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Veterans Administration support for medical research: opinions of the endangered species of physician-scientists¹

STANLEY ZUCKER^*,2, JOHN C. CRABBE^**, GEORGE COOPER, IV, FRED FINKELMAN, COREY LARGMAN, ROBERT W. MCCARLEY, LOUIS RICE, JANET RUBIN, BRUCE RICHARDSON^||, FREDERICK SEIL^**, GORDON L. SNIDER^¶ and ARTHUR A. VANDENBARK^**

Veterans Administration Medical Centers located in
^* Northport, New York, USA;
Charleston, South Carolina, USA;
Cincinnati, Ohio, USA;
San Francisco, California, USA;
Brockton, Massachusetts, USA;
Cleveland, Ohio, USA;
Atlanta, Georgia, USA;
^|| Ann Arbor, Michigan, USA;
^** Portland, Oregon, USA; and
^¶ Boston, Massachusetts, USA

²Correspondence: Mail Code 151, 79 Middleville Road, Northport, NY 11768, USA. E-mail: stanley.zucker{at}med.va.gov

	ABSTRACT

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
Over the past three decades the Veterans Affairs (VA) Research program has evolved into a powerful, peer-reviewed funding mechanism for basic and translational research that has resulted in numerous important contributions to medical science and improvements in patient care. Continuity in VA Merit Review funding has fostered and nurtured the scientific careers of a large number of physician-scientists who have remained devoted to the mission of performing creative and innovative research that affects the patient care mission of the VA. VA medical research policies have undergone a major overhaul in the past year. Although many of these changes (de-emphasizing bench research and revamping the peer review process) have recently been reversed, the future direction of VA research remains in flux. The goal of this manuscript is to demonstrate the importance of the Merit Review medical research funding mechanism not just to the VA, but to the entire nation’s health care system. To achieve this goal, the opinions of 65 established VA medical investigators were obtained regarding the past success and future direction of VA research. The conclusions reached include the following. 1) Merit Review research funding has been essential to the training, recruitment, and retention of productive VA physician-scientists. 2) The VA research program has contributed both basic and clinical innovations that have led to improvements in medical care. Contributions of VA researchers to excellence in many aspects of patient care at VA hospitals have been extraordinary. 3) Development of initiatives that entice outstanding Ph.D.’s to develop their careers in the VA has been crucial to the success of the program. 4) The VA research program has fostered a mutually beneficial relationship with affiliated medical schools. 5) Better methods to quantify VA research contributions and outcomes are essential for future program development.—Zucker, S., Crabbe, J. C., Cooper, G., IV, Finkelman, F., Largman, C., McCarley, R. W., Rice, L., Rubin, J., Richardson, B., Seil, F., Snider, G. L., Vandenbark, A. A. Veterans Administration support for medical research: opinions of the endangered species of physician-scientists.

Key Words: VA training • basic research • patient care

	INTRODUCTION

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
THE MEDICAL RESEARCH ENTERPRISE of the United States is poised to escalate its contributions to humanity’s health and well being. However, the disconnection between the promises of basic science discoveries and the translational delay in delivery of better health care to patients remains problematic (1) . The bridge between bedside and bench with its long history of partnership and cross-fertilization between M.D.’s and Ph.D.’s sets the American medical research enterprise apart from its counterparts in Europe and Japan. Nonetheless, it is evident there are flaws in the structure of the nation’s medical research edifice, which urgently needs repair. A major defect is the progressive and dangerous decline in the number of physician-scientists, M.D.’s who are devoted to discovery of new knowledge about health and disease through research (2 , 3) . The term physician-scientist is meant to be inclusive, covering basic, disease-oriented, patient-oriented, population-oriented, and prevention-oriented research. Numerous reports have described the grave concerns of the National Institutes of Health (NIH) and proposed remedies involving the concerted action of the entire country’s research enterprise. New initiatives have been introduced to enhance the recruitment and training of physician scientists who will speed up the process of transporting new medical discoveries from the bench to the bedside (1 2 3) .

