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What is the VA? The Largest Educator of Health Care Professionals in the U.S.
This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.1 That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.
This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.
When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.2 Currently, the VA has more than 40 different health care professional training programs under its auspices.
This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.
Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.3 Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.4
From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.
Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.
Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.
The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.
The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.5
The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.
According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”6 It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.
The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:
“The emphasis on teaching was fantastic, and far superior to most other rotations.”
“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”
“The VA is the best place for medical students to work.”7
1. U.S. Veterans Health Administration Office of Academic Affiliations. 2015 statistics: health professions traineees. U.S. Department of Veterans Affairs website. http://www.va.gov/oaa/docs/OAA_Statistics.pdf. Accessed June 14, 2016.
2. Office of Academic Affiliations. 70th anniversary of academic affiliations. U.S. Department of Veterans Affairs website. http://www.va.gov/OAA/OAA_70th_Anniversary.asp. Update February 18, 2016. Accessed June 4, 2016.
3. Oppel RA, Goodnough A. Doctor shortage is cited in delays at V.A. hospitals. The New York Times. May 29, 2014.
4. Zonana HV, Wells JA, Getz MA, Buchanan J. Part I: The NGRI Registry: initial analyses of data collected on Connecticut insanity acquittees. Bull Am Acad Psychiatry Law. 1990;18(2):115-128.
5. Foster C. V.A. official visits HSC, as agency seeks to hire health care workers. UNM HSC Newsbeat. November 11, 2014.
6. VA Nursing Academic Partnerships. Oregon Health and Science University website. http://www.ohsu.edu/xd/education/schools/school-of-nursing/about/loader.cfm?csModule=security/getfile&pageid=2301310. Accessed June 14, 2016.
7. McDonald R. McDonald: Academic affiliations a source of strength for VA, medical schools. U.S. Department of Veterans Affairs website. http://www.blogs.va.gov/VAntage/18655/mcdonald-academic-affiliations-a-source-of-strength-for-the-va-medical-schools. Updated March 30, 2015. Accessed June 14, 2016.
This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.1 That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.
This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.
When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.2 Currently, the VA has more than 40 different health care professional training programs under its auspices.
This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.
Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.3 Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.4
From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.
Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.
Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.
The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.
The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.5
The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.
According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”6 It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.
The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:
“The emphasis on teaching was fantastic, and far superior to most other rotations.”
“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”
“The VA is the best place for medical students to work.”7
This July, medical students, residents, and fellows in almost every medical and surgical specialty will join nurses at all levels of training, undergraduate and graduate pharmacists, dentists, and allied health students to train at a VA hospital. The VA Office of Academic Affiliations (OAA), which coordinates this massive educational effort, reported that in 2015, the last year for which data are available, 123,552 health care trainees were enrolled in VA programs.1 That’s in addition to the hundreds of health care professionals trained in the 4 branches of the armed services, including students at the Uniformed Services University of the Health Sciences and those receiving a health care education through the PHS. Federal institutions are easily the largest contributors to health care education in the nation and very likely in the world.
This mission to educate the U.S. health care workforce is not new. This year marks the 70th anniversary of the collaboration between the VA and academic affiliates across the country to ensure a highly qualified cadre of health care professionals care, not only for veterans, but also for the public. Hence, the OAA motto: To educate for VA and for the nation.
When allopathic and osteopathic medical schools are combined, there are partnerships between the VA and 90% of U.S. medical schools. More than 70% of all U.S. practicing physicians trained at a VA facility at some time.2 Currently, the VA has more than 40 different health care professional training programs under its auspices.
This educational mission is a core VA function that is enshrined in law as are VA’s other 3 core charges. According to the statute, the VA secretary shall “to the extent feasible without interfering with the medical care and treatment of veterans, develop and carry out a program of education and training of health personnel.” The primary clinical care, education, and research functions of the VA are inseparable, and none can be carried out without an adequate number of qualified staff.
