Mission Betrayed

In his book, Mission Betrayed: How the VA Really Fails America’s Vets, Michael J. Mann, MD, draws on his years of experience working in the Veterans Health Administration to write a compelling exposé of the widely criticized government agency.

Dr. Mann, a cardiothoracic surgeon and innovator of genetic and molecular therapies, argues that the inexcusably long wait times that received much media attention in 2014 are only a part of the problem. His book documents a deeply flawed system that allows VA administrators to conceal mediocrity, abuse and neglect.

Dr. Mann joined the faculty at the University of California, San Francisco (UCSF), in 2003, having received an A.B. (summa cum laude) in synthetic chemistry from Princeton University and an MD from Stanford University. He completed his fellowship in cardiothoracic surgery at UCSF, and has been named to the U.S. News and World Report list of Top Doctors in the United States. Limited space allows Dr. Mann in the following interview to only scratch the surface of VA malfeasance, but still paints a disturbing picture of an agency in serious need of reform.

LE: You say that the VA scandal of 2014, which centered on waiting times for patients, was just the tip of the iceberg. Why?

MM: As shocking as many of the 2014 revelations may have been, they pale in comparison to the true, appalling depth of abuse to which our veterans are routinely subjected at the VA. Just about any thoughtful medical academician who has worked at the VA could tell you that the VA wait list scandal was nothing more than a reflection of the way everything is managed in that monolithic federal institution. And when an entire, badly broken healthcare system boils down to the generation and worship of a few dramatically misleading statistics, the disheartening result is not only a danger zone for our unsung heroes, but the violation of one of our nation’s most important promises to a deserving, underserved population.

There is great resistance in medicine to airing our own dirty laundry—the VA is a deep-set fixture in American medicine that very few care to rock. I actually began to collect my own notes of VA abuses after leaving my part-time involvement as the leader of a surgical sub-specialty program at the San Francisco VA in 2011. Although I had begun to organize these notes even before the 2014 wait-list scandal erupted, I was subsequently convinced to complete a memoir of my time at the VA. (My book is) the result of an effort to make sense of those notes and to put them into a larger perspective, a perspective that reflects back on the countless stories that have too quietly been told since the 2014 wait-list scandal broke.

LE: In your book, you recount specific cases you were involved with, including that of a veteran you call Edward Perry, who had lung cancer that was caught early, but who nevertheless ended up dying after the VA mishandled his case.

MM: Edward Perry was one of many vets who were not given a chance to receive high-risk but potentially lifesaving surgery at the San Francisco VA and at VA hospitals nationwide.

In fact, the San Francisco VA has been recognized as one of the best medical centers in the entire VA system. And by 2008, our hospital staff had grown accustomed to receiving blanket emails from our administration highlighting data that portrayed the Veterans Health Administration as the “best healthcare system in America,” statistics that proved that the VA had superior “quality of care” and “patient satisfaction.” Why then did Edward Perry fail to receive this superior quality of care? Why did we not save his life? And why do so many other vets who trust the VA fail to receive the quality of care our nation has promised?

Over time, I realized that beyond this paradox was a more insidious connection between these very claims of superlative VA care and the deaths of patients like Edward Perry. Perry did not die from the high risk of his case. He was killed by an increasingly effective systemic VA approach that limits the negative impact of high-risk cases on VA statistics, and therefore on the careers of VA administrators.

LE: How did that systemic approach work?

MM: It was about the numbers. Limiting the number of deaths following surgery raised the rating of a VA hospital, and in so doing enhanced bureaucrats’ careers (and annual bonuses). Without the need for any orchestrated conspiracy, decisions for or against surgery in particular cases were too often based not on the rights and well-being of the patients, but on the likelihood that surgical outcomes—outcomes that had at one time rescued the VA from harsh congressional scrutiny—would remain blemish-free. There was no need for conspiracy. It was simply the VA way.

