In his second inaugural address, Abraham Lincoln urged congress, “to care for him who shall have borne the battle and for his widow, and his orphan.” The Veterans Administration (VA), a cabinet-level federal agency, has since adopted this quote as their motto. The VA is best known for operating the US’ largest integrated health system, the Veterans Health Administration (VHA). The VA provides comprehensive health care for 8.76 million Veterans across the entire continuum of care from home health services to critical care and everything in between. As part of their wide-ranging health services, the VA employs gastroenterologists with all types of clinical interests to serve the needs of the Veterans in the care of the VA [1]. Pursuing a career as a VA gastroenterologist has numerous appealing aspects and some features that may make it less attractive, depending on your preferences. The VA is a unique place to practice medicine and should be considered as an appealing employment option by any fellow, particularly one with academic aspirations.

Academic Careers at the VA

The VHA has an educational and research mission in addition to caring for Veterans. Ninety percent of allopathic and 80% of osteopathic medical schools are affiliated with the VA, and over 70% of VA physicians have an academic appointment [1]. There is strong institutional support for teaching medical students, residents, and fellows.

The VHA Office of Research and Development supports preclinical and clinical research, with several funding mechanisms including career development awards to help investigators early in their career [2, 3]. The VA’s robust EMR with an embedded research infrastructure facilitates collaboration by clinical outcomes investigators across the country. The integrated EMR and ample funding opportunities have been used to make both basic science and clinical discoveries, including the discovery that the hormone ghrelin is linked to obesity [4] and a seminal study establishing colonoscopy as the “gold standard” for colon cancer screening [5]. Many VA researchers are nationally recognized leaders in the field of gastroenterology, having served as editors of major GI journals (including this journal) and presidents of GI societies, and have received prestigious national and international awards [3, 6, 7].

Clinical Practice at the VA

The scope of clinical gastroenterology and hepatology varies among VA facilities, from general gastroenterology to advanced endoscopy and transplant hepatology. The practice of medicine at the VA can be very rewarding since caring for these brave individuals who have often sacrificed so much for their country can be deeply meaningful. Shepherding a Veteran to liver transplant or preventing a colon cancer is usually followed by sincere and heartfelt gratitude, often to a greater and more meaningful extent than occurs in the general population.

The VA has used an award-winning electronic medical record (CPRS) for over 25 years [8]. Though the interface is a bit old-fashioned looking, record keeping is intuitive, simple and comprehensive [9]. Clinic slots are scheduled for 30 min, rather than 20 as is common in many commercial practices [1]. While there are internal controls and authorizations required for some medications and procedures, these are sensible cost and utilization controls requiring the provider to justify the use of newer and more expensive treatments when older therapies are considered adequate. The VA contracts nationally for medications, usually negotiating much lower costs than in the private sector, and there are no insurance companies to deal with and no prior authorizations required. Gastroenterologists working for the VA are free to focus on their academic, administrative and clinical interests such that the VA enables physicians to avoid worrying about the business aspects of running a practice. Legal exposure to malpractice is limited as the federal government, not the individual provider, is named in malpractice suits [1].

A career at the VA can facilitate a good work-life balance, with all federal holidays off and 26 days of paid leave per year. Working for the VA and thus the federal government provides eligibility for federal benefits including the federal employee retirement system, thrift savings plan, and federal pensions in addition to 401(k) retirement savings plans, and federal employees health benefits [10]. These benefits are even more lucrative for military Veterans. The VA pays competitive salaries based upon which region physicians are employed and physicians are eligible for performance bonuses.

Potential Pitfalls of Working at the VA

While there are compelling reasons to work for the VA, there are some considerations that may not make it a fit for everyone. GIs working for the VA may deal with lower pay, working conditions, and benefits as compared to the private sector, especially for some of the more lucrative jobs and in certain regions in the country. The VA is a complex federal bureaucracy, particularly with credentialing, human resources, and IRBs. There are also occasionally limits on specific therapies. For example, the VA may limit the use of propofol for moderate sedation during endoscopic procedures [11] or as stated previously, patients must fail multiple medications before being eligible for newer medications for IBS such as rifaximin or linaclotide. VAs can also vary widely in terms of academic programs, university integration, and the breadth of pathology encountered. Although the majority of patients are men, this is beginning to change as more women serve or have served in the military. US citizens are preferred for VA jobs, and non-citizens will only be employed if positions remained unfilled by qualified US citizen applicants. Veterans often face unique challenges, such as significantly higher rates of PTSD, psychological morbidity, and substance abuse [12], which can complicate caring for their GI conditions. Patience, a sympathetic ear and the benefit of the doubt, is required in caring for many patients. Providers must have internal motivation to care for these brave men and women. It is often up to the doctors to drive the system to respond quickly to conditions when closer or more frequent follow-up is indicated. Physicians who simply want a “day job” and who do not seek to gain meaning from their employment need not apply to the VA.

Final Thoughts

Working within the comprehensive care delivery network of the VA can be a rewarding career for the young gastroenterologist. The VA is a unique healthcare entity to work for; working there has its own benefits and downsides. A VA career provides a strong platform on which to launch an academic career with a good work-life balance. There may be bureaucracy to navigate but care is more completely covered than most other settings. The Veteran patient population brings its own joys and difficulties. Compensation is generous but not the most lucrative. A frank assessment of priorities of the applicant and attributes of a particular employment opportunity should be had before considering any job, and the VA is no exception. There are gastroenterologists who happily work at the VA across the country, and any young GI should strongly consider the VA when planning their career.