Two family physicians who currently hold positions with the Department of Veterans Affairs (VA) recently spent some time at the AAFP's Program Directors Workshop in Kansas City, Mo., drumming up enthusiasm about a VA program that could prove very beneficial to family medicine.
Dustin Lillie, M.D., left, program director for the University of California San Diego Family Medicine Residency, has questions for Edward Bope, M.D., after a recent presentation about Department of Veterans Affairs funding for residency positions.
During the March 24 workshop, Kathleen Klink, M.D., the VA's chief of health professions education, and Edward Bope, M.D., the VA's graduate medical education (GME) affiliations officer, encouraged program directors to act quickly.
"There is a tremendous opportunity for family medicine to increase the number of graduate medical education spots we have by working in the VA," Bope told his audience.
The physicians were referring to the Veterans Access, Choice and Accountability Act of 2014 (VACAA),(www.va.gov) a bipartisan response to the VA's health care access issues that provides new authorities, funding and other tools to help support and reform the agency.
As part of that effort, the legislation directs the VA to increase the number of GME residency positions by as many as 1,500 with an emphasis on positions that improve veterans' access to primary care and mental health services.
- Family medicine leaders are encouraged to explore new funding opportunities aimed at expanding graduate medical education spots for residency programs.
- The Veterans Access, Choice and Accountability Act of 2014 directs the Department of Veterans Affairs to add as many as 1,500 graduate medical education residency position by 2024.
- Nearly 1,000 fully funded permanent positions are still up for grabs and by law will go to those programs that speak up first.
"These 1,500 positions are focused on the things family medicine cares about: primary care, mental health and caring for high-need populations in remote, rural and underserved communities," said Klink.
"Most people don't realize that the VA facilities embody the largest teaching health platform for health professionals in the United States," she said. In fact, in a single year, 120,000 health professional trainees come through the VA.
"We (the VA) pay for almost 11,000 resident positions in the United States, so we're the second-largest funder of graduate medical education -- second only to CMS," said Klink. That's nearly $1 billion expended for training.
But family medicine is greatly underrepresented, said Klink. "Of those 11,000 positions, just 124 are family physicians."
In keeping with the title of their workshop, "Seven Compelling Reason to Affiliate Your Family Medicine Program with the Veterans Health Administration,"(707 KB PDF) the pair launched into a discussion of why residency programs really should consider participating.
For example, they pointed out that family medicine has a chance to shine by contributing to the nation's largest health care system -- a system that, by the way, has a history of innovation that includes electronic health records, telehealth, palliative and hospice care, integrating behavioral health with primary care, and patient-aligned care teams (referred to as the medical home in the civilian world).
Furthermore, this aspect of VACAA has proven successful to date, with 547 residency positions approved in the first three years.
The bottom line, said the presenters, is that the VA is serious about bringing family medicine and primary care into its system, and doing so will expand community-based learning opportunities for residents and improve care for veterans. VACAA presents an opportunity for family medicine to get in -- and stay in -- the VA system.
Follow-up With Presenters
After their presentation, Bope and Klink sat down with AAFP News for further discussion about what VACAA means for family medicine.
Bope stressed a sense of urgency. "The number of positions is fixed at 1,500 (with about a third already awarded) and the time period to award is fixed at 10 years," he said.
FP Connects Residency Programs to VA Opportunities
Edward Bope, M.D., a family physician, serves as the graduate medical education affiliations officer at the Department of Veterans Affairs (VA), and he is helping family medicine residency programs understand the expansion opportunities available through special VA funding.
He told AAFP News, "Any program director wanting to expand, any state chapter that is thinking they need more family medicine education in their state, and any university or teaching hospital that wants to increase their impact on the community should be looking at this opportunity through VACAA (the Veterans Access, Choice and Accountability Act)."
A huge part of Bope's job is connecting residency programs with VA facilities in their communities. Email Bope and let him guide you through that process.
"I think it's a 'right now' opportunity to increase GME positions for family medicine. If we take advantage of it, we could have 1,000 more family physicians being trained five years from now. That's the grand opportunity," said Bope.
He emphasized that other specialties also are eyeing the remaining slots. And by law, positions must go to programs that speak up first. In other words, those at the front of the line win permanently funded residency spots.
"Our program directors may not be aware of the urgency," said Bope. "People are still in learning mode. But I'm afraid that while they're asking questions about this opportunity, it will pass them by."
Klink noted the program was gaining traction, citing a recent example to illustrate her point. "Someone just came up to me and said, 'We're starting a new family medicine residency program in southwest Georgia; is there a way I can connect with the VA?' And I said 'Yes.'"
Both Klink and Bope expressed surprise at the number of family medicine residencies that don't realize they are in the same town with a VA facility.
"The VA is used to working with big universities and big teaching hospitals," said Klink. "But it's important for readers to know what an important contribution the VA makes to health professionals' education" and to understand the VA's commitment to the medical home model of care, she added.
Bope and Klink agreed they've never understood the family medicine vacuum within the VA. Based on their various leadership positions during the course of many years, they were more worried about family medicine's place at the universities.
"So I don't blame the VA entirely for not recognizing what we can do for them," said Bope. "It's upon our shoulders to tell them what we can do for them."
Making it Work
Viviana Martinez-Bianchi, M.D., is program director at the Duke Family Medicine Residency in Durham, N.C. She told AAFP News that back in 2015, the designated institutional officer in charge of GME at the VA facility in Durham contacted her about the new money available to primary care.
"She was interested in getting family medicine into the VA and having residents see patients in the VA," said Martinez-Bianchi. "So we put together a plan where three of my residents (each) spend one half-day a week in their second and third years seeing a panel of patients they are assigned to longitudinally in the VA primary care clinic. All residents do rotations at the VA including inpatient and outpatient specialties such as medical intensive care unit, dermatology and surgery."
This is in addition to the residents' attending to their own patient panel at the Duke residency and eventually getting their own VA patient panel.
In a letter to the VA Academic Affiliations Office in 2015, Martinez-Bianchi said she wanted her program's trainees to "gain experience with the health care needs of veteran patients … and lead family physicians to consider careers incorporating care of veterans in their practices and consider working in the VA system after graduation."
Martinez-Bianchi's program obtained one position in July 2015, increased that to two positions the following year and currently has VA funding for 2.5 full-time equivalent (FTE) positions.
Farther north, the University of Minnesota/St. Cloud Hospital Family Medicine Residency, led by program director Thomas Satre, M.D., is another success story in the making.
Initial discussions with the VA about a year ago made Satre aware of the VACAA funding initiative.
"We were looking to expand from a five-five-five to a six-six-six program sometime over the next few years, and so this provided a good opportunity to receive some funding for one of those slots," Satre said in an interview with AAFP News.
The St. Cloud residency expansion is scheduled to start in the 2018-2019 academic year.
"Right now we're looking at one FTE in funding from the VA -- but that could definitely expand up to two FTEs if things work out on both sides," said Satre.
He ticked off several reasons the collaboration works.
"First, it allows us to receive some funding for expansion of our program. And it will provide some great training opportunities for our residents -- including more primary care-oriented surgery and orthopedic experiences. Lastly, it will give our residents exposure to the VA medical system and, hopefully, attract them to that system when they graduate," Satre explained.
He stressed that the training opportunity with the VA isn't limited to just one resident, but rather it is an accumulation of all resident time spent at the VA.
"So I don't have to find a resident who wants to do all of his or her training in the VA; multiple residents are exposed to the VA system," said Satre.
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