Dr. David Shulkin: 9th U.S. Secretary of Veterans Affairs (Raise the Line)
I'm Dr is Desai, the chief medical officer at osmosis. And I have the pleasure of speaking today with Secretary David Shulkin, who was the ninth Secretary of Veteran Affairs, who served under both Barack Obama as well as, as well as Donald Trump and is also the CEO as has been the CEO of a number of large New York City hospitals.
Do Shulin. Thank you so much for being with us today.
Glad to be with you. So do Shulin, you have a number of interesting hats that you've worn in your lifetime as you see, COVID-19 descend on New York as kind of the epicenter here of the world.
What are the top two or three messages you would have for the folks listening that are going to be future health professionals?
Well, I think we're watching History as it unfolds right now, pandemics or something that usually uh 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 health care, it's also a time that exposes all the things that work and don't work in the healthcare system.
And 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.
Um, and it's tough to watch what's happening in cities like New York today that are just, uh, being swamped with patients.
Uh And we're seeing heroic acts of the staff and the administrators doing with 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.
And so it really is supportive care at this point. And uh it's really a incredible um situation for all of us to be watching and to be thinking about how we can do better 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?
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 uh 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. And I think the lesson from New York is how quickly this could happen.
Uh The New York hospitals had very little time before this happened. It happened very suddenly.
The onslaught of patients was considerable. But even with a short period of time, I think that there's been a really good response by the New York City hospitals.
And um not surprisingly, they needed help from the outside. And I think, you know, seeing so many volunteers coming in to help, seeing the federal help, both from the military and from the Department of Veteran Affairs has been really good to see because um 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 that this really brings us all together and connects us as humanity.
Uh And we've got to pull together to get out of this as well. You have experience working with a couple of administrations.
What are some things that you imagine will likely happen in the coming weeks and months in terms of a federal response to help with both New York but the other 49 states as well.
Well, I think first we have to make sure that we're doing everything that we can focusing on saving lives. Um, the, uh, 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, uh, we get through this and we start seeing, um, a return to what we would describe as pre COVID life. I think that there's gonna be a lot of opportunity to dissect what happened to look back and see where the mistakes were and how we can do better.
Uh clearly the one mistake that I think has led towards us being so unprepared and then chasing our tail all along was the lack of preparedness on diagnostic testing.
That's pretty clear. We're gonna need better diagnostic testing and more extensive testing to find our way out of this.
So can they safely return and who does and doesn't potentially have the infection so that they can begin returning to work environments and social environments.
So, uh besides the diagnostic testing though, I think that there are gonna be a lot of lessons in uh 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 and all of this I think will lead to our a conclusion that government and the role of government is fairly unique.
Um, many of us have gotten very cynical about what government's about because we watched Washington over the past couple of years, uh, engage in partisanship and political games and all sorts of nonsense that turned many people off to Washington.
But it now reminds us the primary role 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 probably the bigger risk to us, which are things that can affect the our normal way of life, whether they're gonna be attacks on our utilities, cyber attacks, climate change and now a public health crisis.
And so that reinforces why government is important and 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 the experience and have served in multiple administrations, clearly not a political person, but really a person of substance of science and, and a physician.
And so, uh 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 gonna be so important for future uh crises like this.
You know, you touched on this and I'd like you to tell me more about your thoughts of how we are going to transition from this crisis mode that we are in right now.
Let's call it phase one to the next phase. And New York will obviously make that transition first and 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? And what do you mean by that?
Exactly. Yeah, 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, well, guess what? It's time to go back and resume normal activity.
The fear there is is that if we do that, that the infection just may go up and down and really never leave the community so that this could go on for months and months, maybe even years.
And 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 and the unintended consequences of the health crisis extending out for that long, a period of time, the safer way to get back to nor 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. So what you wanna do is you wanna extend intensively test in the community, you want to identify those people that have developed antibodies to the Coronavirus so that you know that they can safely go back with immunity into the workplace, into normal social settings.
You then also wanna be able to identify those that have been tested and do not have the infection, they can begin to start safely returning into an environment.
What you wanna do is you wanna continue to quarantine and isolate those that are carrying the infection may be asymptomatic, those that are extremely vulnerable, a vulnerable population and you wanna protect them.
So I think the only way to do that is through extensive testing, whether it's either the rapid testing, which, which I believe will make this much easier or the antibody testing or a combination of both so that we can start returning to normal in a systematic way.
Uh But do it in a way that is safe and does not uh allow for the prolongation of this crisis to continue for months and months.
There is this idea that I explored on a video that 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 and 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. Well, I think it's not that different than what we do for going to school with Children before Children enter school.
They need to show that they have either been vaccinated which today we don't have the vaccine but that they've been vaccinated or that they have immunity.
So, so I think that this idea of documented evidence that you are protected is not only for your protection, but it's for for the greater protection of the people around you and the community around you.
