Obama, Media Owe Dr. Perez An Apology

"To hear that a VA official is promoting misdiagnoses of soldiers to save money is unacceptable and is tantamount to fraud. " -- Letter from Barak Obama to Veterans Affairs Secretary James Peake

Obama is just plain, flat out wrong. There are no "misdiagnoses" to save money advocated for in this memo. It is Differential Diagnosis she is calling for. There may well be a fraud here but it is not Dr. Perez. It is fraud for the media and Obama to perpetuate a falsehood.

The Washington Post broke the story on Friday, which included emails from Dr. Norma Perez suggesting to her staff members that they "refrain from giving a diagnosis of PTSD straight out," because of the increasing costs of treating the disorder. -- From CBS News website

I have been a vocal critic of the actions of the VA and its legislative overseers in the treatment of veterans ,especially in regard to PTSD. However, I am appalled at the piling on of Dr. Perez and the poor judgment Obama has shown in his egregious allegations that she was advocating for "misdiagnoses". This demonstrates a failure to get adequate, expert information and also demonstrates an impulsive rush to judgment, weighing in on topics he is clearly ignorant about, and causing harm to a healthcare worker already burdened by an underfunded system which is being slammed by a tsunami of need.

Yesterday, I spent a good bit of time on the phone with Pia Malbran of CBS News in Miami discussing their coverage of this story and what I feel is their over the top, misinformed, and false conclusions regarding what Dr. Perez intended by her memo. Dr. Perez made a good ,solid, clinically appropriate call in her memo for the front line assessment clinicians to consider the Adjustment Disorder Rule Out PTSD diagnosis. Let me make my case to you so you will understand that what appears on its face to be a dirty rotten scoundrel attack on our veterans is nothing of the sort.

For all of you civilians (meaning non-clinical commoners) what Dr. Perez was calling for in her memo was for the assessment clinicians to pay extra close attention to their DIFFERENTIAL DIAGNOSIS. This refers to the process of diagnosis when a clinician looks at a set of symptoms and makes a call :it is like this diagnosis, but not like this, it has features of this, but not this, it could be this but fails to meet all the criteria so it might be this, or it looks like this but the CAUSE of the symptoms might be from a number of different sources. With anxiety symptoms presented by a service member--many of which are consistent with PTSD, one cannot make that call without ruling out other causes of those symptoms.

Everyone has their pantyhose in a twist alleging that Perez was telling clinicians to falsify the diagnosis by calling it Adjustment Disorder rule out PTSD. This is an absolute falsehood. Let me provide an example to illustrate the process:

Sgt. Joe presents to the VA with a set of anxiety symptoms that look like PTSD. The clinician documents that Joe just got back from Iraq three weeks ago and has had these symptoms for two months. A poor diagnostician would judge that "Wow this looks just like PTSD to me" and charts the diagnosis. Except for the fact that it fails to meet a critical criteria for a definitive diagnosis. An experienced, expert clinician would look at the same case and call it Adjustment Disorder r/o PTSD--which is to say "Gee it kinda looks like PTSD but I am not sure because he just got back and the aversive event was JUST a couple of months ago--maybe it is an Adjustment Disorder. I can't really tell right now so I must wait and gather more data." A Rule Out diagnosis is called a PROVISIONAL diagnosis--a temporary diagnosis until one can make a definitive diagnosis.

So why call it an Adjustment Disorder? Well, it is a normal reaction to stress and it resolves within 6 months. How do I rule out PTSD? Well, a good start is that if it doesn't resolve after 6 months it CANNOT BE AN ADJUSTMENT DISORDER. And it is probably PTSD. A provisional diagnosis would not prevent a subsequent diagnosis of PTSD. A provisional diagnosis should never be used to deny service connected disability benefits for it only says that a solid diagnosis has not yet been made. The proper use of a provisional is to allow time to come up with a definitive diagnosis. See why this whole hoopla is crapla?

