A Tale of Two News Reports

On Wednesday, February 25, 2015 two new stories aired, one on National Public Radio (NPR) that I heard riding home that afternoon and the other later in the evening on the CBS Evening News with Scott Pelley. Both stories were on the Department of Veterans Affairs (VA) but I was struck by the contrasting style of the two reports.

The first story was an NPR report on back injuries in nurses (1). According to the report nurses suffer more back injuries than almost any other occupation — and they get those injuries mainly from doing the everyday tasks of lifting and moving patients. The report stated that the VA has invested over $200 million in protecting nurses predominately by providing lifts and other devices for moving patients. VA hospitals across the country have reduced nursing injuries from moving patients by an average of 40 percent since the program started. The reduction at the Loma Linda hospital where the report was focused was closer to 30 percent — but the injuries that employees suffered were less serious than they used to be. Loma Linda spent almost $1 million during a recent four-year period just to hire replacements for employees who got hurt so badly they had to go home. However, this past year they spent nothing because according to the report nobody got hurt badly enough to miss work.

The VA's reputation for accurate information has been called into question. The Phoenix VA was the ground zero of an investigation which eventually discovered that about 70% of VA hospitals were falsifying patient waiting reports (2). Perhaps everything in this NPR report is true, however, the NPR report reminded me of so many I heard over the past two decades where any medical report was accepted by the media at face value. Many of the reports I knew were not true because I worked at the VA. There are several reasons to be skeptical. First, it is from the VA. Second, the director of the Loma Linda VA was Donald F. Moore until late 2012. Prior to that position Moore had been the director of the Phoenix VA. Third, the reported drop in injuries borders on the unbelievable. Nursing supervisors likely need to get approval to replace injured nurses.  Perhaps a directive either not to report any back injuries or that approval of replacement nurses would not be granted was issued. There are many ways to falsify the data, but NPR was nonquestioning in their report.

Later that evening CBS Evening News correspondent Wyatt Andrews reported that he found widespread mismanagement of VA claims. The mismanagement resulted in veterans being denied the benefits they earned, and many even dying before they get an answer from the VA (3). Five whistleblowers at the Oakland, California, Veterans Benefits office told CBS News that more than 13,000 claims filed between 1996 and 2009 ended up stashed in a file cabinet and ignored until 2012. VA supervisors in Oakland ordered marking the claims "no action necessary" and to toss them aside. Whistleblowers said that was illegal. Last week, the VA inspector general confirmed that because of, "poor record keeping" In Oakland, "veterans did not receive... benefits to which they may have been entitled." How many veterans is not known, because thousands of records were missing when inspectors arrived. In the last year, the inspector general has found serious issues in at least six VA benefits offices, including unprocessed claims in Philadelphia, 9,500 records sitting on employees' desks in Baltimore and computer manipulation in Houston to make claims look completed when they were not. VA Central Office said in a statement, "..electronic claims processing [has] transformed mail management for compensation claims ... greatly minimizing any risk of delays due to lost or misplaced mail...For any deficiencies identified, steps are taken to appropriately process the documents and correct any deficiencies." Much of this sounded very familiar and similar to the patient wait times the VA falsified last year.

The CBS report closed with a statement from the Veterans service organization Veteran Warriors, which advocates for veterans who are having difficulty with their claims. The Veteran Warriors said in a statement: "Too many cases have come to light, wherein the VA leaders have destroyed, deleted, hidden and manipulated veterans claims - their very access to benefits and services - and NOT ONE OF THEM has been criminally charged. It is time for our nations' leaders to stop listening to the endless "lip service" of accountability and demand answers. If they do not get them, it is time for repercussions to be felt by those who obviously believe they are above the law and insulated from prosecution." It was clear that the Veteran Warriors did not believe the VA and also clear that neither did CBS News.

