Karen M. Sanders, MD

The US government has a legacy of providing support for veterans. Pensions were offered to disabled veterans as early as 1776, and benefits were expanded to cover medical needs as the country grew and modernized.^1,2 Enacted during the Civil War, the General Pension Act increased benefits for widows and dependents.² Rehabilitation and vocational training assistance benefits were added after World War I, and the US Department of Veterans Affairs (VA) was created in 1930 to consolidate all benefits under one umbrella organization.^2,3

Prior to World War II, the VA lacked the bed capacity for the 4 million veterans who were eligible for care. This shortage became more acute by the end of the war, when the number of eligible veterans increased by 15 million.⁴ Although the VA successfully built bed capacity through acquisition of military hospitals, VA hospitals struggled to recruit clinical staff.² Physicians were hesitant to join the VA because civil service salaries were lower than comparable positions in the community, and the VA offered limited opportunities for research or continuing education. These limitations negatively impacted the overall reputation of the VA. The American Medical Association (AMA) was reluctant to directly admit VA physicians for membership because of a “lower” standard of care at VA hospitals.² This review will describe how passage of 2 legislative actions, the Servicemen’s Readjustment Act and Public Law (PL)79-293, and a key policy memorandum set the foundation for the partnership between the VA and academic medical centers. This led to improved medical care for veterans and expansion of health professions education for VA and the nation.^5,6

GI Bill of Rights

The passage of the Servicemen’s Readjustment Act of 1944, better known as the GI Bill of Rights, provided education assistance, guaranteed home loans, and unemployment payments to veterans.⁵ All medical officers serving during the war were eligible for this benefit, which effectively increased the number of potential physician trainees at the end of World War II by almost 60,000.⁷ Medical education at the time was simultaneously undergoing a transformation with more rigorous training and a push to standardize medical education across state lines. While prerequisite training was not required for admission to many medical schools and curricula varied in length based on state licensing requirements, more programs were adding premedical education requirements and transitioning to the 4-year curricula seen today. At this time, only 23 states required postgraduate internships for licensure, but this number was growing.⁸ The American Board of Medical Specialties was established several years prior to World War II in 1934 to elevate the quality of care; the desire for residency training and board certification continued to gain traction during the 1940s.⁹

Medical Training

In anticipation of an influx of medical trainees, the Committee on Postwar Medical Service conducted a comprehensive survey to understand the training needs of physician veterans returning from World War II.⁷ The survey collected data from medical officers on their desired length of training, interest in specialty board certification, time served, and type of medical practice prior to enlisting. Length of desired training was categorized as short (up to 6 months), which would serve as a refresher course and provide updates on recent advances in medicine and surgery, and long (> 6 months), which resembled a modern internship or residency. Nineteen percent did not want additional training, 22% wished to pursue short courses, and 51% were interested in longer courses. Most respondents also wished to obtain board certification.⁷ The AMA played a significant role in supporting the expansion of training opportunities, encouraging all accredited hospitals to assess their capacity to determine the number of additional residents they could accommodate. The AMA also awarded hospitals with existing internship programs temporary accreditation to allow them to add extended training through residency programs.⁷

Medical schools devised creative solutions to meet the needs of returning physician veterans and capitalize on the available educational benefits. Postgraduate refresher courses that varied in length from hours to months were developed focusing on an array of topics. In addition to basic medical principles, courses covered general topics, such as advances in medicine, to specialty topics, such as nutrition or ophthalmology.⁷ Although the courses could not be counted toward board certification, participation increased by almost 300% in the 1945/1946 academic year relative to the previous year.⁷ Increasing access to the longer training courses, including internships and residencies, was often achieved through experiences outside the clinical setting. Yale University modified its curriculum to reduce time devoted to lectures on published materials and encourage active learning and community outreach.¹⁰ Northwestern University assigned residents to spend 1 of their 3 years “out of residence” in basic science and clinical instruction provided by the medical school. Tuition assistance from the GI Bill supported the additional expenses incurred by the medical school to fund laboratory space, equipment, and the salaries of the basic science instructors and administrative staff.¹¹

Public Law 79-293

Public Law 79-293 was passed on January 3, 1946, establishing the Department of Medicine and Surgery within the VA. The law, which became the basis for Title 38 chapters 73 and 74, allowed VA hospitals flexibility to hire doctors, dentists, and nurses without regard to the civil service regulations and salary restrictions associated with other federal positions.⁶

Concerns about quality of care had been mounting for years, and the release of several sensationalized and critical articles motivated VA leadership to make sweeping changes. One article described neglect at VA hospitals.¹² Excessive paperwork and low economic benefits were identified as barriers to the recruitment of qualified clinicians at the VA.² The VA Special Medical Advisory Group investigating the claims recommended that the VA encourage their hospitals to affiliate with medical schools to improve the quality of care. This group also recommended that new VA hospitals be constructed near academic medical centers to allow access to consultants.² Three large veterans service organizations (American Legion, Veterans of Foreign Wars, and Disabled American Veterans) conducted their own investigations in response to the media reports. The organizations reported that the quality of care in most VA hospitals was already on par with the community but indicated that the VA would benefit from expansion of medical research and training, increased bed capacity, reduction in the administrative burden on clinicians, and increased salaries for clinical staff.²

Policy Memorandum No. 2

The relationship between VA and academic medical centers was solidified on January 30, 1946, with adoption of Policy Memorandum No. 2.¹³ This memorandum allowed for the establishment of relationships with academic medical centers to provide “the veteran a much higher standard of medical care than could be given him with a wholly full-time medical staff.” Shortly after this memorandum was signed, residents from Northwestern University and the University of Illinois at Chicago began clinical rotations at the Hines VA facility in Chicago, Illinois.² By 1947, 62 medical schools had committed to an affiliation with local VA hospitals and 21 deans’ committees were in operation, which were responsible for the appointment of physician residents and consultants. The AMA extended direct membership privileges to VA physicians, and by 1947 the number of residency positions doubled nationally.^14,15 The almost universal support of the relationship between VA and academic affiliates provided educational opportunities for returning veterans and raised standards for medical education nationally.

