Civilian Providers Research Articles

Deployment and Travel Medicine Knowledge, Attitudes, Practices, and Outcomes Study (KAPOS): Malaria Chemoprophylaxis Prescription Patterns in the Military Health System.

.The Deployment and Travel Medicine Knowledge, Attitudes, Practices, and Outcomes Study (KAPOS) examines the integrated relationship between provider and patient inputs and health outcomes associated with travel and deployments. This study describes malaria chemoprophylaxis prescribing patterns by medical providers within the U.S. Department of Defense’s Military Health System and its network of civilian healthcare providers during a 5-year period. Chemoprophylaxis varied by practice setting, beneficiary status, and providers’ travel medicine expertise. Whereas both civilian and military facilities prescribe an increasing proportion of atovaquone–proguanil, doxycycline remains the most prevalent antimalarial at military facility based practices. Civilian providers dispense higher rates of mefloquine than their military counterparts. Within military treatment facilities, travel medicine specialists vary their prescribing pattern based on service member versus beneficiary status of the patient, both in regards to primary prophylaxis, and use of presumptive anti-relapse therapy (PQ-PART). By contrast, nonspecialists appear to carry over practice patterns developed under force health protection (FHP) policy for service members, into the care of beneficiaries, particularly in high rates of prescribing doxycycline and PQ-PART compared with both military travel medicine specialists and civilian comparators. Force health protection policy plays an important role in standardizing and improving the quality of care for deployed service members, but this may not be the perfect solution outside of the deployment context. Solutions that broaden both utilization of decision support tools and travel medicine specialty care are necessary.

Responses among substance abuse treatment providers to the opioid epidemic in the USA: Variations in buprenorphine and methadone treatment by geography, operational, and payment characteristics, 2007-16.

ObjectiveTo identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers.MethodsSecondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007–16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007–16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment.ResultsBuprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035).ConclusionsGreater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

Methodologies Utilized and Lessons Learned in High Threat Environments and Mass Casualty Environments.

In May 2019, the author was awarded the Australian Tactical Medical Association (ATMA) study grant to attend the Special Operations Medicine Scientific Assembly (SOMSA) 2019 in Charlotte, North Carolina in the United States of America. Whilst in the U.S. the author had the opportunity to hear many talks, attend labs and talk to many first responders in high threat and austere environments to learn about how they operate, and the lessons learned from their experiences.
 This report highlights the two objectives of the study grant:
 
 Record the key content and lessons learned by attendance at SOMSA 2019.
 Discuss techniques utilized and lessons learned by first responders operating in high threat environments and mass casualty incidents.
 
 The SOMSA brings together many like-minded pre-hospital, tactical, wilderness, austere, disaster and deployed medicine operators from all around the world to share their learnings with a primary goal to
 advance the art and science of special operations medical care. It is a great opportunity for military and civilian providers to learn, network and engage with industry partners showcasing innovative products and technology.

Understanding the Needs of Female Veterans.

This commentary attempts to frame the article, "Safer Housing for Homeless Women Veterans," in a wider context. It defines female veterans, homelessness, and military sexual trauma. This commentary also tackles a question that often confuses civilian providers regarding who has access to care at the Veterans Health Administration. It does not repeat in detail all of the recommendations in the article, but it advocates their broader use in shelters and transitional housing. Finally, I close with some thoughts about a new generation of young, homeless, female veterans who may have children and how to accommodate their needs.

Provider Acceptance And Beneficiary Access Under TRICARE's PPO Health Plan.

TRICARE provides health benefits to more than nine million beneficiaries (active duty and retired military members and their families). Complaints about access to civilian providers in TRICARE's preferred provider organization (PPO) plan led Congress to mandate surveys of beneficiaries and providers to identify the extent of the problem and the reasons for it. The beneficiary survey asked about beneficiaries' perceived access to care, and the provider survey asked about providers' acceptance of TRICARE patients. TRICARE's civilian PPO plans are required to maintain provider networks wherever TRICARE's health maintenance organization option (known as Prime) is offered. For the years 2012-15, we describe beneficiary access and utilization and provider participation in TRICARE's PPO plans in Prime and non-Prime markets. We also compare individual market rankings for access and acceptance. In both market types, most providers reported participating in TRICARE's PPO network, and most PPO users reported using network providers. In areas where Prime is not offered, PPO users reported slightly better access, and providers were more likely to accept new PPO patients. Areas with low access and acceptance, or where multiple access measures indicate problems, may be fruitful for in-depth investigation.

