Editorial

Mostly it is loss that teaches us about the worth of things.
Arthur Schopenhauer¹

One of the leaders I most respected in my US Department of Veterans Affairs (VA) career was a man who had worked his way up through the ranks to become a medical center director. Usually calm, cool, and collected, he would wax poetic when discussing the hero of the VA Health Care System revolution, Ken Kizer, MD, MPH.

In this issue of Federal Practitioner, journalist Randy Dotinga interviews Kizer about the current challenges facing the VA. Though many readers will have participated in or at least know about Kizer’s unprecedented overhaul of the agency, many others, especially those new to VA, may not. It seemed a fitting time to offer an outline of the immense and positive accomplishments that occurred in the agency during his tenure, especially as, under the current administration, many of his most forward-thinking initiatives seem to be moving backward.²

When President Clinton nominated Kizer to serve as the Under Secretary for Health for the Veterans Health Administration in 1994, the poor quality care the agency delivered was castigated in popular movies like Born on the Fourth of July. Veterans who were seen in that era, and who eventually returned to a far better, kinder VA thanks to Kizer, would often tell me, “Doc, the VA was really bad then, and I was afraid to come back.” The critique of VA health care in the mid-1990s sounds like a bureaucratic déjà vu of many of the concerns Kizer raised in his interview, including fragmentation of care, access barriers, and poor coordination of treatment.³

If anyone was prepared and qualified to take on this seeming mission impossible, it was Kizer. A US Navy veteran with 6 board certifications, he came to the VA following a brave and innovative stint as the top health official in California, where he successfully took on the tobacco lobby and dramatically reduced the state’s rates of smoking and related diseases.⁴

Long before it was the subject of reality TV shows, Kizer dubbed his major renovation of the VA’s antiquated structure an “extreme makeover.”³ Though this description is an oversimplification of Kizer’s monumental efforts, the makeover can be considered in 4 to 6 buckets, depending on how various health policy experts parse the re-engineering efforts.^5-7

Decentralization. Kizer instituted the Veterans Integrated Service Network (VISN) system to coordinate the management and operations of all the hospitals, clinics, and other VA health care entities in what is roughly a region. The locus of decision-making shifted from the VA Central Office to the VISNs, intended to promote more efficient, economical, and streamlined health care delivery.

Capitation. Accompanying this restructuring was a shift to a capitated system focused on preventive care. The Veterans Equitable Resource Allocation system was designed to logically link workload and funding. This was a major shift away from VA’s previous emphasis on inpatient and specialty care and resulted in the closing of multiple hospitals.⁴

Information Systems. I can still remember the first time I sat down at a prehistoric computer to use the Computerized Patient Record System (CPRS). Though now much maligned, then it was like something out of Star Trek, at a time when almost every other health care institution was buried in paper charts. With CPRS, VA suddenly had a pioneering and much-envied electronic medical record that facilitated continuity of care, communication between professionals, and accuracy and completeness of documentation.

Data Driven Performance Improvement. The VISNs and information systems inaugurated a new era of data-driven quality improvement. The assembly and analysis of data enabled VISNs to have real-time input about comparative facility performance.

Performance Measures. The data enabled evidence-based performance measures to be developed and monitored. Though these have now become the bane of many Federal Practitioner readers’ existence, they were originally intended for VISN directors and members of the senior executive service at VA central office. These were tied to incentives that, though recently the subject of watchdog investigation, were intended to motivate and reward high-quality care.⁶

Even this cursory look at Kizer’s accomplishments is more than enough to demonstrate the magnitude of the makeover, and when the time frame of the achievements is factored in, the transformation is the equivalent of a planet changing its orbit at light speed. Rhetoric aside, there are now hundreds of research articles published in top medical and health policy journals, many of them authored by Kizer,^7,8 that have amply demonstrated that when he departed the VA in 1999, it had become “the best care anywhere.” ⁹ For example, a 2000 New England Journal of Medicine article found that from 1994 to 2000, the percentage of veterans whose care met ≥ 90% of 9 of 17 quality standards was > 70% for 13 of the measures, outperforming fee-for-service Medicare.¹⁰

There had been uncertainty about whether Kizer would seek a second term as Under Secretary when he announced that he was leaving. With concise modesty, Kizer said he had met his charge to, “re-engineer the veterans’ health care system so that it could effectively function in the 21^st century.”¹¹

Despite openly and critically discussing the many difficulties the VA currently confronts, Kizer ends his interview on a note of hope. Since he likely knows more about VA than any person alive, we need to trust his judgment that his legacy, which currently seems more in jeopardy than ever before, will somehow prevail. Perhaps I am too melancholic, but I believe it will take a professional of the stature of Dr. Kizer to take us back to that future, and I fear we will not see his likes again.

Mostly it is loss that teaches us about the worth of things.
Arthur Schopenhauer¹

One of the leaders I most respected in my US Department of Veterans Affairs (VA) career was a man who had worked his way up through the ranks to become a medical center director. Usually calm, cool, and collected, he would wax poetic when discussing the hero of the VA Health Care System revolution, Ken Kizer, MD, MPH.

In this issue of Federal Practitioner, journalist Randy Dotinga interviews Kizer about the current challenges facing the VA. Though many readers will have participated in or at least know about Kizer’s unprecedented overhaul of the agency, many others, especially those new to VA, may not. It seemed a fitting time to offer an outline of the immense and positive accomplishments that occurred in the agency during his tenure, especially as, under the current administration, many of his most forward-thinking initiatives seem to be moving backward.²

When President Clinton nominated Kizer to serve as the Under Secretary for Health for the Veterans Health Administration in 1994, the poor quality care the agency delivered was castigated in popular movies like Born on the Fourth of July. Veterans who were seen in that era, and who eventually returned to a far better, kinder VA thanks to Kizer, would often tell me, “Doc, the VA was really bad then, and I was afraid to come back.” The critique of VA health care in the mid-1990s sounds like a bureaucratic déjà vu of many of the concerns Kizer raised in his interview, including fragmentation of care, access barriers, and poor coordination of treatment.³

