I recently interviewed Secretary David Shulkin on my podcast, Thirty Minute Mentors. Here is a transcript of our interview:

Adam: Our guest today is a national leader in the field of healthcare management. Dr. David Shulkin is the former Secretary of Veterans Affairs, and has held leadership positions at five major hospitals and hospital systems. Secretary Shulkin, thank you for joining us.

Secretary Shulkin: I'm glad to be with you, Adam.

Adam: Can you take listeners back to your early days? What attracted you initially to the field of medicine and subsequently, to the field of Healthcare Management?

Secretary Shulkin: Well, I really wanted to be a fireman. I grew up on the street where the fire engines would come down whenever there was a fire, and I'd rushed to the window like most kids, and I'd say I want to be one of them. And then as I got closer to my career choice, my mother really wanted me to be a doctor. And you know, what appealed to me was the ability to rush into emergencies, and to help people, whether it was rescuing people from a fire or from a car accident or some other medical issue that they needed help with. That's what I wanted to do. So I was always that type of person that on the airplane, when they asked for a doctor, my hand goes up. I see a car accident, I'm pulling over to help people. So that's what drove me to medicine.

Adam: I think there are more Jewish doctors than Jewish firefighters. My dad's cousin Mitchell Mendler is one of the rare Jewish firefighters, so there are a few of us out there, but not too uncommon to have a Jewish mom encourage her son to go into the field of medicine.

Secretary Shulkin: Yeah, you know, whenever I interview people for jobs, I want to hear about their professional experience. But I also want to hear about their dinner table and sort of what makes them tick. And families have a big influence on people, particularly at the time of making career decisions. My dad was a doctor. And you know, the family really valued the helping sciences. And so it didn't surprise me that I ended up going that direction.

Adam: What compelled you to pursue a career in healthcare management? You're working as a doctor, what made you decide to make that leap?

Secretary Shulkin: Well, at the time that I went into the specific area of Healthcare Management, it wasn't a slam dunk decision. In fact, doctors really didn't do that, you know, doctors worked hard to basically go out and be full time doctors. And so there really wasn't a career in Healthcare Management. But I couldn't help it because my brain just worked differently when I was a resident in internal medicine. And I finally got to my third year where you have the chance to choose electives. You’re, for the first time, not being told you have to go to this particular part of the hospital to learn this. You get to choose. Instead of choosing what all of my other classmates did, which was to go to cardiology, or gastroenterology or endocrinology, I wanted to understand what made the healthcare system work. So I went on my elective to Blue Cross of Pittsburgh to the insurance company. And that had never happened before. The chairman of the department said, you can't do that. And I said, well, why not? You know, this is important, we have to understand how all this healthcare is going to be paid for and you know, what's gonna happen to the profession of medicine if we don't understand the impact of how it's paid. And he agreed with me, and that's where I ended up doing my elective time and started learning about how the system works at the system level, not just at the individual patient level.

Adam: And you lead many large bureaucratic organizations over the course of your career. None larger, none more bureaucratic than the VA, which we're going to talk about extensively over the course of this conversation and you stood out by cutting through the red tape and ultimately driving results. What are the keys to navigating and succeeding within large bureaucratic organizations?

