Cynthia M.A. Geppert, MD

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

If the hospital or clinic where you work is anything like my medical center, the looming deadline of October 1 is anything but a contemplative occasion. There are encounters to close, budgets to prepare, a flurry of e-mails—either pleading or threatening—to complete consults, mandatory training to finish, and on and on with protean tasks in the parlance of bureaucracy. For many it is the nadir of the mundane, mindless drudgery we slog through all year in pursuit of those transcendent moments when we feel morally certain we have made things better for a real human being.

What is the origin and rationale for the federal New Year beginning on October 1? In 1974, Congress passed the Congressional Budget and Impoundment Act. The act shifted the beginning of the fiscal year—for our purposes the date of the federal New Year—from the first of July to October 1. Shifting the end of the fiscal year 3 months later enabled Congress to have additional time to study and prepare to receive the annual budget from the executive office and productively engage in the subsequent negotiations regarding federal spending priorities.¹

For all of us who practice in a federal health care system, our New Year is fast approaching and will indeed be past when most of you read this editorial. While January 1 may be the date for parades and football for the rest of the country, the federal government is not alone in selecting a different day on which to begin the New Year. In fact, were we to look at most of the world, we would find a variety of dates chosen for reasons both symbolic and functional to be the end of an annum. Let’s look at a few of them to see whether we can glean any hints about how we might sublimate what often seem to be meaningless demands into something more personal and profound.

Currently, we are in the last quarter of the Chinese New Year of the earth dog, which began on February 16^, using a lunar calendar. In the modern era China has adopted January 1 as the official New Year, but the traditional Chinese festival remains among the most popular holidays in China—and for good reason. Historically, the New Year in China was a period of turning away from work to focus on the honoring of family both living and dead, those in heaven and on earth joining in one timeless community. The family home was often thoroughly cleaned to purge any residual bad luck from the prior cycle and to welcome the good fortune sought for the coming year.²

Several weeks before the writing of this column, the Jewish people celebrated Rosh Hashanah (literally, “head of the year” in Hebrew), one of the holiest days of the Jewish liturgical calendar. It is a commemoration of both creation and judgment. Rosh Hashanah ushers in a period of introspection and repentance, of taking responsibility for past actions, and of committing to do better in the future.

There are some common themes in all these celebrations, religious or secular, and among the most prominent is preparation. Too often, preparing in federal service is a word associated with resentment and apprehension. The US Department of Veterans Affairs prepares for the next investigation, the US Public Health Service for the next inspection, and the military, sadly, for the next war. Our thoughts are perforce focused on funding and finances: Will the president and Congress agree on a timely and sufficient allocation of resources for all of us to do our work well and without excessive worry and wear?

With the exception of the most powerful among us, these negotiations are far beyond our ken or dominion, and the new fiscal year becomes yet another imposed burden. I suggest that we all take back some of that power and purpose, not literally but psychologically. No, I am not advocating either sedition or a new Hallmark holiday with “Happy Federal New Year” cards and parties. Instead I am inviting all of us to consider how we can reset as we do with our computers.

Management experts tell us that cleaning our desk can have positive mental and even physical health benefits. I am not there, but I am willing to try to be more organized if you are. Combat veteran and psychologist Dr. Brett Moore offers “tips to police your workspace” as a means to fight against stress.³ Organizing your desk is a way to unclutter your mind so it can regain the attitudinal agility that is key to resilience.

Another New Year’s theme is remembering as a way of consolidating lessons learned and rededicating yourself to continue personal and professional growth in the months ahead. Invent your own rituals to commemorate another year of working for federal health care, even if that custom is to mark your calendar another year closer to retirement! Fall is beautiful in many parts of the country: Go outside for a few minutes a couple of times a week. Find somewhere quiet to sit and look around at the leaves turning and reflect. Reflection is literally, “return of light or sound from a surface.” It does not have to be formal meditation but simply mindfully looking back on the year to see what fruitful images and ideas return to you.

Reflection and preparation prime us for the third theme, which is a rekindling of motivation to be better and the commitment to do things differently, however that is expressed in the unique struggles and rewards of each individual’s career. New Year’s resolutions have become a trite cliché for stores to advertise exercise clothing and the Internet to feature fad diets. The ancient history of resolutions reveals their more spiritual nature as a celebration of the renewal of life.⁴

Virtue ethics tells us to look to walk in the steps of those we admire to know how to stay on the higher moral road: Who in your unit or clinic or office inspires you to aspire? There are a multitude of opportunities to recreate your work personae to be more like those you would emulate, the colleagues who are often able to solve the “impossible” problem, to stand up to the bully, and to find the ethical values in even the most ridiculous or demoralizing rule. Songwriter and performer Bob Dylan was right when he wrote, “You’re gonna have to serve somebody, yes indeed.”⁵ But no matter how oppressive we experience that mastery, we must hold tight and recognize that these forces are external.

No one can stop us from the small acts of compassion toward ourselves and one another that keep us free. Pick up the phone or walk over to see someone you know or used to work with and ask how they are doing. Volunteer for a new committee or service project to feel as though your work is more than your job. Repair a torn relationship or mend a departmental fence so you leave work with less emotional baggage than you carried in with you that morning. The next time you want to say something sarcastic or critical, challenge yourself to be silent instead or say something kind or affirming. As a priest I knew once told me, when someone cuts in front of you on the road, instead of raging “bless them before you start cursing.”

After you read this column, take a few minutes to ask yourself how you can cast off the shadows that gather around us from the media and government and find a new way of letting sunlight into your work life. Happy Fiscal Year 2019 from the Editor-in-Chief.

Adherents of the Abrahamic faiths or students of the Bible as literature will easily recall the circumstances of this famous quotation from the Hebrew Scriptures. Cain has killed his brother Abel, earning the disrepute of committing the first murder in biblical history. Scholars of ethics have answered Cain’s sardonic question in the affirmative: avowing that while the individual is primarily responsible for his conduct and its consequences, the community also bears a responsibility.¹

Many of you will have seen news clips of yet another Department of Veteran Affairs (VA) scandal: This one involving an impaired pathologist. I have purposely not used the pathologist’s name to emphasize that our shared obligation to protect patients from impaired members of the profession goes far beyond this single outrage. Although we might believe we could never be that individual; none of us are immune from depression, dementia, or physical disabilities that diminish our ability to care for patients. Although it is worth noting that having read or watched everything I could find on the story, the “facts” are few and far between, which I will argue later only underscores the problems with professional accountability especially in a large bureaucratic organization.

This column is not meant to impugn or exculpate anyone but to encourage us to reflect on our ethical awareness and response to hints that there might be an impaired practitioner among us. The Fayetteville VA Medical Center (VAMC) in North Carolina—ground zero for this incident—held several town halls in which anxious and angry veterans demanded an explanation for how an impaired pathologist could have placed in harm’s way nearly 19,000 patients.² Of this cohort, 5,250 patients have died since 2005. The VA leadership, including the VISN 16 network director and the interim medical director of the Fayetteville VAMC indicated that out of 911 pathology reports that had undergone expert peer review, an incorrect diagnosis was identified in at least 7 with 1 possible associated death.³

The VA officials estimate that the entire review may involve more than 30,000 cases. The allegations are that the pathologist was impaired due to a substance use disorder, in this case alcohol. In interviews, the physician has admitted the alcohol problem and receiving treatment for it but denied he was ever impaired on duty.⁴ This denial directly contradicts the VA reports that he was intoxicated on duty at least twice.

We do know that the physician in question was enrolled in the Mississippi Physician Health Program (PHP). The Federation of State Physician Health Programs (FSPHP), of which the Mississippi program is a member, provides confidential initial evaluation, ongoing treatment, and monitoring for state licensed health care practitioners with a substance use or other mental health disorder or other condition that could potentially impair their fitness for duty. The PHPs have been career saving for many physicians and other health care professionals. The incentives to return to the practice of medicine are powerful, leading to a higher recovery rate than that of the general population.⁵

According to FSPHP, “While both PHPs and state licensing boards are engaged in patient safety efforts, PHPs primary focus is on improving the health of the physician, and the licensing board’s primary duty is to protect the public.”⁶ This potential conflict of interest has been criticized recently.⁷ News reports suggest that the ambiguity of this relationship between PHP and licensing board may have left a “who’s minding the store” mentality. But here are the facts of this particular case.

In March 2016, an employee reported that the pathologist was intoxicated on duty, and he was immediately removed from service. Of the many elephants in the room, the biggest moral pachyderm is why, given the chronic and progressive nature of substance use disorders did it take 11 years for a formal report leading to action?

Having been in circles of leadership, I know well that often there is much discussed that cannot be disclosed, which frequently contributes to staff demoralization. Dozens of medical center employees over decades must have seen behaviors; some of those employees likely reported their observations. The news reports are silent on this point except for attributing it to “fear of retaliation.” In our current VA climate this is a major intimidator of staff trying to tell the truth and leaders seeking to do what is right. Yet research has identified myriad other motives for not reporting impaired colleagues, including loyalty, collusion, denial, indifference, scarcity of resources, and overwork.⁸

In October 2017, the pathologist was again found intoxicated on the job, attributing it to a migraine headache. The hospital investigated, but the pathologist may have continued working in some capacity. Finally, after the pathologist was arrested for driving while intoxicated March 1 of this year, the interim VAMC director contacted the Mississippi licensing board, declaring that the pathologist “had failed to meet standards of practice” and indicted that he “constituted an imminent threat to patient welfare.” The Arkansas Medical Foundation then rescinded its support of the pathologist, citing the pathologist’s failure to adhere to monitoring and reporting requirements. The Mississippi program followed suit on June 20, and the medical board rescinded his license.

All employees at whatever level are owed due process and respect for their rights, but Congress recently saw fit to legislate further limits on federal employee protections. Most health care administrators still standing in the chaos of today’s VA would tell you that survival is all about when did you know and what did you do about it? But it is not just administrators, the code of ethics of almost every health care profession includes an obligation to report impaired practitioners. Principle II of the American Medical Association Code of Ethics states, “A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.”⁹

If one is in private practice in a small town, it is easier to pull your friend aside on the golf course and say you seem to be having a problem, counsel your friend to get help, often through a PHP. Then if the gentler approach fails, take the harder action of reporting to the medical board or other authority. To report takes moral courage. It takes seeing that the practitioner is not betraying the “white line” of health care professions but honoring the highest commitment of professionalism to the patient.

The last thing we need in our current suspicious and fearful environment is to turn VAMCs and clinics into a dystopia.Yet reporting in a large organization with rules and red tape can seem terrifying, overwhelming, and confusing. A fair, safe, transparent, clear, and consistent means for staff to discharge their ethical obligations is sorely needed. Or else we will be reading about another tragic scandal and asking each other, “How could this have happened?”

Adherents of the Abrahamic faiths or students of the Bible as literature will easily recall the circumstances of this famous quotation from the Hebrew Scriptures. Cain has killed his brother Abel, earning the disrepute of committing the first murder in biblical history. Scholars of ethics have answered Cain’s sardonic question in the affirmative: avowing that while the individual is primarily responsible for his conduct and its consequences, the community also bears a responsibility.¹

Many of you will have seen news clips of yet another Department of Veteran Affairs (VA) scandal: This one involving an impaired pathologist. I have purposely not used the pathologist’s name to emphasize that our shared obligation to protect patients from impaired members of the profession goes far beyond this single outrage. Although we might believe we could never be that individual; none of us are immune from depression, dementia, or physical disabilities that diminish our ability to care for patients. Although it is worth noting that having read or watched everything I could find on the story, the “facts” are few and far between, which I will argue later only underscores the problems with professional accountability especially in a large bureaucratic organization.

This column is not meant to impugn or exculpate anyone but to encourage us to reflect on our ethical awareness and response to hints that there might be an impaired practitioner among us. The Fayetteville VA Medical Center (VAMC) in North Carolina—ground zero for this incident—held several town halls in which anxious and angry veterans demanded an explanation for how an impaired pathologist could have placed in harm’s way nearly 19,000 patients.² Of this cohort, 5,250 patients have died since 2005. The VA leadership, including the VISN 16 network director and the interim medical director of the Fayetteville VAMC indicated that out of 911 pathology reports that had undergone expert peer review, an incorrect diagnosis was identified in at least 7 with 1 possible associated death.³

The VA officials estimate that the entire review may involve more than 30,000 cases. The allegations are that the pathologist was impaired due to a substance use disorder, in this case alcohol. In interviews, the physician has admitted the alcohol problem and receiving treatment for it but denied he was ever impaired on duty.⁴ This denial directly contradicts the VA reports that he was intoxicated on duty at least twice.

We do know that the physician in question was enrolled in the Mississippi Physician Health Program (PHP). The Federation of State Physician Health Programs (FSPHP), of which the Mississippi program is a member, provides confidential initial evaluation, ongoing treatment, and monitoring for state licensed health care practitioners with a substance use or other mental health disorder or other condition that could potentially impair their fitness for duty. The PHPs have been career saving for many physicians and other health care professionals. The incentives to return to the practice of medicine are powerful, leading to a higher recovery rate than that of the general population.⁵

According to FSPHP, “While both PHPs and state licensing boards are engaged in patient safety efforts, PHPs primary focus is on improving the health of the physician, and the licensing board’s primary duty is to protect the public.”⁶ This potential conflict of interest has been criticized recently.⁷ News reports suggest that the ambiguity of this relationship between PHP and licensing board may have left a “who’s minding the store” mentality. But here are the facts of this particular case.

