Abstract
A survey was conducted to evaluate the relationship between Veterans Affairs Healthcare Systems and academic departments of pathology in their respective affiliated schools of medicine. Most (73%) of the responding academic departments were within 5 miles of their Veterans Affairs Healthcare Systems; 60% of Veterans Affairs Healthcare Systems supported 1 to 5 full-time pathologist positions at the Veterans Affairs Healthcare Systems while 70% provided 1 to 5 full-time resident positions; only 34% of academic departments had “without compensation” appointments at the Veterans Affairs Healthcare Systems while 20% had fee-based consulting appointments; 62% of academic departments granted academic appointments to full-time Veterans Affairs Healthcare Systems pathologists while few (26%) had split appointments between the academic department and the Veterans Affairs Healthcare Systems; only half of academic departments granted the same academic privileges to Veterans Affairs Healthcare Systems pathologists as they did to full-time university faculty; 60% of the Veterans Affairs Healthcare Systems pathologists were not involved in recruitment of medical school faculty while 58% of medical school faculty were not involved in recruitment of Veterans Affairs Healthcare Systems pathologists; most academic departments reported no research space at the Veterans Affairs Healthcare Systems (68%) and no Veterans Affairs Healthcare Systems research support (72%); only 23% of academic departments reported a sharing agreement that allows the Veterans Affairs Healthcare Systems to perform clinical work for the academic department while 36% reported an agreement that permits the academic department to perform clinical work for the Veterans Affairs Healthcare Systems; only 32% of academic departments indicated that the Veterans Affairs Healthcare Systems Chief of Pathology and Laboratory Medicine Service is a member of the academic department leadership team. All academic departments reported that the Veterans Affairs Healthcare Systems plays a significant role in education of medical students, residents, and fellows. Strengths and weaknesses of the Veterans Affairs Healthcare Systems/academic department relationships are identified.
Keywords
Introduction
Affiliations between Veterans Affairs Healthcare Systems (VAHCS) and schools of medicine have been pursued as a policy objective of the Veterans Administration (VA) since 1946. The VA Policy Memorandum #2 defined the relationship such that the VA retains full responsibility for patient care and that the schools of medicine accept responsibility for all graduate education and training. 1
The original purpose of the affiliations was to ensure that the VAHCS is staffed with competent physicians who maintain currency with advances in medicine through their medical school relationships, thereby providing veterans with access to an array of specialist physicians. This was especially important in the years following the Second World War. In the late 1960s, an additional policy directed that new VAHCS be built on or near their affiliated medical school campuses. In 1972, the VA Medical School Assistance and Health Manpower Training Act provided grants to assist in establishment of new state medical schools that would be affiliated with VAHCS as well as funds for those medical schools already affiliated with VAHCS in order to enable them to expand class size. 2 Subsequent enhancements have included VA employment (full- or part-time) of medical school faculty, placement of residents in the VAHCS, and access to medical school consulting physicians on either a paid (“fee-based consulting”) or unpaid (“without-compensation” [WOC]) basis. The affiliations also increased the VA involvement in biomedical research as well as education. In 2016, it was estimated that more than 90% of medical schools were affiliated with VAHCS. Furthermore, the VA was deemed to be the largest provider of health care training in the United States, with three-fourths of US physicians receiving at least part of their training at VA facilities affiliated with academic medical centers. 3 From 1978 to 1986, the VA supported more than 12% of pathology residencies. 4
As an additional enhancement, in 1988, the VA enhanced its ability to provide flexible mechanisms for administration of funds other than those appropriated to it for the conduct of VA-approved research. In accordance with Public Law 100-322 (now codified at sections 7361-66 of title 38, US Code), it authorized the establishment of VA-affiliated nonprofit research and education corporations to be located near VAHCS. These private, independent 501c3 state-chartered nonprofit entities support both education and research in order to improve quality of care for veterans. 5
A growing body of literature has described the advantages and disadvantages of the relationships between VAHCS and schools of medicine. 6 -10 As we approach the 75th anniversary of the historic 1946 policy that enabled the affiliations of VAHCS with medical schools, it seems fitting to investigate its effect on academic departments (ADs) of pathology. To the author’s knowledge, there is no literature reporting the relationship of ADs and their affiliated VAHCS.
