- Email: [email protected]
Why should the VA continue academic affiliations?
The American Journal of Surgery 188 (2004) 453– 458
Presidential address
Why should the VA continue academic affiliations? Robert V. Rege, M.D.* Department of Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9031, USA Manuscript received June 10, 2004; revised manuscript July 7, 2004 Presented at the 28th Annual Symposium of the Association of VA Surgeons, Richmond, Virginia, April 25–27, 2004
Abstract Academic affiliations between VA medical centers and medical schools have made an important contribution to the healthcare of veterans and the education of physicians over the last 60 years. The rationale for these affiliations and their establishment following World War II is discussed. The circumstances leading to affiliations and the benefit they afford veterans remain pertinent today. © 2004 Excerpta Medica Inc. All rights reserved. Keywords: Veterans; Student/resident education; Academic programs; World War II
“History repeats itself; that’s one of the things that’s wrong with history.” Clarence Darrow (1857–1938)
Members of the Association of VA Surgeons understand the contribution of VA hospitals to medical student and resident education. Academic affiliations with the VA, now nearly 60 years old, enticed many in this audience to dedicate a major portion of their careers to the care of veterans, and to invest considerable time and effort in improving the VA healthcare system. They have also allowed veterans to routinely access bright, enthusiastic physicians and the latest advances in medicine. On a wider scale, a majority of physicians trained in the United States during the last half of the twentieth century spent a considerable portion of medical student or resident training in a VA hospital. Thus, close ties with academic medicine have not only provided quality care for veterans, but have significantly contributed to the quality of medicine practiced throughout the United States. However, the Department of Veterans Affairs was not established as an educational entity, but to provide a set of defined benefits to a special group of Americans who risked life and limb to protect our country. Why then have such close relationships developed in this country between med-
* Corresponding author. Tel.: ⫹1-214-648-3050; fax: ⫹1-214-6486752. E-mail address: [email protected]
Robert V. Rege, M.D.
ical education and veteran healthcare? Are these relationships advantageous for veterans and are they cost-effective? Such questions often lead to proposals to contract for more care in the private sector, to curtail VA research programs, or to reduce spending for other programs, which are key for the recruitment and retention of academic physicians. Tonight, we will examine the transformation of VA healthcare after World War II, so we might understand how such affiliations arose and why they persist. As World War II approached, the United States was focused on recovery from the Great Depression. Unemployment was extraordinarily high; almost 25% of the population did not have a job and wages were low. The economy was largely agricultural and, compared to the rest of the
0002-9610/04/$ – see front matter © 2004 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2004.07.004
454
R.V. Rege / The American Journal of Surgery 188 (2004) 453– 458
world, the United States was technically backward. The nation’s infrastructure, including transportation systems, was markedly undeveloped and few Americans traveled far from their homes. Even fewer traveled outside the country. There were relatively few civilian airplanes and correspondingly few trained civilian pilots. The United States was far from a military power. The scant 200,000 individuals in the military placed the United States sixteenth in the world in military strength, just below Romania, while world powers measured their strength in millions of men and women. Military weaponry was far inferior to our rivals. The U.S. Army Air Corps consisted of only 20,000 volunteers and 1,257 combat planes, and was only one fourth the size of the German air force. More importantly, Luftwaffe fighter planes and Japanese Zeroes were technically far superior to any plane the United States possessed. The Navy was somewhat better equipped, but still inferior to the Japanese Pacific Fleet. Before the War began, the strength of the Navy was severely crippled by the Japanese surprise attack on Pearl Harbor on December 7, 1941. To succeed in World War II, the United States had to completely retool its economy and transform itself from an agricultural nation to an industrial/military power in just 3 to 4 years. It trained, armed, and supported millions of soldiers and assimilated even larger numbers of civilians, including women, into the workforce to produce supplies and weapons. The most monumental challenge, however, was the establishment of sufficient air power to secure victory. When President Roosevelt asked for production of 50,000 planes in 1941, he was severely criticized and labeled as “crazy” for contemplating such an impossible task. But, by 1944, the nation produced an unheard of 110,000 planes, or about 9,000 planes per month. By War’s end, the United States produced more airplanes than Britain, the Soviet Union, Germany, and Japan combined. The development of an effective air force epitomizes the intellectual and technical strides that the United States made, and the potential of the American public that was harnessed. The nation identified and trained 2.4 million individuals to maintain and fly the airplanes it built. Rigorous physical and mental examinations were used to identify 317,000 potential pilots. They came with raw talent, but little education. Most began with no more than a high school education and few had ever seen an airplane, let alone flown in one. Many lived on farms and still plowed fields behind mules or horses. Most never rode in or even saw an airplane except in a photograph. However, each knew about Charles Lindbergh and The Spirit of Saint Louis and dreamed of flying. To train pilots and support personnel, the United States established what the military historian Steven Ambrose called, “the largest single educational organization in existence” [1]. Training was rigorous. Only 61% of candidates completed pilot training. Those who did not master the didactic courses or flight skills assumed other demanding roles in the air force. It was also dangerous training; 1,175 trainees in
Fig. 1. Lt. Robert A. Rege flew P51 fighter planes from Kings Cliffe, England, January 1945 to May 1945.
