What do VA doctors and dentists have to say about the VA?

During the summer of 2008, the National Association of Veterans Administration Physicians and Dentists sent out a NATIONAL SURVEY ON THE DELIVERY OF PATIENT CARE to its membership of doctors and dentists who work for the Department of Veterans Affairs.

Before getting to the survey or links to the survey, let me say that it gives a balanced picture of how physicians and dentists within the VA system view themselves, the VA system, and patient care. Several trends will be noted in the survey result that we hope NAVAPD will bring to the attention of Congress, since they get nowhere with VA upper and middle administrative management. That appears to be a long on-going trend at the Department of Veterans Affairs.

In all fairness, the overall results of the survey paint a picture that at least anywhere from a quarter to half the professional medical personnel within the VA system know there are systemic problems and the poor to incompetent upper and middle level administration at the VA is the root cause. I’m not going to repeat the survey results in detail here, for you can find them at this link. Suffice it to say that the divisiveness reflected in this survey could be a reflection of the political polarization and divisiveness within the nation, and among America’s Veterans.

However, what caught my attention, and should be of interest to members of Congress, and especially the Secretary of Veterans Affairs is not so much which blocks a doctor or dentist checked on a patient care survey, but what they had to say about the VA. 

My fellow Veterans and Military Families, what these medical professionals charged with the care of America’s Veterans had to say about their VA was in two words – not flattering. Question is that as a lobbying group before Congress is the leaders of NAVAPD bringing these opinions and concerns to the attention of Secretary Shinseki, or the House and Senate Veterans Affairs Committee or do they also FEAR retaliation from the political hacks and entrenched bureaucrats who own the VA hospitals.

Who the heck are the National Association of Veterans Administration Physicians and Dentists (NAVAPD). Founded in January 1975, NAVAPD was formed by a small group of physicians at the Washington, DC, VA hospital. Initially the organization was known as NAVAP, The National Association of Veterans Affairs Physicians. Today they remain the official organization and voice of VA physicians and dentists who proudly serve our nations veterans. They believe the doctor-patient relationship is a sacred, enduring trust, and they believe that the delivery of quality health care within the VA system depends on preserving and strengthening that sacred relationship.

Most important for our readers, Secretary Shinseki, and members of Congress is that the NAVAPD believe it is critical to reform the VA health care system to further improve quality and access in the 21st century. Today the mission of NAVAPD remains essentially the same as it was in 1975. NAVAPD exists to provide a voice for VA physicians and dentists across the country. NAVAPD remains dedicated to improving the quality of patient care in the VA health care system and to ensure the doctor-patient relationship is maintained and strengthened.

Robert L. Hanafin
Major, U.S. Air Force-Retired
Editorial Board of Directors
VT News Network

VA Physicians and Dentist have very little positive to say about the VA?

   LING TO NAVAPD WEBSITE IN BANNER ABOVE!

The original comments were numerically listed to correspond to the survey question being asked, since we are more interested in the medical professionals’ opinions and views of the VA system, I’ve left out the number in order to focus on what they said:

The focus has shifted from patient care to monitors of care and many times that is at the cost of the patient.

Fire the administration and only allow the Service Chiefs to remain 10 years at most.
Absolute power corrupts all.

Our V.A. is a monster bureaucracy. Our lead dentist and upper management don’t want excellent care – just numbers!

Force the clinical division chiefs to do real work and to see patients-get them off their asses.
Communication is essential to successful patient care. Our med center is being run by business men/women. They are not interested in whether the patients are receiving any treatment in a timely manner, just that every patient can be seen within 30 days. We are overwhelmed with new 100% Service Connected and with new discharges. We are working with an outdated and inadequate scheduling program and administrators don’t understand why we don’t like it. Our clinic utilization is now over 100% so they are happy. Yet our ability to provide care and our # of procedures completed has dropped.

Call clinics create extra work for clerks and doctors and are confusing to the patients. For follow-up care, you should be able to send an appointment for up to one year in the future.

My department is a mess because of malicious management, rampart sexism, racism and cronyism. Doctors are treated very poorly, staffing turnover is constant, low pay compared to other VA’s.

The head of nursing is clearly disturbed and should be removed. The director is not qualified. We need more Nurse Practitioners but they should be supervised!!!!! Not independent!!! Nurses won’t take verbal orders which are ridiculous. They keep adding more directives and "trainings" which waste our time. We have some great doctors here but they are being driven away by nitpicking.

I think dental care should be offered to all vets & pay based upon their income, not just vets that are 100% service connected. A lot of vets have very poor teeth which lead to multiple problems. It is very frustrating to us in medicine.