Throughout the VA system in recent years, deaths following surgeries have been drastically, almost miraculously, reduced, just in response to heightened scrutiny. Why? Had surgeons’ skills, and the intricate coordination of complex care suddenly, spontaneously, and drastically improved? Or had people at the VA simply done what decades of box checking and obfuscation had taught them to do—game the system and make sure things looked the way people wanted?

Years after Edward Perry died, the nation was shocked to learn that dozens of VA hospitals had falsified waiting lists to overcome what had begun as an unreasonable bureaucratic demand to schedule every patient within two weeks. Yet no one has ever suggested an organized conspiracy. It wasn’t necessary. Large numbers of VA administrators, doctors, and nurses had simply done things the VA way.

Mr. Perry lived and died the VA way. But what should have mattered more—bureaucrats’ livelihoods or the lives of a veteran and his family?

LE: In another of many examples in your book of VA ineptitude and neglect, you mention the case of a man you call Dan Carney, a diabetic with non-healing ulcers on his feet caused by poor circulation, ulcers that could have been prevented with special “orthotic” shoes.

MM: Mr. Carney had indomitably high spirits. By the time we met, he was about to have his left foot cut off to prevent a potentially lethal spread of infection up his leg and into his bloodstream. Despite a long history of ulcers, and despite the fact he routinely sought care at the VA for years, no one had thought to intervene early, when the simple solution of an appropriate shoe might have made all the difference to his imperiled left foot. Instead, Mr. Carney’s non-orthotic shoes inevitably continued to engender ulcers that threatened not to heal.

LE: What was it like working for the VA? What did you observe about the way they relate to their patients?

MM: The VA wears you down. When you walk into a VA hospital, you don’t always see the kinds of patients you see at most private American hospitals. Many of the vets treated at VA hospitals are poor. Some of them are not so well dressed, not so well put together. Many have lived difficult lives, and it shows in their bearing and the way they walk. They are not used to expecting or demanding the best. They are grateful, most of the time, if they are handed second or maybe even third best. They are generally very grateful for whatever they get at the VA. They are particularly grateful to get it for free.

The collective, perhaps unconscious, attitude of the institution assumes that whatever it provides is basically good enough. Sometimes, individual providers do strive to reach a level of excellence that they are used to at other institutions, but they inevitably accept “reality” when other elements of the VA machinery make that truly excellent care more difficult, or sometimes “impossible” to achieve.

LE: How widespread is that point of view in the VA?

MM: This unspoken attitude applies to nearly everyone in the institution—from the maintenance staff up through the doctors and administrators. It wasn’t, for example, obvious to me and to other VA doctors that we shared such an attitude toward the vets, or that it influenced our expectations of what we needed to accomplish on their behalf. But we did share it. And that was precisely because the attitude was so effectively pervasive: These were the “vets.”

LE: How deeply did that attitude reflect on the quality of the staff?

MM: It was not that all VA employees were incompetent or lazy, or that there were no incredibly talented, hardworking individuals at the VA. Certainly there were. But every VA employee was affected by an institutional laziness, institutional assumptions about what could and could not get done. Even when VA initiatives and congressional appropriations led to updated equipment and facilities, these entrenched attitudes and assumptions remained. If acceptance of reduced pay and professional self-esteem was associated with a career at the VA, there had to be some benefit in return. A quid pro quo. For many—not all, but many—it was the promise of a slow and comfortable pace of work, an environment where checking boxes would fully meet professional expectations and where demands for outstanding performances just did not exist.

For those few who remained committed to achieving the best possible care for their VA patients, the institutional laziness meant that their work would be even harder and more exhausting.

LE: Is there anything you’d like to add in summation?

MM: It is time for American doctors and other healthcare professionals—people who have been aware of what the VA really represents and how our veterans are truly being treated—to force Americans to open their eyes to a much more fundamental failure of their government. A failure both to fulfill a promise and to remain accountable to the men and women who have already sacrificed so much for their country.

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To order a copy of Mission Betrayed, call 1-800-544-4440.