Special considerations for issues related to experiencing past 2SLGBTQ+ discrimination . . .# Table of Contents Introduction
The ability to render accessible, continuous, patientcentred, collaborative, and culturally competent care for Veterans (former members of the military) is important for family physicians and other primary care providers, especially as many may already have Veteran patients in their practice. Caring for Veterans who kept our nation secure through national service can be a rewarding and an enriching experience for family physicians. Additionally, some family physicians/ primary care teams may be uncertain about how best to manage Veterans' care 1 and would benefit from guidance and decision-making tools that can help them better serve Veterans and their health needs.

# Purpose of the Guide
The purpose of this guide is to highlight special considerations for family physicians and other primary care providers in caring for the Veteran population, including contextualizing this information within the College of Family Physicians of Canada TM (CFPC)'s Patient's Medical Home (PMH) 2 vision for the future of family practice in Canada. Family physicians have an essential role in caring for Veterans and in facilitating supportive cooperation between care providers to ensure Veterans receive the best care possible. This guide will share common themes to address the health needs of Veteran patients, providing key factors and context, practical tips, and rewards related to caring for Veterans.
While there are a variety of resources available to Veterans to enhance their health and other aspects of their well-being, there are many different organizations dedicated to Veterans' health across Canada, and the Veterans Affairs Canada (VAC) system can be complicated to navigate. The resources shared in this guide are intended to help primary care providers connect their Veteran patients to relevant resources and allow them to establish and maintain relationships with other care providers for optimal outcomes and follow-up.

# Background
The population of living Veterans in Canada is approximately 629,300, 3 representing almost one in 30 of the adult population in Canada. Former members of the military may have participated in a variety of operations throughout their military career, either abroad or within Canada, including wartime service or special duty area service, humanitarian relief and disaster response, and search and rescue. 4,5 The increase in Canadian military operations during and after the first Persian Gulf War in 1990 has resulted in family physicians caring for more Veterans experiencing the effects of military-related injuries/illness. 6 Only 19 per cent of Veterans in Canada access payment for treatment through VAC 3 ; it is therefore important that family physicians can adequately attend to the needs of all Veteran patients and have knowledge of the resources available to Veterans to help enhance their health and well-being. Being aware of and understanding the military context and potentially related health conditions can also help providers enhance communication and trust with their Veteran patients, and can notably improve the effectiveness of care and treatment. 7 Timely, convenient access to health care is a nationwide issue-in Canada, five million people do not have a family doctor. 8,9 On average, Veterans have a higher use rate of health care providers, including family physicians. Though their health care use is greater than that of the general population, considering Veterans' higher rates of chronic pain, mental health issues, and other conditions, their use is lower than expected. 10 While most Veterans have a family physician, 18 per cent of male Veterans and 13 per cent of female Veterans do not. 10 Veterans face similar barriers to accessing care as the rest of the population, with the additional difficulties of navigating the change from a military health care system to a less structured, civilian system. 10 Though the culture is evolving, a reluctance to admit emotional or physical pain, typical in military settings as a result of stigma, may also act as a barrier and prevent Veterans from seeking care. 10,11,12 Working with Veterans can be a rewarding experience for family physicians. Eligible Veterans have greater access to remuneration for a wide range of additional health care supports through VAC, which family physicians can help them access, potentially leading to better patient outcomes. While Canadian Armed Forces (CAF) members are released from service in all age groups, many Veterans are young or middle-aged upon release. 13 The average age of release is 42, 14 which offers family doctors an opportunity to provide continuous, collaborative care for Veteran patients over many years. This can have a substantial impact on Veterans' health throughout the course of their life post-service. 15 Relevant Factors in Providing Veteran Care and Tips for Family Physicians

