Dr. Shuck and thank you for being with us today presenter to have you here. If he is an important subject to talk about in the area for government a lot of people hear about but dont necessarily know the details. There are a lot of us that dont understand the breadth and depth of what the va does so its great to talk to about the via general uncertain about your book and about your time in the administration. I would love to begin by hearing about what brought you to the va you are very successful in your civilian career and make in that tradition from the civilian world and to the government world can be a bit jarring. What drove you to want to take up working within the government especially with the va . Guest during my 20s i didnt have a chance to serve the way that you did. I spent my time in medical institutions and doing my medical training and its always one of the real regrets that ive had with this amazing country that we have that i wasnt able to get back. Later on in my career i was the ceo of the hospital and i had the opportunity to get a call from the white house. This was right at the time in 2014 when it was a very public crisis in the va where there were allegations that the veterans were dying waiting for care. I remember sitting there as a citizen saying i feel terrible about this. If anybody deserves the best care possible with our veterans. I wish there was something i could do to help and sometimes it happens in strange ways. I got a call from the white house saying would you consider coming to help with the Va Health Care system because we are looking for who understands how Health Care Works from the private sector. I did what everybody tends to do whenever a choice to make. I made a list of pros and cons. The con side was much longer but on the proside it was how can i say no . This was my duty as an american. I didnt think much about it and i said yes im prepared to come and help. Host that is great and for those of you who read the book know that was during the Obama Administration singer one of the few people who have served under the Obama Administration ivana trump administration. I look forward to getting into that. I would love to read a brief quote from your book. Early on the right it is important americans understand that the va system is how it works and why it exists. As is plainly mentioned a lot of people dont understand the scope of what the va is responsible for. I wonder if he could start off by giving maybe an elevator pitch everything the va does produce you know its health care but theres so much more that the va does. Guest one of the reasons i wrote the book was for exactly what you talk about jeremy penn are not sure the American Public understands why the va access but why is an essential part of our National Security system. When we rely on a voluntary military which less than 1 of americans served in but these amazing americans raised their hands and are willing to sacrifice themselves on behalf of all of us. When i go theres a commitment that the country is made to them if they need that help when they come back. There is no other organization thats focused on that. As you said the va provides health care for 9 million veterans that there really 20 million veterans in the country that the va has a large education g. I. Bill. Have some effort towards benefits should somebody require assistance if they are no longer able to work or disabled and it goes all the way through the time of making sure that every veteran when the time comes is buried with dignity and respect so there 114 va cemeteries around the country who do an amazing job supporting families during these tough times. This is an organization the second largest in the u. S. Government employees. 70,000 people many of them veterans themselves. It doesnt amazing job and it really does deserve the support and understanding of the american people. Host out i often point out to people that the va is the secondlargest agency, the secondlargest budget and people i think really should be more informed about everything. Guest i think thats right and if i could just about the health care aspect because it gets so much focus on public attention on the va. When i came from the private sector of the government i had never worked in government before. I had a completely open mind when i was reading all these Horror Stories from the press. I would go there and i would find the system is so broken and so dysfunctional that maybe my job was going to be to close up shop and say you know what the best thing i can do for veterans is eliminate the Va Health Care system and move everybody into private hospitals, something that i did very well. I began to see what the va does and when i say got to see i put on my white coat as a doctor and took care of veterans of whenever visited hospitals dropped the country in which see places like where we bring peer allies veterans skiing down the slopes in aspen colorado. I really began to understand what the va does in the Health Care System is very different than what the private sector does and in fact cant be replaced. The private sector doesnt do things that the Va Health Care system does in all cases. For example our behavioral Health Care System. It is expensive and it is large. Our Health Care System is struggling to try to get access. If we were put these 9 million veterans adjust dump them into the private sector system on a System Authority struggling we just know that veterans would not come out on the right side of that. I became a very strong advocate for making sure that this was a system that works well