If anyone was prepared and qualified to take on this seeming mission impossible, it was Kizer. A US Navy veteran with 6 board certifications, he came to the VA following a brave and innovative stint as the top health official in California, where he successfully took on the tobacco lobby and dramatically reduced the state’s rates of smoking and related diseases.⁴

Long before it was the subject of reality TV shows, Kizer dubbed his major renovation of the VA’s antiquated structure an “extreme makeover.”³ Though this description is an oversimplification of Kizer’s monumental efforts, the makeover can be considered in 4 to 6 buckets, depending on how various health policy experts parse the re-engineering efforts.^5-7

Decentralization. Kizer instituted the Veterans Integrated Service Network (VISN) system to coordinate the management and operations of all the hospitals, clinics, and other VA health care entities in what is roughly a region. The locus of decision-making shifted from the VA Central Office to the VISNs, intended to promote more efficient, economical, and streamlined health care delivery.

Capitation. Accompanying this restructuring was a shift to a capitated system focused on preventive care. The Veterans Equitable Resource Allocation system was designed to logically link workload and funding. This was a major shift away from VA’s previous emphasis on inpatient and specialty care and resulted in the closing of multiple hospitals.⁴

Information Systems. I can still remember the first time I sat down at a prehistoric computer to use the Computerized Patient Record System (CPRS). Though now much maligned, then it was like something out of Star Trek, at a time when almost every other health care institution was buried in paper charts. With CPRS, VA suddenly had a pioneering and much-envied electronic medical record that facilitated continuity of care, communication between professionals, and accuracy and completeness of documentation.

Data Driven Performance Improvement. The VISNs and information systems inaugurated a new era of data-driven quality improvement. The assembly and analysis of data enabled VISNs to have real-time input about comparative facility performance.

Performance Measures. The data enabled evidence-based performance measures to be developed and monitored. Though these have now become the bane of many Federal Practitioner readers’ existence, they were originally intended for VISN directors and members of the senior executive service at VA central office. These were tied to incentives that, though recently the subject of watchdog investigation, were intended to motivate and reward high-quality care.⁶

Even this cursory look at Kizer’s accomplishments is more than enough to demonstrate the magnitude of the makeover, and when the time frame of the achievements is factored in, the transformation is the equivalent of a planet changing its orbit at light speed. Rhetoric aside, there are now hundreds of research articles published in top medical and health policy journals, many of them authored by Kizer,^7,8 that have amply demonstrated that when he departed the VA in 1999, it had become “the best care anywhere.” ⁹ For example, a 2000 New England Journal of Medicine article found that from 1994 to 2000, the percentage of veterans whose care met ≥ 90% of 9 of 17 quality standards was > 70% for 13 of the measures, outperforming fee-for-service Medicare.¹⁰

There had been uncertainty about whether Kizer would seek a second term as Under Secretary when he announced that he was leaving. With concise modesty, Kizer said he had met his charge to, “re-engineer the veterans’ health care system so that it could effectively function in the 21^st century.”¹¹

Despite openly and critically discussing the many difficulties the VA currently confronts, Kizer ends his interview on a note of hope. Since he likely knows more about VA than any person alive, we need to trust his judgment that his legacy, which currently seems more in jeopardy than ever before, will somehow prevail. Perhaps I am too melancholic, but I believe it will take a professional of the stature of Dr. Kizer to take us back to that future, and I fear we will not see his likes again.

Mostly it is loss that teaches us about the worth of things.
Arthur Schopenhauer¹

One of the leaders I most respected in my US Department of Veterans Affairs (VA) career was a man who had worked his way up through the ranks to become a medical center director. Usually calm, cool, and collected, he would wax poetic when discussing the hero of the VA Health Care System revolution, Ken Kizer, MD, MPH.

In this issue of Federal Practitioner, journalist Randy Dotinga interviews Kizer about the current challenges facing the VA. Though many readers will have participated in or at least know about Kizer’s unprecedented overhaul of the agency, many others, especially those new to VA, may not. It seemed a fitting time to offer an outline of the immense and positive accomplishments that occurred in the agency during his tenure, especially as, under the current administration, many of his most forward-thinking initiatives seem to be moving backward.²

When President Clinton nominated Kizer to serve as the Under Secretary for Health for the Veterans Health Administration in 1994, the poor quality care the agency delivered was castigated in popular movies like Born on the Fourth of July. Veterans who were seen in that era, and who eventually returned to a far better, kinder VA thanks to Kizer, would often tell me, “Doc, the VA was really bad then, and I was afraid to come back.” The critique of VA health care in the mid-1990s sounds like a bureaucratic déjà vu of many of the concerns Kizer raised in his interview, including fragmentation of care, access barriers, and poor coordination of treatment.³

If anyone was prepared and qualified to take on this seeming mission impossible, it was Kizer. A US Navy veteran with 6 board certifications, he came to the VA following a brave and innovative stint as the top health official in California, where he successfully took on the tobacco lobby and dramatically reduced the state’s rates of smoking and related diseases.⁴

Long before it was the subject of reality TV shows, Kizer dubbed his major renovation of the VA’s antiquated structure an “extreme makeover.”³ Though this description is an oversimplification of Kizer’s monumental efforts, the makeover can be considered in 4 to 6 buckets, depending on how various health policy experts parse the re-engineering efforts.^5-7

Decentralization. Kizer instituted the Veterans Integrated Service Network (VISN) system to coordinate the management and operations of all the hospitals, clinics, and other VA health care entities in what is roughly a region. The locus of decision-making shifted from the VA Central Office to the VISNs, intended to promote more efficient, economical, and streamlined health care delivery.

Capitation. Accompanying this restructuring was a shift to a capitated system focused on preventive care. The Veterans Equitable Resource Allocation system was designed to logically link workload and funding. This was a major shift away from VA’s previous emphasis on inpatient and specialty care and resulted in the closing of multiple hospitals.⁴

Information Systems. I can still remember the first time I sat down at a prehistoric computer to use the Computerized Patient Record System (CPRS). Though now much maligned, then it was like something out of Star Trek, at a time when almost every other health care institution was buried in paper charts. With CPRS, VA suddenly had a pioneering and much-envied electronic medical record that facilitated continuity of care, communication between professionals, and accuracy and completeness of documentation.

