Military life brings with it unique challenges and stressors that directly influence the health of our nation’s service members and their families. Throughout history and around the globe, those who serve in their nation’s military have received medical care as a benefit of their service. In the United States, the Department of Defense (DoD) provides medical care through its Military Health System (MHS), a federally owned, integrated health care system incorporating both insurance (TRICARE)1 and direct health care delivery. The MHS consists of 59 inpatient hospitals and medical centers and 363 ambulatory medical clinics worldwide and is staffed by both military and civilian personnel. In general, those who are eligible for care within the MHS include active duty and retired (with at least 20 years of service) service members, “dependents” of those service members (including spouses, and children up to certain ages), active duty and retired reservists and their dependents, and Medal of Honor recipients. The Veterans Health Administration system is separate from the MHS and has its own eligibility criteria.
TRICARE is the health care program of the MHS. Implemented in 1994, it is a family of health plans provided to DoD beneficiaries. TRICARE Prime is a health maintenance organization-style plan in which enrollees are assigned a primary care provider who consults for specialty care as appropriate. TRICARE Extra is a preferred provider organization-type plan in which beneficiaries use a civilian health care provider approved by the TRICARE Regional Office. Finally, TRICARE Standard is the non-network benefit in which beneficiaries can obtain care from civilian providers who accept TRICARE; however, an annual deductible and modest cost sharing are required.1 TRICARE allows a significant proportion of DoD beneficiaries, particularly military dependents and retirees, to access health care in the civilian sector. Of the DoD’s approximately 9.7 million beneficiaries, roughly 2 million see civilian providers. The majority of these 2 million patients are retirees and their dependents or survivors (69%), with the remaining patients being active duty dependents (17%) and National Guard and Reserve service members and their dependents (16%).2
To ensure a pipeline of capable health care providers ready to serve in war or peace, the MHS has an integrated medical education system for undergraduate and graduate medical education (GME). Undergraduate medical education within the MHS occurs at the Uniformed Services University of the Health Sciences (USUHS) F. Edward Hebert School of Medicine. USUHS was chartered in 1972 to serve as the nation’s federal academic health center, and the medical school is responsible for creating military medical officers and leaders for the Army, Navy, Air Force, and Public Health Service. Much like the military service academies, USUHS is the “academy” for military medical corps officers, with average class sizes of 170 students, producing approximately 10% of new military physician accessions annually.3 GME training occurs throughout the MHS and includes not only USUHS graduates but also those who have trained in civilian medical schools on service scholarships through the Health Professions Scholarship Program.
As military families are spread across the United States and internationally, and many of those who have served our nation in the past decade are National Guard and Reserve service members who have returned to civilian life, it is probable that all U.S. medical students—not just those at USUHS—will at some point provide care to this patient population. What should we be teaching to prepare graduates to care for those who serve, or have served, their nation? An important first step in understanding how to best care for patients from military families is to bear witness to the fact that the military is a culture. Service members are united by a shared military experience, with military structure being sociologically complex, and military service often involving witnessed or experienced trauma. The spouses and children of service members likewise identify themselves as members of military families. If the military can be viewed as a culture, cultural competency education frameworks are then helpful in curricular development around caring for military members and their families.4 To ensure that our students have military cultural competency, our curriculum seeks to impart essential knowledge, skills, and attitudes to prepare our students to care for those who go in harm’s way.
Knowledge of the basics of service within the U.S. Army, Air Force, Navy, Marine Corps, and Coast Guard facilitates communication between a care provider and the service member patient. For this foundational knowledge, Goldenberg and colleagues’5 “Basic Training: A Primer on Military Life and Culture for Health Care Providers and Trainees” is an excellent resource.