Integration of mCare and T2 Mood Tracker: Illustrating mHealth Usability Testing

Military operational requirements potentially limit access to behavioral health care for service members. Although mobile technology solutions are increasingly viable, a secure method for mobile data exchange between patients and providers has yet to be adopted in military health care. Usability testing is the industry standard prior to implementing new technology. This paper demonstrates usability testing on a secure data exchange system between mCare and T2 Mood Tracker. Sixteen civilian providers in an outpatient behavioral health clinic tested the mCare Provider Portal, and nine uniformed proxy patients tested the Mood Tracker app. The System Usability Scale (SUS) was used as an outcome measure, which is composed of usability and learnability sub-factors. Proxy patients rated the mobile app as acceptable on the SUS, with average usability and above average learnability. Providers had less favorable views of the mCare Provider Portal, which they rated as marginal across all domains. Participants expressed enthusiasm about the potential of the provider web portal/patient smartphone app system, but had concerns about technical difficulties and ethical issues when exchanging data electronically. The results suggest a willingness to use technology to share data between patients and providers, but also a need for refinement of system usability before full-scale implementation.

Civilian Nurses' Experiences Caring for Military Veterans: Qualitative Data From a Mixed-Methods Study.

Over nine million people living in the United States are military Veterans over the age of 65. Many utilize civilian care providers, creating a need for civilian providers to have an understanding of the unique healthcare issues of this population. This article describes the qualitative results of a mixed-methods study of nine home care nurses' experiences caring for Veterans. Three themes emerged from the data: Challenges Coordinating Care, Building a Rapport Takes More Time, and Recognizing Impact of Military Service on Patient's Worldview. As demonstrated in this study, home care nurses care for Veterans every day. Although similarities exist, nurses readily described differences in caring for Veterans compared with non-Veterans that can impact patient outcomes. It is imperative for the nursing workforce to not only assess for military/Veteran status but to also have some knowledge of military culture and Veteran-specific healthcare issues.

Exploring Chiropractic Services in the Canadian Forces Health Services - Perceptions of Facilitators and Barriers Among Key Informants.

Musculoskeletal (MSK) conditions have a significant impact on the health and operational readiness of military members. The Canadian Forces Health Services (CFHS) provides a spectrum of health services in managing Canadian Armed Forces (CAF) personnel health care needs with on-base and off-base services provided by civilian and uniformed health care professionals, including chiropractors. Although chiropractic services are available in US DoD and VA systems, little is known about the facilitators and barriers to integrating on-base chiropractic services within the CFHS. This study explored key informants' perceptions of facilitators and barriers to the integration of on-base chiropractic services within the CFHS. We conducted a qualitative study to describe and understand how an integrated chiropractic service could be designed, implemented, and evaluated within the current interdisciplinary CFHS. Telephone interviews were conducted, using a semi-structured interview guide, to explore key informants' perceptions and experiences of chiropractic care within the CFHS. In total, we invited 27 individuals across Canada to participate; 15 were identified through purposeful sampling, 12 through a snowball sampling technique, and 2 declined. The 25 participants included military personnel (52%), public servants and contractors employed by the Department of Defense (24%), as well as civilian health care providers (24%). All participants were health care providers [physicians (MD) (7), physiotherapists (PT) (13), chiropractors (DC) (5)]. Interviews were audio-recorded and transcribed verbatim. Transcripts were prepared and analyzed using an interpretivist approach that explored key informants' perceptions and experiences. Qualitative analysis revealed numerous facilitators and barriers to chiropractic services in the CFHS. These were categorized under three broad themes: base-to-base variations, variable gatekeeper roles, and referral processes. Barriers to integrating chiropractic services included: lack of clarity about a chiropractor's clinical knowledge and skills; CFHS team members' negative prior experiences with chiropractors (e.g., inappropriate patient-focused communication, clinical management that was not evidence-based, ignorance of military culture); suboptimal bi-directional communication between CAF personnel and DCs across bases; and wide-ranging perspectives pertaining to duplication of services offered by PTs and DCs in managing MSK conditions. Facilitators associated with the integration of chiropractic services within a collaborative and interdisciplinary CAF environment included: patient benefits associated with multiple approaches utilized by different providers; adoption of up-to-date, high-quality evidence and guidelines to standardize care and curtail "dependency" between patient and providers; and co-location of providers to strengthen existing interprofessional communication and relationships. Key informants called for patient care that is collaborative, integrated and patient-centered, rather than "patient-driven" care; civilian providers understanding and respecting military culture rather than assuming transferability of patient management processes from the public civilian sector; standardization of communication protocols and measures to evaluate outcomes of care; and the need to move slowly and respectfully within the current CAF health care system if planning the on-base implementation of chiropractic services. This study illuminated many opportunities and barriers, in complex and diverse domains, related to introducing collaborative chiropractic services in the CFHS. The findings are relevant to increasing understanding and strengthening interprofessional collaborative care within the unique CAF health care delivery system.

