The VA “works” because veterans are less demanding patients

While rotating through the local Veterans Affairs (VA) hospital during my residency in radiology, I noticed a curious phenomenon. When the weather was pleasant a large number of veterans would not show up for their scheduled CT scan or MRI. When the weather was miserable or dangerous the attendance would be maximum.

We named this phenomenon the “VA paradox”: a paradox because this is the opposite of what usually happens.

After deeper analysis I realized this was not a paradox at all. I had the epiphany when I was explaining the risks of intravenous dye for CT scan to a middle-aged veteran. I robotically recited the infinitesimally low risk of kidney failure, allergic reactions, and pain, emphasizing that the benefits of CT scan outweighed risks of the dye.

The veteran stopped me mid-sentence and laughingly pointed to his artificial right leg: “As long as you don’t do that to me doc, that’s fine!”

He had a below-knee amputation for a spreading infection in his foot after being sprayed with shrapnel in Vietnam. He was still grateful to be alive, so grateful that when the weather was sunny, he’d rather enjoy the day in the park than have his surveillance CT scan for his lymphoma.

I felt like a bumbling fool with half the insight of Marie Antoinette. Here were men and women who had stared death in the face, dodged IEDs, endured torture and discomfort that most of us losing sleep over the risks of anti-bacterial soap could not possibly fathom. And here was I obtaining informed consent (and covering myself legally) over risks so absurdly small in comparison. The veteran retained his perspective. Where was mine?

Another veteran was reluctant to undergo a barium enema — a specialized x-ray of the bowel. He was being hounded by his primary care physician to get screened for occult bowel cancer. There is a check box for preventive care which must be ticked to prove you are delivering high value care.

“Cancer is like a landmine. You won’t know it’s there until it’s too late,” I said, in an embarrassingly amateurish attempt to emulate Morgan Freeman’s tone.

“Whatever doc! Do what you have to do.” The unflappable veteran replied dismissively.

Yes, carry on doctors. Carry on with your mass medicalization, obsession with miniscule risks and grand theories about preventive care. Meanwhile leave us to deal with the real dangers.

I recall a dinner conversation with physicians extolling the virtues of a government-run health care system using the VA as an exemplar. I remarked that the VA “worked” because the veterans were low maintenance.

I instantly saw the folly of my statement, which was interpreted as “our veterans don’t ask, so we can ignore them.” I realized that any analysis of the VA could offend many Americans who see in any critiquing of the system an attack on the right of armed forces to health care. I put this down to endearing patriotism, not reflexive sanctimony.

After the recent scandal regarding wait times for the veterans I feel emboldened to say once again: The VA system “works” because the veterans are not so demanding.

Try putting New Yorkers through a 60-day wait for a CT scan and see what happens. Implement VA-style care and budget on equally ill insured Californians, and see what happens. The system would implode.

These men and women, the most resilient, self-deprecating, charming, uncomplaining, and grateful patients that I’ve had the good fortune of encountering, are the least demanding of health care. This does not mean they are the least in need of medical services. Comorbidities in veterans abound, as do rates of drug and alcohol addiction. Neither are they the least deserving of free health care.

But they are not the worried well. They are often the unworried unwell. And their thrift and good manners allow the nation to promise them health care at a bargain price.

This price might have been even more unsustainable were it not for a fortuitous clause in the J-1 exchange visa.

International medical graduates (IMGs) on a J-1 visa must return to their country of origin for at least two years unless they work in an area of need. VA hospitals are areas of need. Many IMGs staff the VA to fulfill the waiver. Once naturalized some leave the VA for the El Dorado of private practice. Many stay on.

The health care of the former service men and women of a nation built on immigration is sustained, in part, by immigration. How is that for a full karmic circle?

To borrow an economic term, health care is highly elastic for the veterans. They use it when symptomatic. When asymptomatic and the weather is nice, they wish to be left alone. It’s just as well they don’t have to pay for health care. I suspect their use would have been even lower.

And good on them. They value their lives, the lives that have not been forfeited in the line of duty. And what a fine testament to the value they place on living, by living each day for the day and resisting the cavalry of medicalization that is conquering the rest of the country?

I enjoyed my rotation at the VA partly because it reminded me of the National Health Service (NHS) in Britain where I trained. Many commentators have made comparisons between the VA and the inevitable structural rationing in the NHS.

