We have to deal with the trauma in veterans early on

My medical center recently cemented an agreement with the Veterans Administration to offer care to veterans who could not be accommodated at the VA. We need paying patients, they need doctors of our caliber — establishing mutual benefit. Military veterans have always been among our patients. During my professional lifetime that has included men of my father’s generation whose young adult years encompassed World War II’s widespread draft. World War I and Korea conscriptions were less universal, but patients frequently had served in these settings. Vietnam service seemed more selective.

Even when employed as a VA physician from 1980-88, the patients’ service — while appreciated — was usually parenthetical to their adult medical illnesses. A minority had permanent sequelae of their service, missing limbs, shell-shock or post-traumatic stress disorder depending on which military conflict, a chemical exposure often still in adjudication, intermingling medical care with compensation. Some were more indirect, numerous alcoholics or other substance abusers, maybe some with hypertension, but these were also highly prevalent in people who never served. By age 60 when people started getting admitted to the hospital more frequently, the diseases I treated at the VA seemed to coincide with those encountered elsewhere. They got admitted, I took the best care of them that circumstances would allow for whatever I thought they needed. In the community hospitals and in the office, I shared patients with the VA. And people came by who just happened to have been in the army as young adults but were pretty mainstream after that, going to college, joining a union or seeking jobs as they became available. As prescriptions became more expensive, the VA would often supply medicines to veterans like my father who saw the doctor or nurse practitioner as a precondition for having the prescription supplied but regarded physicians external to the VA as their doctors.

With systems, particularly governmental ones, process often becomes excessive. This being an important medical center initiative, the VA’s physician representative for this project presented our academic year’s first grand rounds. He extensively outlined process. Every patient admitted to the hospital would have a complete military history, where they served, which unit, injuries, illnesses, anything that might connect to their military service. This seems to me like an invitation for those Type I errors that attribute significance to what is non-contributory to the hospitalization. Even at the VA itself, a 60-year-old did not get his admitting MI from injudicious eating in the mess hall. The need to fill out what may be too comprehensive a questionnaire runs the risk of distraction from more vital information gathering and examination that has a more immediate effect on the current hospital encounter. What we may be doing is propagating an event of young adulthood, labeling it as an imprint which portends a silent forty-year interval until they come to our ER. I think the process needs to be more selective than the speaker’s description to be meaningful. In this era of electronic health records, we already gather reams of historical information that never gets refined or prioritized. We often don’t know its importance. Or as the New York Times once advertised, “you don’t have to read it all, but it’s nice to know it’s all there.” However, which portions you read matters a lot. If the military history acquires an inflated importance by the very time allotted to it, more immediate medical imperatives risk distortion as well.

In addition, why select military service as the shaping event that forms the underpinning of one’s future, then trying to reconstruct this in reverse? Many residents attended this presentation. At age 20 they experienced academic terror, fretting over the organic chemistry exam that might weed them out professionally. At age 25, they endured the Match culminating the rigors of medical school, sometimes overseas. As residents, many departed their families from Asia or Latin America, likely forever. Many will experience burnout. Will the experience of medical training in their 20s be more favorable or less to their health at age 60? And our city campus has a substantial immigrant population. West Africa dominates, but Bangladesh, Ethiopia, Indochina, and the Caribbean are amply represented.

Having had the privilege of engaging in some small talk before pursuing the medical history, a lot of the men were war refugees who came to America as young adults. Many of the women, particularly those of Indochina, were also displaced by extreme poverty or adverse political situations. We have a large African-American population with patients who spent their 20’s in our penal institutions, not college or the army. These are all major traumatic events that have an enduring impact on the psyche and possibly on later health. And let’s not forget those adult patients of another era, within my own professional lifetime, the Holocaust survivors, some known to me as patients, others as neighbors. Military service, while rigorous and formative, probably falls short of the terror to a young adult of having their families perish and fleeing to an unfamiliar place alone.

While it is expedient for the hospital to select out military service as a base of exploration, I wonder if from a health perspective it may be too short-sighted. If emotional and recoverable physical trauma at age 20 portends health outcome at age 60, maybe the source of trauma needs to be more comprehensively explored to include professional training burnout, civilian victims of civil conflict, crime victims, imprisonment, divorce or family abandonment, etc. We have ample numbers of patients in each category. If focusing on the rigors of youthful military service make us more sensitive to those many other disruptions that young adults experience so that we consider this in a more general way than we do now, we might do much of our population a lot of good. But we have to be careful not to engage in excessive information gathering for its own sake and stay focused on our mission of optimal health long past these traumas of young adulthood.

Richard Plotzker is an endocrinologist who blogs at Consult Maven.

Image credit: Shutterstock.com

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