by Sherry Baker

Demas survived and returned home to the United States, decorated for his courage and needing medical care for a leg shattered below the knee. He found that care at Veterans Administration hospitals, where he was fitted with a leg brace and learned to walk again.

Today he fights the battles of old age as an outpatient at the Atlanta Veterans Affairs Medical Center (VAMC), located on Clairmont Road, so close to Emory that upper floors have a view of the campus. Like almost everyone in Atlanta, Demas calls it simply "the VA hospital."

There was a troublesome ulcer a while back, Demas remembers, then a fall several years ago that left him with ongoing back pain. "I go about every three months. The VA hospital's always treated me right," Demas says. "I haven't been to a private doctor since the war. Just the VA. It's the best medicine, the best care."

George Demas is one of some 43,000 veterans who sought medical care last year during more than 380,000 outpatient visits to the Atlanta VAMC. Another 6,500 were inpatients. They are young and old, men and women. To receive care at the VA, they must have seen active military duty. Most come for medical appointments with physicians or therapists; some are research subjects who help Emory scientists based at the VAMC discover better ways to treat their conditions.

They come to a building 12-stories high, connected in the rear by glass-walled bridges to new parking decks. Inside, sunshine pours through the soaring atrium's huge windows that overlook a lobby teaming with activity.

That reality often surprises people who still operate under the assumption that the VA is somehow innately inferior to other area hospitals. It's a prejudice that Robert Pollet, director of research at the center and professor of medicine at Emory, believes is fueled by movies and TV news which use dated, stock footage and depict VA hospitals as sad, not-up-to-par facilities where elderly vets go to die.

"That's not the true picture at all," says Pollet. "This is a beautiful, well-equipped, state-of-the-art hospital. If you didn't know it was a VA facility, you would simply think it was any very fine urban hospital with a busy emergency room, cardiac catheterization laboratory, the whole works. The physical facilities are excellent, and so is the patient care."

In fact, he adds, extraordinary medical teaching, research, and patient care take place at the VAMC, thanks in large part to the Atlanta VA's long ongoing synergism with Emory. This partnership began more than 50 years ago when the US government began encouraging veterans hospitals to affiliate with medical schools as a way to raise the level of medical care for vets.

Like Emory, the VAMC has grown dramatically over the years. A trip to the center today takes you past trucks and construction equipment -- telltale signs of continuing renovations, including modernizing inpatient wards and outpatient primary care clinics.

Through these physical changes and a soaring patient population, one constant at the hospital has remained -- the strong working relationships between the Emory School of Medicine and the VAMC.

"Emory's involvement with the VA certainly isn't unique," Pollet emphasizes. "But this is one of the best examples of the success of a VA/medical school affiliation. The result has been beneficial for the medical school, research, and patients."

The VA affiliation helps Emory recruit and retain highly motivated academic physicians, attracted by the research facilities and work being done by other physician/scientists at the VAMC as well as on the Emory campus. Emory doctors provide care for veteran patients. Emory also gains from the VA affiliation by placing staff, fellows, and faculty at this hospital and offering training programs. Each year, more than 450 Emory residents receive training at the VAMC in 27 specialties.

The patient population is mostly male, but the number of women who rely on the VAMC for health care is growing, as is the number of women who serve in the military. Currently, women make up about 10% of the patient population, but they come in for care twice as frequently as their male counterparts. The VA's Women's Wellness Clinic provides gynecologic and other care for specific female medical needs.

The overall patient load, says Bower, is also undergoing tremendous growth. Patient visits have increased by about 40% since 1996, primarily because of the VA's concerted efforts to encourage vets to rely on the local VAMC for health care and also to make it more accessible. Case in point: a drive to take health care to suburban areas through a VA partnership with Emory.

"We want to get closer to veteran patients. And having a facility in metro Atlanta doesn't help someone living many miles from here," Bower notes. "So we just opened the first joint Emory Healthcare/VA Community Health Clinic in West Marietta. If it works, we hope to collaborate with Emory on similar clinics in outlying areas."

So far the response has been encouraging. Since the clinic opened to veterans in November, more than 420 have sought care at the Powder Springs Road facility, coming from as far north as Rome, Georgia, and representing about 16% of the clinic's patient load. The VA also operates clinics in Midtown and Oakwood, is opening an additional clinic in Lawrenceville, and is considering adding mental health services in each of its community-based outpatient clinics.

