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By JOAN MAZZOLINI
NEWHOUSE NEWS SERVICE
Veterans who offered their lives for their country now may be putting them on the line again in the very hospitals established to heal them.
Nearly 4 million people get free care from the nation's Veterans Affairs hospitals and clinics, but an investigation by The Plain Dealer of Cleveland discovered that the largest full-service health system in the country is operating, sometimes with disastrous results, under many rules that would not be allowed elsewhere.
Among the findings:
Veterans often are treated by residents - doctors in training - who rotate through VA hospitals usually every three months.
The newspaper also found that the federal Office of Inspector General, which inspects VA care as well as other VA programs, has so few investigators that it can't begin to properly handle the 15,000 complaints it gets each year.
One man's trials
It has been 18 months since investigators began looking at the care that Halver Durbin received at the Cleveland veterans hospital.
In July 1999, the then-78-year-old Army veteran was transferred to Cleveland from Dayton, Ohio, for bypass surgery. His surgery was successful, but his chest wound wouldn't heal. Over the following weeks, doctors twice removed dead tissue and breast bone, until his sternum was gone. They then moved a piece of muscle to cover his heart.
That failed, and three weeks later plastic surgeons again were trying to close his chest when they found that his abdomen was badly infected.
They called for a general surgeon; a resident responded.
Dr. John Raaf, chief of surgery at the veterans hospital, was supposed to be in charge of surgery that day. But his usual routine was Mondays at Cleveland's University Hospitals, Fridays at the University Suburban Health Center - the same days he scheduled himself to be at the VA from noon to 5 p.m.
And when the problems with Durbin arose, Raaf was operating at University Hospitals on a patient from his private practice, according to Cleveland VA documents.
As a result, critical decisions about Durbin's surgery were discussed on the phone. The VA's chief surgical resident, also physically at University Hospitals that day and talking with Raaf, relayed back over the phone what Raaf wanted done, according to the documents.
In the end, Durbin was closed up. The next day, a different surgeon, Dr. Cathy White-Owen, was in charge of Durbin. She found him in shock, his body unable to fight off a massive infection. She told him he would die if he didn't have an operation to drain the infection.
Durbin refused. He died three days later. White-Owen, who was a part-time surgeon at the veterans hospital, resigned a few days afterward.
Doctor won't compromise
"I have experienced an unacceptable compromise of my own personal standards of care and have been faced with several situations in which I was required to assume care of patients that I felt were either neglected or mismanaged by another physician," White-Owen wrote to Dr. Jerry Shuck. "In good conscience I can no longer participate in this flagrant itinerant surgical care. It is my understanding that I am not the first surgeon, and may not be the last one, to resign for the reasons mentioned here."
Shuck, then chairman of surgery at Case Western Reserve University's School of Medicine, had great authority over the veterans hospital, which is affiliated with the school.
Shuck declined to comment on White-Owen's resignation, but said hers was not the first complaint.
"I've heard that intermittently in a variety of ways, not just about John (Raaf), but other people, that they're not giving the time they should give and all that," Shuck said. "The VA might get short shrift by some people. That bothers me."
In fact, Raaf was in private practice with a group of surgeons that included Shuck. At the same time, Raaf was paid more than $114,000 a year by the VA for working 35 hours a week.
And Shuck, who went occasionally to the veterans hospital as a $75-a-day consultant, performed more operations than Raaf for the 12 months ending September 1999. Shuck participated in 19 operations, Raaf in 12. For 15 others, Raaf oversaw residents but was not in the operating room.
Raaf declined to be interviewed and VA spokesman David Jewel said Raaf devoted appropriate time to his work at the hospital.
Durbin's family was distraught.
"We were pretty tore up about the way he was treated," said Durbin's son Herbert. "Maybe he would have died anyway, but who knows?"
Hospitals don't compete
The veterans health system has never had to compete for patients. Instead, it has had an essentially captive audience of poor and uninsured patients with no alternative for care.
But the number of veterans is dwindling. They're getting older and sicker and they cost more and more to treat. More than $20 billion was spent on medical care for veterans last year.
Congress grew the system in the face of blue-ribbon commissions, outside analysis and internal investigations done over the decades that revealed dangerous, second-class care. Such studies showed insufficient staff, VA death rates twice what is seen in community hospitals, and excessive heart surgery death rates.
"The system has always been thought of as being second-rate, but also essential...to people worthy or deserving of care," said David Radner, who teaches the history of public health at Columbia University.
"You'll see a lot of money going to the veterans hospitals, but at the same time, the public is suspicious of them. We see veterans as heroes at the same time taking from the public till, an object of welfare. There's always an ambivalence."
This ambivalence, Radner and veterans say, results in an indifference from those who care for the veterans.
For 10 years, attorney Jenni Steffin worked at a veterans hospital. She now represents veterans or their families who sue over VA care.
"Most of the time when people go into a VA hospital, they don't have insurance, and some people, even some health care providers, don't seem to appreciate the fact that the VAs are not charity hospitals," she said.
"They are in fact held to the same standard of medical care as any private facility."
But veterans hospitals don't operate like private facilities.
Numbers fall short
For one thing, they don't have the number of doctors and nurses they need.
After World War II, the 98 veterans hospital
s had a fraction of the number of doctors needed to care for the returning veterans. Medical schools began sending interns and residents to the veterans hospitals. In the 1970s, the VA took care of its shortages by hiring foreign doctors.
But the shortage of full-time doctors continues today.
A review of the staffing levels found some of the nation's largest veterans hospitals - Cleveland, Pittsburgh, St. Louis, Atlanta and Hines VA Hospital outside Chicago - have about half of their medical staffs employed part time. In New Orleans, about two-thirds of the staff doctors are part time.
Because of the shortage, patients often must wait for care. Some wait almost a year.
Last year, veterans at the North Texas system, which includes Dallas, had waits of 228 days to be evaluated for orthopedic surgery and 193 days for neurology. At the Fresno, Calif., veterans hospital, patients had to wait 85 days for a neurosurgery appointment. Patients at the Omaha, Neb., veterans hospital had similarly long waits to see cardiologists and primary care doctors.
Veterans fight back
In Maine, veterans recently picketed the hospital because of long waits and inadequate staffing.
It's not that the problems at veterans hospitals have gone unnoticed.
Settlements and verdicts are increasing, with injured veterans and grieving families being awarded nearly $500 million in the past decade.
The VA's watchdogs, the Office of Inspector General and Congress' General Accounting Office, have put out hundreds of reports over the last several years detailing problems.
Federal officials have been to the Louis Stokes Cleveland VA Medical Center at least five times in the last few years, including this past December, investigating complaints.
Problems in the anesthesiology department alone have brought out investigators at least twice in the last three years.
The most recent federal investigation found that there were anesthesia providers "who are functioning beyond their level of competence," the inspectors wrote last April.
Five of the busiest surgeons had signed affidavits stating they were concerned about the capabilities of the anesthesia providers, and some said they refused to use a particular provider during their operations.
The lead investigator wrote that the stopgap measures the Cleveland veterans hospital has undertaken "because of the lack of adequate number of skilled staff...has forced compromises in quality of care over the 24-hour-a-day service that must be provided."
"The fact is that in this particular report they cited some things we could do better," said Jewel, the Cleveland VA's spokesman. "That is part of how a good program gets better and how the best programs conduct themselves."