Data Driven Performance Improvement. The VISNs and information systems inaugurated a new era of data-driven quality improvement. The assembly and analysis of data enabled VISNs to have real-time input about comparative facility performance.

Performance Measures. The data enabled evidence-based performance measures to be developed and monitored. Though these have now become the bane of many Federal Practitioner readers’ existence, they were originally intended for VISN directors and members of the senior executive service at VA central office. These were tied to incentives that, though recently the subject of watchdog investigation, were intended to motivate and reward high-quality care.⁶

Even this cursory look at Kizer’s accomplishments is more than enough to demonstrate the magnitude of the makeover, and when the time frame of the achievements is factored in, the transformation is the equivalent of a planet changing its orbit at light speed. Rhetoric aside, there are now hundreds of research articles published in top medical and health policy journals, many of them authored by Kizer,^7,8 that have amply demonstrated that when he departed the VA in 1999, it had become “the best care anywhere.” ⁹ For example, a 2000 New England Journal of Medicine article found that from 1994 to 2000, the percentage of veterans whose care met ≥ 90% of 9 of 17 quality standards was > 70% for 13 of the measures, outperforming fee-for-service Medicare.¹⁰

There had been uncertainty about whether Kizer would seek a second term as Under Secretary when he announced that he was leaving. With concise modesty, Kizer said he had met his charge to, “re-engineer the veterans’ health care system so that it could effectively function in the 21^st century.”¹¹

Despite openly and critically discussing the many difficulties the VA currently confronts, Kizer ends his interview on a note of hope. Since he likely knows more about VA than any person alive, we need to trust his judgment that his legacy, which currently seems more in jeopardy than ever before, will somehow prevail. Perhaps I am too melancholic, but I believe it will take a professional of the stature of Dr. Kizer to take us back to that future, and I fear we will not see his likes again.

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

For there was never yet philosopher that could endure the toothache patiently

Much Ado About Nothing by William Shakespeare

Almost anyone who has worked for a long time in a US Department of Veterans Affairs (VA) clinic or hospital has had patients in dire need of dental services who could neither access nor pay for them. I have seen dental problems ranging from older veterans who were nearly edentulous and needed expensive dentures or implants to younger veterans who never had regular dental care and needed a periodontist to save their teeth, to individuals with terrible toothaches that antibiotics could not cure. As Shakespeare quips in Much Ado About Nothing, almost nothing is worse than a toothache.

Many VA primary care practitioners and social workers kept lists of local sliding-scale dentists or arranged for veterans to visit dental and hygiene school clinics for reduced fees. Even when VA dentists were not permitted to see a veteran, many would assist in finding them affordable care in the community. However, that was never enough to meet the oral health needs of veterans. One of the most common complaints of patients who otherwise were pleased with their VA health care was that it did not cover dental services.¹

Most veterans qualify for health care and other VA benefits. Dental care is an exception, with only about a quarter (26%) of the > 9 million veterans active in the Veterans Health Administration (VHA) eligible for care. Even under this restricted eligibility, about 888,000 veterans have received dental services either through the VHA or in the community. In 2025, the VA paid community-based dentists for > 3.5 million procedures for veterans, which underscores the magnitude of the demand.²

Given the gap in dental care, many veterans and their caregivers both personal and professional will likely be encouraged that in February the VA announced plans to improve access to dental care through expanding community care dental services. “Dental health is a critical component of overall well-being,” VA Secretary Doug Collins noted. VA issued a request for proposals (RFP) for a new dental administrator who would oversee the operations of a new network of dental practitioners. The new vendor contract would operationalize general dental services, like tooth extractions, as well as specialized services such as periodontics, dentures, and pharmacy support for dental medications. Most importantly, the new program would cover preventive care to help avoid many of the dental problems veterans now experience. Proposals are due March 16.²

Yet, there is a catch. The community care program will only be available to eligible veterans just like previous dental services both in the VA and the community. I was always somewhat ashamed that despite my working decades at the VHA, I never had a satisfactory answer for veterans who asked me why they were not eligible for dental care. The regulatory response is that eligibility for dental services is a complex determination depending on service-connected military service, and specialized clinical indices. Dental coverage is provided for veterans who have 100% service-connected or total disability, prisoners of war, and veterans whose dental disease exacerbates a comorbid medical condition. Those not eligible for VA dental coverage may still get treatment if they, for example, have a cancer diagnosis and without dental work the chemotherapy treatment would place them at a higher risk of an oral infection. Veterans participating in a rehabilitation program who have poor dentition that prevents them from reaching their rehabilitative goals also may receive VA dental care. In addition, some veterans who are experiencing homelessness and others who did not receive a dental examination prior to discharge from active duty may be eligible for dental benefits.³ VA also offers lower-priced dental insurance for ineligible veterans.⁴

The new RFP does little to expand eligibility of veterans to receive VA dental care, and it is hard to not see the announcement as another step in the privatization of VHA. Medically and ethically, it seems to perpetuate a double standard between physical and oral health that makes no scientific sense.^5-7 I sometimes joke that in medical school we had maybe 2 days of teaching about teeth and even that limited exposure to dental pathology was sufficient for us to learn that chronic conditions like respiratory disease and lifestyle choices like poor diet cause and contribute to dental problems.