Because of its small size relative to the magnitude of the NIH programs and its focused veteran patient population, the Veterans Affairs (VA) research program has received scant public attention in this planned research reform. In contrast to the double digit growth of the NIH budget, VA research appropriations have not expanded. The goal of this manuscript is to examine the VA basic and clinical research program (Merit Review) and to point out the importance of this resource to both the Department of Veterans Affairs and the overall national health care system. In contrast to other publications emanating from extramural panels of experts formed to analyze VA research programs or from individual VA administrators describing their programs, the approach of this report is to summarize the views of a large number of VA medical researchers.

VA medical research policies have undergone a major overhaul in the past year. The proposed changes have been the subject of considerable controversy (4 5 6) . Although many of the changes (de-emphasizing bench research and revamping the peer review process) in the Department of Veterans Affairs’ $400 million health research enterprise have recently been reversed (7) , the future direction of VA research remains in flux. Long-range plans need to be developed. The goal of this report is to provide new information that will be useful in helping to reshape the future of VA research programs.

	HISTORY OF THE VETERANS ADMINISTRATION

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
In spite of its long and rich history of providing care for veterans, most Americans have little understanding of VA programs. The origin of the concept of health care for veterans dates back to 1636, when the Plymouth Colony pilgrims passed a law providing public support for disabled soldiers who fought against the Pequot Indians. In 1789, the first U.S. Congress enacted a law to provide pensions to disabled veterans and their dependents. In 1865, President Lincoln signed legislation creating a National Home for Disabled Voluntary Soldiers. The conclusion of World War I and World War II each created a need for expansion of veterans’ health care services (8) . The modern era of VA research began after World War II as a component of the effort to improve the quality of medical care provided to returning veterans with war-related medical problems.

In 1989, the VA, headed by the Secretary of Veterans Affairs, became the 14th Cabinet-level department in the Executive Branch of the federal government (9) . Currently, the VA is the second largest federal agency and the second largest health care provider in the country with 180,000 full-time employees, 163 hospitals, 800 ambulatory care and outpatient clinics, 135 nursing homes, and various other facilities (10) . The VA funds 8900 residency training positions sponsored by 105 medical schools that are affiliated with VA medical centers (11) . The U.S. Department of Veterans Affairs and its Veterans Health Administration have rapidly transformed during the past decade, restructuring from a hospital-based, specialty-focused system to an integrated delivery system more akin to the private sector, which has the goal of more efficiently providing veterans with health care of the highest quality (11 , 12) .

	MODERN ERA OF VA RESEARCH

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
The modern era of VA research began after World War II as a component of the effort to improve the quality of medical care provided to returning veterans. This goal was accomplished in large part by affiliating with schools of medicine, building new VA hospital sites on or near campuses of medical schools, and adopting a model of medical care used in academic medical centers (8) . This affiliation brought the country’s medical schools and their residency training programs into VA hospitals and thus helped guarantee quality health care to wounded, sick, and disabled veterans while providing an immediate answer to the physician staffing dilemma faced by VA hospitals. This decision also supported American medical education by providing a site at which more than half of American physicians receive training, ensuring a stable base for biomedical research, and influencing the future direction of medical practice and education (8 , 11) . The opportunity for VA staff to hold academic rank and expansion of the VA budget for research was an essential component of physician recruitment and retention (13) .

In 1958, the U.S. Congress formally recognized medical research as one of the three missions of the VA and authorized a portion of the VA’s annual budget for research (11) . The VA’s research mandate was to contribute to the nation’s knowledge about disease and disability by carrying out medical research in connection with medical care and treatment of veterans. While the mission of the NIH is to foster the highest quality health research and research training for the country at large, the primary mission of the VA research program specifically is to foster such research within VA medical centers (14) . By design, the VA’s research program primarily supports physician-investigators who are involved directly in patient care, thereby assuring an orientation toward and priority for solving problems related to the diseases of veteran patients (14) . The involvement of some VA physicians in basic and clinical research was deemed essential to maintaining the intellectual environment required for providing excellent health and medical care (14) . Career Development Awards were developed in the VA and were successful in training the cadre of future VA investigators (15) .