and that we need to modernize and improve absolutely and you touch on a couple of things and i want to make sure we come back to it to privatization things like that, very important topics. Its a large part of your book and either way you think were going to skip over that. We will get to that in time but i want to continue because what you mentioned remind me of a comment saying strictly within the veteran community and even with the va as he bent to one va youve been to one va. You mentioned how especially in the beginning you did a lot of going around to different vas. Why do you think that is that even though we are talking about an agency that has oversight of all these different areas you get somebody different stories and you hear Horror Stories from so many veterans. They loved the care they get at the va they would just like to get access faster and things like that but why do you think theres such a variety of levels of care . First of all the va is under public scrutiny that no other Hospital System in the country point spread as a hospital ceo of the private sector i can tell you Little Things that happen in the va that would never come to the attention of the private sector turn out to be the subject of a congressional hearing in major front page stories. I think the public gets a sense that there are lots of things are happening at va hospitals that dont happen in the private sector but using the private sector comparison of question i would get most frequently as a physician and ceo was what is the best hospital for me to go to . My answer always was interestingly there is no such thing as the best hospital. Their hospitals that are good at something and those same hospitals may not be so good in other specialties and areas. I think thats the thing about the va system. When you have the largest system in the country with thousands of soldiers you will have some better excellent at certain conditions than others and frankly need work on what youre going to find in health care. The va has additional complexity in that it needs to provide care for veterans wherever they live in this country. Therefore we have a large number for veterans who live in rural areas and finding people especially specialists to be able to work in rural areas is the challenge for the va and also the private sector as well. So you have a tremendous variation between what works in the va from one place to another place and thats one of the things end of course i work very it to try to standardize some of these practices. Host reminded me of a very funny story from your first confirmation hearing when senator sullivan from alaska basically said you need to come to alaska because we have a unique set of circumstances here unique challenges to veterans in need to come here and understand that. Guest a little bit more about that jeremy, many people dont understand the Senate Confirmation process and you actually in order to go quickly through a similar process and not require a higher floor vote you have to have unanimous consent. This was when i was undersecretary in the white house said to me good news you have unanimous consent. You are going to be confirmed in the next couple of minutes. Right as the vote was happening senator sullivan said not so quick. I need to have a conversation with the nominee. Called me up and he said listen im standing on the senate floor and im about to cast my vote but i want you to commit to me that in the first 30 days if you are confirmed that you will come to alaska with me because alaska is very different than other states and our veterans have different needs. I said senator we are going to alaska and then the vote went through. Which i imagine was your intention anyway because you mentioned there was a lot of variability geographically speaking in terms of making it difficult to get proper professionals to some of the rural areas. Guest alaska is one of the few states New Hampshire and others that dont have its own hospitals. Meeting the Health Care Needs are extraordinarily challenging. We have to partner with the air force but i was delighted to travel with the senator senator as i was when i went to other rural states with their senators as well. Thats the way you really get to understand how to fix problems that are out there by talking to veterans about what they are experiencing. Host absolutely another thing you did is you continue to see patients during your time in the va which i think might surprise some people. I would say at the time to do it because you are working hard seven days a week but in fact that was something you felt was necessary and vital to your understanding the needs of veterans. Guest i think every leader can do their job more effectively if they understand what the impact of their decisions are. If i were going to be making a decision that i ultimately dead on which electronic records the va would use, how could i make that decision if i had never used the vas electronic record in the i had never been working with patients and nurses and doctors understanding how they interact with a wreck yert. When i would put on my white coat and go and see people no one knew i was secretary and certainly the veterans to know that ive helped me understand what was working and how they were experiencing the decisions that i had to make from the ground level. I think that made me a better and more effective leader. Host absolutely and if had the Electronic Health records which is something i want to talk about. You remind me it was a very funny anecdote talking to veterans and you are white coat on and they dont