Feature

Proper medical care for veterans starts with asking who has served

Lucile Burgo-Black

At least 2.7 million military personnel have deployed to Afghanistan and Iraq since the tragedies of Sept. 11, 2001, according to data in the Journal of General Internal Medicine.

Nationwide, there are almost 22 million veterans in the U.S., according to Lucile Burgo-Black, MD, national co-director of the Postdeployment Integrated Care Initiative at the Veterans Health Administration.

But research indicates that even though these men and women who served have unique medical needs, many of their clinicians never ask their patients about their military status.

Bonnie M. Vest, PhD, research assistant professor at the University at Buffalo surveyed 102 primary care providers in western New York and found only 19% regularly asked their patients about military service history. In addition, the publication Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members reported that of 319 rural primary care and mental health and primary care providers queried, 56% did not regularly ask their patients about military service.

Clinicians need to be more proactive in asking about military service, Burgo-Black, who is also a primary care provider at the VA Connecticut Healthcare System and assistant clinical professor of internal medicine at the Yale School of Medicine, said in an interview.

“The most important action a provider can take to ensure that a veteran receives optimal health care is perhaps the easiest and, ironically, the most neglected: asking if a patient has served in the military and taking a basic military history,” she wrote in Public Health Reports, explaining that a question that takes seconds to ask can shape a patient’s medical care for years to come.

“Veterans have unique health concerns, even if they haven’t been exposed to combat or deployed,” Burgo-Black told Healio Family Medicine. “Even if they haven’t been to war, they are still a special group that needs to be considered.”

Closing the communication gap

Researchers and clinicians suggested several reasons why the majority of clinicians do not ask their patients about their military status.

“The military population is frequently overlooked in civilian primary care due to an assumption that they are treated at the Veterans Health Administration. However, less than 50% of eligible veterans receive VA treatment,” Vest and colleagues wrote.

“Veterans have unique health concerns, even if they haven’t been exposed to combat or deployed,” one of the co-directors of the Postdeployment Integrated Care Initiative at the Veterans Health Administration told Healio Family Medicine. “Even if they haven’t been to war, they are still a special group that needs to be considered.”

Source: Adobe

One doctor recommended changes in how physicians are taught, saying that will ultimately may be what leads more clinicians to ask patients about their military status.

“This [lack of asking] is not because of indifference, but because of an oversight in training. Teaching how and why to take a military health history should be added to medical school curricula along with other medical history questions,” Jeffrey L. Brown, MD, a college professor and consultant on veterans’ health issues, wrote in JAMA describing his experience as a Vietnam Veteran with healthcare in the community and the VA.

“Thousands of medical students, residents, and fellows currently receive some of their training at Veterans Affairs facilities every year, and requiring enhanced courses before their rotations would provide an excellent opportunity for learning this material,” he added.

Burgo-Black added her own reasons for why fewer PCPs ask their patients if they are veterans.

“Since military service became all volunteer, we’re getting less and less connected with folks who choose to serve in the military. While we are still engaged in Afghanistan and have ongoing special operations around the world, the number of service members returning from combat deployments is relatively small at the present time," she said.

Stephen Hunt

Stephen Hunt MD, co-authored material for regarding health care for military veterans in Harrison’s Principles of Medicine, and co-director, VA Post-Deployment Integrated Care Initiative, discussed the initiative.

“The ultimate goal is to ensure informed, veteran friendly and effective health care for veterans across the health care landscape. “We are advocating that in all health care settings, the initial assessment of every adult includes in the psychosocial and occupational history information about the individual’s military service and deployment history,” he said.

If the patient is a veteran

Burgo-Black said if the patient has served in the military, additional questions can determine the impact military service had on the patient:

  • “Tell me about your military experience and how it affected you?”
  • “What was your job and where did you serve?”
  • “Did you see combat, enemy fire, or casualties?”
  • “Were you sick, wounded, injured or hospitalized?”
  • “Were you exposed to blasts?”

All veterans should also be screened for PTSD, substance abuse, depression and suicide risk and asked if they are having problems with relationships and/or at work and school, she said.

