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Editorials

Last 50 Editorials

(Click on title to be directed to posting, most recent listed first)

What Will Happen with the Generic Drug Companies’ Lawsuit: Lessons from
   the Tobacco Settlement
The Implications of Increasing Physician Hospital Employment
More Medical Science and Less Advertising
The Need for Improved ICU Severity Scoring
A Labor Day Warning
Keep Your Politics Out of My Practice
The Highest Paid Clerk
The VA Mission Act: Funding to Fail?
What the Supreme Court Ruling on Binding Arbitration May Mean to
   Healthcare 
Kiss Up, Kick Down in Medicine 
What Does Shulkin’s Firing Mean for the VA? 
Guns, Suicide, COPD and Sleep
The Dangerous Airway: Reframing Airway Management in the Critically Ill 
Linking Performance Incentives to Ethical Practice 
Brenda Fitzgerald, Conflict of Interest and Physician Leadership 
Seven Words You Can Never Say at HHS
Equitable Peer Review and the National Practitioner Data Bank 
   Fake News in Healthcare 
Beware the Obsequious Physician Executive (OPIE) but Embrace Dyad
   Leadership 
Disclosures for All 
Saving Lives or Saving Dollars: The Trump Administration Rescinds Plans to
   Require Sleep Apnea Testing in Commercial Transportation Operators
The Unspoken Challenges to the Profession of Medicine
EMR Fines Test Trump Administration’s Opposition to Bureaucracy 
Breaking the Guidelines for Better Care 
Worst Places to Practice Medicine 
Pain Scales and the Opioid Crisis 
In Defense of Eminence-Based Medicine 
Screening for Obstructive Sleep Apnea in the Transportation Industry—
   The Time is Now 
Mitigating the “Life-Sucking” Power of the Electronic Health Record 
Has the VA Become a White Elephant? 
The Most Influential People in Healthcare 
Remembering the 100,000 Lives Campaign 
The Evil That Men Do-An Open Letter to President Obama 
Using the EMR for Better Patient Care 
State of the VA
Kaiser Plans to Open "New" Medical School 
CMS Penalizes 758 Hospitals For Safety Incidents 
Honoring Our Nation's Veterans 
Capture Market Share, Raise Prices 
Guns and Sleep 
Is It Time for a National Tort Reform? 
Time for the VA to Clean Up Its Act 
Eliminating Mistakes In Managing Coccidioidomycosis 
A Tale of Two News Reports 
The Hands of a Healer 
The Fabulous Fours! Annual Report from the Editor 
A Veterans Day Editorial: Change at the VA? 
A Failure of Oversight at the VA 
IOM Releases Report on Graduate Medical Education 
Mild Obstructive Sleep Apnea: Beyond the AHI 
Multidisciplinary Discussion (MDD) in Interstitial Lung Disease; Some
   Reflections 

 

For complete editorial listings click here.

The Southwest Journal of Pulmonary and Critical Care welcomes submission of editorials on journal content or issues relevant to the pulmonary, critical care or sleep medicine.

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Entries in scandal (2)

Wednesday
Nov112015

Honoring Our Nation's Veterans 

Today is Armistice Day, renamed Veterans Day in 1954, to honor our Nation's Veterans. In Washington the rhetoric from both the political right and left supports our Veterans. My cynical side reminds me that this might have something to do with Veterans voting in a higher percentage than the population as a whole, but let me give the politicians this one. Serving our Country in the military is something that deserves to be honored. I was proud to serve our Veterans over 30 years at four Department of Veterans Affairs (VA) hospitals.

However, the VA has had a very bad year. First, in Washington there were the resignations of the Secretary of Veterans Affairs, Eric Shinseki; the undersecretary for the Veterans Health Administration, Robert Petzel; and the undersecretary for the Veterans Benefits Administration, Allison Hickey. Locally, in the light of the VA wait scandal there were the firing of the Phoenix VA Medical Centers director, Sharon Helman, and her deputies along with the retirement of her boss, Susan Bowers. Furthermore, there seem to be a never-ending string of scandals ranging from the mundane of greed-driven fraud to the more exotic of accusing a VA whistleblower of engaging in sexual threesomes. Despite a healthy increase in funding, there was the threat by VA administrators of closing VA hospitals to meet a VA budget shortfall. This resulted in Congress knuckling under to allow the use of emergency funds. Veterans groups are using billboards to accuse the VA of lying (Figure 1).

Figure 1. Billboard across from the VA October 12, 2015.

I could go on and on. However, the real question is not so much of what dirty deeds are being done, but how the VA administrators get away with it.

There has been both a lack of oversight and lack of accountability. Robert McDonald, who replaced Shinseki, has promised to punish the evil doers but has replaced action with the mantra "all is well" and has done nothing. In several instances wrong-doing has apparently been rewarded, such as Bowers replacement having lied to Congress (1). If the VA cannot police itself-and it apparently cannot-there are a multitude of regulatory agencies that have shirked their oversight responsibilities. I thought it was time to mention a few.

