Veterans Healthcare Administration: stop funding the foreign physicians and foreign physician administrators who are making excessively high paychecks that bankrupt the whole system. The care they provide vets is sub-par. Many can barely speak English which is upsetting to the vets, and the Nigerian and Indian providers practice nepotism in contracts and hiring. No one holds them accountable for any of this. Whoever becomes head of the VHA needs to CLEAN house from the top down. I’m telling you as an employee of a VA system that you could run the system much more efficiently with NO doctors in administration, and getting rid of a large number of clinic-based RNs. The system needs more worker bees such as clerks, techs, and LVNs who tend to do the majority of the work but are always short staffed. Doctors are poor managers and they tend to look out for other doctors. Bonus structures waste so much money that could be better utilized at the patient care level. Physicians who were prior military should be filling most of those clinic and specialty positions, not foreign trained physicians who do not look at the vets as fellow service members. Most of the foreign docs hire on there for easy hours, easy money, and then hire family members and other foreign colleagues into open positions. It is its own version of DEI; but that has also got to be banished from the VA as well. No transgender care through VA facilities. It’s an absolute waste of funding that many other Vets could use for actual service based physical and mental issue healthcare. Also, VA should provide healthcare only to Vets with service rated health issues. The system is overwhelmed with patients who have no military rated conditions but get services at VA facilities. Many of these ex-service members also have private insurance but come to the VA because it’s free with no significant co-pay to them. If the vet has 0-20% disability, then they should only be able to access care at a BA facility for their % rated disability issues so that vets with significant issues aren’t having to wait so long for appointments. Ex. Vet rated 10% disability for hearing or ED shouldn’t be getting screening colonoscopies or CT/MRI imaging at the VA for other non-service related issues. If the system can’t be fixed, then tear it down and start it over as a more efficient and cost effective program/agency. The current system is corrupt, over regulated, and a huge cash cow that provides truly sub-par healthcare. The government could get so much more of a return on the money invested with either a privatized version of VHA or the reduction of top heavy management that would allow for more local/unit regulation.
More on the Veteran’s health system. Principles and Practice of Research Strategies for Surgical investigators, 2d ed. Troidl, Spitzer, Mulder, Wechsler, McPeek, McKneally, Balch, Springer – Verlag Publisher, 1991. Pg. 293 “We do not know the optimal surgeon to population ratio.”
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Photo. “It was unethical to put us in that position,” Dr. Phyllis Hollenbeck said of the overstressed primary care unit at the Veterans Affairs hospital in Jackson, Miss., where she worked.” Dr. Phyllis Hollenbeck, a primary care physician, took a job at the Veterans Affairs medical center in Jackson, Miss., in 2008 expecting fulfilling work and a lighter patient load than she had had in private practice.
What she found was quite different: 13-hour workdays fueled by large patient loads that kept growing as colleagues quit and were not replaced.
Appalled by what she saw, Dr. Hollenbeck filed a whistle-blower complaint and changed jobs. A subsequent investigation by the Department of Veterans Affairs concluded last fall that indeed the Jackson hospital did not have enough primary care doctors, resulting in nurse practitioners’ handling far too many complex cases and in numerous complaints from veterans about delayed care. “It was unethical to put us in that position,” Dr. Hollenbeck said of the overstressed primary care unit in Jackson. “Your heart gets broken.”
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Her complaint is resonating across the 150-hospital Veterans Affairs medical system after the department’s inspector general released findings on Wednesday that the Phoenix medical center falsified data about long waiting times for veterans seeking doctor appointments.
In Washington, the number of lawmakers in Congress calling for the resignation of Eric Shinseki, the Veterans Affairs secretary, grew by late Thursday to nearly 100 — including almost a dozen Democrats — as President Obama prepared to receive an internal audit on Friday from Mr. Shinseki assessing the breadth of misconduct at veterans hospitals. White House aides declined to say whether Mr. Obama would ask Mr. Shinseki to step down.
