Gut-Date Psoriasis. What do we do with him? Go on. We—yes and no, and ultimately, yes. I—any other thoughts? I'd be concerned about the use of biologics. I mean, immunosuppressives can't be good. That's a—yes, that's a good question. Whether—yes, either does he really know he has it, is he taking something he hasn't told us about, or down the road, is this going to be an issue with the need for treatment, which is probably why the book says it's automatically disqualifying. So what I did, I actually left it open, right? I left it open, had him get a formal diagnosis, and we did. And then, once it—he doesn't have to come back, but the information comes in, we review it. And at that point, yes, he was disqualified. All right. Yes, question. So you make a referral to her, or you can tell her to make a referral to her? We can make some referrals. It kind of depends on the condition, on what's needed. Question was, do we make the referral? Do we send him to his own doctor? It depends. In some cases, we'll send them to their own doctor. In behavioral health, we usually send behavioral health eye consults, audiology consults. They always go to our contractor. And with some other conditions, it kind of depends on a resource that we have. We do have a dermatologist we can send them to. And so we did send this one to our contractor. And it's not always at government expense to our contractor. If it may be something protracted, if it's a follow-up of, say, their hypothyroid, and they've always been hypothyroid, and they haven't followed up, we'll send them back to their own doctor. We don't do a consult on them. So that's a good question. Yes, and question. Yeah, I used to sit on the Army Aviation Labor Scanner. So did I. Oh, God, why? That's quite a domicile, by the way. But we used to have a saying, being like Spots, we had a tremendous investment. I'm like a seasoned pilot, cost a lot of money to train. The thing was, you don't have to be in perfect health to die. Yeah. Well, that is one way to put it, really. Let me move along. Unfortunately, we see this not uncommonly. This is a 23-year-old female answered no to everything, including question 103, self-inflicted injuries such as cutting or burning. Closing interview asks again about self-harm. So again, we asked them twice, said no. And we saw this. And what happened? She said, usually, and again, this is a stock photo. Usually, when we see this, it's much more subtle than that. We do look very closely at common sites, forearms, especially non-dominant, forearm, thighs, abdomen, shoulders. Everybody gets inspected closely for self-harm. And usually, well, sometimes they'll disclose it when you ask them directly. Sometimes it's cat, dog, barbed wire, three branches, et cetera, variety of. You know, I always want to. I never knew, but you know. So OK, so what do we do? Well, OK, what's the book say? This was just updated to clarify. Fortunately, it's helpful to us. Basically, the history of self-harm has always been disqualifying. They added otherwise clinically suspected. That helped us to be able to say, we don't argue with them. We don't say, OK, applicant says, blah, blah, blah, otherwise clinically suspected. We're not accusing anybody of anything. And so disposition, do we need any further evaluation? Yeah, yeah, we don't need any further evaluation at that point. Yes, we have to. Why would they refer to a psychiatrist? That's a good question. So why not refer this person to psychiatry behavioral health with any condition at MAPS? And this is, I'm looking at this strictly administratively. Once they're disqualified, we're done. We don't, well, with a few exceptions, when they're done, when we're done, they're disqualified. We don't pursue additional consults because it's not going to change our disposition. Do we tell them? Do they come back to you? I mean, because I can see this happening. They come back and say, let's do, why am I disqualified? Do they have questions? Do they ask, do they come back and ask why are they disqualified? Well, we'll tell them, I will, or at least I will, I will tell them upfront. I'll say, I'll even show them in the book and say, okay, if this, this, and this, this is disqualifying, we have to follow these guidelines. We do not waive things at our level at MAPS. You will now go, you could go back to your service liaison. They will tell you how to pursue a waiver. Service liaison is in the building. Every Army, Air Force, Navy, all the service liaisons are in the MAPS. Everybody, even if they pass when they're done with medical, they go back to their liaison for further processing. But if they are disqualified, then their liaison is responsible for talking to them about how to request a waiver for their condition. Let me do another one. Here's a 24-year-old male. We do see tooth, teeth in need of dental care once in a while. So he has, we see missing tooth, some visible decay on three other teeth. As far as the dental exam, we aren't dentists. We don't have a dentist. We don't have x-rays. So our dental exam is basically, we have them show me their front teeth as best we can see, open like you're at the dentist. I shine a light in, look at all the surfaces as best as possible. That's our dental exam. So it's cursory, but we can certainly see. So basically, we see if there is any decay, any missing teeth, any braces, which sometimes they do, or Invisalign. They can have permanent retainers. That's not a problem. So this individual has, looks like one tooth is missing, and I can see visible decay on three other teeth. He says he has no pain, no difficulty chewing, and