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VA Practice

Sherry M. Wren MD, FACS
Associate Professor of Surgery
Chief, General Surgery Palo Alto Veterans Health Care System
Stanford University
Stanford, CA

Academic Practice within the Veterans Affairs Hospital System

Practice within an academically affiliated Veterans Affairs hospital offers an excellent start to a surgeon interested in either clinical or basic research. Many universities use the VA to place junior faculty so they can acquire clinical experience and be eligible for VA grant funding. It is also a place in which you can get administrative experience and recognition. There are some unique idiosyncrasies to VA practice, and these may vary greatly depending on the region of the country and the level of oversight within your institution.

Pay Classification and Salary Issues

The VA classifies employees as either full time (8/8ths) or part time (1-7/8ths). There are advantages and disadvantages to full vs. part time status that must be understood prior to salary negotiations. Pay is based on a base salary figure for all MD’s within the VA system. Basic Pay is based on Grades (14 or 15) and Steps (1-10). The basic pay for a Grade 15, Step 10 physician was $107,357 in 2002. “Special pay” is then added on to this figure. Special pay consists of additional funds potentially from the following categories: full time status ($9000), tenure (0-$25,000), board certification ($2000 plus $500 total for additional certification), geographic location (<$17,000), exceptional qualifications (<$15,000), executive position (<$45,000), scarce specialty (<$40,000), and postgraduate training ($2000). Special pay makes up almost one third of the total salary. The most important caveat with special pay is that it is given to you on the agreement (signed) that you will work one full year within the VA system. If you wish to leave before the anniversary of your special pay agreement the VA can make you pay back the money given to you in the prior year under the agreement. If you are going to be part time make sure you know the source(s) or your remaining salary what your duties will be to earn the non VA money. It can be very difficult in the current economic times to make up the loss of income when you go to less than full time status.

It is important to understand your commitment to the VA. There are determined “tours of duty” in which you are committed to performing VA activities. The clinical work performed at another hospital should occur outside of your tour of duty. If overlap occurs, in the eyes of the government it is illegal and they consider it double dipping. Know the rules and protect yourself, it will be you and not your chair that gets charged with fraud. There is a bill in Congress that is supposed to simplify the entire salary structure to make it more in line with the AAMC. At this time it is unknown when it will be acted upon.

Another alternative as a part-time VA employee is to work on contract, which does not obligate the individual to specific hours and hence there are no “double dipping” issues. The main disadvantage is that the contract physician would not qualify for any of the grant funding programs.

Clinical Practice

The vast majority of the patients are men, who have often take poor care of themselves, have multiple diseases, and in my opinion are the greatest group of patients you can ask for. There is usually a Women’s Center within the VA, but there are relatively few patients requiring surgical intervention. You truly are a general surgeon at the VA. Hernias, vascular, and colon surgery are the most common clinical cases but there is a good mix of GI cases, endocrine, and MIS. The VA is light-years ahead of most academic centers in computerized medical records, which helps instead of hinders patient care. You always have all clinical information at your desk. A potential downside is your university colleagues may consider you a “second class” citizen as the VA doc. I have never understood this view because the acuity and complexity of the cases and the patients is the same if not higher than at other hospitals. My philosophy has been that if you can do it at the VA you can do it anywhere. The big upside to practice is, it is the most regimented practice I have seen, everything is scheduled and you know what your clinical time will be. Clinics and OR are assigned in a set schedule. This allows for budgeting of time for other activities.

Administration

The VA is an excellent place to get administrative experience. Each facility also has an education budget and this can be used to take formal course work in administrative issues. An example of that is more than one physician I know has had full tuition paid and clinical time off to attend a yearlong course on the business of medicine. These funds have also been applied to courses where new surgical techniques are taught. Investigate these opportunities and take advantage of them if you are so inclined.

Resident and Student Teaching

The VA is one of the only places left within most academic medical centers where you have both the time and the structure to teach the tenants of preoperative and postoperative care. The rigid structure of activities is very conducive to a strong educational program. The VA should be a premier education site within your program.

Research

Research opportunities are among the best resources that the VA has to offer. The VA wants to get as many research dollars as possible to flow through their doors. There are financial incentives for them to have a vigorous research program. This results in an outstanding environment for research. There is a research office and Associate Chief of Research within each VA. They help facilitate your growth as an investigator. This office knows the system and what grants are available. They will be the administrative body though which space, start up packages, technologist help, and funding are all channeled, it is a key relationship to manage well. In addition to any private or NIH grants you may wish to apply for, the VA has a granting agency that is only available to VA employees. You must be at least 5/8ths to get any VA funding unless special circumstances can be negotiated. Special circumstances are much harder to negotiate in current times. Both clinical and basic science research have funding opportunities.