# Military literacy and cultural competency considerations
Understanding and recognizing military experience and context as it relates to Veterans' health can facilitate better care and treatment for military Veterans. 1 Familiarity with military culture can help physicians understand how each Veteran's unique background may influence their preference for care as well as their medical condition, and can strengthen the patientprovider relationship. Recent evidence also indicates that health care providers' improved understanding of military culture positively affects quality of care delivery. 16 Veterans and their families encounter unique circumstances throughout their time in the military and in life after service. A feature of military service that distinguishes it from civilian employment is that members serve under unlimited liability, which means they are subject to being lawfully ordered into harm's way, in circumstances that may lead to death. 17 Veterans can feel a strong sense of identity linked to their military career 7 and make close connections with other members of the military, 18 which can make the transition to civilian life difficult. While for many Veterans this transition is often seamless, for others it can be challenging, 19 especially if dealing with a mental or physical health condition. 18 Frequent moves and periods of separation throughout a military career can also put pressure on family relationships and can sometimes present problems for adjustment to life after service, as captured in the CFPC's previous guides While VAC and the CAF work with CAF members in health planning before they complete their service, some individuals may not have revealed all health concerns prior to release. Health conditions that arise in service may impede normal adjustment after release, 18 and require follow-up, assessment, and treatment with a family physician. If CAF members are released involuntarily owing to health-related employment limitations (one in five), their health conditions have often already been diagnosed and are being treated. 18 Many transitioning members experience identity challenges after leaving service. 22 Military culture often encourages members to think in a collectivist mindset, which emphasizes placing the team before the self with an external locus of control and an emphasis on self-sacrifice. 23,24,25 Teambefore-self attitudes common in the military can sometimes result in Veterans downplaying their pain. 23 Employing active listening with Veteran patients to learn about their experiences in the military and creating a safe environment for them to talk about their military service are particularly important. Veterans may have concerns about disclosure of health issues in ways that could impact their VAC benefitsbuilding patient-provider trust is critical. Taking the time to understand the Veteran's background and their life in the military using open-ended questions can help patients feel understood, and can shed light on issues that may come up over time. When Veterans give their medical history, physicians should take note of the patient's understanding of how their medical issues are linked to their military experience. Physicians can help patients contact VAC and, with permission, can refer them to local VAC offices for remuneration for treatment depending on the medical condition. 18 3 Best Advice -Caring for Veterans

# Resources for supporting Veterans in transition to post-service life
- VAC Assistance Service 26 is a hotline that offers psychological support 24 hours a day. The toll-free number is 1-800-268-7708.
- The Veteran Family Program 27 is funded by VAC and offers supports to medically released Veterans and their families through a Veteran Family Program coordinator at centres across Canada. The program assists Veterans with their transition through delivery of additional information and referral services.
- The Operational Stress Injury Social Support 28 (OSISS) is a peer support network for Veterans, CAF members, and their families who are experiencing an operational stress injury (OSI). As Veterans transition to life after service, peer support and learning from fellow Veterans can be helpful while they adapt.
- The Veterans Transition Network 29 is a charity that provides supportive programs for Veterans across Canada but specifically focuses on those transitioning from military to civilian life. The network offers transition skills programs as well as peer support, and lists a variety of resources for Veterans and their families.
- Veterans support groups exist in various cities across Canada; local Royal Canadian Legions 30 (a nonprofit dedicated to serving Veterans, with community organizations throughout Canada) can offer support and may be able to help direct Veterans to support groups in their city.

# Veterans Affairs Canada referrals and forms
Veterans must apply through VAC to access payment for treatment benefits and care services. Wait times for approvals can sometimes be problematic for those living with various physical or mental health conditions. 12,31 After release, a lack of continuity of care and limited support during the transition to post-service life can amplify the difficulties of adjusting to civilian life. Family physicians can help promote a positive post-release transition for Veterans by taking them on as a priority population in their family practice, rather than having them access a clinic through a wait list. Veterans may delay seeking help after leaving service, by which time issues may become exacerbated, especially if there are barriers to accessing care.
When a Veteran applies to VAC for benefits they will be provided with support and forms for their family physician to fill out regarding their health problems.
A family physician's information regarding a patient's mental, physical, and social health is critical to informing VAC decisions regarding benefits. These forms are an important part of caring for Veterans and their families. 32 Patient access to VAC benefits also enables the family physician to provide better care, as this can improve the physician's options for treatment planning. With the patient's permission, physicians can also write a referral letter to VAC with relevant health information if they believe a patient would benefit from VAC programs. 32

# Tips for family physicians for completing VAC forms
- Before completing the form, ask your patient to list all notable instances from their time in the military including accidents, potential exposures, and where they were stationed. Family physicians can use this information to provide extensive detail on the form, which helps inform VAC in making a decision about the benefit. For example, listing all toxins the Veteran was exposed to can help provide a clearer picture for adjudicators.
- Physicians do not need to make a statement about causality of medical issues as related to service, VAC makes this determination. Respond to the question on the form. For example, note health problems the patient is facing and list their history.
- The Canadian Family Physician (CFP) article Forms for father 32 provides additional information regarding the forms process specific to family physicians.

