Recounts his time as secretary of the Veterinary Affairs department. Ceo and afghanistan veterans of america, and after words has relevant hosts interviewing top authors about their work and after words are also available to listen to as podcasts. Dr. Shulkin, thank you for being with us today. Its an honor to have you here. I think the va is an important subject to talk about and i think its one of the areas of our government that a lot of people hear about, but dont necessarily know many of the details, frankly in the veteran community, i think a lot of us that dont understand the breadth and the depth of what the va does. Im excite today talk about the va in general and certainly about your book and about your time in the administration. If youd like, id love to begin by sort of what brought you to the va. You were successful in the civilian career and a lot of times making a transition from the civilian world into the government world can be a bit jarring. What drove you to want to take up the mantle of working within the government, especially within the va . Well, 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 sort of a busy 20s and thats always one of the real regrets that i had, with in amazing country that we have that i wasnt able to give back and so later on in my career, i was the ceo of a hospital and i had the tonight to get a call from the white house, this was right at the time in 2014 when was a very public wait time crisis in the va where there were allegations the veterans were actually dying waiting for care. And i remember sitting there as a citizen saying, oh, i feel terrible about this. If anybody deserves the best care possible its our veterans and i wished there were something i could do to help. And as sometimes happens in strange ways, i got a call from the white house saying, would you consider coming to help lead the Va Health Care system because were looking for somebody who understands how Health Care Works and from the private sector. And you know, i did what everybody tends to do when they have the choices to make, i made a list of the bros and the cons and the con side as much, much larger than the pro side, but on the pro side, it was simply how could i say no . This is my duty as an american citizen to give back to people who have given up so much and so, i really didnt think much about it. I said yes, im prepared to come and help. Thats great. And that was as nos of you who have read the book know, that was the Obama Administration initially. So youre one of the few people who serve under the Obama Administration and trump administration, so look forward to getting into that. That said, i thought i would start, but id love to read a brief quote from your book, early on you write its important that americans understand what the va system is, how it works and why it exists. As i mentioned, i think a lot of people dont understand the scope of what the va has and what theyre responsible for. I wonder if you could start off by giving maybe you had an elevator pitch talking about everything that the va does, as you well know, it goes well beyond health care, but thats what they do know and how much more that the va does. One of the reasons i wrote the book is exactly what you talked about, jeremy. Im not sure the American Public understands why the va exists, but why its really an essential part of our National Security system that when we rely on a voluntary military, which now less than 1 of americans serve in, but niece amazing americans raise their hand and are willing to sacrifice themselves on behalf of all of us. When they go, theres a commitment that 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 thats focused on that. So as you said, the va provides health care for 9 million veterans, but there are really 20 million veterans in the country. So, the va has a large effort directed towards education, the gi bill. It has an effort towards benefits should somebody require assistance if theyre no longer able to work or if theyre disabled and it also goes all the way through the time of making sure that every veteran, when the time comes, is buried with dignity and respect. There are 114va cemeteries around the country and they do an amazing job supporting families during these tough times. So this is an organization second largest in the u. S. Government, employs 370,000 people who are there, many of them veterans themselves, continuing to give back. They do an amazing job and it deserves the support and understanding of the american people. Thats great and i often point to people, you know, the va is the second largest department. Second largest agency. Second largest budget and people, i think, really just from a civics mind think about everything it does. If i could, just about the health care aspect, because it gets so much focus of the public attention on the va, when i came from the private sector and the government, i had never worked in government before. I actually had a completely open mind when i was reading all of these Horror Stories in the press that i would go there and i would find that the system was so broken and so dysfunctional that maybe my job was just to sort of 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 knew very well. And after i got to the v amount va and got to see what the va does. When i put on the white coat and went out and visited hospitals across country and went to see places like, where we bring paralyzed veterans skiing down the slopes in aspen, colorado. I really began to understand that what the va does in the Health Care System is very different than what the private sector does. And in fact, cant be replaced. And the private sector doesnt do the things that the Va Health Care system does in all cases. For example, our behavioral Health Care System, it is extensive, it is large, where the private sector behavioral Health Care System is really i struggling and trying to get access if we were to put these nine million veterans dump that into the private steck tore sector system, already struggling, we know that the veterans would not come out on the right side of that. So i became a very strong advocate making sure that this is a system that works well, that we need to modernize and approve and it will be a sustainable system. Absolutely. Youve touched on a couple of things there i want to make sure to come back to. 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 why do you think that is that even though were talking about an agency that has oversight of all these different areas you get so a different stories . The negative stories but the ones that make it to the press that you hear Horror Stories about one v. A. But in talking to somebody veterans our membership tells us they love the care they get at the v. A. They would like to get access to it faster and things like that. Why do you think there is such a variety of levels of care that one receives from the v. A. . Guest the v. A. Is under a public scrutiny that know the Hospital System in the country finds. As hospital ceo when private sector i can tell you Little Things that happen in the v. A. That would never come to the tension in the private sector turn out to be the subject of congressional hearings and major frontpage stories. The public gets a sense that there are lots of things that happened in the hospitals that dont happen in the private sector. Again using the private sector comparison the question of would get most frequently being a physician, ceo was whats the best b hospital for e to go to rex answer was interestingly there is no a suh thing as the best hospital. There are hospitals that are good at some things. Those same hospitals may not be so good in some other specialties and areas. Thats the same in the v. A. System. When youre the largest system in the country with over 1000 facilities you are going to have some that are excellent and certain conditions and others that frankly need work on them. Thats what youre going to find in healthcare. But the v. A. Has an additional complexity in that it needs to provide care to veterans whatever they live in this country. So, therefore, we have a large number of our better to live in areas and finding people especially specialists to be able to work in rural areas is a challenge for the v. A. Can also challenge for private sector as well. You have tremendous variation between what works in the v. A. From one place to another place and thats one of the things that i worked very hard to try to standardized some of these practices. Host reminded me of a funny story from your first confirmation hearing when i believe senator sullivan from alaska who basically said you need to come to alaska because we have unique set of circumstances here, unique challenges to veterans and you need to come and understand that before he was going to vote for you. Guest i think just to let people know all the 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 an entire gorbachev to have unanimous consent. This was when i was under secretary and white house said good news, you have unanimous consent, youre going to be confirmed at the next couple minutes. Right as that was happening senator sullivan said, not so quick. Conversatione a with the nominee. He called me upno and said im standing on the senate floor, im about to castng my vote buta 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 alaskas very different than other states and are veterans have different needs. I said were going to alaska, and then the went through. I sai 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