At the heart of the falsified data in Phoenix, and possibly many other veterans hospitals, is an acute shortage of doctors, particularly primary care ones, to handle a patient population swelled both by aging veterans from the Vietnam War and younger ones who served in Iraq and Afghanistan, according to congressional officials, Veterans Affairs doctors and medical industry experts.
The department says it is trying to fill 400 vacancies to add to its roster of primary care doctors, which last year numbered 5,100.
“The doctors are good but they are overworked, and they feel inadequate in the face of the inordinate demands made on them,” said Senator Richard Blumenthal, Democrat of Connecticut and a member of the Senate Veterans Affairs Committee. “The exploding workload is suffocating them.” The inspector general’s report also pointed to another factor that may explain why hospital officials in Phoenix and elsewhere might have falsified wait-time data: pressures to excel in the annual performance reviews used to determine raises, bonuses, promotions and other benefits. Instituted widely 20 years ago to increase accountability for weak employees as well as reward strong ones, those reviews and their attendant benefits may have become perverse incentives for manipulating wait-time data, some lawmakers and experts say.
Representative Jeff Miller, a Florida Republican who is chairman of the House Veterans Affairs Committee, said whistle-blowers at several veterans hospitals had told his staff members that they would be threatened if they failed to alter data to make patient-access numbers look good for their supervisors, one reason he has called for a criminal investigation into the Veterans Affairs hospital system.
“Fear was instilled in lower-level employees by their superiors, and those superiors did not want long wait times,” Mr. Miller said in an interview. “Bonuses [of Senior Executive Service] are tied directly to the waiting times of the veterans, and anybody that showed long wait times was less likely to receive a favorable review.”
The precise role incentives and performance reviews might have played in falsifying waiting-list data remains unclear. In Phoenix, the inspector general’s office said, investigators plan to interview scheduling supervisors and administrators to “identify management’s involvement in manipulating wait times.”
But documents suggest that using the data in annual performance reviews may be commonplace. One review at a Pennsylvania veterans medical center showed that a significant portion of the director’s job rating was tied to “timely and appropriate access,” which would include waiting times for doctor appointments. One of those goals would be met only if nearly all patients were seen within 14 days of their desired appointment date — a requirement not found in the private hospital industry.
Schemes to disguise wait times generally followed a handful of approaches, whistle-blowers and officials in Congress say. In Phoenix, where administrators were overwhelmed by new patients, many veterans were not logged into the official electronic waiting list, making it easier to cloak delays in providing care.
Another strategy, according to documents and interviews, was for Veterans Affairs employees to record the first date a doctor was available as the desired date requested by the veteran, even if they wanted an earlier date.
“Yes, it is gaming the system a bit,” one employee at the Veterans Affairs medical center in Cheyenne, Wyo., explained in an email to colleagues. “But you have to know the rules of the game you are playing, and when we exceed the 14-day measure, the front office gets very upset.”
In Jackson, Dr. Hollenbeck reported that hospital administrators created “ghost clinics” in which veterans were assigned to nonexistent primary care clinics to make it appear that they were receiving timely care.
And in Albuquerque, an employee at the veterans center said some doctors were shocked when they received a memo a few months ago stating that 20 percent of physician “performance pay” would be doled out only to doctors who found a way to limit patient follow-up visits to an average of two a year — a tactic to reduce waiting times by persuading veterans to make fewer appointments.
“Clinic staff were instructed to enter false information into veterans’ charts because it would improve the data about clinic availability,” states a whistle-blower complaint filed by the employee, who did not want to be identified. “The reason anyone would care to do this is that clinic availability is a performance measure, and there are incentives for management to meet performance measures.”
Experts point out that performance reviews and incentives were a crucial element in transforming the Veterans Affairs medical system, considered a medical backwater after the Vietnam War, into a national health care system that, for all its problems, is generally well regarded.
Debra A. Draper, the director of the Health Care Government Accountability Office, said that performance-contract incentives were only one possible explanation for inaccurate wait-list data, and that other factors included lack of oversight and training.
“The Veterans Affairs medical center in Phoenix. An acute shortage of doctors is at the heart of the falsified data here and possibly many other veterans hospitals.”