# Special Considerations When Caring for Veterans
The following section will outline military-related physical and mental health conditions relevant to family physicians caring for Veterans, as well as practical guidance and resources to support the Veteran patient. These include post-traumatic stress disorder (PTSD) and other mental health conditions, Gulf War illness, mild traumatic brain injury (MTBI), health concerns related to past mefloquine use, musculoskeletal disorders (MSDs), chronic pain, hearing loss/tinnitus, and issues related to military sexual trauma and 2SLGBTQ+ discrimination.

# Best practices for managing chronic pain and musculoskeletal disorders
Approximately 20 per cent of the population in Canada lives with chronic pain, and the nature of military work puts Veterans at a greater risk than the general population of experiencing chronic pain. 

# Resources for managing chronic pain and musculoskeletal disorders
- The Chronic Pain Centre of Excellence for Canadian Veterans 38 is a pan-Canadian network that conducts research on chronic pain and works with Veterans to translate this research into practice at pain clinics across Canada.
- The centre shares recent research 39 on chronic pain relevant to clinicians and their care of Veterans.
- Physicians can find a list of clinics 40 where this research is being implemented and where they can refer Veteran patients for evidence-based interdisciplinary care.
- VAC offers rehabilitation services, 41 which include assistance with physical and mental health issues related to service. Veterans can apply through their VAC account, where without requiring a medical release from service they can detail how their health has adversely affected their life.
- A sailor's pain 42 (a CFP article) provides a helpful, detailed approach to managing Veterans' MSDs, chronic pain, and disability.

# Best practices for treating mental health conditions in Veterans
Like many Canadians, Veterans can experience a decline in their mental health that impacts their ability to function. While 48 per cent of CAF Regular Force Veterans released from service from 1998 to 2018 rated their mental health as excellent or very good, a significant number also reported depression (26 per cent), anxiety (21 per cent), PTSD (24 per cent), and suicidal ideation (10 per cent over a 12-month period, 26 per cent lifetime). 43 o VAC offers a network of OSI clinics across the country to help diagnose, treat, and support eligible Veterans with service-related mental health conditions. These clinics work collaboratively with health care providers to help with continuity and follow-up.
- OSI Connect 58 is an app that helps Veterans with OSI learn about OSI and provides assistance through the OSI clinic network. Resources help patients with mental health issues and other conditions, including PTSD, depression, anxiety, sleep, and stress management.
- Mental Health First Aid Canada offers a course on Mental Health First Aid for the Veteran Community, 59 which was created to help Veterans and those caring for them provide support for someone experiencing poor or worsening mental health.
- This course can be helpful for Veterans and their loved ones, and for health professionals and those caring for Veterans. It is free for members of the Veteran community.
- For urgent support, Veterans can call the VAC Assistance Service, 26 open 24 hours a day for confidential help, at 1-800-268-7708.
- Lifespeak 60 is a Web-based platform designed to improve patients' health and other aspects of wellbeing through educational videos, podcasts, tips, action plans, and other resources. It is free for Veterans as part of VAC Assistance Service and can be used anonymously at any time.
- The CFPC Addiction Medicine Members Interest Group has produced the Practical Approach to Substance Use Disorders for the Family Physician, 61 which provides guidance in recognizing and treating common substance use disorders in family practice.