PTSD, contrary to some media reports which report that "First, PTSD is NOT mental illness" IS a very serious illness. Just ask a vet with it. Or a family member of one. But there is a very good reason to be very careful with laying it on someone fresh from the aversive event: Any diagnosis becomes a permanent part of a legal record--your medical record. It is subject to subpoena and in some cases can complicate life choices. There are current movements to make mental illness a reason to deny one the right to carry a firearm.

One does not make a diagnosis of PTSD lightly but clinicians both stateside and in the theatre often seize upon the "diagnosis du jour" and see it in everyone presenting for treatment--especially when you are being slammed and don't have the time or resources to make a more sensitive and accurate diagnosis. It happens with children and the ADHD/ADD diagnosis and is now beginning to be seen with BiPolar Illness in kids as well. Stateside, many many non- military patients are presenting with PTSD like symptoms and telling their therapists that they are certain that they have the disorder when in fact they are having a normal reaction to an aversive stressor that may very well resolve in 6 months. For Perez to remind her clinicians to take care with their diagnoses and to consider that they may be seeing an adjustment reaction is APPROPRIATE. Perez said that they didn't have the resources to make the PTSD diagnosis. I don't hear anybody squawking about THAT except me! Why don't they?

It is a fact that they are getting slammed with a huge number of cases. It is a fact that these cases will cost a great deal of money over the next decades for PTSD is extremely resistant to treatment and there is no known cure. It is a fact that a good clinical manager of any healthcare facility keeps their eyes on clinically appropriate diagnosis AND utilization management--making sure services are not over utilized OR under utilized. She was just doing her job and she made a good call. The VA official who sanctioned her may well have been trying to stem the PR bleed on a very hot button topic. It is very difficult to try to explain differential diagnosis to civilians. Stop the bleed. But they hung her out to dry just as Obama is piling on to make a case for himself as being all Hallmark card on veterans healthcare. The media is wrong . Obama is wrong. Perez made a totally appropriate call. Differential diagnosis is good medicine. But is obviously a dangerous weapon in the hands of the ignorant.

The REAL story with diagnosis and PTSD is the use of Personality Disorders as a pre-existing condition that would deny a veteran benefits precisely because it so interferes with the differential diagnosis process. Personality Disorders frequently feature manipulativeness, gaming, untruthfulness, malingering etc--in other words, you may not be able to believe a word they say. So how can you make a PTSD diagnosis if they are lying to you? That would give them a clinical basis to deny benefits and, according to my veteran buddies, IS being utilized to deny benefits. I am still not convinced that one cannot be a Borderline Personality Disorder and still be at risk for PTSD. I cannot find that chapter in the DSM-IV-TR but that is the wiggle room the VA allegedly is using to deny a service connected disability to some veterans.

Obama and Media, you need apologize to Dr. Perez. She is busting her chops for our military and ex-military and you, from your lofty non-military or mental healthcare experienced perch, need to get the facts Jack before you attack.

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But I get the feeling You Didn't See the E-Mail, You most certainly Don't Know Who Broke this out, it Wasn't the Media, it Was Vote Vets and CREW who received it from one who was sent the E in the forst place!

Suggest you Visit Brandon's Post at Vet Voice, a copy of the E is within the post, from there it Hit the MSM, not the other way around!!!!!!!!!!!!!!!!!

The VA personal work very hard with what their given, but this E was an Uncalled For Policy request, wether it came only from the one who sent it or was pushed on that sender, it certainly Isjn't How You Describe It!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

No offense intended but I don't understand what you are saying here. What's an E? What's an Uncalled For Policy request? Who sent what to whom? Can you explain for those of us who are not in the know?

Thank you.