Most experts agree that soaring demand for veterans’ care has outpaced the availability of doctors in many locations, and that high turnover is a major problem. In the past three years, primary-care appointments have leapt 50 percent while the department’s staff of primary care doctors has grown by only 9 percent, according to department statistics.
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Those primary care doctors are supposed to be responsible for about 1,200 patients each, but many now treat upward of 2,000, said J. David Cox Sr., national president of the American Federation of Government Employees, which represents nurses and other support staff. He said the department spent too much hiring midlevel administrators and not enough on doctors and nurses, a complaint shared by some lawmakers and veterans groups.
The department said this week that it was reviewing the size of patient panels at its hundreds of outpatient clinics and assessing whether more could provide night and weekend hours. The department also said it would increase the number of patients it referred to private medical care, to reduce waiting times.
Critics and supporters of the department agree that many facilities do not have enough physicians. But they disagree about whether that is because the department has poured too much of its hefty federal budget increases into hiring midlevel managers instead of clinicians, or whether the system simply does not have enough funding — or a large enough pool of doctors to hire from — to keep up.
Supporters of the department also note that hospitals everywhere are struggling to find primary care doctors. But some experts say the department has additional hurdles, including lower pay scales. Primary care doctors and internists at veterans centers generally earn from about $98,000 to $195,000, compared with private-sector primary care physicians whose total median compensation was $221,000 in 2012, according to the Medical Group Management Association, a trade group.
Many veteran medical center directors tend to make $160,000 to $190,000; according to 2012 data, those directors given performance awards typically received $8,000 to $15,000 more.
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Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges, said the department’s doctor shortage came down to a simple fact: “It’s just harder to attract physicians to care for more challenging patients while paying them less.”
There are long delays for specialty care, too, veterans say. Kent Carson, a former Marine with epilepsy, said he had tried to make an appointment with his neurologist at the veterans hospital in Nashville after having five seizures in four days in 2012. But Mr. Carson, 29, said he was told he would have to wait more than two months — or go to the emergency room. He has since switched to private insurance through his job as an accountant in Lenexa, Kan. The Nashville hospital did not respond to a request for comment.
“I have seizures, but it’s not life-threatening,” Mr. Carson said. “But I really do worry about vets who have more serious problems.”
Half of these are from two countries, India and Pakistan, which have an English language tradition.
HYPERLINK “Flexner Report - Wikipedia” Flexner Report - Wikipedia
The Flexner Report is a book-length study of medical education in the HYPERLINK “United States - Wikipedia” \o “United States” United States and HYPERLINK “Canada - Wikipedia” \o “Canada” Canada, written by the professional educator HYPERLINK “Abraham Flexner - Wikipedia” \o “Abraham Flexner” Abraham Flexner and published in 1910 under the aegis of the HYPERLINK “Carnegie Foundation for the Advancement of Teaching - Wikipedia” \o “The Carnegie Foundation for the Advancement of Teaching” Carnegie Foundation. Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.
The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. Universities had begun opening and expanding female admissions as part of women’s and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational HYPERLINK “Oberlin College - Wikipedia” \o “Oberlin College” Oberlin College in HYPERLINK “1833 - Wikipedia” \o “1833” 1833 and private colleges such as HYPERLINK “Vassar College - Wikipedia” \o “Vassar College” Vassar College and HYPERLINK “Pembroke College in Brown University - Wikipedia” \o “Pembroke College (Brown University)” Pembroke College.
