By Jonathan Free, DC
As an institution that serves more than 9 million veterans nationwide, the Veterans Health Administration provides a unique environment for patient care with both the patient and provider experience being quite distinct when compared to other healthcare settings. However, one constant no matter what the setting may be is that the patient, and in this case the veteran, should remain at the center of clinical decision making.
The veteran patient population presents a diverse range of personalities, backgrounds and health histories that demand a special attention to detail. Furthermore, the electronic health record (EHR), where a significant portion of a veteran’s health information can be found, is vast. Every image, lab result, clinic note, and referral can be found within the software, with this often amounting to thousands of items that provide additional pixels to the clinical picture.
In my short time as a VA resident, I have discovered that the first step in maintaining a veteran-centered approach to care is preparation. This process will either take place the morning of the clinic visit or the afternoon prior, at which time I will dig into the veteran’s health history. While this evaluation is not the same for every patient, the traditional process of investigating the presenting complaint in the consultation, as well as vital signs, lab work, and imaging will occur. Following this, I will investigate notes from other departments the veteran has seen for their complaint. This may include departments such as physical therapy, rheumatology, neurology, neurosurgery, physiatry and primary care, just to name a few.
Furthermore, consideration of possible red flags can also be prepared for during this preparation time. This may be revealed in a veteran’s recent visits to the emergency department, oncology, endocrinology or other specialty. Due to the high disease burden many veterans carry, this step can be crucial to the care that may be considered. Therefore, a thorough evaluation of the veteran’s case via EHR will regularly establish a stable footing for my clinical expectations, as well as provide a launching point for the start of each clinical encounter.
At the completion of a critical evaluation of their records, and a thorough history and examination, I begin to develop a better understanding of where my care will fall in the veteran’s current healthcare journey. Subsequently, the value I provide may not reside solely in my hands-on therapies and I am prepared to have deeper conversations with the veteran regarding how we can move forward with their care.
These discussions will often include information regarding manipulation, exercise or other therapies I provide, as well as reviewing other options that exist for the veteran. This may involve submission of a referral to pain management or physiatry for consideration of the many injection therapies they provide, or encouraging the veteran to follow up with their mental health care provider where they may discuss cognitive behavioral therapy. Another direction the conversation may take could involve the options provided by the VA’s Whole Health programing or a discussion regarding traditional acupuncture compared to battlefield acupuncture. The purpose of these conversations is to inform the veteran so that they can actively participate in their care.
A final consideration that is frequently discussed during conversation involves travel. A need to see multiple healthcare providers for different conditions can become extremely time consuming. Furthermore, if transportation from the VA or coordination between a veteran and their loved ones is necessary, significant planning can be involved. Therefore, being flexible and working with a veteran to make follow-up visits on the same day as other appointments may work to provide equal parts peace of mind and therapeutic benefit.
While my time in the VA thus far has been short, my process for reviewing cases and working with veterans has become more efficient and effective with every week that passes. Chart reviews continue to present clinical pearls and every conversation with a veteran reinforces the importance of keeping that individual at the center of my clinical decision making.
Dr. Free is the current resident of the VA Connecticut Healthcare System. For more information on the VA chiropractic residencies, read additional posts from ACA’s blog series.