Friday, May 02, 2014

Tough times in the court of King Stupid








Senator Bernie Sanders: Within the veterans' community -- and in fact, the nation both in the public sector and the private sector -- we face a very serious problem as a nation of overmedication. The result of that overmedication is that significant numbers of people treated in the Department of Defense facilities, in VA facilities and in the private sector become dependent upon those medications intended to help them and ease their pain. Pain relief is a huge problem in the country and how we treat that pain in the most effective way is really what we're discussing today. Some people who are treated with a whole lot of medication become addicted -- and I think we all know what happens when people become addicted -- and some in fact will end up taking --  losing their lives through overdoses. And in my state and throughout this country this is a huge problem as well. So this is a major issue which has been discussed in this committee during the last year and we're really glad we have such a distinguished panel to discuss this issue.

We're starting in the US and dropping back to yesterday for a Senate Veterans Affairs Committee.  Iraq voted in parliamentary elections yesterday, we focused on that, there wasn't room for the Wednesday hearing.  Senator Bernie Sanders is the Chair of the Senate Veterans Affairs Committee and Senator Richard Burr is the Ranking Member.

The big news of the hearing?

The big news was about the allegations of deaths.

What allegations of death?

Dropping back to the April 9th snapshot to note this from that day's House Veterans Affairs Committee hearing:

US House Rep Jeff Miller:  I had hoped that during this hearing, we would be discussing the concrete changes VA had made -- changes that would show beyond a doubt that VA had placed the care our veterans receive first and that VA's commitment to holding any employee who did not completely embody a commitment to excellence through actions appropriate to the employee's failure accountable. Instead, today we are faced with even with more questions and ever mounting evidence that despite the myriad of patient safety incidents that have occurred at VA medical facilities in recent memory, the status quo is still firmly entrenched at VA.  On Monday -- shortly before this public hearing --  VA provided evidence that a total of twenty-three veterans have died due to delays in care at VA medical facilities.  Even with this latest disclosure as to where the deaths occurred, our Committee still don't know when they may have happened beyond VA's stated "most likely between 2010 and 2012."  These particular deaths resulted primarily from delays in gastrointestinal care.  Information on other preventable deaths due to consult delays remains unavailable.   Outside of the VA's consult review, this committee has reviewed at least eighteen preventable deaths that occurred because of mismanagement, improper infection control practices and a whole host -- a whole host --  of other maladies plaguing the VA health care system nationwide.  Yet, the department's stonewall has only grown higher and non-responsive. There is no excuse for these incidents to have ever occurred.  Congress has met every resource request that VA has made and I guarantee that if the department would have approached this committee at any time to tell us that help was needed to ensure that veterans received the care they required, every possible action would have been taken to ensure that VA could adequately care for our veterans.  This is the third full committee hearing that I have held on patient safety  and I am going to save our VA witnesses a little bit of time this morning by telling them what I don't want to hear.  I don't want to hear the rote repetition of  -- and I quote --  "the department is committed to providing the highest quality care, which our veterans have earned and that they deserve.  When incidents occur, we identify, mitigate, and prevent additional risks.  Prompt reviews prevent similar events in the future and hold those persons accountable."  Another thing I don’t want to hear is -- and, again, I quote from numerous VA statements, including a recent press statement --  "while any adverse incident for a veteran within our care is one too many," preventable deaths represent a small fraction of the veterans who seek care from VA every year.  What our veterans have truly "earned and deserve" is not more platitudes and, yes, one adverse incident is indeed one too many.  Look, we all recognize that no medical system is infallible no matter how high the quality standards might be.  But I think we all also recognize that the VA health care system is unique because it has a unique, special obligation not only to its patients -- the men and women who honorably serve our nation in uniform -- but also to  the hard-working taxpayers of the United States of America.

Miller is the Chair of the House Veterans Affairs Committee.  Like Miller, Sanders takes this issue seriously and noted it in his opening remarks.  He noted, "I just spoke to the VA's Inspector General yesterday.  There is a thorough investigation taking place in Phoenix and Richard Griffin who is the VA's Acting Inspector General told me that he has the resources that he needs to thoroughly investigate that situation."

Keep that in mind.

The big disgrace that is the VA's Dr. Robert Petzel told the Committee, "I need to say that to date, we found no evidence of a secret list.  And we have found no patients who have died because they were on a wait list."

Did you grasp what just happened because the press didn't?

I've heard Jen Psaki, Marie Harf, Victoria Nuland, Jay Carney, Robert Gibbs, Dana Perino and many more explain, when asked, that they couldn't what?


