In my final working weeks, my medical center had cemented an agreement with the Veterans Administration to offer care at our center to veterans who could not be accommodated at the VA for a variety of reasons . We could use paying patients, they could use doctors of our caliber so our representatives established mutual benefit. We have always had patients who have served in the military. For much of my professional life, that has included most men of my father's generation whose young adult years encompassed World War II with its widespread draft. World War I and Korea conscription was less universal but patients having served in these settings were frequent. Vietnam service seemed more selective. For the most part, even when employed as a VA physician 1980-88, the patients' service while appreciated was largely parenthetical to their congestive failure, COPD, or diabetes. Some had permanent sequelae of their service, missing limbs, shell-shock or post-traumatic stress disorder depending on which military conflict, a chemically related setback often still in adjudication where medical care intermingles with compensation. Some were more indirect, the many alcoholics or other substance abusers, maybe some of those with hypertension, but these were also highly prevalent in people who never wore a uniform. But by age 60 when people started getting admitted to the hospital more frequently, the diseases I treated at the VA did not seem very different from those encountered elsewhere, at least on the Internal Medicine service. 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 though separate payment systems, and people came by who just happened to have been in the army as young adults but were pretty mainstream thereafter, going to college, joining a union, maybe for some latching onto a business, or seeking jobs as they became available without ever acquiring an identifiable occupation. As prescriptions became more expensive, the VA would often supply medicines to veterans like my father and others who saw the doctor or nurse practitioner as a precondition for having the prescription supplied but regarded physicians external to the VA as the doctors they made most of their appointments to see.
With systems, particularly governmental ones, process often becomes excessive. This being an important medical center initiative, the first Grand Rounds of the academic year went to the VA's physician representative to this project. He 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 a good invitation for some errors of the first kind, those Type I errors that attribute significance to what is non-contributory to the hospitalization. Even at the VA itself, by the time somebody is 60 years old and has an MI, it was not the military mess hall that made the cholesterol high. And 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 encounter of hospitalization. What we may be doing is propagating an event of young adulthood, labeling it as an imprint which portends an invisible forty year interval until they come to our ER. I think the process needs to be more selective than what the speaker described in his presentation to be meaningful. In this era of Electronic Health Records, we already gather reams of historical information that never gets refined or prioritized by its importance, since we often don't know its importance. Or as the New York Times advertising once told its consumers, "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, the more immediate medical imperatives risk distortion as well.
The other consideration would be why select military service as the shaping event that forms the underpinning of once's health at some time in the remote future, then trying to reconstruct this in reverse? In attendance at this Grand Rounds were our residents. At age 20 they had a fair amount of academic terror, fretting over the Organic Chemistry final that might weed them out professionally. At age 25 they had The Match culminating the rigors of medical school, some overseas. As residents many departed their families from Asia or Latin America. And by the time they get their certificate, many will experience burnout. Will the experience of medical training in their 20's be more favorable or less to their health at age 60? And our city campus where I saw inpatients and outpatients has an immigrant population. West Africa dominates as the region of origin but Bangladesh, Ethiopia, Indochina and the Caribbean are all represented. Having had the privilege of breaking the ice with some small talk before starting 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 either extreme poverty or a few by adverse political situations. We have a large African American population with patients who spent their 20's in our penal institutions instead of college or the army. No question these are all major traumatic events that have enduring impact on the psyche and maybe on health. And lets not forget those adult patients of another era, though well 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 portend 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 among others. We have ample numbers of patients in each category. If focusing on the rigors of youthful military service make us more sensitive to the many other disruptions that young adults experience so that we consider this in a more general way than we do now, we probably will do much of our population a lot of good over time. 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 the traumas of young adulthood.
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