Department for the Trump Administration but hes interviewed by jeremy butler, ceo of veterans of america. After words is a weekly Interview Program with relevant guest hosts interviewing top nonfiction authors about their latest work. All after words are availablee through podcasts. Doctor shulkin, thank you for being with us. Its an honor to have you here. I think the va is important to subject to talk about in one of the areas of our government that a lot of people hear about but dont necessarily know many of the details. Frankly, even in the veteran community a lot of us dont understand the breadth and depth of what the va does. Im excited to talk to you about the ba in general and certainly about your book and about your time in the administration. Id love to begin by hearing about what brought you to the va. Youre very successful in the civilian career and times making that transition from the civilian world into the government world can be a bit jarring but what drove you to want to take up the mantle of working with the government especially within the va . During my 20s i did not have a chance to serve the way you did. I spent my time medical institutions and doing my medical training and it was a busy 20s. That is always one of the real regrets i had that with this amazing country that we have i wasnt able to get back. Later on in my career i was the ceo of a hospital and i had the opportunity to get a call from the white house and this was right at the time in 2014 when it was a very public way to time crisis in the va where there was allegations of the veterans were dying waiting for care and i remember sitting there as a citizen saying i feel terrible about this. If anybody deserves the best care possible it is our veterans and i wish there was something i could do to help. As sometimes happens in a strange way i i got a call from the white house saying would you consider coming to help lead the va Healthcare System because we aree looking for somebody who understands how healthcare works from the private sector. You know, i did what everybody tends to do when they have these choices. I made a list of the pros and cons and the cons side was much, much larger then the pro side but on the pro side it was simply how good i say no. This is my duty as an american citizen to get back the people who had given us so much and so i did not think much about it but said yes, im prepared to come and help. That is great. As those of you who have read the book know that was during the Obama Administration initially so you are one of the few people who served under both the obama and Trump Administration and look forward to getting into that. That said i would start and i love to read a brief quote from your book, early on the right it is important that americans understand what the va system is. How it works and why it exists. As i mentioned a lot of people dont understand the scope of what the va has and what responsible for. If you could start off by giving maybe you had an elevator pitch to those that you gave or talked about everything the va does because, as you well no, it goes well beyond healthcare but there is so much more that the va does. Right. One reasonable book was exact me what you talked about. Im not sure the America Public understands why the va exists but why it really is an essential part of our National Security system thatan when we relyic on voluntary military whh now is less than 1 of americans serving but these amazing americans raise their hands and are willing to sacrifice themselves on behalf off allll f us and when they go there is a commitment that the country has made it to them that they will take care of them if they need that help when they come back. H there is no other organization that is focused on that. As you said, the ba provides healthcare for 9 million veterans. There really are 20 million veterans in the country so the va has a large effort directed towards education and the g. I. Billdi in the house and effort towards benefits should somebody require assistance that they are no longer able to work or if they are disabled and it goes all the way through the time of making sure every veteran, when the time comes, is buried with dignity and respect and so there are 114 va cemeteries around the country and they do an amazing job supporting families during these tough times. This is a organization, second largest in the u. S. Government, employs 370,000 people who are there, many are veterans themselves looking to give back. It does an amazing job and really does deserve the support and understanding of the american people. Host thats great but i appreciate that. I often point out to people that the va is the secondlargest ofdepartment and second largest agency, second largest budget and people just from a civics mind point should be more informed about everything. Guest i think that is right. If i could, just about the health care aspect because he gets so much focus of the public attention on the va. When i came from the private sector into government i had never worked in government before and i had a completely open mind when i was reading all these Horror Stories in the press that i would go there and find that the system was so broken and so dysfunctional that maybe my job was going to be just to close up shop and say you know what, the best thing i can do for veterans is eliminate the va Healthcare System and move everybody into hospitals, something i knew well. After i got to the va 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 and went out and visited hospitals across the country and went to see places like where we bring paralyzed veterans skiing down the slopes in aspen, colorado and i really began to understand that what the va does is Healthcare System is very different than what the private sector does and in fact, cant be replaced with