When your healthcare is determined by bureaucrats you lose

Vet's death highlights urology clinic wait-time issues

All Gilford Anderson wanted was to find out exactly why his lower extremities, including his genitals, were swelling — and to ask a Phoenix Veterans Affairs doctor whether the swelling was linked to a procedure he'd received last December.

Anderson, who had prostate cancer, had been feeling sick since a stent had been implanted. Over the next five months, his body quickly deteriorated and cancer spread through his bones.

He tried to make follow-up appointments through the VA to no avail, and desperately tried other avenues like the emergency room and his sister's oncologist.

The only person the U.S. Marine veteran could count on to answer his calls was Reggie, a receptionist at the Phoenix VA Health Care System who would transfer his calls. But that couldn't get him answers for his progressing illness.

Anderson, 63, died this month in his Tolleson home. His family members say he couldn't walk by the time he died.

While it is not clear that Anderson ever received improper care, his death dramatizes the frustration encountered by numerous VA urology patients who have reached out toThe Arizona Republic in the past month. Because of a shortage of medical doctors and high turnover in urology staff, they say, it has become difficult to schedule appointments and to see a provider who knows their histories.

VA officials have acknowledged staffing issues in the urology department.

They confirmed that patients are being referred to private care providers and specialists across the Valley, and even to the Tucson and Albuquerque VA centers. There were six urology providers a year ago but most of them retired or left, Sharon Helman, Phoenix VA Health Care System director, told The Republic last month. Helman subsequently was placed on administrative leave amid allegations that up to 40 veterans died while waiting for medical appointments.

The Phoenix VA will spend $100 million in fiscal 2014 to pay for patients to receive care from other hospitals in the community, according to Scott McRoberts, Phoenix VA spokesman. As much as $8 million is to be spent on urology care, he said.

One full-time and one part-time urologist were employed by the Phoenix VA as of last week, according to Dr. Theodore Mobley, the part-time doctor there.

They are joined by a physician assistant and a nurse practitioner to treat what Mobley estimated are about 3,000 prostate-cancer patients.

"I worked there for 10 years, and I have been aware of the long wait times. But I'm not aware of anything I would say was illegal or unethical or malfeasance," Mobley said.

Mobley, who recently came out of retirement part time to help the short-handed staff, said the workload, low pay compared with private practice, and a nationwide shortage of qualified urologists contributes to staff turnover.

Mobley believes four full-time urologists and four full-time midlevel providers such as physician assistants and nurse practitioners would provide adequate staffing.

Staff members work hard to accommodate each patient's unique needs, or help them find appropriate care if it can't be provided at the Phoenix VA, Mobley said.

Before retiring, Mobley, 79, worked 10 to 12 hours every day and was on call at night. He worked weekends to catch up on paperwork. "When you're a kid, that's not terrible. It's not good, but when you're my age, it's devastating. It's just hard to do," he said.

Last year, after Mobley took time off because of a wrist injury, he returned to find the two other urologists he'd worked with had quit, out of frustration over the workload and other issues. So he delayed his retirement until January and returned to work part time, with no night calls.

The Phoenix VA is now recruiting staff for the urology clinic.

Loving family man

Anderson was a doting grandfather. He had nicknames for his grandchildren: Big Dog, Little Dog, Bud, ­Mama and more. He especially fawned over the youngest, a 1-year-old granddaughter nicknamed "Sita," short for "Mamasita."

He loved to cook for his family, play spades and hang out with his neighbors.

He was a Vietnam War-era Marine who enlisted and served for 16 months before being honorably discharged. While he didn't talk about his personal military experience much with his family, he remained a proud Marine for the rest of his life.

Anderson was diagnosed with prostate cancer in 2003, but it went into remission.

When it returned last year, he went to the VA hospital in December for a stent implant to help him urinate. He felt sick after the surgery, and became infected after replacement implants.

"He was doing real, real good, moving around, getting around driving, and going to play golf," said his widow, Brenda. "But when he went in and got his stent put in, that's when he came down."

Over the next five months, he landed at emergency rooms, where doctors unsuccessfully tried to get him into the VA urology clinic, Anderson wrote in a letter to U.S. Rep. Raúl Grijalva's office before he died. The VA referred him to Mayo Clinic, where he received follow-up procedures.

He was too young for Medicare, was waiting for his Medicaid application to be approved, and couldn't afford a private doctor. So he relied on VA care. His medication continued to arrive in the mail. But appointments he had made with the VA urology clinic were canceled, Brenda said.

"That's all he's been getting from them, just the bill. Bills and pills. No care," Brenda said.

Every time he went to the VA, he saw a new physician assistant, nurse practitioner or primary-care doctor who didn't know his prostate-cancer history, Brenda said.

"He was frustrated with it, but there was nothing he could do about it. He had no choice but to wait," Brenda said. "And then when he did go in there, he's got a different nurse, different doctor who doesn't know his case. ... Every time he looked around, he had a different doctor."

He became more ill, and the VA recommended hospice care. He used a wheelchair and still tried to make it to family outings. Sita would play near his feet, under his wheelchair.

Gilford died May 10 in his living room. He was buried Friday during a service at the National Memorial Cemetery of Arizona.

Backlogs of patients

Dr. Sam Foote, who retired from the Phoenix VA in December, told The Republic that many urology patients were being referred to the Tucson VA, Albuquerque VA or to non-VA doctors in the Valley.

Foote and other whistle-blowers alleged a variety of systemic breakdowns at the Phoenix VA, including hostile work conditions that caused quality doctors and nurses to leave, and created backlogs in specialty areas, particularly urology.