Current State

Since the passage of PL 79-293 and PM No. 2, the VA-academic health professions education partnership has grown to include 113,000 trainees rotating through 150 VA medical centers annually from more than 1400 colleges and universities.¹⁶ Most VA podiatrists, psychologists, optometrists, and physicians working in VA medical centers also trained at VA, and trainees are 37% more likely to consider a job at VA after completing their clinical rotations. This unique partnership began 76 years ago and continues to provide clinicians “for VA and the nation.”

The US government has a legacy of providing support for veterans. Pensions were offered to disabled veterans as early as 1776, and benefits were expanded to cover medical needs as the country grew and modernized.^1,2 Enacted during the Civil War, the General Pension Act increased benefits for widows and dependents.² Rehabilitation and vocational training assistance benefits were added after World War I, and the US Department of Veterans Affairs (VA) was created in 1930 to consolidate all benefits under one umbrella organization.^2,3

Prior to World War II, the VA lacked the bed capacity for the 4 million veterans who were eligible for care. This shortage became more acute by the end of the war, when the number of eligible veterans increased by 15 million.⁴ Although the VA successfully built bed capacity through acquisition of military hospitals, VA hospitals struggled to recruit clinical staff.² Physicians were hesitant to join the VA because civil service salaries were lower than comparable positions in the community, and the VA offered limited opportunities for research or continuing education. These limitations negatively impacted the overall reputation of the VA. The American Medical Association (AMA) was reluctant to directly admit VA physicians for membership because of a “lower” standard of care at VA hospitals.² This review will describe how passage of 2 legislative actions, the Servicemen’s Readjustment Act and Public Law (PL)79-293, and a key policy memorandum set the foundation for the partnership between the VA and academic medical centers. This led to improved medical care for veterans and expansion of health professions education for VA and the nation.^5,6

GI Bill of Rights

The passage of the Servicemen’s Readjustment Act of 1944, better known as the GI Bill of Rights, provided education assistance, guaranteed home loans, and unemployment payments to veterans.⁵ All medical officers serving during the war were eligible for this benefit, which effectively increased the number of potential physician trainees at the end of World War II by almost 60,000.⁷ Medical education at the time was simultaneously undergoing a transformation with more rigorous training and a push to standardize medical education across state lines. While prerequisite training was not required for admission to many medical schools and curricula varied in length based on state licensing requirements, more programs were adding premedical education requirements and transitioning to the 4-year curricula seen today. At this time, only 23 states required postgraduate internships for licensure, but this number was growing.⁸ The American Board of Medical Specialties was established several years prior to World War II in 1934 to elevate the quality of care; the desire for residency training and board certification continued to gain traction during the 1940s.⁹

Medical Training

In anticipation of an influx of medical trainees, the Committee on Postwar Medical Service conducted a comprehensive survey to understand the training needs of physician veterans returning from World War II.⁷ The survey collected data from medical officers on their desired length of training, interest in specialty board certification, time served, and type of medical practice prior to enlisting. Length of desired training was categorized as short (up to 6 months), which would serve as a refresher course and provide updates on recent advances in medicine and surgery, and long (> 6 months), which resembled a modern internship or residency. Nineteen percent did not want additional training, 22% wished to pursue short courses, and 51% were interested in longer courses. Most respondents also wished to obtain board certification.⁷ The AMA played a significant role in supporting the expansion of training opportunities, encouraging all accredited hospitals to assess their capacity to determine the number of additional residents they could accommodate. The AMA also awarded hospitals with existing internship programs temporary accreditation to allow them to add extended training through residency programs.⁷

Medical schools devised creative solutions to meet the needs of returning physician veterans and capitalize on the available educational benefits. Postgraduate refresher courses that varied in length from hours to months were developed focusing on an array of topics. In addition to basic medical principles, courses covered general topics, such as advances in medicine, to specialty topics, such as nutrition or ophthalmology.⁷ Although the courses could not be counted toward board certification, participation increased by almost 300% in the 1945/1946 academic year relative to the previous year.⁷ Increasing access to the longer training courses, including internships and residencies, was often achieved through experiences outside the clinical setting. Yale University modified its curriculum to reduce time devoted to lectures on published materials and encourage active learning and community outreach.¹⁰ Northwestern University assigned residents to spend 1 of their 3 years “out of residence” in basic science and clinical instruction provided by the medical school. Tuition assistance from the GI Bill supported the additional expenses incurred by the medical school to fund laboratory space, equipment, and the salaries of the basic science instructors and administrative staff.¹¹

Public Law 79-293

Public Law 79-293 was passed on January 3, 1946, establishing the Department of Medicine and Surgery within the VA. The law, which became the basis for Title 38 chapters 73 and 74, allowed VA hospitals flexibility to hire doctors, dentists, and nurses without regard to the civil service regulations and salary restrictions associated with other federal positions.⁶

Concerns about quality of care had been mounting for years, and the release of several sensationalized and critical articles motivated VA leadership to make sweeping changes. One article described neglect at VA hospitals.¹² Excessive paperwork and low economic benefits were identified as barriers to the recruitment of qualified clinicians at the VA.² The VA Special Medical Advisory Group investigating the claims recommended that the VA encourage their hospitals to affiliate with medical schools to improve the quality of care. This group also recommended that new VA hospitals be constructed near academic medical centers to allow access to consultants.² Three large veterans service organizations (American Legion, Veterans of Foreign Wars, and Disabled American Veterans) conducted their own investigations in response to the media reports. The organizations reported that the quality of care in most VA hospitals was already on par with the community but indicated that the VA would benefit from expansion of medical research and training, increased bed capacity, reduction in the administrative burden on clinicians, and increased salaries for clinical staff.²

Policy Memorandum No. 2

The relationship between VA and academic medical centers was solidified on January 30, 1946, with adoption of Policy Memorandum No. 2.¹³ This memorandum allowed for the establishment of relationships with academic medical centers to provide “the veteran a much higher standard of medical care than could be given him with a wholly full-time medical staff.” Shortly after this memorandum was signed, residents from Northwestern University and the University of Illinois at Chicago began clinical rotations at the Hines VA facility in Chicago, Illinois.² By 1947, 62 medical schools had committed to an affiliation with local VA hospitals and 21 deans’ committees were in operation, which were responsible for the appointment of physician residents and consultants. The AMA extended direct membership privileges to VA physicians, and by 1947 the number of residency positions doubled nationally.^14,15 The almost universal support of the relationship between VA and academic affiliates provided educational opportunities for returning veterans and raised standards for medical education nationally.

