Editorial

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

Memorial Day is the most solemn of all American military commemorations. It is the day when we honor those who sacrificed their lives so that their fellow citizens could flourish in freedom. At 3 PM, a grateful nation is called to observe 2 minutes of silence in remembrance of the heroes who died in battle or of the wounds they sustained in combat. Communities across the country will carry out ceremonies, lining national cemeteries with flags, holding patriotic parades, and conducting spiritual observances.¹

Sadly, almost as long as there has been a United States, there has been a parallel practice dishonoring the uniform and deceiving veterans and the public alike known as stolen valor. Stolen valor is a persistent, yet strange, psychological behavior: individuals who never served in the US Armed Forces claim they have done heroic deeds for which they often sustained serious injuries in the line of duty and almost always won medals for their heroism.² This editorial will trace the US legal history of stolen valor cases to provide the background for next month’s editorial examining its clinical and ethical aspects.

While many cases of stolen valor do not receive media attention, the experience of Sarah Cavanaugh, a former VA social worker who claimed to be a marine veteran who served in Iraq and Afghanistan, was the subject of the Deep Cover podcast series.³ Cavanaugh had claimed that an improvised explosive device blew up her Humvee, crushing her hip. Still she somehow was able to help her fellow Marines and earned the Bronze Star among other decorations for her heroism. That was not the only lie Cavanaugh told: she also told her friends and wife that she had advanced lung cancer due to burn pit exposure. In line with the best-worst of those who have stolen valor, her mastery of manipulation enabled her to become the commander of a local Veterans of Foreign Wars post. Using stolen identities and fraudulent documents, Cavanaugh was able to purloin veteran benefits, donated leave from other VA employees and money, and stole goods and services from various charitable organizations whose mission was to help wounded veterans and those struggling to adjust to civilian life. Before law enforcement unraveled her sordid tale, she misappropriated hundreds of thousands of dollars in VA benefits and donations and exploited dozens of generous veterans and compassionate civilians.⁴

Cavanaugh’s story was so sordidly compelling that I kept saying out loud to myself (and my spouse), “This has to be illegal.” The truth about stolen valor law is far more ambivalent and frustrating than I had anticipated or wanted. The first insult to my sense of justice was that lying about military service is not in itself illegal: you can pad your military resume with unearned decorations or impress a future partner or employer with your combat exploits without much fear of legal repercussions. The legal history of attempting to make stealing valor a crime has almost as many twists and turns as the fallacious narratives of military imposters and illustrates the uniquely American experiment in balancing freedom and fairness.

The Stolen Valor Act of 2005 made it a federal misdemeanor to wear, manufacture, or sell military decorations, or medals (Cavanaugh bought her medals online) without legal authorization. It also made it a crime to falsely represent oneself as having been the recipient of a decoration, medical, or service badge that Congress or the Armed Forces authorized. There were even stiffer penalties if the medal was a Silver Star, Distinguished Service Cross, US Air Force or US Navy Cross, or Purple Heart. Punishments include fines and imprisonment. The stated legislative purpose was to prohibit fraud that devalued military awards and the dignity of those who legitimately earned them.⁵

Next comes a distinctly American reaction to the initial Congressional attempt to protect the legacy of those who served—a lawsuit. Xavier Alvarez was an official on a California district water board claimed to be a 25-year veteran of the US Marine Corps wounded in combat and received the Congressional Medal of Honor. The Federal Bureau of Investigation exposed the lie and instead of the nation’s highest honor, Alvarez was the first to be convicted under the Stolen Valor Act of 2005. Alvarez appealed the decision, ironically claiming the law violated his free speech rights. The case landed in the Supreme Court, which ruled that the Stolen Valor Act did indeed violate the Free Speech Clause of the First Amendment. The majority opinion found the Act as passed was too encompassing of all speech and needed to target only cases in which false statements resulted in actual harm.⁶

The Stolen Valor Act of 2013 amends the criminal code regarding fraudulent claims about military service to include those who don’t only lie but also profit from it, as Cavanaugh did. The revised act specifically focuses on individuals who claim to have earned military honors for the intended purpose of obtaining money, property, or any other tangible benefit.⁷

