Raise the Line Podcast Featuring Former US Secretary of Veterans Affairs Dr. David Shulkin
Published on Apr 16, 2020. Updated on Sep 15, 2020.
Combining the perspectives of physician, New York City hospital leader, and high ranking government official, Dr. David Shulkin shares unique insights with Osmosis Chief Medical Officer and host Dr. Rishi Desai on how the coronavirus crisis will impact how we provide healthcare for generations to come. One of the most significant changes could be permanently altering how frequently telemedicine is used.
Listen to the podcast and read along with the transcript below:
DR. RISHI DESAI: I'm Dr. Rishi Desai. I'm the Chief Medical Officer at Osmosis, and I have the pleasure of speaking today with Secretary David Shulkin, who is the ninth Secretary of Veterans Affairs, who served under both Barack Obama as well as Donald Trump, and has been the CEO of New York City Hospitals.
Dr. Shulkin, thank you so much for being with us today. You have a number of interesting hats that you've worn in your lifetime. What are the top two or three messages you would have for the folks listening that are going to be future health professionals?
DR. DAVID SHULKIN: Well, I think we're watching history as it unfolds right now. Pandemics are something that usually skip a generation, so this is our time, and it's going to be impactful. Pandemics usually leave a lasting impact economically, sociologically, and certainly for those of us who practice in healthcare, it's also a time that exposes all the things that work and don't work in the healthcare system. I think we're watching that right now, and that's going to help us create a new roadmap for where healthcare should go for future generations, and how we can do better if something like this occurs, and almost certainly will occur—we just don't know when. So, the lessons are pretty significant.
It's tough to watch what's happening in cities like New York today that are just being swamped with patients. We're seeing heroic acts of the staff and the administrators doing what they have to try to deal with this situation—and frankly, not having very effective tools, since we don't have treatments or vaccines. It really is supportive care at this point, and it's really an incredible situation for all of us to be watching and to be thinking about how we can do better.
DR. RISHI DESAI: Given that you've had a leadership position in hospitals in New York City, what advice would you have for other hospital CEOs or leadership suites that are trying to figure out how to best prepare for this in their own state or locality?
DR. DAVID SHULKIN: I think hospitals and hospital leaders are doing a pretty incredible job of preparing for this. To see the country acting the way that they are—canceling elective surgeries, shutting down unnecessary practices to be able to be prepared—is really a considerable sacrifice. Many hospitals are financially hurting right now: we're seeing layoffs of some healthcare workers in areas where the COVID infection hasn't hit, but we're doing that all in preparation so that when or if it does hit their communities that they are prepared.
The lesson from New York is how quickly this could happen. The New York hospitals had very little time before this happened; it happened very suddenly, and the onslaught of patients was considerable. But even within a short period of time, I think that there's been a really good response by the New York City hospitals, and, not surprisingly, they've needed help from the outside.
I think seeing so many volunteers coming in to help, and seeing the federal help, both from the military and from the Department of Veterans Affairs, has been really good to see. This is a pandemic that is really demonstrating that the virus doesn't discriminate by geography, it doesn't discriminate by socioeconomic status or political party. This really brings us all together and connects us as humanity, and we've got to pull together to get out of there.
DR. DAVID SHULKIN: I think, first, we have to make sure that we're doing everything that we can, focusing on saving lives. The mortality that we're seeing right now is just devastating, and certainly we're concerned about this spreading to other parts of the country. But after we get through this and we start seeing a return to what we would describe as pre-COVID life, I think that there's going to be a lot of opportunity to dissect what happened, to look back and see where the mistakes were and how we can do better.
Clearly, the one mistake that I think led towards us being so unprepared and then chasing our tails was the lack of preparedness on diagnostic testing. That's pretty clear. We're going to need better diagnostic testing and more extensive testing to find our way out of this. When you start figuring when is the right time and how do you start loosening our social distancing, we're going to need to be able to know who has antibodies to COVID, so they can safely return [to normal life], as well as who does and doesn't potentially have the infection, so that they can begin returning to work environments and social environments.
Besides the diagnostic testing, though, I think that there are going to be a lot of lessons in how disconnected and fragmented our healthcare system was, the supply chain issues, but also the staffing issues, the sharing of resources, the ability to communicate. All of this, I think, will lead to a conclusion that government and the role of government is fairly unique.
Many of us have gotten very cynical about what government's about because we watched Washington over the past couple of years engage in partisanship and political games and all sorts of nonsense that turned many people off. But it now reminds us that the primary role of government is to protect the safety of its citizens. A lot of people have thought about that in terms of military terms—that's why we have a military to defend us against outside invaders—but they haven't really considered the bigger risks to us, things that can affect our normal way of life, whether they're going to be attacks on our utilities, cyber attacks, climate change, and now a public health crisis.