Pick any controversial and embarrassing topic and what do they say, "I'm sorry.  I can't comment on an ongoing investigation."

But Petzel didn't say that -- despite it being an ongoing investigation.

So, in fact, we now know that they can comment on an ongoing investigation, they just don't want to.

After denying any guilt, Petzel then declared, "We think it's very important that the Inspector General be allowed to finish their investigation before we rush to judgment as to what has actually happened."  But he rushed to judgment when he denied it.

Today, the Veterans Affairs Dept released the following statement:

  WASHINGTON – Secretary of Veterans Affairs Eric K. Shinseki made the following statement on the allegations regarding the Phoenix VA Health Care System:
“We take these allegations very seriously. Based on the request of the independent VA Office of Inspector General, in view of the gravity of the allegations and in the interest of the Inspector General’s ability to conduct a thorough and timely review of the Phoenix VA Health Care System (PVAHCS), I have directed that PVAHCS Director Sharon Helman, PVAHCS Associate Director Lance Robinson, and a third PVAHCS employee be placed on administrative leave until further notice. 
“Providing Veterans the quality care and benefits they have earned through their service is our only mission at the Department of Veterans Affairs. We care deeply for every Veteran we are privileged to serve.
“We believe it is important to allow an independent, objective review to proceed. These allegations, if true, are absolutely unacceptable and if the Inspector General’s investigation substantiates these claims, swift and appropriate action will be taken. 
“Veterans deserve to have full faith in their VA health care. I appreciate the continued hard work and dedication of our employees and of the community stakeholders we work with every day in our service to Veterans.”

#   #   #

The issues were covered on Anderson Cooper 360 tonight on CNN (link is video and text).

We'll move back to the hearing to note the issue of alternative and complimentary medicine.

Chair Bernie Sanders:  (A) Dr. Petzel how serious is the problem that you are addressing and (B) and Dr. Martin might want to join in, tell me the role you think complimentary alternative medicine can play in addressing those problems?

Dr. Robert Petzel: [. . . Microphone not on . . .] First of all in terms of the magnitude of the problem, several have mentioned it, we estimate that 50% of the veterans that are coming to us seeking care have some sort of, uh, pain. Uh, much of it is muscular, skeletal, back pains, etc. associated with the, uh, work that a soldier, sailor, air man, marine, uh, maybe doing.  Uh, we are prescribing opiates for somewhere around 650,000 veterans at this particular present time which includes a large number of people and we recognize the fact that this is an issue that has to be addressed very directly.  Uh, I would like to just take a minute before I turn to the, uh, other panel members to describe the opioid safety program that we're involved in to try and get a grip on and reduce the use of opiates which, by the way, has reduced the number of patients receiving opioids in the last eighteen months by 50,000.  Still a lot of people getting it --

Chair Bernie Sanders: 50,000 fewer veterans are now receiving opiates?

Dr. Robert Petzel:  That's correct. The five things that are, uh, the central part of the pain management program are (1) every medical center has to have a pain management clinic, (2) every medical center has a pain consultation service -- VA requires the use of, uh, integrative, uh, cam approaches.  We, uh -- And we make get into the details of this -- we require the use of a step-care model which was developed in the VA and which I think has been adopted by the Dept of Defense now which begins with -- in the primary care clinic -- self-management and management in primary care of pain, if needed, it moves to a secondary pain clinic.  And then finally there are tertiary pain services available.  The centerpiece of this, though, is the opioid dashboard monthly report to the facilities, to the providers of the facilities and to the pain management point of contact about people who are prescribing outside of the standard and patients that are taking medications outside the standard.  That then is followed by education and discussion and consultations with the providers to bring their use of opioids into uh-uh -- into the standard.

Chair Bernie Sanders: If I can interrupt you, we'll take a little bit more time for everybody because we only have four of us here.  But I wonder, if it's okay with you, Dr. Petzel, I wanted to shift over to  Dr. Gaudet, Dr. Marshall, what are you doing with complimentary and alternative medicine and is it, in fact, working?

Dr. Tracy Gaudet:  Uh, thank you, Chairman Sanders.  I think you're, uh, aware that the, uhm, vision for health care -- and Ranking Member Burr referenced personalized proactive patient driven -- central to that- are strategies that are inclusive of complimentary approaches that empower the veteran to take into their own hands -- whether it's pain issues, of course, this extends far beyond pain to the many, many conditions facing veterans and our public that are complex conditions where a simple fix does not exist.  Uhm, so I think that these areas -- particularly pain -- are phenomenal places where the VA is committed to bringing more holistic approaches to veterans.  The veterans are finding them very, very empowering, very much an asset to their compliment of what they can do to address their issues with pain as well as others.  