Despite the complicated nature of Stolen Valor Law, it did prevail in Cavanaugh’s case. A US District Court Judge in Rhode Island found her guilty of stolen valor in all its permutations, along with identity theft of other veterans’ military and medical records and fraud in obtaining benefits and services intended for real veterans. Cavanaugh was sentenced to 70 months in federal prison, 3 years of supervised release, ordered to pay $284,796.82 in restitution, and to restore 261 hours of donated leave to the federal government, charitable organizations, and good Samaritans she duped and swindled.⁸

The revised law under which Cavanaugh was punished lasted 10 years until another classically American ethical concern—privacy—motivated additional legislative effort. A 2023/2024 US House of Representatives proposal to amend the Stolen Valor Act would have strengthened the privacy protections afforded military records. It would have required the information to only be accessed with the permission of the individual who served or their family or through a Freedom of Information Act request. This would make the kind of journalistic and law enforcement investigations that eventually caught Cavanaugh in her lies far more laborious for false valor hunters while at the same time preventing unscrupulous inquiries into service members’ personal information. Advocates for free speech and defenders of military honor are both lobbying Congress; as of this writing the legislation has not been passed.⁹

As we close part 1 of this review of stolen valor, we return to Memorial Day. This day provides the somber recognition that without the brave men and women of integrity who died in defense of a democracy that promotes the political activity of its citizens, we would not even be able to have this debate over justice, freedom, and truth.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

The uselessness of men above sixty years of age and the incalculable benefit it would be in commercial, in political, and in professional life, if as a matter of course, men stopped working at this age.

Sir William Osler¹

The first time I remember hearing the word retirement was when I was 5 or 6 years old. My mother told me that my father had been given new orders: either be promoted to general and move to oversee a hospital somewhere far away, or retire from the Army. He was a scholar, teacher, and physician with no interest or aptitude for military politics and health care administration. Reluctantly, he resigned himself to retirement before he had planned. I recall being angry with him, because in my solipsistic child mind he was depriving me of the opportunity to live in a big house across from the parade field, where the generals lived or having a reserved parking spot in front of the post exchange. As a psychiatrist, I suspect that the anger was a primitive defense against the fear of leaving the only home I had ever known on an Army base.

I recently finished reading Michael Bliss’s seminal biography of Sir William Osler (1848-1919), the great Anglo-American physician and medical educator.² Bliss found few blemishes on Osler’s character or missteps in his stellar career, but one of the few may be his views on retirement. The epigraph is from an address Osler gave before leaving Johns Hopkins for semiretirement in Oxford, England. The farewell speech caused a media controversy with his comments reflecting attitudes that seem ageist today, when many people are active, productive, and happy long past the age of 60 years.³ I do not endorse Osler’s philosophy of aging, nor his exclusion of women (if I did, I would not be around to write this editorial). Not even Osler himself followed his advice: he was active in medicine almost until his death at 70 years old.²

Yet like many of my fellow federal health care practitioners (HCPs), I have been thinking about and planning for retirement earlier than expected, given the memos and directives about voluntary early retirement, deferred resignation, and reductions in force.^4,5 The COVID-19 pandemic sadly compelled many burned-out and traumatized HCPs to cross the retirement Rubicon far sooner than they imagined.⁶

A Google search for information about HCP retirement, particularly among physicians, produces a cascade of advisory articles. They primarily focus on finances, with many pushing their own commercial agenda for retirement planning.⁷ Although money is a necessary piece of the retirement puzzle, for HCPs it may not be sufficient to ensure a healthy and satisfying retirement. Two other considerations may be even more important to weigh in making the retirement decision, namely timing and meaning.⁸

For earlier generations of HCPs, work was almost their sole identity. Although younger practitioners are more likely to embrace a better work-life balance, it is still a driving factor for many in the decision to retire.⁹ It is not just about the cliché of being a workaholic, rather many clinicians continue to enjoy lifelong learning, the rewards of helping people in need, and professional satisfaction. HCPs also spend a longer time training than many other professions; perhaps since we waited so long to practice, we want to stay a little longer.¹⁰ For those whose motivation for federal practice was a commitment to service, these may be even more powerful incentives to continue working.