Like so many areas of veteran care, dental health in veterans is worse compared with those who never served, making it harder to justify the exclusion of dental services from veteran health benefits. A study in Military Medicine looked at 11,539 former service members and found a higher prevalence of individuals with tooth decay, missing teeth, tooth fillings, caries, and periodontitis. While military service per se was not associated with the findings, higher rates of hypertension, hyperlipidemia, depression, and diabetes in veterans compared with nonveterans, which are related to serving in uniform, were covariates.⁸

That depression is an indirect factor in dental disease may seem surprising. However, this is more evidence that human health is truly holistic, with mutual interactions between the body (including the teeth) and mind. Oral care needs to be incorporated into the VA whole health approach for all veterans. In a series of articles in Psychiatric News, VA psychiatrist Antoinette Shappell and VA dentist Pierre Cartier identify several links between dental and mental health.^9,10 Veterans with anxiety disorders may fear going to the dentist even when care is needed. Serious mental illness may result in poor diet, and difficulty performing preventive care. Many psychotropic medications may cause xerostomia that worsens tooth decay and veterans with posttraumatic stress disorder may suffer from bruxism. I regularly saw these conditions when I worked in a primary care psychiatry clinic. Being able to coordinate with VA dentists and staff to provide integrated care would have benefited these already burdened veterans.

An estimated $5.4 billion has been spent on 3.6 million veterans who were seen in emergency departments for dental problems. That cost alone should convince policy makers that the deficit in VA dental care needs to be filled with efficacious high-quality comprehensive dental services for as many veterans as possible. And there are signs that is exactly what is happening in Congress. A bill in the House of Representatives proposes to expand dental care benefits to all veterans eligible for other VA health benefits.¹¹ There are also other legislative initiatives in the works.⁴ Together with the VA’s plans for a new community care dental network, that does give veterans and federal practitioners something to smile about.

If I have seen further, it is by standing on the shoulders of giants.

Sir Isaac Newton (1642-1727) ¹

Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.

So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.² Medical media rapidly picked up the story, likely further discouraging potential applicants.³

There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.

The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”² They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.

It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.⁴ OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.

At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.² Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.⁵

It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”⁶

What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”⁷

The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.⁶ As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”⁷

Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.⁸

The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.⁹ Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value. 

Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.¹ It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?

If I have seen further, it is by standing on the shoulders of giants.

Sir Isaac Newton (1642-1727) ¹

Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.

So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.² Medical media rapidly picked up the story, likely further discouraging potential applicants.³

There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.

The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”² They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.

It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.⁴ OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.

At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.² Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.⁵

It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”⁶

What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”⁷

The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.⁶ As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”⁷

Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.⁸

The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.⁹ Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value. 

Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.¹ It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?

If I have seen further, it is by standing on the shoulders of giants.

Sir Isaac Newton (1642-1727) ¹

Early in residency, I decided I only wanted to work at the US Department of Veterans Affairs (VA). It was a way to follow the example of service that my parents, an Army doctor and nurse, had set. I spent much of my residency, including all of my last year of training, at a VA medical center, hoping a vacancy would open in the psychiatry service. In those days, VA jobs were hard to come by; doctors spent their entire careers in the system, only retiring after decades of commitment to its unique mission. Finally, close to graduation, one of my favorite attending physicians left his post. After mountains of paperwork and running the human resources obstacle course with the usual stumbles, I arrived at my dream job as a VA psychiatrist.

So, it is with immense sadness and even shock that I read a recent ProPublica article reporting that from January to March 2025 almost 40% of the physicians who received employment offers from the Veterans Health Administration (VHA) declined the positions.² Medical media rapidly picked up the story, likely further discouraging potential applicants.³

There have always been health care professionals (HCPs) who had zero interest in working for the VA. Medical students and residents often have a love/hate relationship with the VA, with some trainees not having the patience for the behemoth pace of the bureaucracy or finding the old-style physical environment and more relaxed pace antiquated and inefficient.

The reasons doctors are saying no to VA employment at 4 times the previous rate are different and more disturbing. According to ProPublica, VA officials in Texas reported in a June internal presentation that about 90 people had turned down job offers due to the “uncertainty of reorganization.”² They reported that low morale was causing existing employees to recommend against working at the VA. My own anecdotal experience is similar: contrary to prior years, few residents, if any, are interested in working at the VA because of concerns about the stability of employment and the direction of its organizational culture.

It is fair to question the objectivity of the ProPublica report. However, the latest VA Office of the Inspector General (OIG) analysis of staffing had similar findings. “Despite the ability to make noncompetitive appointments for such occupations, VHA continues to experience severe occupational staffing shortages for these occupations that are fundamental to the delivery of health care.” The 4434 severe occupational shortage figures in fiscal year (FY) 2025 were 50% higher than in FY 2024.⁴ OIG reported that 57% of facilities noted severe occupational staffing shortages for psychology, making it the most frequently reported clinical shortage.

At this critical juncture, when new health care professional energy is not flowing into the VHA, there is an unprecedented drain of the lifeblood of any system—the departure of the bearers of institutional memory. Early and scheduled retirements, the deferred resignation program, and severance have decimated the ranks of senior HCPs, experienced leaders, and career clinicians. ProPublica noted the loss of 600 doctors and 1900 nurses at the VHA so far in 2025.² Internal VA data from exit interviews suggest similar motivations. Many cited lack of trust and confidence in senior leaders and job stress/pressure.⁵

It should be noted the VA has an alternative and plausible explanation for the expected departure of 30,000 employees. They argue that the VHA was overstaffed and the increased workforce decreased the efficiency of service. Voluntary separation from employment, VA contends, has avoided the need for a far more disruptive reduction in force. VA leaders avow that downsizing has not adversely impacted its ability to deliver high-quality health care and benefits and they assert that a reduction in red tape will enable VA to provide easier access to care. VA Secretary Doug Collins has concluded that because of these difficult but necessary changes, “VA is headed in the right direction.”⁶

What is institutional memory, and why is it important? “The core of institutional memory is collective awareness and understanding of a collective set of facts, concepts, experiences, and know-how,” Bhugra and Ventriglio explain. “These are all held collectively at various levels in any given institution. Thus, collective memory or history can be utilized to build on what has gone before and how we take things forward.”⁷