basic flight school, and another 1,888 in advance pilot school, died during training. Once aircrews reached the war zone, combat fatalities were high. At the peak of the war, the United States lost a plane for every enemy plane it destroyed. However, continual replacement of airplanes and supplies, development of technologically superior aircraft, and a continuous stream of expertly trained pilots turned the tide. Training was excellent and American pilots entered combat with an average of 360 hours of flight time, compared to only 110 hours of experience for their enemy. Similar achievements made by the Army, the Navy, and, for that matter, workers in American factories eventually led General Omar Bradley to state without exaggeration that: “American troops are the best ever put in the field by any nation in the history of the World” [2].
Let us examine the training of pilots more closely. The young P51 fighter pilot in the picture (Fig. 1) is my father. He is typical of pilots trained during World War II. These pilots were extraordinarily young, volunteering for service in their teenage years. He graduated at the top of his high school class, but came from a relatively poor immigrant family and had little hope of ever going to college. His choice was a $20/week dead-end job or a chance to serve his country and to master flight. The decision was not hard, and he volunteered for the Air Corps in the fall of 1942. He did not reach the war zone until January of 1945. First, he waited to be called into service. His training then consisted of a month of basic training, 3 months at Penn State University in college level courses, 3 months in basic flight training, 3 months in advanced flight school, and, finally, 3 months in gunnery school. Even after qualifying, he would have to wait for his orders to deploy. More pilots were trained than needed. Thus, he would not fly in combat until he had more than 2 years of training and experience in flying his aircraft. As a fighter pilot, he and Lt. Papuzynsky (Fig. 2) would fly their P51 Mustang, Rose Glori, named after their sisters, in combat missions over Germany from Kings Cliffe, England, during the last 3 months of the war. My father
R.V. Rege / The American Journal of Surgery 188 (2004) 453– 458
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Fig. 2. Lts. Papuzynsky and Rege pose next to their P51 Mustang fighter plane, Rose Glori, named after their sisters.
accumulated 150 hours of combat flight in that short time, nearly half the number of hours needed to complete a tour of combat duty. He advanced rapidly to wingman, a distinguished position in the squadron, and became one of the more experienced pilots in his group. When the war ended, he was on the verge of promotion, but the military no longer needed so many pilots. Like millions of young men his age who had assumed important, responsible roles during the war, he returned to a simple pre-war, low-paying job. Thus, the United States faced what may have been its greatest challenge. Nearly 20 million soldiers, or about 43% of the adult male population of the United States, returned to be assimilated into the peacetime economy. Many mastered skills and assumed responsibilities far beyond anything expected in their pre-war lives, yet they had little education or experience in the workplace. They were no longer simple farm boys and the country was no longer an agricultural nation. More importantly, a large number returned with severe health problems and disabilities. To prepare for their return and to repay the debt it owed its veterans, the nation responded by introducing “a staggering 2,848 bills pertaining to increased or broadened veterans
benefits” [2] into Congress in 1945. The future of the country literally depended on the effectiveness of these veteran programs. However, the Veterans Administration was ill prepared to expand its duties. Controversy peaked in 1945 when an 11-part series in the New York newspaper PM by Albert Deutsch described the VA as a: “vast dehumanized bureaucracy, enmeshed in mountains of red tape, ingrown with entrenched mediocrity. . . prescribing medieval medicine” [2].
