Department of Veterans Affairs: Flawed Models Yield Flawed Results

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Like many, I am both encouraged and a little frightened at the pace of genetic research. It is one thing to map the human genome, but it is quite another to begin “editing” genes or genetic material to promote healthier patient outcomes.

Mind you, I am in favor of reversing or eliminating alzheimer’s, MS, cancer, diabetes and many other terrible diseases, but pushing the boundaries of scientific experimentation often produces unexpected and potentially catastrophic outcomes.
DNA Research

The Department of Veterans Affairs (the “VA”) insists on recommending therapy for treating PTSD and TBI based on “rigorous science,” according to Ms. Schnurr who heads the VA’s National Center for PTSD.

At first glance, Ms Schnurr’s position seems most sensible, but what if the scientific model is flawed?

I recently came across this powerful six-minute Ted Talk on genome sequencing. While Keolu Fox is eloquently arguing for more diversity in genetic research, he is indirectly suggesting that research based on skewed samples may not always produce the same results across all genetic and ethnic types.

I am always wary of people who argue from the basis of scientific knowledge as flawed models can often yield flawed results.

The overwhelming evidence suggests that the VA doesn’t have a clue when it comes to treating PTSD and TBI. So why does the VA leadership continue to insist on scientific certainty? We owe our brave men and women so much more.

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Throwing Snowballs at the Department of Veteran Affairs

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Many years ago I was reading a biographic sketch of the late Canadian Prime Minister, Pierre Trudeau.   According to the biography, teenager Trudeau was arrested by the Chinese police for throwing snowballs at a statue of Mao Zedong in Tiananmen Square.

Chairman Mao

He was released by Chinese police after explaining that “it was a Canadian tradition to throw snowballs at statues of famous people.”    I have no idea if this story is true, but it would not surprise me as the brilliant and iconoclastic Trudeau had a glib answer for most everything.

As readers of Stand For the Troops (“SFTT”) news are aware, we are not satisfied with how the Department of Veterans Affairs (the “VA”) treats Veterans with PTSD and TBI.  As reported last week, Maj. Ben Richards cites numerous internal and external studies demonstrating that VA protocols in treating Veterans with PTSD and TBI have not been effective.

For the well-being of our Veterans and their loved ones, we can only hope that our well-meaning “snowballs” will ultimately have some effect on breaking through the entrenched bureaucracy at the VA.

Sadly, this is unlikely to be the case.  But if hundreds, thousands and tens of thousands of concerned Americans were lobbing snowballs at the VA through their elected officials in D.C., “a thousand flowers might bloom.”   I apologize to Chairman Mao for misquoting him.

If you listen to Dr. Xavier Cifu’s moronic defense of the VA’s “evidence-based” PTSD therapy programs to a Congressional committee, you get the sense that his “own personal opinion” is far more important than any scientific evidence.

Needless to say, not everyone within the VA is as oblivious to its shortcomings  as Dr. Cifu.  For instance,  Paula Schnurr, who heads the National Center for PTSD, which is part of the VA, says

. . . she’s “not concerned about veterans seeking alternative strategies in addition to effective strategies,” as long as the alternative doesn’t replace a method with more evidence behind it.

Schnurr says 90 percent of VA centers across the country do offer some sort of alternative treatment for PTSD. And many have been studied through clinical trials — some, like meditation and yoga, with promising results.

Schnurr also points out one approach to trauma, once approached with broad skepticism, is now on the VA’s list of approved treatments. EMDR — devised in the late 1980s — uses bilateral eye movement, looking side to side, during cognitive behavioral therapy. Only after about a dozen clinical studies did Schnurr feel comfortable recommending it.

“I’m convinced the treatment works; I’m not sure why,” she says.

But as long as the treatment is based on rigorous science, she says, that’s evidence enough.

Ah, there are those magical words again:  “rigorous science.”  What do those words actually mean?   Could the “observational model” be flawed?  At least, Ms. Schnurr has an open mind.

Is the Department of Veterans Affairs too Big to Succeed?

As we have seen last week, the VA continues to use flawed procedures to treat PTSD and TBI yet insists that the “treatment is based on rigorous science.”  Gosh, if the VA’s own internal and external audits demonstrate that standard therapies are not effective in helping Veterans with PTSD and TBI to achieve better outcomes, why not explore other alternatives?

Some weeks ago, we analysed the VA under the microscope of Nassim Taleb’s theory of Antifragility.   Even a superficial analysis of the VA suggests that the organization is Fragile and, in my opinion, far too big to succeed in its mission.

