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Interview: The Honorable David J. Shulkin, M.D., Secretary of the U.S. Department of Veterans Affairs

The Honorable David J. Shulkin, M.D., was nominated by President Donald Trump to serve as the ninth secretary of the U.S. Department of Veterans Affairs (VA) and was confirmed by the United States Senate on Feb. 13, 2017.

Prior to his confirmation as secretary, Shulkin served as VA’s under secretary for health for 18 months, leading the nation’s largest integrated health care system, with more than 1,200 sites of care serving nearly 9 million veterans. Before he began his service with VA, Shulkin held numerous chief executive roles at Morristown Medical Center and the Atlantic Health System Accountable Care Organization. He also served as president and CEO of Beth Israel Medical Center in New York City.

Shulkin has held numerous physician leadership roles including chief medical officer of the University of Pennsylvania Health System, Temple University Hospital, and the Medical College of Pennsylvania Hospital. He has also held academic positions including chairman of medicine and vice dean at Drexel University School of Medicine. As an entrepreneur, Shulkin founded and served as chairman and CEO of DoctorQuality, one of the first consumer-oriented sources of information on quality and safety in health care.

A board-certified internist, Shulkin is also a fellow of the American College of Physicians. He received his medical degree from the Medical College of Pennsylvania, and he completed his internship at Yale University School of Medicine and a residency and fellowship in general medicine at the University of Pittsburgh Presbyterian Medical Center. He also received advanced training in outcomes research and economics as a Robert Wood Johnson Foundation clinical scholar at the University of Pennsylvania.

Shulkin has been named as one of the “50 Most Influential Physician Executives in the Country” by Modern Healthcare. He has also previously been named among the “One Hundred Most Influential People in American Healthcare.” He has been married to his wife, Dr. Merle Bari, for more than 30 years. They are the parents of two grown children.

 

Veterans Affairs & Military Medicine Outlook: How much has the scope of your responsibilities increased or changed as secretary of the VA in comparison with your previous job as under secretary for health?

David J. Shulkin, M.D.: The scope of the job is certainly to represent veterans on all issues, not just health care issues. So therefore, our responsibility to carry out our mission involves health care, of course, but the secretary’s role is to also make sure we’re doing the same type of job and services as it relates to all the benefits that veterans deserve – whether they are disability benefits, whether they are educational benefits, whether it’s home loans or other benefits that we offer. [The role also oversees] our national cemeteries, which [there] are about 170 of them throughout the country, and in addition, all the services that support all three administrations that report up to the secretary that include IT, human resources, finance, etc. So, it’s a much larger role and responsibility.

 

The last time we spoke, you had five priorities for the Veterans Health Administration (VHA) that you were working on. Could you discuss your top five priorities for the VA as a whole? And are these similar to the ones you had at VHA?

They are just like what we had talked about in the first question. They are somewhat broader in their scope than necessarily simply focusing in on health care alone, and while the five are different, there clearly is some continuity among the five. So, the five of them for the department are to broaden greater choice for veterans. And this one is not just for health care, but this really is allowing the veteran to be in the center of the decision-making. This is our overarching strategy that will allow us to evolve as an organization and become more customer focused. So, for health care, this may mean giving veterans more choice about where they get their care and how they get their care, whether it means being able to schedule appointments online from their mobile phones, whether it means giving them more choice out in the community and making that program less administratively complex and more appropriate for a clinical health system like we are, and really changing our policies to allow veterans more choice in the way that they get their care delivered.

The second one is to improve the timeliness of our services. So, in VHA, I was focused on wait times for improving the timeliness of our services for the department; for health, that means, clearly, improving wait times, but we’re doing it somewhat differently. We’re doing it through a strategy of transparency. So, we publish all of our wait times now, and we update those on the website every week so veterans have an ability to see where we’re doing well and where we may not be doing as well so that they can make choices about where they are going to get their health care. Instead of just saying, “I’m sorry we don’t have anything available,” they can see where else in the country or where else in the region they might go. They can see whether they want to wait for that care or go out into the community. But for disability, that means increasing the timeliness of the disability payments, and we are focused on reducing the wait times for that. For appeals, that means decreasing the time that it takes to get a decision on an appeal if a veteran files an appeal.

When you’re committed to transparency – and we’ve really doubled down on that strategy to become the most transparent organization in government– what you end up finding is that sometimes you are telling the good news, but sometimes you’re not.

The third focus of VA is to focus our resources more appropriately, and that means that we can’t invest in everything equally. So … we’ve worked with our veteran groups to get the feedback to determine what are really services that are critical to veterans and what does VA do uniquely for veterans that [is] focused on serving those that were injured or disabled in their tours of duty? So, we have come up with a set of what we call foundational services. They are things like polytrauma, traumatic brain injury, the treatment of PTSD, blind rehabilitation, orthotics prosthetics, spinal cord injury [for which] we are really making sure that we are developing world-class services. So, it means putting more dollars into them, more management attention into them, and really improving our services.

