So I really don't understand why people think VA benefits are so great. I am private sector offers similar if not better benefits plus more salary. Also I don't understand what the complaints about VA red tape are. I mean, private hospitals have to deal with prior auth and arguing with insurance. You don't do that in the VA. I feel like VA is really a place that makes less for less work. It's not that bad and it's not that great.
Working at the VA
- Thread starter iownmle
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Don't you have people to do that for you in your hospital?
What are these private benefits?
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Good question, I've never seen a non-VA or non-state position offer a pension. I will say my income potential is much higher outside of the VA for the same hourly work, but in general, the VA benefits were better than most of what I've seen offered at other institutional positions. I just value more flexibility and not having to adhere arbitrary rules in the VA system.
They also offer 40k a year towards student loans. How common is it for private employers to give loan reimbursement?
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Ime pretty common
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Spotty, more available in harder to fill areas., not so much in desirable metros, I didn't have any loans, so in one instance of a job offer at a place that had some loan reimbursement I just tried to use it to negotiate up other benefits.
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I currently work for the VA. Student loan assistance is a max of 24K yearly for loans, dollar for dollar match for five years or until your med school loans are paid off. At least it was as of last year, I haven't looked in 2021.
I'll speak mostly to some of the positives specific to the VA off the top of my head, since the negatives are well documented already all the time. It's nice to not have to worry about carrying malpractice insurance if you work only at the VA, and having a lower risk of being sued is nice (patients generally have to sue the government first, not you directly.) However, not having to carry malpractice insurance is offset by higher non-VA salary. With the pension - if you can make more money outside the VA and invest it into your retirement, the VA is not any better just because it has the FERS pension. But if you are not great with money, the VA can be a good option. You're not going to get rich working at the VA, but it can be a long and rewarding career and it's not financially worse than public mental health or academia overall.
Not having to do a lot of prior auths or utilization review communication with insurance companies is nice, but that is offset in the VA by the large amount of aribtrary paperwork/documentation you have to do in the VA, which is honestly the worst part of being at the VA.
With the VA you can have any state license and practice at any VA, which is nice. You can move city to city and not worry about rolling over your retirement accounts. Heck, you can even prescribe using the VA hospital's DEA and not have your own if you want (I don't advise it.) The VA is more predictable as far as getting steady cost of living and tenure raises (step grade raises) so you can keep up with inflation. It's steady work for doctors who don't want to be entrepreneurs or take the peanuts academia offers and all the academic politics. And you can still teach residents and medical students as an adjunct prof.
If you like helping veterans, of course the VA is the way to go. I have seen the VA in general improve greatly over the last 15 years in pretty much every area. You always see news stories about what went wrong at some VA somewhere. Ever wonder why that is? Is it because bad things don't happen at non-VA clinics and hospitals? No, it is because by law the VA has to be transparent and give information to the media when asked. That transparency improves care.
The VA offers a lot of ancillary resources not available in other public or private mental health care settings, at minimal cost to veterans compared to non-VA care. I love that I have staff that can refer my patients to an inpatient dual-diagnosis rehab fairly easily, access to rTMS, ECT, and have an intensive case management staff. Lots of times patients don't have as nearly as good access to those things that outside the VA, that is certainly true in my state that always seems to vote against supporting any mental health care initiatives. The VA has easy to use and robust telepsychiatry opportunities and you can get paid the same as you would in person. The VA offers lots of free good quality CME all the time, the main issue is getting time away from your duties to attend, but overall that's a good problem to have.
Go to the VA and look around at the employees and note what type of people you see. The VA is a diverse place to work, not just at the MD level but in most jobs, whether you are on the coast, in the mid-west, in a city, or at a rural VA. There is a reason people of color work for the VA, and it's because federal careers provide stability and better protections against discrimination. I'm proud of that. In my experience, there is a lot more racism and discrimination in institutions outside the VA.
Finally I'll say this, as far as your individual work experience in a VA and It's the same thing my veteran patients say: "If you've seen one VA, you've seen one VA." Some of the VA's are great places to work and get care, others aren't as good. The VA is the largest hospital system in the nation. How nice it is to be at a particular VA, like anywhere else, has a lot to do with the local administration and department leadership and co-workers. If they are committed to helping and good at what they do, and generally nice people, it can be nice. I'm currently at what is considered a very good VA hospital, and we have veterans come from surrounding states and travel extra hours to come here instead of the VA in their own area because they get more personal care here and we have good staff. I will say that in the past I thought of leaving, but that is because I was overworked and we are short staffed. (Steps were taken to retain my services, so that was nice - I'm at a location that is currently good to work for.) But, again, being overworked and burned out is not specific to the VA system, I see that in public health and even academic centers.
