How to fix cracks in the medical system and VA

batchaps4me

batchaps4me

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Chapter 1: TLDR - Intro to Idiot gets Pissed

We have all had or known people that have fallen through the cracks in medical care. Getting specialty care in the VAMC at times can be like picking fly shit out of pepper, you have to know how to be effective and it is tedious as hell. Orthopedics is the one that seems to be critically short of doctors at every VA I have been to and there are a lot of cracks, some intentional most not. This applies to a lot of civilian systems as well and it is important to know how they work in solving these problems. This is not a VA rant, but a display of my ignorance and misplaced anger that can hopefully help others. This is long and I may have to make it multiple posts but please feel free to ask questions.

Guys, it's been a rough year for my back and knees, nothing too serious, just physically rough and old implants. Late last November I told my PCP at the VA that my knees and back were deteriorating rapidly after a fall I had and I would like to see orthopedics. You must have an Xray prior to even get an orthopedic consult at my VA. On New Years Eve I was having a painful back day and had an electric shock sensation in my thigh causing me to fall down 3 steps. I suffered no injuries more serious than about 6 inches of skinned shins on each leg, but it was really difficult to maintain my cherub like demeanor. I knew I need to get checked so I went to the VA planning on getting the Xray and then being seen at UC. No Xray order was put in and I lost my shit. In fairness, I had just driven about an hour after a fall and tbh I shouldn't have been driving. It was FUBAR situation and the best thing to do was leave.

We all know I am crazy as hell and on top of that I have mental health issues. By the time I got home I was seething, unable to walk and in tremendous pain. That evening I spent a couple hours on the Veteran's Crisis Line, not because I was going to harm myself or others ... I was just angry and needed to vent. I can't stress enough what a valuable tool the Veteran's Crisis Line is, and it is there for a lot more than suicide prevention. They follow up and have a lot of resources at their fingertips. USE THEM. This is not relevant to the story per se, but is worth repeating often.

I contacted Patients' Advocate to file a complaint, and they wouldn't have it and just rationalized the system and defending the process. He wouldn't even tell me who to file a complaint with. Oh, I was pissed off beyond belief, and we briefly may have discussed a bit of ancestry mixed in with the latest scandal ( Medical Director and some staff were relieved for sexual harassment, covering up 2 reported sexual assaults on employees, and having orgies of up to 32 employees possibly on VA grounds). I called the Director for Patient Services and was ghosted so I filed an OIG complaint.

Funny thing about the VA OIG process is that it directs complaints directly to the medical center involved and is handed off to the Patients' Advocate for investigation. "We investigated ourselves and found no wrongdoing" was the practical results, which pisses me off more, but that is not the case at all. Wrong tool for the wrong job and I was the idiot using it. This is the crux of what I want to discuss from the process side.

But before I get into that, let me just drop this nugget: I found out today that our ortho does NOT handle spines. I have to start the whole process over, this time I have to get an MRI before they can even offer a consult for treatment. I entered the line today, expect it to take a week to get on the schedule, a three to six week wait for the test to be performed( WAG, the VA does not track this metric), a week for the consult processed with appointment made and then a 2-3 week average wait time for the appointment. Looks like July before I actually get to discuss treatment for falling.

EDIT: I feel the need to clarify that although I am writing this rested and sober, I researched this yesterday and quite frankly may have been on the verge of hallucinating. If I get something wrong, please point it out.

PS: I put the real TLDR intro/summary on the 4th post in honor of my fourth grade English teacher for being the first adult female that wasn't related that me to call me a jackass. She may be the 50th total but was ahead of multitudes of others.
 
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Chapter 2: TLDR- Idiot quit banging head on wall, amazed that headaches abate

Guys, I want to say up front that I have been flat wrong about OIG and patients' advocates. They are generally good at what they do and can offer certain kinds of help with the system. They are limited because of the role, not their intent and that is a huge difference. You just have to use them within the framework of the system and realize they are a customer service provider and have to be viewed through that lens only. They have no admin authority. They can't change the system, can't write anyone up, can't do the roles that are not customer service, they put out small fires with immediate action, normally cutting red tape. Try to use them for other outcomes sets both of you up for failure. Trust me, I have 30 years of experience in doing just that. The outcome for me tended to be self-destructive, just building on frustration and eventually hate. Let's just say that I don't think I would have drowned anyone, but I was willing to hold their head under water for a minute or two ... that's all on me.

But the thing to realize is that in the VA's system using the OIG/PA is that the approach to accountability is that everything is a system failure meaning that if a person messes up, inadequate training is the issue and that is not on the individual as they see it. Now that may sound bad, but from my experience in the safety field is that major companies generally gravitate to that the polar opposite but equally bad everything was the employee's fault. TBH, going case by case is a serious legal liability and either philosophy is at least consistent, which alleviates some of the legal issues. Our company changed philosophies while I was there and one was just as bad from an accountability standpoint.

