Serving those who served: For many Yale physicians, veteran care has become a mission

A decade ago, Yale’s Merilyn Varghese was working as a medical resident in a cardiac intensive care unit when she first encountered a patient population that would change the course of her career.

It was during that time that she first became interested in cardiology. And she found that military veterans were a population unlike any other, particularly when it comes to cardiac risk factors, including post-traumatic stress disorder, depression, and increased levels of hypertension. Working with them, she discovered, offered a unique mission. 

Today, Varghese is an assistant professor of cardiology at Yale School of Medicine and medical director for cardiac rehabilitation and primary prevention at the West Haven VA Medical Center. In her work at the VA, she is focused on one primary goal: improving rehabilitation rates among military veterans. 

“Veterans have given their time, health, all sorts of sacrifices for this country,” she says. “Working with veterans is meaningful. It’s one of the most valuable, enriching clinical experiences I’ve had.”

Among Yale physicians, Varghese is not alone in pursuing this mission. Yale School of Medicine’s longtime affiliation with the VA Connecticut Healthcare System in nearby West Haven has allowed generations of physicians to work with and learn from military veterans. Currently, about 77 internal medicine faculty members alone care for VA patients in numerous clinics, lead educational initiatives, and perform research.

Over the years their efforts have yielded important discoveries in veterans’ health issues and sparked the creation of innovative clinics and services to better meet veterans’ unique health care needs.

Among recent initiatives are the first VA program offering at-home rheumatology care for homebound veterans; the first VA program offering transcatheter aortic valve replacement, a minimally invasive heart valve replacement procedure; a local screening site for national colorectal, cirrhosis, and liver cancer screening trials; a remote HIV care management program; and a mobile services program for homeless veterans.

While its main location is in West Haven, the Connecticut VA Healthcare System also works with clinics around the state. Primary and specialty health care services include mental health services, cancer treatment, palliative and hospice care, physical therapy, and rehabilitation programs, among others. 

The VA is also a training ground for students, providing residency and fellowship programs, as well as research opportunities. 

“Faculty split their time between Yale and the VA, bringing with them expertise, innovation, and a tradition of excellence,” says Chris Ruser, acting chief of medicine for the VA Connecticut Healthcare System and a professor medicine at Yale School of Medicine. “The trainees, overseen by Yale faculty, provide invaluable, high-volume, high-quality patient care services.”

Some trainees, in fact, stay on permanently.

“So many of us who train at the VA will ultimately start our careers here — whether we embrace the mission of serving those who served, are inspired by Yale faculty, or see the educational and research potential of a mission-driven, single payer, population health-based system, we’re hooked,” Ruser says. “These careers sustain the cycle, supporting successive generations of veterans to come.”

Here we take a closer look at just a couple of new Yale initiatives that have potential to reshape critical aspects of veterans’ health care. 

Blood lipid pilot program expands across New England

Maintaining blood cholesterol levels within a healthy range is essential for long-term health. For some people, however, it remains a stubborn and serious challenge. Standard medications and diet changes aren’t always enough. They require more specialized, sustained care.

Three years ago, endocrinologists Daniel Vatner and Varman Samuel set out to address this gap for veterans in Connecticut. They launched a pilot program for individuals struggling with severe lipid disorders, creating what would become the VA Connecticut Endocrine Lipid Clinic. That local initiative has quickly grown, expanding across New England.

Both physicians treat patients within the Connecticut VA system and recognized an unmet need. “We’d been talking about this for a long time,” says Vatner, the clinic’s director. “So, we decided to build a consult service for patients with extremely high cholesterol and triglycerides. The response has been great — we’ve had strong support from primary care providers and cardiologists alike.”

Now operating as the VISN1 Endocrinology Lipid Clinic, the program serves veterans across the region. Specifically, it focuses on patients with dangerously elevated LDL cholesterol or triglycerides — conditions that significantly increase the risk of heart attack, stroke, pancreatitis, and other serious complications.

“There’s a small but vulnerable group of patients with extremely high lipid levels,” Vatner explains. “They face much greater health risks. As endocrinologists, our goal is prevention—helping patients manage conditions now to avoid life-threatening problems later.” 

The clinic combines specialized expertise within the VA’s extensive infrastructure, allowing it to reach patients across state lines. Providers refer patients for advanced care, including genetic testing and newer therapies, and consultations are often conducted via telehealth.

