America's Veterans in Your Practice

The physician assistant (PA) profession has a lengthy, tight-knit, relationship with the Veterans Health Administration (VA). In fact, the first PAs to graduate from Duke University's PA program in 1967 were veterans. Many returning military medics came to the profession in the early 1970s, and the VA was one of the first places to employ these new PAs. While the profession has evolved in many ways over the last 50 years, the relationship with the VA and with the physicians who help care for this population continues to be strong.

The VA is America's largest integrated healthcare system in the U.S. with more than 1,700 sites of care. Currently, there are 21 million veterans in the United States, and although nine million of them are enrolled in VA healthcare, only about six million actually use the system. That means there are upwards of 15 million veterans who receive their healthcare outside of the VA.

Although the number of veterans is declining due to age-related deaths of WWII, Korean War and, Vietnam era vets, we are seeing an increase in requests for care and in the severity of conditions. Additionally, as people live longer, we are treating more chronically ill patients who suffer from smoking related illnesses, diabetes, COPD and other diseases worsened by aging.

This increase in demand for care has brought significant challenges for the VA in maintaining necessary capacity. We have increased funding, hired additional providers and expanded our facilities to add exam rooms and operating rooms. Still, at times the numbers of veterans exceeds the system's capacity. This lack of resources spurred the Choice Act, which has provisions allowing certain veterans to receive federally-funded care outside of the VA.

Under the Veterans Choice Program (VCP), any veteran who lives further than 40 miles from the nearest VA healthcare facility is eligible to receive care from a network of private providers at the VAs expense. So, there is a growing likelihood that physicians, Certified PAs and nurse practitioners will regularly encounter veterans at their practice.

The most significant thing providers can do is identify veterans by asking every new patient "Have you served in uniform?" (Keep in mind that an increasing number of veterans are women, so this is a question for both genders.) The answer will lead to other questions that can identify health problems unique to this population and ensures that those who protect our nation get the comprehensive care they deserve.

If your patient is a veteran, ask follow-up questions about what they did in the service and where they served. Patients who have served in the military may have issues that aren't addressed unless you ask about them. Inclusion of a good occupational history as part of the patient assessment may help identify these additional issues.

Each military profession and conflict have their own occupational hazards, including:

•Because of increased exposure to the elements, many veterans will have skin cancers.

•Those who were in an artillery battalion often have hearing problems.

•Veterans who worked with tanks may have joint or other skeletal problems from repeatedly jumping down from tanks, which can lead to problems with the knees, ankles and hips.

•Those who served in Vietnam have manifestations from Agent Orange exposure.

•Veterans who served in the Gulf Wars may have had excessive exposure to smoke and gasses from burning oil wells or "burn pits."

•Veterans may have mental health issues such as adjustment disorder or PTSD that are difficult to elicit due to the perception that seeking help would be a sign of weakness.

Despite the availability of the Choice Program, many veterans still prefer to receive their care from the VA, where they find a sense of camaraderie and feel safe. When veterans must travel a good distance to the nearest VA facility, every attempt is made to schedule multiple appointments on the same day. The VA provides best-in-class care that attracts many veterans especially in areas such as PTSD and mental health, amputation care, and prosthetic services.

The VA is focused on providing the best care for each patient and providing the right care at the right time from within the VA system or through one of the existing non-VA care programs. Our partnership with private healthcare providers will ensure that our nation's veterans will receive the quality care they deserve.

Denni Woodmansee, MS, PA-C, is Director of Physician Assistant Services for the Department of Veterans Affairs. He is also a Vietnam veteran, having served in the U.S. Air Force. He is the immediate past chair of the Board of Directors of the National Commission on Certification of Physician Assistants.