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Civilian doctors might not know that their patients have served in the military. In this photo Marines march around the World Trade Center memorial after participating in a memorial run in 2012. MarineCorps NewYork/Flickr, CC BY

Veterans’ health care: doctors outside the VA need to know more about the veterans they treat

Each year the military discharges over 240,000 veterans to reintegrate into civilian society. It’s a professional transition, but it’s also a personal one.

Veterans go from TRICARE, the Department of Defense’s own health care system, to navigating the ins and outs of the civilian health care system. Under TRICARE, military service members are cared for in a manner that meets their needs. When they’re discharged, their new health care providers might not know that they were ever in the military.

Asking “Have you served in the military?” may seem like a minor issue, but it’s actually much more important than you might think. And it’s a question that few doctors make a point of asking, even though many medical residents and medical students receive all or part of their clinical training at VA medical centers and hospitals.

In fact, Jeffrey Brown, a professor at Weill Cornell Medical College and a Vietnam veteran, has called it the “unasked question.” When physicians don’t ask, they may miss critical parts of their patient’s medical history, making it harder to provide the best possible care.

Health care providers need to understand how diverse today’s veterans are. In this photo, Vietnam veteran Euretha Shropshire salutes during the national anthem at an interfaith vigil for the victims of the Tennessee shooting. Tami Chappell/Reuters

Why ‘Have you served?’ is a critical question

Contrary to popular belief, most veterans do not receive care from the Veterans Health Administration (VHA) health care system. While eligibility criteria to receive VA care have become more flexible for combat veterans in recent years, overall most veterans don’t go the VA. Only about 30 percent receive health care from the VA after they are discharged. Some might not be eligible for VA health care, or don’t live near a VA health care center. Others might prefer to go somewhere else for care.

The health care providers might not be aware of the chemicals, infections and injuries that military personnel can encounter. Veterans may have been exposed to chemical pollutants or solvents (such as jet fuel, nerve agents or radiation) as well as infectious diseases and blood-borne pathogens. During their careers, they may have also gotten blast injuries, burns or shrapnel wounds. They may also face reproductive health issues or dermatologic issues related to their service. Some may have physical injuries, mental and emotional issues or any combination of these.

Unlike many of our perceptions of the wounds of war – loss of limb or damage to some other body part – veterans also suffer from invisible wounds such as post-traumatic stress disorder (PTSD), military sexual trauma (MST) and traumatic brain injury (TBI), a common wound of Operation Enduring Freedom/Operation Iraqi Freedom.

Veterans may also have experienced physical and emotional trauma, as well as stress from adjustment back to civilian life. For instance, 17 percent of all veterans seeking care at the VA have depression, and 13 percent of Operation Iraqi Freedom combat veterans screen positive for depression within six months of returning from combat.

So asking “Did you ever serve in the military” is an important start. If a patient says yes, then providers should follow up by asking when and where they served and what they did. This can help health care providers arrive at the cause of symptoms, pinpoint sources of support and barriers to wellness. This kind of background information can help providers identify the best medical approaches and develop an effective care plan for veterans and their families.

Part of making sure that doctors ask their patients this critical question is to teach them who veterans are.

Using photographs to teach doctors about veterans

As medical educators and researchers working at the University of Michigan Medical School who also have experience working with veterans, we know how important it is for health care providers to be aware of their patients’ military service.

While serving. Paula T Ross, Author provided

So we developed a massive open online course (MOOC) called Lessons in Veteran-Centered Care aimed at teaching health professionals about providing veteran-centered care. We cover military culture, focusing on patients’ positive capabilities and strengths, and military health history, as well as highlighting available patient resources.

Participants learn how to use and apply principles from the course to improve assessment and triage for patients with PTSD, MST, TBI, anxiety and depression – all the conditions that are more prevalent in the military population than in the general civilian one.

…and as a veteran. Paula T Ross, Author provided

But caring for veterans isn’t just about being able to diagnose PTSD or depression. It’s also about understanding who they are and where they’ve been. To do this we use coursework and key moments from the documentary “Where Soldiers Come From,” which follows five young men as they joined the National Guard, underwent military training, deployed to Afghanistan looking for improvised explosive devices and returned home as combat veterans dealing with PTSD and TBI.

To help health professionals understand how diverse today’s veterans are, we also use 30 pairs of photographs of people during and after their time in service. The collection includes veterans from World War II, the Korean War, the Vietnam War, Desert Storm/Desert Shield and the more recent conflicts in Iraq and Afghanistan. This exercise alone helps demonstrate the age diversity of today’s veterans, most of whom fall between 35 and 74 years old.

The collection also includes several women. Women now make up an increasing portion of veterans, more than two million today, about nine percent of all veterans.

Although men have dominated the veteran population in the past, an increasing number of women have served in recent conflicts. The photographs also illustrate the racial diversity of today’s veterans. About 21 percent of veterans are minorities.

These photos help medical students and physicians in our course visualize the trajectory of US service members from soldier to civilian. We challenge learners to think deeply about the experiences, concerns and perspectives of U.S. military veterans, and to reshape previously held unconscious biases, stereotypes or attitudes toward veterans.

Our goal is to use our photographs to improve veteran care by asking health care professionals to take a similar yet important step, and consider military service or exposure to the military culture during their encounters with all patients.

Medical students who’ve taken the course said it inspired them to be more likely to ask patients if they’ve served and to understand the importance of veteran-centered care. Faculty physicians who took the course said it made them reexamine their own biases about veterans.

Ultimately, we challenge assumptions about what veterans look like and help health care professionals recognize that most veterans look just like other patients. Unless you ask the question, you may never find out this valuable piece of information that can lead to improving health outcomes.

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