Over the years the # of patients per provider has increased beyond ability to give adequate care. At the same time the paperwork has increased for the purpose of proving that care is still good. Completion of this paperwork is how the administration is rated and gets passed down. It takes time from clinical care to do all this paperwork.

The VA is a bureaucracy and is inefficient, pay is poor and administration does not seem to care!

Decentralize decision making and lessen micromanagement. We are currently in a unique situation of having no hospitals because of Katrina! We only have CBOCs

We are a small rural hospital. Administrators start out here and ‘move up." The decisions that have been made by current and past 2 directors have been damaging to care of veterans and morale of staff.

We need an administration that understands more than performance indicators.

As a physician, we need to have more input in the quality of the ancillary staff that is part of the team executing care to the veterans (especially nursing) on your immediate staff.
Our hospital is interested more in making the numbers look good, rather than improving underlying infrastructure. There are more people ‘checking’ the work than there are people ‘doing’ the work!

Our Human Resources processes for hiring staff are a severe impediment to hiring good people.

[Major Hanafin’s comment: in a hostile employment environment like this HR chiefs and staff usually are motivated to ignore Veterans’ preference in hiring. I assess that hiring is based on a who one knows or political affiliation as opposed to merit and capability,]

Multiple problems abound with poor efficiency in the OR and also with the way Human Resources treat physicians.

The Veterans Integrated National System (VINS) and VA Central office leadership is very poor, they are always reactionary not proactive. Does not involve [medical] staff in solving problems Extreme and non productive micromanagement.

Scheduling systems are archaic and restructure performance monitors do not accurately reflect relationship of data collection. Systems over emphasize process rather than outcomes. Human Resources are not responsive to managers and function as autonomous organizations. [Put another way every bureaucracy has mini-empires within, but these lead not only to divisiveness between admin and medical professionals but the result will be dirty endoscopes].

Emergency department needs an emergency physician director, and Medical Specialty coverage is terrible.

Retention of quality professional at all levels of health care within the VA is poor.

We run several specialty clinics that have zero nursing staff support. We should have nursing staff available for our patients and physicians – should be a minimal standard of care. There is not enough physical space, either for physicians or patients, and inadequate number of exam rooms for number of patients scheduled. Not enough computers. This is after a move to new space (inadequate space) for construction of other space. There was very poor communication between management, admin staff, and physicians about this move and future plans.

Quality of care would increase with limiting patient panels (mine is about 1450 at this time and wait time till next avail. appt. is about 2 months) I feel strongly that VA health care should provide basic screening tests (colonoscopy for colon cancer screen). This is not readily available in our system.

There is a tremendous amount of non-patient related computer busy work, masquerading as patient care. It is redundant, unnecessary, takes away pt. care and the more volume of it makes it meaningless. The patients are last on the list.

Biggest problem at our hospital are Human Resources. Very difficult to hire. Second biggest problem is IT, particularly getting new equipment.

We have a severe physician staff shortage. The ER could close we are so short-staffed. We are very short on primary care physicians and primary care staff is over – paneled and over-worked. We lack many specialists and there is poor retention of specialist.

The constant addition of mind-numbing educational courses on the already busy clinical schedule, it is repetitive and IT for it is disjointed and chaotic.

We need more radiology staff and equipment (especially in MRI due to the increasing number of neurological, rheumatological and musculoskeletal complaints). We need to improve communication between primary care physicians and specialists. We need more laboratory staff and equipment (large number of patients; laboratories sent to another laboratory for processing). We need to improve pain management documentation in the progress note (we=physicians) and I am referring especially to what medications have been tried and patients response to medication. Please try to avoid difficulties to read pain assessment and management documents. Thanks!

Overbooking [patients] common, opportunity for small surgical procedures is poor. Staff meetings are a joke, mostly ‘atta boys’s without meaningful discussions.

Poor management – too few beds, incredible expensive for outside hospital care – problems and physician recruitment poor pay scale

Improve administrators need to communicate with medical staff and talk about caring for patients instead of performance measures

Admin does not communicate well – they ignore requests. Make demands on timeline but they ignore these timelines. Human Resources are ridiculous they delay resulting in others being dissatisfied. There is poor communication from admin and staff, also inability/difficulty with unions and firing result in difficulties completing mission.

Primary care is the service that frequently is moved to other sites in the Pittsburgh Area. Little thought of continuity and comfort for the patient is given.

Relationship with university is a problem, plus increasing volume of patients without regard to quantity or improving efficiencies.

