Time for the VA to Clean Up Its Act

One year after a Veterans Affairs (VA) scandal was ignited here in Phoenix, the number of veterans on wait lists is 50 percent higher than at the same time last year, according to VA data (1). The VA is also facing a nearly $3 billion budget shortfall. VA Secretary Bob McDonald has asked for “flexibility” to reallocate billions of dollars in clinical funds to cover the shortfall.

Since the scandal broke last year, VA providers have increased their workloads, adding 2.7 million more appointments than the previous year. However, the VA has played "games" with patient eligibility for years. When money was plentiful VA administrators would open the doors to patients since the following years' budgets were based on the number of patients seen. However, when money was tight, the doors would be slammed shut leaving many patients in the lurch scrambling to obtain health care elsewhere. Now it appears that patients might be returning to the VA.

“Something has to give,” the department’s deputy secretary, Sloan D. Gibson, said in an interview. “We can’t leave this as the status quo. We are not meeting the needs of veterans, and veterans are signaling that to us by coming in for additional care, and we can’t deliver it as timely as we want to.” Now the VA is asking Congress' permission to use clinical funds to pay for the budgetary shortfall.

The VA has threatened furloughs and hiring freezes to reduce spending. This seems to be quite sensible. However, in the past, the VA has cut clinical positions which undoubtedly contributed to longer wait times. For example, when I was chief of pulmonary at the Phoenix VA, one of my physicians retired, giving 6 month notice. However, we were not allowed to replace the physician because of a "hiring freeze". This apparently only applied to clinicians since a new associate director was hired.

As we predicted over a year ago, the VA would continue to be troubled due to lack of reform and oversight (2).  The present VA secretary, Robert McDonald, is still relatively new on the job and inexperienced in both healthcare and government service. His inaction suggests that he may be confused, or worse, listening to long-entrenched central office bureaucrats. Below are some suggestions which could result in substantial savings and would have little impact on patient care.

Furlough the staffs of the Veterans Integrated Service Networks (VISNs), the 21 VA regional offices which are scheduled to be downsized. The VISNs provide no healthcare and the savings in salaries from the nearly 5000 employees would be substantial (2). Similarly, VA central office which grew from 800 employees to 11,000 in less than 15 years could probably do with a few less administrators (3).

Local VA bureaucracies reflect the growth of central office and VISN bureaucracies. It is unclear what many of the hospital associate and assistant directors do other than sit in meetings. Most hospitals could do without them for a while. Similarly, compliance officers and patient "advocates" really serve no purpose. Despite multiple patient complaints about wait times, the lack of action that led to the VA scandal demonstrates that they are not effective. There are also some physicians and nurses who do not see patients. For example, most VA Chiefs of Staff do not see patients. Nursing administration is bloated with "clip board" nurses who do little than attend meetings and create an ever increasing, and seemingly never ending, stream of paperwork for nurses who are already overworked. Surely, we could do without some of these people. 

It seems unlikely that VA officials will implement any meaningful cost savings. Instead they will try to preserve the status quo by petitioning Congress to allow them to shift clinical funds depriving veterans of healthcare. That includes using funds from a new program that was a priority for congressional Republicans called the “Choice Card”. This program allows certain veterans to obtain taxpayer-funded care from private doctors. VA administrators have blamed the budget shortfall on this program along with a new treatment for hepatitis C (1). The VA has been accused of dragging its feet on the Choice program and once again appears to be trying to sabotage the program and keep the funds. Gibson said in the interview that in future years more money will also be needed. He said he intended to tell lawmakers, “Veterans are going to respond with increased demand, so get your checkbooks out.”

