Book Review: It Shouldn’t Be This Hard to Serve Your Country

David Shulkin, MD, the ninth Secretary of Veterans Affairs, is the latest in the seemingly endless cavalcade of fired President Trump appointees whose tell-all books profitably pay penance for their participation in a divisive administration. The cash registers of websites, TV networks, newspapers, and booksellers everywhere can’t stop ringing from peddling controversy from both sides of the fence.  

I wasn’t going to read “It Shouldn’t Be This Hard to Serve Your Country,” to be honest. I’m wary of whitewashed stories told by humiliated former government officials and politicians who decide to bare their souls in a safe environment where only their own uncontested voice is heard. My experience with that kind of book is that the authors always claim to be misunderstood, selfless saints who just want to set the record straight in clearing their good name (as well as the path to future beneficial endeavors). An HIStalk reader sent me an Amazon gift card to cover the book’s cost and said he wanted to hear my take on it, so that guilted me into buying the Kindle version.

It’s a great title, by the way, referring to both veterans and to the author himself.

Shulkin is an internist who didn’t serve in the military, although much of his family did. He served in several medical school roles, was chief medical officer in an academic medical center, was president and CEO of Mount Sinai’s Beth Israel Medical Center in New York City for four years, and was then president of Morristown Medical Center (NJ) for five years before being tapped by President Obama to be the VA’s under secretary for health in 2015.

I generally believe Shulkin’s contention that he was a selfless advocate for the health of veterans, improving the VA system, and trying to protect the VA from the meddling of limelight-seeking members of Congress. Surely he could have found jobs that weren’t so soul-sucking if his goal was self-aggrandizement or lining his pockets.

Spoiler: Shulkin was fired because of the meddling of political appointees who want to see the VA system dismantled and by a president whose vanity requires him to distance himself from underlings who get bad press that interrupts the mandatory adulation.

The snips Shulkin mentions about President Trump suggest that the President has good intentions, values loyalty above all else, rules by executive order while refusing to talk to the other side, doesn’t have the attention span to analyze issues and relies on subordinates to form opinions for him, and is in far over his head in turning the government over to clueless power-grabbers who wage full-time war against career government workers who actually understand the issues. The Trump administration is dogged by infighting, revolving door cabinet members, and leaks of information that, whether factual or not, are often intended to discredit his legitimacy as President.

It’s also clear that the so-called Mar-a-Lago Three – Marvel Comics chairman Ike Perlmutter, physician Bruce Moskowitz, and lawyer Marc Sherman – had the President’s ear, represented themselves as his personal emissaries, and demanded full participation in all aspects of the VA’s operation. Perlmutter reminded Shulkin constantly that he was meeting with President Trump all the time and summoned Shulkin and others to the President’s Florida resort to tell them what to do, not just with regard to the VA’s EHR project, but in all aspects of the VA’s operation. Shulkin insisted that the three “counsel” him individually rather than as a group since the latter could have been interpreted as an illegally operating “federal advisory committee” that requires public oversight. Shulkin says he wasted a lot of his day dealing with them, with Perlmutter calling him several times a day with one naive idea after another.

Shulkin notes that, like President Trump, none of the three had ever even visited a VA facility and declined opportunities to do so. Only Perlmutter is a military veteran and that was in Israel, not the US.

Shulkin spends a lot of pages defending the travel expense controversy that helped get him fired, providing details that he says prove just how ridiculous the claims were that he was junketing around with his wife on the taxpayer’s dime (which was certainly true of other Cabinet members, but not Shulkin, according to Shulkin). I actually believe him here as well, and while I’m skeptical of the whole “fake news” excuse for unflattering exposes, it seems that the Trump-created 24×7 frantic news cycle where tweets earn headlines has roped even credible media outlets into running poorly vetted stories hoping to wrest eyeballs from equally lurid sites. Once Shulkin got on the wrong side of the headlines, the former Obama-Trump golden boy had to be sacrificed to protect the President’s thin skin, not to mention that cabinet member travel excesses stories were all the rage for newspapers back then thanks to former HHS Secretary and jet-chartering Tom Price.

Shulkin describes some of the improvements he made to the VA, often decisively and with little support – fixing the wait time problems, publishing operational statistics, trying to modernize its HR policies of basically firing nobody regardless of their level of incompetence, and addressing veteran suicide. He observed that the competitive innovation model rolled out by former Undersecretary for Health Ken Kizer, MD, MPH – especially a star ranking system — encouraged VA facilities to hoard best practices to keep other facilities from stealing their stars. Shulkin rolled out five priorities for improvement – care access, employee engagement, care coordination, veteran trust, and best practices sharing.

President Trump’s election brought in a flood of political appointees who knew nothing about their assigned areas of responsibility. The “politicals” ran off career professionals, leaked false information to the press, and stabbed each other in the back. Shulkin notes that not only did the President have zero government background, most of the cabinet secretaries he chose didn’t either, and some of them had spent their careers opposing the agencies they were empowered to oversee. Shulkin said he was told to find jobs for 30 people, which he thought was reasonable given the size of the VA. The person the White House had assigned to dole out the plum jobs was a 24-year-old former Trump campaign intern whose father was a “Fox and Friends” host. Shulkin was told that he had to accept any appointees the White House sent over and was given a direct order not to fire them. 

Shulkin had an obvious problem with some of the appointees who claimed to represent the White House or who wanted to oversee other appointees. One of them followed Shulkin’s staff meetings with his own sessions that included only the politicals, who would then be told to do something else in dividing the department between the “secretary’s team” and the “political team.” He was also getting beaten up by members of Congress who told him privately that he was doing a great job, but warned him that they would be grandstanding with bitterly negative criticism once the cameras started rolling. He assigned one of the politicals – who he names specifically – to serve on a White House committee who then leaked false information, threatened outside groups who didn’t support specific bills, and ran his own agenda in claiming to represent the President.

