National Defence Committee on June 12th, 2008

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

This is in almost direct contradiction of some of what we were told particularly in our in camera hearing. In fact, one family from the Atlantic region was very clear that their son still has not—many months after returning from Afghanistan—received a complete diagnosis. He's still dealing with his injuries from Afghanistan. They were very clear with us that they understand the Canadian military well but are very disappointed with the kind of care and attention their son has seen.

My point is that there seems to be this gap between what we're hearing sometimes from individual families and soldiers around post-traumatic stress disorder and acquired brain injury or brain injuries and what we're hearing from people in your position.

[Cdr D.R. Wilcox]

I could speak to that. We do know of cases in which there's been denial on the patient's part. Part of that denial is perhaps misrepresenting the situation to their families, because the wife will want them to seek treatment and they will tell the wife they can't get in.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

That's clearly not the case in what I'm referring to.

[Maj S. West]

You did say something interesting, though, in that he doesn't have a complete diagnosis yet, which suggests to me that he is getting medical care. With a brain injury, with mental health problems, diagnosis is quite complex and may take months. Patients frequently go through several diagnoses.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

I don't want to centre in on one case, because we've heard from more than one person.

[Maj S. West]

This is a common problem. Patients regularly come back and say, “I don't know what's wrong with these psychiatrists you're sending me to. They can't come up with a diagnosis. They aren't doing anything.” In fact, they are working very hard towards a diagnosis. It's extremely frustrating for the patient.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

I'm sure they are. I'm just pointing out that between what we're hearing at your level and at an individual level, there is a gap. It's important to acknowledge that.

[Maj S. West]

The gap is in perception.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

Maybe, maybe not.

[LCol H. Flaman]

I'll just add something, because you did mention the traumatic brain injury. USA Today said it was the signature illness or injury from Iraq and Afghanistan.

We do see brain injury. We obviously see the clear-cut severe brain injuries from rollovers and from explosions and stuff, and those are managed the way they normally are in ICUs. They monitor brain activity, and they do whatever. There are conditions now that they have found, when someone has been involved, for instance, in an explosion of an IED and they haven't identified that there was a concussion, or the person may have been dazed and confused or suffered a loss of consciousness.

Everybody coming through LRMC at Landstuhl now is being assessed. We do get follow-up for anybody who goes through Landstuhl. In fact, for anybody coming back who has been in proximity of an IED or whatever, we are doing the psychometric sort of testing to see whether there are any cognitive effects. Some people think of something like PTSD, which affects your memory and thinking and stuff, as being a mild brain injury when in fact it's something that affects your thought processes and is not an actual injury. But, you see, soldiers don't like to hear that they have a thought process problem. They like to have a physical kind of problem. So a lot of times when we talk about these things, what we mean by traumatic brain injury has to be clearly defined.

At this point, I'm out of my lane. There are experts in fact looking at that to define exactly what we need to do to evaluate it and then treat it.

[Dawn Black, NDP, New Westminster—Coquitlam, BC]

And are they two different things?

[The Chair, Conservative, Rick Casson]

Sorry. We have to move on. We'll hopefully get back to that.

Mr. Hawn.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Thank you, Mr. Chair.

Thank you both for coming.... [Technical Difficulty--Editor]

Just to go back to what Ms. Black was talking about, there's a lot of difference in perception involved in treatment, depending on whether you're the care deliverer or the care receiver. I think it's safe to say that a committee like this will attract the people who have the perception, right or wrong, that the care is not what they would like it to be. Does that follow human nature?

[LCol H. Flaman]

Perhaps I can explain how a person gets involved with medical services in the first place.

Obviously we have to recruit people, so they go through a recruiting process. Somebody in fact asks them if they've had any problems. They get a medical done to determine whether they're fit--their knees or whatever--to come into the forces. I always ask the doctors, when I'm talking to them there, “What picture did they paint on the Thursday afternoon when they had their medical done? Did they want to paint a positive picture or a negative picture?” If a person goes in there and says they're fine, they can do this, they can do the whole job, they're good to go and everything else, the doctor has nothing more to go on. We don't have a little gizmo--like on the starship Enterprise or whatever--that can tell you whether or not someone's good to go. It's all to do with the experience of the clinician. It's all to do with how you gather the information. The most vital part is doing a good history, with enough time to talk to the patient and establish a doctor-patient relationship.