# Post-traumatic stress disorder (PTSD)
Psychological trauma is a psychiatric injury that can arise after exposure to intensely stressful events. 62 Veterans may experience PTSD as a result of events in their military career. Rates of military-related PTSD among Veterans are higher in direct correlation to members' exposure to potentially traumatic events during training, deployment-related combat, or humanitarian operations, or from their role as military police. 63 If not treated, PTSD can become chronic, and manifestations of PTSD can have negative consequences on a social, occupational, and/or interpersonal level. 62 Though it is one of the most common mental health conditions among civilian and military populations, PTSD is often underrecognized by primary care providers. 62 While PTSD related to Veterans' experience in the military is regularly diagnosed during service, some members may not seek treatment until after they have been released from the military. 64
Symptoms of PTSD can present in different ways, depending on factors such as age, gender, and age of exposure. Military-related PTSD symptoms can appear in tandem with other psychiatric disorders and physical health conditions such as chronic pain, medically unexplained symptoms, and addiction issues, and therefore can be challenging to recognize and diagnose. A trauma-informed approach to investigating PTSD is critical; trauma-informed family practices appreciate how psychological trauma can alter the way one thinks, feels, and acts. Traumainformed care operates on five guiding principles: safety, trustworthiness, choice, collaboration, and empowerment. 62
Five-point approach to trauma-informed care for family physicians 45,65 1. Bear witness to the patient's experience of trauma
- Recognize the impact of the trauma and its continuing effect on the patient.
- Help the patient feel they are in a safe space; acknowledge the patient's need for emotional and physical safety
- Ensure consistency and predictability of care; allow adequate time to care for the patient.

# Include patients in the healing process
- Present patients with choices and build collaborative patient-physician relationships to engage them in their care.

# Believe in the patient's strength and resilience
- Empower the patient using a strengths-based approach.
- Use practices that are sensitive to the patient's cultural, ethnic, personal, and social identity
- Display sensitivity to marginalization and systemic abuse.
Family physicians should investigate PTSD as a potential diagnosis if the Veteran has a history of exposure to potentially psychologically traumatic events. Approaches should be personalized to individual patients, and timing is an important consideration when asking about psychological trauma; the patient should be ready and have established a feeling of trust and safety with the provider. 62 In addition to the diagnostic criteria, the US Department of Veterans Affairs National Center for PTSD offers the Primary Care PTSD Screen for DSM-5, 66 a quick, five-item tool to screen for PTSD in primary care. Some Veterans may struggle to express their experiences due to common stigmas around seeking help within the military. 11,12,64 To cope with psychological trauma, some Veterans may develop issues that can affect other parts of their life, which could arise in relation to or outside PTSD. These include depression, anxiety, alcohol and drug use, or issues with relationships, work, and family. 67 Moral injury is the psychological, behavioural, and social result of events where an individual "may perpetrate, fail to prevent, or witness events that contradict deeply held moral beliefs and expectations." 69 It is a psychological injury that has a lasting effect on one's self-image and world view. 70 Moral injury overlaps with PTSD in many ways and is important to understand because of its common occurrence in military personnel and Veterans. Additionally, moral injury can be a barrier to recovery, as people with moral injuries may be reluctant to discuss their concerns because of shame or guilt. 71 The research on moral injury is in its early stages but the Centre of Excellence on PTSD offers several resources for understanding moral injury. 70

# Resources for managing and treating post-traumatic stress disorder in Veterans
- Veterans Affairs: Post-Traumatic Stress Disorder and War-Related Stress 67 This page by VAC provides a thorough background on PTSD and how it can affect Veterans specifically, from common reactions and symptoms to coping and dealing with PTSD. It also details typical treatment options and traumaassociated problems.
- Recognizing Post-Traumatic Stress Disorder in Primary Care 64 details primary care principles for recognizing and treating psychological trauma in patients, including how to make your practice traumainformed. The document also provides case examples of different presentations of PTSD and principles of trauma-informed care, as well as a primary care screening tool for PTSD.
- Horror comes home: Veterans with posttraumatic stress disorder 64 This article provides advice for family physicians treating PTSD in Veterans, including a helpful resource for diagnosing PTSD in Veterans.

