If it weren’t for the round, scaly patch on the young woman’s shoulder, her doctor might never have known that she served in the Navy for 6 years. He wouldn’t have learned about her sun exposure during a year-long station in east Africa, where temperatures regularly reached over 100°F. But because he didn’t ask about her military history, he didn’t hear about the burn pits and dust storms that filled her lungs with toxic particles. He didn’t hear about the infectious diseases to which she was exposed. He didn’t hear about whether or not she was exposed to combat, or if she experienced military sexual trauma. Perhaps if she were an older man with fading tattoos and a Marine Corps baseball cap, he might have thought to ask.
Or perhaps not.
It takes a remarkable amount of courage for an individual to choose to serve in the military. Their time in the service unquestionably impacts their worldview and every other aspect of their lives. Their health and well-being are no exceptions. That is why all health care providers should know how to ask their patients about their military experiences. More veterans receive healthcare outside the Veterans Affairs (VA) healthcare system than within it, and that number is surely to grow if the VA is privatized, as recently proposed. The time is now for healthcare providers to educate themselves about taking a military history. As physician and nurse practitioner resident trainees, we ask these questions as part of our routine screening both inside and outside the VA healthcare system. The patient who was just described was one of us, and the answers to these questions play a large part in how our patients are diagnosed, treated and understood as people.
The location and era of a veteran’s deployment place them at higher risk for certain conditions. For example, Vietnam-era veterans exposed to Agent Orange, a chemical defoliant and herbicide, are at increased risk for ischemic heart disease, diabetes, multiple myeloma, other cancers, and Parkinson’s disease. Veterans who served in Iraq and Afghanistan are at a higher risk for traumatic brain injury due to their exposure to improvised explosive devices. Lacking awareness of these associations can delay appropriate screening, diagnosis, and management.
Most veterans receive care outside of the VA system. As of 2014, 60% of the 21 million US veterans received health care outside the VA. In Connecticut, where we practice, about 75% of the state’s 200,000 veterans are cared for outside the VA. Recent initiatives like the Veterans Choice Program allow veterans the flexibility of seeing non-VA providers. In order for the medical community to continue providing quality medical care for our veterans, we must remain cognizant of how their military history may influence their physical and mental health.
To be sure, some clinicians working in a non-VA setting may be uncertain about what to ask and how to act upon what may be revealed. The VA has made this part easy by creating a user-friendly pocket card for taking a military health history that can be downloaded to a mobile device: https://www.va.gov/OAA/
As our country considers privatizing the VA, the number of veteran patients in the community is likely to rise. Like all VA providers, we know that a military background can have a huge impact on a person’s life, worldview, and health. That’s why undervaluing the impact of a military history is a disservice to our veterans, no matter where they are seen.
This article was prepared by the authors above in his/her personal capacity. The opinions expressed in this article are the author’s own and do not reflect the view of the Department of Veterans Affairs, VA Connecticut Healthcare System or the United States government.
Authors:
Meredith Bertrand, NP1
Eugenia Betz, MD1,2
Alice Grant, NP1
Leila Haghighat, MD1,2
Janet Ku, NP1
Sumit R. Kumar, MD1,2
Mona Lalehzari, MD1,2
Benjamin Y. Lu, MD1,2
J. Nicholas Pumilia, MD1,2
Jonathan Stock, MD1,2
Anna Reisman, MD1,2,3
1. VA Centers of Excellence in Primary Care Education, West Haven Veterans Affairs Hospital, West Haven, CT
2. Department of Internal Medicine, Yale School of Medicine, New Haven, CT
3. Program for Humanities in Medicine, Yale School of Medicine, New Haven, CT.
Categories: Uncategorized
Good post. Very well-written. True that the medical community to continue providing quality medical care for our veterans.
This would be lovely but the fact is it took the VA decades to even admit to Agent Orange leading to health problems, much less identifying the disease processes themselves. Those Vietnam vets are now in their 70s-80s and it’s entrenched, 50 years after the war. The public/lay doctors have no idea what chemicals or environmental hazards are encountered abroad in various combat zone, other than that schistomiasis lecture we all had in med school and “the middle east” and maybe goats and anthrax…also the purpose of these illnesses being identified is for the veteran to obtain treatment and later comes the disability payment. Service-connectedness is determined by the VA, the lay clinicians have no access nor authority in this loop.
We’re not rubes, we just don’t get classified medical info disseminated to us from the DOD. It’s never happened, and it won’t happen. The only way is to talk to the veteran i.e. patient. Oftentimes this identifies the problems, but we simply don’t know what the veteran was exposed to, and we never will. Only the VA itself can bring out educational campaigns to the medical sector, and having ZERO data from the VA on clinical syndromes along with being in practice for 25 years, I’ll believe it when I see it.
Amending my previous comment, if somebody would like to work up such a list, I would be interested in publishing it. Email me if interested.
Good post, as far as it goes. Primary care physician Jane Doe, who never served in the military, might as a result of this article ask about military service. However, how would she know what to look for as a result of the response, whether it be RVN, Iraq, Afghanistan, Africa, or DC? It’s the follow up that is critical? How would a Millennial doc know about Agent Orange? A friend of mine is dying because he used to burn shit in viet nam using benzine. He now has two types of blood cancers. How would she know to ask whether he did that duty and what the implications are?
The problem is that most docs in the private sector don’t know what to look for
There’s an information problem here which says something about the bigger picture.
The Department of Defense has a hard enough time making disability payments, let alone publicly linking service area to known health issues ..
Is there a publicly available list? If not, there should be
As a part of a baseline/initial HEALTH examination, the SOCIAL HISTORY section should begin with the following question. Where were you born and when did you leave that location? And then followed by an iterative sequence of “Where did you live next?” until today. Usually, the person will volunteer the reason for each move. If not, a simple comment might be “How did you happen to move to that location?” Using a paper record, it was easy to use a “arrow dated with the year” for each move.
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It seems strange that you would intimate that a military service commitment seems difficult for the process of healthcare to obtain. Doing a baseline/initial examination, the sequence of moving or occupational history would always uncover this information, unless the person was in secret operations. I was always careful about not probing if this seemed a possibility. If it involved some aspect of their HEALTH, it seemed they always volunteered this spontaneously (such as agent Orange). It was often the entry point into their PTSD issues, occasionally without VA contact for it.
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It helped especially when I revealed my service in the Army after finishing my training in 1973. Admittedly, my experience as a state-side physician was much different. This may be the reason to suspect that very few physicians understand the importance of a person’s military service for the person’s identity and HEALTH stability.