necessarily know who you are. Youve got some startling response from a veteran. Can you tell that story . Guest i would see patients in two ways. I would see them in person in the exam room here in new york city at the manhattan d. A. And then id see them using telehealth from my office in washington to a clinic in grants pass oregon they rural heart of the country so i got to experience both urban and rural telehealth and in person. I was in the new york manhattan d. A. When i saw a patient who came in and i said what can i do for you sir . He said i need a physician to fill out this form and i said id be glad to help you at that. Tell me what the form is forward he said i need a certification because im suing secretary shulkin. I asked him what that was about and he was actually a homeless veteran and was trying to get additional benefits so that he could get himself out of that situation and get himself back on track and needed a physician certification of the issues he was dealing with a set to him well first off we are going to get uniform you need but i dont think im the person to do it. He looked at me and said why . I am secretary shulkin. He said oh no this cant be true we got him on his way and i got another physician to help him. Host excellent and early on you mentioned five priorities he had known you were coming into the va. Could you talk about those five priorities and how you arrived at what they would he and maybe expand them how you feel you did in achieving those . Guest when i first came to the va i not only had never worked in government before but this was an organization that i was going to have to learn and it was such a Large Organization that if i had waited until i truly understood everything about it we be waiting a long time. As i mentioned i entered at a time of crisis. There were veterans literally waiting for help and i didnt feel like i have the time that i normally would if this was a normal situation. I came in and studied the va from the outside the best i could pay that came in and i said we are going to priorities right now. Our single top priority was going to be addressed the wait time crisis. There were hundreds of thousands of veterans waiting more than 30 days for care. Most critical to me was there were 57,000 veterans waiting for Urgent Medical consultation. That was totally unacceptable to me and outside the bounds of what i thought was reasonable. I immediately called for every Medical Center to be opened on the following weekend and during that weekend we contacted those 57,000 veterans and by monday morning we had the list down to 1000 veterans. Once we essentially got the backlog taking care of i wanted to make sure that we never got in that situation again. I did a couple of things. The first is a secretary one of my first decisions was to publicly post wait times. The va today is the only system unaware of the publishes its way times so people can see. The second thing that i did was i established same day service corrupt the entire country so by december of 2017 i was able to tell secretary mcdonald and president obama and every va Medical Center had capable of seeing everyone on the same day basis so wed never been a situation where someone with an urgent situation couldnt be taking care of. We ended up publishing an article in the chairman of the medical association were we studied, we put all these things in place and how the vas way times compared to the public sector. The va turned out to be better and we have made tremendous progress in addressing that issue really with the commitment of the employees and the staff to work there. The other priorities but that was our top priority were focusing on establishing improving employee morale because morale had been terrible there were 45,000 vacancies in the va recruiting people to an organization that has low morale is a significant challenge. Probably one of arm most important priorities was regaining the trust of the veterans that we served. We would say to our staff and the va we dont have any. Price that we cant follow our progress by looking at whether we are doing better with stock price but what we can do we can track whether we are rude ending the trust that we lost of our veterans. Fortunately that began to climb again and is climbing the va today which is very very good news. We had established another priority of creating best practices, learning from one va to another learning what works and doing it across the country so they could decrease some of that variation in the quality of care you have talked about. That was very successful in being able to do that as well. Host thats great and some of these things you brought from the private sector i know there are vast differences as you alluded to in the ways in which we as a country can provide care to civilians and providing care to our veterans. Are there things that we continue to learn from the private sector to improve the way we deliver care to veterans . Guest interestingly as i mentioned before not only did i not have time to learn all the ways of government because i felt there were urgent issues like wait times issues but i deliberately didnt want to start to think as if i was a government employee. I wanted to deliberately bring the industry best practices the way that we thought about things and the private sector to government. What i ended up learning was the government could benefit from many of the practices. Needed a challenge itself and modernize his the ways he was thinking then i learned there was more that i learned in the va that the private sector could benefit