Yale and the VA: Joined at the hip

On the first day of her residency rotation at the VA hospital in West Haven, Susan Kashaf, MD, MPH, treated Kevin Barbour, a Vietnam War veteran. Barbour was exasperated by lingering pain from earlier knee surgery—and he let her know about it.

It was a rough start for a young doctor. “He scared the heck out of me,” recalls Kashaf.

Today, 20 years later, Kashaf is an attending physician at the VA and an associate professor of medicine at Yale School of Medicine—and Barbour is still one of her patients. She has a thank-you card that he sent her after she helped him quit smoking. “It’s a nice reminder of what we do,” says Kashaf.

The warm feelings shared by Kashaf and Barbour are emblematic of the deep and multifaceted relationship between Yale School of Medicine and the VA Connecticut Healthcare System in West Haven that goes back more than 60 years. People involved say the tie is critically important to the delivery of high-quality medical care to veterans in Connecticut—and to vets with complex cases from across New England.

The majority of physicians who work at the VA in West Haven have faculty appointments at Yale. “Our patients get the latest advances in care applied to their problems. They get the depth and expertise of a medical staff associated with Yale, and they can get consultations with the top experts at Yale and Yale New Haven Hospital,” says Michael Ebert, MD, the chief of staff at VA Connecticut. At Yale, he is a professor of psychiatry and associate dean for veterans’ affairs.

Yale School of Medicine leaders say the association provides Yale medical students, residents, and fellows with valuable hands-on training. Plus, the VA’s a fertile environment for conducting medical research. “Yale’s longstanding relationship with the VA is a win-win. It’s been mutually beneficial for the medical students, residents, and fellows who train there; the faculty who conduct research there; and the veterans who receive exceptional care,” says Robert J. Alpern, MD, dean of Yale School of Medicine and Ensign Professor of Medicine (Nephrology).

These days, the Veterans Health Administration is under attack from critics who want to replace it with private health care. However, leaders at VA Connecticut and Yale say the VA system provides outstanding lifelong care in most cases to a patient population whose medical issues tend to be complex and whose physical ailments are often compounded by mental health problems. “The VA is a unique national system that offers a seamless web of services from primary care to specialized services to hospital to geriatric and nursing care. When done correctly, it’s a national model for providing health care,” says John Booss, MD, professor emeritus at Yale School of Medicine, formerly the national program director for the VA’s neurology service.

When Theodis Fenn Sr. returned from Vietnam as a combat infantryman in 1967, he suffered from malaria, hepatitis, anxiety, and burns on his feet from a base camp accident—and had been exposed to Agent Orange, the toxic defoliant. His initial encounters with the VA were disappointing. “They never addressed my problems,” he says.

But eventually Fenn obtained Daniel Federman, MD, a professor of medicine at Yale, as his primary care physician, and things turned around. Fenn has received treatment for PTSD, lung and prostate cancer, diabetes, high blood pressure, and chronic abdominal pain. “Dr. Federman is my lifesaver. Without him, I’d be dead,” says Fenn.

Leaders at Yale and the VA say veterans like Fenn who have complex health problems benefit from the expertise in diagnosis and treatment that medical school faculty can offer. For instance, Yale and the VA Connecticut Healthcare System helped define and establish PTSD as a diagnosis back in 1980, and today researchers at the VA are developing innovative treatments for it.

In return for their dedication to better health care for veterans, Yale faculty physicians and students who practice at the VA get tremendous satisfaction from treating veterans, who are typically grateful and willing to volunteer for studies that might help their comrades. A number of Yale faculty members treat patients at the VA without compensation.

Some veterans become like family to the med students and residents. Uyen To, MD, assistant professor of medicine and a Yale transplant hepatology fellow who did her residency at Yale as well, says she became particularly close to one elderly man—even telling him about her wedding plans. At one point he was near death. He grabbed her hand and vowed, “I’m not going to die before you get married.” He pulled through.

For Yale’s medical students, residents and fellows, the West Haven hospital provides an excellent place to learn and practice in a hands-on environment. In a typical year, more than 200 medical students complete clinical rotations there in a wide range of medical specialties, working closely with attending physicians who also provide classroom training. At any given time, 15 percent of the more than 1,100 residents and fellows are on rotations at the VA—during which time the VA covers their salaries.

“The patients want to help them learn. They have incredibly interesting medical histories and social histories around their military time, so it’s a rich learning experience,” says Seonaid Hay, MD, assistant professor of medicine and associate program director of the Yale Traditional Internal Medicine Residency Program at the VA.

Yale faculty members teaching at the West Haven VA have introduced a number of innovations there. One is the Center of Excellence in Primary Care Education, in which faculty members teach residents how to provide primary care through interprofessional teams. At the VA Connecticut clinics, residents work with teams that include nurses, medical assistants, psychologists, pharmacists, and others to provide care for patients tailored to individual needs. The program started in a few clinics and now includes most of the clinics at the West Haven facility.

The VA provides tremendous research opportunities for students, junior faculty members, and senior faculty alike. The VA is a fertile environment for research partly because of its size and scope. Researchers can study large groups of patients at VA medical centers around the country. Because the VA was a pioneer in electronic medical records in the 1970s, much of its historic data is easily accessible.

“Another attraction is the patients. They’re willing to participate in research because they want to help their buddies. There’s an altruistic drive,” says Fred Wright, MD, the director of research at VA Connecticut and a professor of medicine (nephrology) and of cellular and molecular physiology at Yale.

The VA Connecticut Healthcare System has 25 labs in West Haven, with more than 500 active research projects funded to the tune of $45 million in grants and run by 80 principal investigators —all from Yale. Those labs are currently conducting more than 50 clinical trials.

The program includes several high-performing organizations. The Center for Neuroscience and Regeneration Research, headed by Stephen Waxman, MD, PhD, Bridget M. Flaherty Professor of Neurology, discovers ways to restore function in the nervous system after injuries and strokes. The VA-Yale Clinical Neurosciences PTSD Research Program, headed by John Krystal, MD, Robert L. McNeil, Jr. Professor of Translational Research and professor of psychiatry, and of neuroscience, seeks biological approaches to the treatment of trauma-related disorders. And the NIH-DoD-VA Pain Management Collaboratory Coordinating Center, run by Robert Kerns, PhD, professor of psychology, of neurology, and of psychiatry; Cynthia Brandt, MD, MPH, professor of emergency medicine and of anesthesiology; and Peter Peduzzi, PhD, professor of biostatistics, helps guide clinical trials of nondrug approaches to pain management.

Yale faculty members who serve at the VA are dedicated to making life better for today’s veterans by providing the best care available, and to improving care for generations to come via research and teaching. Every faculty member interviewed for this story said they chose the VA because it’s so gratifying to help veterans.

Veterans interviewed returned the warm feelings. Vietnam vet Bill Broumas shunned the VA after he returned from the war. He received private insurance through his employer. But a few years ago, he decided to give the VA another chance—partly because of the Yale connection. Now he’s a fan. “Every single person I meet there—they’re totally interested in me,” he says. “They all treat me like a human being.”