Letters to the Editor
To the Editor:
My internal medicine residency program’s rotations at an affiliated Department of Veterans Affairs (VA) hospital have been among my favorite training experiences thus far. As a civilian, the VA has exposed me to military and federal health policy, but, more poignantly, has allowed me to serve a population of patients who have served my country. It is a patient population with distinct medical, social, and psychiatric demands that I find particularly rewarding to care for.
Furthermore, the VA serves as the ideal model for “the patient-centered medical home,” giving easy access to specialty services and coordinated care between numerous health professionals, not limited to nutritionists, pharmacists, mental health providers, and social workers. The VA’s pharmacy and laboratory services are particularly patient-centric because they simplify medication access via home delivery and minimize redundancy in testing, respectively. Many VA internists who work in primary care also attend on the general medical floors, which provides a high level of continuity for mentorship over the course of residency training.
The VA’s electronic medical records (EMR) system is unique, both in its integration of VA systems nationwide and also with its inpatient/outpatient connectivity. This serves patients and trainees alike by establishing a high level of continuity between health care settings, which avoids the complications and challenges of fragmented medication reconciliation. This EMR system also provides evidence-based “clinical reminders” for screening tests and vaccinations, which are incorporated into every patient encounter. In this regard, the system actually serves as a didactic tool for trainees, teaching primary and secondary prevention to residents at the bedside. Incorporated within the EMR system is the ability to track a trainee’s “performance” in the primary care setting as measured by patient outcomes such as A1c, LDL, and blood pressure. Such evaluation is critical in the training environment to identify areas that need improvement, and also because this type of electronic tracking might one day be adopted by the private sector as an aid in determining reimbursement. The system also serves patients as well, who are now gaining access to their own records and will soon be able to communicate with their providers electronically.1 Finally, the EMR system also serves as a database that is a powerful tool for mentored research and has already proven a tremendous value to scientists and clinical researchers nationwide.
As the medical profession is criticized by the media for the overuse of diagnostics and billable procedures, the VA provides an example of more judicious testing and interventions. There are no incentives for physicians at the VA (who are salaried) other than to provide the best, evidence-based care permitted within the excellent VA laboratory, pharmacy, and interventional suites. The VA’s experience with this approach should be cited by those who propose health care systems with salaried physicians (as opposed to a fee-for-service reimbursement structure).2
It is a privilege to work and learn at an academic VA hospital. I urge both educators and trainees to embrace the opportunities that such hospitals offer.
Benjamin T. Galen, MD
Third-year internal medicine resident, Yale University School of Medicine, New Haven, Connecticut; firstname.lastname@example.org.
2. Relman AS. Could physicians take the lead in health reform? JAMA. 2010;304:2740–2741