from. This is actually a twoway bidirectional learning that needs to happen between the earth and government in this case the va. Host thats interesting because right now theres an ongoing continue debate about the future of health care and i dont think thats a perspective that is often brought into the conversation about what we can learn from the government is not something that people say you can learn from the government to improve care. Guest i dont think people understand when you look at the outcomes of care across the population which is very popular right now and health care. Its called population health. The va outperforms almost every other major Health Care System. Im not saying there arent some great Health Care Systems out there that this country provides Terrific Care but when you look on average the va performs that are the most of the private sector. If you look at some of the things that we did like for example i made the declaration that i wanted to eliminate hepatitis c from the entire veteran population. There were 163,000 veterans in the va system that had hepatitis c and now fortunately we have several drugs that can eliminate the virus at a 95 or higher cure rate so i didnt see any reason we should have been the veterans that have hepatitis. I went out and Congress Gave us 1. 5 billion to do this. We went out and practically began to contact every veteran that had hepatitis c through today the vas tweet treated well over 100,000 of those veterans well on the way to eliminating hepatitis c. We need to do more than the general population and not Many Health Systems are thinking that way proactively looking at outreach and population health. These are some of the lessons we can learn from the va. Host this gets back to as you mentioned care that veterans get through the va and the studies that you mentioned that show that. As i mentioned our membership generally likes the care they get to the va in there are some things they want to improve. We often hear negative stories in the press about the positive stories. You certainly addressed in the book another area in which the va continues around the problem of military suicide. Its such a complicated issue. Mental health is a complicated issue not only in the military veteran space but we as a country are struggling to understand and figure out how to talk about how to solve. Do you have any insight from your time at the va and to how we can begin to address this issue and how we can cope within them out of the eighth. Guess who tony veterans that they taking their live is a staggering figure that i used to sit there and just say if we let another week go by there goes another 140 of our veterans. There is still so much work to do on that and thats why im pleased that secretary wilkie has continued to make veteran suicide a priority for the va. One of the things when we begin to start taking a look at those this of those 20 veterans a day who take their life only six are getting care in the va system so there are 14 out in the community and my biggest worry is they are not getting any help at all. One of the first initiatives that we did at the va was to start an outreach to community partners. Veterans Service Organizations like iaea and Others Community groups and churches and religious organizations and groups like the united way and other south there and local governments and state governments all began to start working together. Every va Medical Center has what they call a Suicide Prevention coordinator. Many of them have a triple Suicide Prevention coordinators. Their job is to be a there looking for veterans at risk and identify ways to help them. Thats one of the practices that i think the va has in the or should have paid this is an American Public health issue and not just a veteran. We need to do a lot more than the underlying reason why people take their lives is not because they wake up one day and say hey i feel like doing this. They are suffering from something. Could be depression. It could be ptsd. It could be chronic pain. It could be Substance Abuse and other reasons. We have to look at ways of getting to those underlying reasons finding more effective diagnoses and begin to make sure we are proactively identifying how we can intervene and help in there so much more work to do. Lots of promising opportunities to do that. We are looking at Predictive Analytics and more effective therapies but much work needs to be done in this area. Host absolutely. I va has this is the number one priorities as well and unfortunately what we are seeing is the situation is not improving and we of course continue to come out from both the military showing that we are not getting at the problem. I think we shouldnt just be looking at it as an Emergency Response issue but a much broader thing. We need to look at the underlying issues you mention chronic pain and things like that, homelessness, financial issues. So much can be read into that. Which the va loan and the government alone cant solve. The chloe has to be a whole of government and whole of Society Approach to this. The va as the leader for the veteran Community Within the government should be spearheading that but that assure a challenge. Guess who im proud of the work of the va is doing. They are working hard to address issues that like many tough problems americans face we have to do even more and we have to push through some of the barriers that prevented have prevented us from making progress. I think you are right the reason Suicide Prevention of the va has decided to report the data differently to look like a smaller