The process at the VA is simple: vets sign up to be patients there, where they can get all their health care needs met at one location -- without wrestling with all the paperwork, provider rules, and other headaches that have come to be associated with managed care. Prescriptions are filled at no or minimal cost to vets at the on-site pharmacy, one of the largest in the Southeast.

"We are unencumbered here with all the problems of HMOs and PPOs that can leave both doctors and patients feeling frustrated," says Brown, who is also Charles Howard Candler Professor of Medicine at Emory. "We feel very fortunate to be able as physicians here to focus our attention where it needs to be -- on taking care of our patients, teaching our students, and doing research."

When patients aren't happy, they have outlets nonveteran patients don't to let their complaints be heard. "If our patients don't like something, they complain more than patients elsewhere, and we hear them more," says Janet Rubin, co-director of gene therapy research at the VAMC. "The VA is always listening to vets. So are senators and representatives. The VA takes what they say seriously. Patients feel they have a voice here."

Joe Wallace, a 71-year-old Marine Corps veteran with skin cancer, agrees, despite some long waits. "The wait can be like any doctor's office but I'm happy with the care I get here," he says. "Mostly, it is easy coming here, and the pharmacy even mails my prescriptions to my home. They pay attention to patients at the VA. I'd come here even if I had any other choice of a health plan."

Atlanta VAMC At A Glance*

Most teaching of internal medicine takes place at both Grady and the VA. "We see helping med students get started as one of our most important jobs," says Brown. "They come to the VA in the second year to learn physical diagnosis, for example, and later come for the internal medicine program." And the VA's abundance of senior patients - 36% of veterans are 65 or older, compared with 13% of the total US population - is a rich resource for training Emory students in geriatric medicine and gerontology.

When the Emory medical school recently polled residents about their training, the VA consistently received the highest marks of the four Emory-affiliated hospitals. "We pride ourselves on our reputation for being the best place for medical students and residents to get an education when they do rounds -- especially in internal medicine," says Bower.

Rounds at the VAMC - particularly in subspecialties like pulmonology, endocrinology, and cardiology - often turn into on-the-spot lectures about cutting-edge research led by physicians who are also scientists. One day residents may hear endocrinologist and Emory professor of medicine Janet Rubin discuss her findings on the molecular basis of disease and how that relates to osteoporosis. Another day AIDS researcher David Rimland shares how his research found a way to get around drug resistance in an HIV patient.

Faculty based at other Emory-affiliated hospitals usually have their main lab or clinic based at Emory. "But the faculty here has laboratories at the VA where they also do their teaching and supervision of residents," Bower says. "There's more hands-on interaction, and faculty can take students down to the lab where they are doing research."

In all, 88 principal investigators - virtually all Emory faculty members - are engaged in more than 200 research projects at the VA. These include studies on the genetics of cancer, development of new anti-HIV and antihepatitis agents, low-vision devices and aids, growth factor interactions in lung development, and bone and mineral endocrinology.

About half of the research funding comes from the NIH, CDC, other federal agencies, and the pharmaceutical industry. The other half comes from the Department of Veterans Affairs -- an extraordinary source of funding that Emory alone cannot tap into.

Beside applying to NIH and other research funding agencies, Emory-affiliated VA physician/scientists can seek VA support of research that touches on any issues that concern the veteran population. That same research promises to impact health issues affecting populations far beyond the VA.

The ongoing exchange of knowledge continues to benefit both the government-run VAMC and Emory's medical center. For instance, Emory is carefully watching the VA's systematic assessment of up to 60 performance measures each year that help determine if patients are getting the best care possible.

"That means the VA knows how many people get a flu vaccine, or receive a mental health follow-up after discharge, or how many with acute myocardial infarctions are managed within clinical practice guidelines. You won't find that kind of information in most physician practices or in other hospitals," says Leigh Hamby, who oversees quality management programs for the Atlanta VAMC as well as seven other acute hospitals in Georgia, Alabama, and South Carolina.

A recent article in the Journal of the American Medical Association pointed out that only 40%-50% of patients seeking health care within academia and in private practice are treated according to "what we know works. The percentage at the VA runs between 85%-95%," says Hamby, who was in private practice as a general surgeon before coming to the VA. "It's pretty rare to find a system that not only systematically measures its outcomes, but its processes as well."

"We're not the 'in crowd' to some on the Emory campus," says Bruce Blasch, coordinator of the VAMC's aging sensory research program in the Rehabilitation Research and Development Center. "It's not unusual for people who work 100% of the time for the VA, when listing their professional accomplishments, to ascribe them all to Emory and not the VA, so they'll look better."

