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AAMC Reporter: November 2005
A Word from the President:
"Strengthening the Ties that Bind: Our GME Partnership with the VA"
Next year, academic medicine marks a milestone
deserving of much celebration. In 2006, it will have
been 60 years since the Department of Veterans Affairs
(VA) adopted Policy Memorandum 2, the historic
document that launched our invaluable partnership
with the VA. By now, no fewer than 107 of the nation's
125 medical schools have formal affiliation agreements
with VA medical centers; only some 15 percent
of the VA medical centers lack such agreements.
Seventy percent of VA physicians hold joint faculty
appointments at an affiliated medical school and, in
addition to their commitment to serving our nation's
veterans, they commonly cite the teaching and
research opportunities available to them as sustaining
their loyalty to the VA.
While the mutual benefits that have flowed from our
durable partnership with the VA span all of our joint
missions of education, research, and patient care,
none have been more consequential than those attributable
to our partnerships in graduate medical education
(GME). You may not be aware that the VA is now
the nation's single largest provider of GME, given that
it funds almost nine percent of all residency positions.
Because virtually all these positions are in programs
jointly sponsored with an affiliated academic medical
center, they make it possible for close to a third of all
medical residents in the country to receive at least
some of their training in a VA facility.
Recognizing the VA's large stake in GME and the ever changing
nature of residency training in this country,
former VA Secretary Anthony Principi wisely initiated
a comprehensive review of the agency's current GME
activities. The first step in the process involved an
internal VA GME advisory committee, which was
chaired by Timothy Flynn, M.D., associate dean for
GME at University of Florida School of Medicine and
former chair of the AAMC's Group on Resident
Affairs. Following the submission of the internal committee's
thorough report, Secretary Principi appointed
an external, federally chartered advisory committee to
provide an outside assessment and make recommendations
for the future. That effort was headed by Dan
Winship, M.D., former vice chancellor for health affairs
at the University of Missouri and current chief of the
Cook County Bureau of Health Services. All of the other
members of the committee (including myself) have had
considerable experience working in affiliated academic
medical centers.
In its report submitted in September 2005, the advisory
committee strongly reaffirmed the value of the
VA's commitment to resident education and noted the
crucial contributions made by the VA's academic partners
to providing high-quality care to veterans. The
report also underscored the opportunity that the VA
has to exert national leadership for enhancing the
effectiveness of GME generally, just as the VA has
led the nation in enhancing quality, in improving
patient safety, and in implementing an electronic
medical record.
As a specific recommendation, the advisory committee
called for a significant increase in the number of
VA-supported residency positions. Over the last 16
years, the percentage of the country's total residency
positions funded by the VA has fallen from 11 percent
to 9 percent as a result, not of a reduced number
within the VA, but rather of a substantial increase in
non-VA funded GME slots. The committee expressed
concern that the VA not fall short of its historic level
of involvement in the overall GME enterprise, especially
in view of the growing health care needs of veterans
and the growing number of veterans expected to
look to the VA to address those needs. Consequently,
the committee recommended that the VA "retarget" its
funded positions to regain its historic 11 percent share
of the total, and that it achieve this target level as soon
as possible. Doing so would require an immediate
increase of approximately 2,400 positions. Given the
current fiscal pressures under which the federal government
and the VA are operating, the committee was
under no illusions about how soon this ramp up in
positions might occur.
Nevertheless, in planning for the allocation of additional
positions, the VA was advised to take the following
considerations into account:
- The need to support new and emerging specialties
of importance to veterans' health care.
- The opportunity to use new VA care sites to shift
primary care (and other) training towards ambulatory
venues.
- The importance of having an adequate educational
infrastructure and an appropriate patient census to
support any new GME affiliations.
- The advisability — in achieving any desired geographic
balance within the VA system — of
allocating new positions to areas of need, rather
than re-allocating positions from currently
well-functioning programs.
Recently, several members of the advisory committee
had the pleasure of presenting the report in person to
the current Secretary of Veterans Affairs, Jim Nicholson.
All of us were most impressed with the Secretary's
detailed understanding of the issues we addressed, as
well as his clear commitment to furthering the VA's academic
missions and strengthening affiliations with its
academic partners.
When Policy Memorandum No. 2 was signed in 1946,
it anticipated a partnership "without precedent in the
history of Federal hospitalization." The first six decades
of immensely productive collaboration have certainly
affirmed that rousing prediction. As we look to the next
60 years and beyond, we should all pause to reflect on
what it takes to sustain such a relationship. Words that
come to my mind are: trust, generosity, empathy,
communication, equity, respect. Keeping these and like
sentiments in mind should ensure that our mutually
beneficial partnership with the VA will endure.
Jordan J. Cohen, M.D.
AAMC President
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