Government reports and the media have identified the shortage of VA health care professionals as a major contributor to the wait times crisis of the past several years.3 Section 301 of the Veterans Access, Choice, and Accountability Act of 2014 actually requires the VA Office of Inspector General (OIG) to conduct assessments of the staffing shortages in the department. Reports from the OIG have identified 5 critical need occupations: medical officer, nurse, psychologist, physician assistant, and physical therapist.4
From my perspective as a medical officer, I am certain that the reason I went straight to the VA after my residency in psychiatry and have never left is my overwhelmingly positive experience as a medical student and resident. The VA had many of the best teachers in my training programs. The patients were—and still are nearly 20 years later—among the most respectful and appreciative of any I have treated.
Many VA patients considered us, even as trainees, their doctors and often asked us when we were residents whether they could “keep us,” although they knew that as former members of the military, most of us would rotate out of their lives. Yet they also knew that because of the strength of the training programs, a new young doctor would come to take care of them. Even now when the occasional angry patient says, “all you doctors care about is money,” I am proud to say that I could probably make more money in the private sector, but I choose to work at the VA.
Many of my fine colleagues in medicine, nursing, psychology, and allied health also remained at the VA after their training, inspired to provide public health to those who served and were underserved. Those who entered military medicine or the PHS had similar ideals borne of the role models who taught them in those federal institutions. One of the often unappreciated negative consequences of the VA scandal is that it may discouarge students in the health care professions from rotating through or seriously considering careers in the VA.
The VA and the military often do not receive the recognition they deserve as academic medical institutions. Some of the most renowned and accomplished faculty of prestigious medical universities also work at VA facilities. The ability to simultaneously teach gifted students, conduct cutting-edge research, and practice high-quality medicine all in a public health setting are what attracted me and many other idealistic health care professionals to the VA.
The VA, however, has taken active steps to restore its reputation as one of the best places to learn and work. Three outstanding initiatives deserve special attention. The first being a series of visits to medical schools that Carolyn M. Clancy, MD, made when she was the interim under secretary for health. Fortunately for me, she spoke at the academic affiliate of my VAMC (the University of New Mexico School of Medicine), where she talked about the excitement and rewards of VA clinical care and research.5
The VA Nursing Academic Partnerships (VANAP) is another initiative to promote VA as an educator and employer of health professionals. Comprised of 18 competitively selected nursing schools in the nation and the VA, VANAP’s objective is “increasing recruitment and retention of VA nurses as a result of enhanced roles in nursing education.” The New Mexico VA Health Care System, the hospital I practice at, had the honor of being awarded one of these partnerships, and I have been encouraged to see many student nurses choose the training track at the VA and express interest in employment.
According to a nurse at the Oregon Health & Science University VA partnership, “One thing I learned that I did not expect was about the wars the clients had served in. I gained a greater respect for our men and women in the service past and present…I have now an understanding of not only the physical, but also the mental and emotional effects war has on an individual.”6 It is important to realize that even if physicians and nurses in training do not ultimately enter the VA workforce, they still leave their educational experience with a more empathic understanding of the health care needs of veterans.
The salience of the third endeavor, however, has not been widely recognized. In March, Secretary Robert McDonald spoke at a meeting of the Association of American Medical Colleges Council of Deans. His speech traced the history of academic collaboration with the VA; acknowledged the bureaucratic, information technology, and other challenges faced by the VA and its academic affiliates; and reaffirmed the VA’s commitment to academic partnerships. He recognized the significant and lasting contributions the relationship with academic medical centers has had on the care of veterans and the community for decades. His remarks concluded with a vision of the potential the partnership has to transform health education and the delivery of care in the years to come. But perhaps the most hopeful remarks in the speech came not from Secretary McDonald but from the comments of medical students who had rotated at the San Diego VAMC, which he shared:
“The emphasis on teaching was fantastic, and far superior to most other rotations.”
“The vets were a wonderful patient population who really allowed us a great opportunity to learn.”
“The VA is the best place for medical students to work.”7
1. U.S. Veterans Health Administration Office of Academic Affiliations. 2015 statistics: health professions traineees. U.S. Department of Veterans Affairs website. http://www.va.gov/oaa/docs/OAA_Statistics.pdf. Accessed June 14, 2016.