Secretary Shulkin: Well, you know, it probably is true that I've presided over a number of bureaucratic organizations, but I have to tell you, I don't call them that, because the bureaucracy is a man-made creation, and therefore it can be broken down. And if you're the leader of an organization, at the top, it seems a cop-out, to me, to call it a bureaucratic organization. You have to own that. And in actuality, for people that don't follow the VA as closely as I do, or maybe you do, to understand the size of it, it's $240 billion a year budget, it's the second-largest government agency, it employs over 400,000 people. It has facilities all across the country, more than 1,200 of them. So it's a big organization. And in many ways, when people asked me a question like did you add them, I let people know that I found it easier to get change done in an organization the size of the VA, than I did when I ran a large hospital in northern New Jersey, or New York City or Philadelphia. And the reason is that when you run a hospital, and you're the CEO of the hospital, you can sit in your office, and you can make all sorts of decisions about how you think the place should be run. And then you have a medical staff, who basically says, I don't work for that guy, I don't necessarily see things the way that he does. So he can go take a running leap off of a bridge for all I care. And my ability to influence the practice of medicine, being the CEO of a hospital was a lot less than being at the VA where when I was in charge, it had a culture, much more like the military, where people waited for the leader to give a direction, they were actually called directives, you wrote them down. And then they got sent out across the country, and people read them and implemented them. And so I felt that if I understood what was important to get done, it was a thoughtful direction, I wanted the Department of Veteran Affairs to go in. And I carefully crafted the plan to get it done. I could influence and make changes for the millions of veterans whose lives depended upon us making good decisions. And those changes would get done. And frankly, you know, I never really experienced it. As a bureaucratic organization, I experienced it as a very empowering position that you had to take very seriously the level of responsibility and accountability that you had, not only to the veterans, but to the American public and the taxpayers.

Adam: What are the keys to being an effective change agent? You had an easier time enacting change at the VA that you did at the other stops along your journey, but how were you ultimately able to enact change? And how can listeners who want to be change agents ultimately go about bringing effective change?

Secretary Shulkin: I don't want to be overly simplistic Adam, but some of it goes down to pretty simple things. Leaders have to make decisions. And I know that sounds pretty simple. But if you're very clear about what you want to get done, and you tell people why you feel that it's important to get something done. And then you communicate that effectively. I believe that is an important part of what successful leadership is. So let me give you some examples. The reason why I joined the government, the reason why President Obama nominated me to run the VA health care system, was something that was happening in the VA in 2014. That is known as the wait time crisis, where literally hundreds of 1000’s of veterans were unable to get timely appointments, where there were allegations that many veterans were actually dying of their medical conditions because they couldn't be seen in the timely fashion in the Department of Veteran Affairs. And I came in after being confirmed by the Senate unanimously to fix the problem. And by making a decision to fix the problem, I didn't make it in what people thought that I would make it, I made it to say that we are going to go from a huge problem in wait times to exactly the opposite, which was to see patients the very day that they needed to be seen. Same-day appointments. And people said, that's crazy. You can't do that, that's too big a leap. And I just didn't agree. I felt that that was the only way I could assure the veterans in this country and their families and the American public that we were going to solve this wait time issue so that if somebody needed to be seen, they would be seen that day. And by the end of 2016, right before President Obama left office, I was able to tell him, Mr. President, every VA medical center in the country is now seeing patients on same-day appointments. And that we have committed to that, and we're going to be accountable for that. And that's how we're going to solve the problem. In a similar way, Adam, when I wanted to address the issue of hepatitis, which some of your listeners may not realize, veterans have a higher incidence of hepatitis C, than the general population. I basically didn't say I want to improve hepatitis, or I want to reduce hepatitis, I said, I want to end hepatitis among all veterans. We now have drugs that can cure hepatitis C at the 95% level. And so I want there to be no veterans in this country that are untreated for hepatitis C. And we went around, we went about doing that. And today, there would be less than 10,000 veterans in this country that have not been treated for hepatitis C, unlike any other health system in the country. So leadership is about making decisions, explaining to people why you made those decisions, communicating and effectively holding people accountable, being transparent with the results, and showing people if you've made the progress that you said that you're going to make.

Adam: I agree with everything you said. And I want to add that a huge component of leadership is setting a vision, setting a bold vision, and you gave two clear examples where you came in, set a vision, and your team ultimately executed on it. And without the leader setting the tone, things aren't gonna get done. And to that end, I want to ask you about your experience, working under two dramatically different leaders. You were brought into the VA, by President Obama, you were retained by Donald Trump. How did your experiences differ working under such dramatically different leaders? And what did you learn from the experience of working for such dramatically different human beings?

