Spring 2014

The Unasked Question

Military service is too often left out of the patient’s medical profile

By Henry Klapholz, M.D.

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Henry Klapholz says that veterans often do not mention their time in uniform out of a sense of modesty. Photo: Kelvin Ma

I never left the country, nor was I ever anywhere near a battlefield. But I did serve as a major in the U.S. Army when I was assigned to Walter Reed General Hospital in Washington, D.C., for two years in the mid-1970s following my residency, as part of the Berry Plan that enlisted doctors into the U.S. Armed Forces. Entering the Army, I didn’t know what to expect. But I got a small taste of military life then, and came away wholly impressed with the respectful culture that permeated the ranks of men and women in uniform.

With my personal background, I was all ears when I heard about a bold new program launched by President Obama at the end of 2011 to deliver better medical care to our veterans. In order to make good on the initiative, the White House reached out to the Association of American Medical Colleges (AAMC) and asked that organization to promote the program, called Joining Forces, through the nation’s medical schools. I volunteered to head up the Tufts branch of the campaign.

Military service is largely invisible within our medical practices because we doctors rarely inquire about it in the normal course of events. You can imagine my dismay when I realized that I myself had never asked a single patient, in more than 40 years of practice, if they or anyone in their immediate family had ever been in the military and exposed to combat. It is simply the unasked question.

As a lifelong educator of medical students and residents, I have taught students how to take an appropriate history to identify individuals at particular risk for illness. I had always taught that we must ask patients about smoking, domestic violence and occupational exposures, among other things. There were so many items we needed to ask about in order to give us, as physicians, the chance for more careful and detailed follow-up.

Asking about military service is critical, because although about 1 in 10 adults in the U.S. has served in the military, only 28 percent of veterans receive any portion of their health care from the Veterans Administration. This means that many of these men and women are showing up to see us “regular” doctors instead. When we fail to explore their backgrounds in detail, they are inevitably short-changed on effective diagnosis and treatment. For their part, veterans often do not mention their time in uniform out of a sense of modesty.

The silence on both sides of the relationship can do real harm. Every day we are learning more about the lasting medical consequences of battlefield trauma, including psychological damage. Such aftereffects can include major depression, substance abuse, sleep disorders, mood swings, jumpiness and memory and concentration problems. Many of these symptoms occur under the broad diagnosis of post-traumatic stress disorder, or PTSD. Female veterans may suffer a form of PTSD brought on by sexual harassment and trauma that occurred during their service.

We doctors can do a much better job addressing the needs of these veterans. Here at Tufts I have found plenty in our existing systems that needs fixing. Early on, I learned that almost none of the electronic medical records in use at Tufts-affiliated hospitals and clinics contained the key question—“Have you or anyone else in your immediate family ever served in the military?” We are in the process of addressing that lapse.

In addition, our medical school is committed to teaching every student and resident to include an inquiry about military service when taking a patient history. We want to make that inquiry routine. Our next step will be to work with colleagues at other medical schools, through the auspices of the AAMC, to help bring about the change on a national level.

We owe it to the millions of men and women who have stepped up to protect our freedoms. Think of it this way: As a nation we ask these people to serve, and there’s a risk that comes with that service. The least we physicians can do is everything possible to serve them in return.

Klapholz is dean for clinical affairs at Tufts University School of Medicine.

 

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