The authors of this quote offer a modern twist on what Sir Isaac Newton described in more metaphorical language in the epigraph: to survive, and even more to thrive, an enterprise must have those who have accumulated technical knowledge and professional wisdom as well as those who assume responsibility for appropriating and adding to this storehouse of operational skill, expertise, unique cultural values, and ethical commitments. The VHA is losing its instructors and students of institutional memory which deals a serious blow to the stability and vitality of any learning health system.⁶ As Bhugra and Ventriglio put it, institutional memory identifies “what has worked in delivering the aims in the past and what has not, thereby ensuring the lessons learnt are remembered and passed on to the next generation.”⁷

Nearly every week, at all levels of the agency, I have encountered this exodus of builders and bearers of institutional memory. Those who have left did so for many of the same reasons cited by those who declined to come, leaving incalculable gaps at both ends of the career spectrum. Both the old and new are essential for organizational resilience: fresh ideas enable an institution to be agile in responding to challenges, while operational savvy ensures responses are ecologically aligned with the organizational mission.⁸

The dire shortage of HCPs—especially in mental health and primary care—has opened up unprecedented opportunities.⁹ Colleagues have noted that with only a little searching they found multiple lucrative positions. Once, HCPs picked the VA because they valued the commitment to public service and being part of a community of education and research more than fame or fortune. Having the best benefits packages in the industry only reinforced its value. 

Even so, surpassing a genius such as Sir Isaac Newton, writing to a scientific competitor, Robert Hooke, recognized that progress and discovery in science and medicine are nigh well impossible without the collective achievements housed in institutional memory.¹ It was inspiring teachers and attending physicians—Newton’s giants—who attracted the best and brightest in medicine and nursing, other HCPs, and research, to the VA, where they could participate in a transactive organizational learning process from their seniors, and then grow that fund of knowledge to improve patient care, educate their learners, and innovate. What will happen when there are no longer shoulders of giants or anyone to stand on them?

The better part of valor is discretion.

Henry IV, Part 1 by William Shakespeare¹

This is the second part of an exploration of the phenomenon of stolen valor, where individuals claim military exploits or acts of heroism that are either fabricated or exaggerated, and/or awards and medals they did not earn.² In June, I focused on the unsettling story of Sarah Cavanaugh, a young US Department of Veterans Affairs (VA) social worker who posed as a decorated, heroic, and seriously wounded Marine veteran for years. Cavanaugh’s manipulative masquerade allowed her to receive coveted spots in veteran recovery programs, thousands of dollars in fraudulent donations, the leadership of a local Veterans of Foreign Wars post, and eventually a federal conviction and prison sentence.³ The first column focused on the legal history of stolen valor; this editorial analyzes the clinical import and ethical impact of the behavior of military imposters. Military imposters are the culprits who steal valor.

It would be easy and perhaps reassuring to assume that stolen valor has emerged as another deplorable example of a national culture in which the betrayal of trust in human beings and loss of faith in institutions and aspirations has reached a nadir. Ironically, stolen valor is inextricably linked to the founding of the United States. When General George Washington inaugurated the American military tradition of awarding decorations to honor the bravery and sacrifices of the patriot Army, he anticipated military imposters. He tried to deter stolen valor through the threat of chastisement: “Should any who are not entitled to these honors have the insolence to assume the badges of them, they shall be severely punished,” Washington warned.⁴

It is plausible to think such despicable conduct occurs only as the ugly side of the beauty of our unparalleled national freedom, but this is a mistake. Cases of stolen valor have been reported in many countries around the world, with some of the most infamous found in the United Kingdom.⁵

While many brazen military imposters like Cavanaugh never serve, there is a small subset who honorably wore a uniform yet embellish their service record with secret missions and meritorious gallantry that purportedly earned them high rank and even higher awards. A most puzzling and disturbing example of this group is an allegation that surfaced when celebrated Navy SEAL Chris Kyle declared in American Sniper that he had won 3 additional combat awards for combat valor in addition to the Silver Star and 3 Bronze Stars actually listed in his service record.⁶

The fact that for centuries stolen valor has plagued multiple nations suggests, at least to this psychiatrically trained mind, that something deeper and darker in human nature than profit alone drives military imposters. Philosopher Verna Gehring has distilled these less tangible motivations into the concept of virtue imposters. According to Gehring, military phonies are a notorious exemplar: “The military phony adopts a past not her own, acts of courage she did not perform—she impersonates the heroic character and virtues she does not possess.”⁷ There could be no more apposite depiction of Cavanaugh, other military imposters, or a legion of other offenders of honor. ⁸

As with Cavanaugh, financial gain is a byproduct of the machinations of military imposters and is usually secondary to the pursuit of nonmaterial rewards such as power, influence, admiration, emulation, empathy, and charity. Gehring contends, and I agree, that virtue imposters are more pernicious and culpable than the plethora of more prosaic scammers and swindlers who use deceit primarily as a means of economic exploitation: “The virtue impostor by contrast plays on people’s better natures—their generosity, humility, and their need for heroes.”⁷

Military imposters cause real and lasting harm. Every veteran who exaggerates claims or scams the VA unjustly steals human and monetary resources from other deserving veterans whose integrity would not permit them to break the rules.⁹ Yet, even more harmful is the potential damage to therapeutic relationships: federal practitioners may become skeptical of a veteran’s history even when there is little to no grounds for suspicion. Veterans, in turn, may experience a breach of trust and betrayal not only from health care professionals and VA leaders but from their brothers and sisters in arms. On an ever-wider scale, every military impostor who is exposed may diminish the respect and honor all veterans have earned. 

It is clear, then, why a small group of former service members has adopted the cause of uncovering military imposters and adroitly using the media to identify signs of stolen valor.¹⁰ Yet deception mars even these mostly well-intentioned campaigns, as some more zealous stolen valor hunters may make allegations that turn out to be false.¹¹ Nevertheless, 500 years ago and in a very different context Shakespeare was, right on the mark: the better part of valor is discretion in describing one’s achievements, in relying on the veracity of our veteran’s narratives, and when there are sound reasons to do so verifying the truth of what our patients, friends, and even family tell us about their time in the military.¹

The better part of valor is discretion.

