More than 33 million adults in the United States take medication to control high blood pressure — an ailment that can damage their hearts, brains, and kidneys to the point of disability and even fatality. Yet as common as that treatment is today, there was a time when doctors rarely treated hypertension because one option (surgery) was so dangerous and the other (an older class of medications) produced severe side effects with questionable benefits.
“What we didn’t know was, if we treated it, would it make a difference?” says Carolyn Clancy, MD, assistant under secretary for health for discovery, education and affiliate networks at the Veterans Health Administration (VHA).
Then in the mid-1960s, Edward Freis, MD — a physician-researcher at the Washington, D.C., Veterans Administration (VA) Hospital and director of the Cardiovascular Research Laboratory at Georgetown University School of Medicine — led a clinical trial of a new class of drugs that significantly reduced strokes, congestive heart failure, kidney failure, and death in a wide swath of hypertensive patients, with fewer painful side effects.
“That groundbreaking trial changed the equation,” Clancy says, setting off the development and widespread use of hypertension medications.
That’s just one of hundreds of life-changing and life-saving medical discoveries that have been developed from research relationships between medical schools and the VA (now the Department of Veterans Affairs and home to the VHA). These partnerships — which include teaching, patient care, and research — are prevalent throughout the academic medicine ecosystem: 97% of U.S.-based medical schools are affiliated with the VA, and more than 70% of physicians in the U.S. have trained or worked in at least one of the VA’s 170 medical centers, according to the VA.
The collaborative research has produced such innovations as the first nicotine patch to help people stop smoking, the first shingles vaccine, arterial grafts made from synthetic material, scores of prostheses for lost and injured limbs (such as this motorized ankle), and innovations in treating substance abuse and mental illness.
Administrators say the collaborations have increased the research capacity and effectiveness of both medical schools and VA hospitals.
“Neither side could accomplish their mission as effectively as they do without the other one,” says Gerhard Schulteis, PhD, associate chief of staff for research and development at the VA San Diego Healthcare System and professor emeritus at the University of California San Diego School of Medicine.
In December 2022, in a rare display of bipartisan collaboration, the U.S. House and Senate unanimously passed the VA Infrastructure Powers Exceptional Research (VIPER) Act, further solidifying this partnership. The move ensures that academic medical centers and the VA can continue to collaborate on all manner of research that benefits not just veterans but the general public.
Blending staff benefits all
The partnership began with a national medical crisis: An unprecedented surge in soldiers needing care during and after World War II. In part because of improvements in battlefield care, “more service members returned home with wounds that were not previously survivable,” a VA history explains.
“After World War II, the VA was close to collapse,” says Laura Petersen, MD, MPH, associate chief of staff for research at the Michael E. DeBakey VA Medical Center in Houston. “There were only about 1,000 physicians to care for 100,000 veterans.”
Starting in 1946, the agency forged agreements with medical colleges and their affiliated hospitals to help care for wounded veterans (such as by adding residents and their supervisors to augment VA staff) and opened VA hospitals close to medical schools to promote research and innovation between the institutions.
Today, the collaboration is built into the operational structure of many of the institutions, so that they share certain staff, funding, and infrastructure as a matter of course. For example, clinicians at VA hospitals (many of whom conduct research) typically earn a faculty position at the medical school that is affiliated with the hospital.
“Almost all of the practicing clinicians at the Durham VA [hospital] have a Duke appointment,” notes Monte Brown, MD, associate dean of veterans affairs for the Duke University School of Medicine in North Carolina. “Many faculty members spend part of their day at the VA and part of their day at Duke.”
These integrated relationships benefit physician-scientists at VA hospitals and medical schools alike. Those working for the VA get to partner with researchers at the colleges, tap student and postdoctoral scientists to work on their projects, and earn academic promotions. The ability to offer faculty positions at schools of medicine gives VA hospitals “a big advantage in attracting clinical scientists,” says Schulteis at VA San Diego.
Meanwhile, physician-scientists from the medical colleges get to conduct research at the VA facilities, which usually comes with an opportunity to provide care to veterans. “There is an expectation that not only are you doing research, but that you’re also seeing patients,” says Ann Rosenthal, MD, a professor in rheumatology at the Medical College of Wisconsin and associate chief of staff for research at the VA Medical Center, both in Milwaukee. “It’s very clear what we’re here for: to take care of patients and to move medical knowledge forward.”