The fourth area is to modernize our systems, and that means that we are focused on improving the facilities and the technology that we’re using to support our veterans. So, I’ve recently announced that we have 1,100 facilities that are either underutilized or vacant that we’ll be disposing of to reinvest in those facilities where veterans are being serviced. I’ve announced a new electronic medical record to modernize our IT systems. Our accountability log gives us new management techniques. So, we’re modernizing our human resources authorities to be able to make sure the right people are working in VA. So, we are really aggressively trying to modernize the VA.

And the last of the strategies is my only clinical priority and that is to reduce veteran suicide. So that has really been a major focus of ours since I became secretary – to make sure that we are reducing suicides. So, you’ve seen announcements such as that we’re providing emergency mental health care to other-than- honorably discharged. We’ve dramatically improved our hiring in the veterans’ crisis line so we’re answering many more calls and answering those in a more timely fashion. We’re trying to add a thousand new mental health professionals throughout the VA. So [it’s] a number of things that we are focused on to address that last priority. Were there any particular issues you discovered while leading VHA that you can now more effectively address in your new position?

I think the clearest example and the biggest change that I saw from under secretary to secretary was this real focus on transparency and sharing information with the outside world. So, our publishing of wait times, our publishing now of data on quality that compares the VA to private- sector hospitals and health care are focused on … our disciplinary actions so that people know that we are taking the issue of accountability and disciplinary actions very seriously. We just recently started publishing our settlements that we’ve made with employees. So, I think that that is the biggest change that reflects my belief that we have to make sure that everybody understands that we have heard the feedback. We’ve recognized the failures that we’ve had in the past, and the way to move forward is to not only act swiftly and boldly, but do it in a way that we’re sharing exactly what we are doing with the public.

 

It seems like it enables you as well to tell the good news story, because even though the media to some extent focused on things like wait times, veterans – as far as their care is concerned – overall seem to be extremely pleased with the quality of care they get in VA facilities.

Well, we publish the veterans’ satisfaction scores publicly as well. And we show those comparisons to private-sector institutions. When you’re committed to transparency – and we’ve really doubled down on that strategy to become the most transparent organization in government– what you end up finding is that sometimes you are telling the good news, but sometimes you’re not. And in a system as large as ours, with locations all across the country and even beyond, you have everything. So, you have the picture where it’s really working well and actually much better than the private sector or our wait times are well below and our satisfaction is well above the private sector, and then you have places where it really isn’t working well. And that’s what you have to focus on. So, if you looked at our wait times in Guam, they’re horrific. And we have to find different strategies to address that, but as you could imagine, it’s not easy to identify health care professionals that are willing to go to Guam. So, it’s not meant to be excuses, it’s just meant to show the picture realistically how it is.

David J. Shulkin, M.D., secretary of the Department of Veterans Affairs.

In your first “State of the VA” address, you spoke of progress being made as well as acknowledged flaws – like those you’ve just mentioned – identified within the VA. There are many programs, initiatives, research, and resources that have been brought to bear. I wondered if you could just highlight one or two.

Yeah, the reason why I did the disclosure of where our problems are is because I don’t know how you solve problems if you don’t identify them, tell people where the problems are so you can ask for help, and you can start solving some of those or finding solutions to those problems. I think an example where we’re making really good progress is in a little bit of our research program and a little bit of our clinical program with personalized genomics. The reason why I think this is an important example is because it is bringing VA into the modern era of where health care is going, it’s providing some leadership for the rest of the country, and it provides veterans with state-of- the-art care. So, we have a program called the Million Veterans Program [through which] we’re collecting the genomic material on a million veterans – we’re up to more than 600,000 now – and we can match that with their electronic medical records so we now have genomic material and clinical data. And that can help us in the research side in being able to identify new [discoveries] about how to treat conditions, how to diagnose conditions, maybe how to find new solutions for tough problems that have plagued veterans. But we’re moving that also into the clinical realm by allowing veterans to then get personalized genomic information that can make their treatment that they’re going through personalized or individualized. So, it’s a way that we are focusing on things important to veterans: We are improving the timeliness of information, we are modernizing our system, and we are leading the country because there is no other database of this size or effort of this size anywhere in the country at this point.

I think the overwhelming challenge for us is to regain the trust of the veterans and the American public.

You mentioned earlier moving to a next-generation electronic health record (EHR), and as I understand it, that will be the same EHR used by the Department of Defense (DOD). How does that benefit the two systems?