Henry IV, Part 1 by William Shakespeare¹

This is the second part of an exploration of the phenomenon of stolen valor, where individuals claim military exploits or acts of heroism that are either fabricated or exaggerated, and/or awards and medals they did not earn.² In June, I focused on the unsettling story of Sarah Cavanaugh, a young US Department of Veterans Affairs (VA) social worker who posed as a decorated, heroic, and seriously wounded Marine veteran for years. Cavanaugh’s manipulative masquerade allowed her to receive coveted spots in veteran recovery programs, thousands of dollars in fraudulent donations, the leadership of a local Veterans of Foreign Wars post, and eventually a federal conviction and prison sentence.³ The first column focused on the legal history of stolen valor; this editorial analyzes the clinical import and ethical impact of the behavior of military imposters. Military imposters are the culprits who steal valor.

It would be easy and perhaps reassuring to assume that stolen valor has emerged as another deplorable example of a national culture in which the betrayal of trust in human beings and loss of faith in institutions and aspirations has reached a nadir. Ironically, stolen valor is inextricably linked to the founding of the United States. When General George Washington inaugurated the American military tradition of awarding decorations to honor the bravery and sacrifices of the patriot Army, he anticipated military imposters. He tried to deter stolen valor through the threat of chastisement: “Should any who are not entitled to these honors have the insolence to assume the badges of them, they shall be severely punished,” Washington warned.⁴

It is plausible to think such despicable conduct occurs only as the ugly side of the beauty of our unparalleled national freedom, but this is a mistake. Cases of stolen valor have been reported in many countries around the world, with some of the most infamous found in the United Kingdom.⁵

While many brazen military imposters like Cavanaugh never serve, there is a small subset who honorably wore a uniform yet embellish their service record with secret missions and meritorious gallantry that purportedly earned them high rank and even higher awards. A most puzzling and disturbing example of this group is an allegation that surfaced when celebrated Navy SEAL Chris Kyle declared in American Sniper that he had won 3 additional combat awards for combat valor in addition to the Silver Star and 3 Bronze Stars actually listed in his service record.⁶

The fact that for centuries stolen valor has plagued multiple nations suggests, at least to this psychiatrically trained mind, that something deeper and darker in human nature than profit alone drives military imposters. Philosopher Verna Gehring has distilled these less tangible motivations into the concept of virtue imposters. According to Gehring, military phonies are a notorious exemplar: “The military phony adopts a past not her own, acts of courage she did not perform—she impersonates the heroic character and virtues she does not possess.”⁷ There could be no more apposite depiction of Cavanaugh, other military imposters, or a legion of other offenders of honor. ⁸

As with Cavanaugh, financial gain is a byproduct of the machinations of military imposters and is usually secondary to the pursuit of nonmaterial rewards such as power, influence, admiration, emulation, empathy, and charity. Gehring contends, and I agree, that virtue imposters are more pernicious and culpable than the plethora of more prosaic scammers and swindlers who use deceit primarily as a means of economic exploitation: “The virtue impostor by contrast plays on people’s better natures—their generosity, humility, and their need for heroes.”⁷

Military imposters cause real and lasting harm. Every veteran who exaggerates claims or scams the VA unjustly steals human and monetary resources from other deserving veterans whose integrity would not permit them to break the rules.⁹ Yet, even more harmful is the potential damage to therapeutic relationships: federal practitioners may become skeptical of a veteran’s history even when there is little to no grounds for suspicion. Veterans, in turn, may experience a breach of trust and betrayal not only from health care professionals and VA leaders but from their brothers and sisters in arms. On an ever-wider scale, every military impostor who is exposed may diminish the respect and honor all veterans have earned. 

It is clear, then, why a small group of former service members has adopted the cause of uncovering military imposters and adroitly using the media to identify signs of stolen valor.¹⁰ Yet deception mars even these mostly well-intentioned campaigns, as some more zealous stolen valor hunters may make allegations that turn out to be false.¹¹ Nevertheless, 500 years ago and in a very different context Shakespeare was, right on the mark: the better part of valor is discretion in describing one’s achievements, in relying on the veracity of our veteran’s narratives, and when there are sound reasons to do so verifying the truth of what our patients, friends, and even family tell us about their time in the military.¹

The better part of valor is discretion.

Henry IV, Part 1 by William Shakespeare¹

This is the second part of an exploration of the phenomenon of stolen valor, where individuals claim military exploits or acts of heroism that are either fabricated or exaggerated, and/or awards and medals they did not earn.² In June, I focused on the unsettling story of Sarah Cavanaugh, a young US Department of Veterans Affairs (VA) social worker who posed as a decorated, heroic, and seriously wounded Marine veteran for years. Cavanaugh’s manipulative masquerade allowed her to receive coveted spots in veteran recovery programs, thousands of dollars in fraudulent donations, the leadership of a local Veterans of Foreign Wars post, and eventually a federal conviction and prison sentence.³ The first column focused on the legal history of stolen valor; this editorial analyzes the clinical import and ethical impact of the behavior of military imposters. Military imposters are the culprits who steal valor.

It would be easy and perhaps reassuring to assume that stolen valor has emerged as another deplorable example of a national culture in which the betrayal of trust in human beings and loss of faith in institutions and aspirations has reached a nadir. Ironically, stolen valor is inextricably linked to the founding of the United States. When General George Washington inaugurated the American military tradition of awarding decorations to honor the bravery and sacrifices of the patriot Army, he anticipated military imposters. He tried to deter stolen valor through the threat of chastisement: “Should any who are not entitled to these honors have the insolence to assume the badges of them, they shall be severely punished,” Washington warned.⁴

It is plausible to think such despicable conduct occurs only as the ugly side of the beauty of our unparalleled national freedom, but this is a mistake. Cases of stolen valor have been reported in many countries around the world, with some of the most infamous found in the United Kingdom.⁵

