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From the Editor

Valuing the Partnership Between the Veterans Health Administration and Academic Medicine

Lypson, Monica L. MD, MHPE1; Roberts, Laura Weiss MD, MA2

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doi: 10.1097/ACM.0000000000004748
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Alignment of the Veterans Health Administration (VHA) and the field of academic medicine in the United States across the missions of clinical service, education, research, community engagement, and health systems and policy has brought benefit to veterans and to society at large for decades. 1 The majority of practicing physicians in the United States have received training at a Department of Veterans Affairs (VA) site, and the education of physicians at 149 MD-granting medical schools and all 38 DO-granting medical schools involves collaborations with the VHA. 2 This constructive collaboration was formalized with the U.S. Department of Veterans Affairs Policy Memorandum No. 2, 3 signed on January 30, 1946. The partnership was reaffirmed with the thoughtful and enduring analysis provided in The Report of the Blue Ribbon Panel on VA–Medical School Affiliations, 4 commissioned in 2006. This robust relationship is based on mutual goals, such as ensuring optimal care for veterans and veteran patients across every population stratum in the United States, building a strong health care workforce, developing new knowledge of importance to health innovation, and implementing equitable health policies on a broad scale. 4

The VA was established in 1989 as a cabinet-level organization that grew from the Veterans Administration formed in 1930. 5 The VA is a federal executive department comprising the Veterans Benefits Administration, the National Cemetery Administration, and the VHA. The purpose of the VA is to care for those “who shall have borne the battle” and for their families, caregivers, and survivors. 6 This focus on caregiving has been especially important to tightly link the missions of the VA, the VHA, and academic medicine.

The VA has created a transformational platform for training, service innovation, and research. Each year in the VHA, approximately 120,000 trainees across as many as 40 health professions engage with the VHA as a site for training. It is estimated that “70% of physicians rotate through the VA for a portion of their training,” making the VA “the largest provider of health care training in the United States.” 7 By hosting trainees, the VHA fulfills its mission to provide education to a diverse variety of learners, including students in nursing, dentistry, psychology, and physical therapy as well as physicians seeking graduate medical education (GME) and advanced fellowship training. 2,8

The VA is also a site of innovation. For example, the VA performed pioneering work with the electronic medical record decades ago, transforming health care for veterans, training generations of health professions students, and setting the stage for broader efforts with the electronic medical record in the United States. 9 The VA has been well ahead of the curve in telehealth and delivery of health care through novel technology, in part due to the aim of providing care to veterans who reside in rural and frontier communities in this country. 10 The VA also supports research through funding mechanisms including its Office of Research & Development, 11 Rehabilitation Research & Development Service, 12 and Health Services Research & Development, 13 which help promote collaborations with academic institutions locally, regionally, and nationally. The VA is credited, moreover, with taking innovative approaches to building the health professions workforce, with the large investment in physician assistant (associate) training as one example. 14

The historic relationship of medical schools with the VA is one way in which academic medicine demonstrates its commitment to ensuring the good health of all of society. This relationship provides health professional learners across the educational continuum with access to the vast resources of the VHA through educational rotations, part- and full-time dual appointments, and research collaborations. 2 Health professionals benefit from the strengths and experiences that have arisen in the context of an integrated health care system at a level not typically encountered in most other health care settings in the United States.

In 2021, one of us (L.W.R.) asked the field of academic medicine to honor its social contract with society through the 5 (“palmate”) missions of

(1) scientific discovery, (2) education, and (3) clinical care. And … through (4) collaboration with communities and partners…, and (5) commitment to rigorous and forward-looking standards of equity, professionalism, and ethics…. 15

These 5 tenets square solidly with the missions of the VA, and their themes are visited in 3 articles 16–18 appearing in this issue of our journal.

In their Invited Commentary in this issue, 16 Petrakis and Kozal note the 75-year history of the 1946 policy entitled “Memorandum No. 2” 3 that established academic affiliations between U.S. medical schools and the VA, and, more specifically, the VHA. Memorandum No. 2 set the framework for the locations of VA medical centers as well as for state-of-the-art research and discovery focused on improving the health of veterans. The authors, leaders in the VHA and in academic medicine, highlight the continued development of VA research programs, which often involve VA career development opportunities and state-of-the-art multisite studies and which fund investigators who are often medical school faculty members.

Petrakis and Kozal illustrate the impact of the VA by describing how VA-funded investigators have focused on important health issues that not only affect veterans but also society at large, such as tuberculosis, cardiovascular disease, posttraumatic stress disorder, and most recently SARS-CoV-2 (COVID-19). The authors discuss the Million Veteran Program, which continues to be a model for an observational cohort study that will inform science for many years to come.

