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During a Nov. 13 congressional hearing, two “whistleblowers” described in abject detail the culture of negligence that has compromised patient safety at the G.V. (Sonny) Montgomery Department of Veterans Affairs (VA) Medical Center in Jackson, Miss.
The hearing, held by the House Veterans Affairs’ Subcommittee on Oversight & Investigations, examined a variety of serious problems at the Jackson VA center. Two key whistleblowers testified: Dr. Phyllis Hollenbeck, M.D., former physician of family medicine at the Jackson VAMC, and Dr. Charles Sherwood, M.D., former chief of ophthalmology at the facility. They had complained to the U.S. Office of Special Counsel (OSC) in Washington about conditions at the Jackson VAMC, including poor sterilization procedures, understaffing, misdiagnoses and poor management practices that placed patients at risk.
Unsupervised nurse practitioners (NPs) in Jackson VAMC’s primary-care unit, Hollenbeck said, outnumbered physicians by a ratio of three to one - sometimes four to one. “This same cavalier attitude and laxity by medical center and VISN (Veteran Integrated Service Network) leadership toward safe and proper medical care for the veterans empowered the NPs to prescribe narcotics, without physician supervision and without individual DEA (Drug Enforcement Administration) registration numbers,” Hollenbeck said. This practice violates federal and individual state laws and VA handbook regulations.
“Veterans suffer needlessly, even when they do not die,” Hollenbeck said. “Think of a veteran whose fatigue is not just due to his chronic medical problems, but because of minute cardiac arrhythmia. When the subtlety of that diagnosis is missed by an NP, the veteran goes home and dies.”
Hollenbeck said the medical center’s director, Joe Battle, “is fond of reminding us that when you’re at the VA, you’re on the reservation. This translates into: ‘federal supremacy means we don’t have to follow the laws.’ It also means that medical and ethical boundaries are boldly breached. In this case, standing up to the ‘federal specialness’ claim, and ‘going off the reservation’ is a sign of sanity and professionalism. Duty calls us now, as it called the veterans.”
Fellow whistleblower Sherwood, who worked at the Jackson VAMC for 31 years before retiring, criticized VA’s performance-based model for senior executive service managers (implemented in the late 1990s). He told the committee that this compensation model, in a modified form, was extended to physicians by law in 2004 and implemented in 2006.
“The model has been manipulated to emphasize pay and job security at the expense of health and safety of patients,” Sherwood said. Noting that VA performance bonuses for executives have fallen under congressional scrutiny, he said the practice needs to be reformed “to protect patients by adjusting the pay system and preventing administrators from covering up patient injury.”
Erik Hearon, a certified public accountant from Mississippi and retired Air Force major general, testified to the subcommitee that he knew Sonny Montgomery. “His memory means a lot to me, and to the veterans that are supposed to get quality care (at the Jackson VAMC).”
“In May of 2011, there was a hearing held in this very room, where a lot of promises were made by the VA - and I’ve seen no evidence that they were fulfilled,” Hearon said. He then told the subcommittee about one patient at Jackson VAMC he had spoken with a week ago. He was “allowed only to see nurse practitioners, no physicians, for two years.” Earlier this year, he was informed that he had cancer, “had his entire stomach removed in September, and only then was he allowed to see a doctor, who refused to give him leave from work. He was a VA employee as well.” His employment was terminated, according to Hearon, “and it’s just been an absolute disaster.”
Charles Jenkins, president of Local 589, American Federation of Government Employees at the Jackson facility, represents more than 900 employees there. He told the subcommittee he was there to request an investigation into “a number of disturbing and preventable situations that occurred at the Jackson VA medical center. Over the years, management has consistently been inconsistent in responding to staffing problems.”
Jenkins said that, since 2012, Local 589 has submitted 12 written requests to Jackson VAMC Director Joe Battle, to investigate alleged violations by several members of his management team. “Unfortunately, leadership has been very reluctant to address alleged violations of rules and regulations by certain members of their own team.... Despite numerous requests, management waited more than one year to launch an investigation into improper hiring practices....”
Responding to a question from the subcommittee, Hollenbeck said one top challenges facing the Jackson facility is to “reorganize the primary care department to have more physicians.” Although recruiting new doctors “is a problem now, because the word is out about the hospital.”