When I went to college as an undergraduate, my oldest childhood friend went to war as a Marine. The changes I observed in him after he returned from two deployments in Iraq were far greater than just his missing limb; they were life-changing alterations in his personality and our relationship.
I was interested in veterans and the impact of war long before entering graduate school. It didn’t occur to me that being the daughter of a Vietnam veteran who was stoic about his own service might have also naturally peaked my curiosity. As soon as I began training to be a clinical psychologist I knew this was a population I was passionate about working with.
The day I was offered a position training in the VA, I was elated thinking about the meaningful, potentially lifelong career journey I was about to embark on. I committed myself to diligently working with veterans for the next four years.
However, my hope began to dissipate while working at a VA in New York during my internship in 2015-2016. During that year I watched while five staff psychologist positions became vacant in various areas of the hospital, and none of them were filled because of budget problems that lead to a hiring freeze. Veterans were channeled toward a problematic Choice program, where they were met with challenges such as a provider list chalk full of bugs (providers who didn’t know they were on the Choice panel, were out of state, had retired), and treatment needs were thereby not adequately met. The remaining staff in the affected parts of the hospital absorbed the work of the vacant positions, working long and burdensome hours. Many times staff lamented that if the hospital could just fill the positions, so many of the problems would be solved and veterans would be served more efficiently and more effectively.
When I arrived in California for my postdoctoral fellowship in 2016-2017, many similar discussions were taking place, and many of the same challenges were observed: lack of funding, hiring freezes, uncertainty about the future. My dream of working in the VA as a staff psychologist began to seem more and more unlikely. I shocked myself when I began to look outside of the system for future employment opportunities, and am still somewhat dismayed that I have accepted a job outside of the system that I have been so loyally committed to since starting my training.
I still hope to return to the VA at some point in the future, but for now am needing to privilege my own security as an early career psychologist with graduate school debt over loyalty to a system that’s future remains uncertain.
I am currently a psychology postdoctoral fellow at the SFVAMC. This is my second year of training at this facility, and my fourth year of training within VA, having completed practicum training at the Northern California VA and internship at the Bedford VA in MA. I initially sought training at VA because of their reputation as a strong training program, and this has been more than borne out – the quality of training has been exceptional, and the caliber and dedication of the staff has never ceased to impress me. Over the course of my training, I have received inspiration and mentorship that has shaped who and how I am as a psychologist.
While I did not initially set out to be a career VA psychologist, my experiences, and particularly the collaborative work I have done with VA staff, cultivated my dedication to continuing to sustain and grow the projects and work I have done here. My experiences have shown me that VA is an excellent workplace, with meaningful work that improves veteran quality of life as well as making significant scientific contributions across healthcare fields. Unfortunately, the current political climate has negatively affected this vision. The current threat of privatization of VA makes a VA career appear unstable – like all the hurdles of gaining employment are unlikely to result in a position with longevity. With all that VA has invested in training mental health professionals, it is unfortunate to see the talent of my fellow trainees sent out to other healthcare systems because a VA job appears to be short-lived.
Throughout my graduate school experience in clinical psychology, people were always talking about training at the VA. From the beginning, the VA was spoken about as this prestigious, almost unattainable ideal that many people strived for and very few achieved. The dialogue surrounding training at a VA reminded me of people talking about getting accepted to an Ivy League school. From the inside of mental health care training, it was Harvard. It always baffled me how drastically different the discourse was about the VA outside of my training experiences. To the lay public, the VA has been painted as this corrupt and disorganized institution that is failing to provide quality patient care, when to many of us actually inside the system, it is the best of the best.
I was one of the lucky ones that had the opportunity to train in the VA system. I have spent 3 years at the SFVA, and I have also had training experiences outside of the VA. From my perspective, the training and education I have received from staff of all disciplines at the VA has been completely unrivaled. The amount of time and passion that is directed at training competent health care clinicians is state-of-the art. I simply would not be the clinician I am today if I hadn’t had the experiences, and the supervisors at the VA that helped shaped me into the psychologist I am. As I embark on this next phase of completing my postdoctoral fellowship and looking for employment, it is absolutely heartbreaking that it might not be possible for me to stay within the system that I have become so fond of. Aside from my personal heartbreak, it is a disservice to the veteran population that clinicians who are trained specifically to treat this community, which has very unique needs, may not be able to utilize that skillset. I am happy that veterans are speaking out and sharing their positive experiences with receiving health care at the VA. The voice that also needs to be heard is that of VA trainees and staff. The message I would want to convey to my congress representative is this: privatizing the VA would have hugely detrimental effects on the quality of health care veterans would receive, but furthermore would have catastrophic effects on our nation’s ability to adequately train health care clinicians.
My current thoughts related to working in the VA is summed up with one word: uncertainty. I feel a sense of uncertainty about psychologist positions becoming available in areas I want to live. I am uncertain about job security in the long run. Uncertainty about the future of the VA. This sense of uncertainty is related to overarching rhetoric, and it makes me less likely to want to pursue a career in the VA. I find myself being very cautious and overly considerate about every one of my actions and statements due to perceptions of fear and the consequences of voicing my opinions. I believe this is a detriment to the whole system, because without voices changes cannot be made. I think this fear is doubly in play due to issues being a trainee. I have made several life choices and taken a lot of risks thus far in my life. I am looking for a place to settle and establish myself.
