Alan Pitt: Good morning, this is Dr. Alan Pitt. I’m here on Healthcare PittStop, and I feel very proud to have Dr. David Shulkin as a guest today. Dr. Shulkin has become something of a hero to me in his willingness to stand up for what’s right. I recently finished a book called The Price We Pay. It’s sort of an almanac describing what started as a well-meaning system of care but has become closer to a business. It’s made me begin to wonder: Does our role as providers, as healthcare administrators, as people in the industry—does that role begin and end with the patient, or do we, as insiders, as providers, have a responsibility to recognize abuse and to work to fix the system? If we choose to fight that fight, how do we do it in a meaningful way, and what price can we expect to pay as healthcare activists? Dr. Shulkin really has taken the lead on this topic in the media recently. He’s the former head of the Veterans Administration (VA). He has become a voice speaking out against the broken process, and his new book It Should Not Be This Hard to Serve Your Country is recently out. David, welcome.
David Shulkin: Thank you very much, Alan. Glad to be with you.
AP: David, I was struck by your story. For those who aren’t informed, can you tell me a little bit about how you heard you were going to run the VA?
DS: Well, first of all, I came to Washington in 2015 with the Obama administration, when President Obama had asked me to step in when the wait-time crisis was happening, and it looked like veterans were being harmed by not getting access to care. So I had been in Washington for a while, helping correct that situation. When there’s a change of administration, like when President Trump won the election, all of us who were Obama appointees were getting ready to leave the administration. You submit your resignation—that’s a mandatory requirement—and at noon on January 20th you’re expected to pack your bags, gather your boxes, and leave your office. Much to my surprise, on January 11, I learned that President Trump had asked me to be his new Secretary of Veteran Affairs.
AP: That’s just amazing. I read through the article you wrote in Time about this, and for those interested, if you look back to the October 16, 2019 issue of Time, it really goes through the blow-by-blow, if you will, about what happened. What did you feel when you joined the VA? What was your mission there? What were you trying to do?
DS: Well, I was like most Americans: I was in the private sector. I happened to be the CEO of a hospital at the time, and I was reading in the paper and hearing on TV about the horrible conditions that veterans were facing. They were waiting for care, which none of us felt they should be, and I wondered what I could do to help them. Eventually when, by coincidence, I got a call saying that they were asking me to help, I thought, “Well, how could I say no?” If I feel like I had some professional abilities that could help them, to serve the country and to help veterans, I really felt like it was my duty to go and to try to be part of the solution. That’s ultimately what I did. I left my job and moved to Washington to try to fix the largest healthcare system that was, not only the largest in the country, but the one that’s dedicated to our veterans.
AP: That’s very laudable. I think most of us are looking for some purpose. It’s one thing to earn a living, but it’s another thing to have a purpose; a calling, if you will, to try to do things. Now, in my career, I trained at the VA, and I owe a debt of gratitude to many of those very patient veterans, particularly when I was a medical student. In terms of learning to draw blood and interact with patients, they were extremely patient with me. But I will say that the VA has some strengths and it has some weaknesses. Some people point to the VA and say, “This is what healthcare will be like as a single-payer system,” because in some senses it is a single-payer system. And how did you feel about the VA? I know there was an effort on your part to privatize it. Why privatize the VA?
DS: Yeah, Alan, just like you, my last experience with the VA prior to coming to government was when I was a medical student and resident. I had actually worked in three different VAs, and it is funny—that’s where I learned to draw blood as well on a very, very patient veteran who kept encouraging me to try again until I had it right. Many of us, 70% of physicians who trained in the United States, had experiences training in the VA. So I think it’s a special place for all of us. But when I went into the VA later in life, when I joined government, I thought I might find this system that was so broken and so inefficient that the best thing I could do would be to actually shut it down and move everything to the private sector. [The private sector was] a system that I understood very well, having led private sector organizations my entire professional career.
DS: But when I got there, I found something very different. I found that VA was delivering care in a very different way than the private sector. When it came to the needs of veterans, simply moving that care into the private sector wasn’t practical because there weren’t alternatives in the private sector for what veterans needed. One of the ways I learned this was by putting on a white coat and going in and taking care of veterans, by seeing them in the hospitals and taking care of them, even via telehealth.
DS: Using behavioral healthcare as an example, I think most of us know that the behavioral healthcare system in the private sector is often lacking, with gaps in care and difficulty in accessing it. The VA system just has a tremendous infrastructure for treating conditions that veterans need help with. By simply eliminating that system and giving veterans vouchers to go into the private sector, I think we’d be doing them a disservice.
AP: That’s interesting. For those of you listening, behavioral health doesn’t really get paid for. So the private sector is really very understaffed—woefully understaffed—but I think people are coming to recognize that behavioral health or what some people call integrated care, treating the whole patient with both behavioral and physical issues, is really about the future. Quite interesting. So you felt the VA was in fact stronger in terms of treating behavioral health issues than the private sector?