Well, I think it’s really in some ways almost common sense. We know where every one of our customers is going to be coming from, and that’s the Department of Defense. When you enlist in the military, a record is started on you, your information while you’re in the military is captured, and when you leave the military, you become a veteran. So therefore, why shouldn’t there be a consistency and a continuity of that information if you want to do the best job for your customer?

Secondly from a taxpayer/[stewardship] point of view, this just makes sense for the government to have a single system that it can invest in and continue to grow and develop and not have to maintain two separate systems where both the Department of Defense and VA can benefit from their learnings and innovations in clinical informatics. So, I think just in the short period of time since I announced this and these organizations working together, there have been many, many “ah ha” moments where DOD says, “Wow, I didn’t know you were approaching it this way. We can take that and incorporate it into our perspective.” And we know that the DOD has saved us a lot of time and effort because they are already a year-and- a-half into their process. And they’ve been willing to share all that information with us. So, I think this is just good common sense and it’s the right thing to do for veterans.

 

Since 2001, certainly, there have been a number of updates and changes and enhancements to the GI Bill. Could you perhaps describe how the Forever GI Bill – the latest – will improve upon existing benefits for veterans?

Sure. The first thing it does is it takes away the 15-year limit on using your education benefits. It essentially allows a veteran to be able to obtain additional education and advancement in their professional career at any point in their life. And I think that, as we’ve seen with so many people who have gotten out of the military, they might have gone into one part of industry, the technology changed, now they’ve become less desired in terms of employability. Now they can go back and they can retrain or educate themselves to be more professionally successful. It also allows veterans to be able to share this educational benefit with their dependents, which is obviously a really important benefit so that they are able to make sure that they can support their family when they want to provide for their family. So, I think those are two major features. And it’s got some other improvements to give people more educational options than they had in the
past.

 

The last time we spoke, we discussed a little bit about you practicing medicine within the VA. And I wondered if your responsibilities have increased so much that you’ve had to give that up or are you still able to do that occasionally?

Well, it’s something that is very important to me because it allows me to not only get grounded in why I do this job, but it allows me to get a firsthand understanding of what some of these decisions as secretary may mean. So, I was practicing on Monday this week in Manhattan. I’m making all these decisions about the electronic medical record. And one of my patients I was seeing … travels a lot. So his care was split between a number of VAs and Department of Defense facilities, and I had to find his records to get what medicines he was on, etc. So it showed me – because I had not done this with a patient – I had to go in and out of multiple systems to get his information. I was able to do it, but it was a lengthy process, and it reinforced to me how difficult we’ve made it for some of our clinicians to do their job by not designing a system that was well integrated in the first place. So it clearly is difficult for me at times to get away and to have time to see patients, but it is something that is important to me and I will continue to try to do.

 

What do you feel are the most important or the most difficult challenges facing the VA today and in the near future?

I think the overwhelming challenge for us is to regain the trust of the veterans and the American public. When you go through a crisis like we did in 2014, you can quickly lose that trust, and I think we did. And it’s going to take a long time to rebuild that. I think that we’re on our way to rebuilding that, but I think we have to be in it for the long haul, and you have to be committed to a strategy like transparency and improving service. That’s what my five priorities are about. But ultimately that’s our biggest challenge, because if you don’t have [your customers’] confidence and trust … you really can’t fulfill your mission or succeed at it. I think that the biggest challenge, and I said this yesterday at the hearing, that I face on a very practical level rather than global level is the hiring of employees. It’s a very complex process to hire staff, to get the right staff to want to come, but also then to get them onboard and to keep them, because many people first of all don’t have the correct impression of what it’s like to work at VA, and secondly a lot of people just don’t even know how to approach going about getting a government job and then stick with it through the lengthy process. So, I’m looking for ways to be able to streamline that, because ultimately, organizations like ours are service organizations and that’s all about the people that work in your organization.

 

What message would you like to deliver to the reader out there?

Well, we’ve talked about a lot of the things that we’ve done and that we’re focusing on to make VA better. But I want to make sure that people understand that we are listening to veterans and that we by no means believe that we are where we need to be. We have a lot of work to do. Some of that is going to take very aggressive solutions to get us to where we need to go, but that’s our commitment to make the type of changes to make VA both sustainable and effective for future generations of Americans who serve their country. It comes from a belief that I believe VA is an important part of our national security, that when somebody raises their hand and protects their country that they have to feel confident that the country is going to be there for them when they return, no matter what they face. I think that we have not fulfilled that responsibility always in a way that we should, and that’s what we’re really trying to drive toward.

This interview originally appeared in Veterans Affairs & Military Medicine Outlook. Click here to view to read Outlook.

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