Veterans Cartoon by Gary Varval

Cartoonist Gary Varval

As if on queue, the New York Times asks the question:  Did Obama’s Bill Fix Veterans’ Health Care? Still Waiting.

When President Obama signed a sweeping $15 billion bill to end delays at Department of Veterans Affairs hospitals two years ago, lawmakers standing with him applauded the legislation as a bold response that would finally break the logjam.

It has not quite worked out that way.

Although veterans say they have seen improvement under the bill, it has often fallen short of expectations. Nowhere is the shortfall more clear than in the wait for appointments: Veterans are waiting longer to see doctors than they were two years ago, and more are languishing with extreme waiting times.

According to the agency’s most recent data, 526,000 veterans are waiting more than a month for care. And about 88,000 of them are waiting more than three months.

What we are seeing, is increasingly discouraging outcomes for Veterans no matter how much money we allocate to “fixing” the problem.  In economics, one simply refers to this as “decreasing marginal returns on investment.”  This is not to say that some Veterans have not benefited with this new taxpayer largesse, but we should have received far better results if the VA were not so big!

So, if you are wondering what to do on this warm summer day, just pick up a few snow balls and gently lob them in the direction of our Congress and Senate in D.C.    Facing up to the realities that the VA is failing our Veterans is at least the first step toward helping these brave warriors reclaim their lives.

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SFTT News: Week Ending Aug 5, 2016

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Found below are a few news items that caught my attention this past week. I am hopeful that the titles and short commentary will encourage our readers to click on the embedded links to read more on subjects that may be of interest to them.

Drop me an email at info@sftt.org if you believe that there are other subjects that are newsworthy.

Senator John McCain Denounces Trump  on Comments of Muslim Soldier
Senator John McCain sharply criticized Donald J. Trump’s comments about the family of a fallen Muslim Army captain on Monday, a rebuke that provided an opening for other vulnerable Republican senators to do the same, even though they all stopped short of rescinding their endorsements of him.  “While our party has bestowed upon him the nomination, it is not accompanied by unfettered license to defame those who are the best among us,” Mr. McCain, a war hero whose service and capture in Vietnam were also once derided by Mr. Trump, said in a remarkable and lengthy written reproach of his party’s presidential nominee.  Read more . . .

Taliban Ambush US and European Tourists in Afghanistan
Taliban militants attacked a group of 12 American and European tourists escorted by an Afghan army convoy in western Herat province Thursday, leaving at least seven people wounded as the insurgents step up nationwide attacks. The tourists — eight British, three Americans and one German national — were ambushed by Taliban gunmen in the restive district of Chesht-e-Sharif, while en route from the neighboring provinces of Bamiyan and Ghor.  Read more . . .

Scout Tank

General Dynamic Scout Tank

U.S. Army Discussing Plans for New Lightweight Tank
The Army plans to hold a so-called industry day on Tuesday at Fort Benning in Georgia to discuss the requirements for such a vehicle, essentially a light tank, in the areas of lethality, mobility, protection, transportability, sustainability, energy and cyber, according to a statement released on Thursday from the service. The MPF program “will be a lightweight combat vehicle that provides the Infantry Brigade Combat Team long range, precision direct fire capability that ensures freedom of movement and action during joint expeditionary maneuver and joint combined arms operations,” according to the statement.  Read more . . .

Zika Virus Canada Info

Thirty-three US Military Members Reportedly Contract Zika
Thirty-three U.S. military members have infected with the mosquito-borne Zika virus, including a pregnant woman, the Pentagon said on Wednesday.  According to American local reports, these military cases are all outside the continental United States. In addition, six family members of the infected service members also contracted the virus.  Read more . . .

VA Puts Latest Daily Veteran Suicide Rate at 20
On average, 20 veterans a day committed suicide in 2014, a slight decrease from the previous government estimate, but federal health officials are cautious about concluding the suicide problem is getting better.  Rather, they say the Department of Veterans Affairs is relying on a more comprehensive database than ever before, making comparisons to prior studies difficult and possibly offering a truer snapshot than what was captured in the past.  Read more . . .

Increasingly, Veterans Turning to Alternative Treatments for PTSD
The Department of Veterans Affairs estimates up to 30 percent of former American service members — from the Vietnam War to Iraq and Afghanistan — have post-traumatic stress disorder.  They don’t all seek treatment. But among those who do, the VA says 20 to 40 percent don’t get better with the standard regimen of therapy, medication or both.  Read more . . .

