clinical pharmacists

Veterans Affairs is now using clinical pharmacists to handle up to one-quarter of primary care appointments to combat wait times at some medical centers.

Last year, VA implemented changes that allowed clinical pharmacists to handle primary care for many veterans at select facilities. The push is reportedly in an effort not to increase healthcare quality but instead to decrease wait times as cheaply as possible.

The cost of a clinical pharmacist is almost half that of a medical doctor, and VA seeks to double its usage of such pharmacists over that of doctors in the near future.

But don’t veterans deserve to see doctors in a timely manner just like civilians?

Yesterday, Kaiser Health News circulated an article (more like a press release) on its own website that supports the practice – – the article is obviously written using rhetoric of apologetics meaning we need to look into this very carefully:

VA Shifts To Clinical Pharmacists To Help Ease Patients’ Long Waits

“Something astonishing has happened in the past year to outpatient treatment at the Veterans Affairs hospital here.

“Vets regularly get next-day and even same-day appointments for primary care now, no longer waiting a month or more to see a doctor as many once did.

“The reason is they don’t all see doctors. Clinical pharmacists — whose special training permits them to prescribe drugs, order lab tests, make referrals to specialists and do physical examinations — are handling more patients’ chronic care needs. That frees physicians to concentrate on new patients and others with complex needs.

“A quarter of primary care appointments at the Madison hospital are now handled by clinical pharmacists since they were integrated inpatient care teams in 2015.”

The article continues on for another half page or so discussing why this is a good thing while paying minor tribute to the legal implications.

Other publications like USA Today also copied and pasted the entire article but tweaked the headline to make veterans sound like whiners: USA Today – VA treats patients’ impatience with clinical pharmacists.

My opinion on this is much like the recently proposed regulations allowing advanced practice nurses to treat veterans without doctor supervision. Veterans should not have to choose between timely healthcare and quality healthcare, but VA is apparently putting us into this quagmire on the backs of the hysteria over the veterans killed by the wait list fraud that was originally reported out of Phoenix.

One veteran’s comments on the subject, located on USA Today, matched mine. Aside from comments like the ones posted at the bottom of this article, no one else is talking about the problem of VA maintaining the same lack of access to doctors while augmenting access with lesser qualified clinicians who are not licensed to practice medicine.

Veteran Michael Martinez commented, “So in other words…There are not enough Drs to treat our Veterans & the Govt solves this problem by allowing non-doctors to see Vets…Perfect Govt reasoning.”

What do you think? Predictable reasoning?

Is Martinez Onto Something?

Rather than create an environment to encourage the hiring of more doctors with less retaliation and hostility toward colleagues, VA decided to lower its own standards and its cost of care. This experimental treatment scheme is now being run at VA medical centers in Madison, WI, El Paso, TX, and Kansas City, MO.

These days, clinical pharmacists are not the only clinicians treating veterans under new care criteria. This year, VA is also seeking to allow advanced nurses to treat veterans without direct supervision of a medical doctor, which is presently not allowed in 30 states.

VA seems to be exploiting the wait list scandal that existed at least as far back as Bill Clinton’s presidency to now justify hiring lesser trained and lesser qualified clinicians instead of medical doctors.

Meanwhile, VA executives like Sloan Gibson IV tells the American public that everything is back to normal just in time for the election.

Why Clinical Pharmacists vs Doctors?

This is not a question of what is better for veterans at any cost. There can be no question that the advanced training of medical doctors makes their skills set, on average, far superior to that of advanced practice nurses or clinical pharmacists.

Instead, the question to answer is, “How far in the direction of cheaper healthcare resources will VA be allowed to move while risking veterans lives and safety?”

Rest assured this model is not being researched solely for veterans. Instead, once ACA collapses, the single payer model will be rolled out and the VA healthcare model will be the model for American healthcare nationwide.

It is apparent that the primary benefit here is solely focused on reducing the cost of fighting wait list backlogs at the expense of providing veterans with the highest quality healthcare possible.

Presently, clinical pharmacists are outnumbered by doctors at a ratio of 1 to 6. VA hopes to reduce that ratio to 1 to 3.

According to Glassdoor, the average base salary of a clinical pharmacist at VA is $114,000. Meanwhile, the average base salary of a medical doctor is around $198,000 at VA. So the cost reduction motive is clearly the driving force on the back of the wait list scandal.

VA will be able to hire almost two pharmacists for every medical doctor. At this rate, it will likely become even harder in the future to meet with a primary care doctor moving forward.

This means VA intends to maintain its status quo of unreasonably low access to medical doctors to save a buck without longstanding research supporting this kind of reduced training for primary care providers or the legal impact on the practice of medicine bar in every state.

Healthcare will usurp the practice of medicine where nurses and pharmacists will merely check boxes that a computer tells them to consider rather than thinking through the presentation of the patient before them in a cohesive manner while “practicing medicine” as in the past many decades.

This is uncharted territory folks, and it is being done on the backs of the dead veterans whose tragic stories gave rise to the call for immediate solutions. Instead, we are given band-aids to fix massive shortages in access to medical doctors.

Is this the direction and consideration VA promised America when it swore it would reduce the wait list? What other maneuvers does VA have up its sleeve that have not been revealed yet?

Training Of A Clinical Pharmacist

According to the American College of Clinical Pharmacy (ACCP) a clinical pharmacist’s training is described as follows:

“The clinical pharmacist is educated and trained in direct patient care environments, including medical centers, clinics, and a variety of other health care settings. Clinical pharmacists are frequently granted patient care privileges by collaborating physicians and/or health systems that allow them to perform a full range of medication decision-making functions as part of the patient’s health care team. These privileges are granted on the basis of the clinical pharmacist’s demonstrated knowledge of medication therapy and record of clinical experience. This specialized knowledge and clinical experience is usually gained through residency training and specialist board certification.”

The organization explained how these clinicians provide care for patients. The following bullets are straight quotes from the ACCP website:

  • “Provide a consistent process of patient care that ensures the appropriateness, effectiveness, and safety of the patient’s medication use.
  • “Consult with the patient’s physician(s) and other health care provider(s) to develop and implement a medication plan that can meet the overall goals of patient care established by the health care team.
  • “Apply specialized knowledge of the scientific and clinical use of medications, including medication action, dosing, adverse effects, and drug interactions, in performing their patient care activities in collaboration with other members of the health care team.
  • “Call on their clinical experience to solve health problems through the rational use of medications.
  • “Rely on their professional relationships with patients to tailor their advice to best meet individual patient needs and desires.”

Did you see anything mentioned in there about clinical pharmacists taking over as the primary roll for primary care to help reduce any wait times? No, because this kind of scheme would never fly in a civilian facility.

But since we are only veterans, what the hell, right?

Kaiser Promoting Clinical Pharmacists?

Kaiser Health News covered this issue yesterday. Perhaps some of you may recall Kaiser partnered with VA in an initiative to share patient data on population management.

RELATED: Population Management And Genomics Act Core Of Kaiser Partnership With VA

Companies like Kaiser are always looking for ways to cut healthcare costs, and VA seems to prove itself as fertile ground for using and sometimes abusing VA’s guinea pigs – – otherwise known as impoverished veterans who cannot afford lawyers or insurance.

According to Kaiser, the use of clinical pharmacists is as follows:

“The Madison VA allowed clinical pharmacists to take over management of patients with chronic diseases such as diabetes and high blood pressure, participate in weekly meetings with doctors and other members of patients’ care teams and handle patients’ calls about medications.

“They typically see five patients in their office each day, usually for 30 minutes each, and they talk to another 10 by telephone, said Ellina Seckel, the clinical pharmacist who led the changes at the hospital.

“Many issues involve adjusting medication dosages such as insulin, which do not require a face-to-face visit. When Seckel sees patients, she often helps them lower the number of drugs they take because they may cause unnecessary complications.

“Expanding clinical pharmacists’ role in primary care has cut readmission rates and helped more patients keep their diabetes under control, Seckel said.”

The decision to usurp the scope of practice of doctors was met with heavy skepticism. Lanre’ Obisesan, assistant chief of pharmacy at El Paso VA said, “Some physicians feel like it’s a turf war and don’t want to refer their patients because they feel the clinical pharmacist is trying to practice medicine.”

Rather than address this very real ethical and legal potential breach, the Kaiser article shifts gears to highlight how the use of lesser trained clinical pharmacists reduced wait times.

But is this a legal breach? Are these clinical pharmacists “practicing medicine”? I believe they are and as such, they are likely in violation of certain laws within the states they practice within.

Perhaps that is why Kaiser never addressed the concern within the article?

Clinical Pharmacist Articles Elsewhere

Concerned, I began to look around the web for other examples and news articles discussing VA’s use of pharmacists.

The American Pharmacists Association (APA) wrote a brief summary of the Kaiser article using the derogatory title, “VA treats patients’ impatience with clinical pharmacists”. This title was also used by USA Today (I will touch on this below).

Do you see how the wait list scandal, which was allowed to fester since Bill Clinton left office, is now being used to reduce quality of care and cost of care at VA facilities? Is there ever a scandal that goes without a prefabricated solution?

According to the APA, veterans (i.e. patients) were impatient rather than fed up with other fellow veterans dying while VA administrators defrauded the system by boosting their performance numbers through fraudulent schemes to while denying access to healthcare.

You see how the conversation is being turned away from the fraud while instead focusing on veterans as the whiners? You can expect more of this kind of derogatory treatment as we move further away from the recent wars.

In light of the Phoenix VA billboard that was apparently paid for by TriWest and endorsed by all major veterans organizations, it looks like the federal government and its minions are quick at work to rewrite history in time for VA to become the model for American healthcare after a Clinton victory this November.

Aside from the Kaiser article, there was not a lot written on the subject within the news telling me this is more of a policy experiment they are floating right now.

The original Kaiser article, which appears more like a public relations article than a news article, was also published in USA Today. They also used the derogatory title blaming the use of pharmacists on impatient veterans, “VA treats patients’ impatience with clinical pharmacists”.

The full court press will be on to gain approval of this strategy nationwide.

To give you an idea of the conversation, I am providing the following comments from the USA Today article below. Typos were corrected for readability. I would like to see where you all fall on this issue, either for or against

I would like to see where you all fall on this issue, either for or against.

Comments From USA Today On Clinical Pharmacist Story

Scott Gardner “So this is supposed to be good news, but it is not. This is just another way to give veterans sub standard health care. Things will get missed far more often now, and there will be more anti-depressants handed out like candy than ever before…. So sad….I will never step foot in the VA again after the way I have been treated in KC. Total incompetence at ALL levels.”

Michael J Martinez “Thank you for your service. I am sorry and disgusted to see our vets being mistreated like this.”

Ben Francis Tarsitano “Why not just hire chiropractors? Veterans are not entitled to actually be seen by a licensed physician.”