Current State

Since the passage of PL 79-293 and PM No. 2, the VA-academic health professions education partnership has grown to include 113,000 trainees rotating through 150 VA medical centers annually from more than 1400 colleges and universities.¹⁶ Most VA podiatrists, psychologists, optometrists, and physicians working in VA medical centers also trained at VA, and trainees are 37% more likely to consider a job at VA after completing their clinical rotations. This unique partnership began 76 years ago and continues to provide clinicians “for VA and the nation.”

The US government has a legacy of providing support for veterans. Pensions were offered to disabled veterans as early as 1776, and benefits were expanded to cover medical needs as the country grew and modernized.^1,2 Enacted during the Civil War, the General Pension Act increased benefits for widows and dependents.² Rehabilitation and vocational training assistance benefits were added after World War I, and the US Department of Veterans Affairs (VA) was created in 1930 to consolidate all benefits under one umbrella organization.^2,3

Prior to World War II, the VA lacked the bed capacity for the 4 million veterans who were eligible for care. This shortage became more acute by the end of the war, when the number of eligible veterans increased by 15 million.⁴ Although the VA successfully built bed capacity through acquisition of military hospitals, VA hospitals struggled to recruit clinical staff.² Physicians were hesitant to join the VA because civil service salaries were lower than comparable positions in the community, and the VA offered limited opportunities for research or continuing education. These limitations negatively impacted the overall reputation of the VA. The American Medical Association (AMA) was reluctant to directly admit VA physicians for membership because of a “lower” standard of care at VA hospitals.² This review will describe how passage of 2 legislative actions, the Servicemen’s Readjustment Act and Public Law (PL)79-293, and a key policy memorandum set the foundation for the partnership between the VA and academic medical centers. This led to improved medical care for veterans and expansion of health professions education for VA and the nation.^5,6

GI Bill of Rights

The passage of the Servicemen’s Readjustment Act of 1944, better known as the GI Bill of Rights, provided education assistance, guaranteed home loans, and unemployment payments to veterans.⁵ All medical officers serving during the war were eligible for this benefit, which effectively increased the number of potential physician trainees at the end of World War II by almost 60,000.⁷ Medical education at the time was simultaneously undergoing a transformation with more rigorous training and a push to standardize medical education across state lines. While prerequisite training was not required for admission to many medical schools and curricula varied in length based on state licensing requirements, more programs were adding premedical education requirements and transitioning to the 4-year curricula seen today. At this time, only 23 states required postgraduate internships for licensure, but this number was growing.⁸ The American Board of Medical Specialties was established several years prior to World War II in 1934 to elevate the quality of care; the desire for residency training and board certification continued to gain traction during the 1940s.⁹

Medical Training

In anticipation of an influx of medical trainees, the Committee on Postwar Medical Service conducted a comprehensive survey to understand the training needs of physician veterans returning from World War II.⁷ The survey collected data from medical officers on their desired length of training, interest in specialty board certification, time served, and type of medical practice prior to enlisting. Length of desired training was categorized as short (up to 6 months), which would serve as a refresher course and provide updates on recent advances in medicine and surgery, and long (> 6 months), which resembled a modern internship or residency. Nineteen percent did not want additional training, 22% wished to pursue short courses, and 51% were interested in longer courses. Most respondents also wished to obtain board certification.⁷ The AMA played a significant role in supporting the expansion of training opportunities, encouraging all accredited hospitals to assess their capacity to determine the number of additional residents they could accommodate. The AMA also awarded hospitals with existing internship programs temporary accreditation to allow them to add extended training through residency programs.⁷

Medical schools devised creative solutions to meet the needs of returning physician veterans and capitalize on the available educational benefits. Postgraduate refresher courses that varied in length from hours to months were developed focusing on an array of topics. In addition to basic medical principles, courses covered general topics, such as advances in medicine, to specialty topics, such as nutrition or ophthalmology.⁷ Although the courses could not be counted toward board certification, participation increased by almost 300% in the 1945/1946 academic year relative to the previous year.⁷ Increasing access to the longer training courses, including internships and residencies, was often achieved through experiences outside the clinical setting. Yale University modified its curriculum to reduce time devoted to lectures on published materials and encourage active learning and community outreach.¹⁰ Northwestern University assigned residents to spend 1 of their 3 years “out of residence” in basic science and clinical instruction provided by the medical school. Tuition assistance from the GI Bill supported the additional expenses incurred by the medical school to fund laboratory space, equipment, and the salaries of the basic science instructors and administrative staff.¹¹

Public Law 79-293

Public Law 79-293 was passed on January 3, 1946, establishing the Department of Medicine and Surgery within the VA. The law, which became the basis for Title 38 chapters 73 and 74, allowed VA hospitals flexibility to hire doctors, dentists, and nurses without regard to the civil service regulations and salary restrictions associated with other federal positions.⁶

Concerns about quality of care had been mounting for years, and the release of several sensationalized and critical articles motivated VA leadership to make sweeping changes. One article described neglect at VA hospitals.¹² Excessive paperwork and low economic benefits were identified as barriers to the recruitment of qualified clinicians at the VA.² The VA Special Medical Advisory Group investigating the claims recommended that the VA encourage their hospitals to affiliate with medical schools to improve the quality of care. This group also recommended that new VA hospitals be constructed near academic medical centers to allow access to consultants.² Three large veterans service organizations (American Legion, Veterans of Foreign Wars, and Disabled American Veterans) conducted their own investigations in response to the media reports. The organizations reported that the quality of care in most VA hospitals was already on par with the community but indicated that the VA would benefit from expansion of medical research and training, increased bed capacity, reduction in the administrative burden on clinicians, and increased salaries for clinical staff.²

