The U.S. Department of Veterans Affairs (VA) is the largest single provider of professional medical and health education in the country (1, 2) and, because of its educational mission and commitment to providing educational resources, is often the preferred training site for medical students and residents (2, 3). The VA’s adoption of education as a critical mission and its commitment of resources to support this academic mission are quite appealing to many medical schools. The affiliation also allows clinical access to diverse and medically complicated populations, and is cost-effective in sharing clinical and research resources (2, 3). Public Law 79–293, enacted on January 3, 1946, created the opportunity for formal affiliation relationships between U.S. VA hospitals and academic medical centers.
As described in Dr. John Clarkson’s (4) 2002 testimony, the 1946 VA publication “Policy on Association of Veterans’ Hospitals with Medical Schools,” which detailed that the VA would retain full responsibility for the care of patients and that the school of medicine would accept responsibility for all graduate education and training, further codified the relationship between the VA and academic medicine. The policy declared that the intent of the affiliation was to provide “the veteran a much higher standard of medical care than could be given him with a wholly full-time medical service.” This policy still guides VA-medical school affiliations today.
The American Association of Medical Colleges (AAMC) data reflect that 107 of the nation’s 125 accredited allopathic medical schools are currently affiliated with Veterans Affairs Medical Centers (VAMCs). The 1946 Policy Memorandum No. Two also called for the establishment of Dean’s Committees for each affiliation. The Dean’s Committees remain active, vital components of the medical school-VAMC affiliation and are composed of senior medical faculty from the appropriate departments and divisions of the affiliated medical school. The Dean’s Committee is responsible for implementing and integrating educational programs with their partnering VAMCs, as well as for nominating candidates from the medical school for appointments as full- or part-time faculty at the VAMC. Per AAMC data, 70% of VAMC physician staff members currently hold some level of a joint academic appointment (5). The extent of the VAMC/medical school relationship is influenced by the geographical distance between the two institutions, shared educational and research programs, and respect for the needs of the other institution (6).
The VA Merit Review funding program has led to the development of innovative and internationally recognized programs that focus on the clinical problems of special importance to veterans, including the alcohol research center at the Portland VA, the multiple sclerosis center at the Baltimore VA, and the spinal cord center at the Bronx VA (7). In addition, the VA research program has led to discoveries that have helped veterans and nonveterans alike, such as the development of the implantable cardiac pacemaker, CT scanner, and nicotine patch (3). Close cooperation between the medical school dean and the director of the VAMC has resulted in the development of numerous outstanding VAMC research programs. Joint faculty appointments have allowed medical schools and the VAMC to recruit outstanding physician-investigators, teachers, and administrators who are essential to the quality of their academic departments (4, 8, 9). As a result of long-time construction policies that favor VAMC sites near existing medical schools, many of the nation’s medical schools see VAMCs as indispensable partners in achieving their missions of education, research, patient care, and community service (4, 10).
Although there have been occasional concerns about the equality of these partnerships (7, 11), changes now occurring throughout health care are adding new challenges to the VA/medical school affiliation. The VA remains committed to education, but the demands on physicians for patient care are increasing, funding sources are tighter, and there is an increased scrutiny of faculty time and resident supervision. The changing priorities of patients and the marketplace are forcing medical schools and the VA to consider new ways of practicing medicine and interacting with each other (3, 11). The North Chicago VAMC and Rosalind Franklin University of Medicine and Science, who have been partners in education for over three decades and share the same campus, find themselves at the forefront of yet another novel relationship that has been and will be significantly influential.
A year-long study, which considered ways to increase collaboration between the two agencies, was undertaken by a working group chartered by the U.S. Department of Defense and the VA executive council. After several internal reviews, a partnership and an agreement to share resources was formed in 2002 between the North Chicago VAMC and the Great Lakes Naval Hospital, with total integration as the ultimate objective—a significant opportunity because the institutions are located less than 2 miles apart. Under this agreement, the Navy agreed to construct a new ambulatory medical facility for outpatient services, and the VA agreed to provide surgical and inpatient mental health care at the North Chicago VAMC.
