"We have no magic bullet": Diagnostic ideals in veterans' mild traumatic brain injury evaluations.

Abstract

To understand military veterans' and healthcare providers' experiences identifying veterans' personal histories of combat-related mild traumatic brain injury (mTBI) months or years after the injury. Patients and clinical staff of a Veterans Health Administration (VA) Polytrauma/TBI clinic participated in a seven-month ethnographic study, which combined direct observation and interviews with veterans (n = 12) and VA clinicians (n = 11). Data were analyzed thematically. Veterans and staff have different understandings of the value of neuroimaging in care for patients with post-acute mTBI, and different understandings of the role of diagnostic certainty in clinical care. Veterans sought to understand the relationship between their past head injuries and their current symptoms. Clinicians educated veterans that their symptoms could be caused by multiple factors and embraced ambiguity as part of treating this patient population. Patient-provider communication may be enhanced by conversations about common norms of diagnosis and why evaluating mTBI histories departs from these norms. Clinicians should anticipate that patients may expect a diagnostic process that entails neuroimaging and resolves their uncertainty. In the case of post-acute mTBI, patients would likely benefit from education about the diagnostic process, itself.