Peggy Stewart “In addition to clinical pharmacists, there are also physician assistants and nurse practitioners. Are they also being utilized? Probably not – as the El Paso doctors demonstrated – this is a turf war, and even though I the doctor do not have the ability to hold the turf, I will be damned if I ever let someone have a little of it.”

Wainaina Wainaina “Good idea, pharmacist can as well help the patient and manage as well as doctors.”

Michael J Martinez “NO they cannot…If this was true then they WOULD BE Dr’s!”

Jeremy Moretz “Actually- we are “doctors”. We hold a doctor of pharmacy, in the same regards a physician holds a doctor of medicine. Although I never go by “doctor” unless I’m teaching in a classroom. To practice as this kind of pharmacist- you have to have at least two years of training after pharmacy school specializing in medication therapy management and adjustment. If you are cared for at any academic medical center, including the VA- there is a high probability you have a pharmacist on your rounding team helping the team direct medication decision making. To devalue our profession as a “bean counter” is quite offensive- but I won’t be rude, as I’m sure it’s a matter of not understanding the advancement of our profession. We would never claim to diagnose- that is certainly beyond the scope of our training and licensure. Our objective is to aid in medication therapy management and adjustment. To clarify- I don’t actually work at a VA. I work at an academic medical center and round with an advanced cardiology team. I can find a multitude of my physician colleagues who appreciate and value having a pharmacist on their service helping care for their patients. I would kindly ask to fact check understanding of the pharmacy profession before devaluing our collaborative work with physicians.”

Michael J Martinez “Jeremy Moretz You are not a Medical Dr. And you know full well that is what was meant by my statement. If you were qualified to be a medical Dr then you would be. I am not devaluing your contribution to the system. And I didn’t call your profession Bean Counters…it was a reference to the cost of it all. You also round with a team and that is not the way the situation at the VA is being described here. I am pointing out the crap that we are being fed about this being a better situation than actually having more – Medical – Dr’s available to treat our Vets.”

Michael J Martinez “So in other words…There are not enough Drs to treat our Veterans & the Govt solves this problem by allowing non-doctors to see Vets…Perfect Govt reasoning.”

Michael J Martinez “Kaylee Caniff Babble on all you want about it, doesn’t change the fact that there arent enough Drs to treat our Veterans. Instead of hiring more, the govt decides Clinical Pharmacists are a better choice instead. Tell me Kaylee, what VA hospital do you go to for your medical care?”

Anna Showalter “For a chronic illness 30 minutes with a knowledgeable pharmacist, nurse practitioner who may discuss diet, exercise, etc sure beats the 5 minutes we get with a doctor who always checks our BP and heart beat (even with no heart disease present). Oops he/she gives us a refill on our Rx. also.”

Michael J Martinez “Anna Showalter Your comment only clarifies my point…. this is about a shortage of Dr’s and the only solution from the Govts viewpoint is to allow non-Dr’s to handle the cases. Spin it as much as you want, but I guarantee the congressmen who send us to war would never accept being told this crap about compromising on the level of their healthcare just so some bean counter can make the numbers work. Heres a suggestion…how about we MAKE GOOD on our promise to take care of our vets and hire enough Dr’s!”

Jeremy Moretz had some good points about the profession, and I think it is probably wise to have clinical pharmacists working closely with doctors. But unlike where Moretz works, VA is allowing its pharmacists to take on the primary care role, which is dangerous and possibly illegal in some states.

Thoughts On Clinical Pharmacy?

What do you think on this issue? Should VA maintain the status quo of unreasonably lacking access to medical doctors by augmenting care with cheaper, less trained alternatives? Or, should VA hire more doctors?

I know some veterans are comfortable with the lower quality so long as they see someone with medical-type training. I find this low standard unacceptable.

Veterans should not need to choose low standard health care in exchange for at least speaking with someone with medical training for longer than five minutes.

Source: http://khn.org/news/va-treats-patients-impatience-with-clinical-pharmacists/

99 COMMENTS

  1. I try my best to not knock anybody’s profession. As that is what they choose to specialize in and have invested lots of time and money into it. I am sorry but a Clinical Pharmacist is not a Doctor of Diagnosis or Conditions. Yes they may be needed for their knowledge of Medicine’s but not for knowledge of Human Anatomy and Diagnosing Medical Illness’s. If this is going to be the case why not go out and hire a bunch of Veterinarians at least they some Knowledge of Anatomy and Diagnosis.

    It is bad enough we have to be subjected to Nurse Practitioners thinking they are above Doctors since they implemented them. And now the VA thinks Clinical Pharmacist can treat Veterans better than Doctors. Here is the Point I do not knock or down anyone of you for what you choose to do, but that is why Doctors go to school longer have residency training before they can even be called a Doctor. What makes anyone think that we only need a Band-Aid and were good.

    My last thought on this is if you (Non-Military, Doctor, Nurse, Pharmacist, Politician, VA Employee) will not give up your Health Care Benefits of seeing when your sick. Then why the Hell should we. And to furthermore understand what we are saying go buy yourself a AR-15 and Fight Your Own Dam Battle and see if we care about what kind of healthcare Hillary and Bill are going to give you.

    How long do you think this Nation would last if you so called Stuck-up High Polluting Snobbish better than everyone else people had to defend for yourself. It would be a Sad Day as some of you would not have clue of which end the bullet comes out of. Much less how to put bullet into the magazine. I would like to see General Hillary and all the Politicians put on combat gear and defend this Nation that us Veterans call Home.

    • I AGREE 100 PERCENT! ,THESE PEOPLE ARE NOT DOCTORS ,I HAVE BEEN SENT TO PHYSICAL THERAPY ,APPOINTMENTS IN RECENT PAST ,WHEN REQUESTING COLON SCOPE AND FOLLOW UP ON MY LEFT SIDED COLOSTOMY! ,SEEMS THE PEOPLE SCHEDULING YOUR MEDICAL NEEDS APPOINTMENTS ARE A BUNCH OF IDIOTS!,NOT EVEN KNOWING WHAT CERTAIN MEDICAL CONDITIONS ON A MEDICAL RECORD MEAN! I’M TIRED OF THERE B.S. STATUS PROFILING ALSO FOR RECEIVING
      THE NEEDED!!!PROPER CARES! I WOULD LIKE TO ASSAULT THEM THE SAME WAY THEY ASSAULTED ME IN THE ARMY,CALLING IT JUST NORMAL TRAINING!

      • Actually a pharmacist with a PharmD is a Doctor of Pharmacy, in fact your pharmacist will have more knowledge about medications than then the average PCP. Also, PharmDs catch physician errors more than you realize and they are trained in Patient Assessment skills.

      • Lame, Pharmacy, Very Lame.

        If you want a pharmacist handling your health care go for it. We all would prefer having a qualified doctor.

  2. 10/26/2016

    Dear Benjamin Krause,

    You had asked the question: “How far in the direction of cheaper healthcare resources will (the) VA be allowed to move while risking veterans’ lives and safety?”
    The answer is all the way! Who is going to stop them? It is not going to be Award winning [Feb. 2015 George Polk Award] journalist Dennis Wagner from USA Today/Arizona Republic Newspaper or any Congressmen in Arizona, and it appears “…IAVA, DAV, VVA, VFW, American Legion, Purple Heart..”[ “and one other” you could not make out on the new billboard in Phoenix] will not be of much help, either.
    The People, think this VA is going fix itself, like Dennis Wagner, it is not going to go that way, after decades of major events, and now the “Three Years” of Scandal after Scandal; this VA “mess” is going to turn a page.
    Billions lay waste in the hands of treasonous bastards who refuse to help the Veterans. Anyone who had asked questions got reprimanded and those who had helped cover-up this mess kept their jobs, and were promoted, and or allowed to retire [sounds like Aerospace in 1988—190th Allied Signal in Torrance, CA—or the Banking Industry/Wells Fargo].
    Put the brakes on now—it will be a long skid.
    Sincerely,
    Don Karg

  3. “[Is this the direction and consideration VA promised America when it swore it would reduce the wait list? What other maneuvers does VA have up its sleeve that have not been revealed yet?]”

    1) VA Gastroenterologists to be replaced by VA Grounds and Gutters Crews. Why? Because the Rand Corp. has found that since VA Grounds and Gutter Cleaners indeed flush-out drainage systems, there is very little difference between the Human Bowel and VA Gutters. Done.
    2) VA Infectious Disease Specialists to be replaced by same Grounds and Gutters Crews since they have some knowledge of Dutch Elm Disease. Rand Concurs Dutch Elm Disease is SO close to HIV, Hep B & C & Ebola.
    3) VA Oncology & Cancer Specialists replaced by same Grounds & Gutters Crews since they also have the inside knowledge on why the grass is always greener on top of septic tanks and happen to be able to fix a microwave oven in a pinch.
    4) VA Psychiatrists replaced by same Grounds & Gutters Crews, as they are known to be great at conflict resolving through their extensive experience in negotiating wildlife down from trees, namely those escaped from VA experimental labs.
    5) VA Pharmacists replaced by same Grounds & Gutters Crews since they have extensive knowledge of how to rid the grounds and golf courses of pesky vermin. (think Caddyshack)
    6) All VA Witch Dr.’s will continue being Witch Dr.’s but will also be required to serve in the VA Chapel for chicken sacrifices to the Caribbean Gods, which then will be recycled in the VA Cafeteria.

  4. Let’s face it, a pharmacist knows what antibiotic is needed for different infections, what the dose should be according to the patient’s body weight and which is the cheapest option, but they don’t know how to listen to lung and heart sounds, what tests to order to find out why someone’s anemic, or how to insert an arterial line, a chest tube, diagnose vasculitis or glomerulonephritis or how to treat post interferon side effects.

    So they can cross dress all they want but that still won’t make them doctors.

    • You are right about all of those, but if you read the Kaiser propaganda carefully, you see this treatment mode being described as only for routine, minor care in order to sell it. How many in the public would read that and say, gee, why would you not want a fast appointment just to have your blood pressure checked?

      Once it’s sold and in practice, you can bet your life pharmacists will be involved in much more than routine care.

      This does make me wonder though….

      Does the VA have the same protection policies in place for pharmacists as they do for doctors? They brag on their recruiting site that VA doctors don’t need malpractice insurance as well as other ways the VA protects their quacks. Will they extend the same protections to pharmacists? Or let them take full responsibility and swing in the wind? Along with the poor bastard veteran suffering from their mistake?

    • If you get a Doctorate of Pharmacy you are trained in physical assessment and I can assure you we know what tests to order. Pharmacist in civilian hospitals order labs and dose patient medications every day.

      • Nice to have your assurance but still prefer having a qualified doctor for my healthcare. You are free to do what ever gets your kicks with yours.

        Thank you Very Much.