VA administrators appear more concerned with keeping money inside their dysfunctional agency than caring for vets. Based on past history, Congress will probably let the VA shift the money and none of the recommendations above will happen. If furloughs occur, they will be lower level employees and result in little financial saving. Of course, administrative bonuses will be hefty this year because in their eyes, the administrators have successfully averted a financial crisis. Unless there are some fundamental changes made at the VA, the trend of the last 20 years of bloating the bureaucracy at the expense of healthcare will continue.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Oppel, RA Jr. Wait lists grow as many more veterans seek care and funding falls far short. New York Times, June 20, 2015. Available at: http://www.nytimes.com/2015/06/21/us/wait-lists-grow-as-many-more-veterans-seek-care-and-funding-falls-far-short.html (accessed 6/24/15).
2. Robbins RA. VA administrators breathe a sigh of relief. Southwest J Pulm Crit Care. 2014;8(6):336-9. [CrossRef]
3. Kizer KW, Jha AK. Restoring trust in VA health care. N Engl J Med 2014;371:295-7. [CrossRef] [PubMed] 

Reference as: Robbins RA. Time for the VA to clean up its act. Southwest J Pulm Crit Care. 2015;10(6):350-1. doi: http://dx.doi.org/10.13175/swjpcc088-15 PDF

Eliminating Mistakes In Managing Coccidioidomycosis

Tim Kuberski MD, FIDSA

Maricopa Medical Center

Department of Internal Medicine,

Infectious Diseases

2501 East Roosevelt Street

Phoenix, Arizona 85008

This editorial is in response to the article "Common Mistakes in Managing Pulmonary Coccidioidomycosis" by Drs. Galgiani, Knox, Rundbaken and Siever (1).  These authors are eminently qualified to discuss the management of pulmonary coccidioidomycosis. However, these “mistakes” have been made for many years and, truth be known, the authors probably made some of those mistakes when faced with their first patient with a serious Coccidioides infection. What obviously is missing from these experts are solutions to keep the mistakes from happening. I would like to fill in the deficit by offering remedies for important issues raised by the article, and more.

Who am I to offer solutions? I am board-certified in Infectious Diseases (therefore, qualified). I went into private practice in Phoenix 35 years ago solely doing Infectious Disease consultations. As a consequence I am pretty sure I have seen more patients with coccidioidomycosis (I can spell it 4 c’s, 4 i’s and 4 o’s; abbreviated by me as “coccy” which avoids the often used contraction of “cocci” which applies to a completely different pathogen) than anyone in the world. I am not smarter, but there are 5 million people in Phoenix and they all get coccy - this qualifies me as experienced. In addition, I was Clinician of the Year for the Infectious Diseases Society of America (IDSA) in 2007 (validation as a clinician and not a kook). My perspectives have evolved as a problem-solving clinician in the coccidioidomycosis trenches. Early on I quickly came to the conclusion that the IDSA guidelines for the treatment of coccidioidomycosis were of value only to lawyers and administrators, more about that later. Let’s get started on solutions.

Number 1.  To get a license to practice medicine (all specialties) in Arizona you have to demonstrate proficiency in coccidioidomycosis. Before coming to Phoenix I spent some time defending my country in Hawaii and I had to get a medical license to practice medicine in Hawaii. At that time, Hawaii licensure required “proficiency” in leprosy. You were given a booklet on leprosy and then you were given the choice of watching a movie on leprosy or actually seeing patients with leprosy, I chose the latter. Then you had to pass a written test on the diagnosis of leprosy. It must have helped because that test is no longer required and there are no Hansen’s Disease patients on Molokai. Implementing a similar proficiency test for coccy licensure in Arizona might require legislation which should not be too difficult since most of the legislators have either had Valley Fever or heard about it. It would be one of the few things of educational value about getting a medical license to practice medicine in Arizona.

