Twenty-four million of the 305 million people in the United States are veterans, and providing for the health care of veterans is a key and expanding commitment of the U.S. government. In 1930, when President Herbert Hoover signed Executive Order 538 establishing the U.S. Department of Veterans Affairs (VA), there were 54 VA hospitals; there are now 155 VA Medical Centers—with at least one in every state—and a broad network of community-based outpatient clinics stretch across rural and metropolitan areas (
1). In 2007, a staggering $34.9 billion was spent on veteran health care (
1). This accounted for approximately 773,600 inpatient hospitalizations and over 60 million outpatient medical visits (
1,
2). The VA has indeed become the largest medical care provider in the world. With 1.4 million people currently serving in the U.S. Armed Forces, and the broad participation of the U.S. military in unstable areas around the world, it is expected that the health care of veterans will be a priority of growing importance in the coming years (
3).
Academic and research partnerships represent central concerns of the VA. More than half of the physicians currently practicing in the United States received some of their professional training in the VA system (
4). A total of 107 (out of 125) U.S. medical schools have a formal affiliation with VA partners (
5). It was recently reported that more than 30,000 residents and 22,000 medical students are trained in VA settings each year (
5). Furthermore, research itself is a key mission of the VA. In 2006, $412 million was appropriated for VA research, and another $357 million from the VA medical care account was used to support research (
1). In addition to this, the National Institutes of Health (NIH) and other sources provided $882 million for research based in the VA system (
1). There are currently over 3,000 active investigators in the VA, and, interestingly, the majority of these researchers are clinician-scientists (
1).
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The VA and Academic Departments of Psychiatry
The VA is a vital resource for many successful academic departments of psychiatry. Academic programs have been inestimably strengthened by their ability to develop and implement innovative, evidence-based clinical care programs with veterans; provide care for individual veteran patients with a unique array of complex psychiatric diseases; support resident, fellow, and faculty positions; access comprehensive and well-organized electronic databases; and conduct basic, translational, clinical, and community-oriented research through the federal system in support of activities of medical schools. The value of the VA is especially great for departments of psychiatry because the VA is deeply committed to mental health care, prevention, and recovery efforts (
6).
Partnering with academic psychiatry has been and will be essential for the VA to fully accomplish its primary missions of patient care, education, and research. (Its secondary mission is to serve as a backup to the Department of Defense, which is less directly relevant to academic institutions.) Moreover, VA mental health programs that are linked with academic departments have key advantages. For instance, the partnership, in our experience, has a very positive effect on faculty recruitment. Having students to teach, supervise, and mentor brings greater creativity and diversity to the work of an attending physician, as does the opportunity to succeed in an academic system of promotion at the partner medical school. Practicing in an environment that focuses on education, and implementing systemic programs that are built on evidence-based best practices, together help clinicians engage in continuous learning and professional development. Clinicians remain at the top of their fields and aware of newly evolving treatment approaches. Finally, with respect to patient care, the presence of students on treatment teams effectively expands the human face of the clinical workforce: through students, residents, and fellows, there is a clear increase in direct, clinically related contact experiences for patients with the treatment team.
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This Collection of Papers
This issue of Academic Psychiatry highlights the special relationship between the VA and academic departments of psychiatry. This collection was developed through an invited call for papers, and each paper was evaluated through our usual double-blind peer review process. The authors of these papers give focus to many important aspects—as well as potential challenges—intrinsic to the collaboration.
Mohl et al. (
7) discuss how their successful VA-psychiatry department relationship has developed and evolved over many years. The authors emphasize the critical importance of the relationship between the department chairman and the VA mental health service chief. The authors outline the tactics for supporting this relationship, such as active efforts by the chairman to recognize priorities of the VA, and efforts by the VA service chief to identify VA faculty with academic expertise. The authors suggest that collaborative success is reached when the chairman and the chief work together to focus on suitable academic projects that align with faculty interests and responsibilities in the VA system.
