Q&A: Rear Admiral Michael H. Mittelman

Written by Ted McKenna

MEDICAL CATALYST:
Influencing and Directing Medical Support
for NATO and Joint Warfighters

Mittelman was commissioned in the Navy Medical Service Corps in 1980. His first clinical assignment was at Naval Hospital Cherry Point, Marine Corps Air Station Cherry Point, N.C., from July 1980 to September 1984, serving as a staff optometrist and later as head of the optometry department. From September 1984 to August 1987, Mittelman served as head, Optometry Department, U.S. Naval Hospital, Rota, Spain. Mittelman then transferred to the Naval Aerospace Medical Institute, Pensacola, Fla., where he served as head, Optometry Department, and became the first optometrist designated as an aerospace optometrist in 1989. In 1993, Mittelman assumed the duties of deputy director of Research at the Naval Aerospace Medical Research Laboratory, Pensacola, Fla. He then reported to Naval Hospital Great Lakes, Ill., in October 1995 where he held the position of head, Recruit Medicine Department, and also served as the commanding officer of Fleet Hospital 3. In July 1997, Mittelman assumed command of the Naval Ophthalmic Support and Training Activity, Yorktown, Va. While there, he facilitated the establishment of the Department of Defense Optical Fabrication Enterprise. In July 2000, Mittelman assumed command of U.S. Naval Hospital Okinawa, Japan. Following this assignment, Mittelman served as the executive assistant to the surgeon general of the Navy until August 2004, after which he was assigned as a special assistant to the surgeon general at Headquarters, U.S. Marine Corps, Washington, D.C. He then served as the deputy chief of staff, Human Resources, Bureau of Medicine and Surgery. Prior to reporting to his current assignment, Mittelman served as the director, Medical Resources, Plans and Policy Division (N931), Office of the Chief of Naval Operations.

Mittelman is a fellow of the American College of Healthcare Executives and a diplomate of the American Academy of Optometry. He also is an active member of the American Optometric Association and associate fellow of the Aerospace Medical Association. He is past president of the Armed Forces Optometric Society and a member of the National Academies of Practice.

Mittelman’s awards and decorations include the Legion of Merit (five awards), Meritorious Service Medal (three awards), Navy Commendation Medal (two awards), Navy Achievement Medal, Meritorious Unit Commendation (two awards), National Defense Service Medal, Operation Enduring Freedom Medal, Navy and Marine Corps Overseas Service Ribbon (five awards) and the Navy Expert Pistol Ribbon.

Q: How would you describe your missions in the Office of the Command Surgeon at U.S. Joint Forces Command [USJFCOM] as well as in the Medical Branch in Allied Command Transformation [ACT]?
Additionally, what are your roles in medical transformation?

A: The uniqueness of my two roles as the command surgeon at USJFCOM and as the medical advisor at Allied Command Transformation provides me opportunities to influence and direct medical support for both our NATO and joint warfighters. In 2009, beside ongoing doctrinal development and review, our most pressing mission is to support our forces in Afghanistan and Iraq. We must ensure joint and coalition forces have the required medical support throughout the world. We accomplish this by working in several venues to include strategic planning, policy development, joint training and joint force providing. We recently updated our Office of the Command Surgeon, USJFCOM, mission statement to include focus on striking a balance between meeting present and future joint operational medical requirements. To achieve that purpose, our office now is divided into five branches: Joint Concept Development and Experimentation, Joint Force Provider, Global Health, Joint Training and Administration Support.

Our Joint Concept Development and Experimentation branch focuses primarily on medical transformation. Joint force health protection transformation is one critical area where we focus our efforts. In 2004, the deputy secretary of defense tasked USJFCOM to improve war fighting through joint force health protection [JFHP] transformation. Working closely with more than 400 personnel from the Joint Staff, combatant commands, the Office of the Assistant Secretary of Defense for Health Affairs [OASD/HA], and other government agencies, we identified short- and long-term gaps the joint force and medical community need to address. In 2007, the Joint Requirements Oversight Council [JROC] approved the “Joint Force Health Protection Concept of Operations” [JFHP CONOPS]. This pivotal document identified our best estimate of what is required to support joint forces from 2015–2025. Publishing such a document is instrumental in leading medical transformation. This JFHP CONOPS incorporates the services’ transformation planning, is focused at the operational level and implements the JFHP strategy of three interrelated pillars: healthy and fit force; prevention and protection; and medical and rehabilitative care.