I'll speak mostly to some of the positives specific to the VA off the top of my head, since the negatives are well documented already all the time. It's nice to not have to worry about carrying malpractice insurance if you work only at the VA, and having a lower risk of being sued is nice (patients generally have to sue the government first, not you directly.) However, not having to carry malpractice insurance is offset by higher non-VA salary. With the pension - if you can make more money outside the VA and invest it into your retirement, the VA is not any better just because it has the FERS pension. But if you are not great with money, the VA can be a good option. You're not going to get rich working at the VA, but it can be a long and rewarding career and it's not financially worse than public mental health or academia overall.
Not having to do a lot of prior auths or utilization review communication with insurance companies is nice, but that is offset in the VA by the large amount of aribtrary paperwork/documentation you have to do in the VA, which is honestly the worst part of being at the VA.
With the VA you can have any state license and practice at any VA, which is nice. You can move city to city and not worry about rolling over your retirement accounts. Heck, you can even prescribe using the VA hospital's DEA and not have your own if you want (I don't advise it.) The VA is more predictable as far as getting steady cost of living and tenure raises (step grade raises) so you can keep up with inflation. It's steady work for doctors who don't want to be entrepreneurs or take the peanuts academia offers and all the academic politics. And you can still teach residents and medical students as an adjunct prof.
If you like helping veterans, of course the VA is the way to go. I have seen the VA in general improve greatly over the last 15 years in pretty much every area. You always see news stories about what went wrong at some VA somewhere. Ever wonder why that is? Is it because bad things don't happen at non-VA clinics and hospitals? No, it is because by law the VA has to be transparent and give information to the media when asked. That transparency improves care.
The VA offers a lot of ancillary resources not available in other public or private mental health care settings, at minimal cost to veterans compared to non-VA care. I love that I have staff that can refer my patients to an inpatient dual-diagnosis rehab fairly easily, access to rTMS, ECT, and have an intensive case management staff. Lots of times patients don't have as nearly as good access to those things that outside the VA, that is certainly true in my state that always seems to vote against supporting any mental health care initiatives. The VA has easy to use and robust telepsychiatry opportunities and you can get paid the same as you would in person. The VA offers lots of free good quality CME all the time, the main issue is getting time away from your duties to attend, but overall that's a good problem to have.
Go to the VA and look around at the employees and note what type of people you see. The VA is a diverse place to work, not just at the MD level but in most jobs, whether you are on the coast, in the mid-west, in a city, or at a rural VA. There is a reason people of color work for the VA, and it's because federal careers provide stability and better protections against discrimination. I'm proud of that. In my experience, there is a lot more racism and discrimination in institutions outside the VA.
Finally I'll say this, as far as your individual work experience in a VA and It's the same thing my veteran patients say: "If you've seen one VA, you've seen one VA." Some of the VA's are great places to work and get care, others aren't as good. The VA is the largest hospital system in the nation. How nice it is to be at a particular VA, like anywhere else, has a lot to do with the local administration and department leadership and co-workers. If they are committed to helping and good at what they do, and generally nice people, it can be nice. I'm currently at what is considered a very good VA hospital, and we have veterans come from surrounding states and travel extra hours to come here instead of the VA in their own area because they get more personal care here and we have good staff. I will say that in the past I thought of leaving, but that is because I was overworked and we are short staffed. (Steps were taken to retain my services, so that was nice - I'm at a location that is currently good to work for.) But, again, being overworked and burned out is not specific to the VA system, I see that in public health and even academic centers.
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One thing to consider are the trends in 'mental health administration/'leadership'' over the past few years as well as what is likely to happen over the next 5-10 years in the VA system. Generally, as a psychotherapist, you're dealing with cumulative increases in paperwork/ software programs (without commensurate increase in time as a resource), increasing oversight/'accountability' for successful implementation of measurement-based care (read, taking veteran self-report on symptom checklists as an unerring 'gold standard' measure of the treatment targets of interest...while completely ignoring the fact that they realize that their self-reported symptom severity is liable to directly impact their monthly income from service-connection), an absolutely mentally-******ed approach (top-down) to 'treatment planning' via mandates to use a software package/approach that doesn't comport with the way actual (master) psychotherapists do case formulation, treatment planning, and implementation, as well as (given all of the above) a top-down authoritarian management structure that has grown increasingly deaf (even hostile) toward good-faith efforts of experienced and capable clinicians to even broach the above topics and attempt to engage in an 'adult conversation' (i.e., not filled with tropes, thought-terminating cliches, mindless enthusiastic utopian pom-pom waving or drum circle pep rally speeches).
