Can Secretary David Shulkin Fix the VA?

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Can Secretary David Shulkin fix the Department of Veterans Affairs (“the VA”)?  The answer is an emphatic NO!

Department of Veterans Affairs

This is not a commentary on Dr. Shulkin’s inspired leadership or his vision for a vastly improved VA, but a consequence of competing ideologies and a dysfunctional institution.

As Stand for the Troops has stated several times over the past year: “THE VA IS SIMPLY TOO LARGE TO SUCCEED IN ITS MISSION.”

As suggested in last week’s article by Maj. Ben Richards, the care provided by the VA is far different than the “happy talk” its administrators disseminate to a gullible public and Congress.   The disturbing suicide of Veteran Eric Bivins can clearly be laid at the doors of the VA, but does anyone in authority really care?

Will the desperate pleas Eric’s spouse Kimi resonate in the corridors of power in DC?  Probably not.  And yet, Kimi’s description of the troubling treatment provided by the VA is far more accurate than the self-serving assurances that VA “change agents” dispense to the press.

Veterans are giving up hope daily and seeking treatment outside the VA.  If Congress truly wanted to know the extent of the problems in the VA, they would surely spend far more time seeking out the views of Veterans than blindly accept the assurances of its administrators.  Will this occur? Not likely – and even if it were to occur, not much is likely to change.

The VA is like an old automobile that is falling apart.  Sure, we can try fixing it with the same failed strategies that have been used in the past OR how about trying a different approach? Scrap the dysfunctional VA and build a responsive institution that truly attends to the needs of most Veterans?

How Can the VA be Fixed?

With an annual budget of over $180 billion and nearly 350,000 employees, things can easily get off-track.  More to the point, impassioned administrator can run about putting their fingers in the holes of a leaking dyke, but another leak will surface almost immediately.

As I stated previously,

NO AMOUNT OF MONEY or CHANGE IN LEADERSHIP or ENACTMENT OF NEW LEGISLATION will bring about A MORE RESPONSIVE VA.

The VA has become a bureaucracy that answers only to itself and is not responsive to the needs of Veterans.  Frankly, the VA has lost its way and very little will change unless the VA is broken down into far smaller manageable components.

While smaller components of the VA will invariably fail, A SMALLER AND LESS CENTRALIZED VA WON’T COMPROMISE THE FULL MISSION.  

The public seems relieved that Veterans now have a choice of service providers because the Choice Program has been extended by Congress, but for many thousands of Veterans like Eric Bivins and his family, there really is NO CHOICE!

Where the VA is Today

Personally, I believe that Dr. Shulkin has done a remarkable job in addressing some of the more urgent problems at the VA.  While one can argue whether he has done enough, the task he has been given is like being assigned to captain the Titanic after it has hit the iceberg.

The speed with which the VA will sink further into disrepute may be slowed, but SINK it will.

How many more reports do we need from the Office of the Inspector General (the “IG”) that the VA lacks effective governance and oversight?

How many more times to we have to fire ineffective VA employees when the Labor Union intercedes to protect  employee “rights”?

How many more infection risks do Veterans need to overcome at VA facilities?

These are just the latest “issues” that Dr. Shulkin and his staff need to deal with.  Despite evidence of much needed progress to overhaul the VA, these problems are likely to persist.

In fact, every local incidence of inefficiency or incompetence becomes magnified into a matter of national concern and raises further doubts about the VA’s ability to reform itself from within.  Frankly, there are far too many competing mandates for it to do so.

Sadly, our Veterans and their loved ones will continue to suffer until we stop posturing and enact real reform.

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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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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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