Rehabilitation Counseling Competencies for Working with Veterans: Delphi Study Findings

Civilian clinicians are increasingly involved in working with veteran clients, and the demand for services by civilian providers will continue to rise (Luby, 2012). Likewise, recent rehabilitation counseling research underscores the need to address professional competencies for rehabilitation clinicians working with veterans (Frain, Bishop, Tansey, Sanchez, & Wijngaard, 2013). The present study is a focused empirical investigation of clinical competency training for successful rehabilitation work with veterans with disabilities. The authors report quantitative findings from a Delphi study focused on response data provided by a panel of 16 rehabilitation clinicians with expertise in veteran services. Panelists ranked the importance of 18 professional competencies and provided information about their education, training, and professional development. The most frequently identified sources of expertise in veteran issues were on-the-job training (81%) and personal research/reading (43.8%), indicating that clinical training programs may not provide sufficient training in graduate school on professional competencies required for successful rehabilitation work with veterans with disabilities.

Long-term, patient-centered outcomes of lower-extremity vascular trauma.

To describe the long-term outcomes of military lower-extremity vascular injuries, and the decision making of surgeons treating these injuries. Lower-extremity vascular trauma is an important cause of preventable death and severe disability, and decisions on amputation or limb salvage can be difficult. Additionally, the complexity of the condition is not amenable to controlled study, and there is limited data to guide clinical decision making and establish sensible treatment expectations during rehabilitation. A cohort study of 554 US service members who sustained lower-extremity vascular injury in Iraq or Afghanistan (March 2003 to February 2012) was performed using the military's trauma registry, its electronic health record, patient interviews, and quality-of-life surveys. Long-term surgical and functional outcomes, and the timing and rationale of surgical decisions, were analyzed. Of 579 injured extremities, 49 (8.5%) underwent primary amputation and 530 (91.5%) an initial attempt at salvage. Ninety extremities underwent secondary amputation, occurring in the early (n = 60; <30 days) or late (n = 30; >30 days) phases after injury. For salvage attempts, freedom from amputation 10 years after injury was 82.7% (79.1%-85.7%). Long-term physical and mental health outcomes were similar between service members who underwent reconstruction and those who underwent amputation. This military experience provides data that will inform an array of military and civilian providers who care for patients with severe lower-extremity injury. While the majority salvage attempts endure, success is hindered by ischemia and necrosis during the acute stage and pain, dysfunction and infection in the later phases of recovery. Therapeutic/prognostic, level III.

Enhanced Multi-Service Markets: An Evolution in Military Health System Governance.

The evolution of governance models for the Military Health System's (MHS) large hospitals, called medical treatment facilities (MTFs), has culminated with the effort to implement Enhanced Multi-Service Markets (eMSM). The term eMSM refers to two separate concepts. First, MSM refers to those geographic areas, that is, markets, which have the following characteristics: they have MTFs that are operated by two or more Department of Defense (DoD) Services, that is, Army, Navy, or Air Force; there is a large beneficiary population; there is a substantial amount of direct care (i.e., beneficiaries are treated at MTFs instead of TRICARE's purchased care from civilian providers); and there is a substantial readiness and training platform. Second, the term "enhanced" refers to an increase in management authority over clinical and business operations, readiness, and MTF workload. A retrospective review was conducted to study the evolution of military and civilian health care delivery models for the purpose of understanding how governance models have changed since the 1980s to design and manage MTFs with overlapping catchments areas. Primary and secondary data sources were analyzed through a comprehensive literature review. Since the 1980s, the MHS governance models have evolved from testing various managed care models to a regionally focused TRICARE model and culminating with an overlapping catchment area model entitled eMSMs. The eMSM model partially fulfills the original vision because the eMSM leaders have limited budgetary and resource allocation authority. The various models sought to improve governance of overlapping catchment areas with the intent to enhance medical readiness, community health, and individual health care while reducing costs. However, the success of the current model, that is, eMSMs, cannot be fully assessed because the eMSM model was not fully implemented as originally envisioned. Instead, the current eMSM model partially implements the eMSM model. As a result, the current eMSMs operate solely through cooperation and collaboration, without directive authority. Nevertheless, there have been some market-specific initiatives. Further analysis is necessary in the event that eMSM market managers are granted governance authority. This authority would include the ability to allocate the overall market's budget, determine common clinical and business functions, optimize the readiness of both the medical and the operational forces assigned to the market, and reallocate resources to optimize MTF workload. The results of this analysis may determine whether the fully implemented eMSMs optimize patient-centric initiatives as well as improve the market's efficiency and effectiveness.

