WASHINGTON — A gray-haired Vietnam veteran sat rustling on the paper of an examining table at the small veterans clinic in Grants Pass, Ore., on a recent afternoon when his doctor for the day appeared on a screen in front of him, wearing a white lab coat and bulbous headphones.
"Take some deep breaths. All the way in — And, sir, do you want to give me a good cough?" the doctor said as he listened to the veteran's heart and lungs from about 2,400 miles away in his office overlooking the White House.
The doctor was David Shulkin, the new secretary of veterans affairs, and this was not some publicity stunt. Shulkin believes it is impossible to right the stumbling bureaucracy used by 9 million veterans without understanding the experience of patients in the examining room. So Shulkin, the leader of the country's second-largest federal agency, has been seeing patients regularly, both in person and remotely, since he was named the Department of Veterans Affairs' under secretary of health in mid 2015 to help turn it around after the scandal over a cover-up of appointment delays.
"Sometimes leaders get disconnected from their organizations," Shulkin said after he finished the exam. The risk is especially great, he said, because the department has more than 350,000 employees and 1,700 facilities. "There is no better way to understand it than to use it and actually see."
His prognosis for the patient in Oregon: Good. He was doing well, but was stressed from caring for his wife, who has dementia. With the push of a button, Shulkin patched in an on-call psychologist who could help connect the veteran to therapy and a support group.
His prognosis for the Veterans Affairs Department: Not nearly as sunny. "We're in critical condition, but moving toward stable," he said, his brow furrowed. "The VA has experienced a very, very tough time. It lost the most important thing any organization could have: its trust."
Shulkin, by his own admission, is an unlikely choice to overhaul veterans services under President Donald Trump. The son of an Army psychiatrist, he is not a veteran — a first for the head of the agency. And when Shulkin led the medical side of the department in the Obama administration, Trump regularly criticized the agency — and by association Shulkin — as corrupt and incompetent. After the election, Shulkin, who had already packed up his office, was not the president's first choice to lead the troubled agency. He was not even his fourth or fifth.
It was only after a number of leaders in private health care and reliable Republican circles turned down the post that Shulkin's name came up. He was recommended by Trump's ambassador to Israel, David M. Friedman, who knows Shulkin personally, a White House official familiar with the process told the New York Times.
Despite his roundabout selection, veterans groups and politicians of all stripes immediately hailed him as a supremely qualified choice. Shulkin, 57, has spent a lifetime studying how to make health care organizations deliver better care at lower costs.
In a Cabinet of outsiders, many eager to deconstruct the departments they oversee, Shulkin wants to rebuild his. And after Trump was battered by divisive partisan confirmations of his appointees, the mild-mannered defender of government health care was confirmed by the Senate, 100 to zero.
"We haven't passed a kidney stone unanimously in years, much less a Cabinet secretary," said Sen. Johnny Isakson, R-Ga., chairman of the Senate Veterans Affairs Committee. (Trump is so pleased with the distinction that he has taken to calling Shulkin "the 100 to nothing man," he said during an appearance at the department last month.) Even the department's most consistent critics have quieted their sirens, at least for now.
Aware of that unlikely opening and uncertain how long it could last, Shulkin has already made a number of bold moves. In April, the agency began publicly posting wait times and quality data for every veterans hospital and clinic — sunlight he sees as crucial for accountability. In June, it plans to begin offering free mental health care to veterans long barred from its hospitals because of less-than-honorable discharges, including thousands with post-traumatic stress disorder.
"That move really told me what kind of man he is," said Rep. Phil Roe, R-Tenn., chairman of the House Veterans Affairs Committee. "No one told him he had to do it. He saw a problem, said we are going to do it, and he got it done."
That style of decisive action has defined Shulkin's rise through some of the country's largest private medical systems, friends and former colleagues say. But he now faces a bureaucracy far larger and more complicated than any he has encountered.
Beginning at the Medical College of Pennsylvania in Philadelphia, he was drawn into the obscure field of health care management. He became a tireless student of efficiency. Shulkin can tell you, for instance, that postabdominal surgery infections add on average $12,542 to the cost of patient care, and that some surgical mistakes occur more frequently in the first part of the academic year.
By standardizing best practices, Shulkin believed, he could save money and patients. Before long, he was one of the "high priests" of patient-centered care, said Stanley Brezenoff, a longtime health care executive who is the interim chief executive of New York City's health system. Shulkin pushed each system he worked in to train its focus on quality. Financial savings, he argued, would naturally follow.
Constant tinkering was a part of Shulkin's design, according to Dr. David Bernard, who worked with Shulkin in the 1990s to start an innovative disease management program at the University of Pennsylvania Health System, one of the country's top-ranked academic medical systems.
Shulkin came to the Veterans Affairs Department expecting to find a less efficient copy of private health care that would be straightforward to streamline or even privatize. His first clinical visit, with an intoxicated double amputee Vietnam veteran at a hospital in Manhattan, taught him that it would not be so easy.
"This guy was really, really upset, and he was cursing me," Shulkin said. "If I was seeing him in my last hospital, I would have called security. I would have had him removed. I would have sent him a certified letter telling him not to come back."
Many of the agency's patients have a complex mix of physical and mental health issues, he said. "They can't go get care in the private sector," he added. "At least not the comprehensive care the VA gives them."
Since then, Shulkin has become one of the system's most vigorous defenders. At the same time, he has battled his own bureaucracy in an attempt to kick-start changes. He supports a bill now in Congress that would streamline hiring and firing. Currently, it can take six months or more to hire a nurse.
After he first took the job, he grew concerned that the agency was not doing enough to prevent suicide after a news report showed high rates among young combat veterans. Suicide prevention leaders told him that they would put together a summit meeting to respond, adding that it would take 10 months.
Shulkin told them to get it done in one month. When his staff members pushed back, he pulled out a calculator and began quietly tapping, then showed them that during the delay, nearly 6,000 veterans would kill themselves. They got it done in a month.
"For me it was a very important day," he said, remembering the meeting. "It taught our people you can act with urgency, and you can resist the temptation to say we work in a system that you can't get to move faster. I think they learned that you can."