Methodology
A survey was designed to capture detailed information about the relationship between ADs of pathology and their respective affiliated VAHCS. Because this investigation was survey based, the University of California, San Diego Human Research Protections Program deemed it to be exempt from formal review by the investigational review board.
The current allopathic schools of medicine in the United States were identified from the most recent listing in Wikipedia. 11 The website of each US allopathic school of medicine was then queried for reference to an affiliated VAHCS and/or the website of that affiliated VAHCS was reviewed for reference to its affiliated school of medicine. Nondegree granting academic medical centers were not included because the 1946 policy memorandum 1 established that affiliations would be with schools of medicine. In addition, osteopathic schools of medicine were not included in this study due to their smaller number, the fact that many of them lack departments of pathology that offer graduate medical education, and the fact that affiliations were historically launched with allopathic schools of medicine. The website of each identified school was then examined to verify that it had a department of pathology. In order to facilitate contact with those departments, only departments of pathology that are members of the Association of Pathology Chairs (APC) were selected. Eight departments in schools with affiliated VAHCS were not members of APC and were not surveyed. This selection algorithm (Table 1) yielded 86 departments to be surveyed.
Algorithm for Selection of Departments Surveyed.
Abbreviation: VAHCS, Veterans Affairs Healthcare System.
The survey was sent via email to both the chair and the administrator of each department of pathology using contact information from the APC membership directory. A 4-week response time was suggested. A reminder was sent at 2.5 weeks and at 4 weeks to those schools that had not yet responded.
Results
Response Rates
Of the 86 departments of pathology queried, 23 did not respond. Of the 63 respondents (73% response rate), 12 (19%) indicated that, although the school of medicine had an affiliation with the VAHCS, the department did not participate in the affiliation. An additional 8 (13%) indicated that the school of medicine did not have an affiliation with VAHCS. One department indicated that it had affiliations with 3 VAHCSs, and 1 department indicated that it had affiliations with 2 VAHCSs. This information is summarized in Table 2. Thus, 43 departments (identified in Table 3) provided information about the affiliation with their VAHCS. It should be noted that respondents did not always answer each question so that the number of responses for some survey questions were less than 43.
Response Rates for Survey.
Abbreviation: VAHCS, Veterans Affairs Healthcare System.
Pathology Departments Providing Information About VAHCS Affiliation (N = 43).
Abbreviation: VAHCS, Veterans Affairs Healthcare System.
The survey questions and results are indicated below and are also summarized in Table 4.
Survey Results.
Abbreviations: FTE, full-time equivalent; VAHCS, Veterans Affairs Healthcare System.
Geographic Separation
Survey question: What is the distance between your medical school pathology department administrative office and your veterans affairs health care system (if you have more than 1 VAHCS, please provide separate data for each)? (Selections offered: < 5 miles; 6-10 miles; 11-20 miles; >20 miles) (45 responses)
Because 2 departments had affiliations with more than 1 VAHCS, the number of responses (n = 45) exceeded the total number of institutions that provided responses. Almost three-fourths (73%) of departments were located within 5 miles of the VAHCS while 16% were located at 6 to 10 miles, 7% at 11 to 20 miles, and 4% at >20 miles.
Pathologist Positions at Veterans Affairs Healthcare Systems
Survey question: Your pathology department receives the following pathologist VAHCS 8ths (8/8 = 1 full-time equivalent [FTE]). (Selections offered: no 8ths [no VAHCS-supported pathologists]; total of 1 to 5 FTEs [8-40 8ths]; total of 6 to 10 FTEs [48-80 8ths]; more than 10 FTEs [more than 80 8ths]) (42 responses)
All respondents reported some FTE support. Of the 42 responses to this question, 60% indicated 1 to 5 FTEs (8-40 8ths) while 38% indicated 6 to 10 FTEs (48-80 8ths) and 2% indicated more than 10 FTEs (more than 80 8ths; Table 4). In several instances, responses to this question suggested some confusion about where the pathologist support was being provided (ie, to existing medical school-based faculty or to the VAHCS-based faculty). In these cases, a follow-up email was sent to the respondent to clarify the intent of the question.
