A Conversation with Robert Wilkie, Secretary, US Department of Veterans Affairs

VA Medical Achievements:

• VA researchers are credited with the development of six major medical advances:
  • The first implantable cardiac pacemaker.
  • The first successful liver transplant.
  • The nicotine patch.
  • Evidence that one aspirin tablet daily reduces heart attack death rates by half.
  • The concepts leading to the CAT scan.
  • The Gleason score for prostate cancer.
• VA research includes three Nobel Prizes in medicine or psychology.
• Research conducted at the Boston VA addresses traumatic brain injury in athletes (football, hockey, and college levels) and informs Department of Defense strategies for soldier survival in ground combat.
• Prostate cancer is identified as the number one killer of veterans, claiming over 15,000 lives annually within the 9.5 million veteran population.

VA Infrastructure and Scale:

• The U.S. government authorized the first medical facility for veterans in 1811.
• Current operational metrics include:
  • 19.2 million total U.S. veterans.
  • 10 million veterans receiving care through the VA.
  • 152 VA medical centers.
  • 1,400 community-based outpatient areas.

Cultural Shifts and Partnerships:

• The VA culture is described as born from military service, evolving from the era of the 1970s when veterans faced public stigma to a current inclusive approach.
• A 2019 survey shows a 90% approval rating for VA services among the Veterans of Foreign Wars (VFW) membership.
• VFW members report that 9 out of 10 urge other non-enrolled veterans to join the system.
• In the Partnership for Public Service rankings, the VA improved its "best places to work" score from 16th or 17th out of 17 federal departments to 6th, with projections for higher scores in December.
• The "Mission Act," signed by the President roughly one year prior to October 2019, serves as the most transformative legislation since the 1944 GI Bill, creating an integrated healthcare network.
  • This act allows veterans to access private sector care (e.g., Philips, Walmart, academic centers) when it serves their best medical interest.
  • Partnerships established include the Prostate Cancer Foundation, Chamber of Commerce, and Walmart.

Data and Technology Reforms:

• The cost to digitize historical military medical records dropped from a projected $100 million to $5 million due to technological advances.
• The "Million Veterans Program" utilizes supercomputers and Department of Energy resources to analyze a veteran's entire life history, including combat wounds and toxic chemical exposure.
• An electronic health record (EHR) system is set to launch the following year, integrating data from the military entrance processing station through the veteran's life, replacing manual records (e.g., an 800-page paper file carried by a Vietnam veteran).
• The VA is actively promoting artificial intelligence and robotics through academic partnerships at campuses including UCLA, Stanford, Duke, and the University of Chicago.

Mental Health and Suicide Prevention:

• Veteran suicide rates remain critical, with 20 veterans dying by suicide daily; 70% of these individuals are not in the VA system.
• Teenage suicide rates have risen by 56%, and suicide is the leading cause of death for police, firefighters, and veterinarians.
• President Benjamin Harrison initiated the first national conversation on suicide in the 1890s; the VA is currently leveraging this history to form the PREVENTS Task Force.
  • The PREVENTS Task Force includes the NIH, Indian Health Service, Department of Defense, HHS, and HUD.
• The VA budget allocates $9.5 billion specifically for mental health.
• Operational tactics include:
  • Offering same-day mental health services.
  • Screening nearly 1 million veterans for mental issues and suicide risk in the last year.
  • Daily follow-up on approximately 3,000 high-risk veterans.
• A significant portion of veterans who die by suicide belong to the Vietnam era, with issues festering for approximately 50 years since Lyndon Johnson left office.

Nursing and the 21st Century Care Model:

• The VA employs 105,000 nurses out of a total workforce of nearly 400,000.
• VA nurses operate under a unique military culture where rank dictates authority; nurses often lead operating rooms and make life-and-death decisions independent of physician rank.
• The modern VA nurse model integrates data-driven care, utilizing genomic and historical patient data to direct treatment.
• VA nurses possess unique combat experience in triage and critical care that distinguishes them from civilian nursing school graduates.
• The VA aims to define the skills and responsibilities for the 21st-century nurse, marking 2020 as the "Year of the Nurse" in alignment with the 200th anniversary of Florence Nightingale's birth.