First, there are both the Veterans Integrated Service Networks, the regional VA offices, and VA Central Office itself in Washington. Both these organizations have been caught in the scandals and have done nothing. Second, there is Congress. The House Veterans Affairs Committee has seemed to make a sincere effort to identify some of the problems but Secretary McDonald and his cadre of 11,000 in Central Office has repeatedly stone-walled any investigation and Congress has done nothing. Third, there is the White House. The Obama Administration has seemed more interested in declaring the problem fixed than actually fixing the problem and has done nothing.

Those are the obvious but there are some less obvious regulatory failures. First, there are the multiple hospital inspectors. Within the VA is the Office of Inspector General (IG) who is charged with investigating wrong-doing within the VA. Locally they had been called to Phoenix multiple times including for the wait time scandal but have done nothing. The poor performance resulted in the resignation of the acting VA IG, Richard Griffin, under pressure. Second, there is the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO). The Phoenix VA Medical Center managed to go from a "top performer" in 2011 to noncompliant "with U.S. standards for safety, patient care and management" in 2014. Only the naive would believe that a hospital can transition that much in 3 years. There is also the Arizona Board of Medical Examiners and Nursing. Both doctors and nurses were involved in the cover-up of the wait scandal but these boards have done nothing. The VA is the largest system for training future physicians and nurses, and it seems that the future doctors and nurses might not be learning the highest professional and ethical standards. Nonetheless, the Accreditation Council for Graduate Medical Education (ACGME) and American Association of Colleges of Nursing have done nothing.

However, my personal disgust is highest for the Department of Justice (DOJ). It is known that seventy percent of the hospitals were fudging their wait data. The administrators, not the doctors or nurses, received bonuses for short wait times. None of the administrators have gone to jail or even been charged with fraud. None have even had to repay their bonuses. The DOJ has done nothing. If 70% of the doctors were caught faking data to received bonuses, I have every confidence that the legal eagles at DOJ would gleefully put each and every one on trial.

So what can be done? There appears to be no oversight. This was clearly illustrated in the report from the recent Human Resources (HR) team from Central Office sent to Phoenix to help with what can be kindly described as a dysfunctional department. They were essentially shown the door by the acting director, Glen Grippen, saying that he "calls the shots" (2).

The solution is that Mr. Grippen and others of his ilk should no longer call the shots. They have shown a consistent arrogance and disregard for our Nation's Veterans and those that serve them. He and others need oversight, not by a far-off committee in Washington as President Obama has proposed which will likely fare no better than Congress. Oversight could be best provided by local physicians and nurses who have interest in Veteran care but are not employed by the VA. This used to occur in many VA hospitals and was called the Dean's Committee. The dean of the local medical school along with the chairman of the departments of medicine, surgery, pathology, radiology, and others formed a committee that oversaw care at the VA. The committee had interests in the patient care of Veterans but also in the physicians who were faculty at the local medical school and the medical students, residents and fellows who were under their supervision. This committee was a victim of Ken Kizer's "prescription for change" in the 1990s. Now, this old system might be an antidote for Kizer's prescription which has seemed to turn poison.

The VA is pushing to hire more personnel to deal with wait times and lack of patient care. However, it is unclear how many of the new hires are doctors and nurses contributing to patient care and how many are administrators and bureaucrats.  My experiences and conversations with my colleagues convinces me that not all hospitals are as badly managed as those in the Southwest. Those considering a career at the VA need to carefully investigate each hospital to see if it is the type of place that the leadership will provide the resources to care for the Veterans, which is after all, the definition of leadership.

Richard A. Robbins, MD

Editor, SWJPCC

References

  1. Wagner D. Department of Veterans Affairs names new regional health director. Arizona Republic. October 15, 2015. Available at: http://www.azcentral.com/story/news/arizona/politics/2015/10/15/department-veterans-affairs-names-new-regional-health-director/73900478/
  2. Wagner D. VA team blasts Phoenix personnel office. Arizona Republic. November 2, 2015. Available at: http://www.azcentral.com/story/news/arizona/investigations/2015/11/02/va-team-blasts-phoenix-personnel-office/74763366/

Cite as: Robbins RA. Honoring our Nation's Veterans. Southwest J Pulm Crit Care. 2015;11(5):228-30. doi: http://dx.doi.org/10.13175/swjpcc141-15 PDF

Monday
Nov102014

A Veterans Day Editorial: Change at the VA? 

"Meet the new boss,

Same as the old boss.

Won't Get Fooled Again!"

