Researchers with the VA’s National Center for PTSD have conducted empirical studies that reveal significant false negative rates for VA compensation PTSD exams and closely related service connection decisions.
In a recent study, these social scientists conducted independent PTSD assessments of veterans who had filed disability benefits claims for PTSD, some of whom had been awarded service-connected compensation for PTSD and some had not. Recalling that PTSD C&P exam results significantly influence these VBA determinations, this study found significant rates of false negative adjudication decisions.
“Findings revealed that both the number of veterans who are service connected without meeting criteria for PTSD and the number of veterans who meet PTSD criteria but have not been granted SC status are concerning.”
African-American Veterans Less Likely to Receive PTSD Diagnosis and Service Connection than White Veterans
The VA’s National Center for PTSD coordinated another recent study that evaluated the extent to which the service connection status of a large sample of military veterans was impacted by the race of the veteran.Their findings indicated that
“… among veterans diagnosed with PTSD by an independent evaluator, Black veterans were significantly less likely than White veterans to receive both a C&P PTSD diagnosis and to be given PTSD service connection status.” (emphasis added)
Thus, these were false negative conclusions: These African-American veterans actually suffer from PTSD, but the C&P psychologist opined that they did not have PTSD, and the Veterans Benefits Administration did not award service connection for PTSD.
These results are congruent with the impressions of African-American veterans themselves, who have reported less satisfaction with VA compensation PTSD exams compared to White veterans.
“Pilots of a U.S. Army Air Forces fighter squadron, credited with shooting down 8 of the 28 German planes destroyed in dog-fights over the new Allied beachheads south of Rome, on Jan. 27, talk over the day’s exploits at a U.S. base in the Mediterranean theater. Negro members of this squadron, veterans of the North African and Sicilian campaigns, were formerly classmates at a university in the southern U.S.” February 1944.
Implicit Racial Bias Likely a Factor
In addition, these results are consistent with studies in health care generally, indicating that most healthcare clinicians exhibit implicit biases against people of color and that these implicit biases often adversely affect patient care.
More Thorough, Comprehensive Psychological Evaluations Lead to More Equitable Results
Interestingly, when Marx, et al. (2017) conducted an independent evaluation of the same veterans, employing a diagnostic structured interview for PTSD and a standardized measure of disability, the discrepancies between Black and White veterans were no longer seen, i.e., the two racial groups had similar rates of false negative and false positive exam results. The authors noted:
Our findings suggest that more widespread use of psychometric testing in VA PTSD disability exams may help to reduce the racial differences found in both C&P examiner and SC concordance. It may be that the use of psychometric measures of PTSD reduces the possibility that the examiner will be influenced by factors other than those pertinent to the diagnostic process (e.g., implicit racial bias). (emphasis added)
Additional Evidence of High False Negatives and the Importance of Standardized Psychometric Tests
Indirect evidence for unacceptably high false negative rates for PTSD claims comes from the notable success achieved by medical-legal partnerships, i.e., law schools collaborating with psychology graduate schools and medical schools to assist veterans on a pro bono basis. One of the first medical-legal partnerships concentrating on veterans’ disability claims is the Puller Clinic:
William & Mary Law School’s Lewis B. Puller, Jr. Veterans Benefits Clinic was the first of its kind in the nation to forge this type of liaison by seeking relationships with graduate students in psychology training clinics. Law students representing veterans through the Puller Clinic partner with graduate psychology students from three other public universities across Virginia: Virginia Commonwealth University, Radford University, and George Mason University. Puller Clinic students have the ability to seek mental health assessments and evaluations from graduate clinical psychology students working under the supervision of licensed professional faculty. In the first six years of the Puller Clinic’s operation, the law students partnered with psychology students on more than half of the clinic’s cases.
Note that the Puller Clinic provides psychological evaluations and legal advice before the veteran files a Notice of Disagreement, i.e., during a time when veterans rarely receive legal advice and when most veterans cannot afford an independent mental health evaluation.
… the Puller Clinic obtained extensive [psychological] testing and evaluation that led to corrections of veterans’ initial diagnoses. With the help of the thorough testing that was done and the medical nexus opinions obtained from these tests, law students were able to convince the VA to change a previous rating decision—which usually resulted in a denial of benefits—in 84% of the cases.
 Brian P. Marx et al., Validity of Posttraumatic Stress Disorder Service Connection Status in Veterans Affairs Electronic Records of Iraq and Afghanistan Veterans, 77 J. Cʟɪɴ. Psʏᴄʜɪᴀᴛʀʏ 517, 520 (2016) (“This study examined the extent to which veterans’ posttraumatic stress disorder (PTSD) service connection (SC) status corresponded to their PTSD diagnostic status, as determined by a semistructured diagnostic interview. … For current PTSD, results showed a slightly higher proportion of false positives—individuals who did not meet SCID criteria but who did have SC for PTSD—than false negatives—individuals who met SCID criteria but did not have SC for PTSD. For lifetime PTSD, the proportion of false negatives was approximately twice the proportion of false positives. … PTSD diagnostic and SC status are discordant for a significant minority of veterans.”)
 See, e.g., Washington v. Nicholson, 21 Vet. App. 191, 197 (2007) (Hagel, J., concurring) (“Because of the immense importance of medical evidence in the VA claims process,” [medical examinations and opinions] “can bear significantly upon the outcome of the claim for VA benefits.”); cf. 38 U.S.C. § 5103A(d) (“Medical Examinations for Compensation Claims.—(1) In the case of a claim for disability compensation, the assistance provided by the Secretary under subsection (a) shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim.”)