My biggest dissatisfaction has to do with performance measures. It is ludicrous to demand all patients be seen within 30 days regardless of the urgency. This leads to extreme overbooking appointment slots, long patient wait times and rushed visits. Establishing arbitrary numbers such as this leads to poor quality care rather than achieving the goal of better access to care.

This institution has limited capacity to care for complex medical problems our beloved vets have. If VA system wants to make institution top quality VA system has to have qualified physicians and supporting nursing. We do not have either of them

Community-Based Outpatient Clinics (CBOC’s) tend to miss out on some of the activities and educational opportunities available at the medical center

Too much monitoring-micromanaging via Computerized Patient Record System (CPRS) – not interests in Patient’s care only numbers and if "t’s" are crossed an "i’s" are dotted.

As a dentist, I have not had the opportunity to deal directly with the admin. As far as medical care in Boston VAMC, I hear excellent things from my patients. VA Dentistry needs more dentist, dental hygienists and dental assistants to keep up with the dramatic increase in patients who are eligible for care.

[Major Hanafin’s note: this is the first comment I found actually praising a VAMC, and it was a Dental Clinic].

I work at Community-Based Outpatient Clinics (CBOC), not at a hospital. We are transitioning from the Gainesville FL to the Orlando FL systems and this has caused problems.

Respect and appreciation for the doctors would help in many ways. Doctors who become supervisors become monsters something is wrong with the training for physician supervisors.

Biggest problem here is lack of communication of plans for future from admin staff to clinical staff. Also rules from Central Office, at least as interpreted locally can interfere with health care delivery centralized scheduling for clinics are a nightmare.

Nursing remains as a hugely deficient area. While we have many excellent nurses, the adequacy of nurse staffing remains erratic and we have some incompetent nurses with negative attitudes about their work. This is an impact on every aspect of patients experience and all other interpersonal dimensions of the medical center. Human Resources are overwhelmed and appear incapable of basic functions.

Results are as expected when non-physicians are in complete control of every aspect of a hospital. (EG Clinic, nursing and admin)

Overall, I think the hospital admin strives to??? [Who knows?] VA needs to improve care and quality of care. The weakest area is definitely nursing care and ancillary service such as radiology.

More timely communication, more decentralized decision making

[Major Hanafin mentions this one in his article about how many acronyms were being thrown by a senior VA Physician that involves making any decision].

VA needs more specialists, i.e. cardiologist, gastroenterologist to be on call at night.

VA has limited resources! Inadequate space (although downsizing has been mandated from above; beds and staff are insufficient for the mission!) Admin is on a bureaucratic track for advancement and have no commitment (besides lip service) to the local facility.

We don’t have sufficient time to spend with patients. We’re asked to do many things that could be better done by nurses or clerical staff. Executive Admin is very autocratic.

Total disconnect between doctors and top admin [translation upper and middle management at the VA] VA needs a total top down management facelift.

There needs to be a cost benefit analysis of all ‘quality improvement’ measures, since they now take so much time, it is hard to handle patients actual problems.

Could use additional nurses throughout the facility. There are long delays in hiring nurses and other staff. Human resources functions very poorly.

[One significant role Human Resources have played I’ve learned is the game of black balling VA employees who raise these issues noted here. House cleaning Secretary Shinseki should begin with HR. Major Hanafin. In fact, note next comment.]

VA admin is paranoid after what happened to the army surgeon general ex-LTG Kevin Kiley & the Walter Reed Army Medical Center fallout – they "control" what is presented at meetings – especially of medical staff and education and review all Public Private Partnerships to ensure nothing controversial or negative is presented – the emperor has no clothes! No wonder it is so difficult to fix problems.

[Major Hanafin’s note: this is something the Senate and House Veterans Affairs Committee must be weary of when the Department of Veterans Affairs sends any panel of apologists or defenders before Congress. Get the paranoia and control out of the VA system, and you just might fix the systemic problems. Congress will NEVER know what the systemic problems are IF the mission of VA upper and middle management is to ensure nothing controversial or negative is presented to anyone – anywhere. Example: the endoscopy scandal unwinding. The only reason the VA panel had to fess up to the emperor having no clothes is because there was just too many decent people watching and too many Veterans potentially harmed].

Younger physicians should be given more exposure to and responsibility for medical center policy and practices within aim of having them move more speedily into supervisory and management positions. This idea should be pushed hard by management and service chiefs.

[This falls under Major Hanafin’s pet peeve entrenched bureaucrats, especially entrenched over the hill bureaucrats although I’m not proposing age discrimination. I’m old.].

