Alumni Profile

Working as a civilian Physician Assistant contractor for the Department of Defense is something I never really imagined myself doing. But when the opportunity came along, in need of a job and curious about the assignment, I applied. After many weeks of waiting for credentialing and security checks, my application is approved. As a primary care provider, my assignment is to work at Fort Lewis, in Washington state for 14 weeks during the summer of 2009. From there, I will go to Fort Wainwright, Alaska, for 6 weeks, to provide post-deployment assessments for soldiers returning from Iraq to the United States. I am to be away from my tranquil coast-side Santa Cruz home for nearly five months.

I arrive at Fort Lewis to begin work at Madigan Medical Center. With a patient population of nearly 33,00 people it is one of the largest military health centers in the U.S. Before I start seeing patients I must complete another round of credentialing, security checks and orientation; including a seemingly endless barrage of training in subjects like biological warfare, personnel recovery, security, human trafficking and suicide-risk awareness.

As I enter and orient myself to the military world, I realize that I am experiencing a unique culture. The enlisted are multi-racial and international Americans. I meet with American soldiers from all over the world– places like Tonga, Senegal and Puerto Rico¬– as well as from every state in America, particularly the south. Most are young and uneducated, many are coming from shattered lives and looking for security. Others have long proud family histories of military service and some are politically motivated. Regardless of where they come from or the reason they have joined, they share a commonality, their humanity.

I begin to learn the social structure and observe the system operatives. My tactical strategy is to learn the rules of engagement and grasp, as quickly as possible, the institutional knowledge I will need to function effectively as a health care provider in this new environment. I must also learn a new language– the language of acronyms: "get a PHA for the SRP at DCS in the BCTC, soldier, what is your MOS?...91whisky." Respect, mission and service to country are the operating values. The words, "Thank-you for your service", are spoken like the mantra, "Namaste" in yoga class.

The world around me is a curious blend of military and civilian. Active duty military mix in a parallel working environment with non-military professionals. We don't see many soldiers in Santa Cruz but they make up a large part of the population in the Pacific North West. The active duty enlisted are easy to recognize as they dress in combat fatigues at all times. This uniform remains a constant reminder that we are at war.

After 3 weeks of orientation, I am ready to work. I am confident in my medical skills. With two decades of experience, I can easily adapt to disparate working environments. However, productivity goals are expected and necessary to increase capacity. I must learn how the military health care system operates and learn to use an electronic medical record. Both pose daunting tasks. To achieve a 20 minute appointment goal I must divide my patient time skillfully: 7 minutes for a history, 3 minutes to perform an exam, 1 minutes to make my assessment, 4 minutes for health education and a treatment plan and 5 minutes to chart my notes in the electronic medical record. In a perfect world, that might work, but there are so many variables. And staying on time is important.

The military medical system provides socialized medicine to nearly 10 million Americans. Military enlistees, retirees and their families receive health care coverage paid for by the US tax payer. The Department of Defense has established TRICARE as the regionally managed organization that oversees health care delivery, access and payment for the Army, Navy and Air Force world wide. Though ability to pay does not hinder care, members still face the challenge of access to care that plagues the fee-for-service civilian health system. For the Military Health System (MHS), the limiting factor to access is not the numbers of uninsured; it is the lack of providers to meet the demand.

Primary care providers offer preventive medicine, take care of acute conditions and manage chronic disease while operating as the gatekeepers to specialists. However, the wait for an appointment with an assigned provider can take months. Studies have shown that the quality of care in the MHS parallels the quality of care in civilian systems. Yet in the MHS care is frequently disrupted when providers leave on missions, are deployed, retired or quit. Thus, patients find themselves frustrated by a lack of continuity and this fragmentation promotes the perception that quality care is lacking. The challenge that confronts the MHS is that there are not enough health care providers to meet demand. This results from a rapid turn over rate and frequent deployment cycles of military medical providers. Gaps in coverage are difficult to fill and result in delays to access that cause frustration for both the patients and the providers within the MHS.

The military's response to this problem has included hiring civilian medical contractors to temporarily fill the gaps during deployment cycles. Civilian health care contractors augment military medical staff to provide primary care services in military clinics and perform pre and post-deployment health assessments for troops coming and going from Iraq and Afghanistan. Active duty soldiers receive extra medical resources at the troop medical clinics and at daily sick-call services. But full health care coverage and additional resources do not provide an adequate safety net for those with the greatest needs.

For the enlisted soldiers and their families, these needs are great. The uncertainty and stress of a soldier's deployment is mirrored by partners and children. While the divorce rate among the enlisted is not well tracked and remains controversial, the pressure on families is apparent. I treated many young wives suffering depression associated with separation anxiety. Wives who could not bear the separation, take their children and return to families of origin during the 12-15 months their husbands are deployed. Others suffer alone. Over-utilization of the health care system often results from the insecurity and anxiety that drives young women to repeatedly seek unnecessary medical help. As in any civilian population, heavy users of the medical system often have a psychological or emotional need that can not be adequately addressed in a medical visit. For military families, the tremendous physical, mental and emotional stress from combat, long separations and readjustment to family life poses a challenge for the enlisted, their families and the entire military health care system.

As pressure builds seemingly random acts of violence erupt. A murder/suicide occurred on base at the PX at Fort Lewis this summer when a man shot his wife in the cafeteria, then turned the gun on himself. Violent acts such as these, likely result from a complexity of unrelated pressures. The stress of war and multiple deployments are certainly contributors, but as the military reaches and scrapes to build it's volunteer army, the backgrounds of the enlisted may require a different quality of scrutinization. People enter the Military with a history. Violence and abuse along with psychological instability are endemic in American culture. But the Military is the only industry that distributes weapons and trains people to kill. As suicide and homicide rates escalate, all contributing factors must be scrutinized, including evaluating the system itself.

