A First Look at the VA MISSION Act Veteran Health Administration Medical School Scholarship and Loan Repayment Programs.

Background: The US Department of Veterans Affairs (VA) is challenged by physician staffing shortages. The 2018 VA MISSION ACT authorized 2 scholarship and loan repayment programs. The Health Professions Scholarship Program (HPSP) created scholarships for physicians and dentists. The Education Debt Reduction Program (EDRP) increased the maximum debt reduction. The Specialty Education Loan Repayment Program (SELRP) authorized the repayment of educational loans for physicians in specialties deemed necessary for VA. The Veterans Healing Veterans (VHV) program was a 1-year pilot program specifically for veteran medical students. Observations: For academic years 2020/2021 and 2021/2022, HPSP offered 54 scholarships with 51 accepted. In 2020, the VHV program offered 22 scholarships with 12 accepted by recipients at all 5 Teague-Cranston medical schools and 4 Historically Black Colleges and Universities. For SELRP, 14 applicants have been approved in family medicine, internal medicine, emergency medicine, and geriatrics. The average loan repayment is anticipated to be $110,000, which equates to 38.5 VA service years for the 14 applicants. Since 2018, 1546 physicians received EDRP awards with amounts increased from an average of $96,090 in 2018 to $148,302 in 2020. Conclusions: The VA MISSION Act's scholarship and loan repayment programs provide VA with several ways to address physician workforce shortages. Ultimately, the success of the program will be determined by the recruitment of scholarship recipients to VA careers.

Veterans Affairs Graduate Medical Education Expansion Addresses U.S. Physician Workforce Needs.

The United States has a well-trained, highly specialized physician workforce yet continues to have care gaps across the nation. Deficiencies in primary care and mental health specialties are most frequently cited, though critical shortages in multiple disciplines exist, particularly in rural areas. Sponsoring institutions of physician graduate medical education (GME) have created rural residency tracks with modest federal funding and minimal incentives, though efforts targeting shortages in these specialties and geographic locations have been limited. In response to access problems in the Veterans Health Administration, Department of Veterans Affairs (VA), the second largest federal funder of GME with the most expansive clinical education platform, Congress passed the Veterans Access, Choice, and Accountability Act of 2014. This act directed the VA and provided funding to establish 1,500 new positions, a 15% expansion of VA-funded positions at the time. Priority for position selection was given to primary care, mental health, and any other specialties the secretary of VA determined appropriate. Importantly, priority was also given to VA facilities with documented physician shortages, those that did not have GME training programs, those in communities with high concentrations of veterans, and those in health profession shortage areas. Many rural facilities match this profile and were targeted for this initiative. At the conclusion of fiscal year 2021, 1,490 positions had been authorized, and 21 of the 22 VA medical centers previously without GME activity had added residents or were planning to soon. Of the authorized positions, 42% are in primary care, 24% in mental health, and 34% in critically needed additional specialties. Targeted GME expansion in the VA, the largest integrated health care system in the nation, has been successful in addressing physician GME training that aligns with physician shortages and may serve as a model to address national physician specialty and geographic workforce needs.

The Regional Distribution of Psychiatric Residency Positions Funded by the Department of Veterans Affairs and Its Relationship to Rural Veteran Populations.

OBJECTIVE: The authors evaluated the distribution of psychiatry residency positions funded by the Department of Veterans Affairs between 2014 and 2020 with respect to geographic location and hospital patient population rurality. METHODS: The authors collected data on psychiatry residency positions from the Veterans Affairs' Office of Academic Affiliations Support Center and data on hospital-level patient rurality from the Veterans Health Administration Support Service Center. They examined the chronological and geospatial relationships between the number of residency positions deployed and the size of the rural patient populations served. RESULTS: Between 2014 and 2020, the Department of Veterans Affairs has substantially increased the number of rural hospitals hosting psychiatry residency programs, as well as the number of residency positions at those hospitals. However, several geographic regions serve high numbers of rural veterans with few or no psychiatry resident positions. CONCLUSIONS: While the VA efforts to increase psychiatry residency positions in rural areas have been partially successful, additional progress can be made increasing support for psychiatry trainees at Veterans Affairs hospitals and community-based outpatient clinics that serve large portions of the rural veteran population.

A Year 3 Progress Report on Graduate Medical Education Expansion in the Veterans Access, Choice, and Accountability Act.

The VA has made progress in implementing mandates to expand medical residency programs to more rural and underserved locations and to increase access to family care providers, but some specialties, like geriatrics, remain underrepresented.

Pain management by the family physician: the family practice pain education project.

Pain is a common complaint of patients who visit a family physician, and its appropriate management is a medical mandate. The fundamental principles for pain management are: placing the patient at the center of care; adequately assessing and quantifying pain; treating pain adequately; maximizing function; accounting for culture and gender differences; identifying red and yellow flags early; understanding and differentiating tolerance, dependence and addiction; minimizing side effects; and being familiar with and using CAM therapies when good evidence of efficacy exists. The pharmacologic management of pain requires thorough knowledge of nonsteroidal anti-inflammatory drugs, cyclo-oxygenase-2-specific inhibitors, and opioids. A table of equianalgesic dosages is useful because patients may need to move from one opioid to another. Accompanying this article are papers discussing 5 common pain disorders seen by family physicians, including: neck pain, low back pain, joint pain, pelvic pain, and cancer/end of life pain. The family physician who learns these principles of pain management and the algorithms for these common pain disorders can serve patients well.

Evaluation and treatment of posterior neck pain in family practice.

Neck pain is almost universal and is a common patient complaint. Although the differential diagnosis is extensive, most symptoms are from biomechanical sources, such as axial neck pain, whiplash-associated disorder (WAD), and radiculopathy. Most symptoms abate quickly with little intervention. There is relatively little high-quality treatment evidence available, and no consensus on management of axial neck pain or radiculopathy. A number of general pain management guidelines are applicable to neck pain, and specific guidelines are available on the management of WAD. The goal of diagnosis is to identify the anatomic pain generator(s). Patient history and examination are important in distinguishing potential causes and identifying red flags. Diagnostic imaging should be ordered only when necessary because of the high incidence of asymptomatic radiographic abnormalities. First-line drug treatments include acetaminophen, cyclo-oxygenase 2-specific inhibitors, or nonsteroidal anti-inflammatory drugs. Short-term use of muscle relaxants may be considered. Opioids should be used if other treatments are ineffective and continued if improved function outweighs impairment. Adjuvant antidepressants and anticonvulsants should be considered in chronic or neuropathic pain and coincident depression. Epidural steroids should be considered only in radiculopathy. Physical modalities supported by evidence should be used. If symptoms have not resolved in 4 to 6 weeks, re-evaluation and additional workup should be considered.

Management of pelvic pain from dysmenorrhea or endometriosis.

Many women suffer from pelvic pain, and a great many visit their family doctor for diagnosis and treatment. Two common causes are primary dysmenorrhea and endometriosis. Primary dysmenorrhea is best treated by prostaglandin inhibition from nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 (COX-2)-specific inhibitors. Oral contraceptives can be added to improve pain control. Endometriosis can be treated with NSAIDs and COX-2-specific inhibitors as well but can also be treated with hormonal manipulation or surgery. Empiric treatment for endometriosis in selected patients is now accepted, making the disorder easier for family physicians to manage.