- Email: [email protected]
Honoring Those Who Have Served
Invited Perspective
Honoring Those Who Have Served Margaret C. Hammond, MD To fulfill President Abraham Lincoln’s promise, the VA mission is “to care for him who shall have borne the battle, and for his widow, and his orphan.” Many physiatrists rotated through the Department of Veterans Affairs (VA) facilities during their medical student or residency training, and many currently work for the VA. There are currently approximately 610 physiatrists on VA staffs (David Cifu, MD, Rehabilitation Services, and Kathlene Chadband, Spinal Cord Injury/Disorders Services, Veterans Health Administration, oral communications, 2009). VA manages the largest medical education and health professions training program in the United States. It has more than 5000 affiliations with 1700 educational institutions and currently provides clinical training for more than 100,000 individuals each year [1]. Specifically, in fiscal year 2008, 109,882 health professionals participated in training rotations in VA medical centers [2]. More than one-half of the physicians practicing in the United States had some of their professional education in the VA health-care system. Although so many providers have had some exposure to the VA, I thought you might appreciate additional information and a seasoned perspective. This perspective is based on 28 years as a VA physician, 21 years as a spinal cord injury service chief, and 14 years of oversight for the national program as Chief Consultant for Spinal Cord Injury/Disorders Services. My earliest exposure to the VA was an introductory course on patient interviewing skills followed rapidly by management of 38 patients on an inpatient unit during a medical student clerkship. That was my patient load; as I recall, there were about 60 patients followed by the entire team. You can imagine, or recall for yourselves, the need to admit 15 or so patients daily at all hours, review stacks of relevant medical records, transport patients for tests, draw blood, start IVs, perform ECGs, find the paper laboratory results, handle emergencies, hand write notes in the chart, etc. The experience (education) was phenomenal, and the daily work was exhilarating yet completely exhausting. Although those were trying times, I always sensed the uniqueness of the population we served. In the mid 1970s, there were still patients from World War I being treated, and many with experience in World War II and Korea; and of course, the Vietnam War had recently ended. During the Vietnam war, the daily news was very explicit with combat scenes, tallies of casualties and wounded, and so the public (including VA staff) had everyday exposure to the conflict. It was a polarizing time for the country, and many veterans of this conflict had unique needs. Although they certainly obtained support and enjoyed the common bond and camaraderie with each other, most patients were not comfortable sharing their experiences with trainees. It was challenging, but rehabilitation medicine flourished in the VA because there was the honor and duty to restore functional capacity. Since at least 1982, the VA has had a Memorandum of Agreement (MOA) with the Department of Defense to accept active-duty service members for care should they have a catastrophic injury. (An MOA was required because VA has statutory authority to provide care only to veterans.) For these soldiers, return to active duty was not likely and therefore receipt of VA health care was started immediately, with the subsequent acquisition of the full constellation of VA benefits upon determination of service connected status for injuries and/or illness. Although the median age of veterans has gradually increased from 57 in 2000 to 60 in 2009 [3], such active-duty service members were young; many age 18 to the mid-20s. After Vietnam, subsequent conflicts included brief events in Grenada (1983) and Panama (1989), from which several patients came to the spinal cord injury (SCI) unit in Seattle where I was located. In addition to the focused MOA, a much broader mission of the VA is to provide back-up to the Department of Defense for the delivery of health care. With the onset of the Gulf War in 1991, we had emergency meetings to identify available bed capacity to admit patients should massive injuries take place. We watched the bombing on television from our SCI dining room and worried about what the next day would bring. Fortunately, there was a quick ending. PM&R 1934-1482/09/$36.00 Printed in U.S.A.
M.C.H. VA Puget Sound Health Care System, 1660 S Columbian Way (128N), Seattle, WA, 98108-1597. Address correspondence to: M.C.H.; e-mail: [email protected] Disclosure: 9, VA employment Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org This work reflects the view of the author and does not necessarily reflect the opinions of the Department of Veterans Affairs.
