Dr. David Shulkin – A Life in Medicine: People Shaping Healthcare Today

Dr. David Shulkin – A Life in Medicine: People Shaping Healthcare Today


(swoosh) (upbeat music) – First of all, I understand
you have a family background that made you particularly
interested in veterans, so talk about that. – My dad served in the Army, as many people of my dad’s generation did. My grandparents, my
grandfather was a pharmacist for the VA in Madison, Wisconsin. I, of course, trained in
three VAs, like most of us. And I always felt a connection, but I always felt there
was something missing in that I never served. And so when I got called
by the Obama administration to ask to come to help, I just felt like how
could I possibly say no? – And I want to ask one or two questions about your background
before you got to the VA and maybe found one of the
more interesting ones was, I remember in, maybe it was in
the mid 80s when Bill Kelley, who was running Penn’s
healthcare system at the time and you were there, announce that we’re making
a huge push into quality. That was a pretty new concept that we’re gonna focus on quality as a defining feature
of this health system, and you were asked to run that. And then you ultimately, I think became Chief
Medical Officer at Penn. What was your experience in that, and how do you think the quality movement has played out in academic health systems, and you’ve run hospitals
that are academic, you’ve run hospitals
that are less academic. But there’s a lot of hope
in the beginning that, if we embrace this issue
of quality and safety, and really took it on,
we’d make a big difference. How do you think that’s played out? – Yeah. Well I think when I think back to the beginning of my career, I had one thing going for me, and that was my youth and naivety. And so, I went to Bill Kelley who was the Dean & CEO at Penn, who was not necessarily known
for being the nicest guy, and I let him know I
was a clinical scholar, and I said to him, you’ve
got a real problem. And he looked at me
said, I’ve got a problem? (Robert laughing) And he said, why don’t you
tell me what you think it is. And I said, well, you’re running a very expensive academic medical center, there are cranes all over building things, and there’s this thing
called managed care, coming like a locomotive. And unless you can demonstrate why you’re worth all this money, managed care’s gonna choose for the low-cut cost option all the time. So he said, well, what
would you do about it? So I went and I actually wrote
the first job description of a Chief Medical Officer. And I said, you need a doctor who understands what’s
happening in business but can really quantify the quality that we have and measure it. And he took a look at it and he said, okay, you have the job. And, you know, then I
began to really understand that unless the economics
of what you’re trying to do, the way you were paid, the
way hospitals are paid, is aligned with the
product and the outcome, it’s gonna be a really tough road. So my 10 years as Chief Medical Officer was about trying to find
the economic alignment with what we’re trying to do in improving quality and outcomes. – Do you think you moved the needle? – The needle in healthcare
moves really slowly. Sometimes it’s hard to know
if the needle’s moving, or which direction. So I think the journey that I started, which was really in the early
90s when you started as well. I think we have moved the needle, but a lot slower than
I would’ve hoped for. – Okay. Let’s get to the VA, and by the way, this is more VA faculty
in the audience here. – How many people have a VA affiliation? Oh right, wow.
– Wow okay. There you go. – It’s like a town hall for me. – Yeah, it’s kind of fun. – It’s good. – And by the way, I’m
coming to the VA tomorrow to talk about the state
of the departments, so we’re gonna see a lot of each other. – Oh good. – A lot of the book, and
a lot of your experience over the last three years
hinges on this matter of choice. And so, before we get into the particulars of what you try to do,
what happened to you, why don’t you sort of
lay out the arguments. What is the argument
sort of against choice? What are the argument for choice? I know you came down quite in the middle and thought there was a
hybrid that would work best. – [David] Right. – But sort of lay out the two poles here. – Right. I’ll try to do it succinctly. It’s not an easy issue, but the audience probably
understands it pretty well. When the Obama administration asked me to come to Washington as undersecretary, I hadn’t been in a VA in 25 or 30 years. So I, all I knew was what I
was reading in the newspapers, that the VA was a mess, it was killing people
with wait times, you know, all these disasters. So I came, really with
an open mind saying, maybe I’m gonna find a system that’s so broken and so dysfunctional, that the best thing to do would simply be to help transition veterans
to the private sector. I would’ve been okay with that actually, if that’s what I found, ’cause I didn’t have a perspective on it. And when I came, not only did I not find that the system was broken, but I found that it was doing things, that frankly I knew you
wouldn’t be able to find in the private sector. I was a practicing physician, but a hospital CEO running
large health systems all my career in the private sector. I knew if I had a patient as an internist, with a behavioral healthcare issue, even as the CEO, I had
trouble getting them seen. I mean there was just no way we could take nine million veterans and say, good luck, go out and get your behavioral
healthcare issues done, just as one example. So I became a passionate advocate
for strengthening the VA, modernizing the VA, saving the system. Frankly, it’s what veterans wanted. I thought it was fixable. I practiced in the VA. I mean, so that I felt like
I had a basis in reality. And I saw a tremendous system. But I also knew that we
were responding in 2014-15 to a unacceptable long wait time issue, and that we weren’t gonna
be able to fix it alone. So that we had to work
with the private sector. The question is, when you
design a clinical system, how do you keep a strong VA, but also allow people who need the care in the private sector to get that. And I created a vision
for a hybrid system. I thought it was pretty
transparent about it, I published our article describing