E: explains itself but 'e-mail'

Uncalled For Policy Request: explains itself but 'change or demand against a policy that exists'

Sent What to Whom: explains itself but 'link to e {i.e. e-mail} within post is RIGHT THERE!!!!!!!!!!!!!!!!!!!!!!!!!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

I didn't say the media or Obama broke the story. I said they made false assumptions and accusations unsupported by the memo. I am simply posing another interpretation of the memo from one who has been in the position to supervise many clinicians at once who are imprecise in their diagnoses especially when understaffed and dealing with high caseloads. It is not uncommon to see the presenting symptoms with a cookie cutter mentality especially when it is a disorder as high profile as PTSD. I am defending Perez because there are many assumptions made that defame her and her intentions that cannot be supported by anything other than that the VA has done some crappy cost cutting measures. Everyone is assuming that this is another. I am posing another explanation.

I said they made false assumptions and accusations unsupported by the memo. I am simply posing another interpretation of the memo from one who has been in the position to supervise many clinicians at once who are imprecise in their diagnoses especially when understaffed and dealing with high caseloads.

What false assumtions, the E-Mail is Very Clear!!

Another Interpretation? I think not, as I said you Didn't read the e, you instead started spinning a fabrication and accusing others of Assuming Wrong!!

I understand 'understaffing' and 'high caseloads' and as for the VA system, being a Vet, understand Only Too Well the Lack of Support and Monies Needed and not wanted to pay, by this Country For Care of it's Veterans!

I also understand the dedication of the many VA Care workers and volunteers and sadly when these things hit they are the ones accused, but the one who wrote this either did it on their own or was part and partial to a group think!

Luckily I don't have any known negatives of physical nor mental health problems from my Service, 'Nam included, but do know Way Too Many, not only my brother 'Nam Vets, who have had these types of Policies placed in front of them like Walls, we've been Fighting Them For Years and Continue To Do So!!!!!!!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

I am betting that DEFuning is only interested in finding out the truth. She wrote the The Politics of PTSD: Blaming the Veteran series... way back in 2006 -- and probably is one of the first persons to start blowing the whistle on Sally Satel who was actively working to deny Veterans the PTSD diagnosis and instead substitute 'pre-existing condition' type shell games...

If the VA is trying to deny benefits for PTSD they have many other more effective ploys than to use a provisional diagnosis. I am always on the lookout for BushCo to deny veterans benefits and am a very vocal critic. I just honestly can see another very plausible explanation for this memo that the media and most of those weighing in to bash Perez do not see. Just as I don't want to see the veterans get screwed to further a political agenda, I also do not want to see a fellow mental health care professional get screwed to further a political agenda--in this case Obama's.
If he is so concerned about veterans, where has his advocacy been all these years? Where was he when the Institute of Medicine was trying to redefine PTSD? When the VA was headed by a real estate developer? When veterans were called liars when they said they were suffering? I don't remember reading one single thing about him caring jack about our veterans. And I find it curious that he now is all over it after one memo. An investigation is fine--but to allege fraud and misdiagnosis is irresponsible. And the media alleged that she did so to cut costs. That is an assumption not a fact.All she said is that they are seeing lots of cases of veterans seeking compensation. She did not call them liars or frauds. She said make sure you diagnose them correctly and take your time. Use a provisional diagnosis maybe--it will give us some time to get it right. I honestly feel that this memo has been grossly misinterpreted and that the volcanic emotional response to it only further obscures what she may have intended.

I don't think it a crime or fraudulent to be careful of the diagnosis in the interests of precision and in the interests of not giving one a wrong diagnosis that may end up costing the taxpayer. If a veteran gets a wrong diagnosis of cancer and undergoes costly surgery I would feel the same way. It is wrong for the veteran and wrong for the taxpayer. My first impulse upon reading the memo was to say "That stinks!" but the more I read it and actually gave it some consideration, I saw it very differently. We have so much evidence that the VA screws veterans that we jump to conclusions and I honestly feel that is the case here--everybody jumped before they had enough evidence. It is harder for a non-clinician to understand how this can be because differential diagnosis is a difficult subject, supervising clinicians of varying abilities is tough. The memo reader makes the best judgments that they can given the information at hand and their knowledge base. My professional history allows me a little different view and I was trying to offer it in balance. The response on Kos has been unthinking, virulent, and shocking. I still stick by my story but I must admit that I am stunned at the level of invective and lack of critical thinking. I guess I have been away from blogging too long and forgot that the expression of rage is the dominant impetus for those making comments on many blogs. Sheesh.

