By Steven Knope, MD
June 6th, 2014 – For those of you who have not been following the story, the VA medical system has come under attack over the past month after a whistleblower, a Dr. Foote from the Phoenix VA Hospital, disclosed that 40 veterans have died waiting to be seen by a doctor. It is not clear at this point in time if some or all of those men died as a direct result of the delay in their care. However, many of these patients were waiting 6 to 9 months to see a primary care doctor, even after some had been to the emergency room for life-threatening medical conditions.
What we have now learned is that administrators at the Phoenix VA were cooking the books. They not only failed to report the real waiting times for veterans to see a doctor, they submitted phony wait lists to Washington to make the numbers look better, for the sole purpose of securing performance bonuses. In other words, these government employees committed fraud at the expense of the lives of veterans just to secure an undeserved performance bonus.
What we have also learned over the past week is that this fraud is a systemic problem, affecting an estimated 60% of all VA hospitals. As a result, the head of the VA, General Eric Shinseki, just resigned over the scandal. However, his resignation will do nothing to solve the problems of incompetence and corruption in the VA system. How do I know? I spent years training and working in VA medical centers during my residency. I know of what I speak.
My VA Experiences: All medical students and physicians in training spend time at VA hospitals, because these hospitals are linked to academic training centers. I will tell you that the bureaucracy at the VA is even worse than that of the post office or the DMV. Let me give you a little flavor of the way that the VA operates.
When I started working as an intern at the Wadsworth VA Medical Center in Los Angeles, I had an encounter with a charge nurse which illustrates the mindset of many VA employees. I was called to the floor to see a veteran who was having chest pain. After quickly examining him, I walked out of his room, saw the charge nurse in the hall and said, “Excuse me, Nurse. Mr. Jones is having chest pain. I need an EKG stat please.” She responded, “Honey, I’m busy, I’m pass’in out meds.” I looked her in the eye and said, “I don’t think you understand what I just said. This patient is having chest pain and I need an EKG now.” She looked at me down her glasses with great contempt and said, “Honey, let me axe you someth’in. Where you from?” I responded, “Cornell.” She said, “Now you see, that’s your problem. You ain’t at Cornell anymore. If you want a stat EKG, you do it yourself.” And she went back to her routine.
This Was no Isolated Incident: I share this story with you because it encapsulates the real problem with the VA medical system. The problem is a cultural one. Put simply, there are a large number of the employees at the VA – clerks, nurses, career VA doctors and administrators – who are simply unmotivated government employees. Many are incompetent. What’s that you say? You are outraged with my comments? Spend as much time as I have spent in VA hospitals, observe what I’ve observed, and then come back and talk to me. Unless you’ve lived in this system, you have no idea just how bad it is. If you want to hear the truth, I’m here to tell you that the problems with the VA – the shoddy care, the rationing by delay – have been with us for at least 3 decades. The phony waiting lists may be relatively new, but the grossly incompetent medical care and the indifference toward veterans have been with us for decades.
Employee Priorities: First, unlike patients at a private medical center, the veterans don’t come first at the VA. The attitude of many employees is to put in their time, do as little as possible, get out of the hospital as early as possible every day, and wait for their retirement benefits to kick in. Second, unlike employees in the private sector, all VA employees have job security. It is virtually impossible to fire incompetent VA staff. This is because these employees are protected by government employee unions. When I told my superiors about the behavior of this charge nurse, who had worked at the VA for 25 years, they just laughed at me. “Welcome to the VA,” they said. “There is no such thing as disciplinary action here. The VA is a subculture unto itself.”
