The biggest news in ethics recently is the Veterans Affairs scandal, in which secret wait lists were allegedly kept to obscure the long delays for appointments. I seem to have a different perspective than the president, who said:

"How do we make sure that there is no slippage between somebody making a phone call and them getting an appointment scheduled. And let’s have a realistic time for how soon they’re going to get an appointment. Those are things that don’t require rocket science. It requires execution; it requires discipline; it requires focus."¹

Execution, discipline, focus. I think the word the president was looking for was honesty.

Meanwhile, a VA whistleblower who told CNN about the problems at the Phoenix facility said Friday he was saddened by [Gen. Eric] Shinseki’s resignation under such circumstances.

"The VA administrators got way too focused on having good numbers, and they forgot the most important mandate, the reason we all work at the VA – to take care of veterans, to save their lives and give them good medical care," Dr. Sam Foote said.

"The next secretary’s biggest challenge will be to get that refocused and make sure the number one job is taking care of veterans – not worrying about their bureaucratic careers," Dr. Foote added.²

This analysis of being "too focused" echoes the analysis 4 months ago of a scandal involving cheating on proficiency tests at missile bases in Montana. In that situation, people were similarly focused on meeting numbers and lost track of the big picture.

"Leadership’s focus on perfection led commanders to micromanage their people," said [Lt. Gen. Stephen Wilson, the commander of the Air Force’s Global Strike Command,] pointing to pressure to get 100% scores on monthly proficiency exams when only 90% was necessary to pass. ... Leaders lost sight of the fact that execution in the field is more important than what happens in the classroom."³

"This is absolutely unacceptable behavior and it is completely contrary to our core values in the Air Force, and as everybody here knows, the No. 1 core value for us is integrity," Air Force Secretary Deborah Lee James told reporters.⁴

I’ll accept integrity as equivalent to honesty.

As in the VA scandal, the missile scandal initially seemed isolated, but on further investigation was determined to be widespread, with up to 20% of the 190-member force implicated at one point. Equally concerning to leadership was the fact that many more people were aware cheating was going on, but did not act on it. I’ve often seen the term teamwork used to justify that behavior or lack thereof.

Are the delays at the VA hospitals unique? Not in my experience. Just last month while making an appointment to see a sub-subspecialist, I was told they were scheduling 5 months out. I called back to my primary care physician, who made a call, and I was soon contacted with an appointment for about a week later. Did I get any preferential consideration as a professional courtesy because I’m a physician? I don’t know. Very possibly. Did I benefit from knowing the system and anticipating that if I called my doctor, an earlier appointment would be arranged? Absolutely. I’ve made those calls myself advocating for my own patients when I hear about a delay that seems too long. It is part of being a patient advocate.

This is a fairly (that may be a poor choice of adjective) common practice when access is limited, but it can become a significant source of injustice. I’m aware of one health care system with long delays in scheduling subspecialty appointments after hospitalizations, up to 4-5 months. However, they do a great job, when called by a member of their panel of frequently referring primary doctors, at fitting people in early. The impact is that patients who have a personal physician (which correlates with good insurance) routinely jump the queue and get seen promptly. Patients who don’t have an advocate, or who go to one of the low-income clinics, may not get care or get frustrated and look elsewhere. This arrangement allows the system to claim it sees Medicaid patients while actually seeing only a limited fraction. Despicably evil, but effective. Is there discriminatory intent? Unknown and hard to prove. Disparate impact? Absolutely. Public outrage? Nope. Public ignorance, apathy, and a good public relations department seem to avert scandal.

Focusing on the numbers, pay for performance, Press Ganey scores, getting the top box checkmark – do these take focus away from providing the best clinical therapies? One would hope professionalism would keep pediatricians focused on the noble pursuit of providing health care for children. But leadership and an occasional emphasis on honesty couldn’t hurt.

Dr. Powell is a pediatric hospitalist and clinical ethics consultant living in St. Louis.

References

1. http://www.whitehouse.gov/the-press-office/2014/05/30/statement-president

2. http://www.cnn.com/2014/05/30/politics/va-hospitals-shinseki/index.html

3. http://www.cnn.com/2014/03/27/us/air-force-cheating-investigation

4. http://www.cnn.com/2014/01/15/politics/air-force-nuclear-scandal

Scandals, focus, leadership, and honesty