When a nurse, physician, pharmacist, or social worker no longer finds the same gratification and stimulation in their work, whether due to unwelcome changes in the clinical setting or the profession at large, declining health or emotional exhaustion, or the very human need to move onto another phase of life (what Osler likely really meant), then that may be a signal to think hard about retiring. Of course, there have always been—and will continue to be—professionals of all stripes who, even in the most agreeable situation, just cannot wait to retire. Simply because there are so many other ways they want to spend their remaining energy and time: travel, grandchildren, hobbies, even a second career. Because none of us knows how far out our life extends, it is prudent to periodically ask what is the optimal path that combines both purpose and well-being.

All of us as HCPs, and even more as human beings with desires and duties far beyond our respective professions, face a dilemma: a choice between 2 goods that cannot both be fulfilled simultaneously. This is likely why HCPs frequently do what is technically called a phased retirement, a fancy name for working part-time, or retiring from 1 position and taking up another. This temporizes the decision and tempers the bittersweet emotional experience of leaving the profession in one way, and in another, it delays the inevitable.

Over the last few years, I have learned 2 important lessons while watching many of my closest friends retire. First, for those who are still working and those who are retired may seem to inhabit a separate country; hence, special efforts must be made to both appreciate them while they are in our immediate circle of concern and to make efforts to stay in contact once they are emeriti. It is almost as if after being a daily integral aspect of the workplace they have passed into a different dimension of existence. In terms of priorities and mindsets, many of them have. Second, what makes retirement a reality with peace and growth rather than regret and stagnation is owning the decision to retire. There are always constraints: financial, medical, and familial. However, those who retire on their own terms and not primarily in response to fear or uncertainty appear to fare better than those feeling the same pressures who give away their power.¹¹ Having read about retirement in the last months, the best advice I have seen is from Harry Emerson Fosdick, a Protestant minister in the early 20th century: “Don’t simply retire from something; have something to retire to.”¹²

I have not yet decided about my retirement. Whatever decision you make, remember it is solely yours. After a lifetime of caring for others, retirement is all about caring for yourself.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

If I can stop one heart from breaking, I shall not live in vain.
Emily Dickinson¹

The celebration of Valentine’s Day has made the association of hearts with the month of February almost automatic. There is, though, another commemoration of hearts in the second month of the year with special significance for federal practice: American Heart Month. President Lyndon B. Johnson proclaimed February as American Heart Month in 1964 to raise awareness of the enormous human and economic cost of cardiovascular diseases (CVD) that impact many Americans in their prime.

The Centers for Disease Control and Prevention estimates that 1 in 5 deaths in the United States is due to CVD, which includes coronary artery disease, heart failure, heart attack, and stroke.² American Heart Month aims to increase public attention to heart disease prevention and promote research to develop better diagnostic treatment methods for the leading cause of death in most populations.

Forty years after this proclamation, the American Heart Association launched Go Red for Women. On the first Friday of American Heart Month, Americans are encouraged to wear red to draw attention to CVD as the leading cause of death among women as well as men.^2,3 A 2024 report from the American Heart Institute and McKinsey Health Institute attributed at least one-third of the overall health care disparities between men and women to inequities in CVD care. These detrimental differences in the management of heart disease in women encompass both diagnostic misadventures and failure to promptly employ effective therapeutics. CVD morbidity and mortality data for Black women are even higher due to multiple and overlapping social determinants of health.⁴

Higher rates of hypertension, hyperlipidemia, and smoking in women veterans compared with civilians have resulted in an increased risk of heart disease and a 26% higher rate of CVD-related mortality. One in 10 women enrolled in US Department of Veterans Affairs (VA) health care has CVD. Research shows that these women are less likely compared to male veterans to receive counseling about exercise or to be prescribed medications such as statins, even when evidence-based treatment guidelines are followed. The increased rates of heart disease and its complications in women veterans are in part due to risk factors related to military service such as posttraumatic stress disorder (PTSD) and depression, which exceed the rates of nonveteran women.⁵

The heart has a long association with psychological health. For millennia, philosophers and physicians alike believed the heart was the center of the self and the locus of sentience. Even William Harvey, whose discovery of the circulation of blood earned him the title of the father of cardiology, viewed the heart as the life force.⁶ The heart has been explicitly linked to American military trauma since the Civil War era diagnosis of Soldier’s Heart. More recently, mutual genetic vulnerabilities to PTSD and CVD have been posited.⁷ Indeed, research with male combat veterans helped establish the association.

