Staff Perspective: Military Culture in Primary Care

Staff Perspective: Military Culture in Primary Care

I am Dr. Jenna Ermold from the Center for Deployment Psychology and I’m here today with Dr. Christopher Keonig, who is a health communications scientist with San Francisco State University and a health services researcher at the San Francisco VA healthcare system. Dr. Keonig is one of the panelists on our Military Culture in Primary Care Roundtable. I wanted to have an additional conversation with him today about some of the research that he does.

JE: So first off, how did you get into the research you’ve been conducting about patient communication with Veterans?

CK:  So I was employed at the VA and had an opportunity for a research project that was evaluating recent Veterans coming back from Iraq and Afghanistan and their experiences of an integrated care clinic. So as part of the evaluation, I interviewed not only the primary care teams, but also mental health staff, social workers, and other clinic folks. In addition to that research, because we wanted the Veterans’ perspective, I also did a significant number of interviews with Veterans that were returning from the recent conflicts. So as part of that research, I was asking, just in terms of the interview schedule itself around “What was it like transitioning back from military life?” And I sort of stumbled into this topic of transition experience. At first I thought, “Wow, this is really rich stuff.” because there’s two different cultures. Military culture is kind of unique, it’s more systematic than many other cultures. Then the civilian culture also has its own kind of features. These things are sort of, a little bit, in conflict sometimes.  As other aspects of these two cultures that are kind of in coordination, but I was realizing just how rich of an area it was when I started doing a literature review for the project. I noticed that there was very few empirical studies. There was one that was a 1945 by early famous sociologists around World War II transitions. There was another one from 1977 around Vietnam-era Veterans. That was really about it. So I was just really surprised that there was so little empirical literature on the transition experience. So I just kind of stumbled into it based on this project.

JE: From the findings, some of those important findings, how does that kind of come back to primary care? Why is this transition, some of the observations you made about this transition period, why is that relevant to primary care providers to care about and ask about? What were some of the themes that you all came out with?

CK: So this research was using kind of a life course perspective, which means that development is a life-long process, basically, and there’s ups-and-downs to this process. There are particular turning points where significant events occur and so within this life course perspective the transition from military to civilian life is a major transition period. It’s a key turning point in a more formal sense. So having primary care providers know about these experiences, both in the military, on the one hand, and kinda transition back. They all have their own kind of rich points that is important for primary care providers to know about. We talked a little bit about, in the roundtable, exposures of various kinds, whether it be chemical or environmental or sort of traumatic ones that were in the military experience. But coming back home also has kinda various pitfalls and opportunities that Veterans can take care of, or just to be aware of is really important. Those have to do not only with mental health; they have to do with physical health; they have to do with social health, in various ways. And those just in the bio-psycho-social model all of these different aspects of physical, mental, social are all integrated into one. That is really under the purview of primary care, knowing about these different sort of aspects of the full and rich life is important for providers to know about.

JE: From the interviews that you did, were there specific kind of areas or domains that patients really had kind of wanted their providers to ask about, that would have been helpful for them to have that information, in terms of their whole healthcare picture? I think you talked about employment, that there are lots of areas that may be potentially going fine, but may not be going so fine, that can impact the whole healthcare picture. 

CK:  Right, I think that some of the surprising findings were that, first of all, when you realize there are two cultures, that Veterans and service personnel are bi-cultural in military and civilian culture. That’s a pertinent important first step to realize.

JE: That they’re straddling two cultures.

