VA scandals are long-term systemic problems not a few bad apples.

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Dr. Gary Kao is the only one named in the unfolding VA scandal at the Philadelphia VA Medical Center. He and others say he’s a scapegoat. Is Gary Kao a renegade physician, or a sacrificial lamb – or maybe just a doctor who was allowed to get in over his head?

Kao is the only person whom officials have identified in the unfolding scandal over substandard radioactive seed implants at the Philadelphia VA Medical Center. As the radiation oncologist who did most of the implants, Kao played a central role.

However, a huge cast of actors supported and directed him – week after week, for six years – until the VA suspended the program a year ago. Simply put who did Dr. Kao report to, his was his boss? Who was responsible and accountable for Dr. Kao’s actions besides of course Kao?

Punish them but don’t let Doctors be scapegoats for VA systemic problems AND don’t let the right-wing make a mockery out of Veterans benefits and rights.

That is the message that came out of a Senate Veterans Affairs Committee hearing that grilled VA Physician Dr. Gary Kao about the unfolding scandal involving systemic management problems at the Department of Veterans Affairs that are leading to patient deaths, injury, or exposure to HIV or hepatitis. Several issues are becoming glaringly clear; it is way past time for serious Congressional oversight of the VA that includes a through house cleaning of upper and middles management. Secretary Shinseki promised us that when he was selected to lead the agency but has he delivered?

Robert L. Hanafin
Major, U.S. Air Force-Retired
Veterans Advocacy Editor
VT News Network

      Troubles at VA beyond 1 doctor.

By Marie McCullough Philadelphia Inquirer Staff Writer

Extract:

Gary Kao is the only one named in the unfolding VA scandal. He and others say he’s a scapegoat. Is Gary Kao a renegade physician, or a sacrificial lamb – or maybe just a doctor who was allowed to get in over his head?

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Kao is the only person whom officials have identified in the unfolding scandal over substandard radioactive seed implants at the Philadelphia VA Medical Center. As the radiation oncologist who did most of the implants, Kao played a central role.

However, a huge cast of actors supported and directed him – week after week, for six years – until the VA suspended the program a year ago. Simply put who did Dr. Kao report to, his was his boss? Who was responsible and accountable for Dr. Kao’s actions besides of course Kao?

Ms. McCullough reports that “those actors included a medical physicist with little experience in developing implant treatment plans, a radiation-safety committee that allowed crucial radiation-dosage calculations to go undone, and Nuclear Regulatory Commission (NRC) inspectors who let Kao revise two patients’ treatment plans to avoid reporting medical errors, according to the Veterans Affairs investigation report.” From top to bottom, McCullough reported that VA report concluded, there was a lack of concern for patient safety and accountability.

That’s a chilling denunciation, considering that the VA worked with eminent institutions – the University of Pennsylvania Health System and the NRC – to create and run the high-tech brachytherapy program. The treatment involves permanently implanting tiny radioactive beads in the prostate gland. The beads emit cancer-killing radiation for about 10 months. Of 114 prostate-cancer patients who underwent brachytherapy, 92 received suboptimal radiation to the prostate or potentially harmful levels to nearby organs or both.

Kao, who took a leave of absence from Penn on June 24, testified last week before a Senate hearing run by Sen. Arlen Specter (D., Pa.). Kao decried the media’s portrayal of him as a "rogue" and complained that he was being scapegoated. Some observers say he has a point. "I don’t condone the mistakes he made, but I also don’t blame him for feeling that he is being made a scapegoat," said Peter Crane, an NRC lawyer for 23 years and now a sharp critic of the agency. "This was a systemic failure, not the failure of one individual."

Three people with insight into this system wide breakdown were listed as witnesses at the Senate hearing: Mary Moore, the Philadelphia VA’s radiation-safety officer; Joel Maslow, chair of the VA’s radiation-safety committee and a Penn infectious-disease specialist; and Richard Whittington, a Penn radiation oncologist who did a small number of the brachytherapy implants. They were not questioned by the senators, nor were they allowed to speak to reporters.

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Gary D. Kao (seated at table, second from left) was among witnesses at the Senate hearing in Philadelphia. Others included patients and administrators.

Had they cared to, the senators could have asked why the radiation-safety committee allowed a computer-interface problem to go uncorrected for a year, jeopardizing patients’ treatments. Because of the computer problem, patients’ actual post implant radiation doses were not calculated, so no one knew whether they were getting the prescribed amount.

The NRC, another big player in the mess, says in news releases that it responded "aggressively and decisively to the medical errors" at the VA.

But the commission’s public records appear to belie this.

In 2003 and 2005, the NRC investigated two mistakes that the VA reported to it. In both cases, Kao injected half of the radioactive seeds that were meant for the prostate into the patient’s bladder. Although an urologist was able to retrieve the errant seeds, the patients’ prostate glands obviously received less radiation than prescribed. The NRC concluded there was no "medical event" – the regulatory euphemism for medical error – because the patients’ treatment plans were revised to indicate how few seeds actually wound up in their prostates. In light of the scandal, the NRC has reviewed both cases and concluded they were indeed medical errors.

