Chapter One- Edward Perry

I first met Edward Perry in early 2008 in my thoracic surgery clinic at the San Francisco VA. He was sixty-two, tall, lanky, leathery, craggy…. Even before I stepped into the exam room, I already knew a good deal about Mr. Perry and the tortuous route that had led him to my clinic. A few moments earlier, my medical student, Rachel, had interviewed him….She had then briefed me in the clinic hallway outside the small room where Mr. Perry waited, while I took in his daunting radiographic studies on the hallway computer. Edward Perry had lung cancer….

“I really appreciate your taking time to see me, doc,” Mr. Perry said as I shook his hand. His positive sentiment was common among veterans in our clinics, even after their all-too-common long waits for treatment—waits that paradoxically made the doctors’ time seem even more precious to the vets. Patients over at the university hospital often complained about “unreasonably” long waits that vets saw as normal and customary.

“It’s been a long time getting here to see you,” he continued, “a long time since this thing showed up. I know all those other doctors have been trying to help, but they seemed like they were mostly spinning their wheels. But you’re gonna save me now. Right, doc?”…

“Listen, doc.” Mr. Perry’s depression had given way to a sudden anxiousness.…“I’ve got to be there now for the kids, doc. I gotta be their grandpa while Abby gets her life on track. Two or three or even five years is just not enough to make sure the kids have a home to go to and don’t get into trouble…Abby needs her dad now, and I can’t let her down. Doc, you can’t let us down, either…"

Edward Perry’s case was complicated both by a medical history filled with conditions that increased his risk of operative and postoperative complications and by the unnecessary delays that resulted from poorly organized and executed VA care. Not one incompetent doctor or nurse was to blame, but rather a system that was simply not driven by the expectation of excellence—or by accountability to it….

In the end, however, Edward Perry did not die from surgical complications. He never received an operation. Several days after our initial clinic visit, as I was rushing to place his case on my tight surgical schedule, I was informed by one of my administrative supervisors at the San Francisco VA that a right pneumonectomy was too high a risk in a patient who had undergone chemotherapy and who had Mr. Perry’s combination of other serious medical problems. The VA, and our hospital in particular, had to limit the number of surgical deaths recorded in its annual statistics. Although Mr. Perry certainly would have been taken to the operating room and given a shot at survival at UCSF, and although his surgery had been recommended both by the San Francisco VA Tumor Board and by the hospital’s Multi-Disciplinary Chest Conference, the administrator insisted on additional tests to document the patient’s potential risks of cardiac and liver complications. Risks that we had no way of mitigating, risks that the patient had already recognized to be great when he provided a truly informed consent. During the further delays Mr. Perry encountered in scheduling these superfluous tests and evaluations, he contracted pneumonia as a result of the tumor that blocked his right lung. He had already been living on borrowed time, and the seriousness of his infection grew rapidly. He was admitted to the intensive care unit of a hospital near his home. He died there a few days later.

Edward Perry’s death did not contribute negatively to VA postoperative mortality statistics. And his grandchildren are growing up without him.

Chapter Two- "Welcome Back"

I performed my first off-pump bypass as an attending at the San Francisco VA on a patient named Emerson Pitt, a navy veteran in his early sixties. At a critical moment during the procedure, and without taking my gaze off Mr. Pitt’s beating heart, I extended my hand toward the scrub nurse and requested a two-millimeter coronary shunt. What I needed was a specially fabricated, tiny, silicon-tipped tube that I could insert into the two-millimeter diameter of the open coronary artery into which I was about to sew my bypass graft. The shunt would carry much-needed blood flow past the hole I had created in Mr. Pitt’s coronary artery and on toward the heart muscle that was still pumping away and keeping him alive. Without the shunt, the heart muscle had even less blood flow than normal and was already beginning to struggle; it might not have lasted the ten minutes it would take me to sew in the graft.

“Shunt?” the nurse replied. “I don’t have any shunts.”


But what if [the 2014 VA waiting list scandal was] just the tip of an ugly, disturbing iceberg of poor care, neglect, and abuse? As shocking as many of the 2014 revelations may have been, they pale in comparison to the true, appalling depth of abuse to which our veterans are routinely subjected at the VA. Just about any thoughtful medical academician who has worked at the VA could tell you that the VA wait list scandal of 2014 was nothing more than a reflection of the way everything is managed in that monolithic federal institution. And when an entire, badly broken healthcare system boils down to the generation and worship of a few dramatically misleading statistics, the disheartening result is not only a danger zone for our unsung heroes, but the violation of one of our nation’s most important promises to a deserving, underserved population.

Recent revelations of continued failures in an expensive stopgap approach are bad enough. But it is time for American doctors and other healthcare professionals—people who have been aware of what the VA really represents and how our veterans are truly being treated—to force Americans to open their eyes to a much more fundamental failure of their government. A failure both to fulfill a promise and to remain accountable to the men and women who have already sacrificed so much for their country.