WASHINGTON—Former Assistant Secretary of Defense for Health Affairs S. Ward Casscells, MD, spent his last morning on the job at the Walter Reed Army Medical Center where he visited various medical departments and spoke with patients and staff.

For the outgoing top doctor who is a cardiologist and reservist, the medical center is familiar territory. During his two-year tenure he frequently went on patient rounds there, allowing him to stay in touch with what was happening outside of the Pentagon and on the ground in military medicine.

“Dr. Casscells comes in stealth mode a lot. He comes early in the morning when doctors do their rounds. Sometimes, he surprises the young teams in there because they look at him and say, ‘okay who is this?’ Then they realize who he is,” said Walter Reed Health Care System Commander Col Norvell V. Coots, MC, USA, who accompanied Dr. Casscells on his last rounds at WRAMC.

The Administration has not yet named a new assistant secretary of defense for Health Affairs. Ellen Embrey, who most recently served as the acting principal deputy assistant secretary of defense for Health Affairs, will serve as his replacement for the interim.

The Administration will probably recruit a successor who has strong management experience, Dr. Casscells told reporters who accompanied him at WRAMC at the end of April.

“I bet you Secretary Gates will find someone who really is a crackerjack at management. That would not be me,” said Dr. Casscells.

Staying connected to the patients is the advice that Dr. Casscells said he would offer his future successor, if asked. It is something that he says gave him added credibility in the Pentagon when he asked for funding.

“Stick close to the patients and walk humbly,” he said.

Building Military Health Care

During the two years since he took his position, provider morale in the military has improved, Dr. Casscells said. When he took the Pentagon job in 2007, it was in the wake of press reports about substandard living conditions for outpatients at WRAMC and the bureaucratic tangles that patients were encountering in transitioning to the VA. These problems had a negative impact on provider morale.

“People felt they had been dishonored. Because they work for honor and pride they thought, ‘well, what the heck are we doing,’” he said.

At that time many providers expressed interest in leaving the military, Dr. Casscells said.

“Two years ago when I took the job, the lieutenant colonels, colonels, commanders and captains were saying, ‘Dr. Casscells, I am out of here as soon as I can.’ Morale was poor. But our retention now is actually higher in all three services—army medicine, navy medicine and air force medicine,” he said.

The situation at WRAMC improved with the help of the staff there who he said dug “a little deeper,” and worked hard to rectify the problems there.

Challenges To Address

Dr. Casscells said that among the top challenges that the military health system currently faces is access to care. Outpatients face difficulties in obtaining medical appointments at medical treatment facilities in a timely manner.

“It’s hard for outpatients to get an appointment. There are several initiatives to try to improve that access,” he said. “That kind of frustration is serious because people quietly will go to contractor care, civilian care, and in the long run that migration of patients…it jeopardizes what we do here. We need to have enough patients to maintain excellence. Doctors have to maintain their skills. If the hospital is half full you are going to be weaker and weaker instead of stronger and stronger.”

He said he has first-hand knowledge of this problem. The first time he tried to make a medical appointment at WRAMC he had to call eight times before being able to get one. He did not identify himself as a DoD official during the call, but as a reservist.

“Our MTFs, our hospitals have got to solve this appointments process to make it easy,” he said.

Another important issue that must be tackled by a new assistant secretary of defense for health is PTSD and the stigma associated with it that prevents servicemembers from seeking help.

“We are just beginning to make progress on this PTSD problem,” he said. “We now have enough doctors, nurses, psychiatrists and social workers, psychologists to take care of them. We didn’t have that before. We have had two stars and three stars talk about the fact that they have asked for help reducing some of that stigma, but it is still there.”

AHLTA, the military’s electronic medical record, continues to be a headache for healthcare providers, but Dr. Casscells said that work is ongoing to rebuild the system.

“Our AHLTA is still frustrating our providers, our doctors and nurses, so we are totally rebuilding AHLTA,” he said.