Oversight of VA research is conducted by the Office of Research and Development under the directorship of the Chief Research and Development Officer (CRADO). The Office of Research and Development at VA National Headquarters has traditionally been divided into four services: Medical Research, Health Services Research and Development, Cooperative Studies, and the Rehabilitation Research and Development Service. The Medical Research Service, the focus of this report, is by far the largest of the four VA research programs and concentrates on the etiology, pathogenesis, diagnosis, and treatment of diseases affecting veterans and the general population (10) . Recent reorganization divided the Medical Research Service into clinical (Clinical Science Research and Development) and research (Biomedical Laboratory Research and Development) services, with the clinical research arm absorbing the former Cooperative Studies Program.

Research in the VA is funded both intramurally and extramurally. Extramural funding comes mostly from the NIH to VA investigators affiliated with academic institutions. It has been estimated to be at least as large as intramural funding, which comes as the Medical and Prosthetic Research Appropriation from Congress. Extramural research funding at several VA Medical Centers exceeds $20 million per year. Intramural research awards are based on national competitive scientific review by Merit Review Boards comprised of outstanding scientists who are both salaried and nonsalaried by the VA. The Medical Care Appropriation of the VA’s budget also provides research support for clinical time and facilities.

In 1989 it was estimated that the VA supported about one-third of all physician-investigators in this country. In contrast, the specific appropriation for VA research accounts for less than 2% of the federal biomedical research budget (16) . Although VA research has continued to be supported strongly by Congress and the VA’s intramural research budget continued to increase through the 1990 s, it has recently declined considerably in constant, inflation-adjusted dollars while the cost of doing research has risen. The Medical and Prosthetic Research Appropriation has declined in relation to the total VA Medical Care Appropriation, from 2.0% in 1980 to 1.2% in 1996 (12) . Likewise, the percentage of investigator-initiated research proposals that are funded has declined. The net effect of continuous underfunding of VA research has been to reduce the number of Merit Review VA-funded medical research grants from 2400 in 1988 to 1750 in 2002 (11) . The investigator mix of currently funded VA researchers includes 72% physicians and 28% nonphysicians. Training grants for the past year included 75 Career Development Awards to M.D.’s, 80 Merit Review Entry Program grants to Ph.D.’s, and 33 Associate Investigators (granted to M.D.’s and Ph.D.’s within 3 years of completion of their education).

	ASSESSMENT OF VA RESEARCH BY EXTERNAL REVIEW COMMITTEES

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
At the direction of the Under Secretary for Health of the U.S. Department of Veterans Affairs, over a 25 year period five advisory committees have examined the research and educational roles of the VA and how they can optimally mesh with the realigned health care system. These extensive reviews recognized the importance of research funds to the VA as a recruitment incentive for clinical and biomedical investigators; they concluded that the research mission was underfunded and should be expanded (12 13 14 , 17 , 18) . The 1996 committee concluded that VA research was highly meritorious, rigorously peer reviewed, and critical to the patient care mission of the VA. They stated, "the VA system is a national resource for research, both because of its unique access to very large numbers of patients and its tradition of high-quality research." The committee further pointed out that 1) the VA is not satisfactorily recruiting and sustaining the next generation of outstanding clinician scientists; 2) the contribution of VA research to new knowledge has not been sufficiently recognized by the general public and the biomedical community; and 3) although VA research benefited from its affiliation with the nation’s medical schools, these affiliations should be further refined to benefit both partners (15) . Another recommendation included designation of research areas so that VA research could focus better on the specific needs of veterans while maintaining a research base for less common conditions and needs integral to the VA’s mission (12 , 15) . A constant challenge facing VA research has been maintaining an appropriate balance of basic, applied, and outcomes research.