Except for egregious cases, the (PAs and OIG by extension) are internal tools for the hospital. When the system delays care, the hospital admin has to address it within budgetary constraints. The budget always wins and nothing happens outside of a band aid fix that has to be reapplied every time you need that same service. For example, I quit using my C-pap because I couldn't get supplies. Turns out, the C-Pap coordinator had a lucrative side hustle losing supplies out the back door and was eventually caught (she quit her job, paid restitutions and got judicial diversion). You almost had to go through PA to get them about half the time and the complaints were never really addressed. The PA's role was to get the help to the patient, which he did. Not to affect change in the system, which he didn't.
 
Chapter 3: TLDR- Look, A Shiney New Object!

Yesterday I was scrolling through YouTube shorts and got the ad "quit using AI like Google". Y'all know that I'm a people pleasing conformist by very nature, so I decided to quit using AI like that. First, I had to start. It turns out that if you are persistent in forcing direct answers to your questions from linked primary source material only, it works surprisingly well as a search engine. I must say this, that I compare the VA's website to the Warren Commission Report. In that I mean that it is great for messaging and a few other tasks ... I love my healthy vet ... but if you are trying to find information you need, it is cut up and scattered to be inaccessible.

Although I have full faith in my knowledge the quality levels of products produced by our government's lowest bidders, I have to believe that some of it is deliberate hiding of information to keep all problems at the lowest level possible. I agree with that approach, and it is ingrained in military culture. The key difference being that the in the military, you know your options from an interdisciplinary problem-solving approach. At the VA if you go to a PA, you get a customer service approach only. This is not an issue with the person in the role of Patients Advocate. It's an issue that bases itself on the assumption that we know the system and chose to make it a customer service issue. His role is to resolve why it happened, but to get me a dam Xray soon as possible so the system could work. At that point and time, he is correct and any other actions are not only unwarranted from his role. File an OIG complaint and he is rightfully blameless because if had he done less or more, that would not be the case. He solved the customer service aspect of the problem.

Now I am pissed what they didn't suggest to me and never have before in any of our dealings. The shiny objects are called the Quality Management and Patient Safety teams. I dare you to pick any VA hospital, go to va.gov and find out anything about them relative to where they are, office number, building number, how to contact them, what to do with any concerns or what concerns they handle. It is pure conjecture on my part, but I believe they are only going to provide that information if you directly ask for it specifically, and that is probably due to pressures from the civil service, union and local administrative policy.

I want to be clear that QM/PS are also limited on their scope of authority and issues handled and are not designed to handle complaints, even valid complaints. They handle safety incidents that can and do cause injury and the potential for death. Not all, hell most delayed care does not rise to this level and that is the justification for the low-key presence. It is not a complaint department, not part of customer service and to be fair could easily be abused. BTW, you can call your local VA switchboard and they will put you straight through to their office.

I think I am going to write up an incident report after everything shakes out a bit. The grading system uses similar classifications that I am accustomed to and although I do not know the specific scoring formula, I think it rates doing.

The End!
 
Preface And Summary, Read First.

Guys, unless you are in the VA or know someone who is, this is going to be tedious and boring. But if you are in the system, you will eventually run into issues or know someone that has. Nobody teaches you the system, but their every decision in care and conflict resolution is based on the assumption you know it and the verbiage needed to operate in it effectively. If you have an issue and get frustrated to the point of wanting to file complaints for punitive action hoping that will somehow spark change in the system, like me in the last 30 years, prepare to be disappointed. Want to go outside the VAMC to the OIG over what they see as a customer service issue, you don't know the system and what tools to use. Prepare to be wrongheaded for the duration. If you understand the system, the tools are there IF and only IF you use them right. I hope to break down the processes and tolls using my experiences as the example of using the wrong tools for the right job and visa versa.
 
I also just wanted to say that my case is a comedy of errors. I have treatment notes from the doc that don't match the nurse's notes of the same visit and relays a totally incomplete picture of my symptoms. There were sentence fragments and incomplete statements. The truth is that either in saving or transmitting, the computer decided there wasn't enough room for all the words in the box and cut them out based on priority. Like everything else, AI and data entry prompting in the VA is keyword based and prioritized. Apparently once she selected knee instability in a dropdown box, it was prioritized and the AI and data system from that point on guided her and everyone after her that saw my name to treat the knee and only the knee. Check your treatment notes for accuracy after every visit. Better yet, ask the doctor if he can read that part back to you before you leave. Had I done that one thing back in November, all of this would have been avoided.
 
Ok... I saw the first wall of text but since it was you I scanned it and was trying to stay focused. I then scrolled down and thankfully found the summary ( You need an Index on this thing ) and it reminded me of what I was going thru with my doctors ( I am not a Vet and this is not about the VA part of your rant just doctors in general ).

