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This Is How VA Doctors Would Fix The VA

veterans affairsBy Brad Broker

This Physicians News story can be republished for free. (See details)

Now that Congress has passed a $17 billion bill to reform the V.A., the challenge now is to properly use those funds to improve care to our veterans.  The focus of recent problems has been on the politics of the Department of Veterans Affairs. But maybe it’s best to get a new business plan from the people who are actually responsible for providing the health care.

Three physicians from the V.A. published an article in the current Journal of the American Medical Association (JAMA) with recommendations to “improve the care of veterans, create a work environment more conducive to collaboration and teamwork, and develop a more streamlined health care delivery system.”

One of the most important improvements will be greater access to care.  The V.A. needs to concentrate on hiring more doctors.  In just the past three years, primary care appointments have increased by 50 percent.  However, the number of primary care physicians has increased only by nine percent.

“With the increased number of veterans enrolled in the VA health care system, more physicians, nurses, and support staff should be hired to remain commensurate with this growth rate,” according to authors Faisal G. Bakaeen, MD, Division of Cardiovascular Surgery and Alvin Blaustein, MD, Division of Cardiology, at the Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; and Melina R. Kibbe, MD, The Surgical Service, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois.

The authors made a point to suggest that hiring physicians is different than hiring providers. “Although advocated by some, hiring nurse practitioners and physician assistants to replace primary care physicians may be an unwise strategy,” said the V.A. doctors. “This is not the time to test unproven and controversial solutions.”

Another recommendation is to improve the recruitment and retention system for V.A. physicians and employees.  The authors suggest that the V.A. must consider hiring doctors from outside of the V.A. system.  The V.A. “needs to implement changes to attract the best and brightest work force,” they said. “Currently, VA hospitals are viewed as second-tier facilities.”  In addition to offering higher salaries, the V.A. needs to match “its favorable benefit package and rich educational environment with an attractive work environment [to] allow the VA to obtain a quality work-force.”

And an antiquated human resource policy needs to be eliminated.  “The VA has a long history of minimizing terminations of ineffective and poorly performing employees by repeatedly shifting them to other departments,” according to the authors. “Instead, the employment of those who do not perform to a high standard should be terminated.”

Other suggestions include:

  • More accommodating clinical hours. “The US government’s administrative hours concept, defined as 8:00 AM to 4:30 PM, does not apply to clinical care….This change alone could substantially shorten wait times and reduce patients’ failure to keep appointments.”
  • Updating their academic affiliations to provide greater “access to clinical care to veterans and reduce waiting lists.”
  • Improving incentive system.  By creating certain arbitrary goals (i.e. new appointments within 14 days), “the VA has unwittingly created an administrative process that became too focused on numbers.” The emphasis should be on patient-centered outcomes.

(Photo by Robert Couse-Baker via Flickr)


  1. David – lets face it, PAs and Nurses are not enough. If a nurse or PA wants to provide the kind of care a physician provides, they must attend medical school and endeavor through a residency.

    Sure nurses and PAs are helpful and play a part in providing medical care, but they cannot replace a physician. Veterans and all patients for that matter, all deserve the best care – not good enough.

    Nurses and PAs can easily aid in making care available under the delegation and supervision of physicians. Physicians will utilize nurse and PA skill to the full extent of the nurse’s and PA’s expertise.

    The days of the unskilled practitioner offering cures beyond his or her capability are really not all that long past. Those who push nurses and PAs into roles not meant for them (as they lack the education, training, and skill) are terrible and thoughtless. Some of those who push are greedy and envious.

    • You obviously haven’t bothered to research the matter.

      Nurse Practitioners have an overlapping scope of practice with primary care physicians. They provide a variety of critical health services, including evaluating patients, making diagnoses, ordering and interpreting diagnostic tests, writing prescriptions, and managing acute and chronic health conditions—including oversight of patients with multiple and complex chronic illness.

      It’s true that NP education is different from physician education, although such difference is not evidence that one model is superior to the other. NP education is competency-based, rather than relying on clock-hours spent in rotations. This means students only progress once achieving and demonstrating competencies at each program level. One unique aspect of NP education is that students enter these programs averaging 10 years of professional nursing experience. NP programs are well-designed and prepare highly qualified NPs. This is borne out by over 45 years of peer-reviewed research proving that NPs provide high quality and cost-effective care that is “at least” equivalent to that of physicians.

      Currently, 35 states allow NPs to diagnose and prescribe under their own license. The remaining holdout refuse to modernize, primarily because of a powerful medical association. The NP growth rate through 2025 is expected to be 130%. The primary care physician growth rate, despite the need, will be an anemic 9%. We have to do better. Patients need care and clearly, nurse practitioners are stepping up to provide it.

      The institute of Medicine, the Federal Trade Commission, The Commonwealth Fund, and MANY MANY more are supporting the call for nurse practitioner full practice authority to help alleviate the severe physician shortfalls.

      Come up with some plausible solutions or get out of the way while nurse practitioners lead.

    • Actually, David is right. There is absolutely no evidence existing that shows nurse practitioners provide substandard care at all. In fact, it’s quite the opposite – which likely explains why Mr. Speed seeks to belittle and disregard the value NPs bring to the overall health system.

      You would think that since Mr. Speed shares such strong feelings toward his colleagues, he would want to make clear the truth about NP health providers. If his arguments were so strong, he wouldn’t have to hide, fool, or mislead the reader.

      Making unsubstantiated and false claims does nothing to prove his points.

  2. What a disturbing opinion by these 3 physicians. They continue to focus on their profession and forget about what is needed for the VA patients.

    There are simply not enough primary care physicians to meet the needs of the entire country as students are choosing the higher paying specialty tracks. What makes them think that they could actually hire enough to fill the gaps in the VA? Other than making a political point, this editorial did nothing but prove that they are self-centered and clueless about how to address the problem.

    If the authors were serious about creating a collaborative environment, they wouldn’t run down nurse practitioners and physician assistants – two provider types that are top notch and provide high-quality care. the IOM, the National Governor’s Association, the Heritage Foundation, the Federal Trade Commission and a host of others, including physicians such as Dr. Larry Kaiser and Dr. Kenneth Shine – both executives of major health institutes agree that nurse practitioners are valuable providers capable of doing more if only the medical associations would get out of the way. State leaders fall prey to their vicious attacks and fear being targeted at the ballot box by endless campaign donations made against them by the medical associations.

    If physicians continue to employ the head in the sand approach that they have with the general public, then access to care will continue to dwindle and our population will continue to get sicker.

    What a terrible and thoughtless threesome these guys are.

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