Following 1yr rotation at VA (not daily), I have come to see how the VA offers many resources yet manages access to care and these resources in a strange manner. What is cause of this on surface seems unrelenting bureaucracy. From doing paperwork to start the rotation, to scheduling patients, to having patients do simple things such as get EKG, to having to answer to pharmacists who decline to authorize meds due to their rules (one particular is Cymbalta, where they ask a trial of Effexor first). Then there is the electronic medical record that is stuck in 1990s and is completely inflexible, unsearchable, non-user friendly compared to things such as EPIC that we are used to. One more item I found interesting is the process of getting service connected (C&P?), which seems to have diagnoses made that I cannot see at all on exam (cyclothymic disorder? come on). Other things are concerning as well including new patients who were referred to psych and prior to this few days ago saw primary care. Yet primary care didn't include any of their medical history in the chart (although it is the other system that lists their 10+complex medical problems (but the systems are completely separate and not integrated), and on the medical ROS there are medical concern that should have been addressed 2 days prior. I also notice that there are patients with quite complex medical histories who should be managed by MDs/DOs rather than mid-levels for whom these patients are clearly over their heads in terms of complexity. In terms of psychiatric pathology the VA was more intense than our outpatient university clinic. Particularly in Axis II area. Overall great experience, but the VA has a lot to do with how many patients are seeking care in their system.