The primary care physician may refer patients to Phase II for further specialty consultations if he or she determines that it is clinically indicated. These Phase II evaluations are conducted at a regional medical center and consist of targeted, symptom-specific examinations, lab tests, and consultations. During this phase, the potential causes of unexplained illnesses are assessed, including infectious agents, environmental exposures, social and psychological factors, and vaccines or other protective agents. Both Phase I and Phase II are intended to be thorough for each individual patient and to be consistent among patients.

Every medical treatment facility has a designated CCEP physician coordinator who is a board-certified family practitioner or internal medicine specialist. The coordinator is responsible for overseeing both the comprehensiveness and the quality of Phase I exams. At regional medical centers, CCEP activities are coordinated by board-certified internal medicine specialists who also oversee program operations of the medical treatment facilities in their region.

In March 1995, DoD established the Specialized Care Center at Walter Reed Army Medical Center to provide additional evaluation, treatment, and rehabilitation for patients who are suffering from chronic debilitating symptoms. Seventy-eight patients have gone through the Specialized Care Program, which consists of an intensive 3-week evaluation and treatment protocol designed to improve their health status.

The Specialized Care Center has three teams that overlap: (1) the physical team (physiatrist, physical therapist, occupational therapist, fitness trainer); (2) the medical team (internist, physiatrist, specialists, nutritionist); and (3) the psychosocial team (psychologist, social worker, wellness coordinator). Physical training, individualized to the patient, is an important part of the program, as is education. The program works with the patient on issues that result in dysfunction or impairment. The focus is not on the cause of the problems, but rather on how the patient can get better.

SIGNS, SYMPTOMS, AND ILL-DEFINED CONDITIONS (SSID)

The Department of Defense reported to the committee that approximately 17% of the 21,579 patients in the CCEP had a primary diagnosis of SSID, while about 42% had ''any diagnosis" of SSID. The subcategories of SSID are symptoms, nonspecific abnormal findings, and ill-defined and unknown causes of morbidity and mortality. Of the patients with SSID, 96.6% (3,591 patients) of the diagnoses were in the symptom subcategory, 3% (112) in the nonspecific abnormal finding subcategory, and 0.4% (16) in the remaining subcategory (Table 3.1).



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