Until recently, there has been a dearth of research to establish the same connection between CVD and PTSD in women veterans, who have elevated rates of PTSD in part due to higher rates of homelessness and military sexual trauma.⁵ Due in large part to the work of a group of VA and US Department of Defense (DoD) researchers, this is starting to change. A research group conducted a retrospective longitudinal study using electronic health record data from nearly 400,000 women veterans to determine the propensity scores of associations between a PTSD diagnosis and the incidence of heart disease over nearly 5 years. The hazard ratio (HR) for the incidence of CVD in women with trauma was 1.44 (compared with matched controls) and even higher in younger women (HR, 1.72).⁸ Researchers also compared CVD mortality in civilian and veteran women and found a concerning trend: not only were mortality rates higher in veterans, but they also did not benefit from an overall improved trend in deaths from heart disease over the past 20 years.⁹

Two years later, the same VA/DoD research group conducted additional analysis on the dataset used in the prior study to examine potential mechanisms underlying the epidemiological link between CVD and PTSD in women veterans. Women with and without PTSD were matched on age and traditional CVD risk factor parameters. The findings demonstrated an association of PTSD with higher risks of diabetes, hypertension, hyperlipidemia, and smoking. However, these traditional risk factors only accounted for one-fourth of the total association. About 34% of the risk was attributed to depression, anxiety, and substance use disorders, as well as obesity and neuroendocrine disorders. This leaves slightly more than half of the elevated risk of CVD unexplained.¹⁰

This research, along with other studies, have identified several mechanisms elucidating the link. Promising translational research may lead to new diagnostic techniques or improved treatment modalities for CVD in women. The most established etiology is that veterans with PTSD have a higher prevalence of multiple CVD risk factors, including smoking, substance use disorders, obesity, poor diet, sleep disorders, depression, and inactivity. There is also increased recognition that PTSD involves neuroendocrine dysfunction in the stress-response that triggers a cascade of metabolic responses (eg, chronic inflammation) that contribute to the onset and progression of heart disease.¹¹

This burgeoning scientific work on CVD and its close association with PTSD and the role of both traditional and nontraditional risk factors can inform VA efforts to educate frontline VA and DoD clinicians, leading to better care for women veterans. Whether a practitioner provides primary, specialty, or mental health care, this new knowledge can inform efforts to optimize prevention and treatment for both PTSD and CVD. For example, the VA/DoD researchers recommend prescribing antidepressants that are less likely to cause or worsen hypertension and to employ psychotherapies known to reduce the harmful CVD effects of increased stress acting through the hypothalamic-pituitary axis. These studies empower VA clinicians to realize Emily Dickinson’s aspiration to prevent trauma and reduce damage to both the psyche and the soma. The health of every veteran’s heart and mind matters, as does every effort of federal practitioners to protect and heal it.

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

As the movement to improve quality in health care has evolved over the past several decades, organizations whose missions focus on supporting and promoting quality in health care have defined essential concepts, standards, and measures that comprise quality and that can be used to guide quality improvement (QI) work. The World Health Organization (WHO) defines quality in clinical care as safe, effective, and people-centered service.¹ These 3 pillars of quality form the foundation of a quality system aiming to deliver health care in a timely, equitable, efficient, and integrated manner. The WHO estimates that 5.7 to 8.4 million deaths occur yearly in low- and middle-income countries due to poor quality care. Regarding safety, patient harm from unsafe care is estimated to be among the top 10 causes of death and disability worldwide.² A health care QI plan involves identifying areas for improvement, setting measurable goals, implementing evidence-based strategies and interventions, monitoring progress toward achieving those goals, and continuously evaluating and adjusting the plan as needed to ensure sustained improvement over time. Such a plan can be implemented at various levels of health care organizations, from individual clinical units to entire hospitals or even regional health care systems.

