S1E9 | Insights on cancer care from running the VA
S1E9 | Insights on cancer care from running the VA
The Honorable Dr. David J. ShulkinNinth Secretary, U.S. Department of Veterans Affairs
Dr. Pat Basu: Hi, I'm Dr. Pat Basu, president and CEO of Cancer Treatment Centers of America and the host of Focus on Cancer. We have a very special show today, where I welcome former cabinet secretary, Dr. David Shulkin. Dr. Shulkin served as the ninth secretary of Veterans Affairs in the Trump administration, and also served previously in the Obama administration. He's one of the few individuals who has led very complex healthcare organizations ranging from academic medical centers to the public sector. Dr. Shulkin, it's a pleasure to have you here. Thanks for being on the show.
Dr. David Shulkin: Glad to be with you today, Pat.
Dr. Pat Basu: Well, before we dive in and we've got a lot to cover, you're joining us at a very auspicious time. Tomorrow happens to be Veterans Day, a special day where we set aside a time to honor those who have served this great nation. And nobody knows better than you the veteran community, their sacrifice, their service, their heroism. And so I know you'll join me in recognizing the more than 19 million US veterans across the country and honoring them for Veterans Day tomorrow.
Dr. David Shulkin: Yeah. Pat, it really is a very special day for so many people across this country. I would just like to say two things besides wishing our veterans a very happy Veterans Day. First is that less than 1% of Americans now serve in our military as you know it's a completely voluntary military. And so we have a very small minority of our citizens who sacrifice and stand up for the rest of us. I think many people don't know veterans personally now and don't get a chance to meet these remarkable people. But I can assure you, it was one of the best parts of my jobs, spending time with our veterans and seeing just what incredible patriots these people are. And secondly, I want to wish a happy Veterans Day to their families because when a person raises their hand to serve, it really is the entire family that serves. And so this is incredible day of recognition for our veterans and their families.
Dr. Pat Basu: Well, I appreciate you sharing both of those points, David. I served in the Obama White House with a military colonel who was very active in the veteran community, and he shared something very similar to what you said was that after World War II, seemingly, the population that had served was much higher. And there was a lot of relationships, cross- linkage between those who had served and those who had not having relationships with other veterans. There's some statistic, and I don't want to misquote it, but it's a very small percentage now of American citizens who actually know a veteran or have a family member that's been a veteran. And so that's something that we need to really work on because I agree, these are incredible men and women who have given so much of a sacrifice, and you hit the nail on the head, sacrifice from their family lives, sacrifice for the country. I've had the privilege of serving as a physician at the VA system in California and in Illinois. And the same way I feel about cancer patients, they're just amazing. They say thank you. And they're very grateful for us caring for them, although I want to say now you have to thank you back to you. They're just incredible men and women. And I really share that sentiment that I wish everybody could know and interact more with our amazing veterans.
Dr. David Shulkin: Absolutely.
Dr. Pat Basu: Well, you've had a very multi- disciplinary career, as I mentioned, in your introduction. You've led a variety of complex arenas from large academic medical centers, Beth Israel in New York, UPenn and Temple, all the way to the VA system, which is, correct me if I'm wrong, but I believe, probably the largest healthcare system by many measures. You're a physician, a board certified internist. So you've done a lot in public service and medicine. But let's just rewind for our audience. Tell us how you first got into medicine.
Dr. David Shulkin: Well, actually, I wanted to be a fireman, not a doctor. I loved rushing to emergencies and helping people. As soon as I turned 16, I joined the local volunteer fire department. And whenever that fire bell went off, I went running to try to go help people. And in medical school, I always wanted to be an emergency medicine physician. Again, responding to those types of emergencies. I ended up going into internal medicine in large part because of doing what's called the couples match with my classmate, who I met in medical school, who's now my wife of over 30 years, where a computer told us where we'd be going. And so I didn't get to be that emergency physician. But later as I finished my residency and I got into administrative medicine, I was always attracted to situations that really required prompt administrative interventions, situations that had burning platforms that needed to be changed and fixed. And that ultimately was one of the attractions of the VA to me because it was a system of crisis when I entered the VA.