In March 2016, an employee reported that the pathologist was intoxicated on duty, and he was immediately removed from service. Of the many elephants in the room, the biggest moral pachyderm is why, given the chronic and progressive nature of substance use disorders did it take 11 years for a formal report leading to action?

Having been in circles of leadership, I know well that often there is much discussed that cannot be disclosed, which frequently contributes to staff demoralization. Dozens of medical center employees over decades must have seen behaviors; some of those employees likely reported their observations. The news reports are silent on this point except for attributing it to “fear of retaliation.” In our current VA climate this is a major intimidator of staff trying to tell the truth and leaders seeking to do what is right. Yet research has identified myriad other motives for not reporting impaired colleagues, including loyalty, collusion, denial, indifference, scarcity of resources, and overwork.⁸

In October 2017, the pathologist was again found intoxicated on the job, attributing it to a migraine headache. The hospital investigated, but the pathologist may have continued working in some capacity. Finally, after the pathologist was arrested for driving while intoxicated March 1 of this year, the interim VAMC director contacted the Mississippi licensing board, declaring that the pathologist “had failed to meet standards of practice” and indicted that he “constituted an imminent threat to patient welfare.” The Arkansas Medical Foundation then rescinded its support of the pathologist, citing the pathologist’s failure to adhere to monitoring and reporting requirements. The Mississippi program followed suit on June 20, and the medical board rescinded his license.

All employees at whatever level are owed due process and respect for their rights, but Congress recently saw fit to legislate further limits on federal employee protections. Most health care administrators still standing in the chaos of today’s VA would tell you that survival is all about when did you know and what did you do about it? But it is not just administrators, the code of ethics of almost every health care profession includes an obligation to report impaired practitioners. Principle II of the American Medical Association Code of Ethics states, “A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.”⁹

If one is in private practice in a small town, it is easier to pull your friend aside on the golf course and say you seem to be having a problem, counsel your friend to get help, often through a PHP. Then if the gentler approach fails, take the harder action of reporting to the medical board or other authority. To report takes moral courage. It takes seeing that the practitioner is not betraying the “white line” of health care professions but honoring the highest commitment of professionalism to the patient.

The last thing we need in our current suspicious and fearful environment is to turn VAMCs and clinics into a dystopia.Yet reporting in a large organization with rules and red tape can seem terrifying, overwhelming, and confusing. A fair, safe, transparent, clear, and consistent means for staff to discharge their ethical obligations is sorely needed. Or else we will be reading about another tragic scandal and asking each other, “How could this have happened?”

Adherents of the Abrahamic faiths or students of the Bible as literature will easily recall the circumstances of this famous quotation from the Hebrew Scriptures. Cain has killed his brother Abel, earning the disrepute of committing the first murder in biblical history. Scholars of ethics have answered Cain’s sardonic question in the affirmative: avowing that while the individual is primarily responsible for his conduct and its consequences, the community also bears a responsibility.¹

Many of you will have seen news clips of yet another Department of Veteran Affairs (VA) scandal: This one involving an impaired pathologist. I have purposely not used the pathologist’s name to emphasize that our shared obligation to protect patients from impaired members of the profession goes far beyond this single outrage. Although we might believe we could never be that individual; none of us are immune from depression, dementia, or physical disabilities that diminish our ability to care for patients. Although it is worth noting that having read or watched everything I could find on the story, the “facts” are few and far between, which I will argue later only underscores the problems with professional accountability especially in a large bureaucratic organization.

This column is not meant to impugn or exculpate anyone but to encourage us to reflect on our ethical awareness and response to hints that there might be an impaired practitioner among us. The Fayetteville VA Medical Center (VAMC) in North Carolina—ground zero for this incident—held several town halls in which anxious and angry veterans demanded an explanation for how an impaired pathologist could have placed in harm’s way nearly 19,000 patients.² Of this cohort, 5,250 patients have died since 2005. The VA leadership, including the VISN 16 network director and the interim medical director of the Fayetteville VAMC indicated that out of 911 pathology reports that had undergone expert peer review, an incorrect diagnosis was identified in at least 7 with 1 possible associated death.³

The VA officials estimate that the entire review may involve more than 30,000 cases. The allegations are that the pathologist was impaired due to a substance use disorder, in this case alcohol. In interviews, the physician has admitted the alcohol problem and receiving treatment for it but denied he was ever impaired on duty.⁴ This denial directly contradicts the VA reports that he was intoxicated on duty at least twice.

We do know that the physician in question was enrolled in the Mississippi Physician Health Program (PHP). The Federation of State Physician Health Programs (FSPHP), of which the Mississippi program is a member, provides confidential initial evaluation, ongoing treatment, and monitoring for state licensed health care practitioners with a substance use or other mental health disorder or other condition that could potentially impair their fitness for duty. The PHPs have been career saving for many physicians and other health care professionals. The incentives to return to the practice of medicine are powerful, leading to a higher recovery rate than that of the general population.⁵

According to FSPHP, “While both PHPs and state licensing boards are engaged in patient safety efforts, PHPs primary focus is on improving the health of the physician, and the licensing board’s primary duty is to protect the public.”⁶ This potential conflict of interest has been criticized recently.⁷ News reports suggest that the ambiguity of this relationship between PHP and licensing board may have left a “who’s minding the store” mentality. But here are the facts of this particular case.

In March 2016, an employee reported that the pathologist was intoxicated on duty, and he was immediately removed from service. Of the many elephants in the room, the biggest moral pachyderm is why, given the chronic and progressive nature of substance use disorders did it take 11 years for a formal report leading to action?

Having been in circles of leadership, I know well that often there is much discussed that cannot be disclosed, which frequently contributes to staff demoralization. Dozens of medical center employees over decades must have seen behaviors; some of those employees likely reported their observations. The news reports are silent on this point except for attributing it to “fear of retaliation.” In our current VA climate this is a major intimidator of staff trying to tell the truth and leaders seeking to do what is right. Yet research has identified myriad other motives for not reporting impaired colleagues, including loyalty, collusion, denial, indifference, scarcity of resources, and overwork.⁸

In October 2017, the pathologist was again found intoxicated on the job, attributing it to a migraine headache. The hospital investigated, but the pathologist may have continued working in some capacity. Finally, after the pathologist was arrested for driving while intoxicated March 1 of this year, the interim VAMC director contacted the Mississippi licensing board, declaring that the pathologist “had failed to meet standards of practice” and indicted that he “constituted an imminent threat to patient welfare.” The Arkansas Medical Foundation then rescinded its support of the pathologist, citing the pathologist’s failure to adhere to monitoring and reporting requirements. The Mississippi program followed suit on June 20, and the medical board rescinded his license.

All employees at whatever level are owed due process and respect for their rights, but Congress recently saw fit to legislate further limits on federal employee protections. Most health care administrators still standing in the chaos of today’s VA would tell you that survival is all about when did you know and what did you do about it? But it is not just administrators, the code of ethics of almost every health care profession includes an obligation to report impaired practitioners. Principle II of the American Medical Association Code of Ethics states, “A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.”⁹

If one is in private practice in a small town, it is easier to pull your friend aside on the golf course and say you seem to be having a problem, counsel your friend to get help, often through a PHP. Then if the gentler approach fails, take the harder action of reporting to the medical board or other authority. To report takes moral courage. It takes seeing that the practitioner is not betraying the “white line” of health care professions but honoring the highest commitment of professionalism to the patient.

The last thing we need in our current suspicious and fearful environment is to turn VAMCs and clinics into a dystopia.Yet reporting in a large organization with rules and red tape can seem terrifying, overwhelming, and confusing. A fair, safe, transparent, clear, and consistent means for staff to discharge their ethical obligations is sorely needed. Or else we will be reading about another tragic scandal and asking each other, “How could this have happened?”

I write this editorial at the end of June as summer officially begins. Much of the country—my New Mexico home included—is suffering under an unbearable heat wave in which even those without belief pray for rain. Summer for many is associated with vacations, family trips, and happy hours in the swimming pool among other enjoyable activities that provide a welcome and much deserved break from routine and relief from the grind of work and school. In the words of the George Gershwin tune, “Summertime, and the livin’ is easy.”

In stark contrast to this season, where there is more lightness in being, is the heaviness of the news reports about the Department of Veteran Affairs (VA) that have been featured in the media and the federal press. I suspect I am not alone in having a hard time opening those e-mails; feeling once more the weight of failure on the VA and the employees who have dedicated a good part of their careers to its mission. Even for the VA, June has seen an exceptional string of bad press. I ask as you read this column to think about what the adjective bad means in this context. In the conclusion to this column, I will suggest that the meaning is multivalent.

Among the most distressing stories was the USA Today and Boston Globe headline, “Secret VA nursing home ratings hide poor quality of care from the public.”² In an all too predictable sequence, this led justifiably to a cascade of demands from the fifth estate, congressional representatives, the administration, veterans and their families, and watchdog organizations for release of the data, investigation of the allegedly deplorable conditions, and rapid fixes to the problems along with the punishment of the guilty.

As an ethicist I am committed to the principles of transparency and accountability that these entities rightly adjure in the wake of any disclosure of a breach of duty to treat each veteran with the best we have—especially the disabled, elderly, and vulnerable. But I have come to believe that the way in which this cycle of scandal and reaction plays out over and over again in VA facilities across the country, what I call “caring under the microscope,” is actually undermining the righteous goals it seeks to achieve.

I encourage you to try this online. Search for the phrase, “VA under microscope” and see what you get. Briefly read the summary, or the entire story if you have the inclination, and then take a few minutes to reflect on the emotional impact of what you read. Under a microscope is an idiom coined to capture the experience of being the object of close inspection and intense scrutiny. As most everyone knows from their own science education, microscopes magnify images that cannot normally be seen with the human eye, allowing us to observe a more detailed and focused image. The microscope surely helped revolutionize medicine and science. But what effect does such amplified and constant observation have on VA employees?³

For the thousands of staff members who do their job every day with all the empathy and skill, integrity, and dedication they can muster, there is demoralization. Researchers in the health professions describe it as “a feeling state of dejection, hopelessness, and a sense of personal ‘incompetence’ that may be tied to a loss of or threat to one’s own goals or values. It has an existential dimension when beliefs and values about oneself are disconfirmed.”⁴ If you are a nurse assigned to one of VA’s nursing homes, daily striving to ensure patients are clean and comfortable, or a therapist in a continuing living center using all your training to maximize an elder’s mobility and participation in activities, you might well begin to doubt your ability as a professional and question the worth of your work. This is exactly the opposite outcome that the microscopic oversight is intended to attain.

The impact of demoralization on health professionals directly contributes to unprecedented burnout and turnover. Were this not damaging enough, it also has an insidious rippling effect—like contaminated groundwater that poisons where it should be reviving. The humanistic, even spiritual, heart of all the health professions is the relationship between the practitioner and the patient, ideally a relationship of mutual respect and trust. Waves of negative news triggering harsh and unyielding criticism distort even the strongest, purest therapeutic alliances with fear and distrust, just as a microscope not properly focused changes a beautiful image into a blurred muddle.

Worried families of veterans staring at this picture invariably are drawn into the hyper media focus, feeling alarmed and betrayed, even when their loved one may be receiving excellent VA care. In 20 years as a physician and ethicist in VA hospitals, clinics, and community living centers, I know well that bad things happen to good people (both patients and staff). Yet VA patients, families, and staff are seldom offered the wider corrective vision that would note that bad things also happen in other health care institutions and good care is delivered in the VA. Acting Secretary of Veterans Affairs Peter O’Rourke crisply summarized in his response to the nursing home story.⁵

No veteran or any other human being in a VA or any other nursing home should ever be medicated into a zombie state or left alone in pain like those patients reported in the news story. And if the USA Today story improves the care of a single VA patient, then good has been done at least in the short run. Yet we must also take the long view and consider the moral and psychological outcome of prolonged demoralization on the very staff who must carry out the congressional mandates.

In the same time frame as the nursing home scandal, the VA Office of Inspector General also issued a report on the continued understaffing in the VA.⁶ This may be the most concerning aftermath of demoralization. One of my best residents had thought about the VA but in the end made a different choice when he completed his training. When I asked him why he told me, “I am afraid to end up in the newspaper.”

Summer will go by far too quickly. Enjoy it while you can so that with renewed strength we may all search for a better way that the light of truth and heat of power can do what they must while also not withering the spirit of caring that animates the people of the VA.

I write this editorial at the end of June as summer officially begins. Much of the country—my New Mexico home included—is suffering under an unbearable heat wave in which even those without belief pray for rain. Summer for many is associated with vacations, family trips, and happy hours in the swimming pool among other enjoyable activities that provide a welcome and much deserved break from routine and relief from the grind of work and school. In the words of the George Gershwin tune, “Summertime, and the livin’ is easy.”

In stark contrast to this season, where there is more lightness in being, is the heaviness of the news reports about the Department of Veteran Affairs (VA) that have been featured in the media and the federal press. I suspect I am not alone in having a hard time opening those e-mails; feeling once more the weight of failure on the VA and the employees who have dedicated a good part of their careers to its mission. Even for the VA, June has seen an exceptional string of bad press. I ask as you read this column to think about what the adjective bad means in this context. In the conclusion to this column, I will suggest that the meaning is multivalent.

