Working as a VA physician

[TaxExempt]

I recently received a job offer to work in the local VA hospital. I am Board Certified in Internal Medicine, and the position is in their General Medicine Service line, with out-patient and in-patient responsibilities.

The pay is comparable to what I'm getting as a physician in a medical center. The benefits are better (insurance, TSP, etc). The scheduling is more flexible. In terms of malpractice, it seems to be a much better environment to work in.

Am I overlooking something? I've never trained or worked in a VA hospital, so any insights would be welcome!

[Munir]

I suggest that you discuss this issue with VA physicians who had been in private practice or in medical centers previously (or some who left the VA system). They would be in a far better position to advise you on this life/career issue than responders on this investment forum. I'm a retired MD and would be hesitant in offering advice because I never worked in a VA hospital.

[sewall]

I recently received a job offer to work in the local VA hospital. I am Board Certified in Internal Medicine, and the position is in their General Medicine Service line, with out-patient and in-patient responsibilities.

The pay is comparable to what I'm getting as a physician in a medical center. The benefits are better (insurance, TSP, etc). The scheduling is more flexible. In terms of malpractice, it seems to be a much better environment to work in.

Am I overlooking something? I've never trained or worked in a VA hospital, so any insights would be welcome!

As a VA researcher I can add that you're overlooking the positive aspects of access to research data, funds, and environment, if that interests you. I'm not a medical doctor so I can't advise on things medical. Do you have direct access to VA doctors you can talk to?

[TaxExempt]

Thanks Munir and Sewall,

Yes I have spoken to a couple of VA docs, and they are both very satisfied with their jobs. One of them had informed me about the position that I am now considering.

Additional opinions are very welcome.

[Jack]

Users of the VA health system rate their customer satisfaction higher than users of the private health care system.

http://www.govexec.com/dailyfed/0206/021006nj1.htm

[pochax]

my father is a former VA physician and seemed satisfied with his working conditions. during my medical school, i think there was a perception that it was less-than-presitigious since there are many foreign-trained doctors working there, there are occasional media-hype stories of horrible medical care, and a significant number of your patient population may have significant co-morbidities. i imagine much of this perception is not entirely based in reality, but you will have to decide for yourself how such public perception plays into your career decision-making.

having said that, i have a friend who currently works for the VA is seems very satisfied with his practice and quality of life.

[semperlux]

My wife in an internist. She worked rotations at the local VA hospital on the floors every year during her training, and she is now working for a private group. She also has friends who work at a VA, and was trying to find a job at the VA for a while but no openings. From what she tells me:

Positives:
-excellent computer system and extremely convenient since one can access any veteran's medical record across the entire country.
-excellent benefits since it's a government job.
-hours more flexible and desirable.
-once you learn the system...you're set.

Negatives:
-pay not as competitive (comparing her friend who works at the VA vs her private group pay by about 20-25%...didn't feel comfortable asking her friend the exact number even though they are good friends, but got a ballpark number)
-less flexible in terms of retaining benefits if she decides to drop her hours down once we have kids. Current job will consider her full time at 70% of current hours and allow her to keep all benefits while working less.

Can Go Either Way:
-see majority male patients: wife prefers this because no GYN stuff to worry about and she says guys are much easier going and will listens to her more (I think they like her cuz she's pretty...but I'm biased =)
-I personally want to see men, women, old, young, pregnant, everything, and anything....but then again, I'm an ER doc so I'm drawn to variety.

Conclusion:
Depends on the individual. For my wife, I think she would be happier at the VA, and she originally intended to work at a VA, but they didn't have any openings. She's currently still very happy where she is now so everything worked out. So you have to determine what you want from your job and go from there.

