Sunday, January 06, 2008

"VA Logic" in re. to plastic surgery - German style

It's always amusing to hear the United States Veteran's Administration (VA) hospital system celebrated by advocates of universal health care as a model system. If you've ever worked in one, you quickly learn it's a quagmire of competing impenetrable bureaucracies with insane regulations relating to everything. These regulations combined with a unionized workforce can make simple things (like taking care of patients for instance) not so simple. Illogical rules and regulations, and the irrational thinking behind them is what we used to call "VA logic".

VA logic has metastasized to private hospitals in the form of rules like the Federal Emergency Medical Treatment and Active Labor Act EMTALA, the Health Insurance Portability and Accountability Act HIPAA , and the growth industry of "nurses with clipboards" (NWC), nurses who aspire to have no patient contact, but serve vague administrative roles in hospitals harassing everyone. Each of these things started off with the best of intentions, but have spiraled out of control and now serve non-contributory bureaucratic roles.

A recent case from the German military comes to mind, where enforcement of an outdated and illogical regulation on cosmetic surgery led to the dismissal of a female soldier from her position after she'd had a breast augmentation surgery. From the report

A 23-year old female recruit who underwent breast implant is appealing to military authorities for reinstatement after she was booted out of army training in Germany for have boob job. Alessija Dorfmann, who has cup D after the operation, claims she was devastated after being kicked out of the army training as it has it been always her dream to be a soldier with a great figure. "And now my fake boobs have cost me my job," said Dorfmann adding she earned the money for the boob job by working as in an OAP's home before joining the army. "I could not stop crying when they told me. I wanted to work as an army medic and help save lives."However, military chiefs have vowed to review the Dorfmann's plight. "The rule that was brought in because of the increased risk of an injury is under review," said Army spokesman Harald Kammerbauer. "It was introduced more than a decade ago and it may be that it is no longer relevant in the modern army. In future we may be prepared to make exceptions."

Dorfmann will, however, apparently be allowed to join the Navy (go figure). With great pain, I will refrain from any jokes about floaties.

The rationale for this old policy doesn't make much sense, particularly if she had her surgery done when she wasn't on active duty or while on vacation. When done well, the down time after breast augmentation can be fairly modest. One of these days, I'll write down some thoughts on my take the evolution of surgical techniques for breast augmentation which I think we'll be interesting for the lay audience here.

Nurses get breast implants fairly frequently and are usually able to return to work within a week with only mild restrictions. Most breast augmentations in Europe are now done using textured form-stable silicone ("gummy bear") anatomic implants placed over the muscle, which has much less recovery time then the submuscular (partially under the pec muscle) placement that we do more here in the United States (another good topic for another day). Those kind of implants are so solid that they literally cannot physically rupture, although they can "fracture". If this woman was not in a front line position, it's fairly ridiculous to assert she's endangered herself or increased her risk of injury by her surgery.

As an interesting aside, while looking for some information on German nursing, I came across this old World War II propaganda poster from Great Britain which was trying to stir passion among the Brits over the German nurses' reputation for not treating captured wound allied soldiers.

P.S. Warning - Don't do an image search on Google using the term "German nurse" with children or your spouse around, as apparently there is a thriving porn-fetish industry around the theme :)

P.S.S. "French nurse" image searches are even more risque as you end up with both nurses and French maids ;)



Anonymous said...


You are so-o-o-o-o wrong about the U.S. V.A. hospital system. They showed the way to electronic health records, they have scored two handfuls of Nobel Prizes for research and they are first, year after year, in care of their diabetic patients. The only problem is, the system is too small for the huge, huge, patient load so appointments take longer. But IMHO -- and I've worked in health care 25 years -- they are second to none in the U.S. health care industry which is, in comparison, a cottage industry.

Dr. Rob Oliver said...


Ok, I'll quit laughing now.

But seriously....If you've actually had to work in the VA as a Physician, you can not plausibly argue that's it's a great model for the providers.

The VA did initiate an early model for standardized medical records which was a big advance in that you can track people's history from anywhere. However, this was achieved by introducing a clunky EMR interface that decreased physician productivity by 50%+ on the wards and clinics. What takes seconds by hand for simple notes or orders, now entails multiple menus and interfaces to achieve. Don't even get me started on having physicians (the most expensive resource in the system) replacing ward clerks for the tasks of order entries. The VA simply cost-shifted the work and eliminated many of the secretarial positions that existed for data/information entry.

The unionized environment of federal emplyees also makes for an extremely inefficient system for making changes, firing (or promoting) employees, and prevents rapid adapting to real-world needs.

Charlene the L said...

You must have worked for the V.A. in the mid 1960s. Ever heard of one click? Last time I was seated next to my V.A. internist, he asked "Do you want to join the V.A. MOVE program?" I said yes, he clicked the mouse once and said "Done." Ditto a blood pressure med. His total time on computer ordering meds was about five seconds.
Or perhaps you're just not computer literate yet?