Dr. Christopher Nelson was working as a psychiatrist in New York four years ago when he met a dynamic — some might say slightly pushy — Army doctor named Col. Elspeth Cameron Ritchie.
As the Army’s chief of psychiatry, Ritchie encountered challenges, and opportunities, that few civilian psychiatrists like Nelson never see. To Ritchie, military psychiatry was breaking new ground during a decade of war, not only helping service members but driving development in the entire psychiatry field.
Nelson was intrigued. He decided his future was in serving troops as well as being on the cutting edge of psychiatric care. Now he works with formerly deployed Marines at Naval Hospital Camp Lejeune.
But the transition was not easy. And the problems had nothing to do with leaving a rent-controlled apartment in New York City and moving to Jacksonville, North Carolina.
The military culture, he said, was a miasma that proved difficult to penetrate.
“Many of the mistakes I made early on could have been prevented if I’d understood better. But it was seat-of-my-pants,” Nelson said.
Just 36 percent of veterans are treated at the Veterans Affairs Department. And millions of family members as well as troops are treated by civilian physicians. Understanding what these patients have experienced during their time in service is vital to good patient care, military officials said recently in a seminar at the American Psychiatric Association annual meeting.
And although online short courses are available that cover the obvious — rank, military occupational specialties, histories and traditions — the Pentagon is gearing up to promote a new eight-hour course for health care providers to gain a deeper understanding of military culture.
“Military Culture: Core Competencies for Health Care Providers” covers four subjects: health care provider beliefs and biases; military definitions, language and culture; military functions; and the role of military ethos in health behavior.
Four years in the making, the course aims to convey a sense of the warrior ethos — how service members and veterans view themselves, and how health care providers can use that information to provide the best treatments for their patients, said William Brim, a former Air Force psychologist who is now deputy director of the Defense Department’s Center for Deployment Psychology.
“If a service member were to go in for treatment and their therapist takes an approach of, ‘You poor person, they brainwashed you and took way your individualism,’ that might work for some but a lot of service members would nod their heads, walk out and never be seen again,” Brim said. “We are trying to keep that from happening.”
Only about 20 percent of the nation’s medical schools teach military culture, and barely half mention the military when teaching about post-traumatic stress disorder and traumatic brain injury — indications that broader outreach is needed, said Navy Cmdr. Patcho Santiago, a professor at the Uniformed Services University of the Health Sciences.
The new course, which awards continuing education credits to those who take it, seeks to teach the essence of troops and the military services — what makes them tick, the doctors said.
“We sought input from veterans, troops, wounded warriors, civilian providers, spouses and National Guard and reserve members to get their perspective,” Brim said.
And the program doesn’t shy away from difficult topics such as sexual assault, physical injuries, traumatic brain injury and mental health conditions, Brim added.
“We didn’t want to be a shill for DoD or VA and just deliver the mantra,” he said.
According to a Pew study, 77 percent of veterans say they are not understood by the civilian population and 71 percent of civilians say they don’t understand the military.
At the very least, the experts said, even without a course, health care providers from technicians to specialists could learn to ask a few basic questions that ultimately would improve care for service members, veterans and their families.
Questions like: “Has someone or someone close to you served in the military?” and “Where did you serve?” and “what did you do?” can improve treatment, the doctors said.
Santiago cited the case of a Navy culinary specialist second class who deployed to Afghanistan and manned a .50 cal gun on an MRAP as an individual augmentee.
“If a doctor didn’t ask the right questions, he might have missed a key piece of history, like that patient was in the lead vehicle of a convoy and the vehicle behind him was hit by an IED,” Santiago said.
The course, developed in part by the White House’s Joining Forces initiative, will be available through several different websites, including the CDP’s, where it can be taken now, as well as VA’s internal training site, the Pentagon’s website health.mil, the Substance Abuse and Mental Health Services Administration, the APA and others.
Brim’s organization also is developing a one-hour course for primary care providers, a course on the National Guard and courses for service members and families to help them get the most out of doctors appointments.
Physicians attending a workshop on the new course and military cultural competence at the APA annual meeting in New York were eager to take the course and asked pointed questions about reaching Iraq and Afghanistan veterans, many of whom they described as suspicious of psychiatry and therapy in general.
They wanted to know how to reach across the divide of being a health care professional seen as an authority figure, to reach enlisted personnel who may be uncomfortable dealing with others in a position of senior authority.
Among the pieces of advice: know the audience by understanding the rank structure, military occupational specialties and duty stations; ask about a patient’s service and express interest in it; and pull chairs side by side to communicate as equals.
And if all else fails, Air Force psychiatrist Capt. Eric Meyer said, try swearing.
“It helps,” Meyer quipped. “If you have silence after five minutes, just drop the f-bomb. They get it.”