The U.S. Department of Veterans Affairs (VA) health care system offers opportunities and challenges to academic psychiatry programs with which it is affiliated. Among the opportunities are trainee stipends, faculty salaries, research money, and periodic clinical initiatives, which have led the VA to establish one of the most comprehensive mental health systems in the United States. Obstacles include the distinct attributes of the system both as an employer and provider, some of which may be seen as anti-therapeutic, and its national and local political position, which results in a variety of pressures that may run counter to the academic enterprise. Somewhat surprisingly, few articles have been written specifically about these issues and how they might enrich departments of psychiatry at both the VA and other academic medical centers.
The VA’s primary commitment to providing care for veterans makes its challenges in some ways no different from affiliations with other hospitals and health care systems. However, academic centers are able to establish ongoing relationships with county commissioners, boards of trustees, and local insurance providers. In Dallas, leaders of the University of Texas (UT) Southwestern Medical Center have ongoing, active relationships with, and even suggest representatives to, the boards of trustees of a county hospital, a private pediatric hospital, and UT Southwestern hospitals and clinics (which UT Southwestern Medical Center owns). The psychiatry department’s leadership has a long history of serving on state and county mental health department committees (overseeing local community mental health agencies and nearby state hospitals).
Affiliating with a nearby VA hospital can be very different, because it is a national, congressionally funded agency, subject to civil service regulations and responsive to VA Central Office mandates. For example, an academic medical center might establish very good relationships with local veterans’ organizations, collaborating on quality of care, access, or the relationship of academic goals to clinical care, but the national organizations might be pushing Congress or the VA Central Office in a different direction. On any given change in priorities, the VA Central Office seeks input from as many as 1,400 other hospitals, clinics, and nursing homes.
An effect of this entirely different level of organizational structure is a periodic waxing and waning of the VA’s attitude toward its academic affiliations. For example, the VA used to allow programs to use one-sixth of their stipends for non-VA required child and adolescent psychiatry rotations. In the early 1980s, perceiving (perhaps correctly) that some programs were abusing this liberal agreement, the VA ended this arrangement and began scrutinizing much more closely how stipends are used.
In addition, VA Central Office policy must take into account many VAs that have no academic affiliations, those with relatively weak relationships (e.g., occasional medical student rotations only), and those with much more comprehensive educational and scholarly agendas. On one hand, the VA made a decision long ago that one of the best ways it can provide quality care for veterans is by recruiting high-quality, academically oriented faculty to its health care positions and by supporting cutting-edge research that offers the latest insights to its target populations. On the other hand, these are indirect benefits, and when pressures mount to offer basic quality care to veterans on a daily basis (e.g., access, smoking cessation programs, high physician productivity, large number of returning veterans), the VA becomes concerned that academic interests deflect from its core mission.
The current climate, with the return of a large number of injured and traumatized veterans from Iraq and Afghanistan, is a good example. Although the VA must focus on providing basic services to a large influx of new patients, the educational opportunity for students and residents participating in the care of these patients is excellent, and there is an acute need to develop new knowledge and research to understand traumatic brain injury, posttraumatic stress disorder, and spinal cord injuries. A mental health service that has long delays in seeing new patients while members of the service are doing research or training may come under pressure by local administrators, who are, in turn, under pressure from regional and central offices and from Congress.
Prior to 1979, the Dallas VA Medical Center (VAMC) was nonexistent as an academic resource to the Department of Psychiatry at the UT Southwestern Medical Center. Now it is a crucial part of the psychiatry department’s efforts.
Our hypothesis is that several elements contributed to this long-term success: patience, persistence, creative collaboration between the VA service chiefs and department chairs over an extended period of time, and a decision to progress on both educational and research fronts simultaneously from the beginning.
We interviewed several individuals who had been leaders in either the Dallas VAMC psychiatry service or the medical center’s department of psychiatry between 1979 and the present. These interviews were semistructured, with a number of questions prepared (e.g., When did residents begin rotating on the VA psychiatry service? Who were the important recruits during your time and what was their expected role?), but used primarily as stimuli to a broad discussion of the goals, successes, and obstacles encountered by that individual.
The interviewees from the medical center included two psychiatry department chairs, two residency training directors, and three current faculty members who had been residents at the VA during different portions of the last 30 years. From the VA, we interviewed three current or former associate chiefs of service for mental health, one medical director of the service, the current associate training director at the VA (who was a resident and then a staff psychiatrist over the last 21 years), and the current chief of staff, who has served at the Dallas VAMC throughout the 30 years, including as chief of medicine.
As historical themes were put together, the authors frequently sent drafts to various interviewees to be sure the facts and inferences were accurate. We searched the literature on VA academic affiliations to provide a national context for understanding the local events.