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 991-992, November 2009 DOI: 10.1016/j.pmrj.2009.10.009
991
992
Hammond
In the mid-1990s, VA began a major transformation to become the largest and best-integrated health-care system in the United States. Management decisions and structure were decentralized, the electronic health record was implemented, patient safety became a focus, and detailed performance measures to improve the health and quality of care for veterans were defined. On multiple objective indices, VA care exceeds that in the private sector. Examples include performance metrics related to diabetes management, acute myocardial infarction, management of community acquired pneumonia, preventive services such as immunizations, patient satisfaction, etc. A full description can be found in “The Best Care Anywhere: Why VA Health Care is Better than Yours” by Phillip Longman [4]. Staffing is comprehensive, with more than 239,000 employees serving 5.58 million unique patients in 2008 [5]. The electronic health record is the gold standard for efficient documentation, coordination of care between providers, tracking of preventive services, diagnostic support, and record availability for any patient across the country; the days of lost medical records are long gone. With a medical care appropriation of more than $47 billion, VHA employs staff at more than 1400 sites, including hospitals, clinics, nursing homes, domiciliaries, and Readjustment Counseling Centers [6]. Yet, cost per patient has held steady: “between 1995 and 2004, the cumulative increase in the VA’s cost per enrollee was just 0.8 percent, while that of Medicare was a whopping 40.4 percent” [4]. In addition, VHA is the Nation’s largest provider of graduate medical education and a major contributor to medical research. Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) followed in 2001 and 2003, respectively. More than 1.64 million American troops have been deployed to these conflicts, of whom more than 13% are female troops [7, 8]. The SCI System of Care has provided initial rehabilitation services to 477 active duty service members, of whom 151 were injured in theater. In the 24 SCI centers, each day we are caring for young, brave, proud, and resilient service members who have “given their spinal cord to their fellow Americans,” as one patient has phrased it. Their loyalty to their fellow troops is a hallmark of their experience, and one frequently hears of their disappointment at being separated from their buddies. Compounding the challenges of providing rehabilitation for the SCI and other visible wounds, veterans are increasingly experiencing mental health conditions. Nearly 20% of military service members who have returned from Iraq and Afghanistan (300,000) report symptoms of posttraumatic stress disorder or major depression, according to a 2008 RAND Corporation report [9]. Researchers found that about 19% of returning service members report that they experienced a possible traumatic brain injury while deployed, with 7% reporting both a probable brain injury and concurrent posttraumatic stress disorder or major depression [9]. Fortunately, in light of the soldiers’ complex injuries, VA can provide rehabilitation, with the goal of achieving maximal independence, without undue constraints on length of stay. SCI care is delivered by an interdisciplinary team that provides rehabilitation concurrent with acute and subacute medical management; primary and specialty care is delivered lifelong to each veteran.
HONORING THOSE WHO HAVE SERVED
With the exception of patients who transfer in from a nursing home environment, more than 95% of discharges from an SCI center are to noninstitutional care in the community. In addition to the SCI centers (as hubs), the hub and spoke system includes the presence of an SCI team in each of 153 VA facilities (spokes). Care is networked, providing closer geographic access for patients, heightened SCI knowledge beyond that of general primary care, deliberate transitions of care, and tracking of specialty service needs. Concurrently, the polytrauma system of care provides services to patients with traumatic brain injury and multiple comorbidities. For each of these newly injured service members, our mission is the same as that of the first VA SCI Centers from the World War II era. It is to support, promote, and maintain the health, independence, quality of life, and productivity of individuals with SCI throughout their lives. This is accomplished by the efficient delivery of rehabilitation; ongoing medical and surgical care for secondary conditions related to the SCI or when treatment of any conditions are impacted by the presence of the SCI; patient and family education; psychological, social, and vocational services; research; and education. The practice of physiatry in postmilitary casualty management involves essential services that begins in the acute care environment and continues indefinitely—rehabilitation counseling, consultative services within the acute trauma hospital, and evaluation of complex trauma cases to promote sustained quality of life, health, independence, and productivity. As a colleague of mine once noted, “the practice of health care is a high calling which is only ennobled by the privilege of serving those who have defended our country.” It has indeed been an honor to serve such individuals.