VA research has long been recognized for pioneering important medical technologies, including medical use of radioisotopes, dialysis, cardiac pacemakers, and liver transplantation. A feature of VA research that stands out is its capacity to design and rapidly implement large-scale cooperative trials. These trials started in the 1950s with evaluation of chemotherapy for tuberculosis, which played a major role in the rapid development of drug regimens for successful treatment of tuberculosis, which benefited the whole country. Subsequent seminal studies documented the benefits of coronary artery bypass surgery and drug treatment of hypertension (19) . To improve public awareness, the VA has established a website (http://www.va.gov/resdev) describing recent research accomplishments by VA investigators and program developments.

	CURRENT VIEWS OF VA RESEARCH INVESTIGATORS

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
No recent attempt (13) has been made to obtain VA investigator opinions about the future direction of the research program. The VA Medical Research Advisory Group (MRAG, a group of senior VA research scientists appointed by VA headquarters), recognizing the changing climate in the VA research enterprise, agreed at their annual 2003 winter meeting to solicit the views of well established VA researchers. These were classified by NIH and VA Merit Review research funding and publication record. The identification of "established investigators" started with an e-mail communication sent to all members of MRAG and later to the Chiefs of Medical Services at all VA Medical Centers. Respondents were requested to identify established VA researchers, who were then sent a form letter via e-mail. This networking effort led to the collection of 65 Research Investigator profiles summarized below. Included in the list are Chiefs of Medicine, Associate Chiefs of Staff for Research, and winners of the most prestigious VA research award (Middleton Award). One medical investigator (#66) asked that his profile be excluded from the compiled listing; the remainder agreed to have their viewpoints become public information. It should be pointed out that no attempt was made to solicit alternative viewpoints from unfunded VA research scientists. Researchers were asked to discuss with reference to their own careers:

• the importance of VA Research in recruitment and retention of talented physicians and unique aspects of VA training programs that promoted physician development as researchers;
  
• how VA research has led to innovations in clinical care of veterans;
  
• the importance of VA Research in terms of development of strong connections with affiliated Medical Schools;
  
• how the recruitment and training of physician-scientists has improved medical care in the VA, the university, and the community;
  
• how VA funding has been leveraged to develop major programs through NIH and other external funding systems;
  
• the effect of anticipated changes in VA research programs;
  
• Ph.D. researchers were asked to explain the special qualities of their careers that led them to work within the VA rather than following a career path in a university setting.
  

	RESPONSES OF ESTABLISHED VA INVESTIGATORS

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
The complete text of all responses obtained from VA Investigators will be made available to interested readers (see listing in Appendix). The task of selecting and condensing these 110 pages has been challenging. Because of its nonstandardized format, no attempt has been made to provide statistical analysis of the opinions. Comments and commentaries that best portray the opinions of most responding researchers have been summarized. At the heart of the matter is assessing the value of the VA biomedical research program. Ideally, one would like to see a cost/benefit analysis of the VA biomedical research program. The perspectives of deans of medical schools and chiefs of clinical departments would be most informative. Unfortunately, this information is beyond the scope of the current report. It is hoped that the current publication will encourage collection of quantitative data by other sources more appropriately situated to gather this type of information.

	CAREER DEVELOPMENT, TRAINING, AND RECRUITMENT

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
In the current medical care market it is difficult for a new physician who must earn his or her salary by patient care to have sufficient protected time for research activities. Access to VA Merit Review research funding, adequate laboratory space and equipment, protected time to develop new initiatives, and the presence of stable salary support have been the essential components for recruiting and retaining outstanding physician-scientists in the VA. Physician-scientists pursuing bench careers often carry large burdens in terms of maintaining their skills as clinicians while competing for grant dollars in the bruising arena of grant applications. A unique environment for clinical research was created by the VA that has been a magnet for attracting dedicated and talented faculty as well as postdoctoral trainees. The availability of job security in the VA has permitted the undertaking of important but challenging research projects rather than trivial projects that would more rapidly generate publications needed to support requests for future funding.