number, it is not a smaller number. That one up the little bit that this is not about a scorecard. This is about making progress and im not sure that we are there yet. Host i completely agree. Another area i would like to touch on his Women Veterans. This is an area in which again i think a lot of the country doesnt realize how much the landscape has changed. We have more Women Joining the military and certainly more women serving in combat roles and more women are coming back from these deployments needing va care. We certainly hear from it firsthand that women oftentimes dont deal welcome at the va. They are sometimes harassed on the way in with catcalls and things like that and they feel its assumed that they are there with a spouse or boyfriend or Something Like that. What needs to be done to begin to change this culture . It seems as throughout the va and maybe throughout the country frankly that doesnt quite reckon is the service of Women Veterans the same way we recognize the service of male veterans. And what i did instead of waiting for culture to change. To make sure we were providing care with the respect that everyone deserves so it created womens clinics and Women Centers over 120 Medical Centers often have separate entrances but a secure and comfortable environment for women where they go to get their care and dont have to worry about of the abuses that we talked about. These are centers of excellence where people love getting their care there. In some ways it is a shame we have to create separate places for people but we were not willing to try to change attitudes but at the same time we are providing these Women Centers there was a recent public issue of washington dc a month ago where a woman veteran was harassed just walking through the halls and had the courage to talk about that experience i went out publicly supported her in many of the organizations to say this is unacceptable. That we need people like this brave woman to speak out on the half of her fellow veterans and we need to begin to start changing. We need these veterans as well. One of the women we are trying to begin the process is a topdown understanding that there should be a cultural system many people dont know the motto for he who goes to battle for the widow and orphan. It is something that is embracing of the nature of our military and veteran community. And is receive pushback in a lot of corners with that pushback internally when you were in the v. A. Quick. Yes. One of the disappointments i had, the military is a place in our society where diversity has the opportunity that this is the ultimate melting pot. You rely on each other to survive it does remember a republican or democrat, black or white, woman or mail. This is a common mission. So for the v. A. Not to be inclusive to embrace that diversity is a mistake. I understand peoples deep attraction to Abraham Lincolns motto, that was in a different time. We need to recognize the new father of the v. A. Needs to be leading this type of inclusion and if there is motto is time for us to recognize that and i do not believe that Abraham Lincoln would be upset with that. He stood for making sure we were one country together and believe strongly in supporting people who fought for the country as we both do but just talking about the issues and now the importance a couple hundred years after it is time to move toward a more modern motto. Absolutely and there is legislation to change that but the v. A. Has the ability to do it on its own it doesnt need an act of congress. Know it would not. I did not envision chiseling off the Abraham Lincoln part of the building so to honor history and respect and not change the dignity of what he gave to us as a country with a commitment toward veterans. But his original quote talking about widows and orphans, this is not language we traditionally used in 2019 and i think there is a way to honor those original words by talking about new v. A. That could be done for history. I completely agree so now shifting talking big picture about the v. A. Specifically as secretary we touched on a couple of these issues but i think its safe to say that if you look at your service as the secretary under President Trump that underlying policy debate that drove so much of your time there around the Electronic Health records privatization is a word that comes up all the time i dont think most people fully understand. Could you give the audience an understanding of what we mean quick. Privatization to the full six cents would be the concept of shutting down the v. A. Medical centers in the Health Care System to give the voucher to a veteran to say you go and find your own health care in the private setting. And we will pay the bill. That is the ultimate goal. And there is a strong belief the government should not believe be long in those services we talked about this earlier where the governments involvement in the health care is the most effective way to honor our nations commitment to our veterans. Doesnt mean it should not have the ability to go into the private sector or specialized care is available for i think we all believe it should be available but my belief is the complete privatization would be a disaster. We would look back when veterans are not getting the care they deserve and how do we create a system that is . I dont want to see us go in that direction 19 percent of veterans were getting care where i left it was 36 percent so i was strongly in favor of not having veterans getting inferior care that we got them to the private sector. I think this is an issue of policies pursued by