Now, all the doctors in uniform are understandably company doctors. When people come to see us, they understand that we work for their benefit but we're working on behalf of the Canadian Forces. So we're sort of company doctors. When a person comes to see us and says, “I have this back problem that's bothering me”, there's usually an expectation that they may not have to go to the field to train today or tomorrow. And this is anybody, not just in the military; anybody who goes expects they'll get an antibiotic for something or a consultation or something else.

If you get what you expect, you say “I had great service that exceeded my expectations.” If you don't get what you want, you say “That doctor, I'm not sure he really knows what he's doing.”

I'll give you an example. A doctor sees you and you expect antibiotics. But antibiotics may be the last thing you should get. You don't have a condition that requires an antibiotic. If you go there expecting one and you don't get one, you'll sit there and say, “Geez, he wasn't a very good doctor. He didn't even give me an antibiotic. He took an hour to tell me why I shouldn't have one.”

That doctor probably did the most appropriate thing for you. But doctors, as you know, don't have time to spend an hour explaining why they're not giving you an antibiotic when it's much easier to say, “Here you go, you have your antibiotic.” But in two days, when it's not working, you rush back and say, “That doctor wasn't very good. I need another antibiotic.”

Therein lies the difficulty. You have to understand that care is complex. When people say they didn't like their care provider, it's just like what happens to mothers when things don't work out for kids: they get blamed. The one person with probably the most aspects to try to help them gets blamed. And this is the case with the complexity of care delivery.

[Cdr D.R. Wilcox]

Perhaps I can add one thing. It supports our statement that those wait times are accurate.

I looked at the data from the Canadian Medical Association on the number of mental health care providers and our population. I was able to determine the number of psychiatrists, psychologists, social workers, and mental health nurses per 100,000. I compared that with our patient populations on different bases. We far exceed the national average in mental health care providers on our bases. For instance, in Halifax they have five times as many psychiatrists as the national average: psychologists, double; social workers, double; mental health nurses, four times.

This does help support the case that we are able to meet these benchmark wait times: we do have the staff required.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

Is it safe to say that we'll always be in a learning environment with something like this?

[Maj S. West]

Well, we practise medicine, and one of these days we'll figure out how to do it.

[Voices]

Oh, oh!

[Laurie Hawn, Conservative, Edmonton Centre, AB]

This goes for any kind of medicine. It's more dramatic, of course, when it's the kind of medicine practised in the Canadian Forces these days, with the physical injuries and mental injuries and so on.

Experience is the great teacher. Edmonton perhaps has an advantage over other areas because it has more experience. Other countries may have an advantage over Canada because they have more experience. Is the important part the sharing of that experience, helping out the Petawawas, the Gagetowns, or wherever else with what Edmonton has learned?

[LCol H. Flaman]

Yes, but it has to be applied differently. We had some discussions about the army, navy, and air force having different approaches to providing care. There are unique requirements in each environment. Applying an army-centric view to a navy base doesn't work. They have a different relationship with the chain of command. They're totally different environments.

We basically have to apply the general principles--namely, good medicine and enough time for clinicians to establish a relationship. Those are just good principles you should apply no matter what environment. You also have to be credible. The people who are providing the care should have some credibility in terms of knowing the unique demands of soldiers, airmen, and sailors.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

We are looking to expand the number of mental health professionals from 229 to 447 in the next couple of years. That's a great goal, and the money is there, but do you think it's a realistic expectation given the educational environment and the work environment out there?

[LCol H. Flaman]

Well, that is going to be a challenge, because I'll tell you what: there's only a certain limited pool of health care professionals. I'm talking about psychiatrists, doctors, whatever. If we manage to attract them to our clinics, we're going to be taking them away from some other part of society. If we put on a good ability to get psychiatrists, where is that psychiatrist going to come from? He's going to come from someplace where he's already providing care.

So we have to be careful there. We can have all the money we want, but the problem in the health care sector is that we may not have enough of the specialties we require for the whole of society. We are just one part of that whole society.

[Laurie Hawn, Conservative, Edmonton Centre, AB]

There's a military medical training plan, which has been going on forever, to take people from other MOCs and turn them into doctors and so on. I think that was expanded a number of years ago as a special incentive or initiative program for NCMs and reservists who would not have been eligible under the older programs.

How successful has that been? Do we have any kind of numbers there?

[Cdr D.R. Wilcox]

It's been absolutely successful.

[LCol H. Flaman]

By 2011 we'll have enough people in the training pipeline--that is, those people in programs--to in fact meet our PML, or manning list, that's required for physicians.