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The National VA Context
The process and history of the growing VA affiliations with medical schools has been well chronicled elsewhere (1–3). It is important to understand that some VA hospitals are designated Dean’s Committee hospitals. Ideally, they are built geographically close to medical schools. They provide stipends for residents and fellows, offer opportunities for research, and strive to attract staff physicians who qualify for medical school faculty appointments. The Dean’s Committee exists in addition to the usual internal VA hospital structure and consists of the dean of the medical school, all chairs of clinical departments, and selected VA personnel. The committee facilitates communication, develops the relationship, addresses problems, and, above all, works out local solutions for fulfilling the VA and medical school missions simultaneously.
The UT Southwestern Medical Center and the VA North Texas Health Care System overcame several obstacles—from the medical school side and the VA side—to establish a good relationship in education, research, and innovative clinical care (Table 1). The bottom line was that each clinical department and VA clinical service was on its own in deciding what the relationship would be and how to develop it. At this time, the departments of internal medicine and psychiatry appear to have the most developed relationship involving full-time VA physicians who are regarded as very important researchers and clinician educators. The general surgery and physiatry departments also have important educational and research linkages, and other departments vary in their level of involvement. Many use the VA as a significant teaching site for students and residents but do not necessarily have key faculty members on site.
The Dallas VAMC became a Dean’s Committee hospital in 1974 or 1975. As we understand it, this was relatively late in the process of strengthening VA hospital academic ties. In 1977, UT Southwestern Medical Center recruited a new chair of psychiatry who inherited a department with five full-time faculty, three residents, and very little money for development. Although none of the full-time faculty were VA based, residents and students did rotate at the VAMC.
This new chair, striving to build a strong, broad academic department, viewed the VA as an important source of research funding to attract academically oriented faculty members. The VA provides major research funding that is available only to individuals who work primarily at VA installations. In 1979 the chairman successfully recruited a career academic VA psychiatrist as the chief of service. Over the next few years, five academically oriented junior- and mid-level faculty were recruited. To support them, a clinical research unit was established. As part of their recruitment, the department gave them start-up money and/or additional salary support (money raised from the community) and, in the absence of “protected time,” encouraged them to view the students and residents as relieving them of some clinical work.
During the 1980s, there were four chronic tensions. The first was between the department chair and service chief and the local VAMC leadership, generally over space and faculty slots. The local VAMC leadership did not always see the recruitment inducements that the service chief and department chair requested as important to the primary VA mission.
The second was between preexisting VA physicians in the psychiatry service and new VA faculty members. Essentially, two categories of psychiatrists had been created: faculty members (many of whom were committed to VA careers) and purely service-oriented physicians. What was thought to be temporary, until all VA psychiatrists would be full-time faculty members, turned out to be an ongoing conflict at many levels over the identity of VA faculty members. To which institution are they more loyal? How committed are they to serving veterans? How committed are they as academicians?
The third conflict was between faculty members and other VA health care providers. For many nurses, social workers, psychologists, and others, the relationship between taking care of veterans and research and education was not self-evident. This conflict has largely ebbed over the years, because new hires know that they are entering a system dedicated to the traditional academic tripartite model, but it does persist occasionally when nurses and others consider residents as outsiders.
The fourth, and most volatile, running conflict was between residents and VA faculty members. Residents felt that VA faculty were more interested in research than in their education. VA faculty felt that residents were more interested in “punching their tickets” than in truly learning about the exciting developments in the field. This conflict reached its height in the late 1980s, when the medical center’s education committee voted to withdraw residents from the VA. The residents eventually returned after a few months of negotiation, with the VA sites on probation. VA faculty remained very sensitive on this issue for a number of years and were often certain that when there was a shortage of residents, they were invariably pulled from the VA far more than other services.
In the late 1980s, as career VA, service-oriented psychiatrists retired, several graduates of the training program took jobs at the Dallas VAMC as clinician educators. Thus, the VA faculty began to look more like the rest of the department faculty: a mix of clinician researchers and clinician educators. In addition, a new resident training director arrived who had spent a significant part of his training at a VA and had held a VA faculty position for 8 years.
During the 1990s a number of developments occurred that can best be described as increasing the interchange between the Dallas VAMC and UT Southwestern Medical Center. The new resident training director began meeting monthly with VA faculty. The VAMC was an early site for the use of electronic medical records (an important training opportunity for students and residents). The vice chair for research began periodically visiting the VAMC to mentor junior faculty on their projects. Of great importance was the appointment of VA faculty to significant roles in the department’s educational programs, such as the designation of one of the first committed VA clinician educators as the director of the third-year medical student clerkship. As various subspecialties came to be recognized, more and more trainees at all levels rotated at Dallas VAMC sites. The new resident training director began to include the VAMC outpatient clinic as a required rotational site.
