Caring Under a Microscope

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In the midst of winter, I found there was, within me, an invincible summer.And that makes me happy. For it says that no matter how hard the world pushes against me, within me, there’s something stronger—something better, pushing right back.
- Albert Camus1



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

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

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

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

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

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

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

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

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

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

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

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