Working so closely with a large public-health system has also helped to make Penn a leader in health-service research. Gaulton cites as an example the work of Dr. Margaret G. Stineman GM’87, vice chair and director of research in the Department of Rehabilitation and Physical Medicine, and her colleagues on patient classification, which is the basis for current Medicare procedures and has been used to establish industry measures on inpatient rehabilitation, patient mobility, and quality of life.

“The VA is probably the only large mental-health system in the country,” says Dr. David W. Oslin GM’01, associate professor of psychiatry at PVAMC and Penn. Unlike physical medicine, most mental health clinics are still “very isolated,” he says. “They function essentially as individual practices. There’s little integration.” At the VA, there is “a lot more integration and dialogue between physicians working in primary care and psychiatry. It’s the same records, same system.”

Penn’s affiliation with PVAMC provides data that is key to Oslin’s substance-abuse work, which includes research on connections between alcohol dependence and mental illnesses such as depression, he says. “We do 60,000 alcohol screens a year at this facility and there are 3.5 million screens through the nation’s whole [VA] system.” Many veterans participate in Penn clinical trials on such issues as suicide prevention and post-traumatic stress disorder, helping both patients and researchers.

Another benefit of the affiliation is that young doctors are “being exposed to different cultures and ways of doing medicine,” says Oslin. “Their career development isn’t monolithic. This is a fully integrated public-health system. They can take bits and pieces of it and move the field along.” He adds that this is particularly timely now, with health reform prominent on the national agenda and more and more medical schools trying to build system-development into their curriculums.

Dr. Rachel Bennett, a first year intern in psychology, says that PVAMC’s “holistic view” is something she will take with her when she practices. “There is a social mission to help with [veterans’] lives,” she says, explaining how that means working with social workers, veterans’ families, primary-care physicians, and any needed specialists. She says she has treated young Iraq veterans with “post-traumatic stress disorders so bad they have to be hospitalized and can’t hold jobs or relationships,” and notes that it is not unusual for her to spend more than an hour talking to one of them about their experiences and issues. She talks solemnly about how these veterans, the same age as she is, have already sacrificed so much. Eventually, Bennett wants to work with children and adolescents who are victims of severe trauma and abuse. She says that her PVAMC training has helped prepare her, noting that the nightmares and inability to trust are shared by both groups.

Bennett and most other residents say that learning how to counsel patients, being empowered to make decisions, and gaining hands-on experience provide invaluable training. With no overnight phlebotomy service, residents become accustomed to drawing blood. They develop strong relationships with patients and are often the ones asked to deliver bad news or console a family. When staff is short, they might even have to transport patients for tests. “Most hospitals are much more ‘top-down,’” says Flesch. “I’m approaching the end of my medical training and this will make me a better attending physician.” He says that spending time with patients has improved his clinical judgment, for example by making him more aware of the importance of not just relying on an echocardiogram but “paying attention to the physical exam and what’s going on in the heart.” When Mariani leads residents on rounds, she points out how she uses all of her senses to evaluate patients—listening to their breathing, noting how a sore smells, feeling the skin, etc.

Doctors say that being “hands on” and having more autonomy leads to innovation and improvements in care. Dr. Samuel Kuna M’06, associate professor of medicine and chief of the pulmonary, critical care, and sleep section at PVAMC, says that at the VA he has been able to experiment with many new programs, such as group sessions for clinical management. While that program ultimately saved money, Kuna says it would have been difficult to try it in a system dependent upon third-party payers and using established billing codes and procedures. PVAMC opened an on-site sleep center in 2003 to serve the increasing number of veterans suffering from stress-related sleep disorders. It treated more than 1,800 veterans in 2008 with inpatient and home-based programs that monitored their sleep and used combinations of talk, drug, and behavioral therapies.

As a training site for future medical leaders, Penn is known for providing access to state-of-the-art technology, cutting-edge research and world-renowned physicians. Students and residents who do a rotation at PVAMC say they also benefit from something simpler but often transformational: time to spend with a special group of patients, from whom they learn firsthand what it takes to be a doctor. It is, says Judd Flesch, “a special privilege to help veterans.”

Randy Mintz-Presant is a freelance writer in Philadelphia.

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Crossing the Street By Randy Mintz-Presant

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