2. Office of Academic Affiliations. 70th anniversary of academic affiliations. U.S. Department of Veterans Affairs website. http://www.va.gov/OAA/OAA_70th_Anniversary.asp. Update February 18, 2016. Accessed June 4, 2016.
3. Oppel RA, Goodnough A. Doctor shortage is cited in delays at V.A. hospitals. The New York Times. May 29, 2014.
4. Zonana HV, Wells JA, Getz MA, Buchanan J. Part I: The NGRI Registry: initial analyses of data collected on Connecticut insanity acquittees. Bull Am Acad Psychiatry Law. 1990;18(2):115-128.
5. Foster C. V.A. official visits HSC, as agency seeks to hire health care workers. UNM HSC Newsbeat. November 11, 2014.
6. VA Nursing Academic Partnerships. Oregon Health and Science University website. http://www.ohsu.edu/xd/education/schools/school-of-nursing/about/loader.cfm?csModule=security/getfile&pageid=2301310. Accessed June 14, 2016.
7. McDonald R. McDonald: Academic affiliations a source of strength for VA, medical schools. U.S. Department of Veterans Affairs website. http://www.blogs.va.gov/VAntage/18655/mcdonald-academic-affiliations-a-source-of-strength-for-the-va-medical-schools. Updated March 30, 2015. Accessed June 14, 2016.
1. U.S. Veterans Health Administration Office of Academic Affiliations. 2015 statistics: health professions traineees. U.S. Department of Veterans Affairs website. http://www.va.gov/oaa/docs/OAA_Statistics.pdf. Accessed June 14, 2016.
2. Office of Academic Affiliations. 70th anniversary of academic affiliations. U.S. Department of Veterans Affairs website. http://www.va.gov/OAA/OAA_70th_Anniversary.asp. Update February 18, 2016. Accessed June 4, 2016.
3. Oppel RA, Goodnough A. Doctor shortage is cited in delays at V.A. hospitals. The New York Times. May 29, 2014.
4. Zonana HV, Wells JA, Getz MA, Buchanan J. Part I: The NGRI Registry: initial analyses of data collected on Connecticut insanity acquittees. Bull Am Acad Psychiatry Law. 1990;18(2):115-128.
5. Foster C. V.A. official visits HSC, as agency seeks to hire health care workers. UNM HSC Newsbeat. November 11, 2014.
6. VA Nursing Academic Partnerships. Oregon Health and Science University website. http://www.ohsu.edu/xd/education/schools/school-of-nursing/about/loader.cfm?csModule=security/getfile&pageid=2301310. Accessed June 14, 2016.
7. McDonald R. McDonald: Academic affiliations a source of strength for VA, medical schools. U.S. Department of Veterans Affairs website. http://www.blogs.va.gov/VAntage/18655/mcdonald-academic-affiliations-a-source-of-strength-for-the-va-medical-schools. Updated March 30, 2015. Accessed June 14, 2016.
Lessons From History: The Ethical Foundation of VA Health Care
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
We are all familiar with the constellation of ethical lapses ignominiously referred to as “the VA scandal of 2014.” Amid the negative publicity, Congressional hearings, and legislative and agency efforts, little attention has been given to the historic foundations of the VA that make it a unique and vital part of American health care. Yet, unless the new positive initiatives, such as the Veterans Choice Program, are built on core VA ethical principles and values, the new model of health care delivery may undermine VA’s distinctive mission.1
That mission began in the last months of the bloodiest conflict in American history—the Civil War. In his second inaugural address, President Abraham Lincoln presented the fight to end slavery in the U.S. in religious and moral terms. The VA was conceived conceptually and institutionally in this speech as a part of the strategy to reunify the divided nation and an effort to heal an anguished people. In the words that grace the walls of many VA hospitals, President Lincoln articulated our commitment to those who fought and died in a terrible war for an awesome cause:
With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.2
Although couched in poetic terms, this speech established the VA in the technical language of organizational systems as an “entitlement program.” Currently, there are 3 major federal entitlement health care programs: Medicare, Medicaid, and the VHA.3 The U.S. has other social entitlement programs, such as Social Security, unemployment insurance, food stamps, and federal retirement programs. In political and economic theory, “entitlement” is defined in the ethically salient language of rights. This is the type of “program that offers individuals who meet eligibility requirements personal financial benefits (or sometimes special government-provided goods or services) to which an indefinite (but usually rather large) number of potential beneficiaries have a legal right.”4
However, there is a morally and politically important difference between the majority of these other entitlement programs and the VA. Citizens pay taxes during their working life into tax-based programs like Social Security and Medicare and thus, they have a “title to” benefits. They have, in simple economics, earned these benefits and have a right to them. Veterans also have paid into the system, but the payment is not monetary; it is in blood, sweat, tears, and in some instances, life itself. In a civilized society, the contributions made by service members bear the highest value, ones that cannot be counted in money. This obligation of reciprocity to provide health care to those who served is what defines the fundamental ethical nature of VA as an organization and what makes it different from all other systems, however noble their missions.