Working the System: During my pre-med days, I used to watch reruns of the TV show M.A.S.H. One of the characters on the show was a clerk named Radar O’Reilly. He was the guy that everyone went to see when things needed to get done. It wasn’t the colonel that had the ultimate power in the M.A.S.H. unit; it was the clerk, Radar. This is literally true in the culture of the VA. I developed a reputation among the clerks as a “good doc;” a young resident who actually cared. They wanted to be in my clinic, because unlike some of the career doctors who just punched a clock, they knew I would take care of them. So I took care of the clerks’ medical needs. In turn, they helped me move the immovable system for my other patients. I would walk into their office, tell them that I was getting the run around for a colonoscopy or specialist appointment, and things would magically get done. It was just that simple.
The payback for their help was not always cheap. I once got paged by an ER clerk at 9 pm on a Sunday night. He knew that I had exotic birds as pets. His 5-year-old son had a parakeet that had flown into a jar of cooking oil sitting out on the counter. He asked if I would come to his home that night to save his son’s bird. What he did not tell me was that the address he gave me was in the middle of Watts. So at 9 pm, I unknowingly drove into the ghetto to save a five-dollar parakeet.
As I got out of the car, this clerk’s neighbors looked at me like I was insane. What was this crazy white boy doing in the neighborhood, especially at night? My patient escorted me into his house. I washed the cooking oil off the bird with a detergent, tucked the bird in a blanket to keep him warm and the clerk walked me back to my car. I honestly felt lucky to get out of that neighborhood alive. But from there on out, whatever my patients needed in the ER, they got.
The Vets: Though the VA system leaves much to be desired, the vets that I treated at these hospitals were great. One of my fondest memories was caring for an 85-year-old vet who had an acute cardiac arrhythmia. I was called to see him when he was short of breath. He was in heart failure due to a rapid heart rate. He said he was old and begged me to let him die. I told him that I could fix his problem and make him better. I refused his request and started wheeling him to the ICU. I had to transport him myself, because he would have died had I waited for an orderly to help me. We got him stabilized quickly in the ICU. Within an hour he was feeling better. We later became friends and he turned out to be a fascinating guy.
I took care of this man in my clinic for two years, until he passed away. One day after his death, I got a call from this patient’s son. It turned out that his son was a big shot in Washington. He invited me to the Hollywood Bowl. I was making peanuts at the time and had a medical school debt of $100,000 at 18% interest. I could never have afforded to go to the Hollywood Bowl. When I arrived at the concert, I was escorted to the front section of the auditorium, where I learned that the wealthy people in LA have dinner served to them at the Bowl. This man had taken the time to learn that it was my birthday. This was his birthday present to me for taking care of his father. After dinner, he had a chocolate cake with candles delivered to our table. He told me about his father’s life. I learned what a strong and great man his dad had been. I began to see just who I had been entrusted with treating at the VA. These were incredible men, many of whom were getting far less than they deserved.
Men Who Gave in their Prime: When we look at elderly veterans, we often forget that their sacrifices were in the prime of their lives, when they were young and robust, with their entire lives ahead of them. They didn’t risk their lives for us in their 80s, with little to lose. They risked it all for us when they had so many pages still unwritten. Many came home with terrible wounds, both visible and not so visible. The wealthy and successful vets got private insurance and had private doctors outside of the VA. Those less fortunate trusted that their government and fellow citizens would take care of them. But they have been let down.
The Solution for the VA Scandal: We say that we honor our vets for their service, but in truth, we do not. After all of their sacrifice, when they are sick, injured and infirmed, we send them to VA hospitals for their care – places that we ourselves would never go. Places that we would never send our loved ones. And the problem is not a matter of inadequate funding of the VA. The VA’s annual budget has more than tripled over the past decade to $154 billion in 2014. Yet the care remains poor.
If we are serious about caring for veterans, their medical care should be turned over to the private sector. Veterans should be given a medical voucher and allowed to see private medical doctors and go to private hospitals for their acute medical care. $154-billion would pay for a lot of good medicine every year for these men and women. The VA system should be wound down and closed. It is a corrupt and unfixable bureaucracy. The incompetence goes from top to bottom. It is a money sink for tax payers and a liability for our war heroes.