The weak reporting on medical issues has been apparent to me for some time. The CBS report suggests that this may be changing. The VA scandal may point out that medical reports need to questioned just like other news stories. Truthfulness does matter and the VA continually blaming clerks and other lower level employees for administrative inadequacies or attacking the whistleblower has become tedious. Even the present inspector general's report blamed the closing of the Veterans claims on "poor record keeping". In this instance CBS news was doing their job questioning the VA but NPR was not.

Richard A. Robbins, MD

Editor

SWJPCC

References

1. Zwerdling D. At VA hospitals, training and technology reduce nurses' injuries. NPR. February 25, 2015. Available at: http://www.npr.org/2015/02/25/387298633/at-va-hospitals-training-and-technology-reduce-nurses-injuries (accessed 3/7/15).
2. Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. [CrossRef]
3. CBS News. Whistleblowers: Veterans cheated out of benefits. February 25, 2015. Available at: http://www.cbsnews.com/news/veteran-benefits-administration-mismanagement-uncovered-in-investigation/ (accessed 3/7/15).

Reference as: Robbins RA. A tale of two news reports. Southwest J Pulm Crit Care. 2015;10(3):143-4. doi: http://dx.doi.org/10.13175/swjpcc038-15 PDF

The Hands of a Healer

The article in this month’s SWJPCC - "Physical Examination in the Intensive Care Unit. Opinions of Physicians at Three Teaching Hospitals" (1), is a fascinating insight to medical practice and how it has changed with the advent of new technology. The study at three large teaching facilities addressed the questions of how often a physical exam was performed in the ICU, what the perceived utility of the physical exam was, who examines patients most,  and an interesting question pertaining to what exactly constitutes a physical exam. Participants were given theoretical scenarios and answered questions pertaining to the role of a physical exam.  Even though the format was a questionnaire and not direct observation, the results support what I see in clinical practice. The results show that the physical exam, at least in the ICU, is not deemed a critical tool in our armamentarium and that reliance on technology has supplanted the traditional exam. One point that has yet to be formally addressed by this or other studies, is actually how often the physical exam changes the clinical course.

Those of us in my generation remember the days when physical exam was paramount. Indeed, when I was in medical school in England, it was essential and when we presented cases, we had to make a differential diagnosis solely based on the history and physical exam, and then, and only then, would we order specific tests. That was about 25 years ago in London. I suspect that many of my colleagues from that era or earlier, had similar experiences. Modern US practice is to use the physical exam, order a battery of tests and imaging, then come up with the diagnosis.  It has not been shown unequivocally that our reliance on modern imaging and labs is necessarily better.

There are still some scenarios that no laboratory test can pick up. Even in pulmonary medicine, we still teach to treat the patient, not the ABG; and the diagnosis of respiratory failure does not require anything other than a look at the patient. Wheezing shows up on no commonly use lab or imaging in the ICU (excluding less commonly used techniques such as measurement of respiratory system resistance using the ventilator’s sensors and algorithms). There is no question that modern testing is more accurate and provides much more information to us than any, even Oslerian levels of clinical examination could. It also leads to work ups for incidentalomas that may have no real relevance. Conversely all of us probably have anecdotal stories of an exam changing the course. For example, I recall the physical exam that picked the cause of the patient’s agitation, an ulcer on the back of a ventilated, heavily sedated patient. This led to less use of benzodiazepines and a focus on pain control perhaps preventing or mitigating the clinical detriments of excess sedative use in the ICU.

Ordering tests and imaging is usually quicker for the MD than doing a physical exam – one can order three CT scans on three patients in less time than it takes to physically go and exam three patients. This is clearly an improved efficiency for the MD’s work load. The question is then whether the improved efficiency for the MD and added information about the patient from the ancillary testing is worth the extra cost. The physical exam is free except insofar as the time it takes and the effect this has on billing, i.e. that it is still a necessary part of the billing matrix.