Among the most distressing stories was the USA Today and Boston Globe headline, “Secret VA nursing home ratings hide poor quality of care from the public.”² In an all too predictable sequence, this led justifiably to a cascade of demands from the fifth estate, congressional representatives, the administration, veterans and their families, and watchdog organizations for release of the data, investigation of the allegedly deplorable conditions, and rapid fixes to the problems along with the punishment of the guilty.

As an ethicist I am committed to the principles of transparency and accountability that these entities rightly adjure in the wake of any disclosure of a breach of duty to treat each veteran with the best we have—especially the disabled, elderly, and vulnerable. But I have come to believe that the way in which this cycle of scandal and reaction plays out over and over again in VA facilities across the country, what I call “caring under the microscope,” is actually undermining the righteous goals it seeks to achieve.

I encourage you to try this online. Search for the phrase, “VA under microscope” and see what you get. Briefly read the summary, or the entire story if you have the inclination, and then take a few minutes to reflect on the emotional impact of what you read. Under a microscope is an idiom coined to capture the experience of being the object of close inspection and intense scrutiny. As most everyone knows from their own science education, microscopes magnify images that cannot normally be seen with the human eye, allowing us to observe a more detailed and focused image. The microscope surely helped revolutionize medicine and science. But what effect does such amplified and constant observation have on VA employees?³

For the thousands of staff members who do their job every day with all the empathy and skill, integrity, and dedication they can muster, there is demoralization. Researchers in the health professions describe it as “a feeling state of dejection, hopelessness, and a sense of personal ‘incompetence’ that may be tied to a loss of or threat to one’s own goals or values. It has an existential dimension when beliefs and values about oneself are disconfirmed.”⁴ If you are a nurse assigned to one of VA’s nursing homes, daily striving to ensure patients are clean and comfortable, or a therapist in a continuing living center using all your training to maximize an elder’s mobility and participation in activities, you might well begin to doubt your ability as a professional and question the worth of your work. This is exactly the opposite outcome that the microscopic oversight is intended to attain.

The impact of demoralization on health professionals directly contributes to unprecedented burnout and turnover. Were this not damaging enough, it also has an insidious rippling effect—like contaminated groundwater that poisons where it should be reviving. The humanistic, even spiritual, heart of all the health professions is the relationship between the practitioner and the patient, ideally a relationship of mutual respect and trust. Waves of negative news triggering harsh and unyielding criticism distort even the strongest, purest therapeutic alliances with fear and distrust, just as a microscope not properly focused changes a beautiful image into a blurred muddle.

Worried families of veterans staring at this picture invariably are drawn into the hyper media focus, feeling alarmed and betrayed, even when their loved one may be receiving excellent VA care. In 20 years as a physician and ethicist in VA hospitals, clinics, and community living centers, I know well that bad things happen to good people (both patients and staff). Yet VA patients, families, and staff are seldom offered the wider corrective vision that would note that bad things also happen in other health care institutions and good care is delivered in the VA. Acting Secretary of Veterans Affairs Peter O’Rourke crisply summarized in his response to the nursing home story.⁵

No veteran or any other human being in a VA or any other nursing home should ever be medicated into a zombie state or left alone in pain like those patients reported in the news story. And if the USA Today story improves the care of a single VA patient, then good has been done at least in the short run. Yet we must also take the long view and consider the moral and psychological outcome of prolonged demoralization on the very staff who must carry out the congressional mandates.

In the same time frame as the nursing home scandal, the VA Office of Inspector General also issued a report on the continued understaffing in the VA.⁶ This may be the most concerning aftermath of demoralization. One of my best residents had thought about the VA but in the end made a different choice when he completed his training. When I asked him why he told me, “I am afraid to end up in the newspaper.”

Summer will go by far too quickly. Enjoy it while you can so that with renewed strength we may all search for a better way that the light of truth and heat of power can do what they must while also not withering the spirit of caring that animates the people of the VA.

I write this editorial at the end of June as summer officially begins. Much of the country—my New Mexico home included—is suffering under an unbearable heat wave in which even those without belief pray for rain. Summer for many is associated with vacations, family trips, and happy hours in the swimming pool among other enjoyable activities that provide a welcome and much deserved break from routine and relief from the grind of work and school. In the words of the George Gershwin tune, “Summertime, and the livin’ is easy.”

In stark contrast to this season, where there is more lightness in being, is the heaviness of the news reports about the Department of Veteran Affairs (VA) that have been featured in the media and the federal press. I suspect I am not alone in having a hard time opening those e-mails; feeling once more the weight of failure on the VA and the employees who have dedicated a good part of their careers to its mission. Even for the VA, June has seen an exceptional string of bad press. I ask as you read this column to think about what the adjective bad means in this context. In the conclusion to this column, I will suggest that the meaning is multivalent.

Among the most distressing stories was the USA Today and Boston Globe headline, “Secret VA nursing home ratings hide poor quality of care from the public.”² In an all too predictable sequence, this led justifiably to a cascade of demands from the fifth estate, congressional representatives, the administration, veterans and their families, and watchdog organizations for release of the data, investigation of the allegedly deplorable conditions, and rapid fixes to the problems along with the punishment of the guilty.

As an ethicist I am committed to the principles of transparency and accountability that these entities rightly adjure in the wake of any disclosure of a breach of duty to treat each veteran with the best we have—especially the disabled, elderly, and vulnerable. But I have come to believe that the way in which this cycle of scandal and reaction plays out over and over again in VA facilities across the country, what I call “caring under the microscope,” is actually undermining the righteous goals it seeks to achieve.

I encourage you to try this online. Search for the phrase, “VA under microscope” and see what you get. Briefly read the summary, or the entire story if you have the inclination, and then take a few minutes to reflect on the emotional impact of what you read. Under a microscope is an idiom coined to capture the experience of being the object of close inspection and intense scrutiny. As most everyone knows from their own science education, microscopes magnify images that cannot normally be seen with the human eye, allowing us to observe a more detailed and focused image. The microscope surely helped revolutionize medicine and science. But what effect does such amplified and constant observation have on VA employees?³

For the thousands of staff members who do their job every day with all the empathy and skill, integrity, and dedication they can muster, there is demoralization. Researchers in the health professions describe it as “a feeling state of dejection, hopelessness, and a sense of personal ‘incompetence’ that may be tied to a loss of or threat to one’s own goals or values. It has an existential dimension when beliefs and values about oneself are disconfirmed.”⁴ If you are a nurse assigned to one of VA’s nursing homes, daily striving to ensure patients are clean and comfortable, or a therapist in a continuing living center using all your training to maximize an elder’s mobility and participation in activities, you might well begin to doubt your ability as a professional and question the worth of your work. This is exactly the opposite outcome that the microscopic oversight is intended to attain.

The impact of demoralization on health professionals directly contributes to unprecedented burnout and turnover. Were this not damaging enough, it also has an insidious rippling effect—like contaminated groundwater that poisons where it should be reviving. The humanistic, even spiritual, heart of all the health professions is the relationship between the practitioner and the patient, ideally a relationship of mutual respect and trust. Waves of negative news triggering harsh and unyielding criticism distort even the strongest, purest therapeutic alliances with fear and distrust, just as a microscope not properly focused changes a beautiful image into a blurred muddle.

Worried families of veterans staring at this picture invariably are drawn into the hyper media focus, feeling alarmed and betrayed, even when their loved one may be receiving excellent VA care. In 20 years as a physician and ethicist in VA hospitals, clinics, and community living centers, I know well that bad things happen to good people (both patients and staff). Yet VA patients, families, and staff are seldom offered the wider corrective vision that would note that bad things also happen in other health care institutions and good care is delivered in the VA. Acting Secretary of Veterans Affairs Peter O’Rourke crisply summarized in his response to the nursing home story.⁵

No veteran or any other human being in a VA or any other nursing home should ever be medicated into a zombie state or left alone in pain like those patients reported in the news story. And if the USA Today story improves the care of a single VA patient, then good has been done at least in the short run. Yet we must also take the long view and consider the moral and psychological outcome of prolonged demoralization on the very staff who must carry out the congressional mandates.

In the same time frame as the nursing home scandal, the VA Office of Inspector General also issued a report on the continued understaffing in the VA.⁶ This may be the most concerning aftermath of demoralization. One of my best residents had thought about the VA but in the end made a different choice when he completed his training. When I asked him why he told me, “I am afraid to end up in the newspaper.”

Summer will go by far too quickly. Enjoy it while you can so that with renewed strength we may all search for a better way that the light of truth and heat of power can do what they must while also not withering the spirit of caring that animates the people of the VA.

As usual, it was a hectic Monday on the psychiatry consult service. All the trainees, from medical student to fellow, were seeing other patients when the call came from the surgery clinic. One of the pleasures of being a VA clinician is the ability to teach and supervise medical students and residents. The attending in that busy clinic said, “There is a patient down here who is refusing care for a gangrenous leg, but he is also talking about his life not being worth living. Could someone evaluate him?” That patient, Mr. S, declined to go to either the emergency department or the urgent care psychiatry clinic, so I went to see him. I realized that I had seen this patient in the hospital several times before.

One of the great clinical benefits of working in the VA, as opposed to in academic or community hospitals, is continuity. In my nearly 20 years at the same medical center, I have had the privilege of following many patients through multiple courses of treatment. This continuity is a huge advantage when there is what Hippocrates called a “critical day,” as on that Monday in the surgery clinic.² Also, in many cases the continuity allows me to have a reservoir of trust that I can draw on for challenging consultations, like that of Mr. S.

The surgery resident and attending had spent more than an hour talking to Mr. S when I arrived but still they joined me for the conversation. Mr. S was a veteran in his sixties, and after a few minutes of listening to him, it was clear he was talking about ending his life because of its poor quality. He told us that he had acquired the infection in his leg secondary to unsanitary living conditions. The veteran was quite a storyteller, intelligent, and had a wry sense of humor, which only made his point that his living conditions were intolerable more poignant. He apparently had tried to talk to someone about his situation but felt frustrated that he had not obtained more help.

The surgery attending had already told Mr. S that he would respect his right to refuse the amputation but he feared that Mr. S’s refusal was an expression of his depression and hopelessness, hence, the psychiatry consult. Although Mr. S was not acutely suicidal, something about the combination of his despair and deliberation worried me.

The surgery attending offered to admit Mr. S to do a further workup of his leg. I encouraged him to accept this option and added that I would make sure a social worker saw him and the psychiatry service department also would follow him. Mr. S declined even a 24-hour admission, saying that he had just moved to a new apartment and “everything I have in the world is there and I don’t want to lose it.” This comment suggested to me that he was ambivalent about his wish to die and provided an opening to reduce his risk of harming himself either directly or indirectly.

After the discussion, Mr. S seemed to believe we cared about him and was more willing to participate in treatment planning. He agreed to let the surgeons draw blood and to pick up oral antibiotics from the pharmacy. I promised him that if he would come back to clinic that week, I would make sure a social worker met with him and that my team would talk with him more about his depression. Mr. S picked Friday for his return and assured me that now that he knew we were going to try and improve his situation, he would not hurt himself. Obviously, this was a risk on my part—but the show of compassion combined with flexibility had created a therapeutic alliance that I believed was sufficient to protect Mr. S until we met again.

I returned to my office and called the chief of social work: The dedication of career VA employees forges effective working relationships that can be leveraged for the benefit of the patients. At my facility and many others, many of the staff members who are now in positions of leadership rose through the ranks together, giving us a solidarity of purpose and mutual reliance that are rare in community health care settings. The chief of social work looked at the patient’s chart with me on the phone while I explained the circumstances and within a few minutes said, “We can help him. It looks like he is eligible for an increased pension, and I think we can find him better housing.”

I admit to some anxiety on Friday. One of the psychiatry residents on the service had volunteered to see Mr. S after studying his chart in the morning. Most of us are aware that the aging VA electronic health record system is due to be replaced. But having access to more than 20 years of medical history from episodes of inpatient, outpatient, and residential care all over the country is an unrivaled asset that brings a unique breadth that sharpens, deepens, and humanizes diagnosis and treatment planning.

Sure enough at 10 am, the surgery clinic called to tell us Mr. S had arrived on time. The resident headed to interview him while I contacted the chief of social work. She put out a call for help to her staff, and within 10 minutes an outpatient social worker was in the clinic talking with Mr. S. Compared with his initial visit, Mr. S’s mood was much brighter, and he no longer was endorsing any suicidal ideation or intent. He still did not want his leg amputated, feeling it would rob him of his independence, but he was now willing to consider other treatment options. Mr. S also said he wanted to speak with the palliative care team to know what they could offer.

The social worker arranged new housing for Mr. S that day and help to move into his new place. The paperwork was submitted for the pension increase, and help for shopping and meals as well as transportation was either put in place or applied for. As he left to pack, Mr. S told the surgeon he might not want hospice just yet.

The coda to this narrative is equally uplifting. Several weeks after Mr. S was seen in the surgery clinic, I received a call from a midlevel psychiatric practitioner in the urgent care clinic who had been on leave for several weeks. He too had seen Mr. S before and shared my concern about his state of mind and well-being. He thanked me for having the consult service see him and remarked that it was a relief to know Mr. S had been taken care of and was in a better place in every sense of the word.

