Editorial  |   June 2015
Health Issues Among Military Populations: Are We Providing Health Care or Health and Care?
Author Notes
  •  *Address correspondence to Clinton E. Adams, DO, MPA, Western University of Health Sciences, Dean’s Office, 309 E Second St, Pomona, CA 91766-1854. E-mail:
Article Information
Medical Education / Professional Issues / Psychiatry / Graduate Medical Education
Editorial   |   June 2015
Health Issues Among Military Populations: Are We Providing Health Care or Health and Care?
The Journal of the American Osteopathic Association, June 2015, Vol. 115, 352-354. doi:10.7556/jaoa.2015.072
The Journal of the American Osteopathic Association, June 2015, Vol. 115, 352-354. doi:10.7556/jaoa.2015.072
The number of military personnel has shrunk by more than half from levels 50 years ago.1 According to 2010 data, today’s military consists of fewer than 2.3 million troops.1 A 2013 New York Times editorial2 took the data a step further, highlighting that less than 0.5% of the US population serves in the military, and many of those service members come from military families. The all-volunteer nature of our military has led to a subculture of those who serve, making our military yet another face of diversity. As physicians, we must strive for greater understanding of the unique aspects that weigh heavily in the healing of these patients and their communities. 
The current issue of The Journal of the American Osteopathic Association includes 2 articles that report on the effect of physician practice patterns and comfort level in managing the health of active-duty military and veteran populations. In their article “Relationships Between Polypharmacy and the Sleep Cycle Among Active-Duty Service Members,” Lande and Gragnani,3 from the Psychiatry Continuity Service at Walter Reed National Military Medical Center in Bethesda, Maryland, report on the impact of commonly prescribed medications for depression and sleep problems on the sleep architecture of active-duty military personnel as measured by self-reported insomnia rating scales and home sleep studies. Their data and conclusions shed light on potential iatrogenic causes for the pervasive nature of insomnia. They did not restrict their understanding of insomnia to polypharmacy but to the social and emotional issues related to military service and deployments. Medication use requires monitoring for the expected outcome—if that outcome is not achieved, a different approach is warranted. Therefore, the authors3 call for alternative therapies that have fewer adverse effects to restore health and well-being. A combined treatment approach of communication skills, psychotherapy, systems-based thinking, and osteopathic whole patient care principles, with a focus on health restoration rather than symptom suppression, expands our armamentarium and certainly is the health platform for the future. 
In “Perceptions of Physicians in Civilian Medical Practice on Veterans’ Issues Related to Health Care,” Fredricks and Nakazawa,4 from the Ohio University Heritage College of Osteopathic Medicine at Athens, report on a survey of civilian physicians’ familiarity with and comfort in addressing veterans’ health problems. Their data suggest the need for more research in this area, as well as education for civilian physicians to ensure that they are well prepared to treat this patient population. Their study4 reconfirms that physicians and other health care providers need to apply systems-based practices and interprofessional communication skills to coordinate care in the treatment of veterans and civilians alike. 
Both of these articles3,4 relate to the attitudes, cultural insight, holistic thinking, and treatment of active-duty service members and veterans by practicing primary care physicians and psychiatrists. They also illustrate an important and necessary trend in the diversification of physician research to include findings that embrace many of the 7 core competencies in osteopathic residency training.5 A greater emphasis on the full spectrum of competencies, not just medical knowledge, is needed. 
Core Competencies
The Accreditation Council for Graduate Medical Education (ACGME) identified and endorsed 6 general competencies to assess resident competence: patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, and professionalism.6 The American Osteopathic Association has endorsed a similar set of competencies with the addition of a seventh competency in osteopathic philosophy, principles, and manipulative treatment.5 
Competencies define specific knowledge, skills, behaviors, attitudes, and educational experiences required of residents to successfully complete a graduate medical education (GME) curriculum. Not to embrace competency-based education or some similar model in our effort to meet the challenge of health care reform reminds me of Henry Ford’s saying, “If you always do what you’ve always done, you’ll always get what you’ve always got.” Health care in the United States has not produced population-based outcomes in relationship to the resources expended, as made clear in the Centers for Medicare & Medicaid Services report that average annual expenditures are projected to grow 6% annually through 2023 and that health spending is expected to be 19.3% of the gross domestic product by 2023, up from 17.2% in 2012.7 As the US health care system moves toward accountable care organizations, penalties for readmissions, electronic medical records that may be creating a barrier between the physician and patient as the physician so dutifully records the facts, and a new generation of patients and providers who are “Web enabled” and culturally diverse, do we not need to diversify our intellectual pursuit of thinking and practicing medicine? 
