lesstewert

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Hey, it is the guy who posts in the military forum but has no plans to do military medicine. I just finished my psyche block and I am curious as to how the military deals with these issues I mean obviously the patient has to be treated but there are other issues. For example, what if your fighter pilot comes in just split with his wife and has all of the criteria for a major depressive disorder does he just get an SSRI? Do you tell his commander, how is confidentiality handled in the military? Security clearance issues seem like they would be huge in this respect. Also the specific age range in the military is perfect for going Schizo, most men get it in their 20's, I am sure this is a straight up discharge, is it honorable? Do doctors get to serve on panels that help determine who is discharged honorably or who is too sick to deploy? Wouldn't people often just claim to be too depressed to deploy? Just curious about how the system works.
 

gravy4thebrain

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With regard to discharge, for medical reasons, it is usually characterized as honorable. Unless the serviceman did something to jeopardize it... then it could range. For example, general under honorable for good of the service or failure to adapt. This can be upgraded to honorable if the service member petitions to change it.
 

R-Me-Doc

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lesstewert said:
Hey, it is the guy who posts in the military forum but has no plans to do military medicine. I just finished my psyche block and I am curious as to how the military deals with these issues I mean obviously the patient has to be treated but there are other issues. For example, what if your fighter pilot comes in just split with his wife and has all of the criteria for a major depressive disorder does he just get an SSRI? Do you tell his commander, how is confidentiality handled in the military? Security clearance issues seem like they would be huge in this respect. Also the specific age range in the military is perfect for going Schizo, most men get it in their 20's, I am sure this is a straight up discharge, is it honorable? Do doctors get to serve on panels that help determine who is discharged honorably or who is too sick to deploy? Wouldn't people often just claim to be too depressed to deploy? Just curious about how the system works.
What a great bunch of questions. I STRONGLY URGE EVERYONE WHO IS CONSIDERING GOING INTO MILITARY MEDICINE TO FOLLOW THIS THREAD BECAUSE IT ADDRESSES A HUGE PART OF WHAT YOU WILL BE FACING in the military medical system. And it's not just relevant to psych. I will try to do this justice; some of the other "experienced" folks here can toss in their 2cents also (MilMD, you still out there?)

1. Confidentiality. Theoretically it exists in the military, in practice it does not. Now of course, you certainly can't discuss a soldier's case with anyone who asks, but in the interests of the infamous "needs of the Army" and the fact that the soldier's well being is technically ultimately in the hands of his unit commander, the rules are bent. We have, for example, at my post, a list of "authorized personnel" for every unit with whom you can discuss patient's cases. This usually includes the soldier's unit commander and 1st SGT and a few others. In cases of basic trainees, drill sergeants can ask for and get patient info. As in the real world, case info is usually passed freely from doc to doc if the patient is referred to someone else. Psych cases are somewhat more "confidential" than general medical cases; for example, psych notes are rarely placed in the soldier's general medical record, they are kept in some file locked away in pscyh. This is sort of a +/- as it helps with confidentiality but kind of hurts when I suspect a patient has a lot of pscyh issues but can't really confirm it.

2. Your pilot with depression would most certainly NOT just get an SSRI from his friendly family practice doc and be sent off to fly another day: he'd be sent to psych for in-depth eval and likely be at least temporarily grounded. And pilots know this, so they will often do just about anything to keep hidden any condition (psych or medical) that will take them off flight status. If you think about it, that's scary for both the patient and everyone else. This would absolutely be shared with the command; the pilot would be issued a profile (a form stating what he can/can't due, in this case fly) which would go to his unit.

3. Yes, security clearances can and do get pulled, delayed or denied if a visit to psych shows up in your history. It's not automatic, but you are looked at very, very carefully.

4. You are right, Army shrinks see a lot of 1st psychotic breaks. Patients are usually offered treatment but if it's not working in a relatively short timeframe, you are medically separated.

5. The question of how people are actually medically separated is kind of complex, but I'll try the reader's digest version: A patient has an illness. The army has a regulation (AR 40-501) that lists a whole variety of medically disqualifying conditions. If the illness is listed in the regulation (or even if it's not, since there's always the "miscellaneous other conditions" category) and the problem is severe enough to prevent the soldier from performing their soldierly duties, then the treating physician initiates a "medical evaluation board" (MEB). The initial step is for the doc to document the extent of the soldiers illness/injury and explain why it prevents the soldier from soldiering. That document is then sent to the "Physical Evaluation Board," a panel made up of 3 officers (only one of whom is a physician) who then make the actual decision as to whether the soldier is fit for duty or not. Note that the ultimate decision is NOT made by the treating physician, who presumably knows the patient fairly well, but by a bunch of officers who've never seen the patient and two of whom have no medical knowledge whatsoever. If the soldier is found fit (very unusual), they go back to duty. If they are found unfit, they get a medical retirement from the military. I honestly don't know if this is done via an "honorable discharge" or "medical discharge" or what, but certainly there's no disgrace involved for the soldier.
EVERY doc in the military (except path and rads) will at some point be involved in doing med boards. Almost all of them hate it, because MEBs can be very time consuming, especially in complex cases requiring multiple consultations from multiple specialties, and in cases where the patient is "playing the system" (see next item for more on that one). Specialties that do more than their fair shares of med boards are ortho (probably the busiest), general surgery, psych, neurology, and pulmonary (asthma).

