Adventures in the Veterans Hospital Mental Health Clinic Part I

Kafkaesque: of, relating to, or suggestive of Franz Kafka or his writings; especially:  having a nightmarishly complex, bizarre, or illogical quality.

Rube Goldberg machine: a contraption, invention, device or apparatus that is deliberately over-engineered or overdone to perform a very simple task in a very complicated fashion, usually including a chain reaction. The expression is named after American cartoonistand inventor Rube Goldberg (1883–1970). Over the years, the expression has expanded to mean any confusing or complicated system.

Much to my own relief, I retired recently from my part-time job at the Veteran's Affairs (VA) hospital seeing patients in the mental health outpatient clinic. While I found the patients interesting and challenging, the VA bureaucracy was at times as infuriating as one might guess. 

The Kafkaesque nature of the system in which I worked can best be illustrated by an experience I had with my picture ID card. The VA does extensive background checks on employees - as well they should - and requires fingerprinting when their identification cards get renewed every few years. 

The card contains a computer chip which allows the bearer access to the VA computer system, most notably patient electronic medical records. A few months ago, the computer chip in my ID card malfunctioned - way before its renewal date. I thought it should be no big deal to get it replaced. Yeah right. 

Not only did I have to get fingerprinted again and wait several days for them to be processed, making it extremely difficult to actually treat patients in the interim, but they also required me to produce two forms of picture identification.

The VA did not accept its own picture identification card for this purpose, which had not expired, as one of the two!

Before I go further with more bizarre stories about the place, let me make a couple of things clear. The fact that the VA is a governmentbureaucracy does not mean that private companies cannot be just as nuts - or even crazier. They can certainly be far more hostile. I used to work for one. As a friend of mine who worked for both of my former employers said, at least the VA bureaucracy was predictable in its crazy decision making, while the private firm we worked for was crazy but whimsical. Sort of like the Dilbert comic strip.

Let us turn to the issue that made the news: problems with scheduling patient appontments in a timely fashion. Much of the coverage in the news simply ignored the fact that an influx of new patients who are veterans of the wars in Iraq and Afghanistan has overwhelmed the VA healthcare system. There are just way more people reliant on VA than ever before. This happened without a commensurate increase in funding or staff until just recently, and there is still a lot of catching up to do.

In 2003, The VA expected to see 4.7 million veterans in its hospitals and clinics, up more than 54 percent just from 1996. The influx of newly-injured and/or mentally traumatized vets has continued every year since then as the wars dragged on, and funding of the system for the treatment of these wounded warriors did not keep up. Not even close. Frankly, the politicians who yell "support our troops" the loudest do NOT believe in supporting our troops after they leave the service.

In mental health in particular, visits to mental health clinics have skyrocketed as the military has attempted to change the "macho" culture that discouraged such visits in the past.

So what to make of the bureaucrats who kept phony schedules to hide the fact that veterans often had inordinate waits before they received an appointment? Well, when you give employees a mandate to do something as a condition of continued employment, and you don't give them the tools and resources needed to accomplish the mandate, they will naturally become passive-aggressive and do crap like that. They have no choice. 

And we know how bureaucracies treat whistleblowers, so everybody shuts up and goes about their business doing their best to get around the double bind they are all in.

To get patients seen in a timely fashion, you would think that the place would, at the very least, be very quick about putting in the appointment system the times when various doctors are available in their clinics to see and treat patients. Again you would be wrong. Whole clinic days of mine would disappear from my upcoming January schedule in the computer for an upcoming new year, and it would take two or three months of me complaining about it for the clinic times to reappear. I could not schedule anyone! 

I finally found out why it took so long. At least this is what I was told: There was just one person doing this job. Not one person for a few clinics. One person for the whole humongous medical center! 539 provider schedules, give or take.

Still, in the defense of the VA, at least part of the fault for patients not getting seen in time by a doctor may have in some cases lied with the patients. I can not speak for VA facilities in Phoenix or the rest of the country, but here is a photograph of an actual sign displayed prominently at the entrance to the VA hospital in Memphis:

In addition, at least in the mental health clinic I worked in, one of the doctors was always available to see every walk-in patient who came in without an appointment - even if they hadn't stopped near that sign to get checked in.

Furthermore, the hospital had what they called a "patient advocate's" office, where vets could complain about problems they were having getting seen. The patient advocate was usually very effective at getting them in.

If the patients described in the news media who died before they got in for an appointment were that sick, maybe they should have not just followed the instructions of the schedulers about how soon to come it. "I vas only following orderz" is not a good excuse.