The nature of what is a physical exam is also changing. Incorporating bedside imaging with ultrasound is no more a stretch than was incorporating the auscultatory findings when the stethoscope was first introduced. Palpation and percussion in this study, were not deemed necessary parts of the physical exam, which is in sharp contrast the traditional teaching. The perception amongst US physicians that physical exam is more utilized outside the US (England being a typical example) may or may not be true. From the results of this particular study, it seems not to be the case, as there was no difference in responses amongst those who had medical school training outside the US. However even currently, it is impossible to progress in England to higher postgraduate training MRCP or FRCP (member or fellow of the Royal College of Physicians) without being grilled on a physical exam (2).

So where then is the correct balance? As the authors point out, the classic physical findings we were taught are usually present in extreme or end stage disease whereas our purportedly better technology now finds these processes earlier in the clinical course. Pure reliance on either the physical exam or the ancillary testing is not likely to be the correct approach. The answer has yet to be ascertained. A study addressing how often the clinical exam changes the course of a patient’s care significantly (however one may define this) has yet to be done. My prediction is that within 20-30 years, the physical exam will be almost never done in clinical practice.

Clement U. Singarajah, MD

Associate Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Vazquez R, Vazquez Guillamet C, Adeel Rishi M, Florindez J, Dhawan PS, Allen SE, Manthous CA, Lighthall G.  Physical examination in the intensive care unit: opinions of physicians at three teaching hospitals. Southwest J Pulm Crit Care. 2015;10(1):34-43. [CrossRef]
2. Royal College of Physicians of the United Kingdom. MRCP(UK) part 2 clinical examination (paces) guide notes for candidates 2014. Available at: http://www.mrcpuk.org/sites/default/files/documents/Candidate%20guide%20notes%202014_1.pdf (accessed 1/6/15).

Reference as: Singarajah CU. The hands of a healer. Southwest J Pulm Crit Care. 2015;10(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc002-15 PDF

The Fabulous Fours! Annual Report from the Editor

With the end of 2014, the Southwest Journal of Pulmonary and Critical Care (SWJPCC) completed its fourth year of operation. Our first manuscript was posted on November 11, 2010. We posted 8 manuscripts our first year, 68 in 2011, 113 in 2012 and 164 in 2013 and 167 in 2014 (Table 1).

Table 1. Yearly submissions, total postings and postings by category.

Accompanying our increase in manuscripts, our readership continues to steadily grow, although comparisons to previous years is difficult because the methodology changed in February, 2014 (Table 2).

Table 2. Page views, visits and audience size by month 2014.

SWJPCC continue to evolve and we made some changes in 2014:

• The California Thoracic Society partnered with SWJPCC.
• We added additional associate editors in pulmonary, critical care and imaging from Fresno (Peterson), Albuquerque (Boivin) and Tucson (Arteaga).

Many need to be thanked. First, thanks to our authors. Second, SWJPCC, like all journals, relies upon expert reviewers in order to publish the highest quality manuscripts. We thank the reviewers for their time and effort in the prompt submission of their reviews. A list of reviewers for 2014 is below.

• David Baratz
• Bhaskar Bhardwaj
• Michel Boivin
• Janet Campion
• Gordon Carr
• Michael Gotway
• Steve Klotz
• James Knepler
• Timothy Kuberski
• Manoj Mathew
• Jarrod Mosier
• Michael Peterson
• Robert Raschke
• Julene Robbins
• John Roehrs
• Clement Singarajah
• Karen Swanson
• Henry Tazelaar
• Dona Upson
• Carolyn Welsh
• Lewis Wesselius

Our gratitude goes to the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic Rochester for their support. Thanks to our associate editors who have put in much more work than we had the right to ask. A special note of thanks to those who continue to do regular features in SWJPCC-Bob Raschke and Manoj Mathew for the critical care and pulmonary journal clubs; Mike Gotway, Lew Wesselius and Bob Raschke for the cases of the month; Michel Boivin for the ultrasound for critical care physicians; and Ken Knox for the Medical Image of the Week. SWJPCC acknowledges the Phoenix Pulmonary and Critical Care Research and Education Foundation which has provided the monetary support for SWJPCC, Squarespace our web host, CrossRef for generating the digital object identifiers (doi's) and CLOCK SS for archiving. Last, and most importantly, thanks to our readers. Please visit as often as you can and feel free to provide us with your input.

