Caring for veterans outside the VA system

About three-fourths of nearly 22 million veterans get some or all of their outpatient medical treatment outside the VA health system, creating a need for identifying these patients in a practice and screening for potential physical and mental symptoms.

Most U.S. veterans get at least some of their medical care outside the Veterans Affairs (VA) health system. But the complex physical and mental health needs of these men and women might not be fully addressed or could be missed entirely if their doctors don't know about their military service.

Recent survey data from the U.S. Department of Veterans Affairs indicate that roughly three-fourths of the nearly 22 million veterans get some or all of their outpatient medical treatment outside the VA health system. In recent years, veterans who have had difficulty accessing VA facilities close to home or in a timely fashion also have other treatment options through the Veterans Access, Choice, and Accountability Act of 2014, which allows veterans more flexibility to receive care through non-VA clinicians.

Doctors can screen every patient for military service if they dont see any evidence in the medical record that the question has been previously asked Photo by iStock
Doctors can screen every patient for military service if they don't see any evidence in the medical record that the question has been previously asked. Photo by iStock

Depending on numerous factors, including the conflict they served in, their role there, and how long they served, today's veterans may cope with physical and mental symptoms that can reverberate for decades afterward. But to help them, doctors outside the VA system have to flag their patients' service in the first place, said Lucile Burgo-Black, MD, FACP, co-director of the VA's national Post-Deployment Integrated Care Initiative. “The most important thing we want people to do is ask—in our social and occupational history we are not asking about military service,” she said.

Asking the question

Jeffrey Brown, MD, a retired pediatrician and decorated Army doctor in Vietnam who is a clinical professor of pediatrics at New York Medical College in Valhalla, N.Y., got medical care for decades in the private sector without any doctor asking him about prior military service. He reflected on his military service and subsequent physician interactions in a 2012 JAMA perspective piece.

Because of his experience, Dr. Brown recommends that doctors screen every patient for military service if they don't see any evidence in the medical record that the question has been previously asked. And don't just ask “Are you a veteran?” he advised. “Because younger veterans don't think of themselves as veterans,” he said. “They think that veterans are older guys like me.”

Instead, he said, ask if the man or woman has ever served or knows someone close to him or her who has. That way the doctor might also learn about a veteran spouse who is living with physical or emotional effects that can impact the home environment.

Finding out that someone has served also connects the doctor with the patient, said Stephen Hunt, MD, who co-directs the post-deployment initiative with Dr. Burgo-Black and practices at the VA Puget Sound Health Care System. “Military service, it means a lot to people who have served. We want them to know it means a lot to us as well. Asking them about it gives us a chance to acknowledge their service,” he said.

With just a few follow-up questions, which shouldn't require more than a minute or two, the doctor can then home in on details that might influence a veteran's health, Dr. Hunt said. Among them, ask what branch the veteran served in, whether he or she was deployed, and where and for how long, as well as significant activities and experiences that occurred during the deployment that affected his or her lives and health in important ways.

Knowing veterans' deployment timing and location helps doctors take into account various exposure risks, including chemical and environmental, said Dr. Burgo-Black, who practices primary care at the VA Connecticut Healthcare System. In addition, she noted that some of these men and women might be approaching Medicare age and seeking out a family doctor for the first time, as they develop hypertension, diabetes, and other chronic diseases, and not be aware of potential benefits connected to their service. Moreover, this older population may not ever have been screened for depression, post-traumatic stress disorder (PTSD), or history of traumatic brain injury as has become routine after more recent conflicts, Dr. Hunt said.

“Many of them thought, ‘Well, you just live with the fact that you are not sleeping very well. You just live with the fact that you're having nightmares now and then.’” But those lower-level symptoms might become amplified by a late-life change in circumstances, such as the loss of a spouse or retirement opening up more time to ponder, or perhaps due to age-related cognitive changes, Dr. Hunt said.

Conflict ripple effects

Through various resources, including an online pocket card (see sidebar), VA officials detail the potential health risks broken down by conflict. For example, Vietnam veterans are considered Agent Orange exposed and thus eligible for related medical and financial benefits, Dr. Burgo-Black said. Other risks cut across location of service, including exposure to burn pits, hearing loss related to noisy weapons and other high-impact sounds, and wear and tear on the body, including that caused by carrying heavy equipment.

Women have a higher injury rate than their male counterparts, some of which may result from carrying these hefty loads, which may total 90 pounds or more, said Ishita Thakar, MD, FACP, associate chief of staff for women's health at the Oklahoma City VA Health Care System. “They may be prone to certain injuries such as stress fractures,” Dr. Thakar said.

