Doveryai, no proveryai – Trust, but verify

by U.S. Medicine

July 9, 2014

“Doveryai, no proveryai.” (Trust, but verify) – President Ronald Reagan

Editor-In-Chief, Chester "Trip" Buckenmaier III, MD COL, MC, USA

Chester “Trip” Buckenmaier III, MD, COL, MC, USA

The quote, “trust, but verify,” is actually an old Russian proverb that President Ronald Reagan used during arms control negotiations with Russian President Mikhail Gorbachev in the 1980s. He learned the quote in the Russian language and used the phrase frequently as he and President Gorbachev worked to prevent the promise of mutually assured destruction if the two superpowers failed to get along during that era.

As a teenager in the 80s, I remember the nagging fear, reinforced by television and the movies, of what nuclear annihilation would mean and how close our two countries had come to that unthinkable result with the Cuban missile crisis. The geopolitical issues at play at that time were momentous and far beyond the understanding of a teenager in pursuit of an education and my next date. It is only now as I look back on those tumultuous times within the context of the dangerous situations I find myself in today that the wisdom of President Reagan’s negotiation phrase rings through with crystal clarity. Both leaders knew that they had to trust each other to begin the negotiations that would bring the world back from the brink of nuclear war. Moreover, they understood that successful negotiations without a means to obtain the information needed to verify the tenants of the hard fought agreements that were being instituted was worse than failure; it was potentially catastrophic.

Verifiable, quality information is the life blood for any leader trying to manage a complex organization. As I struggle with the recent news stories detailing VA use of unofficial lists containing tens of thousands of patients who were delayed in receiving care while the institutions involved reported favorable waiting times, I cannot help thinking of Reagan and his quote. While I have no special knowledge of this VA scandal beyond what has been reported, I do know that the vast majority of VA professionals that I work with on a daily basis are fiercely devoted to veterans and their care. They feel just as betrayed as the veterans on those lists.

Yet, despite the many thousands of passionate and caring VA employees, an environment was established that supported the creation of secret patient waiting lists. There is even suggestion that patients may have died waiting for care. The VA currently being discussed in the mass media is so inconsistent with the VA I have worked with for most of my career, the situation boggles my mind.

The first and easiest step is to blame leadership. This past May, Veterans Affairs Secretary Eric Shinseki tendered his resignation under growing pressure from veterans groups and politicians in light of the scandal. Though I have never had the pleasure of meeting Secretary Shinseki in person, I have always had tremendous respect for his qualities as a leader. I will never forget the courage that then Gen. Shinseki, demonstrated in his 2003 testimony before Congress, prior to the Iraq war, where he stated his opinion that the war would take years and cost thousands of American lives. He told the politically unpopular truth as he understood the situation at that time, based on his training and vast experience, and he paid dearly for it.

History, as we know now, would reveal Gen. Shinseki’s wisdom and foresight of the actual cost of the Iraq war in blood and treasure. It was an inspiring example of leadership and personal responsibility in that he placed the needs of the Army and the American public before his own. Personally I thought Gen. Shinseki’s selection as Veterans Affairs Secretary was an inspired choice and I still believe that today. Notwithstanding the current events leading to his resignation, I think the loss of Secretary Shinseki is a loss for the VA system. I understand and agree with the fact that as the boss, Secretary Shinseki is responsible for everything, good and bad that happens in the system. That said, while he is responsible, I would suggest he is not necessarily to blame. Whoever assumes this office will still have to contend with the culture of misinformation that leads to this problem in the first place.

I will even go a step further and suggest that the people directly responsible for the secret lists probably are not horrible people; they were just people placed in a ridiculously difficult situation not of their making. Consider the stress of trying to meet national goals of productivity but not necessarily being adequately resourced to succeed. I am not suggesting that makes it right, but I will refrain from casting the first stone.

At its most basic, it seems to me that the issue precipitating the secret lists boils down simply to supply and demand. The VA’s supply of funded healthcare was being outstripped by the patient demand created by 13 years of conflict on top of all the veterans from the wars of the past 80 years. An interesting civilian medicine sideline to the VA story is an unexpected side effect of the Affordable Care Act, which has resulted in a spike in emergency room (ER) visits as the newly insured seek care they cannot find in an overwhelmed primary care system.

Dr. Ryan Stanton, president of the Kentucky chapter of the ER physician group, in a USA Today article described the lack of healthcare capacity vs demand this way, “We’ve given people an ATM card in a town with no ATMs.” I would suggest that the VA scandal is just the first shot over the bow of a growing national trend of increasing demand for evermore scarce and expensive medical resources.

I am not suggesting that we ignore the fact that those responsible for the secret lists were wrong, rather their actions were a symptom of a much larger problem. Furthermore, damning these individuals and the VA leadership does not solve the problems that led to this scandal in the first place. Leaders within the federal healthcare system, particularly in a time of expanding need and tightening budgets, have to be willing to listen and provide leadership when informed that the system is failing. As federal medicine providers, we must be able to trust each other enough to tell the truth even when the truth is not consistent with the desired “blue sky and sunshine” party line. Yes, as leaders we must be able to trust those we lead to bring us timely and accurate information that reflects reality. We also must take the added step to verify whenever possible that the reality being presented is consistent with ‘reality’ up and down the clinical and administrative chain.

As a young 2nd Lt. of the Reagan era, I once had a crusty old master sergeant advise, “Don’t worry about soldiers complaining, it’s what they do, it’s when they stop complaining that you should watch your back.” As I have expressed many times in this column, I have a particular fondness for federal medicine and the fantastic job we do daily, but no system involving human beings is perfect. If all we ever highlight to our leadership is the “blue sky and sunshine” how can we expect them to lead and help find solutions to the real problems that plague our system? As leaders, when our troops cease all complaining, we should begin to worry. In short, “Doveryai, no proveryai.”

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