that integrated approach to care in the New England
Journal of Medicine and I was willing to
have people debate it, at both the Congressional level as well as in the academic communities, and within the VA itself. And I was on a path to doing that. When the people in the Trump
administration came in, they essentially said, we
don’t really want to do that. What we want to do is, we just
want to get more people out into the private sector because it meets a political
ideology that they believed in. And, you know, even though the press tries to get me to say, well they were trying to do
this for financial reasons ’cause there’s big money
in companies making money when they go out in the private sector. I never saw a financial,
a financial reason why they were driving this. This was purely political ideology. Government shouldn’t be involved in the delivery of services, government’s inherently bureaucratic, and poor quality, and inefficient. So let’s, let’s drive things out. So my belief in the
choice system was that, this was a program that
when it was gonna end in three years, ’cause it started in ’14, it was authorized by Congress
for three years to ’17, we had to find a way to continue to allow veterans to be able to access the private sector in VA to pay for it. So I worked hard to build
the choice system in as a permanent approach rather
than a year to year extension into the system. That was part of my belief about how we would take care of
veterans in this country. But I really wanted it
to be a clinical system, that was integrated in with the VA so that the VA could
decide, a VA clinician, could decide for this particular patient, what’s the best thing for them? Can we provide the care in the VA? Does the VA provide the
quality care we need? But if not, we have access
to the private sector, including right here,
our academic partners. What the people who
fought me on this said, is that we don’t want that. We want open access. We want the veteran just simply to go wherever they would go
and send us the bill. And so, that’s what
passed in the MISSION Act. What passed in the MISSION
Act were what I call, administrative rules
which the term is called the access standards, and they are, if your drive time is more than
30 minutes for primary care, or your drive time is more than 60 minutes for specialty care, you will have access
to the private sector. And in terms of of wait times, it was 20 days for primary care, and 28 days for specialty care. And my belief is, having
done this all my career, I don’t know any healthcare
system that designs its approach on these
administrative standards. You design it on the
clinical needs of a patient, what’s best for them. So if you have a great program
at the San Francisco VA that can really care for veterans, that’s where a veteran could be. But if you don’t have that, or
you don’t have the capacity, then that patient should be able to go out into the private sector
to get their needs met. And so, this was a fight that I had about how do you design the system? Ultimately, once I was fired, the non-clinical access
standards got approved, and that’s where I think
that we have to watch what happens very, very
carefully because right now, and I know it’s reassuring
that a lot of people haven’t seen large numbers of veterans transferring into the private sector, but I will assure you that’s because the system is still being put into place. The third party contractors are still building their networks, getting their contracts in. – Let me add one additional
argument to you here. – Yeah, sure. – I don’t certainly believe
it, but it comes up, which is competition. – [David] Yep. – Not necessarily one or the other, but by establishing some
competition for the VA, you will make the VA better. – I’m a strong believer in that. A couple months before I
left the secretary of VA, I published an article in the
New England Journal saying, competition will save the VA. I started to make our data transparent, and publish our quality data
so that you could compare VA’s to local community hospitals. Of course as the people on the VA know, we’ve always had a system
of internal competition, where it’s, the star system. And my argument always was,
if I’m a veteran in Detroit, I’m not looking whether
I’m gonna get my care at the Detroit VA, or the Miami
VA, or the San Francisco VA. I’m looking at whether I’m
gonna go to Henry Ford, or the University of Michigan,
or you know, a local place. So my belief is, and the
way that the MISSION Act does have a component in there, that if the quality of the VA is below the community standard, that would be an
indication where a veteran could seek care in the private sector. That make sense to me because I do believe that we should all be
accountable for our results, and all have a certain
level of competition based on quality. – So let’s get into the
politics a little bit. So you started under Obama, and actually, why don’t you just quickly tell the story how you found out that you
were staying under Trump? – So I was Obama political appointee. And on January 20th, one
of the, sort of very, very unusual things that
happens in government, when January 20th at noon comes, 4,500 political appointees turn
in their letter resignation and vacate their office by 12 noon. And then, theoretically
4,500 new employees, political appointees come in
with the new administration. Sometimes it takes time
to get through vetting and things like that. And so I had my bags packed,
and I was ready to go. Maybe not psychologically
ready, but you know, my wife was coming down to
pick up the boxes in my office. And I was getting dressed on the morning of January 11th in 2017, this was now nine days
before the inauguration, and I was listening to TV in the morning, and the reporter said, the president elect is gonna hold a press
conference at 11 o’clock today, and at the end of her report she said, and he’s likely to announce
the new VA secretary. And so I said, if I can
I’d like to watch that. That would be–
– Sure. – I’d like to know who it is. You know, I mean this is important to me that we get somebody good in there, that, you know, maybe wants to continue the work that Secretary McDonald was doing. And so long story short, I was able to watch that conference, and that’s the opening segment of the– – That they announced that you were it. – Yeah, yeah.