Beyond Medical Knowledge
In my experience, osteopathic medical students and residents progress through their training focused on and believing their future hangs on 1 competency: medical knowledge. So what happens to the other 6 osteopathic competencies? 
The opportunity and necessity for additional studies of unique and diverse populations has never been more important. We need research relating to core competencies to better understand and address issues pertaining to the increasing frequency of women in the military, the growing percentage of minorities in the military,8 the call for increased access to care through the Patient Protection and Affordable Care Act, the behavioral health advocates who are reporting an increasing demand for care,9 and the 14% decrease in psychiatry training.10 The need, opportunity, and potential for this research is obvious. 
The studies by Lande and Gragnani3 and Fredricks and Nakazawa4 reinforce the need to pause and reflect on the future of health care delivery. Whether or not one agrees with the principles and details of the Patient Protection and Affordable Care Act, one must admit that the stimulus and imperative for change is upon us. It is in times like these—of absolute uncertainty and possible crisis—that imaginative leadership, creativity, and genius emerge. Many authors who have captivated our attention speak to the details and the responsibility we own as health care professionals. Gawande11 gave us the “checklist manifesto” in how to get things right in areas such as health care, but on reflection and personal experience not learned in medical school or residency, he lamented the need for leadership and competencies in caring for patients and their health and wellness.12 Is it just about medical knowledge, or will the “physician of tomorrow”—the 21st century physician—be armed with a broader array of competencies than the “technically competent” physician of the post– Flexner Report era?13 
Next Steps in Health and Care of Military Populations
The studies by Lande and Gragnani3 and Fredricks and Nakazawa4 are not without limitations. The research design of both studies focused on selected samples of the population, which limits the external validity of their findings. However, they raise interesting questions and concerns that require further investigation. Future studies on polypharmacy and sleep should use a prospective randomized clinical design to determine cause and effect relationships rather than correlations from retrospective medical record reviews. Civilian physician surveys could be conducted nationwide for a better sample size and representation for identifying gaps in knowledge. Nevertheless, the work of these authors3,4 remind osteopathic physicians of the importance of investigating issues related to the health care of military personnel, as well as the physicians who care for them, because as osteopathic physicians, we are committed to health and care, not just health care. 
By the numbers: today’s military. National Public Radio website. Accessed May 5, 2015.
Eikenberry KW, Kennedy DM. Americans and their military, drifting apart. New York Times. May 26, 2013. Accessed May 1, 2015.
Lande RG, Gragnani C. Relationships between polypharmacy and the sleep cycle among active-duty service members. J Am Osteopath Assoc. 2015; 115(6): 370-375. doi:10.7556/jaoa.2015.077.
Fredricks T, Nakazawa M. Perceptions of physicians in civilian medical practice on veteran’s issues related to health care. J Am Osteopath Assoc. 2015; 115(6): 360-368. doi:10.7556/jaoa.2015.076.
The Basic Documents for Postdoctoral Training. Chicago, IL: American Osteopathic Association; 2014. Accessed May 6, 2015.
ACGME Common Program Requirements. Chicago, IL: Accreditation Council for Graduate Medical Education; 2013. Accessed May 6, 2015.
National health expenditure projections 2013-2023: forecast summary. Centers for Medicare & Medicaid Services website. Accessed May 1, 2015.
National Center for Veterans Analysis and Statistics. Tables 1L and 3L. In: Projected Veteran Population 2013 to 2043. Washington, DC: US Dept of Veterans Affairs; October 2014. Accessed May 10, 2015.
National Alliance on Mental Illness. State Mental Health Legislation 2014: Trends, Themes & Effective Practices. Arlington, VA: National Alliance on Mental Illness: December 2014. =/ContentManagement/ContentDisplay.cfm &ContentID=172851. Accessed May 10, 2015.
Mechanic D. More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain. Health Aff (Millwood). 2014; 33(8): 1416-1424. doi:10.1377/hlthaff.2014.0504. [PubMed]
Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan Books; 2009.
Gawande A. Being Mortal: Medicine and What Matters in the End. New York, NY: Metropolitan Books; 2014.
O’Hara M, Leicester G. Dancing at the Edge: Competence, Culture and Organization in the 21st Century. Devon, United Kingdom: Triarchy Press; 2012.