Burgo-Black, who led a discussion on caring for veterans at the 2017 and 2018 American College of Physicians Internal Medicine Meeting, added that some of the most common health consequences among veterans who served in a conflict zone, regardless of the specific location, are musculoskeletal, mental health, and respiratory issues.

Veterans are also likely to have mild- to moderate difficulties adjusting to life outside of combat. Thus, PCPs should monitor these patients to see if their difficulties increase or decrease as they spend more time away from military activities, watch for sleep disturbances and involve family members in the veterans’ follow-up care, she said.

“A combat veteran is more likely to have physical injuries (and taking opioid pain medications for them), diagnosable mental health conditions (as well as sub-syndromal mental health issues and military sexual trauma), unexplained symptoms with general health decline, hearing problems, dental problems, psychosocial distress (such as marital, occupational, financial, social issues), risk for injury or death from ‘incidental trauma,’ and at least a two- to threefold increased risk for suicide, Burgo-Black said. “He/she is [also] much less likely to show up for his appointments.”

She also noted that specific conflicts carry specific health risks. World War II veterans are more susceptible to peptic ulcer disease, gastrointestinal complaints and cold injuries as well as psychiatric and psychosocial disorders, Korean War veterans are also likely to have cold injuries, while Vietnam War veterans are more vulnerable to the impact of the herbicide Agent Orange which includes diabetes, ischemic heart disease, Parkinson’s disease, prostate cancer, multiple myeloma, respiratory cancers, those who served in the short first Gulf War have an increased incidence of medically unexplained symptoms and those who have participated in the recent Operation Enduring Freedom and Operation Iraqi Freedom are more likely to experience polytrauma and traumatic brain injury, Burgo-Black said.

One of the co-directors of the Postdeployment Integrated Care Initiative at the Veterans Health Administration told Healio Family Medicine it is critical that clinicians keep the lines of communication open with patients that have served in the military.
Source:Adobe

The broad spectrum of mental and physical injuries to which veterans are more vulnerable than the general population suggests the need for a team-based approach to patient care, Juliette F. Spelman, MD, an internist in primary care and assistant professor of medicine at the VA Connecticut health care system and colleagues wrote in the Journal of General Internal Medicine.

“[Veterans Affairs and Department of Defense] guidelines recommend an interdisciplinary approach involving integrated teams of primary care, mental health and social work providers which can normalize and de-stigmatize mental health treatment,” Spelman and colleagues wrote.

“Recognizing that co-located, interdisciplinary care may not be feasible for many providers, we suggest utilizing local resources and facilitating interagency collaboration with local Vet Centers or with the VA,” they continued.

Available resources

Burgo-Black said websites such as va.gov, afterdeployment.org, maketheconnection.net, militaryonesource.mil and the national resource directory at nrd.gov are some of the many resources clinicians can consult to help their patients who are veterans.

The publication Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members offers additional sources, as do the websites of the Medical University of South Carolina, International Society for Traumatic Stress Studies and Substance Abuse and Mental Health Services.

Burgo-Black said it is critical to consult the resources and keep the lines of communication open with patients.

“Once you know the context of the person you’re taking care of, if you know a little bit about the military, you do such a better job of connecting with them and taking care of them,” she said. – by Janel Miller

References:

Brown JL. JAMA. 2012: doi:10.1001/jama.2012.14254.

Burgo-Black LA , et al. Public Health Rep. 2016;doi:10.1177/0033354916660073.

Burgo-Black LA, et al. A brief military history: The key to good health care for veterans in your practice. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.

Klipatrick DG et al. Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members, Veterans, and their Families. 2011.

Le TD, et al. JAMA Surg. 2018;153(9):800-807. doi:10.1001/jamasurg.2018.1166.

Nagpal BM, et al. Med J Armed Forces India. 2004;doi:10.1016/S0377-1237(04)80111-4].

Spelman JF, et al. J Gen Intern Med. 2012 Sep;27(9):1200-9. doi: 10.1007/s11606-012-2061-1.

Vest BM, et al. Fam Med. 2018;doi:10.22454/FamMed.2018.795504

Disclosures: Neither Burgo-Black nor Hunt report relevant financial disclosures. Please see the studies for those authors’ relevant financial disclosures.

