A Veteran-Centric Model of Care: Crossing the Cultural Divide

Abstract

I served as a Marine Corps officer for 10 years before becoming a physician-scientist. My perspectives on military life and medicine, therefore, developed independently. These 2 worlds crossed paths during residency at the Philadelphia Veterans Affairs (VA) Medical Center. Here, my military service helped me be a better physician. It was also where I first shared my military experiences with my fellow VA physicians, most of whom lacked this experience. Many aspects of the military seemed foreign to them, despite their years of service caring for veterans. As a physician and veteran, I have learned that a better understanding of military culture and its effects on veterans perceptions of health care strengthens the physicianpatient relationship. Failing to appreciate these differences can result in veterans and physicians perspectives being misaligned when managing a veteran s health. The Cultural Divide Between Military and Civilian Life Military life is foreign to most civilians. Early in my military career, my wife shared this with me, When I go through the gates of the base to visit you, I feel like I am entering a foreign country. Being a citizen of both worlds, I did not understand this. To me, U.S. military and civilian cultures seemed the same. However, my wife was right. The U.S. military and civilian cultures do differ in their language, customs, traditions, and laws, much like foreign cultures differ from one another. First, military and civilian language differ. Both use English, but military language is unique, using the phonetic alphabet, vernacular, and uniquely military expressions. Second, military traditions and customs are also unique. A well-recognized symbol of military culture is the salute, a formal greeting given to senior ranking officers. Enlisted military personnel must also greet an officer as Ma am or Sir. Civilians are greeted formally by military personnel as a reminder that the U.S. military serves under civilian leadership, a unique aspect of the U.S. Constitution. Military personnel are not merely being politefailure to use these greetings is punishable by law. In civilian culture, such formal greetings are out of place and often unwelcome, misinterpreted as a comment on one s age. VA physicians without military backgrounds have shared this with me, I feel awkward when veterans call me Sir [or Ma am ]. From the veteran s point of view, however, all physicians in the military are officers. Therefore, it is natural for veterans to address physicians this way. A veteran likely believes that it is inappropriate to address a physician without these courtesies. Understanding such cultural differences that define a veteran may help avoid awkward moments. Third, the military has its own laws. Members of the U.S. Armed Forces are sworn to defend the U.S. Constitution but are not protected by it. They are subject to the Uniform Code of Military Justice (UCMJ), a different system of laws whose purpose is to maintain order and discipline within the military. For example, malingering, or feigning an illness to avoid one s duties, is illegal under the UCMJ (1) and punishable by court martial, which is equivalent to a federal felony. Under civilian law, faking an illness and falsely calling in sick is not illegal. In addition, the rights to privacy are greatly curtailed under the UCMJ. Active duty service members belongings are routinely inspected and searched. I believe most civilians would dislike routine inspections of their homes and belongings. Although a largely unexplored area, I also suspect that veterans perspectives of the Health Insurance Portability and Accountability Act and rights to privacy of medical information are skewed by their military experience. Veteran s Views and Trust of Physicians I believe one unfortunate aspect of military culture may be the inherent distrust of physicians. Most Americans grow up believing that the physician is someone you see when you are sick with the hope of feeling better. In contrast, military recruits first encounter with a physician is at a Military Entrance Processing Station, where a physician can exclude candidates from military service if they are found to be unfit. During periods of drafted service, one might consider it lucky to be excluded for medical reasons; however, in times of voluntary service, medical exclusion denies eager volunteers the benefits of military service (for example, college benefits, vocational training, and future VA health care). This initial physician s examination may be viewed as an obstacle rather than a screening. In addition, a negative perception of physicians may be reinforced later in one s service. Military personnel with special duty status (pilots, paratroopers, divers) require routine medical examinations. These physicals may be perceived as potential threats. For example, failing a flight physical can ground a pilot and terminate his or her career. This perception might also impede receipt of medical care. Soldiers and Marines returning from Iraq and Afghanistan reported fearing the perception of stigma, potentially threatening their careers, as a major reason for not seeking medical support for posttraumatic stress disorder (2). Military experience results in a physicianveteran relationship that differs from the physicianpatient relationship for which physicians have been trained in medical school. Veterans may perceive physicians as threats rather than as allies or confidants and may extend this distrust to their VA physicians (3). Physicians caring for veterans must acknowledge this potential barrier to health care. After military service, the transition back to civilian life, and becoming a veteran, is not easy. Veterans quickly discover that they are different from civilians. They are also in the minorityless than 7% of the U.S. population has served in the armed forces (4). The VA becomes a sanctuary where veterans gather, a place to express the never-fading impressions imprinted by military culture. Crossing the Cultural Divide for Better Veteran Health Care As physicians caring for veterans, we must recognize that they are a culturally unique population and learn more about the culture that defines them. Although most physicians train at a VA hospital (5), a veteran s perception of physicians may differ greatly from those discussed and addressed during medical school and residency. It is crucial to recognize that military service is a key component of social history that influences every aspect of a veteran s life. It may, therefore, be beneficial for physicians to undergo a brief orientation, or boot camp, where some of these foundations of military culture are explained, such as the different service organizations and military specialties, rank structure, and experiences of service members during training and combat. Lectures at VA-affiliated academic centers or during VA orientation, when feasible and when provided by those with military experience, might be appropriate venues. A better understanding of a veteran s experience will, of course, come from our veteran patients themselves. It behooves the civilian physician to ask the veteran patient, Can you tell me about your military service? Expressing a desire to learn more about military life and accepting the potential cultural discomfort that may arise may earn your veteran patients trust. Potentially helpful questions to ask are presented in the Table. Empathizing with a veterans view of their military experience is a critical step in personalized medicine for this population and in creating a veteran-centric approach. Better understanding of military culture may serve as a bridge for physicians to cross the militarycivilian cultural divide and strengthen the physicianveteran relationship. Table. Question Prompts for Veteran s Social History