Veterans Affairs Healthcare Systems “Without-Compensation” and “Fee-Based” Consulting Appointments
Survey question: Do your medical school-employed pathology faculty have any WOC appointments at the VAHCS (no associated 8ths)? (41 responses)
Two-thirds (66%) of respondents indicated that their departments did not have WOC appointments at the VAHCS.
Survey question: Do your medical school-employed pathology faculty have any fee-based consulting appointments at the VAHCS (no associated 8ths)? (41 responses)
The vast majority (80%) of respondents indicated that they had no fee-based consulting arrangements with the VAHCS. The few who reported such arrangements indicated that these were primarily in neuropathology, hematopathology, and dermatopathology.
Medical School Appointments for Veterans Affairs Healthcare Systems-Based Pathologists
Survey question: Do any of the VAHCS-based pathologists lack medical school appointments? (42 responses)
The majority (62%) of respondents indicated that the VAHCS-based pathologists had medical school appointments of varying types, ranging from nonsalaried faculty appointments to adjunct appointments to clinical appointments. The remainder (38%) had no faculty appointments in the department.
Academic Privileges for Veterans Affairs Healthcare Systems-Based Pathologists
Survey question: Do the VAHCS-based pathologists have the same academic privileges in your department (eg, voting rights) as medical school-employed faculty? (43 responses)
Only a slight majority (51%) of respondents indicated that VAHCS-based pathologists had the same academic privileges while the others (49%) had lesser privileges due to the nature of their academic appointment types.
Split Faculty Appointments Between Medical School and Veterans Affairs Healthcare Systems
Survey question: Number of VAHCS-based pathologists that have their salaried appointments split between the medical school pathology department and the VAHCS. (Selections offered: none; 1-5; 6-10; >10) (42 responses)
Almost three-fourths (74%) of respondents indicated that there was no such split and that faculty were either employed fully by the medical school or fully by the VAHCS. Ten respondents indicated that they had 1 to 5 faculty split between the 2 institutions, and 1 indicated that 6 to 10 faculty were split.
Pathology Resident and Fellow Positions Funded by Veterans Affairs Healthcare Systems
Survey question: Pathology residency positions funded by VAHCS (Selections offered: 1-5; 6-10; >10) (43 responses)
The vast majority of respondents (70%) indicated that the VAHCS funded 1 to 5 residency positions while a few (2%) had funding for 6 to 10 positions. The remainder (28%) had no residency positions funded by the VAHCS. Because the total number of resident positions in each department was unknown, it was not possible to determine the percent of residents funded by the VAHCS.
Survey question: Number of pathology fellowship positions funded by VAHCS (no selections provided) (38 responses)
Only 4 (11%) respondents indicated that the VAHCS provided fellowship support: 2 indicated that the VAHCS supported 3 fellows for each of them; 1 received support for 3.5 fellows; and 1 received support for 1 fellow.
Involvement in Recruitment Efforts
Survey question: Are medical school-employed pathology faculty involved in recruitment of VAHCS-based pathologists? (43 responses)
Of the respondents, 58% indicated that medical school pathology faculty are not involved in recruitment of VAHCS pathologists unless such recruitment would have split activity between the medical school and VAHCS (joint recruitment). A lesser number (42%) indicated that medical school faculty often sit on search committees for VAHCS faculty and that the department chair often meets with VAHCS candidates who seek academic appointments.
Survey question: Are the VAHCS-based pathologists involved in the recruitment of medical school-employed pathology faculty? (43 responses)
About the same percent (60%) of respondents indicated that VAHCS pathologists are not involved in recruitment of medical school pathology faculty unless a joint recruitment (including physician scientist recruitment) is involved.
Chief of Pathology and Laboratory Medicine at Veterans Affairs Healthcare Systems
Survey question: Is the chief of pathology and laboratory medicine services at your VAHCS a part of your medical school pathology department leadership team? (44 responses)
Because 2 respondents had affiliations with more than 1 VAHCS, the responses (44) total more than the number of unique respondents (43). Slightly more than two-thirds (68%) of respondents indicated that the chief of pathology and laboratory medicine services at the VAHCS is technically not part of the department leadership team but is involved in other department activities including committees. About one-third (32%) indicate full involvement of the chief on the department leadership team.
