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VA scandals are long-term systemic problems not a few bad apples.

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Dr. Gary Kao is the only one named in the unfolding VA scandal at the Philadelphia VA Medical Center. He and others say he’s a scapegoat. Is Gary Kao a renegade physician, or a sacrificial lamb – or maybe just a doctor who was allowed to get in over his head?

Kao is the only person whom officials have identified in the unfolding scandal over substandard radioactive seed implants at the Philadelphia VA Medical Center. As the radiation oncologist who did most of the implants, Kao played a central role.

However, a huge cast of actors supported and directed him – week after week, for six years – until the VA suspended the program a year ago. Simply put who did Dr. Kao report to, his was his boss? Who was responsible and accountable for Dr. Kao’s actions besides of course Kao?

Punish them but don’t let Doctors be scapegoats for VA systemic problems AND don’t let the right-wing make a mockery out of Veterans benefits and rights.

That is the message that came out of a Senate Veterans Affairs Committee hearing that grilled VA Physician Dr. Gary Kao about the unfolding scandal involving systemic management problems at the Department of Veterans Affairs that are leading to patient deaths, injury, or exposure to HIV or hepatitis. Several issues are becoming glaringly clear; it is way past time for serious Congressional oversight of the VA that includes a through house cleaning of upper and middles management. Secretary Shinseki promised us that when he was selected to lead the agency but has he delivered?

Robert L. Hanafin
Major, U.S. Air Force-Retired
Veterans Advocacy Editor
Veterans Today News Network

      Troubles at VA beyond 1 doctor.

By Marie McCullough Philadelphia Inquirer Staff Writer

Extract:

Gary Kao is the only one named in the unfolding VA scandal. He and others say he’s a scapegoat. Is Gary Kao a renegade physician, or a sacrificial lamb – or maybe just a doctor who was allowed to get in over his head?

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Kao is the only person whom officials have identified in the unfolding scandal over substandard radioactive seed implants at the Philadelphia VA Medical Center. As the radiation oncologist who did most of the implants, Kao played a central role.

However, a huge cast of actors supported and directed him – week after week, for six years – until the VA suspended the program a year ago. Simply put who did Dr. Kao report to, his was his boss? Who was responsible and accountable for Dr. Kao’s actions besides of course Kao?

Ms. McCullough reports that “those actors included a medical physicist with little experience in developing implant treatment plans, a radiation-safety committee that allowed crucial radiation-dosage calculations to go undone, and Nuclear Regulatory Commission (NRC) inspectors who let Kao revise two patients’ treatment plans to avoid reporting medical errors, according to the Veterans Affairs investigation report.” From top to bottom, McCullough reported that VA report concluded, there was a lack of concern for patient safety and accountability.

That’s a chilling denunciation, considering that the VA worked with eminent institutions – the University of Pennsylvania Health System and the NRC - to create and run the high-tech brachytherapy program. The treatment involves permanently implanting tiny radioactive beads in the prostate gland. The beads emit cancer-killing radiation for about 10 months. Of 114 prostate-cancer patients who underwent brachytherapy, 92 received suboptimal radiation to the prostate or potentially harmful levels to nearby organs or both.

Kao, who took a leave of absence from Penn on June 24, testified last week before a Senate hearing run by Sen. Arlen Specter (D., Pa.). Kao decried the media’s portrayal of him as a "rogue" and complained that he was being scapegoated. Some observers say he has a point. "I don’t condone the mistakes he made, but I also don’t blame him for feeling that he is being made a scapegoat," said Peter Crane, an NRC lawyer for 23 years and now a sharp critic of the agency. "This was a systemic failure, not the failure of one individual."

Three people with insight into this system wide breakdown were listed as witnesses at the Senate hearing: Mary Moore, the Philadelphia VA’s radiation-safety officer; Joel Maslow, chair of the VA’s radiation-safety committee and a Penn infectious-disease specialist; and Richard Whittington, a Penn radiation oncologist who did a small number of the brachytherapy implants. They were not questioned by the senators, nor were they allowed to speak to reporters.

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Gary D. Kao (seated at table, second from left) was among witnesses at the Senate hearing in Philadelphia. Others included patients and administrators.

Had they cared to, the senators could have asked why the radiation-safety committee allowed a computer-interface problem to go uncorrected for a year, jeopardizing patients’ treatments. Because of the computer problem, patients’ actual post implant radiation doses were not calculated, so no one knew whether they were getting the prescribed amount.

The NRC, another big player in the mess, says in news releases that it responded "aggressively and decisively to the medical errors" at the VA.