[brainstem]

Depends on your personality

I find the bureaucratic aspects of the VA to be maddening - formulary restrictions regardless of competancy and track record of appropriate use

I also find the clinics can be obsessed with checking off boxes for chronic care and not a focus on the management of the pt in the room

Consults can take weeks

But a number of docs who have tired of the office overhead, high volume treadmill find the VA to be a relief --

The pts are generally grateful --

[wshang]

I did some of my training two VA hospitals. There seems to be a significant contingent of physicians who are among the least productive working there. As a pathologist, we measure productivity in number of surgicals. The group of 3 full-time pathologists working there, with resident help, did less work as measured in surgicals and autopsies performed combined, than the average CAP pathologist. I seem to remember them sitting around in the dingy lounge or reading novels to pass the time.

As a medical student, I remember how a patient who was looking depressed after receiving the diagnosis of Wegener's. In asking him why he might do with his weekend pass, he said he might jump-off a bridge. It turned out, he misunderstood the prognosis, not comprehending the attending's thick Indian accent.

One of the worst pathologists I have worked with finally found a job at a VA hospital. I got a phone call from the chief there, asking me for information to help terminate her. Having gathered that the department had not performed due diligence, QA review of her work within the probationary period, the chief now had to deal with the union.

Realizing personal experiences are by nature slanted, you can take these anecdotes for what they are worth on an anonymous chat board. I don’t know what point you are in your career nor how hard you wish to work. Unless things have radically changed recently, the VA system does not impress me. I hear things may be different among research minded physicians.

There are some fine physicians my encounters within the VA system - I don't mean to smear all my VA colleagues. It seems to be the closest thing to a Soviet hospital we have in this country.

P.S. I initially misread semperlux’s advantage posting to list the tax-free store in VA hospitals.

[RabbMD]

The inefficiencies can drive you crazy. The employees are very much on the clock, and the worst clinical support staff tends to get promoted to supervising positions. That and the formulaic "because that's what the policy says" attitude drove me crazy there as a resident and medical student. But that does not turn off most personalities as much as it does mine.

[Rocket, CFP]

Gynecologist turned mechanic

A gynecologist had become so fed up with malpractice insurance and HMO paperwork and was burned out. Hoping to try another career where skillful hands would be beneficial, he decided to become a mechanic. He went to the local technical college , signed up for classes, attended diligently, and learned all he could. When the time for the practical exam approached, the gynecologist prepared carefully for weeks and completed the exam with tremendous skill.

When the results came back, he was surprised to find that he had obtained a score of 150%. Fearing an error, he called the instructor, saying, "I don't want to appear ungrateful for such an outstanding result, but I wonder if there is an error in the grade."

The instructor said, "During the exam, you took the engine apart perfectly, which was worth 50% of the total mark. You put the engine back together again perfectly, which is also worth 50% of the mark."
This equaled an A. After a pause, the instructor added, "I gave you an extra 50% because you did it all through the muffler, which I've never seen done in my entire career. "

[bhzmark]

a factual nonpolitical article reponsive to the OP (it discusses the merits and demerits of the VHA system) is available at: http://www.bloomberg.com/apps/news?pid= ... Ic5ABThjBk

[wshang]

Thanks for posting that article. Articles like this combat the poor image of the VA system. The last paragraph is emblematic: a researcher says he wouldn't mind sending his family. I think from reading this, my impression is most lay people don't have a clue what is good medical practice. Why don't you ask a doctor who works in a university hospital across the street from a VA, which hospital he'd rather send his family member?

[openmindedisgood]

wshang,

I used to share your view of the VA system. However, the VA system has become significantly better than when I finished training a decade ago. There is likely a spectrum of VA hospitals. As a physician, I have seen a variety of academic and private hospitals, including multiple "prestigious" medical centers. The VA that I work as a physician has better care and equipment than the vast majority of private hospitals in the area. Many of the physician positions are sought after and competitive to obtain. Many of the new physicians that are now joining the VA are highly qualified and exact opposite of your experience. One should not generalize too much from one's own experiene (limited sample size), especially if that experience was the distant past. The world changes very rapidly. The article bhzmark posted is accurate from my personal experience as a clinical physician. As a practing clincial physician, I would rather have myself or my family get care at most of the VA hospitals that I know, rather than most of the regular/private hospitals that I know of in the area.

