The Greatest Decision Trump Has Ever Made

Dr. David Shulkin once gave me this advice, “stop whining and complaining and lead with solutions.” To the many frustrated physicians in this country, this critique is a fair one. I took his words to heart.

Let me start by saying my husband served 20 years in the United States Army and is a proud Veteran. I think our veterans deserve better than Dr. David Shulkin. His ousting as VA Secretary by President Trump this past week is akin to “leading with solutions” from my perspective.

Dr. Shulkin appears to have engaged in considerable double-speak throughout his 13-month tenure in Trump’s Cabinet. In his New York Times op-ed, he wrote, “I will continue to speak out against those who seek to harm the V.A. by putting their personal agendas in front of the well-being of our veterans.”

When it comes to personal agendas, there are few who are as laser focused as this man. Initially endorsing campaign pledges by Trump committing to increased accountability at the VA, his European trip—for which taxpayers paid $122,334—involved more sightseeing and shopping with his wife than “official” government activities. When the Washington Post first reported this story, Shulkin assured the public “nothing inappropriate” took place.

In February 2018, a report released by the Inspector General of Veterans Affairs contradicted his claims. It found Shulkin and his staff committed ethics violations in planning and executing the 10-day international excursion, by altering emails and making false statements to justify the accompaniment of his wife on the taxpayer-funded trip. The VA paid over $4,300 in airfare for his wife alone.

The Inspector General’s report also found Dr. Shulkin had inappropriately accepted tickets to Wimbledon worth thousands and had directed an aide to act as a “personal travel concierge” for the trip. In his op-ed piece, he feigns ignorance, “I am a physician, not a politician.” Based on my personal experience, this is a classic tap dance move by the man who should be known as Dr. Wimbledon.

Just over a year ago, I met Dr. Shulkin in his office while working in Washington DC on behalf of independent physicians. A highly esteemed colleague of mine previously worked at the same hospital with Dr. Shulkin and scheduled a meeting to discuss healthcare reform. My colleague asked for a “wing woman” and I happily tagged along. Knowing their shared history, an exchange of pleasantries seemed far more likely than the haranguing with insults that ensued. In my opinion, Dr. Shulkin was one of the most pompous men I have ever encountered.

Suddenly, he was more politician than physician. Dr. Shulkin said “physicians have no idea what they want” as if he was never one of our kind. In the middle of his tirade, he took a breath. Unable to hold back any longer, I jumped in head first. Whether shocked by the exchange of reasonable ideas or simply surprised at a physician devoid of fear, my comments stopped him cold. He replied, “huh, that might work.” Brilliant, Sir Politician.

As if on cue, his phone rang, and he let us know he and his buddy, President Trump, had important things to discuss. “Now get out of my office and don’t come back.”

I wanted to respond, “if you were the last man on earth, holding the very last morsel of food, I would happily chew off my own arm before giving you the satisfaction of winning.” Instead, I gritted my teeth, smiled, and choked out the word, “gladly.” Obviously, I will not have the opportunity to visit his office again.

He closes his disingenuous opinion piece with “it should not be this hard to serve your country.” Actually, Dr. Shulkin IS hard. Very hard. You are not a veteran yourself, so how could you have any idea what it is like on the battlefield? While selling the notion you were fired for your stand against privatization, that is hardly what happened now is it? You did not act with “the utmost integrity” in support of the 20 million U.S. Veterans. You were charged with fixing a dysfunctional system built to serve a population who have devoted their lives to teamwork and sacrifice. Our veterans deserve better than the healthcare currently being provided to them. While some vilify President Trump for his decisions, let me assure you that firing Dr. Shulkin from a position he should not have held in the first place was great for America – and our veterans.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State who blogs at peds-mommydoc.blogspot.com.

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21 replies »

  1. Lets hope this fellow can actually streamline the VA without compromising the health care.
    At least he will understand that our veterans are aging and their health care costs do as well.
    These men and women were injured serving our country and deserve the best our nation can provide. However, being a practicing physician does not automatically translate to being a good administrator. Lets hope he can navigate around the politics and do his job well. Our veterans deserve it.
    – John from http://www.insurancepanda.com/

  2. I agree with most of your comments. I am against privatization but believe in allowing vets with no other option private care when necessary. Why would he and his staff alter emails if everything was “above board”?

