10-min interview request: How can physicians advocate for veterans?

[Sarah Greenberg]

I'm Sarah Greenberg, a writer for a website called Eye Care Leaders 20/20, which distills the latest medical and business information for eyecare physicians to help them run their practice.

 

We really want to dedicate some of our website content to helping physicians advocate for veterans. As you know, the VA can be disorganized and physicians have been challenged to serve the swelling populations of veterans coming to them. 

 

Would anyone consider speaking with me for 10 minutes one day this week? I would like to ask you the following:

1. If a veteran walks into a physician's office for the first time, what are 3-4 crucial questions that the physician should ask the veteran?
2. What does a veteran medical evaluation entail? Can all physicians perform them?
3. What is the most important piece of advice you can give physicians who want to advocate for their veteran patients with the VA?
4. How can physicians learn more about how to advocate for their patients who are veterans?

Would anyone consider speaking with me about these questions? Or possibly doing an email exhange with your responses?

 

Thank you!
Sarah Greenberg

[broncovet]

Sure. 
Thank you for helping a VEt. 

1.  Questions the doc should ask:

    A.  Is the VEteran seeking disability compensation for the visit today?  There are 3 "Hickson" elements each Veteran must have for Service connection.  They are In service event or aggravation, current diagnosis, and nexus, or link between the two.   Veterans sometimes seek Independent Medical Opinions or Independent Medical Exams for the last two, as the doctor can not create an inservice event.  So, the doctor should focus on a diagnosis, (with symptoms), a nexus, give likely effective date.   The doctor should also show how this affects the VEterans ability to earn a living.  If the Veteran can not drive, then he should so state.  If the Veterans disability presents barriers to employment, he should also state that.  If the Vetran is unemployed, or unemployable, or homeless, the physician should document that, too. 

Example:   of a good nexus and diagnosis. I, (Dr. G), have examined the Veteran and reviewed his records.   The Veteran has been diagnosed with an occular disorder (list the diagnosis) and is unable to see at all in the Left eye.  The Veteran has reported a gunshot wound to the left eye in military service.  This occular disorder and blindness is consistent with a gun shot wound, as there is scar tissue and facial fractures that would most likely be due to a gunshot wound to the face or eye.  In my professional opinion it is "at least as likely as not" that the Vetran's blindness in the left eye is due to the gunshot wound suffered in military service.   Further, the Veteran has a "lazy" eye, and poor vision in the right eye as well.  It is at least as likely as not that BOTH of the Veteran's eye problems are related to the GSW in military service. 

    The physician should NEVER say, "The Veterans eye disorder COULD have been caused by military service.  Or It MAY be caused by military service."  The terms "could, could be, may, might be, maybe" are considered speculative and result in an almost certain denial.  It must be "at least as likely as not" (better than 51% chance) that the Veteran's diagnosis is related to his military service.  Its a good idea to give the physicians rationale for saying so, and the physicians qualifications to make a diagnosis and or opinion..  Its also good to list symptoms of the disorder, and to give a date where its "at least as likely as not" that the Veteran 's symptoms and diagnosis started. 

2.  Any qualified physician can perform an exam and it is submissable to the VA as evidence.    Exception:  VA thinks ONLY VA docs can diagnose PTSD.  Dont ask me why. 

3.  The best piece of advice is to ask the VEteran to ask his VSO if there is a DBQ, and to ask for the records to review.  Do not kill the Veterans claim by using "speculative" language (could, might, its possible that, may, maybe) but rather use, "at least as likely as not", and provide a medical rationale as to why the doctor offered the opinion, such as, "The record is absent any other cause of the Veterans eye disorder other than the gunshot wound in military service.  Therefore, the Veterans eye disorder is at least as likely as not due to the GSW while in milatary service". 

4.  Ask the Veteran, ask him to ask his attorny or VSO for a DBQ/and or read other cases on Veterans law.  Dr. Bash offers excellent Independent medical opinions and Independent medical exams, and knows what it takes so his exams can be used as an example. 

 

 

 

Edited November 18, 2015 by broncovet

[pwrslm]

Big help would be for non VA MD's to complete DBQ's for claims.

Disability questionnaires are used to document disabilities.  VA made them so that any medical professional can complete a DBQ, so they don't need to specialize in any given specialty to fill them out.  You can find a complete list of DBQ's on the VA web sites. 

[Buck52]

Sara Greenburg

Please read some of these post on hadit  and you may find your Answers.

 

........Buck

[Sarah Greenberg]

Wow, broncovet and pwrslm, THANK YOU! Thank you for responding so quickly.

Broncovet, let me make sure I understand what you told me. I've added a little more content based on my own research and the Had It Podcast (so helpful):

1. The most important question an eyecare physician should ask a veteran is, "Are you seeking disability compensation for the visit today?" If so, the veteran needs to meet three requirements in order to receive benefits:

1. Documented event in service, whenever the vet was on active duty-with at least one day within a period of war? This event in service could include a single incident/event (explosion, gun shot, exposure to chemicals).

2. The vet needs a current diagnosis of physical/mental disease or disability, which a non-VA physician can complete, but the physician must be a specialist, correct?

3. A link between the two, or a nexus, a connection between the current diagnosis and the event.
   • The nexus needs to be proved by medical documentation detailing the continued treatment of the disease/illness/injury since the vet discharged from service.

   • The nexus also needs to be on the list of presumptive diseases, diseases/conditions granted an automatic service connection. Is this list the DBQ?

   • The nexus also needs to be proved by a letter from a medical specialist who has conducted an Independent Medical Exam. In the letter, the doctor should focus on symptoms and give a likely date when symptoms began. The doctor should also show how this affects the vet’s ability to earn a living, drive, find a home, etc. The letter must state that the vet’s condition was caused/aggravated more likely than not by active duty service.