But the commission’s public records appear to belie this.

In 2003 and 2005, the NRC investigated two mistakes that the VA reported to it. In both cases, Kao injected half of the radioactive seeds that were meant for the prostate into the patient’s bladder. Although an urologist was able to retrieve the errant seeds, the patients’ prostate glands obviously received less radiation than prescribed. The NRC concluded there was no "medical event" – the regulatory euphemism for medical error - because the patients’ treatment plans were revised to indicate how few seeds actually wound up in their prostates. In light of the scandal, the NRC has reviewed both cases and concluded they were indeed medical errors.

NRC spokeswoman Viktoria Mitlyng said the agency was responsible for the lax care only to the degree that it misplaced its trust in the VA. When the brachytherapy program was created in 2002, she explained, the NRC allowed the VA to create the National Health Physics Program, which was supposed to monitor treatment and report any problems to the NRC. In effect, the VA was its own watchdog.

[Note: This tends to be a trend with most that goes on at the VA. In fact, the trend is so overwhelming that the only reliable watchdog over the VA in years has been an informal yet influential one, Larry Scott's VA Watchdog organization].

"Obviously," Mitlyng said, the National Health Physics Program "didn’t work as well as we expected. We will be looking at increasing our own inspections of the VA."

In his testimony, Kao pointed out that he was part of a team – although he didn’t name any teammates. Another part of his defense sounded less persuasive: He said that in 2002, the NRC had no definition of a reportable medical event. He also said the NRC never trained his team "on this issue."

In fact, a simple Google search (NRC report medical event) brings up the reporting rule, which applies to radioisotope medical use in general, not just brachytherapy.

[Note: if more Congressional staff members would do a Google search on about anything, they could find out just about anything much of it data of value].

Kao also contended that the definition of a medical event keeps evolving and is "a subject of debate" – which is true.

So far only a few of the VA’s 114 brachytherapy patients have come forward to complain and file liability claims.

Soon after officials closed the poor-quality prostate cancer program at the Philadelphia VA Medical Center in mid-2008, Faye Flam at the Philadelphia Inquirer wrote that the entire facility was accredited by the Joint Commission, the main group that assures quality at the nation’s hospitals.

During the recent Senate Veterans Affairs Committee hearing, several senators wondered how the Joint Commission could have given the Philly VAMC its accreditation given that circumstance. In response Robert Wise, vice president of standards and survey methods for the Joint Commission said, "We need to pull back and take a look at this."

The senators also wanted to know if such mistakes were occurring at VA hospitals more than at facilities in the private sector, and whether still more errors in the hospital system would emerge. "What worries me is what else has happened," said Sen. Richard Burr (R., N.C.).

Of note, the Philadelphia VA was not the main focus. Much of the 21/2-hour hearing focused on findings that other VA hospitals had improperly sterilized their equipment, putting more than 200 veterans at risk for HIV and hepatitis B infections after colonoscopies and other screening tests. But the senators’ concerns also encompassed recent revelations that a doctor at the Philadelphia VA Medical Center botched 92 out of 114 prostate cancer radiation treatments, in some cases causing grave injury by placing radioactive pellets in other organs.

"This is an unacceptable way to treat our veterans," said Burr, who called the hearing along with Daniel Akaka (D., Hawaii), the committee’s chairman.

Akaka and Burr directed most questions about the Philadelphia VA not at Dr. Kao but to Gerald M. Cross, the VA’s acting undersecretary for health. Akaka asked Cross whether the VA had any proof of the competence of the doctor who conducted the radiation procedures, Gary Kao, a University of Pennsylvania radiation oncologist who was contracted out to the VA. Akaka suggested that Penn did not consider Kao qualified to do those procedures on its own patients.

"We haven’t looked into that specific allegation," said Cross, "but that doesn’t excuse our lack of oversight."

Cross noted that the Philadelphia VA had just earned good marks from several external expert panels, including the American College of Radiation Oncologists and the Joint Commission.


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12 Comments for “VA scandals are long-term systemic problems not a few bad apples.”

  1. Okay then, Let the veterans buy their own private healthcare plans and be done with it! The free ride is over.

  2. SSG Lem Genovese USA/Retired 91B

    The long, costly and painful goals:

    1.) Initiate a digital CD-Rom medical records file on every VA Patient.
    2.) Establish a Blue Ribbon GAO/OMB/Civilian Med Administrative Experts
    to investigate the following:
    A.} Extensive delays in adjudication process.
    B.} Needless Administrative delays in primary care access
    C.} Analysis of contra-indicative medication from civilian & DVA pharmocolgy
    D.) Begin a “Rogue’s Roster” of fraudulent veterans who do not have the
    military proof of service to merit benefits in the first place and make it
    nationwide on the official DVA website.
    E.} Begin a medical professional “Black List” of Doctors/Nurses/PAs/Techs etc
    who were fired for negligence, malfeasance or malpractice and make it
    nationwide on the DVA official website.
    F.} Begin to rate DVA med facilities based on CIVILIAN STANDARDS OF CARE.

