The AAMC is a strong supporter of Joining Forces, the White House initiative created to further the welfare of military service members, veterans, and their families. The initiative has helped identify a significant public health issue: Although ten percent of adults older than 18 years have served in the military (16 percent of adult men), fewer than 30 percent of veterans receive their health care from the Department of Veterans Affairs (VA). Additionally, most community health care professionals are unaware of patients’ past military service. Both factors lead to significant consequences.
Medical conditions that have a known association with deployment will not be identified in a timely manner; veterans may not receive benefits to which they are entitled; underinsured veterans may not be aware they are eligible for treatment at Veterans Health Administration facilities; and data mining of electronic health records—which might provide early correlation of deployment with specific medical and psychological conditions—are not performed.
The reasons for this discordance include the misconception that veterans who have service-related medical and psychological conditions are already receiving care at VA facilities; and an underestimation of veterans in the health system. To help correct this problem, the AAMC initiated a “Military Health History Work Group.” The group’s initial mission was clear: Ensure that all patients are asked whether they or someone close to them (a spouse, partner, parent, etc.) served in the military.
If the answer is “no,” the military history is complete. But when the response is “yes,” follow-up questions become important. The first is to elicit whether the patient is referring to themselves or someone else. For example, when a spouse is the service member or veteran, the rest of the family might be affected by their prolonged absence, their physical or mental state after returning home, or by various forms of financial hardship.
Next, we recommend asking where and when the patient served. This information can sometimes indicate risk factors for certain medical or psychological conditions. For example, every soldier who served in Vietnam is presumed to have been exposed to dioxin in the toxic herbicide Agent Orange, and is therefore at greater risk for (and may be presumptively service-connected for) cancer, Type 2 diabetes, ischemic heart disease, and other conditions. Job description might be pertinent because it might predispose the patient to specific forms of psychological or physical injury. For example, members of artillery companies often endure hearing loss, which accelerates with age and can become clinically significant in mid-life.
Physicians who have a comprehensive awareness of the workings of the VA or how to make referrals to the VA are best prepared to help veterans. When you identify a patient who served in the military, refer him or her to your local (often state-run) veterans’ agency. All might benefit, but those who should receive extra attention are patients who are uninsured, underinsured, have chronic illness, or require hospice care. In emergent situations, veterans and their health providers need to know about the Veterans Crisis Line (1-800-273-8255), which offers prompt access to VA care and services including suicide prevention and homelessness intervention.
An area that deserves special mention is our effort to include military history in electronic health records (EHRs). Many of the medical conditions now associated with Agent Orange exposure were not identified until many years after the war’s end. Pooled data from EHRs would help to make these associations much earlier, and monitoring might be extended to special populations such as pregnant women. EHR implementers are struggling to decide whether this history should be placed in demographics, past and present medical history, or in the patient’s psychological, occupational, or social history. In many cases, it belongs in all of these—a reminder of how pervasive the effects of past military service can be.
Most of us are aware that the Department of Defense and the VA have had many difficulties integrating their records. But it has gone largely unnoticed that 80 percent of veterans receive at least some of their health care from civilian sources, and that civilian doctors might also require access to this medical information. Community physicians should be aware that they care for a significant number of veterans who are not presently identified as having prior service. Further, for every veteran, there are other individuals close to them who might be affected by deployment-related stress or illness. Unless these issues are addressed, these patients may be misdiagnosed, uninformed that they may be eligible for medical care and services from the VA, or improperly screened for at-risk conditions. Awareness and adding a few simple questions to every patient’s history will go a long way toward improving their care and meeting a national medical and moral obligation to those who served.
—Jeffrey L Brown, MD, is a Clinical Professor of Pediatrics at New York Medical College. He is a former Infantry Battalion Surgeon, Infantry Brigade Surgeon, and Clearing Company Commanding Officer in the U.S. Army Medical Corps; he served in Vietnam. He can be reached at JLBrown@mail.com.