The Institute of Medicine (IOM) identifies 5 domains of quality in health care: effectiveness, efficiency, equity, patient-centeredness, and safety.³ Effectiveness relies on providing care processes supported by scientific evidence and achieving desired outcomes in the IOM recommendations. The primary efficiency aim maximizes the quality of health care delivered or the benefits achieved for a given resource unit. Equity relates to providing health care of equal quality to all individuals, regardless of personal characteristics. Moreover, patient-centeredness relates to meeting patients’ needs and preferences and providing education and support. Safety relates to avoiding actual or potential harm. Timeliness relates to obtaining needed care while minimizing delays. Finally, the IOM defines health care quality as the systematic evaluation and provision of evidence-based and safe care characterized by a culture of continuous improvement, resulting in optimal health outcomes. Taking all these concepts into consideration, 4 key attributes have been identified as essential to the global definition of health care quality: effectiveness, safety, culture of continuous improvement, and desired outcomes. This conceptualization of health care quality encompasses the fundamental components and has the potential to enhance the delivery of care. This definition’s theoretical and practical implications provide a comprehensive and consistent understanding of the elements required to improve health care and maintain public trust.

Health care quality is a dynamic, ever-evolving construct that requires continuous assessment and evaluation to ensure the delivery of care meets the changing needs of society. The National Quality Forum’s National Voluntary Consensus Standards for health care provide measures, guidance, and recommendations on achieving effective outcomes through evidence-based practices.⁴ These standards establish criteria by which health care systems and providers can assess and improve their quality performance.

In the United States, in order to implement and disseminate best practices, the Centers for Medicare & Medicaid Services (CMS) developed Quality Payment Programs that offer incentives to health care providers to improve the quality of care delivery. This CMS program evaluates providers based on their performance in the Merit-Based Incentive Payment System performance categories.⁵ These include measures related to patient experience, cost, clinical quality, improvement activities, and the use of certified electronic health record technology. The scores that providers receive are used to determine their performance-based reimbursements under Medicare’s fee-for-service program.

The concept of health care quality is also applicable in other countries. In the United Kingdom, QI initiatives are led by the Department of Health and Social Care. The National Institute for Health and Care Excellence (NICE) produces guidelines on best practices to ensure that care delivery meets established safety and quality standards, reaching cost-effectiveness excellence.⁶ In Australia, the Australian Commission on Quality and Safety in Health Care is responsible for setting benchmarks for performance in health care systems through a clear, structured agenda.⁷ Ultimately, health care quality is a complex and multifaceted issue that requires a comprehensive approach to ensure the best outcomes for patients. With the implementation of measures such as the CMS Quality Payment Programs and NICE guidelines, health care organizations can take steps to ensure their systems of care delivery reflect evidence-based practices and demonstrate a commitment to providing high-quality care.

Implementing a health care QI plan that encompasses the 4 key attributes of health care quality—effectiveness, safety, culture of continuous improvement, and desired outcomes—requires collaboration among different departments and stakeholders and a data-driven approach to decision-making. Effective communication with patients and their families is critical to ensuring that their needs are being met and that they are active partners in their health care journey. While a health care QI plan is essential for delivering high-quality, safe patient care, it also helps health care organizations comply with regulatory requirements, meet accreditation standards, and stay competitive in the ever-evolving health care landscape.

Corresponding author: Ebrahim Barkoudah, MD, MPH; [email protected]

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

This issue of the Journal of Clinical Outcomes (JCOM) debuts a new cover design that brings forward the articles and features in each issue. Although the Journal’s cover has a new look, JCOM’s goals remain the same—improving care by disseminating evidence of quality improvement in health care and sharing access to the medical literature with our readers. We continue our mission to promote the best medical practice by providing clinicians with updates and communicating advances that lead to measurable improvement in health care delivery, quality, and outcomes.

As we continue the work of improving health care quality, knowledge gaps and unmet needs in the literature remain. These unmet needs are evident throughout all phases of health care delivery. Moreover, the Institutes of Medicine report that centered on efforts to build a safer health care environment by redesigning health care processes remains salient.¹ The journey to continuous improvement in health care, where we achieve threshold change in the quality of each process and across the entire health care system, requires collective effort. Such efforts include establishing clear metrics and measurements for improvement goals throughout the patient’s journey through diagnosis, treatment, transitions of care, and disease management.^2,3 To address evidence and knowledge gaps in the literature, JCOM publishes reports of original studies and quality improvement projects as well as reviews, providing its 30,000 readers with new evidence to implement in daily practice. We welcome submissions of original research reports, reports of quality improvement projects that follow the SQUIRE 2.0 standards,⁴ and perspectives on developments and innovations in health care delivery.