Army Brigadier General Frank T. Hines, an honest and able administrator of the VA for 22 years, had to resign, leaving the agency without leadership. At almost the same time, General Marshall, the Chief of Staff of the Military, resigned for personal reasons and General Eisenhower was contemplating retirement to write his memoirs and, in retrospect, the presidency. Many considered the Chief of Staff position to be the next step in General Omar Bradley’s career, and he looked forward to the promotion. Imagine his disappointment when he was called to meet with General Eisenhower on May 17, 1945 to be told he would not
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receive the appointment as Chief of Staff. President Truman, after contemplating the post-war needs of the country, had spoken to Eisenhower directly and insisted that he, not Bradley, become Chief of Staff. Eisenhower agreed to serve, albeit for 2 rather than the customary 4 years. Truman was adamant that Omar Bradley head the VA. General Bradley immediately realized the significant problems he would face. Change would be difficult since the VA was a large bureaucracy and the agency was strongly influenced by politics. He understood that failure to accomplish change and provide benefits to the returning veterans could easily ruin his military career, but a soldier does not disobey his commander, and he accepted the assignment. His feelings about the position and the explanation for the enthusiasm he exhibited once in the post are best summarized by his own statement to reporters: “I don’t think there’s any job in the country I’d sooner not have nor any job in the world I’d like to do better. For even though it is burdened with problems, it gives me the chance to do something for the men who did so much for us.”
During the first 8 months of his tenure, the number of veterans increased from 5 to 17 million. The benefits granted by Congress, including education, jobs and jobs training, disability pensions, loans, and insurance were overwhelming to provide. To meet demands and to provide easier access to VA services, General Bradley decentralized the VA to more easily reach veterans across the nation by leasing 10 million square feet of space, establishing 13 branch offices, and enlarging the number of VA employees from 65,000 to 200,000 within 2 years. Congress supported the growth by increasing VA budgets to a peak of $6.3 billion. However, the task was not simply accomplished by throwing resources at it. Success was achieved by skillful reorganization of the VA and by just plain diligence on the part of the dedicated staff General Bradley assembled. The most difficult challenge for General Bradley and the VA was providing adequate healthcare to veterans. The VA hospital system was woefully understaffed and the quality of care inadequate for the large number of disabled and injured veterans. Omar Bradley quickly asked Dr. Paul R. Hawley, who had been the chief surgeon in the European Theater of Operations, to join him at the VA. Together, they performed an in-depth study and determined that the most pressing problem was a shortage of doctors. Although 2,300 full-time doctors were serving in the VA at the time, most were “on loan” from the Army and Navy, and would soon be discharged from service. This left only about 500 career VA doctors. The VA needed at least 7 times that number. The pool of potential doctors to hire was small; only about 80 applicants were on the Civil Service list. Even they were not considerations for Hawley since General Bradley described them as “dregs of the medical profession” [2]. New facilities were already planned to address the increase in the
number of patients, but how could the VA recruit the number of doctors needed to staff them? After careful study, Dr. Hawley proposed the establishment of an elite non–Civil Service VA medical corps. Pay would increase to be more in line with the pay for doctors in the military. This proposal would shake the civil service bureaucracy that ran the VA to that point. Even more controversial was his insistence that existing and planned VA hospitals be formally affiliated “with class-A medical teaching institutions.” His rationale “to gain the services of hundreds of interns and residents who could treat veterans under supervision of the teaching staffs” [2] made sense to General Bradley. But this proposal called for radical change and was likely to be opposed by both the executive and legislative branches of government. In particular, affiliations with medical schools meant building new VA hospitals adjacent to the schools, which was a politically sensitive issue. Like military bases, every Congressman wanted to have a VA hospital in his or her district, because it provided jobs and money for the surrounding community. For this reason, VA hospitals had previously been built in rural areas far from medical schools. The need to change locations of VA Hospitals was clearly stated by Hawley who succinctly said: “To hell with the scenery. We want the best doctors” [2]. The matter had to be taken directly to President Truman, who was concerned that he could not renege on previous commitments he had made to Hines and to Congress. General Bradley reminded the President of the importance of providing healthcare to veterans, the large number of excellent doctors and the expertise that the VA would immediately access if affiliated with medical schools, and of promises of full support and trust made to him when he accepted the position. Truman fought for and obtained Congressional approval to move most of the new VA hospitals to sites near medical schools. A special civilian medical advisory group headed by Dr. Charles W. Mayo was established. It reviewed and fully supported Bradley and Hawley’s plans, actively helped in establishing the affiliated programs, and enabled recruitment of academic physicians. In the end, affiliations were established with 63 of the 77 medical schools in the country. Within 6 months of securing affiliations, Hawley recruited nearly 4,000 doctors. Not only did the transition of the VA secure enough quality doctors to care for veterans, it changed its prior emphasis from one of housing wounded and disabled veterans to one of providing acute care and physical/mental rehabilitation for them so they could return to their homes and productive lives. After the transformation, Albert Deutsch, the journalist and critic who began the controversy about the VA in 1945 wrote: “VA medicine had undergone a ‘revolution,’ and Hawley had ‘infused the whole hospital program with a spirit of modern, scientific medicine” [2].
