Douglas R. Bacon, M.D., Editor

Duty, Honor, Country

uty, honor, country — these are words that resonate with a large portion of Americans. Two of the words connote values that were important in my household — I grew up as the son of a World War II veteran. Our country, the United States of America, was representative of an ideal that was worthy of sacrifice. These three small words resonate with the authors of the featured articles in this issue of the ASA NEWSLETTER. Read with pride what our colleagues in the military have accomplished under circumstances that I will most likely never encounter. They are saving the lives of severely wounded soldiers and civilians who could not have been salvaged before and have developed techniques, like their predecessors in our armed conflicts before, that will have application in the everyday world of trauma care.

But after the soldier returns to the United States, after the initial episode has been resolved and his/her acute care and convalescence done, where do these individuals turn for care?

For veterans there are very special places — Veterans Administration (VA) Medical Centers. While I have not personally worn the uniform of our nation, I have served our veterans from 1995-00 as the Chief of Anesthesiology Services in a dean’s VA (a VA associated with a medical school). It is a unique environment from many perspectives and provides care for patients who often cannot afford it or have unique service-connected ailments* in which the world outside the VA has only a passing interest. What made the job, and the working milieu, so interesting was the veterans themselves. The operating room staff was approximately 75 percent veterans, as were many of the physicians and other staff. The patients were gracious, allowing medical students and residents complete cooperation — they understood, somehow, the need of those in training to learn.

One incident clearly demonstrates the unique nature of the VA. Two patients, both scheduled for coronary artery bypass grafting on the same day, shared a room. The first patient was anesthetized at the beginning of the operating room day; the second was to follow as soon as the initial case was done. The original case went well until protamine was administered; then the patient had a reaction and a complete cardiac arrest. This simple case quickly became complicated, and the patient did not arrive in the intensive care unit until 11 p.m. The surgeon went up to see the second patient and to explain why his case had been canceled. The response was typical VA — “Don’t worry about me, doc,” the patient said. “You can do me next week. How’s my buddy doing?”

The fact that so many of the staff were themselves veterans gave our patients a sense of security that they did not have elsewhere. Oftentimes this would come out as the patient was being interviewed about an unrelated issue. Staff was told about problems that the patient had not verbalized to anyone: spouse, family or private care physician.

One day while doing a preoperative assessment on a cataract patient in his late 70s, I asked about his military service. The patient told me that he had been in the infantry through the North African and European campaigns of World War II and had won four Bronze Medals and three Silver Stars, sustaining only a minor thumb wound from shrapnel. With tears in his eyes, he related his survivor’s guilt at having come through the war all right while his dear friends died alongside him on many different occasions. As in the final scenes of the World War II film “Saving Private Ryan,” where the lead character kneels at the grave of the infantry captain who “rescued” him and asks his wife if he has been worthy of the sacrifices made on his behalf, my patient worked tirelessly for the St. Vincent DePaul Society in an effort to be “worthy” of his survival.

The VA also has been critically important to research. There was a separate allocation of funds for research related to problems that veterans have encountered. Many academic research careers have started within the VA system. Support in the form of laboratory space also was possible, and many of the dean’s VAs had research centers as part of the campus that housed the medical center. Obtaining these funds, at least during my term in the system, was never easy. Like most research funding, it was competitive. A proposal had to be written, passed by the institutional review board (IRB) and — if experimental protocol used animals — the animal use committee, and on through the medical center and VA committees before final approval was secured and the funds released. For many, however, the availability of the funding for their research endeavors made a career at the VA palatable.

Yet the VA is not a system without flaws. The anesthesiology service, equivalent to an independent department in the hospital or medical school, was created at the VA where I was employed the day I arrived to chair it. While anesthesiology had been recognized across the world in the preceding 30 to 50 years as an independent specialty, the VA lagged behind. And in creating the service, many of the components of a functioning department according to VA regulations were not provided — simply based upon a lack of resources within the medical center. In point of fact, during the time I was chief, the service turned over each of the five anesthesiologist positions at least once. Salary was often the issue, especially when a physician could increase his/her compensation at least by half by leaving.

