The Veterans Administration needs more doctors

The Veterans Administration problems worsen, as do the problems of the vets seeking care through the VA. Things were already bad a year ago, with revelations that veterans were waiting an excessive amount of time to get seen (read: months), sometimes being deliberately dropped from waiting lists to artificially “decrease” wait times. VA centers were also not making timely referrals to doctors outside of the VA system, their budget was inadequate, there were too few doctors at the VA, and so on.

The VA has made an effort to improve the situation.  In the past year many more patients have been seen (or referred to outside doctors, including specialists). However, seeing and/or referring these patients has come at a cost of about $3 billion.  The VA is now short of money for this program, and is looking at hiring freezes, layoffs, restrictions on some medications and other money-saving options.  It wants to ask Congress to allow it to transfer funds from other budget areas to this program, but doesn’t expect a favorable hearing. Of course, failure to act will negatively feed back into the system, making the problem worse.

When this story broke last year, I went to the VA’s primary website, along with VA medical center websites in Arizona, California, Minnesota, Alaska, Georgia, Michigan and some other states. I specifically looked for job postings for physicians.

Doctor via Shutterstock

Doctor via Shutterstock

EVERY website was advertising for physicians. Most needed internists and family practice physicians, but a number needed specialists: surgeons, ophthalmologists, OB/Gyns, pediatricians, pulmonary doctors, psychiatrists, cardiologists, etc. It’s not just remote VA hospitals and clinics that need specialists; many located in or near large cities need them, too. In some areas, the VA had completely given up the search for permanent physicians, and was instead advertising for locum tenens doctors. These doctors will sign a short-term contract to go to a site — for example, a clinic somewhere in Arizona — and work for a mutually agreed amount of time, usually between a month and a year. When  they leave, the post is open again — maybe for months or years — until another locum takes it.

Not all of these positions are at VA hospitals. Some are at free-standing VA clinics in small towns. One such small VA clinic — either in Arizona or New Mexico, as I recall — wanted a generalist physician. He would work 8-5 Monday through Friday, seeing patients, charting, reading reports, performing minor surgeries, etc. The clinic is about a 2 hour drive from the next-largest town, which has a small hospital. The physician will have to live in the town where the clinic is located, and the clinic staff is a single medical assistant. With no local hospital, that means those in town will come calling at all hours, regardless as to whether they are eligible for VA care. So the doctor will essentially be on call 24/7 for patients who need emergency care, such as women who go into labor (no OB around) and need to be attended to until the helicopter arrives. That is, if the weather allows it to fly. Even though it’s not in the contract to take care of patients after 5 PM, on weekends, or those who are not eligible for VA care, who is going to turn those patients away?

The pay scale and benefits for locum tenens doctors are significantly less than those found when practicing at a hospital or group. And there are other downsides, like limited continuing education, vacation has to be scheduled around when (or if) they can find a doctor to replace the vacationer. The doctor has to learn the VA’s policies, medical records system and other things that are specific to the VA, which is a much more worthwhile investment of time and energy for doctors who are likely to stay for more than a year. And, of course, if the doctor needs a doctor they’re out of luck.

Not all locum tenens arrangements are this bad. A few are worse, some are better. But the better ones seem to involve a lot more paperwork, and still put pressure on doctors to see a lot of patients in a limited amount of time. And there are still restrictions on the drugs that can be prescribed, the out-of-VA specialists that can be used, and so on.

It’s no wonder that these positions go unfilled, and have such high turnover rates.

This upcoming go around with Congress looks like it will be acrimonious and its outcome may do nothing to alleviate the squeeze on VA patients, or doctors.  You can read more on the story here.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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