Despite the many successes of the partnership, there are areas in need of attention and additional investment by academic medicine. These include, as Petrakis and Kozal noted, “academic faculty who are VA-based often feeling removed and underrepresented” in medical school departments and potentially limited financially due to VA pay structures. 16 We agree that the value of the relationship of the VHA with the field of academic medicine is widely underappreciated. We recommend new and redoubled efforts to strengthen the partnership and to support the academic faculty who serve at VHA sites.

In a second article, Moldestad et al 17 describe the milieu in which VA primary care providers view their roles, and reflect on insights, from participants in their qualitative study, into the recruitment and retention of VA primary care clinicians. The authors found that the culture and the singular focus on the mission to care for veterans enable clinicians to go the “extra mile,” to address social determinants of health, and to be collaborative in their care models. This focus highlights the relevance and expectations of the palmate mission of academic medicine. 15 The authors identify possible places where the focus on the VA mission falls short of primary care and academic medicine expectations, however. Focus group participants, including trainees, noted that recruitment and retention are negatively affected when faculty leadership do not allow for adequate funding for a team-based (PACT, i.e., patient-aligned care teams) model of care, and when faculty leaders overlook harassment in the workplace. The authors’ findings resonate with the 5th mission of academic medicine, where everyone, including VA facility leaders, remains steadfast in their commitment to “repeated demonstrations of respect for persons, justice, inclusion, and integrity.” 15

In this issue, Klink et al 18 highlight the VA–academic medicine partnership through the Veterans Access, Choice and Accountability Act of 2014, which expanded GME capacity nationwide by adding 1,500 new positions in areas of need, including positions in primary care and mental health. The VA, as the second-largest funder of GME outside of the Centers for Medicare and Medicaid services, has been able to target both underserved locations and also the need for primary care and mental health in both the VA and the nation. This partnership ensures that U.S. military veterans have timely access to optimal care, 2 now and in the future. The VA’s effort, as well as that of the Teaching Health Center Graduate Medical Education program of the Department of Health and Human Services, have been made in an attempt to construct a future physician workforce that prioritizes the needs of patients and populations by focusing on particular locations and specialties. This helps ensure that academic medicine continues to give attention to communities and standards of equity. All of our teaching hospitals and medical schools could follow the model outlined by the VA and the Department of Health and Human Services in our efforts to create and train the future workforce best suited for communities in need. 6

Each of us, over the course of our careers, has trained, worked, and taught at VA medical centers. One of us (M.L.L.) diligently worked to develop curricula that met the realities of providing health care for the U.S. and global veteran population with a focus on veteran-centered education. 19 This work has been intrinsically intersectional, with central considerations related to health disparities and bias, and lessons that have significance beyond veteran populations. As one of us (M.L.L.) and colleagues wrote a few years ago,

it is well documented that veterans who enroll at the Veterans Health Administration are more likely to be low income, less likely to have access to other forms of insurance, more likely to report lower quality-of-life measures, more likely to exhibit comorbidities, and more likely to have less experience with the doctor–patient relationship compared with veterans that use other, civilian health care systems. 19

In medical education across the continuum, there has been a renewed focus on systems approaches to care, bias, and health inequities both with and without the consideration of access to care, including issues regarding health insurance and mental health. The ability to partner with faculty and staff at the VHA allows educators to use the broad footprint of the VA to learn in a context where access to care and mental health are 2 areas for priority and focus. 19

The experience of caring for veterans further resonates with the importance of learning about implicit bias and the assumptions we may make about the lives of our patients. As noted by one of us (M.L.L.), “We are coming from a place of ignorance. We can’t properly treat [veteran] patients without knowing their military experience.” 19 This same insight holds true for all of our patients. The distinct and unique opportunities for medical and health professions students to learn such an important lesson early in their training are invaluable.

We cannot adequately express the indebtedness and respect we feel for our veteran patients. One of us (L.W.R.) attempted to do so in an article 20 published a few years ago, but at the time of this writing, what she wrote still seems to fall short of the significance of veteran–patients in shaping her identity as a psychiatrist, physician, and U.S. citizen.

These members of the military and veterans helped me understand how courage and vulnerability coexist, how listening without judgment can help someone bear their burdens, and how astute clinical care can turn things for the better—including for those great men and women whose service has allowed our lives to be better. 20

Dr. Quentin R. Youmans communicated his sense of gratitude with particular poignance and perfect eloquence in his poem, “For Your Service,” 21 appearing in our journal in 2020. Here is an excerpt:

Strange fruit that soured on the vine

But an able body, ripe, in Vietnam or Korea.

My dreams achieved

Because of your dreams deferred

Me—dancing in the wind

The pollen residue a herald of progress to  come

Our paths cross in my care for you

And your care for me

Even before our paths crossed.

