Presented at the National Summit Meeting of the National Association of Veterans Administration Physicians and Dentists, Washington, D.C., November 4, 1997:

When Dr. Kizer became Undersecretary for Health some three years ago, he stated that one would witness in the VA Health Care System the most profound change to ever have occurred in a Government Agency. I don't know if he has as yet achieved his goal, but I expect that much more remains to be accomplished. The VA has changed in many respects, far more than I would have believed possible. On the other hand it has not changed in many other respects, which I believe is fortunate, since there is much that is outstanding about this System which should be preserved.

In truth, the clarion call that was sounded for a "new VA" was not welcomed by many of the VA Medical Staff. This should be no surprise, since the traditional priorities of the System were to be reordered. Rather than high-quality medical care to which the Staff subscribes, the new top priority became "customer satisfaction", followed by increased efficiency of health care delivery intended to reduce costs, with only scant mention given to quality of care. It did not take long for management to realize that physicians "did not get the message" and that physicians were "the problem" standing in the way of progress. Management's solution, at a number of Medical Centers, was the typical bureaucratic solution, namely, to create a new level of middle management to bypass the Medical Staff on issues of healthcare delivery. This new VA bureaucracy contains few physicians, is very inexperienced, and has great difficulty in executing its restructuring plans. Its mindset is to refuse to talk with or seek input from the Medical Staff, since the Staff is viewed as having a "conflict of interest" on matters of delivery of medical care. Manging thus becomes management by edict, rather than by consensus.

The message that management failed to grasp is that to achieve its goals, it needs the cooperation and input of its Medical Staff. Take the case of customer satisfaction. I agree that in one sense patients are customers, since they can take their business elsewhere. But they are also patients of one or more physicians. When they are satisfied that their doctors have addressed their medical problems in a skilled manner and are concerned for their well being, they become satisfied customers. Management alone can improve service, but cannot replace the central component, which is the work of physicians. Staff physicians, particularly at medical centers that are losing patients, increasingly understand the necessity for improving both patient and customer satisfaction.

Local management also fails to understand the importance of quality care. Quality depends on a core of medical specialists, not surrogate physicians. Everyone knows this, including VA patients. HMOs are beginning to take quality seriously. If the VA is to assure its patients quality care, it should add to its "Patients Bill of Rights", which is on a wall in every VA hospital, a statement that each patient has a right to be seen and evaluated by a qualified specialist, as appropriate for his or her illness. As the VA moves to a more tightly regulated managed care organization, with gatekeepers to limit access to specialists, reduced physician and support personnel staffing levels, restrictions on access to diagnostic and therapeutic procedures, including drugs, patients will suffer from the resulting decline in thequality of care. Physicians will be in the position of transferring increased risk of poor outcomes to their patients in return for reduced costs. For the VA patient population, which is in large part elderly and poor, the susceptibility to adverse outcomes is far higher than in a younger healthier population. Physicians will play a key role in this risk-cost trade off because of their unique role in the delivery of care.

Drs. David Blumenthal and Arnold Epstein spoke of this in a recent New England Journal of Medicine article as follows: "Physicians have a number of skills and attributes that no other participants in the healthcare marketplace have in quite the same combination: scientific training and understanding of medical diagnostics and therapeutics, an understanding of patients' individual circumstances, an ongoing personal relationship with patients, and perhaps most important, an ethical and professional commitment to placing patients' welfare first. This last creates a confluence of interest between physicians and patients that could anchor an alliance that would be not only politically and economically irresistible, but also the source of profound ethical gratification to physicians".

We physicians therefore have a divided loyalty, to the VA as our employer and to our patients who entrust their health care to us. We cannot abdicate our responsibility to patients and still maintain our status as professionals. Individually, and collectively in our National Association, we will have to take a stand for quality medical care, working as best we can within the constraints of shrinking resources. VA medical staffs and VA management have a shared responsibility for high quality and efficient delivery of healthcare. It is incumbent on both to begin a serious dialog and begin working toward our common goals."