	INNOVATIVE CLINICAL PROGRAMS DEVELOPED BY LEVERAGING EXTRAMURAL RESEARCH FUNDS

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
VA Merit Review funding has led to the development of innovative and internationally recognized clinical programs that focused on clinical problems of special importance to veterans. Just a few examples include the Spinal Cord Damage Research Center located at the Bronx VAMC, the Alcohol Research Center located at the Portland VAMC, the Multiple Sclerosis Center located at the Baltimore VAMC, and the Geriatric Research, Education, and Clinical Centers established at several VAMCs. Interested readers should refer to http://www.va.gov/resdev for updated information.

	MEDICAL SCHOOL RELATIONSHIP

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
The research program at most medical school-affiliated VAs is the essential link to critically important connections with university medical centers. Close cooperation between the Medical School dean and the Director of the VA Medical Center has resulted in the development of numerous outstanding VA research programs. Joint faculty appointments have created a cadre of outstanding physician-investigators, who are essential to the quality of their academic departments. Synergistic advantages accrue to both members of the VA-university partnership. Medical school clinical departments gain a fiscally and administratively sound mechanism to support disease-oriented basic science; VA-affiliated medical centers benefit by attracting excellent physicians dedicated to patient care. Research at VA Medical Centers that have been unable or unwilling to develop close cooperative arrangements with affiliated medical schools has suffered in terms of scientific development, staffing, and financial support.

	IMPORTANCE OF VA RESEARCH TO PATIENT CARE

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
The quality of patient care in VA Medical Centers is directly correlated with the availability of Merit Review grant funding and the closeness of the academic connection with affiliated medical schools. The best clinicians, section and department heads, and other medical leaders within VA hospitals have usually held Merit Review grants. These physician-scientists are the most likely to see their careers at the VA as nontransitory and make the latest advancements in medicine available to their patients. Although their research may have been basic science oriented, many of these physician-scientists are charismatic teachers who have attracted high-quality residents to their VA hospitals.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 
As a group, the respondents have identified several consistent themes. There is a consensus that the quality of patient care in VA Medical Centers is directly correlated with the availability of Merit Review grant funding and the closeness of academic connection with affiliated medical schools. With less than 25% of biomedical research grants currently being funded by the VA Merit Review process and considering the difficulty in ranking this highly selected set of proposals, there is little chaff; further cuts will delete the wheat. Even the fairest and most thoughtful grant review process is insufficiently precise to prospectively identify those studies that will bear the most fruit.

The development of programs that entice outstanding Ph.D. scientists to develop their careers in the VA is crucial to the success of the research program. This is especially relevant today with the progressive complexity of scientific knowledge where the practicing clinician constantly struggles to stay at the cutting edge of medical science. Cross-fertilization between Ph.D. and physician-scientists has resulted in the development of highly innovative clinical programs that have had a major effect on the clinical care of veterans.

VA research scientists have substantially improved the American health care system by developing successful programs that combine specialized clinical talents with high-level innovative research; these programs have considerably improved VA patient care. Training of young investigators in all aspects of medical research has been and should continue to be a priority. Successful translational research is built upon broad-based fundamental research. Abdication of basic research to the NIH and other funding agencies would relegate the VA to derivative research; discovery research will suffer. Smaller VA research programs that are most dependent on intramural funding to support their research infrastructure would be especially hard hit by drastic changes in VA funding. In summary, VA research scientists (both M.D.’s and Ph.D.’s) have greatly influenced the American health care system by developing a successful program that combines specialized clinical talents with high-level research. Restriction of basic research funding will undermine the quality of health care provided to U.S. veterans and the position of VA medicine at the forefront of the nation’s health care.

The following VA Medical Researchers contributed personal sketches that form the basis of this article (see Appendix). Associate Chief of Staff for Research (ACOS), Chief of Medicine, and winner of the coveted William S. Middleton Award (one VA research scientist selected per year) are listed in parentheses.

