Military and veteran health

This unit describes the skills, knowledge and attitudes expected of all GPs in this area of practice. The specific skills and knowledge required of GPs working in the Australian Defence Force (ADF), including registrars, are detailed elsewhere.

Australian Defence Force GPs and GP registrars are central to maintaining the health of the ADF workforce and therefore require special skills in addition to those normally expected of civilian GPs. Like other occupational health medical practitioners, ADF GPs need to manage the dual responsibility of balancing the interests of the patient with those of their employer.

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Australian general practitioners (GPs) are central to the provision of healthcare for more than 600,000 ex-serving members of the Australian Defence Force (ADF).1 GPs may also be required to provide health services to the approximately 60,000 permanent ADF members and 39,000 members in the reserve force, in civilian and military settings.2 ADF serving members may also choose to visit a GP for additional health services.

The primary healthcare needs of serving and ex-serving ADF members include the same health needs of comparable non-serving populations. These include occupational medicine, prevention and treatment of musculoskeletal conditions, mental health and substance abuse, chronic pain and Aboriginal and Torres Strait Islander health. Three per cent of currently serving ADF members are Aboriginal and Torres Strait Islander peoples, making the ADF one of Australia’s largest employers of Aboriginal and Torres Strait Islander peoples.3 The health needs of serving and ex-serving ADF members may also include those specific to military service (eg aviation and underwater medicine). There are also significant numbers of Commonwealth and other nations’ ex-service personnel who have migrated to Australia who may present with similar issues. Family members of serving and ex-serving members also face some particular health issues that may differ from the civilian population.4

Military systems have been historically male-oriented, resulting in a systemic under-representation of women’s health issues in military medicine, research and development. Factors contributing to female-specific health issues for ADF members include training strategies, operations, human factors (eg body size) and personal protective equipment. 5,6 GPs need to take these factors into account when assessing and managing serving and ex-serving female ADF members.

Serving ADF members are accustomed to accessing ADF healthcare services, but after discharge, often lack experience in managing their own health. They may not have learnt how to navigate the Australian civilian health system and may be unaware of specialist service access, wait times and out-of-pocket costs of care as their health literacy skills may be underdeveloped.7 GPs are in an ideal position to assist ex-serving members to fully re-engage with the civilian primary healthcare system and Department of Veterans’ Affairs (DVA) services.

GPs also need to be attuned to the specific healthcare needs of ex-serving members, recognising that around 12% of all ADF discharges are due to medical conditions that preclude service in a military environment.8 Following discharge, there is often a significant worsening of mental health symptoms in some ex-serving members a few years after leaving military service. A lack of social support due to frequent moves associated with military service and difficulties maintaining intimate family relationships from prolonged deployment, service at sea or training activity separations, may aggravate these mental health problems.7 GPs should aim for early identification of physical and mental health conditions through appropriate and sensitive history-taking.

References
  1. Australian Institute of Health and Welfare. A profile of Australia’s veterans 2018. Cat. no. PHE 235. Canberra: AIHW, 2018 [Accessed 26 October 2021].
  2. Gill GF, Bain R, Seidl I. Supporting Australia’s new veterans. Aust Fam Physician 2016;45(3):102–06.
  3. Reed RL, Masters S, Roeger LS. The Australian Defence Force Post‑discharge GP Health Assessment. Aust Fam Physician 2016;45(3):94–97.
  4. Open Arms. Family. Canberra: Open Arms, 2019 [Accessed 30 November 2021].
  5. Australian Institute of Health and Welfare. Serving and ex-serving Australian Defence Force members who have served since 1985: Population characteristics 2019. Canberra: AIHW, 2021 [Accessed 26 October 2021].
  6. Barbeau P, Michaud A, Hamel C, et al. Musculoskeletal injuries among females in the military: A scoping review. Mil Med 2021;186(9–10):e903-e931. doi: 10.1093/milmed/usaa555.
  7. van den Berk Clark C, Chang J, Servey J, Quinlan JD. Women's Health and the Military. Prim Care 2018;45(4):677–86. doi: 10.1016/j.pop.2018.07.006.
  8. Australian Government Department of Defence. Defence Annual Reports. Canberra: Department of Defence, [date unknown] [Accessed 26 October 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate sensitivity around discussing military and veteran health and a history of military service with patients and their families
1.1.1, 1.1.2, 1.1.3, AH1.3.1
  • outline the personal barriers that patients may have in disclosing their military-related health
1.1.1, 1.1.2, 1.1.3, 1.3.1
  • recognise and respect a patient’s reluctance to disclose their past service history and events that may have occurred during military service
1.1.2, 1.1.3, 1.3.1
  • use a trauma-informed approach in the management of conditions related to military service
1.4.3, 1.4.4
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • incorporate military and veteran health issues and past military service into history-taking, including mental health
2.1.1
  • sensitively and respectfully take a history and perform an examination in the context of reluctance by the patient to discuss past events and trauma
2.1.1, 2.1.2, AH2.3.1
  • identify military health-related general practice conditions and injuries early, especially in ex-serving defence force members
2.1.3, 2.1.4
  • describe the requirements for working with external agencies that manage medical and welfare needs of active and former defence personnel
2.3.2, AH2.3.2
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • describe the pattern of general practice conditions affecting defence force personnel and veterans
3.1.1, 1.2.3
  • describe the military health issues specific to various groups within the ADF, for example, women
3.1.1, 3.2.2
  • outline the participation of Aboriginal and Torres Strait Islander peoples in the ADF
AH3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • manage the potential tensions between the medical requirements of the defence forces with those of the patient
4.1.1, 4.1.5
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • respect confidentiality when serving members choose to access civilian GP services rather than ADF health services
5.2.5
  • encourage veterans to fully re-engage with the primary healthcare system upon service discharge in a culturally safe and appropriate manner
5.1.2
  • provide reports to address specific requirements of a patient’s DVA claim
5.2.3
  • detail how eligible patients and their families can access medical and other assistance from DVA and related services
5.2.4
  • perform an ADF Post-discharge GP Health Assessment
AH5.2.1
  • counsel serving ADF members using civilian GP services in fulfilling their obligations to advise defence health services of any treatment that has the potential to affect their employability or deployability
5.2.1, 5.2.3, 5.2.4, 5.2.6