REFERENCES 1. VHA Directive 1400, Office of Academic Affiliation, September 14, 2009. Available at: http://www1.va.gov/vhapublications/. Accessed November 4, 2009. 2. VA Statistics at a Glance, National Center for Veterans Analysis and Statistics (008A3); 2009. Available at http://www1.va.gov/vetdata/docs/ 4X6_summer09_sharepoint.pdf. Accessed November 4, 2009. 3. Annual VA Information Pamphlet, National Center for Veterans Analysis and Statistics; 2008. Available at http://www1.va.gov/vetdata/docs/ Pamphlet_2-1-08.pdf. Accessed November 4, 2009. 4. Longman P. The Best Care Anywhere: Why VA Health Care is Better than Yours. Sausalito, CA: PoliPointPress, LLC; 2007. 5. Fact Sheet, Office of Public Affairs, Department of Veterans Affairs, January, 2009. Available at: http://www1.va.gov/opa/fact/vafacts.asp. Accessed November 4, 2009. 6. VHA Leadership. Available at: http://www1.va.gov/health/AboutVHA. asp. Accessed November 4, 2009. 7. Department of Defense Personnel and Procurement Statistics. Contingency Tracking (CTS) Deployment File for Operation Enduring Freedom and Iraqi Freedom. Washington, DC: Department of Defense; October 2007. Available at: http://veterans.house.gov/Media/File/110/2-7-08/ DoDOct2007-DeploymentReport.htm. Accessed November 4, 2009. 8. Statistical Abstract of the United States: 2006, Table 501, Washington DC: US Census Bureau, Department of Commerce, 2006. Available at: http://www.census.gov/prod/2005pubs/06statab/defense.pdf. Accessed November 4, 2009. 9. Tanielian T, Jaycox LH, ed: Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008.
Honoring Those Who Have Served Margaret C. Hammond, MD To fulfill President Abraham Lincoln’s promise, the VA mission is “to care for him who shall have borne the battle, and for his widow, and his orphan.” Many physiatrists rotated through the Department of Veterans Affairs (VA) facilities during their medical student or residency training, and many currently work for the VA. There are currently approximately 610 physiatrists on VA staffs (David Cifu, MD, Rehabilitation Services, and Kathlene Chadband, Spinal Cord Injury/Disorders Services, Veterans Health Administration, oral communications, 2009). VA manages the largest medical education and health professions training program in the United States. It has more than 5000 affiliations with 1700 educational institutions and currently provides clinical training for more than 100,000 individuals each year [1]. Specifically, in fiscal year 2008, 109,882 health professionals participated in training rotations in VA medical centers [2]. More than one-half of the physicians practicing in the United States had some of their professional education in the VA health-care system. Although so many providers have had some exposure to the VA, I thought you might appreciate additional information and a seasoned perspective. This perspective is based on 28 years as a VA physician, 21 years as a spinal cord injury service chief, and 14 years of oversight for the national program as Chief Consultant for Spinal Cord Injury/Disorders Services. My earliest exposure to the VA was an introductory course on patient interviewing skills followed rapidly by management of 38 patients on an inpatient unit during a medical student clerkship. That was my patient load; as I recall, there were about 60 patients followed by the entire team. You can imagine, or recall for yourselves, the need to admit 15 or so patients daily at all hours, review stacks of relevant medical records, transport patients for tests, draw blood, start IVs, perform ECGs, find the paper laboratory results, handle emergencies, hand write notes in the chart, etc. The experience (education) was phenomenal, and the daily work was exhilarating yet completely exhausting. Although those were trying times, I always sensed the uniqueness of the population we served. In the mid 1970s, there were still patients from World War I being treated, and many with experience in World War II and Korea; and of course, the Vietnam War had recently ended. During the Vietnam war, the daily news was very explicit with combat scenes, tallies of casualties and wounded, and so the public (including VA staff) had everyday exposure to the conflict. It was a polarizing time for the country, and many veterans of this conflict had unique needs. Although they certainly obtained support and enjoyed the common bond and camaraderie with each other, most patients were not comfortable sharing their experiences with trainees. It was challenging, but rehabilitation medicine flourished in the VA because there was the honor and duty to restore functional capacity. Since at least 1982, the VA has had a Memorandum of Agreement (MOA) with the Department of Defense to accept active-duty service members for care should they have a catastrophic injury. (An MOA was required because VA has statutory authority to provide care only to veterans.) For these soldiers, return to active duty was not likely