A few more questions:

1. After completing the IME and DBQ, does the physician submit the paperwork, meaning the letter and the DBQ to the VA? Or does the vet submit the paperwork?

2. After completing the paperwork, should the physician then have the vet work with an attorney or VSO. What is a VSO? Should all vets seek legal help? Can the eyecare physician help the vet get in contact with legal help? 

3. Should eyecare practices have print-outs of DBQ’s so that they can fill them out when treating a vet?

Thank you so much for your help!

[Vync]

Hi Sarah,
To add on to previous responses, here are my opinions:

#1
Serving during a period of war is important to know, but the event in service may be caused by other reasons like training accidents, exposure to toxins, etc... For example, I served during wartime, but was never deployed to a war zone or participated in combat. One of my injuries was caused by a mistake during a surgical procedure while I was in service. Some veterans here have contracted hepatitis C through blood transfusions or from unsanitary immunization jet air guns while in the service. Problems like hepatitis may not have been detected while the veteran was in the service, but appear years later, so the in-service event might not be documented.

#2
The physician does not need to be a specialist, but it carries more weight. For example, the VA generally considers the level of expertise of a "medical professional" from lowest to highest similar to this nurse, nurse practitioner, doctor, and specialist, with more weight being given to those toward the right. If a VA nurse practitioner performs an exam, but the vet has an opinion by a doctor or specialist, the VA is supposed to give more consideration to the opinion of the latter because of their expertise.

#3
Not all vets may get continued treatment of a condition, such as a homeless vet. In the military, soldiers are conditioned to be tough, not complain, and duty to the country takes precedence over their own medical problems. I know plenty of veterans who had big problems during service, but their records only show preventative care, immunizations, etc... They just toughed it out, but did not realize they would suffer after they left the service.

The vet must currently have the condition. Some might have had a surgery during service where a medical component was left inside the body on accident. The vet could be experiencing illness or pain periodically, but suddenly learns what happened much later.

The presumptives list is basically certain criteria where the mere diagnosis of specific conditions usually warrants service connection. Some have detailed limitations, such as appearing in a certain time frame from service. The presumptives vary on the period of service and circumstances. Below are links to Agent Orange and Gulf War presumptives:

http://www.publichealth.va.gov/exposures/agentorange/conditions/

http://www.benefits.va.gov/COMPENSATION/claims-postservice-gulfwar.asp

Nexus letters/independent medical opinions may vary in complexity. Some physicians may hesitate to write an opinion because they did not treat the vet initially. Some may feel they could be the victim of legal action, but this is typically not the case. That's why the VA accepts a lesser burden of proof than 100% medical certainty. Even though the dictionary definition of "probably" is 50/50% or more, the VA does not see it that way as Broncovet described. The examiner should use jargon the VA understands, such as:

50%/50% likely = "as likely as not" (this is the equivalent of "probably", "possibly", or "may be"
75% likely = "more likely than not"
100% likely = "is due to"
 

If the non-VA examiner is not certain, but the evidence appears plausible, then the 50/50 jargon should be used.

If the medical treatment records are available showing the event/treatment of the condition, the examiner should state they reviewed the veteran's medical records from (whatever facility) dates (list dates or range) and then state their medical rationale nexus. If the vet provides legitimate case studies supporting their claims and the examiner feels these are relevant, they should also be included. The VA regional office loves to deny on technicalities by stating the non-VA examiner failed to review the records. In some cases, this might not always be possible due to VA shredding scandals, fires, etc...

Don't forget secondary conditions. Sometimes a disability may be caused by treatment of or medication used to treat an existing condition. If the veteran is already service connected for a condition or is in the process of filing for service connection for it, this could qualify. For example, the vet is prescribed medication for his condition, but develops a new problem that could be caused by the medication. It is similar to the warning messages in pharmaceutical commercials or in the medications received from the pharmacy. Sometimes medication is revoked from market due to dangerous side effects. If you look at this article, you will find that unsanitary equipment exposed some veterans to HIV, which is a good example of treatment causing a disability.

Additionally, sometimes a family member might try to file a claim for a deceased vet. Of course, the vet will not be able to be examined, but the service and medical records might be present. The examiner should consider going through the records and opining because it could help their family members obtain benefits. This is especially important if the vet died because of a service connected illness or if they family is trying to get the illness connected.

 

Additional questions
#1
The examiner should keep a copy of the DBQ, but can provide one to the vet. The vet can submit it to the VA as evidence for their claim. The VA will likely want to obtain a copy of it directly from the examiner, so the vet will need to fill out a release of information request form authorizing records from whatever dates and/or topics be released to the VA. It is good for examiners and their staff to know this, but some may only keep records going back X years.

#2
An attorney is optional. A VSO is a Veterans Service Organization, such a Veterans of Foreign Wars, American Legion, Disabled American Veterans, Vietnam Veterans of America, etc... or even their local state of county department of veterans affairs office. Regardless of the VSO or attorney, the veteran is responsible for their own claim. Not all organization members or attorneys may be as effective as others. VSO's usually provide free services and then invite the vet to be a paying member of their organization, but attorneys might collect a percentage of any retroactive benefits payments. I personally recommend VSO's first unless a vet's life is at stake or may become homeless. Some attorneys would provide advice and then assist if the vet is denied. Attorneys can become invaluable in cases where an appeal has been consistently rejected. It is up to the veteran to decide which path to take. Some vets decide to go it alone. Others seek advice from multiple sources.

#3
Anyone can get current copies from this link to all the DBQs by name, including eye care. It is probably better to pull them from here instead of having printed copies on hand because the VA tends to update them without notice.

 

I hope this helps!