Chair Bernie Sanders: In --

Dr. Tracy Gaudet:  Yes, sir? 

Chair Bernie Sanders:  In English --

Dr. Tracy Gaudet:  Yes, sorry.

Chair Bernie Sanders:  What am I -- What are you offering a patient?  So somebody walks in, they have chronic pain, they're concerned about over medication.  You are concerned.  What are the therapies that you are offering?  And are they in fact working?  These are fairly radical ideas in a certain sense, right? Or not?

Dr. Tracy Gaudet:  I don't know how radical they are but I think that the conditions -- that the therapies that are most promising and are most often utilized right now in the VA are very parallel to the DoD and the public so they tend to be mind-body approaches such as meditation, acupuncture movement therapy such as yoga, Tai Chi, spinal manipulation.  These are -- These are the general approaches that seem to have the greatest promise that are relatively, you know, non-invasive and low risk.

Chair Bernie Sanders: Now I have been impressed.  I have been to VA facilities all over the country and I've been to a couple of DoD facilities and I am amazed.  You know, twenty or thirty years ago, I think it's fair to say, that if we were talking about this list of therapies, people would have thought that they may have been a few folks in California or certain places that might be utilizing them -- not the Dept of Defense or the VA.  So, in terms of programs like the acupuncture, is it working?  What can you tell us about your success rates or non-success rates? Does the success work?

Dr. Tracy Gudet: I think the most evidence that actually exists for acupuncture as it relates to pain, our research Office of Evidence Synthesis just finished a comprehensive look at all the evidence related to acupuncture and it's a very useful document because it basically says where is their evidence for the use of acupuncture, do we know and is there evidence of benefits, do we know it's not a benefit or is there a category where we just don't know from the research?  The areas where there is the strongest evidence for acupuncture are pain -- chronic pain, headaches, migraines have the best evidence.  So it's a rational place to start.  

Chair Bernie Sanders:  Alright Dr. Marshall, if I walk into your beautiful facility in Minneapolis -- I was just there a few days ago -- and I am in pain, what are my options other than drugs?

Dr. Marshall: I would say at Minneapolis, we view pain management  as a full spectrum opportunity to engage with a patient and move them towards healthier and a more functional life so we have deployed various complimentary, alternative modalities at different levels of our facility.  For instance, nurses -- we trained 900 nurses in January of this year -- a four hour training in complimentary and alternative medicine and integrative nursing.  Modalities that we trained nurses in specifically that included acupuncture, reflexive breathing, meditation and essential oils and aroma therapy so --

Chair Bernie Sanders: Do your -- Do your patients gravitate -- when you tell them that these therapies are available, do they say, 'Nah, I really don't want that'?  Or do they say, 'Hey, I would like to experience that.'?  What do they say?

Dr. Peter Marshall:  There's a lot of variability.  Uh, some patients, uh, express a strong desire for opioid pain medications.  Many patients, though, are very open, once they learn that these are a standard part of our medical treatment at Minneapolis VA, I think many patients are gravitating towards these kind of services.

Chair Bernie Sanders: And can you tell us some success stories?  Are there people have gone and they are in pain and are heavily medicated, got rid of the medication and then because of complimentary medicine -- Dr. Gaudet, do you have stories that -- or Dr. Marshall?

Dr. Peter Marshall: Yes. I-I would like to talk briefly about a program that we have just started.  This is part of the VA's efforts to have, uhm, our, uh, Council for Accreditation of Rehabilitation Facilities, CARF, rehab VISN at each facility.  So we started in January of this year.  We recruited the director of the Mayo Clinic Pain Rehab Center who is now leading our efforts.  So that program, which is just starting at Minneapolis VA, had seven veterans.  Four of them were on opiaids. Three of them were tapered off and one was tapered down. And the cornerstone of that program that's a three week intensive program, the cornerstone of that program is activating patients' innate healing abilities through the use of primarily complimentary and alternative modalities including cognitive behavioral therapies: meditation, relaxation breathing, Tai Chi, yoga and other active -- 

Committee Chair Bernie Sanders:  So you have some specific indications that these therapies are working

Dr. Peter Marshall: Yes.

Committee Chair Bernie Sanders:  Okay.

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