The controversy about the Affordable Care Act is the latest round in a long American struggle over the nature of health care. Is it a basic human right as most European countries have decided? Is it a commodity like other goods in our capitalist society, and so the object of the laws of supply and demand? Is it a privilege earned through employment, insurance, or other qualifications in accordance with our bootstrap ideology? Is it a service given to the poor and disabled as an expression of government’s parens patriae duty to care for all its citizens?5 Unresolved as the question remains for many Americans, for veterans the issue was settled in 1865 when President Lincoln declared that those members of the armed forces who suffered illness or injury in battle or died in war have a legally guaranteed and perhaps a religiously sanctioned right to health care.
Legislation would later specify and expand veterans’ benefits to include more extensive and intensive health care to veterans whose disabilities are connected to their service as well as those with few financial resources. This prioritization underscores an important point: What entitles patients to benefits are the mental and physical injuries that veterans have sustained as a result of military service along with the social and economic costs often associated with their service. It also introduces an additional dimension of fairness to the entitlement criteria. These eligibility rules cohere with the original purpose of the VA as it seeks to “care for him who shall have borne the battle” and those for whom the war had taken the greatest toll (clinically or socioeconomically).
There are health care experts, politicians, even ethicists, who have called for either complete overhauling or dismantling of the old and swaying VHA edifice and furloughing or firing its demoralized and overworked staff. But before the wrecking crews come in and the ranks of committed and competent VA employees are sent packing, the naysayers should stop and realize that no matter what may be gained in that process, we will have profoundly changed the founding purpose and mission of the VA. The VA has one reason for existence—to care for veterans. Long before patient-centered care and medical homes were bywords in health care parlance, they were the words of ethical justification for the VHA as a health care agency. No moral agent, be it a person or an institution, can serve 2 masters. The VA is the only major health care system in the U.S. that does not have dual and often conflicting interests, whether in mission-readiness, profit, religious faith, or local and state politics.
There may be disagreements about the nature and scope of VHA’s problems and their solutions, but we should all recognize that a deeper ethical problem exists if the federal government and VHA fail to fulfill the obligation of reciprocity so eloquently described by President Lincoln. Economics can inform and empower but never fully resolve what is at the heart an ethical issue. Accountability and integrity are fundamental ethical values that are easily eroded by a singular and punitive focus on rules and rule-breaking that have guided too much of VA’s action and inaction, as well as the reaction of Congress. The military motto is to “leave no solider behind.” President Lincoln created the VA to honor this promise to veterans when they returned to civilian life. We must not allow engagement in partisan clashes to prevent us from fulfilling our moral commitment to those who actually fought and supported the nation’s battles.
Aknowledgements
The editor thanks Virginia Ashby Sharpe, PhD, for her insightful comments on an earlier draft of this editorial.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
1. Shulkin DJ. Beyond the VA crises-becoming a high-performance network. N Engl J Med. 2016;374(11):1003-1005.
2. U.S. Department of Veterans Affairs. The origin of the VA motto: Lincoln’s second inaugural address. U.S. Department of Veterans Affairs Website. http://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed March 21, 2016.