Fatal Wounding Pattern and Causes of Potentially Preventable Death Following the Pulse Night Club Shooting Event

Background: Mortality following shooting is related to time to provision of initial and definitive care. An understanding of the wounding pattern, opportunities for rescue, and incidence of possibly preventable death is needed to achieve the goal of zero preventable deaths following trauma. Methods: A retrospective study of autopsy reports for all victims involved in the Pulse Nightclub Shooting was performed. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author. Wounds were considered fatal if they involved penetration of the heart, injury to any non-extremity major blood vessel, or bihemispheric, mid-brain, or brainstem injury. Results: There were an average of 6.9 wounds per patient. Ninety percent had a gunshot to an extremity, 78% to the chest, 47% to the abdomen/pelvis, and 39% to the head. Sixteen patients (32%) had potentially survivable wounds, 9 (56%) of whom had torso injuries. Four patients had extremity injuries, 2 involved femoral vessels and 2 involved the axilla. No patients had documented tourniquets or wound packing prior to arrival to the hospital. One patient had an isolated C6 injury and 2 victims had unihemispheric gunshots to the head. Conclusions: A comprehensive strategy starting with civilian providers to provide care at the point of wounding along with a coordinated public safety approach to rapidly evacuate the wounded may increase survival in future events.

Prevalence of Pain Diagnoses and Burden of Pain Among Active Duty Soldiers, FY2012.

Soldiers are at risk for acute and chronic pain due to the mental and physical challenges of military duties and ongoing training for force readiness. With the burden of pain on any individual attributable across pain sources, a broad perspective that goes beyond prior characterizations of pain is important. We aim to further the understanding of pain's effects among non-deployed active duty soldiers and the Military Health System (MHS), by describing prevalence of 10 painful conditions, reported pain levels, duration of pain and impact of pain on military duty limitations. Data are from the MHS Data Repository including outpatient MHS direct care encounters, claims for outpatient purchased care from civilian providers, and vital records, for all soldiers continuously enrolled in TRICARE and not deployed in FY 2012. Ten pain-related diagnostic categories were conceptually derived for this analysis and identified using ICD-9-CM diagnostic codes. We report the FY 2012 prevalence at the soldier-level (N = 297,120) for each pain category as a primary diagnosis, as well as in any diagnostic position, and at the soldier-level for reported pain level, duration, and military duty limitations. Institutional Review Board approval was obtained prior to analyses. Overall, 63% of soldiers had at least one pain diagnosis and 59% had a primary pain diagnosis during FY 2012. Back and neck pain (22%), non-traumatic joint disorders (28%), and other musculoskeletal pain (30%) were the most frequent categories for primary diagnosis. Nearly two-thirds of soldiers had a primary pain diagnosis in more than one category, and 23% in four or more categories. Moderate or severe pain levels were reported at least once during the year by 55% of soldiers who had a primary pain diagnosis. In the subsample of soldiers with primary pain in the first quarter, duration and chronicity of pain diagnoses varied by pain category: the back and neck pain category was the most common for both persistent pain occurring in each quarter of FY 2012 (23%) and chronic pain lasting for at least 3 mo (62%). In most pain categories, the majority of soldiers were released without duty limitations. These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.