Policy Memorandum No. 2

The relationship between VA and academic medical centers was solidified on January 30, 1946, with adoption of Policy Memorandum No. 2.¹³ This memorandum allowed for the establishment of relationships with academic medical centers to provide “the veteran a much higher standard of medical care than could be given him with a wholly full-time medical staff.” Shortly after this memorandum was signed, residents from Northwestern University and the University of Illinois at Chicago began clinical rotations at the Hines VA facility in Chicago, Illinois.² By 1947, 62 medical schools had committed to an affiliation with local VA hospitals and 21 deans’ committees were in operation, which were responsible for the appointment of physician residents and consultants. The AMA extended direct membership privileges to VA physicians, and by 1947 the number of residency positions doubled nationally.^14,15 The almost universal support of the relationship between VA and academic affiliates provided educational opportunities for returning veterans and raised standards for medical education nationally.

Current State

Since the passage of PL 79-293 and PM No. 2, the VA-academic health professions education partnership has grown to include 113,000 trainees rotating through 150 VA medical centers annually from more than 1400 colleges and universities.¹⁶ Most VA podiatrists, psychologists, optometrists, and physicians working in VA medical centers also trained at VA, and trainees are 37% more likely to consider a job at VA after completing their clinical rotations. This unique partnership began 76 years ago and continues to provide clinicians “for VA and the nation.”

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) operates the largest integrated health care system in the United States, providing physical and mental health care to more than 9 million veterans enrolled each year through a national system of inpatient, outpatient, and long-term care settings.¹ As 1 of 4 statutory missions, the VA conducts the largest training effort for health professionals in cooperation with affiliated academic institutions. From 2016 through 2020, an average of 123,000 trainees from various professions received training at the VA.² Physician residents comprised the largest trainee group (37%), followed by associated health students and residents (20%), and nursing professionals (21%).² In VA, associated health professions include all health care disciplines other than allopathic and osteopathic medicine, dentistry, and nursing. The associated health professions encompass about 40 specialties, including audiology, dietetics, physical and occupational therapy, optometry, pharmacy, podiatry, psychology, and social work. 

The VA also trains a smaller number of advanced fellows to address specialties important to the nation and veterans health that are not sufficiently addressed by standard accredited professional training.³ The VA Advanced Fellowship programs include 22 postresidency, postdoctoral, and postmasters fellowships to physicians and dentists, and associated health professions, including psychologists, social workers, and pharmacists. 3 From 2015 to 2019, 57 to 61% of medical school students reported having a VA clinical training experience during medical school^.4 Of current VA employees, 20% of registered nurses, 64% of physicians, 73% of podiatrists and optometrists, and 81% of psychologists reported VA training prior to employment.⁵

Health professions education is led by the designated education officer (DEO) at each VA facility.⁶ Also known as the associate chief of staff for education (ACOS/E), the DEO is a leadership position that is accountable to local VA facility executive leadership as well as the national Office of Academic Affiliations (OAA), which directs all VA health professions training across the US.⁶ At most VA facilities, the DEO oversees clinical training and education reporting directly to the facility chief of staff. At the same time, the ACOS/E is accountable to the OAA to ensure adherence with national education directives and policy. The DEO oversees trainee programs through collaboration with training program directors, faculty, academic affiliates, and accreditation agencies across > 40 health professions.

The DEO is expected to possess expertise in leadership attributes identified by the US Office of Personnel Management as essential to build a federal corporate culture that drives results, serves customers, and builds successful teams and coalitions within and outside the VA.7 These leadership attributes include leading change, leading people, driving results, business acumen, and building coalitions.⁷ They are operationalized by OAA as 4 domains of expertise required to lead education across multiple professions, including: (1) creating and sustaining an organizational work environment that supports learning, discovery, and continuous improvement; (2) aligning and managing fiscal, human, and capital resources to meet organizational learning needs; (3) driving learning and performance results to impact organizational success; and (4) leading change and transformation through positioning and implementing innovative learning and education strategies (Table 1).⁶

In this article we describe the VA DEO leadership role and the tasks required to lead education across multiple professions within the VA health care system. Given the broad scope of leading educational programs across multiple clinical professions and the interprofessional backgrounds of DEOs across the VA, we evaluated DEO self-perceived effectiveness to impact educational decisions and behavior by professional discipline. Our evaluation question is: Are different professional education and practice backgrounds functionally capable of providing leadership over all education of health professions training programs? Finally, we describe DEOs perceptions of facilitators and barriers to performing their DEO role within the VA.

Methods

We conducted a mixed methods analysis of data collected by OAA to assess DEO needs within a multiprofessional clinical learning environment. The needs assessment was conducted by an OAA evaluator (NH) with input on instrument development and data analysis from OAA leadership (KS, MB). This evaluation is categorized as an operations activity based on VA Handbook 1200 where information generated is used for business operations and quality improvement. ⁸ The overall project was subject to administrative rather than institutional review board oversight.

A needs assessment tool was developed based on the OAA domains of expertise.⁶ Prior to its administration, the tool was piloted with 8 DEOs in the field and the survey shortened based on their feedback. DEOs were asked about individual professional characteristics (eg, clinical profession, academic appointment, type of health professions training programs at the VA site) and their self-perceived effectiveness in impacting educational decisions and behaviors on general and profession-specific tasks within each of the 4 domains of expertise on a 5-point Likert scale (1, not effective; 5, very effective). 6,9 The needs assessment also included an open-ended question asking respondents to comment on any issues they felt important to understanding DEO role effectiveness.