Marijuana PTSD

PTSD Marijuana Study Now Recruiting Veteran Volunteers
Researchers in Maryland and Arizona are looking for veteran volunteers to smoke up to two joints’ worth of marijuana a day in a new study designed to find out if pot helps relieve symptoms of post-traumatic stress disorder. “We’re not arguing that cannabis is a cure, but our hypothesis is that it will at least reduce the symptoms,” says physician and study organizer Dr. Sue Sisley. The $2.2 million study, paid for by a grant from the state of Colorado to the nonprofit Multidisciplinary Association for Psychedelic Studies, will be conducted at Johns Hopkins University in Baltimore, Maryland, and Sisley’s Scottsdale Research Institute in Phoenix, Arizona.  Read more . . .

Feel you should do more to help our brave men and women who wear the uniform or our Veterans? Consider becoming a member of Stand For The Troops.

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The VA Can’t Handle the Truth So Why Not Lie

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In a moving round-table discussion hosted by Stand for the Troops (“SFTT”), Maj. Ben Richards provides a devastating overview of why the Department of Veterans Affairs (the “VA”) is failing to provide adequate care to brave Veterans suffering from PTSD. Let Ben explain why in his own words:

Drawing from internal and external VA studies, Maj. Richards exposes the great fraud perpetrated by the VA that claims to be providing adequate treatment to Veterans who suffer from PTSD and TBI (“traumatic brain injury”). Clearly, those in VA management are well aware that current treatment protocols to treat PTSD and TBI are seriously flawed.

Why is it necessary, for VA spokespersons like Dr. Xavier Cifu to articulate banal nonsense to Congress that seeks to provide better treatment for our Veterans? More to the point, why don’t those in authority within the VA simply acknowledge that “we don’t have the answers,” rather than persevere supporting treatment therapies that simply don’t work and may, in fact, be harmful?

Everyone realizes that egos and big money are on the line, but shouldn’t the well-being of our men and women in uniform and Veterans come first?

SFTT has long been partnering with several alternative treatment therapies designed to provide Veterans with options. Sadly, most of these protocols are not endorsed or supported by the VA. We long ago concluded that the entrenched bureaucracy within the VA appears to be far more interested in promoting its own path to wellness rather than acknowledge that other alternative therapies may provide benefits.

As Maj. Richards points out, the recommended VA treatment protocols do not work and those in VA’s management know that they are ineffective. Therefore, it seems evident that Congress and others must look beyond the VA to provide Veterans with PTSD therapy alternatives.

There is a growing awareness around the country that the VA is simply out of step with reality and several states are taking matters into their own hands to provide privately funded therapy programs.  In particular, Maj. Richards is able to avail himself of Hyperbaric Oxygen Therapy in his home state of Minnesota.

Also, it was recently reported that a Joint study by Tel Aviv University, IDF, Walter Reed Army Institute of Research and National Institutes of Health finds computerized training before deployment could prevent PTSD.

In fact, Dr. Yuval Neria, a Special Advisor to SFTT’s Medical Task Force,  explains that computerized training protocols may help patients cope with PTSD more effectively.

Biased Threat Attention Computerized Training Protocols

Dr. Yuval Neria, Professor of Medical Psychology at the Departments of Psychiatry and Epidemiology at Columbia University Medical Center, and Director of Trauma and PTSD at the New York State Psychiatric Institute presents his Attention-Bias-Modification Treatment (ABMT) designed to implicitly modify a PTSD patients’ biased threat attention via computerized training protocols.

 

SFTT helped fund these experimental studies by Dr. Yuval Neria.  In the video above, he describes in scientific terms some promising breakthroughs on computerized training protocols to assist both Veterans and civilians cope with PTSD.

While I guess we should take some solace in the fact that Veteran suicides have now fallen on a daily basis from 22 to 20, the fact remains that we have tens of thousands of Veterans who are receiving inadequate treatment.  The suicide of one Veteran is too many, so let’s hope that the Department of Veterans Affairs wakes up to the challenge rather than disparage other treatment alternatives.

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Why Veterans with PTSD are Seeking Alternative Therapy

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It is becoming increasingly clear that the Department of Veterans Affairs (the VA) is no longer able to provide the care or therapy that Veterans with PTSD demand.  Increasingly, Veterans are seeking alternative therapy outside the VA.

Department of Veterans Affairs

According to New England Public Radio, a large percentage of Veterans seek alternative therapies for PTSD despite explicit warnings by the VA that many of these therapies are “untested.”

The Department of Veterans Affairs estimates up to 30 percent of former service members — from the Vietnam war to Iraq and Afghanistan — have Post Traumatic Stress Disorder. They don’t all seek treatment, but among those who do, the VA says 20 to 40 percent don’t get better with the standard regimen of therapy, medication, or both. Increasingly veterans are seeking out alternative mental health care — and much of it untested.