Clinical Research

The National Surgical Quality Improvement Program (NSQIP) is the largest database in the world on surgical outcomes. It was initiated and implemented by the VA in 1994. The purpose is to provide information on surgical outcomes such as morbidity and mortality rates among the VA Medical Centers that perform major surgery. It was developed as a risk-adjusted model where the statistically determined expected outcome (E) is compared with the actual observed outcome (O) for all patients in the study. This database has been a gold mine for surgical outcomes publications and can be queried. Click here for the cardiac program (VA Intranet site) or the non-cardiac surgery program.

The Cooperative Studies Program (CSP) is a mechanism through which large clinical trials can be funded and administered within the VA. “The CSP has a goal to encourage and support VA investigators to conduct clinical research and data collection across facilities. CSP itself has a structure that provides the framework for clinical trials. The Program allows for flexible proposal development by investigators that is supported by an extensive network of professional biostatisticians, health economists, pharmacists, programmers, administrators, and support staff within CSP.”

Basic Research

The VA has a large funding program available to VA investigators. Excerpts of programs from the VA websites http://www.va.gov/resdev/default.cfm and http://www.hsrd.research.va.gov/for_researchers/ are listed below.

New Investigators

  • Associate Investigators Program provides opportunities for clinicians and non-clinicians with limited research experience to gain postdoctoral research training under the guidance of one or more senior health services researcher(s).
  • Research Career Development Award (RCDA) is for fully trained clinicians who are early in their research career (no more than five years beyond completion of their last clinical training, fellowship, or other postdoctoral training). These awards provide mentoring and research support for up to three years of concentrated health services research activity.
  • Advanced Research Career Development (ARCD) Award is for fully trained clinician-investigators, with at least three years of postdoctoral research experience, who need additional mentoring to become fully independent. The awards provide three years of research support for concentrated health services research activity.
  • Merit Review Entry Program (MREP) is intended to provide beginning doctoral-level non-clinicians (no more than 5 years beyond receipt of their PhD or last research training or fellowship) interested in health services research with an opportunity for a period of concentrated mentoring and research activities. The awards provide three years of research support designed to prepare awardees to enter the more competitive VA HSR&D Merit Review Program.

Established Investigators

  • Career Development Enhancement Award (CDE) supports established clinician scientists by providing the opportunity for a research sabbatical of up to one year to learn new research skills. To be considered for a CDE award, the individual must have been an independent investigator, within VA, for a minimum of six years. During the award period, the awardee must devote 100 percent time to research.
  • Investigator Initiated Research (IIR) enables VA clinicians and social scientists to pursue their personal research interests while advancing HSR&D priorities and contributing to the quality, effectiveness, and efficiency of VA health care. The IIR program spans the traditional, enduring areas of health services research (cost, quality, and access) as well as emerging areas and current topics (e.g., patient safety).
  • Medical Research Service (MRS) Merit Review Award Program (MERIT)is the principal mechanism for funding investigator-initiated research by VA scientists to conduct fundamental biomedical and behavioral studies of disorders and diseases of importance to the health of veterans. It is an intramural program, supporting research conducted by eligible VA investigators at VA medical centers or VA‑approved sites.
  • Research Career Scientist (RCS) Award: RCS awards are for established, non-clinician, independent investigators and initially provide up to five years of funding. Career Scientists at the RCS level must have a minimum of six years of independent research support (VA or other) and must have current VA/HSR&D project support.
  • Senior Research Career Scientist (SRCS) Award: Selected individuals who have held a RCS aware for a minimum of five years may advance to an SRCS award. These senior level awards recognize VA health services researchers who are international leaders in their field. Awards are for seven years and are renewable indefinitely.

Association of VA Surgeons

The AVS membership is open to any surgeon with a VA appointment. The organization has a scientific meeting every year at which both basic and clinical research abstracts are presented. Manuscripts from the presentations are considered for publication in the American Journal of Surgery. This is an excellent forum to meet and network with fellow VA surgeons whose mission it is to further the clinical, research, and teaching missions of surgical care within the VA.

Strategy

When you are considering a job within an academic VA medical center take the time to understand all of the components. Understand your pay structure and if you are not full time, delineate responsibilities that you will have to make up that pay differential. Ask to meet with the Administrative Officer (AO) of Research and specifically inquire about VA start up funds for your project. The VA is a wonderful environment for clinical care, teaching, and research; the three reasons we went into academics in the first place.