When you walk into the Veterans Affairs (VA) Medical Center in La Jolla, it is immediately clear that the hospital is different. Unlike the hospitals across Interstate 5, it has no vaulted ceilings, or plush leather couches; no expensive paintings and sculptures. The only adornment is a grand piano set on the ground floor that plays old time jazz tunes amidst the bustle of patients, staff, and families.
The Veterans Health Administration is the largest integrated health care system in the United States, with an annual budget of some $68 billion, and responsibility for overseeing delivery of care to more than 9 million veterans. But the VA has been under intense scrutiny in recent months: its leadership is in flux and it is still recovering from a 2014 scandal involving wait times at some facilities. In this Q&A, we talk with Dr. Erik Owens, Chief of Surgical Service at the San Diego VA Medical Center, and Professor of Vascular Surgery at UC San Diego, to understand the issues, get to know him personally, and hear his hopes for the future of the institution.
May 31, 2018 | Interview by Lindsay Morgan
You've been Chief of the Surgical Service at the VA Medical Center in La Jolla since 1999. What is the VA?
The VA was founded in the 1940s after World War II, when there was a large number of veterans coming back from the war who needed health care. Today, it's one of the largest, most transparent healthcare systems in the world, probably rivaled only by the Canadian healthcare system in terms of numbers. In the American health care system, aside from Medicare and Medicaid (CMS), there's no comparison. In 2017, the Department of Veteran's Affairs launched an online tool [Access and Quality Tool] that publicly provides data on wait times and quality of care. Nobody does that.
Part of the reason it's so transparent is that it's taxpayer funded, which raises the bar in terms of accountability.
It's also a central part of medical training in the United States, having been established around the same time as the U.S. medical school system was being established in its modern form. Today, the VA is the largest provider of health care training in the United States.
You were just two years out of a vascular surgery fellowship when you got the job as Chief, following the sudden death of then-VA Chief Nick Halasz. Was this role an accident or did you come to UC San Diego knowing that you want to work at the VA?
I've always felt a kindred spirit with the veterans, so when this opportunity arose, I grabbed it. I never served in the military, but I feel that working here is my way of giving back. I know a lot of people who have gone to all corners of the world to serve the underserved, but you don't have to go other parts of the world to serve the underserved. They exist right here in our own community.
In recent years, scrutiny of the VA has focused on how long veterans have to wait to see a doctor or receive a treatment—existing patients are supposed to see a doctor between 14 and 30 days after requesting an appointment. The issue made the headlines in 2014, when instances of altered numbers were uncovered.
What's going on here?
The wait times problem stems from what we like to refer to as unfunded mandates—where expectations were placed on VA medical centers to provide a certain level of care, but appropriate resources weren't available. In situations like that, leadership teams are vulnerable. I think most medical centers were doing their best to comply with the mandates to see patients within a certain amount of time, but they just didn't have the resources to do it.
In terms of surgical care, I don't think our wait times are that different from wait times at other facilities in the community. I was challenged a few years ago to address this issue in a public forum for a reporter. I checked with other healthcare systems in the area, like Kaiser Permanente, which is a similarly organized healthcare system to the VA. And a lot of their wait times were not terribly different from ours, especially for surgical procedures. At the San Diego VA, the current average wait time to see a primary care physician is 1.35 days, to see a medical or surgical specialist is 5.11 days, and to see a mental health provider is 2.47 days.
Primary care has been the focus of increased resources over the last several years, to the point that our primary care colleagues can often offer same-day access. The challenge is, when the primary care doctors see everybody so quickly, they generate lots of patients that need surgical referrals. And then the next piece of the machinery has to work at the same level, or at the same speed, or at the same capacity in order to keep everybody happy. Specialty care—both medical and surgical—has been under-resourced. As an example, we still have the same number of operating rooms here as when we opened in 1972.
Nope. When you have a limited number of ORs and OR time, you are forced to make choices about who gets their procedure first. Every day, we triage aneurysms and cancer patients and heart surgery and do our best to work in more elective procedures such as knee replacements, hip replacements, and cataracts. Wait times are most challenging for orthopedics and ophthalmology, both of which offer surgical care to patients with non limb- or life-threatening problems. These are the types of patients who often do not get surgical care within the 30-day requirement—even in the community.
