Sunday, May 04, 2014

Congress and Veterans


Dona: Last Wednesday, the Senate Veterans Affairs Committee held a hearing to discuss alternative medical approaches in the VA.  Another topic actually ended up dominating the hearing.  Present at the hearing and reporting on it  were C.I. with "Iraq snapshot" and "Iraq snapshot," Ava with "Senate Veterans Affairs Committee reviews alternative care (Ava)," Wally with "Begich tried (Wally),"  Ruth with "Senator Richard Blumenthal" and Kat with  "Petzel lied to Senate Veterans Affairs Committee." Okay, Wally, the basics?

Wally: The Committee's Chair is Bernie Sanders and Richard Burr is the Ranking Member.  There were two panels of witnesses.  The first was the VA's Dr. Robert Petzel with Dr. Tracy Gaudet and Dr. Peter Marshall, the Army's BG Norvell Coots with Col Kevin Galloway, and the National Institute of Health's Dr. Josephine Briggs.  The second panel was the University of Vermont's Dr. Janet Kahn and RTI International's Dr. Mark Edlund. And the title of the hearing was Overmedication: Problems and Solutions.

Dona: Okay.  Thank you.  Now Chair Bernie Sanders noted the following, I'm quoting from C.I.'s report:

Senator Bernie Sanders: Within the veterans' community -- and in fact, the nation both in the public sector and the private sector -- we face a very serious problem as a nation of overmedication. The result of that overmedication is that significant numbers of people treated in the Department of Defense facilities, in VA facilities and in the private sector become dependent upon those medications intended to help them and ease their pain. Pain relief is a huge problem in the country and how we treat that pain in the most effective way is really what we're discussing today. Some people who are treated with a whole lot of medication become addicted -- and I think we all know what happens when people become addicted -- and some in fact will end up taking --  losing their lives through overdoses. And in my state and throughout this country this is a huge problem as well. So this is a major issue which has been discussed in this committee during the last year and we're really glad we have such a distinguished panel to discuss this issue.  

Dona (Con't):  Ava, as you've pointed out before, this is a key issue for Sanders.

Ava: Right, he advocates for alternative means, alternative medicines, for dealing with pain and stress.

Dona: Such as?

Ava: Relaxive breathing, Tai Chi, yoga, acupuncture, etc.

Dona: These are not seen historically as being part of the landscape of western medicine.

Kat :  Correct.  And he made that point in the hearing, Sanders did.  How twenty or thirty years ago, these techniques and practices might just be advocates by "few folks in California." Which, by the way, he's made before and, as someone from California, usually rubs me the wrong way.

Dona: Really?

Kat: It's left unstated that California was in the lead or that people, including our current governor who was also our governor in the 70s --

Dona: Jerry Brown.

Kat: Right, Jerry Brown.  He was ridiculed for this as much as the state was. So, if people are going to bring this up -- Sanders or whomever, maybe a little "Turns out Brown was right" needs to be actually stated and not left implied.

Dona: Okay.  Well Ruth's participating by phone, the rest of us are in California.  Kat, Ava, C.I. and I live in California.  Wally's home is in Florida.  Just for disclosure.  So what exactly should be said?  Can I get like an example?

C.I.: Sure. He's talking about acupuncture?  Or even just alternative medicine, he can note that then-Governor Jerry Brown signed into law a bill making acupuncture legal back in 1976.  I'm not really bothered by it.  I see what Kat's saying and I understand it.  But it's not a huge issue to me personally.  If it is an issue to Kat, then, no doubt, is to others as well so a statement about 1976 and what Brown did would get the message across much better than saying "a few folks in California."

Ava: And, to add to that, if you're from the state or living it, it's probably smart for a politician to exercise a little more care when speaking about it.  Like C.I., I didn't care one way or another except to think that he's used that line in at least three other hearings and it's kind of old by now. But, yeah, if it's offending someone, you need to construct a better way to note the progress and it's also always good to note the people who paved the way -- such as Jerry Brown.

Dona: Alright.  So what's the story?  This is being used.  Is it working?

Wally: That wasn't addressed.

Ruth: No, it really was not.

Wally: The best that could be offered were percentages of people who had switched from opiate drugs to these therapies.

Ruth: And the witness Dr. Janet Kahn was specific that she was not seeing this as an either/or issue.

Dona: Right.  Let me quote from Ava's report for that.

