Published in Federal Times, November 17, 1997, page 10:

Dozens of Veterans Affairs Department doctors, at a gathering to discuss the future of the agency, vented frustration over a changing system they feel is leaving them and their patients out in the cold.

"Doctors are being removed from more and more of the decision-making processes, and they are being replaced by people who never went to medical school," said Samuel Spagnolo, president of the National Association of VA Physicians and Dentists and a doctor at the Washington, D.C. VA medical center.

The Nov. 4 summit in Washington, hosted by the association, brought more than 100 doctors and dentists together with other health professionals, government leaders, and interest groups to discuss the future of the VA's health care system.

VA is going through "enormous" change, Spagnolo said, partly due to the oversight of Kenneth Kizer, VA's undersecretary for health.

Like the private sector, VA is moving toward a "managed care" system that is replacing hospitals with clinics, inpatient care with outpatient care, and doctors with nurses in some circumstances.The changes are popular with Congress and the administration because of restructuring and cost savings. According to VA, the changes have led to:

Kizer was met at the summit with a skeptical crowd of physicians and dentists who told of problems with the changes.

One of the trends that angers doctors most is giving increased responsibility to advanced-practice nurses.

The supervision of nurses is inconsistent, and not all nurses given broader responsibilities have advanced-practice degrees, said Herbert Rose, past president of the association, and associate chief of staff of research and development at the Bronx VA medical center in New York.

"It crosses a line, and that line rests with physicians," Rose said. "Unfortunately, it's a trend that will dilute quality care and increase risks to patients."

Increased responsibility for nurses is about "combining skills and talents," not about replacing doctors, Kizer said.

The changes also are a distraction to doctors, Rose said.

"Like most physicians, I wish Washington would leave us alone to practice medicine."

Like many at the summit, Rose said the changes promote cost savings over quality care.

"Management took a bureaucratic solution, added middle management, and bypassed doctors," he said.

Rose drew applause when he suggested the VA "Bill of Rights", posted in each hospital, include a statement that "every patient has the right see a health specialist."

Robert Kaplan, an internist and infectious disease specialist at the Long Beach, Calif. VA medical center, said that is now not always possible. A 10 percent staff cut there has affected primary care "very, very severely", with some patients being sent elsewhere, he said.

Some said they believe managed care, with its emphasis on cost savings, is inappropriate for VA patients, most of whom are elderly and have special care needs.

Mark Tucker, director of dental affairs for the Association and an oral surgeon in Tampa, Fla., objected to business terms, such as "client" and "customer" being applied to patients.

Doctors and dentists are asked to see more outpatients, more of whom are indigent, aging, or disabled, in shorter time, Tucker said. And they have more responsibilities because of the staff cuts.

"Doctors are typing reports, taking vital signs, and cleaning the care areas," he said.

clinicalfreedom: "the ability of the patient and the physician to do all that is medically necessary without interference."