I see another similarity. The NHS “worked” because the population it served was not demanding. It was a good fit for the stiff upper lip, resilient Brit with good manners. It’s now imploding because the citizens are more risk averse, their lips now loose and demanding. They obsess about LDL cholesterol. They Google “headache” and throng emergency departments after seeing the results of the web search.

It’s not administrative ingenuity or integrated electronic medical records that’s responsible for the low cost of the VA. It’s the veterans that are to be thanked. Lest we forget.

At the VA I saw a curious inversion of Robert Southey’s anti-war poem, “After Blenheim”:

“But what good came of the barium enema?”
Quoth the veteran.
“Why that I cannot tell,” said I.
“But ’twas a famous EMR.”

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad. This article originally appeared in Forbes.

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  • doc99

    Apparently the Veterans who use the VA services are a lot like most doctors in matters of dealing with authority.

    • Patient Kit

      Chain of command is an important part of military culture. So is serious repercussions for insubordination. Should we start calling you all Sarge instead of Doc?

  • Patient Kit

    Try making New Yorkers wait 60 days for a CT, indeed. That’s a long time to wait if your doc believes you need a CT. I had a CT last month that was pre-approved/authorized at 5pm on a Thursday and I had the CT done the next day, Friday, at 1pm. It was not an emergency and I didn’t “demand” that timeframe. I just arranged it because it was easily available. And, for the record, I’m currently covered by Medicaid. From what I can tell from reading here, that timeframe is not typical across the US for Medicaid patients?

    I tend to resist sweeping generalizations about any big group of people, such as vets or New Yorkers. Do you really think New Yorkers are demanding and vets are undemanding? I just have to wonder about the general characterization of vets being so passive about their medical care. I realize that there are plenty of women vets but I imagine that the majority of vets are men. And men, in general (!)), tend to be ambivalent about or resistant to going to the doctor. I wonder whether that is more of a factor than “vets are undemanding”.

    • Eric W Thompson

      That is odd that you got in so quickly for anything non-emergeant. I would assume doctors would not send anyone in for a CT who they did not feel needed one? If the CT schedule is so open, they are probably losing money. Expensive equipment needs to be fully scheduled. If health care has openings to where a patient can have routine next day appointments there is over supply, underutilization and loss/waste of money.

      • Patient Kit

        Keep in mind that I am in NYC where there seems to be a lot of competition for patients between hospitals, docs and imaging.

        In my case, this pelvic/abdominal CT was part of one of my series of checkups after being diagnosed with and having surgery for ovarian cancer one year ago. I’m being monitored for recurrence every 3 months for the first 2 years post-surgery by my GYN oncologist. This is the first CT he ordered in a year, so he doesn’t overdo it with the CTs. It was necessary/advisable but not an emergency.

        Even though my doc is a hospital-based attending, I had my CT done outside of the hospital at an independent imaging center in my neighborhood. This imaging place is big and is open 7 days a week and until 11pm on weekday evenings. It’s always crowded but they always seem to fit me in quickly. I’m a good customer, having had regular mammograms there as well as imaging for several serious orthopedic injuries (fractured femur, ruptured Achilles tendon, torn meniscus). This imaging place will send (and pay for) a car service to pick patients up and bring them back home if their condition makes it hard for them to get there on mass transportation. I was actually surprised when my doc’s office suggested I get the CT done outside of the hospital because it would be more convenient for me. I hear there is a lot of pressure on docs to keep their patients inside their hospital system for everything they need.

        I don’t know. All I’m doing is reporting my own personal experience during this year on Medicaid. Maybe my Medicaid experience hasn’t been typical. Maybe I’m not a typical patient. I know that my awesome doc isn’t typical. :-D And neither is my awesome home city.

        • Eric W Thompson

          Many places won’t take Medicare anymore. Medicare and Tricare patients are also finding it harder to locate providers that take them as the payments are so low. Many practices either refuse or restrict the numbers they accept. And why not? In some cases the payments do not cover costs. That is the reality and it is steadily getting worse.

          • Patient Kit

            I understand that and we need to do something about that, namely, increase reimbursement rates for treating Medicare and Medicaid patients.

            If reimbursement rates were better, do you think doctors would be willing to see more Medicare and Medicaid patients? Or would the government rules and regulations and red tape still be a deal breaker for most docs?