Among veterans of the more recent conflicts in Afghanistan and Iraq, the three most common conditions are musculoskeletal problems, mental health conditions, and “non-specific signs and symptoms,” according to findings published in 2012 in the Journal of General Internal Medicine. The third nonspecific group included symptoms ranging from fatigue to various cognitive symptoms, such as memory, attention, or concentration difficulties, according to the researchers, who reviewed the conditions reported by nearly 772,000 veterans.

Some veterans might suffer a cluster of clinical issues, said Karen Seal, MD, MPH: pain, PTSD, and traumatic brain injury. These are dubbed the polytrauma clinical triad because they frequently occur together, she said. Coping with these challenges can spawn others. A veteran struggling with PTSD might be prone to depression or attempt to self-medicate with drugs or alcohol, she said.

Dr. Seal, a researcher on veterans' health issues and a professor of medicine at the University of California, San Francisco, was involved with a 2009 study in the American Journal of Public Health, which found that the percentage of Iraq and Afghanistan veterans getting diagnosed with at least one mental health condition through the VA system increased from 6.4% in 2002 to nearly 37% in 2008.

By 2008, slightly more than one in five, 21.8%, had been diagnosed with PTSD and 17.4% were diagnosed with depression, according to the analysis, which involved nearly 290,000 veterans getting medical care. Women were more vulnerable than men to depression, but men faced more than double the risk of a substance use disorder.

Tailoring the exam

Non-VA physicians should stay alert to physical symptoms that might indicate mental health struggles, said Dr. Seal, who directs the Integrated Care Clinic for Iraq and Afghanistan veterans at the San Francisco VA Medical Center. For example, a veteran struggling with sleep may indicate that there is an underlying mental health problem, she said. A doctor who wonders if a veteran has PTSD can start asking about potential signs, such as nightmares or intrusive thoughts or hyperarousal, she said.

Military sexual trauma, which the VA defines as sexual assault or repeated, threatening harassment experienced during military service, is another issue to consider during the exam. One in four female veterans and one in 100 male veterans respond “yes” when their VA clinicians ask if they have experienced military sexual trauma, the VA has reported.

Dr. Thakar said that when examining patients with a history of military or other sexual trauma, heightened sensitivity is paramount. With the physician exam, doctors should start with explaining what it entails, ideally while the patient is still clothed, she said. Once the exam begins, explain what's being done before proceeding, even if it's to check the heart or the lungs.

Have a chaperone present, and don't stray any further into the patient's personal space than necessary, Dr. Thakar said. It's a good idea to avoid loud or snapping-type noises, she said. If patients have a reaction during a procedure, halt it if feasible. Acknowledge their stress and give them a chance to ground themselves, she advised.

Clinicians should also keep in mind that pain can be associated with underlying mental health issues, Dr. Seal said. She was the lead author on a study, published in JAMA in 2012, finding that 48% of veterans from Afghanistan and Iraq treated through the VA health system were diagnosed with at least one pain-related condition.

“We rarely see pain without an underlying mental health condition that, if it's not addressed, continues to drive this vicious cycle of chronic pain,” said Dr. Seal, who also directs the Integrated Pain Team clinic at the San Francisco VA. For instance, a patient with depression is more likely to experience pain, she said. The more the pain is felt, the worse the depression can become, and vice versa.

To start opening up the conversation, Dr. Seal will ask veterans if they experienced any physical problems during their service. That question naturally segues, she said, into another: “Did any emotional stuff come up while you were over there?” This can be a way to encourage veterans to share physical or emotional symptoms that occurred then or after returning home, she said.

“It's OK to talk about your chronic pain. It's OK to talk about your sleep,” said Dr. Seal, listing some of the physical symptoms that veterans might describe. Most veterans feel that it is really “not OK to start talking about the fact that a balloon pops and they freak out. Or that they are having terrible problems connecting with their girlfriend or their children,” she said.

Dr. Seal advised doctors treating veterans to not move too quickly to suggest a referral to a psychiatrist or another mental health clinician. Veterans might resist, thinking they are just going to be “put on a pill,” not realizing there are other options, such as cognitive behavioral therapy. Doctors should consider compiling a list of mental health resources to keep handy, from the names of psychologists to a local veterans' support group to other avenues such as yoga or meditation resources, she said.

Dr. Seal also suggests adopting a nonjudgmental communication style such as motivational interviewing, along with a dose of patience. “You can start to build trust with patients over time,” she said, “such that they start to share some of the underlying mental health problems that may be going on.”

Dr. Brown offered another piece of salient advice for clinicians to consider: Regardless of veterans' military experiences, good or bad, service will always form the background of their personal life stories. Although he had to seek out help himself late in life, when anxiety and sleeplessness suddenly flared shortly before retirement, he also feels that he achieved a lot of growth during his war experience.

“It is a sentinel event, and for a lot of people it's not an all-bad event,” he said. “For me, it actually created an identity. I felt like I was part of this unit—that they were like my family.”