Secretary Shulkin: Yeah, I don't think it will come as a surprise to anybody listening to this, that you probably couldn't pick two different people, different styles, two different bosses to have. And it's important that I think people understand before they hear my answer here that I didn't have political allegiance to either one of them. I didn't enter government because I was running for something or because I wanted to fulfill some type of political goal or philosophy. I was basically an average citizen, like everybody else minding my own business. I happen to be a CEO of a hospital, when I got a call from the president of my country saying, we need your help. And I said, how can you say no to that, particularly when it's for our veterans? So I entered, really, without a political bone in my body. I was confirmed by the Senate twice, 100 to zero. I think I was the last cabinet member ever confirmed 100-zero. I hope someday there are others. But there has not been any sense. But people who work with me didn't know if I was a Republican or Democrat. And I thought that was perfect, because when you serve our veterans, you know, and they serve our country, we can't just have Democrats serving our country or Republicans serving our country and service. We need them to be American. So basically, getting back to your question, the public probably gets a pretty accurate picture of what it was like to work for these presidents. President Obama was extremely thoughtful, extremely analytic. Think of him like your college professor, you would hand in data to him, which we would call briefs. He would study them, he would mark them up and ask questions, and they were good questions and you'd have a good discussion. He usually sent you back home with some homework. And that meant that decision-making and policymaking was slower because President Obama thought about the impact of his decisions, the unintended consequences, the secondary consequences of making a decision. And by its very nature, that leads to more thoughtful policy but slower decision making. President Trump was, as you could imagine, exactly the opposite. When you would try to bring him briefs or analytic information, he would say, I don't want to see that. I want to hear directly from you what your recommendations are and why and why you're making those recommendations. And when he developed the sense that the person that was making those recommendations knew what they were talking about, was confident, and he had confidence in them he wanted to know less, he just wanted to hear directly how he could help. So my relationship with President Trump was one where I was the only member of the cabinet who had been in the previous administration, I knew my job pretty well, I knew my agency extremely well. I had been working nonstop to fix it. I knew exactly what I wanted to do when I became secretary, I had a game plan. And by the way, some of those parts of the game plan, I wasn't able to get done in the Obama administration, because they were still thinking about them. And they didn't believe that, necessarily, you know, they were always the right things to do. So I went in with a lot of requests for President Trump. And he would often say to me, well, if we do this, would it be good for veterans? And I would say, Mr. President, it would be good for veterans. And I think we should do it. And he would say, go ahead and do it then. And I was able to get a tremendous amount done. In my first year as secretary, I got 11 legislative bills, through Congress, which as you remember, was a very divided Congress, and to the President's desk for his signature. And again, because I was able to get 100 to zero confirmation, because both parties felt I was acting on behalf of veterans, not because of a political ideology, I was able to largely get the support of both Republicans and Democrats. And the President used to look at me and say, I don't understand how you are getting all this stuff done. And I said, because I'm focusing on what's right for our veterans. And he would say, well, I agree with that. And he would sign the bills into legislation. And so I found it very easy to work with him until the craziness caught up with it. And, you know, again, I'm not trying to be political here, but the Trump administration was unlike the Obama administration, and that there were just things happening and a disorder to the way that the administration was drawn. Political appointees running amuck, following their own agendas, people working across purposes. And it became essentially a nightmare to work. And people started to work directly against me because, frankly, I wasn't their choice for Secretary. The last thing they wanted was an Obama holdover. They wanted their own people in there. And so it began to get so chaotic. And I think that people saw a lot of evidence of this in the Trump administration, not necessarily directly from the president as much as a consequence of his management style that just led to no longer being able to get the work of the office done. At least I wasn't able to any more.

Adam: So much of what transpired in both experiences and so much of your journey as a doctor, your journey as a medical leader, and then your time in both administrations can be categorized as driven by relationships, building relationships, and managing relationships directly with the two different presidents with the members of the respective administrations driving all the way down to building relationships with your colleagues, your employees, your patients. What are the keys to building winning relationships?

