Statement
Of the
Association of
American Medical Colleges
On
Veterans Major
Medical Facilities Construction
Presented to the
Subcommittee on Health
Committee on Veterans’ Affairs
United States House of
Representatives
By
Donald E. Wilson, M.D.
Vice President for Medical Affairs and Dean
University of Maryland School of Medicine
April 24,
2002
Good Afternoon Mr.
Chairman and Members of the Subcommittee. Thank you for the opportunity
to address you on this important issue. I am Donald Wilson, vice
president for medical affairs, University of Maryland, and dean of the
School of Medicine. Today, I am representing the Association of
American Medical Colleges (AAMC). The AAMC represents the nation’s 125
accredited allopathic medical schools, over 400 major teaching hospitals
and health systems including 72 Veterans Affairs Medical Centers, 98
academic and scientific societies representing 105,000 faculty members
and the nation’s 66,000 medical student and 97,000 residents. As I am
sure you know, 107 of those 125 medical schools maintain formal
affiliation agreements with VA medical centers and these agreements are
mutually beneficial to both the academic partner and the VA in each of
the VA’s three major missions of patient care, research and education.
The Subcommittee, I am
sure, is familiar with the importance of the affiliation agreements to
both the VA and the affiliated health professions schools. The AAMC has
testified to this relationship several times over the last few years;
however, those statements have most often focused on the education and
patient care missions rather than research. From the standpoint of a
dean of an affiliated medical school, I see the VA research program as
an opportunity for collaboration, as a dedicated funding source that the
faculty at my school can access, and as a tool I can use in faculty
recruiting. The success rates for VA research grants are greater than
those of the NIH and the natural physical proximity of the facilities
lends itself to collaborative research efforts.
One of the problems
that the research facilities face is the competition in the VA Minor
Construction budget account for limited funds. The VA research program
has seen some significant increases in recent years, but funds are
statutorily prohibited from being used for construction or renovation.
Even if they were able to be used, the program is still not big enough
to address the critical research needs and the facilities issues.
Research facility needs less than $4 million are funded through the
Minor Construction line item, competing against other VA facility needs
not necessarily related to research such as parking lots, elevators, air
conditioners, etc. For this reason the AAMC believes that the research
enterprise would be well served if the Subcommittee supported a separate
funding stream that would be dedicated to upgrading and improving
existing research facilities. From the affiliate standpoint, it would
allow an academic institution to count on the VA facility as a potential
site for state-of-the-art research. As recommended by the Friends of VA
Medical Care and Health Research Coalition, such a line item would fund
one-time construction or renovation projects, and be merit-reviewed
based on VA’s assessment of needs. The Friends of VA have recommended
an appropriation of $45 million for this account in the first year.
There are many
anecdotal examples of problems with research competing with other
needs. One example is the air vent intake at the VA Boston Healthcare
System that is located over the hospital loading dock and draws exhaust
fumes into the laboratories in certain instances. It would take
$300,000 to relocate the intake, but in six successive years, funding
has not been available, which limits the potential research that can be
conducted in this laboratory by both VA and the affiliated Harvard
researchers. Another relates to a researcher who has funding lined up
for a grant that requires storing tissue samples in sub-zero freezers,
which are covered as a direct cost of the grant. The space has been
allocated, but the researcher is unable to secure $30,000 to upgrade the
electrical system to support the freezers. VA researchers in
Gainesville, Florida are unable to conduct certain types of research
because their “wet lab” countertops are made of particle board and
formica, rather than the standard stone, and are easily burned and
stained from exposure to heat and chemicals. At the Southern Arizona VA
Health Care System in Tucson, one of the buildings has no elevator and
patients involved in clinical research are required to climb stairs.
They also spend precious resources outsourcing kennels for dogs because
no funding is available to bring the existing kennels into line with
AAALAC or FDA standards.
