A letter to civilian providers

Dear Community Medical Providers,

How many Veterans do you have walking through your door who are either newly discharged from the military or have been going to the VA clinic for treatment? Probably not many. In all your multi-cultural training, did you consider Veterans as a having a culture all of their own? My hope is that the thought has crossed your mind. Even with an awareness of a difference, it is easy to fall out of practice of being culturally sensitive if you are not a Veteran yourself or not interacting with them on a regular basis. With the increase in the ability of Veterans to access non-VA doctors, it is reasonable to expect more Veterans to walk through your doors. Veterans, especially those who have spent significant periods of time serving or being seen in VA clinics, are likely to have become accustomed to a different manner of engaging in treatment than civilians. Adapting to the style of interaction and manner of this engagement is important to promoting the success of Veteran’s treatment. With this in mind, I offer areas to consider so we may best help serve those who served our country:

Please be direct. Be blunt. If you use any attempt to sugar coat or handle Veterans with kid gloves, you will lose them with the first grain of sugar. Understand that sugar coating is often interpreted as “This practitioner believes that I am not strong enough to handle what I am about to hear”.

Take time to explain. Standard procedure; got it. This “take time to explain” is more about the process than the diagnosis or type of test. It’s standard procedure to explore underlying causes through routine testing, such as basic blood work. Being thorough is a good thing. Many civilians understand that this is part of the process. More than once I have heard a Veteran express confusion regarding a civilian doctor checking things which seem unrelated to their complaint or ailment. There are times when Veterans have misinterpreted this as not being heard or believed about their perception of what was possibly the issue.

Ask “do you have any questions?”. That’s a question I get from my doctor every time. I ask them. Lots of other people ask them. In the military... you rarely ask them. Decisions are made by whoever is in charge of that area. Doctors are in charge of medical treatment. If the doctor has decided on a certain treatment, then the decision has been made. Yet, the civilian doctor will ask “do you have any questions?” because the patient is in charge of the patient’s body. Encourage them to ask questions and to question their agreement with the treatment plan so that the Veteran takes control of their health. Help them to collaborate with you rather than just do as they are told.

Give expressed permission for them to turn down treatment, testing, or a course of action. Veterans are seen all the time by the VA and are prescribed medication, fill them, stop taking them for a variety of reasons, and then don’t say anything to the doctor. The reasons they go about things in this manner varies, but the mindset isn’t always easy to shift when seeing someone outside the VA. Seems to me it would be better for you to know if they stop taking a certain medication rather than having them hide it. Permitting refusal allows for them to share this information. Additionally, a Veteran may just not return rather than refuse a treatment to their doctor. Reinforcing their voice in the decision making process can make all the difference. It’s the difference between choosing not to see the doctor because of their plan and choosing to make a different treatment plan with that doctor.  Along with “do you have any questions?”, it may good to also ask “what do you think about that plan (or treatment, etc)?”. If you get anything close to “you’re the Doc” or “if that’s what you think I need”,  stop and inquire more about what THEY think they need. There is a difference between consenting to treatment and agreeing with treatment. Don’t confuse consent with agreement.

Now, switch gears. Once you have a treatment plan, assign the task. Tell them directly they are to go make the next phone call or appointment needed to move forward with the plan. Put a timeline on it and be specific about what needs to happen next.

The world of a Veteran went from black and white to very very gray when they were discharged from the military. The culture they lived within is very different from our own. Some Veterans are able to switch over quite well. Others struggle. Just as we interact differently to accommodate those we work with who are from another country or religion, we should do so with our Veterans as well.

These are the very basic struggles with medical care which have come to my attention. Further understanding of their overall struggles may be beneficial to your success with these men and women. Familiarize yourself with Veteran reintegration issues and military culture. It could make all the difference in how effective we are in doing our jobs.

Posted on November 11, 2018 and filed under PTSD, awareness.

Helpful Hints for Veterans and Civilian Medicine

I am starting to see an increased number of VA connected Veterans utilizing civilian doctors through their private health insurance for a variety of reasons.Recently, I had the opportunity to be involved in one Veteran’s experience navigating the world of civilian medical doctors. Seeing a civilian doctor is something that is almost second hand nature to those who have not served. Most of us have been seen by a civilian doctor since a young age and learned how to work with a doctor as an independent living skill. Therefore, we have an awareness of when to call a doctor, either for a regular check up or when ill. This basic understanding runs deeper than just scheduling. Civilians have a natural grasp of the process, the doctors’ intentions, and the regular follow ups. Based on my observations of this individual and reports of other Veterans, I would like to offer the following tips to effectively navigate the world of civilian medicine:

TAKE CHARGE OF YOUR HEALTH

Regular check ups are not scheduled for you and sent by notice in the mail. You need an appointment; you call yourself. If you are supposed to follow up, you are responsible to set that appointment. If treating your ailment requires regular intervals of treatment, again, it is not standard practice to send notice in the mail. Yup, you have to make sure you stay on top of it.