Number 2. Develop a reference laboratory solely for Coccidioides testing.  Even if you do everything right in managing coccy, one of the major impediments to the management of coccy is a lack of a rapid and accurate test for the disease. A not un-common scenario (i.e., “mistake”) is a primary care physician, recently moved to Arizona and trained elsewhere sees a patient on a Friday evening as an outpatient. The patient has a mild community-acquired pneumonia and has an occasional wheeze on examination. The patient gets oral doxycycline and a short course of steroids and told to schedule a follow up appointment in a week. A coccy serology is too frequently not ordered, but if it is done, the results will come back in a minimum of 4 days later and often still does not get back to the physician in a timely way. Follow up does not happen as the steroids made the patient feel better - for a while. The next time the physician finds out about the patient, the coccy has disseminated or a letter is received from a lawyer. The point is that serology for coccy is inaccurate too often and the turn-around time too long. Some of the smaller hospitals do not do coccy serology testing on a daily basis and/or on the weekend. That means patients with a fulminant pneumonia in the ICU do not get a serologic diagnosis until precious time has passed. The solution is a reference laboratory that does only coccy-related tests rapidly and accurately. In my experience, non-clinicians like laboratory directors and pathologists decided the fate of coccy serology. Over the years I have had meetings with every hospital in Phoenix (more than 10) about the status of their coccy testing generally without sustained success. These tests need to be taken out of the hands of hospitals and commercial laboratories. The vast majority of my complicated coccy patients have had their serology tests done by Dr. Demo Pappagianis at his coccy laboratory at the University of California at Davis. These patients were followed by serologies done at that laboratory for over 20 years with amazing consistency and accuracy, illustrating that it can be done. A good businessman with good technicians under the right circumstance should monopolize coccy testing to the benefit of the Arizona community.

Number 3. Arizona needs a coccidioidomycosis registry. Perhaps now that there is a medical school in Phoenix, an effort can be made to collect better clinical and epidemiologic data on cases to enable clinical trials on the treatment of coccy. I mentioned the IDSA guidelines for the treatment of coccidioidomycosis previously. Those guidelines are on the basis of expert opinion and not much validated science – there are no double-blind controlled studies on the treatment of any type of infection due to coccy. If you are a physician dealing with a patient with disseminated coccy and have no experience with the disease – those guidelines are of no substantial help. The IDSA guidelines should be abandoned and substituted with a good review on the treatment of coccy written by Dr. Galgiani and if you are still lost, call the Valley Fever Centers of Excellence for advice. Huge amounts of time and money are squandered on these guidelines.  A coccy registry – similar to a tumor registry, would provide the opportunity to do good clinical studies in Phoenix because of its population base.

Since coccy is a reportable disease in Arizona there should be an effort to establish more detailed information on patients hospitalized in Arizona. Most major hospitals have infection control nurses who are accustomed to data collection. I propose they fill out more detailed information on patients hospitalized with complicated coccy. The infection control nurses should be incentivized by compensating the infection control department for each report. There is much more information that could be collected (i.e., socio-economic impact) on the various forms of coccy. You get the picture. Since Arizona has the most reported cases of coccy in the Country we should be the leader in coccy and related issues.

Another interesting observation is that there are many more deaths in Arizona due to coccy than Ebola. Considering the amount of money given to Arizona devoted to Ebola, we need to develop a registry for Ebola and coccy, since we will never see a case of Ebola. In addition, when a coccy patient is entered into the registry a serum specimen should be collected and maintained at the reference laboratory for seroepidemiologic and other studies for emerging new tests and research.

Conclusions

The usual excuses for not implementing these suggestions are there is no money and/or time. However implementing these three recommendations would do more for coccy in Arizona and help resolve the “mistakes” made by its physicians than anything that has happened in the past 35 years. Money will always be an issue, but implementing mandatory proficiency in coccy should not be too difficult by absorbing it into the licensure process. A central coccy laboratory should be self-sufficient if run as a business. A coccy registry would need “orphan disease” status to get start up funds and should be maintained ideally by the new medical school in Phoenix and/or the Valley Fever Centers of Excellence. It will require experts like the authors, the Arizona legislature, Maricopa Medical Society and the new medical school to join forces to make Arizona a leader in all things coccy – except “mistakes”.

Reference

1. Galgiani JN, Knox K, Rundbaken C, Siever J. Common mistakes in managing pulmonary coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10(5):538-49. [CrossRef] 

Reference as: Kuberski T. Eliminating mistakes in managing coccidioidomycosis. Southwest J Pulm Crit Care. 2015;10:250-2. doi: http://dx.doi.org/10.13175/swjpcc062-15 PDF

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