Several efforts were also undertaken to reorganize service delivery for the VA North Texas Health Care System. These were universally initiated by the VA psychiatry service, commonly from multiple motivations and in response to various directives from the VA Central Office. Heavy and rapidly growing service demands were a constant challenge to education and research. Each reorganization was seen as an opportunity to integrate academic pursuits with service delivery improvements. By far, the two most important reorganizations were the move to a product-line model in 1997, followed by the institution of a primary care team model a year later. Another important step was to employ residents as moonlighters in the triage area.
Together, these changes resulted in a major decrease in inpatient utilization. Not only did this radically ameliorate “service versus education” conflicts, but it also opened the way for mental health leadership to focus on developing innovative services that offered excellent teaching opportunities. The psychiatry service responded to a variety of requests for proposals that the VA Central Office issued, including services for substance abusers, patients with posttraumatic stress disorder, patients with serious and chronic mental illness, women veterans, veterans outside of the immediate Dallas area (i.e., north and east Texas), and the homeless.
In 2002, the associate chief of staff for mental health (formerly the chief of the psychiatry service), who had overseen the above, stepped down and was replaced by a new individual who was primarily a researcher from a VA with a longer track record of successful academic collaboration. This individual was important in changing the lingering cultural conflict between the VA North Texas Health Care System and UT Southwestern Medical Center in a variety of ways, including having more college faculty visit the Dallas VAMC, establishing key teaching conferences at the VA, and insisting that all VA faculty members obtain full-time college appointments and progress toward promotion. But his closeness to the school evoked mistrust in the local administration when the VA system entered one of its periodic skeptical attitudes toward academic collaboration, and he has since been replaced by a highly admired clinician educator who has continued most of his policies and added to them.
At this time the VA North Texas Health Care System is heavily involved in all aspects of academic life at the medical center’s psychiatry department (Table 2). As successful as this may appear, a level of uncertainty and insecurity is still felt, because the affiliation is largely without higher level administrative commitment at either institution and its success is still well behind places such as Seattle, Yale, or UCLA, which are on more solid footing, with a longer history of very active Dean’s Committees and academically oriented local VA leadership. They have been more successful at obtaining grants by more faculty, including VA-funded education and research centers. Their VA faculty include several nationally recognized clinical research leaders, who have spent most or all of their careers at a particular academically affiliated VA.
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Reflections and Thoughts
A more consistent stance from the VA nationally and a more activist local leadership at the university would have made the process easier. But, perhaps more important, the refusal of department and service leaders to wait for more support enabled a hesitant, sometimes erratic, but eventually successful academic collaboration to evolve. Various VA Central Office initiatives and mandates were scrutinized for how they might be tailored to meet local VA needs and simultaneously advance the academic collaboration. By slowly moving forward, it gradually became clear to the local VA leadership that quality of care, access, and patient satisfaction were improving.
The shared commitment of the department chair, vice chairs for education and research, and the local VA psychiatry service chief was crucial. In this instance, two of the department’s leaders had trained at a VA, and one had been on faculty at a VA, and they understood the quirks and needs of the system. The VA service chief during the 1980s and 1990s had been a non-VA faculty member at two strong academic programs. Thus, all knew the long-term strategic goal. The only question became one of tactics, identifying the varying priorities of the VA (e.g., substance abuse at one point, posttraumatic stress disorder (PTSD) at another, later on increasing women veterans, access to care, and efficiency of services) and finding projects and individuals who fit the current priorities. There were plenty of disagreements among the leaders in this effort, but there was a shared long-term agenda. It is clear that the prior VA ties in some of the leadership were important, but they do not appear to be a necessity.
Our impression, based on discussions with general psychiatry training directors at annual meetings of the American Association of Directors of Psychiatric Residency Training, is that many VA academic relationships emphasize education with little effort in the area of research. It is possible to develop thriving educational programs in collaboration with the VA but to go no further. We suspect that the early decision to begin by recruiting researchers (we claim no advance wisdom here) paved the way for broader, greater accomplishments down the road. Five to 7 years later, we began adding clinician educators, seeking to attract some of our own best graduates. However, this sequencing created inherent conflicts, noted above, which had to be tolerated. Ideally, clinician educators and clinical researchers would be recruited in tandem, but limited slots are available at a given time.
It is important to note that this has been a 30-year process. Patience and persistence were crucial attributes among all the players. It would have been easy to give up and focus on other relationships at various moments, such as when research funding decreased or moved away from mental health issues or when the VA Central Office became much more preoccupied with immediate direct clinical service issues. But for UT Southwestern Medical Center, the long-term outcome has been extremely positive, with unique educational programs and core research efforts based at the VA North Texas Health Care System.
The authors wish to express their appreciation to Drs. Kenneth Z. Altshuler, Clark Gregg, and Gerald Melchiode for their reflections, remembrances, and advice in this project.
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.