– What’d you think? – And, I was by myself. So at first I thought, what did he say? (Robert laughing) – But then he kept on saying, and David’s gonna be great, and so, and then, within around 30
seconds, my cellphone rings. And it’s Rick Scott, the Governor of Florida congratulating me. – [Robert] That’s nice. – I was like,
(Robert laughing) you know? So obviously, other
people knew about this. You know, just so. But you know, it was the
beginning of understanding that the things that we expected, ’cause here’s what I expected when President Obama nominated
me for undersecretary, they wanted me that day when they were gonna do the
announcement at the White House. We had gone over the press statements. They had given me a list of people that I was to call
before the announcement, the ranking and the majority leaders of both the House and Senate
Veterans Affairs Committee, so they wouldn’t be surprised. They wanted a list of validators from me, a Bob Walker that the New York Times could call and say, so what
do you think of this guy? Was it a good nomination? And they had rehearsed what I would do with the press interviews. So it was very, very well thought out, and so I just assumed
that’s what would happen to anybody else who was, this
was the secretary position. But like, you know, I mean, you know, as you know this president
does things differently. – Yeah. Now one of the things that was striking about the early part of your tenure is, and I don’t know your politics, and we’re very careful not
to talk about your politics. You made clear there were certain things about being in the Trump administration that you thought actually
were working better than the Obama administration in terms of your ability to
get things done in the VA. – Yeah. So, you know, I’m sure as you know, Bob, but just so other people know, so in the Trump cabinet, I was not only, the only who was from
the Obama administration, but I was the only one who
had 100 to 0 confirmation. I was only one who had been
in their agency before. So I have no learning curve. I knew exactly, I had a plan. And I wanted to carry it out. And so, while other people
were learning their jobs or figuring out how to
destroy their agencies, whatever they were trying to do, (Robert laughing) I was like, I got things
I want to get done. And one of the things
about this president is, he likes to sign stuff, you know, he likes to say I’m
getting stuff done, right? I mean, may not always
understand exactly what it is, but if you bring in things and you say, look, this is good for
veterans, let’s do this. He’s like, all right,
let’s do this, you know? And so, it was a very, very
productive time for me. And I’ll give you, I’ll
give you some examples, and you know, this audience
may not necessarily always agree with everything
that I did, which is fine. But, and this dates back
to sort of our careers in what we think improves quality, and what motivates change. One of the big things that
I’ve always believed in, besides an economic alignment, is transparency of data. So when I was undersecretary, I had developed, not me personally, but the team under the
undersecretary in Washington had developed a public
display of wait times. And I really wanted to
publish our wait times. I felt that, it would first of all, show pretty different picture than most people felt
about what we really did. But it would be an accountability
to not only our veterans, but to our employees and our physicians about how we’re performing. And so I had that system ready, and the Obama administration
would just not let me do it. – Why do you think? – They felt, and I’m not talking about, this didn’t go up to President Obama, so I’m talking about people really, you know, at the, the
people that were involved in veterans’ issues at the administration, felt that if we were
transparent with data, that the press would simply go to the worst performing VA in the country, the Wyoming VA or something like that, with 100 day wait time, and that would be the front page story and it was embarrass the administration. And you know, I was okay with that. You know, that’s how you get better. That’s how you know
where the problems are. But they really felt
that this would not be in the interest of the organization that was trying to, you know, walk it’s way out of a crisis already, which sort of focus
attention in the wrong place. So within a week of me being secretary, I said push the button. No, I didn’t even ask anybody. I just said, look, I understand
this may not go the way that I hope it goes, but in
fact, there was no pushback. People appreciated the fact, and there were some
hospitals not doing as well and some medical centers
doing much better. In fact, as you probably know, I published an article
on JAMR about a year ago that showed that VA
wait times are actually much better statistically,
significantly better than the private sector. And in fact, that’s what this data shows. And VA to the day, is
the only health system in the country that I’m aware of, that publishes its wait times. Except for ED wait time billboards, which are just marketing things. But I still hear, when I
go and I talk to audiences, oh those VA wait times are terrible. You know, how could you be
making veterans wait that long? And I’m like, try getting an appointment for a primary care doctor in Boston. – Or San Francisco. – Yeah.