In response to a rising media tide of concern about the direction VA care is headed, Congress and the VA have issued a strong statements, “debunking” what they called the “myth” of privatization.³ Yet for the first time in my career, many thoughtful people discern a constellation of forces that could eventuate in this reality in our lifetimes. The title and message of this column is that the VA cannot be privatized, not that it will not be privatized. Also, I did not say that it should not be privatized. As I have written in other columns, that is because ethically I do not believe this is even a question.⁴ Privatization breaks President Abraham Lincoln’s promise to veterans, “to care for him who has borne the battle.” A promise that was kept for Mr. S and is fulfilled for thousands of other veterans every day all over this nation. A promise that far exceeds payments for medical services.

I also do not mean the title to be a rejection of the Veterans Choice Program. The VA has always provided—and should continue to offer—community-based care for veterans that complements VA care. For example, I live in one of the most rural states in the union and recognize that a patient should not have to drive 300 miles to get a routine colonoscopy.

The VA cannot be privatized because of the comprehensive care that it provides: the degree of integration; the wealth of resources; and the level of expertise in caring for the complex medical, psychiatric, and psychosocial problems of veterans cannot be replicated. Nor is this just my opinion—a recent RAND Corporation study documents the evidence.⁵ There are many medical services in the private sector that may be delivered more efficiently, and Congress has just passed the Mission Act to allocate the funds needed to ensure our veterans have wider and easier access to private care resources.⁶ Yet someone must coordinate, monitor, and center all these services on the veteran. It is not likely Mr. S’s story would have had this kind of ending in the community. The continuity of care, the access to staff with the knowledge of veterans benefits and health care needs, and the ability to listen and follow up without time or performance constraints is just not possible outside VA.

The other evening in the parking lot of the hospital, I encountered a physician who had left the VA to work in several other large health care organizations. He had some good things to say about their business processes and the volume of patients they saw. He came back to the VA, he said, because “No one else can provide this quality of care for the individual veteran.”

As usual, it was a hectic Monday on the psychiatry consult service. All the trainees, from medical student to fellow, were seeing other patients when the call came from the surgery clinic. One of the pleasures of being a VA clinician is the ability to teach and supervise medical students and residents. The attending in that busy clinic said, “There is a patient down here who is refusing care for a gangrenous leg, but he is also talking about his life not being worth living. Could someone evaluate him?” That patient, Mr. S, declined to go to either the emergency department or the urgent care psychiatry clinic, so I went to see him. I realized that I had seen this patient in the hospital several times before.

One of the great clinical benefits of working in the VA, as opposed to in academic or community hospitals, is continuity. In my nearly 20 years at the same medical center, I have had the privilege of following many patients through multiple courses of treatment. This continuity is a huge advantage when there is what Hippocrates called a “critical day,” as on that Monday in the surgery clinic.² Also, in many cases the continuity allows me to have a reservoir of trust that I can draw on for challenging consultations, like that of Mr. S.

The surgery resident and attending had spent more than an hour talking to Mr. S when I arrived but still they joined me for the conversation. Mr. S was a veteran in his sixties, and after a few minutes of listening to him, it was clear he was talking about ending his life because of its poor quality. He told us that he had acquired the infection in his leg secondary to unsanitary living conditions. The veteran was quite a storyteller, intelligent, and had a wry sense of humor, which only made his point that his living conditions were intolerable more poignant. He apparently had tried to talk to someone about his situation but felt frustrated that he had not obtained more help.

The surgery attending had already told Mr. S that he would respect his right to refuse the amputation but he feared that Mr. S’s refusal was an expression of his depression and hopelessness, hence, the psychiatry consult. Although Mr. S was not acutely suicidal, something about the combination of his despair and deliberation worried me.

The surgery attending offered to admit Mr. S to do a further workup of his leg. I encouraged him to accept this option and added that I would make sure a social worker saw him and the psychiatry service department also would follow him. Mr. S declined even a 24-hour admission, saying that he had just moved to a new apartment and “everything I have in the world is there and I don’t want to lose it.” This comment suggested to me that he was ambivalent about his wish to die and provided an opening to reduce his risk of harming himself either directly or indirectly.

After the discussion, Mr. S seemed to believe we cared about him and was more willing to participate in treatment planning. He agreed to let the surgeons draw blood and to pick up oral antibiotics from the pharmacy. I promised him that if he would come back to clinic that week, I would make sure a social worker met with him and that my team would talk with him more about his depression. Mr. S picked Friday for his return and assured me that now that he knew we were going to try and improve his situation, he would not hurt himself. Obviously, this was a risk on my part—but the show of compassion combined with flexibility had created a therapeutic alliance that I believed was sufficient to protect Mr. S until we met again.

I returned to my office and called the chief of social work: The dedication of career VA employees forges effective working relationships that can be leveraged for the benefit of the patients. At my facility and many others, many of the staff members who are now in positions of leadership rose through the ranks together, giving us a solidarity of purpose and mutual reliance that are rare in community health care settings. The chief of social work looked at the patient’s chart with me on the phone while I explained the circumstances and within a few minutes said, “We can help him. It looks like he is eligible for an increased pension, and I think we can find him better housing.”

I admit to some anxiety on Friday. One of the psychiatry residents on the service had volunteered to see Mr. S after studying his chart in the morning. Most of us are aware that the aging VA electronic health record system is due to be replaced. But having access to more than 20 years of medical history from episodes of inpatient, outpatient, and residential care all over the country is an unrivaled asset that brings a unique breadth that sharpens, deepens, and humanizes diagnosis and treatment planning.

Sure enough at 10 am, the surgery clinic called to tell us Mr. S had arrived on time. The resident headed to interview him while I contacted the chief of social work. She put out a call for help to her staff, and within 10 minutes an outpatient social worker was in the clinic talking with Mr. S. Compared with his initial visit, Mr. S’s mood was much brighter, and he no longer was endorsing any suicidal ideation or intent. He still did not want his leg amputated, feeling it would rob him of his independence, but he was now willing to consider other treatment options. Mr. S also said he wanted to speak with the palliative care team to know what they could offer.

The social worker arranged new housing for Mr. S that day and help to move into his new place. The paperwork was submitted for the pension increase, and help for shopping and meals as well as transportation was either put in place or applied for. As he left to pack, Mr. S told the surgeon he might not want hospice just yet.

The coda to this narrative is equally uplifting. Several weeks after Mr. S was seen in the surgery clinic, I received a call from a midlevel psychiatric practitioner in the urgent care clinic who had been on leave for several weeks. He too had seen Mr. S before and shared my concern about his state of mind and well-being. He thanked me for having the consult service see him and remarked that it was a relief to know Mr. S had been taken care of and was in a better place in every sense of the word.

In response to a rising media tide of concern about the direction VA care is headed, Congress and the VA have issued a strong statements, “debunking” what they called the “myth” of privatization.³ Yet for the first time in my career, many thoughtful people discern a constellation of forces that could eventuate in this reality in our lifetimes. The title and message of this column is that the VA cannot be privatized, not that it will not be privatized. Also, I did not say that it should not be privatized. As I have written in other columns, that is because ethically I do not believe this is even a question.⁴ Privatization breaks President Abraham Lincoln’s promise to veterans, “to care for him who has borne the battle.” A promise that was kept for Mr. S and is fulfilled for thousands of other veterans every day all over this nation. A promise that far exceeds payments for medical services.

I also do not mean the title to be a rejection of the Veterans Choice Program. The VA has always provided—and should continue to offer—community-based care for veterans that complements VA care. For example, I live in one of the most rural states in the union and recognize that a patient should not have to drive 300 miles to get a routine colonoscopy.

The VA cannot be privatized because of the comprehensive care that it provides: the degree of integration; the wealth of resources; and the level of expertise in caring for the complex medical, psychiatric, and psychosocial problems of veterans cannot be replicated. Nor is this just my opinion—a recent RAND Corporation study documents the evidence.⁵ There are many medical services in the private sector that may be delivered more efficiently, and Congress has just passed the Mission Act to allocate the funds needed to ensure our veterans have wider and easier access to private care resources.⁶ Yet someone must coordinate, monitor, and center all these services on the veteran. It is not likely Mr. S’s story would have had this kind of ending in the community. The continuity of care, the access to staff with the knowledge of veterans benefits and health care needs, and the ability to listen and follow up without time or performance constraints is just not possible outside VA.

The other evening in the parking lot of the hospital, I encountered a physician who had left the VA to work in several other large health care organizations. He had some good things to say about their business processes and the volume of patients they saw. He came back to the VA, he said, because “No one else can provide this quality of care for the individual veteran.”

As usual, it was a hectic Monday on the psychiatry consult service. All the trainees, from medical student to fellow, were seeing other patients when the call came from the surgery clinic. One of the pleasures of being a VA clinician is the ability to teach and supervise medical students and residents. The attending in that busy clinic said, “There is a patient down here who is refusing care for a gangrenous leg, but he is also talking about his life not being worth living. Could someone evaluate him?” That patient, Mr. S, declined to go to either the emergency department or the urgent care psychiatry clinic, so I went to see him. I realized that I had seen this patient in the hospital several times before.

One of the great clinical benefits of working in the VA, as opposed to in academic or community hospitals, is continuity. In my nearly 20 years at the same medical center, I have had the privilege of following many patients through multiple courses of treatment. This continuity is a huge advantage when there is what Hippocrates called a “critical day,” as on that Monday in the surgery clinic.² Also, in many cases the continuity allows me to have a reservoir of trust that I can draw on for challenging consultations, like that of Mr. S.

The surgery resident and attending had spent more than an hour talking to Mr. S when I arrived but still they joined me for the conversation. Mr. S was a veteran in his sixties, and after a few minutes of listening to him, it was clear he was talking about ending his life because of its poor quality. He told us that he had acquired the infection in his leg secondary to unsanitary living conditions. The veteran was quite a storyteller, intelligent, and had a wry sense of humor, which only made his point that his living conditions were intolerable more poignant. He apparently had tried to talk to someone about his situation but felt frustrated that he had not obtained more help.

The surgery attending had already told Mr. S that he would respect his right to refuse the amputation but he feared that Mr. S’s refusal was an expression of his depression and hopelessness, hence, the psychiatry consult. Although Mr. S was not acutely suicidal, something about the combination of his despair and deliberation worried me.

The surgery attending offered to admit Mr. S to do a further workup of his leg. I encouraged him to accept this option and added that I would make sure a social worker saw him and the psychiatry service department also would follow him. Mr. S declined even a 24-hour admission, saying that he had just moved to a new apartment and “everything I have in the world is there and I don’t want to lose it.” This comment suggested to me that he was ambivalent about his wish to die and provided an opening to reduce his risk of harming himself either directly or indirectly.

After the discussion, Mr. S seemed to believe we cared about him and was more willing to participate in treatment planning. He agreed to let the surgeons draw blood and to pick up oral antibiotics from the pharmacy. I promised him that if he would come back to clinic that week, I would make sure a social worker met with him and that my team would talk with him more about his depression. Mr. S picked Friday for his return and assured me that now that he knew we were going to try and improve his situation, he would not hurt himself. Obviously, this was a risk on my part—but the show of compassion combined with flexibility had created a therapeutic alliance that I believed was sufficient to protect Mr. S until we met again.

I returned to my office and called the chief of social work: The dedication of career VA employees forges effective working relationships that can be leveraged for the benefit of the patients. At my facility and many others, many of the staff members who are now in positions of leadership rose through the ranks together, giving us a solidarity of purpose and mutual reliance that are rare in community health care settings. The chief of social work looked at the patient’s chart with me on the phone while I explained the circumstances and within a few minutes said, “We can help him. It looks like he is eligible for an increased pension, and I think we can find him better housing.”

I admit to some anxiety on Friday. One of the psychiatry residents on the service had volunteered to see Mr. S after studying his chart in the morning. Most of us are aware that the aging VA electronic health record system is due to be replaced. But having access to more than 20 years of medical history from episodes of inpatient, outpatient, and residential care all over the country is an unrivaled asset that brings a unique breadth that sharpens, deepens, and humanizes diagnosis and treatment planning.

Sure enough at 10 am, the surgery clinic called to tell us Mr. S had arrived on time. The resident headed to interview him while I contacted the chief of social work. She put out a call for help to her staff, and within 10 minutes an outpatient social worker was in the clinic talking with Mr. S. Compared with his initial visit, Mr. S’s mood was much brighter, and he no longer was endorsing any suicidal ideation or intent. He still did not want his leg amputated, feeling it would rob him of his independence, but he was now willing to consider other treatment options. Mr. S also said he wanted to speak with the palliative care team to know what they could offer.

The social worker arranged new housing for Mr. S that day and help to move into his new place. The paperwork was submitted for the pension increase, and help for shopping and meals as well as transportation was either put in place or applied for. As he left to pack, Mr. S told the surgeon he might not want hospice just yet.

The coda to this narrative is equally uplifting. Several weeks after Mr. S was seen in the surgery clinic, I received a call from a midlevel psychiatric practitioner in the urgent care clinic who had been on leave for several weeks. He too had seen Mr. S before and shared my concern about his state of mind and well-being. He thanked me for having the consult service see him and remarked that it was a relief to know Mr. S had been taken care of and was in a better place in every sense of the word.

In response to a rising media tide of concern about the direction VA care is headed, Congress and the VA have issued a strong statements, “debunking” what they called the “myth” of privatization.³ Yet for the first time in my career, many thoughtful people discern a constellation of forces that could eventuate in this reality in our lifetimes. The title and message of this column is that the VA cannot be privatized, not that it will not be privatized. Also, I did not say that it should not be privatized. As I have written in other columns, that is because ethically I do not believe this is even a question.⁴ Privatization breaks President Abraham Lincoln’s promise to veterans, “to care for him who has borne the battle.” A promise that was kept for Mr. S and is fulfilled for thousands of other veterans every day all over this nation. A promise that far exceeds payments for medical services.