Still, it is clear that the VA does tend to be a lot more concerned with looking good rather than actually doing good. For an illustrative example, a mandate came out that veterans who were diagnosed with mental trauma and post traumatic stress, either from war or military sexual assault, had to receive a certain number of psychotherapy sessions within a prescribed period of time after their initial evalutation.

The hospital administrators recently bragged in an e-mail to the department that they had met the target. 

What they actually did was to put all of these patients into group therapy, which in my experience was, in a lot of cases, next to worthless - instead of giving them the much more effective individual treatments. The VA where I worked does not have nearly enough psychologists on staff to provide individual treatment to everyone who needs it, and the ones they do have are mostly busy doing other things because they are maldistributed as well. 

For post traumatic stress disorder uncomplicated by major personality disorders, in my estimation the most effective psychotherapy treatment is something called prolonged exposure (PE), a type of desensitization treatment. Another treatment that is "empirically validated" - by which some people mean that there are some studies, no matter how pathetic, showing that it is minimally effective - is called cognitive reprocessing therapy (CPT). That in my experience is less effective for a lot of patients than PE.

Commensurate with my experience at the VA in Memphis, an article in the journal Psychiatric Services by Watts and others published in May of 2014 found out that, nationwide, the percentage of veterans who received any sessions of either PE or CPT was six percent. Six percent! But our VA bragged about fulfilling the mandate because the veterans were seen by a mental health professional the correct number of times. Well sort of seen, anyway.

More on looking good rather than doing good in upcoming posts in this series, coming soon to a blog near you.

Adventures in the Veterans Hospital Mental Health Clinic Part II

Continuing on from my post of 3/17/15 on the Kafkaesque nature of the VA bureaucracy, their motto seemed to be, "If we find a problem in the system, we'll come up with a ridiculous solution that may make the problem even worse. Or at the very least, create a whole new set of problems."

For example, not too long ago there were a couple of serious foul-ups at the VA Memphis hospital that were caused by patients being mis-identified by staff and given the wrong treatment. This sort of thing can have disastrous consequences, of course, and it happens from time to time in almost all hospitals. It is quite a serious issue. Of course, in these cases dire consequences are most likely to result  with surgery or in a busy emergency room; such events are fairly rare in outpatient clinics.

The VA solution: Every doctor was instructed to verify every patient's full social security number and full name immediately at the beginning of every single appointment. We were told to do this, not just for patients we did not recognize, but even for our regular patients who we have been seeing for years! And we were told that we had to document that we had done this - again every single time - in the patient's electronic medical record (EMR). No one anywhere else does this.

That may seem like a small although illogical request that wouldn't take much time. The trouble was, we were asked to document a whole bunch of other things almost every visit. Most of these things were completely irrelevant to the visit at hand. For instance, there are so-called "clinical reminders" to ask about certain information at most visits whether it concerned the reason for the patient's visit or not (example shortly). 

With limited time to see each patient and to document the relevant information in the EMR, this added a significant amount of time to a visit that would then not be available to actually evaluate the patient's progress for the problem that was being actively treated.

Most of the clinical reminders were checklists, about which I have complained many times on this blog. One particularly ridiculous clinical reminder was a requirement to perform a depression screening checklist, the PHQ-9. This is just what it says it is - a screening test to see who should be evaluated further for depression. 

It is meant to be used by primary care docs and other non-psychiatric physicians to determine who should be referred to a psychiatrist for these further evaluation, and who does not need one. It is meant to cast a wide net, meaning a positive test does not mean that you have a clinical depression - only that you might and should therefore be screened further.

The VA wanted the psychiatrists to ask their patients to fill one out! If a patient is already being evaluated by a psychiatrist, the purpose of PHQ-9 is no longer operant, so filling one out is completely pointless and an utter waste of time. Unless, of course, someone is such a bad psychiatrist that they think a psychiatric evaluation does not include an evaluation for depression.

I refused to do the PHQ-9's, because I perform a complete bio-psycho-social psychiatric evaluation when I first see a new patient, and I was not going to short change my patients by further shortening our already limited time together by asking questions I already knew the answer to, or was about to go into far more detail about than is possible with a PHQ-9.

Actually, there was at least one psychiatrist on staff who did not do a complete evaluation of every patient. Because this psychiatrist did not make waves, that clinician was allowed to practice what I consider to be piss poor psychiatry for years. Then the doc left. I will discuss what happened in that situation in Part III of this post.