– Yeah. – Yeah. – One of the other themes
of your experience was, the emergence of the sort
of separate power center in your world, of people who
came in and were political, quote on quote. I heard you on The Daily, on
the New York Times podcast. – [David] Yeah. – About a month ago,
and they brought you on to talk about the Ukraine because it felt like
your experiences provided some insight as to how one
could have the normal channel and then this separate channel. So first of all, talk
a little bit about Ike and the first time you learned there was this sort of other way that things might happen
than the traditional, than what you thought the
sort of hierarchy was. And then what you came to learn about this separate center of power and its influence on what you were gonna be able to do. – I’m not sure what I experienced is probably that much different than what happens in almost
every administration. Presidents have the people that
they rely upon as advisers, that don’t have traditional
government roles. They’re friends, and
people that they respect, that they pick up the phone and they call. And there’s always been
political appointees. So the president had a group of people that were his friends. Happened to be Mar-a-Lago members, that, way before I ever met the president, that had, he had asked
to help improve the VA. Now, none of them really had
any knowledge or expertise in healthcare or healthcare
management, or veterans. But I think that they
genuinely wanted to try to help in whatever way they could. The head of that group, you know, runs a comic book company, so you can make your own
judgements about that, but you know– – [Robert] So that was, that was Ike. – Yep, yep. But, and the political appointees saw their job as carrying
out what they felt that they were elected to do, which, like in many other agencies,
was take down what they called the deep state, or the swamp, and replace it with what they
felt was something better. Now the problem is, you know,
like in the healthcare bill, you knew that they were against Obamacare but they never really
articulated what they were for. And so, that was, that was
some of the problem here. – But in your case you knew
precisely what they were for. – Yeah, yeah, yeah. But, but there’s not a thoughtful level of what the secondary consequences are, and how you get there, and
what the transition is. By the way, I am not,
and I was never against having open access so that a
veteran gets to decide where, if they’re gonna go to the VA
or not based on competition. My belief was, if you
do that all of a sudden, if you make that a political decision, you will, the consequence of that will be, that you will literally
destroy the VA system because the VA has never
been given the tools, the resources, and the legislative ability to truly compete with the private sector. And so what I had hoped is, that we would over a
10 year period of time, begin and start putting VA on the path to truly be competitive, to
allow it to be modernized. And let’s just take an example. By law, the only way VA
is allowed to be paid, or the VA is allowed to pay,
is on a Medicare fee schedule, on you know, essentially
a fee or service system. Where the rest of the private sector is now moving towards being able to do value-based contracting
and risk-based contracting. And so, you have to
change the legislation, start allowing VA to be on equal footing, and allow it to compete,
and allow it to act like it’s a payer as well as a provider. So all those things were sort of laid out in a 10 year plan to allow ultimately, where veterans would have the choice, ’cause I believe in the VA, and the people who work in the VA, that they will have no problem competing if you give them the right
tools, and resources, and legislative abilities. So, but anyway, the political, the political appointees
as I describe in my book, I believe, had a objective and the means to which they would get to that objective, almost justified whatever they did. So what I’ve described,
and evidence to it, that they simply went outside the bounds of decent behavior to
achieve their objective, and part of that objective was, they never really wanted me as secretary, they wanted one of their own as secretary, and so, let’s get him out of the way. And for people who think
I’m a little bit paranoid, you know– – I thought so before I read the book. – Yeah, yeah, yeah.
– I don’t anymore. – Yeah, yeah, I mean,
you know, they would– – It’s remarkable. – Well, the paranoid thing was a, was actually a deliberate plant of theirs. They released all the newspaper,
so was happy to print it, that I was so paranoid
that I had armed guards outside my office. Well I will tell you, I was
in presidential succession. I had 27 armed guards
around me all the time. Every cabinet member does. Always had, every secretary
has armed guards around them if you’re in presidential succession. So, but why the press would print that, and the associate it with, he’s paranoid ’cause he has
guys with guns around him. Well, you know, that was
just normal, always had that. But, in terms of this issue, and I think what Bob’s saying ’cause he read the book, is that people were coming
up to me all the time saying, these guys are out to get you. And my attitude was, I don’t
have time for this nonsense. I’ve got a agency to run. Let them, they’re a
bunch of harmless kooks. Let them do what they’re doing. Until one day, a staff member
brings to my deputy secretary, a memo that was printed out
from their personal email, but left on the copy machine at VA, because that’s where you print
it out, it acts as a printer. And on this memo, was detailed a plan. We’re going to get rid of the
secretary’s chief of staff, ’cause she’s a Democrat. We’re going to next, get
rid of his deputy secretary because he, even though he’s a Republican, doesn’t align with the
president’s ideology. We’re going to get rid
of the undersecretary and put in one of our own, and then we’re gonna get
rid of the secretary, and we’re gonna do it, and they described how
they’re gonna do it. And so when I saw that, I said well now it’s
really hard to ignore this. This is a, essentially an overthrow of, essentially a cabinet secretary. – [Robert] And when you began– – But they, they followed the plan, and they were pretty successful. – Yeah no, I mean– – [David] Got rid of all of us. – Right. I mean, if you think about, they carried out exactly
what they intended to do. – [David] Exactly what they
said they were gonna do. – When you heard the Ukraine stuff begin, and the idea of a separate
channel, was that like, PTSD? Was it like, now I know
exactly what this– – No.
