In a classic movie line from Casablanca, the anything but naive Captain Renault proclaims “I’m shocked, shocked to find that gambling is going on in here”, shortly before being handed a wad of money (his winnings) by a casino worker.

And so when I hear politicians proclaim to be “shocked” about the atrocious treatment of veterans within the Veterans Affairs hospital system, my only response is that I am more than shocked that they are shocked! The type of care that has engendered such public and congressional outrage was the norm throughout my 7-year tour of duty as a staff neurosurgeon almost 2 decades ago inside a flagship VA hospital. With rare exception (spinal cord injury, rehab for brain trauma), patient care inside the VA system I knew, was totally second rate with customer service on par with the California Department of Vehicles. As a young and newly minted neurosurgeon, I yearned to practice the kind of high quality care I delivered as a resident, but the opposing bureaucratic forces within the VA system were omniscient. Throughout so much of my VA experience I felt like a sordid part of an uncaring bureaucracy and wanted more than anything else to move onto a better job, which in time is what happened. One particular event more than any now shapes my perspective of the VA.

Aspiring to be a young Turk neurosurgeon delivering state-of-the-art care for malignant brain tumors, I implemented, after a lot of sweat and tears, an immune therapy program inside my VA hospital, which at the time was quite an avant-garde approach to this dreadful disease. Despite some interesting preliminary results in a Phase 1 study, a few patients had problems with brain swelling. However, the VA hospital I was in had no equipment for monitoring intracranial pressure (ICP). To remedy this shortcoming I filed the appropriate paperwork to request an ICP monitoring device as part of the capital budget process. Despite a considerable effort my plea fell on deaf ears.

Months later, within a day of the government’s fiscal year being closed, I got a frantic call from the chief of staff’s office informing me that there were unspent funds in the VA system and I had a few hours to get my request for an ICP monitor into the system….which of course I did.  But to no avail, I did not get my device and I was forced to manage my patients much like a third world country neurosurgeon. The following year I again submitted my request through the capital budgeting process, and low and behold, when that failed again, I got a second panicked call in the whee hours of the fiscal year suggesting yet another hurried opportunity to procure the object of my desire before the VA funds disappeared into some fiscal black hole. Yet it was Deja vu all over again and the funds were never to come my way. Believe it or not this cycle repeated itself a third year, and soon I would be yet another three-time VA loser in the budget cycle.

Not long after this farce had ended, I found deliverance at the university mother ship. Now free of my VA purgatory, I felt only eternal gratitude. About a year later, while in the middle of an operation, my pager went off and I instructed the circulating nurse to answer it. With the phone put to my ear, I heard a voice on the line tell me he was the manager of the loading dock of the VA hospital and he had just received a shipment for me: a Camino ICP monitor.  Almost 10 years later I do wonder if my $30,000 unused monitor isn’t still sitting somewhere on that loading dock…..along with a long line of neglected military veterans.

Yes it is true that the recent “shocking” revelations about the VA system are almost 2 decades removed from my personal experience. As a simple physician in the trenches, I cannot say for sure how best to care for today’s military veterans. However my experience suggests that a radical decentralization might improve both morale and the quality of care.