The Role of the VA in its Accomplishments to Medicine and Surgery
The Role of the Veterans Administration in its Accomplishments to Medicine and Surgery The history of VA Medicine has been characterized by fabulous discoveries (often stepping stones), many leading to paradigm shifts in medical and surgical care, failures, Nobel laureates, birth of medical specialties, great institutions (VA’s) with great individuals, policies, ground breaking ways of obtaining and delivering vital patient information and first class medical organizations that passed on to others important medical and surgical information.
For almost 100 years, the United States Department of Veterans Affairs has led to advances in health care for not only Veterans, but all Americans. Many modern medical advances originated as experiments or trials in the VA, and many, but not all of these milestones, now benefit patients worldwide. This was accomplished in many ways including the VA affiliation with medical schools, formation of the Department of VA Research and Development Program, the Collaborative Studies Program and Quality measures, most notably the NSQIP. The foremost goal of early Veteran’s Bureau was forming a program to “mine” rich clinical data to gain knowledge through follow-up studies within a large system with many patients of similar backgrounds.
In 1925, the Section of Medical Research had been formally established as part of the Veteran’s Bureau. Philip B. Matz, M.D. became Chief of Medical Research Subsection (1925-1938). He established a statistical system for tracking patient outcomes. The VA’s first medical journal was the United States Veteran’s Bureau Medical Bulletin. It published articles reflecting clinical experience, review articles, original research and statistical studies from VA hospitals. Every VA physician nationwide was asked to submit at least one article and the journal published continuously until 1944. The early VA research program almost completely disappeared during World War II. Relatively few links exist between the research program of the 1920s and 1930s and the later emergence of medical research after World War II. After World War II, a rejuvenated VA medical care system emerged. The 1946 formal partnerships with medical schools formed strong bonds to academia with the signing of Public Law 293. Prior to this, VA had 83,339 beds in 98 hospitals. None of the hospitals had accredited residency programs, and as an example, the 1000 bed VA hospital in Palo Alto had only five physicians. The day after signing of Public Law 79-293, fifty-six medical residents were placed at Hines VA. Paul Magnuson M.D. drafted a plan to have medical school deans supply staff for VA hospitals in order to ensure that the VA Health Care System was staffed with competent physicians. These physicians would be current with advances in medicine through their medical school relationships.
Soon after this affiliation was created, the initial trials began which were the first Cooperative trials through many VA Medical Centers. The first trials involved the effectiveness and proper dosing of streptomycin as an effective treatment for tuberculosis. This trial set the standard for future trials and established the critical importance of trial design, ethical considerations, comparison of the experimental regimen to controls, prospective comparisons, randomized assignment to treatment, inclusion of a sufficient number of patients for validity, and, that statistical guidance should be provided at all stages. The further initial trials demonstrating the effectiveness of chlorpromazine for neuropsychiatric disease and the treatment of hypertension and demonstrating how it can minimize cardiovascular morbidity were truly remarkable.
The Atomic Medicine Program was truly an advance in VA Medicine. The VA designated six VA sites as radio-isotope centers. As time progressed, these centers focused more on physiology rather than therapeutics such as the “atomic cocktail.” From this, both the development of imaging techniques such as that which occurred for thyroid disease at the Wadsworth VA and the development of the radioimmunoassay at the Bronx VA were landmark developments. The latter resulted in both Rosalyn Yalow (Bronx VA) and Andrew Schally (VAMC New Orleans sharing the Nobel Prize in 1977. In 1998, Ferid Murad, who had been at the Palo Alto VA from 1981-1986, won the Nobel Prize for his discoveries relating to nitric oxide and vascular biology. The Atomic Medicine Program at the VA was the genesis for the development of the specialty of Nuclear Medicine as well as the Nuclear Medicine resident training programs.
Michael DeBakey M.D. is considered by many to be the father of modern VA healthcare. He introduced the concept of marrying medical and surgical teams from local hospitals with VA facilities to provide treatment of Veterans returning from World War II. He provided the Houston VA with its first surgical staff. In Building 203 of the Houston VA, he conducted some of his early vascular studies that involved cardiac pump devices, the heart lung machine and vascular grafts. Dr. DeBakey had purchased a yard of Dacron graft from a local merchant; he had sought to purchase nylon, but it was unavailable. Using his wife’s sewing machine, he fabricated the first cylindrical Dacron grafts. The first surgery employing the Dacron graft was performed on September 2, 1954 at the Houston VA. It was successful and the patient survived another 13 years. He also proposed a follow-up system to determine the natural and post-treatment history of such diseases and conditions in Veterans, which included, among others outcome of arterial injuries, peripheral nerve injuries, tumors of the testes, effects of radiation on the gastrointestinal tract and causes of mortality in Veterans with ulcerative colitis.