That gives VA patients access to top clinical specialists, and enables those specialists to treat and study a patient population whose medical needs differ significantly from the general population. The incidence of limb injuries and loss, traumatic brain injury, or post-traumatic stress tends to be higher among veterans, notes Terence Keane, PhD, associate chief of staff for the VA Boston Healthcare System and assistant dean for research at the Boston University Chobanian & Avedisian School of Medicine.
“You’ve got access to a diverse population of patients who like to volunteer for studies,” says Clancy at the VHA. “Many of the veterans we serve think about this [study participation] as another way of giving back.”
In addition, having doctors from university hospitals treat and study patients at VA hospitals strengthens ties between the institutions in a way that is unplanned and lasts a lifetime: Many of these doctors choose to build careers in the VA. For example, Petersen did her internal medicine residency training at Brigham and Women’s Hospital and Harvard Medical school, where she rotated at what is now the Boston Medical Center.
“I loved the patients,” Petersen recalls. “I loved the challenge of the clinical issues that they experience as a result of their service, and how we can help them.”
After her fellowship, Petersen joined the staff at the Boston VA Medical Center, then moved to the VA Medical Center in Houston, where she also serves as a professor at Baylor College of Medicine. At the VA, Petersen conducts research to improve health care quality and oversees the research that the institutions jointly conduct.
Access to grants expands research
The integration of staff and resources between medical colleges and VA hospitals gives each of them access to resources they might not have on their own.
“Senior investigators need a lot of money to investigate things fully, to ensure that they have enough staff to do world-class quality research,” Keane says. Yet because the VA is a government agency, he notes, salaries are capped at lower levels than they are at private institutions. For researchers employed by the VA, “you’ve got to supplement your research” with funding from other agencies.
As one way to accomplish that, universities affiliated with VA hospitals receive grants from the National Institutes of Health (NIH) and elsewhere, with an agreement that the university will carry out the projects with VA researchers, who typically have dual positions on the university faculty. This provides a way to leverage university resources (such as specialized equipment or staff with special skills) to carry out large projects.
Consider geriatric research, which is a major focus for the VHA because 46% of its patients are age 65 and older, compared with 18% of the nation’s non-veteran population, according to the Department of Health and Human Services. In 2020, for example, the NIH granted $1.7 million to researchers at Boston University’s medical school, working with the VA Medical Center there, to study the impact of traumatic stress on the premature onset of age-related diseases and neurocognitive decline.
As part of a nationwide project, the NIH provided $90 million in grants for dozens of institutions — including VA hospitals working in partnership with medical schools — to study whether taking statins (which are used to lower cholesterol) can prevent dementia, disability, and heart disease in people age 75 and older. The four principal investigators are from Duke and the Wake Forrest University School of Medicine.
At the same time, university-based researchers can collaborate on grants that are issued by the VA to its own employees, by working on joint projects with VA-based researchers or serving as investigators on VA-funded projects through their own positions at VA hospitals.
“That has saved me in numerous spots where I did not have NIH money” to carry out a study, Rosenthal says. One example was a study published in 2018 showing how genetic mutations contribute to the development of calcium pyrophosphate deposition disease, a type of arthritis marked by calcium crystals in the fluid around joints.
With the recent passage of the VIPER Act, medical schools and VA hospitals can continue to launch projects in response to new medical needs, just as they responded to the needs of soldiers returning from WWII. The COVID-19 Observational Research Collaboratory — a multi-site project involving medical colleges as well as other universities — has built a medical database of hundreds of thousands of veterans who were infected with SARS-CoV-2. The project has published numerous studies covering such issues as the use of medications among infected veterans, their vaccination acceptance, and self-harm and suicide among those infected.
The hope is that those findings will enable scientists and frontline doctors to improve disease prevention and care for everyone.
“Over the five decades I’ve worked in [the] VA, I’ve seen the remarkable outcomes of these initiatives,” says Keane at VA Boston Healthcare. “It’s a mutually beneficial relationship.”