Lucile Burgo-Black

At least 2.7 million military personnel have deployed to Afghanistan and Iraq since the tragedies of Sept. 11, 2001, according to data in the Journal of General Internal Medicine.

Nationwide, there are almost 22 million veterans in the U.S., according to Lucile Burgo-Black, MD, national co-director of the Postdeployment Integrated Care Initiative at the Veterans Health Administration.

But research indicates that even though these men and women who served have unique medical needs, many of their clinicians never ask their patients about their military status.

Bonnie M. Vest, PhD, research assistant professor at the University at Buffalo surveyed 102 primary care providers in western New York and found only 19% regularly asked their patients about military service history. In addition, the publication Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members reported that of 319 rural primary care and mental health and primary care providers queried, 56% did not regularly ask their patients about military service.

Clinicians need to be more proactive in asking about military service, Burgo-Black, who is also a primary care provider at the VA Connecticut Healthcare System and assistant clinical professor of internal medicine at the Yale School of Medicine, said in an interview.

“The most important action a provider can take to ensure that a veteran receives optimal health care is perhaps the easiest and, ironically, the most neglected: asking if a patient has served in the military and taking a basic military history,” she wrote in Public Health Reports, explaining that a question that takes seconds to ask can shape a patient’s medical care for years to come.

“Veterans have unique health concerns, even if they haven’t been exposed to combat or deployed,” Burgo-Black told Healio Family Medicine. “Even if they haven’t been to war, they are still a special group that needs to be considered.”

Closing the communication gap

Researchers and clinicians suggested several reasons why the majority of clinicians do not ask their patients about their military status.

“The military population is frequently overlooked in civilian primary care due to an assumption that they are treated at the Veterans Health Administration. However, less than 50% of eligible veterans receive VA treatment,” Vest and colleagues wrote.

“Veterans have unique health concerns, even if they haven’t been exposed to combat or deployed,” one of the co-directors of the Postdeployment Integrated Care Initiative at the Veterans Health Administration told Healio Family Medicine. “Even if they haven’t been to war, they are still a special group that needs to be considered.”

Source: Adobe

One doctor recommended changes in how physicians are taught, saying that will ultimately may be what leads more clinicians to ask patients about their military status.

“This [lack of asking] is not because of indifference, but because of an oversight in training. Teaching how and why to take a military health history should be added to medical school curricula along with other medical history questions,” Jeffrey L. Brown, MD, a college professor and consultant on veterans’ health issues, wrote in JAMA describing his experience as a Vietnam Veteran with healthcare in the community and the VA.

“Thousands of medical students, residents, and fellows currently receive some of their training at Veterans Affairs facilities every year, and requiring enhanced courses before their rotations would provide an excellent opportunity for learning this material,” he added.

Burgo-Black added her own reasons for why fewer PCPs ask their patients if they are veterans.

“Since military service became all volunteer, we’re getting less and less connected with folks who choose to serve in the military. While we are still engaged in Afghanistan and have ongoing special operations around the world, the number of service members returning from combat deployments is relatively small at the present time," she said.

Stephen Hunt

Stephen Hunt MD, co-authored material for regarding health care for military veterans in Harrison’s Principles of Medicine, and co-director, VA Post-Deployment Integrated Care Initiative, discussed the initiative.

“The ultimate goal is to ensure informed, veteran friendly and effective health care for veterans across the health care landscape. “We are advocating that in all health care settings, the initial assessment of every adult includes in the psychosocial and occupational history information about the individual’s military service and deployment history,” he said.

If the patient is a veteran

Burgo-Black said if the patient has served in the military, additional questions can determine the impact military service had on the patient:

  • “Tell me about your military experience and how it affected you?”
  • “What was your job and where did you serve?”
  • “Did you see combat, enemy fire, or casualties?”
  • “Were you sick, wounded, injured or hospitalized?”
  • “Were you exposed to blasts?”

All veterans should also be screened for PTSD, substance abuse, depression and suicide risk and asked if they are having problems with relationships and/or at work and school, she said.

Burgo-Black, who led a discussion on caring for veterans at the 2017 and 2018 American College of Physicians Internal Medicine Meeting, added that some of the most common health consequences among veterans who served in a conflict zone, regardless of the specific location, are musculoskeletal, mental health, and respiratory issues.

