NEW YORK - David Shulkin, the physician tasked with overhauling the biggest health system in the country, is listening to the heart of an infantryman.
Stomach pains and vomiting brought Pierre Auguste, 24, into the veterans walk-in clinic at the VA NY Harbor Healthcare System in Lower Manhattan. Once a month, Shulkin escapes his Washington office and sees patients here, to learn more about the system from the front lines.
As the undersecretary of health for the Department of Veterans Affairs, Shulkin is responsible for the health care of nearly 8.8 million vets. He commands 168 medical centers and 1,600 clinics from Philadelphia to the Philippines, and oversees a $68.6 billion budget.
It has been 10 months since he was lured from the private sector to straighten out a system roiled by allegations that veterans were dying while waiting for care. Some former detractors are impressed with his plan to offer same-day appointments for primary care at each hospital by year's end; others insist nothing has changed.
Most of Shulkin's time is spent running the massive health system, testifying on Capitol Hill, and visiting VA facilities that haven't seen an undersecretary in decades.
But the longtime Philadelphia resident says the time he spends in the clinic is invaluable.
"I've always approached my job first as a physician," Shulkin said. "I'm here to help and take care of patients. I'm an administrator second."
He sees patients in Manhattan because he doesn't want the staff at Philadelphia's VA hospital to feel that he's "breathing down their necks."
The clinic waiting room, newly finished with wood-paneled walls and polished tile floors, was empty the morning Auguste arrived. The young vet, who recently completed a four-year stint with the 10th Mountain Division, was seen without delay.
Inside the examination room, Shulkin asked Auguste how he was adjusting to civilian life.
"I don't want to talk poorly about civilians," Auguste said. "But they don't know what's going on inside a vet's mind."
He tells Shulkin he has reenlisted and expects to be deployed to Afghanistan in the fall.
"You're going to be OK," Shulkin said. "We're going to take good care of you."
Asked later if he knew that the doctor he saw at the walk-in clinic was CEO of the VA health system, Auguste took a step back and laughed.
"No way!" said Auguste. "The guy acts so normal."
An agency in need of help
When Shulkin was hired last June, the VA was reeling under a barrage of patient anger, bad publicity, and congressional outrage.
In February 2014, a whistle-blower in Arizona claimed that at least 40 patients had died while waiting to be seen by VA doctors in Phoenix. Government investigators said they couldn't determine whether those patients could have been saved with swifter care, but the underlying problems led to the ouster of former VA Secretary Eric Shinseki, and brought lasting scrutiny to the agency and its lengthy wait times.
A VA audit released in June 2014 found that more than 57,400 veterans had been waiting 90 days or longer for new-patient appointments nationwide.
Subsequent investigations found supervisors had instructed employees to falsify wait times, and schedulers had created secret waiting lists to cover up delays.
Some politicians and veterans groups called for the VA system to be dismantled in favor of private providers.
Shulkin, 56, was one of nearly a dozen executives conscripted from the business world to reinvent the agency. Shulkin's new boss, VA Secretary Robert A. McDonald, was CEO of Procter & Gamble.
Shulkin had a reputation as a turnaround expert. On matters of health-care quality and safety, he "was viewed nationally as a guru," said David Bernard, chief medical officer of Mount Sinai Beth Israel Medical Center in New York, where Shulkin was president between 2005 and 2009.
Shulkin's home base has remained in Gladwyne, where he lives with his wife, dermatologist Merle Bari. After earning his M.D. degree at Medical College of Pennsylvania, he interned at Yale and was a resident at the University of Pittsburgh, where he met Bari. He spent more than a decade in hospital management in Philadelphia, serving as chief medical officer at the University of Pennsylvania Health System, Medical College of Pennsylvania, and Temple University Hospital.
At the once-struggling Beth Israel Medical Center, Shulkin was widely credited with boosting patient satisfaction and employee morale, said Stephen Klasko, CEO of Jefferson Health System, who has forged his own reputation as a health-system innovator.
