AAMC Reporter: July 2006

Sixty Years Later, Academic-VA Health Care Affiliation Still Strong

With the influx of returning World War II veterans in 1946, the architects of Public Law 293, which created the Department of Medicine and Surgery within the Veterans Administration (VA), composed a memorandum establishing an affiliation between this federal health care division and most of the country's medical schools. It was a bold move that would forever change the face of the nation's health care, both public and private.

"By June 1946, some 12.8 million men and women were returned to civilian life — all veterans," wrote Gen. Omar N. Bradley, with Clay Blair, in General Bradley's autobiography "A General's Life," published in 1983. Amazingly, during General Bradley's first eight months as VA administrator immediately after the war, the number of veterans in the United States nearly tripled, from almost 5 million to close to 17 million.

At that time, what shocked and mobilized both VA and academic physicians into action was the fact that fewer than 1,000 physicians were employed by the nation's VA hospitals, according to an account written by Paul B. Magnuson, M.D., who was then chair of the Department of Orthopedic Surgery at Northwestern University Medical School. To complicate matters further, most of these hospitals were located in remote areas, "some of them on Indian reservations, others as much as fifty miles from the nearest through-line railway stop," he wrote in his 1960 autobiographical book, "Ring the Night Bell," which recounts his instrumental role in crafting the document that governs the affiliation between the Veterans Health Administration (VHA) and academic medicine.

Malcolm Cox, M.D.

Clearly, something needed to be done, and thus began a successful partnership between the VA and academic medicine. Sixty years later, the relationship forged in VA Policy Memorandum No. 2 by General Bradley, Maj. Gen. Paul Hawley, whom General Bradley tapped to head the VA medical department, Magnuson, and other physicians has "never been stronger," in the words of Malcolm Cox, M.D., VHA chief academic affiliations officer.

"The affiliation agreement, or partnership, that was established back in 1946 has become the biggest and most successful public-private partnership in the VA's history," Cox said.

Starting with Northwestern University Medical School and the University of Illinois College of Medicine, and followed soon after by the University of Minnesota, 107 academic medical centers have since formally allied themselves with the VA. It is a move that experts feel has benefited medical care in both VA and teaching hospitals, as well as elevated the level of medical education in the United States.

"The benefits to the affiliates, the medical schools and the academic medical centers in general is that it expands the learning environment for their trainees," Cox said. "It's had this remarkably synergistic effect that is a conceptual win-win situation for both sides in this partnership."

Jonathan B. Perlin, M.D., Ph.D., M.S.H.A., F.A.C.P., is the VA's undersecretary for health. In a recent written statement, he called this partnership "an integral part of VA's ability to provide high-quality health care to veterans," adding that, "our educational programs provide excellent training for clinicians who will serve not only veterans, but the broader population."

Robert A. Petzel, M.D.

In agreement is Robert A. Petzel, M.D., network director for the VA Midwest Healthcare Network (VISN 23) and a member of the AAMC Council of Teaching Hospitals and Health Systems Administrative Board. Mutual need on the part of both the VA and medical schools led to the affiliation, said Petzel, and reciprocal benefit helps keep the relationship strong. With the large numbers of returning veterans after World War II, the VA needed first-rate facilities to address their health care needs, he explained. At the same time, medical schools needed to expand their teaching facilities to accommodate returning veterans who had not completed their medical training before leaving for military service, Magnuson reported in his book.

"This arrangement, I think," said Petzel, "fulfilled both of those needs admirably."

Physicians in the academic affiliates to the VA have joint appointments in their medical schools and the VHA, which each pay part of their salaries. These joint appointments have expanded the educational resources available to medical students, as well as the opportunities for training and work experience for students and faculty, said Joseph Keyes, J.D., AAMC senior vice president and general counsel. And, as medical schools try to expand their enrollment to meet the 30 percent increase recently recommended by the AAMC to ameliorate a predicted physician shortage, the greater pool of educational resources afforded by the collaboration with the VA will become increasingly important, Cox said.

