'I Refused to Diagnose as They Wanted'

By the time Dr. Michael Chen stepped down, he had been serving the Army for more than thirty years. The psychiatrist had treated soldiers at several bases and looked forward to continuing his work at a new installation after being transferred.

Chen's enthusiasm was short-lived. Soon he began clashing with his superiors. "I refused to diagnose as they wanted," he says. "They wanted the diagnoses to be personality disorder, instead of PTSD." The psychiatrist says the soldiers he saw weren't suffering from pre-existing conditions; they had PTSD and traumatic brain injury (TBI). Chen says he relayed this information to his colonel, to no avail. "The establishment wants to hear what the establishment wants to hear."

Chen is not the doctor's real name. Because he fears retribution from the Army, the psychiatrist agreed to speak only if his name and base were not revealed. He says he wasn't the only doctor pressured to misdiagnose: Other psychiatrists were pressed as well, resulting in numerous fraudulent diagnoses of personality disorder. "I've seen that story happen hundreds of times," he says.

While serving at the Army hospital, Chen did diagnose personality disorder. But eventually the absurdity of the recommended diagnoses proved too much. The psychiatrist recalls one soldier who returned from Iraq with a massive hunk of his right calf missing. "They thought he had personality disorder," Chen says, the anger in his voice suddenly palpable. "Imagine: You get your leg blown off, you get a Purple Heart and now they say it's from personality disorder. It's absurd." Frustrated, the psychiatrist approached the commanding general of the hospital. Chen says he met with the official numerous times. But the pressure to misdiagnose continued.

"It's just criminal," he says. The doctor says that at his base wounded soldiers were treated like broken appliances: When they no longer functioned, the command simply wanted to "throw them out" with a pre-existing condition. "And it's appalling to me that my colleagues would go along with it."

The psychiatrist says he doesn't blame the commanding general for the pressure on him and other doctors to misdiagnose soldiers. Their meetings made it clear that the general was simply taking orders from "high up on the food chain." In some sense, says the doctor, that was to be expected, because with personality disorder, there's so much money at stake. The Nation reported in April that the military is saving $12.5 billion in disability and medical care by discharging soldiers under Chapter 5-13, a figure drawn from a recent Harvard study by Professor Linda Bilmes. Chen believes $12.5 billion is a gross underestimate--that from what he's seen at his medical center, if all the wounded soldiers returning from Iraq were properly diagnosed, the long-term cost of benefits would be exponentially larger.

As it was, says Chen, the medical ethic at the Army hospital followed the guidelines of the Knorr memo, which urged doctors not to take soldiers' descriptions of their ailments at face value. The psychiatrist's own approach was radically different. "If a soldier said he had PTSD, I wrote up 'PTSD.' Finally I was told I couldn't see any more soldiers because I diagnosed PTSD too much." Chen left the hospital soon after. Today he treats patients at a nonmilitary facility.

Dr. Brian Harrison still works for the military. Like Dr. Chen, his years as an Army psychiatrist have been contentious. Harrison says that at his medical center, "there has been a tradition of 'underdiagnosing.'" That means soldiers with PTSD don't always receive that diagnosis. And their health isn't always the top concern. Foremost on the command's mind, says Harrison, is getting soldiers back to Iraq. He says doctors at his base understand that when wounded soldiers seek treatment from them, their job is to get the soldiers back to the battlefield, even if they are traumatized. The psychiatrist quotes his hospital's chief of Behavioral Health as saying, "If they're not suicidal or homicidal, they're fit to go back." If they don't meet that standard, the doctors are to get rid of them fast. Wounded soldiers are "seen as damaged merchandise," Harrison says. "The command wants people like that out of their hair, out of their way."

Harrison is also a pseudonym. The doctor says he is speaking out in violation of an e-mail from his superiors ordering psychiatrists at his facility not to talk to the media. If he gives his name, he says, he could be fired.

The doctor says he has never been pressured to misdiagnose. The biggest challenge he has faced is making a correct diagnosis, given the brevity of his appointments. Until recently, he was allowed to meet with soldiers for an hour. But now, he says, the chief of his department has pressed him to cut his evaluation time to half an hour and make future appointments between fifteen and thirty minutes. "I can't do an evaluation in half an hour," says the psychiatrist. "To properly diagnose a soldier, you need at least an hour." Like Chen, Harrison doesn't blame his department's chief, noting that there's pressure on him from his superiors--"the money managers," Harrison calls them. "Those jackasses--they don't have any clinical experience, they've never worked with soldiers, and they don't care."

The bitterness in his voice is broken suddenly with a warm laugh. "Maybe I'm just old-fashioned," says the elderly doctor. Harrison has been practicing psychiatry for almost forty years and still insists on some decidedly "old-fashioned" techniques, like interviewing soldiers' families when diagnosing a pre-existing condition to see whether the soldiers' troubles existed before joining the service. Other doctors at the Army hospital "don't make any effort to do that," he says. "And they don't have time to. They're busy herding people through."

Surgeon General Pollock declined to comment on Chen's and Harrison's allegations. In a statement, she says she is disturbed by the idea that "individuals [are] pressuring providers to falsify diagnoses.... Such conduct, of course, would be totally unacceptable." Pollock advises doctors who feel under pressure to diagnose personality disorder to contact the Inspector General. She asks soldiers who feel they have been misdiagnosed to approach her directly. Due to "my concern over these issues, they may provide their information to me and I will have the staff review their records."

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