DS: But what I found was, was that the things that VA did extraordinarily well weren’t readily available in the private sector, and yet, veterans required services that the VA wasn’t doing as well as the private sector. So the system I ultimately designed was really something of a hybrid. If you put the veteran at the center of your decision-making and say, “Let’s just do what’s right for them. Let’s put aside where they get care, and let’s just do what’s right for the veteran,” you end up with a system where you have a strong VA that is able to deliver on those services that veterans really need and that the VA does uniquely well, and you end up with a system that allows veterans access to the private sector when they need services that the VA doesn’t provide, doesn’t provide well, or has long wait times. So it’s this integrated system between government and the private sector that I think really meets the needs of veterans.
AP: That’s very interesting, a hybrid model. Now, I know that during your tenure at the VA, you were moving to privatize, to provide improved access for veterans at the VA. You told me while we were at this meeting recently, HLTH, the numbers were up dramatically, is that correct?
DS: That’s correct. When I first joined the VA, 19% of veterans were getting care in the private sector. When I left three years later, that number was up to 36%. And I believe very strongly in being transparent about my decision-making. I wrote up the vision for this model of a hybrid system and published it in the New England Journal of Medicine. I spoke about our wait times publicly. I was very open about how we were going to make these decisions and how we aimed to involve staff at the VA in those decisions, and I felt like we’d found the formula for fixing the problems in the VA. We had significantly reduced wait times, we had improved quality, and we were making a great deal of progress toward that model. But in a system as big as the VA, this will take years and years to fully implement, and simply can’t be done overnight when you have 375,000 employees who work in the system.
AP: Yes, that’s an enormous, enormous system. And then, you’re making these strides, you have this hybrid model, it makes sense, and then kind of summarily, via tweet, you are relieved of your role at the VA. What happened there? Why did it happen?
DS: Well, it may have been somewhat surprising at the time, but I think Americans have since come to learn that President Trump does things differently than other presidents. So now we’ve seen 17 members of the cabinet, of course, I was one of them, who have rotated through, and many were fired the way that I was. This is reality: When you serve in the Cabinet, you serve at the pleasure of the President, so I knew that could be one of the outcomes. And I think if you work in this administration, you should probably be planning on something similar happening to you as well, or at least know that that’s a possibility.
AP: I did note that when the vote went, you had 100-0 for approval to take this Cabinet role, which is unheard of. It’s amazing.
DS: Yes, I was the only one in the Trump cabinet who had a 100-0 confirmation vote from the Senate, and it makes sense. I didn’t enter government service for a political reason or because I belong to a specific political party, I went to help fix the system for our veterans, and so I operated in a bipartisan manner. People still don’t know whether I’m a Republican or Democrat, and that’s what I’ve always wanted. I wanted to get work done, and that’s how I think we got 11 major bills through in my first year as secretary—because I did everything in a bipartisan way.
AP: Interesting. So then there were, and I hate to use this turn of phrase, but trumped-up stories against you, by some folks within the administration. Why were they opposed to the road? I mean, you were clearly privatizing; doing what they wanted, I guess—what do you think happened there, that you became a target?
DS: Well, that’s the reason I wrote this book. The title is It Shouldn’t Be This Hard to Serve Your Country, and that title has a double meaning. First is that, I believe that when you serve your country and you go off and defend us, when you come back, it shouldn’t be difficult to receive the services you need. Unfortunately, our veterans have to go through too much bureaucracy and duplication.
DS: But the second reason I wrote this book is that I’m sincerely concerned about what’s happening to public service in the environment that we see today. Individuals who raise their hand to come and serve their country are subjected to personal attacks and information spread about them to attack their integrity and their reason for serving, and frankly, this is what happened to me. There were a group of political appointees in my agency, a small group, and I don’t believe I was ever their choice for secretary. I think that they wanted things run a certain way, and they probably believed that I wasn’t operating the department the way they wanted. So they started to do what we now see commonly in Washington: They started to leak information often that wasn’t correct. That takes on a life of its own in Washington, and I believe that ultimately shortened my tenure as secretary.
AP: Yeah, I saw there was some note that you found—a memo on a copier or something—that outlined their plans to have you removed. Do you have some sense of how they wanted to run it, how different their vision was than yours? Did you ever get to that idea of what they were thinking?
DS: Well, that’s the irony of it. People who use underhanded tactics to achieve their goals, often are not willing to come out and verbalize their objectives and hopes. I basically operate from a place where I encourage people to have diverse opinions, and I want them to challenge my ideas, and if people would come out and talk about these differences openly, I think that’s how you get good solutions, and that’s how democracies work best. But I think that I was dealing with people who were not willing to do that. Instead, they just wanted to achieve their political goals. In this case, that goal was to have me removed from the office of the Secretary.