– Feels like. – I think the thing
that’s really clear to me is that the behaviors that I saw, have been repeated time and time again. So really nothing’s changed. I was the first to come out and
to describe these behaviors, but as I watched the Ukraine issues, you had a ambassador to the Ukraine, who, you know, and again, I work hard not to try to be political. I’m just trying to sort of describe what I think was factual. But I think most Americans who watched, saw unbelievably
dedicated public servants, who took their jobs really seriously and it served this country
in the state department and in the military, in incredible, in ways that as an American,
I felt proud about, who were undermined, and innuendos, and false allegations, and
back channel information, so that then they get moved out. Or they’d get essentially, to the point that they’re unable to
do their jobs anymore. And to me, that’s a sad
thing for our country because we need people like that. We need people who want
to do public service, who do it well, who can
help the government achieve, you know the goals on
behalf of our citizens, and this type of behavior
works against that. – So I don’t want to spend any time on it unless you want to, you know, one of the main mechanisms
they used to undermine you was to trump up all this stuff about this Europe trip, which
sounds like it was really, essentially made up. You’d gotten permission for everything, your wife was legitimately
traveling with you. Anything you want to say about
that, or just leave it there? – You know, I think, I think it is, it is hard for me to come to terms with the role of the press in this. Because look, I understand. You have some unscrupulous
people that wanna do things, you know, leak false information, and they’re gonna do what they do. But for the press to participate in this, and to just print, you know, it look– – ‘Cause it’s a good story. – It’s a good story, it gets
headlines, it get clicks. You know, drives ratings,
I understand that. But the facts were, in
my view, pretty clear, you know, which is, secretaries
don’t do their travel. They have large staff that do
that, with approval processes, and trips are planned
out months ahead of time, and not only did VA approve everything, but so did the state department,
and so did the White House, and so there was nothing at all done, but when you slip out a story to the press and then somebody prints it,
and then everybody prints it, and then it takes a life of its own. I think it undermines those that are trying to do public service. – Want to do a quick
lightning round of things I’d love you to just comment on briefly. Why don’t we start with, being the designated survivor
at the State of the Union. – Yeah. Well first of all, it was
one of my favorite TV shows. – Yeah, pretty good.
– And so– So, you know, and I’m
sitting in my office, this is the first State
of the Union address, and the phone’s ringing in my office. And I pick up the phone
and there’s nobody there, but the phone’s still ringing. And then I realize, it’s not my phone. There’s some phone off in the corner, which I had never seen. So I walk over to it, and I pick it up. And it’s a special hotline
to the White House. No one told me that. (Robert laughing) So they said, you know, we’d like you to be the
designated survivor. You can’t tell anybody. You have to make sure
that everybody believes that you’re going to
the State of the Union. In fact, we will not tell the other people in the White House that it’s you until we’re about 20 minutes before. So my security team and my office were all prepared for
me to go, and my family. They said, we’ll see you
tonight as you’re walking in. And then about six o’clock that evening, my secretary comes in and goes, there are 20 secret
service agents outside, who want you to go with
them onto a helicopter. And I was like, okay, I know. But, so, it was actually an
incredible experience of which, I can’t talk about a lot of details, but suffice it to say, I watched the State of the Union pretty far underground somewhere. And I did it with about 4,000 people. The seriousness in which the government takes the continuity of government, should something happen to us, I think made me feel very proud. That people really are there, that they know how this
government will continue. They take their jobs seriously,
and it would have been, God forbid something like that happens, it would have been almost an instantaneous full government running, so that we wouldn’t be disrupted. So I think, most people
here will never see that, but they should have confidence that there are people
taking that very seriously. – I think you would’ve
been a great president. At least as good as, at least as good as
Kiefer Sutherland I think. – Yes. – The Charlottesville news conference. – Yeah. I had made the decision, fairly, almost from the day I
went into government, that I didn’t have political aspirations, I wasn’t doing this because
it paid well or anything else. I was doing it out of a
belief that our veterans really deserve better than
I thought I was seeing. And I had decided that I was going to have principles I believed in, and if that ended up
resulting in me getting fired, or being asked to leave,
I would be okay with that. What I wouldn’t be okay with, was trying to bend my principles because I felt like I
wanted to keep my job. So, and there were several
times that this happened, but when Charlottesville happened, I happened to be with the president, literally as it was happening. He was as his golf club in Bedminster, I had gone up to join him
for signing of a bill, the GI Bill. And it was just literally me and him. It was sort of weird,
there were no aids around. I mean he had secret service
but there was no staff around. And he said to me, he was
playing golf of course. And he said to me, David, what’s going on in Charlottesville? And I’m like, what are you asking me for? And so I was watching it on TV, so I said Mr President,
it doesn’t look good. Looks like this is getting out of control. And then we went out and
we did our bill signing. And the press wasn’t asking
questions about the bill, they were asking questions
about Charlottesville. And I was pretty
uncomfortable with the way that the president was responding, and the White House’s
response to that issue. And I decided I needed to speak out. And I called my family and I said, I’m gonna speak out on what I think is happening at Charlottesville, and I just need you to be prepared, this is probably gonna be my last day. And I could live with that. And my daughter said to me,
in fact, if you don’t do that, if you don’t speak out, then
we haven’t learned anything about our history, and I
couldn’t live with that. So I had my family’s
support, which was important. And I went to, it’s very interesting. I was watching this morning actually, about the fact that it’s been 100 days without a press briefing, right? But when I was there,
the podiums were open and I could just walk up to the podium. And all the cameras would
turn on, sort of like this. – Very, very similar.