  5. Let me ask this: If you had a legal case and needed representation, would you hire someone like a paralegal in training to do all the work a State Bar Certified Attorney can perform? Most cases, no! Same goes for medical care. A pharmacist usually has intimate knowledge on medications and interactions of those medications from a purely academic, what’s written by Drug Companies…NOT actual patient in the trenches, bedside manners, as a good Dr. should have (unless at the VA).
    This move by the VA would be akin to asking the airport baggage handlers to fill-in as mechanics on the jet engines. The baggage handlers have experience being around and ducking from hitting those large engines, so through osmosis, naturally know how to work on them as well….R-R-R-ight. Cheap Rat Bastards!

    • A VA Pharmacist is specifically, more like an assembly line worker, not so much your friendly Walgreens Pharmacy. It would actually make more sense for a VA Pharmacist to sit-in for a Ford or GM Assembly Plant Worker on the Line rather than playing Dr. or better yet, as a fast food drive thru window teller. “Want ketchup with those fries?” 🙂

  6. Ain’t it obvious DVA and VHA are there to kill us. That is their purpose, looks better than a DD214 and a pair of cement shoes. Least at Tomah VA they prescribed enough opiate that you would be so far out of it you wouldn’t really care. As far as this veterinarian goes wouldn’t be so bad if they didn’t stick the thermometer up your ass. At VA if they did that you wouldn’t be terribly sure if it was in fact a thermometer. Veterinarians would have better bedside manner.

  7. I like what Albert Dodd wrote. Let all those in government, who never served, pick up a weapon and fight their own damn wars! (paraphrasing)! When their injured, and return, let them use “clinical pharmacists” as their primary care physician. Bet they’d have a different opinion.
    Of course, all our politicians “opted out of Obamacare”.
    Plus, the shit’s going to hit the fan in 2017, due to it’s failure. Many will be without healthcare.

    How many times have y’all heard a VHA employee say, quote: “We work as a team!” That’s nothing more, in my opinion, than a way for these asswipes to get away with lots of “medical malpractice”.
    Until there’s a complete overhaul of VA’s nationwide, the corruption will continue.

    There’s so much “wrong” going on in our government, it’s hard to distinguish between the “BULL” and the “SHIT”!

  8. What is the difference between this and a gaggle of foriegn dr’s from the middle east that dont speak english and could care less about veterans.

    At least with with nurses and pharmicists you can have someone to hold a conversation with while you are being killed at the evil empire…er I mean VA

    • Bill,

      Sorry but many of the nurses and pharmacists at the VA are just like the doctors who are a “gaggle of foreign dr’s from the middle east”. So it will still be hard to Hold a conversation while you are being killed.

      • Seymore,
        I wonder how many of those “foreign” VA employees are here on a “work visa”? Wouldn’t that be an interesting to find out?
        When I, occasionally, use VHA, there’s more foreign healthcare positions than in the lower rank and file.
        Plus, I always knew, to become a citizen, one had to be able to speak “ENGLISH”!

  9. So what”s new,,, over 47 years of this crap I have seen,,, They have and will not ever be able to solve as told all of you laying in my room and a light bulb went out took it up front to the nurses station,,, they brought it back inserted it back in,, and said had to call maintaince to replace it ,,, many hours later in the dark,,, Maintaince replaced it ,,, just one of 1000s of professional ways they practice,,, But don’t worry there hiring overseas replacements to take care of us,,,, YEP,,, I don’t go to the VA any longer I will die at home,,, If that must be,,,

  10. Just spoke to the head pharmacist at the retail pharmacy I have gone to for 6 years now and had him read this article and before he even got 1/4 into it he looked-up and said to me, “We pharmacists indeed have PhD’s and similar educations as M.D.’s, and we CAN administer basic flu shots, wellness sessions, blood pressure…BUT we are not to be used in lieu of or employed as M.D.’s as we DO NOT take the specific medical residency requirements as M.D.’s, with our expertise concentrated in Chemistry and Bio…are you serious, the VA wants to use pharmacists to fill a short-fall…without direct supervision of an Attending M.D.???!!”

    He then read more and asked me after taking a phone call, “What, did the VA run out of money already or is the real deal the VA cannot get enough competent M.D.’s to work in a scandal blighted environment ?”

    YES…great guy and he can totally relate to our plight with the VA. He also said that State’s Laws can differ slightly from each other and he wondered if they are only able to get away with this because it’s Federal Property. I had no answer but he also made another good point in jest as I was leaving, “Maybe this way anything documented will later be found erroneously awarded because they were not M.D.’s after all?”

    Is the VA that low or simply spent too much money on “art” and needs to cut some throats, err, corners?

    • I wanted to clarify that my pharmacist, when talking of differences in education and “Medical Residency Req.’s”, he pointed to the couple of Grad Students doing just that; working for extended periods of time, experiencing first-hand different facets of…running and keeping track of a Pharmacy…not diagnosing. For example, a Grad Student doing Medical Residency to work in their Specialty or Gen Practice, get that experience there, whereas those same M.D.’s in training do not go and spend a couple years working with pharmacists…because pharmacists do the heavy lifting and often know much more than the M.D.’s prescribing, as far as the interactions and side effects…but not diagnosing unless it was some sort of National Disaster Triage….but this is the VA, supposedly “World Class Care”….if you’re a VA Employee.

  11. I’m all FOR increased access but NOT AT THE COST OF REDUCED QUALITY OF CARE…No Pharmacist has the training of an MD. That’s why they have a PHD on their name instead of an MD…I love nurses…They’re great people and those that go into the field usually do so from the standpoint of caring for their patients. My niece is a Neonatal Nurse Practitioner at Princeton Baptist Medical Center and Neonatal Nurse Practitioner at UAB Critical Care Transport. She transports critical care infants (usually in a helicopter ) and is eminently qualified for her job (getting critical infants to a place where they can be better treated than where they are..)…As a matter of fact, I would bet that most of the MDs that she is transporting kids too would flounder in the high pressure atmosphere she operates in…(no pun intended ) She’s GREAT at keeping kids alive till they get where they need to be…HOWEVER, She’s still not an MD…When she gets the kids to UAB Hospital, their care is turned over to an MD who specializes in Pediatric care ( probably assisted by other Pediatric Nurses that specialize in in-house care…) I sent her a link to this discussion and here was our interaction..

    ME Hi Sweety…I need your perspective as a Nurse…Are you up for a discussion on whether or not NPs and Pharmicists should be providing primary care at VA hospitals and clinics without an MD’s oversight??? Here’s the article I’m commenting on… I (and I’m sure other commenters ) would like to get your perspective as a respected practitioner of the art and science of Nursing…You can just reple here and I’ll forward your comments (un-edited of course )http://www.disabledveterans.org/2016/10/26/clinical-pharmacists-now-handle-primary-care-for-veterans-affairs/#respond

    Her: Just read the article. My concern would be with a clinical pharmacist being the primary healthcare provider. After diagnosing the present issue they probably would be a great resource for managing medications and educating the patient and their families. NNP’s and pharmacists sometimes have more time to spend with our patients which would allow for proper education and answering questions regarding diagnoses, prognoses, care management, medications, and follow up. NNP’s are highly regulated; we practice only under the supervision of a collaborating physician. I call them for questions, concerns, or advise on difficult cases. They are and must be available to us 24/7. There is also a strict standard of supervision after the fact in which our H&P’s, diagnosing, treatment plans, etc…are strictly reviewed and critiqued by our collaborating physicians. Our masters level training is specialized to a particular patient population (neonatal, pediatric, adult health, geriatrics) and we must pass boards in our specialty before applying for a license in our state. If the VA wants to use NP’s I feel it should be at the patient’s choice, for more routine cases/follow up’s, and always under the investigation of a collaborating physician. I’m not familiar with the qualifications and educational background of a clinical pharmacist. Do they have training in Anatomy & Physiology, Pathophysiology, Cellular Biology, Genetics, Psychology, etc…? These are basic level nursing requirements. Are these clinical pharmacists practicing under the supervision of a collaborating physician? I would welcome their input in medication questions and management, but I would be asking about their qualifications and supervision. If they are to be used as providers it should be at the choice of the patient.
    ME:One of my chief concerns at the VA has always been that even the MDs they employ are often not held to the same standards as MDs outside the VA… They are often from third world schools and the VA almost never requires them to be up to the standards of the state they are practicing in…
    If they don’t hold the MDs up those standards how can we expect them to hold Pharmacists and NPs up to those standards…
    Her:Agree; if those administrators and congressmen wouldn’t send their own families to these providers then they shouldn’t be sending vets to them.
    You don’t know HOW MANY TIMES I’ve seen Vets express the same idea in this and other forums…Sorry for the HUGE post But I needed to get all my thoughts in…

  12. Pharmacists have been helping Vets for quite a while. If you use the anti coagulation clinic to have your INR checked monthly, it’s done totally by a pharmacist. Doctors don’t even work this clinic, they just refer. Plus if there is a prescription problem, I would like to have a Pharmacist working the problem.

  13. I am going to flat out say it, I don’t care what anyone says…Hiring these pharmacists to do a doctors job is being done on purpose. First, they are out of money because “again” it went into the pockets for bonuses. Second: what a better way to knock off the veterans in a quickly and timing matter…sure! over medicate, push those pills even more than they already have! mix up some mad cocktails to knock these veterans off even faster. Effing pill pushers!! Not to cure the problem..only to mask it!
    I am sure many veterans have been so highly over medicated it’s sicking. I know, because over the years the VA has had my husband so over medicated he couldn’t even function or get out of bed, which I call “Soft Kill” slowly dying from being over medicated to the point it starts to shut down major organs and rip your insides apart. Thanks to the VA the Metformin they had my husband on for so many years in high doses has finally taken it’s toll on my husbands kidneys, and now he is in stage 3 renal failure. All the Nurse practitioner NP could say was “OOPS” My husband was taking over 12 or more medications on a daily basis, doses of two or more pills a day. He has finally weened himself off all these drugs that were slowly killing him. Now he can function, get out of bed, take a shower and get dressed. But the damage has already been done, and now he is dying…not much longer to go. Is this what we need to replace our doctors? Pill pushers? really? Haven’t we learned our lesson from the damage that has already been caused and the many veterans who have already died as a result? This is their main goal..to knock off as many veterans as possible, get rid of you guys because you have become such a burden to the VA system.
    These doctors have quit the VA, walked off the job because they are mistreated by VA management. They are not allowed to practice medicine unless it’s done the “VA Way” not their way. These doctors are fed up with the rules and regulations of the VA way and are not allowed to treat patients the way they want to. So they have quit and now these VA’s are short handed on medical staff. Such a sad situation for everyone involved.
    So with that being said…if you want my opinion…this is a extremely bad idea to put pharmacists in place of doctors!! Shut the VA down and give all the Veterans a medical card to seek outside medical care.

    • Your comment makes me think of a question.
      First the setup. Many vets will recall patriotic commercials on TV or radio or other media, trying to get young people to join the military.
      The patriotic theme is really ramped up to appeal to most Americans love of and willingness to serve their country to get them to join, particularly after attacks like on 9/11.

      Why doesn’t the VA attempt to recruit doctors in the same manner?

      Instead, they promise protection from malpractice suits, perks, low hours worked, low patient load and no requirement for malpractice insurance.