Just lay this at Obama's Feet:

If he is so concerned about veterans, where has his advocacy been all these years? Where was he when the Institute of Medicine was trying to redefine PTSD? When the VA was headed by a real estate developer? When veterans were called liars when they said they were suffering? I don't remember reading one single thing about him caring jack about our veterans.

Every question you have there, And Way Too Many More, we have been asking of This Whole Country, for Years!!

I'm not sticking up for Obama, but Your Attacking Him, and Him Only Reads Volumes, he's a part of a Society that is Way to Arrogant and Apathedic!!

Where's your Outrage over the Totally Republican Controlled Federal Government that got us into these Debacles, Never Once thinking of the returning Who They Readily Sent Into Occupations, with the Support of Over 3/4's of this Country!!

And don't just blame the present, This Has Been Going On For Years under All Political Ideologies!!!!!!!!!!!!!!!

The one who sent the E should have Known the reaction should it come public, but they too are a part of an ever growing society with a lack of common sense!!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

Gotten that Impression Cho if it didn't read between the lines, Loud and Clear, 'Hillary Supporter'!!!!

It could of, and Should of, been written Much Differantly and not as the Political Use Of Veterans Care as a Political Putdown!!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

That can be gone after:

May 16, 2008, Washington, DC - Senator Daniel K. Akaka (D-HI), Chairman of the Veterans’ Affairs Committee, sent a letter to Veterans Affairs Secretary James Peake today, in response to a recently disclosed email from a VA mental health professional which suggested that time and money could be saved if VA stopped diagnosing veterans with post-traumatic stress disorder. Akaka also made a statement on this matter earlier today, calling the email “disturbing and disappointing.”

Though he isn't running for president and leading, thanks to the other candidate, those she surrounded herself with, and especially the otherwise sane but gone completely wacky supporters! But hey Politics is Politics and if using Veterans Care as a Political Putdown everyones in play, Apparently Akaka gets it All Wrong As Well, along with the Vets at Vote Vets the folks at CREW and Every Vet who understands the system and the country they serve or served!!!!!!!!!!!!!!!!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

Jim can you add your blog link to your signature? I went looking for it the other day and have lost it. Thanks!

The most Important Question, in trying to make this a political put down.

You should have asked, Right Out Of The Gate:
"Why is Obama showing the Rage and Not McCain?"

As soon as this hit the wires McCain should have started the Questioning into the meaning, Not Obama, and I might add where's Clinton on this, wife of an Ex-President!!!

You should be Glad Obama, at least, is showing his Concern!!!!!!!!!!!!!!!!!!!!!

As for this Dr. Perez, she Needs To Explain to the Veteran Community!!

Tell the world: My America Doesn't Torture!

"The wise man points to the stars and the fool sees only the finger - and discusses it 24/7 on cable."

When I first heard the item about Dr. Perez from the media I was naturally outraged. On the other hand I see your point about the rush to diagnosis especially when you tie it in to what in my opinion is premature diagnosis of mental illnesses in children and the extension of the category of mental illness to personality issues like shyness.

However I cannot understand why you are singling out Barack Obama for his comment. Wouldn't it be more appropriate to write an open letter explaining why you think his remarks were misjudged.

Even though I am sure that is not your intent, your post reads as an excuse to attack Barack Obama on a tertiatry mistake (if you are correct about Dr. Perez. This is about deadly serious issues concerning our veterans not a well-intended if mistaken intervention by a candidate.