What’s ahead for 2015? We hope to improve the content, especially the scientific content, for 2015, but we will continue to emphasize clinical medicine and education. Sleep submissions have been lagging and we hope to increase the number of submissions. CME will continue to be offered for the previous 12 Pulmonary, Critical Care, and Imaging Cases of the Month for a total of 36 CME offerings at any one time. We would welcome suggestions for any improvements.

Richard A. Robbins, MD

Editor, SWJPCC

Reference as: Robbins RA. The fabulous fours! annual report from the editor. Southwest J Pulm Crit Care. 2015;10(1):8-10. doi: http://dx.doi.org/10.13175/swjpcc001-15 PDF

A Veterans Day Editorial: Change at the VA?

"Meet the new boss,

Same as the old boss.

Won't Get Fooled Again!"

            -Peter Townshend

Today we honor our veterans. A year ago VA patients languished on waiting lists waiting for healthcare. VA administrators hid the truth at over 100 VAs and took bonuses for meeting their wait time goals. Money has been poured into the VA, patients in rural areas are seen outside the VA, and it is now supposedly easier to fire other senior VA officials. Dennis Wagner authored an article in the Arizona Republic that claimed the VA has made some changes but more changes are needed (1). I agree with the need for change but would argue that there has been no real change at the VA.

Last week I saw a VA patient in my private practice. He was paying for tiotropium or Spiriva®, a long-acting anticholinergic used in chronic obstructive pulmonary disease, out of his pocket. He was under the impression that the VA did not "carry" tiotropium. I told him that this was not true and that he should go to the VA and ask to be seen in pulmonary clinic if his primary care physician could not prescribe tiotropium. He was sent to the pharmacy where the pharmacist wanted to know why I would prescribe this expensive drug. He was sent back to my office for a response. I xeroxed a copy of my notes and gave them to the patient. I do not know whether he got the tiotropium but my guess is that probably not without some hassle. This is unchanged from prior to the scandal when patient care was undermined by healthcare support staff. No real change there.

Last night, the new Secretary of the VA, Robert McDonald, was on "60 Minutes" (2). He announced that he is "reorganizing" the VA. Although details were not stated, this sounded mostly like a consolidation of websites, not a bad thing, but hardly a "reorganization". He also said how sorry he was for past mistakes and how the new VA was going to do better. I had déjà vu going back to the mid 90's with Ken Kaiser's "Prescription for Change" (3). Eric Shinseki, the VA secretary recently forced to resign, used similar rhetoric and was "mad as hell" at the falsified wait lists (4). No real change there.

McDonald used the term "customers" to refer to VA patients (2). This has occurred off and on since the mid 90's and is a term some healthcare providers find offensive. We do not flip burgers at McDonald's and find it inappropriate and offensive to equate healthcare professionals with businessmen selling Charmin, Luvs, Pampers, Gillette razors, Covergirl makeup, etc. No real change there.

Earlier this week, the VA named a new director at the Phoenix VA, ground zero of the VA scandal (5). He is the former director of the Milwaukee VA and director of the VA's Rocky Mountain regional network, apparently coaxed out of retirement to serve for about a year as director at the troubled medical center. He replaces two directors who served a matter of months. While director at the Rocky Mountain VA region he named Cynthia McCormack, former chief of nursing at the Phoenix VA, as director of the Cheyenne VA (6). Cheyenne was second only to Phoenix in having the widespread falsification of wait times discovered. Sharon Helman, the Phoenix VA director sits at home suspended while collecting a paycheck but McCormack appears to continue to direct the Cheyenne VA. No real change there.

