Welcome to Unit 04.01 of Service Transformed: Lessons in Veteran Centered Care. I'm Monica Lypson, and today we're gonna talk about military history taking, and how that can really address veteran health concerns. The objectives here is to really understand the relationship between medical history taking and healthcare delivery. As well as really acknowledge and evaluate your interests and the approach to military and veteran centered care. In this segment, we're gonna specifically talk about your skills as a healthcare professional in terms of history taking. As you might recall from your education in the health professions, the aims of taking a medical history is really to try to understand the background of the patient's presenting illness. It allows you to identify sources of support, identify strengths. It explores the symptoms. It also provides a window into what types of medical care will actually succeed for a patient. There's some very interesting studies that started in the late-70s, where this idea about how important the history was as we were developing more and more diagnostic tools. The CT scan was just coming on board and there were multiple other modalities in terms of basic chemistrys and hematologys that were allowing us to look deeper into a patient's medical Illness. However, in a famous study in 1979 in the British Medical Journal, it was actually found that in the presentation of about 630 patients, the history was still the most important factor in both making a diagnosis and thinking about the management of the patient. So, if you look 56% of the diagnostic assessment came from the history, and only 1% for instance came from urine tests. A follow up study said, okay, in 1992 we said, oh, we have these little elaborate diagnostic tests now. We have enhanced ultrasound. We have MRIs. And the idea was actually, is the data still real about how important the history and physical exam is to the presenting medical problem? And this study, again, in the Western Journal of Medicine from 1992, played out again how important the history was in outpatient presentation of a medical illness. This is why we're gonna focus on not only getting the history but what importance the military history might have for a veteran. This is an important quote from a focus group participant when he talked about the healthcare providers need to understand what being a veteran is all about. What the experience is all about. They need to know what happened to the guys in World War II. They need to know what happened to the guys in Vietnam. They need to understand what the life was like for all of these different veterans so they can better know what conditions they deal with. So they can know the mindset of these people. So here the veteran is actually saying, it's important for you to understand the context for which a veteran might present to healthcare. One of the ways we talked about this in previous sessions, is really to understand the assets that patients bring to the encounter. And so, you wanna ask all your patients, veterans or non-veterans, what are they most proud of? What resources are available to them in their community? What kind of support systems they may have? And actually, do they even know anyone with a similar condition that has managed it successfully? So that they can reach out to them as a potential support system. This video, that you'll be able to view, really focuses on the skill set needed to actually take a military history. The first three minutes of this video provides a nice explanation of the military health history. When thinking about critical questions and what that that military history might be, you wanna ask the following question. Would you like to even talk about your military experience? That's the first question. Some might decide decline. You wanna ask, did they know someone close to them or themselves who served in the military? And then you wanna follow up. When did they serve? Where? What did they do? Did they see combat, enemy fire, or casualties? This gives you a perspective on their experience. And then overall question, how has the military service affected you going forth? One of the interesting perspectives though, is that military services often overlook part of a patients medical history and was recently dubbed the unasked questions in this editorial in JAMA. And if you remember, only 30% of veterans actually present to the veterans health administration for their healthcare. 70% are seeing civilian physicians. So this is still an important part of everyone's repertoire. Again, here's some examples that Brown talks about in terms of the four critical questions about the military health history. You wanna ask how they affected their life. And then what is the respondent's belief about their experience, etc. Again, a quote from a focus group participant. Combat experience is the most important thing you have. But nobody actually wants to know about it or talk about it. This is an important part of who defines many veterans and how they define themselves. Here's a most fascinating study that actually looked at military respondents asking where they ever asked about their military service? Only 63% were asked about that within the VA healthcare system. Tricare,if you remember, is the Department of Defenses insurance plan. And only a little bit of half of those patients have been asked about their military service. And then the numbers go down from there. And it's much less likely that people will ever ask about military service. Only about a third of people experience healthcare either in the private sector as part of federal or state healthcare plans such as Medicaid or Medicare. So as we think about it, there's other critical aspects of the interview or in fact the physical exam, that actually have an impact that you want to ask about why the military history is important. If you think about the mental status examination, which is part of the psychiatric or neurologic assessment. It's important to seek and reveal signs of mental illness. It's applicable to all patient encounters, and again, if you don't ask about a potential history of combat or other issues, military sexual trauma, that might have occurred while in the military, you missed this big area of a patient's experience. In addition, there's actually physical characteristics that you want to pick up as part of the mental status exam, including mood, cognitive state, aging, etc, which actually gives you insight into what might be happening to a patient. So, one of the activities we want you to think about a little bit on your own is, think about how you would write your own description of yourself or a friend in the appearance section of the mental status examination. What would be other's impressions of you from your description as you write it down? And as you do that, think about how you're gonna write a note in the medical history. Be it you're doing a nursing assessment, you're part of the pharmacy team or part of the medical team, think about how you would write that assessment piece.