those who favor the dismantling of the v. A. It would be politically unpopular but if you watch the impact of these policies over the years that will come i believe it will lead to a point where there is complete privatization so what i argue in the book to say what will happen with all these policies are very closely monitor to make sure theres not the unintended consequence before its too lat late. There is the appropriate role of congress and the role of the press to make sure theyre looking at what is happening and im trying to raise not disability but be cautious. I am optimistic of where the v. A. Is going. But being an expert in healthcare i see that we are more vigilant of these unintended consequences. You said Something Interesting that could confuse the audience of how the percentage of private care rose and some people would say are you working toward privatization cracks can you unpack that a not wanting to privatize. It can be confusing and often now just what happens in washington, if you are not at what in and of a political spectrum one and says we are in complete control of healthcare by the government we dont want the government involved at all and if you have to be in the middle with a compromise solution where i am its a very lonely place in washington and people tend not to understand it. But i believe as a physician the right answer in healthcare is to do the right thing and for your patient so if you are a veteran what should you want . The very best care possible. Where the v. A. Can provide these things i dont think are readily available in the private sector there should be a strong v. A. Focusing on areas that the private sector doesnt i mentioned ptsd traumatic brain injury prosthetics and environmental exposure to toxic agents like in combat this is what the v. A. Does extraordinarily well. But it cant do everything well so if you are a veteran you need specialized care you should be able to get that in the private sector i imagine a hybrid system with the strong and modern centers of excellence and the ability to seek the private sector when those are not available. I publish that as a model of care in the new england journal of medicines everyone can see the plan that i have for the v. A. And frankly just makes sense for veterans. You talk about this in the book this term this debate comes up over the mission act and before that the term was choice talk about what that bill does or will do. It was passed one year ago and implemented but there is still a lot of confusion. You spend a lot of time on the bill. Talk about what it would do. I spent all three years in government leading up to that passage when the crisis happened in 2014 Congress Quickly responded and obama said that they should go into the community if they need care that was called the choice act. That was temporary and meant to last for three years and also hastily put into place so this calm plex and difficult to navigate but at the ability for veterans to go into the private sector into a Permanent Program so was no longer temporary and second it simplified the way to use that system of care so it wasnt so difficult that veterans that i worked very hard to get done so the mission act which is now law that President Trump signed it is very good. The danger of the mission act is somewhat technical but i cannot over emphasize how important. That the rules that govern how they can go into the private sector are the access standards. I knew this was so important but we were not ready yet. So i asked congress to be at the discretion of the secretary give a year so the secretary could come forth with a well thought out plan and congress that i would do that as well. I was not there the president had fired me and now secretary wilkie had to produce the access standards. I think he made a decision that these standards will continue to be based on administrative rules. How many minutes it takes you to drive to the v. A. And how many days you need to wait for an appointment. I would have chosen a different path based on clinical rules. They get decisions based on clinical situation i am a doctor what is best for my patients. So i say if you are a veteran that lives next door to a nextdoor to a v. A. Medical center you should have the same ability if somebody live 65 minutes away. This is a mistake of the access standards. And this can be changed so there is flexibility not trying to say but this is to be studied very carefully and we have to monitor it. Leading to bad consequences and the adjustment that we made to make. Host and you also write about your efforts to craft legislation so talk about the groups how they work and influence your time at the v. A. When the president comes into the administration the group that supported the old president that leave and generate 20th and 4000 new political appointees come into the ministration and there are 30 political appointees and they are generally there for the right reason but i have a number of them that were more political ideologues they had necessarily and they believe differently that these access standards and the mission act should move toward the action of administrative rules to open up the v. A. Which i believe would be leaning toward privatization but when the mission act and went to the senate v. A. Committee it was 14 in favor of the bill that i proposed and one soul senator voted but the political appointees align themselves with that senator and ultimately that minority bill and up getting into these access standards. Instead of the v. A. Acting there were two voices. And the appointees who had the