Shulkin went on to a similar task - and accolades - at the Morristown Medical Center in North Jersey, which, under his leadership, was deemed the safest hospital in New Jersey by Consumer Reports and selected by Fortune magazine as one of the best places to work in America.
Last year, he resigned the $1.3-million-a-year post in Morristown to take the VA job, where he is paid $170,000 to serve millions of veterans, lead thousands of employees, and cope with hundreds of politicians.
"It's a heck of a lot easier to see why [the VA would] want him, rather than why he'd want that job," Klasko said. "He had a lot of other choices and he's taken on what looks like an impossible task."
Shulkin said his decision came down to a sense of duty.
"It was clear that VA was in need of reform, and when the president asked for help, I could not say no," Shulkin said. "First, I felt I could help and my private sector experience was relevant. Second, that this was my chance to give back to those that had stepped up to serve our country."
Though not a veteran, Shulkin has a military pedigree. His father was an Army psychiatrist and his grandfather was a veteran of World War I who later served as chief pharmacist at the VA facility in Madison, Wis.
'A different model of care'
Shulkin acknowledges he at first wondered if the VA could provide benefits that the private sector could not.
"Why don't we just voucher out the care?" he recalled asking himself. "Why should we need a VA?"
But 10 months on the job - and the stories that patients like Pierre Auguste tell him of struggling in the civilian world - changed his thinking.
"We provide a different model of care, which treats the physical along with the psychological, the social, and the economic aspects of health, all of which contribute to the well-being of the patient," he said.
Even critics of the system do not dispute that the VA is a world leader in treating polytrauma and spinal and traumatic brain injuries, and in developing prosthetics.
Yet the quality of care means nothing to the vet who can't get in to see a doctor, said Shulkin, explaining why he believes the VA needs assistance, not replacement.
According to VA data, about 7.5 percent of scheduled appointments - or 484,756 patients - were waiting more than 30 days to be seen as of April 1.
"It's become clear that the VA alone can't meet all of the health-care needs of veterans," Shulkin said. "We have to work more closely with the private sector."
To do that, Shulkin said, the VA is building a network that will stitch together the VA-run facilities with selected private-sector practices. Already, the VA has increased veteran access to private care by 40 percent, he said, adding that he still wants patients best served by the VA's "world-class care" to remain in the system.
Skepticism in Congress
Some in Congress aren't convinced the VA is on the road to recovery.
Rep. Jeff Miller (R. Fla.), the chairman of the House Committee on Veterans' Affairs, called Shulkin "a good man who is doing his best to turn around the Veterans Health Administration." But unless the Senate passes a bill to allow senior VA executives to be fired or demoted for mismanagement or incompetence, he said, the VA will continue to "lurch from one scandal to the next."
VA Secretary McDonald, in a speech April 10 to the United Veterans Committee of Colorado, said his office has terminated more than 2,900 employees since July and asked for disciplinary action against hundreds of employees connected with faking wait-time data.
"You can't fire your way to excellence," McDonald said.
U.S. Rep. Robert Brady (D., Pa.) said his constituents continue to report "horrible service, or lack thereof" at the Philadelphia VA. An internal audit released in 2014 reported 400 vets had waited 90 days or more for their first appointments there. A spokeswoman for the local VA said the facility has extended its hours and is adding 41 doctors and 74 nurses to reduce delays.
Others voice cautious optimism, crediting the VA's top doc with beginning to reshape the beleaguered agency.
Shulkin "has brought a great energy to the VA and a great sense of urgency to transforming VA health care," said Jackie Maffucci, research director for the Iraq and Afghanistan Veterans of America, a nonprofit organization for new vets. "The VA certainly can't declare victory on the access challenges, but with Dr. Shulkin leading the effort, there is a great foundation to build on."
Carlos Fuentes, a spokesman for the Veterans of Foreign Wars, said many veterans were already noticing improvements.
"We're seeing those programs starting to bear fruit," he said, noting increased access to private-sector care and a recent one-day "stand down" that provided care or sped up access to appointments for 80,000 veterans.
"That's a sure sign of a culture change," Fuentes said.