# - Centre of Excellence on Post-Traumatic Stress Disorder and Related Mental Health Conditions 56
- The Canadian Centre of Excellence on PTSD and Related Mental Health Conditions establishes community relationships to create networks of support for Veterans, first responders, and their families. The centre engages in knowledge collection and translation for the practical use of research.
- Family physicians can also directly recommend these resources to their patients for help with PTSD:
- The Operational Stress Injury Social Support 28 (OSISS) program is a peer support network for Veterans, CAF members, and their families who are experiencing an OSI. Individuals can contact an OSISS coordinator through the website.
- PTSD Coach Canada mobile app 72 allows Veterans to learn about PTSD and offers resources to manage their symptoms.
- MDcme.ca is a Memorial University of Newfoundland Faculty of Medicine resource that offers accredited online medical education for primary care providers in Canada, including a course to help health care professionals recognize PTSD 73 and learn about appropriate treatments.
The Centre of Excellence on PTSD offers the tool kit, Understanding and Addressing Moral Injury: A Toolkit for Leaders. 74 Section 1 provides an overview of moral injury and concrete actions to address it.

# Best practices for managing military-related hearing loss/tinnitus
Hearing loss and tinnitus related to military service are common concerns for Veterans. 75 The prevalence of hearing loss in younger CAF members is much higher than in the comparable general population in Canada, and many persons with mild hearing loss do not recognize their condition. 75 Hearing loss and tinnitus rates in CAF members are unlikely to decrease because hearing protection in military occupations remains difficult to mitigate. 75 It is important to diagnose even mild hearing impairment, as hearing loss can have a negative impact on Veterans' quality of life and well-being, 75 including impeding social interactions and limiting the ability to hear sounds necessary for daily living and work life.
There are no objective tests to diagnose tinnitus 76 but there are ways to manage the symptoms. The US Department of Veterans Affairs uses a progressive management program 77 with a team of health care providers to produce individualized management plans to reduce the impact of tinnitus on patients' lives.

# Resources for treating Veterans with hearing loss/tinnitus
- VAC provides a thorough overview of tinnitus 78 and hearing loss 79 and their impacts on quality of life, as well as of pension-eligible military-related events that could lead to these disorders.
- Veterans can receive compensation for hearing loss and tinnitus through VAC disability benefits. 80 - Veterans can obtain access to treatment benefits 81 for hearing loss/tinnitus through their VAC health care card, which can cover home health, audiologist and other specialist visits, medical equipment, and other supports.

# Best practices for managing effects of mild traumatic brain injury
Mild traumatic brain injury (MTBI) is an injury that typically results from a severe impact to the head. It can cause a range of chronic physical, mental, emotional, and behavioural symptoms. 82 While family physicians are likely familiar with treating concussion in civilian populations, additional attention should be paid to MTBI history in Veterans. MTBI is more frequent in Iraq/Afghan War Veterans but it can also occur in non-deployed service members. In addition to blunt force trauma and combat-related blast injuries, exposure to blasts in training exercises (and, in snipers, exposure to very close and repeated recoil from rounds of high-caliber rounds) can also result in MTBI. 83,84 Though no diagnostic test can establish MTBI in patients, in Veterans with persistent symptoms physicians should ask about the patient's MTBI history and conduct a physical examination with special consideration of neurological functioning. 83 Brain injuries can heal without lasting damage but Veterans with cognitive and psychological symptoms should be referred for mental health treatment. Strong collaboration between the patient, the family physician, and the supporting health care team (including mental health care providers) can pave the way for optimal results, as well as physicians' consideration of the relationship between the patient's military service and the injury. 83

# Resources for treating Veterans with symptoms related to MTBI
- OSI Clinics, 58 mentioned above, can also be used by Veterans with MTBI. Physicians can refer patients to OSI clinics for treatment by reaching out to the closest VAC office, where case managers can help potential clients access services.

# - Persistent Symptoms Following Mild Traumatic Brain Injury (mTBI): A Resource for Clinicians and
Staff 82 provides more detail for clinicians and health care providers in treating symptoms of an MTBI and gives thorough explanations of MTBI related to military service.