3. Shi L, Singh DA. Delivering Health Care in America: A Systems Approach. 3rd ed. Sudbury, MA: Jones and Bartlett; 2004.
4. Johnson PM. A glossary of political economy terms: entitlement program. Auburn University Website. https://www.auburn.edu/~johnspm/gloss/entitlement_program. Accessed March 21, 2016.
5. Should all Americans have the right (be entitled) to health care? ProCon.org Website. http://healthcare.procon.org/view.answers.php?questionID=001602. Accessed March 21, 2016.
6. Core values and characteristics of the department. Fed Regist. 2012;77(135):41273-41276. 38 CFR Part 0.
Our Sacred Trust
It is my great pleasure and privilege to have been chosen to serve as editor-in-chief of Federal Practitioner, where I have long been a member of the Editorial Advisory Association, a reviewer, and a contributor. I want to thank James Felicetta, MD, my predecessor, for his many years of excellent stewardship of an increasingly informative and interesting monthly journal that also saw expansive growth especially online and in special issues.
As long as I can remember, the military and medicine have been inextricably linked in my life. My father was a career U.S. Army doctor who won a Bronze Star Medal for valor in World War II and was one of the founders of military pediatrics. My mother was a U.S. Army nurse. In my first career in theology, I worked as a religious educator and lay minister at a military base.
When I entered medicine as a second career, it was my good fortune to receive much of my medical and psychiatric training at VA hospitals. Inspired by the physicians who taught me, I joined the VA straight out of residency and have been there ever since, during both the good and bad times, and never wanted to be anywhere else.
I have spent my nearly 15 years in the VA not in behavioral health care but at the interface of medicine and psychiatry. My professional interest has always been training and consulting to physicians, nurses, and other health care professionals in primary care, medicine, and surgery who are providing vital medical care for patients also struggling with psychiatric, addictive, and pain conditions. Federal Practitioner has done excellent work in this area in the past, and it is one we hope to expand considerably in the future.
Suicide and the treatment of patients with posttraumatic stress disorder, chronic pain, and addiction are among the greatest challenges that our clinician readers face, and it is our obligation to offer timely, targeted news coverage and clinical articles to aid them in their noble efforts.
My other passion is bioethics, and it has been my honor to teach ethics at the university level and to serve as an ethics consultant on many levels of the VA. Ethics also is an increasingly visible and salient domain we hope to spotlight in coming journal issues.
I am also fortunate to have an outstanding editorial staff as collaborators: Reid Paul, Joyce Brody, Robert Fee, and Teraya Smith. We also have a talented and dedicated Editorial Advisory Association of health care professionals from the DoD, VA, and PHS, and we intend to actively engage them in expanding our contributors and readers. And we invite each of you to join us in improving the scholarly quality and clinical relevance of this journal. In coming editorials, I will outline some of our primary goals for the journal, and I invite you to write me with suggestions for the future direction of Federal Practitioner.
This journal fills a unique role in health care, because no other publication is dedicated to the service of the servants of the public in DoD, VA, and PHS. We want to feature the clinical innovations, research advances, and organizational initiatives of the men and women who carry out this sacred trust to care for the health of the military, veterans, and the public.
It is my great pleasure and privilege to have been chosen to serve as editor-in-chief of Federal Practitioner, where I have long been a member of the Editorial Advisory Association, a reviewer, and a contributor. I want to thank James Felicetta, MD, my predecessor, for his many years of excellent stewardship of an increasingly informative and interesting monthly journal that also saw expansive growth especially online and in special issues.
As long as I can remember, the military and medicine have been inextricably linked in my life. My father was a career U.S. Army doctor who won a Bronze Star Medal for valor in World War II and was one of the founders of military pediatrics. My mother was a U.S. Army nurse. In my first career in theology, I worked as a religious educator and lay minister at a military base.
When I entered medicine as a second career, it was my good fortune to receive much of my medical and psychiatric training at VA hospitals. Inspired by the physicians who taught me, I joined the VA straight out of residency and have been there ever since, during both the good and bad times, and never wanted to be anywhere else.
