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Editor’s Note: Today we welcome Dr. Kathleen Kozak to our stable of regular Civil Beat contributors. Kozak is an internist at Straub Clinic in Honolulu, specializing in preventative health, travel medicine, women’s health and wellness. Her passion for healing and healthcare spills over from time to time into public health issues and even the political arena. You can catch her Hawaii Public Radio show, “w,” on Mondays at 5 p.m.

The scandal that claimed Kauai-born Veterans Affairs Secretary Eric Shinseki, who resigned on May 30, was long in the making.

Some details of the mess at the department’s health care facilities have been hashed over in the media. Others are yet to come.

So here’s a little perspective. The scandal grew out of a decades-old and ever-increasing patient backlog in the VA system, as well as an inadequate effort to expand access to care. It all began long before Shinseki or his boss, President Barack Obama, were in their current jobs. This should probably lead to questions about who is really responsible.

Veterans Day at Punchbowl Memorial.

John Hook/Civil Beat

I’ll leave that to others to decide while I take aim at a more constructive question: Where did the backlog come from?

Veteran’s Affairs medical system enrollment skyrocketed as a result of three wars dating back to the early 1990s — President George H. W. Bush’s Operation Desert Storm to liberate Kuwait, then the wars his son initiated in Iraq and Afghanistan, and passed on to President Obama. The funding for the medical care of returning veterans didn’t keep up with the growing need.

In addition, the economic crisis that began in 2008 also increased the number of veterans who were in difficult straits and in need care.

Shinseki took the top job at Veterans Affairs in 2009.

Since other people are talking about such issues, I’ll put forward some details that people who aren’t injured vets and their families might not be aware of, like how the system actually works.

Hawaii offers a good window into the problem.

My suggestions may seem simplistic, but they’re definitely a place to start. … This could save pain, suffering and lives.

To access medical care in the VA system, a veteran first registers with the administration. A doctor at our local VA here recently told me there are currently about 1,000 veterans who have registered on this gateway “wait list.” It only takes a few months at most for each of them to get their initial exam.

From there, veterans are assigned a primary care physician, or PCP. It is this step — waiting to be assigned a doctor— where much of the delay occurs. Some veterans wait years on this list, because primary care doctors are busy caring for other veterans and there just aren’t enough openings for new patients.

Although there are other serious problems at the VA, the basic problem with access to care is this bottleneck.

So what can be done about this part of the problem? There are two main choices: hire more doctors or have current staff work more efficiently.

It’s obvious that the VA needs to hire more primary care doctors. But that takes time. So what can be done to help right now?

There are three basic ways to address the shortage of primary care physicians at the VA without waiting for more doctors to be hired.

Before getting to possible remedies for this problem in the VA, it is worth noting, that the solutions also apply to the civilian medical community in Hawaii. After all, there are some similar problems. Just ask a senior citizen who lives in Hilo about the challenges of finding a new doctor who takes Medicare insurance. Even at my own clinic, the next available appointment to establish care with a doctor is almost a month away. In many other clinics, it’s even longer.

So here is what should be done, for veterans and civilian care.

First, doctors should do more of what they are best at: seeing patients. Between 20 percent and 30 percent of my day is spent dealing with paperwork, filling out boxes on the electronic medical record, putting historical information into the chart, signing forms, ordering labs, etc. Doctors should be spending as much of their time as possible seeing patients and other staff should do the secretarial work.

One of my VA colleagues told me that most of her appointment time is spent going through papers and filling out boxes on the electronic medical record system that she uses (which is very similar to mine).

A universal electronic medical record system that can be used by all facilities, whether they serve vets or civilians, throughout the United States would certainly help. It would also be easier to have trained staff populate the electronic record with pertinent information, liberating doctors from data-entry work. Everyone would win with such a change.

Second, there is a nationwide shortage of medical doctors in primary care. In order to meet the demand, we should utilize the expertise of nurse practitioners, physicians assistants and the like to do basic follow-up care which would enable doctors to address more complex cases. This would result in more openings for new patients. This model for primary care expansion is currently being used in the non-military community throughout the islands.

Lastly, many veterans have community primary care physicians, but they go to the VA anyway so that a VA doctor can write their prescriptions. That’s because the pharmacy at the VA doesn’t accept prescriptions written by anyone else. Allowing any doctor — particularly if they are already certified to participate with other government agencies, such as Medicare or Medicaid — to have their prescriptions recognized would further help to minimize duplicative visits. This would expand access to those veterans who are still waiting for primary care physician access and who do not have community care.

My suggestions may seem simplistic, but they’re definitely a place to start, and they could help to improve the availability of primary care physicians to veterans. Once vets are “in the system,” their medical needs can begin to be met. This could save pain, suffering and lives.

Other aspects of the crisis in the VA are still being uncovered — such as inappropriate bonus pay for administrative “efficiency.” But focusing on any such issues, while important on a number of levels, won’t solve the most basic problem, which is that patients can’t get in to see a doctor because there aren’t enough slots for former military personnel who are new to the system.

With that in mind, I’m not sure that Shinseki’s resignation actually helped the situation. Maybe it will, or he may just have provided a scapegoat for larger and long-term problems that still exist in the VA system.

Time will tell, but without addressing the basic issues of getting veterans through the front door, for them, nothing else matters.