Surprised by the VA: For One EP, a Career Switch Meant a Welcome Change of Pace

No Comments

change rmTransitioning to the VA meant a new patient population and new bureaucracy… yet the end result was unexpectedly satisfying

Transitioning to the VA meant a new patient population and new bureaucracy… yet the end result was unexpectedly satisfying


change w

In my current position as an emergency physician with the Veterans Health Administration (VHA), prior military service is often the initial connection made with a patient. Depending on how urgent the patient’s issue is, the conversation will often go deeper, into where, and in what capacity, they served. After a 37 year career in emergency medicine that has spanned military ERs, a small community ER, a large community ED and an academic ED, I’ve landed at the Hunter-Holmes-McGuire VA Medical Center, where I’ve practiced for the past 5 years. In that time I’ve found that this link between practitioner and patient, involving the patient’s military service and how the patient can be served, is what makes practicing emergency medicine at the VA unique… and valuable. While the VA work environment has its challenges – no work environment is perfect – if I could go back in time six years, I would still make the decision to be where I am.

People often wonder how a VA ED setting compares to a typical ED in terms of work environment, patient mix, electronic health records (EHR) and other aspects of practice. I accepted a position in the VA knowing that I would leave behind stabilizing significant trauma patients, as well as evaluating and treating children. But what I would gain was the opportunity to care for those who have served their country while teaching residents and medical students. Plus I would be practicing in an environment not driven by financial survival, and I would be attempting to modernize and improve emergency medical care.


Within the VA system (and by “system” I mean “huge bureaucracy”), emergency medicine is in transition. Traditionally, emergency rooms (many are still called this in the VA) have been part of the Primary Care Department’s domain and most of the physicians staffing the ER are still primary care physicians plus mid-level practitioners. In a process that’s more like turning a battleship than a jet ski, the VA is upgrading its emergency care from ERs to true EDs with EM-boarded physicians. In some VHA facilities where EM-boarded physicians are on staff, EM residents have begun rotating through the department.

At McGuire VA where I currently work, the VHA is supporting an EM-IM residency which will eventually host 10 residents (2 per year group for the 5 year residency). The reality in quite a few VA facilities – particularly for those who have trained in EM residencies or have practiced in other than a small rural ED – emergency medicine in the VA is a 5 – 10 year step back in time. For example, long-resolved struggles over the “turf” of airway management and procedural sedation are still front-burner issues at the VA.

One thing I found easy to adapt to and use was the VA’s EHR, VistA. This is likely because it has been online for some time with a majority of the “bugs” worked out.  It is adaptable and the IT personnel have been flexible and willing to work with the development of new and innovative templates for orders, etc… Notes are template driven but include the capacity for the practitioner to develop their own folder of personalized templates. In addition the EHR has capabilities for voice-recognition dictating of notes.  

I do miss seeing pediatric patients. But there is variety creeping into the VA – the once male-dominated patient population is seeing an influx of female veterans. An increasing number of gynecologic issues has meant we need GYN backup, which appears to have caught the system by surprise.


Another issue that wasn’t foreseen was the economic downturn, which increased the number of veterans eligible for care (Eligibility for care is determined by a veteran having a service-related condition, or economic need. Veterans like me can’t be VA patients).

The increased patient population has created significant growing pains for the VA facilities. So now, the VA – like so many other places, has a problem with boarders, and even diversion. Also the number of requests from civilian ED’s to transfer patients to the VA for admission has increased. It’s frustrating but we are assisted by administrators who attempt to keep transfers out of our already-busy ED, and make use of empty beds in other VA facilities in our region.

So as you can see from my description, EM in the VA is in flux. It has its pros and cons but considering how much healthcare is changing in general, it is certainly a practice setting that I would recommend to someone looking for a change and a challenge.

We all know, whether we’re talking about a renovation or working under a new ED director, that change is not painless. But, pain has its benefits, too. Being part of a team focused first on serving those who have served and then on being agents of change is rewarding. Plus the simple fact is that although change is slow within this system, it is likely to be lasting… because, well, change is slow.

Edward J Read Jr MD, FACEP
is an Assistant Professor in the Department of Emergency Medicine at Virginia Commonwealth University. He is also an Attending Physician in the Emergency Medicine Department at McGuire VA Medical Center in Richmond, Virginia.

Part of the Rethinking the VA series
Other articles in series: 
The V.A. By the Numbers
The New V.A. System: Two EPs Shed Light On Advances in V.A. Emergency Medicine

Leave A Reply