Why should the readers of the ASA NEWSLETTER care about the VA system?

On January 30, 2006, the Rochester Post-Bulletin, our daily newspaper, ran an editorial titled “VA is the Model for Health Care.” Written by Paul Krugman, a columnist for The New York Times, the article unequivocally states that the VA is the model that reform of the health care system in the United States should take. Mr. Krugman writes about the reforms of the 1990s that transformed the VA into a leader in health care. As a participant in one small way in those reforms, I agree that the VA had much to change to deliver care more effectively. But what came down to us at the medical center level was an emphasis on numbers. Physicians were given 20 minutes, to be reduced to 15 several years later, in which to see returning patients. Failure to keep to schedule was cause for review, which had many possible consequences.

Our director, one of the leaders of this revolution, was an excellent manger. Yet he wanted me to be the chief of surgery, not as a temporary measure, since most of our surgeons were part-time employees, but to recruit, retain and improve the quality of surgical care in the medical center. What was disturbing in this vision was that physicians were widgets that could be interchanged, an anesthesiologist for a surgeon, or if the need be, an internist or cardiologist. He failed to appreciate the unique qualities each specialty brought to patient care and the needs of our veteran patients for those skills.

In the end, my frustration with the VA administration was twofold. First, there was a lack of appreciation for the care delivered by physicians. Second, the lack of funding and the prospect that only budget cuts were in the future made building an anesthesiology department with seriously needed pain and critical care services impossible. Funding was a heartbreak issue as the VA budget had not changed in a decade, thus suffering, through the decreased buying power inflation caused, a de facto cut of about 30 percent. Our interpretation of the VA “revolution” was that Washington seemed not to care about the patient; rather, often meaningless statistics were all that mattered. These experiences have led me to strongly oppose the federal government assuming responsibility for all health care in the United States.

Since I left the VA, improvements have been made, and the “revolution” has met with some wonderful accomplishments. Focusing on geriatrics, the VA has had great success in managing several chronic conditions, especially diabetes, and continues to be on the forefront of prosthetic research. The World War II population, which extensively uses the VA, has helped to spur these changes. In point of fact, several recent studies demonstrated that the VA outperformed the private sector in diabetes management, and patient satisfaction with the care received is at an all-time high, especially when compared to medicare. Yet the high-priced surgical, invasive medical and anesthetic fields continue to burden the system, and the demand for new, expensive prosthetics will tax a system that had been successfully metamorphosing into masterful geriatric care. Will the VA budget be enough to care for those who literally have put their life on the line to defend our nation?

The uniformed services, and perhaps even more so the VA system, represent how and what the federal government believes in as a health care delivery system. We need to listen to what our colleagues in the VA and the military tell us, for perhaps they are the future of a federalized health care system. In the end, the current VA system cannot be about statistical outcomes, but rather needs to focus upon, in Abraham Lincoln’s words, “…him who shall have borne the battle, and for his widow and his orphan ….”** It has to be about the price of freedom.

One way we can support our uniformed service and VA colleagues is to advocate for an increase in VA and armed forces medical budgets. While this would not benefit as many ASA members directly as reforming the equally absurd Medicare rules of payment, it would send a clear message as to where our priorities are. At the very least, we ought to make it one of our talking points with our representatives during the Legislative Conference.

In many ways, our honor is at stake, for how we treat those who bear the cost of freedom speaks volumes about who we are as a society and what we value as a country. It is our duty to fulfill Lincoln’s vision.

— D.R.B.

* What is not often well understood is that the VA treats conditions connected with the individual’s time in the service. However, medical conditions that develop after military service are not automatically treated. Each veteran is subject to a needs test and is asked about any applicable private insurance.

return to top