In this presidential election cycle, health care issues are at the forefront of political discussions. In particular, presidential candidate Donald Trump has spotlighted the issue of caring for veterans by offering a 10-point plan.1 Mr. Trump insists that his plan would ensure that veterans have convenient access to the best quality care and “decrease wait time, improve health care outcomes, and facilitate a seamless transition from service to civilian life.”2
Whether one agrees with Mr. Trump’s policy proposals or not, one thing is clear: We need to provide better care for our veterans.3 Even the Veterans Choice Program, enacted 2 years ago, has shown signs of substantial difficulties.4 The improvement of veteran care likely requires a multifaceted approach. There are many factors that can, and do, hinder the optimal delivery of care, but the shortages of nurses, pharmacists, nurse practitioners, physician assistants, and other health care providers is one of the most important.5
The shortage of physicians, which is the focus of this editorial, is especially acute.5 The Office of Inspector General (OIG) determined that a shortage of medical officers (defined as health care providers with an MD or DO degree) was the top issue affecting veteran care and the nurse shortage was second.5 However, the study did not break down the physician shortage by clinical specialty. According to other reports, the VA’s specialty physician shortage seems to vary. While some VA medical centers (VAMCs) had a shortage of primary care physicians (PCPs), others had a greater need for specialists.6,7
Enhancing communication regarding the importance of veteran care, improving the VA physician recruitment process, and reducing the compensation disparity between VA physicians and non-VA physicians may help reduce the VA physician shortage indicated by OIG. Still the best way to resolve the VA physician shortage is unclear.
I propose that instituting a service requirement for graduating residents is possibly a more effective way to solve the VA physician shortage. I will delineate my argument in 3 simple points: fairness, feasibility, and altruism.
The VAMCs have been the backbone of resident physician training and therefore deserve to be served by the graduating residents they help to train. Historically, VAMCs often have been affiliated with nearby medical schools to provide veterans with state-of-the-art health care. In turn, VAMCs provide some of the best training opportunities for resident physicians and medical students. Drs. Magnuson and DeBakey conceived the idea of a “marriage” between a VAMC and a medical school following World War II.8 With few exceptions, the best residency programs have at least 1 VAMC affiliation. According to the 2016 ranking of the best medical schools in the U.S. by U.S. News and World Report, 13 of the top 15 medical schools have a VAMC affiliate.9 Currently, the VA has formal affiliation agreements with 135 of 141 medical schools.8
Each year, VAMCs provide practical experience to medical students, resident physicians, and other health care trainees. In 2013, more than 20,000 medical students, 41,000 resident physicians, and 300 fellowship physicians received part or all of their training at VAMCs. Overall, about 70% of all U.S. physicians received their training at VA facilities.
Moreover, VAMCs provide not only the training facility and opportunity, but also substantial financial support to train residents: They currently fund more than 10,000 full-time equivalent positions for residents, about one-third of all resident positions in the U.S.8 While other federal government funding for residency training programs has flat-lined, the VA is the only federal government agency that has received increased funding recently.8 Most of the remaining federal funding for residency programs is provided through Medicare.
Given that the federal government (and the VA in particular) has provided so much support for resident physician training, it is perhaps fair that we ask our graduated residents to help solve the VA physician shortage. In addition, VA could consider tying in this service with a student loan reduction program, which would make this arrangement not only ethically compelling, but also financially practical.
Currently about 30,000 resident physicians graduate from 4,756 programs in the U.S. yearly.10 It has been estimated there is a shortage of 1,400 VA physicians in the U.S. The VA needs < 5% of graduating resident physicians to serve in VAMCs for 1 year in order to completely and certainly solve the physician shortage problem.
To be sure, the optimum resolution would be for the VA to recruit permanent physicians who build long-term, trusting relationships with patients and continuity of care. However, with the current situation in which permanent positions are left unfilled, a short-term program may be better than the status quo. In addition, having experienced the VA working environment, some of these newly graduated physicians serving short-term at the VA may decide later to make the VA a permanent home.
How do we then carry out this requirement? First, we could ask for volunteers once the VA determines the exact number of physicians needed in a given year. If resident physicians volunteers cannot meet VA’s needs, the remaining slots can be filled using a lottery.
Logistically, a lottery can be achieved in the following way. The process needs to be started 3 years before graduation due to residents’ need for advanced career planning. For the 3-year residency program, the lottery would be held at the beginning of the first year of residency. For the 5-year residency program, the lottery would be held at the beginning of third year of residency. All residency programs would be required to report the names of residents and residents who volunteer for 1 year VA service after residency to a central government depository, which would run a random, computerized process to generate names of the residents for the obligation. Residents would learn the lottery results no later than the end of that training year, so residents would have 2 years to plan for their careers, either for a permanent job or additional fellowship training, according to the lottery outcomes. Obviously, federal legislation would be needed to fund and establish the rightful authority to enforce the arrangement.