Because of the joint medical community’s innovation and diligence over the past several years, joint warfighters currently suffer the lowest died-of-wounds and disease, non-battle-related rates we have ever seen. Advances in medical technology have helped, and these likely will continue at an exponential pace. We must continue to leverage these to support joint forces during home base and expeditionary operations. Our findings from the JFHP CONOPS are posturing DoD to address gaps and further leverage these advances to best support the joint force. The overarching purpose of the JFHP CONOPS is to support analysis of capabilities and gaps through capabilities-based assessments in six functional areas: joint casualty management; joint medical logistics and infrastructure support; joint medical command and control; joint patient movement; joint health surveillance, intelligence and preventive medicine; and joint human performance enhancement. Although the JFHP CONOPS directs solution development, many identified gaps are already being used to prioritize resources and drive medical research and development initiatives today. An enterprisewide approach is under way to prioritize top gaps in these functional areas. The deliverable will enable the Military Health System [MHS] to look across the joint medical community and develop an integrated investment strategy for solution analysis.

Two examples of solution development initiatives currently under way include the epidemic outbreak surveillance [EOS] advance concept technology demonstration and the joint medical distance support and evacuation [JMDSE] joint capability technology demonstration [JCTD]. EOS will provide near real-time environmental surveillance and clinical diagnosis by integrating MHS information management and information technology [IT] systems. It will improve our environmental surveillance capabilities of biological threat agents and the clinical response to influenza-like pathogens. It contains pathogen agent detectors and peripheral data collection, distribution and analysis data systems that potentially can identify a sudden increase in flu cases in a specific area and then identify if the flu cases have characteristics of a specific strain such as Avian flu. EOS is transitioning from a concept into two programs of record [POR] this year.

In October, we started a $19 million JCTD—JMDSE. JMDSE will employ advanced technologies to adapt current tele-maintenance technology for battlefield telemedicine. It will provide virtual triage and automated patient monitoring/care at a distance, aerial precision delivery capabilities from helicopters, fixed wing aircraft and unmanned aerial systems [UAS] to bring small medical bundles or equipment forward to dispersed forces and develop CONOPS for future UAS casualty evacuation of sick and injured from denied or remote areas technical solutions. This demonstration has support from the services, U.S. Special Operations Command, U.S. Pacific Command and a number of government organizations.

While our efforts concentrate on supporting USJFCOM, Joint Staff and OASD/HA, our work at ACT is very much interrelated. The ACT medical staff is leading the medical transformation process in NATO. I work closely with our NATO colleagues and with my direct counterpart at allied command operations [ACO], the operational arm of NATO. Our ACT and ACO medical staffs work together on doctrine and training to ensure we continue to deliver quality medical care to the warfighter. The most pressing issue for ACT medical in 2009 is support of our warfighters in Afghanistan. In the long term, we must ensure medical capabilities developed by each nation enables support for all NATO missions. To accomplish this, we will continue to identify the best available practices in NATO and share them among the nations to ensure a uniformly high standard of medical care is provided to the force. Where there is an identified need for improvement, and no solutions currently exist, we must develop them through experimentation. Lastly, we are working to assist nations such as Albania and Croatia as they prepare to join NATO.

Q: Is there any end state and how would you measure the progress toward transformation to date?

A: Transformation never really has an end state. It is a dynamic and ongoing process that must continue into the future. The world, our operational environment and our adversaries are always changing and adapting. We must remain agile, flexible and be prepared to deal with the inevitable surprises that will come our way. While we are making tremendous strides in joint medical transformation we will continually re-assess and identify gaps and create solutions to meet future challenges. Dealing effectively with these challenges requires innovative and organizational solutions that allow standing joint task forces and other organizations to operate routinely across combatant command boundaries without disrupting the integrity of those organizations. Any discussion about transformation and future challenges would not be complete without highlighting two recently published documents: the “Joint Operating Environment” [JOE] 2008 and the “Capstone Concept for Joint Operations” [CCJO]. JOE 2008, a USJFCOM publication, lays out the problem statement, describes future operational environments the joint force may encounter and sets demand signals for future challenges. The JOE is a companion to the CCJO. The CCJO, signed by the chairman of the joint chiefs, articulates his vision for how the future joint force will operate to address the challenges and meet the demands of future operating environments. Both have great implications for the joint medical community.

