Before joining the Department of Veterans Affairs in 2015 as under secretary for health, Dr. David Shulkin built a reputation as a patient-focused health care administrator. Part of his legend includes walking the floors of New York’s Beth Israel Medical Center after midnight to investigate why the night shift performed more poorly than others.
At the time, he was CEO.
That might carry more than a whiff of micromanagement if not for other working habits that, taken together, paint a more benign picture of an executive who wants to observe a hospital’s workings rather than interpret them solely from a chart, and who embraces unconventional thinking. Shulkin still sees VA patients, for instance, to remain connected with the organization’s inner workings.
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It’s a far cry from his undergraduate days at Hampshire College, where he researched ways to slow or stop the aging process. Now 57, Shulkin no longer participates in clinical research, but he oversees a research budget of $673 million, which includes a spate of new clinical investigations into the brain health of veterans.
Shulkin visited with STAT this week while in Boston attending the VA’s Brain Trust summit on brain health at Harvard Medical School.
This conversation has been edited and condensed.
Of all the brain-related research you’re following on veterans, which component is the most critical right now?
Of the 2.5 million service members who’ve returned from our recent conflicts in Iraq and Afghanistan, 20 percent return with some type of traumatic brain injury. We need to find a better way to diagnose those injuries. That includes the development of a biomarker or a diagnostic test that may include imaging as well. I’ll meet with Jeff Immelt from GE to talk about why it is so critical that we work with them on imaging, and partner with industry to find ways that in the past have really not led to the fruitful diagnostic tools we need.
Then we can look toward the most effective treatments and future prevention. In 2016, our research discovered that the majority of the injury that results from TBI, particularly in veterans, impacts the cerebellum. So now you can start developing strategies targeted toward the cerebellum.
In recent years, some researchers have seen links between traumatic brain injury and suicide. You’ve called suicide your top clinical priority. What’s the status of that battle inside the VA?
Of course it’s not an issue that just impacts veterans; it’s an American public health crisis. There are 120 Americans taking their life every day, and 20 of them happen to be veterans. I don’t think we’re doing enough, and I don’t think there’s enough research in this area, and I don’t think there’s enough effective interventions. So we’re approaching it as a multifaceted intervention.
We are trying to identify those that are at risk earlier: We’re using predictive analytics, and a tool that no other health system in the country has. It’s called REACH VET, where we’re using our electronic medical record data to identify those at higher risk of suicide, and proactively reaching out to them and trying to connect them with help before an event would happen.
We have research going on right now to look at those linkages between TBI and behavioral health issues, including depression and suicide. But we also know that suicide has social and socioeconomic aspects as well, so we’ve targeted our homeless population, because they are at higher risk of suicide.
And recently one of my first decisions as secretary was to authorize the mental health services for those that are other than honorably discharged, which we’ve never done before. When I saw that population being isolated without access to health care and at a higher risk for suicide, I felt it was essential that we take that step to be able to offer those services.
Have you seen results in the numbers yet?
Not yet. Our data on veteran suicide is the largest database in the world, so these are large data collections, and it lags years. The latest data we have is 2014.
When you opened up VA services to those who have less-than-honorable discharges, what sort of resistance did you encounter from the rest of the veterans community?
One of the things I’ve learned in government is that you will not make any decision that somebody doesn’t disagree with. What I believe in is principle-based leadership. And when you have an objective — and in this case it’s to eliminate veteran suicide — you’re going to have to make decisions whether they’re popular or not, and as long as it’s achieving our objective, we’re going to stick with that.
How often do you communicate with President Trump, and to what extent has the turmoil — for lack of a better word — at the White House recently affected your ability to get the president’s quick attention on matters facing vets?
This president is very accessible to me. He has made it clear to both me and his staff that the issue of veterans and fixing the services for veterans is among his highest priorities. So therefore, any time I need access to the president, I can get that. On a regular basis he wants to check in and make sure that I am getting what I need, and there has not been any barriers to me getting input from him or asking him for help.
Does that extend to Congress as well? They’re also distracted by a lot of this, and you need to at times communicate with the heads of committees and get their attention.
I know this may sound disappointing, but honestly I do not experience Washington as a partisan town. And it’s not that I don’t read the newspapers and watch the television, but my experience is that when I deal with members of Congress and the president, it is issue-focused on fixing the VA system. I have the cellphone numbers of every one of my committee chairs; I can get access to them at any point, and they are there, despite all of the things going on in the country, in a very focused way, helping me address the issues at VA. Veteran issues are not Republican or Democratic. They really are pure bipartisan issues.
The Urban Institute last month reported that nearly half a million vets are covered under Obamacare, and that a repeal of that law or a Medicaid rollback could send many of those vets to the VA, which already strains to treat its 9 million patients. What can vets now in the VA system expect if that comes to pass?
The veterans of this country can expect the VA will be there for them. We take that responsibility seriously. That is our mission. And we are planning for any event that would create additional veterans seeking care. We are creating that capacity. I am not going to put plans in place until there is a law that I can review to see the impact of it. Part of my job as secretary is to plan for any contingency, because I will not allow this country to go back into a crisis in the VA system. But let’s remember, there’s still a lot more work to do before there’s a piece of legislation for me to review and to make that assessment.