The needs assessment was administered online via SurveyMonkey to 132 DEOs via email in September and October 2019. The DEOs represented 148 of 160 VA facilities with health professions education; 14 DEOs covered > 1 VA facility, and 12 positions were vacant. Email reminders were sent to nonresponders after 1 week. At 2 weeks, nonresponders received telephone reminders and personalized follow-up emails from OAA staff. The response rate at the end of 3 weeks was 96%.

Data Analysis

Mixed methods analyses included quantitative analyses to identify differences in general and profession-specific self-ratings of effectiveness in influencing educational decisions and behaviors by DEO profession, and qualitative analyses to further understand DEO’s perceptions of facilitators and barriers to DEO task effectiveness.^10,11 Quantitative analyses included descriptive statistics for all variables followed by nonparametric tests including χ2 and Mann- Whitney U tests to assess differences between physician and other professional DEOs in descriptive characteristics and selfperceived effectiveness on general and profession- specific tasks. Quantitative analyses were conducted using SPSS software, version 26. Qualitative analyses consisted of rapid assessment procedures to identify facilitators and barriers to DEO effectiveness by profession using Atlas.ti version 8, which involved reviewing responses to the open-ended question and assigning each response to predetermined categories based on the organizational level it applied to (eg, individual DEO, VA facility, or external to the organization).^12,13 Responses within categories were then summarized to identify the main themes.

Results 

Completed surveys were received from 127 respondents representing 139 VA facilities. Eighty percent were physicians and 20% were other professionals, including psychologists, pharmacists, dentists, dieticians, nurses, and nonclinicians. There were no statistically significant differences between physician and other professional DEOs in the percent working full time or length of time spent working in the position. About one-third of the sample had been in the position for < 2 years, one-third had been in the position for 2 to < 5 years, and one-third had been in the role for ≥ 5 years. Eighty percent reported having a faculty appointment with an academic affiliate. While 92% of physician DEOs had a faculty appointment, only 40% of other professional DEOs did (P < .001). Most faculty appointments for both groups were with a school of medicine. More physician DEOs than other professionals had training programs at their site for physicians (P = .003) and dentists (P < .001), but there were no statistically significant differences for having associated health, nursing, or advanced fellowship training programs at their sites. Across all DEOs, 98% reported training programs at their site for associated health professions, 95% for physician training, 93% for nursing training, 59% for dental training, and 48% for advanced fellowships.

Self-Perceived Effectiveness

There were no statistically significant differences between physician and other professional DEOs on self-perceived effectiveness in impacting educational decisions or behaviors for general tasks applicable across professions (Table 2). This result held even after controlling for length of time in the position and whether the DEO had an academic appointment. Generally, both groups reported being effective on tasks in the enabling learning domain, including applying policies and procedures related to trainees who rotate through the VA and maintaining adherence with accreditation agency standards across health professions. Mean score ranges for both physician and other professional DEOs reported moderate effectiveness in aligning resources effectiveness questions (2.45-3.72 vs 2.75-3.76), driving results questions (3.02-3.60 vs 3.39-3.48), and leading change questions (3.12-3.50 vs 3.42-3.80).

For profession-specific tasks, effectiveness ratings between the 2 groups were generally not statistically significant for medical, dental, and advanced fellowship training programs (Table 3). There was a pattern of statistically significant differences between physician and other professional DEOs for associated health and nursing training programs on tasks across the 4 domains of expertise with physicians having lower mean ratings compared with other professionals. Generally, physician DEOs had higher task effectiveness when compared with other professionals for medical training programs, and other professionals had higher task effectiveness ratings than did physicians for associated health or nursing training programs.

Facilitators and Barriers

Seventy responses related to facilitators and barriers to DEO effectiveness were received (59 from physicians and 11 from other professionals). Most responses were categorized as individual level facilitators or barriers (53% for physician and 64% for other professionals). Only 3% of comments were categorized as external to the organization (all made by physicians). The themes were similar for both groups and were aggregated in Table 4. Facilitators included continuing education, having a mentor who works at a similar type of facility, maintaining balance and time management when working with different training programs, learning to work and develop relationships with training program directors, developing an overall picture of each type of health professions training program, holding regular meetings with all health training programs and academic affiliates, having a formal education service line with budget and staffing, facility executive leadership who are knowledgeable of the education mission and DEO role, having a national oversight body, and the DEO’s relationships with academic affiliates.

Barriers to role effectiveness at the individual DEO level included assignment of multiple roles and a focus on regulation and monitoring with little time for development of new programs and strategic planning. The organizational level barriers included difficulty getting core services to engage with health professions trainees and siloed education leadership. 

Discussion

DEOs oversee multiple health professions training programs within local facilities. The DEO is accountable to local VA facility leadership and a national education office to lead local health professions education at local facilities and integrate these educational activities across the national VA system.

The VA DEO role is similar to the Accreditation Council for Graduate Medical Education designated institutional official (DIO) except that the VA DEO provides oversight of > 40 health professions training programs^.14,15 The VA DEO, therefore, has broader oversight than the DIO role that focuses only on graduate physician education. Similar to the DIO, the VA DEO role initially emphasized the enabling learning and aligning resources domains to provide oversight and administration of health professions training programs. Over time, both roles have expanded to include defining and ensuring healthy clinical learning environments, aligning educational resources and training with the institutional mission, workforce, and societal needs, and creating continuous educational improvement models.^6,16,17 To accomplish these expanded goals, both the DEO and the DIO work closely with other educational leaders at the academic affiliate and the VA facility. As health professions education advances, there will be increased emphasis placed on delivering educational programs to improve clinical practice and health care outcomes.¹⁸

Our findings that DEO profession did not influence self-ratings of effectiveness to influence educational decisions or behaviors on general tasks applicable across health professions suggest that education and practice background are not factors influencing selfratings. Nor were self-ratings influenced by other factors. Since the DEO is a senior leadership position, candidates for the position already may possess managerial and leadership skills. In our sample, several individuals commented that they had prior education leadership positions, eg, training program director or had years of experience working in the VA. Similarly, having an academic appointment may not be important for the performance of general administrative tasks. However, an academic appointment may be important for effective performance of educational tasks, such as clinical teaching, didactic training, and curriculum development, which were not measured in this study.