Research Support for Veterans Affairs Healthcare Systems Pathologists
Survey question: Total amount of VA merit award grants to VAHCS-based pathologists (Selections offered: none; <$100 000; $100 000-$250 000; $250 000-$500 000; >$500 000) (39 responses)
Most respondents (72%) indicated that the VAHCS pathologists had no grant support from the VAHCS while 2 indicated more than $500 000 of total federal support, 6 indicated $100 000 to $250 000, and 1 indicated <$100 000.
Survey question: Total amount of research space (wet and dry) provided by the VAHCS to your VAHCS-based pathologists (Selections offered: <500 square feet; 500-1000 square feet; 1000-2000 square feet; 2000-5000 square feet; and >5000 square feet) (41 responses)
Most (68%) of the respondents indicated that their VAHCS provided no research space to the VAHCS pathologists while 4 indicated <500 square feet; 5, 500 to 1000 square feet; 3, 1000 to 2000 square feet; and 1, 2000 to 5000 square feet. No one reported more than 5000 square feet of space.
Survey question: Does your VAHCS have a veterans medical education and research foundation through which the research grants of VAHCS-based pathologists are administered? (30 responses)
A slight majority (53%) of respondents indicated that their VAHCS had established a 501c3 nonprofit foundation to administer research and education funds.
Sharing Agreements for Clinical Services
Survey question: Is there a sharing agreement to permit medical school pathology clinical work to be performed by the VAHCS-based pathologists? (43 responses)
The vast majority (77%) of respondents reported that they had no such agreement with some respondents, indicating that this would necessitate separate clinical privileges at the medical school.
Survey question: Is there a sharing agreement to permit VAHCS pathology clinical work to be performed by the medical school-based faculty? (42 responses)
Again, the majority (64%) of respondents indicated that there was no such agreement, in part due to the need for separate clinical privileges and in part due to difficulty in moving these agreements through VAHCS review.
Educational Activities
Survey question: Are the VAHCS-based pathologists actively involved in teaching (check all that apply) (Selections offered: medical students only; residents/fellows only; other) (38 responses)
All respondents were engaged in teaching at some level. Most (55%) respondents indicated that the VAHCS-based pathologists were engaged in teaching a combination of medical students, residents, and fellows. Four of these also taught pathologist assistant students, clinical laboratory scientist students, cytotechnology students, histotechnology students, graduate students, and postdoctoral fellows. One of the 4 was also the director of undergraduate medical education for pathology at the medical school. Of the others, 40% taught only residents and fellows, and 5% taught only medical students.
Perceived Strengths of the Affiliation
Survey question: Perceived strengths of the VAHCS affiliation for your pathology department (check all that apply). (Selections offered: diversifies the training experiences for pathology residents; increases the number of pathology residents; increases the number of pathology faculty; provides additional pathologist expertise; provides research support, eg, grants, space, for VAHCS-based pathology faculty) (117 responses from 39 respondents)
The perceived strengths of the affiliation were identified as diversification of the training experiences for pathology residents (28%), increasing the number of pathology residents (22%), increasing the number of pathology faculty (21%), providing additional pathologist expertise (16%), and providing research support for VAHCS faculty (13%).
Perceived Weaknesses of the Affiliation
Survey question: Perceived weaknesses of the VAHCS affiliation for your pathology department (check all that apply) (Selections offered: loss of indirect costs when research grants flow through the VAHCS; issues related to intellectual property ownership; issues related to pathology residency training experience (content, quality, etc); issues related to VAHCS-based pathologist engagement in the medical school pathology department; cultural/work–environment issues between VAHCS-based pathologists and medical school-based pathology faculty; issues related to difference in salary and benefit structure for VAHCS-based pathologists and medical school-employed pathology faculty) (52 responses from 26 respondents)
Perceived weaknesses of the affiliation were distributed approximately evenly among all of the selections, except for intellectual property ownership (8%). Narrative comments suggested frustrations with delays in processing of agreements as well as concerns related to human resources requirements at the VAHCS.