and therefore receipt of VA health care was started immediately, with the subsequent acquisition of the full constellation of VA benefits upon determination of service connected status for injuries and/or illness. Although the median age of veterans has gradually increased from 57 in 2000 to 60 in 2009 [3], such active-duty service members were young; many age 18 to the mid-20s. After Vietnam, subsequent conflicts included brief events in Grenada (1983) and Panama (1989), from which several patients came to the spinal cord injury (SCI) unit in Seattle where I was located. In addition to the focused MOA, a much broader mission of the VA is to provide back-up to the Department of Defense for the delivery of health care. With the onset of the Gulf War in 1991, we had emergency meetings to identify available bed capacity to admit patients should massive injuries take place. We watched the bombing on television from our SCI dining room and worried about what the next day would bring. Fortunately, there was a quick ending. PM&R 1934-1482/09/$36.00 Printed in U.S.A.
M.C.H. VA Puget Sound Health Care System, 1660 S Columbian Way (128N), Seattle, WA, 98108-1597. Address correspondence to: M.C.H.; e-mail: [email protected] Disclosure: 9, VA employment Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org This work reflects the view of the author and does not necessarily reflect the opinions of the Department of Veterans Affairs.
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 991-992, November 2009 DOI: 10.1016/j.pmrj.2009.10.009
991
992
Hammond
In the mid-1990s, VA began a major transformation to become the largest and best-integrated health-care system in the United States. Management decisions and structure were decentralized, the electronic health record was implemented, patient safety became a focus, and detailed performance measures to improve the health and quality of care for veterans were defined. On multiple objective indices, VA care exceeds that in the private sector. Examples include performance metrics related to diabetes management, acute myocardial infarction, management of community acquired pneumonia, preventive services such as immunizations, patient satisfaction, etc. A full description can be found in “The Best Care Anywhere: Why VA Health Care is Better than Yours” by Phillip Longman [4]. Staffing is comprehensive, with more than 239,000 employees serving 5.58 million unique patients in 2008 [5]. The electronic health record is the gold standard for efficient documentation, coordination of care between providers, tracking of preventive services, diagnostic support, and record availability for any patient across the country; the days of lost medical records are long gone. With a medical care appropriation of more than $47 billion, VHA employs staff at more than 1400 sites, including hospitals, clinics, nursing homes, domiciliaries, and Readjustment Counseling Centers [6]. Yet, cost per patient has held steady: “between 1995 and 2004, the cumulative increase in the VA’s cost per enrollee was just 0.8 percent, while that of Medicare was a whopping 40.4 percent” [4]. In addition, VHA is the Nation’s largest provider of graduate medical education and a major contributor to medical research. Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) followed in 2001 and 2003, respectively. More than 1.64 million American troops have been deployed to these conflicts, of whom more than 13% are female troops [7, 8]. The SCI System of Care has provided initial rehabilitation services to 477 active duty service members, of whom 151 were injured in theater. In the 24 SCI centers, each day we are caring for young, brave, proud, and resilient service members who have “given their spinal cord to their fellow Americans,” as one patient has phrased it. Their loyalty to their fellow troops is a hallmark of their experience, and one frequently hears of their disappointment at being separated from their buddies. Compounding the challenges of providing rehabilitation for the SCI and other visible wounds, veterans are increasingly experiencing mental health conditions. Nearly 20% of military service members who have returned from Iraq and Afghanistan (300,000) report symptoms of posttraumatic stress disorder or major depression, according to a 2008 RAND Corporation report [9]. Researchers found that about 19% of returning service members report that they experienced a possible traumatic brain injury while deployed, with 7% reporting both a probable brain injury and concurrent posttraumatic stress disorder or major depression [9]. Fortunately, in light of the soldiers’ complex injuries, VA can provide rehabilitation, with the goal of achieving maximal independence, without undue constraints on length of stay. SCI care is delivered by an interdisciplinary team that provides rehabilitation concurrent with acute and subacute medical management; primary and specialty care is delivered lifelong to each veteran.