[bhzmark]

another good source of information is: http://www.washingtonmonthly.com/featur ... ngman.html

[gkaplan]

If I have health insurance through my employer, can I still use the local VA facility for my health care needs and medical supplies? (I'm a vet - Priority 7.)

Thanks.

[arthurdawg]

If I have health insurance through my employer, can I still use the local VA facility for my health care needs and medical supplies? (I'm a vet - Priority 7.)


Thanks.

Most likely you can use both together, but you will have to have a VA primary care doc to access most of it. (note: I'm a little rusty with the VA, haven't worked there since my fellowship.) You should give the local VA a call and let them sit down with you and detail what they can add, as they can often take care of medicines very cheaply for you.


to add to the above:

The VA has made major strides since the 70s and early 80s. Very good for primary care and such, a little slow for specialty consults and advanced testing. I worked there for a couple of years as a fellow and it was a great teaching experience. Unfortunately, we were the only medical oncology outpost at the VA for about 500 miles and lots of our patients had to drive insane distances to see us.

[GeekedOut]

If I have health insurance through my employer, can I still use the local VA facility for my health care needs and medical supplies? (I'm a vet - Priority 7.)

Thanks.

I had this very same question, and was answered within the past six months. I was told that the VA will always pay for whatever ailments stem from service connected injuries. In addition, you always have access to the VA system.

The difference is that if you go in for treatment of ailments not related to your service, and you have separate health insurance, the VA will send a bill to your insurer. If your insurer refuses to pay, it does not come back on you. In other words, you do not have to pay a cent unless you are over the means testing for copay, in which case you pay the copay and that's it.

My own experience with the VA has been with two systems collocated with UC Campuses, and I have never felt better treated. It may differ in the sticks, but I would not trade this free health care for any amount of riches.

FWIW, my last doctor got a degree in physics from Harvard before deciding on Medical School at Stanford. I think the OP would be in good company within this august body.

[gkaplan]

Thanks for answering my questions.

[biasion]

VA is pretty good. You don't work much. I specifically went out of my way during training to go to VA because the software was so good.
Supposedly the VA work hours were the longers, but most residents spend only 1-2 months so they never really learn the system. One of my best friends actually works there and I had a lot of guidance/connections, and since I hated residency so much, the VA was basically my "VAcation from the teaching attendings and all their baloney".

Everyone is so lazy that is a good thing, it means the administration can't be bothered picking on the residents like they did at my regular teaching hospital. The attending would leave at noon and half the time we'd round on the phone. Weekends were even better, home by 10am, even cross covering other team's patient (cut/paste works well to speed up how fast you write daily progress notes!).

I also am friendly with a few docs on the staff, and I was so efficient with the record that despite a huge work load of 12+pts, sometimes 1-3 ICU patients (I am also IM) and an open ICU with full complement of patients (seeing both floor, step down, telemetry and ICU pts) I was done most days after rounds by noon. It was great, and spent much of the day drinking coffee with said attendings. They knew where to hide so we wouldn't get caught shirking. It doesn't look good when most residents have bags under their eyes, their interns all bleary eyed and typing on the computer "hunt and peck" until 6pm while you cut and paste your way tornado style to a 10am finish most days.

One attending in particular was so awesome that we always left early and at times socialized at his house (where he had the CPRS remote access so we could put in orders over lunch). What good memories. The VA for me was like how most people describe their college experience!

The key is learning to use the software to speed you up, but not showing everyone how fast or efficient you can be. You can be done most days very quickly and have wonderful life style, just don't show it! So don't get caught spending too much time in the cafeteria and don't socialize with your superiors! It's not a bad job overall, great lifestyle, no risk (you can't get sued).

