Ilene Robeck, MD, is section chief of the Post Deployment Clinic and the Ambulatory Care Pain Clinic at the James A. Haley VA Hospital in Tampa, Florida.

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Questions

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Evelyn Corsini, MSW:

Please tell us how your experience as a primary care physician, with expertise in addiction medicine, led to your current position at the James A. Haley VA Hospital.

Ilene Robeck, MD: I was trained at the University of Buffalo and did an Internal Medicine residency at Georgetown University. I participated in a Medical Psychiatric Liaison Fellowship Program and then became the Medical Director for Comprehensive Addiction Treatment Services in Fairfax, VA. While working at this drug and alcohol program I had my own practice and taught internal medicine. I realized that pain was a big issue in substance abuse relapse, so I began to specialize in treatment of patients with substance abuse and chronic pain. I was fortunate to be able to work with Dr. Howard Heit, a leader in the field of pain management, for a number of years.

When I moved to Florida I missed working with chronic pain patients, and that is how I came to work at the Veteran’s Health Administration. The Post Deployment Clinic is a primary care interdisciplinary program at VHA facilities that is the first stop for veterans returning from Afghanistan and Iraq. Many VA facilities have these clinics, and those that do not, have primary care providers with extra training who will assess post deployment patients. This assures that all returning veterans will see a provider with extra training, and with access to resources that this group of veterans may need. The Ambulatory Care Pain Clinic is a primary care program for all patients with pain and substance abuse or mental health issues.

EC: Can you describe specific issues, common to veterans returning from Iraq and Afghanistan, all primary care clinicians should understand?

IR: This is very important, as the current data I have suggests that about half of returning veterans do NOT register at the VA for care, and are receiving all of their health care in the community. Of the over 23 million military veterans living in the United States, approximately 3 million have served in Operation Enduring Freedom (Afghanistan) or Operation Iraqi Freedom. As a group, these veterans have returned home with a different set of problems than what we saw from Viet Nam or World War II.

The most important thing to understand is that better combat armor, use of armored vehicles, and improvement of medical care in the field and in the evacuation of casualties, has led to an increased number of military with survivable injuries. Blast injuries are very common, and along with their other injuries, many of the military have experienced a traumatic brain injury, posttraumatic stress disorder (PTSD), and have chronic pain.

Those veterans who are identified with one or more of these problems need coordinated resources and they will continue to be followed in either a Post Deployment Clinic or by a primary care provider with training in post deployment issues.

EC: How is the VHA responding to the challenges of this new population of veterans?

IR: Many new initiatives have begun at the VHA to deal with these challenges. The VA is now developing a Medical Home Project to provide important resources in one place, including a pharmacist, social worker, and a dietician. In our Post Deployment and Ambulatory Care Pain Clinic in Tampa, primary care providers work closely with mental health providers, and other interdisciplinary staff. We have learned that veterans with substance abuse, mental health, and complex medical needs, did not do well when referred out to a number of specialty clinics. The VA’s goal is to have providers with special training in post deployment issues, embedded in each primary care clinic.

In the Ambulatory Care Pain Clinic we see patients at least every other month. The nurse practitioner will communicate with patients between visits, but will also see the patient in person if indicated. Patients can always call with their concerns. We want to offer our patients more opportunities to try alternative treatments and to increase their involvement in their care. We have started a six session “Chronic Pain School”, and have invited patients and family members from throughout our system in Tampa.

EC: Can you describe other new initiatives and services that are available through the VHA?

IR: Our staff at the VHA is becoming more expert at diagnosing TBI, which often can present with subtle signs that are sometimes first identified by an employer or a family member. A mild TBI can be hard to diagnose as the symptoms of memory problems, irritability, depression, and anxiety, may overlap with symptoms of PTSD, substance abuse, and chronic pain.

Veterans with TBI should be referred to the VHA so that they can access the special services that are only available to them there. For example, we can provide devices that can help with their cognitive problems, such as PDAs and smart phones, and teach the veteran how to use them. They can get specific psychological testing to help identify their disorder, and receive physical therapy, occupational therapy, and vocational rehabilitation.

EC: Why do you think that only half of the veterans who are eligible for VHA health services, make use of them?

IR: There are probably a number of reasons. While VHA clinics are trying to move into rural areas, for some patients, the convenience of a closer location is most important. It is a very high priority for the VA to continue to improve access for all veterans, in multiple ways. Some veterans may have the perception that the system is inaccessible or intimidating and that is still holding them back. The Medical Home project is one of many attempts to make the system less intimidating and more comprehensive for all veterans.

Many of our returning veterans are female. We recognize that women have different issues than men. Some facilities have separate Women’s Health Clinics and more are being set up, with dedicated groups of providers with appropriate training. VHA clinicians need to understand the special issues that women face: childcare responsibilities; higher incidence of sexual trauma; migraine headaches; fibromyalgia; the need to be alert to the potential for pregnancy when prescribing medication. These women will also have the same risks as men, for TBI, PTSD, and chronic pain.

EC: Can you recommend helpful resources for those clinicians who are working with veterans and their families?

IR: There are two websites with excellent resources for veterans and their family members. The site www.sesameworkshop.org has a great deal of content for children on many issues, including dealing with deployments, homecomings, changes when a parent returns with an injury, and grief. Another good site, www.afterdeployment.org also has multiple topics and areas that are worth exploring.

In addition, I encourage all primary care providers to develop a connection with a VHA facility, so they will understand what services are available, and how to use the VHA system for the resources their patients may not be able to find elsewhere.