the private sector doesnt do the things that the bl Healthcare System does. For example, our behavioral Healthcare System is extensive and large and where the private sector behavioral Healthcare System is really struggling and trying to get access if we were to put these 9 million veterans just dump them into the private sector system on the system that already is struggling to meet its needs we just note that the 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 tt that it will be a sustainable system. Host absolutely. You touched on a few things i want to make sure we can come back on and privatization in things like that and very important topics with a large part of your book and i dont want you to think i will skip over that but i think we will get to that in a little time but i want to continue with [inaudible] youis mentioned a comment saying that within thehi veteran community i think even within the va that if you been to one va event 21 va and he mentioned especially in the beginning he did a lot of going around to visit different mbas and things like that but why do you think that is . Even though were talking about an agency that has oversight over all these areas you get so many different stories but unfortunately, i think, negative stories are the ones that gets e e press but you hear Horror Stories about one va but then talking to so many other veteransns our membership often tells us they love the carrot that they get at the va but they just owned or would like to get ask us to it faster and things like that but whyd you think there is that there such a variety of levels of care that one receives . In guest first of all, the va is under a public scrutiny that no other Hospital System and the country finds. As the hospitals ceo in the private sector i can tell you Little Things that happen in the va that never would come to the attention in the private sector turn out to be the subject of congressional hearings and major front page stories. I think the public gets a sense that there are lots of things are happening in the va hospitals dont happen in the private sector but again, using the private sector comparison the question i would get most frequently being a physician ceo was what is the best possible hospital for me to go to in my answer always was interestingly there is no such thing as the best hospital. There hospitals that are good at some things and those same hospitals may not be so good and other specialty areas so i think that is the same in the va system where he had the largest system of the country with over 1000 facilities you will have some that are excellent at certain conditions and others that frankly need work on them and that is what you will find in healthcare. The va has an additional complexity and that it needs to xiprovide care to veterans wherever they live in this country and so therefore we have a large number of her veterans who live in very rural areas and finding people, especially specialists, to be able to work in rural areas is a challenge for the va and the challenge for private sector as well. You have a tremendous variation between what works in the va from one place to another place and that is one of the things that of course, i worked very hard on the tried to standardize some of these practices. Host absolutely. That reminded meth of a funny story from your first confirmation hearing where the senator from alaska basically said you need to come to alaska because we have a unique set of circumstances here, unique challenges to veterans and you need to come here to understand that before he was going to vote for you. Guest yeah, i think a lot of people know more about that journey i and many people dont understand the Senate Confirmation process and you actually, in order to go quickly through assignment process and not require a entire floor vote you have to have unanimous consent and this was when i was under secretary and the white house said to me good news, you have unanimous consent and you will be confirmed in the next couple of minutes. Right is that vote was happening senator sullivan said not so quick, i need to have a conversation with the nominee te called me up and said listen, im standing on the senate floor and about to cast my vote but i wanted 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 different than other states and our veterans have different needs. I said senator, we are going to alaska and then the vote went through. [laughter] host imagine that was your intention anyway because he mentioned there was a lot of variability, geographically speaking in terms of making it difficult to get proper professional to some of the rural areas. Guest alaska is one of the few states, New Hampshire and irwaii being the others that dont have its own va hospital and so meeting the healthcare needs of those h spaces is extraordinarily challenging with the partner in anchorage where we partner with the Air Force Hospital but i was delighted to travel with the senator as i was when we went to other states with the senators as well because that is 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 was you continue to see patients during your time in the va which might surprise some people that you had, i would not say the time to do it because you are working very hard seven days a week in there but in fact that was something you felt wasnt necessary and vital to understanding the needs of the veterans. Could you expand on that . Ou guest i think every leader can do their job more effectively if they understand what the impact of their decisions are. If i was going to be making a decision as i ultimately did on which electronic record va would use the big decision how could i make that decision if i never use the va electronic record and if i had never been working with patients and nurses and doctors to understand how