As usual, it was a hectic Monday on the psychiatry consult service. All the trainees, from medical student to fellow, were seeing other patients when the call came from the surgery clinic. One of the pleasures of being a VA clinician is the ability to teach and supervise medical students and residents. The attending in that busy clinic said, “There is a patient down here who is refusing care for a gangrenous leg, but he is also talking about his life not being worth living. Could someone evaluate him?” That patient, Mr. S, declined to go to either the emergency department or the urgent care psychiatry clinic, so I went to see him. I realized that I had seen this patient in the hospital several times before.
One of the great clinical benefits of working in the VA, as opposed to in academic or community hospitals, is continuity. In my nearly 20 years at the same medical center, I have had the privilege of following many patients through multiple courses of treatment. This continuity is a huge advantage when there is what Hippocrates called a “critical day,” as on that Monday in the surgery clinic.2 Also, in many cases the continuity allows me to have a reservoir of trust that I can draw on for challenging consultations, like that of Mr. S.
The surgery resident and attending had spent more than an hour talking to Mr. S when I arrived but still they joined me for the conversation. Mr. S was a veteran in his sixties, and after a few minutes of listening to him, it was clear he was talking about ending his life because of its poor quality. He told us that he had acquired the infection in his leg secondary to unsanitary living conditions. The veteran was quite a storyteller, intelligent, and had a wry sense of humor, which only made his point that his living conditions were intolerable more poignant. He apparently had tried to talk to someone about his situation but felt frustrated that he had not obtained more help.
The surgery attending had already told Mr. S that he would respect his right to refuse the amputation but he feared that Mr. S’s refusal was an expression of his depression and hopelessness, hence, the psychiatry consult. Although Mr. S was not acutely suicidal, something about the combination of his despair and deliberation worried me.
The surgery attending offered to admit Mr. S to do a further workup of his leg. I encouraged him to accept this option and added that I would make sure a social worker saw him and the psychiatry service department also would follow him. Mr. S declined even a 24-hour admission, saying that he had just moved to a new apartment and “everything I have in the world is there and I don’t want to lose it.” This comment suggested to me that he was ambivalent about his wish to die and provided an opening to reduce his risk of harming himself either directly or indirectly.
After the discussion, Mr. S seemed to believe we cared about him and was more willing to participate in treatment planning. He agreed to let the surgeons draw blood and to pick up oral antibiotics from the pharmacy. I promised him that if he would come back to clinic that week, I would make sure a social worker met with him and that my team would talk with him more about his depression. Mr. S picked Friday for his return and assured me that now that he knew we were going to try and improve his situation, he would not hurt himself. Obviously, this was a risk on my part—but the show of compassion combined with flexibility had created a therapeutic alliance that I believed was sufficient to protect Mr. S until we met again.
I returned to my office and called the chief of social work: The dedication of career VA employees forges effective working relationships that can be leveraged for the benefit of the patients. At my facility and many others, many of the staff members who are now in positions of leadership rose through the ranks together, giving us a solidarity of purpose and mutual reliance that are rare in community health care settings. The chief of social work looked at the patient’s chart with me on the phone while I explained the circumstances and within a few minutes said, “We can help him. It looks like he is eligible for an increased pension, and I think we can find him better housing.”
I admit to some anxiety on Friday. One of the psychiatry residents on the service had volunteered to see Mr. S after studying his chart in the morning. Most of us are aware that the aging VA electronic health record system is due to be replaced. But having access to more than 20 years of medical history from episodes of inpatient, outpatient, and residential care all over the country is an unrivaled asset that brings a unique breadth that sharpens, deepens, and humanizes diagnosis and treatment planning.
Sure enough at 10 am, the surgery clinic called to tell us Mr. S had arrived on time. The resident headed to interview him while I contacted the chief of social work. She put out a call for help to her staff, and within 10 minutes an outpatient social worker was in the clinic talking with Mr. S. Compared with his initial visit, Mr. S’s mood was much brighter, and he no longer was endorsing any suicidal ideation or intent. He still did not want his leg amputated, feeling it would rob him of his independence, but he was now willing to consider other treatment options. Mr. S also said he wanted to speak with the palliative care team to know what they could offer.
The social worker arranged new housing for Mr. S that day and help to move into his new place. The paperwork was submitted for the pension increase, and help for shopping and meals as well as transportation was either put in place or applied for. As he left to pack, Mr. S told the surgeon he might not want hospice just yet.
The coda to this narrative is equally uplifting. Several weeks after Mr. S was seen in the surgery clinic, I received a call from a midlevel psychiatric practitioner in the urgent care clinic who had been on leave for several weeks. He too had seen Mr. S before and shared my concern about his state of mind and well-being. He thanked me for having the consult service see him and remarked that it was a relief to know Mr. S had been taken care of and was in a better place in every sense of the word.
In response to a rising media tide of concern about the direction VA care is headed, Congress and the VA have issued a strong statements, “debunking” what they called the “myth” of privatization.3 Yet for the first time in my career, many thoughtful people discern a constellation of forces that could eventuate in this reality in our lifetimes. The title and message of this column is that the VA cannot be privatized, not that it will not be privatized. Also, I did not say that it should not be privatized. As I have written in other columns, that is because ethically I do not believe this is even a question.4 Privatization breaks President Abraham Lincoln’s promise to veterans, “to care for him who has borne the battle.” A promise that was kept for Mr. S and is fulfilled for thousands of other veterans every day all over this nation. A promise that far exceeds payments for medical services.
I also do not mean the title to be a rejection of the Veterans Choice Program. The VA has always provided—and should continue to offer—community-based care for veterans that complements VA care. For example, I live in one of the most rural states in the union and recognize that a patient should not have to drive 300 miles to get a routine colonoscopy.
The VA cannot be privatized because of the comprehensive care that it provides: the degree of integration; the wealth of resources; and the level of expertise in caring for the complex medical, psychiatric, and psychosocial problems of veterans cannot be replicated. Nor is this just my opinion—a recent RAND Corporation study documents the evidence.5 There are many medical services in the private sector that may be delivered more efficiently, and Congress has just passed the Mission Act to allocate the funds needed to ensure our veterans have wider and easier access to private care resources.6 Yet someone must coordinate, monitor, and center all these services on the veteran. It is not likely Mr. S’s story would have had this kind of ending in the community. The continuity of care, the access to staff with the knowledge of veterans benefits and health care needs, and the ability to listen and follow up without time or performance constraints is just not possible outside VA.
The other evening in the parking lot of the hospital, I encountered a physician who had left the VA to work in several other large health care organizations. He had some good things to say about their business processes and the volume of patients they saw. He came back to the VA, he said, because “No one else can provide this quality of care for the individual veteran.”