There continued to be many advances and firsts. In 1958, under the leadership of William Chardack M.D., Andrew Gage M.D. (former AVAS president) and Wilson Greatbach M.D., the VA contributed to the development and early use of the implantable cardiac pacemaker, thereby assisting many patients in preventing potentially life-threatening complications from arrhythmias. In 1960, William Oldendorf, M.D., a neurologist at the West Los Angeles VA, pioneered concepts that led to the development of computerized axial tomography (CAT) scan. He was for an alternative to painful pneumoencephalography for patients who needed brain imaging. He believed that composite pictures of the brain from X-ray images at right angles might work. He used his son’s toy train, a phonograph turntable and an alarm clock motor to build his prototype. Later, other non-VA researchers turned his idea into a reality. In 1963, Thomas Starzl M.D., Ph.D. performed the first successful liver transplant at the Denver VA. Because of this and his pioneering work on immunosuppression, Dr. Starzl was awarded the William S. Middleton Award in 1968, the highest honor awarded to VA scientists in recognition of their outstanding scientific contributions and achievements relevant to the healthcare of Veterans. Oscar Auerbach, M.D. of the East Orange VAMC, autopsied the lungs of smokers and non-smokers who died of lung cancer and discovered that that the lungs of most smokers, regardless of the cause of death, showed signs of neoplasm and that heavy smokers were much more likely to die of lung cancer than non-smokers. Dr. Auerbach simulated smoking in beagles. He found that one-third of dogs that “smoked” developed the same kind of lung neoplasia that humans did and that all of the non-smoking dogs had normal lungs. He also later determined that smoking causes myocardial damage.
There were a number of critical Cooperative Trials performed in General Surgery and its subspecialties. These included randomized trials investigating four different surgical procedures for duodenal ulcer disease, the effect of both portacaval shunting and sclerotherapy for esophageal varices, the treatment of refractory ascites in alcoholic cirrhosis, the effects of preoperative TPN in malnourished patients and a randomized trial of medical and surgical treatment of gastroesophageal reflux. The VA was also influential in trials of utilizing preoperative mechanical and antibiotic bowel preparation to minimize septic complications in colorectal surgery. In addition, trials studying outcomes of open and laparoscopic treatment of inguinal hernia and the management of complex, contaminated abdominal wall hernias using biological mesh were also performed. The flagship studies involved cardiac surgery where, as far back as the 1970s, randomized trials comparing cardiac bypass versus medical therapy for stable angina as well as trials studying mechanical versus bioprosthetic aortic valve replacement were performed. In 2009, a VA Cooperative trial demonstrated that traditional “on pump” method of coronary artery bypass surgery yields better outcomes after one year than “off pump” bypass. In vascular surgery, a number of trials were performed including the comparative efficacy of vascular bypass materials in lower extremity revascularization, treatment of symptomatic carotid stenosis, angioplasty in the lower extremity, carotid endarterectomy in carotid stenosis, small aneurysm detection and management and most notably, open versus endovascular repair (OVER) for Abdominal Aortic Aneurysm. Of important historical significance was the development of the Brescia-Cimino fistula at the Bronx VA developed by James Cimino M.D. and M.J. Brescia M.D. in 1966. At that time, Veterans presented with fistulas caused by trauma. As an easy access point for phlebotomy, Cimino convinced surgeon Kenneth Appel M.D. at the Bronx VA to create these in patients with chronic dialysis. The AV fistula for hemodialysis became the standard for vascular access for hemodialysis.
The VA contributions to clinical cancer care were tremendous. The early VA Cancer Study Groups developed, defined and perfected the multicenter trial in cancer. It was the primary tool for determining which cancer treatments are useful, useless or harmful in which clinical situations. The NCI – VA Collaborative Group studied the effects of adjuvant treatments given patients at the time of their surgery for primary cancers. Over a span of 25 years, over 12,000 patients were studied involving cancers of the lung, pancreas, esophagus, stomach, colon and rectum. Some of the most important findings of this group turned out to be negative results. During those times, adjuvant therapy did not improve outcome for cancers of the stomach, pancreas, esophagus or lung, preoperative radiation did not improve outcome of surgery for lung cancer, preoperative radiation did improve the chance of cure in rectal cancer and 5-FU-based adjuvant chemotherapy increased disease-free survival and overall survival in colon cancer. In 2000, a study demonstrated that colonoscopy is superior to sigmoidoscopy screening for colon cancer. In the subspecialties, elegant studies demonstrated the ability of larynx sparing treatment of patients with head and neck cancer and the new ways to manage early stage prostate cancer.
In 1985, Congress enacted Public Law 99-166 mandating that the VA compare postoperative morbidity and mortality rates for each type of surgical procedure it performed with the prevailing national standards. Initial studies by John Stremple M.D. (former AVAS president) demonstrated that perioperative morbidity and mortality were comparable between the VA and the private sector. One of the VA’s finest contributions was by Shukri Khuri M.D. who, initially through the VA, developed the NSQIP program which was instrumental in identifying ways to improve surgical care and became the first national, validated, outcomes-based, risk-adjusted and peer-reviewed program for the measurement and enhancement of the quality of surgical care.
This is only a smattering of the medical accomplishments that have occurred within the VA. Others have included prosthetics, post traumatic care, women in medicine, telemedicine, electronic medical records, genetic profiling of disease, epilepsy and deep brain stimulation surgery as well as many others. The future continues to be bright for novel accomplishments by VA physicians and investigators. Our association, the Association of VA Surgeons, formed by our first president, Lloyd Rogers M.D. of the VAMC Syracuse, has been a vehicle to develop disseminate information to other individuals across the world.