Progress in U.S. and NATO medical communities is often measured in number of lives saved and mitigation of the impact of injury and illness through disease prevention, public health and casualty care. These are of equal importance whether we are caring for U.S. troops, coalition partners, host nation colleagues, internally displaced persons and even our adversaries, when necessary. Additionally, coordination and collaboration are vital to our joint and coalition successes. We will continue to transform and improve processes and develop new methodologies to meet the present and future operational needs of joint and coalition forces.

Q: Since coming on board in mid-2008, what has been your vision and direction for the surgeon’s office?

A: The easy—and correct—answer is that my vision supports that of my commander, General [James] Mattis, in his dual roles as NATO’s supreme allied commander transformation and commander of USJFCOM. Both of my offices must be relevant, agile and able to respond quickly to the warfighter’s medical requirements. I believe in execution and not creating bureaucracy to solve problems. One thing I’ve learned over the years is that it’s relatively easy to talk a problem to death, but the only way you’ll succeed in solving a problem is to address it head on, be prepared to take some risk and go with the 80 percent solution. We are engaged in a fight with an agile enemy on a fluid battlefield that has increased medical requirements. Our job is to support the joint and coalition forces and look for things to support our forces’ current and future needs.

I bring an operational background with several years working in the Pentagon on the OPNAV and Navy Medicine headquarters staff to this job, thus my focus is on the operator. My first priority after reporting on board was to become savvy on USJFCOM’s role as the Joint Force Provider [JFP] and learn more about the overall global force management [GFM] process that falls under the Joint Staff—in addition to attempting to become familiar with all the acronyms used both by USJFCOM and ACT.

Our JFP team is the medical focal point for this USJFCOM mission. As the DoD joint force provider, USJFCOM recommends assignment of almost all conventional forces in the continental United States to provide trained and capable forces to commanders in the field. Building a joint force requires coordination with active forces, the Reserve and National Guard to ensure deployment of an integrated, task-organized team. During the past two years, our medical planners were instrumental in meeting combatant commanders’ conventional medical support requirements. The direct efforts of our staff provided joint sourcing recommendations for a range of operations including Iraqi Freedom and Enduring Freedom.

This is a complex process because it involves tasking the services to provide personnel and materiel in support of the warfighter. To help facilitate communication and ensure our service and component command surgeons and their staff were knowledgeable on both the GFM and JFP processes, we hosted two expeditionary medical operations meetings. These improved attendee working knowledge of these pivotal joint operational processes, enhanced transparency, facilitated teamwork and garnered trust with the stakeholders.

As medical advisor to ACT, my staff and I work to support the commander’s vision that “ACT will be NATO’s leading agent for change; enabling, facilitating and advocating continuous improvement of military capabilities to enhance the military interoperability, relevance and effectiveness of the alliance.” My own vision and directive is to expand and improve medical support to our forces by working closely with ACO in ongoing operations. I also am ensuring we maintain a clear view of NATO’s future needs. The primary role of ACT is to look forward to ensure adequate medical support for future operations.

Finally, I am focused on improving linkages between the ACT and USJFCOM medical staffs to better communicate and share ideas, concerns and projects in order to best align our work collectively to support the joint and coalition forces.

Q: What are some of the accomplishments that can be attributed to the Office of the Command Surgeon, USJFCOM and to the Medical Branch, ACT?

A: While we are the catalyst, or the office of primary responsibility, for many initiatives, the strength of what we are able to accomplish lies in leveraging and enabling capabilities inherent to DoD, USJFCOM, our multinational partners, interagency and intergovernmental organizations as well as industry and academia. We partner with line and military medicine colleagues in all four services, as well as the Coast Guard, combatant commands, Joint Staff, Office of the Assistant Secretary of Defense for Health Affairs and NATO. It is the strength of these interactions and partnerships that ensure success.