At least we have a 'union.'
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Yeah, I feel for the therapists. I mostly do medication management and have had somewhat less to do with these issues. Also, LPCs, LMSWs, and even PhD psychologists seem like they have to take more from admin than physicians. A lot of the things said to them as requirements are more suggestions to physicians, at least around here.
Veteran entitlement is an issue at times, but I guess I'd rather have that problem compared to having more veterans who deserve benefits not get them as happened to many veterans who served prior to 9/11, but seems to happen less with the current generation of veterans (i.e.; OIF/OEF). There is sort of a undertone of "you are a bad American" if you say no to a veteran a lot of times. Patient satisfaction coupled with rah rah patriotism irks me sometimes. And I say no a lot to inappropriate benzos.
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To add to this--I've never seen a VA with a non-compete. VA has some pretty straightforward limitations (e.g., don't refer patients eligible for VA care to your own non-VA practice for the same services you provide at VA; don't use VA resources for non-VA work), but not much beyond that.
Also, if you like training and in addition to adjunct intructorship/professorship, odds are the VA system itself will have trainees with whom you can be involved in varying capacities. And there's at least a chance you'll get some protected time for this. I'm often able to request to block a psychiatrist's schedule for an hour so they can present a seminar to psychology interns, for example.
On the downside, as others have said and as can probably be the case anywhere, VA is a somewhat top-heavy organization, and having a bad boss can be really frustrating/demoralizing.
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if you had to estimate, what percentage of your patients are male/female ?
Female veterans are about 9.4% of the population. However, women are statistically more likely to seek help, particularly mental health help. So I'd estimate about 15% on inpatient units. It will vary a lot by what exactly you do, of course.
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75% male in my clinic. I occasionally see pregnant or lactating veterans. A few transgender also. Given the sheer size of my panel I see a lot of female veterans.
Regarding age, generally age 25 and up, with majority of all genders being over 60. The two main groups I see are Vietnam and Afghanistan/Iraq. Third largest group is 80s and early 90s veterans. I still have one or two Korean war combat veterans. Those guys are really neat people.
Also, regarding orientation, I reckon I see LGTBQ in about the same proportion as seen in most non -VA clinics.
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Like you said, if you've seen one VA you've seen one VA, but some things I thought were worth addressing as I've worked in 3 VAs now:
I generally do agree with this. The primary VA I work at has one of the nicest/newest inpatient units in the city and the outpatient clinic has improved significantly even in the past year or two.
This I disagree with though. I've never seen a VA that offered TMS and ECT is highly variable (only in 1 of the 3 VAs I've worked at). All of the VA's I've worked at also only offer a maximum of 12 sessions of psychotherapy (outside of the PTSD program). If ongoing therapy is needed patients have to be referred out and it doesn't always get approved. There is an excellent residential PTSD program in our VISN though, which from what I've heard is better than any of the private options in our area. One thing I will say is that the VA does often do a good job of offering a referral to a private program if it's not available through our VA(s). The few patients I've referred out for TMS have been approved and they do often approve referrals to residential programs not available through the VA. There's also very good wrap-around support through CM and SW, which is one thing I do wish would become more common outside the VA.
This will vary a lot as well. Other than the ancillary staff the VAs I've worked at have been much less diverse than our local private hospitals and there is a very obvious divide based on position (many Asian and black nurses, Almost exclusively white and Indian physicians). In terms of racism, it's a mix in terms of employees and not that different than outside the VA (maybe a little worse). The VA patients as a whole are much more racist than the gen pop though, this was true at all VAs I've been at in 2 different geographical regions.
I generally do agree with this. The primary VA I work at has one of the nicest/newest inpatient units in the city and the outpatient clinic has improved significantly even in the past year or two.
This I disagree with though. I've never seen a VA that offered TMS and ECT is highly variable (only in 1 of the 3 VAs I've worked at). All of the VA's I've worked at also only offer a maximum of 12 sessions of psychotherapy (outside of the PTSD program). If ongoing therapy is needed patients have to be referred out and it doesn't always get approved. There is an excellent residential PTSD program in our VISN though, which from what I've heard is better than any of the private options in our area. One thing I will say is that the VA does often do a good job of offering a referral to a private program if it's not available through our VA(s). The few patients I've referred out for TMS have been approved and they do often approve referrals to residential programs not available through the VA. There's also very good wrap-around support through CM and SW, which is one thing I do wish would become more common outside the VA.
