Jul 19, 2019
By Julia L. Close, MD
I’m leaving the VA.
After over 10 years of service as staff physician, I will no longer work at our Veterans Administration (VA) Medical Center. It is not for the reasons you may think. The national news media’s portrayal of the VA in recent years has been less than flattering, but this overall depiction is far from an accurate portrayal of my experience. It’s quite the opposite—I understand the elements of quality care, and we have been providing it every day to veterans with cancer. I truly love working at the VA.
I have taken an opportunity for advancement as an educator within academics, and with it I will no longer carry a dual appointment. As of July, I’ll be full time at the university. This transition has left me reflecting on what it means to work at the VA.
I grew up hearing tales of a legend lost by my family too early—my maternal grandfather, a career Marine who served in World War II and Korea. During the latter, while in his 20s, he was diagnosed with Hodgkin’s lymphoma and given a terminal prognosis. He began receiving his care from the VA, often traveling to other VA sites to receive experimental therapy (including nitrogen mustard and radiation). He and his doctors proved the prognosis wrong—he wasn’t terminal. He lived close to another 20 years, long enough to see his three children go off to college. In his 40s he died from lung cancer, likely a secondary cancer. Nestled in my family’s stories of a practical joker and war hero turned history teacher, there are stories of compassionate care, first aggressive and later palliative, all given at the VA.
In retrospect, it is not surprising I ended up as a thoracic oncologist at the VA. I was seeking to understand a man I only knew as a rich picture painted by family. With every veteran with lung cancer I’ve treated, I’ve met a little piece of my grandfather.
Until recently, I was honored to be chair of the Veteran’s Health Administration Oncology Field Advisory Group. In this role I have worked with oncologists at VAs all over the country. Over and over again, I have met hard-working oncologists dedicated to the VA mission. Many formerly served or are serving in the military while others, like myself, have servicemen and -women as family. The VA’s formal mission is:
To fulfill President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans.1
We live out this mission every day.
While their active service may be decades in the past, the effects of those experiences on veterans are long lasting. I recall one Korean War vet, long estranged from his family. As we met at what would be our final visit, I let him know we were transitioning to a palliative approach for his lung cancer. He would likely die in the next few months, if not weeks, and supportive care alone was the best option.
He silently reached into his wallet and pulled out a weathered headshot of a young man in uniform. I immediately recognized a younger version of my patient, as he placed the photo between us and tapped on it. “This was me, before I was a prisoner of war.” He told me about his capture and his rescue. He thought he would die then. He was thankful for the compassionate care he had received at the VA. Between silent tears, I thanked him for his service.
The VA has set in place resources to address issues related to homelessness and post-traumatic stress disorder, both frequent complications of experiences from previous service time. These issues are potentiated with chronic illness. I’m thankful for the social workers and mental health professionals we work with side by side. This presents a challenging, but rewarding, aspect of care not often present in my panel of patients at the university.
Working at the VA has had its challenges, including managing the reputation of the VA. When VA waitlists made national headlines, I was the Hematology/Oncology Section chief for our local VA. I took many calls from veterans—some currently cared for in our clinic, others needing care in the very near future—who told me over the phone that I needed to find them care elsewhere. Their faith in the VA was lost. A few even told me they knew I was killing patients because they had heard it on TV. These were heartbreaking calls to take and a challenge to manage. With most, I listened, and then offered support and evidence that we were not what they had heard. Most agreed to be seen in our clinic. A few sought care elsewhere. Many of our patients in clinic assured us that they still believed the VA was a great place to get care.
There is a fair amount of data that cancer care at the VA is as good if not better than the care in other health care systems. For example:
- In a study comparing aggressiveness of care of older patients with metastatic cancer treated within the VA to matched similar men enrolled in fee-for-service Medicare living in Surveillance, Epidemiology and End Result (SEER) areas, men with metastatic lung or colorectal cancer treated by the VA were less likely to receive chemotherapy in the last 14 days before death or be admitted to an ICU within 30 days of death.2
- In a study comparing survival rate for older men with cancer in the VA compared with fee-for-service Medicare enrollees in SEER areas, survival rates of colon cancer and non-small cell lung cancer were better in the VA. Survival rates for rectal cancer, small cell lung cancer, multiple myeloma, and diffuse large B cell lymphoma were similar.3
- Compared with the fee-for-service Medicare population, the VA patient population received the diagnosis of colon and rectal cancer at earlier stages and had higher rates of curative surgery for colon cancer. They were also more likely to receive standard therapies in diffuse large B cell non-Hodgkin lymphoma and multiple myeloma. The VA population had lower rates of intensity-modulated radiation therapy.4
- The University of California at Davis completed an exploratory evaluation among individuals with different health insurance coverage comparing survival and quality of treatment for five common malignancies based on data extracted from the California Cancer Registry. The executive summary states, “VA patients had the longest intervals between diagnosis and initiation of treatment for breast, colon, rectal, lung, and prostate cancers, but their treatment outcomes compared favorably to patients with other types of health insurance and they were generally more likely to receive recommended treatment.”5
Those of us who practice oncology within the VA are not surprised by these studies.
Like many of us, large portions of my training were completed at the VA. The halls I walked this morning are the same ones I have passed for the last 20 years, albeit with many different titles and many different white coats. As I pass the friendly faces and dedicated staff I have worked with for so many years, many stop to remind me they think I’ll be back. Perhaps they are right.
- U.S. Department of Veterans Affairs. “About VA.” Accessed May 15, 2019.
- Keating NL, Landrum MB, Lamont EB, et al. Cancer. 2010;116:3732-9.
- Landrum MB, Keating NL, Lamont EB, et al. J Clin Oncol. 2012;30:1072-9.
- Keating NL, Landrum MB, Lamont EB, et al. Ann Intern Med. 2011;154:727-36.
- Parikh-Patel A, Morris CR, Martinsen R, et al. 2015. Disparities in Stage at Diagnosis, Survival, and Quality of Cancer Care in California by Source of Health Insurance. Sacramento, CA: California Cancer Reporting and Epidemiologic Surveillance Program, Institute for Population Health Improvement, University of California Davis.
Dr. Close is the associate dean of graduate medical education and an associate professor at the University of Florida College of Medicine. She serves on ASCO’s Professional Development Committee (past chair), Workforce Advisory Group, and In-Training Exam Task Force.