I also do not mean the title to be a rejection of the Veterans Choice Program. The VA has always provided—and should continue to offer—community-based care for veterans that complements VA care. For example, I live in one of the most rural states in the union and recognize that a patient should not have to drive 300 miles to get a routine colonoscopy.

The VA cannot be privatized because of the comprehensive care that it provides: the degree of integration; the wealth of resources; and the level of expertise in caring for the complex medical, psychiatric, and psychosocial problems of veterans cannot be replicated. Nor is this just my opinion—a recent RAND Corporation study documents the evidence.⁵ There are many medical services in the private sector that may be delivered more efficiently, and Congress has just passed the Mission Act to allocate the funds needed to ensure our veterans have wider and easier access to private care resources.⁶ Yet someone must coordinate, monitor, and center all these services on the veteran. It is not likely Mr. S’s story would have had this kind of ending in the community. The continuity of care, the access to staff with the knowledge of veterans benefits and health care needs, and the ability to listen and follow up without time or performance constraints is just not possible outside VA.

The other evening in the parking lot of the hospital, I encountered a physician who had left the VA to work in several other large health care organizations. He had some good things to say about their business processes and the volume of patients they saw. He came back to the VA, he said, because “No one else can provide this quality of care for the individual veteran.”

There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.

In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.² The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.

Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.³ Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.⁴

VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.⁵ In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.⁶ According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.⁷

Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.

The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.

But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”⁸ Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.

Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.

The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.^9,10

The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.

Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”⁵ The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.¹¹

Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”⁵

Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.

There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.

In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.² The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.

Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.³ Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.⁴

VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.⁵ In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.⁶ According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.⁷

Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.

The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.

But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”⁸ Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.

Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.

The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.^9,10

The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.

Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”⁵ The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.¹¹

Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”⁵

Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.

There were so many developments that occurred in the first months of 2018 that could potentially affect federal health care—the government shutdown, the proposed change in rights of conscience protections for federal health care professionals (HCPs), and more debate about medical marijuana in the VA—that it was hard to pick just one topic to discuss this month. In the end I felt it was time to examine how and in what ways the new VA policy on medical marijuana may have changed.

In 2014, before I became editor-in-chief of Federal Practitioner, I wrote an article analyzing the legal and ethical conflicts that arise for VA clinicians who practice under the federal regulations that prohibit them from prescribing medical marijuana or from completing forms or providing referrals for their patients who live in states where medical marijuana is legal.² The article summarized the events and issues that led to the VA issuing a policy on medical marijuana in 2011. When that article was written, medical marijuana had been legalized in 20 states.

Now in March 2018, 29 states have passed legislation to permit marijuana use for medical purposes.³ Prior to issuing the revised version of its medical marijuana policy, the VA rumor mill went into high gear. Anticipatory stories predicted dramatic changes from the extreme of the VA penalizing veterans who used medical marijuana to allowing doctors to prescribe it. Such massive shifts are not typical of any bureaucracy, and indeed some VA officials denied that the revision represented any substantive movement in either direction.⁴

VHA Directive 1315, Access to Clinical Programs for Veterans Participating in State Medical Marijuana Programs was issued December 8, 2017.⁵ In accordance with federal regulation, its issuance superceded VHA Directive 2011-04 of the same title.⁶ According to the directive, its emphasis on discussion with veterans was a significant policy shift. “Major changes include adding policy to support the Veteran-provider relationship when discussing the use of medical marijuana and its impact on health including Veteran-specific treatment plans.” It should be noted that the prior directive did not prohibit or even discourage such conversations, and accompanying less official guidance actually promoted them.⁷

Interestingly, the new directive does not instruct HCPs to ask about medical marijuana in the way questions about alcohol, tobacco, and drug use as well as many other lifestyle factors are mandated. Asking a veteran about marijuana use would be a step toward medical mainstreaming. The burden is still on the veteran to bring up the subject—not an easy thing to do in light of the fear among some veterans that the VA will curtail benefits for a veteran caught using medical marijuana.

The new directive is a minor move toward appropriate medicalization. Practitioners are advised to discuss medical marijuana use with any veteran for whom it “may have clinical relevance” or who asks about medical marijuana. This underscores the need for VA practitioners to have access to up-to-date information in order to keep up with their Internet savvy patients and combat ever proliferating myths about the panacea-like properties of medical marijuana.

But when it comes down to the devilish details, the primary rules provide no deliverance from the impasse between state and federal law. Marijuana remains a Schedule I drug under the Controlled Substances Act. For purposes of federal health care, it still is, “a substance with a high potential for abuse without a currently acceptable medical use in treatment in the United States, and lacking accepted safety for use under medical supervision.”⁸ Although many vocal veterans as well as some federal practitioners, HCPs in the wider medical community, and more recently a number of politicians would challenge this regulation, federal lawprohibits prescribing medical marijuana. The new VA directive is more explicit in stating that VA practitioners cannot complete forms enrolling veterans or permitting their registration in state-approved medical marijuana programs. This restriction was implicit in the prior directive but has been a continuing source of confusion for HCPs. The new directive at least clarifies these restrictions.

Another point of clinical misunderstanding had been about whether HCPs in the VA could refer patients to state-approved medical marijuana programs and what exactly referral entails. There is a direct prohibition in the new directive on making referrals, yet the term remains undefined. Nothing in the directive contradicts the right of a veteran to access their medical records for purposes of registering for state-approved programs. But the directive does forcefully restate that if a veteran appears in an HCP’s office or at the pharmacy with an authorization or registration for medical marijuana from a state-approved program, the VA will neither provide the product nor pay for its purchase elsewhere. The more rules-based form of this directive also strongly states that possession of marijuana on VA grounds even for medical purposes and with state approval is a violation of federal regulation that may be prosecuted under the Controlled Substance Act.

The new directive does clarify a question that had arisen about VA employees’ participation in state-approved medical marijuana programs. VA employees, even those who do not receive their care at the VA, are prohibited from using medical marijuana. Individuals who use marijuana for medical indications often do so daily. Considering that a person may test positive for marijuana months after regular use, a segment of VA staff may be at risk for violating federal drug-free workplace regulations.^9,10

The administrative aspects of the directive are tightened, which will help clinicians know what they are supposed to do when a veteran reports medical marijuana use; it is hoped that this will bring more consistency and fairness to the process. Practitioners continue to be required to enter a veteran’s reported use of medical marijuana in the electronic medical record under the section Non-VA/Herbal Medication/Over the Counter. When HCPs discuss the use of medical marijuana with patients, the requirement to document those discussions is instructive.

Those looking for a relaxation in the VA’s clinical approach will find little to cheer about. But there are a few rays of hope for those HCPs and patients trying to do the best they can in this catch-22 situation. First, the VA has stood firm that veterans cannot be excluded from other types of VA medical care due to their use of medical marijuana. “Veterans must not be denied VHA services solely because they are participating in State-approved marijuana programs.”⁵ The directive specifically acknowledges the clinical areas in which veteran medical marijuana use has been the most contentious: PTSD, substance use, and pain management. It also encourages HCPs to review potential drug interactions and how marijuana use may affect other types of medical or psychiatric care. These 3 areas also are the object of intensified congressional pressure and veteran service organization lobbying for the VA to not only incorporate these modalities into VA care, but also to expand research.¹¹

Second, the phrase “modifying treatment plans,” which understandably makes patients and their advocates apprehensive, is qualified. To those clinicians who would prefer, either because of concerns of professional liability or personal belief, to have a black-and-white stance on the use of medical marijuana, the directive mandates that they must deal with the gray. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis.”⁵

Third, those modifications cannot be unilateral pronouncements, but must be the result of shared decisions making and mutual discussion. The only ground on which a practitioner can exercise any degree of soft paternalism is when the use of medical marijuana and treatment for another condition represents an evidence-based threat to the health and safety of the veteran. “Providers need to make decisions to modify treatment plans based on marijuana use on a case-by-case basis, such decisions need to be made in partnership with the Veteran and must be based on concerns regarding Veteran health and safety.”⁵

Overall the policy has no big surprises, leaving those who hoped the revision would bring a softening of the VA’s institutional position and federal law frustrated. Those who sought a strengthening of VA policy based on those same regulations regarding the use of medical marijuana will be equally thwarted. And those clinicians who are just trying to do the right thing as HCPs who work for the federal government and for their patients who are interested only in relief from their most troubling ailments, will stay right where they were, suspended over the ethical chasm that medical marijuana generates between state and federal law.

The articles in this special issue reflect a number of emerging trends in federal practice. The first is that the optimal delivery of mental health clinical care as well as the conduct of cutting-edge clinical research are most often inter- and multidisciplinary collaborations. A background in public and military service instills the experience and training to maximize teamwork in the health care professionals of the VA, DoD, and PHS. Pharmacists, neuropsychologists, psychiatrists, social workers, nurses, and others come together to advance the science and scholarship that are the backbone for building efficacious patient-centered health care. Just as important, most of these articles reflect a partnership between VA and academic medical centers. The knowledge and skill of each partner amplifies the other to produce novel insights, which can be readily translated into treatment progress that benefits patients.

A case in point: Neurology and psychiatry have historically been different disciplines. However, some thought leaders recently suggested that the explosion of neuroscience has narrowed the gap between the specialties to a single field, as demonstrated by Langevin and colleagues. The authors propose the use of deep brain stimulation to treat patients with posttraumatic stress disorder (PTSD). Deep brain stimulation is a process in which electrodes are inserted into targeted areas of the brain and alter the neural impulses and physiology to relieve neuropsychiatric symptoms and, thus, modulate neural structure and function.

Up to one-third of veterans with PTSD also may have a substance use disorder. Pary and colleagues review the research on another trend in mental health treatment that is fast becoming a best practice: the integrated, coordinated treatment of co-occurring substance use and mental health disorders. This approach provides a comprehensive look at the diagnosis and treatment of depression and bipolar disorder coexistent with alcohol use disorder with both psycho- and pharmacotherapy.

Through its unique primary care psychiatry clinics, the VA has pioneered integrated care for individuals with serious mental illness and chronic medical conditions that may result in frequent hospitalization and increased overall health care utilization. Gill and colleagues emphasize the urgency and importance of these efforts given the increasing number of active-duty service members and veterans who served in Iraq and Afghanistan and are diagnosed with mental and physical conditions. Their outcomes data suggest that directing outpatient resources to patients with specific demographic and clinical factors may be beneficial.

The challenges of providing team-based care to patients with mental health disorders is borne out in the research of Lee and colleagues. Their examination of the risk of hospitalization for patients with PTSD who have been treated with benzodiazepine and opioids is a reminder of the challenge of treating patients with multiple comorbidities. The authors caution that prescribers should “limit benzodiazepine and opioid use in this population and consider safer nonpharmacologic and pharmacologic treatment options when possible.”

Many of these trends coalesce in my discussion with Larry Davis, MD, Distinguished Professor of Neurology at the University of New Mexico School of Medicine and Chief of Neurology at the New Mexico VA Health Care System. Dr. Davis describes a successful teleneurology program that treats patients in underserved rural areas in New Mexico and Colorado. He also touts the benefits of teleneurology to address the shortage of neurologists. Many of the most common and serious neurologic conditions, such as epilepsy, Alzheimer, and Parkinson, are managed through a teleneurology program that includes education and support for patients and caregivers.

The articles in this special issue reflect a number of emerging trends in federal practice. The first is that the optimal delivery of mental health clinical care as well as the conduct of cutting-edge clinical research are most often inter- and multidisciplinary collaborations. A background in public and military service instills the experience and training to maximize teamwork in the health care professionals of the VA, DoD, and PHS. Pharmacists, neuropsychologists, psychiatrists, social workers, nurses, and others come together to advance the science and scholarship that are the backbone for building efficacious patient-centered health care. Just as important, most of these articles reflect a partnership between VA and academic medical centers. The knowledge and skill of each partner amplifies the other to produce novel insights, which can be readily translated into treatment progress that benefits patients.

A case in point: Neurology and psychiatry have historically been different disciplines. However, some thought leaders recently suggested that the explosion of neuroscience has narrowed the gap between the specialties to a single field, as demonstrated by Langevin and colleagues. The authors propose the use of deep brain stimulation to treat patients with posttraumatic stress disorder (PTSD). Deep brain stimulation is a process in which electrodes are inserted into targeted areas of the brain and alter the neural impulses and physiology to relieve neuropsychiatric symptoms and, thus, modulate neural structure and function.

Up to one-third of veterans with PTSD also may have a substance use disorder. Pary and colleagues review the research on another trend in mental health treatment that is fast becoming a best practice: the integrated, coordinated treatment of co-occurring substance use and mental health disorders. This approach provides a comprehensive look at the diagnosis and treatment of depression and bipolar disorder coexistent with alcohol use disorder with both psycho- and pharmacotherapy.

Through its unique primary care psychiatry clinics, the VA has pioneered integrated care for individuals with serious mental illness and chronic medical conditions that may result in frequent hospitalization and increased overall health care utilization. Gill and colleagues emphasize the urgency and importance of these efforts given the increasing number of active-duty service members and veterans who served in Iraq and Afghanistan and are diagnosed with mental and physical conditions. Their outcomes data suggest that directing outpatient resources to patients with specific demographic and clinical factors may be beneficial.