This will vary a lot as well. Other than the ancillary staff the VAs I've worked at have been much less diverse than our local private hospitals and there is a very obvious divide based on position (many Asian and black nurses, Almost exclusively white and Indian physicians). In terms of racism, it's a mix in terms of employees and not that different than outside the VA (maybe a little worse). The VA patients as a whole are much more racist than the gen pop though, this was true at all VAs I've been at in 2 different geographical regions.
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I'm late to the game here. I recently started working as a doc at the VA after a 23 yr career owing my own practice. THE VA IS THE ABSOLUTE DUMBEST PLACE YOU WILL EVER WORK! I find the providers are good. But the 'big brother' admin are the dumbest of the dumb.
Now, I'll explain. Their CPRS (computerized patient record system......that the rest of us on planet earth call EMRs) is a 1997 ridiculous outdated MS DOS charting system. The VA/gov't recently spent......no wasted....$80 BILLION to try to come up with a new system as they know it's horrible and causes most doctors to end up quitting. It failed. So, 80% of my time is clicking a mouse, typing and copy-n-pasting non-stop. I've actually counted them. 420+ (minimum) mouse clicks for the average patient. 6,200 clicks per day. 31,000 clicks per week. After using EMR for 23 years my fingers actually have bruises on the pads from the 8 straight hours of non-stops clicking.
In between the non-stop clicking and typing, I peek at patients. But make no mistake, patients are secondary at the VA. Or actually tertiary. Doing stupid training is first ('How to Answer the Phone', 'How to Deal with Irate Patients', 'Showing Respect to Your Fellow Human'. Totally insulting to the intelligence-- stupid training that I have to find time to do in between my pts or during my 30-minute lunch. So that's priority # 1. An idiot admin actually told me to give her my cell number and she's arrange that I could do my 40 hours of training at home -on my own time. I laughed and laughed and laughed. No freaking way I'm doing the VAs work on my own time. This is the reason I sold my private practice.....to get rid of the admin hassles. But it's 100 times worse here. I even still have to code the insurance and write up the constant PAs (prior authorization) for the pts to get their meds. I might as well be in private practice and make more money doing the same work. And that's exactly what I'm going to do.
Priority #2
Documenting the chart. Non-stop, ridiculous amount of documenting. Then they have "Chart Reviewer" that constantly harasses you to document it this way or that way. I ran into a former pt of mine in the hallway. She told me that SHE was the head of these idiot Chart Reviewers. I happen to know, over the 23 yrs of see her and her family, that she is one of the dumbest people on earth. The kind of patient you cringe when you see on your schedule. I know these 'reviewers' are telling me incorrect things. I've documented for 23 yrs, wrote a book on insurance coding and survived 2 Medicare audits with flying colors. I KNOW how to document and code! But I/we have ******* high school grads telling me I need to do this or than on my charts. Put this or write it this way. They have zero experience in medical care. Just hired off the street and, instantly become your BOSS! This charting in an inefficient and outdated system and the constant harassment is what causes MOST doctors to quit. The charts are basically a Word document so you are writing a small book on each patient (even with templates).
I have to open 9 different programs on my computer each morning just to start the day. Sometimes they work. Sometimes they don't. The place is paperless so you have 25-35 random people messaging you on the computer non-stop all day, needing this or that or whatever. The printers are all locked in rooms. Why they lock up $100 printers is beyond me. So anytime the needy, whiny pt needs something printed, it a hassle.
Priority # 3 is Patient Care. It's an afterthought. I have 10 minutes to see the patient and it take 30+ minutes to document the encounter.
There are very few people in charge at the VA. We have no boss. No one in charge of the clinic where I work. 70% of employees are admin people and they all seem to have only ONE job each. Absolutely no cross-training. So, to get anything done, you are jumping from employee to employee to employee. They will all 'pass the buck' to the next person.
I could go on and on (but my typing fingers are too sore). I'm quitting the VA after 2 months. My goal in life now is to stop any doctor from wasting their time going there. It takes anywhere from 6 months to a full year just applying. Again, a ridiculous process which should have told me how bad it would be. Only when providers refuse to work there will it change. So, by me staying there, I would be contributing to the problem.
I worked at the VA part-time in 2003. I thought that maybe it would have improved in 20 years.........but it hasn't.
The only doctors that survive there are those that are meek and mild and are raised by the VA (having done their training there and just never leaving). Those that are insecure in their skills and need 'big brother' to run their lives (not surprisingly, all docs in my clinic are female these days). Frankly, I think the docs that survive have developed 'Stockholm's Syndrome' where they fell in love with their abuser/capture (the VA). I feel sad for them.