Awareness of military population demographics also helps one understand that being part of the military is but one of several cultures or groups to which the service member belongs. Within the military there are two populations of personnel—officers and enlisted—each with its own rank structure. Officers almost always have a four-year college degree and are responsible for all aspects of their military unit. Enlisted personnel make up 83% of the active duty military force and execute the work of the military under officer direction. Enlisted personnel generally join the military after completing high school. Women make up 14.2% and 16.4% of enlisted and officer ranks, respectively.6 Race distribution for enlisted (68.3% white, 18.4% black, and 3.8% Asian) differs slightly from that of officers (78.1% white, 8.7% black, and 4.1% Asian); 12.3% of enlisted and 5.5% of officers self-identify as Hispanic.6
In addition to demographics, knowledge of the prevalent illnesses and chronic injuries within this population identifies key areas in which to develop at least diagnostic, if not also therapeutic, competence.4 For example, 11% to 23% of Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans are thought to have experienced at least one episode of mild traumatic brain injury (TBI). Because of the exigencies of war, TBI may go undiagnosed in a war zone, and lingering symptoms may present or become more obvious months to years after injury. This complicates the transition of care of our injured service members from acute care to rehabilitation to returning to non-MHS health care for the rest of their lifetime. Joint Department of Veterans Affairs (VA)/DoD clinical practice guidelines for TBI provide detailed diagnostic and management recommendations and provide a longitudinal care plan that helps non-MHS providers receive and continue the care of these patients.7
Posttraumatic stress disorder (PTSD), whether associated with TBI or not, affects an estimated 10% to 20% of all OIF/OEF veterans and independently increases risk for suicidal ideation. Up to 80% of patients with PTSD also have substance use disorders, and prospective studies have shown that PTSD and depression precede or worsen alcohol and drug misuse, suggesting self-medication of psychiatric symptoms.8 Depression, anxiety, and adjustment problems are also associated with war fighting experiences. Smoking and hypertension are both more common in active duty military who deployed, as compared with those who did not deploy, with multiple deployments adding risk.8 Service in certain parts of the world confers risk for infectious diseases such as tuberculosis, malaria, leishmaniasis, and parasitic infections, which may not manifest until years after such geographic exposure. At USUHS and within the MHS, we provide instruction on all these prevalent conditions—current best practices are available from our DoD’s Deployment Health Clinical Center,9 in joint VA/DoD clinical practice guidelines,10 and from resources through USUHS.11
Finally, it is important for health professionals to have knowledge of resources available to military service members and their families. Military One Source,12 provided by the DoD at no cost to active duty, National Guard and Reserve members (regardless of activation status) and their families, connects individuals at any hour, 365 days a year, with a professional who has a master’s degree in social work or other counseling service. Military One Source meets a broad range of needs including parenting and child care, relationships, stress, grief, relocation, deployment, money management, spouse employment and education, reunion, and the particular concerns of families with special-needs members.
Taking a military history is a critical skill to practice in the evaluation of all new patients. At USUHS we incorporate this in the psychosocial history in medical interviewing. A basic military history includes the branch of service, rank, dates of service, deployment locations, and the individual’s job in the service. A more nuanced history adds information on combat and blast exposures, illness and injuries during deployments, as well as screening for chronic pain, sleep distur bances, tobacco, alcohol or substance abuse, depression, PTSD, sexual abuse, and suicide risk.7 The Military Health History Pocket Card for Clinicians13 is an excellent resource for taking a military history. It begins with four questions that should be asked of any patient with military experience: (1) Tell me about your military experience. (2) When and where do you/did you serve? (3) What do you/did you do while in the service? (4) How has military service affected you?
In addition, one should also ask patients of all ages whether they have a family member in the military. Evaluating a child with recent difficulties in school, for example, might reveal that the child’s mother is about to deploy. Too often we forget to ask, and fall short of discovering the underlying stressor otherwise not volunteered or even recognized by the patient or family.
Providers can practice attentive listening with service members and their families experiencing the stress and emotions inherent to predeployment, deployment, or homecoming time periods. Deployments can occur every one to three years and may be unpredictable in length, setting, or danger. Military families living distant from bases (as is often the case in Reserves and National Guard activated for deployment) are more vulnerable and could lack the social support network characteristically found “on base.” For redeployment (home coming), active duty and their families should all give themselves time to readjust to each other; in general, we say that it often takes an amount of time equal to the deployment for families to feel things are back to normal.
