VA released 927 pages of the training it gives the contract clinicians who examine Veterans. 80 of those pages are about toxic exposure. The word "rationale" appears 682 times in the stack. "Agent Orange" appears four times. And the exposure database the training tells examiners to rely on only holds records going back to the 1990s, which means that for every Veteran in a photograph like the one below, there is nothing in it at all.
There is a Jamey Johnson song called "In Color." An old man is going through black and white photographs with his grandson, and for every picture there is a story the picture cannot hold. The wise grandpa just says, “you should have seen it in color.” Boy, I like that song.
I thought about it the entire time I was reading this FOIA production, because VA has built an examination system that can only see in black and white, and its built like that on purpose. (Shocking.)
What I Asked For and What Came Back
I asked VA’s Medical Disability Examination Office for the training materials it gives to contract examiners. Not the contracts. Not the quality metrics. Just the training itself, the actual courses a clinician sits through before VA says their word becomes God’s own word.
What came back is 927 pages. It is twenty-one separate documents, web courses printed out slide by slide, a few job aids, one assessment, and one item I will come back to because it is funny in a way nothing else in this stack is funny.
I read all of it. Here is what is in there.
927 Pages Later
80 are specifically about toxic exposure. That is 8.6% of the production.
158 more pages are Gulf War material, which is partly about environmental hazards and partly about undiagnosed illness and the mechanics of a general medical examination. I counted those separately because I do not want to be accused of cooking the number in either direction. Call it exposure adjacent.
The other 689 pages are something else entirely. Military sexual trauma. Mental health examinations. Hearing loss and tinnitus. How to write a medical opinion in general. How to tell correlation from causation. Recertification modules that repeat courses already sitting in the same stack.
I want to be careful here, because the easy version of this story is dishonest. Nothing on that list is wasted. MST examinations are hard and the training I read for them is genuinely good. Interview techniques, the marker rules under 38 C.F.R. § 3.304(f)(5), examples of what a marker looks like in a personnel file. If you have an MST claim, a contract examiner has been taught how to handle you. That is a real accomplishment and somebody at MDEO should be proud of it.
That is exactly what makes the comparison fair. VA knows how to build this kind of training. It has done it. It just has not done it here.
Every Document, End to End
The 3 longest items in the production have nothing to do with toxic exposure. The military sexual trauma course runs 192 pages, and its recertification module adds 50 more, so 242 pages against the 80.
The 2 courses that are purely about toxic exposure, the Camp Lejeune Contaminated Water course and the PACT Act course, are 33 pages and 40 pages. They sit 10th and 11th on the list.
And at the very bottom, the Toxic Exposure Risk Activity Medical Opinion Checklist. One page. It is the first page of the production, and it is one page long. This to me is the tell all. The PACT Act was signed in August 2022. Here we are 4 years later and VA hasn’t done squat to train examiners on non-presumptive toxic exposure claims.
The Recertification Game
4 of the 21 documents are recertification modules. Gulf War recertification at 56 pages, Medical Opinions recertification at 51, MST recertification at 50, General Certification Overview recertification at 42. That is 199 pages, more than a fifth of everything VA sent me, and it is material an examiner has already covered.
I am not saying recertification is wrong. Refreshing a clinician on what he learned two years ago is sound practice. I am saying that when VA was asked what it teaches examiners, more than a fifth of the answer was we teach them the same things again, and none of the four recertification modules is about toxic exposure.
There is no TERA recertification. The 30-minute PACT Act course is a one-time dog and pony show.
75 Minutes = Qualified
Now the second half, which is what the toxic exposure training actually says.
The Camp Lejeune course states its own run time is 45 minutes. The PACT Act course states it is30 minutes. 75 minutes and you are qualified as a VA examiner to opine on complex medical questions related to chemical and God knows what exposure!
That is the only dedicated toxic exposure curriculum for the clinicians VA hires to decide whether a Veteran’s cancer came from his service. An hour and a quarter. Less time than the Gulf War general medical examination course, which states 1.5 hours.