The San Diego VA plans to build additional operating rooms and a hybrid suite, with construction beginning in 2019—will that help?
Yes. But the whole project will take 5-10 years. Until we have more ORs, we cannot expand our internal surgical capacity. We've been requesting OR project funding for a while. Our project competes with every other major VA project across the country. So, if there's a VA elsewhere in the country that has a more critical need, it'll probably get priority. Congress has to budget a certain amount of money, and these projects are literally approved at that level.
The wait time issue is inextricably linked with the Choice Program, which was enacted by Congress in 2014, and allows some veterans to see private doctors (at government expense), but only in cases where they have to wait more than 30 days for an appointment or drive more than 40 miles to a facility. Since it was enacted, approximately 30% of veteran's medical care is provided outside the VA system. Is the Choice Program the right approach to improve veteran's health care? Or does it exacerbate problems instead of fixing them?
My strong opinion is that the VA provides the best care to our veterans and should be resourced and staffed to do that. And where there are deficiencies, there should be great attention given to ensuring staffing and resources are made available. Because I think the veterans are best served at the VA.
We have found that most of our surgical patients choose to stay here, even if we tell them that their surgical care cannot be provided within a certain period of time. They choose to stay in the queue and wait the extra time. And we like that. We feel like that the doctor-patient relationship is so critical in surgery; it's not like just getting a radiology test. And when the patient goes out into the community for something and then comes back, we often don't know what was done, the medical records can be difficult to obtain, and we often find it difficult to understand the care that was delivered by the community physician.
There's a national debate going on right now. Fifty percent of people think the VA should be modified to a program that offers vouchers for patients to go find care in the community. The other 50 percent feel that the VA should be better resourced and better staffed to manage the patients we were designed to take care of.
What do you think?
I believe the VA should be staffed properly, we should be resourced properly, and we should be given whatever we need to provide health care. Our veteran patient population have very complex medical, surgical, and mental health problems. I'm not convinced the community is equipped to offer the comprehensive care we do.
And why would you send a patient out for surgical care to the community—and I'm not in any way belittling the care in the community—but why would you offer a veteran surgical care in the community from a group of physicians or surgeons that you don't know, you don't know anything about their quality data, when you have decades of quality data from your own institution that says the care's excellent? [The Rand Corporation did a review of the literature and found that the quality of care delivered by the VA is generally equal to or better than care delivered in the private sector.] We have very transparent, very accurate data about the outcomes of patients who come here with various surgical diagnoses, and to send them to the community hoping they get the same level of care, is a roll of the dice.
In the current system, the coordination of care in the community often remains the responsibility of providers at the VA. We are being asked regularly to approve care and/or review the care being offered in the community. As you can imagine, coordinating the care of veterans in the community is not exactly what attracted most providers, especially surgeons, to the VA. They would rather provide that care themselves.
The VA also has advantages in terms of its ability to organize care. If you're a veteran in Southern California, you have two places where you can get your cardiac surgery: San Diego or Los Angeles. If you live in Riverside, even though there's a VA near you [i.e., Loma Linda], you're not going to get your cardiac surgery there, because the VA has decided that we don't need a cardiac surgery center at every VA medical center. So Los Angeles and San Diego are properly resourced to do it, and if you live in Riverside you get a referral. And we've found that most patients don't mind traveling an hour or so to get their cardiac surgery. The VA can also leverage its weight when it comes to pharma—they get bottom price on everything.
So maybe moves to privatize the VA are not about improving healthcare or even efficiency. Maybe they're about ideology.
Certainly there are areas where we are deficient. Ok, let's address them. Let's be candid. In the near future, you're going to hear from the silent majority—and that's the veteran groups—who are going to speak very openly about the care they receive here, and I don't think they're going to go quietly. If you tell them that they're going to be sent to the community and that they need to find their own doctor with a voucher, I think they will begin to speak up. Right now, they're not really a part of the discussion. Everyone else is telling them what they should want or will have. And my sense is that they feel strongly about the VA system. They feel at home because everyone here is one of them. Twenty-five to 30 percent of our employees are also veterans. So, the patients and the staff relate immediately. That aspect of care will clearly be lost if these patients are sent to the community. When a patient feels comfortable in an environment or setting and the healthcare is excellent, which I think it is, I think we have a better chance of serving that veteran patient.