      The VA uses a cheap method to appeal to certain people to recruit, and then wonder why they have problems recruiting competent people, or cannot get better doctors.

      It would be the same result if the military recruited using the same tactics. They would recruit a bunch of thugs running from the law with no conscience or care for their country.

      • I remember Bobby going on a speaking circuit to many medical schools two years ago shortly after he first got hired as Sec. He was explaining to students in med school about the “virtues” of joining the VA, like taking part in medical research projects to help mankind and other stuff that may be appealing to perspective newbe’s that were about to graduate Med school to come join the VA instead of going to private practice elsewhere. He thought many would see that as doing some sort of good for mankind, and far more important than making a higher annual salary if one joined a private group practice. He also told them the gov. would pay a lot of student debt off if they committed to the VA for 5 years or something like that. I guess he didn’t do such a great sales job since relatively few bought in on that. The whole ‘push’ fizzled out – not a word about how well (or how bad) his circuit speech plan worked (it was a waste of time). This guy Bob acts like some sort of a do-do bird that lacks reality, and I think he is a total waste of time. I don’t think he could sell himself out of a wet paper bag. His plans always suck.
        I have friends from high school who have become pharmacists, and they are not allowed to diagnose patients. They fill a Rx the dr. writes and advises on effects. That’s all.

      • I had forgotten about Bob doing that. Being he couldn’t sell a life jacket to a drowning man, I’m not surprised it flopped.

        Rather than a huge horde of ass covering PR flacks or interior designers, they should have a specific office to do recruiting, and do it in a way other than trying to tell smart young doctors how to start work avoiding responsibility and accountability for their actions.

        I also can’t see why they couldn’t have a program recruiting kids in High School to join the National Guard or Reserves for training in anything having to do with medical care, nursing, pharmacy, xray tech, etc., requiring they work at a VA during the term of their service, and guaranteeing them conversion to a full time VA employee in the hospital of their choice once their service term is up. Or released to work anywhere they choose.

      • 91Veteran,
        You brought up a great point. A few years back, the military WAS caught enlisting criminal “gang bangers”. Don’t you remember that little bit of “scandal” the Army had to downplay?

      • I recall reading about that, and thinking that it seemed more hype than reality from the little I read.

        Yes there may have been gang bangers going in to the military, but I wondered how many thought they were escaping that life, and went back to it once they got out. Or how many may have been a cook or supply person when they went in, ended up in a gang when they got out, and when busted for whatever…someone claimed they went in to the military at the direction of their gang to learn tactics, with the claim made by someone just to increase their chance at a federal grant or to get federal equipment.

        I’m not defending gangs, but I do wonder how widespread the problem really was. The military always lowers their standards to get recruits when they ramp up for war. I just can’t understand the thinking and dedication of going into the military as a gang member simply to learn tactics and be a better gang banger when they get out. One would think a gang banger would get as much from playing Xbox every day.

        Perhaps it was more widespread than what I recall.

      • YES YOUR COMMENTS OF ENLISTING CRIMINAL S WAS GOING ON IN 1978 ,AS I WALKED INTO A RECRUITING STATION ,IN MIAMI,FLORIDA, REQUESTED ENLISTMENT IN ARMY ,,WAS INSTRUCTED TO RAISE MY RIGHT HAND AND REPEAT THE OATH ,THAT THEY TOLD ME,IT WAS ABOUT A 20 MINUTE AFFAIR ,WALKING OUT THE DOOR WITH BOARDING PASS FOR PLANE TO FORT SILL ,OKLAHOMA ,THE NEXT DAY! UPON ARRIVING ,I WAS PUT IN A ARTILLERY UNIT FOR TRAINING,MY FELLOW ENLISTED PEOPLE WHERE NOTICEABLY, INTERESTING AS ONE INDIVIDUAL FROM HOLLAND TOLD ME OF HIS STORY OF ENTERING THE USA ILLEGALLY WITH STOLEN DOCUMENTS,AND OTHER COLORED INDIVIDUALS ,CAME STRAIGHT OFF THE STREETS OF MIAMI,WITH EXTREME HATE TOWARDS WHITE PEOPLE,AS THEY DEMONSTRATED UPON ME ,WITH PHYSICAL ASSAULTS AND THREATS ,I WAS PERHAPS THE SHORTEST TERM HONORABLY DISCHARGED PERSON THERE AS THE ASSAULTS ON ME RESULTED IN EXTREME PAIN AND SUFFERING ,WITH SEIZURE ACTIVITY ,AND A VISIT TO REMOLDS ARMY HOSPITAL,I GOT THE HELL OUT AS BEING KILLED BY MY OWN FELLOW TROOPS WAS NOT IN MY PLANS! THANKS FOR THE MEMORYS ,ARMY STRONG! LOL

  14. Mike,
    I don’t think anyone is putting down Pharmacist. The issue is not having them diagnosing medical problems. I for one don’t want an x-ray technician managing my perscriptions????????

  15. Well my pharmacist at the VA isn’t allowed to write a prescription in the state . I really haven’t seen a pharmacist, that I know of. But now they’re trying to give me nurses instead of doctors . I am doing my best to get out of the VA. and I agree, what good can a nurse or pharmacist do you at a hearing?

  16. I see no problem with this. At any facility outside the VA where a patient has the rights to address any problem with legal and licensing authorities.

    I read this Kaiser propaganda last night, and thought those pharmacists at Madison and other VAs are likely given unlimited resources just so the VA could claim this works. We all know the reality of the VA expanding this where those same resources will not be available, and a veteran will be stuck with a single pharmacist, with no ability to change to a doctor or get a medical mistake addressed.
    I notice in the ACCP description the terms “collaborate” and “part of a team”, which clearly means a pharmacist in that setting is a part of a team supervised by a physician. The reality at the VA would not be so rosy.
    When I went to the VA in OKC, there was no mention of treatment by a team. When I got to Madison, I was assigned to a team, and I truly believe it was a team based on the providers comments about discussing it with the team, and the appointments I had with other team members depending on the condition.
    When I got to Grand Junction, I am again assigned to a “team”, but it is a team of 1…which is what treatment by a VA pharmacist would be.
    I think this would work if it worked as advertised where pharmacists stuck to the routine things like blood pressure, diabetes management and prescriptions and a veteran had a right to immediately see a doctor for anything more serious, but again, that would not be reality at the VA.
    A veteran would be seen by a pharmacist, and if they needed to see someone like Ortho, they would still wait weeks to see that specialist, if at all. Given its the VA, they would likely require an appointment with a physician to review and approve the appointment before seeing Ortho.
    As for legalities in any of the states, that will not matter. The VA ignores licensing requirements or any other legality a state requires by simply claiming they are exempt. I’ve proven that here in Colorado, but nobody cares.
    …just like nobody will care about pharmacists being the sole provider for a veteran because the poor treatment will not affect them.

    • my experience with p.a. doing [email protected] exams for 14 years at saint cloud v.a.,in Minnesota ,I noted that she had a license to practice in Georgia,and was a contract employee, with little regards for the true welfare of the veteran being examined using her rubber hammer and a stethoscope,lol,failing to record veterans medical complaints ,and failing to record her entire session ,with one goal in mind to deny the veteran any compensation benefits! my american legion case worker ,quit her job and found another job ,shortly after she looked at the medical reports filed by the [email protected] examiner in saint cloud!

  17. I don’t know about primary care, but I have been followed by a clinical pharmacist that specializes within the pain clinic for over a year now. It has been some of the best care that I have ever received. Maybe I’ve been lucky.

  18. This comes as no surprise to me. As a licensed optician, I was informed that VA contractors providing prescription eyewear are not required to comply with a state’s laws requiring eyewear be fitted & dispensed by licensed practitioners. The simple reason for this? The VAMC is FEDERAL property and is not part of the state, therefore state regulations do not apply. In other words, when you cross the border from your state to the VAMC, the rules no longer apply and your rights have been forfeited.

    • From personal experience, you can bet your ass the VA will bill private insurance for those glasses for whatever the prevailing rate is, regardless of VA policies or what the VA might pay.
      I am not service connected for any eye condition, but I was referred to the eye clinic by the VA. Once done, I was told by the VA eye clinic contractor that I could only choose frames under a specific dollar amount because that is all the VA would reimburse them for.
      It was interesting to see a statement from my insurance company how much the VA billed them for, which was much more than the rate they paid the outside clinic.

      I’m sure the extra amount went into whatever VA slush fund they have hidden away.

  19. Good points May. What is interesting about the Federal vs State issue is that it’s not as clear cut as people might thing.

    In this instance, VA wants to have its cake and eat it too when it comes to recording. The federal law indicates single party consent meaning if you are a party to the conversation, you can record. Some states prohibit this, and VA likes to say it is illegal when it’s not (plus VA has been caught secretly recording veterans and employees on a regular basis)… Now when it comes to using clinicians who are otherwise prohibited from the practices you discuss in a certain state, they trumpet that federal law applies. How convenient…

    As an aside, some state laws still apply in some situations depending on whether the land is owned by the Fed or leased to the Fed by the state.

    • As I was told about the new south charlotte nc clinic – the most expensive (and largest) VA clinic built by the VA to date,…it is totally leased…land and building. I had read that ALL VA CLINICS are leased now, and only the VA hospitals are owned. So your nearest VA Hospital operates under one set of laws, and the clinics that are part of that hospital operates under a different set of laws. Their is no uniformity here…no transparency here….no shit here.
      Problem really is that the VA HCS will be the primary model for steady move to first party payer system for everyone in the U.S.. That’s when the people will open their eyes. This is what’s planned by someone who might be the next leader of our country. Get me a spaceship.

  20. I’ve spent YEARS searching for a full-fledged medical doctor that is knowledgeable about Gulf War Illness (GWI) including diagnosing and treating the disease based on current published scientific medical literature. My search has only uncovered a plethora of VA medical doctors who not only do not know how to diagnose or treat GWI, they have been indoctrinated by the VA to believe that the disease doesn’t even exist despite the overwhelming evidence that it does, including literature published by the VA itself.

    Now I have to deal with a pharmacist that understands even less?

    GTFO!

    In any civilized country, the entire VA system would be flushed and rebuilt from the ground up. I think we call it “reform.”

    I hate the VA. I hate the bastards that deny that I am desperately ill and in nearly constant debilitiating pain and refuse to acknowledge and treat my disease. I hope they all hang from their balls over a pit of burning oil and suffer a long, painful death because that is exactly what they have sentenced me to.

    Thank you to the pharmacists that are there when I have questions about my medications and the ones who toil daily to fill countless prescriptions. I appreciate your job but please stay in your corner of my care team and let the truly ignorant doctors fuck up my care and let me live in unforgiving pain.

    • Peter,

      If you are still looking for a doctor that is a full-fledged medical doctor that is knowledgeable about Gulf War Illness (GWI) including diagnosing and treating the disease based on current published scientific medical literature. You may want to try contacting Dr. Meryl Nass, M.D. she list her phone and email address on her blog at “anthraxvaccine.blogspot.com/”.

