Viewpoint: Providing Better Health Care for Our Nation's Veterans

by Thomas J. Lawley, M.D., dean, Emory University School of Medicine and chair, AAMC's VA-Deans Liaison Committee

The electronic greeting outside the Veterans Affairs (VA) Medical Center in Atlanta reads "Serving Our Nation's Heroes." As the dean of Emory University School of Medicine, which shares a backyard and much more with the hospital, that message always gives me a great sense of satisfaction.

I'm not alone. Most VA hospitals are intentionally located near medical schools, and most of us in the AAMC feel the same sense of pride for our role in the care of veterans and for the VA's role in the future of medicine, through its support of graduate medical education and research.

The VA health system has been intertwined with academic medicine, to the benefit of both, for over half a century now, since the first affiliation agreements began in 1946. That public law established the predecessor of the Veterans Health Administration and provided the legal basis for VA hospitals affiliating with schools of medicine, allowing the medical schools to staff VA hospitals with top-notch medical school faculty physicians, residents, and interns. The joint appointments that resulted have achieved the law's goal: to afford "the veteran a much higher standard of medical care than could be given him with a wholly full-time medical service."

The agreement also has made the VA the nation's largest provider of graduate medical education. More than 30,000 medical residents rotate through the system every year, in addition to 20,000 medical students and yet other health professionals.

Approximately 70 percent of VA physician staff members have some level of joint academic appointments. Some schools report a 90 percent affiliation. Under the current system, both full-time and part-time VA physicians receive additional salary from their medical school affiliate. In fact, as VA compensation schedules have fallen further and further below the market, the recruitment of promising physicians to the VA - especially in scarce specialties and subspecialties - is often made possible only by the existence of such joint appointments.

With these strong affiliations, VA hospitals are better able to gain access to the full range of medical specialties and expertise generally available only at an academic medical center, and medical students and residents, supervised by attending physicians, participate in the care of millions of veterans and become better physicians for America's communities.

Late last fall, as chair of the AAMC's VA-Deans Liaison Committee, I testified before the House Committee on Veterans Affairs, Subcommittee on Health, on a proposed physician compensation reform bill. Recognizing the lack of competitiveness in VA salaries, and especially in specialty pay, which has not increased at the VA since 1991, the Bush administration's proposal is to benchmark VA physician salaries to the 50th percentile of the AAMC's associate professor salary and incorporate performance-based pay as well as geographic, specialty, and productivity measures to bring VA physicians' salaries in line with those in the non-federal workplace.

What's not to like? While the AAMC is supportive of increasing salaries of VA physicians, we don't believe it goes far enough. Benchmarking to the 75th percentile of the AAMC's associate professor salary level would increase salaries for over 99 percent of all VA physicians and would, we believe, better ensure the VA remains on the cutting edge of medicine, able to compete for the best and brightest physicians.

The AAMC also believes that there should be no steps taken to prohibit VA chiefs of staff from receiving any compensation from an affiliated medical school. Doubtless this part of the proposal was intended to emphasize the need for chiefs of staff to function as the VA's independent representatives without conflicts of interest - as they should. But since chiefs of staff generally do not make business decisions for the VA, academic affiliations - and related compensation - should not cause unmanageable conflicts of interest.

On the contrary, as the primary liaison between the VA and the medical school (often holding the title of associate dean), it is essential chiefs of staff have strong academic credentials and credibility. It's also essential that the VA have at its disposal all the incentives possible to recruit the most qualified individuals possible to pursue such a leadership position.

In short, the AAMC is one of the biggest supporters of the VA and of the Department of Veterans Affairs Health Care Personnel Enhancement Act. We hope to see it be more, not less. We argue that case in honor of our nation's heroes and of an affiliation agreement that has resulted in better care for the nation's veterans and, through research and an enhanced academic environment, for all our citizens.

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