Although a handful of administrators have been fired by the VA, the data falsification was rampant, with most VAs apparently falsifying their records (2). Yet these administrators retain their jobs and continue to rule their healthcare empires. McDonald claimed that names had been turned over to the Department of Justice (DOJ), but the DOJ declined to prosecute, and that administrative law judges were blocking the firing of administrators (2). No real change there.

The VA still functions with a lack of oversight. Congressmen make statements and issue press releases when politically convenient. The VA office of inspector general (VAOIG) still does investigations in response to whistle-blowers. After turning over their findings to VA central office to water down, the VAOIG usually makes some recommendations that are quickly accepted but not acted on by the VA (7). No real change there.

Lastly, there is the popular media. For years we heard about Ken Kizer's "Prescription for Change" and the miracle of the transformation to the VA (3,8). This infuriated many of us who knew it was not true (9). We wondered why the press was so accepting of the claims. They certainly are not on other political issues. However, in this case Dennis Wagner of the Arizona Republic, CNN and several other news sources stayed with the story and ferreted out the truth. Real change there. Hopefully, news media with continue their investigative reporting and question VA officials when they put forth self-serving data that is difficult to believe. This is my hope and may be the only result of the VA scandal that will force change. Hopefully the media "won't get fooled again".

Richard A. Robbins, MD

Editor

Southwest Journal of Pulmonary and Critical Care

References

1. Wagner D. Much change in wake of VA scandal; more needed. Arizona Republic. November 8, 2014. Available at: http://www.azcentral.com/story/news/arizona/investigations/2014/11/08/phoenix-va-scandal-changes/18716281/.
2. 60 Minutes. Robert McDonald: cleaning up the VA. Aired November 9, 2014. Available at: http://www.cbsnews.com/news/robert-mcdonald-cleaning-up-the-veterans-affairs-hospitals/.
3. Kizer KW. Prescription for change. March 22, 1995. Available at: http://www.va.gov/HEALTHPOLICYPLANNING/rxweb.pdf
4. Cohen T, Frates C. Shinseki 'mad as hell' about VA allegations, but won't resign. CNN. May 23, 2014. Available at: http://www.cnn.com/2014/05/15/politics/va-scandal-eric-shinseki-preview/.
5. Wagner D. VA names new director for Phoenix medical center. Arizona Republic. November 4, 2014. Available at: http://www.azcentral.com/story/news/politics/2014/11/04/phoenix-veterans-affairs-medical-center-interim-director-brk/18467665/.
6. Cheyenne VA Medical Center. Leadership team: Cynthia McCormack. Available at: http://www.cheyenne.va.gov/about/leadership.asp.
7. Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. [CrossRef]
8. Jha AK, Perlin JB, Kizer KW, Dudley RA. Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med. 2003;348(22):2218-27. [CrossRef] [Pubmed]
9. Robbins RA, Klotz SA. Quality of care in U.S. hospitals. N Engl J Med. 2005;353(17):1860-1. [CrossRef] [PubMed] 

Reference as: Robbins RA. A veterans day editorial: change at the VA? Southwest J Pulm Crit Care. 2014;9(5):281-3. doi: http://dx.doi.org/10.13175/swjpcc150-14 PDF

A Failure of Oversight at the VA

On September 8, 2014 the Washington Examiner reported that the Central Office of the VA was allowed to change language in the VA Office of Inspector General (VAOIG) report on delays in patient care at the Phoenix VA Medical Center (1). Crucial language that the VAOIG could not “conclusively” prove that delays in care caused patient deaths at a Phoenix hospital was added to its final report after a draft version was sent to agency administrators for comment. Rep. Jeff Miller, chairman of the House veterans' committee, said "there are significant differences between the final IG report and the draft version ...". The following day Richard Griffin, the acting VAOIG, vigorously defended the independence of his office and bristled at the allegations that the VA was allowed to alter his office's report. However, his denials and indignance seem disingenuous.