Valuing military cultural competence and consciously committing to improving care delivery to military service members and their families are both important in caring for this patient population.4 Assigning due importance and respect for the influence that military stressors have on health helps providers seek out these stressors in the patient interview. Destigmatizing mental health treatment is crucial to negotiating barriers to early intervention, and joint DoD and VA guidelines recommend an interdisciplinary approach, involving integrated teams of primary care, mental health, and social work providers to help achieve this goal.8 A longitudinal view of the military patient is also important. Feeling responsible for the patient both now and in the future potentiates excellence in both preventive care as well as in transitioning care from the MHS to the next provider team (in the VA or elsewhere). For example, the student understanding that the PTSD in a patient today, if untreated, can lead to substance abuse in the future (with consequent risks of multiorgan disease, unemployment, and homelessness) is inspired to ensure that the patient’s treatment is uninterrupted during the transition of care.
What can the academic medical community of practice begin to do now to introduce and incorporate aspects of military medicine into their curricula and experiences of their trainees? We offer the following recommendations:
- Introduce military cultural competency training early in medical school. Ready-made resources exist in the iCollaborative Joining Forces collection.14
- Require the military history to be taught as a routine part of the introductory clinical skills training courses present in all medical schools.
- Involve military treatment facilities (MTFs) as training sites for medical students and residents. Whereas many MTFs serve as clerkship sites for USUHS, they also serve as sites for local civilian medical schools. Use the military experience as a context to illustrate prototypical diseases, such as TBI, PTSD, depression, and infectious diseases.
- Look within your own medical school classes and faculty for those who have military experience and backgrounds. They can be a resource for informing curriculum development and bridging cultural barriers. Incorporate Wounded Warriors15 and other military service members or veterans into the medical school curriculum. Patients have a vital role to play in informing medical school curricula, and in this context could be part of an advisory group, participate as standardized patients in training programs, or help with curriculum development.
Through efforts by the Association of American Medical Colleges and the Joining Forces initiative, there is now, more than ever before, a national conversation about military service, health care, and how we are all responsible for the care of our military members and their families. Your colleagues at USUHS and throughout the MHS stand ready to collaborate to advance the care of those who have sacrificed and been willing to serve in harm’s way.
Acknowledgments: The authors acknowledge Dean Arthur Kellermann for his thoughtful review of the manuscript.
2. U.S. Government Accountability Office. Defense Health Care: TRICARE Multiyear Surveys Indicate Problems With Access to Care for Nonenrolled Beneficiaries. 2013 Washington, DC Government Accountability Office http://www.gao.gov/products/GAO-13-364
. Accessed April 4, 2014
3. Farrell BS. Military Personnel: Status of Accession, Retention and End Strength for Military Medical Officers and Observations Regarding Accession and Retention Challenges. 2009 Washington, DC Government Accountability Office:Report 09-496R
4. Betancourt JR. Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Acad Med. 2003;78:560–569
6. Office of the Secretary of Defense, Personnel and Readiness. Population Representation in the Military Services: Fiscal Year 2011 Summary Report. 2012 Washington, DC Department of Defense
7. Sessums LL, Jackson JL. In the clinic. Care of returning military personnel. Ann Intern Med. 2013;159:ITC1–ITC15
8. Spelman JF, Hunt SC, Seal KH, Burgo-Black AL. Post deployment care for returning combat veterans. J Gen Intern Med. 2012;27:1200–1209
9. Department of Defense Deployment Health Clinical Center. About PDHealth.mil. www.pdhealth.mil/main.asp
. Accessed April 24, 2014
10. U.S. Department of Veterans Affairs. VA/DoD Clinical Practice Guidelines. www.healthquality.va.gov
. Accessed April 24, 2014
13. U.S. Department of Veterans Affairs Office of Academic Affiliations. . Military Health History Pocket Card for Clinicians. http://www.va.gov/oaa/pocketcard/
. Accessed April 24, 2014