He also struggled with high-level VA positions that remained unfilled because the White House didn’t like some of his choices, including “a former CEO from one of the country’s largest public health systems” who was rejected because he had once served on a healthcare advisory committee for Hillary Clinton.

It was surprising to me how much influence that veterans service organizations such as American Legion and Disabled American Veterans wield. One of those that had been basically ignored as lobbying group a by the Obama administration – the Koch Brothers-funded Concerned Veterans of America – was welcomed by the White House despite its agenda of privatizing the VA. That issue kept Shulkin in trouble – nobody wants to admit to voting veterans that they want to shut down their healthcare system, so everybody accuses each other of having a hidden privatization agenda.

Shulkin says he made the right choice to replace the VA’s skunk works-developed VistA software. It made the VA paperless and was widely known because two-thirds of doctors trained in the US rotate through the VA, but Shulkin says the VA had made a mistake in allowing each of its 130 medical centers to create their own customized instance of it. He also noted the lack of interoperability with the Department of Defense’s systems, the high cost of maintenance, and the estimated $19 billion the VA would have spent to modernize VistA.

He admits, however, that he was naive in not realizing how his job would be threatened by his decision to bypass traditional contracting and to simply choose Cerner outright because “I was convinced that immediate action was necessary” because of a never-ending lack of DoD interoperability.

The VA engaged with Cerner under a little-used government contracting option called “determination of findings,” which allows a detailed vendor discussion without a formal commitment. He denies New York Times reports that cited a White House leak saying that Jared Kushner was advocating for Cerner. He says he was instead being pushed by former DoD employee John Windom and members of Congress to get moving with Cerner so the VA could align with DoD’s implementation schedule.

Shulkin says his main requirement was interoperability and Cerner wasn’t convincing in that area, offering only minor sharing of administrative data and the dataset used for government reporting. Or as he put it, “The Cerner team was in full sales mode.” He told Cerner’s then-President Zane Burke that he was ending negotiations until Cerner stepped up to the interoperability plate.

Shulkin worked with outside groups and with academic medical center CIOs to make sure the Cerner contract was solid. However, he was getting pushback from the political appointees, some of whom started showing up uninvited to EHR meetings and reporting back to the Mar-a-Lago Three with their concerns about the contract. One of the politicals was telling everyone that Shulkin was rushing to sign a flawed Cerner contract, urging that he be fired before he did so. Which, as it turns out, was exactly what happened.

In the last conversation Shulkin had with President Trump, the President told him, “You’re killing me with all the bad press coming out of the VA” and asked about the Cerner contract, “Can’t you find a cheaper alternative?” Later that afternoon, Shulkin – who had learned he was being hired as VA secretary only when he saw it on TV news — was fired by tweet. Access to government email and phones had already been turned off. He wasn’t allowed to return to the VA to pick up his personal items or to say goodbye to his team. He then was warned by a colleague that the politicals were making up a story that he had walked off with sensitive government information after being fired, so he returned all his electronic devices at 10 at night.

Shulkin notes that seven weeks after he was fired, “The political appointees apparently determined what I had known all along: the options for IT modernization were limited and the Cerner contract was the best option for the VA and for taxpayers. In the end, the right decision was made, and the VA was on its way to gaining a cutting-edge system to propel it into the future.” He also notes that the President took credit for the VA’s accomplishments at a White House event to which no Democrats or VA professionals had been invited. Shulkin was surprised that the press didn’t pick up on a published email in which one of the politicals laid out the firing of Shulkin, his deputy secretary, and his chief of staff, which was to be coordinated by Citizen Perlmutter to happen only after the President was able to take personal credit for completing several VA initiatives.

Shulkin had a lot of problems with the VA’s OIG, a 1,000-employee, much-feared organization that he accuses  of being “secret police” that aren’t always fair or thorough in their investigations.

He says he worries most about the clueless politicals who have run off qualified employees who could have overseen the Cerner project, explaining, “Getting a contract signed is one thing, but carrying out the real work involved is quite another. My years of experience with EHR implementations taught me that doing this well will require participants with real experience and knowledge that is unfortunately in short supply within the VA’s political leadership today.”

I found this book to be interesting, but depressing. Government is even more dysfunctional than we probably all suspect, and the motives of those involved can often be traced back to pettiness and personal gain (and the same can be said of the press, most likely). I don’t have a clue about how to fix that, but I do believe that David Shulkin was doing good for veterans until that opportunity was taken away by partisan politicians who accept incompetence as long as it is cloaked in political loyalty, just like the politicians who came before them and those who will follow.

As a cheap seats observer, I didn’t find Shulkin’s explanation of why he needed to rush into a no-bid Cerner contract to be convincing, but he’s right that he didn’t have any great alternatives. The Coast Guard’s struggle with Epic probably killed its chances, self-development was a non-starter, and not choosing Cerner when the DoD had already done would have been politically risky. He gives himself a convenient excuse should the project fail, warning in advance that incompetent VA politicals aren’t capable of implementing Cerner. 

The book was more interesting than I expected. Glimpses into how government works were fascinating, although not always encouraging. Maybe Shulkin is the self-sacrificing saint he describes in his book or maybe he isn’t, but regardless, I’m left with a more positive impression of him than before (and I was fairly positive about him before). He was unanimously confirmed twice for high-level VA jobs under wildly different administrations, developed consensus that crossed party lines, and as far as I can tell made veteran wellbeing his agency’s top priority. I think veterans were better off when he was in charge.