Editor’s Note: Below is the second of three posts on providing care to members of the military, veterans, and their families. Read additional perspectives on this issue. Be sure to also read the commentaries by Gleeson and Hemmer and by Lee et al, which are online now.
By: Jeffrey L. Brown, MD, clinical professor of pediatrics, New York Medical College, associate clinical professor in psychiatry, Weill Cornell Medical College, member, AAMC Military Health History Initiative, and decorated combat battalion surgeon, 25th Infantry Division, Vietnam
Recent press reports have focused public attention on deficiencies of care at Veterans Health Administration (VHA) facilities. But the important role that community physicians play in providing health care for veterans and their families has largely escaped scrutiny.
During 1966 and 1967, I served in Vietnam as a combat infantry battalion surgeon. When I learned from a New York Times article—not from my personal physicians—that I was at risk for cancer, heart disease, and diabetes from daily exposure to dioxin in Agent Orange, it occurred to me that I had never been asked by any of my primary care or specialist physicians whether I had served in the military. My survey of the literature and interviews with many veterans and physicians revealed that this experience was typical of a systemic problem. Ten percent of the adult population (including 16 percent of adult males) has served in the armed forces, and 80 percent of them receive most of their health care from non-VA civilian sources; most veterans’ families are insured by employers, Medicare, and Medicaid. But the great majority of physicians and health care facilities do not routinely identify which of their patients are veterans. The public health consequences of this omission are not trivial. If ten percent of the adult population was exposed to asbestos, it would be standard medical practice to ask every patient about past exposure. But when equal numbers of patients have been exposed to a multi-risk military environment that can create short- and long-term health issues, it is virtually ignored.
Adverse medical sequelae of not identifying patients with previous military service include erroneous diagnosis of service-related conditions, failure to screen and counsel patients about known risks, inappropriate referrals, incomplete psychological and social history, not obtaining needed services for underinsured patients, and an inability to mine data in medical records for associations between illness and deployment. These deficiencies cross all specialties, including obstetrics and pediatrics: Fifteen percent of active duty military personnel are women who may be at greater risk for sexual abuse, birth defects, or problems of pregnancy. And one-third of active duty personnel have children under the age of 11 who may have adjustment problems when parents return to civilian life. Oncologists may be treating underinsured veterans who develop lung or prostate cancer after Agent Orange exposure. Primary care physicians may encounter patients whose service-related post-traumatic stress disorder or traumatic brain injury is masquerading as substance abuse or somatic complaints. Or, they may be treating patients for fibromyalgia and chronic fatigue caused by undiagnosed Chronic Multisystem Disease (Gulf War Syndrome).
Veterans don’t usually offer information about their military service unless they are asked a direct question such as, “Did you or someone close to you ever serve in the military?” But physicians don’t ask because they erroneously believe that they aren’t treating veterans in their practice and that most veterans are already receiving service-related health care at the VA. For similar reasons, most medical schools do not include veterans’ cultural awareness and military history-taking in their curriculum or continuing medical education programs. This lack of problem awareness is so pervasive that even medical students and residents who rotate through VHA facilities (70 percent of U.S. medical school graduates) are not required to have this training.
If downsizing the military occurs as planned (world events may preclude this), there will an increased number of veterans returning to civilian life who will visit community doctors. The Affordable Care Act will probably provide more veterans with health insurance, and the recent passage of the Sanders-McCain bill is likely to expand the role played by civilian doctors in rendering care.
Physicians and other providers have a professional obligation to identify veterans and to achieve at least a general understanding of why and how to ask questions pertinent to their medical and psychological wellbeing. Medical educators have a complementary responsibility to teach this information to them.