The challenges of providing team-based care to patients with mental health disorders is borne out in the research of Lee and colleagues. Their examination of the risk of hospitalization for patients with PTSD who have been treated with benzodiazepine and opioids is a reminder of the challenge of treating patients with multiple comorbidities. The authors caution that prescribers should “limit benzodiazepine and opioid use in this population and consider safer nonpharmacologic and pharmacologic treatment options when possible.”

Many of these trends coalesce in my discussion with Larry Davis, MD, Distinguished Professor of Neurology at the University of New Mexico School of Medicine and Chief of Neurology at the New Mexico VA Health Care System. Dr. Davis describes a successful teleneurology program that treats patients in underserved rural areas in New Mexico and Colorado. He also touts the benefits of teleneurology to address the shortage of neurologists. Many of the most common and serious neurologic conditions, such as epilepsy, Alzheimer, and Parkinson, are managed through a teleneurology program that includes education and support for patients and caregivers.

The articles in this special issue reflect a number of emerging trends in federal practice. The first is that the optimal delivery of mental health clinical care as well as the conduct of cutting-edge clinical research are most often inter- and multidisciplinary collaborations. A background in public and military service instills the experience and training to maximize teamwork in the health care professionals of the VA, DoD, and PHS. Pharmacists, neuropsychologists, psychiatrists, social workers, nurses, and others come together to advance the science and scholarship that are the backbone for building efficacious patient-centered health care. Just as important, most of these articles reflect a partnership between VA and academic medical centers. The knowledge and skill of each partner amplifies the other to produce novel insights, which can be readily translated into treatment progress that benefits patients.

A case in point: Neurology and psychiatry have historically been different disciplines. However, some thought leaders recently suggested that the explosion of neuroscience has narrowed the gap between the specialties to a single field, as demonstrated by Langevin and colleagues. The authors propose the use of deep brain stimulation to treat patients with posttraumatic stress disorder (PTSD). Deep brain stimulation is a process in which electrodes are inserted into targeted areas of the brain and alter the neural impulses and physiology to relieve neuropsychiatric symptoms and, thus, modulate neural structure and function.

Up to one-third of veterans with PTSD also may have a substance use disorder. Pary and colleagues review the research on another trend in mental health treatment that is fast becoming a best practice: the integrated, coordinated treatment of co-occurring substance use and mental health disorders. This approach provides a comprehensive look at the diagnosis and treatment of depression and bipolar disorder coexistent with alcohol use disorder with both psycho- and pharmacotherapy.

Through its unique primary care psychiatry clinics, the VA has pioneered integrated care for individuals with serious mental illness and chronic medical conditions that may result in frequent hospitalization and increased overall health care utilization. Gill and colleagues emphasize the urgency and importance of these efforts given the increasing number of active-duty service members and veterans who served in Iraq and Afghanistan and are diagnosed with mental and physical conditions. Their outcomes data suggest that directing outpatient resources to patients with specific demographic and clinical factors may be beneficial.

The challenges of providing team-based care to patients with mental health disorders is borne out in the research of Lee and colleagues. Their examination of the risk of hospitalization for patients with PTSD who have been treated with benzodiazepine and opioids is a reminder of the challenge of treating patients with multiple comorbidities. The authors caution that prescribers should “limit benzodiazepine and opioid use in this population and consider safer nonpharmacologic and pharmacologic treatment options when possible.”

Many of these trends coalesce in my discussion with Larry Davis, MD, Distinguished Professor of Neurology at the University of New Mexico School of Medicine and Chief of Neurology at the New Mexico VA Health Care System. Dr. Davis describes a successful teleneurology program that treats patients in underserved rural areas in New Mexico and Colorado. He also touts the benefits of teleneurology to address the shortage of neurologists. Many of the most common and serious neurologic conditions, such as epilepsy, Alzheimer, and Parkinson, are managed through a teleneurology program that includes education and support for patients and caregivers.

In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.

Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.

On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.¹

Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.² More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.

The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.³

I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.

Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”⁴ Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.⁵

Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.

Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”⁶ National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”⁷

Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.⁸

Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.

Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.

In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.

Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.

On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.¹

Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.² More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.

The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.³

I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.

Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”⁴ Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.⁵

Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.

Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”⁶ National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”⁷

Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.⁸

Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.

Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.

In my December 2017 editorial, I presented a values-based roundup of the year. That column explained the criteria for the selections of the most right and most wrong in 2017 in terms of 3 ethical theories: utilitarianism, deontology, and virtue ethics. December featured the good in federal practice. This month, the editorial turns to the bad in federal practice.

Sadly, there were far more candidates for the ethical worst of 2017 in the DoD, VA, and PHS than those of us dedicated to federal service would wish to see. Unfortunately, this reflects both the current state of our society and the nature of the human condition.

On Sunday morning, November 5, 2017, near my hometown of San Antonio, Texas, a gunman in military gear and firearms murdered 26 people who were worshipping at a rural Baptist church. The context of this horrific offense simultaneously mocked the fidelity of our armed forces and a religious faith that in many forms has been a foundation of our nation. Leading forensic mental health experts advise against using the name of mass murderers to avoid perversely glorifying them, and I will adopt that wise convention here.¹

Soon after the massacre, news organizations reported that the perpetrator had served in the Air Force, stationed in my adopted home of New Mexico. The shooter had been given a bad conduct discharge after a court-martial in 2012 found him guilty of brutally assaulting his then current wife and their child.² More than 1 military law expert has opined that perhaps the discharge should have been dishonorable, given the brutality of the conduct, although whether that verdict would have made it more likely, the crime was reported is not certain.

The day following the mass shooting, the Air Force euphemistically acknowledged that it had made an “error,” “mistake,” in not reporting the attacker’s violent history to the federal database, which tracks such offenders to prevent them from lawfully purchasing a weapon. These words and others, such as blunder and failure, used in the media do an injustice to the worshippers’ lives lost that ill-fated morning.³

I must stop here and emphasize as strongly as possible that the selection of this attack is in no way meant to demonize the Air Force as an agency or any individual serving in it. In fact, further investigation suggested that all branches of the armed forces did not fulfill their reporting obligations under the law. Nor am I making the unprovable claim, as some politicians have hinted, that if the Air Force had followed its procedure and policy, the shooter would never have taken 26 innocent lives. Although I note that this is exactly the assumption driving a number of lawsuits brought by the victims’ families against the Air Force for its failure to follow its rules.

Rather, I chose this terrible incident because of its universality and generalizability as a paradigm of what philosopher Hannah Arendt called the banality of evil. As she wrote in her book Eichmann in Jerusalem, “There is a strange interdependence between thoughtlessness and evil.”⁴ Although the law must deem the attack a capital crime, ethics should see it as a the ripple effect of hundreds of small moral failures of dozens of individuals and the system that neither inspired nor held them accountable for taking routine tasks as morally serious. An Office of Special Investigations officer told CNN, “The system as it is now is personality dependent, which is obviously irresponsible and broken,” noting that accurate recording of case details depends on the discretion of individual case workers.⁵

Those federal workers are no better or worse than any of us. This bloody tragedy that might be dismissed as an administrative oversight powerfully demonstrates that even the smallest task matters greatly. It is the systemic, long-standing, repeated nature of the DoD’s improper reporting of servicemen and women that makes this action ethically problematic and warrants my selection as the worst event of 2018.

Major newspapers on November 7 carried a report from the Associated Press with a damning headline, “Pentagon has known of crime reporting lapses for 20 years.”⁶ National Public Radio reported that several Inspector General investigations had documented that over this period the DoD was not regularly reporting violent offenses to the National Criminal Information Center database as mandated. A Fordham law professor and gun regulation specialist quoted on the program zeroed in on an absence of accountability as the leadership flaw that permitted rank and file staff to ignore their protocols. “It’s a ‘who’s watching the watchers’ kind of issue,” he said. “There is no oversight over the Air Force or over the FBI that demands that these regulatory obligations are actually followed through with.”⁷

Finally, after the tragedy, it was discovered that the Air Force had not just 1 but 2 chances to prevent the gunman from future firearm purchases. The shooter had escaped from a psychiatric facility—his status in the psychiatric hospital was unclear—but it is known that he was admitted after he had smuggled weapons onto the base and threatened to kill his commanders. His hospitalization should have been reported to the national database, which would have raised a red flag when he tried to buy guns.⁸

Each of the hundreds of prosaic decisions that indirectly contributed to the Texas shooting was borne of a juggernaut of small compromises from procrustean bureaucratic leadership at the top to mindless conformity at the bottom: a breach all 3 ethical theories. Even if 1 unfiled report leads to no untoward outcome, it is clear that for utilitarianism, it is safer and sounder public policy to take lawful steps to prevent individuals with violent pasts and the potential to kill others from purchasing firearms. Deontologically, whether by omission or commission, not reporting such individuals violates the duty of veracity, as it withholds the truth from those who have a right to possess it. Finally, for this horror to be possible, many people had to not act with integrity, accountability, and trustworthiness.

Many may criticize my a choice to begin the new year so inauspiciously drawing attention to ethical failures and such a malicious crime. I would counter this criticism with the contention that a sober analysis of serious moral lapses in terms of the ethical theory introduced last month is a most salutatory welcome to 2018. So as we embark upon a new year in federal practice, let us strive not only for clinical expertise and administrative efficiency, but also for moral excellence.

It is customary at the end of the year for editors of journals and magazines to publish “the best and the worst of the year” or top 10 lists of events or articles of the year, or even the “most important” discoveries or people of the year. Some publications survey their readers; others invite experts to opine on the selection. What is nearly always missing from these newsworthy roundups are the criteria for determining what meets the mark. But this is a crucial piece of missing information, and without it, many of these rankings have little worth.

Words like important, best, and worst are not factual claims but value judgments. For a value judgment to have validity, there must be a substantive basis for making the determination. Put less ponderously, readers need to understand what makes a person, action, or decision valuable or important.

Being a medical ethicist, I tend to think in terms of good and bad, right and wrong—hence, the title of this editorial. But even these essential terms of evaluation in our language must have a frame of reference or at least a description to have meaning when applied, especially if the terms are to be compared. For moral philosophy, the parent of medical ethics, these frames or bases for making judgments about the rightness or wrongness of conduct are often found in ethical theories.

Three of the most recognized and significant ethical theories are consequentialist, deontology, and virtue ethics. It is important to understand these theories to grasp how I decided on my list of the right and wrong of 2017. However due to space limitations, I will only provide a nutshell summary of these theories. Readers interested in cracking the nut wider may want to consult the references on ethical theory at the end of the essay.¹

Consequentialist theories—utilitarianism being the most well known in health care—argue that what makes an action right or good is what brings about the most happiness for the most people. What is determinative of rightness is the outcome.

In direct opposition to consequentialism is deontology. The consequences do not matter at all to the deontologist, right and good have to do with intent, and the only truly right intent is acting for the sake of duty alone.

Virtue ethics finds the core of right and good in the character of the virtuous person. Right actions and good intent each spring from the root of an individual of moral excellence.²

Establishing these ethical theories as the criteria for judgment, I now turn to my choice for the right and the good, the “best” of federal practice in 2017. (Next month my editorial will focus on the bad or the “worst” of 2017 federal health care.) Upfront, I acknowledge these choices are subjective, but I justify them by using the theories set forth. We welcome readers to send us their selections.

The Best

While journalists and politicians have widely criticized the White House response (or lack thereof) to the destructive storms that occurred during this hurricane season, little attention has been paid to the response of the 3 federal health care agencies, which was quick, dedicated, and caring. And it is this response that makes it my best of 2017. The vulnerability of areas from Houston to Puerto Rico, some of which still lack the basic services of civilization, are struggling with loss of life and hope, powerless to protect what is left in the wake of the storms, only amplifies the desperate need for the human and material resources that the DoD, VA, and PHS have committed.

Testifying before the Senate Homeland Security and Governmental Affairs Committee, Robert G. Salesses, deputy assistant secretary of defense, chronicled the outpouring of DoD aid. “Military units cleared critical roadways, transported life-sustaining commodities, provided fuel distribution, conducted assessments of civilian hospitals, and provided medical support to include evacuating patients back to the continental United States.”³

The VA Disaster Emergency Medical Personnel system also went into high gear. In my facility and in many others, there were so many volunteers that facility leaders had to balance their clinical needs with the selfless desire to help the veterans and fellow federal practitioners who were in harm’s way.

According to Susan Wentzell, VISN 8 deputy communication manager and content manager:

“Despite the destruction caused by these monster storms, Veterans continued to receive vital health care and other support, thanks to the selfless efforts of thousands of dedicated VA employees who rallied together to provide around-the-clock care for patients sheltered-in-place in the eight large, hurricane-constructed VA hospitals and to get services back up and running in dozens of outpatient clinics impacted in the Southeast corridor of the U.S. and the Caribbean.”⁴

When Hurricane Maria ravaged Puerto Rico, medical personnel from the VA and the PHS Commissioned Corps staffed Federal Medical Stations in Manati and Bayamon, Puerto Rico, which provided cared for up to 250 people at a time. The officers of the Commissioned Corps also helped support the civilian health care infrastructure.

From a utilitarian perspective, the benefit of these relief efforts is obvious. They were literally life-saving and health preserving for the thousands who were injured in the wreckage of wind and rain, ill from the collapse of public services, as well as those psychologically traumatized. And had these men and women of the VA, PHS, and DoD not come to the aid of the victims of these unprecedented national disasters, the toll of human suffering and bereavement would have been far worse.

