"The clearest representation of what we can accomplish collectively"

An advisory board member explains why he joined VHPI

By Edward Machtinger, M.D.
VHPI Advisory Board Member

I’m writing this blog to explain why I was so delighted to accept the invitation to join the Advisory Board of the Veterans Health Care Policy Institute. It’s because I am committed to the group’s mission of providing excellent healthcare to veterans. It’s also because of my own professional experiences with the delivery of healthcare at the VA.

There are two things that immediately come to mind when I think about the VA.

The first is that the VA is the clearest representation of what we can accomplish collectively as a country as we try to care for each other. The VA is squarely focused on the dignity and health of individual patients instead of on profiteering from procedural care and hospitalizations.  

As a physician and professor of medicine working outside the VHA system, I understand how important this is. I have long been working toward changing the US healthcare system so that it is more responsive to patients than profit. At times, this has been both challenging and demoralizing. The VHA is a concrete realization of so much of what I hope to achieve with my own patients, my university, and the health system in general.

Secondly, the VHA has served as my most important source of inspiration in my clinical practice as an HIV doctor caring principally for women of color. As I worked with my patients, it became obvious to me that most of them were not dying from HIV. Instead my research and experience demonstrated that they were were suffering and dying from the cumulative results of childhood and adult physical, sexual and emotional abuse, as well as from many forms of structural violence – such as racism and zenophobia. Deaths from from substance abuse, overdose, depression, and suicide and violence far outweigh deaths from HIV itself. This realization led me to dedicate my career to addressing the health impacts of childhood and adult trauma on health and well-being.

Most health care systems and those work in them barely recognize that trauma and structural violence are the single most important social determinant of health in our country. The VA on the other hand is almost entirely guided by this understanding. The VA system helped me understand the key components of an effective healthcare response to trauma.

Here are just a few examples of what I’ve learned from the VA:

Because the VA is a completely integrated and interdisciplinary system and is not principally motivated by profit, it is far more possible to deal with the physical and psycho-social – even economic – dimensions of the challenges that most patients face.

Because of their deep understanding of the impact of trauma on health, psychologists and other types of behavioral health specialists are integrated into the VA’s primary care clinics. Behavioral health is also integrated into almost every other aspect of their provision of medical care. And medical care is integrated into practically every type of mental health service the VA offers. This integrated, interdisciplinary model of care – now totally intuitive and necessary to me – is not found in most other systems of care in this care. Fortunately, a new awareness of the need for this type of care is emerging and even more fortunately, we have the VA health system to learn from.

Here is another example that has had a huge impact on how I practice medicine: the VA has developed a team-based model of primary care that brings all staff together to plan and coordinate the various dimensions of effective care for complex patients.  In these meetings, every member of the health care has an equal voice and is encouraged to offer their opinions and expertise about the care of each individual patient. This upends the traditional physician based, top down model of care.

This is precisely what we’re trying to replicate in the clinic I run at UCSF. We now have a clinic-wide interdisciplinary meeting prior to every clinic. These meetings include nurses, social workers, case managers, medical assistants, and physicians and nurse practitioners. We discuss each of the patients coming in to be seen that day and we coordinate a plan for each of them.  

This serves not only to develop a more effective treatment plan for their inter related medical and psychosocial issues but also serves to reduce the isolation of providers and other staff who themselves can become over whelmed and burned out by caring for patients with highly complex medical and mental health illnesses.  

We have also taken from the VA the power of having a separate weekly psychosocial team meeting at which the providers of various forms of behavioral health care, including social work, psychiatry, case management and substance use counselors can work together to match each patient with the behavioral health services they need and are ready for. We have found that patients are now more likely to accept these services than they are when physicians or nurse practitioners are acting alone.

There is one more thing I would like to add. It is completely clear to me that the recent attacks on the VA are in fact due to its success. The model of care at the VA and its excellent health outcomes, which are documented in study after study, are clearly superior to those that I see elsewhere throughout the private and academic health care system.   

These outcomes challenge the idea that government programs are bad or incapable of providing services that are both superior – and cheaper – to those available in the private sector. The only explanation for these attacks that makes sense to me is that some people have a purely ideological objection to programs run by the government.

The VA has served as a beacon of hope and a model of effective and compassionate care for our entire health system.  

It is my hope that I can help strengthen and sustain its vital services by replicating them and demonstrating their efficacy in the university and private health sector. I also am committed to lending my voice, time and energy to the crucial advocacy of the Veterans Health Care Policy Institute so that we can use research to educate our community about what it takes to deliver high quality care to veterans and, ultimately, to our entire population.

Brett Copeland