    The DVA hasn’t had a major overhaul of its standards & practices since the Class of
    1946 came home. The rust and cobwebs have to be removed for the 21st Century.

    • This would be a good start. This list needs to be sent to the Honorable Eric Shinseki. The only thing I would add is some remedies for each of these things listed. For instance the delays in the adjudication process. If they give us a certain amount of time to get our evidence or appeals in then they need to be held to the same amount of time to come to a decision or it whould automatically default to our favor. That would stop some of the ‘deny and lie until we die.’

  3. Bob, I don’t think that is Iraq vets in those wheelchairs facing off
    the VA police at the West L.A. VA Medical Center is it? I believe
    those fellows are a lot older, or at least I hope so.

    • Hey Charlie,

      Where were those old vets when Californias civilization was handed over to Mexico?
      And why werent they using their VSO membership to protest the VA’s denial to allow the babies of serviceman exposed to depleted uranium to receive government compensation?

      You’re not wrapped to tight Charlie.

  4. The VA isnt shit. Shinseki needs to grow some balls.
    The only ones who seem to have some balls today are the Iraq veterans.

  5. Understand that the position of VA secretary is a executive branch post and as such the congress can not tell him what to do ! He works for the Potus and it can only advise……………. That being said they can call these doctors,supervisors and administrators before them and charge them with crimes assault, murder Etc. ……………………….. Now that would stir things up

  6. Where is Shensiki?  What has happened to this man?

    We have an 8 year nightmare to clean up.  We need an activist, not  a quiet and reflective, soft spoken manager.

    This is a war and we are losing.

    g

    • Shinseki knows when he is outgunned. He also knows that the entire VA system, and quite possibly the federal workers union, will crush him like a bug if he really tries to clean house.

      In short, Shinseki isnt the type to fall on his sword. Were he to be honest with us, he would probably admit that we, the veterans, lack the political will to get this problem under control. To an extent, he would be right.

      Lucky for us, sites like this are beginning to have an impact. Perhaps Shinseki will go to bat for us in 2011. At the current rate of VA scandals coming to light, it might be long before that.

      The ball is in our court.

  7. Veterans Advocacy Editor

          – Just another fed program. The injustice to the vets on the colonoscopy fiasco should be front and center, yet it isn’t.

          – Yeah, I want to be massively taxed to give up my private health care for VA or Indian Health System federal health insurance.

           – I want to pay extra to get third world care.

           – And folks want Obamacare!

           – The dirty secret is that the major VA Medical Centers – all or nearly all of them have a Medical School next door – center around the needs of med students, interns, residents, and fellows……with the exception of primary care guys, the former have carte blanche, no questions asked………the VA also runs tons of research and experimental stuff, with and without the knowledge of we patients.
    ["Frankly, any Vet could admit this regardless our other political views." Major Hanafin]

          – Veterans health is (at best!) the second priority of the VA. Others might feel differently per their own experience, but this is what I have repeatedly seen and been subjected to for more than 7 years now……

          – Be very careful and engage your doc with all you know. The fact that vets are contracting death diseases because of the VA is criminal. ["An amen to that, however I'd have to add that WE must engage our VA doctors, especially VA doctors about everything they know, demand they give the appropriate medical advice and guidance. I've personally learned that unless Veterans are not forceful about what we want, what our medical needs are, AND know what the VA is and is not capable of providing us - VA physcians and dentists will not volunteer information on what options are avialble due to a tradition of pressure from upper management to cut costs at the price of Veterans lives." Major Hanafin].