Destigmatizing Experiences of Combat Veterans Engaged in Civilian Disaster Relief: Implications for Community Transition

Combat veterans possess some attributes of differentness that may cause others in society to create stigmatized perceptions of them and devalue their skills. Direct interaction/contact allows targeted individuals—in this case, combat veterans—to demonstrate their value by dispelling negative attitudes or beliefs others may have of them. A previous study reported that the disaster relief setting facilitates contact among combat veterans and non-military civilians. This study applied Modified Labeling Theory (MLT) to assess if the stigma and labeling experience among combat veterans volunteering in disaster settings provides a nuanced understanding. Semi-structured interviews were used to assess perceptions of male Team Rubicon (TR) members (n=9) who provide disaster relief in civilian settings. All participants served in combat. Data were thematically analyzed. Findings suggest 1) combat veterans were not stigmatized by their label; and 2) personal contact with civilians impacted by disaster helped TR members a) to demonstrate their value, and b) feel more optimistic about connecting with civilians in other contexts. Our findings suggest that veterans working with peer combat veterans and civilians in disaster settings provided a destigmatizing condition whereby combat veterans felt less stigmatized by others and more interpersonally connected with civilians. It is recommended that since the majority of services for veterans come from civilian community providers, it is imperative that providers be sensitive to military culture and experiences of those serving in combat to avoid further stigmatization of veterans.

A Retrospective, Radiographic Outcomes Assessment of 1960 Initial Posterior Root Canal Treatments Performed by Endodontists and Dentists

IntroductionThe Air Force Dental Service has established evidence-based treatment standards for endodontics, including 3-dimensional filling of the canal system, cuspal coverage restoration of endodontically treated posterior teeth, and use of rubber dam. The purpose of this retrospective study was to determine the effect of these standards on outcomes of initial posterior root canal treatments (RCTs) completed by Air Force (AF) and civilian dentists with and without accredited postgraduate training. MethodsTreatment and follow-up radiographs of AF members who had an initial posterior RCT completed in 2011 were evaluated. A survey of all radiographs was performed to determine the (1) RCT obturation quality, (2) healing of periapical pathosis, and (3) presence and quality of cuspal coverage restorations. ResultsA total of 2262 RCTs were examined, with 1960 RCTs meeting inclusion criteria for at least 1 evaluation category. For RCT obturation quality, 1810 RCTs were evaluated, and 96.0% were considered adequate. For cuspal coverage restorations, 1856 RCTs were evaluated, and of these 2.7% were inadequately restored. Healing of periapical pathosis was 91.5% and 85.7% for AF and referred civilian providers, respectively. Survivability was 94.4% for endodontists, 95.3% for AF general dentists with additional training, 87.9% for AF general dentists without additional training, and 78.4% for civilian general dentists. Overall, survivability was 94.1% for a follow-up period ranging up to 47 months, with a mean of 27 months. ConclusionsIn this retrospective, radiographic analysis, evidence-based practices as followed in the Air Force Dental Service and accredited postgraduate training resulted in improved treatment outcomes.

An Interprofessional Education Project to Address Veterans’ Healthcare Needs

Background/Objective: The number of veterans and their families seeking healthcare and support within civilian communities is increasing worldwide. There is a need for healthcare providers to provide sensitive, comprehensive care for veterans with both physical and behavioral health conditions. Many civilian providers are unfamiliar with veterans’ issues and need training on military culture and combat experiences in order to provide compassionate, high quality care. An interprofessional (IPE) course to increase health professional students’ understanding of military culture and the associated health problems of veterans was implemented and evaluated. Methods: An 8-week IPE immersion course was offered for students with clinical experience at a Veterans’ Health primary care clinic and a didactic component. The class content included military culture, behavioral and physical health disorders common among veterans, and the related behavioral and pharmacological treatments. Faculty-led discussions with students in IPE teams used veteran-focused case studies and standardized patients to prepare students to work in IPE teams in the clinical care of veterans. Results: This educational project was evaluated using quantitative surveys and qualitative reflection questions and focus groups. Students scored high for readiness for interprofessional learning pre-course. Post-course students reported valuing the team approach to veterans care and students engaged in high levels of communication and collaboration within the team. Students’ knowledge scores increased related to understanding of military culture and their patient advocate role. Conclusions: Students learned about military culture and the provision of humanistic, high quality care for military veterans in this clinical and didactic immersion IPE course.

Self-Reported Changes in Comfort Level With Basic OB/GYN Procedures After Deployment.