      • Dr. Nass is good, but is she still involved? I met her some years ago, and she was doing research then. I don’t know how much she was involved in the treatment side.
        Dr. Beatrice Golomb is good. I believe she is in San Diego and has been very involved in both research and treatment of Gulf War veterans for years. In fact, she is involved in a research project right now.
        Drs. Baraniuk and Haley are very good for Neuro research. I don’t know how much Haley is doing any more, or how much either might be involved in treatment.

        Do a search using CDMRP or GWIRP and you should find a good deal about independent research that has been conducted for GWI.

  21. This has actually been going on for much longer than you think. My fist visit to Dallas V.A. I was given an appointment with a pharmacist for my blood pressure.

    I did not know it was a pharmacist till I got to my appointment and the clerk stated the Pharm D will see you now.

    Being a 25 year nurse, I asked her why I was there and she stated to treat me for high blood pressure. I explained to her that she was not a medical doctor. They do a medical rotation, but this in no way makes them M.D., if it did they wouldn’t go to school for 5 and 6 years and be able to work. Unlike M.D.s that have to go to school for seven then do internships and so forth.

    A pharmacist main schooling is on the chemical makeups of medications and how they react in the human body and with other meds. I would rather have a qualifed Doctor listening to my heart than a Pharm D, as Dallas V.A. calls them. I walked out and transferred to the Fort Worth V.A.

  22. The worst care I ever received from VA was from a Ph.D. Pharmacist who was my pain management ‘Dr.’, which is one of the few positions that I feel that they should be allowed to handle in lieu of an MD. I specifically asked her if she was a doctor during our first visit, and she said yes, well knowing that I meant an MD. My father, who has his Doctorate in Communications, would never have mislead anyone in this manner. Not the same thing, but you get my meaning. The disabled vets that I know who have had her handle their pain meds refer to her as the ‘Marquis de Sade of Pain Management’, or the ‘Pain Nazi’! She went so far as to take a vacation over Christmas without alerting another Dr. to handle my meds, and failed to put in a refill that I needed. The Pain Management office said that I would have to wait until she returned in January to do my refill (due December 24th). Were it not for the Patient Advocate I would have spent the holidays in severe withdrawal, risking my health and life. This is a very bad idea! PA/LNPs would be a far better idea, and also be cost effective.

    • exactly happen to me,,, wasn’t even a Doctor but pretending acting as a Doctor and when asked she called herself a MD,,,, as the months went by things happened bad for me,,, and the Med in Pain and other help all stopped when she also went on Vacation,,,, I got mad and wrote to the ND Governor on I wanted my Medicine I needed them,,, and what happened the Sheriff of Lamoure Country drove up to my door,,, and was told I was going to commit suicide,,,We my wife and I invited him in,,, and said that was a lie and showed the email sent and what happened,,,, after over a hour of talking,,, he left,,,, and nothing got better NOTHING,,,,

      • The governor wouldn’t be able to help since the VA is federal, but either Heitkamp or Hoeven can help, and you should contact either, or both, and get them to help. Or Cramer should be able to help.

  23. Under VA’s theory and Jeremy Moretz’s explanation of “Dr equivalencies”, heck, next we’ll have PhD EDs doing lab tests and trauma screenings. I mean, after all…they’re doctors too! I don’t know about you but having a PhD Pharmacist tell me how good my medicines are and what not to take with them isn’t helping prevent my next stroke or heart attack that could have been diagnosed with proper diagnosis and relevant lab/test requests. But then too, all I use VA for is to fill prescriptions…I leave actual diagnosis and treatments to competent civilian doctors.

  24. You would think that using Nurse Practitioners and Physician Assistants would be good enough. Why in the hell would the VA have to stir everybody up with this latest venture? The midlevels have a supervising physician so lets just stop right there. Thanks.

    • there not acting using Nurse Practitioners and Physician Assistants ,, but are instructed to make decisions of a MD ,,, to cut down crowding clown,,,

  25. WHY NOT ADVERTISE TO OUR ARMED FORCES BEFORE THEY FINISH THEIR TERM OF SERVICE ! ? ! ? —
    A Different Approach to Health Professions Education: The Uniformed Services University of the Health Sciences (USU) is the nation’s federal health professions academy — akin to the undergraduate programs of the U.S. military academies at West Point, Annapolis and Colorado Springs. And like the academies, STUDENTS ARE NOT CHARGED TUITION; they repay the nation for their education through service. In many respects, USU’s curricula and educational experiences are similar to those of civilian academic health centers, with one important difference: its emphasis on military health care, leadership, readiness and public health set USU apart. 
    The F. Edward Hébert School of Medicine offers doctorate degrees in medicine, doctorate and master’s degrees in public health and related disciplines, doctorate degrees in medical and clinical psychology, and interdisciplinary Ph.D. degrees in three military-relevant areas of science: molecular and cell biology, neuroscience and emerging infectious diseases. To enroll, students must be U.S. citizens and have a bachelor’s degree from an accredited college or university in the U.S., a U.S. territory or Canada. Each year approximately 30 percent to 40 percent of incoming students have prior service either as academy graduates, ROTC program participants OR AS SERVICE MEMBERS. The remainder come from civilian backgrounds with no prior military experience.
    During my 22 years active duty in 2 branches of military service, NEVER ONCE did I hear anything about this wonderful opportunity. Instead, I was insulted by VA Voc Rehab Counselors and took out many student loans after I retired from the Army.
    Why keep USU a secret? Todays military students are tomorrows VA doctors.

    • I cannot fathom that either. Back in the mid to late 80s, I was in a Reserve hospital unit in Madison. It was supposed to be a 1000 bed hospital then, so it had lots and lots of nurses, a number of other medical care personnel, and several doctors that ranged from Major to Colonel.
      For some reason their mission changed, and the unit was greatly reduced, but when I was there, there were many O-1 through O-3s in the unit that were going to UW Madison for some medical field.

      If I had to guess, I would bet the Pentagon decided that number of medical people in the military were not needed, and decided to reduce their numbers.

      When I returned to WI in the mid 90s, the Director of the VA was an officer in that unit, and had a medical background. Not the pencil pushing administrative hacks they have now.
      It was the best VA I have ever been seen in.

  26. SO WHAT ELSE IS NEW?… PLEASE NOTICE I AM NOT SURPRISED. THE VA MOTTO IS TO KILL VETERANS AND WHAT BETTER WAY TO DO IT THAN WITH STUDENTS, RESIDENTS, INTERNS, INEXPERIENCED PHYSICIAN ASSISTANTS, NURSE PRACTIONERS AND NOW CLINICAL PHARMACISTS. WHY NOT USE A PLUMMER? OH, I’M SORRY, THEY COST MORE THAN REAL DOCTORS. SILLY ME!…WHEN ARE YOU VETERANS GOING TO GET THE MESSAGE? THEY WANT YOU DEAD. YOU AND YOUR MONTHLY CHECKS ARE COSTING THEM MONEY THAT COULD BE BETTER SPENT ON SEXY SECRETARIES THAT CAN’T TYPE, HAWAII VACATIONS WITH $3,000 BOTTLES OF CHAMPAGNE AND OTHER NECESSITIES. STOP BEING SO SELFISH. JUST ROLL OVER AND DIE LIKE A GOOD SOLDIER. DON’T COMPLAIN. DON’T FIGHT FOR YOUR RIGHTS. JUST GIVE UP AND GIVE THEM WHAT THEY DESERVE. AFTER ALL, THEY EXPECT THAT OF YOU. YOUR A VETERAN. TAKE ONE FOR THE TEAM. SHUT UP. SIT DOWN AND DO WHAT YOUR TOLD. YOUR USED TO TAKING ORDERS AREN’T YOU? THEY DEPEND ON THAT. JUST BE GRATEFUL FOR THE ABILITY TO WALK INTO ANY VA HOSPITAL OR CLINIC AND GET SUBSTANDARD MEDICAL CARE THAT ISN’T FIT FOR YOUR DOG AND EXPERIMENTAL MEDICATION THAT HASN’T EVEN BEEN TESTED ON LABORATORY RATS. WHAT ARE YOU COMPLAINING ABOUT? YOU HAVE YOUR ORDERS. DIE AND LEAVE YOUR FAMILY AND LOVED ONES WITH ABSOLUTELY NOTHING. MISSION ACCOMPLISHED. NOW STAND BEFORE THE ALMIGHTY GOD AND TELL HIM YOU DID THE RIGHT THING…….SEE IF HE BELIEVES YOU.

  27. Personally after my experience with the VA. I definitely will not ever consider using any doctor, nurse or pharmacists that has either worked or trained at any VA facility. After everything that I have heard from others on this site it seems pretty clear none of them can ever be trusted.

    The VA should be changing to meet the recommendations of the Commission on Care not working to make the deadliest heath care system in America even deadlier.

    It should be rather easy to fund and don’t even have to hire or train anybody to do it. All they need to do is take that now out of work lower than pond scum at the Pentagon who were harassing National Guard Veterans who were clawing back reenlistment bonuses and have them do a claw back on the $58 Billion the Pentagon spent on never delivered projects.

    The audit released this week showing the $58 billion waste can be found at:

    “acq.osd.mil/fo/docs/Performance-of-Defense-Acquisition-System-2016.pdf”

    • Maybe we all should call Ash Carter and recommend that. I know that he is in Paris right now and Pretty sure all the regulars on this site know what Hotel he is staying at. The 5 star luxury Hotel own by the VA called the Hôtel de luxe du 8e arrondissement de Paris, près des Champs-Elysées, le Pershing Hall.

      Their phone number is on their website at: “pershinghall.com/en/”

      • “Waste report: Guard’s racecars, bomb-sniffing elephants”

        Photo of the National Guards Race Car.

        “militarytimes.com/story/military/capitol-hill/2015/05/07/mccain-waste-report/70937622/”

      • I am certain that cost a few peanuts to clean up.

        That mess was almost as bad as when they tried Air dropping them in to Syria to provide advanced weaponry to the “Moderate Rebels” aka Al Nusra Front or better known as Al Qaeda, or ultimately know world wide by other nations as the American Foreign Legion.

