The Veterans Health Administration medical center in Cecil County was so understaffed that at one point, federal investigators report, three doctors were caring for 5,000 patients.
"I am not able to think of any acceptable or practical way to do all that you are requesting and provide adequate patient care to the veterans we are actually seeing," one of the physicians wrote to superiors in February 2014. "We three ... have been covering [for two absent providers] since at least the end of September. We have had very little help. ... How long are we expected to continue like this? We need help."
The physician's comments were included in a report issued this week by the Veterans Affairs inspector general's office, which investigated concerns related to four VA patients at the request of Sen. Barbara A. Mikulski, a Maryland Democrat. Two of the patients had died; one from cancer, the other from a self-inflicted gunshot wound.
The four were among the 55,000 patients treated by the VA in Maryland annually. The VA is the nation's largest health care system.
Since the investigation, Maryland VA officials say, they have developed a contingency plan for bringing in doctors during staff shortages. They say they have made other changes in response to problems at the Cecil County center in Perry Point and the downtown Baltimore center.
"We concur with the recommendations in this report," Dr. Adam M. Robinson Jr., the acting director of the Maryland VA Health Care System, wrote in a response included in the report. "Staff have initiated improvement actions."
Mikulski said she was disappointed in the inspector general's findings.
"I've heard directly from Maryland veterans about their delays in access to critical care and the quality of that care," Mikulski said in a statement. "I called for the VA to get to the bottom of this, and unfortunately this report confirms what we have all feared. Delays and bureaucratic dithering are unacceptable."
Mikulski said she would "hold the VA's feet to the fire" and make sure officials implement the recommendations from the inspector general.
Investigators led by Assistant Inspector General John D. Daigh Jr. found long waits for joint surgery at the Baltimore center, an inadequate job of contacting a patient who needed mental health care and poor coordination for patients seen by both VA doctors and community doctors.
The report is the latest blow for the beleaguered Veterans Affairs health system, which has come under fire for long delays for veterans seeking care. The issue led to the ouster of VA Secretary Eric K. Shinseki last year.
Veterans faced delays of at least 31 days in obtaining appointments at the medical centers in Maryland in more than 7,000 cases during a recent six-month period reviewed by the Associated Press.
The VA outpatient clinic in Glen Burnie had the longest delays. Nearly 8 percent of appointments were not scheduled within 30 days, well above the statewide rate of 2.9 percent and the national rate of 2.8 percent. VA officials attributed the delays in Glen Burnie to the loss of two of the clinic's five primary care doctors.
VA Secretary Robert A. McDonald formed a MyVA Advisory Committee last month to tap government, nonprofit and private-sector leaders for help in "reorienting the department to better meet the needs of veterans."
"The collective wisdom of our committee members is invaluable," McDonald said in a statement announcing the formation of the committee. "Each of them understands that VA must improve customer service and focus the department on the needs of our veterans."
McDonald visited with nursing students at Johns Hopkins last fall as part of a national recruiting tour aimed at getting more medical professionals to consider careers with the VA.
In Perry Point, the staff of five primary care physicians leading Patient Aligned Care Teams, or PACTs, dropped to three after one physician became ill and another missed scheduled clinic days because of "unforeseen personal events and a serious illness," the report found.
From October 2013 to September 2014, the three remaining doctors were left to manage the care of more than 5,000 clinic patients, investigators found, far beyond the VA recommendation of 800 to 1,200 patients per doctor, according to the report.
The VA responded in early 2014 by sending a part-timer to Perry Point, but that doctor ended up covering for an urgent-care doctor on military leave instead of helping the primary care physicians.
"Because of ongoing PACT provider absences, clinic staff often had to reschedule patient appointments more than once," investigators reported. This was the case for the patient who committed suicide, but the inspector general's staff could not determine whether the rescheduled appointments had any effect on the patient.
Another patient told Mikulski's office he faced delays in getting hip replacement surgery in Baltimore. Investigators found that the Baltimore VA offered joint surgeries only once per week, with two to three surgeries each time.
By August 2014, 56 patients were waiting for hip or knee replacements at the Baltimore VA, with an average waiting time of 137 days.
Patients are usually treated first with physical therapy, medication and weight management before surgery is scheduled. They must complete a series of screenings before surgery.
The inspector general's office said it could not substantiate an allegation that the VA missed a patient's cancer diagnosis. Health records showed that the patient had been seen frequently and showed no symptoms that would indicate cancer.
The patient "developed a rapidly progressive lung cancer" that was diagnosed at a community hospital.
The VA was notified, but the patient soon died at the community hospital.