Sunday, April 26, 2015

He's gone racialicious








"What is your estimate as to the number [of ob-gyns] that are needed now and in the future compared to the number that are available?" Senator Richard Blumenthal asked this week.

He was asking a basic and important question.

But the Veterans Health Administration's Chief Consultant on Women's Health Services, Dr. Patricia Hayes, had no answer.

Make no mistake, she had a lot of words.  She attempted to say nothing in a huge amount of words -- apparently to run out the time clock.

Senator Richard Blumenthal wasn't having it and cut her off.

Ranking Member Richard Blumenthal:  Here's what I would suggest and I don't mean to interrupt you but for planning and management within the VA with regard to this specific speciality,  to be regarded as effective and competent, I would think that you could give us numbers of doctors in this speciality that are available now to meet the need, what the unmet need would require in additional numbers, and what it will be in the future?  Because you can't really tell if you're meeting the need unless you have that estimate of numbers.

There was no excuse for her non-answer.

There was no excuse for not being able to provide a hard answer, an actual figure.

She attended Tuesday's hearing knowing the sole topic was women's health.

And yet the most basic question for women's health, the practice solely devoted to women's health -- obstetrics and gynecology -- was a topic she hadn't considered.

Women veterans have been lucky to have Senator Patty Murray as a champion.  Murray treated their issues seriously before she became Chair of the Senate Veterans Affairs Committee and she's considered to treat these issues seriously (she continues to serve on the Senate Veterans Affairs Committee but she has gone on to leadership on other committees).

I think Senator Bernie Sanders, who replaced Murray as Chair, was a hideous leader of the Committee.

For example, when it broke that the veterans were being denied treatment, put on a secret wait list to hide this treatment, the official figures fudged, that veterans were getting sicker as they waited and that some died as a result -- when that emerged and was the dominant story in the news cycle, Bernie not only went on with his previously planned hearing on holistic (alternative) medicine but he stated at the start that he didn't want anyone to ask about this scandal because that was for another time.

Yes, Bernie, acupuncture is far more important than people dying.

That was sarcasm.

Bernie was a failure.

He refused to demand accountability from then-VA Secretary Eric Shinseki.  Shinseki suffered one disgrace and one scandal after another until even US President Barack Obama could see Shinseki had to go.  But up to that point, Bernie was still defending him.  (In the House, idiot Corinne was defending him the same way.)  Bernie repeatedly placed Eric Shinseki's comfort over that of veterans.

He was a failure.

Senator Johnny Isakson is now the Chair of the Senate Veterans Affairs Committee.

Already, he's done a better job than Bernie.

Tuesday's hearing was entitled "Fulfilling The Promise To Women Veterans."

Isakson just became Chair in January.

Do you know how many hearings Bernie's Committee held?

Counting reports from VSOs (Veterans Service Organizations), the answer is 35.

And how many of those hearings focuses solely on women?


Retired US Army CPT Christina L. Mouradjian:  As a patient at the VA, I have received some of the best care, from some of the best doctors, however that experience is tempered by the fact that I have also received some of the worst care not only by doctors and care providers but by the system itself. For years I complained to my doctors at the VA of numerous symptoms that were summarily dismissed; I was told I was too young to have any issues, I was told the basic blood work came back normal, and the ultimate betrayal, I was told I was not really being honest. These symptoms worsened and worsened, until finally I was forced to pursue medical advice out of the VA on my own. Once my bloodwork and MRIs proved positive for Cushing’s disease and the brain tumor that caused it, the VA started to take me seriously, it’s hard to argue when you’re staring at an MRI with a big white mass in the middle of someone’s head. But the years of suffering both physically, mentally and emotionally that I had to endure in order to get someone to listen is not something I would wish on anyone, and something that should not be happening to any veteran. The road to recovery for Cushing’s patients is not easy, there are countless tests and months of observation and then the inevitable brain surgery. There are the frequent visits to Endocrinology, neurology, the ENT, the list is long. But what complicates this, is that at the VA you may never see the same doctor twice. So not only do you have to repeat your story to every specialist under the sun, you have to repeat it to a revolving door of white coats who are hearing it for the first time. Or even worse, the specialist you may need to see may have left and it may be months before a new one is found and you can get an appointment. I know this because I have lived it. While I was stationed in NYC, I had to travel to three separate VA facilities in three separate boroughs because no one facility had all the specialists I needed. For allergy treatment alone I had to travel from Brooklyn to the Bronx, sit through what could easily be over an hour in traffic and $30 in tolls, for a fifteen minute appointment. Coordination of care is essential in any system that aims to treat the whole person, and at the VA the system is counterproductive to enabling this process. Prior to my brain surgery, which the VA only did on the second Tuesday of every month, my surgery date was cancelled three separate times. So three separate times I prepped, I had family come down and take off work as I could not be left alone for the first few days of recovery, and three separate times I was told another case was more important or that they could not get all the required doctors in the same room together, or that the doctors did not have a chance to review my case yet. They would have cancelled the fourth date also had I and my family not called the patient advocate and voiced our complaints. After brain surgery there were other nightmares. The was the MRI in which the attendant, rushing because I was the last patient before she could leave for the day, did not remove the metal nodes from my body, and too weak to squeeze the panic button, because my arm was sewn to a stabilizer in order to keep the pic line in, I could do nothing but weep silently while the metal burned welts into my skin. There was the resident doctor who had not researched my disease before mourning rounds and not knowing the main symptom of Cushing’s is weight gain said he could not tell if I was presenting because I was so heavy. It’s hard to have faith in a system when you have read more on your condition then the doctors who are supposed to be treating you. Navigating the VA can be daunting, and even more so as a female veteran. The women's clinic is often well segregated from the rest of the facility. Often times you have to traverse to the basement of the hospital next to the lab to find it, and once you get there it is obvious that it is an afterthought. Perception is part of the issue. For women veterans to feel like they belong, they need to know that their care is just as important as their male counterparts. They need to trust their care providers and they need to know that their care is a priority.