Rubin makes the same observation: "I don't know why there's a feeling we are different, but some people do play down their VA affiliation. Maybe it's because our salaries come from the VA, although we are on the Emory faculty. Some people may think of us as government employees, and that has a negative connotation. It's too bad because the truth is we are part of Emory, and we are a tremendous resource for the medical school."

Robert Rich, dean of research for the Emory School of Medicine, agrees that the VA plays an invaluable role in the medical school's missions. Besides the basic research labs funded by VA appropriations, Emory benefits from collaborative clinical research programs conducted through the VA and its state-of-the art specialty labs and instrumentation, such as mass spectrometry, microarray analysis of gene expression, and DNA sequencing core, all of which support researchers throughout Emory.

Still the concerns of Emory faculty at the VA sound familiar to Rich and to Larry Turner, assistant dean for research, both of whom heard similar complaints when they were at Baylor, another VA-affiliated medical school. Turner points out that VAMCs by definition operate somewhat independently from medical schools, despite their affiliations. "This independence, in part due to their mission and how they're funded, is a source of strength to the total research effort. Yet, it does influence our interaction with the VA and whether some of the faculty based there think of themselves as 'full Emory.'"

An unfortunate perception, however, Turner acknowledges, is that VA funding is somehow inherently less valuable to Emory than NIH funding. That may in part be because NIH research funding is often considered the "gold standard" of funding, primarily because NIH grants are available to all faculty in all medical schools. VA funding is not. NIH funding is often used as a universal measure to rank how well academic medical centers compare to their peers.

However, Turner says, "We think VA science should not bow its head to anyone."

Perhaps a more relevant difference, he continues, is in the way Emory provides infrastructure support to researchers who are based on the Emory campus and those at the VA. When a researcher wins a grant from the NIH, the grant provides two categories of funding: The first is funding for the direct costs of the proposed research, such as salary support and supplies.

The second category of funding (a fixed percentage of the direct costs) is for many of the "indirect" costs of conducting the research, such as the costs of laboratory space, electricity, and administrative and other overhead. Medical schools, including Emory, rely heavily on these "indirects" to recover much of the cost of the infrastructure that they must maintain to support faculty research activity. When a VA-based researcher receives VA funds, the VA has already paid for the scientist's research lab and related expenses at the VAMC.

"The VA provides infrastructure support, such as buying new equipment, providing seed funds, and paying for utilities or maintenance for faculty who are based there. We try to do the same for faculty based at Emory," Turner says.

If an Emory faculty member based at the VA receives an NIH award, Emory spends no money for operations of the research space at the VA. But because Emory does incur costs in administering the grant, Emory receives indirects to cover the administrative costs of the grant -- about half the indirect costs it would need to receive from an on-campus researcher's NIH grant. Increasingly at issue is whether and to what extent some of that money should be made available to departments to help offset mounting administrative, purchasing, and human resources costs that departments incur in managing faculty at any Emory research space, including the VA.

Emory's new Research Space Management Incentive Program will address this by putting a portion of indirect costs of all grants to Emory into an account controlled by individual department chairs. "We're working to find an equitable way to share with them the money we've recovered," Turner says.

He pauses and laughs: "Heck, we are even trying to get that doggone bridge rebuilt!"

From the Director  /  Letters

On the front lines of health care

Half century of cooperation (photos)

Research: The VA's secret weapon

Designer medicine

Moving Forward  /  Noteworthy

Unfinished business: The prospects for health care reform in the 107th Congress

Looking for greener pastures

That bridge once spanned Candler Lake in nearby Lullwater Park, joining Emory and the VA, but was removed in 1992. In recent months, efforts have mounted at both the VA and Emory to rebuild the bridge and allow Emory investigators and VA-based Emory faculty, staff, and residents to walk the short distance between the VAMC and the Emory campus. Negotiations to build the bridge continue amid concern that it would increase foot traffic through the environmentally sensitive park.

To many faculty, the bridge seems a logical way to make access quick and easy between the VAMC and the Emory campus. And the symbolism of Emory literally and physically joined with the VA is also obvious.

Whatever the outcome and whether access is by foot or car or both, the ties between the two organizations appear to be stronger than ever and growing, as does admiration of policies and programs at both institutions.

"We have an extraordinary relationship at the VA that benefits patients, students, residents, and faculty alike, not to mention the world-class research that they do," says Emory School of Medicine Dean Tom Lawley. "It's a gem."

Sherry Baker directs public relations for the Emory Heart Center.