I transferred from a VAMC about 50 miles away to my current location in March 2008. I left the other facility after 20 years because increasing barriers to communication and general incompetence of the management made coming to work in the morning an anxiety experience. I see some problems at the new facility but it is smaller and communication is better.

[This is the second half positive thing a doctor had to say about the VA!]

Poor morale and inefficient hiring practices here have resulted in 20 unfilled positions for physicians and significant nursing shortages [former whistle blowers need not apply, and that’s another travesty, because in most cases so-called former disgruntled VA employees tried too hard to bring the comments listed here to someone’s attention only to live in a never ending cycle of VA retaliation. It’s way past time for the retaliation to stop and given shortages of doctors and nurses who do not complain – former employees should have access to an Office of Special Council that is never politicized in support of cost savings or VA patient care], high turnover especially in CBDCs and recruitment of mediocre staff.

[See what I mean by the VA throwing around so many acronyms? CDDCs, I found three different meanings on Google and none of them fit. Major Hanafin]

I am pleased with the quality of care. We are not able to admit patient at times due to lack of hospital beds.

[This is the third half decent thing a medical professional had to say about the VA].

The pharmacy has too much power at our hospital. My perception is that too much is asked of the physicians, whom the vast majority accept and accomplish but there is little respect for the physicians on the part of admin. ‘Just do it, don’t complain." This affects morale which can possibly affect patient care as well as negatively affect physician retention.

The VA is tops; however, I would be happier with some control over nurses, who are too independent or can’t be disciplined – or incentives should be accrued. [Can’t figure out if this is a decent comment in favor of the VA or a complaint?]

Fewer patients should be assigned to each Primary Care Provider [PCP]. 1200 is too many. I have only about 2500 appointment slots to care for them, so they can never get in to see me when they need to.

My answers are skewed because I work at a Community-Based Outpatient Clinic and am seldom at the VA hospital. As always the higher ups need to listen to the troops – our director does that but the managers under him don’t

We are too subject to potential influence.

[This guy sounds like he’s giving testimony before Congress on some VA panel getting a butt kicking. What the heck does he/she mean by potential influence?]

Our hospital has no ER, Operation Room, or Mental Health Clinic staffs. Yet what staff we do have are required to manage walk-in emergencies, including intoxicated patients and detox, though we have no access to meds and we are expected to stay on time with fully scheduled clinic. Physician to patient ratio exceeds 1:1000, may be great than this, yet physicians are being ‘graded’ on achieving advanced clinic access when demand grossly exceeds supply of appointment slots. Still, I feel proud and amazed at the high quality of care we deliver in spite of this.

Need attention to primary care – too few exam rooms, inaccurate data used to calculate panel sizes – deaf management – a pulmonologist and surgeon.

The VAMC needs a new front office [management and staff] that would believe in collegial management rather than brutal top-down management.

My dissatisfaction results from one particular person who happens to be my boss.

[Nuff said here, because the probability of management retaliation within the VA is a reality not a threat].

Need more healthcare providers to accommodate the growing veteran population.

Incompetent chief of staff – inexperienced – should be replaced

THAT’S ALL FOLKS!!!

In closing, and as this LINK confirms, I did not arbitrarily pick out only the negative comments being made by medical professionals within the VA system. What we see is truly how doctors, dentists, and I would have to say nurses feel about the working environment within the VA.

Members of Congress and Secretary Shinseki, sir we would believe that if you conducted a top-down upper and lower management clean up and purging of the entire VA system, not only would professional medical personnel be happier, but patient (Veteran) care would be enhanced if not perfect.

Lastly, the intent of this post was not to be apologists for the VA Medical staff for when and if professional medical personnel have screwed up they should accept responsibility and accountability along with the consequences including termination. However, this should be the standard set more so for upper and middle administrative management at the VA who putting it mildly GETS IN THEIR WAY!

In sum, let us a Veterans, VA patients, Veterans and famiies in general not cop a confrontational attitude with the over VA rank and file despite the scandals being of a medical or surgical nature. That’s something for the VA malpractice lawyers to get into.

Yes, there are quite a few bad apples within the VA system, in fact an orchard full, but a good apple (manager) at the VA is only as good as the standards and example he/she sets. Our focus must be on helping the professional medical staff, including nursing staff, get the stagnant bureaucrats out of their way.

Helps us at VT, help then by contacting your Senators, member of Congress, and of course Secretary Shinseki and let them know how our VA’s professional medical personnel feel about the VA and us.

Robert L. Hanafin
Major, U.S. Air Force-Retired
Editorial Board of Directors
VT News Network

Robert L. Hanafin

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.