The pay isn't so hot, but they can't tax you on just how nice the lifestyle is. I work a LOT more in private practice, but I make more than triple what the VA pays. I also work about triple the VA work load, which isn't overwhelming because that approaches zero. Typical IM work load is 1200 patients, but half your visits no show and you don't have any same day urgent care (all urgent visits go to ER). A busy day will be 12 patients. Problem at VA, especially the primary care clinic is that if they see you are under whelmed and you don't have a lot of seniority, they will dump all the patients your way. I know more than a few young attendings this happened to. In pvt practice, this is good, you make more money. As a VA employee, you still make your very low base salary, so again, don't let on just how efficient you are, and make sure to complain a lot and show mediocrity so you won't be singled out as being too efficient and then punished with more work (like any government job).

Once I am financially set in a few decades I may consider a VA job, but I just am too restless and too driven for that kind of pace when the light of my youth still shineth.

So it depends on what you want. Great lifestyle, good benefits, pension for very little actual work, but you can make a lot more in private practice. It all comes down to your core values. And if you are very industrious, you could end up getting singled out for a lot of work but little pay. If the latter is the case, pvt practice much better, especially given how lucrative and in demand primary care is (see my other posts about how wonderful medicine can be and how to do it).

[HearDoc]

Thanks for posting that article. Articles like this combat the poor image of the VA system. The last paragraph is emblematic: a researcher says he wouldn't mind sending his family. I think from reading this, my impression is most lay people don't have a clue what is good medical practice. Why don't you ask a doctor who works in a university hospital across the street from a VA, which hospital he'd rather send his family member?

The ACSI researchers, by design, did not talk to anyone still on that wait-list, let alone to anyone refused enrollment altogether. They randomly selected veterans who had just completed a course of care and asked them more than a dozen questions about the care itself, but none about any frustrations beforehand.

More statistical cherry picking to produce whatever result you want to
use.....

[wshang]

. . . the VA system has become significantly better than when I finished training a decade ago. There is likely a spectrum of VA hospitals.

Although my personal experience is more than a decade old, my recent anecdote about the hapless hire who eventually eventually getting a VA job when no one else would hire, isn't. One certainly hopes the VA system has improved in caring for those who have sacrificed for our well being.

don't let on just how efficient you are, and make sure to complain a lot and show mediocrity so you won't be singled out as being too efficient and then punished with more work.

This is the funniest backhanded compliment. On those hard days, I too have daydreamed of retiring to the VA after making enough money. Reading your posting not only made me LOL, but it reminded me about Michelle Rhee, Chancellor of the DC public schools efforts to clean out the listless, deadwood, school staff.

[biasion]

. . . the VA system has become significantly better than when I finished training a decade ago. There is likely a spectrum of VA hospitals.

Although my personal experience is more than a decade old, my recent anecdote about the hapless hire who eventually eventually getting a VA job when no one else would hire, isn't. One certainly hopes the VA system has improved in caring for those who have sacrificed for our well being.

don't let on just how efficient you are, and make sure to complain a lot and show mediocrity so you won't be singled out as being too efficient and then punished with more work.

This is the funniest backhanded compliment. On those hard days, I too have daydreamed of retiring to the VA after making enough money. Reading your posting not only made me LOL, but it reminded me about Michelle Rhee, Chancellor of the DC public schools efforts to clean out the listless, deadwood, school staff.

A lot of the problem is efficiency. Obviously I worked as a resident there for many months (close to 1 out of my 3 years) by choice. The VA was seen as a really, really hard rotation because you have NO SUPERVISION. This is different as attending,but the same political item applies.

Basically no one gives a turd of human excrement. This is actually a good thing. In our pill popping, "DO SOMETHING" society which is foaming at the mouth rabid to magically demand an immediate solution to today's problem that MUST be started yesterday or else (not an error, just showing how cuckoo most people's expectations are), the VA was a refreshing dose of mellow out don't give a shit.