This collection also features three highly worthwhile empirical studies looking at VA-based education activities. Rohrbaugh et al. (
8) share their findings from a survey designed to compare the educational value of two programs: the first is an innovative collaborative program at the VA in which psychiatric residents complete their primary care training requirement through the Psychiatry-Primary Care Education (Psy-PCE) initiative, and the second is traditional training in which psychiatric residents fulfill their internal medicine learning requirements on the medicine inpatient wards. The Psy-PCE initiative is essentially a program in which primary care is provided to patients in a VA mental health clinic. The authors state that the Psy-PCE training experience offers many advantages, including its closer resemblance to later psychiatric practice (i.e., greater ecological validity), its focus on the recognition of physical illness, and its emphasis on health promotion and disease prevention. The results suggest that psychiatric residents who participate in the Psy-PCE program may also learn more about the epidemiology of physical illnesses in the mentally ill patient population.
Tucker et al. (
9) compare the results of VA-trained third-year medical students’ performance on the National Board of Medical Examiners (NBME) psychiatry subject examination with the results of those who completed their rotation at non-VA sites, and found the results to be equal. These two studies are especially welcome additions to the education literature—few studies have assessed the effectiveness of VA-based educational efforts, and the results offered here are encouraging.
Rorhbaugh et al. (
10) describe an innovative utilization of the VA’s comprehensive computerized medical records to provide an individualized resident physician practice prescribing profile. The profile includes a cost analysis of the medications prescribed and allows residents to look carefully at the prescription patterns they are developing. The profiles were easily pulled for a resident outpatient clinic. The authors used the profiles to assist their residents in practice-based learning.
Atre-Vaidya et al. (
11) describe a unique academic tripartite relationship between Rosalind Franklin Chicago Medical School, the local VA (North Chicago VA Medical Center), and the Great Lakes Naval Hospital. Here the naval hospital and the VA hospital have put resources together to provide care to their constituents in one hospital context. This initiative has benefited all three organizations in a very substantive way. The residents and medical students benefit, for instance, from opportunities to care for a wider range of patients (including pediatric and OB-GYN patient services) on the main campus. By combining resources and programs, the VA and the Department of Defense experience economies of scale and have more efficient hospital services. Both the VA and the Department of Defense, moreover, are better positioned to recruit physicians because of the academic affiliation.
Scaturo and Huszonek (
12) review the current VA medical system and many of the recent trends in patient care, such as telemedicine, mental health care integrated into primary care clinics, traumatic brain injury assessment and treatment, and polytrauma treatment teams. They further explore the impact of these trends on current approaches to psychiatric and psychology training. While the authors found that there have been important innovations in assessment and care, they caution readers about the importance of evidence in assessing the value of these programs, which may appear to give quick or immediate symptom relief but may not produce enduring positive outcomes for patients.
Despite the mutuality of missions and benefits for the VA and academic departments of psychiatry, there are many challenges to keeping the collaboration constructive and balanced. For example, medical schools are responsible for training students, residents, fellows, and other learners with respect to health issues that are relevant to people of all ages and both genders; because veterans seeking care are typically middle-aged and older men, the VA often cannot provide sufficient diversity in clinical populations needed by academic training programs. Other challenges include the different work expectations between academic practice and government positions. The federal system—whether in the VA or at NIH—is based on the expectation of a 40-hour work week; this time-effort equation is different than in most academic settings.
On the other hand, there are challenges and additional responsibilities for VA-based faculty as well. VA researchers affiliated with the medical universities are required to work with a second institutional research board. Beyond their usual patient care duties, VA faculty perform extra work in the training and teaching of students and residents. From a system perspective, students in the VA environment require more and specialized facilities and add complexity to safety and security issues. Information systems and computer equipment requirements are also increased with the involvement of students and residents in clinical training settings.
Both the Department of Veterans Affairs and academic departments of psychiatry are best served when they work closely together to develop and maintain a positive collaborative partnership. The overlap in missions and the benefits to both agencies are quite apparent, and it is our view that these shared commitments and strengths will continue to grow in the coming years. We suggest that leaders in the VA and academic department agencies will increasingly need to nourish the relationship and to harmonize the system asymmetries and conflicting priorities that arise. Both agencies need to work to align research and education efforts with the unique patient populations found within the VA medical system.
It is clear that the Department of Veterans Affairs will continue to play a major role in psychiatric care, education, and research in the future. Our authors in this issue share some of the essential ideas and methods to best work out an academic relationship with the VA and share some of the creative and innovative products of an ideal partnership between the VA and academic psychiatry departments.
At the time of submission, Dr. Lehrmann disclosed no competing interests. Disclosures of Academic Psychiatry editors are published in each January issue.