And so that reinforces why government is important; it makes you understand why it's so important to have people in government that are competent at what they do. They understand the business that they're taking care of, and that they have the experience to be able to help provide leadership at times like this. And that's why so many people are grateful for people like Dr. Fauci, who have experience and have served in multiple administrations—clearly not a political person, but really a person of substance, of science, and a physician. I hope this will encourage more people to consider roles in public service and consider getting that type of experience so they can help serve in roles that are going to be so important for future crises like this.
DR. RISHI DESAI: You touched on this, and I'd like you to tell me more about your thoughts on how we're going to transition from this crisis mode that we're in right now—let's call it phase one—to the next phase, and New York will obviously make that transition first. We're obviously not there yet, but people are wondering about that already, and you brought up even more testing. Can you speak to that a little bit more: what do you mean by that, exactly?
DR. DAVID SHULKIN: I think that there are two paths to what happens now. We either start seeing a decrease in infections, which maybe we're beginning to see now, but it's early on, but we continue to see a decrease, and so people naturally assume that it's time to go back and resume normal activity. The fear there is that if we do that, the infection just may go up and down and really never leave the community, so this could go on for months and months—maybe even years. We've heard some predictions just recently that this may be with us for 18 months. That would be the biggest disaster to us, economically and sociologically; the unintended consequences of the health crisis extending out for that longer period of time. The safer way to get back to normality is to do this now in a way that we can actually see what's happening.
If we had had diagnostic testing months ago, we could have prepared much better. What you want to do is, you want to extensively test in the community. You want to identify those people who have developed antibodies to the coronavirus, so that you know who can safely go back with immunity into the workplace, into normal social settings. You then also want to be able to identify those that have been tested and do not have the infection. They can begin to start safely returning into the environment. What you want to do is continue to quarantine and isolate those who are carrying the infection (and maybe asymptomatic), and those who are extremely vulnerable: you want to protect them.
I think the only way to do that is through extensive testing, whether it's the rapid testing, which I believe will make this much easier, or antibody testing, or a combination of both, so that we can start returning to normal in a systematic way, but do it in a way that is safe and does not allow for the prolongation of this crisis to continue for months and months.
DR. RISHI DESAI: There's this idea I explored in a video we made around immune certificates: a nationalized certificate program where people can show that they have a certain titer and then they can return to essential work and start reopening businesses. Specifically, healthcare providers could go back and do high risk procedures if they have declared immunity. I'm curious to hear your thoughts on that idea.
DR. DAVID SHULKIN: Well, I think it's not that different from what we do for going to school with children before children enter school. They need to show that they have either been vaccinated—today we don't have the COVID-19 vaccine, of course—but that they've been vaccinated, or that they have immunity. Every time that I've entered the hospital as a physician to get on staff, I've had to show that I have immunity to measles, mumps, rubella, and hepatitis. So I think that this idea of documented evidence that you are protected is not only for your protection, but it's for the greater protection of the people around you, and the community around you. I actually think that this makes a great deal of sense.
DR. RISHI DESAI: There's this idea of flattening the curve; I know you know that phrase. There's also the idea of raising the line of healthcare capacity, or just raising the line, so that we can deal with the mountain of cases that are in front of us. I'm curious to hear your thoughts on initiatives that (if there are physicians in New York right now listening in) they could currently take either in their own hospitals, or maybe at this level of the city or the state, that would help to raise healthcare capacity.
DR. DAVID SHULKIN: I think we've seen some pretty incredible acts in improving the capacity with hospitals surging up to almost 60, 70% of their beds and converting ambulatory parts of their hospital and operating rooms into intensive care units, or repurposing a common space area to hold more beds. I think that we've seen a lot of innovation and ingenuity in being able to create more capacity.
I think the shortage is always going to be with the hospital workers, the professionals themselves. This infection, which is primarily a respiratory infection, requires people who have experience in intensive care unit settings in pulmonary disease, management of ventilators—what respiratory therapists and others do... These are not people that you can just easily substitute for, or create that type of competency overnight. I think that that's been one of the challenges. The way that I think that we need to begin to raise the capacity there is by leveraging those people's skills as much as we can.
One of the most controversial things that I did—I didn't realize it would be so controversial when I was at the Department of Veterans Affairs—was when I was dealing with a shortage. I was dealing with the wait time crisis for veterans, so I made the decision to give full practice authority to advanced practice nurses. That meant that it allowed them to practice without the supervision of the physician. I did that for a specific reason: we didn't have enough healthcare professionals, particularly in rural parts of the country where there weren't many doctors. That decision turned out to be not only one of the most important decisions I made, because it helped us meet capacity, but it made high quality care available to people who didn't have it before.
We're seeing this now by allowing doctors to cross state lines to be able to get licensed easily. I actually just reactivated my license in New Jersey; I had let it lapse for a bit, but the governor issued an emergency statute that physicians could reactivate their licenses. I think that this is really showing us how we can all work together and expand that capacity to deliver healthcare in a time like this.