USJFCOM’s Global Health Branch is composed of two Air Force international health specialists and an Army preventive medicine officer. It has been actively engaged with several organizations in furthering capabilities to support the medical component of the DoD mission of security, stability, transition and reconstruction [SSTRO] operations. In November 2005, DoD published DODD 3000.05, “Military Support for Stability, Security, Transition and Reconstruction [SSTR] Operations.” This document states, “Stability operations are a core U.S. military mission that the Department of Defense shall be prepared to conduct and support. They shall be given priority comparable to combat operations and be explicitly addressed and integrated across all DoD activities including doctrine, organizations, training, education, exercises, materiel, leadership, personnel, and facilities and planning.” It went on to direct that the under secretary of defense for Personnel and Readiness shall “ensure DoD medical personnel and capabilities are prepared to meet military and civilian health requirements in stability operations.” To this end, our Global Health staff is engaged with the DoD Civil Military Medicine Working Group to address these key issues and recommend solutions.

After working with more than 100 personnel worldwide, our Global Health Branch finalized a comprehensive paper on stability operations to assist line and medical communities. The paper, titled, “Emerging Challenges in Medical Stability Operations White Paper,” was signed by the USJFCOM chief of staff and published in 2007. This paper since has been used as the basis for training medical stability operations, including a module the Global Health team spearheaded and built in conjunction with the joint knowledge development and distribution capability [JKDDC]. JKDDC provides premier relevant, timely and globally accessible joint training to prepare individuals to support integrated operations.

Our Global Health team also is making progress in the whole-ofgovernment approach with a specific focus on public health systems and interactions with Department of State and international health entities. They are engaged with partners from the OASD/HA, the Department of State, U.S. Agency for International Development and other nongovernmental agencies to determine the best whole-of-government approach and develop a way ahead. Preliminary concepts include taking care of the joint force, delivering emergent humanitarian assistance, and providing support to host nations as they build their own military and civilian health capacity.

Our goal is to take these concepts and capabilities the United States developed and employed over time, in an ad hoc fashion, and institutionalize them to provide better support to the joint force. Joint doctrine provides the main mechanism for institutionalizing these concepts. To date, we have published several doctrinal changes in joint publications that specifically address the joint medical community’s role in stability and civil-military operations. Last, the Global Health Branch provides support to the combatant commands. Our branch chief was a key adviser to the command surgeon, Africa Command, as they developed their concept of operations. Our ACT Medical Branch also has some significant accomplishments regarding training, doctrine and information management/ information technology. Specifically, we championed ratification of three new pieces of doctrine called Allied Joint Medical Publications: medical planning, aeromedical evacuation and medical intelligence. Also, our staff delivered in-built training for the casualty rate estimation tool to ACO.

We also shaped the Hungarian Ministry of Defense proposal for a Medical Center of Excellence that meets NATO’s requirements. In the area of training, we delivered five medical courses for the NATO School in Oberammergau, Germany, and we promulgated a joint areas functional training guide. Additionally, there was experimentation to develop the medical information and coordination system [MEDICS]. The development of this capability is focused on 2012 for the delivery of a disease surveillance system for NATO as well as reporting modules of the International Security Assistance Force.

Q: What are some of the biggest challenges facing joint medical care, especially in the combat environment?

A: Expeditious and effective medevac will remain a key focus— getting our wounded warriors to treatment facilities as quickly as possible is paramount. We’ve done a great deal of training first responders to control bleeding and breathing on the battlefield. If a first responder can control bleeding and breathing within the first “platinum 10 minutes” following injury, current data show survival increases dramatically. We need to reinforce this training. We also will need to develop new capabilities and change the capacities of existing ones.

In the areas of joint training, we are excited to be a part of the USJFCOM urgent requirement JCTD, future immersive training environment [FITE]. This will provide military trainers and trainees a high-fidelity, immersive training simulation environment that creates and reinforces complex tactical and human dimension decision-making tools. We see many opportunities for medical training in FITE from modeling and simulation, information management/ IT and beyond—initial care given to wounded warriors during the “platinum 10 minutes” in FITE scenarios may be a critical link to improving their survival.

Changing demographics and national shortages of medical professionals will force us to select, educate, train, equip and manage our people differently. This can have a significant impact on our joint medical force, especially if we are unable to recruit key combat-related specialties.