Most prostate cancers grow slowly. Not every patient needs to be seen several times a year. It depends on how much the cancer has progressed. They may see different doctors and nurses, Mobley said. Doctors may watch patients for a long time without recommending any treatment to avoid adverse side effects, he said.

The network of private doctors who see patients from the VA are quality caregivers and often have specialized skills, Mobley said.

A representative from Grijalva's office was not allowed to comment on specific casework. The Phoenix VA also declined to provide medical information.

"We offer our deepest condolences to the family. Out of respect for their privacy, we can't talk about Mr. Anderson's care specifically," McRoberts said in a statement. "Every death is a tragedy. The Phoenix VA Health Care System maintains robust internal reviews of every death to ensure standards of care are met."

While official details of Anderson's case are not public, the frustration he and his family felt is palpable.

Other urology patients said they have experienced similar frustrations with long wait times or dropped appointments.

It took Wylie Brooks, 66, 10 months to schedule an appointment before he was able to see a urologist at the Phoenix VA. He has prostate cancer now in remission.

In December, he went to the VA emergency room and waited two hours to be taken in for tests. Another two hours later, he was sent to a private hospital, where they found he had kidney stones.

"They don't have anybody over there that can treat us, even look at us, properly," said Brooks, an Army veteran who did three tours in Vietnam. "They have to farm everything out to civilians."

James Rehner, 63, was diagnosed with prostate cancer two years ago.

The Army veteran has had a positive experience with the Phoenix VA urology clinic.

He was being seen every four months to monitor his testosterone levels while the cancer was in remission, and his appointments were scheduled on time.

The only scheduling issue he had was this spring, after his physician assistant left. He had no one to see regularly anymore, he said.

"I was lucky," Rehner said. "When everyone left, I was in remission."

Republic reporter Dennis Wagner contributed.

Timeline: The road to VA wait-time scandal

• Early 2012: Dr. Katherine Mitchell, a Department of Veterans Affairs emergency-room physician, warns Sharon Helman, incoming director of the Phoenix VA Health Care System, that the Phoenix ER is overwhelmed and dangerous. Mitchell now alleges she was told within days by senior administrators that she had deficient communication skills and was transferred out of the ER.

• Later in 2012: The U.S. Department of Veterans Affairs orders implementation of electronic wait-time tracking and makes improved patient access a top priority. In December, the Government Accountability Office tells the Veterans Health Administration that its reporting of outpatient medical-appointment wait times is "unreliable," that scheduling policies are not uniform nationwide and that improvements are needed.

• March 2013:

The GAO's Debra Draper tells a subcommittee of the House Veterans' Affairs Committee: "Long wait times and inadequate scheduling processes at VAMCs (medical centers) have been persistent problems, as we and the VA Office of Inspector General have reported."

• July 2013:

In an e-mail exchange among employees at the Carl T. Hayden VA Medical Center in Phoenix, an employee questions whether administrators are improperly and unethically touting their Wildly Important Goals program as a success because it shows a dramatic reduction in wait times for patient appointments.

• September 2013:

Mitchell files a confidential complaint intended for the VA Office of Inspector General, channeled through Arizona Sen. John McCain's office. Her list of concerns instead goes to the Office of Congressional and Legislative Affairs and eventually back to the VA, which responds in February 2013. It does not address her most serious complaints. Mitchell is placed on administrative leave.

• October 2013:

Dr. Sam Foote, a doctor of internal medicine at the Phoenix VA, files a complaint with the VA Office of Inspector General alleging that purported successes in reducing wait times stem from manipulation of data, not improved service, and that vets are dying while awaiting appointments for medical care.

• December 2013:

Foote retires and meets with

Arizona Republic

reporter Dennis Wagner. He details allegations that patients have died while awaiting care at the Phoenix VA and that wait times have been falsified. The same month, inspector general's investigators visit Phoenix to look into whistle-blowers' complaints.

• April 9:

Rep. Jeff Miller, R-Fla., chairman of the House Committee on Veterans' Affairs, says during a hearing that dozens of VA hospital patients in Phoenix may have died while awaiting medical care. He says staff investigators have evidence that the Phoenix VA Health Care System keeps two sets of records to conceal prolonged patient waits for appointments and treatment.

• May 1:

U.S. Secretary of Veterans Affairs Eric Shinseki places Helman and two others on administrative leave pending an outcome to the inspector general's probe.

• May 2:

Mitchell goes public with her allegations about mismanagement of the Phoenix VA system and her concerns about wait times, noting that she and a co-worker moved to protect some documents as evidence.

• May 5:

The American Legion's national leaders call for Shinseki's resignation. Shinseki says he intends to stay put.

• May 8:

Shinseki orders records audits of all VA health-care facilities around the U.S. a day after U.S. Rep. Ann Kirkpatrick, D-Ariz., makes the request.

• May 9:

McCain, R-Ariz., holds a veterans' town hall in Phoenix where he proposes a new system that would allow veterans to go outside the VA to seek private health care at government expense.

• May 12:

Steve Young takes over as interim director of the Phoenix VA Health Care System.

• May 15:

The U.S. Senate Committee on Veterans' Affairs holds a four-hour hearing. Acting Veterans Affairs Inspector General Richard Griffin reveals that the team probing complaints about Phoenix VA facilities includes criminal investigators.

• May 16:

Dr. Robert Petzel, undersecretary for health and second in command at the Department of Veterans Affairs, departs the agency. Shinseki says Petzel resigned, though the agency had announced Petzel's planned retirement last September.

• May 21:

President Barack Obama pledges the administration will thoroughly investigate allegations at VA facilities in Phoenix and across the country and will punish any misconduct.

There will be no consequences for the incompetence only the bureaucrats favorite answer, we'll do a study. The VA is Kafkaesque.