And I can't end this without saying something. The patients at the VA are NOT HEROs. They are welfare recipients using the VA instead of Medicaid. If you work there, you will be working in a welfare clinic 100%. I feel I can say this as a Marine Corp combat veteran myself. These pts are the most entitled people on earth, that for some reason, think/have been told that a few years in the Army should endow on them a free lifetime of medical care and thousands of dollars of meds and appliances per year. We even send them free supplies of artificial tears automatically in the mail.
There is no need for the horribly inefficiently run gov't VA system. It's always been flawed and always will be. If the gov't wants to pay for veteran care, they should just pay outside providers. It would be far less expensive in the long run.
Now, I'll explain. Their CPRS (computerized patient record system......that the rest of us on planet earth call EMRs) is a 1997 ridiculous outdated MS DOS charting system. The VA/gov't recently spent......no wasted....$80 BILLION to try to come up with a new system as they know it's horrible and causes most doctors to end up quitting. It failed. So, 80% of my time is clicking a mouse, typing and copy-n-pasting non-stop. I've actually counted them. 420+ (minimum) mouse clicks for the average patient. 6,200 clicks per day. 31,000 clicks per week. After using EMR for 23 years my fingers actually have bruises on the pads from the 8 straight hours of non-stops clicking.
In between the non-stop clicking and typing, I peek at patients. But make no mistake, patients are secondary at the VA. Or actually tertiary. Doing stupid training is first ('How to Answer the Phone', 'How to Deal with Irate Patients', 'Showing Respect to Your Fellow Human'. Totally insulting to the intelligence-- stupid training that I have to find time to do in between my pts or during my 30-minute lunch. So that's priority # 1. An idiot admin actually told me to give her my cell number and she's arrange that I could do my 40 hours of training at home -on my own time. I laughed and laughed and laughed. No freaking way I'm doing the VAs work on my own time. This is the reason I sold my private practice.....to get rid of the admin hassles. But it's 100 times worse here. I even still have to code the insurance and write up the constant PAs (prior authorization) for the pts to get their meds. I might as well be in private practice and make more money doing the same work. And that's exactly what I'm going to do.
Priority #2
Documenting the chart. Non-stop, ridiculous amount of documenting. Then they have "Chart Reviewer" that constantly harasses you to document it this way or that way. I ran into a former pt of mine in the hallway. She told me that SHE was the head of these idiot Chart Reviewers. I happen to know, over the 23 yrs of see her and her family, that she is one of the dumbest people on earth. The kind of patient you cringe when you see on your schedule. I know these 'reviewers' are telling me incorrect things. I've documented for 23 yrs, wrote a book on insurance coding and survived 2 Medicare audits with flying colors. I KNOW how to document and code! But I/we have ******* high school grads telling me I need to do this or than on my charts. Put this or write it this way. They have zero experience in medical care. Just hired off the street and, instantly become your BOSS! This charting in an inefficient and outdated system and the constant harassment is what causes MOST doctors to quit. The charts are basically a Word document so you are writing a small book on each patient (even with templates).
I have to open 9 different programs on my computer each morning just to start the day. Sometimes they work. Sometimes they don't. The place is paperless so you have 25-35 random people messaging you on the computer non-stop all day, needing this or that or whatever. The printers are all locked in rooms. Why they lock up $100 printers is beyond me. So anytime the needy, whiny pt needs something printed, it a hassle.
Priority # 3 is Patient Care. It's an afterthought. I have 10 minutes to see the patient and it take 30+ minutes to document the encounter.
There are very few people in charge at the VA. We have no boss. No one in charge of the clinic where I work. 70% of employees are admin people and they all seem to have only ONE job each. Absolutely no cross-training. So, to get anything done, you are jumping from employee to employee to employee. They will all 'pass the buck' to the next person.
I could go on and on (but my typing fingers are too sore). I'm quitting the VA after 2 months. My goal in life now is to stop any doctor from wasting their time going there. It takes anywhere from 6 months to a full year just applying. Again, a ridiculous process which should have told me how bad it would be. Only when providers refuse to work there will it change. So, by me staying there, I would be contributing to the problem.
I worked at the VA part-time in 2003. I thought that maybe it would have improved in 20 years.........but it hasn't.
The only doctors that survive there are those that are meek and mild and are raised by the VA (having done their training there and just never leaving). Those that are insecure in their skills and need 'big brother' to run their lives (not surprisingly, all docs in my clinic are female these days). Frankly, I think the docs that survive have developed 'Stockholm's Syndrome' where they fell in love with their abuser/capture (the VA). I feel sad for them.