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Fig. 3. The 20th Fighter Group, 77th Fighter Squadron. Lt. Robert A. Rege is spotlighted at RAF Kings Cliffe, England. The insert is an enlargement of Lt. Rege, second row, sixth from left.
General Bradley’s tenure at the VA was considered highly successful and it enhanced his career. After 2 years he was rewarded with the appointment as the Chief of Staff of the military. General Bradley summarized his experience in the VA as follows: “By reason of my position in the U.S. Army in World War II, I had been compelled to send hundreds of thousands of men into battle. In countless Army field hospitals, I had seen the maimed stoically enduring nearly unbearable pain. Nothing I have done in my life gave me more satisfaction than the knowledge that I had done my utmost to ease their way when they came home” [2].
The unique affiliations that he and Hawley established continue today and serve the VA well. In my opinion, the benefits our nation provides for its veterans are not just payment for the sacrifices they made, they are an investment in the nation’s future and each of us benefit. Almost every one of the twenty million veterans returning from World War II received some benefit through the VA in the form of insurance, loans, disability payments, education or job training. When the GI Bill of Rights passed, Lt. Robert A. Rege received a college education he otherwise could not have afforded. He eventually obtained a Master’s Degree in Engineering and became a research engineer at United States
Steel Corporation where he and several colleagues obtained a patent for a key process used today in the production of steel. The process, called argon degassing, enabled continuous casting, as opposed to batch processing of high-quality steel and, at the time of invention, decreased the cost of producing steel. Toward the end of his career, he worked closely with several young English engineers on other new technologies in steel making. They not only took great interest in his experience in steelmaking, they were enamored with his war experiences and asked many detailed questions about his service in England. Just before he retired, my Dad went to London to present their work at a scientific meeting. His English colleagues insisted that he visit their company. It was built on the runway he used for his combat missions. They also located his squadron portrait (Fig. 3) at a local pub. It seems fitting that he returned at the end of his career to the site from which he literally flew himself into opportunities which would shape our family for the next half a century, and which would eventually allow me to stand before you as President of the Association of VA Surgeons. Most importantly, 6 million World War II veterans, less fortunate than my father, received some form of healthcare from the VA hospital system. Hawley was correct; they
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benefited greatly from exposure to medical students, residents and academic faculty, as would veterans that followed in the Korean, Vietnam, and Gulf Wars. I do not believe from my readings that Hawley foresaw the benefit that VA hospitals would have for medical trainees or the impact it would have on medical care in general across the country. However, we in medicine owe a great deal of thanks to President Truman, General Omar Bradley, and Dr. Paul R. Hawley who dedicated themselves to the veterans of World War II. They had the vision and courage to build a durable healthcare system for veterans when such a system was not popular or “politically correct.” A symbiotic relationship continues between academic institutions and VA hospitals today. Could the VA attract either the number or quality of physicians it currently enjoys without these academic affiliations? Would it revert to the pre–World War II mediocrity? Academic affiliations arose from a great general’s desire to care for the men and women who protect freedom in this great nation. Nothing but the best health care was acceptable for them. The nation that had accomplished the impossible by becoming “the largest single educational organization in existence” [1] and training its technologically unsophisticated youth into a military force that was “the best ever put in the field by any nation in the history of the World” [2] understood the value and power of education and teaching
institutions. With the military challenges of the twenty-first century and return of our newest set of veterans, medical school affiliations remain just as pertinent to VA healthcare today as they did 60 years ago. As long as there are wars and veterans, it is the dual role of the government and academic medicine to ensure that veterans receive the highest quality medical care the nation has to offer. That is why it is essential that the VA continue its strong ties with academic medicine. I would like to conclude by thanking each of you in the Association for the dedication and expertise you provide to our veterans, and for the role you play in training the nation’s future surgeons. I would also like to thank the Association of VA Surgeons for the honor they have bestowed upon me by electing me as its president. My time spent working in the VA has been essential in my career and I feel blessed to have had the opportunity to serve my country in the U.S. Navy and my fellow veterans in the VA Healthcare System.
References [1] Ambrose SE. The Wild Blue. New York: Simon & Schuster, 2001. [2] Bradley ON, Blair CA. A General’s Life. New York: Simon & Schuster, 1983.