The next chapter in health care delivery improvement will encompass value-based care.⁵ This new era of clinical outcomes management will dictate the metrics and outcomes reporting⁶ and how to plan future investments. The value-based phase will increase innovation and shape policies that advance population health, transforming every step in the care delivery journey.⁷ The next phase in health care delivery will also create a viable financial structure while implementing effective performance measures for optimal outcomes through patient-centered care and optimization of cost and care strategies. In light of health care’s evolution toward a value-based model, JCOM welcomes submissions of manuscripts that explore themes central to this model, including patient-centered care, implementation of best practices, system design, safety, cost-effectiveness, and the balance between cost optimization and quality. For JCOM’s authors and readers, our editorial team remains commited to the highest standards in timely publishing to support our community through our collective expertise and dedication to quality improvement.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

Disclosures: None reported.

The Institute of Medicine brought much-needed attention to the need for process improvement in medicine with its seminal report To Err Is Human: Building a Safer Health System, which was issued in 1999, leading to the quality movement’s call to close health care performance gaps in Crossing the Quality Chasm: A New Health System for the 21st Century.^1,2 Quality improvement science in medicine has evolved over the past 2 decades to include a broad spectrum of approaches, from agile improvement to continuous learning and improvement. Current efforts focus on Lean-based process improvement along with a reduction in variation in clinical practice to align practice with the principles of evidence-based medicine in a patient-centered approach.³ Further, the definition of quality improvement under the Affordable Care Act was framed as an equitable, timely, value-based, patient-centered approach to achieving population-level health goals.⁴ Thus, the science of quality improvement drives the core principles of care delivery improvement, and the rigorous evidence needed to expand innovation is embedded within the same framework.^5,6 In clinical practice, quality improvement projects aim to define gaps and then specific steps are undertaken to improve the evidence-based practice of a specific process. The overarching goal is to enhance the efficacy of the practice by reducing waste within a particular domain. Thus, quality improvement and implementation research eventually unify how clinical practice is advanced concurrently to bridge identified gaps.⁷

System redesign through a patient-centered framework forms the core of an overarching strategy to support system-level processes. Both require a deep understanding of the fields of quality improvement science and implementation science.⁸ Furthermore, aligning clinical research needs, system aims, patients’ values, and clinical care give the new design a clear path forward. Patient-centered improvement includes the essential elements of system redesign around human factors, including communication, physical resources, and updated information during episodes of care. The patient-centered improvement design is juxtaposed with care planning and establishing continuum of care processes.⁹ It is essential to note that safety is rooted within the quality domain as a top priority in medicine.¹⁰ The best implementation methods and approaches are discussed and debated, and the improvement progress continues on multiple fronts.¹¹ Patient safety systems are implemented simultaneously during the redesign phase. Moreover, identifying and testing the health care delivery methods in the era of competing strategic priorities to achieve the desirable clinical outcomes highlights the importance of implementation, while contemplating the methods of dissemination, scalability, and sustainability of the best evidence-based clinical practice.

The cycle of quality improvement research completes the system implementation efforts. The conceptual framework of quality improvement includes multiple areas of care and transition, along with applying the best clinical practices in a culture that emphasizes continuous improvement and learning. At the same time, the operating principles should include continuous improvement in a simple and continuous system of learning as a core concept. Our proposed implementation approach involves taking simple and practical steps while separating the process from the outcomes measures, extracting effectiveness throughout the process. It is essential to keep in mind that building a proactive and systematic improvement environment requires a framework for safety, reliability, and effective care, as well as the alignment of the physical system, communication, and professional environment and culture (Figure).

In summary, system design for quality improvement research should incorporate the principles and conceptual framework that embody effective implementation strategies, with a focus on operational and practical steps. Continuous improvement will be reached through the multidimensional development of current health care system metrics and the incorporation of implementation science methods.

Corresponding author: Ebrahim Barkoudah, MD, MPH, Department of Medicine, Brigham and Women’s Hospital, Boston, MA; [email protected]

Disclosures: None reported.