And I can't end this without saying something. The patients at the VA are NOT HEROs. They are welfare recipients using the VA instead of Medicaid. If you work there, you will be working in a welfare clinic 100%. I feel I can say this as a Marine Corp combat veteran myself. These pts are the most entitled people on earth, that for some reason, think/have been told that a few years in the Army should endow on them a free lifetime of medical care and thousands of dollars of meds and appliances per year. We even send them free supplies of artificial tears automatically in the mail.
There is no need for the horribly inefficiently run gov't VA system. It's always been flawed and always will be. If the gov't wants to pay for veteran care, they should just pay outside providers. It would be far less expensive in the long run.
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Why did an optometrist come into the psychiatry and psychology forums specifically to bitch about the VA in a weirdly sexist post? Weird.
Anyway I don’t know why you’re complaining about only spending 10 minutes with patients or how your one patient is so dumb…I don’t think I’ve ever had an optometrist spend more the 10-15 min with me max in my entire life unless we were doing contact fittings or something.
Anyway I don’t know why you’re complaining about only spending 10 minutes with patients or how your one patient is so dumb…I don’t think I’ve ever had an optometrist spend more the 10-15 min with me max in my entire life unless we were doing contact fittings or something.
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Good catch, I missed that! My experience with the VA was very different from what the above poster described. I have posted elsewhere but if you work at the VA you will need to deal with rigid schedules and a lot of administrative inflexibility. It is also a "my way or the highway" position where you just need to do what is handed down to you, for example a lengthy Suicide Risk Assessment that basically re-hashes an admission note when it truly isn't clinically necessary to document all that again. Still, if you can deal with that part of it working at the VA really isn't bad! The workload is pretty light, contrary to what the above poster says you work with some malingerers/ whiners but also with plenty of motivated patients who do engage well, and you can have a low-average salary with great work-life balance.
I don't have any plans to go back to the VA, but I still look back (mostly) fondly on the time I spent working there.
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And if you are spending 30 minutes documenting on each follow-up encounter in psychiatry you are really doing something wrong! I can count on one hand the number of times I spent staying late because I could not keep up with documentation when I was at the VA (zero!).
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Had to double check, suddenly I felt like I was in glassdoor.com.
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I will disagree significantly with this. I can count the number of times I left my outpatient clinic on time as a resident on one hand. CPRS isn’t difficult to use, but the documentation burden (ie every screen/annual update) is excessive to the point of either needing to stay late or just not meeting standards (which I admit I would not). Two of my previous co-residents work in that same clinic as attendings and have said nothing has changed. They say they either stay late or just don’t do some of the screens like we all used to.
Well, take it for what it's worth because I'm definitely "Stockholmed." I do agree that it is common for residents to stay late. You're literally learning a new system. However, it most certainly is NOT common for attendings to stay late once they have figured out how to use the computers. VA workload is lower than average. Personally, I adore CPRS. Complex GUIs do not inherently make things better and CPRS is definitely the best EMR not designed specifically for billing. The optometrist is right in that patients who use the VA do tend to be poorer and have less access to other resources. However, it's not some sort of moral failing that we offer the services as a country. It should be the minimum for everyone. Of course there are abuses and we should actively root out fraud and waste, but the whole concept of getting upset with someone receiving eye drops in the mail is really kind of gross. It's also demonstrably not true that sending care outside of the VA results in cost savings or improvements in care overall. The VA, for all its problems, consistently delivers the highest quality care for the cost in the US and has for decades.
Lololol we all just gonna disagree with eachother the documentation is not that hard. I never stayed late at the VA OP. Just document with the patient present make eye contact and type your not. Have templates built out. Copy forward notes and appropriately edit in current details and screens. 30min for documentation is wild
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Yea, can't disagree with the bolded more. CPRS is legit one of the worst EMRs I've worked with. Wildly unintuitive and with hard stops that drove me up a wall. I don't hate the VA as a whole, but the bureaucracy is what killed me and CPRS is just a straw that breaks the camel's back kind of thing.
The basic note isn't the issue. If that's all you had to do at every appointment it wouldn't be a big deal. The problem is the OTHER notes you have to fill out for various screenings (Columbia for any SI, CSRE for positive CSSRS, annual DV for everyone, bi-annual treatment plan update with S.N.A.P. update, etc) that create the burden. I know that some of those are national policy and thought they all were, but apparently some are just VISN policies where I was at. When you have to write 3-4 separate notes for a single encounter (I typically had to write at least 2 separate notes per encounter) or face the unending e-mails about not meeting protocol it's just obnoxious and does not add value to treatment.
