The emperor’s new VA

Like the silent townspeople in Hans Christian Andersen’s “The Emperor’s New Clothes,” many health-care professionals who have worked within the Veterans Health Administration likely have realized an unsettling truth but have been unwilling to speak out: that the wait list scandal of 2014 and every disturbing report of VA failings since are not aberrations in an otherwise sound institution.

Instead, these failings are reflections of a frightening iceberg of entrenched institutional mediocrity, incompetence and indifference lurking beneath the surface of an intentionally deceptive guise of “quality care.”

{mosads}What I suspect these VA townspeople have painfully realized in their hearts to be true, as did I, is that there persists in and about the VA an attitude that it is a second-rate health system designed to deliver care to a population that’s treated as second-class patients. The needless neglect and abuse of veterans, and the ongoing, horrific and unnecessary loss of veteran life and limb, are inevitable consequences of this simple yet largely unacknowledged truth.

A majority of American-trained doctors spend time working in a VA hospital. During education and training, I rotated in and out of three of the system’s “best” VA facilities. As a young professor, I spent part of my time for eight years heading a surgical subspecialty program at one of those hospitals. I had no misconceptions of joining an outstanding health-care system but I was determined, as are many of my colleagues, to make a difference for the veterans under my care.

During my VA tenure, I saw veterans undergo amputations, not because of shrapnel-induced combat injuries but because of botched management of otherwise treatable conditions. I watched other veterans die unnecessarily, as a result of poor administrative management or sheer medical incompetence. Others were denied an opportunity to pursue potentially lifesaving care because of the potentially negative impact their treatment might have on VA statistics — statistics that, incidentally, were used to determine annual financial bonuses for local administrators.

In fact, the VA has displayed consistently outstanding performance in one area of health care administration: the presentation of quality-of-care data that misleadingly suggest outstanding performance.

Prior to the 1980s, the VA essentially was left alone to wallow in its more comfortably accepted, though appalling, mediocrity. When Congress finally was forced to demand accountability, the VA soon exceeded all other U.S. health-care providers in identifying the very few details of care that watchdogs would monitor as “indicators of performance.” While leaving its foundation of mediocrity and neglect entirely untouched, the VA has poured massive resources into making those few details of care look superlative. The result today is widespread defense of an indefensible system, often by veterans’ advocacy groups.

The VA is not devoid of dedicated, talented or hard-working people. But those people are up against institutional laziness and inertia that they eventually learn to accept as immutable and absolute. My attempts to increase the workload of a lackadaisical operating room were met with disdain and eventual retaliation. And on more than one occasion, I was forced to withhold life-and-death surgery from desperate veterans because their cases, if unsuccessful, would threaten the hospital’s national VA ranking.

In June, President Trump signed into law “one of the largest reforms to the VA in its history,” better protecting whistleblowers and facilitating the firing of “poor performers.” Congress is considering how to extend and possibly fix the Veterans Choice program. The VA may have an electronic medical records system within a few years, although its first EMR — a truly revolutionary advance in its day — did nothing to alter decades-long, unspoken acceptance of poor care. Although each of these Band-Aid solutions and others address specific VA dysfunctions, they ironically have the more detrimental effect of providing false reassurance that something meaningful is being done about our veterans’ overall predicament.

The VA does not need tinkering with individual problem areas. If we are to continue to offer this immense, unwieldy system as the means to fulfill Abraham Lincoln’s promise to American veterans and their families, the VA will need the major overhaul recommended by people such as former White House deputy chief of staff Rob Nabors. After investigating for just a few months in 2014, Nabors discovered within the VA what he described as a “corrosive culture.” Yet that part of the story remains swept under the rug, or, as it were, under the emperor’s new clothes.

Unnecessary veteran suffering won’t go away until the public can fully comprehend the shocking extent of the VA reality. Truly effective solutions will require upheaval in one of our government’s largest institutions, and will be neither easy nor politically expedient. But until such an approach is forced by public awareness and outrage, veterans will continue to suffer and die.

Michael J. Mann, M.D., is a professor of surgery and director of the Cardiothoracic Translational Research Laboratory at the University of California, San Francisco, and author of the recently published book, “Mission Betrayed: How the VA Really Fails America’s Vets.”