During the spring semester of 2014, I interned as a research assistant at the Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT). This experience aided in my understanding of the research being conducted to benefit veterans.
Located in San Antonio at Audie L. Murphy Hospital, VERDICT is a joint project between the VA and the University of Texas Health Science Center at San Antonio. VERDICT’s mission is “to improve the health of veterans by researching methods of improving the performance of clinical microsystems” (VERDICT, Executive Summary 2011). It was funded through the Veterans Administration Health Services Research and Development (HSR&D) Research Enhancement Award Program (REAP) in 2005. It is now in transition to becoming the Center for Improving Veterans Health Through Research (CIVHTR), which is a Division of the South Texas Veterans Health Care System. Its recently developed research collaborations with the Department of Defense are seeking to understand the complex challenges faced by Operation Enduring Freedom/ Operation Iraqi Freedom (OEF/OIF) veterans and to identify factors that optimize post-deployment health. Its partnership with the DOD allows the sharing of information and strategies that can help increase veterans’ care not only locally but nationally as well.
VERDICT’s goals are to provide effective evidence-based care within the clinical microsystem for complex and understudied problems and to identify effective theory-based strategies to improve the functioning of the microsystems. These goals are being carried out by its interdisciplinary team of scientists, which includes experts in deployment-related comorbidities, rehabilitation medicines, behavioral medicines, measure development, outcomes research, complexity science, intervention development, and implementation science. These innvestigators are developing and implementing interventions to improve outcomes of veterans by concentrating on the interdependencies in the clinical microsystems.
According to the National Center for PTSD, Post Traumatic Stress Disorder affects 11-20% of OEF/OIF veterans. PTSD is a mental condition occurring after an injury or a severe psychological shock. It involves reliving the event, avoidance, and hyperarousal. It was added to the Diagnostic and Statistical Manual of Mental Disorders third edition, DSM-III, in 1980 following extreme advocacy for a diagnosis that was not stigmatizing. Though this was achieved by directly connecting the symptoms to the war experience and focusing on flashbacks and nightmares the stigma of seeking mental health services is still a considerable obstacle within the military culture.
I conducted a literature review to gain an understanding of what is currently being achieved in the field of PTSD, with my focus on how military culture affects the treatment and outcome of these veterans. Culture, which plays a vital part in the military being able to reach their goals, includes the beliefs, practices, values, language, attitudes, and customs of a certain group. Military culture also has its own specific practices, language, customs, and skills which influence behavior, discipline, teamwork, and loyalty: Military culture finds worth in certain characteristics such as “bravery, courage, impassivity, and hardiness while discouraging others such as overt displays of emotion” (Greenberg 2010). The military mindset, which is instilled during basic training, allows for effective functioning during combat and shapes how military personnel perceive their part in war. However, it also increases the stigma associated with seeking mental health services, because veterans fear stigma from family and individuals with whom they work, as well as supervisors, or those in command over them. Self-stigma, or internal beliefs, can also cause psychological distress, since the military culture stresses bravery and courage, which conflicts with seeking help.
VERDICT is conducting several projects focusing on post-deployment health for OEF/OIF veterans using the data collected from the Trajectories of Resilience and Complex Comorbidity (TRACC) study. One project is “Identifying and Validating Complex Comorbidity Clusters in OEF/OIF Veterans.” Research is showing there are patterns in the clustering of comorbid conditions. A methodical identification of these clusters is needed to recognize long-term patterns and to “develop interventions aimed at improving coping, social integration, and support” for this group of veterans” (U.S. Department of Veterans Affairs 2014).
This project, which involves database analysis, survey, and chart abstraction, seeks to help understand characteristics of people in each cluster and obtain insight into the risk factors associated with it. This specific project uses a random sample of individuals from each of the clusters to receive surveys. Chart abstractions, which are also being conducted for each of these people who respond to the survey, are the process of entering the electronic chart with clinical data from the traditional paper record or other sources such as the medical records, clinical notes, laboratory and radiology results, and operation notes. This study is looking at information covering exposures while on active duty and family history of chronic diseases by studying trends in each subject’s medical records. My primary tasks involved reading the entire medical records of patients who were part of the study, analyzing the information to determine what condition(s) the patient has, what caused it and how it was treated. The information from the chart abstractions will be compared to responses on the surveys. The surveys will then be followed up with phone interviews to obtain a person’s lifetime history of TBI, a health profile including physical and mental components of health, and the Veteran’s recent health status. I was able to participate in these interviews and the proceeding follow up meetings. The results of this project will be used to develop programs that improve upon the physical and mental health of veterans.
Another project being conducted is the “Community-Based Care for OEF/OIF/OND Veterans with PTSD.” The goal of this study is to find out what therapy means to different providers and if evidence based therapies are being utilized. “Recognizing that evidence-based practices (EBPs) for post-traumatic stress disorder (PTSD) can result in significant symptom reduction and improved quality of life for Veterans with the disorder, the Department of Veterans Affairs (VA) has invested in making EBPs for PTSD available at every VA facility nationwide” (U. S. Department of Veterans Affairs 2014). Many recent veterans though prefer to seek care from community providers as an alternative to the VA. With little known about the PTSD practices that are being used by these community providers it is difficult for the VA to identify suitable steps to improve access to EBPs for veterans with PTSD. This project is sending out 4,000 Community Provider Stakeholder Surveys to psychotherapists, prescribing providers, and organizational or community providers. Preparing these surveys allowed me to learn REDCap, a secure web application, designed to support data capture for research studies and allows users to build and manage online surveys and databases quickly and securely. I gained knowledge of the basic tools of the program such as sliders, variable names, and skip logic. Sliders are how you make a question into a percent answer, variable names help group questions together with other similar questions, and skip logic is where additional questions will become available depending on the answer given.
Working at the VA Hospital allowed me to interact with a variety of veterans. In the mazes of hallways I would pass older veterans who proudly wore Vietnam Veteran hats, younger OEF/OIF veterans many with missing limbs, and even some veterans with service dogs. I enjoyed being able to greet them and direct them to where they needed to go as I learned the lay out of the hospital. I was also able to work with several on the research team from different branches of service. My previous involvement with veterans, besides my husband, had only been with active duty members. This experience permitted me to interact with them on a more personal level.
I will continue to work at VERDICT as a research assistant in the upcoming months and have been invited to attend the DOD/VA Healthcare conference. This year’s focus is on facilitating progress and innovation in military and veteran healthcare. Some include the relationship of TBI to PTSD, the assimilation to civilian life with PTSD symptoms, and understanding the importance of resilience in military culture. I will also work on up-coming projects including a grant proposal covering reintegration problems veterans are facing after returning from deployment and the VA Vascular Injury Study that is based on TRACC with added data from the DOD. I will continue to shadow in meetings and interviews discussing on-going projects and future research. Interning at VERDICT has been a valuable experience that has helped in my understanding in a research context the kinds of difficulties experienced by veterans.
- Greenberg, Neil. 2010. “The Impact of Culture Clash on Deployed Troops.” Military Medicine: 958-963.