Much has been written recently about depleted and depressed morale across the VA. You've been here for a long time—have you noticed an ebb in recent times, and how do you motivate your teams?
Morale is hard to measure. I think the morale of the surgeons for whom I'm directly responsible is excellent. That's partly to do with our relationship with UCSD and the opportunities that affords them.
But in general, yes, it's been tough. This crisis, this introspection being done nationally, very transparently by everyone—hurts. When you see a news story about one patient or a group of patients, at another VA, there's this automatic association with your VA and the work you're doing, when the reality is, there's no direct connection at all. That was just an issue that happened locally. But that's what we have to deal with almost every day—what's going on in the system, what problems arose elsewhere in our system and how we can avoid the same problem or issue. Collectively, it makes the VA stronger since we all learn from each other, especially when we are transparent and proactive. But at times there has been some reactionary administration and it has eroded the morale.
But I don't think it takes a lot to turn it around. The personnel I work with are interested in working hard and caring for the patients. In fact, they get a lot of job satisfaction when they care for the sickest patients. We try to have fun and highlight how appreciative we are of everyone working in the building.
You did your residency at Pennsylvania State, and your fellowship in vascular surgery at the University of Washington in Seattle. Then you came straight here. Your first day was June 30, 1998, almost 20 years ago to the day. What drew you to UC San Diego?
I saw here the same things I see today: lots of amazing and different opportunities. Vascular surgery was just being recognized as a specialty of surgery and was building its own traditions. UCSD had lots of opportunities on the academic front. It had a strong VA. It had tons of research opportunities. I've always been interested in being part of the process of building something. And that's why I thought UCSD was the best fit for me.
Has there been a patient in recent memory whom you've interacted with where you thought—yeah, I'm doing what I should be doing.
It's a regular event that I'm impressed with the appreciation that our patients offer in ways that you can't even imagine sometimes. About a year ago, I was standing in line with my white jacket on, buying my lunch, when the gentleman in front of me said: You're a doctor here right? I said yes. And he said: I'd like to buy you lunch. When I asked him why, he told me that his father, who was in the ICU, was having a tough time and that everybody—the nurses, the doctors—was doing a great job taking care of him, and he wanted to say thank you.
I was taken aback. I told him my name, gave him my card, and said that if there was any way the surgical teams could help his father, he should let me know. That's just a simple story, but those kinds of interactions happen pretty regularly around here. People will just stop you and say: thanks doc, for all that you're doing for us.
It means a lot to these folks and it means a lot to me. I always try to remind the medical students and trainees to think about what these patients have done and what they've been through. They've sacrificed a lot, and they deserve the best care we can offer them.
How have things changed in the 20 years you've been at UC San Diego?
Back then it was just two of us—Steve Sparks and me. In fact, there was a period in 2002 when I was the only vascular surgeon on the schedule—the only one in the whole system.
Oh my word.
Putting together the call schedule was pretty easy. And there was no need for division meetings.
You could just talk to yourself.
Today, I am blessed to have excellent partners, including Dennis Bandyk, John Lane, and Andy Barleben. It's the best it's ever been.
Your pathway to vascular surgery wasn't totally linear—something I always find reassuring. You made your start in chemical engineering.
When I was 26, I got laid off from my job as a chemical engineer along with 20 other engineers, on a Friday afternoon. So I decided to spend a year in Norway—my mother is Norwegian. I spent a lot of time outdoors in Norway, hiking and backpacking and doing a lot of things out in the wilderness, and it came to my attention that I really didn't know a lot of first aid. So, when I got back to the U.S., I signed up for a first aid course. That was too simple, so I did an EMT training program. I thought that was kind of interesting, so I signed up for volunteer rescue squad.
I was still working as a chemical engineer at this point, and in both fields, there was a lot of problem solving, which appealed to me. But the chemical engineering work was a little dry. Whereas, on the rescue squad, I usually spent one or two shifts each week, often times overnight, riding for the rescue squad in Richmond, Virginia, engaging face to face with patients. I realized there was a part of me that I wasn't fulfilling in engineering. So I decided to quit chemical engineering and go to medical school.
So a career change, and you learned Norwegian to boot.
I still speak it fluently.
Do you ever get Norwegian patients here?
Not very often. Speaking Norwegian in San Diego isn't much of a help. It's not quite like Minnesota.