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Residency Training at Walter Reed

After my positive medical school experience and understanding the impact of psychiatry in the military, I decided to apply for psychiatry residency program. However, I found it difficult to entirely let go of the broad medical knowledge acquired in medical school. One of my mentors told me about the Army’s combined residency training program that extends psychiatry residency by a year but the trainees receive training in both psychiatry and internal medicine. All the military services have their own residencies. The Army trains its residents in psychiatry at Walter Reed National Military Medical Center, Bethesda, Maryland and Tripler Army Medical Center in Hawaii. The Navy shares the Walter Reed program but also has a second residency program in San Diego. The Air Force has programs in San Antonio, Texas and Dayton, Ohio. The Army is the only service with the combined psychiatry and internal medicine program which is located at Walter Reed. Psychiatry programs are 4 years but combined programs tend to be 5 years, as was the case with mine. On July 1st, 2009, I began my combined medicine and psychiatry residency in the medical intensive care unit at Walter Reed.

One of my very first patients was a young man on life-support with severe delirium. He was evacuated out of Afghanistan after being found down. He had multiple seizures but without any clear etiology. Subsequently, findings on his blood gases were very suspicious for cyanide poisoning. The case was subsequently confirmed when his locally acquired Afghan chewing tobacco was heavily contaminated with cyanide [11]. He ended up with permanent hypoxic brain damage, neuropathic pain and severe Parkinsonian symptoms. I often saw him going to his appointments with his young wife pushing him in his wheelchair around the hospital. While initially the focus of his care was medical stabilization, his mental health took greater prominence over the course of several months. It was my early lesson in the artificial separation and compartmentalization of how we deliver medical and psychiatric care. Over the course of this month, I also helped stabilize two severe suicide attempts by young soldiers. One of these soldiers overdosed on valproate and came very close to succeeding due to liver damage and swelling in her brain. The medical care she received saved her life. The following year, however, she succeeded in killing herself by hanging. This was just the first month of my training and all of these patients were on my medicine rotation. Thus it became more and more clear to me that medicine and psychiatry would be importantly linked in my future medical career. This dual role was greatly helpful among my interaction with those evacuated due to injuries from war related trauma or illness.

The majority of trauma patients were medically evacuated out of theater and brought to our hospital with polytraumatic injuries. Those with severe burn injury were taken to the Army’s burn center in San Antonio, Texas. We were also tertiary referral center for the Department of Defense. When a soldier was deemed unfit on the frontlines, they were sent back, going up the echelon of care. As the earlier data from GWOT suggested [9], up to 97 % of psychiatric patients were seen briefly, provided “psychological first aid” and returned to duty. If further care was needed, soldiers were sent up the chain and our hospital was usually the last stop, accumulating the sickest and more complicated psychiatric cases. Those troops with physical traumatic injuries would also eventually end up at Walter Reed. Most of the soldiers would arrive within the first 36-48 h after their injuries and salvage operations in combat theater. The majority of the wounded troops had polytraumatic injuries and were admitted to the surgical services. Patients with primarily medical problems were admitted to internal medicine service.

Psychiatric patients were brought back on the same flights. There was a big difference however between psychiatric and non-psychiatric evacuees. For safety, suicidal patients were escorted by 1-2 soldiers from their units. Essentially, each psychiatric casualty led to loss of several soldiers from that particular unit. Besides suicidality, patients often had combination of depressive symptoms and acute stress. We received brief summaries of presentations from the evacuations office in advance and reviewed electronic medical records to prepare for arriving soldiers. At the peak of war in Iraq, it was not unusual for psychiatric patients to outnumber patients with primary medical and surgical problems. Admitting these soldiers was often overwhelming amount of work with attempts to get collateral data from theater. This involved dealing with time zone differences and often worsened by uncooperative and sometimes angry patients who were involuntarily admitted. The majority of my psychiatric patients during residency came from Iraq when the number of troops serving there outnumbered those in Afghanistan. Most of these patients had suicidal thoughts serious enough to make them a liability on the battlefield.

The age of active duty military service members is skewed with a concentration of young adults. Their median age also happen to be peak age for the presentation of the majority of psychiatric disorders. It places disproportionate amount of risk for depression, anxiety and psychosis in the military. The age range also parallels that of suicidal behaviors. These facts also present unique experiences for military psychiatrists in-training. While majority of people who are diagnosed with Schizophrenia or Bipolar disorder with mania are well into their psychotic state when they are finally diagnosed, this is different in the military. In military medicine, soldiers often present with early and subtle presentations of these disorders. Unlike our civilian counterparts with psychotic disorders, our patients, being in the Army, are constantly under the magnifying glass and unit leaders pick up subtle changes in their soldiers. Sometimes these symptoms on the battlefield were not subtle. I had several memorable cases where a soldier in his psychotic state would display bizarre behaviors that also placed the safety of other troops at risk. Safety is top concern for all psychiatric evaluations but this take special importance in the military. Our pool of potential patients are armed and well-trained in using them.

Over the course of my training from medical school into my residency, perceived stigma was a proven barrier for soldiers to seek mental health care [2]. The military and the Veterans Administration (VA) made great efforts to reduce these. Some of those interventions included education, as well as establishing certain financial incentives. These factors, such as financial incentives or attached meanings, made diagnostic process very nuanced. This helped me appreciate the power of diagnostic labels. We are demanded to balance the two roles as physicians and military officers: advocating for the patient, as well as ensuring Army mission obligations are met. There were also other lessons to be learned. It included the bureaucratic lessons that were important for my competent system based practice. Some of which were understanding reasons for discharging a soldier from the service or retaining them, influences of diagnostic labels on disability evaluation outcomes etcetera. It also required flexibility as these rules or practice patterns changed. For example, prior to GWOT, it was fairly expedient to discharge someone with a personality disorder who could not adapt to military life. This behavior on the part of psychiatrists had to change when almost all service members had at least one combat tour. The idea was that the deployment placed the individual at risk for psychopathology. The most important of these were post-traumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). At minimum, we assumed their symptoms were exacerbated by combat experience. These policies and decisions have implications for both the practitioner and the soldier.