Mouradjian shared her experience (which didn't end with that excerpt) to the Committee -- a Committee tha under Bernie Sanders' leadership couldn't be bothered with women's issues.

In four months of leadership, Isakson has already done more than Bernie did in two years.

So applause for that to Isakson.

And applause to Senator Richard Blumenthal who is Ranking Member on the Committee and who has emerged as another senator who, like Patty Murray, can focus on women veterans as he demonstrated in hearing already this year.

As Blumenthal observed in his opening remarks, "There are too many homeless women veterans.  There are too many women veterans in need of medical care" -- his brief opening remarks.  He entered his full opening (written statement) into the record but noted he'd rather hear from the witnesses than hear himself speak.

There were two panels and Hayes was part of the first panel.  She was accompanied by Dr. Susan McCutcheon and Royse Cloud.  The second panel was Nevada Women Veterans Advisory Committee's Dr. Anne Davis, Disabled American Veterans' Joy J. Ilem and and army veteran Christina Mouradjian.

If you're new to our coverage of VA hearings, we're generally more interested in the second panel where witnesses are honest.  The first panel is always government flunkies who seem to get promotions and raises based upon how well they refuse to answer to Congress or even how well they flat out lie to Congress -- Allison Hickey, we mean you.

While we have little desire to embrace (or endure) the Allison Hickeys of the world, we do embrace truth tellers.  While the first panel struggled to answer direct questions or provide even basic figures, the second panel was composed of three women prepared to address topics and explore possible solutions.

For perspective, we'll include this from Disabled American Veterans Joy J. Ilem opening statement:

As a service-disabled veteran, I know first-hand the challenges women face during military service and when they return home. I, like many women who served, did not understand on leaving military service the benefits and services to which I was entitled, despite the fact that I suffered an injury during my service as an Army medic while stationed at the Army 67th evacuation hospital in Wurzburg, Germany. It was not until nearly a decade after I had discharged from the military that a fellow veteran contacted me and told me about DAV. He urged me to file a VA disability claim and seek VA treatment. I resisted for months and remember asking him, "are you sure I can use the VA health care system?" I didn't think of myself as a veteran, and knew next to nothing about filing a disability claim or for which benefits I might be eligible. Today, many women who have served still do not readily self-identity as veterans. The good news is a concerted effort is being made to change this trend and ensure that women veterans are recognized for their military service and gain information about their earned benefits. The number of women serving in the military, their roles, and their exposure to combat has dramatically changed during our war years in Iraq and Afghanistan. Likewise, over the past decade we have seen a dramatic rise in the number of women seeking health care and other benefits from VA with expectations that this trend will continue. According to VA, the number of women veterans using Veterans Health Administration (VHA) services increased by 80 percent between fiscal year (FY) 2003 and FY 2012.  Currently, over 635,000 women veterans
Along with this significantly increased demand, VA experienced a shifting age demographic and inclusion of younger women veterans enrolling in VA health care, which required significant changes in both policies and clinical practice. According to VA, the number of women veteran patients under 35 years of age has increased by 120 percent between FY 2003 and FY 2013.
New providers with expertise in women’s health were needed; clinical space in many locations was insufficient to meet rising demand; and privacy and safety concerns were prevalent. VA providers suddenly needed to be knowledgeable about reproductive health services, conducting breast and gynecological examinations and becoming aware of the possibility of pregnancy when treating younger women of child-bearing age to ensure medications and recommended treatments did not pose a risk of birth defects. Many VA providers were not seeing enough women patients to be proficient in women’s health, necessitating VA to institute a mini-residency program to help clinicians refresh their knowledge and skills. All prenatal and obstetric care is referred to private providers, and mammography services are provided by non-VA providers for about 75 percent of enrolled patients through VA’s fee basis medical care program, complicating coordination of care for women veterans.
Other trends in this population that impact health policy and planning became evident as well. According to VA, more than half (57 percent) of women veterans under VA care are service disabled, some of whom are very young. These women will be eligible for lifelong VA care for their service-connected conditions. Women veterans were also presenting with unique post-deployment health care and mental health needs. More than half (57 percent) of the women who served in the wars in Iraq and Afghanistan (OEF/OIF/OND) have sought VA care following military service and have targeted health care needs, including chronic musculoskeletal pain; mental health conditions including post-traumatic stress disorder (PTSD), anxiety, depression, and substance-use disorders (SUD); genitourinary system, endocrine and metabolic disorders; and respiratory conditions. Given the greater exposure of service women to combat, the specific medical profile of this group, and women who have sustained traumatic war-related injuries, it became clear there was a need for adjustments to not only primary care services but specialized care, transition services including supportive counseling, and psychological services.