           – I am fortunate….my VA primary is a PA and also a Vietnam Vet…..I have a great relationship with and trust him…..I always get the required policy speech/whatever, but he has not once steered me off-course or wrong whatever happens in other clinics/services…..having been in-country at exactly the same time and also a medic allows an understanding between us that sometimes doesn’t require spoken words…., other Vets I have met who are also his feel the same about him…..very, very lucky…… ["Problem is that there are currently precious FEW Veterans working within the VA system in significant numbers to relate to US." Major Hanafin]

          – Back in the mid-70s, I worked briefly for the VA and was assigned to a VA Hospital as a counselor. One of the things I noticed was that there were, with some exceptions, two types of physicians working there. American-born and trained doctors who were in their 70, 80s and 90s. Some you could almost call "feeble". The remaining doctors were young, but they were foreign born and trained. There were few, if any, young or even middle-aged American doctors working there. So I quickly figured out that the best, most competent doctors were out in the private sector making the big bucks while these guys, mabye not so competent, were working for the government, making far less money. not much of that has changed…….then there is the attitude problem of the slackers on the bloated non-professional staff with gummint-jobs-for-life, to add insult and unnecessary and uncalled-for grief to injury….["This is the refrain most often heard from the right-wing, especially the Stolen Valor crowd. In fact, this would be their basis for doing away with the VA system completely in lie of well, as most Reich wingers admit private heath insurance ala TRICARE the same as us Retired Military get. However, that's comparing apples with oranges for one is viewed by the entire Veterans' community as an entitlement program with mandatory funding from DOD (military retirees), and the other has mixed reviews as each year VSO leaders have to crawl before Congress, beg, and plead for adequate and advanced funding that doesn't rate the clout of the Defense budget. For once Uncle is through with us, we become VETERANS!" Major Hanafin]

         – The only complaint about care from the VA is you absolutely cannot get in for emergencies, they are great for preventive care, anything else Medicare is a godsend.

    Complete comments can be found at Freepers. [www.freerepublic.com]

  8. Veterans Advocacy Editor

          Way back in 2007, then Senator Barrack Obama of Illinois criticized the Department of Veterans Affairs for not asking more questions about doing background checks on doctors before hiring them. Obama wanted to know how a doctor could get a job in his state in January 2006 while the doctor was under investigation for negligence in another.

          "This is an extremely alarming revelation that calls into question the adequacy of the oversight exercised by the VA as it evaluates and monitors those who provide care to our veterans," [www.boston.com] Obama wrote to the VA in 2007, which had reassigned four administrators at the Marion VA Medical Center, pending results of an independent investigation.

    size0army.mil2889320090423090425_400

          Now, that Congress is up in arms about systematic VA failures across the nation that hit the media almost weekly, why is President Obama so silent on the subject?

          A word of caution, do not take Veterans Today raising questions about the VA, President Obama, his VA Secretary or how the House and Senate has failed to provide adequate oversight of the VA as partisan political attacks. We are assessing this story as people who mostly voted for Barrack Obama, but also had a little bit of hope that Secretary Shinseki meant what he said about reform at the VA. However, reality is the Shinseki never promised an in-depth house cleaning of VA upper and middle management as he was advised by some of the most aggressive VSOs and Veterans Activists groups, but instead continues to rely on advice and council from mainstream VSOs who have a vested interest in not doing anything to make the VA look bad.

          That said, the right wing is going to take advantage of this situation to attack Barrack Obama’s and Democratic Party plans for any national health care system note the comments that appeared on the long running right-wing website freerepublic.com  included in comments to this article.  We’ve been trying best we could to forewarn those non-Veteran proponents behind this national socialized medicine approach that they had to look at the failures and vulnerabilities plus achievements of the VA system the only model available within the United States before trying to sell such a broken program to cover the rest of the nation. In sum, readers that is why the Obama administration is staying mum on VA scandals, and why Secretary Shinseki is not only failing to reform the VA, he too remains silent on the systemic problems.

         POINT: How come when the House or Senate has a scandalous hearing regarding the VA, the VA Secretary is not on the hot seat along with those VA personnel who work for him/her?

          The right-wing and this is not necessary all Veterans and Military Families mind you, in fact precious few Veterans, calls for disbanding the VA in favor of private health care for Veterans or none at all. Frankly, we cannot see how any VETERAN could go along with advocating taking away benefits and rights we as Veterans have earned unless even as Vets they cannot relate to the rest of us?

          We at Veterans Today are not calling for the downfall of the VA by far, what we are demanding is that the VA be serious reformed in a way that has not been possible since Vietnam. Max Cleland took the first crack, and in this respect we may be more sympathetic to Democrat Party attempts to fix the broken system but each political party has failed by the very nature of their political competition and the fact that today both parties are composed of primarily those who refuse to serve the nation in uniform. Hell, even those politicians asking the questions, even if they are not the hard questions have never served in uniform. Even window dressing to show an attempt to get Veterans on Congressional staffs is flawed with misconceptions and stagnation of VSO leadership that has made just as much a career in the Washington beltway as the politicians they wine, dine, and golf with. That’s not activism it’s politics as usual.

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