Presidential address
Why should the VA continue academic affiliations? Robert V. Rege, M.D.* Department of Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9031, USA Manuscript received June 10, 2004; revised manuscript July 7, 2004 Presented at the 28th Annual Symposium of the Association of VA Surgeons, Richmond, Virginia, April 25–27, 2004
Abstract Academic affiliations between VA medical centers and medical schools have made an important contribution to the healthcare of veterans and the education of physicians over the last 60 years. The rationale for these affiliations and their establishment following World War II is discussed. The circumstances leading to affiliations and the benefit they afford veterans remain pertinent today. © 2004 Excerpta Medica Inc. All rights reserved. Keywords: Veterans; Student/resident education; Academic programs; World War II
“History repeats itself; that’s one of the things that’s wrong with history.” Clarence Darrow (1857–1938)
Members of the Association of VA Surgeons understand the contribution of VA hospitals to medical student and resident education. Academic affiliations with the VA, now nearly 60 years old, enticed many in this audience to dedicate a major portion of their careers to the care of veterans, and to invest considerable time and effort in improving the VA healthcare system. They have also allowed veterans to routinely access bright, enthusiastic physicians and the latest advances in medicine. On a wider scale, a majority of physicians trained in the United States during the last half of the twentieth century spent a considerable portion of medical student or resident training in a VA hospital. Thus, close ties with academic medicine have not only provided quality care for veterans, but have significantly contributed to the quality of medicine practiced throughout the United States. However, the Department of Veterans Affairs was not established as an educational entity, but to provide a set of defined benefits to a special group of Americans who risked life and limb to protect our country. Why then have such close relationships developed in this country between med-
* Corresponding author. Tel.: ⫹1-214-648-3050; fax: ⫹1-214-6486752. E-mail address: [email protected]
Robert V. Rege, M.D.
ical education and veteran healthcare? Are these relationships advantageous for veterans and are they cost-effective? Such questions often lead to proposals to contract for more care in the private sector, to curtail VA research programs, or to reduce spending for other programs, which are key for the recruitment and retention of academic physicians. Tonight, we will examine the transformation of VA healthcare after World War II, so we might understand how such affiliations arose and why they persist. As World War II approached, the United States was focused on recovery from the Great Depression. Unemployment was extraordinarily high; almost 25% of the population did not have a job and wages were low. The economy was largely agricultural and, compared to the rest of the
0002-9610/04/$ – see front matter © 2004 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2004.07.004
454
R.V. Rege / The American Journal of Surgery 188 (2004) 453– 458
world, the United States was technically backward. The nation’s infrastructure, including transportation systems, was markedly undeveloped and few Americans traveled far from their homes. Even fewer traveled outside the country. There were relatively few civilian airplanes and correspondingly few trained civilian pilots. The United States was far from a military power. The scant 200,000 individuals in the military placed the United States sixteenth in the world in military strength, just below Romania, while world powers measured their strength in millions of men and women. Military weaponry was far inferior to our rivals. The U.S. Army Air Corps consisted of only 20,000 volunteers and 1,257 combat planes, and was only one fourth the size of the German air force. More importantly, Luftwaffe fighter planes and Japanese Zeroes were technically far superior to any plane the United States possessed. The Navy was somewhat better equipped, but still inferior to the Japanese Pacific Fleet. Before the War began, the strength of the Navy was severely crippled by the Japanese surprise attack on Pearl Harbor on December 7, 1941. To succeed in World War II, the United States had to completely retool its economy and transform itself from an agricultural nation to an industrial/military power in just 3 to 4 years. It trained, armed, and supported millions of soldiers and assimilated even larger numbers of civilians, including women, into the workforce to produce supplies and weapons. The most monumental challenge, however, was the establishment of sufficient air power to secure victory. When President Roosevelt asked for production of 50,000 planes in 1941, he was severely criticized and labeled as “crazy” for contemplating such an impossible task. But, by 1944, the nation produced an unheard of 110,000 planes, or about 9,000 planes per month. By War’s end, the United States produced more airplanes than Britain, the Soviet Union, Germany, and Japan combined. The development of an effective air force epitomizes the intellectual and technical strides that the United States made, and the potential of the American public that was harnessed. The nation identified and trained 2.4 million individuals to maintain and fly the airplanes it built. Rigorous physical and mental examinations were used to identify 317,000 potential pilots. They came with raw talent, but little education. Most began with no more than a high school education and few had ever seen an airplane, let alone flown in one. Many lived on farms and still plowed fields behind mules or horses. Most never rode in or even saw an airplane except in a photograph. However, each knew about Charles Lindbergh and The Spirit of Saint Louis and dreamed of flying. To train pilots and support personnel, the United States established what the military historian Steven Ambrose called, “the largest single educational organization in existence” [1]. Training was rigorous. Only 61% of candidates completed pilot training. Those who did not master the didactic courses or flight skills assumed other demanding roles in the air force. It was also dangerous training; 1,175 trainees in
Fig. 1. Lt. Robert A. Rege flew P51 fighter planes from Kings Cliffe, England, January 1945 to May 1945.
