Doctoring Health Care Health Care Reform

The VA healthcare system — Can we handle the truth?

Memorial Day weekend is an apt time to consider the recent accusations of wrongdoing in the VA healthcare system. It’s an opportunity to face the truth.

As a free American, I am connected to veterans. It has always been remarkable that young people give their life or health for their country, but now, in this me-centric era, it is stunning that they do. It is truth to say that veterans deserve our respect and our care. Consider also that recent wars have been fought on the backs of the underprivileged, a fact that strengthens the calling to care.

I am also connected to veterans’ healthcare. For it is in the VA system that I learned to be a doctor—a feeling doctor, an imperfect doctor, a human doctor. It’s ironic, and not often said, that the $48 billion-dollar VA healthcare system gives as much as it takes. It’s impossible to put a value on the benefit to society from the legions of caregivers who emerge from years of training in the VA system. Algorithms be damned; wealthy Americans benefit from what young doctors learn in the VA system. Veterans give when they serve in battle, then they give again as patients, as teachers.

And it’s not just the past that connects me to veterans’ healthcare. My wife Staci works as an attending physician in hospice and palliative care at the Louisville VA. When we share stories, I mostly tell of relieving the palpitations of the rich, she of relieving the suffering of dying veterans. Another irony of the VA: you don’t get Staci if you have private insurance.

That’s the thing about veterans’ healthcare. Buried deep within the maddening levels of bureaucracy are the Staci’s, the angels. And don’t think for a moment it’s just VA doctors who are special. There are armies of caring nurses, therapists, van-drivers–the list goes on and on.

So what about these stories of corruption? Veterans are dying on long waiting lists. Administrators are cooking the books to cover up the fact that you can’t deliver the same care to many as you can to few.

We should set out two givens. One is that the accusations remain alleged, and the other is that no right-minded person advocates for dishonesty. That said, it is most instructive to view the response to this “scandal.” Here we see real problems: a collective failure to note the obvious, the gaming of the story to simplistically knock down a single-payer system, or perhaps the dumbest of all, holding this up as an indictment of Obamacare.

Failure to see the obvious:

You simply cannot deliver suburban excesses—the antithesis of efficient and honest healthcare–to the growing numbers of veterans. Thank goodness. Both Dr. Harlan Krumholz and Dr. Kevin Pho remind us that if evidence, not hype, is considered, the VA system performs either better than, or comparable to, the private sector.

Yet this should be obvious to anyone who reads anything about US healthcare. It’s clear that the private system is broken. If you hold up the US private system—with its humanity-extracting EHRs, expanding layers of bureaucracy, conflicts of interest, expense, inequalities, and geographic and racial differences in care–as a model that the VA should aspire to, you are not mastering the obvious. My colleague at Dr. Melissa Walton Shirley suggests veterans should be moved to the private system. I wouldn’t do that; veterans deserve better than our mess.

Knocking the single-payer system:

This is a stretch. You are not saying a single-payer health system leads to dishonesty while the free-market system brings out the squeaky clean, are you? (I was going to hyperlink examples of predatory medicine, but that seemed like piling on.)

Let’s face the fact that humans will always behave according to human nature. We are mostly good but incentives exert influence. Reward heart catheterizations and you get heart catheterizations. Allow direct-to-consumer advertising and you get disease mongering.

The question is not so much which system could be better (single payer or free-market); that’s unknowable, really. The pragmatic question is which system–that covers all–can we accept and afford. My take as to why the VA system, with its wait times, student doctors, salaried employees, and sicker patients, performs as well as its more expensive wasteful competing system is that doctors don’t control nearly as much as we think we do. We immerse ourselves in the hubris of control. I’m John Mandrola, and only I can save you from AF.

In reality, the basics of medical care are not always that complicated or expensive—and the human body is remarkably resilient.

Yes, of course, patients die waiting for medical care. It’s utter nonsense to call that a scandal. Why? Because patients die regardless of medical care, and too often, as a result of medical care. This death-denying culture has led to a major humanitarian crisis, one playing out in nearly every ICU in this country.

But please don’t misunderstand. I’m not arguing that medical care is pointless, or that we should not try to extend and improve human life. Rather, it is time to adjust the mindset that more care or faster care is always better care.