Now, 75 minutes could be enough if those 75 minutes were dense with the thing an examiner actually needs, which is: what does this substance do to a human body, and how would you know? So let us look at what is in there.
The Database That Starts in the 1990s
The PACT Act course spends its first lesson on where exposure information lives. The centerpiece is the Individual Longitudinal Exposure Record, ILER, a joint DoD and VA database that, in VA’s words, "verifies toxic exposure throughout a Service member’s military service."
Here is the entire slide on what ILER is and where to find it:
Read that twice, because there are three separate admissions stacked in one slide.
The database only goes back to the 1990s. So, for a Vietnam Veteran, a Korea Veteran, a Cold War Veteran who worked around solvents at a depot in 1968, the exposure-verification system contains nothing. Not a thin record. No record at all. The system VA built to prove exposure began after those men were already home. Nice.
The examiner cannot access it anyway. He is not given the database. He is given whatever a claims processor decided to drop into the eFolder.
And not all TERA claims have a record in it. VA underlined that part itself.
So, the instruction to the examiner is: base your opinion on an exposure record that may not exist, that you cannot look up, and that for an entire generation of Veterans could not exist by design.
That is the gap the song is about. The photograph is flat and gray and there is a man in it who could tell you what the air smelled like, and the record says nothing, and the record is what counts. Just not to the VA.
What a TERA Opinion Actually Requires
Here is what the examiner is asked to produce. The PACT Act course shows the new Section VIII that was added to the Medical Opinion DBQ:
Synergistic combined effect. What the hell does that even mean? That is a real concept and a hard one, it is the question of whether two or more exposures together do something neither does alone. I think. It is the kind of question that occupies toxicologists for careers.
A contract examiner with 75 minutes of training is asked to opine on it, for a Veteran he met an hour ago.
And the training’s answer to how he should do that is not science. It is a reading list. The course tells him the TERA Memorandum Examiner Job Aid "provides website resources for the examiner to review when certain exposure(s) are indicated," and that his "review of supporting reference material is not limited to the websites included." Go look it up. On your own. For a disability examination that pays a flat rate. Talk about an incentive to keep repeat customers.
The Slide That Tells You How to Say No
Now here is the part that made me take a break for a few.
Lesson 3 of the PACT Act course covers how to write the rationale. It gives the examiner two slides: one listing reasons for a negative opinion, one listing reasons for a positive opinion. Here is the negative slide, complete:
And here is the positive slide, complete:
Look at the two side by side.
The denial slide hands the examiner a worked example. It names a specific competing cause, tobacco, and tells him it can result in lung and other types of cancer. It is a sentence he can lift and use. Every one of us who reads these examination reports has read that sentence, or something close enough to it that you would not be able to tell the difference. However, not once has an examiner ever explained how or why these risk factors apply to this particular Veteran.
The grant slide is circular. A positive opinion is appropriate when there is evidence of a relationship. Thank you. And it arrives with homework attached, find the peer-reviewed literature and cite it in your rationale.
I am not alleging that anybody sat in a room and designed it this way. I have no evidence of that. But one of those slides lowers the cost of saying no, and the other raises the cost of saying yes, and they are consecutive slides in the same lesson. Where there’s smoke there’s…fire.
The One Course That Does It Right
Which brings me to Camp Lejeune, and to the reason I know VA can do this when it decides to.
The Camp Lejeune Contaminated Water course is 33 pages and 45 minutes, and it is good. It names the chemicals, trichloroethylene, perchloroethylene, benzene, vinyl chloride. It lists the eight presumptive conditions, kidney cancer, liver cancer, non-Hodgkin’s lymphoma, adult leukemia, multiple myeloma, Parkinson’s disease, aplastic anemia and other myelodysplastic syndromes, bladder cancer. (Why would VA be requesting a medical opinion for a presumptive condition though?) It gives a worked positive rationale, including the examiner’s actual reasoning that benzene exposure is associated with a significant increase in hypertension, with the sources. It gives a worked negative rationale too. Tinnitus is not caused by those solvents, the Veteran’s MOS was rifleman, noise is the likelier cause, and that negative example is fine, because it reasons from the chemistry to the condition instead of reaching for his cigarettes.