Chair Bernie Sanders:  You said that the issue here is not to deal with pain but to deal with the person  In the real world -- In the real world someone walks into your door with the issues that I've described.  The easy path is to overmedicate.  Historically, we have done a lot of that.  You've got a pain, here's some drugs.  You're proposing a different way. In plain English, and maybe some concrete examples, what does that mean?  What does that mean?  What do you do with that individual who walked in your door?

Dr. Janet Kahn:  So I hope I made it clear that I am not suggesting either/or --

Chair Bernie Sanders:  No, no, no.  We understand.

Dr. Janet Kahn:  Okay.

Chair Bernie Sanders:  Absolutely.

Dr. Janet Kahn: And I want to say clearly that I am not a physician. [She has a Phd.]

Chair Bernie Sanders:  Right.

Dr. Janet Kahn:  Okay. So that said, yes, I assume a physician would address issues of pain directly.  But at the same time because of people's literal experience with pain and their capacity to handle and cope with pain and manage whatever level of pain they are experiencing is influenced by these other things -- like their general state of anxiety or whether or not they're sleep deprived and therefore on edge in a different way.  We want to come up under them in terms of those elements of life at the same time as addressing the pain directly.  That's what I'm saying. 

Dona (Con't): And it's good that the point was made that this isn't either/or and that, for example, yoga and medication can be a two-pronged effort to treat pain issues.    But I'm confused regarding the inability to say whether or not this is working?  And, for the record, when I was pregnant and having severe lower back pain in my last two months of pregnancy, I saw an acupuncturist and it was extremely helpful.  I'm all for alternative medicines.

C.I.: This is how the hearing got away from the topic.  Another issue would be the focus even though it was the planned topic.  But it's also true that the witnesses weren't prepared or didn't care about the topic -- the witnesses from the government.  For example, the VA's Dr. Tracy Gaudet was completely unprepared to speak to the issue and it was like Sanders was pulling teeth to get her to speak.  Equally off-putting was her manner of speaking.

Wally: Amen.

Dona: How did she speak?

Wally:  She was being silly.  Almost like she was trying to flirt.  There was a lack of attention to detail and a huge lack of seriousness when she was addressing Sanders questions.

Dona: Okay, I see what you mean -- Wally and C.I. -- I'm looking over the reports done and this is from C.I.'s report:

Chair Bernie Sanders: So, in terms of programs like the acupuncture, is it working?  What can you tell us about your success rates or non-success rates? Does the success work?

Dr. Tracy Gudet: I think the most evidence that actually exists for acupuncture as it relates to pain, our research Office of Evidence Synthesis just finished a comprehensive look at all the evidence related to acupuncture and it's a very useful document because it basically says where is their evidence for the use of acupuncture, do we know and is there evidence of benefits, do we know it's not a benefit or is there a category where we just don't know from the research?  The areas where there is the strongest evidence for acupuncture are pain -- chronic pain, headaches, migraines have the best evidence.  So it's a rational place to start.  

Dona (Con't): The doctor sounds like an airhead.  She's specifically asked if it works by Sanders and she never answers.  She brings up a study but never explains what the study found.  She ends with the study found "the strongest evidence for acupuncture are pain -- chronic pain, headaches, migraines have the best evidence."  Best evidence of what?  She never says.  She's unprepared and she's not listening to the questions being asked or else intentionally refusing to respond.  And there's agreement, on the Committee, that this is a serious issue?

Kat: Richard Burr's Ranking Member which means he's from the party not in control of the Senate.  Sanders is an independent, a Socialist, who votes with the Democrats.  Burr is a Republican.  Let me quote from Burr to answer your question:

Turning to the subject of today’s hearing, as many of you know, the United States is facing an epidemic of prescription drug abuse.  That’s why it is important that we are here today to conduct oversight over the care veterans who have chronic pain receive from VA.  It is critical that we ensure that VA is taking the necessary steps to address the over-use of certain medications and the potential risks of misuse and dual prescriptions.  It has been estimated that as many as 50 percent of male veterans and as high as 75 percent of female OEF/OIF veterans struggle with pain.  The prevalence of chronic pain will likely increase as more service members transition into the VA system.  These numbers demonstrate the need for VA to provide quality pain management services to ensure veterans with chronic pain are able to live productive and healthy lives.  

Dona: Which indicates the Committee has agreement that pain management services are needed.  So what's the problem with the VA?

Ruth: Maybe the problem is that the mission has been defined and handled wrongly.