I have spent my nearly 15 years in the VA not in behavioral health care but at the interface of medicine and psychiatry. My professional interest has always been training and consulting to physicians, nurses, and other health care professionals in primary care, medicine, and surgery who are providing vital medical care for patients also struggling with psychiatric, addictive, and pain conditions. Federal Practitioner has done excellent work in this area in the past, and it is one we hope to expand considerably in the future.
Suicide and the treatment of patients with posttraumatic stress disorder, chronic pain, and addiction are among the greatest challenges that our clinician readers face, and it is our obligation to offer timely, targeted news coverage and clinical articles to aid them in their noble efforts.
My other passion is bioethics, and it has been my honor to teach ethics at the university level and to serve as an ethics consultant on many levels of the VA. Ethics also is an increasingly visible and salient domain we hope to spotlight in coming journal issues.
I am also fortunate to have an outstanding editorial staff as collaborators: Reid Paul, Joyce Brody, Robert Fee, and Teraya Smith. We also have a talented and dedicated Editorial Advisory Association of health care professionals from the DoD, VA, and PHS, and we intend to actively engage them in expanding our contributors and readers. And we invite each of you to join us in improving the scholarly quality and clinical relevance of this journal. In coming editorials, I will outline some of our primary goals for the journal, and I invite you to write me with suggestions for the future direction of Federal Practitioner.
This journal fills a unique role in health care, because no other publication is dedicated to the service of the servants of the public in DoD, VA, and PHS. We want to feature the clinical innovations, research advances, and organizational initiatives of the men and women who carry out this sacred trust to care for the health of the military, veterans, and the public.
It is my great pleasure and privilege to have been chosen to serve as editor-in-chief of Federal Practitioner, where I have long been a member of the Editorial Advisory Association, a reviewer, and a contributor. I want to thank James Felicetta, MD, my predecessor, for his many years of excellent stewardship of an increasingly informative and interesting monthly journal that also saw expansive growth especially online and in special issues.
As long as I can remember, the military and medicine have been inextricably linked in my life. My father was a career U.S. Army doctor who won a Bronze Star Medal for valor in World War II and was one of the founders of military pediatrics. My mother was a U.S. Army nurse. In my first career in theology, I worked as a religious educator and lay minister at a military base.
When I entered medicine as a second career, it was my good fortune to receive much of my medical and psychiatric training at VA hospitals. Inspired by the physicians who taught me, I joined the VA straight out of residency and have been there ever since, during both the good and bad times, and never wanted to be anywhere else.
I have spent my nearly 15 years in the VA not in behavioral health care but at the interface of medicine and psychiatry. My professional interest has always been training and consulting to physicians, nurses, and other health care professionals in primary care, medicine, and surgery who are providing vital medical care for patients also struggling with psychiatric, addictive, and pain conditions. Federal Practitioner has done excellent work in this area in the past, and it is one we hope to expand considerably in the future.
Suicide and the treatment of patients with posttraumatic stress disorder, chronic pain, and addiction are among the greatest challenges that our clinician readers face, and it is our obligation to offer timely, targeted news coverage and clinical articles to aid them in their noble efforts.
My other passion is bioethics, and it has been my honor to teach ethics at the university level and to serve as an ethics consultant on many levels of the VA. Ethics also is an increasingly visible and salient domain we hope to spotlight in coming journal issues.
I am also fortunate to have an outstanding editorial staff as collaborators: Reid Paul, Joyce Brody, Robert Fee, and Teraya Smith. We also have a talented and dedicated Editorial Advisory Association of health care professionals from the DoD, VA, and PHS, and we intend to actively engage them in expanding our contributors and readers. And we invite each of you to join us in improving the scholarly quality and clinical relevance of this journal. In coming editorials, I will outline some of our primary goals for the journal, and I invite you to write me with suggestions for the future direction of Federal Practitioner.
This journal fills a unique role in health care, because no other publication is dedicated to the service of the servants of the public in DoD, VA, and PHS. We want to feature the clinical innovations, research advances, and organizational initiatives of the men and women who carry out this sacred trust to care for the health of the military, veterans, and the public.