inability to eat certain foods. Let's go to the book. Yes. The question is that if they did not have a permanent, let's say, removable dentures, appliances of some sort. Would that be a basis for exclusion? Questions if they do not have any permanent, like for example, this individual with a tooth missing, he doesn't have any kind of bridge or permanent appliance, is that disqualifying? Well, let's find out. We'll look at dental. We'll look at the book under D and E. So, as far as caries, eight or more teeth with visually apparent decay, cavities, or caries. Is he okay in that department? Yes, he is. And large edentulous areas of greater than four contiguous missing teeth, unless restored by a well-fitting prosthesis, blah, blah, blah. So, is he missing more than four contiguous teeth? No. So, what say you? He is good to go. So, he passes. And now he can go to see a dentist. Sadly, when we deployed in 91, what was the number one emergency issue? Probably dental. Dental emergencies. So, the question was, what's the number one emergency on arriving in country and in deployment in 91 was dental emergencies. What? Yeah, for National Guardsmen. I was told that it had to be not only well-fitting, but it had to be permanent. That's when you got removable. It may be. Yes, it may be removable. I had one applicant who had very bad, eight or more, lots and lots of bad teeth. And he showed up about six months later, they were all pulled, he had dentures, they were fully functional, they were comfortable, he could eat and chew and everything. And he got, his profile got changed. He was qualified. So, yes, they may be removable, partial or complete. Was that a temporary disqualification? No, he was a permanent, because again, we didn't know. Temporary was really only used, do we know that they have an end point in the disqualification? So, he was permanent. There's a good example of somebody who was permanently disqualified. We need to bring the call court too. But, monitoring. Okay. Is that for me, Jeffrey? Sorry, I'll mute myself. Okay. And I see a chat that may be from a while ago. So, there's a chat about the self-harm. You can disqualify based on only a suspicion of self-harm. So, you don't need a definitive diagnosis for that particular standard. That is correct. That was specified in our new DOTI, because it was kind of vague before. So, we were doing it anyway, because it was clearly, self-harm is pretty pathognomonic and normally non-dominant arm, parallel scars, parallel to one another, usually perpendicular to the long axis of the arm. Very typical self-harm. So, yes, we do for that particular standard. That is correct. Okay. So, let's do another one. So, this 18-year-old male answered yes to heart surgery and said he had a history of repair of a VSD at age three months, no cardiac symptoms currently. And so, we'll go to the standard and under the heart chapter, section five, corrected. Sorry. So, history of this, except, I think, history of any congenital anomalies of the heart or great vessels other than, this is other than the following conditions. And this is one of, so, this is an exception. So, this is okay if they have a whole standard, normal current echocardiogram within the previous 12 months and no residual symptoms. And so, what do we do? We got some records. We got records and we found that he actually, we got the operative. We always look at operative reports if possible. I know sometimes with older applicants and had surgery as a child, they may or may not be available, but we request them and look at them if we can. Current cardiology evaluation echocardiogram. And we find out he actually had already followed up with a cardiologist. Echocardiogram shows no current VSD or other abnormalities. Cardiologist says he's good to go. He has no restrictions, prophylaxis, additional imaging. So, what do we say? He's good. So, we will qualify him. Okay, check time. I do want to leave a few minutes for additional questions, but we'll see if we can do one or two more. This is an example of a nice lady I was, I was, yeah, I was interviewing and I noticed something right away. She has an exotropia. She did disclose. She answered yes, she had had exotropia and some eye surgeries so far. So, there's an eye standard. So, eye standard says exotropia more than 10 prism diopters. Used to just say exotropia. So, we could just, that's when we could, remember I said we don't diagnose. Well, that's kind of obvious that we could just go from there. Now, they've given us specific prism diopters. So, we actually, we left it open, got an eye consult, so they could measure the exotropia and prism diopters. And so, they did the eye consult. So, what do we say? So, exactly, yeah, I don't know what it actually was. I kind of threw that number out there. But, so, she does not meet the standard. Could she have to pay for a residential? Eye consults, we'll do eye consults. Yeah, we have a, we pay for those. So, eye consults are often done with, let's see, actually here's my next one's a vision question. We'll do eye consults in cases of where they fail the vision because if they fail vision for astigmatism, we want a detailed exam. They have to do corneal topography, manifest refraction, so that we rule out keratoconus, lattice degeneration, and with the severe myopia, we need a good retinal, good dilated exam to make sure there's no retinal pathology. So, and here's another, here's an eye exam, or eye example. This applicant disclosed wears glasses, his distance visual acuity is 2200, without correction, 2020, 2025, with correction. So, we do an auto refraction, and