The last two decades of American history have been marked by ongoing military conflict, with nearly 2.6 million U.S. service members deployed to hostile war zones. Combat soldiers involved in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn have often served multiple tours and return with unique health care needs. Addressing the medical concerns of veterans in both civilian health care systems and the Veterans Affairs (VA) health care system, where staff are already familiar with issues of military reintegration, remains difficult despite its increasing importance.1
In response to this, the Joining Forces Initiative was launched in 2010 to improve the nation’s commitment to caring for veterans and their families.2 This initiative has received the endorsement of the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine, and both organizations have pledged a commitment to improving the veteran-centered care training of the next generation of physicians with particular attention to posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI).3
PTSD and TBI are especially important to combat veterans, as they impact approximately 13.8% and 6.7% of returning veterans, respectively,4 but they may occur among civilians as well. For example, the National Institute of Mental Health estimates that PTSD occurs in approximately 7.7 million American adults, who for the most part are not veterans, and according to Centers for Disease Control and Prevention data,* each year approximately 1.7 million people incur a TBI, and there are 1.37 million emergency department visits, 275,000 hospitalizations, and 52,000 deaths due to TBI annually.5
Despite the noble intent of the Joining Forces Initiative, several potential barriers exist that may prevent achieving its aim, including the social distance between patient and provider (see below), the increase in military personnel, and the general lack of preparation of health care professionals who work with veteran patients. Previous research has indicated that veterans experience health care disparities based on socioeconomic status, geographic factors, communication styles, and provider bias.6 It is well documented that veterans who enroll at the Veterans Health Administration are more likely to be low income, less likely to have access to other forms of insurance, more likely to report lower quality-of-life measures, more likely to exhibit comorbidities, and more likely to have less experience with the doctor–patient relationship compared with veterans that use other, civilian health care systems.7 Not only does this create a significant social distance between patient and provider, but unfortunately, many health care professionals hold stereotypes or unconscious biases toward low-income patients.8
Workshop content and instructional methods
In fall 2013, we developed and implemented a faculty development workshop for practicing clinicians using the documentary Where Soldiers Come From to aid in the Joining Forces Initiative’s aim to improve our nation’s commitment to improving health care for U.S. military veterans.
Within the medical education context, faculty development is critical for ensuring that trainees obtain proper education, witness appropriate role model behavior, and receive effective feedback. For example, trainees often learn to care for military patients through their rotations at affiliated VA hospitals (e.g., in 2013, over 20,000 medical students and 40,000 residents received medical training at a VA location9), where their cultural competence develops from modeled physician behavior, engaging instructors, and direct patient care.
We designed the workshop to develop faculty teaching skills in the area of veteran-centered care as well as to improve health care delivery to veteran patients. To achieve these aims, the workshop included topics on unconscious bias, the service member trajectory (i.e., going from civilian to active duty military to veteran), health care disparities, and strategies for overcoming barriers to treating veteran patients with PTSD and TBI. The workshop design adhered to well-established principles known to promote and sustain skill development through hands-on experience and practice exercises, which provide participants with a mechanism for thinking about how to incorporate what they learned into their everyday practice.
The workshop engaged faculty in active-learning techniques—(1) images in education, (2) trigger video, (3) critical thinking and reflective writing, (4) think–pair–share, and (5) large-group discussion—and was centered on scenes from the documentary Where Soldiers Come From, which specifically highlights the issues of reintegration and adjustment to civilian life as well as PTSD and TBI. The film traces five young men from the Upper Peninsula of Michigan in their journey as National Guard members, including their deployment to active duty, searching for roadside bombs in Afghanistan, and coping with invisible war wounds and the readjustment to civilian life after returning home. We used this documentary as a trigger video because many of the invisible wounds of war include psychological and cognitive injuries, and this documentary takes the viewer over the trajectory of how the injuries occurred, the manifestation of symptoms, and how soldiers deal with these injuries in their everyday lives. The scenes selected provide distinct insight into the military service trajectory and veteran patients’ health care experiences, both of which can impact the patient–provider relationship and ultimately health outcomes.
After viewing scenes from Where Soldiers Come From, participants had the opportunity to reflect on their thoughts, feelings, and perceptions and to subsequently interact with their peers in large groups to elicit their peers’ understanding of service member life and health care trajectories. In small groups, participants also discussed the issues that arose in each scene as the basis for exploration of their own personal and professional experiences to ultimately discover how to best engage their learners on related topics. In addition, before viewing the scenes, participants were asked to view photographic images of three different military service members (an older veteran, a younger new enlistee, and a scene of soldiers in combat) for reflection purposes, as mitigating health care disparities based on socioeconomic status requires the acknowledgment of the disparity as well as a critical awareness of the impact of assumptions, biases, and prejudice that arise amid physician–patient interactions. See Table 1 for a description of workshop activities.
The content of this workshop has been published in MedEdPORTAL and can be accessed there for reference and use.10 The materials include everything necessary to conduct the workshop (e.g., facilitator instructions, sample evaluation, PowerPoint presentation, learner materials). The film’s director has granted permission to use the clips for educational purposes.
Setting and participants
As of spring 2015, this workshop has been conducted at three separate locations (two VA centers and one national conference) with 46 health care professionals. Among the 37 participants who completed the anonymous workshop evaluations (response rate of 80%), 27 (73.0%) were physicians, 3 (8.1%) were nurses, and 1 (2.7%) was a psychologist (6 [16.2%] did not list their role). Thirty-one (83.8%) indicated that they practiced in a VA center. The participants self-selected to attend the workshop and were informed of the data collection both in writing and verbally at the beginning of each workshop. All data collected were anonymous, and all aspects of this project were approved by the University of Michigan Medical School institutional review board.