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Use the terms ‘serving’ and ‘ex-serving’ when describing Australian Defence Force (ADF) members in preference to terms such as ‘veteran’, which some people may interpret as applying only to people who have been in a war zone.
  2. Recognise that the most important aspect of the initial consultation is developing a relationship with the patient, especially in the context of prioritising the management of multiple, complex and chronic health issues. Patients may not disclose the extent of their conditions when they first present, sometimes due to the traumatic nature of past events. Patients will disclose relevant information in their own time once they feel safe within the patient–doctor relationship. To facilitate this relationship, learn about and incorporate knowledge of the stages of the military service lifecycle into patient assessment and management. For example, recruitment, garrison, operations, return home, transfer from permanent to reserve forces, and discharge.
  3. The ADF is one of the largest employers of Aboriginal and Torres Strait Islander people in Australia, and culturally appropriate services are available to support serving and ex-serving Aboriginal and Torres Strait Islander ADF members.
  4. GPs are central to the management of mental health conditions in serving and ex-serving members as part of a multidisciplinary team. Perhaps the most important thing a GP can do is to encourage and empower their ex-serving patients to fully re-engage with the civilian primary healthcare system and Department of Veterans’ Affairs (DVA) services. Many serving members have become accustomed to accessing healthcare through their defence health service and consequently may have low health literacy and familiarity with navigating the civilian health system. Ex-service organisations have DVA-trained individuals who can assist in lodging claims and accessing support. Ex-serving patients are strongly encouraged to access an advocate's support to guide them through the claims process.
  5. A Medicare-funded comprehensive health assessment may help the ex-serving member to realise that there may be a problem. Once problems are identified, the veteran should be encouraged to apply for DVA support to allow rapid access to a comprehensive system of treatment support. Many ex-serving members can be referred for psychiatry, psychology and mental health social work, and occupational therapy services. Family members may be eligible for some benefits.
  6. Serving and ex-serving members may present with the same primary care issues as the wider population as well as conditions related to their military service; for example, musculoskeletal conditions and substance use disorders. They may not realise or may actively deny that their health conditions are related to their service. Assess the risks or refer for further assessment. Assess and identify any health problems early, including mental health issues.
  7. Clinicians providing healthcare to serving ADF members may need to reconcile the patient’s needs with those of the employer, similar to occupational medical officers who may face professional challenges when providing health services for an employer.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Military and veteran health

Geoffrey is a 43-year-old software engineer who presents with difficulty sleeping, daytime tiredness and back pain. He has intermittent and sometimes severe back pain which he says is from injuries acquired when he was in the Australian Defence Force (ADF).

Geoffrey says the pain sometimes makes him aggressive. His girlfriend, who he lives with, told him that he really needed to see someone about his moods and that she’s fed up with him. Geoffrey says that he’s not a good sleeper anymore and he has vivid nightmares and dreams. He drinks most days and says he often sits around feeling nothing. He joined the ADF at age 19 and has served in East Timor and Iraq. Geoffrey says that he’s come in today to get something to help with the back pain.

Questions for you to consider Clinical exam assessment area Domains

How will you build a therapeutic relationship with Geoffrey?

