Another VA Hospital Ugly Secret

It seems like every week exposes a new problem at hospitals run by the Veterans Administration. It seems like a new scandal every month. A nurse participates drunk in surgery. Veterans die while waiting for treatment. Patient records falsified. Administrators retaliate against whistleblowers rather than correct deficiencies. Right now, the VA system is the poster child for the inefficiency of government and failed promises to our veterans.

There are many wonderfully gifted, talented and selfless doctors and nurses who provide quality care to our veterans on a regular basis. However, just as any other government agency or even many for-profit hospitals, the VA is not immune to finding ways to cut expenses. Unfortunately, cutting expenses often correlates with cutting the quality of care at the expense of our veterans. One such shortcut that may be in play at a VA hospital near you is the use of residents from a local “teaching” hospital as “independent contractors” to provide care, including surgical care, to our veterans. When the VA relies on resident physicians to care for our veterans, the VA allows inexperienced, student physicians to practice becoming doctors on our veterans. Typically, residents transition to the next level (get promoted) after June 30. There is a big difference in the experience and training of a resident beginning his third year (July) and one completing it (the following June). That makes July, August and September the most dangerous times for resident directed care because at that time, even the most experienced residents have only two years of residency training behind them.

It is true that even at some of the best hospitals in the world, residents deliver patient care. However, the difference is that in these hospitals a fully qualified and likely board-certified physician controls all facets of the patient’s care. That physician is the patient’s primary, point of care provider. When the patient returns for follow-up examinations and treatment, the same attending physician who controls the care is most familiar with the patient. Different residents may help with the patient’s treatment as they rotate through, but the experienced, well-qualified doctor remains in control. The attending physician is the consistent factor in the patient’s treatment and it is the attending physician who controls that treatment.

In contrast, at a VA hospital which uses residents as “independent contractors,” it is the resident who may control the veteran’s treatment. The veteran never sees an attending physician unless the resident recognizes when the level of care needed by the patient exceeds the resident’s expertise. It is the resident who decides whether or not she/he needs the help of the attending.

This is the fatal flaw of the system. The quality of care provided to the veteran depends solely upon a resident who exercises absolute control over the veteran’s care at a time when the resident is just beginning to learn his craft and may not yet know what he/she does not know. This system creates an inherent and unavoidable conflict for the resident who is expected to exercise independence and autonomy in order to validate receiving greater responsibility and autonomy, while on the other hand the resident must be willing to freely admit the need for help from the same people who expect him to be independent.

Virtually everyone in the United States believes that every veteran deserves outstanding, free medical care as a reward for the sacrifices and risks our veterans have undertaken for us. The reality is that the agency entrusted with fulfilling that promise is guilty of cutting corners at the expense of quality care. The only way for a veteran to protect himself/herself is to be knowledgeable about this potential danger, and act knowledgeably.

Steps to take during treatment at the VA:

1. Ask every doctor if he/she is a resident.
2. Ask what year of residency he/she is in.
3. Be especially wary of resident directed care in July, August and September.
4. Demand to be examined/seen by the attending physician. It is your right. At the very least demand that the attending physician personally oversee the resident providing care. Just because the attending physician will review the chart is NOT appropriate supervision.
5. NEVER consent to a surgery without specifying on the consent form that only the experienced, attending physician can perform the surgery. (Let the resident learn on someone else.)