He commented,

Upon reflection, I realized that patients “serve” us in many ways. We learn from them and their ailments, fine-tuning our skills so that we can provide ever-improving care. Mr. L served his country, fighting to maintain the liberties we citizens hold so dear. And he served me and other Black physicians like me, sacrificing so that we can achieve our dreams. 22

It is unclear what academic medicine would look like today without the sawdust-dry and astonishingly visionary U.S. Department of Veterans Affairs Memorandum No. 2. The VHA and academic medicine have aligned their work, together building optimal clinical care practices, investing in education programs to create a large and growing health professions workforce, and developing new knowledge and innovative efforts such as the electronic record, plus engaging with communities, growing health systems, and implementing policy on a broad scale. The relationship has survived, despite many challenges, because of the many shared, salutary effects of the enduring partnership. Nevertheless, that partnership—and, importantly, the people who make up the partnership, composed of patients, trainees, and faculty—deserve our appreciation and attention for the coming decades to confer similar good.

References

1. Association of American Medical Colleges. The VA and academic medicine: Partners in health care, training, and research. https://www.aamc.org/media/25196/download. Accessed April 12, 2022.
2. U.S. Department of Veterans Affairs, Office of Academic Affiliations. To educate for VA and the nation. https://www.va.gov/oaa. Accessed April 12, 2022.
3. U.S. Department of Veterans Affairs. Policy memorandum 2: Policy in association of veterans’ hospitals with medical schools. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf. Accessed April 12, 2022.
4. Veterans Health Administration, Office of Academic Affiliations. The report of the Blue Ribbon Panel on VA-medical school affiliations: Transforming an historic partnership for the 21st century. https://www.va.gov/oaa/archive/brp-final-report.pdf. Accessed April 12, 2022.
5. U.S. Department of Veterans Affairs. VA History Office. https://www.va.gov/history/index.asp. Accessed April 12, 2022.
6. U.S. Department of Veterans Affairs. I CARE. https://www.va.gov/icare. Accessed April 12, 2022.
7. Kerschner JE. The value of Veterans Administration medical centers in academic medicine. WMJ. 2016;115:162–163.
8. Moore JT. Why the VA matters: Resident education, research and patient care. Am J Surg. 2017;214:1002–1006.
9. Digital VA. History of IT at VA. https://www.oit.va.gov/about/history.cfm. Accessed April 12, 2022.
10. Veterans Health Administration, Office of Rural Health. Telehealth. https://www.ruralhealth.va.gov/docs/ORH_Telehealth_Fact_Sheet.pdf. Accessed April 12, 2022.
11. U.S. Department of Veterans Affairs, Office of Research and Development. BLRD/CSRD resources for the VA research community: V. Scientific review of research applications. https://www.research.va.gov/services/shared_docs/resources.cfm#5. Accessed April 12, 2022.
12. U.S. Department of Veterans Affairs. Rehabilitation research & development service (RR&D). http://www.rehab.research.va.gov. Accessed April 12, 2022.
13. U.S. Department of Veterans Affairs. Health services research & development. http://www.hsrd.research.va.gov. Accessed April 12, 2022.
14. American Academy of Physician Associates. PA students eligible for Veterans Affairs scholarship program. https://www.aapa.org/news-central/2017/03/pa-students-now-eligible-veterans-affairs-scholarship-program. Accessed April 12, 2022.
15. Roberts LW. Innovation and leadership across the five missions of academic medicine. Acad Med. 2021;96:1623–1624.
16. Petrakis IL, Kozal M. Academic medical centers and the U.S. Department of Veterans Affairs: A 75-year partnership influences medical education, scientific discovery, and clinical care. Acad Med. 2022;97:1110–1113.
17. Moldestad M, Sayre G, Rinne S, et al. Perspectives on training and working in the VHA: Implications for primary care physician recruitment and retention. Acad Med. 2022;97:1175–1183.
18. Klink KA, Albanese AP, Bope ET, Sanders KM. Veterans Affairs graduate medical education expansion addresses U.S. physician workforce needs. Acad Med. 2022;97:1144–1150.
19. Lypson ML, Ross PT, Zimmerman N, Goldrath KE, Ravindranath D. Where do soldiers really come from? A faculty development workshop on veteran-centered care. Acad Med. 2016;91:1379–1383.
20. Roberts LW. Sacrifice and service, protectors and teachers: The role of military and veteran patients in training early-career psychiatrists. Acad Psychiatry. 2015;39:349–350.
21. Youmans QR. For Your Service…. Acad Med. 2020;95:1876.
22. Youmans QR. Commentary on “For Your Service….” Acad Med. 2020;95:1877.
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