NRC spokeswoman Viktoria Mitlyng said the agency was responsible for the lax care only to the degree that it misplaced its trust in the VA. When the brachytherapy program was created in 2002, she explained, the NRC allowed the VA to create the National Health Physics Program, which was supposed to monitor treatment and report any problems to the NRC. In effect, the VA was its own watchdog.

[Note: This tends to be a trend with most that goes on at the VA. In fact, the trend is so overwhelming that the only reliable watchdog over the VA in years has been an informal yet influential one, Larry Scott’s VA Watchdog organization].

"Obviously," Mitlyng said, the National Health Physics Program "didn’t work as well as we expected. We will be looking at increasing our own inspections of the VA."

In his testimony, Kao pointed out that he was part of a team – although he didn’t name any teammates. Another part of his defense sounded less persuasive: He said that in 2002, the NRC had no definition of a reportable medical event. He also said the NRC never trained his team "on this issue."

In fact, a simple Google search (NRC report medical event) brings up the reporting rule, which applies to radioisotope medical use in general, not just brachytherapy.

[Note: if more Congressional staff members would do a Google search on about anything, they could find out just about anything much of it data of value].

Kao also contended that the definition of a medical event keeps evolving and is "a subject of debate" – which is true.

So far only a few of the VA’s 114 brachytherapy patients have come forward to complain and file liability claims.

Soon after officials closed the poor-quality prostate cancer program at the Philadelphia VA Medical Center in mid-2008, Faye Flam at the Philadelphia Inquirer wrote that the entire facility was accredited by the Joint Commission, the main group that assures quality at the nation’s hospitals.

During the recent Senate Veterans Affairs Committee hearing, several senators wondered how the Joint Commission could have given the Philly VAMC its accreditation given that circumstance. In response Robert Wise, vice president of standards and survey methods for the Joint Commission said, "We need to pull back and take a look at this."

The senators also wanted to know if such mistakes were occurring at VA hospitals more than at facilities in the private sector, and whether still more errors in the hospital system would emerge. "What worries me is what else has happened," said Sen. Richard Burr (R., N.C.).

Of note, the Philadelphia VA was not the main focus. Much of the 21/2-hour hearing focused on findings that other VA hospitals had improperly sterilized their equipment, putting more than 200 veterans at risk for HIV and hepatitis B infections after colonoscopies and other screening tests. But the senators’ concerns also encompassed recent revelations that a doctor at the Philadelphia VA Medical Center botched 92 out of 114 prostate cancer radiation treatments, in some cases causing grave injury by placing radioactive pellets in other organs.

"This is an unacceptable way to treat our veterans," said Burr, who called the hearing along with Daniel Akaka (D., Hawaii), the committee’s chairman.

Akaka and Burr directed most questions about the Philadelphia VA not at Dr. Kao but to Gerald M. Cross, the VA’s acting undersecretary for health. Akaka asked Cross whether the VA had any proof of the competence of the doctor who conducted the radiation procedures, Gary Kao, a University of Pennsylvania radiation oncologist who was contracted out to the VA. Akaka suggested that Penn did not consider Kao qualified to do those procedures on its own patients.

"We haven’t looked into that specific allegation," said Cross, "but that doesn’t excuse our lack of oversight."

Cross noted that the Philadelphia VA had just earned good marks from several external expert panels, including the American College of Radiation Oncologists and the Joint Commission.


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Readers are more than welcome to use the articles I've posted on Veterans Today, I've had to take a break from VT as Veterans Issues and Peace Activism Editor and staff writer due to personal medical reasons in our military family that take away too much time needed to properly express future stories or respond to readers in a timely manner. My association with VT since its founding in 2004 has been a very rewarding experience for me. Retired from both the Air Force and Civil Service. Went in the regular Army at 17 during Vietnam (1968), stayed in the Army Reserve to complete my eight year commitment in 1976. Served in Air Defense Artillery, and a Mechanized Infantry Division (4MID) at Fort Carson, Co. Used the GI Bill to go to college, worked full time at the VA, and non-scholarship Air Force 2-Year ROTC program for prior service military. Commissioned in the Air Force in 1977. Served as a Military Intelligence Officer from 1977 to 1994. Upon retirement I entered retail drugstore management training with Safeway Drugs Stores in California. Retail Sales Management was not my cup of tea, so I applied my former U.S. Civil Service status with the VA to get my foot in the door at the Justice Department, and later Department of the Navy retiring with disability from the Civil Service in 2000. I've been with Veterans Today since the site originated. I'm now on the Editorial Board. I was also on the Editorial Board of Our Troops News Ladder another progressive leaning Veterans and Military Family news clearing house. I remain married for over 45 years. I am both a Vietnam Era and Gulf War Veteran. I served on Okinawa and Fort Carson, Colorado during Vietnam and in the Office of the Air Force Inspector General at Norton AFB, CA during Desert Storm. I retired from the Air Force in 1994 having worked on the Air Staff and Defense Intelligence Agency at the Pentagon.