An additional challenge we face today is our ability to assist embedded training teams [ETTs]. It has been reported that medical personnel working on these teams would benefit from additional training to aid in the work of health service support. We are working to identify requirements for these teams and develop courses of action to ensure team members are prepared to go when called on.

In ACT, we are challenged to enhance the trust between partner nations to promote better multinational medical care, execute distributed and urban operations and focus on the future while continuing to support ongoing operations.

Q: I know that your command has a key role in collecting and understanding lessons learned. Can you tell me a little more about that capability and how it is used to impact medical care in the field?

A: USJFCOM’s Joint Center for Operational Analysis [JCOA] collects, processes, analyzes and distributes medical lessons, issues and observations from military operations, exercises and significant events. JCOA produces compelling recommendations for change derived from direct observations and sound analysis of current joint operations. For the Military Health System, this helps define and drive relevant joint medical training and concept development to support today’s warfighter issues and challenges. During stages of the JFHP transformation initiative, service and joint lessons were examined and cross-referenced to validate gaps and ensure relevance of prioritized gaps across the MHS. This active effort captured valuable information that is assisting in defining and improving future medical requirements for joint force commanders.

JCOA medical lessons learned also have been used to enhance USJFCOM’s Joint Warfighting Center [JWC] exercises, medical observer/trainer exercise support, modeling and simulation, experimentation and prototype development, doctrinal development, and real-world operational training. During the USJFCOM Joint Task Force Senior Medical Leader Seminar, senior leaders got updated on medical lessons learned. JCOA published valuable medically related reports, including lessons learned from Operation Iraqi Freedom, tsunami relief, Guatemala mudslides, Katrina medical evacuation and the Pakistan earthquake.

At ACT, we review medical lessons learned from all NATO nations using data collected by the Joint Analysis Lessons Learned Centre [JALLC]. The JALLC is NATO’s lead agency for analysis of operations, exercises, training and experiments, and for the collection and communication of lessons learned. JALLC currently works with NATO operations in Kosovo, Iraq and Afghanistan and on maritime security operations in the Mediterranean.

JALLC’s analysis process embraces all aspects of an operational issue, from doctrine and training through to operational processes, logistical and medical support, command and control, and communication processes. After a thorough review and analysis of medical lessons learned, the findings are communicated to forces in current operations for real-time use and employment. Armed with this information, medical personnel can support NATO headquarters and commands, and also enhance NATO’s transformation.

Q: In hand with that is your role as the joint training facilitator. Do you actually engage in actual training of caregivers, identify areas where training needs enhancement or a combination of both?

A: The USJFCOM JWC coordinates the military’s overall joint training efforts. Joint training focused on joint doctrine and joint tactics, techniques and procedures provides a solid basis for successful engagements in real-world operations. Our command provides highly realistic training in a joint context, and we revise the content as necessary by infusing lessons learned and best practices. Additionally, we refine the execution of the training through development of advanced technologies in conjunction with joint operational exercises. We are more than a facilitator. We are DoD’s joint trainer.

The command’s joint training focus primarily is targeted at the Joint Task Force [JTF] headquarters level. Our office is engaged in a variety of command training venues and the bulk of training is focused on enabling senior medical department officers to be successful in joint operational roles. While some of our “students” are caregivers, we train them to function in joint operational leadership roles versus delivering hands-on patient care. Only a few organizations train medical personnel for the joint operational environment. We see our work in this arena as critical to the MHS and the joint force.

Our Joint Training Branch focuses on four key areas: joint individual training; joint collective training; joint enabling capabilities; and support to the Medical Education and Training Campus in San Antonio. Accomplishments in the joint individual training arena include the development of a JKDDC course on the role of the JTF surgeon. Additionally, the Joint Training Branch is the execution arm for the command’s annual JTF senior medical leader seminar. The seminar provides senior medical department officers with knowledge to lead as a JTF surgeon or work in the joint operational arena in a leadership position. We bring in key speakers to address issues in expeditionary medicine and operating in the joint environment. To date, we have trained approximately 600 medical leaders in these seminars since we started. This year’s four-day seminar will be conducted in Suffolk, Va., from July 28–31, 2009.