At the conclusion of the workshop, participants completed an evaluation with both Likert-scale and open-ended questions. (A pre/posttest design was not used because we were looking at self-reflective processes regarding experience and care of veterans.) Evaluation questions were designed to specifically obtain feedback on the instructional methods, content of the documentary and workshop, influence on future care, participants’ experience with veterans and knowledge of issues pertaining to military personnel, and participants’ attitudes toward veterans in general.
The evaluation results indicate our workshop’s successful delivery of the principles of veteran-centered care, including identifying disparities for veterans, and incorporation of active-learning techniques in teaching. Because most participants were employed by an integrated federal (military or VA) health care system, the participants who completed the evaluation (n = 37) included 31 (83.8%) VA employees, who may possess a heightened sensitivity and awareness toward these issues. Yet, many of our results suggest that this workshop positively influenced these health care providers to give additional consideration to the background and experience of the veteran patients they encounter. Additionally, the questions with fewer positive responses may be explained by the participants’ preexisting expertise in the diagnostic criteria for PTSD or how to initiate a referral within the VA system. Though we suspect providers in non-VA settings will similarly benefit from this workshop, we cannot conclude this without further study, as there were too few non-VA participants to yield a significant subset analysis.
Twenty-five of 32 (78.1%) participants indicated that the workshop activities changed their knowledge, attitudes, and/or skills; 22 of 34 (64.7%) stated that they had a better understanding of how to develop a care plan for veterans; and 27 of 34 (79.4%) stated that they gained a better understanding of how to prepare for issues around returning veterans. Even with most of the participants being VA employees, 33 of 34 (97.1%) participants indicated that the scenes from the documentary helped them to reflect on their own attitudes toward veterans (see Table 2).
When asked how they would change their approach to veteran patients with symptoms of anxiety or depression after viewing scenes from the documentary (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A331), 9 of 37 (24.3%) participants indicated that they would show compassion and/or empathy, 4 of 37 (10.8%) would ask about service and use open-ended questions, and 3 of 37 (8.1%) would notice mistrust and/or anger. Two of 37 (5.4%) participants indicated that they would not change their approach, and 0 of 37 (0%) indicated that they would consider depression, consider socioeconomic status, or ask about social support. These findings may suggest that providers felt that incorporating compassion and empathetic techniques, and allowing patients to express themselves thoroughly through open-ended questions, would improve care. They also suggest that fewer participants were willing to tackle difficult mental health and psychosocial issues in their routine medical care visits.
Open-ended evaluation questions were also included at the end of the workshop evaluation and inquired specifically about how the workshop or scenes from the documentary had impacted the participants’ perspectives on veterans and their care (for example responses, see Table 3). Data were analyzed using an interpretive thematic analysis. Three of us (M.L.L., P.T.R., N.Z.) independently reviewed all participants’ narrative responses to identify key words and phrases. These terms were subsequently classified into individual codes, using each response as the unit of analysis. After the codes were developed, inter coder reliability was performed to give validity to themes created by each coder. For each participant response, we assigned the level of agreement with a numeric code 0 (no agreement), 2 (two coders agree), or 3 (all coders agree). As a validation method, one of us (K.E.G.) independently read participants’ responses and confirmed the original codes. Once agreement was determined, quantitative data were imported into SPSS 20.0 (IBM Corporation, Armonk, New York) to perform frequency analysis. The resulting data support the notion that the development of military cultural awareness can facilitate or improve health care delivery for veterans.
Through this workshop, we have been able to shed light on veteran-centered care topics through our presentation at a national meeting and acceptance in MedEdPORTAL, and to teach skills that directly align with the Joining Forces Initiative as it relates to medical educators.
A higher standard for the delivery of veteran-centered care has become increasingly important with the surge of returning military personnel. Improv ing quality of care will require the collaboration of comprehensive teams that include patients, family members, and health care staff to provide excellent and personal guidance throughout medical encounters.
Because so many veterans seek care in civilian health care settings and from health care providers in nursing, social work, pharmacy, and dentistry, it is equally important that providers in these settings, as well as providers within the VA health care system, gain knowledge and perspective regarding veterans and their care. To address the issue of veteran-centered care education more broadly, we have developed a massive open online course for health professionals, using most of the content from this workshop, which will be offered in spring 2016.
Although this workshop was originally designed for faculty learners, it would also be effective, with some slight modification (e.g., revisions to questions about how to train others), for other levels of learners (e.g., medical students, residents, fellows). Our workshop appears to promote reflection among VA providers about the veterans they care for. Another important next step will be to deliver this workshop to and collect evaluation data from non-VA providers.
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3. Association of American Medical Colleges. Serving Those Who Serve America: Joining Forces: Results of an AAMC Survey. 2012.Washington, DC: Association of American Medical Colleges.
4. National Institutes of Health and the Friends of the National Library of Medicine. PTSD: A growing epidemic. NIH MedlinePlus. 2009;4:1014https://www.nlm.nih.gov/medlineplus/magazine/issues/winter09/articles/winter09pg10-14.html
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. Accessed January 22, 2016.
6. National Center for Ethics, Veterans Health Administration, Department of Veterans Affairs. An Ethical Analysis of Ethnic Disparities in Health Care: A Report by the National Ethics Committee of the Veterans Health Administration. August 2001. Washington, DC: U.S. Department of Veteran Affairs; http://www.ethics.va.gov/docs/necrpts/NEC_Report_20010801_Ethnic_Disparities_in_Health_Care.pdf
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9. Heisler EJ, Bagalman E. The Veterans Health Administration and Medical Education: A Fact Sheet. June 6, 2014. Washington, DC: Congressional Research Office; https://www.fas.org/sgp/crs/misc/R43587.pdf
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