support of the white house and that was the issue and ultimately the decision to make a change of the secretary. As you wrote in the book but the idea of privatization came up very early with your initial conversation with the president elect do you think the president wants to move toward privatization or is this a situation where lower level have the agenda but is not communicated up the chain quick. Thats a fair question. I dont think im at the point that i can speak for what the president wants. He was focused on is what we are doing good for veterans . I will give him the event of one the benefit for goi do believe these political appointees have a much stronger ideology with concern veterans for america and i think every american who cares about that and should be putting forth their ideas not all of those ideas are bad ideas. But there are two camps of decisionmakers and that in many ways they found the way to get the president on their issues and i think continuing to drive the v. A. I happen to believe thats in the veterans best interest and now we have seen that toward the approach that they wanted. I dont know if he has put himself into the details of the policies. Theres a lot more want to talk about. We will do a speed round. Two things. Medical cannabis. Many veteran organizations are actively trying to get the v. A. To be involved in. At a minimum to do research there is a bill to drive research around the utility of medical cannabis. They are untold numbers of versed and anecdotal accounts how much it has helped them overcome their issues. And and some of that foundational into talk about the hazards and agent orange debate and with those combat zones and resulting in those deployed Service Members breathing in those talks it dash toxic fumes now they come back having very Serious Health issues. Can you touch on both of those topics and what the v. A. Is doing and what its not quick. I will do that quickly. I am a physician with scientific training i tried to look at things scientifically. That cannabinoid system is a system with extreme potential to help improve health and wellness. I am strongly in favor of any effort that will give us more evidence and research so the v. A. I believe should be involved and open to research for anything that would help veterans improve their lives including medical cannabis thats different than recreational that the benefits is at the payroll of veterans especially with a crisis of suicide. And legislative help is beneficial. This is an area we have backwards. That we wait until there is Scientific Evidence to make policy changes that has resulted in veterans waiting decades to get the help they need. To talk about agent orange by 50 years ago people were exposed. Today in 2019 they are still fighting for benefits. For some folks it has scientifically shown to be toxic have yet not been approved our veterans are still waiting for the health that they need to go for veterans not getting Health Benefits and clearly they have exposure to those toxic elements because science has not yet shown it but we need to turn that around if somebody sacrifices with the benefit of the doubt if they are not in that location that they said they were then we need to change that policy. And they are just not learning from the mistakes that we made from Vietnam Veterans and we are making them wait and suffer 55000 veterans of the registry and we study that but in the meantime there are people who really need our help that is responsible to have helping our veterans. I appreciate that those are two issues that are important to us im sorry we dont have more time because they are incredibly important so there is legislation pushing for the government and the v. A. To take real action on this. You write about this in your book it does have the ability and the authority to do research is that just a stalling tactic or maybe generally they dont feel they could until they get legislative guidance on cannabis i think they want to do the research it is so incredibly difficult to get these Research Grants approved because a very restricted target the researchers in Charleston South Carolina wanted to talk about the get around that bureaucratic legislation. You convened a meeting of former v. A. Secretaries how did that go over and did you learn and do you stay in touch quick. One of the biggest problems of a Big Organization like government is the constant turnover. Almost every two years theres a new v. A. Secretary and the undersecretary position that i held and vacated february 2017 is still open to this day. Not a Senate Confirmed a person. So when you have the turnover there is not a consistency of vision. So i believe it was incumbent upon me to learn from my fellow secretaries and i felt very comfortable to move things along so we brought them all together and then being appreciated to be tapped into. I think i have identified a formula to make great progress but when you leave nobody ever invites what did you learn . That is a travesty and a failure of leadership. So i wanted to write the book so future leaders of the v. A. Could pick it up and say this has been tried before i think that is a duty or responsibility that i have and i will continue to speak out and advocate for veterans. Host this is an Incredible Opportunity to talk to you i appreciate your time in service at the v. A. I know its incredibly challenging it is very much under the spotlight but also held up to a high standard. Its an honor and is a fantastic organization and hard work standing up to make sure were doing the hard work. I appreciate your time