basic flight school, and another 1,888 in advance pilot school, died during training. Once aircrews reached the war zone, combat fatalities were high. At the peak of the war, the United States lost a plane for every enemy plane it destroyed. However, continual replacement of airplanes and supplies, development of technologically superior aircraft, and a continuous stream of expertly trained pilots turned the tide. Training was excellent and American pilots entered combat with an average of 360 hours of flight time, compared to only 110 hours of experience for their enemy. Similar achievements made by the Army, the Navy, and, for that matter, workers in American factories eventually led General Omar Bradley to state without exaggeration that: “American troops are the best ever put in the field by any nation in the history of the World” [2].
Let us examine the training of pilots more closely. The young P51 fighter pilot in the picture (Fig. 1) is my father. He is typical of pilots trained during World War II. These pilots were extraordinarily young, volunteering for service in their teenage years. He graduated at the top of his high school class, but came from a relatively poor immigrant family and had little hope of ever going to college. His choice was a $20/week dead-end job or a chance to serve his country and to master flight. The decision was not hard, and he volunteered for the Air Corps in the fall of 1942. He did not reach the war zone until January of 1945. First, he waited to be called into service. His training then consisted of a month of basic training, 3 months at Penn State University in college level courses, 3 months in basic flight training, 3 months in advanced flight school, and, finally, 3 months in gunnery school. Even after qualifying, he would have to wait for his orders to deploy. More pilots were trained than needed. Thus, he would not fly in combat until he had more than 2 years of training and experience in flying his aircraft. As a fighter pilot, he and Lt. Papuzynsky (Fig. 2) would fly their P51 Mustang, Rose Glori, named after their sisters, in combat missions over Germany from Kings Cliffe, England, during the last 3 months of the war. My father
R.V. Rege / The American Journal of Surgery 188 (2004) 453– 458
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Fig. 2. Lts. Papuzynsky and Rege pose next to their P51 Mustang fighter plane, Rose Glori, named after their sisters.
accumulated 150 hours of combat flight in that short time, nearly half the number of hours needed to complete a tour of combat duty. He advanced rapidly to wingman, a distinguished position in the squadron, and became one of the more experienced pilots in his group. When the war ended, he was on the verge of promotion, but the military no longer needed so many pilots. Like millions of young men his age who had assumed important, responsible roles during the war, he returned to a simple pre-war, low-paying job. Thus, the United States faced what may have been its greatest challenge. Nearly 20 million soldiers, or about 43% of the adult male population of the United States, returned to be assimilated into the peacetime economy. Many mastered skills and assumed responsibilities far beyond anything expected in their pre-war lives, yet they had little education or experience in the workplace. They were no longer simple farm boys and the country was no longer an agricultural nation. More importantly, a large number returned with severe health problems and disabilities. To prepare for their return and to repay the debt it owed its veterans, the nation responded by introducing “a staggering 2,848 bills pertaining to increased or broadened veterans
benefits” [2] into Congress in 1945. The future of the country literally depended on the effectiveness of these veteran programs. However, the Veterans Administration was ill prepared to expand its duties. Controversy peaked in 1945 when an 11-part series in the New York newspaper PM by Albert Deutsch described the VA as a: “vast dehumanized bureaucracy, enmeshed in mountains of red tape, ingrown with entrenched mediocrity. . . prescribing medieval medicine” [2].
