A Veterans Affairs mental health clinical pharmacist practitioner, who works in the Midwest, shares this anonymous essay:
On Wednesday, January 29th, I, along with two million other federal employees, received an email from the Office of Personal Management with the subject line “Fork in the Road.”
It was the middle of my work day, and with a few minutes before my next appointment I began to read, absorbing the words “consolation,” “divestures,” “reductions in force,” and “termination,” feeling my stomach tighten. Eventually I am able to piece together that I am being offered a buyout based on the notion that my work as a federal employee is a waste of taxpayer dollars. A follow-up email later in the week with a link to the FAQ would confirm this with the words, “We encourage you to find a job in the private sector[.] The way to greater American prosperity is encouraging people to move from lower productivity jobs in the public sector to higher productivity jobs in the private sector.” The sensation in my stomach develops from a tight anxiety to a sickening anger.
For context after graduating pharmacy school I completed two years of residency training at the Milwaukee Veterans Affairs (VA) Medical Center, specializing in psychiatric pharmacy my second year. In 2020, I took a job at another VA in the Midwest as a Mental Health Clinical Pharmacist Practitioner in our substance use disorder clinic. This was a new role funded by the Office of Rural Health to increase access to care for veterans with substance use disorders living in rural areas. While in this role, I expanded access to medications for alcohol and opioid use disorders and was selected as a winner of the VA National Clinical Pharmacy Practice Office “Strong Practice Competition.” I currently work with our Primary Care Mental Health Integration clinic, a team designed to offer same day access. Every day I see veterans who are seeking help for various mental health conditions and substance use disorders and can see them the very same day they show up to a primary care appointment.
Back at my desk, staring at my inbox, I read that we can expect “a few agencies and even branches of the military […] to see increases in the size of the workforce” and yet they are encouraging every single employee of the Veterans Health Administration — or VHA — to resign because we need to move from “lower productivity jobs in the public sector to higher productivity jobs in the private sector.” I feel as if I have been punched in the gut. The president of my country does not believe that the services provided by the VHA are valuable enough to continue funding. After several re-reads, I am left with the sense that this new administration intends to effectively cut off our water supply and let us slowly dry up, regardless of the consequences.
I take a deep breath. I close my email. And I go back to seeing my patients scheduled for the day. I listen to the veteran who’s describing symptoms of sleeplessness and hyperarousal that stem back to a traumatic event occurring during their military career. They tell me how they have increasingly been relying on alcohol because that has been their only way to sleep without nightmares. They express worry about how their symptoms and alcohol use are negatively impacting their family. I listen, I summarize back to them, and I ask if there is anything else that would be important for me to know. I transition to asking questions about their priorities. I ask, “Out of all the things we have talked about, what is the most important to you?” “What do you want to focus on first?” “What tools would be most helpful for you right now?” And then we talk about the tools. We talk about medication options: antidepressants, anti-craving medications, and medications for nightmares that decrease the hypersensitivity of the fight-or-flight part of the nervous system. We discuss options for referral to our specialty care clinics for evidence-based treatment for alcohol use or post-traumatic stress disorder. We explore whether they would like to participate in a VA clinical trial evaluating a new smartphone application designed to help reduce drinking. We consider the option for virtual appointments in the case they are unable to drive to our clinic in the middle of their work day. I ask if the veteran has any questions about all the options we have discussed. And then, together, we make a plan.
The appointment ends and in the few minutes before my next appointment, I can still feel this email looming over me. I read through it again and cannot help but ask, what research supports the claims being made? If two million government employees are being encouraged to resign from their jobs, what evidence is backing this decision? What evidence points to the benefits of privatization? Or the necessity of complete return to in-person work versus having provisions for virtual care? I reflect on the over six years I have worked at the VA and the impact I have seen on veterans' lives. I think about how my own position has evolved to provide virtual coverage to three of our smaller clinic locations, located hours apart, that are not large enough to support funding to have a provider on the ground at each site. With all these experiences, how can I readily accept that all of this could be so disposable?
But as a health care professional, I am trained to not only rely on my own experiences but to practice according to evidence-based medicine. Every single decision I make over the course of my day is informed by published peer-reviewed research. So much like if I was encountering an uncertain clinical situation, I turn to the evidence.
Four systematic reviews published in 2011, 2017, 2018, and 2023 have all shown that veterans get either the same or better care through VA health care. Studies from 2015 and 2017 showed better outcomes for PTSD and depression, respectively, from telemedicine-based collaborative care teams. A cohort study from 2024 shows that an increase in virtual mental health visits was associated with a significant decrease in suicide related events.
This evidence speaks loudly and clearly. And yet, I am still left with this pit in my stomach. I am left feeling disheartened and discouraged. While I know the contents of that email will not pressure me to resign, I worry that my workplace will be drained of resources essential to the care of veterans in these coming months. I am left writing a letter to my Congress members asking that they consider the evidence and the consequences of these executive orders. But I am also left with the belief that my work is both meaningful and valuable. And that I will continue to show up to work, regardless of the honey-potting and scare tactics residing in my inbox.
