Clinical Review

A Year 3 Progress Report on Graduate Medical Education Expansion in the Veterans Choice Act

Fed Pract. 2018 February;35(2):22-27

References

1. U.S. Department of Veteran Affairs. Policy Memorandum No. 2. Policy in association of veterans’ hospitals with medical schools. https://www.va.gov/oaa/Archive/PolicyMemo2.pdf. Published January 30, 1947. Accessed December 13, 2017.

2. U.S. Department of Veteran Affairs, Office of Academic Affiliations. 2017 statistics: health professions trainees. https://www .va.gov/OAA/docs/OAA_Statistics.pdf. Accessed January 8, 2018.

3. IHS, Inc. The complexities of physician supply and demand 2016 update: projections from 2014 to 2025, final report. https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf. Published April 5, 2016. Accessed December 13, 2017.

4. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Ann Fam Med. 2015;13(2):107-114.

5. Holder KA. Veterans in rural America 2011-2015. https://www.census.gov/content/dam/Census/library/publica tions/2017/acs/acs-36.pdf. Published January 2017. Accessed January 18, 2018.

6. Weeks WB, Wallace AE, Wang S, Lee A, Kazis LE. Rural-urban disparities in health-related quality of life within disease categories of veterans. J Rural Health. 2006;22(3):204-211.

7. U.S. Government Accountability Office. GAO-18-124. VHA Physician Staffing and Recruitment. https://www.gao.gov/assets/690/687853.pdf. Published October 19, 2017. Accessed January 23, 2018.

8. Veterans Access, Choice, and Accountability Act, section 301 (b): Increase of graduate medical education residency positions, 38 USC § 74 (2014) .

9. Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits Improvement Act of 2016, 38 USC §101 (2016).

10. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv. 2009;60(10):1323-1328.

11. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80(5):507-512.

12. West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308(21):2241-2247.

13. Stimmel B, Haddow S, Smith L. The practice of general internal medicine by subspecialists. J Urban Health. 1998;75(1):184-190.

14. Shea JA, Kleetke PR, Wozniak GD, Polsky D, Escarce JJ. Self-reported physician specialties and the primary care content of medical practice: a study of the AMA physician masterfile. American Medical Association. Med Care. 1999;37(4):333-338.

15. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286(9):1041-1048.

16. Accredited MD programs in the United States. http://lcme.org /directory/accredited-u-s-programs/. Updated December 12, 2017. Accessed January 8, 2018.

17. Osteopathic medical schools. http://www.osteopathic.org/in side-aoa/about/affiliates/Pages/osteopathic-medical-schools.aspx Published 2017. Accessed January 8, 2018.

18. Lincoln A. Second inaugural address. https://www.va.gov/opa/publications/celebrate/vamotto.pdf. Accessed January 8. 2018.

Current Progress

To date the OAA has offered 3 RFP cycles consisting of planning/infrastructure grants, and 4 RFP cycles for salary/benefit support for additional resident full-time equivalent (FTE) positions. Resident positions were defined as residency or fellowship FTEs that were part of an ACGME or AOA-accredited training program. Figure 1 illustrates the geographic distribution of awarded GME positions.

There are midwestern and northwestern states that still do not have GME training at local VAMCs or CBOCs. The use of planning and infrastructure grants by smaller VAMCs with lower complexity ratings (level 1 facilities are considered the most complex and level 3 are the least) to develop GME is illustrated in Figure 2.

In primary care specialties (family medicine, internal medicine, and geriatrics, a total of 349.4 FTE positions have been approved (Table 1). Due to a low number of applications, only 6.3 of these positions were awarded in geriatrics. In mental health, 167.6 FTE positions have been approved, whereas in critical needs specialties (needed to support rural/underserved healthcare and improve specialty access) 256.5 FTE positions have been added.

Overall, 773.5 FTE positions have been approved as of September 30, 2017, with nearly half in primary care, and about one-third in other critical needs specialties (Figure 3).

Notably, 8.5% (65.6 FTEs) of the positions were allotted to self-designated rural sites. Family medicine programs have been awarded 82.6 FTE positions and osteopathic programs 33.4 positions (Table 2). Rotations through VA training sites provide experience for an average of 4 residents per FTE, though this number varies greatly among different sites and specialties.

Discussion

There are several important desired short-term outcomes from VACAA. The first is improved access to high-quality care for both rural and urban veterans. There is an emphasis on primary care and mental health because shortages in these areas across the U.S. are well established.^3,4,10 Likewise, rural areas have been prioritized because often there is a disparity of care.

Urban areas and the wide variety of important subspecialties needed to support primary care and mental health were not neglected, with a significant portion of positions assigned to urban centers in a wide variety of specialty fields. Some question whether internal medicine should be considered a primary care specialty when only about 20% of internists graduating from residency plan to pursue primary care careers.^11,12 Although the percentage is small, a significant amount of primary care in the U.S. is provided by internists, and many that identify as subspecialists choose to practice in a primary care setting.^13,14

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One area of concern is the small number of applicants in geriatrics. Even with VACAA specifically targeting geriatrics as a primary care specialty, we have only received enough applications to approve 6.3 positions over the first 3 years of the program. As the veteran and overall population in the U.S. ages, it is important to develop a medical workforce that is willing and able to address their needs.

The VACAA statute is not intended to alter medical students’ career choice but rather to provide funded positions for those choosing primary care, geriatrics, psychiatry (including psychiatric subspecialties), and experience in the VA clinical settings. The hope is that this experience will encourage practitioners to competently care for veterans after training in the VA and/or other civilian settings.

By enabling smaller VA facilities to become training sites through planning and infrastructure grants, residents have the opportunity to gain experience in more rural settings. Physicians who choose to train in rural areas are likely to spend time practicing in those areas after they complete training.¹⁵The process of developing facilities with no GME into training sitestakes time and resources. Establishing an education office and choosing site directors and core faculty are all important steps that must be done before resident rotations begin. Resources provided through VACAA have enabled the VHA to reduce the number of VAMCs with no GME activity to just 3.

Another benefit of VACAA GME expansion is the opportunity to engage new LCME/AOA-accredited medical schools and ACGME/AOA-accredited residency-sponsoring institutions.^16,17 Representatives of these institutions may have perceived a reluctance of their local VAs to develop GME affiliations in the past. This statute has enabled many VAMCs to use nontraditional training sites and modalities to overcome barriers and create new academic affiliations.

However, VACAA only provides funds for training that occurs in established VA sites of care. This can hinder the development of partnerships where other funding sources are required for non-VA rotations. Another VACAA limitation is that it does not fund undergraduate medical education as does the Armed Forces Health Professional Scholarship Program (HPSP). In addition, the primary financial relationship is between the VA and the sponsoring institution, thus VHA cannot send residents to underserved locations.

Conclusion

The VHA has a rich tradition of educating physician and other health care providers in the U.S. More than 60% of U.S. trained physicians received a portion of their training through VHA.² Through VACAA GME expansion initiative, the 113th Congress has asked VHA to continue its important training mission “to bind up the Nations wounds” and “to care for him who shall have borne the battle.”¹⁸

Acknowledgments
In memoriam – Robert Louis Jesse MD, PhD. Dr. Jesse, the Chief of the Office of Academic Affiliations passed away on September 2, 2017, at age 64. He had an illustrious medical career as a cardiologist and served in many leadership roles including Principal Deputy Under Secretary for Health in the U.S. Department of Veterans Affairs. His expertise, visionary leadership, and friendship will be missed by all involved in the VA’s academic training mission but particularly by those of us who worked for and with him at OAA.