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I read they had a hiccup.
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Nope. They completely scrapped it.
The Cerner transition has indeed experienced many hiccups. Not entirely sure it is dead yet, but I can hope. Unlike others, I really, seriously, do like CPRS. I agree that more metrics should be built into single notes as opposed to spread across multiples, but I don't think Cerner will fix anything.
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Oh jeez, that's wild. Pretty out of the VA world but I can't imagine that being a cheap semi-transition.
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So not 100% sure, but a colleague at the VA (outpatient director) said it’s been completely scrapped. Another Cerner person I know also said that they’re no longer working on a new EHR. My understanding was it was because they couldn’t create a system that was compatible with old records and the sheer volume of records that would need to be transferred to a new system was too much for Cerner/Oracle to handle. Supposedly they’re just modifying CPRS, though I have no idea how. I think that’s part of why they restructured their initial contract to be multiple 1 year contracts that have to renew.
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Instead of spending that money they spent on Cerner and giving billions of taxpayer money to its shareholders and executives, they should have invested to update and improve CPRS; and I would have been very happy.
Now we use CPRS booster to enhance to function of CPRS which it should have built in already. Duhhh.
Now we use CPRS booster to enhance to function of CPRS which it should have built in already. Duhhh.
Totally agree. The entire Cerner contract was...inappropriate. It wasn't even put out to bid as far as I can tell. I hope you all are right that it was completely scrapped, but I believe right now it is instead in a sort of month to month contract (down from the year to year which was originally a five year contract). Remember there are several VAs that have already launched and are using Cerner right now, although it is a tiny number due to the problems. So there is an ongoing need. Hopefully they do indeed dedicate that money to CPRS renovation instead.
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Dammit. This thread just reminded me that there's some banal VA training I have to do yesterday for a rotation that isn't due to start until next year. Because VA...
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If there's one thing about VA that I'd hammer home, it's to stay on top of the administrative requirements.
It may take them weeks/months/years to accurately record you've gotten it all finished, but rest assured that the moment you miss a mandatory training deadline, they'll immediately cut off your PIV card, computer access, email, etc. As a former (psychology) training director, this was the bane of my existence.
Mysteriously, they are not nearly as efficient in getting all those things turned back on.
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Eh don't tell my program director but I'm treating this as a 'future me' problem. I'm not worrying about it till after CAP boards. If I dun effed up, I'll have 3 months to fix it which means that I'll get to snowboard instead of going to work since the VA won't figure it out till March or April.
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I was considering working at the VA, but after talking to a few people, I have completely dropped the idea. Seems like anything else is better.
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I know you like it there, but it seems you are the exception. I have talked to a few people that worked at my local VA and it was bad. They were all overworked, with admin trying to put more tasks into their jobs. One of my attending was supposed to do outpatient and they wanted her to do consults as well.
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I strongly considered VA after my active duty time as I did enjoy working there in residency. I've talked to a few psychiatrists that I either worked with at the VA in residency or were in my training program with me who went to the VA after their service commitment was up. They seemed pretty happy. I'd say "anything else" would be better than active duty but I'm sure there's a lot of headaches working with the VA as well. But it is very dependent on the specific VA as the saying goes, if you've seen one VA then you've seen one VA.
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Can people still just walk in and be seen for outpatient? If you have a full schedule, can a new patient or follow up walk and you have to see them?
I can't promise that there isn't any VA anywhere in the country where you might be expected to see an emergent walk in between your scheduled panel patients. There is a complex conflict of always having same day access available to patients and having fully booked schedules for UM that is extremely challenging for managers. However, it's not good practice and it's certainly not what the VA Central Office recommends in terms of flow. If there are not dedicated staff available for walk-in's then each outpatient provider should have a certain amount of same day "access" slots kept open on specific days of the week to triage such patients, particularly for emergencies such as suicidal ideation. This is an excellent question to ask at your interview as it shows an interest in how outpatient works and a reasonable concern for the workload.
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Regarding this post, it is written in a very non-PC way, but many elements ring true, in particular the bits about the amount of clicking in CPRS (can be partially alleviated by CPRS booster if your facility has not blocked it), arbitrary documentation that serve no clinically useful purpose, silly training modules, and low-quality support/administrative staff. These elements will be less prominent at better VAs, but they will always be present to some extent. Whether one chooses to work for the VA will depend on the specific VA under consideration and how the other job options compare. Poor quality support staff, bad EMRs, and paperwork headaches exist in the private sector as well, but is as a whole more prevalent in the VA because there are no real incentives to increase efficiency at the systemic level. If Optometry Master had a private practice before coming to the VA, it is not a surprise that he did not last long at the VA, because staying in the VA typically does require a more passive personality to be able to tolerate the problems and inefficiencies.
