The Emergency Room
But while I was there, something else was going on. I first saw it on Facebook - a story that went viral of some veterans waiting for care in the Emergency Room. What was shocking was an elderly veteran lying on the floor just a couple of feet in front of the reception desk. Here is an account that made it all the way to Great Britain.
Background
I am a disabled veteran and receive all of my medical care through the Durham VA Medical Center and the Raleigh Community Based Outpatient Clinic. I've had numerous appointments at Durham in the Endocrinology, Gastroenterology, Nephrology, Cardiology, Urology, Audiology, Orthopedic, Dental and Eye Clinics for the last 6 years. From a patient's perspective, I think I have an idea of what works well and where improvement is needed.
I have also been in the Emergency Room. Several times I made the 130 mile round trip to get care for minor things because it would take weeks to see my primary care physician. Four times somebody else took me. The worst was when gastritis turned into a diabetic coma. At the ER my blood glucose was 13 times higher than the upper limit of normal. The stress my body was under caused a heart attack. My kidneys shut down and it took over 6 gallons of intravenous fluid to get them restarted. I spent 10 days in ICU. But I was alive. I was alive because the Durham VA Medical Center ER team acted promptly, appropriately and professionally.
Other times when my problems were what are classified as "routine" in the initial triage that all patients receive, it was much like a typical ER. While admittedly feeling pretty cruddy, the waits are interminable, the seats breathtakingly uncomfortable, the experience endured only so that I could have a chance at feeling better walking out than I did walking in. Perhaps part of the problem is that the receptionists and triage nurses see people who are on the edge of death, horribly injured or in other exceptional distress. For those of us who are just "routine" we wait and wait and wait until those who are sicker get treated.
What happened last week to the ill veterans in that story was inexcusable. Equally unforgivable is that instead of getting off her lazy but and finding somebody - anybody - who could help those veterans, the lady who posted on Facebook was too busy taking pictures and being indignant to actually get those gentlemen some help.
The Big Picture
Like any large organization, the Durham VA Medical Center is a mixed bag. My Endocrinologist (who is also on the faculty of the Duke Medical School) and the Endocrine Fellows she trains are universally outstanding. Once while in ICU, she put one of the fellows on my case for a day with the instructions, "Don't break him." Though board certified, that poor fellow was scared.
I also have a Nephrologist who though on a fellowship is also top-notch. As my adventures in kidney failure inevitably spiral into a bad place, she takes great pains to make me a partner in my care. She explains the chemistries involved, the alternatives available to me and has earned my confidence that I am getting the best care available. That care is delivered with professionalism, compassion and in a way that assures me that she is going the extra mile.
On the other hand, there are more than a few things I would happily change. As a result of Type 1 Diabetes, I have some rather horrible and frequently debilitating gastrointestinal complications. Those entail frequent appointments in the GI department. Like many teaching hospitals, fellows, interns and medical students provide the bulk of the clinical care under the supervision of a more senior physician. While two sets of eyes on a case are usually a good thing, the frequent turnover of providers is not. I've had 5 different GI doctors, and with each change the progress that has been made with my old doctor is wiped out when the new one starts on my case.
After 6 years, 5 doctors and with my GI problems getting worse with no relief in sight, one of them suggested I see a gastroenterologist at the Wake Forest Medical School. He is reputed to be THE world leading expert on my particular problem. To send patients outside the VA when the needed care cannot be provided, something called "Veterans Choice" was created by Congress. If care was unavailable, would take more than 30 days to provide, then the VA would contract for that care and the veteran would get help. That request for me to go to Wake Forest was first mentioned to me on June 28, 2016. Two weeks ago I was finally given an appointment - May 31, 2017. That is 11 months if anyone is counting.
While fighting the bureaucracy to get that appointment, I came to the end of the line when I was told to call the Patient Advocate Office. They are the people dedicated to ensuring that difficult problems get resolved, logjams are broken up, or if not, a rational explanation is given to the veteran. I made the call. The phone rang and rang. Nobody picked up. After a couple of minutes, it didn't go to voiice mail - it automatically disconnected.
I was furious. Over a year earlier, in a Town Hall Meeting, I got up and mentioned that I'd tried to call the Patient Advocate Office at 3:00 one afternoon. I got a recording saying that they were closed for the day (but the recording said 4:30 was when their office hours ended). No voicemail, either. I suggested that they might want to use voicemail for times when nobody was available. I was assured that they had it.
Recommendations For Improvement
To better serve veterans, it might be useful if the VA thought a bit like their customers - the veterans.
1. In the military, somebody is always in charge. They also report to somebody. It's called a chain of command. Walk into any Infantry Company or Cavalry Troop and right inside the door for all to see are pictures of the chain of command. Walk into a VA clinic and the impression is that the receptionist runs it. Have a problem? Chances are the receptionist can't help, but the head of the clinic can. Post a picture and contact information for the person running the clinic. Add one for the person they report to, and so on.
2. Also in the military, leaders are readily identifiable. Sometimes it is by rank, or back when I was in the Army, leaders wore green tabs on their epaulets. At the Durham VA, you can't tell if that older gentleman in the tie is the Chief of Staff or a stock clerk in the canteen. For a patient, whether in a clinic or on a ward, the cacophony of scrubs, lab coats and various combinations make it impossible to tell who is a surgeon or an orderly. To patients, family members and the employees, that is useful information.
3. Fix the damn phone system. Finding the number to a clinic is next to impossible. The system is atrocious, there is nothing resembling a useful phone directory. The introductory spiel from the Hospital Administrator and the phone options runs nearly two minutes. If you really care (like the interminable recording states) then spare me the speech and help me to get the person I need on the phone in a timely manner.
4. Speak to veterans. Not in some formal advisory council meeting, not in a mailed survey, or by reading social media comments. Leaders from hospital executives to clinic and department leaders need to make time to get out of their office and speak to veterans. One on one. Face to face. Ask smart questions, like "what can we do better to help you?" or "if you were in charge, what would you change" or "tell me what you need that we aren't providing." Any decent Corporal worth his salt know how to do that. VA leaders should be no different.
5. Use social media. I'm on your email list - don't just use it to tell me about snow events. Got something coming up (like a Town Hall!) use it for that periodically. Put a functional calendar of future events on your Facebook page - don't use Facebook to only talk about things in the past that might have interested me.
6. Appoint a contact person for each clinic who can answer questions from veterans and family members. Many clinics don't run 5 days a week, and it is up to the veteran to figure out when it is operational, and to use that to get the timing right to ask a question.
Above all, for veterans the VA is an unfathomable bureaucracy. Sometimes we don't know what to ask. If we do, the most insanely difficult thing in the world is figuring out who would know, and even harder than that is to find them. If you can figure out how to overcome that, then in my book the VA would not only walk on water, they'd skip on whitecaps.
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