Implicitly, the VA is telling Veterans that seek alternative therapies to treat PTSD that they they do so at their own risk.  

In fact, the VA is arguing that treatments not endorsed by the VA are probably a hoax.    This is the same FEAR SYNDROME used by the Roman Catholic Church during the Medieval ages to maintain discipline among parishioners.

As I have suggested earlier, the VA is broken and its $180 billion annual budget is clearly not addressing the needs of its constituents.

Ask yourself these simple questions:

  1. If prescribed VA therapies were effective, why would Veterans need to seek alternative forms of treatment?
  2. If prescribed VA therapies are “tested,” why don’t these therapies seem to be effective?
  3. Is treating the symptoms of PTSD (for instance, pain and depression) with “tested” prescription drugs the same as treating the core problem?

Sadly, the VA has become more of a gate-keeper of self-serving in-house solutions than a caregiver to the many brave men and women who have served our country so valiantly.

Spokespersons for the VA like Dr. Xavier Cifu ridicule other forms of therapy while vigorously defending their own “tested” but seriously flawed version of the truth.

As an outside observer, one can only shake one’s head when therapies such as Hyperbaric Oxygen and acupuncture are summarily dismissed by the VA despite decades of use in many parts of the world, including our own.

I guess those in Congress will argue that the VA is simply too big to fail.   Nevertheless, the VA fails many of its constituents on a daily basis.   For instance, Brandon Ketchum, a former Marine and Army National Guardsman who served 3 tours of duty in Iraq and Afghanistan, committed suicide recently after he was turned away by the VA in Iowa City.

How much longer do we need to see promised reforms within the VA?   Sadly, many Veterans are expressing their despair by turning away from “tested” VA prescriptions to embrace other forms of therapy.  Their message seems loud and clear to anyone listening.

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The Fragility of the VA

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I just started reading Antifragile:  Things That Gain With Disorder by Nassim Taleb.   For those who may not be familiar with Mr. Taleb, he is Professor of Risk Engineering at New York University’s Polytechnic Institute and the author of the highly acclaimed The Black Swan.

Now it may seem a bit incongruous to examine the Department of Veteran Affairs (the “VA”) through the eyes of Nassim Taleb, but there are a number of clear signs that the VA is a BIG and IMPORTANT institution that has lost its way.  In effect, the VA is FRAGILE.

Found below is a superficial but effective video summary of Antifragile, which describes the process to analyze the fragility, robustness or antifragility of “almost everything about our world.”

In Mr. Taleb’s remarkable book, he joyfully examines the human body, science, biological and economic systems, business, medicine, regulation and even psychiatric well-being from the three types of exposure: fragile, robust and antifragile.

Without belaboring the point, there are many examples which clearly demonstrate that the VA is “fragile” if not broken. In fact, one could argue that the system is already in terminal decline propped up by self-serving bureaucrats to effectively deny proper medical care to our Veterans.

Fragility of the VA

While this conclusion is seen through the lens of Nassim Taleb in Antifragile, all one needs to do to reach a similar conclusion is to scan the countless unheeded GAO reports citing the failings of the VA or pour over the numerous Congressional hearings on the VA.   True reform of the VA has simply become a platform to promote self-serving sound-bites by politicians and VA bureaucrats.

I will focus on just a few observations from Mr. Taleb’s book which – in my opinion – makes the case:

SFTT has long argued that prescribing potentially lethal prescription drugs to Veterans with PTSD is both ineffective and dangerous. Consider this position under the optics of Mr. Taleb:

” . . . only resort to medical techniques when the health payoff is very large (say, saving a life) and visibly exceeds its potential harm . . . Otherwise, in situations in which the benefits of a particular medicine, procedure, or nutritional or lifestyle modification appear small – say aiming for comfort – we have a large potential sucker problem.”

Sadly, our brave Veterans and Jane and John Doe Public have been suckered big time by the VA.

Mr. Taleb effectively describes the propensity of the VA to prescribe drugs rather than promote other alternative therapy programs.  He goes on to say that “. . . pharmaceutical companies are under financial pressures to find diseases and . . .  and are looking for disease among healthier and healthier people, lobbying for reclassification of conditions, and fine-tuning sales tricks to get doctors to overprescribe.”