What are the barriers to achieving this?

How would you ask about his military service?

How would this differ for a similar case in a female?

How would this be different if Geoffrey was an Aboriginal or Torres Strait Islander?

  1. Communication and consultation skills
1,2,5

How do you identify that a patient is a current or former member of the defence forces?

Why is it important to know which arm(s) of the defence force (Navy, Army, Air Force) Geoffrey served in?

What are the sensitivities about history-taking for a current of former defence force member?

How would you assess for conditions specific to Geoffrey’s military service? (Refer to guiding topics section.)

How would you rapidly assess Geoffrey’s safety and the safety of others?

  1. Clinical information gathering and interpretation
2   

In Geoffrey’s case, what is the interplay between his physical health, mental health, sleep and alcohol use?

What key features would you be looking for when making any diagnoses?

How would you prioritise Geoffrey’s differential and possible diagnoses?

  1. Making a diagnosis, decision making and reasoning
2

What are your management objectives for Geoffrey?

How would you prioritise these?

What might Geoffrey’s expectations be of this visit?

Are you likely to resolve these issues today? If not, how will you manage them?

  1. Clinical management and therapeutic reasoning
2   

What are some of the barriers to Geoffrey accessing treatment?

How would Geoffrey’s health literacy affect his ability to access support and treatment?

How would you involve his partner, family and any other supports?

  1. Preventive and population health 
1,2,3

If you were providing Department of Veterans’ Affairs (DVA) funded services, what are your professional obligations when interacting with the Department?

If Geoffrey was a current ADF member and you were his medical officer, what would your responsibilities be to his employer?

  1. Professionalism
4   

If you were providing Department of Veterans’ Affairs (DVA) funded services, what are your professional obligations when interacting with the Department?

If Geoffrey was a current ADF member and you were his medical officer, what would your responsibilities be to his employer?

  1. General practice systems and regulatory requirement
5   

How would you use an ADF Post-discharge GP Health Assessment or a DVA Coordinated Veterans’ Care Program assessment in Geoffrey’s situation?

  1. Procedural skills
2   

How does the complexity of Geoffrey’s presentation add to the uncertainty of management?

What strategies would you use to manage this uncertainty?

  1. Managing uncertainty
2   

What would be your concerns and red flags about Geoffrey?

How would you assess and manage suicidal ideation?

How would you assess Geoffrey’s safety and the safety of others, such as his supports and family?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Using the learning resources list, become a registered Department of Veterans’ Affairs (DVA) provider.

  • Were you able to become a DVA provider? What does this allow you to do? What are your responsibilities as a DVA provider?
  • Did you access any of the DVA online training information or information for GPs listed in the learning resources section?

Identify who is eligible for a veteran health check – use the link in the learning resources section to the information for GPs on the DVA website. Find out how to perform this health check.

  • Who is eligible?
  • What is the process and procedure for performing the health check? What templates can you use to document the process?

List the range of DVA services available for eligible patients.

  • What are the range of veteran cards and what services do they cover?
  • How do patients apply for DVA services and benefits? What is the role of veteran advocates in accessing these services?
  • Outline how ex-serving members can access mental health services.

Write a plain language, brief explanation of the role of DVA benefits and the application process and use this as a basis to provide information to eligible patients.

  • What key DVA benefits did you include in your explanation? How did you outline the steps of the application process? Did you include the role of advocacy services?
With a supervisor

Present a case of one of your ex-serving ADF member patients to your supervisor. Use the assessment areas listed in this unit to identify key management issues. If you have not seen a military patient, use the case study above as an example.

  • How did you identify the patient as being a serving or ex-serving member?
  • Were there any sensitivities around taking a history about military service?
  • Was the patient’s presentation related to current or past military service? If yes, describe how.
  • How did you deal with the key management issues you identified? Were some issues more urgent than others? How did you prioritise them?
  • Did you or do you plan to access DVA services for this patient? Which services?

Discuss the uncertainty and complexity of managing ex-serving members with complex psychological problems. Include in your discussion issues around the assessment of self-harm and safety of the patient, and the safety of their family and friends.

  • What are some common comorbidities seen in ex-serving members?
  • How are conditions and problems prioritised during management?
  • How do you assess self-harm? What increases the risk of self-harm to the patient, and harm to others, such as their families and social supports? How are these risks managed?
In a small group

Role-play the following scenarios.

  1. Sensitively taking a history of military service and potentially past traumatic events.
  2. Sensitively taking a history of an ex-serving member who has been exposed to significant trauma. (Refer to the resource Specific populations and trauma types: Military and ex-military personnel, chapter 9 from the Australian posttraumatic stress disorder (PTSD) guidelines.) After reviewing the resource, include potential traumatic events that an ex-serving member may have been exposed to.
  • What presentations may suggest the need to screen for conditions such as PTSD?
  • How do you screen for potential PTSD? How can these skills be applied in your practice to other groups of people at risk of PTSD?

