Considerations for dermatologists when treating U.S. Military Service Members.

Civilian dermatologists sometimes provide care to military service members. This article provides an overview of special considerations that are relevant to the dermatologic treatment of members of the U.S. Armed Forces. We provide a review of the potential implications of certain conditions and treatments for medical retention standards and discuss how service-connected disabilities due to skin conditions are rated and compensated. Understanding service members' circumstances and priorities can help guide discussions and decisions about their care.

Introduction

Active-duty U.S. military service members are often stationed far from a major military medical facility and referred to civilian dermatologists for specialty care. Moreover, some civilian patients in a dermatology practice may be serving in a part-time capacity as members of the U.S. Guard or Reserve and the treatment they receive could impact their military service regardless of their source of health insurance or method of payment. As a general rule, the standard of care and ethical obligations that adhere when treating members of the armed forces are no different than for any other patient, similar to military physicians who are bound by the same medical and ethical norms as their civilian counterparts (Annas, 2008).

Nonetheless, the nature of military service is such that certain diagnoses and treatments can have significant career and financial implications for the patient. Although these considerations are not expected to impact the provision of adequate and appropriate care, a basic understanding of the military’s disability evaluation system can help clinicians appreciate their military patients’ priorities and concerns as they navigate the process of seeking treatment while meeting military requirements. Ideally, a service member’s informed consent to treatment will take into account not only the medical risks and alternatives disclosed by their physician but also a cognizance of the potential impact on their continued service and entitlement to certain veterans’ benefits (Paterick et al., 2008).

Fitness for duty

The U.S. military services have an obligation to maintain a fit and ready force. Federal law empowers the secretaries of the military departments to separate or retire any service member who is determined to be “unfit to perform the duties of his office, grade, rank, or rating because of physical disability” (U.S. Government Publishing Office, 2012). Assessing the reasonable performance of duties takes into account an individual’s ability to carry out “common military tasks” such as wearing heavy gear, firing a weapon, and subsisting on field rations, complete their required physical fitness test, deploy to potentially austere environments, and perform any specialized or hazardous duties that are associated with their particular career field. Adjudications of fitness also consider whether the member’s condition poses a “decided medical risk” or “imposes unreasonable requirements” on the military for accommodation (U.S. Department of Defense, 2014).

When a service member has a potentially disqualifying medical condition, they may be referred for a determination of fitness for duty. Dermatologic conditions that may be inconsistent with retention and deployment standards are generally those that are chronic, unresponsive or prone to exacerbations despite treatment, require frequent follow-up care, or interfere with the wear and use of military gear. Duty limiting conditions are typically identified by the service member’s primary care manager either through direct observation or via consultation notes from specialists and then forwarded for further evaluation for continued military service within a year of diagnosis or when the condition is deemed relatively stable (U.S. Department of Defense, 2014, U.S. Department of Defense, 2016).

Medical retention standards are driven not solely by diagnosis but also by the extent, nature, and duration of the required treatment and medication regimen. Procedures or prescriptions that necessitate “frequent clinical monitoring, special handling, or severe dietary restrictions” may render the service member’s condition potentially unfitting. For example, whereas psoriasis itself is not usually inconsistent with retention standards (although it may require an evaluation for certain special duties), psoriasis that is either not susceptible to control or controlled only with systemic medications or ultraviolet light therapy can be service disqualifying (U.S. Department of Defense, 2016). As a practical matter, this sometimes means that it may be in a service member’s best interest to exhaust the most conservative medical options before proceeding to more aggressive treatment, particularly if there is uncertainty on the best course of action and the patient is nearing eligibility for a military pension if able to remain on duty. The need for prescriptions that are immunosuppressive, anticoagulant, or require constant refrigeration also can render a service member non-deployable and thus nonretainable if required to be taken for any substantial length of time.

Compensability of disabilities

In its 2008 military budget, Congress mandated that the U.S. Departments of Defense (DoD) and Veterans Affairs (VA) work in tandem to ensure that individuals who are removed from service due to disability receive timely and appropriate benefits (Table 1; U.S. Congress, 2008). Under this system, eligible service members with potentially disqualifying conditions are provided a compensation and pension (C&P) examination by the VA to enable the agency to rate each service-connected disability. The military branches determine whether service members are fit for duty and, if not, which conditions are unfitting. The VA determines appropriate ratings and benefits for all conditions that are incurred during or aggravated by military service, irrespective of the DoD’s fitness determination (U.S. Department of Defense, 2014, U.S. Department of Veterans Affairs, 2017).