However, the main
reason for my being here this afternoon is not to testify to the poor
condition of VA research facilities, but rather to the value of the VA
research facilities to the affiliation agreements. One of the obvious
benefits is that state-of-the-art research facilities help in the
recruitment of top researchers to the affiliated school and therefore,
to the faculty of the VA medical center as well. In best case
scenarios, top-notch research facilities help both the VA and the
affiliate to leverage their research funds. For example, a partnership
between the Penn State Milton S. Hershey Medical Center and School of
Medicine and the Lebanon, Pennsylvania VA Medical Center recently
undertook a joint project to renovate laboratory space at the Lebanon
VA, which will allow researchers with joint appointments to draw down
additional federal research dollars from VA and other sources. Under
this agreement, the affiliate came up with 75 percent of the needed
funds, but without the VA contribution, the project could not have gone
forward. As a result, significant research related to regulating blood
pressure in cardiac patients, and kidney failure has been able to move
forward.
Another good example of
the collaboration between affiliates and the VA is at the Texas A&M
University System Health Science Center School of Medicine. Several
years ago, they began a three way initiative with Scott and White
Memorial Hospital and the Central Texas Veterans Health Care System to
build a world-class Cardiovascular Research Institute in Temple, Texas.
In the true spirit of partnership, these three entities have all
contributed significant resources to the initiative, with the university
providing the faculty salary lines, the private hospital providing
substantial start-up resources, and the VA producing the building. With
completion of the building expected this fall, they plan to have three
major research groups in Molecular Cardiology, Vascular Biology and
Hypertension occupying 35,000 square feet in the building on the VA
campus. The interim dean at Texas A&M expects to begin recruiting basic
and clinical scientists to the VA within the year. This initiative
would not have come about without the full cooperation of the local VA
medical center director and the ability to redirect some funds that were
targeted for another building. However, the resulting institute
provides much greater benefit than any of the partners would have been
able to establish on their own.
However, not all the
affiliations have such positive stories to tell. At the University of
Iowa School of Medicine, about half of the 40,000 square feet of VA
research space is located in an aging building that was originally
constructed in the 1950s and converted to research space in the 1970s.
The HVAC system is so outdated that the labs still use window air
conditioners and steam radiators. Researchers are forced to work at
night during summer months to avoid melting some of their lab gels and
triggering heat shocks to some of their cell lines. The building has no
fire sprinkler system or sensors and the Fire Marshall has recommended
that the building be discontinued as a research laboratory. As if that
wasn’t enough, the building has no elevators and large equipment must be
fork lifted or craned into the second floor. And due to the age of the
building, it can only handle 200 pounds per square foot instead of the
standard 600 pounds, limiting the types of instrumentation that can be
brought in. All of these issues are unfortunate, but what is perhaps
the most disappointing issue at the Iowa VA medical center is that the
university feels it cannot in good conscience ask students or postdocs
to join these labs. As a result, the university has chosen not to
respond to specific program announcements from VA. By undermining the
ability of individuals and institutions to leverage additional support
from VA and other sources, the quality of science being conducted in the
labs is being compromised. Although this extreme example may need major
rather than minor construction funds to remedy the problems, the
resulting decision to not pursue research funding due directly to the
deteriorated state of the facility is a disturbing conclusion.
Dilapidated research
facilities also hinder the recruitment process for faculty at both the
VA and the affiliated medical school. The University of California, San
Diego and the VA San Diego Healthcare system have been unable to recruit
a top Hepatitis C specialist because the research space is lacking.
Similarly, the University of Colorado Health Sciences Center and the
Denver VA Medical Center have been repeatedly turned down by top
cardiologists, pulmonary and gastroenterology physicians who cited poor
quality research facilities as a major factor in their decisions. This
inability to recruit impacts severely on the quality of care for
veterans.