80% of the work as a resident is either tracing down the patient's entire history. Thanks to VA computer, EVERYTHING, literally EVERY medicine prescription, stress test, consult or colonoscopy is in the same system. So instead of calling the pharmacy and getting in touch with umpteenth private attendsins, a VA admission, even for ICU patient was a joke. You'd just renew with ONE CLICK (literally) all the outpatient meds, quickly look through everything, and within 10-15 minutes know the patient as well as their primary care doc thanks to everything being accessible in the record.

*crude profanities removed

The VA was a sigh of relief from this as a resident. There is no threat of being sued. You get to care for the nation's heroes! I can't tell you how many Pearl Harbor, Phillipines, Normandy, bomber, battleship whatever heroes I met.

As a child I read and was told by my grandparents about these heroic, selfless people who saved our country from certain doom. If it wasn't for these heroes, certainly we would have to wake up every morning and wave a "heil hitler" to a nazi flag.

So yes,the VA was wonderful for residency. I can be a lot of work as a resident because you have very little supervision. But that is what I most loved about it! I was a good doctor. Sure, I had my faults, but I was being judged on tasks that had NOTHING to do with being a good doctor.

So much of my time was not involved with actually caring for patients, wasted, calling around gathering data that was impossibly hard to gather or kissing up to superiors so odious, so hateful, so unhappy in life they wre demeaning everything around them that breathed. In that sense, maybe the vets erred. Japan should have won WW2: that way I would order ritual Seppuku on a prescription pad for them, and without any "coup de grace" beheading from an assistant either!

The differece is this: most residents at the VA hated it. They had no appreciation for history. They didn't appreciate WHY most of these vets were so crazy that at night when covering the hospital, the hallways were full of screams, of crazies in the throes of withdrawal, of why these people were so nuts despite being on 5 psych meds. How soon our society forgets.

I managed to exploit the computer system. Instead of spening 80%of my work day calling pharmacies, kissing ass and tring to dodge bullets. IE, sometimes, as a resident, if you call cerain doctors to ask more history in the interest of taking better care of patient because you are in a confused, very combat like situation and need to get some fast answers, they will complain to your program you are a bad doctor because "your clinical judgement is bad".

Gone was this. I could look on the computer. I even constructed templates for pre-written progress notes. I didn't have to write anything new, just clicked on what I wanted, deleted what I didn't need. Do realize that medical documetation also takes a long time, as in 1 hour of documenting for every hour of patient care. That is pretty crazy, but thanks to macros I could just save in the computer and even order sets that could be saved (like pneumonia or alcohol withdrawal).

While with my regular hospital 12 patients would take me all day, at the VA even a full 12 patient (or sometimes more, as the VA is permissive ,they would violate the residency limits all the time) load was a joke. I had the feeling that I could be the ONLY internal medicine resident and manage all four teams of patients in an 8-10 hour work day. Attendings loved and trusted me, and vice versa.

Oh god, there were 2 attendings to whose houses I went with my intern to scarf down various foods, delights. They would take us out of the workday. One had so much art at his house, we would spend the whole day talking about European oil paintings or asian ceramics while eating exotic fish etc. The chief resident would "wonder" where our team wound up, and my attending would always vouch "teaching rounds". It was the bomb. I was free, and I got to talk all day with my patients about 'nam, battleships, B-17's. It was heaven.

The dark side was there though. I was actually offered a job at the local VA, but turned it down because of what I had heard and saw. I know that my personality type would not thrive there as an attending. I know with my restlessness and "urge", I could make 2-3x or more the same money (of course, at 2-3x the work) in pvt practive. I knew my enthusiasm would be punished. And yet I felt the "laziness" was a good thing.

