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A new development may mean that even more veterans
will be seeking care outside the VA system. Congress passed
a law so that as of November 5, 2014, veterans with VA
benefits are able to use a new "Veterans Choice Card" to
receive those hard-earned rewards from civilian providers
under a number of different circumstances--if they live 40
or more miles away from a VA center that offers the ser-
vices needed or if they would have to wait more than 30
days for an appointment, for example.
As a result, community physicians will need to be more
aware of their patients' military service or veteran status to
treat them more effectively. Parks suggests asking patients
directly whether they have served in the military. If they say
yes, probe a little further: "Tell me a little bit about that.
Where have you been? How long did you serve?" Learning
about a patient's military service at the beginning of your
physician-patient relationship can help save time and guess-
work throughout the treatment process, he says.
Starting the
Conversation
oing through medical school, we are taught a near-
ly exhaustive list of things to ask for a history and
physical. Among those questions, one we are not
taught to ask is about service in the military. I
believe we should be teaching to ask this question, and it
would be a standard part of the social history," Parks says.
"Ninety percent of the time, the answer is no, and the ques-
tion takes less than five seconds. But for about 4.8 percent
of New Jersey residents, the answer can give insight into the
patient and the patient history."
One method to help elicit information about patients'
military service is the WARRIORS
mnemonic, developed
by Dr. Like as an interviewing and assessment framework
for providing culturally competent, patient-centered care to
veterans and military service personnel:
W
: War and Military Experience
A
: Affect
R
: Relationships
R
: Risk Factors and Responses
I
: Injuries/Illnesses/Injustices Experienced
O
: Opportunities and Challenges Faced
R
: Resources, Supports, and Interventions
S
: Service Delivery Experiences
With regard to the area of risk factors and responses, for
example, possible questions to ask patients could include:
"What are some of the risks you were exposed to, and how did
you respond to that? Was there anything you were exposed to
that you are worried about today?" Dr. Like explains.
"These sorts of open-ended questions give us a bigger
picture of what's going on," he says. "You need to avoid
dwelling completely on deficits and negativity, but also
include a discussion of an individual's strengths and
resilience, as well as the opportunities and positives experi-
enced as a result of their military service."
The best first steps, Dr. Terregino says, are to ask the ques-
tion about service, thank the individual for his or her service,
then get to the issues and find help. "It is a way of being wel-
coming, receptive to sharing concerns, and empathizing," she
adds. "We have to walk in their boots--to be as empathetic
as we can, without having been on the battlefield."
Health care professionals need to invite patients to open
up about their experiences, providing encouragement and
legitimization for what the veterans are feeling and experi-
encing, agrees Evelyn L. Lewis, MD, MA, FAAFP, chief
medical officer of the Steptoe Group, vice president of the
American Academy of Family Physicians Foundation, and
22 Robert WoodJohnson
I
MEDICINE
he best first steps are to ask the question about service,
thank the individual for his or her service, and then get to the
issues and find help," says Carol A. Terregino, MD '86 (facing page,
center) with Steptoe Group team members (left to right) Linda Harris,
lead facilitator; Ron Koshes, MD, lead facility/subject matter expert;
Ronald J. Steptoe, CMR, chair, and CEO; Evelyn L. Lewis, MD, MA,
chief medical officer; and Robert C. Like, MD, MS.
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