TAKING CHARGE COMES WITH CHOICES

It is a lot easier when you’re given an order and it is expected that you follow. When you are in charge of your health (civilian medicine), you have choices. I work with many Veterans who are prescribed medication and afraid to refuse or make it known that they don’t want to take it. Many Veterans are told they need certain testing and they do so because they were told they “have to”. Civilian doctors’ recommendations are just that - recommendations. Refusal of medication or testing comes with no consequences outside of the impact it may have on your health. Requests for exploration of different medications are widely accepted. Second opinion? You get to have those too. Civilian doctors know that it’s just part of the profession. Patients may seek a second opinion and not compromise their relationship with their primary physician. Seeking a second opinion is often a smart idea when dealing with major illness because it GIVES YOU OPTIONS, which allows you to choose what’s right for you rather than just being told what is right for you. It’s always YOUR body in the world of the civilian physician.

DON’T CONFUSE  A THOROUGH  DOC AS NOT LISTENING

Civilian physicians have much more freedom in their approach to their patients. Go in for a pain in your back and they may draw to test basic blood work. They may discuss potential causes which, to the patient, may seem unrelated. Fairly routine. Underlying causes are also something to consider. Something they can consider. If you feel you are not being heard, you can ask them to take another look, answer your questions, and review your concerns. You are paying them for a service. Collaborate with them rather than follow them. They aren’t a superior giving orders.  If you feel you are still not being heard? There are lots of fish in the sea as they say. Go to another doctor. There are plenty and you get to choose who you see.

BE HONEST

“If I get treatment and it works, I lose my rating”

When using the VA as a mental health provider, Veterans have been warned that they may not  be candidates for certain treatment (i.e., EMDR) because of the fear that losing their VA rating may compromise their ability to progress in treatment. Yes, the general understanding is that your VA disability benefits can be reduced if you get healthier. My research has not yielded any statistics regarding the rate of benefit reduction. My position is: If a Veteran is seeing me (with the exception of being court ordered) then their level of discomfort has reached a point where they want to make progress. A civilian practitioner is usually not connected to the VA or your benefits; hence, the overriding position is to improve your health and quality of life. Feeling better may not be a bad thing.

SOMETHING DOESN’T SOUND RIGHT? DON’T DROP THE ISSUE

Doctors are human. The Veteran who prompted my desire to provide these tips was scheduled for a review of his medical testing with a doctor other than the doctor who initially examined them. This Veteran had been scheduled to see an alternate doctor to accommodate the Veteran’s limited schedule. But when the alternate doctor called to say the Veteran had to see his original doctor, the Veteran accepted this and scheduled an appointment a month out to see the original doctor. Didn’t make sense, but the Veteran did as they were told. Upon prompting, the Veteran called back and explained their confusion. The office acknowledged that the Veteran was correct! Who’d a thunk it. They rescheduled to an earlier appointment with another doctor and things moved forward. Question, question, question. It goes back to taking charge. Trust that  you know what you need for your own health

Posted on November 11, 2018 and filed under PTSD, awareness.

Understanding Eating Disorders

As warm weather rolls in, so do the commercials for diet plans, liposuction, fat freezing, gym memberships, fat shedding supplements, and on and on. An overwhelming number of advertisements identify aspects of our appearance as flaws and encourage expensive steps to improve those flaws in order to achieve happiness. This message of striving (and starving) for an unrealistic physical appearance is sometimes as blatant as “stop letting that stubborn fat keep you from being happy”. Other times it is the more subtle advertisements and entertainment with portrayals of the happy human with an unrealistic body. The body, they don’t tell the audience, has been enhanced and altered through airbrushing, lighting, and make up (both body and facial).

All of this exposure and how often does the message “these are altered and unrealistic body images” come up in daily life? Look around and we find it is no where near the hundreds of thousands of negative images which are seen over the course of a day or week. Some of these are so subliminal we don’t even realize we are seeing them, they are just running in the background like barely noticeable music played in a mall.

So why is this concerning? These images can contribute to dangerous eating disorders. The Diagnostic and Statistical Manual, the guide to identifying mental health related disorders, even states that the culture of valuing body image is one of the factors which contributes to the development of eating disorders. Such disorders can lead to malnutrition, dehydration, irreversible bone mineral loss, organ damage and other ill effects on health. Mental health related concerns are the continued diminish of self-esteem, neglect of prosocial areas of life due to progressive obsession over food and weight, ongoing negative self-image, increased depression and anxiety, isolation due to fear of being overweight, lack of enjoyment in life, and a number of other mental health related issues. The most common age group in which eating disorders occur is teenage years through the 20’s. This is a critical time related to the development of a healthy body and the development of the brain. Lack of necessary nutrition can negatively impact this process.

One positive aspect is that parental involvement still vey much exists within the age group most afflicted. This offers the opportunity for support in prevention and recovery. Empowering parents with education regarding the signs, and ways to reduce the risk of eating disorders, hopefully, will reduce the rate of these disorders and make for healthier adults.

The following educational piece starts with understanding that each disorder has their own unique distinguishing behaviors. The two main weight related disorders are Anorexia and Bulimia.