While many brazen military imposters like Cavanaugh never serve, there is a small subset who honorably wore a uniform yet embellish their service record with secret missions and meritorious gallantry that purportedly earned them high rank and even higher awards. A most puzzling and disturbing example of this group is an allegation that surfaced when celebrated Navy SEAL Chris Kyle declared in American Sniper that he had won 3 additional combat awards for combat valor in addition to the Silver Star and 3 Bronze Stars actually listed in his service record.⁶

The fact that for centuries stolen valor has plagued multiple nations suggests, at least to this psychiatrically trained mind, that something deeper and darker in human nature than profit alone drives military imposters. Philosopher Verna Gehring has distilled these less tangible motivations into the concept of virtue imposters. According to Gehring, military phonies are a notorious exemplar: “The military phony adopts a past not her own, acts of courage she did not perform—she impersonates the heroic character and virtues she does not possess.”⁷ There could be no more apposite depiction of Cavanaugh, other military imposters, or a legion of other offenders of honor. ⁸

As with Cavanaugh, financial gain is a byproduct of the machinations of military imposters and is usually secondary to the pursuit of nonmaterial rewards such as power, influence, admiration, emulation, empathy, and charity. Gehring contends, and I agree, that virtue imposters are more pernicious and culpable than the plethora of more prosaic scammers and swindlers who use deceit primarily as a means of economic exploitation: “The virtue impostor by contrast plays on people’s better natures—their generosity, humility, and their need for heroes.”⁷

Military imposters cause real and lasting harm. Every veteran who exaggerates claims or scams the VA unjustly steals human and monetary resources from other deserving veterans whose integrity would not permit them to break the rules.⁹ Yet, even more harmful is the potential damage to therapeutic relationships: federal practitioners may become skeptical of a veteran’s history even when there is little to no grounds for suspicion. Veterans, in turn, may experience a breach of trust and betrayal not only from health care professionals and VA leaders but from their brothers and sisters in arms. On an ever-wider scale, every military impostor who is exposed may diminish the respect and honor all veterans have earned. 

It is clear, then, why a small group of former service members has adopted the cause of uncovering military imposters and adroitly using the media to identify signs of stolen valor.¹⁰ Yet deception mars even these mostly well-intentioned campaigns, as some more zealous stolen valor hunters may make allegations that turn out to be false.¹¹ Nevertheless, 500 years ago and in a very different context Shakespeare was, right on the mark: the better part of valor is discretion in describing one’s achievements, in relying on the veracity of our veteran’s narratives, and when there are sound reasons to do so verifying the truth of what our patients, friends, and even family tell us about their time in the military.¹

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

April is the cruellest month, breeding
Lilacs out of the dead land, mixing
Memory and desire, stirring
Dull roots with spring rain.
T.S. Eliot¹

The epigraph for this column is from The Waste Land, T.S. Eliot’s postmodern poem that, in part, reflects his experience of the destruction of an entire way of living and a generation of young men in the wake of the First World War. The terrible contemporary toll suicide has taken on veterans and the active-duty military makes it easy to forget that suicide is an inveterate and disturbing aftermath of all wars.²

There is a profound and elemental connection in the human mind between Spring and renewal. In almost every culture and religion, across nearly every historical epoch and location, Spring is associated with themes of growth, returning life, light, and hope. On a more prosaic modern level, almost all of us—us—especially those in Northern climates—look forward to warmer weather, more time spent outdoors, and the simple joys of seeing perennials return in the garden and birds nest in blooming trees.

It is a paradox of human life that suicide is more common in the season of rebirth than in the season of decline. The bare trees, freezing temperatures, and icy darkness that accompany winter in much of the world inherently lead us to contemplate our mortality. The counterintuitive finding that individuals, many of them veterans, take their own lives more often in Spring creates a cognitive dissonance to be explored in this editorial.

As a layperson, I too assumed there were more suicides in winter, especially around the holidays when the expectation of belonging, privilege, and pleasure painfully reminds the alienated, lonely, homeless, and ailing of all they lack and all they have lost. As a psychiatric intern, I anticipated that the inpatient US Department of Veterans Affairs (VA) ward where I was training would empty with the arrival of nicer weather. Instead, I was mystified when the opposite occurred and the unit was overflowing with manic and suicidal patients.

The Centers for Disease Control and Prevention National Center for Health Statistics ranked suicide by month from 1999 to 2010. Contrary to popular belief, more suicides occurred in late Spring and Summer than any other season.³ A 2023 study of systematic reviews of seasonal variation in mood disorders, suicide risk, and health care utilization found that suicide was 11% to 23% higher, suicide attempts resulting in emergency department visits showed an increase of 1.2% to 1.7%, and hospital admissions for mania rose 7.4% to 16.0% in Spring and Summer, compared with Fall and Winter.⁴ This general population finding is also seen in veteran and military cohorts. A recent study analyzed VA and US Department of Defense (DoD) data from 133,867 veteran suicides from 2001 to 2021. Results showed that veteran suicides were highest in Summer.⁵

The rise of suicide in the Spring was first observed in the 17th century and has been the object of scientific study for at least 3 decades. That research has produced several different hypotheses from a variety of disciplines, none of which are conclusive as of this writing. Cho and Lee note that the phrase “Spring fever” is a much more serious illness for those with a predisposition or diagnosis of unipolar or bipolar disorder than the quotidian irritant that afflicts those without affective disorders.⁶ In residency, I learned that longer exposure to light in Spring led to an imbalance in neurotransmitters that triggered manias. This is a simplistic version of the complex circadian interactions of temperature, climate, light, and other environmental variables causing dysregulation or misalignment of our natural biological cycles and those of nature proposed by chronobiologists.⁷

Sociological and criminal justice scholars underscore that an increase in temperature may exacerbate violent tendencies, especially in older males—a demographic profile more frequently found in veterans—and those already prone to acting out their frustrations with firearms.⁸ Psychologists have hypothesized that individuals with depressions persevere through Winter by telling themselves they will feel relief in the Spring. Too often the coming of Spring brings not reprieve but a deadly combination of deeper mental desperation coupled with the release from winter lassitude that energizes the now hopeless person to put ideation into action.^4,9 The elevation of suicide rates in Spring is likely multidetermined with all these putative causes contributing in different variations to every individual who tragically dies by suicide.