Similarly, Robert Dickler, senior vice president of the AAMC Division of Health Care Affairs, said that the opportunity to share resources with VA medical centers has helped increase the number of educational opportunities available to medical students in the United States.

In addition to greatly expanded educational resources, the association with the VA has provided research opportunities to students, residents, and faculty in teaching hospitals, especially in the area of rehabilitation, Dickler added. Approximately 30,000 medical students and about 20,000 residents rotate through the VA health care system at some point in their medical training.

"It has made medical education better," said Dickler, "and the general perception, I think, is that medical education and the relationship with academic medicine have helped maintain and improve the care offered at the VA medical centers."

The VA-academic relationship has improved patient care in veterans' hospitals in three main ways, according to Petzel. First, the affiliation agreement requires that VA physicians have the same qualifications expected of medical school faculty. Second, combining education and research within patient-care facilities helps attract first-rate physicians. Finally, medical care is always improved when patients are treated in an academic atmosphere that combines teaching and continual questioning of treatment methods, Petzel added.

"I think that the affiliations with the medical schools that began in 1946 have tremendously improved the quality of care in the VA health care system," Petzel said. "It was a landmark event from that perspective."

This is in marked contrast to the state of affairs in VA hospitals in the years prior to 1946. As described by Magnuson in his book, VA physicians, who then were employed by the civil service, were "hemmed in by regulations and practically forbidden to do any research, attend any medical meetings, or otherwise keep in touch were scientific progress." The bureaucracy was such that patients sometimes had to wait days for treatment, Magnuson added, and the idea of a teaching hospital was, at that time, a foreign concept to VA medical centers, which were not accredited for residencies or internships. In 1946, however, that all changed with the affiliation agreement with academic medicine. "Basically, what this agreement does from the conceptual perspective is it opens the VA to physicians both in training and on staff at the medical schools and academic medical centers," Cox explained. "It allows the VA, essentially, to work with the cream of the crop, both at the trainee and staff levels."

In an effort to continue this successful collaboration, the VA has plans in place, adopted last October, to increase the number of residency positions that it supports. While the number of VA-funded residency positions has not changed from an average of about 8,000, the number of residents in the country is increasing, meaning that the percentage of residency slots supported by the VA has fallen from a historic high of 10 percent to 11 percent to 8 percent to 9 percent currently, according to Cox. Beginning in July 2007, the VA will provide about 350 new residency stipends to its academic affiliates. In the next three to five years, the VA hopes to have added about 1,500 to 2,000 new residency positions in an effort to reach and maintain its former record high of 11 percent of residencies supported nationwide, Cox added. Although the current budget covers only 2007, Cox said that he is optimistic that the VA will be able to continue these higher graduate medical education (GME) funding levels in subsequent years.

Another recommendation included with the GME enhancement plan and adopted by the VA was the continued endorsement and support of the affiliation agreement between the VHA and academic medical centers. "It's a general endorsement of the utility of this relationship," Cox explained.

As is the case with nearly every relationship, communication is vital to success. Through its VA Deans Liaisons Committee, the AAMC meets regularly with VA staff members to discuss issues, concerns, and joint projects. In addition to this committee, the high-level advisory group known as the VA Special Medical Advisory Group, or SMAG, that General Hawley established 60 years ago, still exists today and counts as one of its current members AAMC immediate-past president Jordan J. Cohen, M.D.

"There's been a long tradition, internal to the VA, of developing good relationships with academia and having a good advisory mechanism," Keyes said.

The AAMC and the VHA currently are planning a celebration to mark their 60th anniversary to take place at the association's 2006 annual meeting in Seattle this fall. As they did 60 years ago, these two longtime associates will discuss how to provide the best medical treatment for the country's returning veterans: this time, from the wars in Iraq and Afghanistan.

— By Anne Blank, Special to the Reporter

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