History
In the late 19th century, what came to be called HYPERLINK “Medicine - Wikipedia” \o “Modern medicine” modern medicine emerged after a struggle with other forms of medicine such as HYPERLINK “Homeopathy - Wikipedia” \o “Homeopathy” homeopathy. This new medicine was grounded in antiseptic surgery, the HYPERLINK “Germ theory of disease - Wikipedia” \o “Germ theory of disease” germ theory of infectious disease (which informed a large number of effective HYPERLINK “Public health - Wikipedia” \o “Public health” public health measures), and the HYPERLINK “Scientific method - Wikipedia” \o “Scientific method” scientific method, including HYPERLINK “Evidence-based medicine - Wikipedia” \o “Evidence-based medicine” evidence-based medicine and HYPERLINK “Clinical trial - Wikipedia” \o “Clinical trial” clinical trials. In 1904 the AMA created the HYPERLINK “http://en.wikipedia.org/w/index.php?title=Council_on_Medical_Education&action=edit&redlink=1” \o “Council on Medical Education (page does not exist)” Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human HYPERLINK “Anatomy - Wikipedia” \o “Anatomy” anatomy and HYPERLINK “Physiology - Wikipedia” \o “Physiology” physiology followed by two years of clinical work in a HYPERLINK “Teaching hospital - Wikipedia” \o “Teaching hospital” teaching hospital. In 1908, the CME asked the HYPERLINK “Carnegie Foundation for the Advancement of Teaching - Wikipedia” \o “Carnegie Foundation for the Advancement of Teaching” Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME’s reformist agenda and hasten the elimination of medical schools that failed to meet the CME’s standards. The president of the Carnegie Foundation, HYPERLINK “Henry Smith Pritchett - Wikipedia” \o “Henry Pritchett” Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.
At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: “Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated.” The Report became notorious for its harsh description of certain establishments, for example describing Chicago’s 14 medical schools as “a disgrace to the State whose laws permit its existence… indescribably foul… the plague spot of the nation.”
Recommended changes
When Flexner researched his report, many American medical schools were “proprietary”, namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word “quack” flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.
Flexner looked this situation in the face. Using the HYPERLINK “Johns Hopkins School of Medicine - Wikipedia” \o “Johns Hopkins University School of Medicine” Johns Hopkins University School of Medicine as the ideal HYPERLINK “Flexner Report - Wikipedia” \l “cite_note-0#cite_note-0” \o “” [1], he boldly recommended that:
Admission to a medical school should require, at minimum, a HYPERLINK “Secondary school - Wikipedia” \o “High school” high schooldiploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.
The length of medical education be four years, and its content should be what the CME agreed to in 1905.
Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.
Less known is Flexner’s recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become “true university teachers, barred from all but charity practice, in the interest of teaching.” Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner’s recommendations down to the present day. Recently, however, schools have increased their emphasis on HYPERLINK “Public health - Wikipedia” \o “Public health” public health matters.
Consequences of the report
To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
The quality of medical education is invariably high;
Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;
No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
Each state branch of the HYPERLINK “American Medical Association - Wikipedia” \o “American Medical Association” American Medical Association has oversight over the medical schools located within the state;
Medicine in the USA and Canada becomes a highly paid and well-respected profession;
The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as HYPERLINK “Price discrimination - Wikipedia” \o “Price discrimination” price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;
Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.
The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. “An education in medicine,” wrote Flexner, “involves both learning and learning how; the student cannot effectively know, unless he knows how.” Although the report is more than 90 years old, many of its recommendations are still relevant—particularly those concerning the physician as a “social instrument… whose function is fast becoming social and preventive, rather than individual and curative.”
Closure of many medical schools
According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting HYPERLINK “Doctor of Medicine - Wikipedia” \o “M.D.” M.D. or HYPERLINK “Doctor of Osteopathic Medicine - Wikipedia” \o “D.O.” D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report’s recommendation that all “proprietary” schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report’s recommendations.
American medicine becomes a less diverse profession
One of the consequences of Flexner’s advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper middle class white males. The small “proprietary” schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities. At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the HYPERLINK “Leonard Hall (Shaw University) - Wikipedia” \o “Leonard Hall (Shaw University)” Leonard Medical Center, the oldest four-year medical school in the country for African-Americans. Ironically one of the schools was located in his own hometown of HYPERLINK “Louisville, Kentucky - Wikipedia” \o “Louisville, Kentucky” Louisville, Kentucky, HYPERLINK “Louisville National Medical College - Wikipedia” \o “Louisville National Medical College (page does not exist)” Louisville National Medical College.