AP: Interesting. So they don’t trust the system; they would just subvert it and go around. It’s so unfortunate. Since writing your book, have you gotten much in the way of blowback?
DS: I’ve been contacted by literally hundreds of veterans and employees at the VA who have thanked me for speaking up and for advocating for veterans. I wrote this book not as a tell-all, not to be critical or to attack people, but to be constructive, because I believe that it’s essential for this country to have a strong, sustainable VA system, and it’s essential for this country that we have a reset of the environment in Washington to get rid of its toxicity. It’s not helping Americans, and it’s not the way that our government should be running. I hope that by speaking out and telling my story in a very personal (sometimes painful!) way, that will help us have the type of dialogue and discussion to get to a better place.
AP: Just before this interview, I was up reading a case. This patient was sent to us, and the outside reading Radiologist had clearly done a poor job, which resulted in this patient being air lifted to my hospital. A lot of expense, a lot of worry. I’m trying to look for both small ways and large ways to make a change where I see things that are wrong, and that could be somebody who’s not performing well, up through and inclusive of things like insurance brokers, PVMs, things that we know as insiders are providing little value at high cost to the consumer. Do you have advice for people who are looking for ways to kind of make a difference in healthcare? What should they be doing?
DS: Oh, I think that’s such a broad question, because there are so many ways that people can make changes to our system to improve it. I think the big strategy is, I believe, transparency. I still think that we have patients who are unable to get the information they need to make the right decisions, whether it’s the price of services or the quality of services or just choice of services. I think anything that empowers consumers more is going to be helpful. I think we’re going to be looking at disruptive technologies and new ways of doing things in healthcare, and we’re seeing that as there’s a switch from a business-to-business model, to a business-to-consumer model, and we’re seeing the technology companies beginning to turn their attention to healthcare, whereas in the past, I think they probably felt it was too complicated. But I am expecting that we’re going to see a lot of innovation and disruption in the way we do business, and I think that there are policy changes that need to happen at the federal level. Some of the regulations and rules that we have, I think, prevent the adoption of high-quality services, like health rules that prevent access across state lines to telehealth services, but I also think that we need to move much more and much quicker to value-based payments. When you see a change in the payment system, you often see a change in the clinical model care as well.
AP: So if you had a physician or a healthcare administrator who’d had a personal experience in healthcare, and they said, “This has got to change,” do you have any advice for them on taking a next step to being what I’ll call a healthcare activist for system change, as opposed to a healthcare advocate, which is usually just representing the patient?
DS: I think I would begin with speaking out, much like I did in my book. I’m speaking out, or I’m giving my thoughts and advice. People tend to respect and listen to their healthcare professionals, and when a doctor or a nurse or a pharmacist comes up and tells their story with a positive suggestion about what needs to change, people listen. I think that we need more of that; we need more of this activism that you’re talking about, in order to effect change. Then individuals start to collect in groups and start to get bigger. This is how every major change has happened in the world, which is the spread of ideas.
AP: That’s really interesting. We could be something of a viral agent, both for first awareness, followed by activation of the public, because that’s really how it all gets done. And for you, personally, how do you foresee continuing to be a change agent? In terms of speaking out, are you going to write additional books? What do you hope to do?
DS: I don’t have a well-formulated path. I’m trying to follow my instincts, but clearly, I’m a person who very much believes in mission and believes that we need to do better, and so I will continue to look for the best ways to prompt that change. I’ve started to work with companies that, I think, are likely to be part of that disruption in healthcare, part of the transformation of our current model care to a better model care. I will continue to publish and speak and work in academic institutions to be able to share my ideas with others. And I, of course, I enjoy very much interacting with groups of people and speaking to groups who are interested in hearing new ideas about how to make these changes.
AP: I really applaud you for your efforts, even though I know it comes at some personal cost. I hope more physicians can be like you, more people—more insiders—can be like you. Very appreciative.
DS: Well, Alan, when people ask what are you most proud of in your career, I often hear a very similar answer from people that I respect, and that is that they’ve been able to mentor somebody younger than them or somebody who is up-and-coming in their career to be able to carry on and have an impact of their own. And so, to me, having been able to work with so many people, particularly in training institutions, now seeing them go on and do great things on their own, is really where the greatest satisfaction lies.
AP: I completely agree. I have the good fortune to be able to mentor people here as well, and to look for ways not only to teach them how to be better doctors, but how to be better agents of change. David, I want to thank you so much for your time, and I really recommend your book It Shouldn’t Be This Hard to Serve Your Country, which is very apropos in these times, and I hope people take away lessons from your courage. Thank you.
DS: Thank you, Alan.