Walter Reed and the VA

I know I promised this a long time ago, and I apologize. But have your parents in town, spend two painful weeks at work, go on vacation, and suddenly you'll notice that a month has gone by. I have a bunch of other things to write about, so I wanted to get this done, and I apologize for the text heavy format. Before I get into my analysis of this issue, I want to do recognize some people and some biases.

Shout-outs:
1) Everyone who is eligible for treatment at the VA or military hospitals . Thanks for your sacrifice.
2) Defense Secretary Robert Gates. He made heads roll over this in a way previously foreign to President Bush's administration. Rummy would still be giving cyclic arguments to the press about the unknown unknowns. If Gates had cleaned up Abu Ghraib, we might have a little more respect on the international scene.
3) The Press. Nice job keeping at this story. I wish you had been this dogged about pursuing stories on WMD and Nigerian Uranium, instead of being an a bullhorn for the administration. Welcome back to the game.

Biases:
1) I worked at the Atlanta VA as a student, and the San Francisco VA as a resident. I loved it.
2) I'm not sure if my observations at VAs attached to medical schools apply to other VA hospitals.
3) I was offered a job at Tripler Army Hospital in Hawaii. They needed civilian docs because many of their specialists were deployed. I turned it down, but only because I didn't want to move to Hawaii.
4) I'm a doctor, so I may not give the MDs as much blame as we deserve.

Let's do Walter Reed first. It was terrible, and it should NEVER have happened. There are two specific points about it that I want to discuss.

First, the worst of it appears to have been related to outpatient care. Not a big surprise. If you've tried to do anything medical from home, you know that "pre-authorizations" are a pain. Once you're in the hospital, I can do almost anything I want, and they have to pay for it as "acute care". If they want to fight it, they have to try to do it after the fact, and convince a bunch of doctors that I should have known it was unnecessary when I did it. Once you're discharged from the hospital, it gets harder again. Insurance companies (and MediCare/Cal) make it easier to get a hospital day covered than help or therapy at home or in a nursing facility, even though the latter is much, much cheaper.

Second, it seems that there was a problem getting paperwork done. This problem is not unique to the military, though we should make a special effort there. I can barely get through health care paperwork, so I don't have high hopes for my patients who aren't lawyers. When there are people paid to help with this stuff, they are often clock punchers. Even some of those who started as idealists get burnt out. (See below) That said, I have met a few amazing social workers and case managers.

On to the VA. In large cities, the VA Hospital is usually associated with a major medical school (SFVAMC and UCSF, Atlanta VA and Emory). The attending physicians are usually university faculty, and the house staff are high quality trainees. So, with regard to the doctors, the medical care is about what you'd get at a university hospital. The staff is hit or miss -- some are great, some have jobs way over their heads; but you can usually get more money elsewhere, so most people are there because they want to be. Honestly, the VA was always my favorite place to work -- the patients are the best, and you feel like you are doing someting worthwhile.

Most of the limitations of the VA system derive from the fact that it is basically a rationed system. They have a budget from the government, a certain number of patients, and they do the best they can. They group some therapies to certain hospitals by region -- the SFVAMC did the heart bypasses for veterans as far away as Reno, NV. Since we only had one or two surgeons, they often had to wait. It didn't matter if they were a General or a Private, they went in order of wait or illness. There are ways for sicker patients with imminent problems to speed through the system -- but they need to get into the system first. The big problem becomes getting that first appointment with a primary care doctor.

One answer will be to add more primary care doctors -- but there are budget limitations. The other answer involves changes in our focus on preventative health, as a system and on a personal level. I don't mean to sound harsh, but too many veterans never see a doctor until there is a crisis. If we could get these men and women into the system before things go bad, we'd have them hooked in when the problems arise.

Notice, by the way, that the problems at the VA and Walter Reed are common to any rationed, managed health care system. If I had my choice, I'd go to the VA over Kaiser in a heart beat. Financially speaking, both the VA and Medicare run at a significantly lower administrative overhead cost than other managed health systems.

These problems also reflect the poor planning of President Bush and his staff. The Iraq war adds daily to the roll of soldiers who will need treatment at these facilities, but there seems to be no strategy for this "surge". Like the ground/civil war in Iraq, it will probably be a mess left for the next commander-in-chief to fix. I hope he or she is up to the challenge.

Posts Script: I finished this post on the day of the tragic massacre at Virginia Tech. My condolences to the family and friends of all the victims. The coming discussions of violence, the second amendment, etc., are important; but they can bring back the people who lost their lives.