The finding of differences in self-ratings between physicians and other professionals on profession-specific tasks for associated health and nursing suggests that physicians may require additional curriculum to enhance their knowledge in managing other professional educational programs. For nursing specifically, this finding could also reflect substantial input from the lead nurse executive in the facility. DEOs also identified practical ways to facilitate their work with multiple health professions that could immediately be put into practice, including developing relationships and enhancing communication with training program directors, faculty, and academic affiliates of each profession.

Taken together, the quantitative and qualitative findings indicate that despite differences in professional backgrounds, DEOs have high self-ratings of their own effectiveness to influence educational decisions and behaviors on general tasks they are expected to accomplish. There are some professionspecific tasks where professional background does influence self-perceived effectiveness, ie, physicians have higher self-ratings on physician-specific tasks and other professionals have higher self-ratings on associated health or nursing tasks. These perceived differences may be mitigated by increasing facilitators and decreasing barriers identified for the individual DEO, within the organization, and external to the organization.

Limitations Our findings should be interpreted with the following limitations in mind. The selfreport nature of the data opens the possibility of self-report bias or Dunning-Kruger effects where effectiveness ratings could have been overestimated by respondents.21 Although respondents were assured of their anonymity and that results would only be reported in the aggregate, there is potential for providing more positive responses on a needs assessment administered by the national education program office. We recommend further work be conducted to validate the needs assessment tool against other data collection methods, such as actual outcomes of educational effectiveness. Our study did not incorporate measures of educational effectiveness to determine whether self-perceived DEO effectiveness is translated to better trainee or learning outcomes. Before this can happen, educational policymakers must identify the most important facility-level learning outcomes. Since the DEO is a facility level educational administrator, learning efeffectiveness must be defined at the facility level. The qualitative findings could also be expanded through the application of more detailed qualitative methods, such as indepth interviews. The tasks rated by DEOs were based on OAA’s current definition of the DEO role.6 As the field advances, DEO tasks will also evolve.^22-24

Conclusions

The DEO is a senior educational leadership role that oversees all health professions training in the VA. Our findings are supportive of individuals from various health disciplines serving in the VA DEO role with responsibilities that span multiple health profession training programs. We recommend further work to validate the instrument used in this study, as well as the application of qualitative methods like indepth interviews to further our understanding of the DEO role.

The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.¹ One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.² Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.³

In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.^4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.

Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.

To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.

Associated Health Professionals

Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).^6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).

One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.^8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.¹⁰ The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.

The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.

Funded Training Positions

As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.

The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.

The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.

Interprofessional Education

As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.¹¹ There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.¹² Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.^13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.

Pain Management Pharmacy

The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.¹⁷ These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.

Rural Health

The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.¹⁸ The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.¹⁹Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.¹⁹

When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.²⁰ As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.²¹

Pregraduate to Postgraduate Programs

The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.²²This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.

Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.

While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.

In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.

Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.²³ Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.

Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.

Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.

Conclusions

Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.

The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.

The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.¹ One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.² Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.³

In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.^4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.

Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.

To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.

Associated Health Professionals

Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).^6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).

One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.^8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.¹⁰ The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.

The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.

Funded Training Positions

As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.

The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.

The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.

Interprofessional Education

As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.¹¹ There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.¹² Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.^13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.

Pain Management Pharmacy

The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.¹⁷ These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.

Rural Health

The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.¹⁸ The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.¹⁹Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.¹⁹

When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.²⁰ As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.²¹

Pregraduate to Postgraduate Programs

The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.²²This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.

Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.

While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.

In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.

Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.²³ Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.

Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.

Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.

Conclusions

Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.

The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.

The US Department of Veterans Affairs (VA) is the largest health care delivery system in the United States, comprising 1293 sites of care, including 171 medical centers.¹ One of the 4 statutory missions of the VA is to train health care professionals (HCPs) to meet the needs of the VA and the nation.² Through partnerships with more than 1800 accredited colleges, universities, and training programs, the VA provides training annually to nearly 118,000 health professions trainees (HPTs) across a variety of health care professions, and all of whom provide direct clinical care to veterans.³

In the VA, the Office of Academic Affiliations (OAA) is charged with overseeing health professions training and the VA’s partnership with medical and associated health (AH) professions schools, which was first codified in Policy Memorandum No. 2 in 1946.^4,5 Given the scope and breadth of health professions education offered through the VA, OAA is in a unique position to address health care shortage areas as well as influence the educational standards for certain professions.

Many of these health care professions fall under the rubric of AH, which include mental health (MH) specialties, rehabilitative specialties, and others. These professions are critical to address in the expanding world of health care in the United States with its increased specialization and emphasis on coordination of care with interprofessional teams. During the 2019/2020 academic year, the VA provided clinical training to approximately 21,000 AH HPTs from > 40 professions with just over 20% receiving financial support through the OAA. Of the HPTs who train at VA without compensation, most spend shorter amounts of time in clinical rotations in the VA, are in pregraduate-degree education programs where payment for clinical rotations is not expected and may not be eligible for hire immediately on completion of their clinical training experience. The 17 funded professions have been strategically selected by the OAA to ensure a robust pipeline of HCPs to meet the needs of veterans and the nation.

To meet the demands of AH professionals (AHPs), the OAA implemented targeted expansion over the past 10 years. While not exhaustive, this paper describes several expansion efforts based on VA special initiatives, including enhancing clinical access in rural settings and shifting toward postgraduate-degree training and specialization. By aligning expansion with VA priorities as well as trends in health care more broadly, the OAA can ensure that there is a supply of well-trained AHPs who have developed the requisite competencies to contribute to our nation’s health care needs. Further, expansion can help train and recruit health professionals who can be hired into VA positions ready to care for the complex needs of veterans.