I don't know if you're familiar with the reactions, but basically the first number is the sphere of the power. Second number is a cylinder, measure of astigmatism, axis we don't care about. So, does he, is he qualified? Let's see, what does it say? So, a reminder, his is down here. Here are the criteria. So, does he correct with lenses to at least 2040? Sorry, that's near. Distant visual acuity, does he pass correct to 2040 in each eye? Yes, he does. The old standard of the 2100 here, and the 20, they used to have this convoluted chart. We don't do that anymore. They have to have 2040 or better in each eye, not both eyes together. Near can just be any one eye. Are these now uniform across the board? Yes, good question. Are these standards uniform? Yes, there is still a 40-501 with all the standards for, for enlistment. Now, they refer you to the DOTI. This is across services, thankfully. So, every services. Now, for retention, it's a little bit different, but for enlistment, they're universal. What about people who are trying to go service academy or ROTC scholarship? Because they used to have those kinds of breakouts. Yes. Also, and they were much, much more rigorous on those than they were for general applicants to service. ROTC service academies are handled a little bit differently. And so, yeah, it's kind of complex. We have been drawn into doing some of that, but then DOD does them. So, yeah, we don't generally, we don't do this. Let's just say we don't really get into doing those. The standards are different. They may, yeah, I'm not sure about what they do with the, yeah, the ROTC and service academies there. We don't do those. So, I can't really comment on that. Yes. Do you accept corneal surgical procedures for correction? Yes, good question. Do we mean people that have had refractive surgery? So, the question is regarding refractive surgery. Yes, used to be when I went in, it was disqualifying. I had to get a waiver. Now, it is not disqualifying as long as it has been more than 180 days. Then their vision is stable, demonstrated by two examinations at least 30 days apart. Of course, they have to have no complications, etc. So, yes, in that case, they are. And importantly, their pre-surgical refraction has to meet the standard. So, you can't have bad myopia, astigmatism, get it corrected, and then you still will not meet the standard. And the reasoning is because the severe myopia and astigmatism may indicate other kinds of eye pathology, but the LASIK or BRK doesn't eliminate that eye pathology. So, they are still disqualified even after surgery. And again, and the standard here. So, as far as refractive error, spherical equivalent. So, as far as the myopia, spherical equivalent, greater in excess of plus or minus 8. And that's up here. Sphere plus half the cylinder. Sometimes we do have to actually calculate it because it's close. He's not close. You can see that it's going to be less than 8. This plus, sorry, first number plus half of the second number, clearly less than 8. Astigmatism in excess of plus or minus 3. Does he meet the standard? So, yes, he is good. He qualifies. What we see, probably our most common disqualification is actually vision because we do see a lot of people that do have astigmatism or myopia, hyperopia, beyond that. So, but they're frequently, again, they all get eye consults. If their eyes are otherwise healthy, a waiver is fairly, is pretty likely, depending on how bad. Sometimes we see it's really, really like very high. And then sometimes they don't. But again, always up to the service. And let me do one more because this is kind of interesting one. This happened to my colleague. Answered no to any ear questions. And he looked in his ear and he saw this. So, and actually happened to another colleague about a week ago. So, I haven't seen this yet. So, that's two for us. Well, what do we think about that? So, because that's probably see the infection when we have. Yeah, that's true. It's pulling out. Yes. Yeah. So, yeah, good news. We can we can see the infection. But is this going to be disqualifying? Probably. We think this is probably going to be disqualifying, but let's look it up. And under ears, basically any pressure equalization tubes within 24 months. So, even if he had had them and they fell out six months ago, he's still, he's still. And I keep saying one more. Okay. One more. I want to keep that time. Am I good for time? Okay. We'll do one more because then I would just want to make some final comments. So, here's our female. This is, we do this back examination during the neuromuscular exam. We see an obvious suspected scoliosis and she said, we see this fairly often. So, she acknowledges the doctor did say once she had a curve in her back, but she didn't have anything to worry about. She never got any imaging. She has no back pain. And what are we going to do with? Well, we'll look at the book, of course. And it says scoliosis, if a current deviation or curvature of a spine and as far as scoliosis greater than 30 degrees, seems like a lot to me, but measured by the Cobb method. What are we going to do? So, we can't tell. We don't try to measure it from, you know, any kind of the little devices we use to measure. We'll send her for an x-ray. We'll leave her open. The thoracic spine is actually under upper extremity. So, it should be open under the upper extremity. We'll get a spine x-ray. And remember, it says that it's one of the qualifications is it symptomatic. So, we always ask, do you have back pain? Do you have, they always say no, of course, but we document they have no back