For psychiatrists considering the VA as a career option, a difficulty that many people are not fully aware of is the issue of secondary gain. Compared to other specialties with more "objective" ways of diagnosing such as physical exam and imaging, psychiatry is very heavily dependent on information reported by the patient. This means that it is quite easy to embellish or outright lie about symptoms and impairments if an incentive exists. Unfortunately, an incentive indeed exists in the VA in the form of service connection (VA disability payments), which can be as high as $3400 per month tax free (more if married, with dependents).
I would estimate that at least 30% of my outpatient panel consists of patients seeking "treatment" so that they can get their purported symptoms and impairments documented in the chart, which they can then use as evidence to increase service connection. Those who have already attained a satisfactorily high level of service connection +/- SSDI are also unlikely to report any improvement, out of concern that the service connection payments will be decreased. It leads to a frustrating dynamic in which patients are rewarded for being (or reporting that they are) sick or dysfunctional, making them highly disincentivized against reporting any improvement. I estimate that perhaps 15% of my panel is truly invested in treatment for the purpose of functional improvement.
Fan_of_Meehl also mentions this secondary gain element in his post. The large numbers of patients seeking psychiatric treatment with the intention to never get better is probably the most dissatisfying part about the VA for me.
Yep, there's malingering and it might indeed be higher than a general outpatient setting because the potential benefit is about 3x higher than SSDI. However, I find the stress of dealing with that is really heavily outweighed by having all the possible resources you could want to treat any actual given condition without concerns about getting it paid for and patients generally having the finances to care for themselves, which is really not the case with SSDI. I think it's important to always remember that this is not a population from a general outpatient setting. Sure, the vast majority of veterans were never involved in any sort of combat, but that doesn't mean they haven't had much worse traumas relative to the average person. They come from much lower SES than the average outpatient. People join the military for a lot of reasons, but an extremely common one is to escape horrific childhoods or other living settings. Ultimately, our goal should be helping people get to the highest level of functioning we can. That's more important than whether we believe they actually meet 5 out of 9 criteria for depression or not. Leave that to the VBA.
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Sure but I think the point above is that this then gets leveraged into service connection....because you can try to leverage almost anything into service connection. So people then want it said that their prior trauma disorder was worsened because of their time in the military.
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I personally do not find the additional treatment resources at the VA to help with the dissatisfaction I feel about malingering. The resources are nice for other reasons, but the people who are malingering are not helped by the resources. They will utilize therapy, residential treatment, etc. not to attain a higher level of function, but to get documentation of how sick and dysfunctional they are. Not being the one responsible for service connection determinations does not really make this malingering easier to bear. In fact, it is more galling. Perhaps I ended up unlucky with my patient panel and have a larger proportion of patients who are not interested in improvement, which means that I have fewer opportunities to feel satisfied about the plentiful resources for patients who want to get better.
Obviously, I’m still at the VA, meaning that I’ve determined that the pros outweigh the cons for now. However, very independent and entrepreneurial people would not do well at the VA, because the inefficiencies and the malingering would be much more painful to them.
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I would add that the clinical record can be used as a part of C&P evaluations, and can also come up in medicolegal cases outside VA. When VA clinicians then state that a patient has a certain condition, and particularly if that diagnostic decision arises from a relatively poor evaluation and/or out of a desire to advocate for the patient (or not wanting to upset them by telling them they don't have PTSD/dementia/etc.), that very well can contribute to financial payouts.
I'd also say that the readily available resources at VA can lead to resource overutilization. The treating provider sees that what they're doing "isn't working," so they refer to all sorts of other services that also eventually find their interventions don't work, which in situations that don't involve outright malingering can induce very real iatrogenesis.
Edit to add that the above, in my experience, applied to a minority of patients at VA, but it was a sizable minority (and varied by service). Most patients were great
RE: CPRS, I may be in the minority, but I actually liked it once I got used to it. But I also grew up with DOS and Windows 3.0.
Alllll that said, there are definitely worse places to work than VA; it has its perks, it just may have a shelf life for many doctors.
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I know this doesn't help outpatient (personally I can't do outpatient in any setting), but inpatient, at least, you can generally get formal malingering assessments like the SIRS, dot counting, MENT, etc done when you need to and these are also considered in C&P and medicolegal cases when appropriate.