We'll note this exchange from the second panel.

Chair Johnny Isakson: You said you were not an isolated case and you referred to many other women that had similar experiences -- obviously not with Cushing's but with other complications.  Would you elaborate on that for just a moment?

Retired US Army CPT Christina L. Mouradjian: That is correct.  I know myself and several of my friends in the service have had a hard time just either accessing care or getting doctors to listen to the particular issues that are unique to them.  Particularly with mental health issues, there is often times lack of a response to women.  So just, one of the big issues is getting a female provider.  I know that a lot of the female veterans that I have served with do not necessarily feel comfortable telling their story to a male who might not be able to sympathize with what they've gone through as a woman in general.  The physical issues aside, some of the very delicate that we face as women, we're just not comfortable sharing those with a male.  So one of the biggest hurdles is just being able to get access to a provider, feeling comfortable enough to get the help they need. 

Chair Johnny Isakson:  Well that actually is the point I was going to lead up to.  One of the things we are looking at in the Veterans Choice Bill, we had two issues -- one was the forty mile rule which we have dealt with but the other was the care -- nearest the care of the veteran's needs.  And in your particular case, you had a very specialized need.  Cushing's is not a -- it is a very rare condition, is that not correct?

Retired US Army CPT Christina L. Mouradjian:  It is very rare.

Chair Johnny Isakson:  And obviously the VA wasn't prepared initially either to diagnose or to recognize it.  Is that correct?

Retired US Army CPT Christina L. Mouradjian:  That is correct. 

Chair Johnny Isakson:  But you had enough symptoms to know that something was wrong and that you needed care.  Is that correct?

Retired US Army CPT Christina L. Mouradjian:  Yes.

Chair Johnny Isakson:  Did you ever consider going for a second opinion outside of the VA or were you limited and not able to do that on your own?

Retired US Army CPT Christina L. Mouradjian:  No, I'm fortunate enough that my mother is in the medical field so I did have an advocate in my corner who had enough background to guide me so I had personal resources in my life that could verify that the treatment I was getting at the VA was actually -- after I was diagnosed -- sufficient to deal with it.  

Chair Johnny Isakson:  But without the advocate you may never have gotten that care.  Is that correct?

Retired US Army CPT Christina L. Mouradjian:  Absolutely.

Chair Johnny Isakson:  Well that is my point and I know the VA folks are staying for the rest of the hearing -- and I appreciate you'll staying.  This is a -- there's a message in this story to us. Obviously, there are things we can do to make sure that you go from lack of diagnosis or misdiagnosis to appropriate diagnosis and that there's an ombudsperson to help you along the way.  You were fortunate enough to have a mother to help you do that but a lot of our women veterans don't and I think it's important that we recognize that there ought to be some way for communication or ombudsmanship to be available to the veteran who thinks they need the service and the care.  Ms. Ilem?

Joy Ilem: I would just like to follow up.  I think that's a great idea.  I think with the cultural transformation that Secretary McDonald's trying to implement throughout the system there needs to be a specific line for women veterans to take on this role.  I know VA has lost some of their lead women veteran program managers throughout the system.  I mean, they've been critical over the years.  When I have a problem, when a woman veteran calls, and I call the women veteran health service, they're right on it.  They want to know.  They want to help.  But they have to have the staff out there of somebody leading that understands these particular issues. 

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