Quality Problems with VA Medical Care

I get up early and usually watch MSNBC’s “Morning Joe” for want of anything better to do. It’s usually entertaining and I can switch back and forth to Fox and Friends to get conservative views of the news, too.

But one area where Morning Joe fails is its understanding of health care issues. Today’s show was a good case in point. Pundit Mike Barnicle was expounding on the VA political mess. Twice he offered his analysis that scheduling delays were a big problem but that “once you get there” the care is “remarkably good,” and “first rate.” Those pronouncements are totally wrong and not based on any understanding of what is wrong and has been wrong with the VA for a long time.

It is the quality of VA medical care that should be at issue. Yes, scheduling delays are bad as are the cover ups of changed and gamed record keeping and scheduling systems.  But what is really bad is how the quality of VA care has suffered.

You only have to look at lawsuits filed against the VA for medical malpractice to see how the VA has failed to promote a culture of quality medical care. Take the case of the late Christopher Anglesey, a 32 year old Army veteran with a history of traumatic brain injury and PTSD, who had been awarded a Bronze Star in Operation Iraqi Freedom. His wife and 5 small children filed a medical malpractice case after he died from a lethal cocktail of drugs given by doctors at the VA Hospital in Salt Lake City after he suffered a broken leg. http://www.deseretnews.com/article/705389413/Widow-of-decorated-Iraqi-vet-files-wrongful-death-suit-against-VA-hospital.html?pg=all

The VA settled the Anglesey case. But the case raises disturbing questions about how veterans get combinations of drugs – narcotics and other Central Nervous System and respiration depressing drugs – when there is a sophisticated VA computerized electronic medical record system that should warn doctors and pharmacists to not prescribe dangerous combinations of drugs.  You can find the expert reports in this case on PACER, the electronic record system for federal courts.

Part of the VA’s quality problem is related to its being a training ground for medical students and newly minted doctors. Almost every doctor trained in the U.S. has rotated through medical and surgical experiences at VA hospitals and clinics. My training included rotations at the Durham, N.C. and Houston V.A. hospitals. My first month of internship was spent at the Houston V.A. hospital on a pulmonary disease inpatient unit. There are few areas of medicine more complex than a ward full of veterans with severe COPD and other chronic diseases. For sure, that experience was the equivalent of being thrown into the ocean with heavy seas to learn how to swim. A Duke professor used to tell us in medical school that “It’s tough to kill people,” jokingly trying to reassure us about the dangerous mistakes medical trainees make, often in the initial few months of each training year which starts in July.  The good luck that patients need to survive trainee ignorance is especially needed at VA hospitals.

My own favorite VA “war story” ( And almost very doctor who has trained at a VA has a story or two or three.) involved the teaching imparted to me one morning at “Morning Report” at the Durham VA Hospital by the Chief of Medicine at the time, Dr. Wendell Rosse. Rosse was a distinguished hematologist. He heard my report about seeing a veteran with atypical chest pain in the Emergency Department the night before. I told how I had worked up the patient and determined the symptoms to be not related to his heart, and not be life-threatening, and had sent the man home to be later worked up as an outpatient. Rosse was quick to point out that in the future he wanted all such patients admitted, not for their safety, but because the Durham VA was coming up for some sort of budget review and he wanted the inpatient admission numbers pumped up to justify more money for the hospital. But that was way back in the 1970s long before the now popular “less is more” philosophy of doing as little as possible without getting sued mentality. I was, however, working on the team that had shown from Duke data that acute heart attacks could be treated with markedly reduced inpatient stays for uncomplicated patients. But Rosse’s directive to the trainees was a good example of how the VA budget process was manipulated independent of medical need.  Don’t get me wrong:  I am not criticizing the late Dr. Rosse. He was a dedicated teacher and researcher. But he was a product of the VA budgetary process that has been dysfunctional for a long time.

The best solution to the VA “crisis” is to give veterans vouchers and let them get more of their care in the private sector. It’s a “crisis” that’s been around for a long time.  But if the VA hospitals were shuttered, there would be increased pressure on the private sector and where would trainees get their hands on experience in how to care for patients? Someone has to be the “guinea pigs” for medical trainees. Veterans are used to meet that need, but nobody advertises it. There is a big medical literature on the issue of how well VA care stacks up with care in non-VA settings for things like cardiovascular care, organ transplantation and diabetes care. I will explore that topic in another blog. What concerns me is that those comparisons are mostly done by VA researchers and one wonders how independent and objective they really have been.

For now, I’ll just hit the mute button next time Mike Barnacle starts pontificating on health care topics or switch over to ESPN to watch the top plays of the day.

Veterans deserve more honest and informed advocacy for the severe problems that are plaguing the quality of VA health care. Mike Barnicle should stick to rooting for the Red Sox.

Or Barnicle and his producers could host a panel of VA doctor whistleblowers and hear about the real problems of VA health care.

In fairness to Barnicle, he’s not the only commentator claiming that VA care is good. The NY Times published an op– ed piece by a former VA doctor that made that same assertion. Here’s a letter I wrote to the Times which of course they did not publish:

Re: “Why I Blew the Whistle on the V.A.” NY Times op ed page A19, May 24, 2014

Dr. Foote asserts that the V.A. “does a very good job at providing chronic care…”

With respect to the management of chronic pain, that is not the case.

On October 10, 2013, the House Committee on Veterans’ Affairs Subcommittee on Health held a hearing on the misuse of narcotic painkillers by the V.A. in treating veterans with chronic pain.

Widows and veterans testified about the V.A.’s failing to abide by its own 2010 pain management clinical guidelines that resulted in patient deaths. Two physician whistleblowers testified about how V.A. administrators told them to prescribe narcotics against their better medical judgment. The House members, several of whom were also physicians, demanded answers from the V.A. in 30 days. Almost 5 months later, the V.A. came back to Congress and failed to answer important questions. This is not a problem of a “mismatch between the V.A.’s mission and its resources.”  This is a problem of V.A. administrators not being held accountable and being arrogant and feeling that they are untouchable. The V.A. has addicted thousands of veterans to narcotic painkillers. The V.A. has prescribed narcotic painkillers to thousands of veterans with sleep apnea which is in violation of their own written clinical guidelines.  You don’t need an extensive internal investigation to show this. It would be simple to write a program that looks at all veterans prescribed drugs like hydrocodone, oxycodone, and benzodiazepines and also look at all those with a diagnosis of sleep apnea. Those patients would need immediate scrutiny for their safety, and those who administered or caused to be administered these potentially lethal cocktails of drugs could be investigated and educated or held accountable.

The V.A. currently has all the resources it needs to investigate this outrageous patient safety problem of their own causing. But they lack the will to do so.    

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