Anorexia is the most commonly acknowledged eating disorder. This may be do the shock of the rapid weight loss and sickly appearance of Anorexia. Anorexia has multiple root causes. The most common roots can be an attempt to establish a sense of control, a response to distressing events, or exposure to body shaming or unrealistic expectations of how an attractive body is defined. At first, Anorexia can appear as healthier eating or superficial focus on appearance, which may come with the increased self-awareness accompanying puberty and teenage years. The distinction can be made when:

  • There is rapid and extreme weight loss

  • Inability to see weight loss

  • Obsessive focus on weight (e.g., complaining about body image, pinching of areas to measure how much fat they can grab, constant criticism of body shape)

  • Extreme reduction of food intake

  • Obsessive calorie counting

  • Overuse of laxatives, diuretics, or exercise (differs from Bulimia in there is no binging and are used despite low calorie intake)

  • Detailed food diary

  • Use of diet pills or engagement in fad diets when at a low weight

  • Somatic issues such as stomach pains, constipation, dizziness, headaches, fatigue on a regular basis

  • Lack of engagement of activities, such as swimming, where body shape is more easily observed by others

  • Justification of weight loss due to extracurricular activities (dance, wrestling, gymnastics)

  • Stunted puberty (girls show delayed menstruation or discontinuation of menstruation)

  • Hanging posters (or following on social media) of idealized body types rather than their talent or attraction to the person

  • Struggle to or hiding eating due to shame

  • Consistent use of the bathroom following a meal (indicative of self-induced vomiting)

  • Daily weighing, sometimes multiple times in a day

  • Extreme intolerance to cold


Bulimia is known, but less common. Bulimia is more about not gaining weight than losing weight. It also comes with a fear of being overweight. The distinguishing factor of Bulimia vs Anorexia is that there are bouts of uncontrolled eating of an extreme quantity of food in a short period of time followed by some type of purging to avoid weight gain. This usually does not come with an extreme loss of weight or noticeable change in weight. The lack of change in body shape makes it less noticeable that Bulimia is present. The signs to look for:

  • Times of extreme eating within approximately 2 hours or less, sometimes consuming food they normally would not eat or to the point of being ill

  • Consistent use of the bathroom following a large meal (indicative of vomiting)

  • Excessive use of laxatives, diuretics, diet pills or stimulants

  • Diary of food consumed vs what is purged (extreme versions include weighing what was purged such as vomit, urine and feces excreted)

  • Development of “chipmunk cheeks”, which is due to the swelling of salivary glands

  • Referred to as Exercise Bulimia, obsessive exercise as a form of purging noted by longer than reasonable engagement in one exercise session (e.g., running up and down stairs for hours rather than sets or the use of exercise equipment beyond the standard hour session)

  • Erosion of the esophagus

  • Tooth erosion

  • Constant irritation of the lips

  • Severe acid reflux


Additional tips:

  • In some cases, the use of vomiting can lead to uncontrolled reflexive vomiting upon eating without the intention of purging.

  • There is a trend among those who support the engagement in Eating Disorders to don red beaded bracelets in order to identify themselves to others with eating disorders.

  • Another clear sign is involvement in ProAna or ProMia websites. ProAna are sites dedicated to providing tips and support on how to maintain anorexia. ProMia are sites encouraging Bulimia. Both of these sites maintain the position that eating disorders are a lifestyle choice rather than a disorder. ProAna sites label those with an eating disorder as a “Rexie” or an “Anorexie”. A “Rexie” is someone who defines their Anorexia as achieving success in developing a high level of self-control, power over self, and strength. An “Anorexie” is someone who uses Anorexia for sympathy rather than manifesting the strengths of a “Rexie”.

If you have concerns, exploring your child’s search history may be eye opening regarding these sites and other weight loss sites they have been exploring.

Just like addiction, Eating Disorders can be a lifelong recovery process with the risk of some relapses in the process. Just like addiction, Eating Disorders come with a high level of denial, manipulative behaviors to maintain the disorder, and justification of their behaviors.

There are inpatient and outpatient clinics specific to the treatment of eating disorders. There are support groups, unlike ProAna and ProMia groups, focused on recovery. Eating Disorders can be difficult to watch in the people we care about. It can bring about anger and fears in the loved ones of those struggling with this condition. There is significant information to help understand Anorexia and Bulimia.

This article was broken up into two separate articles; Understanding Eating Disorders and Prevention of Eating Disorders. Click here to read about Prevention

Some quick tips to remember when dealing with the dynamics of an eating disorder:

  • Don’t engage in a power and control struggle as it may increase the severity

  • Remember, the desire for control is one facet feeding their behaviors. Don’t increase their resistance by constantly insisting that they eat.

  • Discussing food with someone who is food obsessed is not the best approach

  • Don’t express anger at them or withdraw; they already carry enough shame

  • Do try to express understanding of how they are feeling, identify the pressure our society unfairly places on them, and work together to find ways to improve their health and begin recovery.