pain, no functional limitations, active in sports, whatever. Do the x-ray. So, it's a 25 degree thoracic levocurvature with an apex at T8. She's under 30, asymptomatic. So, we can, she is qualified. Yep. Yes. Yes, she is. Yes, sir. So, I'm actually going to stop there with the examples because I just want to jump past some of these. I want a few comments just about what do we want from our civilian physicians and other providers? Well, basically, if we send somebody for follow-up, like an orthopedic injury, and they never followed up, we want to know, is it healed? Is it, do they have any restrictions? If it's a cardiac condition, do they have any restrictions? A need for further imaging, further testing? So, as much information as can be provided regarding that. Think about any restrictions, not just general limitations. How about to activity? How about to environmental exposures, to austere medical conditions? Do they need more than routine surveillance, further treatment? Any orthopedic, very important. Sometimes we'll see, oh, they're cleared, but they have to wear a knee brace. Well, then they're not really cleared without limitations. So, commenting on, is there any need for a brace, any other protective equipment? The progress notes. We like clinic, just clinic progress notes, imaging reports, operative records, pathology reports, lab tests. What's not needed, not helpful for our purposes are things like after-visit summaries, patient portal documents. Letters are not helpful. We get letters all the time. So-and-so is fit for duty. Well, that's not helpful. Nursing notes, anesthesia notes, not really. We don't, if they've been hospitalized, we don't want the whole 900-page record. We just want the H&P, the consults, the imaging, and what would be helpful to us. Facility, office generator record, again, the patient portal documents and after-visit summaries aren't usually helpful. Is peer-to-peer. Usually people are good. Once in a while, we'll get the letter, you know, that doesn't, maybe it thinks it's going to a layperson and describes the herpes simplex is whatever they go on to describe the condition. So, just keep in mind, it is, if we do ask for correspondence, it's going to, it will be reviewed by a physician or another licensed provider. And so, just sometimes we get letters. Again, it's a letter, which automatically is usually not helpful. But sometimes we'll get, we saw this patient in follow-up. He has had no issues. He has full, usually it's full range of motion and no anemia or something like that. And he's cleared for military service. Not helpful. Better, or excellent exam. This is, I made this up, but it's supposed to be a progress note, right? Date, clinic, HPI, past medical history, medications, examination. So, knee issue. Examination of the knee, normal field scar, range of motion. Excellent. That's very helpful. Knee was stable. All the appropriate stability tests for the affected joint. Also, again, very helpful. Cleared to return to sports with no limitations. That's, you know, that works for us. Follow-up is needed. So, that's all much more helpful to us. But just in closing, I really like what I do. So, it's, it was a good, good job for me as a, as a retiree, wanting to work kind of part-time, no call, a lot of flexibility. They are very short. So, again, I'm not a recruiter. I'm not, you know, hiring for anybody, but if anybody's interested, it's a, it's a great job for somebody who wants to keep active. So, if you have any other questions about, you know, about, or qualifications, let me know, maybe a minute or two for questions. Dr. Clark. I, sometime in the military, I get a number of, you know, always psyched. Yes. How long has it been since we were in Key West? Yeah. Okay. Quick question is again. So, patient comes into the civilian physician saying they, first of all, yeah, they come in. I need to be cleared for XYZ in this case for a psych issue. The consulting first was a family physician, a primary care physician. Sometimes we almost always will want that, especially, you know, an orthopedic cardiologist for cardiac issues. Behavioral health is one of the issues that we use our own consultants, unless otherwise indicated, we don't like them to go to their own behavioral health kind of for obvious reasons, because it's very, in a way it's subject. So, you can just, I mean, basically you can do what, what you can do. You can interview the person, you can record your examination, their mental status examination, record what they tell you, and you can send it on to us. What we, what we really can't take, you know, again, sometimes a sufficient position will say so-and-so is cleared for the military. You can't, you probably don't want to say that anyway. Some of the people do. And in any case, if you do, it's not something we can't, you know, it's not helpful to us. So, all you can do is see the person. You may make a referral. You're kind of doing two, maybe looking at it from two angles too. You're looking at, are they healthy? Do they need referral for their own health care? Then we would do that. Whether or not we can use it as another matter, but you can just do your exam, do your interview, do your exam, document it. Is there a diagnosis? And then your recommendations, and they can send that to us and we will consider it. So, that's what I would do. Thank you. You're welcome.

Dr. Klatka

Military Entrance Processing Station

preventive medicine

occupational medicine

medical evaluations

medical history

electronic medical records

recruitment practices

medical disqualifications

military readiness