Yet despite decades of public education, this dangerous fiction stubbornly persists in the educated public and even among many health care professionals, in part due to misguided media. For years, the Annenberg Public Policy Center (APPC) has made busting this myth of holiday suicides in the media an organizational initiative. A 2023 APPC survey found that 4 of 5 Americans picked December as the month when suicide rates were highest. The organization has been analyzing holiday—related media reports for decades; those results show some improvement, with the most recent analysis of media reports somewhat better and 40% communicating erroneous information. ¹⁰

APPC believes the opinion that suicide is more common around the holidays will persuade those struggling with an exacerbation of a mental health condition or an acute crisis to attempt or die by suicide, believing it to be a reasonable social response. While recognizing there is a real risk of such contagion behavior, I believe the reverse problem is more concerning. As I observed during my internship, the acceptance of the fiction that everyone is happy in Spring may even blind health care professionals from detecting clues that patients and even our loved ones are contemplating suicide. Our relief that Winter has passed and enjoyment of Spring activities can fool us into believing everyone else is also feeling fine and doing well and miss an opportunity to intervene and treat mania or depression to save a life—the medical manifestation of renewal.

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴

We have a tradition at Federal Practitioner where the December editorial usually features some version of the “best and worst” of the last 12 months in government health care. As we close out a difficult year, instead I offer a cautionary yet promising story that epitomizes both risk and benefit.

In some quarters, 2024 has been the year of AI (artificial intelligence).² While in science fiction, superhuman machines, like the Terminator, are often associated with apocalyptic threats, we often forget the positive models of human-technology interaction, such as the protective robot in Lost in Space. While AI is not yet as advanced as what has already been depicted on the screen, it is inextricably interwoven into the daily fabric of our lives. Almost any website you go to for business or pleasure has a chatbot waiting to help (or frustrate) you. Most of us have Alexa, Siri, or another digital assistant organizing our homes and schedules. When I Google “everyday uses of artificial intelligence,” it is AI that responds with an overview.

Medicine is not immune. Renowned physician and scientist Eric Topol, MD, suggests that AI represents a “fourth industrial revolution in medicine” that can dramatically improve health care.³ The US Department of Veterans Affairs (VA) has been at the forefront of this new space.⁴ The story recounted below encapsulates the enormous benefits AI can bring to health care and the vigilance we must exercise to anticipate and mitigate risk for this to be an overall positive transition.

The story begins with a key element of AI change—the machine learning predictive algorithm. In this case, the algorithm was designed to predict—and thereby prevent—the top public health priority in federal practice: suicide. The Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was launched in 2017 to assist in identifying the top 0.1% of veterans at the highest risk for suicide.⁵

At least at this stage of AI in medicine, the safest and most ethical efforts come from collaborations between health care professionals and AI developers that maximize the very different strengths of each partner. REACH VET is an exemplar of this kind of teamwork. Once the algorithm analyzes > 60 variables to identify veterans at high risk for suicide, data are communicated to a REACH VET program coordinator, who then notifies the practitioner responsible for the veteran’s care so they can put into action evidence-based suicide prevention strategies.⁵

VA researchers in 2021 published a study of 173,313 veterans comparing outcomes before and after entry into the program using a triple differences design. Veterans participating in the program reported an increase in outpatient visits and documentation of safety plans, and a decrease in emergency department visits, inpatient mental health admissions, and recorded suicide attempts.⁶

A US Government Accounting Office analysis found that “REACH VET had identified veterans who had not been identified through other methods.”⁷ This was not just an example of AI hype: as a relatively rare and statistically complicated phenomenon, suicide is notoriously difficult to predict and model. Machine learning algorithms like REACH VET have unprecedented potential to assist and augment suicide prevention.⁸

In 2023, veteran service organizations and journalists raised concerns that the AI algorithm was biased and ignored critical risk factors that put some veterans at increased risk. Based on their analysis, they claimed that the algorithm did not account for risk factors uniquely associated with women veterans, namely military sexual trauma and intimate partner violence.⁹ Women are the most rapidly growing VA population, yet too often they encounter health care disparities, harassment, and stigmatization when seeking care. The Congressional Veterans Affairs committees investigated and introduced legislation to update the algorithm.¹⁰

VA experts dispute these claims, and a computer science PhD may be required to understand the debate. But as the history of medicine has shown us, every treatment and procedure has benefits and risks. No matter how bright and shiny the technology initially appears, a soft scientific underbelly emerges sooner or later. Just as with REACH VET, algorithm bias is often discovered during deployment when the logic of the laboratory encounters the unpredictable variety of humankind.¹¹ Frequently, those problems are—as with REACH VET— not solely or even primarily technical ones. The data mirror society and reflect its biases.

For learning organizations like the VA and the US Department of Defense (DoD), the criticisms of REACH VET signal the need to engage in continuous performance improvement. AI requires the human trainers and supervisors who teach the machines to continuously revise and update their lesson plans. The most recent VA data show that in 2021, 6392 veterans died by suicide.¹² In Congressional testimony, VA leaders reported that as of May 2024, REACH VET was operating in 28 VA facilities and had identified 6700 high-risk veterans.13 REACH VET can save veteran’s lives, which is the sine qua non for our federal health care systems.

The algorithm should be improved to identify ALL veterans so they receive lifesaving interventions. Every veteran’s life is sacred; the algorithm that may prevent suicide must be continuously improved. That is why our representatives did not propose to ban REACH VET or enforce an AI winter on the VA and DoD. Instead, they called for an update to the algorithm, underscoring the value of machine learning for suicide prediction and prevention.

The epigraph from one of the top AI ethicists and scientists in the world makes the point that AI is not the moral agent here: it is fallible humans who must keep learning along with machines. That is why, at the end of 2024, VA experts are revising the algorithm so REACH VET can help prevent even more veteran suicides in 2025 and beyond.¹⁴