COMMENTARY

The VA Way: Inefficiency at Its Best

Melissa Walton-Shirley

Disclosures

May 23, 2014

According to a 2010 Congressional Budget Office document, the Veterans Administration provides over $48 billion in healthcare "at little or no charge for more than five million veterans annually." Services include "routine health assessment, readjustment counseling, surgery, hospitalization, and nursing-home care." Another less recognized but very valuable service to our country includes the provision of a fertile training ground for physicians, including the cardiologists of tomorrow.

I owe a lot to the Veterans Administration healthcare system. It was there in the early 1990s that I touched my first patient. Wearing a short white coat, I fumbled with the ophthalmoscope, more of an adornment than tool, and when I spied that ever-elusive optic disc for the first time, I felt a deep sense of satisfaction. This brief respite from the classroom was a joyful validation of my journey to becoming a physician, and the VA hospital for nine years would have a front-row seat to my metamorphosis.

To a young physician who was in love with the idea of the practice of medicine since kindergarten, it was a veritable Disney World of medical procedures, odd diagnoses, and clinical scenarios. Toward the end of my residency and then into my fellowship, my time there evolved into an intense love-hate relationship. I loved the autonomy, the opportunity to learn procedures, and the great responsibilities given to young trainees. I literally skipped out of the cath lab after my first day, having been handed the manifold for the first time and "allowed" to inject my first coronary artery. But as much as I loved my training experiences there, I loathed even more the red tape and the "because-I-said-so" rules that made no sense from the standpoint of service, such as the limited number of caths we could book on a daily basis.

Our cath-lab director was both a superb human being and a dedicated employee. The nurses and techs guarded the safety of our veterans with an iron fist, but there were long waits to get into our lab and even longer waits for interventional services that at the outset of my career had to be obtained out of state. Many veterans who needed a service had to fight hard to avoid falling through the widening cracks of that untouchable behemoth of a healthcare system. When I heard of the recent investigations into the Veterans Administration of healthcare, I breathed a sigh of relief. Scrutiny is so painfully long overdue.

My first serious disappointment involved the inability to get a patient with severe coronary artery disease to another facility in another state for more definitive care. I was an intern on the cardiology service. His family would call us weekly through an overhead page to ask whether we were making any headway. In turn, I made weekly phone calls to every entity I could think of to try to get that patient his procedure. My resident told me one day very matter-of-factly "not to bother," because he had died. I've never forgotten the sting of unnecessary death at the hands of inefficiency. Even as I write this note, my mind flashes back to a sea of white tile floors, shiny metal cabinets, glass fronts, the smell of alcohol, a stairwell, and the sound of a heavy steel door slamming against the silence of defeat. That sickening realization echoed in my subconscious night after night. I had failed to navigate the system for a patient in need, but in an odd way, this terrible defeat benefited others, as it bred a lifelong determination to never fail in that way again.

As our facility grew busier, patient-to-nurse staffing ratios grew, and routine care became more difficult. We had some very excellent and dedicated nurses who taught me much of what I know today, but many times they were simply overwhelmed. Even basic care was a challenge some days, and with a glaring lack of staffing, bed changes, routine water-pitcher maintenance, and the delivery of medication on time were difficult, to say the least.

As a resident, I interrupted my rounds one day and confronted the charge nurse about the shortcomings of the night shift who had left patients without urgent bed changes, without pain relief, without even hydration. Pale and irritable from a long 12-hour shift, she tossed her clipboard down with a clang on the chair in front of me and said, "Here! You do it! Let's see you take care of 40 patients with one nursing assistant," and then walked off.

I wrote up a list of all the issues I had encountered at the request of a concerned respiratory therapist (also a veteran) who was fed up with the inefficiencies as well. Somehow, the list found its way to the desk of a local congressman. The crap hit the fan, and I was reprimanded gently by my superior, who asked a lot of questions. When I explained all the challenges of the past two months, he then smiled, having fulfilled his requirement for a necessary interrogation, and said, "Go back to work—and by the way, it helps that you are pregnant," my white coat no longer able to contain my enormous belly. My being pregnant should have had nothing to do with the outcome, but at that point, I'd take any perk I could get and drove back to the salt mines.

Proving that familiarity breeds contempt, our frustrations increased every year that passed at the VA. On numerous occasions, we contacted "Dr X," who had ascended the ranks of our VA system to achieve a cushy directorship position. He offered no help and denied there were any problems. He was a contentious hardheaded obstructionist who regularly announced his belief that coronary bypass surgery was a costly sham procedure and no veteran should be sent for it except perhaps those with left main disease, and then they were sent begrudgingly. The tension in our relationship peaked when he threatened to call security because I had transferred a patient with unstable angina to a downtown hospital for surgery. He caught me taking the patient’s carotid ultrasound results to the surgeon who had requested them. Stupidly defiant, I replied, "There is the phone, doctor," pointing to the lobby desk. "I suggest you pick it up and make your call, because I'm going and I'm taking these images with me."

Though I put on a brave front, my eyes were glued to my rearview mirror as I floored my little white Honda Accord downtown, fully expecting to see blue lights. With every page for the next few days, I expected to be called back to my residency program office, but nothing ever happened. The patient got his surgery and recovered uneventfully, and I got a deep sense of satisfaction for outfoxing the ever-watchful Dr X.

After I entered private practice, I continued to occasionally wrangle with the VA system. There were stupid rules that some hospitals couldn't accept a patient "after 5 pm on a Friday." Others accepted "no transfers on the weekend," and worst of all, a patient died because there were no beds available at a VA facility. Even though the surgery program with which the VA dealt accepted this patient as a bypass candidate, I could not get the VA hospital officials to confirm they would cover the bill. The bone of contention was that if I sent him directly from my community hospital to the bypass-surgery hospital they would not guarantee anything. They would cover the procedure only if I transferred him to their hospital and then to the bypass-capable facility, but their hospital had no beds. After numerous phone calls on behalf of his family and myself, the best the VA would do was to say, "Well, it will probably be covered, but there is no mechanism to address this, so just let him undergo the surgery and we will address it then." After a week of wrangling, he was so disgusted that he left our facility AMA and died soon afterward, ignoring my advice just to drive to their ER. He said he'd rather die than take the chance of sticking his family with a $70K bill, so that's exactly what he did.

I could share enough training war stories to fill a book, but the real issue here is that men and women who have actual war stories to tell sometimes don't get the best medical care. Although one could argue that these issues could happen anywhere, it is shocking when they happen at a facility dedicated for the sole purpose of caring for its own.

The solution? I have long been an advocate for abolishing most of the VA healthcare system in favor of having veteran care funded at private facilities. I believe the larger specialty hospitals should remain open, specifically those that deal with all aspects of combat-related injuries, burns, rehab, and posttraumatic stress.

It is said that the fabric of a society can be judged by how well it treats the sick and the frail. We should also judge our integrity as a nation by how well we care for those who have been willing to sacrifice their lives and their health for their country. It is honor we owe to those who died in combat, but it is loyalty we owe to those who survived.

At this point in American medicine, where technology has surpassed caring and monetary conquests have trumped nurturing, even in the private sector, we can only hope the best and the brightest can come up with a solution we can admire. Maybe with the weaknesses in the VA system exposed and vulnerable, the greatest strategists in the world can flank the enemy of inefficiency and overcome the necessary obstacles to make the VA system the greatest system on earth.

Happy Memorial Day to all American veterans and their families. We owe you more than any of us could ever repay, but shoring up the failings of your healthcare system would be a great start.

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