Table 1

Integrated disability evaluation system: Procedural steps

U.S. Department of Defense	U.S. Department of Veterans Affairs
Identification of duty limiting condition(s)
Screening and referral to Medical Evaluation Board
	Development of claim for veteran benefits
	Disability examination (Compensation and Pension examination)
Medical Evaluation Board (two or more physicians) documents potentially disqualifying condition(s) and refers to Physical Evaluation Board, if appropriate
Informal Physical Evaluation Board makes fitness determinations
	If unfit, Veterans Affairs rates all service-connected conditions (both unfitting conditions and other claimed conditions)
Informal Physical Evaluation Board applies Veterans Affairs ratings for unfitting condition(s) to determine military compensable percentage
Service member can request Formal Physical Evaluation Board (formal hearing) to contest Informal Physical Evaluation Board findings and is entitled to counsel
Formal Physical Evaluation Board (at least three members including one physician) holds hearing and makes fitness determinations
Service member can request appellate review by their military branch
	Service member can request a rating reconsideration for their unfitting conditions
If unfit, service member is separated or retired with appropriate military benefits	Service member begins receiving Veterans Affairs benefits
	Veteran can appeal Veterans Affairs ratings for all service-connected conditions

The VA utilizes a rating schedule to evaluate each claimed condition on the basis of the C&P examination and other available evidence. The assigned percentage ratings are intended to correlate with “the average impairment in earning capacity” that results from the disease or injury and to “compensate for considerable loss of working time” due to the attendant disability in the civilian employment market (U.S. Department of Veterans affairs, 2015). The military accepts the VA’s ratings but only applies them to conditions that are deemed unfitting for continued service. As a result, an individual’s combined VA rating will usually be higher than their military compensable percentage because the latter is a subset of the former. The combined VA rating determines the veteran’s monthly VA compensation. The military rating determines whether a service member who is found unfit is eligible for medical retirement with health benefits (for disabilities of at least 30%) or discharge with a one-time severance payment and no benefits (for disabilities rated below 30%)(U.S. Department of Defense, 2014, U.S. Government Publishing Office, 2012).

The VA rating schedule includes 33 skin conditions. Unlisted conditions can be rated under “closely related disease or injury” on the basis of an analogous diagnosis in terms of the functions affected, anatomical localization, and symptomatology. The VA is precluded from rating “the same disability under various diagnoses” but can provide separate ratings for distinct manifestations of a condition. For example, burn scars can be rated and compensated both for the extent of disfigurement and for causing permanent pain. Dermatitis or eczema is rated on the basis of the percentage of exposed areas of the body affected and the extent of therapy that is required. Acne is noncompensable if superficial but can be rated if characterized by “deep inflamed nodules and pusfilled cysts” and particularly if affecting the face or neck. When skin malignancies require systemic chemotherapy or extensive surgery, they are rated as total (100%) during active treatment and then subject to rerating thereafter (absent recurrence or metastasis) on the basis of residual scars, disfigurement, or impairment (U.S. Department of Veterans Affairs, 2017).

The assignment of disability ratings by the VA has no bearing on the fitness adjudications by the military. As such, it is nearly always in the service member’s best interest to ensure that the percentage ratings accurately and fully reflect their degree of disability. The VA is not confined to consider examinations that are performed by its employees and contractors and can rate claims on the basis of “a statement from a private physician” or any hospital or examination report “from any government or private institution” provided it is adequate for rating purposes (U.S. Department of Veterans Affairs, 2017). Private medical treatment records and statements from treating physicians can also help substantiate and supplement VA disability claims, particularly when the service member or veteran is seeking an increased evaluation on the basis of new medical evidence. Standardized VA forms exist to guide physicians in their evaluation of skin diseases (U.S. Department of Veterans Affairs, 2014a) and scars and disfigurement (U.S. Department of Veterans Affairs, 2014b) for the purpose of rating and processing disability benefits.

Conclusion

In his second inaugural address, shortly before his untimely death, President Lincoln implored the nation “to care for him who shall have borne the battle.” Medical care for service members and veterans is a direct outgrowth of that commitment. Dermatologists both within and outside of the military who care for members of the U.S. Armed Forces can enhance their communication with these patients by understanding their unique circumstances and appreciating the collateral implications of medical decisions.

Epilogue

Growing up, a routine feature of our evenings was my mom taking a few minutes in private to call and check up on patients. While we were doing homework, playing, or relaxing, my mom was busy empathizing, listening, reassuring, and commiserating. Often, when talking to patients with late stage melanoma or their loved ones, she would emerge teary-eyed and shaken, then quickly revert to once again taking care of all of us. Knowing no different, I figured this was what all physicians did and that reaching out to patients at home to express concern and solidarity was routine practice. It never occurred to me that in her compassion and dedication to patient care, as in so many other things, my mom was and simply is extraordinary. How she managed it all—caring mother, loving wife, devoted daughter, superb clinician, renowned academician, inspiring trailblazer, fearless leader, supportive mentor, cherished friend—I will never know but I am certain we are all the better for her presence and immensely proud to call myself her son. CK