Within my own VA
affiliation in Baltimore, we are in drastic need of about 20,000 net
square feet just to meet our current research space needs. Even though
the existing building was only completed in 1993, it is based on designs
that took into account the level of research funding from the late
1970s. Funding had increased more than eightfold by the time
construction was completed. This year, the VA Maryland Health Care
System (VAMHCS) has been awarded about $12.5 million in VA research
funding. Those same principal investigators have obtained additional
funds from non-VA sources for a total research enterprise of $33
million. Because of a lack of space, at least 18 of those researchers
are being housed in University of Maryland School of Medicine
laboratories at the expense of the university. Such relationships are
only possible because of the close working relationship between myself
and the Baltimore VA medical center leadership.
Because of unique
geographic and architectural restrictions on the Baltimore VA medical
center, the most viable option is to purchase additional space that
could be used jointly by the VAMHCS research program and the University
of Maryland School of Medicine. In a VA central office survey, the
Baltimore VA medical center ranks second nationally in terms of needed
renovation with a price tag of approximately $3.5 million needed to
ameliorate the current situation. However, minor construction and
renovation projects like this one are forced to compete with some of the
clinical needs of the VA health care system. I would not suggest that
research facility needs should outweigh the needs of the clinical
program, but I would suggest that a better process is needed so research
facility needs are not consistently left at the bottom of the list.
The importance of the
VA affiliation to the research program is not limited to facility
issues. The gerontology division at the University of Maryland School
of Medicine is totally housed at the VA, and our new state-of-the-art
cardiovascular exercise research facility is housed at the VA even
though 85 percent of it was funded by the School of Medicine. The VA
will soon have a human performance laboratory to look at things such as
gait analysis to help diagnose and treat patients suffering from
movement disorders and stroke. Additionally, a significant proportion
of the Parkinson’s disease and multiple sclerosis research that goes on
at the School of Medicine is located at the VA. Again, I cannot stress
enough that these types of relationships are mutually beneficial to both
the VA and the School of Medicine and that the ultimate benefits go to
the patients. But the full impact of the potential of the relationship
cannot be realized while the VA research facilities are inadequate. For
the affiliation partnership to flourish, resources need to come from
both partners. Currently, the biggest need on the VA side is research
space and I believe that a dedicated funding source for VA research
facilities that does not compete directly with clinical needs is
necessary to further our shared goals.
In the first session of
the 107th Congress, the House passed legislation (H.R. 811)
that would have dedicated funding for VA facility construction, with a
portion set aside for urgent research needs. I have also had the
opportunity to briefly review H.R. 4514, the “Veterans’ Major Medical
Facilities Construction Act of 2002.” First I would like to commend
both this subcommittee and the full House VA committee for their
leadership and support on this issue. Second, I would like to urge the
Congress as a whole to implement a proposal that would provide a
dedicated, peer-reviewed funding stream for VA research facility needs.
The AAMC, as a member of the Executive Committee of the Friends of VA
Medical Care and Health Research Coalition, has endorsed the approach of
a separate appropriations line item that I noted earlier in my
statement. Whichever approach the committee chooses to pursue, a new
authorization or a new appropriations line item within the existing
structure, I urge you to make sure than research is not relegated to the
bottom of the pile.
In conclusion, let me
state again the mutually beneficial characteristics of the VA academic
affiliations. It is well documented that the affiliations improve
patient care as well as the education of the next generation of our
nation’s health care professionals. The value of research to the
affiliations, the subject of today’s hearing is not as well known. My
affiliation is not unique. Many affiliations are marked by departments
and divisions that are housed in VA space. Many, if not most, of the VA
researchers hold joint faculty appointments at the affiliated medical
school. The walls between School of Medicine and VA research projects
are often blurred as space, funding, and salary support usually come
from multiple sources. In order for these affiliations to work with the
highest possible efficiency it is necessary for the facilities in which
the research is conducted to be state-of-the-art. At the same time, the
patient care strains on the VA medical care budget are well documented.
VA research facility needs should not be forced to compete against those
clinical needs, but nor can they be ignored.
Thank you again for the
opportunity to testify this afternoon.
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