Secretary Shulkin: Well, if I knew the answer to that, you know, maybe I'd still be in government. I think you're absolutely right. I think that, you know, particularly for those of us who were trained in medicine, and then found ourselves in management positions, it really was hard to understand that, you know, just knowing about how the science of medicine works, and being competent at your job is really not enough to succeed. In the chief executive job or a top management job, it really is about working with people, and managing relationships. And, you know, the part that I struggle with and I think that's an accurate word. I always have to work at it and always know I can do a better job at it- is to find good working relationships that align with the values of the organization and the mission of the organization, the work which is the reason why I found it so challenging, particularly in the Trump administration, to do that was because many of the political appointees that I struggled with, I didn't share the values of honesty and principle-based decision making and truthfulness and transparency. I felt like they had a political objective, and they felt that whatever means they needed to be able to get there justified the way that they would get there, whether that meant, you know, doing something that frankly, I didn't feel was either ethical or truthful. They felt justified in their minds because they really felt that they needed the organization to go in and jerk different directions. So I struggle with relationships with people where it's not based upon the same value system. And, you know, that's probably something that I could have managed better. Frankly, I think I should have probably fired a bunch of people a lot earlier than I did. Because in my view, when you have people that are not ethical, and that you can't trust, they shouldn't be on your team. And I felt that these were a protected class of people because they were appointed in a political appointment through the president, that I didn't feel like it was my duty or my authority to fire them. But in retrospect, I believe I should have done that much earlier.

Adam: I’ve had this similar conversation with so many of America's top leaders, and a question that I'll ask is, on a scale of one to 10, how important is ethics when it comes to leadership? And I've asked this question to Fortune 500 CEOs, I've asked this question to founders of household name companies, to retired generals, every single person, says 10. And we'll dive into why. And you explained in great detail why it's so important for, not only the leader to have strong ethical views, but for every member of the team to lead ethically. And it must have been extremely difficult for you personally, when toward the end of your tenure as VA secretary. You are accused of wrongdoing, after the dust settles, you are ultimately cleared. But this is a moment where you're being accused of something. You're a leader who values integrity, values honesty, values ethics. What are the best lessons you learned from that experience that you can share with listeners? What did you learn?

Secretary Shulkin: Well, look, first of all, I just want to comment on what you said. Everybody can say that ethics is at the top of their list, but ethics is not black and white. The people that I strongly disagree with, and that I may even label unethical don't necessarily perceive their behavior in the same way and may actually be feeling the same way that my behavior was unethical because people view their ethical decisions through the lens of their belief system. And to simplify it for people that are trying to follow this conversation saying what is going on to simplify it? There was a basic disagreement that I had with political appointees over whether we should privatize the VA and move it into the private sector versus continuing to strengthen it as a government run agency. I had the position that I did not want to privatize the VA. Other people who opposed me felt that I needed to move quicker towards privatizing the VA. So when you look at decisions based upon that lens, you can see how people's ethics to them, to me, may look different. In Washington, it doesn't matter. It doesn't matter if you're on the side of right, or you're the side of wrong. It doesn't matter whether you're acting ethically, or potentially unethically. What matters in Washington, is the perception. And then, in Washington, the allegation itself becomes the perception. So as soon as they were able to get it into the narrative, that there was a potential wrongdoing, game over, there's no way to defend yourself in Washington. And that's the nonsense that prevents a person like me from trying to do the work of the nation of protecting our veterans. I feel strongly that people who go into public service and are trying to do the right thing for the country should never experience that type of atmosphere, and hate and frankly, meanness that I saw firsthand, that my family saw firsthand, in just trying to perform the work of public service, and you know, we need to return to civility, and return to allowing people to do their job without experiencing this type of partisan politics.

Adam: One of your first initiatives as VA secretary was pushing to expand access to mental health care to veterans, who had been barred from VA hospitals due to less than honorable discharges, which includes 1000’s of veterans with PTSD. Why is mental health so important to you as a leader?