Associated Health Professionals

Overseen by the OAA, AH expansion is designed to address the specific needs of the VA and the US health care system. Data from the VA Workforce Management and Consulting (WMC) shows that the VA employment of AHPs has grown from 87,351 AHPs hired in fiscal year (FY) 2010 to 119,120 as of April 2020. This represents an average yearly growth rate of 3.4% and a total growth rate of 36%. The Bureau of Labor Statistics predictions for 2019/2029 suggest that certain AHPs are expected to have a 10-year growth rates of 20% or more to meet the changing health care needs of patients especially as the population ages; the growth rates for many AHPs far surpasses that of physicians, which is anticipated to be 4% (Table).^6,7 The VA WMC expects an additional 52,283 AHPs will be hired by the VA by FY 2030 based on the 10-year average growth rate (Kali Clark, Veterans Health Administration Workforce Management and Consulting Office, email communication, May 28, 2020).

One of the driving forces behind the growth rate is the move toward using AHPs to supplement health care for a variety of health conditions.^8,9 Examples include the integration of rehabilitation professionals, alternative care professionals (eg, massage therapists, practitioners who offer training in yoga and meditation), chiropractors, MH professionals, and pharmacists in the treatment of chronic pain, the use of a wider range of professionals in the treatment of MH conditions, and the integration of MH professionals into traditional medical settings, such as primary care. This intentional move to a more well-integrated model of interprofessional care is apparent in many other health care systems throughout the United States. Within the VA, this shift may be most evident through the introduction of the Whole Health model of care. The Whole Health model of care uses an interprofessional team to assess and care for veterans, using a personalized health plan addressing medical and MH conditions as well as behavioral, social, or spiritual concerns.¹⁰ The Whole Health model of care provides veterans with access to a variety of health care services, including but not limited to MH services, spiritual interventions, exercise-based programs, yoga, meditation, and nutrition counseling.

The OAA and AH education division have focused expansion to meet the increased need for MH and rehabilitation providers, to enhance interprofessional education, and to emphasize postgraduate-degree clinical training. This focus reflects the trends seen in health care training broadly throughout the nation and the intentional pivot is a model of these trends and a model for how to intentionally address these trends. Specific to the VA, focused expansion plans have allowed OAA to address VA strategic initiatives such as pain management and caring for rural veterans.

Funded Training Positions

As a result of recent AH expansion efforts, there has been a 33% increase in stipend-funded positions during the past 10 years, a rate that directly corresponds with the growth of AHPs in the VA. Recent AH expansion efforts can contribute to a particularly positive impact in highly rural and underserved areas where recruiting providers remains challenging.

The OAA launched the Mental Health Education Expansion (MHEE) initiative in 2012, which has now added 782 funded training slots across 10 health professions, 8 of which are psychology, pharmacy, chaplaincy, professional MH counseling, marriage and family therapy (MFT), social work (SW), occupational therapy (OT), and physician assistant (PA). Through the MHEE initiative, the VA has established funded internships for licensed professional mental health counselors and marriage and family therapists, as these professions are targeted for expanding the overall MH workforce in the VA. The OAA currently funds more than 50 total HPT positions for these 2 professions with an aim of increasing their recruitment to the VA MH workforce over the next decade. The MHEE is aligned with specified VA priorities to train a future VA workforce prepared for interprofessional collaboration and clinical care in an increasingly integrated and complex environment. This expansion effort also aligns with an increasing understanding of the importance of addressing the MH needs of our nation by ensuring there is an adequate supply of competent, well-trained clinicians entering the workforce.

The OAA has created and expanded residencies and fellowships in multiple rehabilitation professions, including chiropractic, physical therapy (PT), and OT. With the increased focus on the management of chronic pain in the nation combined with a specific emphasis on this clinical need in the VA, chiropractors have been deemed essential HCPs. In 2014, the VA established 5 chiropractic residency programs while partnering with the Council on Chiropractic Education to develop accreditation standards for residency training. OAA’s efforts have yielded 5 accredited residency programs, the first in the United States. In 2020, the VA doubled the number of available chiropractic residency programs, and future expansion is anticipated. Since 2010, PT residencies have expanded from 1 to 28 programs (42 funded positions) across 4 board certification specialties: cardiovascular-pulmonary, geriatric, neurologic, and orthopedic. Similarly, the VA was one of the first organizations to achieve accreditation for OT fellowships; there are currently 5 accredited OT fellowship programs across 3 areas of practice: assistive technology, MH, and physical rehabilitation. The VA OT fellowship program focused on assistive technology is the only program in the United States at this time.

Interprofessional Education

As one of the primary focus areas for AH expansion, interprofessional education (IPE) has been recognized as increasingly important for the provision of health care and the development of HPT programs. IPE can develop professionals who appreciate the roles of diverse professions and can use teamwork to enhance clinical outcomes for patients.¹¹ There also are a growing number of professional organizations supporting the Interprofessional Education Collaborative with many representing AHPs.¹² Collaboration across HCPs is an important way of reducing health care costs by enhancing clinical outcomes, communication, and teamwork.^13-16 The VA and the nation’s health care system benefit from the by-products of interprofessional collaboration through investment in targeted training programs. In each phase of the AH expansion, special consideration was given to applicant programs offering unique and innovative clinical and educational experiences consistent with the promotion of interprofessional care. In doing so, increased numbers of AH HPTs have engaged in team-based clinical care.

Pain Management Pharmacy

The efforts of AH to align expansion with high-priority agency-wide efforts has resulted in the growth of pharmacy residency positions focused on pain management. Pharmacy postgraduate year (PGY) 2 residencies focusing on opioid reduction are an example of VA efforts to improve response to managing chronic pain and the long-term risks from opioid use during this national public health crisis.¹⁷ These residency programs focus on strategies to reduce the use of opioid medications in the clinical setting and teaching effective clinical interventions for reducing the rates of opioid addiction in veterans while still recognizing the need to identify and treat chronic pain. Before expansion efforts in 2018, there were 6 pharmacy residency programs focused on opioid use reduction in the VA, 8 pharmacy PGY2 residency positions were added in academic year 2019/2020, an additional 5 positions are being added in academic year 2021/2022 with the explicit goal of managing patients with high-risk chronic pain.

