As a country I believe we tried to take care of our veterans the right way but unfortunately that begat the Veterans Administration medical system. Having worked in two VA hospitals and referred patients to several more, I feel I am qualified to talk about this system. The people of this country wanted to give their veterans the best medical care at no cost but you can't trust the government to accomplish something with which they have no experience. The result is a huge bureaucracy which tends to exclude the people it should help or at best make access to the care they deserve very difficult for the patient and/or referring physician. I could tell horror stories about countless telephone calls to VA hospitals trying to get a veteran admitted but being turned down for bureaucratic reasons such as we can admit him or her if he/she can drive themselves but if they need ambulance transport we won't pay for that. If they could drive themselves they probably don't need admitting, don't you think. I could tell stories of patients being admitted for testing then having to wait several days for those tests, meanwhile tying up beds needed for much sicker patients in private hospitals. You might ask why weren't the patients in need of tests but not really sick admitted to wait for tests? Because that is the VA way. Please note I did not say there was substandard medical care; I personally know many excellent physicians in the VA system especially those affiliated with medical schools. The medical and nursing staffs working in the system have to function by rules and regulations not developed by them which leads to the problems I have mentioned.

So how do we fix this problem? I wish I had a good answer, I don't. How do you dismantle a huge bureaucracy? I don't know that this country has ever accomplished that. I do know that it will be a long and painful process but the system can and does need to be reformed. Enough personal ranting for now, stay tuned and I will take on the HMO's at another time.

One other thing about the VA system (I just thought I could stop) is that the patients feel disconnected; they don't feel they have one doctor who they can get to know. This building relationships is one of the main reasons why I like what I do. This morning, for instance, I saw a lady because of menopausal symptoms which I could treat fairly easily but, because I had built a relationship with her, we also discussed her husband, the grandson who they are raising because his mother (their daughter) is a heroin addict, and their church. I know I felt better after the visit, not because I could cure their daughter's problem, but because she had enough trust in me to risk talking about some things that were bothering her. If you are directed from physician to physician (or provider to provider as we are now known) you don't build up a trust for any one. One of the major keys in helping someone get well is the trust they have in you to help them get well or solve their problem.

Life has a way of getting you back. This afternoon was the drug seeking patient. Lots of times you can see them coming a mile away, other times they are not so transparent. The one this afternoon fit into the former category. His shoulder, knee and (pick your joint) hurt terribly, so bad he could not even ride in a car. It was the worst pain ever. He had had numerous surgeries on the affected joint(s) and this was the worst pain ever. Only one of two narcotic pain meds would work and he told you in no uncertain terms that anything else was a waste of time. Although knowing the answer already, you call the pharmacy he listed as his primary; they laugh and ask what name is he using this time and tell you some of the long list of physicians he has seen before you. Armed with this ammunition you go back to face him. He tells you that he really is hurting and it is the worst ever. You kindly but forcefully tell him we will not prescribe any narcotics for him; he stands his ground saying he needs something; you write him a prescription for Ibuprofen. He says this is a waste of time; you more forcefully tell him that he will get no narcotic prescription from this office and the exit is that way. He begs the nurse on the way out for a narcotic prescription; then stops at the next medical office down the hall and tries to be seen to get pain medication. The nurse there asks us what happened, we explain, and they refuse. He threatens to go to the emergency department of the hospital our building is connected to so we alert them that a drug seeker may be headed their way. They laugh and ask what name he is using this time also and promise to let the social worker there, who has been trying to work out some management plan for him, know about this. Of course, we had already called the social worker, got his voice mail as usual, and left a message that whatever he has been trying to work out for this man isn't working.

The day ended well however. The lady I told you about Monday who had been riding her scooter and was struck by the minivan as it turned out, was back today because the driver's insurance company wanted her seen again to be sure she was ok. She is, just sore which she understands. She is more concerned about the damage to her scooter which is her only means of transportation. She brought the police report of the accident and we laughed about the fact that it listed a drivers license number for her and she hasn't had one in at least 20 years, it had her address wrong, and the driver who hit her had a handicapped license plate. She wonders if it was for impaired vision. A good laugh is the perfect end for this day at the office.

Home on time, for me. Post the first part of this update, help Delanae deal with a minor problem with Stacey (daughter) then go for a run in the rain. Good run since the temperature is near 60 and therefore the rain was not cold then on the way home I hear this woman's voice doing a radio commercial for a local internet business. Near the end of the commercial I realize the voice I like is my wife's; it is her first commercial in more than two years and most of her midwest accent is gone. I tell her I love the new voice when I get home; of course she says the commercial is one of her worst ever but I know the company she is doing it for is going to love it enough to cut some nationwide commercials as they have talked about doing before.(Sorry about the long sentence I couldn't get it to stop) Now to eat dinner then watch ER which is the only primetime show I watch. I watch it to heckle the show's mistakes; I catch myself yelling at the doctor actors "you can't do that" or "no real ER doctor would do that". Sometimes worse! My wife hates it when I heckle the show but I can't help it. See you tomorrow.

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Friday November 12, 1999

This update is later than usual. Locusts or something ate up the time I normally have during the day to write some thoughts so I am doing this at home after my day has ended. Therefore this update will tend to be a little shorter probably. Weather report today is rainy and mild but more winter like weather expected next week.