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Veterans are also likely to have mild- to moderate difficulties adjusting to life outside of combat. Thus, PCPs should monitor these patients to see if their difficulties increase or decrease as they spend more time away from military activities, watch for sleep disturbances and involve family members in the veterans’ follow-up care, she said.

“A combat veteran is more likely to have physical injuries (and taking opioid pain medications for them), diagnosable mental health conditions (as well as sub-syndromal mental health issues and military sexual trauma), unexplained symptoms with general health decline, hearing problems, dental problems, psychosocial distress (such as marital, occupational, financial, social issues), risk for injury or death from ‘incidental trauma,’ and at least a two- to threefold increased risk for suicide, Burgo-Black said. “He/she is [also] much less likely to show up for his appointments.”

She also noted that specific conflicts carry specific health risks. World War II veterans are more susceptible to peptic ulcer disease, gastrointestinal complaints and cold injuries as well as psychiatric and psychosocial disorders, Korean War veterans are also likely to have cold injuries, while Vietnam War veterans are more vulnerable to the impact of the herbicide Agent Orange which includes diabetes, ischemic heart disease, Parkinson’s disease, prostate cancer, multiple myeloma, respiratory cancers, those who served in the short first Gulf War have an increased incidence of medically unexplained symptoms and those who have participated in the recent Operation Enduring Freedom and Operation Iraqi Freedom are more likely to experience polytrauma and traumatic brain injury, Burgo-Black said.

One of the co-directors of the Postdeployment Integrated Care Initiative at the Veterans Health Administration told Healio Family Medicine it is critical that clinicians keep the lines of communication open with patients that have served in the military.
Source:Adobe

The broad spectrum of mental and physical injuries to which veterans are more vulnerable than the general population suggests the need for a team-based approach to patient care, Juliette F. Spelman, MD, an internist in primary care and assistant professor of medicine at the VA Connecticut health care system and colleagues wrote in the Journal of General Internal Medicine.

“[Veterans Affairs and Department of Defense] guidelines recommend an interdisciplinary approach involving integrated teams of primary care, mental health and social work providers which can normalize and de-stigmatize mental health treatment,” Spelman and colleagues wrote.

“Recognizing that co-located, interdisciplinary care may not be feasible for many providers, we suggest utilizing local resources and facilitating interagency collaboration with local Vet Centers or with the VA,” they continued.

Available resources

Burgo-Black said websites such as va.gov, afterdeployment.org, maketheconnection.net, militaryonesource.mil and the national resource directory at nrd.gov are some of the many resources clinicians can consult to help their patients who are veterans.

The publication Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members offers additional sources, as do the websites of the Medical University of South Carolina, International Society for Traumatic Stress Studies and Substance Abuse and Mental Health Services.

Burgo-Black said it is critical to consult the resources and keep the lines of communication open with patients.

“Once you know the context of the person you’re taking care of, if you know a little bit about the military, you do such a better job of connecting with them and taking care of them,” she said. – by Janel Miller

References:

Brown JL. JAMA. 2012: doi:10.1001/jama.2012.14254.

Burgo-Black LA , et al. Public Health Rep. 2016;doi:10.1177/0033354916660073.

Burgo-Black LA, et al. A brief military history: The key to good health care for veterans in your practice. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.

Klipatrick DG et al. Serving Those Who Have Served: Educational Needs of Health Care Providers Working with Military Members, Veterans, and their Families. 2011.

Le TD, et al. JAMA Surg. 2018;153(9):800-807. doi:10.1001/jamasurg.2018.1166.

Nagpal BM, et al. Med J Armed Forces India. 2004;doi:10.1016/S0377-1237(04)80111-4].

Spelman JF, et al. J Gen Intern Med. 2012 Sep;27(9):1200-9. doi: 10.1007/s11606-012-2061-1.

Vest BM, et al. Fam Med. 2018;doi:10.22454/FamMed.2018.795504

Disclosures: Neither Burgo-Black nor Hunt report relevant financial disclosures. Please see the studies for those authors’ relevant financial disclosures.