            -Peter Townshend

Today we honor our veterans. A year ago VA patients languished on waiting lists waiting for healthcare. VA administrators hid the truth at over 100 VAs and took bonuses for meeting their wait time goals. Money has been poured into the VA, patients in rural areas are seen outside the VA, and it is now supposedly easier to fire other senior VA officials. Dennis Wagner authored an article in the Arizona Republic that claimed the VA has made some changes but more changes are needed (1). I agree with the need for change but would argue that there has been no real change at the VA.

Last week I saw a VA patient in my private practice. He was paying for tiotropium or Spiriva®, a long-acting anticholinergic used in chronic obstructive pulmonary disease, out of his pocket. He was under the impression that the VA did not "carry" tiotropium. I told him that this was not true and that he should go to the VA and ask to be seen in pulmonary clinic if his primary care physician could not prescribe tiotropium. He was sent to the pharmacy where the pharmacist wanted to know why I would prescribe this expensive drug. He was sent back to my office for a response. I xeroxed a copy of my notes and gave them to the patient. I do not know whether he got the tiotropium but my guess is that probably not without some hassle. This is unchanged from prior to the scandal when patient care was undermined by healthcare support staff. No real change there.

Last night, the new Secretary of the VA, Robert McDonald, was on "60 Minutes" (2). He announced that he is "reorganizing" the VA. Although details were not stated, this sounded mostly like a consolidation of websites, not a bad thing, but hardly a "reorganization". He also said how sorry he was for past mistakes and how the new VA was going to do better. I had déjà vu going back to the mid 90's with Ken Kaiser's "Prescription for Change" (3). Eric Shinseki, the VA secretary recently forced to resign, used similar rhetoric and was "mad as hell" at the falsified wait lists (4). No real change there.

McDonald used the term "customers" to refer to VA patients (2). This has occurred off and on since the mid 90's and is a term some healthcare providers find offensive. We do not flip burgers at McDonald's and find it inappropriate and offensive to equate healthcare professionals with businessmen selling Charmin, Luvs, Pampers, Gillette razors, Covergirl makeup, etc. No real change there.

Earlier this week, the VA named a new director at the Phoenix VA, ground zero of the VA scandal (5). He is the former director of the Milwaukee VA and director of the VA's Rocky Mountain regional network, apparently coaxed out of retirement to serve for about a year as director at the troubled medical center. He replaces two directors who served a matter of months. While director at the Rocky Mountain VA region he named Cynthia McCormack, former chief of nursing at the Phoenix VA, as director of the Cheyenne VA (6). Cheyenne was second only to Phoenix in having the widespread falsification of wait times discovered. Sharon Helman, the Phoenix VA director sits at home suspended while collecting a paycheck but McCormack appears to continue to direct the Cheyenne VA. No real change there.

Although a handful of administrators have been fired by the VA, the data falsification was rampant, with most VAs apparently falsifying their records (2). Yet these administrators retain their jobs and continue to rule their healthcare empires. McDonald claimed that names had been turned over to the Department of Justice (DOJ), but the DOJ declined to prosecute, and that administrative law judges were blocking the firing of administrators (2). No real change there.

The VA still functions with a lack of oversight. Congressmen make statements and issue press releases when politically convenient. The VA office of inspector general (VAOIG) still does investigations in response to whistle-blowers. After turning over their findings to VA central office to water down, the VAOIG usually makes some recommendations that are quickly accepted but not acted on by the VA (7). No real change there.

Lastly, there is the popular media. For years we heard about Ken Kizer's "Prescription for Change" and the miracle of the transformation to the VA (3,8). This infuriated many of us who knew it was not true (9). We wondered why the press was so accepting of the claims. They certainly are not on other political issues. However, in this case Dennis Wagner of the Arizona Republic, CNN and several other news sources stayed with the story and ferreted out the truth. Real change there. Hopefully, news media with continue their investigative reporting and question VA officials when they put forth self-serving data that is difficult to believe. This is my hope and may be the only result of the VA scandal that will force change. Hopefully the media "won't get fooled again".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

  1. Wagner D. Much change in wake of VA scandal; more needed. Arizona Republic. November 8, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/11/08/phoenix-va-scandal-changes/18716281/.
  2. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/.
  3. Kizer KW. Prescription for change. March 22, 1995. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
  4. Cohen T, Frates C. Shinseki 'mad as hell' about VA allegations, but won't resign. CNN. May 23, 2014. Available at: http://www.cnn.com/2014/05/15/politics/va-scandal-eric-shinseki-preview/.
  5. Wagner D. VA names new director for Phoenix medical center. Arizona Republic. November 4, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/11/04/phoenix-veterans-affairs-medical-center-interim-director-brk/18467665/.
  6. Cheyenne VA Medical Center. Leadership team: Cynthia McCormack. Available at: http://www.cheyenne.va.gov/about/leadership.asp.
  7. Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. [CrossRef]
  8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-27. [CrossRef] [Pubmed]
  9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef] [PubMed] 

Reference as: Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. doi: http://dx.doi.org/10.13175/swjpcc150-14 PDF