Discussion| Volume 30, ISSUE 5, P533-539, September 2012

Download started.


Ethical issues regarding caring for dermatology patients in the U.S. Department of Veterans Affairs Health Care System


      The U.S. Department of Veterans Affairs (VA) operates the largest integrated health care system within the United States. VA budgets continue to escalate in an environment of heightened financial prudence and accountability. Despite having received many awards in areas from patient satisfaction and safety to product innovations, like any health care system, the VA is not immune to ethical conflict that requires exploration and evaluation. Several VA dermatologists, including section chiefs, were interviewed, and their responses to ethical complexities encountered or anticipated were analyzed in fictional case scenarios. Five morally concerning issues were highlighted. These include (1) providing care in a teaching setting with limited resources to a patient population with few other health care alternatives; (2) stereotyping patients, altogether an uncommon act, is possibly easier to do in the VA and has the potential to negatively affect patient care; (3) service-related disability claim cases often include medical opinion and findings documented in the medical record when judgments are made, thus the VA physician can have a significant effect on the outcome of these claims; (4) whether the VA provides a setting for apathetic physicians to thrive or instead allows for a more meaningful work experience and then how to manage the subpar performer; (5) except for the treatment of HIV lipodystrophy with injectables, primary cosmetic procedures are prohibited at the VA and can lead to difficulties for the VA dermatologist attempting to comply in a era where dermatology is being more closely associated with cosmesis.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinics in Dermatology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Zhang J.
        The digital pioneer. The Wall Street Journal.
        October. 2009; (Available at:): 27
        • United States Department of Veterans Affairs : Office of Public Affairs Media Relations
        VA receives 2006 innovations in government award. Office of Public and Intergovernmental Affairs, Washington, DC2006 (Available at:)
        • Merritt
        • Hawkins
        • Associates
        2009 survey of physician appointment wait times. Merritt Hawkins and Associates, Irving, TX2009 (Available at:)
        • Crawford G.H.
        • Gutman A.
        • Kantor J.
        • James W.D.
        Patients’ attitudes toward resident participation in dermatology outpatient clinics.
        J Am Acad Dermatol. 2005; 53: 710-712
        • Townsend B.
        • Marks J.G.
        • Mauger D.T.
        • Miller J.J.
        Patients’ attitudes toward medical student participation in a dermatology clinic.
        J Am Acad Dermatol. 2003; 49: 709-711
        • Krause LK
        • Townsend L
        • Orser ML
        • et al.
        Benchmarking U.S. Department of Veterans Affairs dermatologic services: results from a national survey.
        J Am Acad Dermatol. 2011;
        • Capozzi J.D.
        • Rhodes R.
        • Gantsoudes G.
        Ethics in practice. Terminating the physician-patient relationship.
        J Bone Joint Surg. 2008; 90: 208-210
        • Willis D.R.
        • Zerr A.
        Terminating a patient: is it time to part ways?.
        Family Pract Manage. 2005; 12: 34-38
        • American Academy of Dermatology
        Code of medical ethics for dermatologists. AAD, Schaumburg, IL2006 (Available at:)
        • Lanning M.L.
        Vietnam at the movies.
        Faucett Columbine, New York1994
        • Rowe P.
        Busting Vietnam stereotypes. The San Diego Union-Tribune, November 11, 2005.
        (Available at:)
      1. Jackson K.T. The encyclopedia of New York City. Yale University Press, New Haven & London1995
        • Brende J.O.
        • Parson E.R.
        Vietnam veterans: the road to recovery.
        Plenum Press, New York & London1985
        • Kessler R.C.
        • Sonnega A.
        • Bromet E.
        • Hughes M.
        • Nelson C.B.
        Posttraumatic stress disorder in the National Comorbidity Survey.
        Arch Gen Psychiatry. 1995; 52: 1048-1060
        • Interagency Council of the Homeless
        The forgotten Americans—homelessness: programs and the people they serve. Interagency Council of the Homeless, Washington, DC1999 (Available at:)
        • Community Homelessness Assessment, Local Education and Networking Group (CHALENG) for Veterans
        The Sixteenth Annual Progress Report. CHALENG, Washington, DC2009 (Available at:)
        • Kulka R.A.
        • Schlenger W.E.
        • Fairbank J.A.
        • et al.
        Trauma and the Vietnam War generation: report of findings from the National Vietnam Veterans Readjustment Study. Brunner/Mazel, New York1990
        • Figley C.R.
        • Leventman S.
        Strangers at home: the Vietnam veteran since the war.
        Praeger, New York1980
        • Wood E.
        Worshiping the myths of World War II.
        Potomoc Books Inc, Washington, DC2006
      2. Tanielian T. Jaycox L. Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. RAND Corp, Santa Monica, CA2008
        • United States Department of Veterans Affairs : Office of Public Affairs Media Relations
        VA extends “Agent Orange” benefits to more veterans: parkinson's disease, two other illnesses recognized. U.S. Department of Veterans Affairs, Washington, DC2009 (Available at:)
        • United States Department of Veterans Affairs
        Veterans compensation benefits rate tables effective December 1. U.S. Department of Veterans Affairs, Washington, DC2009 (Available at:)
        • United States Department of Veterans Affairs : Office of Public Affairs Media Relations
        White House seeks $125 billion for veterans in 2011: homelessness, claims increases and access—priorities for VA budget. U.S. Department of Veterans Affairs, Washington, DC2010 (Available at:)
      3. United States Department of Veterans Affairs. VA 2011 budget fast facts. Washington, DC: U.S. Department of Veterans Affairs. Available at:

      4. United States Department of Veterans Affairs. VA plans, budgets, and performance home. Washington, DC: U.S. Department of Veterans Affairs. Retrieved from Available at:

      5. United States Department of Veterans Affairs. National Center for Ethics in Health Care. Washington, DC: U.S. Department of Veterans Affairs. Available at:

      6. TED Ideas Worth Spreading. Barry Schwartz: using our practical wisdom. New York, NY: TED Ideas Worth Spreading. Available at:

        • Weber P.J.
        • Moody B.R.
        • Foster J.A.
        Inverted pyramidal biopsy.
        Dermatol Surg. 2001; 27: 681-684
        • Krupa Shankar D.S.
        • Kushalappa A.A.
        • Suma K.S.
        • Pai S.A.
        Multiple dermatofibromas on face treated with carbon dioxide laser.
        Ind J Dermatol Venereol Leprol. 2007; 73: 194-195
        • Conrado L.A.
        • Hounie A.G.
        • Diniz J.B.
        • et al.
        Body dysmorphic disorder among dermatologic patients: prevalence and clinical features.
        J Am Acad Dermatol. 2010; 63: 235-243
        • Phillips K.A.
        Suicidality in body dysmorphic disorder.
        Prim Psychiatry. 2007; 14: 58-66
        • Phillips K.A.
        • Coles M.E.
        • Menard W.
        • Yen S.
        • Fay C.
        • Weisberg R.B.
        Suicidal ideation and suicide attempts in body dysmorphic disorder.
        J Clin Psychiatry. 2005; 66: 717-725
        • Phillips K.A.
        • Diaz S.
        Gender differences in body dysmorphic disorder.
        J Nervous Mental Dis. 1997; 185: 570-577
        • Koblenzer C.S.
        The dysmorphic syndrome.
        Arch Dermatology. 1985; 121: 780-784
        • Phillips K.A.
        • Dufresne R.G.
        • Wilkel C.S.
        • Vittorio C.C.
        Rate of body dysmorphic disorder in dermatology patients.
        J Am Acad Dermatol. 2000; 42: 436-441
      7. Panangala SV. Congressional Research Service (CRS) Report for Congress. Veteran's Medical Care: Fiscal year 2009 appropriations. July 29, 2008.

        • Krugman P.
        Health Care Confidential [op-ed]. NY Times.
        (January 27, 2006. Available at:)
        • Stein R.V.A.
        Care is rated superior to that in private hospitals.
        (Washington Post, January 20, 2006. Available at:)
        • Arnst C.
        The best medical care in the U.S. Business Week.
        (July 17, 2006. Available at:)