The New V.A. System: Two EPs Shed Light On Advances in V.A. Emergency Medicine

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VA rmIf you’re an emergency physician, you could be forgiven for seeing the beleaguered Veteran’s Administration as a second-tier place to work. To get a look behind the negative headlines, EPM editor-in-chief Judith Tintinalli talked to two emergency physicians who transitioned into VA hospital emergency medicine.

If you’re an emergency physician, you could be forgiven for seeing the beleaguered Veteran’s Administration as a second-tier place to work.


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To get a look behind the negative headlines, EPM editor-in-chief Judith Tintinalli talked to two emergency physicians who transitioned into VA hospital emergency medicine: Brian Hancock, ACEP past-president and Curtis Snook, former toxicologist for the EPA. Their outlook was surprising, and suggested that the VA Hospital system indeed can offer great work opportunities for emergency physicians.

EPM: Brian, tell us about the VA system and your current position.


Brian Hancock: After a fruitful career in ACEP leadership, I was the Chief of Staff for the Fargo, North Dakota  VA Healthcare System. I moved to Ann Arbor about a year ago to take the position of Chief Medical Officer for the Veterans Integrated Service Network 11 (VISN). There are 22 VISN networks, and each has a Network Director, Chief Medical Officer, and Deputy Network Director. The VA sponsors 152 hospitals and 800 community outpatient clinics.

EPM: What is the typical VA ED like?

BH: There has been tremendous progress in the past several years or so in upgrading VA EDs. The VA offers a great opportunity for any emergency physician. Our ED population is changing. Until the most recent surge of vets, we were caring for older and middle-aged men. Our population now has patients as young as the 20’s, and we anticipate that women will be at least 15% of our VA patient population over the next few years. The practice in each ED reflects the capabilities and service lines that each facility provides. We treat mostly medical patients, and no pediatrics. Patients tend to be very ill, with multiple comorbidities. MVCs and minor trauma are common, but major trauma and knife-and-gun club victims are mostly taken directly to trauma centers.

EPM: Why don’t we ever hear about the VA as a dynamic place to work?


BH: The VA as a federal agency doesn’t publicize its opportunities very well.

EPM: Why is EM important to the VA?

BH: Emergency medicine is important in the VA as in the private sector, as a primary site for access to healthcare.  Because of their broad knowledge, EPs are well suited to both clinical and administrative leadership roles. They have a broad view of healthcare across specialties and are excellent leaders. Emergency physicians can be a real force for improvement in the VA system. Washington wants to listen and wants to improve care. The goal is to provide the highest quality of care to our veterans seeking emergency care. Recently, salary increases were provided that make the position even more attractive. We care for a challenging clinical population in a good teaching and practice environment. Plus, I can’t say enough about the mission – the honor it is to care for vets.

EPM: Curtis, your EM career is as varied as they come, and now you are the ED Director at the VA in White River Junction, Vermont. How did you end up there?

Curtis Snook: I trained in EM at the University of Cincinnati and did a tox fellowship. The first Icelander trained in emergency medicine, Jon Baldursson was a classmate of mine, so I went to Iceland after my fellowship and a couple years on faculty to help him develop emergency medicine and toxicology. I stayed seven years. I came back to UC in 2002 on the EM faculty and served on the ABEM Med Tox Subboard. In 2006 an opportunity came to join the Environment Protection Agency as a medical officer working on a terrorism response team. After a while I missed clinical work and started working first a few shifts a month and then full-time at the Cincinnati VA. Then I wanted to move back to the northeast, so I looked on the USAJOBS ( website and found a position as ED Director at the White River Junction VA about a year ago.

EPM: The assumption to outsiders is that being a physician in the VA, under the federal government, means lots of rules and strict protocols. Is that fair?

CS: There are challenges being an emergency physician who is also a federal worker. The 40-hour work week and 80-hour pay period can make it difficult to staff a 24/7 schedule. Federal rules make it difficult to make staffing changes as human resources must review the applicant’s qualifications for specific positions. There’s lots of responsibility for clinical administrators, but not always sufficient power, and sometimes the process of change is slow. On the flipside, in a small hospital like the White River Junction VA, positive changes can get done more quickly. Very large VA EDs, like Pittsburgh, have been able to achieve full departmental status, which shows that things are moving in the right direction. Benefits for federal workers are superior, insurance coverage is phenomenal, and malpractice is not much of an issue.

EPM: Do emergency physicians have a special role to play in the VA system?

CS: Emergency physicians are healthcare’s best diagnosticians. In the VA system, there is lots of disease to find that a non-emergency physician could easily miss. For example, at UC during my whole time there, I saw 1 or 2 cases of epidural abscess. In the VA, I diagnosed 3 cases over about a year’s time. The cardiovascular risk is very high, and you develop a low threshold for testing. And, by the way, the transfer of patients from the VA to a higher or different level of care is crucial when needed and appropriate, particularly at smaller facilities, and emergency physicians with their broad knowledge of standards of care across specialties and acumen in recognizing severe illness, are extremely valuable to patient care in these settings.

EPM: What do you like most about working at the VA?

CS: Caring for vets is very rewarding. They have given so much for our country. I especially enjoy the WWII generation. They are so stoic – they don’t complain and always thank you. Caring for them and all of our veterans is a great honor.

BH: My Dad is a Pearl Harbor survivor. When I grew up, all his friends called him ‘chief’. He didn’t tell me his story until very recently. He signed up for the Navy in 1938. One day, he told me about the ‘Battle of the (Navy) Bands’ competition which was scheduled for the evening of December 7, 1941. He was offered the chance to sleep over on the Arizona the evening of Dec 6— to hear the final competition the next evening. But Dad had to be in the dispensary at 7 AM on Dec 7, so he didn’t stay on ship. When the attack alarm rang that morning at 7:55 AM , he was in the dispensary, and started treating all the burns as best as he could, and later found out that all the band members of the Arizona had been killed in the Pearl Harbor attack. When I look at a vet, I think, what I’m doing today is for my Dad, who is now 93. I talk to heroes everyday. Their stories are unbelievable.

Judith Tintinalli, MD, MS is the Editor-in-Chief of Emergency Physicians Monthly

Illustration of the VA hospital in Ann Arbor, Michigan by Daryl Alexsy

Part of the Rethinking the VA series
Other articles in series: 
Surprised by the VA: For One EP, a Career Switch Meant a Welcome Change of Pace
The VA By the Numbers

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  1. As a resident I enjoyed the VA. The presence of young veterans nowadays encourages PTSD training for staff. However, as a Board certified physician I find the application process inappropriate and frankly rude. You are treated like a criminal and interrogated. I worked in Afghanistan recently, but as a result of the application rape proffered by the VA I will remain outside the system and stay in the private sector.

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