HONORING THOSE WHO HAVE SERVED
With the exception of patients who transfer in from a nursing home environment, more than 95% of discharges from an SCI center are to noninstitutional care in the community. In addition to the SCI centers (as hubs), the hub and spoke system includes the presence of an SCI team in each of 153 VA facilities (spokes). Care is networked, providing closer geographic access for patients, heightened SCI knowledge beyond that of general primary care, deliberate transitions of care, and tracking of specialty service needs. Concurrently, the polytrauma system of care provides services to patients with traumatic brain injury and multiple comorbidities. For each of these newly injured service members, our mission is the same as that of the first VA SCI Centers from the World War II era. It is to support, promote, and maintain the health, independence, quality of life, and productivity of individuals with SCI throughout their lives. This is accomplished by the efficient delivery of rehabilitation; ongoing medical and surgical care for secondary conditions related to the SCI or when treatment of any conditions are impacted by the presence of the SCI; patient and family education; psychological, social, and vocational services; research; and education. The practice of physiatry in postmilitary casualty management involves essential services that begins in the acute care environment and continues indefinitely—rehabilitation counseling, consultative services within the acute trauma hospital, and evaluation of complex trauma cases to promote sustained quality of life, health, independence, and productivity. As a colleague of mine once noted, “the practice of health care is a high calling which is only ennobled by the privilege of serving those who have defended our country.” It has indeed been an honor to serve such individuals.
REFERENCES 1. VHA Directive 1400, Office of Academic Affiliation, September 14, 2009. Available at: http://www1.va.gov/vhapublications/. Accessed November 4, 2009. 2. VA Statistics at a Glance, National Center for Veterans Analysis and Statistics (008A3); 2009. Available at http://www1.va.gov/vetdata/docs/ 4X6_summer09_sharepoint.pdf. Accessed November 4, 2009. 3. Annual VA Information Pamphlet, National Center for Veterans Analysis and Statistics; 2008. Available at http://www1.va.gov/vetdata/docs/ Pamphlet_2-1-08.pdf. Accessed November 4, 2009. 4. Longman P. The Best Care Anywhere: Why VA Health Care is Better than Yours. Sausalito, CA: PoliPointPress, LLC; 2007. 5. Fact Sheet, Office of Public Affairs, Department of Veterans Affairs, January, 2009. Available at: http://www1.va.gov/opa/fact/vafacts.asp. Accessed November 4, 2009. 6. VHA Leadership. Available at: http://www1.va.gov/health/AboutVHA. asp. Accessed November 4, 2009. 7. Department of Defense Personnel and Procurement Statistics. Contingency Tracking (CTS) Deployment File for Operation Enduring Freedom and Iraqi Freedom. Washington, DC: Department of Defense; October 2007. Available at: http://veterans.house.gov/Media/File/110/2-7-08/ DoDOct2007-DeploymentReport.htm. Accessed November 4, 2009. 8. Statistical Abstract of the United States: 2006, Table 501, Washington DC: US Census Bureau, Department of Commerce, 2006. Available at: http://www.census.gov/prod/2005pubs/06statab/defense.pdf. Accessed November 4, 2009. 9. Tanielian T, Jaycox LH, ed: Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: Rand Corporation; 2008.