In terms of how my thoughts have changed over time, I have always enjoyed working in the VA and always kept it as an option. I thoroughly love to work with veterans and their families. My family has a number of veterans and active duty military in it. The VA has attracted me as a good place to work for years. I appreciated the energy that came with the VA and the implementation of evidence-based treatments and research. Only recently have my thoughts change to uncertainty and doubt. I find myself being more wary, far more than I ever was in graduate school.
Thus, I am searching for jobs elsewhere. I feel a certain sense of attachment to the VA, as it has made such a positive impact on my training and abilities. I feel certain that I will reconsider VA work in the future should the uncertainty be reduced.
100% of the patients I have talked to who received services through Choice have stated that Choice is inferior to VA services. If this is important for this project, I hope this is captured somewhere.
My Hidden VA List by Dena E. Rifkin, M.D.
I knew the call was coming, and I knew when I saw the number what the voice at the other end would tell me. My oldest patient had died quietly at home that day, a week after his birthday and exactly that long after deciding that he was done, forever, with hemodialysis. It had provided him with many good years, but as he entered his mid-90s, life had become increasingly difficult. He knew, and I knew, it was time to say good-bye.
A few days later, I attended the funeral of this man — undoubtedly among the last few veterans of World War II that I will see as a physician. I have been working at Veterans’ Affairs (VA) hospitals since my student days. At that time, the wards were crowded with survivors of the Pacific theater, the battles of Normandy and North Africa, the places and times I had previously known only from history lessons.
The first patient I was assigned as a third-year clerk on the medical ward at the West Haven, Connecticut, VA Hospital was one of those men. Bluish and breathing with difficulty owing to chronic lung disease, he was silent as my third attempt at an arterial blood draw failed. I withdrew my needle, apologizing profusely, and backed out of the room in shame.
“Doc, just where do you think you’re going?” he called after me. It was no use explaining that I had barely been on the wards before — “doc” it was. I told him, in barely a whisper, that I’d just go find someone else to draw a blood sample.
“No chance of that, doc. Not while I have another arm,” he said, rolling up his sleeve. A survivor of the D-Day landings, he had seen horrors much worse than a 25-year-old medical student carrying a blood-gas kit. I hit the artery, and he shook my hand with great satisfaction.
Now, these men of the “greatest generation” are a dwindling presence, their stories growing more precious as their numbers shrink.
My patient’s memorial service was joyful, full of friends, laughter, and reflections on a lifetime of adventures. I saw the arc of a full life, my patient’s trajectory from a strikingly handsome young pilot to a rugged horseback rider to the man I had known — a man whose life, despite diminishing physical health, was a powerful force to the end.
I drove home alone, along the desert roads of San Diego’s East County. And I began to think about the other patients I had lost.
In the Computerized Patient Record System at the VA hospital in San Diego — the same system I used as a medical student in Connecticut and the same one VA doctors use in Phoenix and everywhere else in the country — any clinician can keep a “personal list” of patients: one list for the clinic, one for the inpatient unit, and so forth. On my list, I keep the names of all my patients in the dialysis unit, alive or dead. I add new names when someone new arrives, but I can’t make myself remove the other names from the list.
The patients who are no longer with me are my hidden VA list, the reckoning sheet by which I evaluate my work.
My hidden list reminds me of some of my most difficult days as a doctor. It reminds me that shortness of breath can be a sign of acute myocardial infarction, that renal-cell cancer can recur years after the initial diagnosis, that men can get invasive breast cancer. Sometimes, I feel, I may sink under the weight of these names. As time passes, though, the weight of the list balances me. It prevents me from being too sure of anything, yet it also keeps me from hesitating to trust my instincts.
My hidden list reminds me of some of the best we can offer, of patients whose lives were lived to the fullest — and were made better by VA care. Patients for whom death was not painful or frightening or unexpected, but simply the inevitable end of a story well told. Many of these patients, I am convinced, would not have lived as long or as well without the safety net of VA care.
My hidden list is full of stories, and it’s a treasure trove of history. For me and for many of my colleagues, work at the VA takes on greater significance with each passing year. In my professional lifetime, we will mark the passing of the last World War II veteran. The stories of frigid nights in North Korea will become fewer, until they, too, are silenced. The tumult and chaos of Vietnam will grow still. Scars visible and invisible may all heal with the passage of time, but they will remain in memory on my hidden list.
I have little doubt that my first VA patient is dead now, along with many others I met as a trainee. I wish I could tell him how much he gave me when he held out that second arm.
Nowhere else than at the VA have I felt as much that I was a part of something greater than myself. We “care for him who shall have borne the battle” in a system that, for all its woes, remains a singular presence in the confused patchwork of medical care that is American medicine. Enter the VA medical system and you know that your critical medical data are available to every provider at every VA hospital in the country in ways unimaginable in the private sector; you know that care delivered in the VA system often meets or exceeds the quality standards of the private sector.1 You know, moreover, that you and the person sitting next to you in the waiting room will get the same level of care, because there is no mysterious and fickle insurer to reckon with at the end of the appointment.
I don’t know what happened in Phoenix or elsewhere, what those hidden lists hold, what grief lies there. I wish those reporting on this scandal would do more to separate issues of access to care from problems with the quality of care. I do know that, all around the country, physicians who trained at the VA or who have chosen to live out their medical career with the VA have their own hidden lists, their indelible memories of men and women who entrusted their care to us. Let us continue to work for them.
The opinions expressed in this article are those of the author and do not necessarily represent those of the VA.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
This article was published on June 4, 2014, at NEJM.org.
From the Veterans Affairs Healthcare System, San Diego, and the University of California, San Diego — both in San Diego.