Dr. Pat Basu: Well, that's a great story. Glad to hear that you and your wife go on 30 years strong. I remember when I first started med school, our dean looked out in the audience and said... We had a class of about 90 people and said that there would be at least three couples that come out of the class. And he turned out to be right. So I'm glad to hear that. In many ways, given your career, you've been putting out figurative fires probably as a leader throughout your career. And we'll talk a bit more about that.
Dr. David Shulkin: And Pat, let me just add that nothing ever happens purely by chance. You have to know yourself as a person. I knew that once I went to medical school, I'd be spending way too much time with my books. So I better give myself the best odds. So although I was fortunate to have gotten into a number of different medical schools, I ended up choosing to go to the Woman's Medical College of Pennsylvania. Now, it's called Drexel University because the class was 60% women. And I figured I'd have a better chance of meeting somebody. So that plan fortunately worked out. 30 something years later, I'm happy to say that was a good choice.
Dr. Pat Basu: David, you and I have known each other personally. And so I know a little bit of your story, although I did not know the Drexel Woman's College part of it. I do know that both of your grandfathers fought in World War I, and you have a rich personal history rooted in serving the US. In many ways, you've always had this thread of public service, of dedication to the country in parallel or maybe in some ways even before your pursuit of medicine. Tell us a bit of how you ended up at the VA.
Dr. David Shulkin: Yeah. Well, first of all, let me just reinforce that we're all products of where we came from. And I grew up in patriotism and respect for your country and giving back was always part of it. My paternal grandfather, actually, when he first came to this country, opened up his own pharmacy. And he was a terrible businessman because he kept on giving away all the medicine to the people who couldn't afford to pay for it and ultimately went out of business. And early on, became the very first pharmacist at the Madison, Wisconsin VA. And so he worked at the veterans administration his entire professional career mostly. And so I would hear stories from him about how much he loved taking care of his fellow veterans. My dad was a psychiatrist and I was actually born on an army base in Highland Park, Illinois, not too far from where you live, Pat. And so being part of the veteran community was always a big deal for me. But I never got a chance to serve myself. I just missed the Vietnam draft. And I was in medical school in my 20s and training. And so never had a chance to serve. Ultimately, much later in my career after I had become a chief executive officer of several hospitals, I had an opportunity to have lunch with somebody who I didn't know at the time. He invited me to lunch. And at the end of the launch, he asked me, he said, " David, you've had a really great career. Do you have any regrets?" And I said, " Maybe the only regret is that I never really got a chance to directly give back to my country and to serve. I'm reading in the newspaper about all this horrible wait times going on for our veterans in this wait time crisis that had led to the resignation of the current secretary. I just wish there was something I could do to help." About an hour later, my phone rang, my cell phone, and I picked it up and they said, " Is this Dr. Shulkin?" And I said, " Yeah, it is." And they said, " This is the White House." And I thought, of course, somebody was pranking me. But in fact, it was the White House. And they asked whether I could come and meet with them that day to talk to them about whether I might help take over and fix the VA healthcare system, which of course I ended up saying, " Absolutely, if there was something I could do to help and to give back." I felt like I had developed some skills that might be helpful. It was an easy answer for me, Pat.
Dr. Pat Basu: Well, fantastic. I'm sure it was knowing you and knowing your patriotism. I do know what it's like to get a somewhat of surprise phone call from the White House. And as you know, I had a chance to work at the White House in 2010. You did some really remarkable things, were a tremendous leader during that time. Take us back to that era. What were some of the big accomplishments and objectives that you were looking to achieve at the US Department of Veterans Affairs while you were there?