To understand why, we need to go back a few years. First, the Phoenix VA overspent its Fee Basis consult budget in 2010. This is the money budgeted to send patients outside the VA for care. To do this a request was filled out and reviewed. Although the Chief of Staff often reviews these requests, this responsibility was delegated to the associate chief of staff for ambulatory care, Keith Piatt. He nearly always approved these requests. Dr. Piatt had other duties including patient care and limited expertise in several of the areas he was requested to evaluate. Furthermore, poor accounting made if unclear if there was sufficient money to pay for these consults. However, rather than questioning why so many patients were outsourced, the VAOIG blamed the problem on the inadequacy of Dr. Piatt's reviews (2). Given this recent IG investigation, it is not surprising that the Phoenix VA administrators were reluctant to outsource patients.

Second, Sam Foote, the initial whistleblower at the Phoenix VA contacted VAOIG in October, 2013. However, according to Foote the VAOIG did not seem to take his allegations seriously, and did what appears to be a superficial investigation (1). So Foote went to the House Committee on Veterans Affairs this past February. Only after the scandal was made public did the VAOIG acknowledge the inadequate care at the Phoenix VA.

Third, the VA prematurely made press releases prior to the release of the VAOIG's final report attempting to exonerate their responsibility (1,3). The final VAOIG report, apparently altered by the VA, was "unable to conclusively assert that the absence of timely quality care caused the deaths of these veterans.” Although this would hardly seem to be an exoneration, media outlets widely reported that whistle-blower allegations were exaggerated and that veterans were not severely affected by wrongdoing at the Phoenix VA medical center. However, in several instances it would seem likely that delayed care contributed to premature patient deaths and would was questioned in a Senate hearing on September 10, 2014 (3).

Fourth, VAOIG investigators corroborated virtually every major allegation of wrongdoing submitted by the first whistle-blower, Dr. Sam Foote (3). Nevertheless, the report and congressional briefing papers contain passages that appear to criticize Foote and his credibility, emphasizing that "the whistle-blower did not provide us with a list of 40 patient names" referring to VA patients Foote said died while awaiting care in Phoenix. This passage was apparently added by VA Central Office. Foote said the portion of the report about him is "false and misleading" because he and other whistle-blowers provided 24 names to inspectors and explained where to identify16 more. The VA report acknowledged that Foote had supplied at least 17 names and that others could not be traced because documentation had been destroyed by VA employees. Rather than defending their indefensible actions, VA Central Office has apparently resorted to denial, indignance, and blaming the whistleblower.

Fifth, the VA continues to obfuscate and obstruct investigations. According to the VAOIG, managers at 13 VA facilities lied to investigators about scheduling problems and other issues and officials at 42 of the 93 sites engaged in manipulation of scheduling, including 19 sites where appointments were cancelled and then rescheduled for the same day to meet on-time performance goals (4). However, it remains unclear whether officials at the Phoenix and Cheyenne VAs have been fired or even suspended. Citing privacy issues, the VA has refused to comment. However, in 2011, Jack Bagdade, a Phoenix VA physician, was fired for violation of the Hatch Act (5). His firing was widely publicized locally. Bagdade was lobbying Senator John McCain for a new research building at the Phoenix VA. Bagdade forwarded an e-mail from McCain's office entitled "Drink Beer for John McCain". If Bagdade's termination for forwarding an e-mail was appropriate punishment (and I am certainly not saying that it was), then what is appropriate punishment for VA administrators who knowingly manipulated patient appointments for their own personal gain, altered records and then lied to investigators?

Several of the VA administrators involved are also licensed physicians and nurses. However, both the Arizona Board of Medical Examiners and Arizona Board of Nursing have been strangely silent. Altering medical records and then lying about it would seem to be a clear violation of the Arizona statues.

