The Veterans Administration (VA) is as indelible and resilient as the patients it serves. The service has changed, succeeded beyond belief and otherwise trudged along to the present. As a preclinical medical student, one hears all kinds of things about “this one VA patient,” without any context, and it piques curiosity. Without reference, one might look to the organization itself for a glimpse of the personality mentioned. The VA stands sentinel, guarding the health of our military men and women through the unknown and unexpected consequences of war.
In 1978, the VA began to assign a constellation of otherwise unrelated symptoms to Agent Orange exposure, the defoliating chemical used broadly in the jungles of Vietnam. This first foray into long-lasting effects of occupational exposure led the VA to offer care for diseases with unusually high prevalence among its patrons with yet unknown associations. The list of symptoms associated with Agent Orange evolved well into the 1990s to include a number of diseases: sarcoma, non-Hodgkin’s lymphoma, lung cancers, prostate cancer, multiple myeloma, peripheral neuropathy and veterans’ children born with spina bifida. Unconditional care continued into the Gulf War, whose veterans began to exhibit an unexplained constellation of fatigue, rash, shortness of breath, headache, joint pain, GI distress, chest pain and other symptoms. The VA tackled the unexpected in perpetual fulfillment of Lincoln’s call.
This constant evolution renders the institution almost progressive. As early as WWII, women returning to the post-war workforce were granted the same hiring priority as returning men. The Center for Women Veterans was founded in 1994 along with the Center for Minority Veterans, to ensure both gender-specific needs and equal access. The centers are utilized well and filled a gaping need. Thirteen percent of all Gulf War veterans are women.
Imperfection, too, shadowed the institution’s progress. The very first secretary of the Veterans’ Bureau was imprisoned after two years and convicted of conspiracy to commit fraud. Poor care in the 1980s lead to public outcry and 2014 unveiled widespread internal manipulation (Weeks). Altogether the VA itself assumes a history of its own: full of triumph, disappointment and adversity and is overall oddly human.
The VA guards its own health tradition, one of vigilance and ultimate generosity to those similarly defined. As medical students, perhaps far from our academic hospitals and further still from our lecture halls, we neither appreciate nor spectate but partake in its unfolding. An encounter at the VA is one with both a person and an institution who share pure intention and a fullness of spirit as only age allows. And as with any other encounter we meet the patient, objectively learn the history and dare ourselves to improve upon it.
That time for improvement is indeed the present. The VA’s colorful past might very well pale when compared to its near-present flounderings. The VA Scandal of 2014 revealed the system’s ongoing flaws and the dire need for a generation of new, attentive practitioners. The affair is complicated and resolutely riddled with bias even after almost three years’ hindsight. Multiple sources best provide appropriate context and those referenced here are largely apolitical.
Each new VA patient is guaranteed a primary care appointment within two weeks of acceptance of his or her discharge paperwork (Zezima). The goal sounds lofty, even for well-resourced private practice clinics, and the idealism was indeed misplaced. It was discovered that many veterans instead waited about 115 days for an appointment to establish care. The delay was, in fact, deliberately negligent. Some alleged that many died of treatable illness while waiting for these initial visits. Doctors who complained were apparently shuffled within the system or placed on leave. The claims were many but those confirmed are listed in the Department of Veterans Affairs Access Audit, released May 30th, 2014. Secretary of Veterans Affairs Eric Shinseki resigned following its results. The full report is available here (condensed findings begin page 3). A few particular findings well encapsulate both the magnitude and the injustice of the infuriating debacle:
- “Overall, 13 percent of scheduling staff interviewed indicated they received instruction (from supervisors or others) to enter in the “desired date” field a date different from the date the Veteran had requested. At least one instance of such practices was identified in 76 percent of VA facilities.”
- “Eight percent of scheduling staff indicated they used alternatives to the Electronic Wait List (EWL) or Veterans Health Information Systems and Technology Architecture (VistA) package. At least one such instance was identified in 70 percent of facilities.”
- “Findings indicate that in some cases, pressures were placed on schedulers to utilize inappropriate practices in order to make waiting times (based on desired date, and the waiting lists), appear more favorable.”
Public outcry following the nauseous chain of events prompted passage of H.R. 4031, the “Department of Veterans Affairs Management Accountability Act of 2014.” It authorizes the Secretary of Veterans Affairs to remove or reassign any individual of the Senior Executive Service. It passed the House without amendment on May 21st, 2014. The bill, however, neither restored faith nor mollified the public scorn over a laundry list of unforgivable travesties.
The past three years proved hardly reparative. Despite an overwhelmingly bipartisan sense of injustice, many negligent VA employees remained on the VA payroll. Supervisors lacked the authority to terminate employees despite obvious unprofessional behavior. Congress passed the “VA Accountability and Whistleblower Protection Act” on June 13th, 2017 to strengthen the VA Secretary’s power to fire substandard staff. The final vote was 368-55 in favor and, after a bitterly polarized election year, sounds like unfathomable cooperation. Greater ‘cleaning house’ power is necessary but hardly a guarantee of improvement. The scandals here present both a screaming need for resolution and, with Congressionally mediated turnover, unique opportunities for young physicians to engage a rightfully skeptical public and restore.