  3. I could buy the idea that he was fired for his unethical behavior if that same metric was being applied to Trump’s other appointees, which is not the case. You really can’t stay in a luxury bldg in DC for $50 a night. When you take your wife to the city that just happens to be great place to see the eclipse, it probably wasn’t business. You can get a really good table for less than $30,000. Etc. To be clear, if the charges against Shulkin are true, I am glad to see him go. I wish they would do the same with the others and set an example. If they don’t, I hope that the next guy elected will drain the swamp of that kind of stuff.

    As a vet, both enlisted and an officer, and having worked at a VA, though only as a med student and resident, I think that the VA does enough unique things it should not be privatized. It is much better at mental illness issues and drugs than most private hospitals also. Use private care when a VA facility is too far away, or the private facility has better care in that area. I don’t think that the person running the VA has to be a vet, but it will always be more difficult to gain trust and acceptance if they are not. There are plenty of vets with good management skills, so I don’t think that should be that much of an issue.


  4. We don’t know all the facts. He had many chances to say things you said above. Those are all reasonable. I wonder why he clammed up about those Wimbledon tix?

  5. Barry, I’m fascinated how much you want to give him the benefit of the doubt. “I’m skeptical at how much power he had.” He could have told us that his efforts at sweeping change were stifled everywhere he turned, instead of claiming his stand against privatization got him canned.

  6. I do not support privatization either, Jim. Shulkin claims he was fired for being against it, i am pointing out that may not be the reason. He was not a good fit for the job in my opinion based on having run a hospital.

  7. I had far more freedom at BCBSRI. No question. We weren’t even unionized. That being said, when we downsized, we were criticized, but that’s far different. There are so many ways that any secretary, including that of the VA, can be stymied, from political to budgetary constraints, to presidents with questionable vision.

  8. Jim – While I agree that the Secretary of Veterans Affairs doesn’t necessarily have to be a veteran, I’m skeptical about how much power he (or she) actually has to initiate or lead significant changes. Everything from political pressure that resists closing of underutilized facilities to civil service protections that make it very difficult to remove incompetent employees make it difficult to improve the agency and how it functions. Even hiring more doctors and nurses to reduce wait times in Phoenix would probably be stymied by budget constraints. There have been any number of good people that have led the VA in recent decades but it’s pretty darn heard to move the change needle in that bureaucracy.

    I suspect that you had far more power to make changes, including changes to the culture of the organization if needed, when you were CEO of Rhode Island Blue Cross than any VA Secretary will ever have. That’s unfortunate.

  9. I’m not qualified to comment on Dr. Shulkin, but I’m not sure being a veteran is a necessary prerequisite to running the VA. I’d rather have a very good CEO type that can make the changes needed systemically. That being said, I agree with those who are against privatization of veterans’ healthcare. I assume I’m in Tier 1, being disabled due to combat wounds in Viet Nam. As such, I’ve received very good care, and use the VA instead of my Medicare coverage when it makes sense and is convenient. There are some VA services that are unavailable where I live (Cape Cod), and I have received authorization to use private service in two instances since I started using the VA in 2012 (I also thought I’d not use the VA in order to free it up for those who had less resources than I…which the local VA folks said was “stupid” of me).

    I think the VA physicians and extenders do have a very valuable specialized knowledge of veterans, and especially the mental/emotional challenges so many have. At least here, they are very vigilant about such things as delayed PTSD and suicide. But I think I had more PTSD from being a health insurer CEO than from Viet Nam, but that was more recent.

  10. Niran, all cabinet secretaries have a security detail and there may also have been some aids with him. We don’t know all the facts here. A lot of these stories get blown out of proportion by people with an agenda. Personally, I don’t care if he took his wife with him. The VA’s budget is $200 billion a year and it has 360,000 employees. All of these people at this level take huge pay cuts to serve their country. The cost of the conference is much ado about very little or nothing in my opinion.

  11. There’s privatization and then there’s privatization.

    It would be very difficult to find the expertise in battlefield injuries and their complications anywhere outside the VA, and it would be a disaster to disband those centers of excellence. Good private insurance would work for some vets, but the danger is that it would just be a profit-oriented inferior version of Medicaid managed care – and that would be a tragedy.

  12. I agree with you Barry about supplementing the system with private care. I don’t support privatization. I do not believe Shulkin was fired for the “privatization” issue. In response to your earlier comment, it doesn’t cost $122k to go to a medical conference Barry. That is more than I make in a year. That is money paid out by taxpayers and it is frivolous waste in my humble opinion.

  13. Peter — I don’t see private care as a replacement for VA care. Instead, I view it as a supplemental option when VA care is not available to veterans on a timely basis. Also, the VA should always be the first line provider for vets who need care related to battlefield injuries including PTSD because it has so much more experience treating those conditions.