# Special considerations for issues related to military sexual trauma
While issues related to sexual assault and harassment are not unique to the military, family physicians may encounter Veterans who experienced sexual trauma during their military service. Approximately 1.6 per cent of Regular Force members reported military-related experiences of sexual assault, with women impacted at a significantly higher rate (4.3 per cent) compared with men (1.1 per cent). Indigenous members were affected at a greater rate (3 per cent) than non-Indigenous members (1.5 per cent), as were members with disabilities (3 per cent) compared with those without disabilities (1.5 per cent). 85 Exposure to sexual harassment or assault during military service 86 is different from civilian sexual trauma, as it is a work-related injury and can involve a sense of moral injury due to institutional betrayal in addition to the sexual misconduct. 87,88 Veterans who experienced military sexual trauma (MST) may have resulting PTSD; studies from the United States indicate a strong link between the two. 86,89 Evidence-based psychotherapies can be effective for treating MST. 90 Family physicians should work collaboratively with the Veteran and the Veteran's VAC case manager to ensure referral to psychotherapists with military cultural competencies to ensure evidence-based treatments.

# Resources for treating patients who experienced military sexual trauma
- Veterans who experienced sexual trauma during their military service may be newly eligible for VAC benefits, 91 even if previously denied.
- The Department of National Defence Sexual Misconduct Response Centre offers a 24/7 phone line 92 (1-844-750-1648) where CAF members can call to receive free, confidential support from a Sexual Misconduct Response Centre counsellor who can also refer patients to resources and services for further assistance. While the service is not tailored to Veterans, Veterans may call to receive support.
- The Centre of Excellence on Post-Traumatic Stress Disorder has created a Military Sexual Misconduct and Military Sexual Trauma Fact Sheet 93 that explains what MST is, provides statistics on MST, and lists other important factors to consider regarding MST.
- VA Beyond MST app 94 is a self-help tool for survivors of MST that helps users develop coping skills and manage symptoms in order to improve their quality of life.

# Special considerations for issues related to experiencing past 2SLGBTQ+ discrimination
While members of the 2SLGBTQ+ community have been able to serve in the Canadian military since 1992, discrimination based on sexual orientation still affects many soldiers throughout their service. 95 For Veterans who served prior to 1992, experiencing adverse psychological, physical, and social impacts (depression, stress, substance use) due to having to hide one's sexual orientation, or harassment/dismissal because of their sexual orientation, was not uncommon. 96,97 In the civilian population, evidence has demonstrated that 2SLGBTQ+ individuals are at a greater risk for mental health conditions than heterosexual individuals. 98 Research indicates that 2SLGBTQ+ individuals in the military are also at a higher risk for mental health conditions such as depression. 99 Experiencing anti-2SLGBTQ+ discrimination can increase one's risk for mental health issues. 100,101 Past experiences of discrimination can also prevent 2SLGBTQ+ people from accessing health care, 98 and some needs may not be appropriately addressed if health care providers are unaware of a patient's sexual orientation. Family physicians treating 2SLGBTQ+ Veterans should strive to create safe, accepting spaces and help to facilitate culturally safe care in collaboration with local 2SLGBTQ+ outreach services, to which they can refer patients.

# Resources for managing issues related to experiencing past 2SLGBTQ+ discrimination
- Ontario HIV Treatment Network's report Facilitators and barriers to health care for lesbian, gay and bisexual (LGB) people 98  may also be able to provide support to physicians looking for more resources to help patients who have experienced past 2SLGBTQ+ discrimination.
- VAC has a 2SLGBTQ+ Veteran hotline for those with service-related injuries who have not applied for benefits: 1-800-487-7797. 105
- Rainbow Veterans is a Veterans group that offers support to members who experienced discrimination while in the CAF because of their sexual orientation.

# Current military Veteran health concerns
Below are a few examples of health issues of concern to military Veterans of Canada from all eras:

# Current Military Veteran Health Concerns Resources

# Cannabis for Medical Use
As of 2016 VAC reimburses Veterans for the medical use of cannabis. 106 Medical cannabis is increasingly used by Veterans in Canada; medical cannabis reimbursements account for one in five medical reimbursements by VAC. 107,108 Evidence is mixed on outcomes of cannabis use. Some research has shown an association between cannabis use and poorer health outcomes among the general population 109,110 and among Veterans. 111 Various studies have shown some minor benefits of cannabis use for chronic pain. 107 Though AUD and cannabis use often co-occur in Veterans, Veterans who use cannabis for medical reasons show lower alcohol use than nonmedical users. 112
- The CFPC has provided guidelines 113 and recommendations for physicians regarding authorizing cannabis for medical purposes, including authorizing use only after conventional treatments have failed. 114 Provincial health care provider regulators across Canada have also provided guidelines for cannabis authorization. A Clinical Practice Guidelines article from CFP 115 outlines considerations for prescribing medical cannabis in primary care settings, which advises limiting the use of medical cannabinoids but highlights specific circumstances in which there is evidence demonstrating its benefit.
- A recent practice guideline 116 summarized that cannabis provided small benefits for chronic pain relief, physical functioning, and sleep quality for those with chronic pain, and a small risk of transient harms, concluding that the evidence supports a weak recommendation for a cannabis trial. However, there are a number of evidence limitations for health care providers to consider when discussing cannabis use with Veterans. 117

# Gulf War Illness
After service in the Gulf War of 1990-1991, a number of CAF Veterans described various symptoms which they understood as resulting from exposures during their Gulf War service. Extensive research has been conducted and is ongoing to understand these health issues. Though research has not provided sufficient evidence for a medically diagnosable condition, the term Gulf War illness (or chronic multisymptom illness) is used for these issues. 22,118 Certain conditions have been reported more commonly in Gulf War Veterans than in non-Gulf War Veterans and civilians, including symptoms of fibromyalgia and chronic fatigue syndrome. 119 Some conditions reported under the umbrella of Gulf War illnesses include major depression, anxiety, asthma/bronchitis, chronic fatigue, and cognitive dysfunction, but many have medically unexplained symptoms.
Similar to the civilian population, Veterans can have diagnosable medical issues and medically unexplained symptoms, both of which can be treated using traditional approaches. In a comprehensive study on Gulf War illnesses, the National Academy of Medicine (formerly Institute of Medicine) in the United States recommends that providers employ a long-term, integrated approach to helping patients manage their symptoms.
- VAC provides a thorough overview of Gulf War illness, including relevant research in Canada.
- The U.S. Department of Veterans Affairs provides guidance 120 for clinicians on how to diagnose and treat those with Gulf War illness.

# Current Military Veteran Health Concerns Resources

# Past Mefloquine Use
Mefloquine is an antimalarial medication, and was the CAF's most commonly used antimalarial until evidence demonstrated that some patients were experiencing adverse psychiatric effects from its use, particularly patients with existing psychiatric illnesses. 121 Some patients report long-term effects from mefloquine use, although in 2017 the CAF released findings from the Surgeon General's review, which did not find evidence supporting this claim. 122 Patients reporting health issues should be treated for the symptoms they are experiencing. For example, physicians can establish a treatment plan for patients experiencing PTSD regardless of its cause.
- Veterans can apply to claim any medical condition with supporting documentation from their doctor.
- Chapter Five of the Surgeon General's 2017 report 122 on mefloquine examines the evidence for short-term and long-term adverse effects of mefloquine use.

# Polypharmacy
Polypharmacy-the use of five or more medications to manage symptoms-is common in Veterans with comorbid and complex physical and mental health conditions, especially in older adults. 123 Evidence suggests potential negative effects of polypharzmacy. 

# Accessible care
A key feature of the PMH is its ability to improve access to care. 125 This includes timely access, virtual access, and access to a variety of specialty services. Since higher rates of chronic mental and physical health conditions are common in Veterans, it is essential that they can access care when needed. A PMH setting allows Veterans to access the most appropriate care provider available while maintaining continuity of care.

# Patient-and family-partnered care
Patients play an important role in their care; their perspectives and history factor into their health experience.
Taking the time to understand patients' feelings, background, and experiences can strengthen the trust between patient and provider. For Veterans, military service and experience can be an important part of their identity and are often related to their health and well-being. 22 Involving Veteran patients as partners in their care can help them feel that they have more opportunities to talk about their needs, and that they are active participants in the management of their health and treatment plans. 125 Families are often involved in the care of their loved ones, helping the patient through illness and providing reliable health information. 126 Veterans' families have also experienced the unique pressures of their family member's military career, including frequent moves, the stress of occupational risks posed to the serving member, and the adjustment from military to civilian life. 20 Involving families and caregivers in the Veteran's care process (with the patient's permission) can facilitate better communication and enhanced care for the patient while decreasing stress for the family. 127 Patients should determine their level of involvement as partners, but options such as allowing them to access their medical information, providing them with self-management tools, and offering evidencebased information about their care can improve patient satisfaction and the patient-provider relationship. 12