We need to get past the idea that all of medicine should be big and bold, like treating a heart attack. The policy of indiscriminate mammography teaches such a lesson. American women were sold a pink-wrapped bill of goods. It turns out that mortality from breast cancer in the single-payer British system is essentially identical to that in the US. Now, when I see a woman with chemotherapy-induced heart disease, I can’t help but wonder whether this was an early-detected cancer that did not require therapy.

Until recently, I had to keep these thoughts to myself—as one of the ways the healthcare machine of ours survives is by making such thoughts seem heretical. Where are the pink bows for the masses of elderly patients with dementia entombed in nursing homes? Where are the pink bows for the Hepatitis C patients who can’t afford Gilead’s new wonder cure? Where are the pink bows for the underprivileged kids coming home from our wars with PTSD and drug addiction? The private system has no bows for these folks.

Indicting Obamacare:

This is a huge mistake. Obamacare fails because it lacked the courage to do enough. Its proponents avoided the truth. (Maybe they had to.) What policymakers set out to do was to correct a great American scar—that a country this rich does not provide basic healthcare to all its people. The problem was that Americans were not told the truth. A leader (or leaders) should have said that to get care to all people, excesses and inefficiency would need to be removed. Hospitals would not look like luxury hotels. Medicine and surgery would be for the ill, not the worried-well. Evidence, not eminence, would guide medical care. And prevention of disease would come not from doctors but from patients.

But Americans didn’t get the truth. We got magical thinking about metaphorical free lunches, insurance reform, cost-saving EHRs, patient-safety “quality forums,” and the like. Nonsense. All of it.

The VA system is the truth. Rationing is the truth. Triage is the truth. Imperfection is the truth.

And yes, death, too, is the truth.

Learning from mistakes

The most important means for improving medical care is learning from mistakes. As Dr. Krumholz notes, one of the reasons the VA story came to light was their accountability. They were courageous enough to record and document wait times, and in so doing, they exposed layers of bureaucracy separating veterans from caregivers.

The ultimate job of healthcare is to deliver health. This is not done in boardrooms or on white screens. It’s done in the exam room, face to face. It’s done by listening, seeing, touching and teaching. It’s done imperfectly, and not with immortality as the goal, but rather, the betterment of life in the short time we are present.

So I ask, are we sober enough to see the truth? Are we courageous enough to accept the truth? Can we learn from mistakes, or, are patients destined to the same fate as students?


11 replies on “The VA healthcare system — Can we handle the truth?”

Dr. J.

Have you just joined the ranks go apologists for a bureaucratic system of healthcare?

I think most everyone does and should agree with you that Veterans deserve the best healthcare from our country.
Interestingly, while our Veterans fought to protect our freedoms, our government and VA system take away their freedoms to choose where, who and when they receive healthcare.

If our Veterans fought for our freedom, maybe it’s time we gave them freedom as well.

We do not have a free market system that has failed. We have a third party system controlled by government and insurers, among other players that has failed. The argument about a free market failure does not hold up.

Physicians all want to do the right thing. We are all on the same side, the improved health of our patients. The debate we are having is how to provide that, not whether we should.

If freedom is what our Veterans fought for, give them healthcare freedom, give them the opportunity to choose where to go for their healthcare and the means to do it that is fair, honest and where they are responsible for managing the costs.

We all manage our lives in many ways. Healthcare is not so special that we should give this freedom up to ANY bureaucracy.

Thank you for your excellent apolitical discussion of the VA and its role in United States Health care and your sobering assessment of what would be necessary to promote rationality in American health and health care.

Currently, EHRs are intrusive and burdensome. However, applying principles described in Atul Gawande’s book “The Checklist Manifesto,” EHR systems could be simplified and include patient-facing components that would promote patient participation in care.

At $9,000 per person per year, and rising, the Unites States health care system is approaching unsustainability. When push comes to shove, as it soon will, I hope that voices like yours will be heard.

Dr. John, I’m reasonably sure that someone hijacked your keyboard and password, and posted something that would have made even Lenin and Marx blush. You should check into it. Obamacare not big enough? Doesn’t impose enough centralized control? The IPAB it creates (but hasn’t yet implemented) is not powerful or unaccountable enough? Hospitals must all be of one design, with one approach to providing medical services? No one may have any treatment unless everyone can have it? Spoken like a true progressive, — actually like a true communist, but there isn’t much difference –one who thinks a bureaucracy and its technocrats knows best, and implements what it knows fairly and efficiently, despite all the evidence to the contrary. But this is stunning: “The VA is the truth”. If so, then we are all doomed.