Rural Health

The lack of MH providers in rural areas has received much attention and is particularly important in the VA because veterans are more likely to live in less populated areas.¹⁸ The VA mandate to address this population was codified by the creation of the Office of Rural Health in 2006 via 38 USC § 7308.¹⁹Creating health professions training programs in rural settings provides HPTs the opportunity to learn professional competencies and train with faculty knowledgeable about this population—all of which provide a comprehensive training experience and serve as a recruitment pathway to hire HPTs into staff positions at these sites.¹⁹

When MHEE was initiated, not all regions of the country had funded VA psychology training programs, and this geographic gap in psychology training was a contributing factor to recruitment difficulties for psychologists in rural areas. As a result, the request for proposal process in the OAA highlighted and incentivized rurality when considering funding for new training programs. The OAA defined rurality as the number of patients served by the proposed health care facility who lived in a rural or highly rural zip code according to VA Support Service Center Capital Assets data.²⁰ As a result, VA psychology doctoral internships expanded to be available in all states, the District of Columbia, and Puerto Rico. MH training programs were started in the highly rural states of Montana and Wyoming. These expansion efforts promise to be an essential component to addressing the gaps in coverage in rural settings as noted in recent research.²¹

Pregraduate to Postgraduate Programs

The OAA AH education division supports a significant number of pregraduate-degree and postgraduate-degree training. Some professions, such as psychology, pharmacy, SW, PT, speech pathology, OT, and nutrition/dietetics receive funding at both levels of training. More recent, the OAA has started to move funding from pregraduate to postgraduate-degree positions, specifically within professions where pregraduate funding is uncommon for both federal and nonfederal training positions. The effort is designed to better align stipend-paid training programs with the VA Professional Qualification Standards and the final level of training required for employment in the VA.²²This means that HPTs receive stipend support during the highest level of their clinical training before degree conferral, eligibility for VA employment, or while participating in a postgraduate-degree residency or fellowship.

Additionally, this shift in focus and the resulting internal assessment of professions has allowed the OAA to fund more specialized training opportunities, which sometimes go beyond what is required by accrediting bodies or for recruitment into VA positions. For example, the OAA is supporting SW fellowship programs and PA residency positions to allow for greater specialization within these professions; the accrediting agencies for both professions have recently finalized their accreditation standards, and the OAA played a role in moving these standards forward.

While postgraduate residencies and fellowships are not required for all AH HPTs or for employment in the VA, there is a shift in some professions to encourage postgraduate training in advanced competencies in specialized areas. Participation in a residency or fellowship training program affords HPTs additional time and diverse clinical experiences to acquire clinical skills, all while under the supervision of a highly trained practitioner. This additional training also allows for a longitudinal assessment of the HPT to ensure an alignment of the HPTs’ knowledge, abilities, and skills with the expectation should they pursue VA employment.

In academic year 2019/2020, the OAA AH education division in conjunction with the PA national program office transitioned the entirety of the PA pregraduate-degree student positions (415 funded positions) to residency positions, increasing residency positions from 19 to 32 funded positions. This shift in emphasis for funding did not negatively impact the total number of pregraduate PA students receiving training in the VA and has created a pipeline of residency graduates who are ready to enter VA staff positions. To date, the VA has 14 PA residency programs across 3 specialties: emergency medicine (EM), MH, and primary care/geriatrics. Of these tracks, the VA offers 5 EM and 4 MH residencies that position graduates to be eligible for specialty certification. The National Commission on Certification of Physician Assistants established Certificates of Added Qualifications (CAQ) to recognize and document specialty knowledge, skills, and experience. The VA MH residency programs have been established to align with the CAQ expectations, and residents immediately qualify to take the CAQ examination after the completion of training.

Currently, the same process to move pregraduate to postgraduate funding is being implemented for PT and OT. Within the PT profession, there is increased momentum toward residency and fellowship training programs to respond to the changing complexity of the health care systemand reduce the need of complex care to be provided by non-VA providers in the community.²³ Both PT and OT have entered the initial phases of transitioning to residency or fellowship-funded positions. The OAA is partnering with these professions to move positions to postgraduate degree within the next 3 years with a commensurate increase in funding. The initial data indicate that 80% of graduated VA PT residents are board-certification eligible, and 89% of those who are eligible passed the examination on their first attempt.

Since 2013, the VA psychology training also has realized a growth in postgraduate-degree residencies. Psychology residency positions have increased 99% to 453 funded positions. This growth represents increased specialization in neuropsychology, geropsychology, rehabilitation psychology, and health psychology. Additionally, postgraduate residencies meet most jurisdictional requirements for postdoctoral supervised experience and better prepare HPTs to enter specialty staff positions that are necessary to care for aging veterans.

Additional professions are being targeted for postgraduate-degree training programs, including dietetics and speech pathology, to align with upcoming changes in the qualification standards for employment. While the process to transition positions to postgraduate-degree training programs can take 3 to 5 years, the outcomes are expected to result in better prepared HPTs who can fill staff vacancies in the VA.

Conclusions

Through its funding and oversight of numerous professions, the OAA is uniquely situated to adapt its portfolio to meet the needs of the VA and the nation. Over the past 10 years, the OAA has expanded its total number of HPT positions to enhance interprofessional care, respond to the VA’s strategic initiatives, address the care needs of rural veterans, and shift positions to postgraduate training programs. The OAA’s investment in high-quality training programs builds a strong health care workforce ready to meet the needs of an increasingly complex and integrated health care environment.

The OAA anticipates future expansion, especially related to promoting rural training opportunities and shifting to postgraduate training programs as a means of promoting advanced health care and health system competencies while continuing to align with workforce projections. Furthermore, while there are data on the percentage of VA staff who participated in OAA training program through the VA All Employee Survey (AES), the range for AH professions is wide. For example, about 37% of rehabilitative staff reported participating in an OAA training program, and 72% of VA psychologists reported having an OAA training experience. To maximize the hiring of HPTs, OAA will continue its partnership with WMC to enact programs aimed at streamlining the hiring process so that veterans have access to HCPs who are specifically trained to work with them.