# Long-term care and Home Care Services

# Caring for Veterans in the Patient's Medical Neighbourhood
The Patient's Medical Neighbourhood (Neighbourhood) 132 is a broader network of care involving providers and services outside the family practice. In a Neighbourhood, family practices coordinate and share responsibility for patient care with other health care providers and community services (e.g., mental health and addiction services, pharmacy, social, and community supports, etc.). In caring for Veterans, a Neighbourhood setting can help connect Veterans with relevant resources in their community, such as 2SLGBTQ+ health care centres, personalize their care, improve patient outcomes, and encourage continuity as a result of the existing relationship between the family practice and providers in the Neighbourhood.

# Community adaptiveness and social accountability
A PMH adapts to the needs of the community and works to understand how patients experience the health care system differently, based on intersecting social determinants of health. Indigenous, female, 2SLGBTQ+, and disabled Veterans are disproportionately affected by mental and physical health conditions. 128,129,130 Physicians caring for Veterans in these populations in the PMH are aware of socioeconomic influences on Veterans' health and work to respond to these differences at the patient, practice, community, and policy level. 132 Family doctors can act as advocates for their patients and encourage government to establish policies that improve Veterans' health and other forms of well-being.

# Comprehensive team-based care with family physician leadership and continuity of care
An interprofessional primary care team approach offers a host of benefits to patients, including improved access to care, better continuity of care, and enhanced access to specialty resources. The interprofessional nature of PMH teams allows health professionals with expertise in different disciplines to effectively work together to deliver comprehensive and specialized care to patients. In a PMH, family physicians work collaboratively with nurses, psychologists, social workers, physiotherapists, and other health care providers to provide convenient access to a varied range of high-quality care services.
Within the general population in Canada there is a high prevalence of patients with comorbid, complex chronic conditions. 131 Team-based, patient-centred primary care is crucial for effective management of health conditions over the long term and can be especially beneficial in treating Veterans when combined with the additional resources available through VAC programs. Many VAC programs encourage collaboration with family physicians, including OSI clinics and rehabilitation services. Open communication between VAC providers and the family physician can broaden options for effective treatment planning and can facilitate optimal patient outcomes. 32 In PMH settings, interdisciplinary primary care teams are knowledgeable about community resources and engaged with local organizations. As some Veterans may be newly transitioning to life after service, a PMH referral to resources in their community can help them find peers undergoing similar experiences, direct them to selfmanagement resources, and encourage a personalized and holistic approach to their well-being.

# Conclusion
Caring for Veterans can be deeply rewarding for family physicians. As the physician-patient relationship is at the core of the profession, connecting with Veterans, learning about their military service, and understanding their perspectives can be an enriching experience.
Treating Veteran patients allows family physicians to care for those who served Canada's population and often made great sacrifices to do so.
Additionally, many Veterans have been released from service at a young age or in middle age; physicians' active management of health conditions can have a tremendous impact on their ability to remain healthy, active, working, and participating in social and family life over decades. Early management of conditions with the right interventions can have lasting effects on Veterans and their families. Veterans have greater access to a variety of services and support than the general population; eligible Veterans can receive VAC funding for interprofessional care. This can facilitate enhanced treatment planning for the physician.
While 20 per cent of the Veteran population uses VAC services, there are many more Veterans who have health issues that may not be service-related. 3 Nevertheless, the military context and an understanding of Veterans' background remain important. Learning about and recognizing Veterans' experience can greatly enhance the provider-patient relationship and improve patients' health outcomes in the long term. Additionally, many Veterans may not know they can access VAC or may fear being denied benefits; family physicians can play a substantial role in facilitating access to benefits for which they are eligible. Working collaboratively with Veterans, VAC, and other health care teams and providers, in alignment with the PMH vision's principles of care, family physicians can have a significant and long-lasting impact on the health and well-being of their Veteran patients.