Butler. After words is a weekly Interview Program. They are also available to listen to as podcasts. Doctor shell can, honor to have you here. There was allegations that veterans were dying waiting for care. I remember sitting there as a citizen singing, i feel terrible about this. If anybody deserves the best care possible, its our veterans. Wish there was something i could do to help. It sometimes happens in strange ways. I got a call from the white house singing, would you consider coming to help lead the va Healthcare System because we are looking for somebody that understands how healthcare works from the private sector. I did what everybody tends to do when you have these choices to make. I made a list of the pros and cons. And the con side was much larger than the pro side. But on the pro side, it was simply, how could i say no . This was my duty as an american citizen to give back to people have given us so much. So i didnt think much about it but i said yes, im preparedto help. Thats great. Those of you who read the book, that was during the Obama Administration initially. User both under the obama and trump administration. I look forward to getting into that. That said, i thought id start. Id like to read a brief quote from your book. Early on you right, its important that americans understand what the va system is point how it works and why it exists. As ive slightly mentioned, i think a lot of people dont understand the scope of what the va has what they are responsible for i wonder if you can start by, maybe you had an elevator pitch you gave talking about everything the va does. It goes well beyond healthcare as well. But thats what most people know about. Right. One of the reasons i wrote the book is exactly the reason you talk about. Im not sure the American Public understands why the va exists. Why its an essential part of our National Security system. When we rely on a voluntary military, which now than less then one percent serve in. That these amazing americans raise their hand and are willing to sacrifice themselves on behalf of all of us. When they go, theres a commitment the country has made to them that they will take care of them if they need that help when they come back. And there is no other organization focused on that. So the va provides healthcare for 9 million veterans. But there are 20 million veterans in the country. The va has a large directed toward education, the g. I. Bill and effort toward benefits. For those that require assistance if there no longer able to work or disabled. And it goes through the time of making sure every veteran when the time comes is buried with dignity and respect. So there are 114 va cemeteries and they do an amazing job supporting families during these tough times. So this is an organization, secondlargest in the u. S. Government. Employees 70,000 people. Many are veterans themselves. It does an amazing job and does deserve the support and understanding of the american people. I appreciate that. I often point out to people that the va is the secondlargest department and agency. Secondlargest budget. People i think from a civics mine point should be more informed about everything that the va does. In the healthcare aspect gets so much attention. When i came from the private sector into government, i had never worked in government before. I had a completely open mind when i was reading these Horror Stories from the press. That i would go there and find this system was so broken and so dysfunctional that maybe my job would be 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 everyone into private sector healthcare which is what i knew very well. After i saw what the va does. When i think got to see, i put on my white coat as a doctor and took care of veterans and visited hospitals across the country and went to see places like where we bring paralyzed veterans, skiing down the slopes in aspen, colorado. I began to understand what the va does in the Healthcare System is very different than what the private sector does. In fact, cant be replaced. The private sector doesnt do the things that the va Healthcare System does. For example, our behavioral Healthcare System, it is extensive, it is large. The private sector is really really and trying to get access. If we were to put these 9 million veterans and dumped them into the private sector system that is already struggling. We know the veterans would not come out on the right side of doctor soy became a strong advocate for making sure this was a system that works well. That we need to modernize and improve that it will be a sustainable system. You touched on things that i want to make sure we come back to privatization are important topics. A large part of your book. We will get to that. But i want to continue with this setting because you mentioned reminded me of a comment saying within the veteran community, if youve been to one being, youve been to one va. You mentioned how in the beginning you did a lot of going around to visit different vas. Why do you think that is that even though we are talking about an agency that has oversight of all of these areas, you get so many different stories . Unfortunately, negative stories are ones that often make it to the press. But in talking to so many veterans, membership tells us they love the care they get. They would like to get access to it faster and things like that and why do you think there is that theres such a variety of levels of care that one receives . First of all, the va is under public scrutiny that no other Hospital System in the country fines. As a hospital ceo in the private sector, Little Things that happen in the va that would never come to the attention in the private sector turn out to be the subject of congressional hearings and major frontpage stories. I think the public gets the sense that there are lots of things happening in va hospitals that dont happen in the private sector. But using the