The project is being done in several phases. Phase 1 began in October 2003, during which inpatient mental health at Great Lakes Naval Hospital was transferred to the North Chicago VAMC. In December 2004, the blood bank was relocated to the VA. Phase 2 began with a $13 million modernization of the North Chicago VAMC surgical and emergency care facilities. In June 2006, the Great Lakes Naval Hospital’s inpatient medical, surgical, and pediatric functions were transferred to the North Chicago VAMC. Navy physicians became staff at the VA and started treating Navy patients and dependents as well as veterans.
The final phase includes building a state-of-the-art federal ambulatory care clinic located on the medical center’s campus and named Captain James A. Lovell Federal Health Care Center. The Department of Defense will fund the $130 million facility with military construction money. This will be a three-story clinical addition with a ground floor attached to the North Chicago VAMC inpatient facility, with completion expected in 2010. It will operate under a single line of authority, overseen by a board of directors, with one combined Navy/VA medical staff.
Advantages to Collaboration
The agreement has proved advantageous for the VA and the Department of Defense as well as the medical school. It expands services at the North Chicago VAMC by providing previously unavailable surgical services in the newly renovated operating rooms and emergency services to veterans and Department of Defense beneficiaries. The addition of obstetrics and gynecology and pediatric services for the Navy expands training opportunities for students from medical and other health professional schools.
Further, by eliminating the need for dual administrative structures, this agreement also has significant fiscal advantages. The Navy benefits from its interaction with the fairly stable VA staff, compared with its 3–4 year turnover of uniformed physicians. The North Chicago VAMC and the Navy can also collaborate in less obvious ways, such as in providing long-term care for the chronically mentally ill. The Navy has a number of psychiatric inpatients with long-term care needs, but its focus is not generally on long-term care. The Navy transferred its inpatient psychiatric workload to the North Chicago VAMC, which specializes in such care. This joint initiative marks the beginning of renewed and unprecedented collaboration between the health care resources of the VA and the Department of Defense. The medical school has been a willing third party that also benefits from the relationship.
The Role of the Medical School
Throughout its near 100-year history, the Chicago Medical School at Rosalind Franklin University of Medicine and Science has been community based. It has not had an on-campus hospital facility but has relied entirely on clinical affiliations with community partners for the clinical training of its students. With class sizes of 185 students, this has been a significant undertaking, requiring several such partners.
Chicago Medical School has enjoyed a rich, longstanding partnership with its neighbor, the North Chicago VAMC. As a Dean’s Committee medical center, most programmatic initiatives that have involved the school’s students and residents have had the influence of the North Chicago VAMC. Over the years, the North Chicago VAMC’s emphasis of long-term psychiatric care and transfer of surgical and medical subspecialty services to other hospitals led to it having a relatively small medical service. As a result, although the North Chicago VAMC was geographically suited to serve as the primary site for Chicago Medical School students’ clinical education, its limited size and scope of services significantly restricted its use for clinical clerkship assignments.
Concurrent with its relationship with the North Chicago VAMC, Chicago Medical School also had an affiliation with the Great Lakes Naval Hospital. The psychiatry department sent trainees to inpatient and outpatient Navy facilities. These were unique experiences that benefited the trainees tremendously; however, with several supervisors on active duty, the availability of clinical educators became limited, and the psychiatry department had to reduce its assignment primarily to outpatient Navy experiences.
Lack of an on-campus primary clinical partner prevented Chicago Medical School third- and fourth-year medical students from sharing the same campus as first- and second-year medical students. The school wanted to have one-third or more of its clinical students on the main campus. Thus, the concept of the Captain James A. Lovell Federal Health Care Center appealed to the university.
As a testament to the collaborative spirit and vision and to their commitment to education, the VA and Department of Defense included Rosalind Franklin University from the beginning, making the federal health care center a tripartite initiative. The medical school and one or more of the university’s most senior administrative officials were involved in the strategic planning process, including administrative decisions and planning and implementing major initiatives, such as the creation of a pediatric floor and children’s clinical services in the North Chicago VAMC.
