“Military Medicine” would be grossly incomplete without a physician’s input, particularly one who spends so much time with veterans. I asked Eric Young, MD, a hospitalist at the Denver Veterans Administration (VA), for his perspectives on service, medicine, their intersection and the greatest opportunities for medical students. All of this article’s insights are his own.
I asked him to tell me a bit about himself and what drew him to the VA. He grew up in Phoenix, attended UC San Diego for undergrad and graduated from the University of Colorado School of Medicine in 2004. He completed his internal medicine residency in Colorado, fulfilled his chief residency at the VA and is now starting his fifth year as a faculty hospitalist. He did not serve but comes from a military family. In medical school he always enjoyed the patient population and military educational experience garnered at the VA. “Even if you don’t practice there,” he reminded, “1/10 of our nation’s population served in the military and one in four are related to a veteran. You will have veterans in your care, and it’s a significant element of the social history, just like marriage and family.” Service impacts health in a vast number of ways in addition to the psychiatric interface of which the provider would be completely ignorant without a simple question.
I then asked the impossible: “Can you describe a typical VA patient?” He gently reminded, “Stereotypes exist, but that’s all they are.” Dr. Young runs the School of Medicine VA Sequential Teaching (VAST) program, an integrated third-year clerkship opportunity that allows students to fulfill the majority of their rotations at the VA. “The stereotypes might trace back to military service,” he admits, but most likely to the ‘warrior ethos.’ A soldier’s self-care (no complaints, ‘tough it out’) poorly accommodates a medical condition 25 years later. Stoicism in particular might discourage care until a condition advanced. Independence, frequently combined with traumatic brain injury and post-traumatic stress disorder, further complicate access even with ample resources. Furthermore, VA patients hardly represent all veterans. Fewer than a third of all veterans seek care at the VA and more than half of that population still seeks supplemental care elsewhere. Our military trusts many practitioners who in turn must redefine the conception of both the patient and the VA’s scope.
Indeed, the institution itself seeks objective measurement in a political climate often devoid of exactly that. Dr. Young outlined the philosophy: “The VA is in the spotlight because they are the model for what a single-payer system would look like. But it is a highly politicized model. When things go wrong, people are immediately and not inappropriately upset.” VA metrics reflect a country’s commitment to the health of those who served and are extrapolated to a nationwide, civilian system. The VA thus seeks rigor instead of rhetoric and much to its benefit. Recent articles in JAMA note that VA outcomes are as good or better when compared with outside facilities. Wait times, too, while hardly tolerable, fairly well reflect the delay to see a highly specialized physician in private practice. The inaccurate picture of the VA frames two characters, a typecast patient and a tired hospital, both easily debunked with an apolitical lens. “And remember,” Dr. Young emphasized, “that the price is phenomenally lower than typical for that population in private communities.”
Despite its intimate familiarity with sacrifice, the VA stubbornly refuses both a reduction in quality and an increase in cost. I asked if the community (physicians, patients, other providers) were satisfied and Dr. Young replied, “objectively, yes.” Enrolled patients’ care is excellent. “It’s the people outside with fewer inroads that are frustrated. It’s not unique to the VA, but it is a known problem. You’re on the phone for a while.” When asked about the most effective improvements the answer sounded similar: a large investment in primary care. “You need to find enough physicians (adequately paid and supported) that you can have high-functioning clinics with frequent callbacks and rapid response to acuity.” Yet the VA draw to a new primary care physician hardly entices. Many recruits arrive either determinedly reluctant or passionate but susceptible to professional fatigue. They lack support and often choose between a job well done and overall improvement. The VA, however, is hardly able to guarantee incentives to entice the rising best of primary care.
This hesitancy filters through the ranks to schools and young physicians despite the facility’s eagerness to educate and grant otherwise rarely encountered student autonomy. I asked how well medical students were received at the VA; some university patients freely express their disappointment when scheduled with anybody other than the department chair. His enthusiastic response: “Not aberrant at all! Medical students are fully integrated into the culture, perhaps more so than any other large health care system.” Despite the short coat, junior physicians are expected and ultimately respected as physicians on the team. In addition to fewer billing hassles, an incredibly grateful population and ease of documentation, the VA culture is far more welcoming than most other institutions and students might avail themselves of the hospitality. “Some say privatize the VA, or just pay for insurance for all veterans,” Dr. Young said, “yet trainees that spend time at the VA account for a huge percentage of medical education.” The facility itself is a societal value particularly to students.
Other numbers render it an ideal forum aside from the number of pre-professionals it courts en masse. The bare pathology best reinforces the simple essentials that young physicians might easily forget. Dr. Young admitted, “You see a lot of bread and butter clinical conditions, sometimes in more advanced stages. Tons of heart, lung, cancer, internal medicine, surgical things and probably not your super rare University Hospital case.” Despite an admitted lack of female and underserved care, a rotation at the VA might cement proper management of routine cases in memory and prove a far better education than a glimpse of the genetic defect referred to a tertiary center.
Most medical students, however, flee the lecture hall to unique pathology and shiny facilities and neglect quality health care. I asked what mistakes medical students most often make and received an arresting response: “Don’t confuse great health care with great health care facilities! Thoughtful, energetic, well-trained physicians who practice in the utmost evidence-based fashion; that is excellent health care.” The best defy discouragement and abhor the “things are probably broken” excuse. A patient may need a test whose duration far exceeds time available. “Well, then, be more creative” are the exact words medical students need to hear and most would jump at this opportunity over the chance to stand in the back and observe. I anticipated a bit of this future freedom and asked essentially how medical students should practice. Dr. Young instructed to simply ask about veteran status. “Beyond that,” he reminded, “it is reasonable to ask if military service has affected his or her self.” If you keep it open-ended, “they’ll tell you.”
I concluded with a typical MS2 question that barely hid my anxiety and excitement for next year: “What do you think all med students should know before they step in to the VA their third year?” The answer is to think of the VA as a clinical lens to your country’s history. “If someone says that he’s a Vietnam Vet, ask him to tell you about it.” Our culture already forgets recent history and the experience of a huge conflict that involved everybody. He advised at the end of our conversation to: “Use this experience to learn of the roots and sacrifices. And, obviously, the medicine too.”