The army is attempting to better understand and to intervene to meet the needs of its soldier population. The DoD Center for Deployment Health Research-Post Deployment and Occupational Health Epidemiology conducts health studies to understand the behavioral needs of deployed soldiers. Risk behaviors, injury reduction, and exposure risks are assessed and behavioral interventions which include Post-deployment assessments, are being implemented. A DoD task force, which includes civilians, has recently been established in an attempt to study the problem of troop suicide and will report findings in the summer of 2010.

"Everyone Cares, Never Accept Defeat... Army Suicide Prevention". Risk awareness billboards are posted prominently on base to encourage soldiers to seek help should they need it. All military personnel are required to complete suicide prevention training. Yet, the system is not fail-safe. In part, this is because the MHS is stretched beyond capacity as it strives to meet the demand for care. However, there are safety-net services for soldiers. Family support services help families struggling with deployment issues. Foster families are available for single soldiers. Education to decrease stigma and improve identification of post traumatic stress disorder (PTSD) is reinforced among the soldiers, officers, families and health care providers.

Yet, even with support, challenges exist in getting help when and where it is needed. The effects of recurring PTSD are likely to be minimized by the soldier and overlooked by providers. For soldiers, symptoms of depression and anxiety can look like weakness. Soldiers are being prepared to fight a war and they do not want to be perceived as weak. As a result, symptoms of depression, anxiety and PTSD often remain hidden and untreated, until they become unbearable and can result in violence.

The army core values instruct soldiers to put the welfare of the nation, the army and subordinates before their own. Selfless-service, loyalty and duty are a part of these core values. With soldiers doing 3-4 deployments symptoms of depression, anxiety and PTSD frequently co-exist and can amplify, while remaining undetected. This problem is likely to grow as thousands of troops move from Iraq into Afghanistan.

It is mid-August and I have arrived in Fairbanks, ahead of the soldiers. The small frontier town is quiet, for the time being. A battalion of 4,700 soldiers are to return from 12 months of deployment in Iraq– infantry-men, airborne, fire command, mortar gunners, officers, medics, cooks, engineers, mechanics and Generals¬–will fly in by plane loads over a 6 week period. Upon landing, the first adjustment this Battalion confronts is a 100 degree climate change as the temperature plummets from 130 degrees in Iraq to 30 degrees in Fairbanks. To breathe fresh air again and to see green trees after facing suffocating sand storms, unbearable heat and noxious fumes from the burning trash pits, is a relief. The arriving soldiers welcome the two days of leave they are granted before they must, yet again, don their combat fatigues, leave their families and join their company to complete a mandatory post-deployment health assessment.

As a health care provider, I am a part of a medical team that includes eight midlevel health care providers and one doctor along with several social workers and behavioral health specialists. The soldiers are processed as they return by companies from Iraq. This team can screen nearly 400 soldiers daily. The health care providers review an electronic health questionnaire each soldier fills out via PDA while still in Iraq, a take a focused medical history and assess behavior health risk. The questionnaires collect data that will be used for research and give soldiers an opportunity to report and record injuries and trauma sustained while on duty. Exposures to toxic substances, symptoms of traumatic brain injury, post traumatic stress disorder and behavioral health risks for alcohol abuse and mood-disorders are assessed via this primary screening. Providers use the electronic medical record to make referrals to medical and mental health specialists and to access medical records that were recorded during previous deployments worldwide. Following the medical assessment, the Behavior Health Specialists play an important role in providing a secondary mental health screening. They also offer the Providers a referral source for immediate mental health support, if indicated.

All providers on the team are alert for the unstable soldier who is at risk for causing harm to himself or to others. Yet, tragedies will happen, as our team encountered when a soldier from the Battalion died by his own hand within two days of returning from Iraq. He had not yet completed his post-deployment assessment and it will never be known if screening might have identified him as a risk and prevented his death.

An enhanced post-deployment health assessment program was established nearly four years ago as an outcome of military deployment studies demonstrating that deployment related health problems for soldiers evolve over time. The physical and mental stress soldiers endure may not be apparent during the immediate post-deployment period but will often emerge three to six months later.


Bringing soldiers in for assessment offers continuity by reuniting soldiers with their company and providing an opportunity for support. During the post-deployment assessment, soldiers meet individually with health care providers who are trained to ask questions that focus on behavioral needs. Providers establish empathy with soldiers and encourage them to express concerns so that those who need help can be identified.

Army statistics demonstrate a steady increase in the number of suicides of enlisted white males under the age of 25. These numbers have increased over the past six years with a sharp upward spike that began in 2006, and continues to rise. While there is no simple solution to this problem, the answer, at least in part, may lie in the realm of the obvious. Many of the soldiers I interviewed struggled with overwhelming feelings of isolation, depression and boredom during their deployment; yet most claimed that these symptoms lifted once they reunited with family and friends. All humans seek love, and meaningful connections with others is essential to well-being.

Upon completion of my assignments in Washington and Alaska, I return to the gentle tranquility of Santa Cruz, California. As I re-enter the provincial familiarity of my home environment I realize that, in the broad spectrum of the thousands of people I have met over the past five months, it is the unique characteristics and diverse qualities of individuals that builds the capacity of the United States military. My biggest learning during the summer of 2009 was to understand that the US military is far greater than the politics that encompass it, and as diverse as America Herself. In witnessing such diversity in a uniformed society, I gained a deeper respect for the complexities and contradictions inherent in military ethos. A struggle can exist between competing forces such as the harsh requirements of military endeavors with the sentient nature and human needs of individuals. But the remedy resides in greater understanding; for it is through compassion and acts of humanity that we will find ways to secure the well being of our soldiers and encourage peace in our society.