private sector comparison, the question i would get most frequently being a physician ceo, whats the best hospital for me to go to . My answer always was, interestingly, there is no such thing as the best hospital. There are hospitals that are good at something. And those same hospitals may not be good in other specialties. I think thats the same in the va system. When you have the largest system. You have some that are excellent at certain conditions. And others that frankly need work. Thats what youll find in healthcare. But the va has an additional complexity in that it needs to provide care to veterans wherever they live in this country. So therefore, we have a large number of our veterans who live in very rural areas. Finding people, especially specialists to be able to work in rural areas is a challenge for the va and private sector as well. So you have a tremendous variation between what works in the va from one place to another place for thats one of the things that of course i worked very hard on two standardized some of these practices. That reminded me of a funny story from your first confirmation hearing. When senator sullivan of alaska basically said, you need to come to alaska because we have a unique set of circumstances here. You need to understand that before he was going to vote for you. I think just so people know more about that. Many people dont understand the Senate Confirmation process. You actually come in order to go quickly through a senate process and not require an entire floor vote, you have to have unanimous consent. The white house said to me, good news, you have unanimous consent. You will be confirmed in the next couple minutes. Right as that vote was happening, senator sullivan said, not so quick. I need to have a conversation with the nominee. He called me up and said, im standing on the senate floor. 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 in our veterans have different needs. I said, senator, we are going to alaska. And the vote went through. [laughter] which i imagine was your intent anyway. You mentioned there was a lot of variability geographically speaking especially, in terms of making it difficult to get proper professionals to some of the rural areas. Alaska is one of the few states, New Hampshire and hawaii being the others that dont have its own va hospital. So meeting the healthcare needs of those states is extraordinarily challenging with the partner. In anchorage, we partner with the air force hospital. But i was delighted to travel with the senator. Because thats how you understand how to fix problems out there by talking to veterans about what theyre experiencing. Another thing you did issue continue to see patients during your time in the va. Which i think mightsurprise people. That you have the though ai would take the time to do it. But in fact, that was something you felt was necessary and vital to you understanding the needs of the veterans. Could you expand on that . 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 the va would use. A big decision. How could i make that decision if i had never used the vas electronic record. And if i had never been working with patients and nurses and doctors understanding how they interact with the record. When i would put on my white coat, no one knew i was secretary. It helped me understand what was working and how they were experiencing the decisions i had to make from the ground level. I think that made me a better and more effective leader. You touched on the Electronic Health record which is Something Else i want to talk about it a little bit. You remind me, theres a funny anecdote when you were in your doctor capacity talking to veterans. Youve got your white coat on and they dont necessarily know who you are. Youve got startling responses from a veteran. Could you tell that story . I would see patients to ways. In person in the exam room. Here in the city at the manhattan ba. Then i would see them using telehealth from my office in washington to a clinic in oregon. A very rural part of the country. I got to extend both urban and rural. But i was in the new york manhattan va. I saw a patient and what can i do for you, sir . He said i need a physician to fill out this form and i said id be happy to do that. He said im i need certification because i am suing secretary shulkin. He was homeless and was trying to get additional benefits to get himself out of that situation and get himself back on track. Needed a physician certification of his issues that he was dealing with. I said to him, well, sir. First of all, im going to help you. But i dont think im the person to do it. He said why, i said because i am secretary shulkin. We got him on his way and i got another physician to help them. You early on mentioned five priorities you had when you are coming into the va. Could you talk about those five priorities and how you arrived at what they would be . And maybe you can expand on how you feel you did in achieving those goals . When i first came to the va, i not only, never worked in government before. This was an organization that i was going to have to learn. It was such a Large Organization that if i had waited until i truly understood everything about it, wed be waiting a long time. As i mentioned, i entered at a time of crisis. There were veterans literally waiting for care that needed help and i didnt feel like i have the time that i normally would if this was a normal situation. So i came in having studied the va from the outside the best i could i came in and said we will have priorities right now. If we change them later thats 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 that there were 57,000 veterans waiting for an Urgent Medical consultation. That was just, waiting more than 30 days. That was totally unacceptable to me. And outside the bounds of what i call reasonable. I immediately called for every Medical Center to be open on the following weekend