6. Do people fake illness to avoid deployment or other unsavory duty? You betcha. Let's face it, malingering is as old as the military. And you know what? In this golden age of the internet, just about anyone can surf the web for an hour or 2 and come up with a great story for their severe depression, intractible migraines, paralyzing back pains, debilitating fibromyalgia etc . . . . all things for which (surprise!) there are no real physical or lab correlates. The hard core malingerer knows that if he whines long and loud enough, and keeps showing up in docs offices day in and day out, eventually someone will get sick enough of him to start a med board just to get rid of him. This is one of the biggest things that military docs hate about the military; not only will these fakers eventually get out, but they will actually receive some level of disability compensation for their "service related" illness.

Hope that answers some of your questions. And again, all you future military docs need to read along!

RMD 1-4-3
 

militarymd

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R-Me-Doc said:
What a great bunch of questions. I STRONGLY URGE EVERYONE WHO IS CONSIDERING GOING INTO MILITARY MEDICINE TO FOLLOW THIS THREAD BECAUSE IT ADDRESSES A HUGE PART OF WHAT YOU WILL BE FACING in the military medical system. And it's not just relevant to psych. I will try to do this justice; some of the other "experienced" folks here can toss in their 2cents also (MilMD, you still out there?)

1. Confidentiality. Theoretically it exists in the military, in practice it does not. Now of course, you certainly can't discuss a soldier's case with anyone who asks, but in the interests of the infamous "needs of the Army" and the fact that the soldier's well being is technically ultimately in the hands of his unit commander, the rules are bent. We have, for example, at my post, a list of "authorized personnel" for every unit with whom you can discuss patient's cases. This usually includes the soldier's unit commander and 1st SGT and a few others. In cases of basic trainees, drill sergeants can ask for and get patient info. As in the real world, case info is usually passed freely from doc to doc if the patient is referred to someone else. Psych cases are somewhat more "confidential" than general medical cases; for example, psych notes are rarely placed in the soldier's general medical record, they are kept in some file locked away in pscyh. This is sort of a +/- as it helps with confidentiality but kind of hurts when I suspect a patient has a lot of pscyh issues but can't really confirm it.

2. Your pilot with depression would most certainly NOT just get an SSRI from his friendly family practice doc and be sent off to fly another day: he'd be sent to psych for in-depth eval and likely be at least temporarily grounded. And pilots know this, so they will often do just about anything to keep hidden any condition (psych or medical) that will take them off flight status. If you think about it, that's scary for both the patient and everyone else. This would absolutely be shared with the command; the pilot would be issued a profile (a form stating what he can/can't due, in this case fly) which would go to his unit.

3. Yes, security clearances can and do get pulled, delayed or denied if a visit to psych shows up in your history. It's not automatic, but you are looked at very, very carefully.

4. You are right, Army shrinks see a lot of 1st psychotic breaks. Patients are usually offered treatment but if it's not working in a relatively short timeframe, you are medically separated.

5. The question of how people are actually medically separated is kind of complex, but I'll try the reader's digest version: A patient has an illness. The army has a regulation (AR 40-501) that lists a whole variety of medically disqualifying conditions. If the illness is listed in the regulation (or even if it's not, since there's always the "miscellaneous other conditions" category) and the problem is severe enough to prevent the soldier from performing their soldierly duties, then the treating physician initiates a "medical evaluation board" (MEB). The initial step is for the doc to document the extent of the soldiers illness/injury and explain why it prevents the soldier from soldiering. That document is then sent to the "Physical Evaluation Board," a panel made up of 3 officers (only one of whom is a physician) who then make the actual decision as to whether the soldier is fit for duty or not. Note that the ultimate decision is NOT made by the treating physician, who presumably knows the patient fairly well, but by a bunch of officers who've never seen the patient and two of whom have no medical knowledge whatsoever. If the soldier is found fit (very unusual), they go back to duty. If they are found unfit, they get a medical retirement from the military. I honestly don't know if this is done via an "honorable discharge" or "medical discharge" or what, but certainly there's no disgrace involved for the soldier.
EVERY doc in the military (except path and rads) will at some point be involved in doing med boards. Almost all of them hate it, because MEBs can be very time consuming, especially in complex cases requiring multiple consultations from multiple specialties, and in cases where the patient is "playing the system" (see next item for more on that one). Specialties that do more than their fair shares of med boards are ortho (probably the busiest), general surgery, psych, neurology, and pulmonary (asthma).

6. Do people fake illness to avoid deployment or other unsavory duty? You betcha. Let's face it, malingering is as old as the military. And you know what? In this golden age of the internet, just about anyone can surf the web for an hour or 2 and come up with a great story for their severe depression, intractible migraines, paralyzing back pains, debilitating fibromyalgia etc . . . . all things for which (surprise!) there are no real physical or lab correlates. The hard core malingerer knows that if he whines long and loud enough, and keeps showing up in docs offices day in and day out, eventually someone will get sick enough of him to start a med board just to get rid of him. This is one of the biggest things that military docs hate about the military; not only will these fakers eventually get out, but they will actually receive some level of disability compensation for their "service related" illness.

Hope that answers some of your questions. And again, all you future military docs need to read along!

I'm still here.
There is no such thing as confidentiality in the military....They make a show of it, but the CO does whatever he/she wants....It is quite a farce.