  28. This is not new, at least at some locations, since we have it at ours. I’m one of the patients being phone “managed” by the pharmacist for diabetes. In some instances, it’s actually a student calling, who then re-calls after consulting with the pharmacist. If there is some issue, then PCP does oversee from what I’ve experienced. I’m not sure it’s much worse than if it was the PCP (MD in my case) directly, instead, considering medical notes from said PCP that are just based, many times, on untruths. On occasion, when I have gone for an actual appointment with PCP, she does seem harried, even as that is no excuse to state in notes what has been done, when it hasn’t. BP is taken because it’s the nurse taking it, as well as temperature, and pulse. The Stethoscope remains right where it was when she entered the room, except the notes read differently than the truth, including omitting some physical complaints. Sure, I’m aware of how the record can be requested to be amended and how a vet can make concerns known aka as “complainer.” At our location, nope, not “allowed” to change provider, not from Women’s Health, anyway, something else that was “supposed” to work better which just serves to give less options, at least at our location. To get good services, this should not be a fight, like some type of power trip some of them are on. It can be overwhelming. Yet, I’m still trying to figure out how either provider is better than the other. If I were to ask to be referred to Endocrinology, there are two options, neither which makes much of a difference for better. I can take a trek over to the VAMC at a distance that is not manageable for me, just not far enough for referral to Choice, or I may be able to make use of the TV medical that is being used quite a bit at our clinic, even when it does not seem prudent. That is one avenue that was started some time ago for mental health and it leaves a lot to be desired like, yesterday, when the system was down after vet spouse went to appointment for psychiatry. Since it had been down for some time, there were two patients ahead with their missed appointments, in case the system was fixed, so could be added as a third and wait time unknown, if it were fixed, or re-schedule the appointment and try again next time, but I digress. Apparently, the TV health takes care of two birds with one stone, but not necessarily as a plus for a vet. So, that takes me back to still wondering which is really better, if any?

  29. Back some years ago Walgreen used Pharmacist to give flu shots, a woman ahead of me screamed loudly as the shot were injected, after her experienced if I hadn’t paid for it already I would have backed out of being vaccinate, the injection were very painful. You are talking about Pharmacist who were trained in medical Schools who have not practice medicine in Primary Care since medical school at best they would by rusty in Practicing Medicine now, and it could lead to someone’s death.

  30. Did you gentleman see the DR without being screened and taken care of if possible by your primary care medic while you were in the military? When I was the hospital corpsman in the Navy 1961-1974 the men I was responsible for didn’t see the “doctor” unless they specifically requested it or it was something that I thought was beyond my ability to treat. Essentially I was a high grade dr. mom for them.

  31. Oh SWELL!!!
    Just what we need…more “quacks” opining on conditions they have NO BUSINESS opining on!

    I have a 14+yo claim and ALL C&P exams are inaccurate, because of Physician Assistants rendering a medical opinion on something, they have very little education/experience in.
    Example: Having an Optometrist examine you for a hangnail.

    MY situation involves Ortho/Neuro. From here on in, I am no longer going to any more C&P exams. It angers me to no end, when these dimwhits “play doctor”, by rendering orthopedic opinions and are never accurate.
    Further, only ONE C&P examiner used a GONIOMETER to measure my ROM, BUT…only after I mentioned for her to comply to DVA requests that she uses it to note an accurate angle…NOT “Guess it”!
    You’ll notice when attending a C&P exam (for Ortho issues) that a majority of these so called ‘doctors’, do NOT use the Goniometer, when it states for them to do so, right on the first page of the “DBQ”(Disability Benefits Questionnaire)!
    INSIST on them doing so. If they refuse, inform them, that It is YOUR RIGHT to have an accurate exam, free from LIBEL, along with, false and misleading statements about your true conditions.
    I’ve had BVA Administrative Law Judges, when REMANDING my case, they would specify for an Orthopedic exam/opinion.

    The NEW argument, directly tied in to this story, is that these Pharmacists do NOT specialize in your condition, unless they were educated in that specific field!
    I’ve had General Practitioners opine on conditions (ortho/neuro), that they had no business rendering an opinion on.
    When adjudicators review the doctors notes, they view what was mentioned on the DBQ as “Gospel” (or at least a BIG part of it) in concluding if you’re disabled or not.

    I suspect that this corrupt agency is just “cost cutting corners” with this Pharmacist examiner bullshet, as yet another ploy to deprive benefits to those who are truly entitled to it, when a good majority of Veterans do not have the “physical signs” and must obtain an “Outside Medical Opinion”, when dealing with the DVA.
    This agency is corrupt to the core and must be torn inside out, in order to fulfill its objective.

    “…to care for him who shall have borne the battle and for his widow, and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”
    Abe Lincoln

  32. You have the real bitch. PNA, PA etc. are not qualified to do C&P examinations. And none of you got a military discharge or re-enlistment or enlistment physical done by anyone less than an MD. Yes sometimes the GP failed to make the referrals to specialists that should have been made. But at least you had an MD do the exam.

    • If they are already doing it, it shows just how little veteran health means to The VA. I recently asked about a more advanced procedure for my 20+ years of every day pain and my “doctor” shook his head as if he never heard of such a thing; BECAUSE THEY ARE NOT DOCTORS. The VA needs to understand there will never be a bonus and they need to ” ..do it for our veterans great sacrifice.” Who am I kidding? That will never happen. Like the guy who just got 400 million for inventing a Hep C vaccine? You can’t tell me he did not experiment on veterans for HIS MONETARY GAIN. That is called a “God Complex”. Remember the Tuskegee Experiments with Syphilis? That wasn’t that long ago; and very racially biased as well.

      • Try capsaicin for nerve pain. I was in a pain clinic in DC. Unending sciatic pain. The pain specialist said “it’s real” even though there is no reason for it. Because of the duration of the original cause the system gets lazy and feels the pain in the brain when there is no longer a point of pain. Example, pain in amputated limbs.

        I accidentally put too much capsaicin on a couple of times. After the severity interrupted the pain the never ending pain subsided. Read up on “pain” and search neurology pain specialists. Ask the VA for a pain clinic location with a real life pain specialist.

  33. They tout that the VA is comparative to the best healthcare in America. 90% of my health care is coming from someone other that a doctor. I know wonder if my P and C compensation exam was performed by a P. A. or doctor. Part of being a doctor used to include allot more than just a degree. Many of these VA people seem to highly suspect to me. My own health is failing and has me “up against the wall.” There seems to be no compassion and no desire to aggressively treat anything. If you just need routine check-ups, meds, disability devices, fine… that may be, however if you need serious medical care, care that requires serious training, well, i don’t know I have personally met many veterans who have had issues with post-surgical complications. Or possibly back for the process to be done again. A Lot of the work there is redundant and a waste of tax dollars.. The service they report to have are, for some, elusive and hard to find. I don’t know how much more I can stand it… the VA is helping me to death. I just lie in the bed all day suffering from back and neck pain, and the associated cramps and spasms. They upped my Gabapentin up to 900 mg 3 x a day, 1500 mg of Methocarbamol 3 x a day, hydrocodone 5/325 mg 3 x a day, and Tylenol 3 3 x a day. I have been taking the 5/325 for over a year now. I have suffered though many painful nights and days. The 3 bad discs in my neck, bad disc at t10/t11, L4/L5 L5/S1 getting worse and twisting my back with scoliosis. The VA content with me just “learning to live with it.” I have every for help but my complaints go to congress, back the VA, back to congress, and it’s always the same old dog and pony show. My hud/vash case manager lied to me, and advised me to me put my stuff in storage, my cats in the cat carriers, and live in a tent in the woods for a little while. Then she tried to tell me other false information to deceive me. I think they train them to be this way? I have a video of one such encounter. https://www.youtube.com/watch?v=vX8B2IeiNnk

  34. I feel that I’m the minority here, which is unfortunate as both a vet and a clinical pharmacist (I’ve worked in this capacity at the VA as well as at a top-ranked health care system where I’m currently employed). There seems to be a lot of black and white approach–this pharmacist isn’t a doctor (MD, DO) and therefore provides poorer healthcare than a physician would provide (I don’t want to get into the weeds of the validity of pharmacists being “doctors” but not “docs”, or whatever semantics are being played throughout the comments, as it isn’t relevant as I explain below). This would only be true if the pharmacist was working outside the scope of their practice, which was the result of legislation (state and national) that is based on the CURRENT content being taught in pharmacy schools today. Did pharmacy schools of old provide a more retail or “physician helper” level of education? absolutely–and it stopped in the 1980s.
    Since then pharmacists spend (85% of pharmacy students) 4 years in undergraduate education and 4 years in pharmacy school, then spend an additional 2 years in residency to be able to work with patients in the capacity described in the related article. Throughout this time pharmacists receive approximately 10x more medication and therapy education than physicians receive throughout all of their medical education. i.e. pharmacists working in a certain specialty or GP knows more about the medications and their effects within certain disease states than the physicians working in those same fields. Do physicians have fantastic diagnostic and procedural training? Of course…that’s their job.
    During my time at the VA, I would see 10-12 patients for 30 min appts. each. At these appointments we would go over all medication related needs for specific disease states: DM, HTN, HLD, anticoag. The reason these disease states were chosen is that they are primarily managed by medications and our patients had a great deal of comorbid states and polypharmacy. I would adjust doses based on the most current, up-to date guidelines and research that I’m required to be informed on. My visit with my patients did not remove the biannual need for appointments with their PCP. Additionally, I would review the MD’s patient charts after they saw their patients….yes, we dare to second guess the “doctor”, and by doing so I would fix anywhere from 1-8 major medication errors (these errors were as benign as physicians following very old standards of practice to major contraindicated medication choices based on comorbid states and lab values). That being said, I would change those mistakes and send a note to the physician to complete the care loop. Also, every physician I worked with would come to me and other clinical pharmacists for medication advice (i.e. I have such and such a patient on these meds, this state, etc. what should I do?) and found us to be absolutely necessary to quality care. You may think…well that speaks to the quality of the docs at the VA or they just don’t have enough time for their patients or just not enough docs in general, which may be true, but that isn’t an issue at my current healthcare system.
    I’m currently employed by a top 10 national healthcare hospital system and our practice for ambulatory care also is modeled similarly to the VA’s. I have my own patient panel that I see in primary care and, as with the VA, this doesn’t remove patients from seeing their PCP as they would have normally seen then without pharmacists. At my current location my patients are like the VA: multiple comorbidities, chronic pain, mental health needs, and are older. I see around 10 patients per day with the same 30 min time frame, and function with the same disease states with the addition of a few others including pain, gout, HF, COPD, to name a few. Since implementing this pharmacist led addition to primary care we have seen nearly a 25% reduction in readmissions for HF and COPD, reduced first-time hospitalizations for HTN and DM-related admits (data is still being compiled ~12% currently, and less conclusive) additionally we have seen a reduction in medication cost burden for patients and are currently seeing an increase in patient/life years (scientific measure of how long people live due to some sort of intervention). Additionally, we have seen a 22% reduction in physician prescribed medication errors and an increase in our system’s patient satisfaction survey results. The primary care docs these patient are seeing are the best in the world–most have written many papers, published journal articles, are a part of national committees, and boards of medicine–so I mean it when I say, “best”.
    All in all, this was an attempt to remove some of the anxiety that many may have that pharmacists are just an undertrained physician–not true, we aren’t physicians and therefore we don’t perform medical procedures or diagnosis or perform anything beyond the capabilities of our training, but we are amazingly trained at knowing what medication to use and how much in each patient population type.