CK: Yeah. Second of all, there are unique identities that go with each culture. Some Veterans would articulate some conflicts around these two different identities. Because identities are context sensitive, so if we are in a military context those identities will kind of come to the forefront. It’s like rising cream from milk, you know? Whereas in the civilian identity, other things rise to the top and other things drop down from the military culture. When you transition, it’s blended. It’s like there’s still separating out in various ways. So just knowing there are some identity things that are going on is an important conceptual model to just even be aware of. So within that broad backdrop there were some areas, in particular these three domains, there was the intra-personal or psychological domain, there was the education or professional domain, inter-personal or social domain. Again, so kind of going along with that bio-social-psychological model, here are these three different elements that sort of are all intertwined together in various ways.  I think that prior literature has shown that, in particular, that when Veterans start the transition, the re-entry point, once they just return to civilian life, is a shock. It’s sudden, it’s completely different. It’s like switching on a light, from being in the dark to being in the light all of the sudden. Or making a transition from one kind of culture to another. I had one Veteran say to me “It’s so different being on the base where we had to go to the PX and there would be maybe five or six different types of cereal available and then coming back home and there was an entire aisle of cereal.” And just how shocking it was and how it was just mind-blowing that there was an aisle of cereal. They had forgotten, she had forgotten how much cereal that was. It’s a funny example in a way, but it shows what civilian people take for granted. That transition in particular, just the consumerism versus kind of the functionalism of the military culture is just such a shock for some people.

JE: Can you tell us a little more about what were the methods you used to get to some of these findings we’ve been discussing?

CK: So these were in-depth interviews with a large number of Veterans. Part of the interview schedule originally was asking about challenges to readjustment and with the reentry experience and challenges to readjustment. Part of what I was noticing though when Veterans were answering the questions about challenges is that they were also saying pieces of advice or things that they wish they would had known before they came back and other aspects of opportunities that they had found that they hadn’t noticed before in their civilian identities.  So it was this pairing of hearing about challenges and then a short time later saying the opportunities for growth that was really striking to me.  So I started systematically asking, as soon as I heard a challenge, I would start asking about opportunities for growth. And then vice-versa, sometimes when I heard that things were going well, this was an opportunity they hadn’t taken before, that I would counter that with the challenges. It was that dynamic of pairing the challenges with opportunities for growth that really lead to this discovery of the different domains, as well as the conflict of identity that was happening between these two cultures.

JE: It seems like that piece of when faced with a challenge, looking for opportunities in growth is very consistent with military culture.

CK: Absolutely.

JE: Some of the tenants that are instilled throughout a military career. PCMs and providers understanding that, I think, can help put into context if that’s coming up in their office. Or do what you’re saying you did, methodologically, and ask them specifically about opportunities for growth and make sure they’re attending to that when it’s voiced.

CK: Absolutely.

JE: What about next steps? What do you think are some next step you want to take?

CK: Well, I think that more research needs to be done around Veterans’ endogenous resources for growth, especially post-deployment. There’s a lot of work that’s not really know about the transition into family life. One of the big challenges, in the literature at least, has been that romantic partners or intimate partnerships and friendships are the two most challenging aspects of reintegration for many Veterans. Because all of the sudden, the camaraderie of military culture is gone. The structure and the organization that facilitates that kind of really intense friendship, same-sex friendship that’s non-sexual in content, is really rich and there’s not a lot of opportunities in the civilian context to be able to make those kinds of bonds. So I think that’s a ripe area for more research; is this how do you grow your friendships so that you can sort of mirror something that’s as meaningful as what you encountered in the military. Similarly, with your intimate partnerships, coming back to a relationship, if you have children, if you’re married, if you have a girlfriend or boyfriend. It’s very important. I think those questions are interesting. Another really significant and fascinating area is the emerging areas of sexualities among military members. Now that it seems like the U.S. military is becoming more open to various sexual orientations and gender expressions, how does that play out back in the civilian world? Where things are, while it’s kind of hyper-newsified, it may not be well-understood. So there’s a lot more talk about transgendered individuals coming to the VA. The VA has now just agreed to pay for sex reassignment surgeries. That’s fascinating. So I think these areas of kind of sexualities are also really important and interesting questions.

JE: That’s great. Thank you, first of all for being on our military culture panel.

CK: My pleasure.

JE: And for taking time today to wrap up with some further descriptions of your research.

CK: Thanks.

JE: Hope to talk again soon!

Keep an eye out for our upcoming roundtable course on Military Culture in Primary Care, coming soon!

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Jenna Ermold, Ph.D., is a clinical psychologist working as the Lead, e-Learning Strategies for the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Her responsibilities include developing online training materials for behavioral health clinicians to improve competency in working with military members and their families.​