– Right. And I could say whatever I wanted. And I used that a bunch of times. So I walked up and I said, I
want to talk about the GI Bill. Now I knew that the press
didn’t care about the GI Bill. So the very next question was, so what do you think
about Charlottesville. And I said, look, I’m not
speaking for the president, I’m speaking as a citizen or
as a member of the cabinet. I think it’s outrageous. I think we have to stand up against white supremacists and neo-Nazis, and if we don’t, it’s, you know, this is what our veterans in
World War II fought against, and these are the values of this country, and it’s unacceptable
to stay silent on this. And you know, either the president wasn’t watching TV that day, or you know, but, there were people on
the White House press office that were very unhappy with me. But I didn’t get fired that day. – I’m gonna ask a couple
more, then we’ll open up. I have to ask about Cerner. So, that was, I think your call, right, to say that we can’t
run a software company, and we’re going to bring
in a vendor-built system. So what led to that call? – Well, you know, if you
date back about the issue that the Department of Defense
and VA’s medical records have never been fully
interchangeable, interoperable. It actually is a 20 year history
of congressional hearings and people calling to do this. And again, in the Obama administration, this was a very active debate. And I sat as undersecretary in lots of hours of committee meetings, and I was pretty sure that
nothing would ever get decided. And by not getting anything decided, it’s like the San Francisco
VA being rebuilt, right? Lots of discussion. We’re gonna move it,
we’re not gonna move it. We’re gonna build a new research building but we’re not gonna allocate
the right amount of money. Years pass, and you still
live with a building and a facility that frankly,
we all know we can do better. So when I became secretary,
I said I’m not doing this. I’m not going into endless discussions. And I undertook a process that had never been done before VA, only twice before in government, called the Determination of Findings. Which was, I decided this myself. In fact, there were only six people in VA who had to sign
confidentiality statements, that they even knew that I
was looking at this issue, and that I would make the determination. ‘Cause I was not willing to go into endless committee meetings, I was not willing to go into
vendors competing for RFPs and then protesting
contracts and all that stuff. So I looked at all of the data myself. And I’m talking about telephone books, full binders full of data. And I ultimately decided that I needed to create a system that was interoperable with the DOD because it
impacted the lives of veterans, that this was a public safety issue. And when I came out with a
decision, Cerner had no idea. I called the president of
Cerner that day, and I said, I just want to tell you, in one hour, I’m gonna be making a
press release saying, I’m gonna be awarding us the ability to enter into a contract with you. And they were very surprised about it. But I did it very deliberately. First thing to happen is I was sued. I was sued by Meditech, a
competitor who makes an EMR. And the judge took a look at the way which I made this decision with data, and threw the case out. And so all that did was,
it gave us the ability to skip over years of what
I believed would have been, meeting after meeting,
committees after committees, where we wouldn’t have gotten anywhere, gave us the ability to enter negotiations, for a direct contract. And then it took us a
year to essentially enter into a contract with Cerner,
which is now being implemented. But, it was extremely controversial. There were a lot of people
that were very upset about it. By the way, I use VISTA. I like it a lot. I think it was a very good
system, but I will tell you, the cost to update and
to modernize the system, was 17 to 20 billion dollars. We could not hire the
software programmers in months to be able to keep up with it. The system was literally falling apart, and my fear is if we didn’t do something, people were gonna end up getting hurt. – And my last question, and
we’ll open up in a few minutes. I finished the book not being 100% sure what you think about President Trump. – [David] Yeah.