When a soldier is medically discharged, the Department of Defense (DOD) and the VA has complex rating schemes which decide the type of financial compensation a soldier may receive. Often, percentage ratings are used which indicates a monthly disability payment of their discharging base pay salary. For example, a young soldiers such as PFC Smith with two year time in the Army earns $1838 a month in base pay salary in 2015. If he receives 50 % rating for a particular condition, then he would get half of that, a minute $919 per month. It could be a reasonable sum for anyone combining it with a full time salary. However, those leaving with disability that prevents them from doing any paid work leaves a lot to be desired. Anyone discharged with a personality disorder often did not rate any compensations. During the middle of my residency training, the military and the VA announced 50 % compensation for PTSD. This was a significant action besides the financial compensation. It communicated the disease nature of psychiatric illness and not a moral weakness. It also identified this diagnosis with combat service and in a sense became a badge of courage. These forces influenced the diagnostic climate significantly during my training. It attached caveats to the more puritanical approach to diagnostic aspects of psychiatry. Playing the dual role proved frustrating for me and it was the most challenging adjustment, balancing the two. The most helpful lessons came from my mentor who helped me realized that such constraints aren’t unique to military psychiatry. That our civilian colleagues work within similar constructs. Their dealings include disability considerations, insurance coverages, financial and access-to-care constraints. I am continuing to better myself dealing with these issues and my next job as a Division psychiatrist will provide significant opportunities.

I also discovered a significant number of negative preconceptions I carried about patients with addictions. I dreaded that particular rotation and was expecting a difficult time. The opposite came true. Most of my patients had struggled all their lives with substance, predominantly alcohol, before joining the Army. A lot of these patients had deployed. One such memorable case was of a soldier who was medically evacuated for going into severe withdrawals after landing in Afghanistan. A significant number of soldiers had combat PTSD and had begun drinking to self- medicate. Those with dual diagnosis were first intensively treated for addictions and then referred to our IOP’s Trauma Tract at Walter Reed. For these patients, their combat experiences significantly exacerbated their addictions. I began to see addiction as a disease the more I learned. This was among the many ways I felt personal growth interacting with patients. They had lost significant amount of their dignity and self-respect. I found addictions to be an area that truly exemplifies the biopsychosocial model. Patient received individual and group therapy, had social interventions such as alcoholic anonymous, and benefited from advances in pharmacotherapies. I also enjoyed the training due to its high impact on physical health. While training as an internal medicine resident, I had taken care of patients with acute alcoholic hepatitis or end stage liver disease in the intensive care unit. I had also seen other chronic sequelae of substance use. One particular case was of a high ranking retired officer who had developed Korsakoff psychosis. This training helped me realize the potential for averting future disaster with successful treatment.

The greatest stimulation during my psychiatric residency came from working on the consult service. This service specialized in psychosomatics, geriatrics and pain. In the midst of the war, the wounded healed on surgical and medical wards and their only access to psychiatry was through the consult service. In the beginning of GWOT, hospitalized patients with clear need for psychiatric care often declined consulting with mental health specialist. The leadership attempted to target this stigma. They implemented policy to see all returning hospitalized soldiers. We identified ourselves as being from Preventive Medical Psychiatry service and would make it clear that we see ALL returning soldiers. It is on this service when I fully understood the value of supportive therapy. A modality that is there to support whatever rationalization or denials the patient has to keep them going. Many of the young soldiers, with the advent of advanced body armor, survived terrible injuries. This also meant prolonged hospitalizations, numerous surgeries with frequent exposure to deliriogenic medications such as anesthetics or narcotics, and majority being in constant pain. Literature shows, especially among young males, that this type of setting leads to a regressed state. We had plenty of patients that fit this profile. Our service was often called upon to assist with provider-patient frictions. As in child psychiatry, where the target of intervention is often the parents, we often identified care-givers in need of interventions. We assisted care-givers and providers by enhancing communications, supportive therapy and helping with recognition of provider burnout. The consultation service also played a significant role assisting patients with pain using numerous modalities. It included treating underlying sleep problems or anxiety. We also used clinical hypnosis and progressive relaxation techniques. We also played a role in recommending psychopharmacological interventions to help with pain. Psychiatry also became a leading partner on the team in identifying complex drug-drug interactions. It was on this service, I began to fully appreciate the value of my dual psychiatry and internal medicine training using my medical and subcultural knowledge.

The military health system provided significant educational opportunities for those of us in training. It included unique opportunities to work with the war wounded who may be missing one or more of their extremities. Their realities also included permanent loss of independence with colostomy or ileostomy bags, and genital mutilations. However, from a broad psychiatric training perspective, there are gaps in exposure to type of patients and settings that are typical in community psychiatry. This includes patients with severe chronic mental illness, underserved patients, and inpatient child and adolescents. There is also limited exposure to civilian practices outside the single payer military health system. In order to make these gaps, we trained at numerous civilian facilities in the greater Washington DC area. Armed with the knowledge resulting from our residencies, military psychiatrists have been able to help keep our service members mission ready and in the fight.

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