“To Conserve Fighting Strength”: The Role of Military Culture in the Delivery of Care
Introduction: There are ongoing discussions about reorganizing the delivery of health care within the US Armed Forces. The military cultural context of care has beneficial qualities for patients with orthopedic and extremity trauma acquired during deployments to conflict zones.
Methods: The study included 35 participants with lower limb amputations who had been discharged from the Amputee Patient Care Program ≥ 12 months prior to the study. Participants were interviewed using a lightly structured schedule designed to elicit accounts of community integration, which attended to reports of belongingness supported by accounts of social engagement in work, school, family, and social events. Interviews were analyzed using a modified content analysis approach.
Results: Participants generally described their postcare lives as “successful” that had been built on “good outcomes.” For most former patients, remembering the social intensity of their rehabilitation program was an important element in their narratives of recovery. Weekly amputee clinics worked to alleviate stress and anxiety in participants’ minds around the complexities of their injuries and care.
Conclusions: Participants reported that features of their care were particularly valuable to their recovery and their current assessment of their injury related health. These features are present, in part because of the military cultural context that is part of the framework of care delivery.
Program Description
This article is grounded in research conducted in the US Armed Forces Amputee Patient Care Program at WRNMMC. The study received WRNMMC Institutional Review Board approval in February 2012 and again for the continuation study in January 2015. The lead investigator for the research project was a medical anthropologist who worked with a research unit in the WRNMMC Department of Rehabilitation.
The main period of data collection occurred in 2 waves, the first between 2012 and 2014 and the second between 2015 and 2019. Patients arrived at WRNMMC within several days from the site of their injuries (nearly all were from Iraq and Afghanistan) via military medical facilities in Germany. After a period of recovery from the acute phase of their injuries, patients transitioned to outpatient housing and began their longer phase of care in the outpatient MATC.
On MATC admission, patients were assigned an occupational therapist, physical therapist, and prosthetist. In addition, rehabilitation physicians and orthopedic surgeons oversaw patient care. Social work and other programs provided additional services as needed.2 Patients were treated primarily for their orthopedic and extremity trauma and for neuropsychiatric injuries, such as mild traumatic brain injury. Other behavioral health services were available to support patients who reported symptoms of posttraumatic stress disorder, anxiety, depression, or other neuropsychological issues.
Patients had multiple daily appointments that shifted throughout the duration of their care. Initially a patient might have 2 physical therapy and 2 occupational therapy appointments daily, with each session lasting about an hour. Appointments with the orthotics and prosthetics service, which could be considerably longer were added as needed. These appointments required multiple castings, fittings, adjustments, and other activities. This also was the case with wound care, behavioral health, and other services and departments.
Cultural Competency
A recently published special issue of Academic Psychiatry described the important role that basic knowledge of military culture plays in effective care delivery to active-duty service members, guard and reserve, and veteran patients and families.4 Reger and colleagues also emphasized the importance of awareness of military culture to civilian clinicians particularly those providing care to service members.5
This concern with gaps in knowledge about recognizing the realities of military culture has given rise to an emergent literature on military cultural competence training for clinical providers.6 Cultural competence in health care settings is understood to be the practice of providing care within a social framework that acknowledges the social and cultural background of patients.7 In the military context, as in others, these discussions often are limited to behavioral health settings.8 This emergent literature provides researchers with important insights into understanding the scope and scale of military culture and the importance of delivering culturally competent care.
Beyond the concept of cultural competence, recognizing the importance of culture can be used to understand positive therapeutic impacts. In discussions of culture, service-members, veterans, and family members are shown to have adopted a set of ideas, values, roles, and behaviors. Mastering an awareness of those attributes is part of the process of delivering culturally competent care. At WRNMMC and other military treatment facilities, those attributes are “baked in” to the delivery of service—even when that service is provided by civilians. How that process operates is important to understanding the impact of the organization of clinical care.