Doesn’t Dr. David Xavier Cifu fit the bill as an effective lobbyist for the pharmaceutical industry?  Unless I misunderstand, Dr. Cifu is suggesting that we should treat military personnel with concussions (or worse) with drugs and get them back to duty as quickly as possible.  His argument is based on his own personal experiences of having six concussions and that this is the treatment he prescribes to his family.

Despite being shunned by others in the medical profession, Dr. Cifu could be right.   The real question we should all ask is this:  What if Dr. Cifu is wrong?  In effect, Dr. David Cifu – as a proxy for the VA – is effectively condemning thousands of Veterans to the same flawed treatment procedure.

One might ask what treating PTSD by the VA has to do Nassim Taleb’s theory about Antifragility or Incerto?  Actually, a great deal.  Mr. Taleb would argue that fragile government bureaucracies like the VA are highly susceptible to arrogance and the inability to distance themselves from the predictive but flawed models they so vigorously defend.

Mr. Taleb would no doubt argue that it is better to have many “small” therapy programs that can fail rather than expose ourselves – and the lives Veterans they claim to support – to a potentially catastrophic mis-diagnosis.

With its $180 billion budget, it is now time to unravel this bureaucratic behemoth in the hope that more robust and, hopefully, antifragile therapy can emerge from a decentralized health management approach for our Veterans.   If we don’t move in this direction soon, the lives of hundreds of thousands of brave Veterans and their loved ones could be negatively affected.

Sure, there will be mistakes, but we won’t have all our eggs in one basket.  Are you listening, Dr. Cifu?  Let’s spare the VA and the brave Veterans that rely on its services the Black Swan effect.

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The VA and Veteran Suicides: Sleeping Beauty Wakes Up

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Only a cynical person could look with amusement on the recent self-serving announcement by the Department of Veterans Affairs (“VA”) that it is taking “additional steps” to address Veteran suicides.   I realize that it is somewhat difficult to get a $180 billion a year bureaucratic behemoth to focus on an issue that has been front-page of every major media outlet, the DoD and even the VA for well over 10 years.

In fact, many legislators and many grieving families are simply scratching their heads and asking the question that most any sane American would ask:   Hasn’t the VA been focused on Veteran suicides all along?   I guess the simple conclusion is this:  Yes, the VA is aware that approximately 22 Veterans commit suicide each day, but our management believes that these “additional steps” will help stem the tide:

Several changes and initiatives are being announced that strengthen VA’s approach to Suicide Prevention. They include:

  • Elevating VA’s Suicide Prevention Program with additional resources to manage and strengthen current programs and initiatives;
  • Meeting urgent mental health needs by providing Veterans with the goal of  same-day evaluations and access by the end of calendar year 2016;
  • Establishing a new standard of care by using measures of Veteran-reported symptoms to tailor mental health treatments to individual needs;
  • Launching a new study, “Coming Home from Afghanistan and Iraq,” to look at the impact of deployment and combat as it relates to suicide, mental health and well-being;
  • Using predictive modeling to guide early interventions for suicide prevention;
  • Using data on suicide attempts and overdoses for surveillance to guide strategies to prevent suicide;
  • Increasing the availability of naloxone rescue kits throughout VA to prevent deaths from opioid overdoses;
  • Enhancing Veteran Mental Health access by establishing three regional tele-mental health hubs; and
  • Continuing to partner with the Department of Defense on suicide prevention and other efforts for a seamless transition from military service to civilian life.

Veteran Suicides

While I guess we should all take some solace from the fact that these “additional steps” may help reduce suicides among Veterans, many of us wonder why it has taken so long for the VA to recognize that its current treatment process has proved to be inadequate.  Indeed, the VA seems more intent on throwing cold water on alternative therapy programs than doing much at all to help get Veterans in help they need for PTSD and TBI.   More prescription drugs is not the answer according to the F.D.A., but I suppose it will be difficult for the VA to radically change its modus operandi.

Having been in business for many years, I am suspect when people tell me they are “taking steps.”   To paraphrase the late British columnist Bernard Levin, I have no idea whether these are “fast steps,” “double-time steps,” or as is often the case for bloated government bureaucracies: “marching in place and hoping for a better outcome.”

Judging from the VA’s record, I am not at all convinced that these “additional steps” – even if implemented – will improved the outcome so fervently desired by Veterans and their loved ones.  For the most part, these “additional steps” seem more like a public relations initiative rather than something will bring about a major change in the way PTSD and TBI are diagnosed and treated by the VA.  I hope I am wrong.

Accountability and responsibility is a theme well understood by the brave men and women who serve in our armed forces.  Sadly, accountability and responsibility seem to be in short supply at the VA.  We should all be outraged!

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