Discussion
In the nearly 75 years since VA Policy Memorandum #2 1 authorized affiliations of VAHCS with schools of medicine, both parties have been advantaged to varying degrees, largely depending upon the nature of the respective affiliations and the compatibility of the individual institutions. As indicated by Leeman and Kilpatrick, 6 those affiliations that were most beneficial were characterized by a relationship of trust, extensively shared education and research programs, and a high degree of physician interaction and integration. They noted that these characteristics were influenced by the distance between the VAHCS and the affiliated medical school (shorter distance is better), the VAHCS level of organizational complexity (more complexity is better), the degree of managed care penetration (more is better), and the continuity and academic orientation of the VAHCS leadership (stable leadership is better). These authors also noted that changes in the health care environment and in the VAHCS are affecting affiliation relationships as the health care focus is changing from a hospital acute care system to an integrated delivery system that emphasizes primary care. Such changes may cause medical schools to depend more than ever on VAHCS as training sites for generalists and the primary care specialties while the VAHCS may need to depend less on medical schools for specialist physicians.
Petersdorf 7 advocated that appointments in the VAHCS be no more than 7/8 in order to allow time for more compensated medical school–related activities on the part of VAHCS-based faculty. He also advocated that the VAHCS chief of staff be an associate dean at the medical school. Gronvall 8 opined that the VAHCS will play an even more important role as community hospitals abandon educational programs because of competitive cost pressure. From time to time, there have also been reports suggesting that the VAHCS may be the “lesser partner” in the affiliations with the medical school controlling the relationship and the VAHCS being expected to pay a disproportionate share of medical education costs. 9,10
Although there is literature on the affiliation between schools of medicine and VAHCS, there are no published reports investigating the details of relationships between individual departments and their affiliations with VAHCS. Accordingly, this study was undertaken in order to investigate the relationship between ADs of pathology and their respective affiliated VAHCS.
As with any survey-based study, this study has its limitations. These included some initial confusion about the question regarding VAHCS support of pathologists. In each instance, a follow-up email to the respondent indicated that the question was intended to query employment of pathologists at the VAHCS and not the support of existing medical school faculty. Subsequent responses appeared to acknowledge understanding of this. Another limitation was the exclusion of 8 ADs that had affiliations with a VAHCS but were not members of the APC. Combined with the 23 departments that did not respond, a possibility of up to 31 departments with potential affiliations with VAHCS were not included in this study. That said, the author has no reason to suspect that the nonrespondents had different affiliation characteristics than the respondents. Still another limitation might have been in use of the term “VAHCS-based pathologists,” for this could have excluded nonpathologist MD and PhD basic scientists as well as PhD clinical laboratorians in the count of VAHCS-based pathology and laboratory medicine service faculty. Also, nondegree granting academic medical centers were excluded from this study, even if their departments of pathology were members of APC and even if some of their programs had joint training programs with a VAHCS, because formal affiliations with the VAHCS historically were established with schools of medicine. Additionally, the 43 responding institutions did not always answer every question in the survey, diminishing the power of the survey. The lack of anonymity of responses may have potentially biased the survey, particularly with respect to identifying perceived weaknesses in the affiliation relationship (only 26 unique respondents). However, in attempt to maximize response to the survey it was deemed important to be able to contact each department chair and/or administrator individually. Although osteopathic schools of medicine were not included in the study, there is no reason to believe that findings would be different for any that would have departments of pathology that offer graduate medical education. Finally, it should be emphasized that this survey represents only a “snapshot in time” and thus may not reflect the historical contributions of each party to the affiliation.
Despite these limitations, useful conclusions can still be drawn from this study. This study found that most affiliated VAHCS were located within 5 miles of the AD and supported 1 to 5 full-time pathologist positions at the VAHCS as well as 1 to 5 full-time resident positions. Although most departments granted academic appointments to full-time VAHCS pathologists, these appointments were often different in nature (eg, adjunct, clinical), and in only half of the cases the appointments carried the same full academic privileges as other medical school faculty. Medical school pathology faculty were usually not involved in the recruitment of VAHCS, and VAHCS pathologists were usually not involved in recruitment of medical school faculty. Most medical school faculty did not have WOC appointments, did not have fee-based consulting agreements with the VAHCS, and did not have their employment split between the medical school and the VAHCS. Most VAHCS pathologists had no research support or research space from the VAHCS. In most instances, there was no sharing agreement that allowed clinical work to be performed in either direction across the 2 sites. Most of the time, the VAHCS pathology and laboratory medicine chief was not a member of the AD leadership team. However, in all instances, the VAHCS pathologists played a major role in educating medical students, residents, and fellows.