DR. RISHI DESAI: Do you mind speaking specifically on the role of telehealth and telemedicine and that sort of technology at this point in the pandemic?
DR. DAVID SHULKIN: As I mentioned earlier, pandemics tend to change the way that we do things after they end, and I believe healthcare will change dramatically because of this. One of those areas, I believe, will be a greater use of telemedicine.
Telemedicine has actually been around for about 40 years. Doctors have used telephones, but the video capacity has also been around for a long time. The reason why it really has not taken off prior to this has been because of the reimbursement issues—it's been hard to get paid for telehealth—and the regulatory barriers. When I went to the Department of Veterans Affairs and we had a big issue with access to healthcare, I wanted to use telemedicine, and wanted to use it in a much more broad-based way, particularly in rural parts of the country.
Fortunately in the Department of Veterans Affairs, we don't have reimbursement issues. We get our money through Congress, who tell us, "Go and do what's right for veterans," so I was able to expand the use of telehealth considerably—last year, 900,000 veterans received their care through telemedicine. But I did find we had some of the same regulatory barriers that have prevented telemedicine from being used. Our doctors weren't allowed to deliver telehealth outside of VA facilities, they weren't allowed to cross state lines outside the VA facilities, and so I took that on to change those regulations.
About three years ago, I went to meet with President Trump. I brought my telemedicine equipment with me to the White House, where I cared for patients from my office in Washington who lived in a rural part of Oregon. And I said, "Mr. President, I want to show you how I practice medicine using telemedicine." After he had a chance to see it, he said, "This is great!" And I said, "But Mr. President, the regulations are preventing us from helping more veterans."So, we were able to get those regulations changed three years ago and drop all of the cross-state issues and many of the regulatory barriers.
Now, in this crisis, Medicare has done the same thing for all Americans. While they've announced it to be temporary, I certainly hope that this is not temporary. In fact, I think it will be hard to put the genie back in the bottle—these will be permanent changes for the way that we just practice and use technology when it makes sense for our patients, and to provide better access.
Of course, this pandemic was almost specifically ideal for the use of telemedicine. We wanted to keep people away from hospitals who didn't need it and keep them out of the waiting rooms of doctor's offices where they could get infected or infect somebody else. Most people with COVID—90%—stayed at home. Telemedicine is a good way to be able to stay on top of and connect with your healthcare providers. So I think that's one of the lessons that we'll see out of the COVID infections.
You know, we're a health education platform and we also do training. I'd like to get your thoughts on that, because one of the things that we're doing right now is, we have launched a free CME course around COVID-19 to get, let's say, a health practitioner who does practice in another field up to speed on this particular infectious disease.
Separately, to your point about NPs practicing without the supervision of an MD, that sort of capacity growth is needed in other areas. For example, you might have someone that is checking vital signs, or moving a patient, or helping to enable a patient to eat—that frees up an RN to do other things. And so we're creating a free training program to train up frontline healthcare workers to do those kinds of tasks, to enable others to do other tasks. I'm curious to hear your thoughts on the use of, not just telemedicine, but really a broad-based education to beef up, or to build up, our healthcare capacity and raise the line in that way as well.
DR. DAVID SHULKIN: The longer that I've been in practice, the more I've come to understand that healthcare delivery involves teams. It involves teams of people who have different sets of skills and competencies. Allowing people to each contribute what they can, and allowing the professionals to be able to practice at the top of their license, to use the skills that they have, really expands both the reach but also the quality outcome that can be delivered by that team.
I've had experience with pharmacists who, in the Department of Veterans Affairs, prescribed medications. We think of pharmacists as behind the counter, dispensing medications, but they are quite effective at interacting with patients and making decisions and giving information about how to take medications, the side effects, and improving compliance in ways that, frankly, as a physician—I just don't have that expertise in those medications.
Working together and allowing people to contribute also helps. I also (in times of crisis) very much like to hear stories like that of the surgeon who, following their cases, picked up a broom and a cloth and started cleaning rooms, because that's what was needed. When you look at infections and you know, the importance of good cleanliness and hygiene practices, there are shortages now of environmental health care workers in many of our hospitals... People need to drop the boundaries and just do what it takes to get the job done. That really demonstrates just how important everybody on the team is, and those lessons are long-lasting. That surgeon will be remembered for what they did, long after this pandemic is a memory.
DR. RISHI DESAI: That's a really good point to close on: the fact that what we do now will be remembered for a long time, at all levels. I think that your point about America coming together and everybody rolling up their sleeves and doing whatever's needed is commendable. One thing I'll say for you specifically as a health care provider: thank you so much for doing that. It's a huge honor to have someone who is literally on the front lines also taking the time to talk with us about it today.
DR. DAVID SHULKIN: I'm really glad to have spent the time with you. Thank you.