    Saying a physician is better able to manage the complexities of medications than a pharmacists just lacks perspective. Would you trust your primary care doc to perform your brain surgery? No, of course not–I wouldn’t either. A neurosurgeon has spent countless hours over the course of years specifically studying the nervous system and it’s many complexities–they’ve spent years perfecting the techniques required for complex surgery success. My primary care doc is still a great doc–he completed medical school just like the neurosurgeon, spent years after medical school to specialize in primary care and I would trust him every day with the needs I know he is able to meet. I think sometimes we pine for things that we are familiar with or look at the world as how we remember it was or look back at how we have been misrepresented or taken advantage of during active duty and we are jaded by that. I mean I’ve had my own problems with the system, but that is unrelated to the role pharmacists can and do play in our care, and I ask not to scapegoat them or claim them to be a cheap and lower quality fix–it just isn’t the case. There are plenty of things terribly wrong with our healthcare system, and well-trained pharmacists caring for vets or civs in this capacity is not even close to one of them.

    • Well, Jay…That’s all well and good , and I am SOOO happy for your patients at the “top-ranked health care system” at which you presently work, but I think you need to read the headline of the article…I don’t know how long ago you worked at the VA, but the current model VA is nothing like what you describe…

      What the VA is doing is REPLACING MDs WITH PHARMACISTS…not as team members assisting MDs but as PRIMARY CARE PROVIDERS. Guess you missed that part of the article. I only wish that the VA worked as you describe…

      If you think the VA system is so good, why are you not working there now instead of at the “top-ranked health care system” at which you presently work?

    • I don’t disagree that this would be a good way of reducing wait times for patients who simply need medications adjusted, managed or renewed, and would work very well where state or federal regulations require a pharmacist to follow very strict rules, but this is the VA we are talking about.
      Your experience as a patient in the VA is likely better than most veterans when the treating doctor, PA or nurse knows you are well aware of what constitutes proper care, but for those of us without medical training and a background working in it, anything goes, because many in the VA are arrogant and think all veterans are knuckle dragging heathens.
      You mention completing the patient care loop. In a large number of cases in the VA where veterans are left to fend for themselves, that care loop consists of the nurse or PA spinning a loop in their chair and not consulting with anyone. In your scenario of completing the loop by correcting medication errors and returning notes to the doctor, that is commendable. In the VA reality, that patient would have been down the road with their contraindicated prescriptions long before you got a chance to even read the doctors notes, although I do say the VA in some places has gotten much better at a pharmacist reviewing prescriptions before issuing them.
      You mention cost. The VA is doing this simply and solely because of cost, and you do not acknowledge reality if you believe the VA would not cut many other corners to reduce those costs, including turning your 30 minute appointments into 10-15 minutes, if that.
      I would be curious though, would the VA bill for a pharmacist appointment at the same rate as a PCP appointment and add the difference to their slush fund?
      I would have no problem seeing a pharmacist for how this is described, if it were outside the VA. Inside the VA, the reality is a veteran would face even more delays in seeing a doctor if needed, if they could get an appointment at all.
      I would encourage you to visit the VA is Lying Facebook page where you can find multiple examples of veterans waiting weeks to see specialists for some very serious health conditions. That problem will not be fixed by sending them to pharmacists. Pharmacists might have very good training, and you might try very hard to provide good care to your patients, but that is you, and a veteran may need to see specialists for health conditions requiring timely care, and this idea used in the VA would only delay that care.

      Unless you are saying you would pull out all the stops to advocate for that veteran and demand they see a specialist when needed and without delay.

    • Thanks for the presentation, Jay. But as Don and 911 say that is not the current case. If you see a MD it is likely to be by video connect. The VA just isn’t employing enough physicians to make the loop.

      • I just called once again to make sure my medicine is being filled again month after month year after year my meds were not being filled ,,, which as usuall don’t receive my medicine as prescribed on top of that these are meds that all have withdrawl problems, if not taken ,,, I’m tired and tired of this,,,, This new way they started over 4 years ago has caused me great pain mentally and physically every month,,, but I am wrong and they are right as they say,,, is there a solution yes,,, but they won’t back to what actaually worked and not this new way ,,, which I am always waiting for 3 to 7 days after the date,,, actually I”M SICK Of it,,,,I really which I could go and by my own private care,, then depend on a broken VA system,,, which won’t get fixed ,,,do to the truth of why would any good people want to take care of us if the system is being contaminated by the incompetent leaders in the VA system,, I’ve been there seen them fire the great and good people and replace it with the BROWN NOSERS,,,, oh don’t get me wrong there are still good ones in the VA system,,, don’t know why or how they put up with these butt head leadership,,, but they are hanging in there,,,

    • J- As I stated in my original post, I agree there are many issues within the system as I’ve been on the receiving end of many, but I think that particular point is unrelated to the core of the issue as pharmacists being added to primary care teams. I’ve waited a long time for resolution of issues and was furious too, I’m just hoping that we aren’t applying a “if the VA thinks this is good it must be bad across the board for healthcare” label. I do wish you the best in resolving it, and wish I had an advocate when I was going through similar issues.
      Don Avant- I’m not sure why there is such an heir of sarcasm in your response to me, as there was no heir of elitism on my part when describing my current workplace (if it came across that way I apologize). My intention was to contrast the VA (a place that most people specifically here feel is terrible) with a facility that someone would be hard-pressed to claim does a poor job with their care. For the recent history of my employment at the VA, I stopped working at the VA in Feb 2016 because my mother was very ill and eventually passed, but in the meantime needed her son to take care of her because that is what we do with family. I’m not sure why my personal life matters to you or why the implications were tossed about, but as a kind and respectful person I will indulge your need for my personal reason for each site of employment I choose. I wish you the best and hope that your cynical approach doesn’t leak further into how you deal with others. Additionally, I read the original article, as I highly advise you to do, as it in no place states that care is being “replaced” by pharmacists–the reality of the phrasing that may lead you to believe this is explained by the fact pharmacists are seeing patients with chronic disease states far more often than they would have ever seen their PCP in any setting in the US. While standard of care is 1-2 visits with PCP plus any standard procedures and tests that may be needed. i.e. I (in Feb of this year) would see the same patient anywhere from 4 times/yr to 12 times/yr depending on their needs–this allowed for better coordination and setup prior to their appointment with the PCP.
      911Veteran- I appreciate your response, it had good points and thoughts. I’m sure, sadly, that I may receive better care than non-medically trained vets because if I feel there is an error I know what to ask, and this is unfortunate. I think this also speaks to what you said about providers there having a sense of “holier than thou” approach to vets. I trust that this is your experience and that truly makes me sad. At my location there was absolute respect for vets (especially from any pharmacy students who are eager to help in the care of vets).
      In the case of PAs/NPs, I don’t want to throw any professions under the bus, but in all intents and purposes PAs and NPs are not as well trained as physicians or pharmacists. Most PA/NP programs are 1-3 years and don’t always require additional undergraduate education. Pharmacists spend the exact same amount of time as physicians in school, while those other providers spend 1/4- 1/6 the amount of time. That isn’t to say that they can’t still provide great care, and often times not closing care loops falls more on either misunderstanding or laziness (I hope more the former, as that can be corrected). I would be willing to bet that the majority of pharmacists in these roles not only complete the loop but take pride in doing so as pharmacists are trained that complete care is vital to successful care (and it should never be about some false turf war). I won’t deny that cost is a driver of this–you are absolutely correct. Cost is a driver of the majority of things that are done in the nation, and as long as healthcare systems, drug manufacturers, etc. can make big bucks off of us they will. But this pretense doesn’t necessarily put it at odds with what pharmacists are capable of providing for their patients. But if the VA did bill out for our service at the same rate as physicians and pocketed the rest I would be angry as well, and if that is true it needs immediate reform, but that reform could be in more transparency and not allowing the big dogs running the show to make millions of dollars a year.
      I will certainly visit the page you suggested, as veteran care is a big part of my life (even though current life circumstances doesn’t allow me to work for the VA) and I hate the mistreatment, in any perceived fashion, of vets. As for referrals, I make referrals every day in my current job and during my 7 years at the VA. I have been trained (and receive continued education yearly and must sit for board certified recertification exams every 7 years) to evaluate patients for all possible emergent needs as well as have been trained to have an equal understanding of diseases as physicians (we receive the same amount of training of basically how to diagnosis as physicians receive on pharmacology and medication background). This level of education doesn’t provide us with the knowledge base to diagnose, nor would I want to diagnose–it’s not my training, but I have been very well trained in disease states and all of their symptoms and what level of care each state needs. From this training I’m very well positioned to make proper referrals to specialist providers. So I can’t speak for my entire profession, I can speak personally and say that absolutely yes, I pulled out all the stops to ensure each and every patient I made contact had the highest quality care and saw whoever they needed to see next in a timely fashion (I usually would make the referral with the patient in the room and check provider and patient availability). Wish you the best, and thanks for your respectful response.
      Lem- I’m sorry to hear that your VA is only connecting with your via video connect. I recognize that this is/can be a huge problem, and there are many many more with the VA and the healthcare system as a whole. Really, my goal was to say that whether the VA is just using us (pharmacists) just to cut cost or whatever the case may be, this doesn’t mean that pharmacists are not top tier providers that provide the best possible care for their defined role, as personally and from my local colleagues, I can say we provide great care. Take care.

      • If the VA had medical providers such as yourself throughout their system, it would not be the disaster it is simply because you have pride in a job well done, and compassion for those you are treating…both of which are severely lacking in far too many VA providers of any profession.
        It is really telling that an xray tech has a better bedside manner than the Nurse Practitioner falsifying my records or the nurses refusing pain medication among other serious mistakes.
        In far too many instances, the VA may have good providers such as yourself, but they don’t stay long or get fired. They are beaten down and ruined by the bureaucracy who’s focus is not on providing compassionate care for veterans, but on pinching pennies because it means a bigger bonus for them. Means they can hire 127 Interior Designers. Means they can spend millions on “art”.

        Being a veteran, it’s tough to understand why medicine, wheel chairs, prosthetics, etc. are denied at the same time such wasteful spending happens.

        Good providers either get ruined or leave.

        Veterans like myself and many others have become very cynical from the experience.

      • This may be partly my fault. During the 2008 campaign I suggested to Dr. Cutler, the first point man for Obama Care, that military medicine would be a good model if bonuses were provided for better health and satisfaction of care, plus minimum standard of time with the care giver and a credit card type log in AND LOG OUT, with opportunity to register satisfaction immediately. Time from check in to check out logged automatically.

        So we have the “pharmacist mate” care for speedier care for minor complaints. (a 70% compensated veteran like me would go buy a cold remedy instead of going to the DR except it is cheaper for me to go see someone at the clinic or in my case call my Choice primary care physician for one of my 12 authorized visits) It took some time to get the card log in and there still isn’t a card log out or a satisfaction survey on log out. Occasionally we get one in the mail.

        Will things get as good as they were at the LA clinic in the early 1980s prior to Reagan’s attack on “entitlements”. I hope so but I doubt it.

