1. Chief of Staff and Research C. Diana Nicoll, MD, PhD, MPA Chief of Staff, SFVAMC Associate Dean, UCSF School of Medicine Professor and Vice Chair of Laboratory Medicine, UCSF

2. The four missions of the VA Patient care Education Research DOD support COS is responsible for the quality of clinical care and for providing an academic environment suitable for education and research

3. Competition for Resources The four VA missions compete for resources e.g. space, Medical Center funding support, clinician scientist time COS must establish and maintain balance between these missions Balance is difficult since (at SFVA) most physicians have research funding and academic promotion depends on research success (not clinical productivity )

4. Partnerships needed to establish a common strategic plan for VA Research COS Medical Center Director ACOS for Research Research Foundation CEO Clinical Service Chiefs Affiliate Dean and Department Chairs

5. COS must bridge differences in incentives Medical Center Director is rewarded for clinical volume and quality (as judged by performance measures) Affiliate Dean and Chairs focus on medical student teaching (for which VA has no reward system) and research productivity of VA faculty (not clinical contribution)

6. Relationship of COS (as Associate Dean) with affiliate COS/Associate Dean for VA must be a strong advocate for the VA at the affiliate As a result of my advocacy, in 1995 UCSF Chancellor and Dean agreed to allow VA faculty to have grants (including NIH) administered by our VA Research Foundation SFVA research program subsequently grew to become the largest VA research program (78 million dollars) successfully leveraging VA’s academic investment

7. COS, Service Chiefs and recruitment and retention of physicians Recruitment and retention of physicians is a major responsibility of COS and Service Chiefs Success requires commitment of significant research time and resources for clinician scientists who must also provide needed patient care Balance can be difficult because of growing clinical demands and increasing competition for research grants The academic “ triple threat” (an individual who is clinician, teacher and researcher) is an endangered species (if not extinct)

8. Synergy between the VA, VA Research Foundation, Affiliate and DOD All our physicians are jointly recruited by the VA and UCSF (based on VA clinical need) so liaison roles of COS and Clinical Service Chiefs (Vice Chairs) with the affiliate are important Recruitment packages involve contributions from VA Medical Center, VA Research Service, VA Research Foundation and affiliate Department DOD research funding provides an additional opportunity for VA researchers (M.D.s and Ph.Ds) so VA-DOD relationship is significant

9. COS, ACOS for Research and the VA Research Foundation COS and ACOS for Research are ex-officio members of the Board and Executive Committee of the Research Foundation This is critical since the strategic plan for research at the VA must be set by the VA and not the Foundation and the VA must know how the Foundation funds are being used COS and ACOS for Research have responsibility for taking this leadership in research direction which must reflect clinical needs of veterans

10. COS and ACOS for Research ACOS is asked to provide resources for current and additional programs (space, lab renovation, core facilities etc) and to oversee compliance with research subject (both human and animal) safety and privacy etc COS must support the ACOS for Research and advocate for research when resources (space and money) are being allocated by Medical Center resource committees and the Medical Center Director

11. COS, ACOS for Research and Medical Center Director Medical Center Director, as the final arbiter of resource allocation, is vital to the support of Research Service Medical Center Director needs to respect the role of Research in contributing to all the VA missions and to have confidence in and trust the COS and ACOS for Research The relationship between these three will directly affect the success of any research enterprise which must to be able to recruit and retain top-flight researchers in conjunction with academic affiliates.

12. Medical Center Director Involvement in Research Briefings by Chief of Staff and ACOS for Research Research & Development Committee Research Foundation Board of Directors

13. Benefit of Research to Medical Center and Medical Center Director New knowledge Cutting-edge technology/treatment for patients Recruitment tool VERA contribution Indirect costs Good publicity in medical journals and the media Interest by congressional representatives and VA leadership Enhanced Medical Center reputation with affiliate and the general public