 U.S. Dᴇᴘ’ᴛ Vᴇᴛᴇʀᴀɴs Aғғ., Oғғ. Iɴsᴘᴇᴄᴛᴏʀ Gᴇɴ., Rᴇᴠɪᴇᴡ ᴏғ Cᴏᴍᴘᴇɴsᴀᴛɪᴏɴ ᴀɴᴅ Pᴇɴsɪᴏɴ Mᴇᴅɪᴄᴀʟ Exᴀᴍɪɴᴀᴛɪᴏɴ Sᴇʀᴠɪᴄᴇs, Rᴇᴘ. Nᴏ. 7R1-A02-114 (1997) (“Disability benefit payments are based, in part, on interpretations of medical evidence by the Veterans Benefits Administration (VBA) disability rating specialists. That evidence is developed by physicians employed or supervised by the Veterans Health Administration (VHA), in the form of compensation and pension (C&P) examinations. … VBA cannot complete payment action on veterans’ disability claims until examination results are received.”) [emphasis added]
 Mathis v. McDonald, 834 F. 3d 1347, 1353, (Fed. Cir. 2016) (Reyna, J., dissenting from denial of rehearing en banc) (“VA regional offices use the opinions prepared by examiners in determining whether to award a veteran disability benefits. The decision whether to award benefits often turns on whether the disability is shown to be connected to the veteran’s military service. See, e.g., McClain v. Nicholson, 21 Vet. App. 319, 320–21 (2007). In other words, as in this case, the service connection issue is often dispositive.”)
 The VA Medical Examination and Disability Rating Process: Hearing before the Subcomm. Disability Assistance & Memorial Aff. of the H. Comm. Veterans Aff., 110th Congress 63-65 (2008) (statement of Michael McGeary, Senior Program Officer & Study Dir., Comm. Med. Evaluation Veterans Disability Benefits, Bd. Mil. & Veterans Health, Inst. of Med., Nat’l Acad.) (“Applicants for disability compensation are asked to provide their medical records and, under the duty-to-assist law, VBA helps them obtain those records, especially their service medical records. In nearly every case, VBA has applicants undergo a compensation and pension, or C&P, examination performed by a Veterans Health Administration (VHA) or contractor clinician.”) [emphasis added] [PDF]
 Marx et al., supra note 1; Cf. Darren W. Holowka et al., PTSD Diagnostic Validity in Veterans Affairs Electronic Records of Iraq and Afghanistan Veterans 82 J. Cᴏɴsᴜʟᴛ. Cʟɪɴ. Psʏᴄʜᴏʟ. 569, 573 (2014) (PTSD diagnoses assigned by treating clinicians in veterans’ electronic medical records, as compared to an independent structured diagnostic interview, showed a 9.3% false negative rate for current PTSD and a 13.7% false negative rate for lifetime PTSD).
 Brian P. Marx et al., The Influence of Veteran Race and Psychometric Testing on Veterans Affairs Posttraumatic Stress Disorder (PTSD) Disability Exam Outcomes, 29 Psʏᴄʜᴏʟ. Assᴇssᴍᴇɴᴛ 710 (2017).
 Marc I. Rosen et al., Racial Differences in Veterans’ Satisfaction with Examination of Disability from Posttraumatic Stress Disorder, 64 Psʏᴄʜɪᴀᴛʀɪᴄ Sᴇʀᴠɪᴄᴇs 354 (2013) [HTML] [PDF] (“Overall ratings of C&P examination quality were predominantly ‘excellent’ or ‘very good’ by both African American and Caucasian veterans. However, African American veterans rated their examinations as having been of lower quality and rated their examiners lower on interpersonal qualities than Caucasian veterans did. This finding persisted even after controlling for other potential predictors of dissatisfaction. It is remarkable that despite the limited range of satisfaction in this study, only veterans’ race and race alone predicted lower ratings by veterans.”); see also Hillary A. Wandler, The Role of Culture in Advocating for Accurate Diagnosis and Rating of Veterans Psychological Disabilities, 2 Mᴇɴᴛᴀʟ Hᴇᴀʟᴛʜ Lᴀᴡ & Pᴏʟ’ʏ J. 1, 6 (“… communication between the veteran and the medical examiner [is] a truly pivotal part of the veteran’s claim. This is where veterans’ cultural backgrounds and identities can become crucial factors in their journeys through the claims process, with the potential to significantly impact [what, if any, benefits they receive]. Any person’s cultural identity is intimately intertwined with his or her psychology. Culture adds a layer of complexity to diagnosing a client suffering from a mental illness.”); cf. Ulrich Schnyder et al., Culture-sensitive Psychotraumatology, 7 Eᴜʀ. J. Psʏᴄʜᴏᴛʀᴀᴜᴍᴀᴛᴏʟ. 31179 (2016) [PMC5055610].
 William J. Hall et al., Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review, 105 Aᴍ. J. Pᴜʙ. Hᴇᴀʟᴛʜ e60, e60 (2015) [PMC4638275] (“Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color.”).
 Chloë FitzGerald & Samia Hurst, Implicit Bias in Healthcare Professionals: A Systematic Review, 18 BMC Mᴇᴅ. Eᴛʜɪᴄs 1, 14 (2017), [PMC5333436] (“A variety of studies, conducted in various countries, using different methods, and testing different patient characteristics, found evidence of implicit biases among healthcare professionals and a negative correlation exists between level of implicit bias and indicators of quality of care.”)
 Marx et al., supra note 7, at 717.
 Stacey-Rae Simcox, Lightening the VA’s Rucksack: A Proposal for Higher Education Medical-Legal Partnerships To Assist the VA in Efficiently and Accurately Granting Veterans Disability Compensation, 25 CORNELL J. L. & PUB. POL’Y 141, 175-176 (2015).
 Id. at 180.