Veterans health care: Question authority!

Look online at various Department of Veterans Affairs patient initiatives and prepare to be dazzled.

Recent years have seen the VA expand its footprint over community after community with programs festooned with the typical government alphabet soup such as PCMH and PACT. These stand for “patient-centered medical home” and “patient aligned care teams.” While these collaborations appear to border on something a 21st century Marcus Welby M.D. might tout the programs also face the immediate danger of being quarantined to the bureaucracy ward.

Like most VA programs these initiatives are well-intentioned but also destined to constant undermining by forces beyond control of hands-on patient caregivers.

The PACTs seem to be working well at the Beaumont (Texas) VA Outpatient Center where I see my primary care team, or “Teamlet” in PACT jargonese. I now can send my blood glucose readings by secure e-mail each week to my nurse who, in turn,  enters them in her computer where she can keep a close watch on my Type 2 diabetes. This monitoring along with my medication and diet has brought my A1C reading, which measures your average blood glucose control for the past 2 to 3 months, from the verge of my requiring insulin shots to something much more manageable. Still, diabetes control requires more than simply eating right and taking your metformin.

Foot care is also another component of diabetic care especially if the patient has foot infections or abnormalities. Mine has had both including a wound that hasn’t fully healed in several months. My large toenails also require a special trimming that is beyond my ability. I have asked my primary care folks for a couple of years now if I could get a referral to a podiatrist. I was once told by a doctor that a patient had to have an infection before a consult could be given. I later found that out to be false. When I finally had an infected toe, I asked my primary caregiver to get me a podiatrist referral. She said that she would do that. I eventually forgot about that and finally asked my nurse if a consult had been ordered. She looked on her computer and apparently found a note indicating consults to podiatrist care in Houston could only be given to those with foot emergencies. Since I had previously found erroneous information on that subject, I decided to “question authority.”

Since I am a free-lance journalist and blogger, sometimes even a serious one such as now, I sometimes contact Bobbi Gruner, the VA spokesperson for the Houston VA, with questions. Ms. Gruner replied that she did not believe the podiatry policy I was quoted to be correct. She referred me to someone whose department is over that podiatry branch.

The answer I was given was that ” … there is no policy we are aware of that states the podiatrists now only see emergency patients.” This was according to Sangita Shah, who is the administrative officer of the Houston VAMC surgery department. Ms. Shah also asked for the “last four” numbers of my Social Security Number, which hopefully means she will look into my case.

I have no answer why I have twice received incorrect policies or policy interpretations in response to my request to see a foot doctor. I have my suspicions, but do not know for sure. What such problems show is how far the VA strays from their own goals of consistency. The Veterans Health Care Administration, VHA, is one of three administrations within the VA. It covers health while the remaining two administers benefits and cemeteries. They got you coming and going might be a good motto. But the VHA acknowledges collaboration and integration within the preamble to its vision statement:

 “This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement.”

Integration is a key word to examine. In the manner it is used in the vision statement the word “integration” implies cooperation, harmony and an interrelatedness.  It isn’t just the so-called “home-centered” care that the VA exclaims will move boldy forth. I came across a temporary worker program for medical professionals in the VA. It has joined the private medical world in developing a “Locum Tenens” program. The Latin phrase loosely means to “hold a place.”  The VA describes a locum tenens physician as one who temporarily fills in for another while they are out on vacation, maternity leave, professional development or so forth, A flyer for the program touts: “A Consistent Practice: Coast-to-Coast.

 “Here, you’ll find consistent patient care delivery methods and a single Computerized Patient Record System that’s networked nationwide. Learn it once, and it’s smooth sailing after that.”

 Such a promise is, well, not exactly accurate at least from this patient’s point of view. But if it is inconsistencies you are looking for one can certainly find a home in the VA health care system. Travel from one hospital to the other and don’t expect to find the same medicine you have been taking. If you are looking for a new drug and especially one that is expensive, you will not likely get it from VA pharmacies. As I have also found recently don’t expect hospitals and outpatient clinics to be on the same page when it comes to billing. Don’t even the expect the toll-free call center one phones to ask billing questions to be on the same page with the hospitals. Inconsistencies found such as this one regarding PTSD care for recent war veterans have begun to attract public and congressional attention. But many other dissimilarities remain.

VA health care can be among the best to be found in the country. That has not always been the case. That isn’t always the case now. That isn’t for the vast majority of its employees’ lack of trying. The best way to ensure that one receives the care they deserve is to stay attuned to their treatment, ask questions, and when something does not seem fair or right, it just might not be.

It may go against the grain of those who spent many years of their lives taking orders, especially the older veterans, to ask probing questions of your medical providers. But it is your life we are talking about here. If some VA medical policy seems inconsistent or unjust it might be time to do, as old Ben Franklin supposedly admonished was a citizen’s responsibility: question authority.