Army Brigadier General Frank T. Hines, an honest and able administrator of the VA for 22 years, had to resign, leaving the agency without leadership. At almost the same time, General Marshall, the Chief of Staff of the Military, resigned for personal reasons and General Eisenhower was contemplating retirement to write his memoirs and, in retrospect, the presidency. Many considered the Chief of Staff position to be the next step in General Omar Bradley’s career, and he looked forward to the promotion. Imagine his disappointment when he was called to meet with General Eisenhower on May 17, 1945 to be told he would not
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receive the appointment as Chief of Staff. President Truman, after contemplating the post-war needs of the country, had spoken to Eisenhower directly and insisted that he, not Bradley, become Chief of Staff. Eisenhower agreed to serve, albeit for 2 rather than the customary 4 years. Truman was adamant that Omar Bradley head the VA. General Bradley immediately realized the significant problems he would face. Change would be difficult since the VA was a large bureaucracy and the agency was strongly influenced by politics. He understood that failure to accomplish change and provide benefits to the returning veterans could easily ruin his military career, but a soldier does not disobey his commander, and he accepted the assignment. His feelings about the position and the explanation for the enthusiasm he exhibited once in the post are best summarized by his own statement to reporters: “I don’t think there’s any job in the country I’d sooner not have nor any job in the world I’d like to do better. For even though it is burdened with problems, it gives me the chance to do something for the men who did so much for us.”
During the first 8 months of his tenure, the number of veterans increased from 5 to 17 million. The benefits granted by Congress, including education, jobs and jobs training, disability pensions, loans, and insurance were overwhelming to provide. To meet demands and to provide easier access to VA services, General Bradley decentralized the VA to more easily reach veterans across the nation by leasing 10 million square feet of space, establishing 13 branch offices, and enlarging the number of VA employees from 65,000 to 200,000 within 2 years. Congress supported the growth by increasing VA budgets to a peak of $6.3 billion. However, the task was not simply accomplished by throwing resources at it. Success was achieved by skillful reorganization of the VA and by just plain diligence on the part of the dedicated staff General Bradley assembled. The most difficult challenge for General Bradley and the VA was providing adequate healthcare to veterans. The VA hospital system was woefully understaffed and the quality of care inadequate for the large number of disabled and injured veterans. Omar Bradley quickly asked Dr. Paul R. Hawley, who had been the chief surgeon in the European Theater of Operations, to join him at the VA. Together, they performed an in-depth study and determined that the most pressing problem was a shortage of doctors. Although 2,300 full-time doctors were serving in the VA at the time, most were “on loan” from the Army and Navy, and would soon be discharged from service. This left only about 500 career VA doctors. The VA needed at least 7 times that number. The pool of potential doctors to hire was small; only about 80 applicants were on the Civil Service list. Even they were not considerations for Hawley since General Bradley described them as “dregs of the medical profession” [2]. New facilities were already planned to address the increase in the
number of patients, but how could the VA recruit the number of doctors needed to staff them? After careful study, Dr. Hawley proposed the establishment of an elite non–Civil Service VA medical corps. Pay would increase to be more in line with the pay for doctors in the military. This proposal would shake the civil service bureaucracy that ran the VA to that point. Even more controversial was his insistence that existing and planned VA hospitals be formally affiliated “with class-A medical teaching institutions.” His rationale “to gain the services of hundreds of interns and residents who could treat veterans under supervision of the teaching staffs” [2] made sense to General Bradley. But this proposal called for radical change and was likely to be opposed by both the executive and legislative branches of government. In particular, affiliations with medical schools meant building new VA hospitals adjacent to the schools, which was a politically sensitive issue. Like military bases, every Congressman wanted to have a VA hospital in his or her district, because it provided jobs and money for the surrounding community. For this reason, VA hospitals had previously been built in rural areas far from medical schools. The need to change locations of VA Hospitals was clearly stated by Hawley who succinctly said: “To hell with the scenery. We want the best doctors” [2]. The matter had to be taken directly to President Truman, who was concerned that he could not renege on previous commitments he had made to Hines and to Congress. General Bradley reminded the President of the importance of providing healthcare to veterans, the large number of excellent doctors and the expertise that the VA would immediately access if affiliated with medical schools, and of promises of full support and trust made to him when he accepted the position. Truman fought for and obtained Congressional approval to move most of the new VA hospitals to sites near medical schools. A special civilian medical advisory group headed by Dr. Charles W. Mayo was established. It reviewed and fully supported Bradley and Hawley’s plans, actively helped in establishing the affiliated programs, and enabled recruitment of academic physicians. In the end, affiliations were established with 63 of the 77 medical schools in the country. Within 6 months of securing affiliations, Hawley recruited nearly 4,000 doctors. Not only did the transition of the VA secure enough quality doctors to care for veterans, it changed its prior emphasis from one of housing wounded and disabled veterans to one of providing acute care and physical/mental rehabilitation for them so they could return to their homes and productive lives. After the transformation, Albert Deutsch, the journalist and critic who began the controversy about the VA in 1945 wrote: “VA medicine had undergone a ‘revolution,’ and Hawley had ‘infused the whole hospital program with a spirit of modern, scientific medicine” [2].
