image Frederick L. Greene, MD

Clinical Professor of Surgery
UNC School of Medicine
Chapel Hill, North Carolina

With many mixed emotions, I have followed the trials and tribulations of the Veterans Administration health system over the past year. Following the scandal uncovered at the Veterans Administration Medical Center (VAMC) in Phoenix and the Office of Inspector General’s report condemning approximately 40 other VAMCs for scheduling issues, the story recently reached a fever pitch, highlighted by the resignation of the Cabinet official responsible for VAMC activities.

This is a particularly sad story for me. As a Navy veteran, I am angry over the way fellow veterans have been treated as clinic wait times were manipulated, fudged and misrepresented by VA underlings and administrators who apparently benefited economically by reporting erroneous wait times for patients. We have yet to hear the full and devastating fallout from this heinous activity.

As a former chief of surgical services in the VA system, I weathered the heated discussion in the late 1980s and early 1990s regarding lack of quality in the VA’s surgical services. This critique did have a positive outcome and led to a full discussion of the importance of risk adjustment of surgical patients and the launch of the VA National Surgical Quality Improvement Program (NSQIP), now called VASQIP in the VA system. This quality initiative, which began in VA hospitals, currently permeates many hundreds of non-VA facilities under the leadership of the American College of Surgeons. Unfortunately, this important positive program launched in VA facilities by surgeons is now overshadowed by all the negative discussion regarding falsification of wait times and the unfortunate outcomes that have have resulted.

Probably the greatest emotion and visceral response for me emanates from the most important aspect of my VA involvement. A significant part of my surgical training took place in a VAMC. My very first rotation as a surgical intern was at the West Haven VA hospital, in Connecticut. Throughout my years as a surgical trainee, the VA provided me with predominantly positive experiences. Attendings assigned to the VA were some of the best in my academic medical center and were dedicated to giving optimal care to every veteran.

In all of the discussion regarding the fallout of the recent scandal in the VA system, I have seen nothing regarding the effect on the many medical students, residents and fellows who receive training annually in VA medical centers. I wonder what these young men and women are thinking; I wonder what their program directors and designated institution officials are thinking. One of the positive outcomes that might derive from the current VA illness is to encourage teaching institutions that are involved in collaborative education programs with VA medical centers to take a more hands-on role. Training programs cannot allow their trainees to work in institutions and be exposed to practices that are antithetical to good patient care. Young physicians rotating through VA hospitals—or any health care institution, for that matter—should be educated in system-related core competencies enabling them to recognize and report inappropriate care when they see it.

I am hopeful that good things will come from the latest VA debacle, just as NSQIP (VASQIP) was born out of the surgical quality concerns of the 1980s and 1990s. Whatever dialogue ensues regarding issues of poor care, let us not forget an important fallout of these unfortunate events—the effect on our trainees in the VA system. The VA system is desperate for more physicians to work at its hospitals. The 150 VA hospitals and more than 800 outpatient VA clinics are struggling to care for the approximately 9 million veterans enrolled in VA health care (N Engl J Med 2014 June 14. [Epub ahead of print]). The system must clean up its problems so that young physicians will seek employment in VA facilities and find real satisfaction in taking care of our ever-growing veteran population.

There is no better time to reflect on the role of teaching a new generation of physicians than this month when many residents will begin their training in parent institutions closely associated with VA medical centers. There is no better time than now for the VA health care system to commit itself to excellence for both the veterans it cares for and the physicians it trains. Our VA hospitals must be examples of excellence in every respect; the training needs of young physicians demand it.