Deontologically, each of these government employees did their duty; many volunteered, and even those who were ordered to assist did so with a compassion and dedication that went far beyond doing a job. None of the historic drives of humankind to place themselves in harm’s way—power, money, or fame—motivated those who answered the call; only a duty to serve and an intention to help.

Each person who left the security of home and the comfort of friends and family displayed the highest qualities of virtue ethics: altruism, professionalism, empathy, and integrity among other virtues.

In preparing for this column, I read stories of health care practitioners and nonclinical staff who not only reached out, but also reached beyond any expectation, clearly demonstrating outstanding professionalism and humanism.

I end with just one of these inspirational accounts. As Hurricane Irma approached the Florida coast, veteran employee Tim Myers braved the coming storm to get to work. That is far harder and braver than it seems, because Myers, who is a pharmacy technician and delivers medications to inpatients at the James A. Haley VA, is a quadriplegic in a wheelchair. The humility of his laconic description of his supererogatory conduct is equally impressive. “I appreciate that, but it really wasn’t that big of a deal to me,” Myers said.  “I mean, I had to get here.”⁵

It is customary at the end of the year for editors of journals and magazines to publish “the best and the worst of the year” or top 10 lists of events or articles of the year, or even the “most important” discoveries or people of the year. Some publications survey their readers; others invite experts to opine on the selection. What is nearly always missing from these newsworthy roundups are the criteria for determining what meets the mark. But this is a crucial piece of missing information, and without it, many of these rankings have little worth.

Words like important, best, and worst are not factual claims but value judgments. For a value judgment to have validity, there must be a substantive basis for making the determination. Put less ponderously, readers need to understand what makes a person, action, or decision valuable or important.

Being a medical ethicist, I tend to think in terms of good and bad, right and wrong—hence, the title of this editorial. But even these essential terms of evaluation in our language must have a frame of reference or at least a description to have meaning when applied, especially if the terms are to be compared. For moral philosophy, the parent of medical ethics, these frames or bases for making judgments about the rightness or wrongness of conduct are often found in ethical theories.

Three of the most recognized and significant ethical theories are consequentialist, deontology, and virtue ethics. It is important to understand these theories to grasp how I decided on my list of the right and wrong of 2017. However due to space limitations, I will only provide a nutshell summary of these theories. Readers interested in cracking the nut wider may want to consult the references on ethical theory at the end of the essay.¹

Consequentialist theories—utilitarianism being the most well known in health care—argue that what makes an action right or good is what brings about the most happiness for the most people. What is determinative of rightness is the outcome.

In direct opposition to consequentialism is deontology. The consequences do not matter at all to the deontologist, right and good have to do with intent, and the only truly right intent is acting for the sake of duty alone.

Virtue ethics finds the core of right and good in the character of the virtuous person. Right actions and good intent each spring from the root of an individual of moral excellence.²

Establishing these ethical theories as the criteria for judgment, I now turn to my choice for the right and the good, the “best” of federal practice in 2017. (Next month my editorial will focus on the bad or the “worst” of 2017 federal health care.) Upfront, I acknowledge these choices are subjective, but I justify them by using the theories set forth. We welcome readers to send us their selections.

The Best

While journalists and politicians have widely criticized the White House response (or lack thereof) to the destructive storms that occurred during this hurricane season, little attention has been paid to the response of the 3 federal health care agencies, which was quick, dedicated, and caring. And it is this response that makes it my best of 2017. The vulnerability of areas from Houston to Puerto Rico, some of which still lack the basic services of civilization, are struggling with loss of life and hope, powerless to protect what is left in the wake of the storms, only amplifies the desperate need for the human and material resources that the DoD, VA, and PHS have committed.

Testifying before the Senate Homeland Security and Governmental Affairs Committee, Robert G. Salesses, deputy assistant secretary of defense, chronicled the outpouring of DoD aid. “Military units cleared critical roadways, transported life-sustaining commodities, provided fuel distribution, conducted assessments of civilian hospitals, and provided medical support to include evacuating patients back to the continental United States.”³

The VA Disaster Emergency Medical Personnel system also went into high gear. In my facility and in many others, there were so many volunteers that facility leaders had to balance their clinical needs with the selfless desire to help the veterans and fellow federal practitioners who were in harm’s way.

According to Susan Wentzell, VISN 8 deputy communication manager and content manager:

“Despite the destruction caused by these monster storms, Veterans continued to receive vital health care and other support, thanks to the selfless efforts of thousands of dedicated VA employees who rallied together to provide around-the-clock care for patients sheltered-in-place in the eight large, hurricane-constructed VA hospitals and to get services back up and running in dozens of outpatient clinics impacted in the Southeast corridor of the U.S. and the Caribbean.”⁴

When Hurricane Maria ravaged Puerto Rico, medical personnel from the VA and the PHS Commissioned Corps staffed Federal Medical Stations in Manati and Bayamon, Puerto Rico, which provided cared for up to 250 people at a time. The officers of the Commissioned Corps also helped support the civilian health care infrastructure.

From a utilitarian perspective, the benefit of these relief efforts is obvious. They were literally life-saving and health preserving for the thousands who were injured in the wreckage of wind and rain, ill from the collapse of public services, as well as those psychologically traumatized. And had these men and women of the VA, PHS, and DoD not come to the aid of the victims of these unprecedented national disasters, the toll of human suffering and bereavement would have been far worse.

Deontologically, each of these government employees did their duty; many volunteered, and even those who were ordered to assist did so with a compassion and dedication that went far beyond doing a job. None of the historic drives of humankind to place themselves in harm’s way—power, money, or fame—motivated those who answered the call; only a duty to serve and an intention to help.

Each person who left the security of home and the comfort of friends and family displayed the highest qualities of virtue ethics: altruism, professionalism, empathy, and integrity among other virtues.

In preparing for this column, I read stories of health care practitioners and nonclinical staff who not only reached out, but also reached beyond any expectation, clearly demonstrating outstanding professionalism and humanism.

I end with just one of these inspirational accounts. As Hurricane Irma approached the Florida coast, veteran employee Tim Myers braved the coming storm to get to work. That is far harder and braver than it seems, because Myers, who is a pharmacy technician and delivers medications to inpatients at the James A. Haley VA, is a quadriplegic in a wheelchair. The humility of his laconic description of his supererogatory conduct is equally impressive. “I appreciate that, but it really wasn’t that big of a deal to me,” Myers said.  “I mean, I had to get here.”⁵

It is customary at the end of the year for editors of journals and magazines to publish “the best and the worst of the year” or top 10 lists of events or articles of the year, or even the “most important” discoveries or people of the year. Some publications survey their readers; others invite experts to opine on the selection. What is nearly always missing from these newsworthy roundups are the criteria for determining what meets the mark. But this is a crucial piece of missing information, and without it, many of these rankings have little worth.

Words like important, best, and worst are not factual claims but value judgments. For a value judgment to have validity, there must be a substantive basis for making the determination. Put less ponderously, readers need to understand what makes a person, action, or decision valuable or important.

Being a medical ethicist, I tend to think in terms of good and bad, right and wrong—hence, the title of this editorial. But even these essential terms of evaluation in our language must have a frame of reference or at least a description to have meaning when applied, especially if the terms are to be compared. For moral philosophy, the parent of medical ethics, these frames or bases for making judgments about the rightness or wrongness of conduct are often found in ethical theories.

Three of the most recognized and significant ethical theories are consequentialist, deontology, and virtue ethics. It is important to understand these theories to grasp how I decided on my list of the right and wrong of 2017. However due to space limitations, I will only provide a nutshell summary of these theories. Readers interested in cracking the nut wider may want to consult the references on ethical theory at the end of the essay.¹

Consequentialist theories—utilitarianism being the most well known in health care—argue that what makes an action right or good is what brings about the most happiness for the most people. What is determinative of rightness is the outcome.

In direct opposition to consequentialism is deontology. The consequences do not matter at all to the deontologist, right and good have to do with intent, and the only truly right intent is acting for the sake of duty alone.

Virtue ethics finds the core of right and good in the character of the virtuous person. Right actions and good intent each spring from the root of an individual of moral excellence.²

Establishing these ethical theories as the criteria for judgment, I now turn to my choice for the right and the good, the “best” of federal practice in 2017. (Next month my editorial will focus on the bad or the “worst” of 2017 federal health care.) Upfront, I acknowledge these choices are subjective, but I justify them by using the theories set forth. We welcome readers to send us their selections.

The Best

While journalists and politicians have widely criticized the White House response (or lack thereof) to the destructive storms that occurred during this hurricane season, little attention has been paid to the response of the 3 federal health care agencies, which was quick, dedicated, and caring. And it is this response that makes it my best of 2017. The vulnerability of areas from Houston to Puerto Rico, some of which still lack the basic services of civilization, are struggling with loss of life and hope, powerless to protect what is left in the wake of the storms, only amplifies the desperate need for the human and material resources that the DoD, VA, and PHS have committed.

Testifying before the Senate Homeland Security and Governmental Affairs Committee, Robert G. Salesses, deputy assistant secretary of defense, chronicled the outpouring of DoD aid. “Military units cleared critical roadways, transported life-sustaining commodities, provided fuel distribution, conducted assessments of civilian hospitals, and provided medical support to include evacuating patients back to the continental United States.”³

The VA Disaster Emergency Medical Personnel system also went into high gear. In my facility and in many others, there were so many volunteers that facility leaders had to balance their clinical needs with the selfless desire to help the veterans and fellow federal practitioners who were in harm’s way.

According to Susan Wentzell, VISN 8 deputy communication manager and content manager:

“Despite the destruction caused by these monster storms, Veterans continued to receive vital health care and other support, thanks to the selfless efforts of thousands of dedicated VA employees who rallied together to provide around-the-clock care for patients sheltered-in-place in the eight large, hurricane-constructed VA hospitals and to get services back up and running in dozens of outpatient clinics impacted in the Southeast corridor of the U.S. and the Caribbean.”⁴

When Hurricane Maria ravaged Puerto Rico, medical personnel from the VA and the PHS Commissioned Corps staffed Federal Medical Stations in Manati and Bayamon, Puerto Rico, which provided cared for up to 250 people at a time. The officers of the Commissioned Corps also helped support the civilian health care infrastructure.

From a utilitarian perspective, the benefit of these relief efforts is obvious. They were literally life-saving and health preserving for the thousands who were injured in the wreckage of wind and rain, ill from the collapse of public services, as well as those psychologically traumatized. And had these men and women of the VA, PHS, and DoD not come to the aid of the victims of these unprecedented national disasters, the toll of human suffering and bereavement would have been far worse.

Deontologically, each of these government employees did their duty; many volunteered, and even those who were ordered to assist did so with a compassion and dedication that went far beyond doing a job. None of the historic drives of humankind to place themselves in harm’s way—power, money, or fame—motivated those who answered the call; only a duty to serve and an intention to help.

Each person who left the security of home and the comfort of friends and family displayed the highest qualities of virtue ethics: altruism, professionalism, empathy, and integrity among other virtues.

In preparing for this column, I read stories of health care practitioners and nonclinical staff who not only reached out, but also reached beyond any expectation, clearly demonstrating outstanding professionalism and humanism.

I end with just one of these inspirational accounts. As Hurricane Irma approached the Florida coast, veteran employee Tim Myers braved the coming storm to get to work. That is far harder and braver than it seems, because Myers, who is a pharmacy technician and delivers medications to inpatients at the James A. Haley VA, is a quadriplegic in a wheelchair. The humility of his laconic description of his supererogatory conduct is equally impressive. “I appreciate that, but it really wasn’t that big of a deal to me,” Myers said.  “I mean, I had to get here.”⁵

An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.¹ Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.

The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”¹

The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.

It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.² All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.

Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.

There is a shortage of addiction and pain specialists in and outside the federal system.^3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.

Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”⁵

But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.

While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.

An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.¹ Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.

The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”¹

The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.

It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.² All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.

Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.

There is a shortage of addiction and pain specialists in and outside the federal system.^3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.

Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”⁵

But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.

While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.

An esteemed ethics colleague forwarded me a Washington Post column that raises an important, neglected aspect of the Choice program and other VA forms of purchased care: potentially unequal and uneven standards of care.¹ Congress authorized Choice to increase veterans’ ability to access needed clinical care in a timely and effective manner. The emphasis on access though may have inadvertently led to an equally serious gap in quality, especially for ethical standards of practice.

The Washington Post columnist Joe Davidson compares the often less demanding standard of opioid prescribing in the community with those of the VA and DoD. This difference in the monitoring of prescriptions the reporter suggests may be contributing to the epidemic of completed suicides—many by medication ingestion—and nonfatal but serious opioid overdoses. As Davidson writes, “The gap in coordination, adding to different clinical standards among VA and non-VA community providers, can be deadly. Health professionals outside the VA are not required to follow departmental guidelines.”¹

The VA and DOD are required to follow rigorous, evidence-based practices, documented in the VA/DoD Practice Guideline for Opioid Therapy for Chronic Pain revised and reissued in February 2017. In addition, VA has a comprehensive, systematic, and standardized program of education and monitoring its Opioid Safety Initiative (OSI). The OSI was launched to improve and rationalize opioid prescribing especially when opioids are combined with benzodiazepines, which increases the risk of lethal outcomes from overdoses.