    • Ok Jay,

      How about you answer Two question.

      1.) Why is there no research being released from the VA on the connection between the new Direct Acting Antivirals and hepatocellular carcinoma?

      2.) What is the latest body count for the new Direct Acting Antivirals for Hepatitis C at the VA?

      Please consider the following before answering.

      1.) From Clinical Trials dot Gov: “The Regression of Liver Fibrosis and Risk for Hepatocellular Carcinoma (ROLFH) Study (ROLFH)”
      Stated Purpose of the research: “ This study aims to demonstrate that patients with chronic hepatitis C (CHC) and B (CHB) experiencing regression of liver cirrhosis after effective antiviral therapy have decreased risk for hepatocellular carcinoma (HCC).
      The Study went through Multiple enrollment periods but ultimately was Canceled with no research published.
      “https://clinicaltrials.gov/ct2/show/NCT01831037?term=hepatocellular+carcinoma&rank=2”

      2. “This article has a delayed release (embargo) and will be available in PMC on February 20, 2017.” Information Embargo Notice: “https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966339/”
      “Future of Hepatocellular Carcinoma Incidence in the United States Forecast Through 2030”; Jessica L. Petrick, Scott P. Kelly, Sean F. Altekruse, Katherine A. McGlynn, Philip S. Rosenberg: J Clin Oncol. 2016 May 20; 34(15): 1787–1794. Published online 2016 Apr 4. doi: 10.1200/JCO.2015.64.7412, PMCID: PMC4966339

      3. “High rate of early cancer recurrence following direct-acting antiviral treatment for hep C virus”, Study shows much higher than expected recurrence rates, particularly among those most recently treated for hepatocellular carcinoma, European Association for the Study of the Liver. Public Release: 14-Apr-2016, “https://www.eurekalert.org/pub_releases/2016-04/eaft-hro041316.php”
      Excerpt from the study: “April 14, 2016, Geneva, Switzerland: A new study fast-tracked for publication today in the Journal of Hepatology has shown that patients with a prior history of hepatocellular carcinoma (HCC) and who have been treated with direct-acting antivirals (DAAs) for Hepatitis C (HCV) infection have a higher than expected early recurrence rate of their liver cancer than previously thought – with the rate in some subgroups exceeding 40%.”

      4. “Liver Fibrosis and Body Mass Index Predict Hepatocarcinogenesis following Eradication of Hepatitis C Virus RNA by Direct-Acting Antivirals.” 2016 Oct. 1. “https://www.ncbi.nlm.nih.gov/pubmed/27694754”

      • One more question Jay.

        1.) How come the VA is not reporting the cases of reactivation of Hepatitis B caused by direct-acting antiviral treatment?

        Thank you Jay.

      • Sorry one more question Jay.

        Since the research outside the US definitively show that in all case of patients who received direct-acting antiviral treatment for hep C virus. At minimum 7.4% will develop hepatocellular carcinoma and in some subgroups the rate of those developing hepatocellular carcinoma is greater than 40%.

        Are Veterans being told this before beginning direct-acting antiviral treatment?

      • One thing I would like to point out to you Jay about your statement “Since then pharmacists spend (85% of pharmacy students) 4 years in undergraduate education and 4 years in pharmacy school, then spend an additional 2 years in residency to be able to work with patients in the capacity described in the related article.”

        That is not true anymore. They lowered the bar on requirements substantially.

        Currently the requirements are you need a two year associates degree and they do not require that it is connected to pharmacology to start earning your Doctoral degree in Clinical pharmacology.

        Source: *U.S. Bureau of Labor Statistics

        “Pharmacists must earn the Doctor of Pharmacy (Pharm.D.) degree from an accredited college or university. According to the U. S. Bureau of Labor Statistics (BLS), the Pharm.D. replaced the Bachelor of Pharmacy, which is no longer offered (www.bls.gov). Before applying to a Pharm.D. program, you must complete a minimum of two years of specific professionally study, although you can also complete a 4-year degree program, such as a Bachelor of Science in Pharmaceutical Sciences. You might consider taking courses in biology, chemistry, physics and mathematics during your undergraduate years.

        After undergraduate school, you’ll need to apply to a graduate program leading to the Pharm.D. degree. You can expect to devote four years towards the completion of such a program. Generally, the programs combine coursework with professional experience. Some of the essential topics covered in the program include pharmacy and the law, pharmacology, physiology and pharmaceuticals, pharmaceutical management and pharmacotherapy.”

        Given at the VA statements such as ” Generally, the programs combine coursework with professional experience.” means on the job training and attending some of those 3 to 4 hour classes at the different association get togethers held through the year to cover the coursework.

        Essentially to earn your Dr. degree in Clinical Pharmacology through the VA program it takes a two year degree in almost any field to be eligible and then working as a doctor for about 4 years while attending all your association conventions.

  35. Hey Seymore Klearly (clever),
    I’m not completely sure where your desire for me to answer questions regarding the direct acting antivirals comes from, as I didn’t speak to their value in the treatment of Hep C. I will certainly read the articles you posted. Direct acting antivirals is a very broad category as there are at least 4 (off the top of my head) mechanisms of action that would fall in this category, each acts in different genotypes and in specific cell cycle stages. This is typically something that a pharmacist would have within the scope of their sub-specialization. Speaking strictly from an academic standpoint, affecting cell cycling always comes with risk, especially if the viral/bacterial/fungal cycle is similar to cell cycles within the human body (using similar mediators and transmitters). If there is a shared step, there is absolutely a risk to affect human cell cycles, and in doing so will create a risk (not an absolute) for DNA/RNA damage that can potentially lead to uncontrolled cell growth.
    As far as the educational component grows, you had good sourcing, but unfortunately interpreted what was written incorrectly. I suggest going directly to a college of pharmacy’s website and read through their prerequisite requirements for entry and then read their 4 year coursework breakdown (hopefully this can give some clarification to your misunderstanding). While it’s true that admission to pharmacy school itself technically only requires 2 years, two things tend to stand in the way of that: 1.) If you call any accredited pharmacy school in the country and ask them how many of their entering students have a bachelors degree prior to matriculation, they would all say at least 80%, with now the majority of well established schools being 100%. Once those students matriculate pharmacy school, their are required to complete 3 years of didactic education (classroom work) and one year of rotational work (intern) prior to graduating with a Pharm.D. Additionally, during the didactic years, pharmacy students will participate in further rotational hours during the evenings and on weekends. To relate this to medical school, prior to starting medical school students will have completed a 4 year bachelor degree. New medical students will spend 4 years in medical school; the first 2 years being didactic (classroom) and the last 2 being experiential/rotational (intern) before they graduate with an MD/DO degree. So technically speaking, pharmacy school has more time in the classroom than medical school and medical school has more time on the job–you can have your opinions to the value of either. After medical school/pharmacy school, newly licensed practitioners will go through a various number of years in residency. Residency consists of long work weeks that is all experiential with additional projects and research that is not typically performed by currently practicing providers. There is zero exclusions to these standards (other than what I stated) in the US to be a licensed pharmacist or physician. I hope this clarified some of the confusion with the standard training new pharmacists receive. I think a good rule for understanding educational requirements is that they almost always increase, rarely decrease-120 years ago physicians became MDs after 3 years of college in many areas of the US. Reasons for the increase (my opinion): citizens feel that more education equals better professionals and more education means more money for colleges to squeeze from their students, just to name a few.

    • Hi Jay,

      First thank you for your response to my questions but I assure you they were not asked to be clever. They are merely question I thought that you might be able to answer as person who holds your degree and title. In retrospect I guess it would be better to ask a physician.

      On a more personal note, have you ever read the report to the Carnegie Foundation by Abraham Flexner in 1910 for the advancement of teaching titled “Medical Education in the United States and Canada”. After the recommendations of the report were implement by 1922 the United States Medical Community was fast tracked to becoming the number one in Ranking of the World’s Health Systems. That lasted right up until the mid-1990s.

      Since the 90s the United States medical system ranking has slipped to the 37 position. That is according to the World Health Organization’s Ranking of the World’s Health Systems.

      Also since the mid 1990s medical error have increased exponentially and have risen to the top of the leading causes of death in the United States.

      From a recently Medscape Medical News :

      “”If medical error was a disease,” they concluded, “it would rank as the third leading cause of death in the United States,” after heart disease and cancer. Medscape Medical News covered this analysis with the headline “Medical Error is Third Leading Cause of Death in US.”May 26, 2016”

      A full copy of Flexner’s report can be found at:

      “http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf”

      If you get a chance to read the report I am sure you will be able to conclude the recent decisions to allow Nurses, Physicians assistants and clinical pharmacist to administer primary care is going to be devastating to the Veteran population receiving care through the VA.

      • So all the “team approach” has done is make medical care cost more? Actually, do you think our mobility may be a problem. I haven’t seen the same physician more than 5 out of my last 500 chronic care visits. Either because I moved or they did. And that is the primary reason for poor results in the VA. How often do you get to see the same care giver?

      • Lem

        The changing faces of those physicians may have something to do with the changing face of the student body at the School that is providing the physicians. Between students completing internship requirements, to physicians graduating, completing research assignments to changing rotations to other facilities or hospitals.

        In regards to the team approach with the changing face of the student body again affecting the dynamics of any team. After all they are only in training and the school get paid by the students they can move through their system.

  36. No matter how or what is said here ,, This practice is only practiced here were they have no fear of being sued over improper care meds etc,,, I know if it wasn’t for the private sector I would be Dead Today on there giving me medicine, that totally blew up threw the weeks in fluid,, to were I was close to death ,,, couldn’t feel my body ,,,l didn’t even new what was happening except I was having trouble getting breath to talk,, and one morning woke up in totally numbness,,, and taken to local hospital and guess call it Drained,,,

    • Wrong. File an SF 95 and sue. Or file a claim for being worse off for the treatment given even if the treatment was for a non service connected condition and you ended up the worse for it. For the Claim within the regular VA claims system you don’t have to prove maleficence or incompetence as you do with the SF 95 District Court route.

      • oh yea I am worse off for 27 year of wrong meds to treatment today I HAVE SAID ON THIS SITE WERE and what I have today is only only of my grandpa and mom and dad have gave me to have what Ihave today,,, the VA has totally taken and ruined financially and almost ended my life over twice,, and saved only by the private sector,, not the VA,,, IF I could write a book on the abusiveness of the VA system since 1972 I would,,,, GOD I WOULD,,

  37. Ben, can you research whether or not we can use the Choice card if the only medical provider available in the next 30 days is a pharmacist? Any loopholes there?

    • Call the number on your card. The provider’s have to be under contract and approved. You have to get approval for every procedure and visit. Not just the visit. It is complicated as hell and if you don’t toe the line you end up with the bill. speaking from experience. so far $220.00 down.

      • Lem, the Choice people are clueless. I am aware of how it all works, but the ‘pharmacist’ issue is different than the norm. Just asking Ben for a legal opinion. Thanks.

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