I had a patient whose heart stopped and he died at 1am on telemetry. I never got a call, and I was on call that night. My intern found out the next morning that the patient had died because she checked the telemtry strip and found 6 hours of flatline! OF course, the patient was DNR/DNI, so even if I had been alerted the patient's heart had stopped (and I was expecting it), I couldn't been able to do anything.

Another time my intern rounded on a patient in rigor mortis . Rigor moris is what happens hours after you die: muscles for lack of energy become rigid after death, takes a few hours for this to happen, you have to be very "cold and blue". Strange, but your muscles actually need energy to RELAX! Your muscles will naturally contract, but most of the oxygen and energy is actually used to make them relax and cock like a revolver, ready to fire the next movement. So in essence, the movement is the downstream, easy and expected function. In other words, muscles act like capacitors, storing energy/charge. So when you die, your muscles stop dong this and after a while seize up, and the corpse will become stiff. It does take a few hours.

Now, on this occasion, my intern wandered in to round on this patient maybe 30 minutes after the nurse's aid had documented a blood pressure and pulse that were the same in the chart as had been measured for the last many days (alone, a questionable sign). Those vital signs were indeed documented as poisitive, in other words, a blood pressure and pulse were recorded at that time. But patient was in RIGOR MORTIS! He was stiff as a board and dead as a doornail. He would have to have been dead for longer than the time between the vitals were documented and my intern first saw the patient to get so stiff. What does this imply? Not measuring vitals and just copying the same number endlessly? perhaps.

Still, no harm no foul. The fact remains that both of these events were expected.

I think the "regular", lawyer dominated healthcare system does way more injustice to old people. Have you read my posts about my anger, my opposition to this "911 emegency" approach to trying to resuscitate 90 year olds, breaking their ribs. I still have nightmares and bawl like ababy about this. My wife has forbid any hospital conversation, the suffering, death and pain I have witnessed in that capacity is more than most men deserve to see in a thousand lifetimes. Dr. Mengele? Sure, I was he. I was forced to break ribs, mechanically ventilate old people that I thought deserved to die (in a good way, like "die nicely in their sleep"), but was ordered to disturb them from their eternal slumber. The guilt, the sickening texture of breaking ribs with my hands, seeing the whole corn kernels of their last meal watching them puke as I try to intubate them. I have repressed that. I don't remember the last time I cried about that, but I am pretty tearful sharing this tonight. And you need to know. People need to know. That was the VA difference. While there was that callous "government employees don't give a shit" attitude, IMHO a shit wasn't given about the things that don't deserve a shit to be given, see what I am saying? Because most institutions give a shit about those things because people have unreasonable, crazy expectations.

I practice with that sense of protection from my patients. I don't beat arond the bush. A handful of patients do get turned off by my very intense approach, but 98% appreciate my attempt to educate them, to illuminate them through life's journey. I feel like I get paid very fairly for it. I think I am doing better for me and for my patients than I could at VA. But I work very hard, very, very hard.

I still have a large number of vets. They like the "double dipping", having VA for free stuff and then seeing private doc for the boutique medicine 2nd opinion. I like that. They are some of my favorite patients.

So if you like VA, go ahead. Low pay, low work, but fabulous work environment. Can make more, do better in private practice, but from a risk/reward profile, a very "efficient" job. Take it from a veteran of that particular conflict.

Just make sure you thank your patients for what they have done. Give back.

We get to invest, to armchair talk about all this diehards baloney and have good jobs and not be slaves becaue of the vets' sacrifices. Thank a vet today, they will apreciate it.

God bless.

[TaxExempt]

After spending a few weeks talking to VA and other physicians, and some deep introspection, I have decided to go ahead and take the VA job. Thanks to all for the detailed and insightful posts!

Now I'm tying up loose ends in my old job, including the pesky issue of tail insurance for which I'm starting a new thread.

Thanks again.

[drjohnjack]

The VA physicians who had been in a private practice or in a medical center could help you on that. They could give you much information about the VA job.

philippine sig spammer - banned - jeff mc