A second change in the way VA research is done is point-of-care research, which is an attempt to take large clinical trials, particularly those that are comparing two well-accepted health care interventions: things that might both be standard of care, but may not be quite equal. Point-of-care research allows us to compare these interventions in a prospective, randomized fashion as they are used in the clinic. This will potentially give us the opportunity to run very large clinical trials that are capable of detecting somewhat small differences in reasonable time and at a reasonable cost. Now, why might that be important? Say we’re treating somebody for depression. Well, maybe one antidepressant is 5 percent better than another. A traditional randomized control trial can’t be big enough, at finite cost, to detect that small a difference. But 5 percent is a big deal if you’re one of those 5 percent who gets an immediate response. And it can have a tremendous impact down the road. So being able to identify things that are just slightly better at a reasonable cost has, in a health care system that takes care of six million people, a tremendous effect. Maybe 10,000 individuals might be effectively treated who weren’t treated effectively before.

We’re planning to launch a large point-of-care study over many sites comparing two diuretics used for the treatment of hypertension. One of them, chlorthalidone, has been used in most of the trials looking at the effectiveness of treating hypertension using diuretics. But the other, hydrochlorothiazide, is actually prescribed about 10 to 20 times as often, both inside and outside the VA, as chlorthalidone. It’s thought by many to be equivalent, but some of the hypertension experts think that maybe chlorthalidone will be better, because it has a longer half-life and so it should, they think, maintain and keep blood pressure from spiking so much over the course of a 24-hour day. The only way to know this, again, is through a clinical trial, and a clinical trial of this sort would be prohibitively expensive if done in the traditional way. But we believe this point-of-care randomization approach will make it possible for us to do this trial and do it at a more affordable cost.

Now that the wars in Iraq and Afghanistan appear to be winding down and service members are redeploying, do you think the close working relationship between VA and DOD research programs will continue?

Those collaborations aren’t going to go away. I think there are a couple of reasons for that: One, the collaboration is the right thing to do. Two, the personal relationships are good. Terry Rauch and I can finish each other’s sentences, we’re so much alike. Also, our research isn’t something that necessarily immediately benefits the soldiers, sailors, airmen, and Marines serving today. Many things that we do will take five or 10 or 15 years to truly pay off. As long as the United States plays a leadership role in the world, our uniformed men and women are going to be placed in harm’s way. And we need to be looking forward.

At the same time, obviously, there’s sometimes a crunch in health care access for veterans. Health care needs are immediate, and research is seen as having a future payoff. So there can be a tendency to say: ‘Well, we’ll put off the research and see our patients now.’ For a short period of time, this is perfectly appropriate and reasonable. But over a long period of time, if this continues, it’s like eating your seed corn. You have a problem with next year’s harvest. And so having a health care system embedded in a deeply political environment, I think, creates challenges, because the political system is not always as strong in thinking about the future as it is in dealing with the present.

How do you think VA research will position itself to anticipate what lies ahead for service members? That seems really difficult.

Some things will be difficult. But some things we can predict. We know from looking at the history of warfare that what we call post-traumatic stress disorder now, and what we call traumatic brain injury now, are things that have been going on for a very long time. We as human beings are not changing our physiology very quickly, and there’s nothing about the nature of warfare that’s going to make those issues go away.

One of the huge differences about warfare today, which I think we can prepare for to some degree, is the fact that now people are surviving injuries that would have been lethal in previous conflicts, which makes it much more important that we be aggressive in developing assistive devices and technologies of all sorts, such as tissue engineering, to try to ultimately be able to replace missing body parts. It’s important that we be looking forward to how to make whole those people who have survived – but survived with much more severe, chronic injuries than people would have dealt with in previous conflicts. That survivability is going to continue to go up. Our colleagues in DOD who do emergency surgery and emergency medicine are getting better all the time. And there is no doubt they’re going to be getting better, that we’ll be seeing more folks who survive more and more serious injuries. And we can anticipate that and work on it today.

It’s lovely when a research study that we do today benefits somebody who’s with us today. But those are not the only people who are called to serve, and our job is to look forward. I believe that the job of research is to help invent the future of health care.

What are some of your other goals for VA research – things you’d like to see happen while you’re in charge?

We’re dealing with a lot of challenges. One is that obviously research is fairly expensive – because of changes in technology, the cost of doing research tends to increase faster than the cost of living as a whole. In addition, the cost of conducting clinical trials, because of a desire to do a superb job of human-subject protection – and the regulatory burdens that go along with that, as well as scientific standards for doing clinical trials – all those things have increased the cost of doing clinical trials, at a rate that appears to be faster than the rate of increase of health care costs as a whole. This poses a challenge in a fiscally constrained environment. And that’s obviously some of the reason behind trying to transform the methods by which we do research, but that ultimately only takes us part of the way we need to go.

The second set of challenges, which also has a financial implication, is that the range of problems that we deal with in the Veterans Health Administration is very, very wide. And veterans who suffer these problems would like to see us engaged in research for two reasons. One is they believe that research may benefit them personally, or benefit those that suffer from similar problems coming in the future. Second, having clinicians in the health care system engaged in research assures that VHA is able to bring top-quality health care to the veterans these clinicians serve. That research-engaged physician is absolutely compelled, not just because of clinical care, but also because of his or her research interest, to keep up with the literature and change with the times.