Spokane VA will boost psychiatric staffing

Amid a revolt by its staff psychiatrists, the Spokane Veterans Affairs Medical Center has begun expanding a behavioral health department strained by an increasing number of veterans seeking help. In a July 24 e-mail, all four of the department’s psychiatrists and one psychiatric nurse practitioner said they would refuse to accept new patients. They said they could not add to their caseloads, which they said in some cases were more than 70 percent above the VA standard. “We have an ethical obligation to be available to our patients for timely appointments and communications,” the e-mail said. “We are no longer able to fulfill these obligations to our huge caseloads, let alone offer this to the dozen new patients coming into the clinic each week.” The e-mail was electronically signed by Dr. William Brown, Dr. Minerva Arrienda, Dr. Adalina Carter and Dr. Jeffrey Schack and psychiatric nurse practitioner Patrice Griffin-Codd. Their stand came amid increasing concern across the nation about the mental health of service members returning from Iraq and Afghanistan and after a spike in suicides last year among veterans in the Spokane area. An investigation by the VA’s office of Medical Inspector found that from July 2007 through July 7, 2008, at least 22 Spokane-area veterans killed themselves, including 15 who had had contact with the Spokane VA Medical Center. Dr. Gregory Winter, chief of behavioral health, said that he understood his colleagues’ position but that they were duty-bound to treat veterans. “It was communicated to them that we don’t have the option of not seeing new patients,” Winter said Wednesday. No one has been permitted to refuse new patients. However, he said, adjustments were made in psychiatrists’ schedules and time carved out time to see patients, some of whom have complained of waiting three months or more to spend a half-hour with a VA psychiatrist. Medical center Director Sharon Helman said she has approved increasing the behavioral health staff to eight psychiatrists and a total of 80 employees, up from 50. Two new psychiatrists will arrive next month. In the meantime, the medical center has hired two psychiatrists on a temporary basis. Helman said a miscommunication with the psychiatric staff led them to mistakenly believe there was a hiring freeze, a belief the doctors noted in their e-mail to Winter. But she said it is difficult to find psychiatric professionals when VA and nongovernment hospitals across the nation are recruiting them. “We encourage staff to bring up concerns,” she said. “We have addressed those concerns.” The psychiatrists wrote that the new job openings in behavioral health came at the insistence of Winter and the medical center’s former chief of staff, Dr. Nirmala Rozario. “Due to the Herculean efforts of Drs. Winter and Rozario, we were able to again get approval for hiring,” the e-mail said. “But clearly there is a lack of appreciation for how the care of our veterans is suffering from the current state of affairs,” the e-mail said. “And this has led to a crisis.” The psychiatrists said they are obligated “to practice within community standards and to refuse to enable any system that endeavors to circumvent this.” The medical center also is seeking a new chief of staff to replace Rozario and a new chief of behavioral health to replace Winter, who said he will take a yearlong sabbatical. One year ago, the medical center’s behavioral health staff included eight staff psychiatrists and a nurse practitioner as well as Winter, the e-mail said. One psychiatrist has been on medical leave. Spokane VA behavioral health service provides inpatient care in an eight-bed unit at the medical center as well as outpatient services. The center and its clinics in Wenatchee and Coeur d’Alene serve 215,000 veterans in Eastern Washington, North Idaho and Western Montana. Helman also said she is negotiating with private health care providers in places such as Republic, Wash., and Libby, Mont., to provide health services “where the veterans live.” Winter said Spokane VA is anticipating another wave of patients with the return from Iraq this month of the Washington National Guard’s 81st Heavy Brigade Combat Team. The psychiatrists’ e-mail said their caseloads in some cases exceed 850 patients. The VA standard, they said, is fewer than 500 patients per provider. Winter said a review of his colleagues’ caseloads showed they were smaller than they stated but higher than the current VA average of about 650 patients. VA records obtained by Veterans for Common Sense, a Washington, D.C.-based, veterans advocacy group, show that U.S. military operations in Iraq and Afghanistan have created nearly 1 million veterans. More than 425,000 are being cared for at VA hospitals. Of these, nearly 194,000 are being treated for mental health conditions, including 115,000 diagnosed with post-traumatic stress disorder.