To assess the specialty-specific procedures and clinical encounters U.S. Army obstetrician/gynecologist (OB/GYN) providers felt were affected by deployment and identify skills and areas that may benefit from postdeployment training. Active duty Army OB/GYN physicians were invited to participate in an anonymous web-based survey to rate their comfort level and experience performing specialty-specific procedures before and after military deployment. Physicians rated their comfort level on a 5-point Likert scale (1 = very uncomfortable to 5 = completely comfortable). Statistical analysis included Pearson χ(2) and McNemar's χ(2) with a p value of <0.05 considered significant. Of the 100 physicians eligible to complete the survey, 66 responded (response rate = 66%). Their responses demonstrated a statistically significant perception of decline in their comfort level with nearly every obstetric and gynecologic procedure and clinical encounter evaluated. Time away from regular clinical practice during deployment results in providers feeling less comfortable with many common OB/GYN procedures and clinical situations. Although these results are not a measure of actual performance, this information helps define targets to focus refresher training for providers who leave their normal scope of practice for deployment. These findings apply to civilian providers leaving practice for other reasons as well.

Still in Uniform: Treating Active Military Members in a Civilian Psychiatric Facility

ABSTRACTAdmissions of military members (MMs) to community psychiatric hospitals are increasingly common, bringing unfamiliar challenges to civilian providers. To broaden the knowledge base on psychiatric issues facing MMs, investigators collected demographic and clinical variables from medical records of inpatients treated on a community hospital unit that specializes in MM treatment. Military members in this study had high rates of post-traumatic stress disorder (PTSD), depression, anxiety, and substance use disorders. Future research and information focusing on the psychiatric needs of MMs is greatly needed. Educating community mental health providers to help them better understand the unique challenges of working with active duty MMs will improve care and outcomes.

Respecting Other Cultures

INTRODUCTION Military and civilian providers frequently confront profound cultural challenges both here and abroad. One example recently occurred in a small medical clinic in a remote village in the Middle East. A father brought his daughter in with appendicitis, but said that he would allow her to have an appendectomy only if the surgeon was a woman. The only surgeon in that clinic was male. Out of concern for the girl’s life the clinic staff decided that they could carry out the surgery behind closed doors so that the father wouldn’t know and then lie about the sex of the surgeon. They were also very aware of a similar incident, which occurred in clinic similar to theirs in the same country. There, a father made this same request but a male surgeon did the surgery nevertheless and informed the father afterwards. The surgery was successful, but the daughter was thrown to her death out of a speeding car on the way home from the clinic. With full understanding of the risks, the treatment team chose to do the surgery and their fabrication of the events apparently was successful. This case illustrates starkly how critical momentous cultural conflicts can be. The starting presumption of providers usually should be to respect others’ cultural beliefs, but as this case illustrates, there are times that accommodation of patients’ and the providers’ beliefs cannot be reconciled. In this column I shall consider a range of cases that pose this conflict; some with straightforward ethical answers, others with no clear answers.

Treating Veterans of Iraq and Afghanistan: A State Needs Assessment of Civilian Physicians in Internal and Family Medicine

Background: With the return of troops from Afghanistan and Iraq, growing numbers of primary care physicians in the United States are treating veterans and their families for war-related conditions. However, little is known about civilian providers’ capacity to address the needs of this population. Objectives: This study sought to assess civilian internists and family physicians’ knowledge, confidence, practices, and training needs in treating war-related conditions of recent veterans and their family members. Method: An anonymous needs assessment survey was administered online by the Maryland Board of Physicians. A convenience sample of physicians in internal and family medicine (N=145) reported on their treatment and referral practices, knowledge and confidence in treating 14 veteran conditions, and preferred training modalities. Results: Only 12% of respondents were military veterans, but 42% of internists and 22% of family physicians reported some training in a Veterans Administration or Department of Defense facility. Although more than 70% of respondents treated veterans in their practices, approximately 60% never screened for military status and more than 40% never referred patients for VA care. Internists and family physicians did not differ significantly in their knowledge or confidence in treating any of the targeted conditions. Overall, both groups reported low knowledge of best practices and limited confidence in treating war-related conditions of veterans and family members. Respondents reported substantial interest in training to treat veteran patients through face-to-face trainings and webinars. Conclusion: Civilian primary care physicians are often the first practitioners consulted by veterans and their spouses/partners about war-related conditions. Findings reveal a clear need to enhance their capacity to treat this population. Trainings should: improve providers’ screening for military/veteran status, increase knowledge of best practices for treating war-related conditions, enhance physician confidence in providing care, and improve coordination of treatment between VA and civilian health providers.