“I feel like I’ve stepped back in time.” An all-too-common phrase recited by almost every healthcare provider when they start working at the Manchester Veteran’s Affairs (VA) Medical Center after working in the private sector. We all joke about our period of “VA culture shock,” but when the fog clears, it becomes clear that something is very wrong.
Something systemic that extends far beyond the crumbling walls of the VA.
Recently, the Secretary of VA visited Manchester VA, bringing the same recycled message of “change” that others before him have used, but with the added goal of “restoring trust,” something his predecessors have not delivered. Veteran organizations have written some glowing reviews of the new secretary, and I hope their optimism isn’t wasted. But, working on the inside, I will say he is only one human being who is far too insulated to know what the experience is on the front lines of VA Healthcare.
This is something that plagues leadership in the VA and something many whistleblowers before me have reported. While high-level managers are insulated, they are reliant on a system of metrics, numbers, and percentages. With a hyper-focus on metrics, the chain of command looks for ways to improve numbers to make their VA look better. Inevitably, this leads to the manipulation of data in ways that may not even be noticed at first glance by people who are participating in a system of “we’ve always done it that way.”
In 2015, the Manchester VA produced a group of whistleblowers, mostly doctors, all with chilling tales of malfeasance and poor oversight of VA programs and metrics. The most serious of these was the story of a doctor who found Veterans had unnecessary spinal cord injuries due to poor care or management of care by the Manchester VA. In the end, the VA was forced to investigate after the group went public with their allegations. When the VA reported their findings, they stated that almost all allegations were “unfounded.” Imagine your doctor telling you that your inability to walk and the fact you wear diapers was because of poor medical care, only to have the VA outright deny this? Knowing this doctor was one of the more well-respected pain doctors in the area, does this restore trust with the Veteran community? These doctors blew the whistle the same year a federal court awarded a Manchester VA patient $21M due to poor management of a stroke, leading to a second, more devastating stroke.
What is often missed in reviewing these public stories about the VA is why the whistleblowers decided to go public in the first place. The group in 2015 hired an attorney to represent them after they had exhausted all internal reporting methods, which are extensive. Only in the public light did the VA decide to investigate, and members of Congress made promises of more oversight. More oversight and more layers were added to an already bureaucratic system.
The obvious question at this point is, why aren’t there more whistleblowers? I’m here to tell you there are many, many more that are swept away under the bureaucratic system of federal oversight. This system is tasked with oversight of VA systems and investigation of whistleblower complaints. As VA employees, we have yearly training that encourages us to “report wrongdoing.” The training lists a myriad of oversight agencies and how to contact them with your concerns. A new agency called the “Office of Accountability and Whistleblower Protection” was set up as a response to news reports of whistleblower retaliation in the VA. Though they have already had their own scandal and accounts of bullying within, some lawmakers question this as an ineffective, redundant agency.
I spent years reporting many issues concerning the care of our nation’s Veterans to multiple levels of management in Manchester and received almost no response on most issues and never any resolution. I recall one meeting I had with a middle manager (the VA has many layers of management) and my surprise at how I only received a medicated-looking stare as I told my observations, including:
- Poor patient care
- Gender discrimination
- Data manipulation
- Fraudulent documentation in Veteran medical records.
- Unnecessary delays in care and treatment
Any one of these issues should have been addressed and thoroughly investigated, but in a world of mixed messaging, promises were made and not delivered. Even after all the news stories of issues in the VA, management seemed either unable or uninterested in addressing these issues. Before I left the Manchester VA, I worked up the courage to file a whistleblower complaint and thought I would finally get some resolution and closure on what I see as a profound injustice. I was wrong.
In the next installment of this series, we will explore the process whistleblowers experience and how the system is set up against them. You may be surprised what happened when I informed our elected representatives in Washington DC, of these issues.