The most significant perceived strengths of the affiliations were diversification of the training experiences for pathology residents, the provision of additional pathology faculty and residents, and the provision of additional pathologist expertise. Interestingly, although most VAHCS pathologists reported no research support or space (at least at the time of this survey), 13% of responses regarding perceived strengths of the affiliations indicated research support as a strength (Table 4). Perceived weaknesses included issues related to culture and work environment, pathology residency training issues, salary and benefit differences between the 2 sets of faculty, loss of indirect costs for grants obtained by VAHCS pathologists, and lack of engagement of VAHCS pathologists in the department.
Narrative comments provided by some respondents indicated considerable variability among the respective affiliations, ranging from full integration of anatomic pathology cases into the medical school department workflow to no integration at all. The immense value of the educational experience for trainees was recognized by all. In a few instances, respondents expressed frustration with perceived rigidity of the VAHCS contracting and human resources processes.
Overall, this study suggests a high level of satisfaction with the relationship between ADs of pathology and their affiliated VAHCS, leading to the conclusion that the original intent of the VAHCS-school of medicine affiliations has been realized to the benefit of both entities, at least for the discipline of pathology. Despite this success, both entities should vigorously seek to enhance the relationship further, particularly in view of the declining financial support for medical education. Finally, it is interesting to speculate about whether these findings would be noted for other medical disciplines in a VAHCS/AD affiliation.
Footnotes
Acknowledgments
The author thanks the following department of pathology chairs and administrators for their responses to this survey: Charles E. Alpers, Jennifer Anderson, Christopher Andry, Robert Challender, Anne Champeaux, Michael J. Clare-Salzler, Michael Cohen, Alice Coogan, Jonathan W. Cooper, Michelle Cooper, Jayanta Debnath, Justin Deese, Neil Detweiler, Brian Donawa, John Eble, Lauren Elmore, Donna Espenberg, Fang Fan, Andreas Friedl, Danny Fuemmeler, Leo Furcht, Kuruvilla George, Margaret Gilshannon, Jeffrey Golden, Steven L. Gonias, Donna Hansel, Clifford V. Harding, Michael Harhen, Eyas Hattab, Vicky Hernandez, Paul C. Herrmann, Nicole Hilmoe, Jiaoti Huang, Jennifer Hunt, George Inman, Merce Jorda, Michael Joshi-Guske, Sandra Jaros, Chester Darrell Jennings, Nancy Joste, Nitin Karandikar, Marsha Kinney, Michael Koch, Steven Kroft, Rachel Kulow, Martin Lawlor, Andrea Ligler, Patricia Malinowski, James S. Malter, Martin Matzuk, Joey McCall, Terri McFeature, Kelly McNeill, Joseph Meyer, Roseanne Meyer, George K. Michalopoulos, Douglas C. Miller, Jeffrey Mize, Edwin Monuki, Jon S. Morrow, Michael Nasr, George Netto, Kim Ockunzzi, Amy Orange, Charles Parkos, Lisa Previte, James Revett, Brian Rudolph, Cathleen Quade, Candiano Rienzie, Nancy Risenhoover, Amyn M. Rojiani, Elizabeth Rosaschi, Scott Rosenthal, David Roth, John B. Schweitzer, Kenneth R. Shroyer, Brian Smith, Sanford A. Stass, Michael L. Talbert, David Titus, Tim Travis, Amy Trickett, Kai Wang, Andrew Webb, Wendy Wells, Gail Whitney, Dani Zander, and Julie Zimmer. The author thanks Fred Sanfilippo and Kai Wang for reviewing the survey instrument and providing useful comments prior to its distribution.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
