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 practi