If we are going to blame Democrats for weighing in on social issues like poverty and the failure to provide decent medical care to most of the population, and the treatment of veterans, or ending the war in Iraq, then what should they be talking about. Sure these are potentially vote getting issues, but for good reason.


DEFuning knows the position Perez is in (the difficulty of getting a sh*tload of new clinicians trained and operating quickly to provide maximum care) because she has held similar positions. Whether or not DEFuning's interpretation is correct about Perez's intentions (as DEFuning also indicates she doesn't really know), I believe DEFuning is sensitive to a someone who is trying to do a good job by our vets (DEFuning has long been an extremely vocal advocate for PTSD sufferers and extremely dedicated to exposing the Bush Administration's attempts to deny Vets appropriate treatment).

I think, also, as Jim indicates above, that because she feels the Media jumped on it opportunistically, that her message gets lost because people think she's bashing Obama.

Hope that explains, Carol.

I wrote this about Obama because he was the one who ran his mouth and made a wild charge. This has nothing to do with Hillary or McCain or anyone else. He was rash in his charge of "fraud"! And by stating that she was telling people to "misdiagnose"! That is an outrageous rush to judgment. Obama made that statement--no one else did. You do not go around accusing people of fraud without knowing the facts. And to address Jim and others --I DID read the e-mail memo. Very very closely and that is why I wrote this diary to address what I think are misjudgments and false charges.

I have read comments to my post on many different websites and EVERY ONE OF THEM get's it wrong. She DID NOT tell them to give the diagnosis of Adjustment Disorder to people with PTSD. She told them that they must give it a provisional diagnosis. A temporary diagnosis until they can tell what it really is. Period. NOT EVERYONE WHO PRESENTS WITH SOME OF THE SYMPTOMS OF PTSD WILL HAVE PTSD.

I understand that the VA has been crappy. That is not my argument here. This is about Obama being crappy to a woman before he knew all the facts. I don't care if 3000 politicians pile on the VA. That does not make the charge any more valid without more facts being known. My alternative narrative does not fit with some people's agenda so they are very emotional in rejecting it. I had hoped that a little reality orientation would make people a bit more thoughtful about trashing this woman but I see clearly that few are interested in the facts. Or reason.

and believe there has been a big jump to conclusions that are not supported by the email from Dr. Perez. I guess it is understandable that some lay people might have initially questioned or misunderstood Dr. Perez's suggestions but am disappointed that the media and others have not given this more critical thought. If one is advocating for the best veteran's care, both immediate and long term, her email seems quite reasonable. Correct diagnosis is important for the treatment of any disease or disorder. One would hope for a more positive response to professionals who are seeking to provide our vets with an accurate diagnosis instead of taking an easier route. And we should all know the downside that comes with not using care and caution when it comes to governmental programs that have finite resources. Anything in the future that can be used to negate the spending of funds because their is a perceived misuse or waste involved, will ultimately hurt the veterans rather than help them.

Thanks for being a sentient being. It is very frustrating to hear so many just make a knee jerk rush to judgment--or more accurately rush to an emotional response instead of good judgment. What I never got to address (due to being called so many bad names by readers!) was that an inaccurate diagnosis of PTSD can also prevent a full review of what OTHER complicating factors may be. That soldier presenting with PTSD that does not meet all clinical criteria for the diagnosis may have TBI that is undiagnosed--that is traumatic brain injury. TBI is extremely serious and some if its symptoms can mimic PTSD, especially upon first presentation to a clinic. The point is sometimes you really just don't know and it is better to use a provisional diagnosis than to make the WRONG diagnosis. Everyone assumes that the clinicians she was addressing are all brilliant diagnosticians when in fact some of them have probably never cracked a DSM in their lives and just cookie cutter these cases. Anyone who reads a lot of medical charts can tell you that.

So, I read the email but I don't know what C&P is.