So, I will try keep this short and sweet tho. About a year and 5 months ago I dropped a glass in my kitchen and it broke. I tried to step out of the radius of the broken glass and stepped right on a piece of glass and split my heel open. Immediately I tried dressing the wound and thought I could just wait a few weeks for it to heal ... but no. after two weeks I went to a podiatrist. He "cleaned" it up and wrapped it and had me coming in every two weeks where he would stare at it then do what they call debridement and wrap it up and send me away until another two weeks had passed.

This went on for the better part of a year with me complaining that it was not healing ( they measured the wound every visit ) and he would just shake his head say "Well some folks heal slower than others blah blah blah". I was not happy but this was my first experience with a Podiatrist and even Google said the heel was the worst place to get a wound because it heals so slow there so I waited patiently.


One day I came in and another doctor saw me for that visit... she told me the other doctor had gone to another practice ( sounded sketchy to me ) but on that first visit with her she declared she was going to perform surgery on my foot and shave my heel bone and close this wound ... I was some what skeptical since the other doc never mentioned the bone at all. After another visit I get a call that this doctor was no tin my insurance network yet so I just cut ties then... was tired of the run around.

Got another doc and she she took one look and was like "Oh ok, lets get you fixed up here" and did what she called an aggressive debridement. She said I had "tunneling" in the skin around the wound and that should have been cut out in the first place. So literally in the two weeks between the first and second visit my wound healed half way closed. I was astounded.

Now it is down from being a hole in my foot about the size of a silver dollar to about the size of a nickel now. Folks, the doctor you get matters... I got drastically different results between all three doctors and if I had gone to the one with the all the 5 star reviews first I would have been walking on this a lot sooner... I have spent the last year and a half in a medical boot and changing the dressing every day. Pain in the ass and it hurt like hell a lot of days.

Heh.... so there's my wall of text. I should be out of the medical boot in about a month at the most.
 
Tenncock said:
Ok... I saw the first wall of text but since it was you I scanned it and was trying to stay focused. I then scrolled down and thankfully found the summary ( You need an Index on this thing ) and it reminded me of what I was going thru with my doctors ( I am not a Vet and this is not about the VA part of your rant just doctors in general ).

So, I will try keep this short and sweet tho. About a year and 5 months ago I dropped a glass in my kitchen and it broke. I tried to step out of the radius of the broken glass and stepped right on a piece of glass and split my heel open. Immediately I tried dressing the wound and thought I could just wait a few weeks for it to heal ... but no. after two weeks I went to a podiatrist. He "cleaned" it up and wrapped it and had me coming in every two weeks where he would stare at it then do what they call debridement and wrap it up and send me away until another two weeks had passed.

This went on for the better part of a year with me complaining that it was not healing ( they measured the wound every visit ) and he would just shake his head say "Well some folks heal slower than others blah blah blah". I was not happy but this was my first experience with a Podiatrist and even Google said the heel was the worst place to get a wound because it heals so slow there so I waited patiently.


One day I came in and another doctor saw me for that visit... she told me the other doctor had gone to another practice ( sounded sketchy to me ) but on that first visit with her she declared she was going to perform surgery on my foot and shave my heel bone and close this wound ... I was some what skeptical since the other doc never mentioned the bone at all. After another visit I get a call that this doctor was no tin my insurance network yet so I just cut ties then... was tired of the run around.

Got another doc and she she took one look and was like "Oh ok, lets get you fixed up here" and did what she called an aggressive debridement. She said I had "tunneling" in the skin around the wound and that should have been cut out in the first place. So literally in the two weeks between the first and second visit my wound healed half way closed. I was astounded.

Now it is down from being a hole in my foot about the size of a silver dollar to about the size of a nickel now. Folks, the doctor you get matters... I got drastically different results between all three doctors and if I had gone to the one with the all the 5 star reviews first I would have been walking on this a lot sooner... I have spent the last year and a half in a medical boot and changing the dressing every day. Pain in the ass and it hurt like hell a lot of days.

Heh.... so there's my wall of text. I should be out of the medical boot in about a month at the most.
Click to expand...
I put the index there on purpose, it was about the only thing I could think of to be a jackass, and I have to manage expectations of me. Were I you, I would take a copy of my records to that 5-star for another opinion of the early treatment. Don't get me wrong in that it sounds like you are finally getting the right care but IF you feel there was anything inappropriate, it may be worth investigating and reporting the incident if nothing else to stop the practice. In a lot of cases though, doctors have a wide latitude to be conservative or aggressive in treatment. My advice, and I am not a lawyer, is that if you really want to find out start simply by using the web to check the methods used compared to the symptoms you were having at the time. Hell, the next time you are getting seen, complement the speed of the healing and ask why it took so long to get aggressive in the treatment. If the answers match up, it probably would be a moot point to pursue if you are set on a particular solution.
 
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