August 9, 2022


In the early 1980’s I was offered and accepted a faculty position as a psychiatrist in the Miami VA. I was looking forward to having a regular schedule, paid vacations and more family time. It also gave me an opportunity to help the nation’s best, our veterans. Accustomed to the toils of private practice, it was surprising to me when told that if desired I could wait weeks to learn about the system before being assigned patients. Of course, I refused and was given “kudos” by the then chief for being able to do so! Veterans were given appointments of 30 or 60 minutes, but my colleagues generally did not take more than 10 m. in the majority of the cases. We, as any other employee punched a card at 8 am upon arrival and at 4.30 pm when leaving. We were given two 15 m. breaks and a 30 m. lunch time. Even though we had many valuable members on the professional staff, the prevailing culture was to do your work quickly, never volunteer for committees (I was told “if you volunteer they will give you more assignments and unpaid work”), and don’t make waves. It was ugly and depressing if not for the fact of my pleasure of helping and listening to the veterans.

When I found out of many opportunities to go to VA sponsored policy meetings that no one wanted to attend, I took that chance. Sure enough, as I was warned, from that moment on I was the local representative to these national forums. Little did I realize then what changes would occur that slowly, but surely turned my responsibilities more to the administrative end. During the conferences I met many administrators from Washington’s central office that like me were there by default but shared the same goals of seizing the opportunity given to try to improve our organization. With time, many of us were given leadership chances and my bonding with the CO administrators (now in position of power) gave me the ability to receive funding to establish new and innovative programs. Using the nucleus of excellent physicians and administrators, tremendous help from the then new Chairman of the University’s MH department, and the hiring of young, promising professionals, the improvement of the services offered became apparent. In part due to the need for treatment for the Vietnam veterans, the Veterans Administration Hospitals became part of the top echelon in the nation for delivery of care.

At this time when problems in the system have been noted, I tried to find out what, if anything had gone wrong. The program in question where a veteran died by an apparent overdose happened in a program inaugurated under my watch, so that doubled my interest. The VA has always been subjected by the demands of a government bureaucracy that exerts with rules and regulations a negative influence on its main function; medical care. Politicians of all branches and both parties generally pay no attention to the pleas for help given; only showing up to the facilities in times of elections.

Only two Representatives, one Democrat, one Republican, were helpful in my endeavor to improve what we were offering. Many of the gains were due to the innovative ideas of the staff, our sense of unity of goal, and the fact that we purposely ignored many rules. The media feeds on what is wrong, paying no attention to what is working. Mr. Phillip Longman, author of books on health care, testified in a hearing a couple of weeks ago on his findings that reflect my own, and many veterans and staff experiences; “The answer that emerged was not one I expected. But as study after study now confirms, the VA system as a whole outperforms the rest of the health care system on just about every metric that health care quality experts can devise. These include adherence to the protocols of evidence-based medicine, investment in prevention and effective disease management, use of integrated electronic medical records, and, importantly, patient satisfaction.

Just how the VA transformed itself is an inspiring story, involving front-line employees bringing about a revolution from below, as well as courageous leadership at the top…”
As far as the unfortunate incidents in Miami, with the sudden death of a veteran, and reports of delay in receiving care, with hidden “lists”, after being mostly ignored by the present administrators, I was able to find out by several well placed sources “the other side of the story”. The often mentioned “waiting list” is not as simple as it sounds. I was told it is only one of many measures of appropriate care “electronic wait list”, and as regulations usually go, even after reading them several times we have to conclude that it takes a lot of time to be able understand what they really tells us in order to begin to ascertain where to place blame. Like I have always said “good medicine comes from dedication not regulation”.

As I was prompted to do, I read the IG report on the veterans apparent overdose death, it conclusions and recommendations were clear and promptly accepted by the Hospital and measures taken. What is not said, and is unclear is if these lapses were directly responsible for the untimely death that occurred in a program that is considered mostly outpatient. The VA needs continued improvement but we should not “throw the baby with the bath water”, I suggest giving choices to vets to seek help elsewhere if not seen immediately, giving more administrative responsibilities to providers, indeed it IS a Hospital, and more budgetary control, and limiting the excessive impediments to care, secondary to the bureaucratic demands.

I will also strongly recommend more openness in the responses after a crisis, stonewalling only produces suspicion of wrongdoing, and to our media to do their investigative work properly instead of an overt emphasis on the sensational.

Fernando J Milanes MD
ACOS MH, Miami VA Hospital (retired)
Vice-Chairman UN Dpt. of MH ( retired)
Miami, FL.