Dona: Okay, expand.

Ruth: My late husband was a doctor.  I am using that as a basis for my response here.  But the Senate and the VA seem to think the answer is finding traditional doctors who will use acupuncture or whatever else as a compliment.  That is considered the 'victory.'  That is not a victory.  They are asking doctors -- and only a few, we are talking about test programs for the most part -- to move just a tiny bit.  And that is failure approach.

Dona: Because?

Ruth: The bulk of medical doctors do not believe in alternative medicine.  Mr. Sanders is choosing an incremental process that will have achieved nothing long after he is gone -- from Congress and from this world.  You need to stop defining victory as swaying a few doctors in the VA medical system.  You need to bring in people whose specialize in acupuncture and yoga and Tai Chi as full partners in the system who can help co-develop programs.  Otherwise, you have a vanity problem that is not being addressed.  It is not just a god complex that I am referring to.  I am speaking of doctors who are trained at pricey medical schools and instinctively look down upon other ways of healing, non-traditional healing.  They are making a division like the people who made a division between arts and crafts in order to denigrate what is labeled "crafts."  You cannot bring in this new system unless the providers of these alternative methods are full partners in developing the new programs.  Otherwise, vanity and self-interest on the part of medical doctors will win out.  That is my opinion.

Dona: I see what you're saying.  Ruth, in your report, you wrote about your senator, Richard Blumenthal, and how he tried to get answers.  This goes to what Wally and C.I. were talking about with regards to Chair Sanders attempting to get answers, I feel.

Ruth: I would agree with you.  Senator Sanders was dealing with the first panel, the government officials, and they did not appear prepared.  Senator Blumenthal encountered the same thing.  There was a lot of abstract talk and references to 'success' -- an undefined success but one the VA insisted was there.  The officials to the Committee that the number of service members -- active duty, we are not talking about veterans here -- who were receiving opiates had gone down significantly.  Mr. Blumenthal wanted to know something concrete and he asked for numbers.  The number 26% was given.  That was the number, in 2011, for active duty service members who were prescribed opiates.

Dona: And, as I know from your report, that's 26% of all active duty, not 26% of active duty injured.

Ruth: Correct.  So Senator Blumenthal wanted to know what was the decrease that the panel kept stressing?  And he was told at first that there was not a number and then BG Coots announced, shuffling through papers, that the 26% had dropped to 24%.

Dona: 2%?

Ruth: Correct. 2% was presented as this huge drop.  And while clearly 2% is a small number, so insignificant that it really does not warrant mentioning, there's also the fact that, at the end of 2011, most US troops left Iraq.  I was talking to C.I. about this, so let me toss to her.

C.I.:  Ruth's point is that the 2% is not worth mentioning also because there is most likely an increase somewhere in the system and this should have been asked about in the hearing.  These numbers are not about veterans.  So DoD should have been present to answer.  But the 2% is ridiculous.  With the bulk of US troops leaving Iraq -- a defined combat field by DoD which still, this year, gets combat pay for all US military personnel stationed there -- with the bulk leaving in 2011, by 2013 there should have been a huge reduction in the number of active duty being prescribed opiates.  Yes, people will always have injuries on bases -- your typical every day injuries. But by shutting down a battlefield, there should have been a much larger drop.

Dona: Okay, I get it.  You're saying these are active duty numbers so removing a combat zone at the end of 2011 should have resulted in a greater percentage drop within three years.  Yeah, good points, I agree.  The hearing was forced to address the latest VA scandal, this one in Arizona.  At the Phoenix Medical Center, there are allegations that the VA has maintained two lists -- the official list which makes it appear everyone gets timely treatment and an unofficial list.  The unofficial list allegedly tracks the long delays that vets are facing for medical appointments.  It is said that 40 veterans have died as a result of these delays.  Sanders, Blumenthal, Burr and Senator Mark Begich all noted this was an important issue and that answers were needed.  I'm going to insert this from C.I.'s  April 9th snapshot where she's reporting on that day's House Veterans Affairs Committee hearing:

US House Rep Jeff Miller:  I had hoped that during this hearing, we would be discussing the concrete changes VA had made -- changes that would show beyond a doubt that VA had placed the care our veterans receive first and that VA's commitment to holding any employee who did not completely embody a commitment to excellence through actions appropriate to the employee's failure accountable. Instead, today we are faced with even with more questions and ever mounting evidence that despite the myriad of patient safety incidents that have occurred at VA medical facilities in recent memory, the status quo is still firmly entrenched at VA.  On Monday -- shortly before this public hearing --  VA provided evidence that a total of twenty-three veterans have died due to delays in care at VA medical facilities.  Even with this latest disclosure as to where the deaths occurred, our Committee still don't know when they may have happened beyond VA's stated "most likely between 2010 and 2012."  These particular deaths resulted primarily from delays in gastrointestinal care.  Information on other preventable deaths due to consult delays remains unavailable.   Outside of the VA's consult review, this committee has reviewed at least eighteen preventable deaths that occurred because of mismanagement, improper infection control practices and a whole host -- a whole host --  of other maladies plaguing the VA health care system nationwide.  Yet, the department's stonewall has only grown higher and non-responsive. There is no excuse for these incidents to have ever occurred.  Congress has met every resource request that VA has made and I guarantee that if the department would have approached this committee at any time to tell us that help was needed to ensure that veterans received the care they required, every possible action would have been taken to ensure that VA could adequately care for our veterans.  This is the third full committee hearing that I have held on patient safety  and I am going to save our VA witnesses a little bit of time this morning by telling them what I don't want to hear.  I don't want to hear the rote repetition of  -- and I quote --  "the department is committed to providing the highest quality care, which our veterans have earned and that they deserve.  When incidents occur, we identify, mitigate, and prevent additional risks.  Prompt reviews prevent similar events in the future and hold those persons accountable."  Another thing I don’t want to hear is -- and, again, I quote from numerous VA statements, including a recent press statement --  "while any adverse incident for a veteran within our care is one too many," preventable deaths represent a small fraction of the veterans who seek care from VA every year.  What our veterans have truly "earned and deserve" is not more platitudes and, yes, one adverse incident is indeed one too many.  Look, we all recognize that no medical system is infallible no matter how high the quality standards might be.  But I think we all also recognize that the VA health care system is unique because it has a unique, special obligation not only to its patients -- the men and women who honorably serve our nation in uniform -- but also to  the hard-working taxpayers of the United States of America.

Dona (Con't): Jeff Miller is a Republican.  He is the Chair of the House Veterans Affairs Committee.  So not only is this scandal a bipartisan concern, it's also a House and Senate concern.   Wally, what was Begich's question?

Wally: Senator Mark Begich asked the VA's chief witness at the hearing, Dr. Robert Petzel, exactly what figures the VA leadership in DC was receiving from the Phoenix VA?  And he couldn't get an answer.  Petzel danced and stone walled and ate up time.

Dona: Ava, any closing thoughts as we wrap up?

Ava: Sure.  I think C.I. had a really great point on Thursday that became more significant on Friday.  In her Thursday report, she noted all the spin Petzel gave and how he kept putting his imprint on this issue and how it really wasn't an issue and blah, blah, blah.  In her Thursday report, C.I. pointed out that when there's an ongoing investigation into an issue -- and there is an ongoing investigation -- members of the department are not supposed to be commenting.  The standard reply goes like this, "I'm sorry. I'm unable to answer that question because there's an ongoing investigation."  And they supposedly don't want to try to influence the investigation.  But there was Petzel testifying to it non-stop, in ways that always made him look good and innocent and capable of his job, etc.  On Friday, CNN was among the new outlets noting that VA Secretary Eric Shinseki had issued a statement.

Dona: Right. Hold on a second Ava and let me read that into this from  Scott Bronstein, Drew Griffin and Neili Black (CNN) report on Friday:

He's the leader of the Department of Veterans Affairs, which runs the VA hospitals where dozens of U.S. veterans died waiting for simple medical screenings.

Yet in the six months that CNN has been reporting on these delays, Eric Shinseki has been silent. And he hasn't spoken out on the matter to any other news organization, either.
Early Friday evening -- after this story appeared on -- the VA gave a response, via spokesman Drew Brookie. He explained that the VA's inspector general's office (referred to as OIG), which is probing the matter, "advised VA against providing information that could potentially compromise their ongoing investigation at the Phoenix VA Health Care system."

Ava: As C.I. was pointing out Thursday, that is the policy and Petzel was in violation of it.  And C.I. reported on that before Shinseki's Friday statement and I believe she's still the only one who has reported on it.

Dona: Okay.  This is a regular feature we do here and will continue to do here.  This is also a rush transcript.  Our e-mail address is

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