That is what toxic exposure training looks like when VA writes it properly.
It exists for Camp Lejeune because Congress wrote a statute specific to Camp Lejeune and VA had to implement it. Where the law named the place, the water, and the conditions, VA built training that names the place, the water, and the conditions.
Where the law left the question open, which is everywhere else, which is the entire non-presumptive TERA universe the PACT Act created, VA built a checklist.
What Is Not There
Across all 927 pages, exactly 39 pages name any specific chemical or exposure agent at all. 4 of them name benzene, trichloroethylene or vinyl chloride, and all four are inside the Camp Lejeune course. Dioxin appears nowhere in the production. Neither does PFAS. Neither does hexavalent chromium. Depleted uranium appears once, in a list.
"Agent Orange" appears four times across 927 pages, on 3 pages, and not once as instruction, it turns up in passing in a general medical-opinion course and in an assessment question. There is no herbicide exposure course. There is no burn pit course. There is no airborne hazards course. There is no particulate matter course.
And there is no toxicology at all. Not a dose-response curve, not a latency table, not a route-of-exposure discussion worth the name, nothing on how to weigh a 30-year gap between exposure and diagnosis. The closest the stack comes is a 74-page module on telling correlation from causation in the abstract, which, read against everything above, is almost poignant.
What This Means If You Have a Claim
If you are a Veteran with a non-presumptive condition, you believe came from something you were exposed to, here is the practical shape of what you are up against.
The clinician who examines you has had 75 minutes of training on toxic exposure, and possibly none at all if he was certified before these courses existed. He cannot look up your exposure record. If you served before the 1990s, there is no exposure record. He has been told to consider the synergistic combined effect of everything you were exposed to, and he has been given a reading list instead of an education. Whatever that means. And the most concrete piece of guidance in his training for how to write a rationale is an example of how to attribute your cancer to your smoking. Classic VA.
So do the work for him. Put the literature in the file yourself, with the study, not just the conclusion. Put the exposure in the file yourself. Buddy statements, unit histories, your own account of what you handled and how often and whether anybody gave you a mask. If there is an ILER summary, make sure somebody has actually bookmarked it where the examiner will see it. Do not assume any of it reached him, because the training tells him plainly that it might not have.
And if the opinion comes back and the rationale is one sentence about tobacco, now you know where that sentence came from. It came from slide 34. I call it the slide 34 rationale. Copy and paste. And examiners are getting paid millions for it.
Read It Yourself
All 927 pages are below, compressed and split into four parts because the original production is a behemoth. The original page numbering is preserved throughout, so "page 68 of 927" means the same thing in these files as it does in this post.
Part One is the one to read. It holds the TERA checklist, the Camp Lejeune course, the PACT Act course and the Gulf War recertification — pages 1 through 157, which is every page I have quoted here.
The full production, in four parts
TERA Medical Opinion Checklist, Camp Lejeune Contaminated Water, PACT Act: Key Terms & Medical Opinions, Gulf War Medical Examination: Recertification. 7 MB.
DownloadMDE Military Sexual Trauma and the VA Examination Process, and the MST, Medical Opinions and General Certification recertification modules. 16 MB.
DownloadGulf War General Medical Examination, the Four Disability Patterns guide, and DMA Medical Opinions. 14 MB.
DownloadDMA Mental Health Examinations, the Gulf War final assessment, the ILER and medical-opinion job aids, Correlation vs. Causation, and the Vendor PACT Act guidance. 13 MB.
DownloadI am going back to VA for the rest. The certification requirements, whether any of this is mandatory, and what percentage of the examiner workforce has completed the PACT Act course at all. That number is the one I actually want.
In the meantime, go look at the photograph again. Those men came home and some of them got sick, and the system that decides whether to believe them starts its records in the 1990s.
You should’ve seen it in color.
Godspeed.