Congress also has to accept some responsibility for their lack of oversight. The problem of inadequate numbers of physicians has been known for years (6). Recently appointed VA Secretary, Robert McDonald, pointed out that the Phoenix VA has now hired 53 additional full-time employees in recent months to help alleviate the appointment backlog (4). He did not mention how many of these employees are physicians nor did he mention how many of the patients were outsourced. However, it seems likely that the hires were merely new administrative personnel to outsource the care of patients. One senior VA official who asked not to be identified said that morale at the VA is poor and doubted that the VA will be able to fill the multiple physician vacancies commenting "Who would want to work here?".

Congress passing a bill to make it easier to fire senior VA administrators suggests they realize there is a problem. However, the legislation still leaves the control of the money up to the very people who misspent it bringing about the present crises. It is also unclear who will do the firing. To date no administrators have been fired despite the law supposedly making this easier. It seems unlikely that any VA administrators are going to fire their colleagues for doing what they are probably also doing or know about. "One of the chief lessons of the VA scandal is that we cannot rely on VA, alone, to effectively identify and correct problems plaguing the department," said Rep. Jeff Miller, chairman of the house veterans' committee. "Oversight and feedback from outside stakeholders is crucial to ensuring VA delivers the benefits and services our veterans have earned." (7). I agree. However, it is doubtful based on their lack of action that either the VAOIG or VA Central Office will take any substantive action to hold those accountable for this scandal and its cover-up.  A reasonable solution is to establish a system for local oversight by physicians, nurses and patients (8). Rep. Miller is right, we cannot rely on the VA to fix this problem and oversight is crucial.

Richard A. Robbins, MD*

Editor

References

1. Taupin M. IG let veterans affairs officials alter report to absolve agency in phoenix deaths. Washington Examiner. September 8, 2014. Available at: http://washingtonexaminer.com/ig-let-veterans-affairs-officials-alter-report-to-absolve-agency-in-deaths/article/2553035 (accessed 9/10/14).
2. VA Office of Inspector General. Review of Alleged Mismanagement of Non-VA Fee Care Funds at the Phoenix VA Health Care System. November 8, 2011. Available at: http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 9/10/14).
3. Wagner D. Critics: VA influenced Inspector General to change Phoenix report for spin-control. Arizona Republic. September 10, 2014. Available at: http://www.azcentral.com/story/news/politics/investigations/2014/09/10/report-phoenix-va-deaths-raises-questions/15375005/ (accessed 9/10/14).
4. Daly M. Watchdog: VA managers lied to investigators about delays. Associated Press. September 9, 2014. Available at: http://www.azcentral.com/story/news/nation/politics/2014/09/09/watchdog-va-managers-lied-delays/15334159/ (accessed 9/10/14).
5. Kujz S. Valley doctor loses job over invitation to have beer with Arizona senator. ABC News. March 25, 2011. Available at: http://www.abc15.com/news/region-phoenix-metro/central-phoenix/valley-doctor-loses-job-over-invitation-to-have-beer-with-arizona-senator (accessed 9/10/14).
6. Robbins RA. VA administrators gaming the system. Southwest J Pulm Crit Care 2012;4:149-54. Available at: http://www.swjpcc.com/editorial/2012/5/5/va-administrators-gaming-the-system.html (accessed 9/10/14).
7. Jordan B. Congressman takes va oversight on the road. Military.com news. August 12, 2014. Available at: http://www.military.com/daily-news/2014/08/12/congressman-takes-va-oversight-on-the-road.html (accessed 9/10/14).
8. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef] 

*The views expressed are those of the author and do not necessarily represent the views of the Arizona, New Mexico, Colorado or California Thoracic Societies or the Mayo Clinic.

Reference as: Robbins RA. A failure of oversight at the VA. Southwest J Pulm Crit Care. 2014;9(3):179-82. doi: http://dx.doi.org/10.13175/swjpcc119-14 PDF