(audience laughing) – I mean I was 100% sure what
you felt about your experience and the political people
who were undermining you, and yet I came out with
a little bit unsure whether you thought he
didn’t really understand fully what was going on on his watch, that he actually has some
significant political skills, and you give a few examples
of where those were clear. It wasn’t obvious whether you thought he was really the puppeteer
and running all this, or he was a little bit out of the loop and there were a lot of
things done in his name that we’re pretty, pretty sorted. Where do you stand on that? – Well, you know, that
was somewhat deliberate. – [Robert] I guessed that. (Robert laughing) – And, you know, we’re living
in a very divisive country. Maybe not in San Francisco
or the east coast, but you go to other parts of the country and people that care deeply about veterans also are very, very strong
supporters of the president. And I just didn’t believe
that it was going to help us care for veterans, by
me becoming political and sharing my views on things. And in fact, when I left and I was fired, several members of the Senate and Congress held a reception for me, and Senator Tester who
was our ranking Democrat in the Veterans Affairs Committee, stood up and said, you know, I’ve worked with David
for over three years, and I couldn’t tell you today whether he’s a Democrat or Republican. And I said perfect. It’s exactly what I always,
you know, sought to do. The, you know, what I’ve
said about the president is, is that, you know, unfortunately with this division in our country, and I’m sure we even have it
in this room to some extent, people expect that everything that he does is either great if you’re a really pro, you know, right-wing supporter, or everything he does
is really, really awful if you’re a progressive. And the truth is, is that in his style, which is not analytic, not
really thinking through, a lot of things he’s a,
he believes that he knows the right thing and he makes
a lot of gut decisions. There are going to be good
decisions when you do that, and there are gonna be some bad decisions. So I think you get a pretty mixed bag. On veterans’ issues since, and I think you saw some
of this in the video, he had a lot of confidence in me. And so he really let me
drive a lot of the policies and we got 11 major bills through in my first year as secretary. So I happen to think that that style actually worked well
for VA and for veterans, and that’s what it was about. It was also that same style that ultimately lead to
these people with influence, being able to cause the
type of chaos that now, we’ve seen 18 members of
the cabinet come and go. Unprecedented level of
change, and you know, just for the people on the VA, just to give you a sense. My position as undersecretary, where I left that position
when I became secretary in February of 2017,
right, is still unfilled. There is not a senate
confirmed undersecretary. That is the CEO position of VHA. – [Robert] Yeah, yeah. – And so, this lack of
continuity, the constant turnover, it creates a place where
career people say, you know, I’m just gonna wait it
out because, you know, there’s nobody there who’s got my back. And so, so I think that
the president’s style has some good parts to it and some parts that are pretty concerning about, this is the way we’re running government. – Right. Open it up for time for a
couple of questions or comments. – [Man] I remember about
15 or 20 years or so, there was a big push for
technology assessment and phased introduction
of new technologies in the VA system. I remember Ken Kaiser who was
the Chief Medical Officer, who was pushing that, and it seems to me that there’s less of that now in the VA. Can you tell us why? – Well first of all, when
I was undersecretary, I would play a game with people who’ve been in the VA a long time. I’d bring them up on stage and I’d say, look, if we were a public company, what year was our stock price the highest? And inevitably long timers in the VA would always say it was the early 90s, when Ken Kaiser was undersecretary. ‘Cause he created a sense of innovation, and he created a focus on safety, and he really had people feeling proud that they worked in the VA. And I used to say, most people think he’s still undersecretary, you know? (Robert laughing)
– He left 20 years ago. – Yeah, exactly. But what’s happened is, is
that there is no incentive for people who are career VA people. I’m not talking about the
physicians and nurses, I’m talking about the administrators. To take risk and to make decisions. And so the status quo does tend to stay and it’s hard to get innovation. Unless you have a leader who is willing to take the cover for you. So Ken Kaiser was one of those leaders who was willing to say, you know, most people were trying to kill VISTA when it was underground, and the doctors were doing it secretly. Ken Kaiser came out and said no. I’m gonna stand behind
this, we’re gonna do it. And that’s why VA had the first major EMR. And I was doing that too. I was saying, listen,
I’m gonna take the heat. We’re gonna do innovation,
so I created new centers to allow technology in to come in quicker. We have a center called The Center for Compassionate Innovation, where it doesn’t have to have
the rigor and the science. If there’s a ability to help veterans by being on the cutting
edge and innovative, I wanted to create a
pathway to do that quicker. So unless you have a leader, and I’m talking about somebody probably, either Washington based or a local based medical center director, who’s willing to say, if it’s a problem, I’m gonna take the fall. It’s really hard to see this
happen in the VA right now. – Take one or two more. Yeah. – [Laura] My name’s Laura Perry, I’m a geriatrician and
a former chief resident from the Washington DC VA that was under a big
investigation during your tenure. – Right. – [Laura] I was hoping you
could speak a little bit about sort of, what happened there and specifically whether you think that the conditions are right for similar issues to arise in the future in other VA medical centers, or if you have hope that
that kind of problem has been eradicated. – What do you think, what do you think the problem at the Washington DC VA was? – [Laura] So during my tenure, we particularly noted that despite having many of
us be whistleblowers, I’m talking about the conditions of inadequate human resources, and terrible inventory
management, no one was listening. – Right. – [Laura] And there were years and years of reports that went unheeded until finally someone
started paying attention. – So–
– And lives were lost. – Yeah, yeah, yeah. Well, I think you said
the problem accurately, which is that there were
problems that people knew about and leadership wasn’t listening. And that’s why, when I
learned about the conditions, I fired the VA Medical Center director. Now, I actually, if you read the book, I had to fire him a couple times. – [Robert] Mhm, yeah.