            I realize that I have been extremely lucky to have been able to access such excellent medical care while on Medicaid. My medical care this last year and a half while on Medicaid has been just as good as the care I got while covered by a very good Blue Cross plan for 20 years. My care this year has all been with docs based at a teaching hospital. When I go back to private insurance and have more private practice options again, I’m planning on staying with my awesome doc at the hospital. Not only is he a terrific doctor, but he treated me when I was in real crisis after a private practice doctor abandoned me when I lost my BC insurance. Now, going forward, I’m sticking with my hospital-based doc.

            If private practice docs are refusing to see Medicare patients too, I might as well just start building my doctor-patient relationships at the hospital instead of in private practice. That way, I’ll have docs I can stay with when I eventually each Medicare age. A lot will likely change in our healthcare system in the next 10 years though.

          • Eric W Thompson

            Reimbursement rates help. Even seeing patients that pay enough to ‘break even’ doesn’t cover living expenses, let alone school loans. Break even means the doctor is seeing patients at less than minimum wage. So doctors can only afford to see a few of what are essentially charity patients. Some probably overcharge those who can pay to make up for it. Doctors on salary at the hospitals have no such worries. But someone does pay. If the city goes into another budget crisis and gets cuts, who pays the bills topping up medicare & medicaid bills then? Someone ALWAYS has to pay. Care isn’t free.

          • Patient Kit

            Believe me, as someone who has paid heavy taxes for decades, I do know that somebody does pay for every bit of healthcare that is delivered — regardless of who provides or pays for that medical care. I know that the care I’m receiving under Medicaid is not free. Not free for the system and not free for me because I have paid heavily into that system over the years.

            I also understand that getting care at the hospital is the most expensive possible way to get care. But if private practice doctors refuse to see us, what choice do we have but the hospitals? Surely, you agree that patients in need of medical care should seek out and get the best possible medical care they can get for themselves and their families? I’ve never used the ER for anything that wasn’t an emergency. And perhaps I saved the system a little money by having my CT scan outside of the hospital. It really is both absurd and ironic that, as a Medicaid patient, my only real option is expensive hospitals. And it sounds like it will be the same situation once I’m old enough to be covered by Medicare.

            So, you tell me – is there any reason for me to look outside of the hospitals for private practice doctors who really don’t want to see me when I can get excellent care from docs at the hospital, even while they work under the corporate gun? What I hear constantly here at KMD from private practice docs is that you don’t want me as a patient. I’m a really good patient too. But if you don’t want me as a patient, dnt fault me for going to the hospital docs who do want me.

          • Eric W Thompson

            Of course you should go where you can get care. My family has only Tricare which uses the same reimbursement rates as Medicare and many places don’t accept it. How long any providers and hospitals will accept them would only be a guess.

            If your hospital funding gets cut, where does that leave you? There does seem to be some evidence that two tiers of care are emerging in this country. To give us credit that is definitely the case in Europe.

            I don’t see anyone faulting you. But can you fault the doctors when if they see you, it costs them? Every time you go in, they lose $. It is not that they don’t want you, they have families to feed also.

  • QQQ

    For anyone imagining this is some sort of “new” problem with the VA you
    should find the 1992 movie Article 99, all about just the kinds of “new”
    problems being unearthed at the VA. And before that that was a spin-off
    of MASH with Col. Potter where he had to fight the same kind of stuff
    at a VA hospital he was running after the Korean War. Not new, but it
    should be addressed and fixed. Just as it should have been after Korea,
    after Vietnam, after Desert Storm……… Instead it’ll be a campaign
    gotcha and it’ll be business as usual after November. If you are
    imagining that politicians from either party really have any intention
    of changing things much, think again.

  • QQQ

    “Government treating NHS like failing bank, says Lancet”

    http://www.theguardian.com/society/2013/aug/16/government-nhs-failing-bank-lancet

  • Eric W Thompson

    The VAH I work had is scheduled out weeks in advance for routine appointments. The doctors are fully employed. Any emergency type complaint is sent to the emergency department right away. I don’t see how, or why, Phoenix got away with secret lists.

  • Patient Kit

    Yet again, I miss the point? I was responding to doc99, who compared how most docs deal with authority as being similar to how “undemanding” vets deal with the VA. I don’t think I missed his point. I was agreeing that docs don’t seem to confront authority well. And maybe that is, in part, because medical education has a rigid hierarchy as does the military. What point did I miss that doc99 was making? And why are most of your responses to me about “liberals”, no matter what we’re talking about?

  • ninguem

    The VA “works” because the government can exempt itself from the rules the rest of us must follow.