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Threatened VA Hospital Closure Raises Larger Training Concerns

By Martha Frase-Blunt
Special to the AAMC Reporter

A resident at the University of Illinois at Chicago College of Medicine talks with a patient at West Side VA Medical Center. Under a VA proposal, inpatient beds would be reduced at West Side and inpatient service would be ended at Chicago's Lakeside VA Medical Center.

Every year, more than 50,000 medical students and residents rotate through the nation's 173 Veterans Affairs (VA) medical centers. More than half the nation's physicians have received some part of their medical training in VA hospitals. That may change, at least in Chicago.

A proposal to discontinue inpatient services at a downtown Chicago VA hospital has raised concerns among medical schools about how the VA's latest attempt to restructure its health system could impact medical education, research programs, and veterans' health care.

In July, VA Under Secretary for Health Thomas L. Garthwaite, M.D., announced a proposal to end inpatient service at the 126-bed Lakeside VA Medical Center and to renovate the West Side VA Medical Center, reducing it from 219 to 177 inpatient beds. The plan aims to save approximately $720 million over 20 years. A final decision is expected this fall.

The proposal is the first made under the VA's Capital Asset Realignment for Enhanced Services (CARES). Designed to assess veterans' health care needs and develop delivery options to meet those needs, CARES is the outcome of a 1999 General Accounting Office report recommending that the VA perform comprehensive studies in its 106 markets, identifying the greatest potential for savings through the restructuring of its capital assets in those markets.

The VA contracted with management consultants Booz-Allen Hamilton to conduct an independent study of the Veterans Integrated Service Network comprising the Chicago area, the upper peninsula of Michigan, and Wisconsin. Booz-Allen proposed nine options, and the one affecting Lakeside was selected as the most promising. The next phase of CARES will cover seven additional networks, while the third and final phase, scheduled to start in 2002, will incorporate the remaining networks nationwide. Northwestern University Medical School Dean Lewis Landsberg, M.D., is so concerned about the closure of Lakeside, he has stated that the school would most likely sever ties with the medical center even though outpatient care would continue there. He has also presented an alternative plan to the VA.

"In addition to fewer training slots, Chicago-area veterans would lose valued relationships with Northwestern faculty, the same physicians who care for patients at Northwestern Memorial," he says. "Over and above compensated activities, Northwestern faculty routinely donate their services free of charge to veterans at Lakeside."

Research will also be affected, he asserts. "Closing Lakeside threatens important research collaborations between the VA and Northwestern, including $6.9 million in VA-related sponsored research currently under way at Lakeside and Northwestern, such as rehabilitation for limb amputees and spinal cord injury patients, prostate cancer, and other research topics with applications for both the veteran and general populations."

According to Frances Murphy, M.D., deputy under secretary for health at the VA who is charged with implementing CARES, the focus of the program "is not to downsize or close facilities but rather to provide more accessible, high-quality care for more veterans. In the proposed options for improving the delivery of health care to veterans, all of VA's missions were taken into account." She notes that the study considered academic affiliation issues such as the number of residents and students receiving training and the number and type of training programs involved.

Dr. Murphy explains that the VA is "firmly committed" to maintaining its existing affiliation with Northwestern and that, under the Chicago proposal, student and resident training may continue at the Lakeside outpatient clinic. "In addition, inpatient training with Northwestern faculty supervision is possible at the West Side VA Medical Center, only six miles from Lakeside," she says. "Joint affiliation with both Northwestern and the University of Illinois is entirely feasible."

Training constitutes a critical mission at VA hospitals, according to Friends of VA Medical Care and Health Research (FOVA), a coalition of more than 80 academic, medical, scientific, and advocacy associations, of which the AAMC is an active member. Jeff Coughlin, legislative coordinator for the Association of Professors of Medicine, another FOVA member, explains that more than 70 percent of VA medical centers have long-term care components, which provide experiences critical to the development of future physicians.

"As the veteran population ages along with the general population, it's important that residents and students learn about geriatrics and complex aging-related illnesses," Coughlin says. In turn, veterans benefit from access to an academic medical center envir-onment that can deploy the latest technologies and research advances. "And because the VHA comprises the largest health care system in the country, it presents unique clinical research opportunities. VA research programs attract world-class investigators; students and residents have the opportunity to learn from the nation's best and to see research results translated directly into clinical practice."

"The VA is one of the best places for students and residents to get training in the medical problems affecting veterans," agrees Alan Otsuki, M.D., assistant dean for medical education at Emory, which is affiliated with the Atlanta Veterans Affairs Medical Center. He estimates that 15 to 18 percent of Emory's undergraduate medical education occurs in the VA setting, and the figures are comparable for GME. "The VA system adds richness to our students' clinical experiences. Losing VA patients and facilities would significantly impact medical education overall. Even though our system could absorb this loss, we'd have difficulty making up for its enriching presence in our education system."