It is not just journalists who have expressed concerns about this disparity in prescribing rigor: The VA Office of Inspector General and several veterans service organizations also have called attention to what is in effect a double standard in care.² All these entities have underscored another aspect of the Choice program that widens the quality and, hence, safety chasm—the fragmentation of clinical communication between community and VA providers. It is true that as of this writing, every state has passed prescription monitoring program (PMP) legislation. Prior to the change in federal regulation, VA was not permitted to release its controlled substance prescriptions to these pharmacy databases. But in the interest of patient safety, the privacy rules were modified to permit VA pharmacies to share records with the states. This has been a huge step forward in identifying patients who are receiving opioids, benzodiazepines, and stimulants, among other drugs, from a VAMC and 1 or more community prescribers.

Of course, it would be hubristic provincialism to think that there are not excellent clinicians and outstanding institutions in the community that equal or surpass the DoD/VA practice criteria. We are fortunate that because of Choice, veterans and service members now have available to them this level of expertise, which often is not present in smaller federal health care facilities. What is concerning, however, is those prescribers whose practice patterns are routinely and significantly below the bar and thereby place veterans in harms way.However, the efficacy of the PMPs to notify practitioners of prescribing patterns is dependent on the conscientiousness, given the death toll, even the conscience, of those who have prescribing privileges. I should emphasize that prescribing medications is a privilege and that states bestow this power only to those professionals who have met the stipulated education, training, credentialing, and licensing requirements. This professional preparation is crucial when there is not a shared medical record. Without the medical record, the practitioner, especiallyone who does not check the PMP or who does not have sufficient education and training in addiction and pain, is dependent on the history of the patient. The very substances being prescribed or sought may impair the ability of the patient to provide an accurate history due to ignorance, addiction, pain, or fear of losing pain relief.

There is a shortage of addiction and pain specialists in and outside the federal system.^3,4 Therefore, we need Choice in order to meet the needs of service members and veterans. Congress has authorized bureaucratic mechanisms and payment sources to enable veterans to receive treatment from community providers. But a regulatory means to ensure that those providers adhere to the same high standards of care as that of VA and DoD practitioners must be established.

Critics of the VA have in many cases rightly made accountability the watchword of their campaigns. To its credit, the VA has embraced the cause in the I CARE value of integrity. “Act with high moral principle. Adhere to the highest professional standards. Maintain the trust and confidence of all with whom I engage.”⁵

But that sense of responsibility must extend to all those who provide care to veterans—especially those who prescribe medications that have the immense double-edged potential to relieve pain and disability but at the same time also cause suffering and death.

While this inability to enforce VA/DoD responsible prescribing requirements in the community is likely more urgent and life threatening, there still are many other federal clinical and organizational policies and regulations to which the community is not required to adhere. I will discuss some of these and their potentially negative implications in future columns. For the promise of Choice to be realized, we all must work together to bear the highest possible standard of care for those who serve and have served.

If I simply let the title of this column stand alone, I suspect most readers of Federal Practitioner would fill in the blank with diseases, such as cancer, HIV, or even devastating genetic conditions, just as I would if presented with the statement without explication.

I read the sentence several weeks ago on a website for caregivers of patients with dementia while browsing for quite a different purpose, and it has haunted me ever since. As a consultation psychiatrist who has spent my career as a VA hospitalist, I am well aware of the sad reality of dementia, but against the backdrop of the aging veteran population, the poignancy of the human tragedy overwhelmed me.

Almost every day on the medical and surgical wards of the VA hospital where I have worked for nearly 2 decades, I see an aging veteran population. There are days when the average age of inpatients is pushing 70 years, and there are many patients in their 80s and 90s. The statistics show that my facility is by no means unique in the VA. Data from the American Community Survey Profile of veterans in 2015 indicate that the median age of veterans is 64 years whereas that of nonveterans is 41.1 The survey emphasized that this age factor has a rippling effect on many other demographic parameters, such as disability, income, and employment, all, in turn, impact the epidemiology of health and illness.¹

It is not just age that increases the likelihood that a veteran will develop dementia: Research has identified several aspects of military service that raise the risk of being diagnosed with major neurocognitive disorder, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition designation for dementia. Many families, patients, and even a few health care professionals may not realize that major neurocognitive disorder is the new neuropsychiatric term for dementia.

Also, many health care professionals do not realize that dementia is the sixth leading cause of death in the U.S.² Traumatic brain injury, posttraumatic stress disorder, and depression are identified as potential contributors to a higher incidence of dementia in service men and women often with onset at an earlier age.³ Given the prevalence of these comorbidities in persons who were in the military, the VA and DoD will face the medical and psychosocial challenges of providing not only clinical treatment, but also a range of social services for military personnel and veterans. Indeed, federal institutions like the GRECC (Geriatric Research Education and Clinical Center) already are engaged in cutting edge research, delivering high-quality medical treatment, and specialized geriatric and dementia care education and support.

Despite these impressive efforts, too often families ask me 2 crucial questions when a patient is already at a moderate or severe stage of the disease: Is there a cure, and will they get better with or without treatment? This lack of knowledge and understanding is by no means confined to federal health care.

A 2015 report from the Alzheimer’s Association found that 45% of patients with Alzheimer disease or their caregivers were not told about the diagnosis by the doctor.² Doctors reported that they were more likely to have informed the family of a cancer diagnosis at least in part because they felt there were treatments available and in some cases a cure.

Families ask these questions of me and other health care professionals in the hope of finding guidance. Often the veteran has been hospitalized after behavioral disturbances or wandering have made it impossible to care for the loved elder at home. The family is faced with a double blow: learning the patient has an incurable terminal disease and having to make the decision to place a grandmother or father in a nursing facility. Granted this woeful decision may have to be made even when the family has been fully informed at the time of diagnosis, but it is more distressing when the decision is needed immediately based on safety.

Husbands and wives of 50 years or more and adult children, graying themselves, often ask the second question about improvement. Although treatments exist that can help relieve symptoms and slow progression temporarily, the inexorable and tragic course of the wiping away of memory cannot be reversed or halted.

Not surprisingly, practitioners avoid telling patients and families about a dementia diagnosis because those conversations are painful and difficult. However, the news is much less agonizing to hear when there is time to enjoy the good days that remain and to make arrangements for finances and families. For these important reasons, VA emphasizes shared decision making as the cornerstone of geriatric care. Yet there can be no shared decisions without the compassionate and truthful telling about the diagnosis and the prognosis.

If I simply let the title of this column stand alone, I suspect most readers of Federal Practitioner would fill in the blank with diseases, such as cancer, HIV, or even devastating genetic conditions, just as I would if presented with the statement without explication.

I read the sentence several weeks ago on a website for caregivers of patients with dementia while browsing for quite a different purpose, and it has haunted me ever since. As a consultation psychiatrist who has spent my career as a VA hospitalist, I am well aware of the sad reality of dementia, but against the backdrop of the aging veteran population, the poignancy of the human tragedy overwhelmed me.

Almost every day on the medical and surgical wards of the VA hospital where I have worked for nearly 2 decades, I see an aging veteran population. There are days when the average age of inpatients is pushing 70 years, and there are many patients in their 80s and 90s. The statistics show that my facility is by no means unique in the VA. Data from the American Community Survey Profile of veterans in 2015 indicate that the median age of veterans is 64 years whereas that of nonveterans is 41.1 The survey emphasized that this age factor has a rippling effect on many other demographic parameters, such as disability, income, and employment, all, in turn, impact the epidemiology of health and illness.¹

It is not just age that increases the likelihood that a veteran will develop dementia: Research has identified several aspects of military service that raise the risk of being diagnosed with major neurocognitive disorder, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition designation for dementia. Many families, patients, and even a few health care professionals may not realize that major neurocognitive disorder is the new neuropsychiatric term for dementia.

Also, many health care professionals do not realize that dementia is the sixth leading cause of death in the U.S.² Traumatic brain injury, posttraumatic stress disorder, and depression are identified as potential contributors to a higher incidence of dementia in service men and women often with onset at an earlier age.³ Given the prevalence of these comorbidities in persons who were in the military, the VA and DoD will face the medical and psychosocial challenges of providing not only clinical treatment, but also a range of social services for military personnel and veterans. Indeed, federal institutions like the GRECC (Geriatric Research Education and Clinical Center) already are engaged in cutting edge research, delivering high-quality medical treatment, and specialized geriatric and dementia care education and support.

Despite these impressive efforts, too often families ask me 2 crucial questions when a patient is already at a moderate or severe stage of the disease: Is there a cure, and will they get better with or without treatment? This lack of knowledge and understanding is by no means confined to federal health care.

A 2015 report from the Alzheimer’s Association found that 45% of patients with Alzheimer disease or their caregivers were not told about the diagnosis by the doctor.² Doctors reported that they were more likely to have informed the family of a cancer diagnosis at least in part because they felt there were treatments available and in some cases a cure.

Families ask these questions of me and other health care professionals in the hope of finding guidance. Often the veteran has been hospitalized after behavioral disturbances or wandering have made it impossible to care for the loved elder at home. The family is faced with a double blow: learning the patient has an incurable terminal disease and having to make the decision to place a grandmother or father in a nursing facility. Granted this woeful decision may have to be made even when the family has been fully informed at the time of diagnosis, but it is more distressing when the decision is needed immediately based on safety.

Husbands and wives of 50 years or more and adult children, graying themselves, often ask the second question about improvement. Although treatments exist that can help relieve symptoms and slow progression temporarily, the inexorable and tragic course of the wiping away of memory cannot be reversed or halted.

Not surprisingly, practitioners avoid telling patients and families about a dementia diagnosis because those conversations are painful and difficult. However, the news is much less agonizing to hear when there is time to enjoy the good days that remain and to make arrangements for finances and families. For these important reasons, VA emphasizes shared decision making as the cornerstone of geriatric care. Yet there can be no shared decisions without the compassionate and truthful telling about the diagnosis and the prognosis.

If I simply let the title of this column stand alone, I suspect most readers of Federal Practitioner would fill in the blank with diseases, such as cancer, HIV, or even devastating genetic conditions, just as I would if presented with the statement without explication.

I read the sentence several weeks ago on a website for caregivers of patients with dementia while browsing for quite a different purpose, and it has haunted me ever since. As a consultation psychiatrist who has spent my career as a VA hospitalist, I am well aware of the sad reality of dementia, but against the backdrop of the aging veteran population, the poignancy of the human tragedy overwhelmed me.

Almost every day on the medical and surgical wards of the VA hospital where I have worked for nearly 2 decades, I see an aging veteran population. There are days when the average age of inpatients is pushing 70 years, and there are many patients in their 80s and 90s. The statistics show that my facility is by no means unique in the VA. Data from the American Community Survey Profile of veterans in 2015 indicate that the median age of veterans is 64 years whereas that of nonveterans is 41.1 The survey emphasized that this age factor has a rippling effect on many other demographic parameters, such as disability, income, and employment, all, in turn, impact the epidemiology of health and illness.¹

It is not just age that increases the likelihood that a veteran will develop dementia: Research has identified several aspects of military service that raise the risk of being diagnosed with major neurocognitive disorder, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition designation for dementia. Many families, patients, and even a few health care professionals may not realize that major neurocognitive disorder is the new neuropsychiatric term for dementia.

Also, many health care professionals do not realize that dementia is the sixth leading cause of death in the U.S.² Traumatic brain injury, posttraumatic stress disorder, and depression are identified as potential contributors to a higher incidence of dementia in service men and women often with onset at an earlier age.³ Given the prevalence of these comorbidities in persons who were in the military, the VA and DoD will face the medical and psychosocial challenges of providing not only clinical treatment, but also a range of social services for military personnel and veterans. Indeed, federal institutions like the GRECC (Geriatric Research Education and Clinical Center) already are engaged in cutting edge research, delivering high-quality medical treatment, and specialized geriatric and dementia care education and support.

Despite these impressive efforts, too often families ask me 2 crucial questions when a patient is already at a moderate or severe stage of the disease: Is there a cure, and will they get better with or without treatment? This lack of knowledge and understanding is by no means confined to federal health care.

A 2015 report from the Alzheimer’s Association found that 45% of patients with Alzheimer disease or their caregivers were not told about the diagnosis by the doctor.² Doctors reported that they were more likely to have informed the family of a cancer diagnosis at least in part because they felt there were treatments available and in some cases a cure.

Families ask these questions of me and other health care professionals in the hope of finding guidance. Often the veteran has been hospitalized after behavioral disturbances or wandering have made it impossible to care for the loved elder at home. The family is faced with a double blow: learning the patient has an incurable terminal disease and having to make the decision to place a grandmother or father in a nursing facility. Granted this woeful decision may have to be made even when the family has been fully informed at the time of diagnosis, but it is more distressing when the decision is needed immediately based on safety.

Husbands and wives of 50 years or more and adult children, graying themselves, often ask the second question about improvement. Although treatments exist that can help relieve symptoms and slow progression temporarily, the inexorable and tragic course of the wiping away of memory cannot be reversed or halted.

Not surprisingly, practitioners avoid telling patients and families about a dementia diagnosis because those conversations are painful and difficult. However, the news is much less agonizing to hear when there is time to enjoy the good days that remain and to make arrangements for finances and families. For these important reasons, VA emphasizes shared decision making as the cornerstone of geriatric care. Yet there can be no shared decisions without the compassionate and truthful telling about the diagnosis and the prognosis.