and during that weekend, we contacted those 57,000 veterans and by monday morning, we had that list down to less than 1000 veterans. So once we essentially got the backlog taken care of. I wanted to make sure we never got to that situation again. I did a couple things but the first is, as secretary, one of my first decisions was to publicly post our wait times. The va today is the only system im aware of. The second thing was, i established same day services. Throughout the entire country. By december 2016, i was able to tell secretary mcdonald and president obama every va Medical Center had the capability of seeing people on the same day basis. So wed never be in a situation where someone with an urgent issue couldnt be taken care of. We ended up publishing an article. We had made tremendous progress in addressing that issue really with the commitment of the employees and the staff that work there. The other priorities were focusing on establishing and improving employee morale. Because it had been terrible. There were 35,000 vacancies. Recruiting people to an organization that has low morale is a significant challenge. Probably one of the most important priorities was regaining the trust of the biggest veterans we serve. [indiscernible] we can track whether we are beginning the trust we had lost of our veterans. Fortunately, that began to climb as well. Which is very good news. We had established another priority of creating best practices. Learning from one va to another and doing it across the country so we could decrease some of that variation quality of care. That was very successful in being able to do that as well. Some of these things you brought from the private sector. I know there are vast differences as you either eluded to including the ways we as a country can provide care to civilians and how we can provide care to our veterans. Are the things we can continue to learn from . Max interestingly, not only did i not have at the time, to learn all the ways of the government. Because i felt there were urgent issues like the wait time issues. But i also 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 we thought about things to government. What i ended up learning was that the government could benefit from many of the practices that the private sectors does. Needed to modernize some of the ways it was thinking. I actually learned there was more i learned in the va that the private sector could benefit from. This is a twoway bidirectional way of learning between the private sector and the government and in this case, the va. Theres an ongoing debate about the future of healthcare. Thats not usually something that people can usually say, we can learn from the government. When you look at the outcomes of care across a population which is very popular right now. Called population health. The va outperforms almost every other major Healthcare System. Not saying its the very best. When you look on average, the va performs better than most private sectors. If you look at what we did for example, i made the declaration that i wanted to eliminate hepatitis c from the entire veteran population. We have a drug, several drugs, that can eliminate the virus. At a 95 percent or higher cure rate. I didnt see any reason why we should have any veteran who had hepatitis. I went out. Congress gave us 1,000,000,000 and a half dollars to do this. [indiscernible] we need to do more of that in the general population. Proactively looking at outreach and population health. But these are lessons we can learn from the va. Here that veterans get through the va often is there are studies that show. Our membership generally likes the care they get from the va. We too often hear the negative stories and not the positive. You didnt mention as one of your priorities but you certainly addressed in the book, another area in which the va gets slammed is around the problem of military and veteran suicide. Its such a collocated issue. Mental health is a collocated issue not only in the veterans and military space but we as a country are struggling to understand. Do you have any insights from your time at the va in your time as to how we can address this issue both within and without of the va . The single highest clinical priority i established was to reduce veteran suicide. 20 veterans a day taking their life. Its a staggering figure that i used to sit there and say, if we let another week go by. There goes another 140 of our veterans. There is still so much work to do on this and thats why im pleased that secretary wilkie has continued to make veteran suicide a priority for the va. One of the things when you start to take a look at this. 20 veterans a day take their life, only six are getting care in the va system. So there are 14 out in the community. My biggest worry is there not getting help at all. So one of the first initiatives we did at the va was to start outreach to community partners. Veterans service organizations, Community Groups and churches and religious organizations. Groups like the united way. Got local governments and state governments. All to begin to Work Together to identify veterans at risk and finding them treatment. Every va Medical Center has something called a Suicide Prevention coordinator. Many of them have multiple. Their job is to be out there looking for veterans at risk and identify ways to help them. Thats one of the practices i think the va has that the private sector should have. But we need to do a lot more. The underlying reason why people take their lives is not because they wake up and say, i feel like doing this. Theyre suffering from something. Could be depression. Ptsd. It could be chronic pain or substance abuse. Other reasons. With a look at ways of getting to those underlying reasons. Finding more effective diagnosis and treatment. And really begin to make sure that we are proactively identifying how we can intervene and help. Theyre so much more work