Roger Albin, M.D., Ann Arbor

Grover Bagby, M.D., Portland

William A. Banks, M.D., St. Louis

William A. Bauman, M.D., Bronx

Gail A. Bishop, Ph.D., Iowa City

Bradley E. Britigan, M.D., Iowa City

Eugene Butcher, M.D., Palo Alto (Middleton Award 2001)

Robert H. Carter, M.D., Birmingham

Kenneth L. Casey, M.D., Ann Arbor

Philip Cohen, M.D., Philadelphia

George Cooper, IV, M.D., Charleston

Timothy L. Cover, M.D., Nashville

John C. Crabbe, Ph.D., Portland

Michael Cynamon, M.D., Syracuse

George Deepe, M.D., Cincinnati

William C. Duckworth, M.D., Phoenix

Peter M. Elias, M.D., San Francisco

Fred Finkelman, M.D., Cincinnati

James Finkelstein, M.D., Washington, D.C. (former Chairman of Medicine)

Douglas Galasko, M.D., San Diego

Ralph A. Giannella, M.D., Cincinnati

Gary S. Gilkeson, M.D., Charleston

Andrew P. Goldberg, M.D., Baltimore

Steve Goldman, M.D., Tucson

David M. Guidot, M.D., Atlanta

John Hackman, Ph.D., Miami

John Hamilton, M.D., Durham

Jeffrey Kaye. M.D., Portland

John H. Krystal, M.D., Connecticut Healthcare

Corey Largman, Ph.D., San Francisco

Ellis R. Levin, M.D., Long Beach

Allen S. Levine, Ph.D., Minneapolis

Charles Lieber, M.D., Bronx (Middleton Award 1977)

David Lieberman, M.D., Portland

Alan Lichtenstein, M.D., West L.A.

Adhip P. N. Majumdar, Ph.D., Detroit

Neil Mandel, M.D., Milwaukee (ACOS for Research)

Robert W. McCarley, M.D., Brockton (Middleton Award 1998)

William M. Nauseef, M.D., Iowa City

Joseph T. Neary, Ph.D., Miami

Edward A. Neuwelt, M.D., Portland

Michael D. Norenberg, M.D., Miami

Makio Ogawa, M.D., Charleston

J. M. Patel, Ph.D., Gainesville

Robert J. Shmookler Reis, M.D., Little Rock

Louis B. Rice, M.D., Cleveland (Chief of Medicine)

Bruce Richardson, M.D., Ph.D., Ann Arbor

Anne Richmond, Ph.D., Atlanta

Lynn C. Robertson, Ph.D., Martinez

Damaris J. Rohsenow, Ph.D., Providence

Janet Rubin, M.D., Atlanta

Sami Said, M.D., Northport (Middleton Award 1981, former ACOS for Research)

George A. Sarosi, M.D., Indianapolis (Chief of Med icine)

Fredrick J. Seil, M.D., Portland

Cliff Shults, M.D., San Diego

Martin Steinberg, M.D. (retired), Jackson (former ACOS for Research)

Mark H. Tuszynski, M.D., Ph.D., San Diego

Kenneth L Tyler, M.D., Denver

Arthur A. Vandenbark, Ph.D., Portland

Peter Walzer, M.D., Cincinnati (ACOS for Research)

J. Brice Weinberg, M.D., Durham (ACOS for Re search)

David Wofsy, M.D., San Francisco

Marco A. Zarbin, M.D., Ph.D., East Orange

Justin Zivin, M.D., Ph.D., San Diego

Stanley Zucker, M.D., Northport

	FOOTNOTES

 
¹ The views expressed in this article are those of the authors and do not represent the views of the Department of Veterans Affairs.

Received for publication January 29, 2004. Accepted for publication May 13, 2004.

	REFERENCES

TOP ABSTRACT INTRODUCTION HISTORY OF THE VETERANS... MODERN ERA OF VA... ASSESSMENT OF VA RESEARCH... CURRENT VIEWS OF VA... RESPONSES OF ESTABLISHED VA... CAREER DEVELOPMENT, TRAINING,... INNOVATIVE CLINICAL PROGRAMS... MEDICAL SCHOOL RELATIONSHIP IMPORTANCE OF VA RESEARCH... CONCLUSIONS REFERENCES

 

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