Working at the VA

[Sanman]

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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.

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.

I definitely agree about the malingering and the "what can I get for free" culture of some patients that often breeds non-compliance. That said, from a mental health perspective it balances out compared to some of the insurance shenanigans I have also dealt with on the outside. These problems tend to come up less in other specialties because of the lack of concrete work-ups (bloodwork, imaging, etc). That said, things like low SES also are less of an issue with mental health as many folks with more severe forms of mental illness fall into the same low SES background. It won't compare to a cash PP or a higher SES clientele, but I find it to be one of the best places to be employed if you want to work with a population that is historically low on resources.

The one thing I will say is that telehealth at the VA has been much easier to implement and one of the reasons I have chosen to stay here longer than expected.

 

[Stagg737]

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.

Agree, I wouldn't work at the VA for many reasons but I've also seen far worse. And that shelf life is 5 years to hit that minimum time for FERS pension.

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.

I worked at 3 different VA inpatient services in residency (4 if you include the inpatient addictions program) and have never seen or heard of anyone performing or referring for any actual malingering assessment. Maybe you do that where you are, but that did not happen where I worked. If you've worked at one VA...

The one thing I will say is that telehealth at the VA has been much easier to implement and one of the reasons I have chosen to stay here longer than expected.

Uh, what? Hopefully this is something they've finally figured out, but when I did my outpatient year at the VA (2020-21) telehealth was an absolute cluster****. There were days when almost every appointment I had was just via a phone call because no one could figure out how the heck to work VVC, even IT. To be fair, none of the 3 clinics I worked in during outpatient year did telehealth well at that point, but the VA was by far the worst.

 

[Sanman]

Uh, what? Hopefully this is something they've finally figured out, but when I did my outpatient year at the VA (2020-21) telehealth was an absolute cluster****. There were days when almost every appointment I had was just via a phone call because no one could figure out how the heck to work VVC, even IT.

It has gotten better in that aspect and there is an IT helpline now. That said, VA is not as beholden to state laws which make some of this easier assuming you are not a trainee (trainee laws were more complicated and a pain, though I did get paid to basically log on and "supervise" while actually doing nothing at times). Converting to phone call is not as big of a deal to me when you are on salary as it would be in the real world where payment may become an issue. Sure, the talking heads can complain about it, but the check still clears...

 

[comp1]

VA telehealth is pretty good now, even for inpatient. I think it went through the same growing pains as everyone else in 2020, but it's blossomed. The problem, as with everywhere else, is finding practitioners who are willing to do any face to face work since the VA patient population skews older and less inclined to want any telehealth.

 

[Sanman]

VA telehealth is pretty good now, even for inpatient. I think it went through the same growing pains as everyone else in 2020, but it's blossomed. The problem, as with everywhere else, is finding practitioners who are willing to do any face to face work since the VA patient population skews older and less inclined to want any telehealth.

This is going to be an ongoing issue for outpatient. The younger providers are more inclined toward telehealth and as a midcareer person I would immediately leave for private practice if forced back to in person. I can open my own office around the corner instead.

 

[Stagg737]

VA telehealth is pretty good now, even for inpatient. I think it went through the same growing pains as everyone else in 2020, but it's blossomed. The problem, as with everywhere else, is finding practitioners who are willing to do any face to face work since the VA patient population skews older and less inclined to want any telehealth.

This is going to be an ongoing issue for outpatient. The younger providers are more inclined toward telehealth and as a midcareer person I would immediately leave for private practice if forced back to in person. I can open my own office around the corner instead.

Glad to hear it's gotten better. I remember as a resident having some days where every appointment was a phone call because no one could figure out VVC and being told by admins that I needed to be "seeing" them and not doing phone calls. I also remember they told me to just continue phone calls when every one of my patients cancelled one week because they refused to do telehealth and the clinic policy was nothing in-person during the height of the pandemic. Probably didn't help that my clinic was partially the previous geri-psychiatrist's clinic, but I feel like that's a pretty large percentage of all VA outpatient clinics.

 

[Jules A]

This is going to be an ongoing issue for outpatient. The younger providers are more inclined toward telehealth and as a midcareer person I would immediately leave for private practice if forced back to in person. I can open my own office around the corner instead.

Absolutely and yet at the VA I worked the treatment plan, procedures and medications were essentially what the vets dictated or demanded. The CBOCs might have to start setting boundaries. 😳

 

[Stagg737]

Absolutely and yet at the VA I worked the treatment plan, procedures and medications were essentially what the vets dictated or demanded. The CBOCs might have to start setting boundaries. 😳

Until the admins and department chairs stop having panic attacks every time a vet whispers the S word I have no faith in appropriate boundaries in the VA system. At least not where I’ve been.