    By the same token, Bellevue is a safety net hospital in NYC while NYU is a highly regarded private hospital just a few blocks north on 1st Avenue. Most people who have a choice would prefer to go to NYU for just about any care. However, if you happen to suffer a significant gunshot wound, you would be better off at Bellevue because it sees so many more of those compared to NYU and has much more experience in treating them..

  14. Always the skeptic, Michael. Your point is fair. I thought everyone knew I am part of the National Physicians Council. I apologize for not being more transparent. My views are my own and not endorsed by any specific group.
    I hope that information helps you place my post in better context. I am not a member of AMA, AAPS, or Physicians for anything. I am however a member of Practicing Physicians of America which is currently working on a movement called #physiciansrise. You should check it out. You will hate it. It goes against everything you believe about physicians.

  15. Barry, there is a Veterans Choice Program (VCP) for private care outside the VA. My father-in-law had terrible treatment and diagnosis from private Medicare docs in Florida, non-combat illness as he never saw WII combat. He finally went to the VA and got great care with proper diagnosis and all for free. The VA had terrible incentives that rewarded cost cutting not care – that has changed. If you want a better system then pay more for it.

    I’d like to know the satisfaction scores for VA care and private care. Privatizing VA care will cost this country 10s of millions more in medical and drug costs. Frankly, we should all be under Medicare for all.

  16. Unfortunately, THCB provided no affiliation. The phrase “representing independent physicians” presumably means a particular group with a particular agenda, which could be anything from the AMA to Physicians for a National Health Plan (doubt it) to the Association of Physicians and Surgeons, a group that makes the AMA look like a bunch of liberal wimps. I’m not justifying Shulkin’s behavior, but the politico-medical context would be helpful.

  17. First, I think it’s worth noting that while there are 20-22 million veterans in the U.S., only about 9 million have access to the VA healthcare system due to limited capacity. The VA has eight eligibility tiers that help determine which veterans it can serve. I was in tier 8 (ineligible), the lowest, for many years until Congress added heart disease to a list of diseases and conditions deemed to be caused by potential exposure to Agent Orange for anyone who served in Viet Nam for even one day. I was there for a year from 1968-1969. While my heart disease probably has nothing to do with Agent Orange exposure, the VA rates me 30% disabled and I’ve had a VA healthcare card since 2010. The disability rating moved my tier rating from eight to two but I don’t use the system because I don’t need it and would rather free up the capacity for veterans who do need it. Many of us also have Medicare and lots of the poorer veterans also qualify for Medicaid.

    The VA has a lot of specialized expertise in battlefield injuries including amputations and PTSD which civilian doctors see relatively little of. My understanding is that the VA does a very good job treating those conditions. For more common diseases and conditions, veterans should have the ability to access private sector doctors if they live in regions where the VA’s capacity is inadequate. Since there are huge differences in the population of veterans in various regions of the country, some states and cities have way more VA capacity than they need and some don’t have enough. I would love to see average inpatient occupancy rates for each of the 155 VA hospitals nationwide. It would be helpful if the VA could downsize or even close hospitals that are grossly underutilized and free up the resources to increase capacity where it’s needed most. However, politics make it impossible to close large facilities. That’s a shame.

    Outgoing VA Secretary David Shulkin is the former CEO of Beth Israel Hospital in New York City. I’ve had several procedures at BI over the years, including my CABG in 1999, and had no issues with my care. For the record, Dr. Shulkin claims that he attended all 43 hours of meetings at the recent conference he attended in Europe. He did some sightseeing after meeting hours and attended the Wimbledon tennis tournament on a Saturday. Do you expect him to stay in his hotel room when there are no meetings going on rather than take in some sights? I don’t.

  18. Everyone needs to start somewhere. It’s as good a place as any.

  19. Nothing beats the marriage of arrogance and incompetence. Not sure what the objection to privatization is anyway. Why not let those who serve get the best available care? If the VA aimed to build a superior system for veterans, they would have done that by now. Well, now that he is fired, he needs to stop whining and complaining about it, and lead with solutions…if he even knows what he wants.

  20. I am lead to believe that persons who chose to live within tightly controlled arenas eventually lose their capability to communicate with empathy. Of the four most important attributes of a Caring Relationship, empathy is the most important. Verified many years ago by Carl Rogers, Ph.D., the other attributes are Warmth, Non-critical Acceptance, and Honesty. They all become more valuable when co-occurring for long periods of time.