“The VA system makes this kind of collaboration possible,” Vatner says. “There are specialized programs across the country — like a major genetics initiative in Utah — that support multiple VA centers. We wanted to start regionally and build from there.”

Right now, the focus is on expanding awareness. Lipid clinics are relatively rare and often concentrated in major urban centers, which leaves many patients without access to advanced care.

“We’re working to connect with more primary care physicians across the network,” Vatner says. “These clinics are few and far between, and access can be a real barrier. Our goal is to bring this level of care directly to the patients who need it.”

Closing the cardiac rehab gap

Cardiologist Merilyn Varghese, who completed her internal medicine residency at Yale, started working at the VA in West Haven in 2023 and quickly focused on improving cardiac rehabilitation rates among military veterans.

“These rates abysmally low across all populations and veterans are no exception,” she says. “I’m passionate about intervening to improve participation rates, and the time is now. We need to do something urgently.”

To this end, Varghese has undertaken new research initiatives exploring why rehab rates are so low among veterans and how to change that.

The West Haven VA already had a strong rehab program in place when Varghese arrived, but she wanted to take a closer look, and a two-year grant to study national cardiac rehab uptake rates, including sex-based differences, kicked things off.

“Veterans are not a population that’s been really thoroughly studied from the cardiac rehab perspective,” she says. “My take was, if I want to figure out how to improve rehab uptake, I need to first figure out what uptake is.”

In earlier work, her team found that cardiac rehab rates among Medicare beneficiaries — never great — truly plummeted with the arrival of the COVID-19 pandemic, and by the end of 2021 they still hadn’t recovered. In her current study, the rates of rehab uptake hovered at around 10%. (The Centers for Disease Control and Prevention has set a national goal of 70%.)

Those receiving rehabilitation services had particular kinds of cardiac events, “and they’re now being told, ‘Come to rehab so that you can get better, improve your quality of life, and possibly prevent another cardiac event,’” Varghese says. “And only 10% are showing up.”

To make matters worse, she says, the stakes for veterans appear to be even higher.

“One thing we’ve learned is that veterans have a different set of cardiovascular risk factors than the civilian population,” Varghese says. “Many of the traditional risk factors like high cholesterol hypertension, obesity, diabetes, are in higher prevalence among veterans.” 

It also appears that women veterans, who comprise a growing segment of the military, may be most vulnerable.

“A pivotal study in 2023 comparing women veterans to civilian women found that women veterans had an increased mortality rate from cardiovascular disease,” Varghese says. “We’re not sure why, and this is one of the areas that needs more research.”

But why do veterans as an overall cohort have higher cardiac disease risk factors? “That’s another question that really needs to be parsed out and answered,” Varghese says.

The higher prevalence of conditions like PTSD and depression among veterans may offer a clue.

“The connection between coronary artery disease and these stressors hasn’t been fully fleshed out yet,” she says. “But my hypothesis is that in the upcoming years, we’re going to see more data pointing out that these stressors greatly affect us all the way down to our blood vessels, unfortunately.”

With all these risk factors, why is there such resistance to rehab? Varghese’s work has turned up a few reasons.

“Some people feel they don’t have time to go to three sessions per week for 36 weeks,” she says. “The data show that things like scheduling, transportation, distance to a cardiac rehab facility all affect whether people go. Of course, this assumes that providers are referring everyone eligible to cardiac rehab.”

And then there’s the “fear factor,” something that Varghese says a good rehab program can help patients overcome. “Many patients are scared even to go for a walk after a cardiac event,” she explains. “When they have this life-altering diagnosis, it changes everything. They worry that they’ll have another heart attack or something else will go wrong. Our job is to remind them that rehab is monitored. It’s safe, and we’re here to support them every step of the way.”

The rehab pipeline really begins right after the cardiac event with physicians ensuring that all qualifying patients are referred to rehab, Varghese says. Making that rehab accessible and flexible — sometimes through hybrid or home-based programs — also helps.

Rehab is also about more than exercise. It has a multidisciplinary focus that covers topics such as tobacco cessation management, nutritional counseling, stress management, and medication management. 

“The patients who stay in rehab often say afterwards that they feel better than they ever have,” Varghese says. “Some of that might be because they now have a stent in their heart, but some is also actually because they’re not scared anymore, and that makes a huge difference. My goal is to get every veteran who needs rehab into it.”