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Fig. 3. The 20th Fighter Group, 77th Fighter Squadron. Lt. Robert A. Rege is spotlighted at RAF Kings Cliffe, England. The insert is an enlargement of Lt. Rege, second row, sixth from left.
General Bradley’s tenure at the VA was considered highly successful and it enhanced his career. After 2 years he was rewarded with the appointment as the Chief of Staff of the military. General Bradley summarized his experience in the VA as follows: “By reason of my position in the U.S. Army in World War II, I had been compelled to send hundreds of thousands of men into battle. In countless Army field hospitals, I had seen the maimed stoically enduring nearly unbearable pain. Nothing I have done in my life gave me more satisfaction than the knowledge that I had done my utmost to ease their way when they came home” [2].
The unique affiliations that he and Hawley established continue today and serve the VA well. In my opinion, the benefits our nation provides for its veterans are not just payment for the sacrifices they made, they are an investment in the nation’s future and each of us benefit. Almost every one of the twenty million veterans returning from World War II received some benefit through the VA in the form of insurance, loans, disability payments, education or job training. When the GI Bill of Rights passed, Lt. Robert A. Rege received a college education he otherwise could not have afforded. He eventually obtained a Master’s Degree in Engineering and became a research engineer at United States
Steel Corporation where he and several colleagues obtained a patent for a key process used today in the production of steel. The process, called argon degassing, enabled continuous casting, as opposed to batch processing of high-quality steel and, at the time of invention, decreased the cost of producing steel. Toward the end of his career, he worked closely with several young English engineers on other new technologies in steel making. They not only took great interest in his experience in steelmaking, they were enamored with his war experiences and asked many detailed questions about his service in England. Just before he retired, my Dad went to London to present their work at a scientific meeting. His English colleagues insisted that he visit their company. It was built on the runway he used for his combat missions. They also located his squadron portrait (Fig. 3) at a local pub. It seems fitting that he returned at the end of his career to the site from which he literally flew himself into opportunities which would shape our family for the next half a century, and which would eventually allow me to stand before you as President of the Association of VA Surgeons. Most importantly, 6 million World War II veterans, less fortunate than my father, received some form of healthcare from the VA hospital system. Hawley was correct; they
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benefited greatly from exposure to medical students, residents and academic faculty, as would veterans that followed in the Korean, Vietnam, and Gulf Wars. I do not believe from my readings that Hawley foresaw the benefit that VA hospitals would have for medical trainees or the impact it would have on medical care in general across the country. However, we in medicine owe a great deal of thanks to President Truman, General Omar Bradley, and Dr. Paul R. Hawley who dedicated themselves to the veterans of World War II. They had the vision and courage to build a durable healthcare system for veterans when such a system was not popular or “politically correct.” A symbiotic relationship continues between academic institutions and VA hospitals today. Could the VA attract either the number or quality of physicians it currently enjoys without these academic affiliations? Would it revert to the pre–World War II mediocrity? Academic affiliations arose from a great general’s desire to care for the men and women who protect freedom in this great nation. Nothing but the best health care was acceptable for them. The nation that had accomplished the impossible by becoming “the largest single educational organization in existence” [1] and training its technologically unsophisticated youth into a military force that was “the best ever put in the field by any nation in the history of the World” [2] understood the value and power of education and teaching
institutions. With the military challenges of the twenty-first century and return of our newest set of veterans, medical school affiliations remain just as pertinent to VA healthcare today as they did 60 years ago. As long as there are wars and veterans, it is the dual role of the government and academic medicine to ensure that veterans receive the highest quality medical care the nation has to offer. That is why it is essential that the VA continue its strong ties with academic medicine. I would like to conclude by thanking each of you in the Association for the dedication and expertise you provide to our veterans, and for the role you play in training the nation’s future surgeons. I would also like to thank the Association of VA Surgeons for the honor they have bestowed upon me by electing me as its president. My time spent working in the VA has been essential in my career and I feel blessed to have had the opportunity to serve my country in the U.S. Navy and my fellow veterans in the VA Healthcare System.
References [1] Ambrose SE. The Wild Blue. New York: Simon & Schuster, 2001. [2] Bradley ON, Blair CA. A General’s Life. New York: Simon & Schuster, 1983.