Contact a local veterans group and invite a member to talk about their experiences of health services.

  • What local ex-serving member and veteran groups are in your area? How do these differ from advocacy groups?
  • What sensitivities do you need to consider when inviting an ex-serving member to talk about their health experiences? What measures can you put in place to follow up and ensure that the person has been well supported throughout the process?

Discuss health conditions that are more frequent or unique to military settings (see guiding topics section).

  • What are the range of conditions that serving and ex-serving members are more likely to experience and acquire? How does military service impact on the aetiology of these conditions? How are they managed?
  • Are there differences in management approaches for serving and ex-serving members?
With a friend or family member

Research the history and culture of the Australian Defence Force (ADF) and its broader role in society. Discuss this with a family member or friend.

  • What is their understanding of the role of the defence forces in society? What do they know about the history and culture of the ADF? How does their understanding compare to your research?

Ask a friend or family member if they know someone who has served or is serving in the ADF.

  • How has their service impacted on their family?
  • How might this influence your management of a serving or ex-serving member and their family in your practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Understand common presentations in serving and ex-serving Australian Defence Force (ADF) members and their possible aetiologies related to military service:
    • environmental health conditions, including exposure to agents more likely to occur in a military setting. If suspected, these will require referral for specialist assessment. (For more information on environmental hazards see the Occupational and environmental medicine unit.)
    • acute and chronic musculoskeletal conditions
    • acute and chronic pain
    • mental health conditions including depressive disorders and anxiety disorders, such as post-traumatic stress disorder (PTSD)
    • substance use disorder
    • comorbid medical conditions.
  • Understand the experience and meaning of military culture in relation to health and mental health.
  • Understand the role of the Australian Defence Force (ADF) and Department of Veterans’ Affairs (DVA) in caring for the health of serving and ex-serving military members, including the potential tensions between providing services for the patient and services for an external organisation.
  • Understand eligibility requirements for DVA benefits and an overview of the application process.
  • Be aware of the culturally appropriate services available to Aboriginal and Torres Strait Islander ADF members.
ADF doctors and registrars
Additional areas of content and focus include:
  • Garrison Health – the provision of health services to entitled ADF personnel including training of ADF medical personnel and providing operational health support to the ADF. (See the RACGP Standards for Garrison Health Facilities in the Australian Defence Force.)
  • conducting medical risk assessments and advising on mitigation; for example, fitness for operational duties
  • working closely with international colleagues on joint operations and in joint health facilities, operating independently overseas in both developed and less developed nations
  • provision of aviation and/or underwater medicine services in support of flying and diving operations
  • provision of advice to Command regarding maintaining optimum workplace health and performance in demanding conditions.

Deployments to remote national and international locations during operations and exercises may require additional skills; for example, emergency medicine and trauma skills, retrieval medicine, tropical medicine and refugee health. This includes working in remote environments with restrained resources.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
A series of articles about management of Australian veterans.
Online resources
RACGP practice standards for assuring high quality healthcare services for currently serving ADF members. Best starting point for accessing GP information and resources for serving and ex-serving ADF members. Access all the information required to become a DVA healthcare provider here. Clear information on who is eligible for DVA services. Information on performing one-off comprehensive health checks for ex-serving ADF members; includes Medicare rebates. Quick reference to comprehensive post-discharge health checks. A starting point for accessing supports for Aboriginal and Torres Strait Islander serving and ex-serving ADF members. Excellent chapter of the RACGP-endorsed Australian PTSD guidelines that concisely outlines and illustrates approaches to the management of specific mental health conditions unique to the military environment. Mental health support for Navy, Army and Air Force personnel, veterans and their families. Information about the veteran experience for GPs.
Learning activities
Modules on the range of DVA services available and how they can be accessed.
Other
Resources for all current and ex-serving ADF members and their families. An excellent starting point for linking patients to advocacy services that can support them when making DVA claims. Free consultations to all Australian practitioners and organisations with queries about veteran mental health. An independent, professional scientific organisation of medical and allied health professionals with objectives that include promoting the study of military medicine and bringing together those with an interest in military medicine. RACGP ADF GPs and registrars can access further training support through this specific interest group.
  • The Royal Australian College of General Practitioners Specific interests – Military Medicine and Veterans’ Health.
RACGP ADF GPs and registrars can access further training through their military employment training and policy through Defence Health Manual and other Garrison health directives and materials.

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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/military-and-veteran-health 17/05/2022