Every year a number of graduating vascular trainees look for jobs in academic surgery to develop a career as a surgeon-scientist in basic, translational or health services research. The current era of productivity-based compensation and competing demands in clinical, teaching, research and administrative responsibilities pose significant challenges to that career path.
But the United States Department of Veterans Affairs—the VA—provides a supportive environment like no other in academic surgery with protected time, dedicated resources and funding for research.
VA research has three overarching strategic priorities: increasing veterans’ access to high-quality clinical trials, increasing the real-world impact of VA research and putting VA data to work for veterans.1
The VA Office of Research and Development (ORD) consists of four research services.2 The Biomedical Laboratory Research & Development Service (BLR&D) supports preclinical research on animals, tissues and biological specimens from humans to further understanding of health and disease from a molecular, genomic and physiologic standpoint.
Clinical Science Research & Development Service (CSR&D) encompasses all human volunteer research and clinical trials to study new treatments and improve clinical practice. Within this division, the Cooperative Studies Program (CSP) conducts large multicenter clinical trials.
Health Services Research & Development Service (HSR&D) sponsors research to study quality, access to care, cost and outcomes to improve healthcare delivery for veterans.
Unlike the National Institutes of Health (NIH), the VA will support research on cost effectiveness of therapies and budget impact analyses for programmatic evaluation. And Rehabilitation Research & Development Service (RR&D) focuses on innovative research to restore function and decrease disability in veterans.
Each division has multiple centers of excellence nationwide that can be excellent resources for new and existing surgeon-investigators as they set up labs and secure funding.
The core research funding award mechanisms for surgeons are the Career Development Awards (CDAs) and the VA Merit Review Awards. These federally sponsored grants provide substantial salary support, ensuring protected time for research, and are awarded exclusively to investigators with VA appointments.
The CDA program is intended to attract, develop and retain talented researchers to the VA.3 Candidates must be United States citizens. The CDA-1 is akin to a postdoctoral award and offered only by RR&D. The CDA-2 is the main award mechanism for junior surgical faculty. It is offered by all four services and provides three to five years of salary for research funds under appropriate mentorship within the VA. This is a considerably higher level of research support than NIH K awards. It is ideal to have at least one mentor who is VA-Merit funded.
While applicants needn’t be VA-appointed, they do need a VA appointment to be funded. Surgeons can receive up to 75% of salary support. They must also contribute 1/8 or 2/8 full-time equivalents to clinical service. CDA awards come with full VA indirect cost payments, thereby strongly incentivizing local VAs to support them.
Merit Review grants are similar to independent research parent R01s. Funding generally is for two-to-four years and investigators need to be at least 5/8 in terms of their VA appointment. The budget is approximately $1.2 million for four years for most services and $1.5 million for studies with multi-site exemptions.
There are multiple other pilot awards or focused Request For Applications (RFAs) sent out each year, typically oriented around VA strategic priorities and new efforts.
The VA’s many rich data sources can be used by vascular surgical investigators for a variety of research and operational projects to build their research programs.
The VA Corporate Data Warehouse (CDW) is a large repository of veteran data nationwide, including diagnoses, procedures, pharmacy, orders, labs, microbiology, physiologic measurements and text documents. Data can be queried and analyzed using the VA Informatics and Computing Infrastructure (VINCI) platform.4
The VA Surgical Quality Improvement Program (VASQIP) database captures cardiac and noncardiac surgeries at all VA facilities. This was the first national surgical registry and was the template used to develop the private-sector American College of Surgeons-NSQIP. The VASQIP data has many advantages, as data can be linked to center information and CDW data to answer hypotheses that are not possible through ACS-NSQIP.5
The Million Veteran Program (MVP) is the largest biobank in the world, collecting genomic information on a million veterans. This program provides another unique and exciting opportunity for VA investigators interested in studying genetic influence on health and disease.6
VA Clinical Assessment, Reporting and Tracking System for Cath Labs (CART) collects information for all invasive cardiac procedures performed by cardiologists at VA medical centers. The program maintains an independent research and publications committee that reviews proposals from VA investigators on a semi-annual basis.7
VA investigators and the VA CSP have always contributed to important trials in vascular surgery, influencing the management of vascular disease.8–11 Two very important vascular clinical trials have numerous VA sites and VA investigators as site principal investigators (PIs).
The sites are recruiting veterans to answer research questions that will influence management of chronic limb-threatening ischemia (CLTI) and carotid disease for many years to come. The trials are BEST-CLI (Best endovascular vs. best surgical therapy in patients with critical limb ischemia)12 and CREST-2 (Carotid revascularization and medical management for asymptomatic carotid stenosis trial).13
A number of VA vascular surgeons are PIs of active large national trials, including Panos Kougias, MD, on the TOP (Transfusion trigger after operations in high cardiac risk patients) trial, comparing liberal vs. restrictive transfusion strategies for high cardiovascular risk patients undergoing surgery;14 and Philip Goodney, MD, for PROVE-AAA (Preferences for open vs. endovascular repair of abdominal aortic aneurysm) to test if a decision aid can better align patients’ preferences and their treatment type for AAA.15
The ability to care for veterans and perform impactful research that improves both veterans’ lives and those of vascular patients at large is a calling and a privilege.
As the largest nationalized healthcare system in the U.S., the VA will continue to be an important part of training and career development for surgeon-scientists. (The references for this article can be accessed at vsweb.org/VA1220references.)
Shipra Arya, MD, is a member of the SVS VA Surgeons Committee.