Impact of Collaboration for Psychiatry Training
The North Chicago VAMC is the primary training site for psychiatric residents and medical students, but it limits trainees’ exposure to older male veterans. This necessitates that the department of psychiatry has an additional affiliate to provide exposure to women and children—an inner city general hospital 30 miles away. The department of psychiatry wanted to create a single-site residency.
Since October 2003, medical students and psychiatric residents from Chicago Medical School have been assigned to the Navy inpatient unit at the North Chicago VAMC. The pathology encountered by trainees in this unit is unique and quite different from that of other adult civilian inpatient units. The patient population primarily consists of very young adults and offers exposure to adolescent behaviors and pathology in both genders. Trainees also evaluate emancipated teenagers subjected to adult legal standards of patient care. Often these patients present with their first episode of mental illness or access health care for the first time for previously existing psychiatric and general medical conditions. This exposure allows trainees to have an impact in the early stages of an illness and possibly prevent illness progression through quality care.
Medical students and psychiatric residents are exposed to a variety of psychiatric pathologies, such as severe personality disturbances, phobias, agoraphobia, adolescent catatonia, eating disorders, gender identity disorders, and at times, malingering. Many of these disorders are rarely seen in other general adult inpatient units. Trainees also have the opportunity of doing extensive evaluations and getting collateral information from military commands and families. Although most of these patients are young and generally healthy, some have both severe psychiatric and general medical conditions (e.g., history of syncope, seizures, head traumas, genetic syndromes, and cardiac abnormalities).
Trainees are also exposed to the concept of industrial medicine/psychiatry. They observe and practice a more confrontational style of assessment and, at times, very aggressive treatment management. Trainees become familiar with the responsibility of assessing the patient’s present and, more important, future ability to function in a harsh, very stressful military environment. They also understand the concept of protecting the third party (i.e., the risk of thousands of service members dying if a particular patient sent back to duty cannot do his or her job). Such evaluations enhance the trainees’ capabilities of advocating for their patients and making accurate short- and long-term risk assessments.
Psychiatry is, in general, heavily regulated by law. This unique federal setting combines both civilian state law and military law. Trainees are exposed to the challenges of such complex legal implications and learn to council their patients toward the best management and disposition.
One other challenging aspect is aftercare planning and continuity of care. Military patients come from all 50 states and sometimes from all over the world. Trainees are encouraged to obtain collateral information from faraway families and previous health care providers. They also establish psychiatric follow-ups in a wide variety of settings—from the patient’s family doctor close to home to distant places, where the nearest physician’s assistant is an hour-long flight away from the patient’s location.
Extensive exposure to patients from all over the world also provides trainees with a great learning experience in understanding the importance of various religious, spiritual, and ethnic backgrounds.
Expansion of medical surgical services at the North Chicago VAMC has already allowed consultation-liaison trainees to have increased, diverse experiences that include both genders. In the future, residents will be able to consult on medically and surgically ill adults and children of both genders, allowing the residency to become a single site residency.
This unique facility will allow students and residents to care for patients throughout the full military life cycle—from newly enlisted service members to those with veteran status. Although this process is difficult, the benefit is the continued provision of accessible, high-quality health care for active-duty and veteran patients that benefits taxpayers by reducing costs and duplication between these two health care delivery systems. At the same time, the collaboration will allow seamless delivery of care to patients, from entry into the armed forces through veteran status. The envisioned end result will be a full-service clinical facility with greatly enhanced capabilities for student and resident education and clinical research. As a university affiliate, the James A. Lovell Federal Health Care Center will represent itself as a “sum” far greater than the two component parts of its VA and Navy hospital predecessors.
Manuscripts authored by an editor of Academic Psychiatry or a member of its editorial or advisory board undergo the same editorial review process, including blinded peer review, applied to all manuscripts. Additionally, the editor is recused from any editorial decision making.
At the time of submission, the authors disclosed no competing interests.