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.”