So I actually think that this makes a great deal of sense going back to the current state of events, you know, New York is still in the throes of the worst of it.
Right now, there's this idea of flattening the curve. I know, you know that phrase, there's also the idea of raising the line of health care 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 ways that, you know, if there are physicians in New York right now listening in that 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.
Well, first of all, I think we've seen some pretty incredible acts in improving the capacity with hospitals surging up to almost, you know, 60 70% of their beds and converting ambulatory parts of their hospital and operating rooms into intensive care units, creating common space area to hold more beds.
So 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.
And these are not uh people that you can just easily substitute for or create that type of competency overnight. So, so I think that that's been one of the challenges, the way that I think that we need to begin to, you know, raise the capacity.
There is uh by leveraging those people 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 Veteran Affairs was um I was dealing with the 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.
And I did that for a specific reason because we didn't have enough healthcare professionals, particularly in rural parts of the country where there weren't many doctors.
And that decision turned out to be not only I believe one of the most important that I did because it helped us meet capacity, but it made um you know, high quality care available to people who didn't have it before.
So I think using uh other professionals who have this experience, other than physicians, 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 where I had let it lapse for a bit, but the governor issued a emergency statute that physicians could reactivate their licenses.
Uh So, so 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.
So doctor s, do you mind speaking specifically on the role of telehealth and telemedicine in that sort of technology at this point in the pandemic?
Yeah. As I mentioned earlier, pandemics tend to change the way that we do things after they end.
And uh I believe healthcare will change dramatically because of this uh one of those areas I believe will be of greater use of telemedicine.
Uh telemedicine has actually been around for about 40 years. Uh 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 Veteran Affairs and we had a big issue with access to health care.
I wanted to use telemedicine and wanted to use it in a much more broad based way, particularly to rural parts of the country.
Fortunately, in the Department of Veteran Affairs, we don't have reimbursement issues. We get our money through Congress who tells 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 doctor weren't allowed to deliver telehealth outside of va facilities.
They weren't allowed to cross state lines outside of va facilities. And so I took that on to change those regulations about three years ago.
Uh I went to actually 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, Mister President, I wanna show you how I practice medicine using telemedicine. And uh after he had a chance to see it, he said this is great.
And I said, but mister 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 the cross state issues and many of the regulatory barriers that now in this crisis, Medicare has done the same thing for all Americans.
So while they've announced it to be temporary, I certainly hope that this is not temporary. In fact, I think it'll be hard to put the genie back in the bottle that 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.
And 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.
So most people with COVID, 90% stayed at home and you know, telemedicine is a good way to be able to stay on top of and connect with your healthcare provider.
So I think that's one of the lessons that we'll see out of the COVID infections. Yeah, I hope you're right.
And I expect that you will be right because I think you're, you're spot on and we're passionate about doing this a few years ago.
So that's a great point. Yeah, great.
You know, we're a health education platform and we also do training and I'd like to get your thoughts on that because one of the things that we're doing right now is launching, we have actually launched a free CME course around COVID-19 to get, you know, let's say a health practitioner who does uh 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 are creating a free training program to train up frontline healthcare workers to do those kinds of tasks to enable others to do other tasks.
So I'm just curious to hear your thoughts on the use of not just telemedicine but really broad based education to beef up or to build up our healthcare capacity to raise the line in that way as well.
Yeah, the longer that I've been in practice, the more that I've come to understand that healthcare delivery involves teams and it involves teams of people who have different sets of skills and competencies and 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.
Um I've had experience with pharmacists who in the Department of Veteran Affairs prescribe medications. You know, we think the pharmacist 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 and side effects and improving compliance in ways that frankly as a physician, I just don't have that expertise in those medications.
I think that working together allowing people to contribute also helps. I also in times of crisis, very much like to hear the stories of the surgeon that, uh, following his cases picked up a broom and, and they, um, you know, and a cloth and started cleaning rooms because that's what was needed.
And when you look at infections and, and, uh, you know, the importance of good cleanliness and hygiene practices. Um, and there are shortages now of environmental healthcare workers in many of our hospitals, people need to drop the boundaries and just do what it takes to get the job done.
And that really demonstrates uh how important everybody on the team is and those lessons are long-lasting. They will, that surgeon will be remembered for what he or she did long after this pandemic is a memory.
Yeah, that's a really good point to maybe even close on is the fact that what we do now will be remembered for a long time at all levels.
And I think that your point about America coming together and everybody rolling up their sleeves and doing whatever is 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 that literally on the front lines.
Also taking the time to, to talk to us about it today. Great.
I'm really glad to have spent the time with you. Thank you.
Thank you so much for being with us today. Doctor Shulin.
I'm Doctor Desai. Thank you for joining us for today's show.
You can join osmosis to raise the line and flatten the curve by simply going to osmosis.org/covid-19. Thanks a lot.
Take care.
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