Regarding joint collective training, our staff provides medical support to key USJFCOM hosted or supported exercises by the JWC. These include: Unified Endeavor, a mission rehearsal exercise [MRX] that directly supports U.S. Central Command; combatant command priority exercises; and NATO exercises. We assist in development of training scenarios by providing timely and relevant information from lessons learned and best practices. Additionally, we strive to ensure the training audience is challenged during the exercise by replicating current conditions in an area of operations and building those conditions into the exercise scenario. However, there are many more exercises than the active duty staff can support. So, we use the expertise resident in our Army, Navy and Air Force medical department reserve officers. It is a win-win for us, the line and the reservists. The exercises are periodic and predictable, so our reserve team can project in advance what exercises they can support based on their skill set and schedule.

Additionally, we support the Joint Enabling Capabilities Command [JECC] under the JWC. The JECC has tailorable capability modules to meet specific joint operational requirements and includes deployable modules with joint functional area expertise. The JECC unites USJFCOM organizations to deliver tailored, specialized support to meet emerging requirements of joint force commanders worldwide. Our medical planners supported Hurricane Katrina operations, Combined Disaster Assistance Center-Pakistan following the earthquake, JTF Lebanon and, most recently, Combined JTF Horn of Africa.

In addition to supporting joint training events hosted by USJFCOM, our staff also teaches at ongoing joint medical education and training venues. These include the Joint Staff-sponsored joint medical planners course in Bethesda, Md., and the Joint Operations Medical Managers Course sponsored by the Defense Medical Readiness Training Institute at Fort Sam Houston in San Antonio.

Finally, I am one of six voting members on the Joint Medical Education and Training/Medical Education and Training Campus [METC] Flag Officer Steering Committee. The METC is a Base Realignment and Closure action that co-locates all [except aerospace medicine] medical basic and specialty enlisted training at Fort Sam Houston, with the potential of transitioning to a joint training effort. This BRAC initiative, in conjunction with Quadrennial Defense Review initiatives, provides great opportunities to foster joint medical education and training for our MHS personnel. As my staff constantly reminds me, “Who will train medical personnel on joint ‘medical’ doctrine and other key joint concepts that enable joint interoperability and joint deployability if we, as a joint medical community, don’t do it ourselves?” In the future, I look forward to ensuring METC is a platform for joint medical education and training to enhance joint interoperability and deployability for the joint medical force.

Q: It has been noted that you were the first active duty optometrist to reach flag rank in any branch of the military. Does an optometrist bring a different perspective to the command and has there been any particular reason why it never occurred in the past?

A: As an optometrist, I help everyone see everything much more clearly! Seriously, I don’t think my being an optometrist brings any different perspective to this job than if I were a general surgeon or family physician. However, I do think my optometric training, augmented with my background in public health, provides me with the analytical and decision-making skills necessary to address problems from a patient-centric perspective. Placing our patients first does help drive us to the right answers. As a Navy Medical Department officer and a Navy optometrist, I developed a joint perspective early in my career by working side by side on any number of missions with my U.S. Marine Corps partners and health care providers from the other services. The Armed Forces Optometric Society, an organization comprising all federal service optometrists, provided me with the opportunity to work with my joint and interagency colleagues throughout my entire career. As a member of that organization, jointness was a very natural state.

What really has had the greatest impact on me has been the time I’ve spent caring for our warfighters and their families, spending time in theater to see, first hand, what our young men and women accomplish every day, and fighting the budget and programming fights in D.C. I have been extremely blessed to have had wonderful leaders, mentors and role models who gave me opportunities others had not previously enjoyed. This, coupled with a great family support system that allowed me to do some pretty neat things, played the biggest role in getting me to where I am today. I can’t tell you how lucky, honored and privileged I feel to be able to represent my optometric and Medical Service Corps colleagues in such an important and dynamic environment.

Q: Final thoughts?

A: I greatly appreciate the opportunity to discuss the work USJFCOM and ACT medical teams are doing to support joint and coalition forces. The work we do at these two commands will help to ensure we maintain the medical readiness of our nation and those of our allies. It is an honor and privilege to lead such a talented and energetic group of professionals who are all working toward the same goal—winning today’s fight and keeping America and our NATO allies strong to ensure we prevail in the future. ♦

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