(Robert laughing) – Because, because this is what happened. I fired him the first time, and the Merit Systems
Protection Board judges brought him back and then put him back in. And so then I got the law
changed, and I fired him again. And then he sued, and
now he was reinstated. So–
– You also tell, you tell the story.
– This is the challenges. – You tell the story
of the person who ran, who drove the getaway car for a bank heist and could not be fired. – [David] Right, right, right. – So how do you, how
do you deal with that? – And the psychiatrist who
was watching pornography with his, in the patient exam room, and I couldn’t fire him because
it wasn’t child pornography. If it was child pornography, that would have been a felony, but adult pornography
isn’t so we couldn’t, so I got the law changed to
be able to do some of that. But you know, I don’t think, you know, look, I’ve run private
hospitals, you know. – [Robert] It’s not that easy. – Yeah, and you often do
have the wrong leaders. The Washington DC VA was led, I’m sure you know who it was, by a person who was really, really strong with external communication. He represented the community well. He was an African-American leader, we don’t have many of those, and he was extraordinary
at community relations. And as we learned, he just
wasn’t paying attention to things that frankly
are just outrageous, like when surgeons have to stop procedures ’cause they don’t have the equipment. To me, that’s like, you know, it’s like flying an
airplane without gasoline. You know, you just can’t do that stuff. So, you know, we needed
new leadership there, and you know what? I think this is where it’s
important that whistleblowers do feel safe in coming forward and talking about those issues. – This will be the last one, Jeff. – [Jeff] Jeff Kohlwes, San Francisco VA. I just got my 20 year pin. – Good yeah.
– Thank you, thank you. (Robert applauding and laughing) – [Jeff] But I wanted to ask, how do we flip the narrative a little bit? Because I think it’s really important to have whistleblowers, and I think it’s really
important to think about this. But when we look at
quality and safety metrics, we compete beautifully
with private hospitals. And also, there are incredible
number of, you know, sort of amazing things going on at the VA, and we seem to never, that never seems to make it to the press. How do we change that? – Well, first of all, I
completely agree with that. I think that as a private hospital CEO, I knew the things that I would
deal with only in my office, that nobody ever would know about, ’cause we’d keep it,
you know, under wraps, become front page stories in the VA, become congressional
hearing, you know, content. And therefore, the entire
system gets labeled as having the problems
that people think about. And so getting the good news out, getting the good stories out, I think is a real challenge in this type of media environment, because good news just doesn’t seem to be of strong interest. So the only approach that I believe is, is that you have to really
go with full transparency. And one of the things that I did again, my staff really tried
to talk me out of it, was when Sean Spicer was press secretary and pretty much didn’t want
to do press briefings either, I walked up to the White House press room and I essentially said, I want
to talk about 13 major issues in the VA that if we don’t fix, are gonna continue to
be problems for decades. And people tried to talk
me out of ’cause they said, all you’re going to do
is focus on the negative. And I said, no. The only way that you’re gonna gain credibility with the press, is if you tell ’em what the problems are, why you need to be
focused attention on that, and then that gives you
the ability to talk about as you begin to fix it and
as you begin to get better. And I do believe that’s a strategy. It’s a longer term strategy
than pitching a positive story. But I believe that we’ve lost the trust of the public and of
our veteran community, and when you do that,
you have to rebuild it. And I think, I think that’s
the way that we need to do it. I am concerned that many
members of this administration have sort of walked away from the press, have hidden, aren’t as open
as I would like to see. But, you know, and you know, but I think that there is a path forward and that’s part of what, you know, it’s part of the reason
why I wrote the book, was because I wanted to show
that there was a formula for fixing the VA and for
addressing some of these issues, but you need to have consistency of it. You just can’t, one day, be open to the press and then the next day not do any interviews, which is more, what we’re finding right now. – David, thank you for visiting us and thank you for your leadership truly. – Thank you. (audience applauding) (upbeat music)

Daniel Yohans

2 thoughts on “Dr. David Shulkin – A Life in Medicine: People Shaping Healthcare Today

  1. mar c says:

    America has health care based on law suit avoidance i am told. After 26 years in munich and prague working, i am shocked how bad it really is now. Doctors sit behind desks and outsource everything. Comparing my experience in munich where all doctors use ultasound ?in their office and draw blood and can check your thyroid liver and anything else they think nay be a problem, american doctors do nothing but order tests with someone else. No wonder so many people are so sick

  2. iamtherepairguy says:

    Thank you for your good work, Dr. Shulkin. — a current VA doc.

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