they interact with the record. When i would put on my white coat and go and see people no one knew i was secretary in the veterans did not know that but it felt or helped me understand what was working and how they were experiencing the decisions i had to make from the ground level and i think that made me a better more m effective leader. Host absolutely. If you touched on the Electronic Health records which is something i also wanted to talk about in a little bit but you remind me theres a funny anecdote that when you are in your doctor capacity talking to veterans as you said you have your white coat on and they dont necessarily know who you are and you got some sort of startling response from a veteran but could you tell that story . Guest i would work or keep patients i would see them in person, in the exam room, here in new york city at the manhattan va and then i would see themem using telehealth from my office in washington to a clinic in oregon a rural part of the country so i got to experience both urban and rural using telehealth and in person but i was in the new york manhattan va when i saw a patient who came in and i said what can i do for you, sir and he said i need a position to fill out this form and i said id be glad to help you with that, can you tell me what the form is for and he says yeah, i need a certification because im assuming secretary a show can and i asked them what that was about and he was 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 position of certification of his issues that he was dealing with and so i said to him sir, first of all, i will help you. We will get you the form you need but i dont think im the person to do it. He looked atin me and said why d i said because im secretary shulkin and he said no, no, this cant be true. [laughter] but we got him on his way and i got another position to help them. Host you also early on mentioned five priorities that you had when you were coming into the va because you talk about those five priorities and how you arrived at what they would be and maybe you can expand on some of how you feel you did in achieving those goalt during your term. Guest when i first came to the va i not only 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 would be waiting a long time but as i mentioned, i entered in a time of crisis and there were veterans literally waiting for care that needed helpti and i did not feel like i had theat time that i normally would if this was a normal situation so i came in having studied the va and i came in and said we will have priorities right now and if we change them later on that is okay but our single top priority was going to be to address the wait time crisis. There were hundreds of thousands of veterans waiting more than 30 days for care but most critical to me was there were 57000 veterans waiting for an Urgent Medical consultation. That was just way more than 30 days and that wasnt totally unacceptable to me and outside the bounds of what i thought was reasonable. I immediately called for every Medical Center to be open on the following weekend and during that weekend we contacted those 57000 veterans and by monday morning we had that list down to less than 1000 veterans. Once we essentially got the backlog taken care of i wanted to make sure that we never got to that situation again so i did a couple of things. First is at secretary one of my first decisions was to publicly post the wait times. The va today is the only system that i am aware of that t publishes its wait times so that people can see. The second thing that i did wasl i established Sameday Services throughout the entire country. By december 2016 i was able to tell secretary mcdonald and president obama that every va Medical Center had the capability of seeing people the same day basis so we would never be in a situation so that someone with an urgent issue cannot be taken care of. We ended up publishing a article in the journal of the American Medical Association where we studied after we put all these things in place how the bas wait time compared to the private sector and what people and the American Public thought and the va turned out it to be better and that we made tremendous progress in addressing that issue really with the commitment ntof the employees and the staff that worked there. The other priorities but that was our top priority were focusing on establishing, improving employee morale because morale had been terrible and there were 45000 agencies in the va and recording people to an organization that had low morale is a significant challenge. Probably one of our most important priorities was regaining the trust of the veterans that we served and as i always say to her staff in the va we dont have a stock price. We are a Government Organization so we cant follow our progress by looking whether we are doing better with stock price but what we can do is we can track whether we are regaining the trust that we had lost of our veterans and fortunately that again began to climb as well and it was very good news. We had established another priority of creating best practices and learning from one ba to the other and learning what works and then doing it across the country so we could decrease some of that variation in quality of care that you had talked about and that was very successful and be able to do that as well. That is how we established that. Host that is great. Some of the things they brought from the private sector i know there are vast differences as you already alluded to between the ways in which we as a country can provide care to secivilians and the way in which we can provide care to our veterans but were there things or are the things that we can continue to learn from the private sector to improve the way we deliver care . Guest interestingly as i mentioned before not only did i not have the tim