Secretary Shulkin: Well, it always starts with something personal. And the personal thing for me was that one day, I got a call when I was at the Department of Veteran Affairs that a husband and wife, Howard and Jeanne Summers wanted to come and see me. Now, I had a lot of requests from people who wanted to come and spend time with me. But I decided this one would be important. And they came to see me and they shared with me the letter that their son Daniel had left them right before he killed himself. He was a Marine, Daniel, and how he struggled and how the VA had let him down in his treatment, to the point that he felt there was no other choice but to take his own life. And I decided right there and then that this was going to be something that I needed to dedicate my time to fix. It turns out that Daniel lost his life, but every day 20 veterans take their life from suicide. And so it became the top clinical priority for me in the VA. There's only one thing at the top of the list, this was it, there was nothing hotter than preventing veterans suicide. And so this became my top priority.

Adam: The past year and a half has been dominated by a global health crisis. Everyone's been impacted in some capacity. Looking forward, what are the most important trends related to healthcare that all leaders should be aware of?

Secretary Shulkin: I think that this pandemic exposed about everything possible, have a system that has fragmented itself, and as dysfunctional, and if leaders don't pay attention to what didn't work, as well as what did work, then there's really not going to be major changes, we might as well just go back to the way that it was. Some of those changes, of course, have to start with some pretty obvious lessons. It's important to be prepared for emergencies whether it's a viral pandemic or it's a cyber attack or it's a utility outage or it's a staffing shortage. Leaders need to prepare for emergency situations and they need to have plans in place to address problems before they occur. That's pretty obvious. But when you take a look at some of these problems that we saw, there were major supply chain problems in being able to get basic necessities that leaders have to now make sure that they address, they have to take a look at staffing issues, because there were severe staff shortages, and there will continue to be in the future, they have to take a look at how the system really was not capable of sharing resources beyond hospitals and health systems. So you had in the same cities, some hospitals having everything they needed, like protective equipment, and other hospitals not having enough and no ability or willingness to share among themselves. So there are a lot of lessons to learn. We can talk about the digital and virtual lessons that people learn and talk about the, you know, inability to provide care outside of facility-based care, like hospitals and medical offices providing more care in the home. So there are lots of things that I think are really important to look at, and to learn from and make a stronger, more resilient health system following this public health emergency.

Adam: What can anyone listening to this conversation do to become a better leader?

Secretary Shulkin: I always think that leaders need to do a bunch of things that I've always done to try to get better. The first one is, obviously, learning that you can get better, even great leaders try to get better. And that's why when you look at the real star athletes, the people at the top of their field whose names you know, they all have coaches, and I don't mean a single coach, I mean multiple coaches, because they know that if they want to stay at the top of their field, they have to continue to evolve and learn and do better. I think one often does better by trying to learn from others that they respect. I'm a constant reader of books by other people listening to podcasts, meeting people, talking to them, trying to learn what has made them successful, that I might be able to learn from myself. I think that leaders practice communication, they practice listening. They practice in trying to develop other people around them to be as good as they are, if not better. And they continue to measure themselves in their organizations and hold themselves accountable for the results that they need to get to serve whatever constituents they're serving.

Adam: Secretary Shulkin, thank you for all the great advice and thank you for being a part of Thirty Minute Mentors.

Secretary Shulkin: Thank you for having me.

Adam Mendler is the CEO of The Veloz Group, where he co-founded and oversees ventures across a wide variety of industries. Adam is also the creator and host of the business and leadership podcast Thirty Minute Mentors, where he goes one on one with America's most successful people - Fortune 500 CEOs, founders of household name companies, Hall of Fame and Olympic gold medal winning athletes, political and military leaders - for intimate half-hour conversations each week. Adam has written extensively on leadership, management, entrepreneurship, marketing and sales, having authored over 70 articles published in major media outlets including Forbes, Inc. and HuffPost, and has conducted more than 500 one on one interviews with America’s top leaders through his collective media projects. A top leadership speaker, Adam draws upon his insights building and leading businesses and interviewing hundreds of America's top leaders as a top keynote speaker to businesses, universities and non-profit organizations.

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