Dear Dr. M:
I read this on twitter and just about fell over. Welcome to the dark side, chum. Be careful where and when you say these things as the blow back can be pretty nasty. Fortunately you’re in a high prestige sub-specialty so you should be fine.

I worked in hospitals in France and New Zealand during training and they reminded me of nothing so much as the VA. I loved the VA. I think that healthcare should be MORE like the VA rather than the other way round.

You are so right about the fact that unlike everyone else, the VA actually looks at outcomes. There are surgeons out in practice who are horrible, but my patients are seen by them for reasons beyond my control. In private-land the incompetence often gets hushed up. The fact that the VA has scandals is to its credit.

Dr. J

I work in an Emergency Department less than one mile from the Phoenix VA.

They are frequently on ambulance diversion. Their doctors tell me they can not handle strokes, heart attacks, or broken hips. They struggle to deliver the most basic critical care.

They do not have a MRI machine, or if they do it is frequently unavailable. The MRI is often seen as an expensive waist, but if you have spinal cord compression it is priceless.

I hear the calls of the frustrated angles working in that system on a daily basis.

The great thing about the VA always being on divert is that we get to treat the nations veterans, a job we all enjoy. I am glad they are considering allowing those of us in the private sector to participate in their care to relieve the pressures on the system.

The truth is that the care our veterans receive in my local VA hospital is not acceptable.

We seem to be right on the same path. I’m in health IT but other half for 10 years is a doctor so I saw and heard a lot. I’m a healthcare blogger who wrote an early EMR so I get it. I don’t develop anymore, but I’m with you on the algorithms and putting the human back in the picture as I wrote we have become a nation of stat rats and magpies who just repeat them.

The problem as I see it is that we have too many out there that can’t tell the difference between the “real” world values and virtual values. I let it roll a bit on this interview below with some of my feelings. I talk about the VA and here in the so Cal area, Vets get sent to private hospitals all the time when ERs get crowded, mostly older Vets and they don’t have Medicare B or C or Tri-care so hospitals eat it. I look at it this way, doctors deal with the “real” world every day and there’s a name for that: Patients.

Talk about dumb algorithms, we have stories like this where a Vet gets his benefits cut to $6 a month as the VA overpaid him over time. You know what it was just $3000 over payment, eat it I say as it was direct deposits and at 89 years old he may have missed it.

I get frustrated at the entire system and even the White House is stuck in too many virtual values and they can’t see it either and I write about it a bit as they have become one big template anymore and their consumer correspondence website shows it, boring very virtual and does little. I call this “The Grays”…

I have a special section too you can check out called “The Attack of the Killer Algorithms” that helps consumers understand the math and the query monsters that create the models that are failing and why. There are 4 good videos in my footer too that explain the madness of quantitated justifications for things that are not true.

My father received excellent care from the VA hospital in Atlanta during the 60’s and the 70’s when the demand on the system was being overwrought with wounded veterans coming from Vietnam. It probably couldn’t have extended his life, but if he’d have followed his doctor’s instructions no doubt the quality of the life he had would have been better.

Tell you the truth though, I have been much less impressed with the lack of care that my son has received through them for an injury that he received in 2010 when he was repelling out of an Air Assault helicopter in Iraq. If a torn rotator cuff has not responded to physical therapy after 4 years, it’s not going too. The VA deserves all the indictment they are getting.

If you shut up truth and bury it under the ground, it will but grow, and gather to itself such explosive power that the day it bursts through it will blow up everything in its way.
As quoted in Dreyfus : His Life and Letters‎ (1937) edited by Pierre Dreyfus, p. 175

This appeared on the opening page of Tyler Hamiltons book “The Secret Race”. Your post today reminds me a bit of his initial attempt to wake people up to the realities of a situation. I read your blog 10 minutes after perfoming a stress test on an 80+ y/o Male with known advanced cancer, and no one batted in eye. Thats the healthcare system at work. Disturbing….

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