Dr. David Shulkin: I believed that this was a system that was worth saving. And I believe that it's part of our responsibility as a country that when you send men and women, your sons and daughters, essentially, off to conflict, that you do have a responsibility to make sure that they're okay and the care for them if they need the help when they come back. So that was the basic belief system that I had, which is that this was a system that was experiencing problems when I got there. It was my job to help make it better and leave it in a better place when ultimately I would leave the organization. And just to give people a sense of the timing, this wait time crisis that I talked about happened in April 2014. That's when it became public leading to the resignation of the secretary and the undersecretary and many other people, including criminal charges that were being pursued against people in the VA because of this wait time issue. By the time that I got to Washington, it was not until July of 2015. So that was approximately 15 months after the wait time crisis. And that had to do with the entire process of vetting a candidate that would have to go through confirmation by the US Senate and appointed by the president. So that was a long period of time. Of course, President Obama was the commander in chief and president at the time. But when I finally arrived in Washington 15 months later, the wait time crisis hadn't been fixed. In fact, it wasn't clear to me that there had been much progress at all. So I had a burning platform. I had a real clear purpose that I really didn't focus on anything other than making sure that our veterans were seen when they needed to be seen, and that they weren't waiting and being harmed because of that wait. And so I ultimately made the commitment to President Obama that I would fix this. And I was able to tell him by December of 2016 that every VA medical center across the country was seeing patients on a same day basis. So any veteran who came and had a urgent medical problem, whether it was a physical problem or a emotional problem, a behavioral healthcare issue, would be seen on that same day. And that was the way that I was able to assure that we finally got the wait time crisis fixed. The way that I went about doing that was through a number of different things. First is that I made sure that this was the priority of the organization. I held what was called a national stand down, which is a military term that you stop doing everything else, but focus on something that's really a critical mission. And so we got rid of the wait time, which was up to 550,000 veterans waiting more than 30 days for care. We got rid of that wait time pretty quickly. And then we dramatically expanded our use of telehealth to be able to take care of veterans in parts of the country that we didn't have healthcare professionals in enough supply. We then gave advanced practice nurses and pharmacists independent practice authority so they could practice at the top of their license. And that expanded our capabilities. We hired a whole bunch of new providers to be able to fill in the vacancies that were there. And we posted our wait times publicly on our website so that everybody could see whether we're making progress or if we had problems in certain areas. So when you put all those factors together, the response of the people who worked in the VA was phenomenal. And we were able to get the VA wait crisis over. In fact, now, the VA has better wait times than you would find in the private sector. And still to this day, the only healthcare system that posts publicly its wait times.
Dr. Pat Basu: Well, that's amazing. What a terrific, frankly portrait in leadership and instead of accomplishments on a critical objective. There are many parallels, and you and I have talked about them, in veterans care and cancer care. One of them is the failure of execution despite a good mission or strategy. I think most people when they look at veterans and look at cancer care, 99% of people say, " Yes, that's a population that really needs our help and needs our attention." Translating that into execution though is a very different story. And look, across American healthcare, the access and the wait times are simply too long in so many other areas. But for veterans, prior to your arrival and certainly for cancer patients now, it's an issue. Just drawing a little bit on that thread of leadership during crisis, so you arrive there, burning platform, folks have been fired, criminal charges being brought, just that number is staggering. The number of veterans waiting for... I believe you said over 500, 000 waiting more than 30 days. Really, some principles of leadership during crisis. You went through an execution plan of standing down so the focus could be brought on to this and some very tactical things that you did. But just generally speaking, what are some of the things you've learned or attributes about leading during crisis from your prior experience?
Dr. David Shulkin: Well, I think the first job of any leader is to tell the organization what the reality of the situation is. And so you don't hide bad news, but you come out with a accurate assessment. And the leader is really the only one that's empowered to give that true picture. Then you have to set a priority, and you have to offer a plan and a vision for moving forward. And as you said, that has to be a very specific operational plan. So everybody in the organization understands what their role and responsibility in addressing that priority is. The leader then has to be consistent in messaging because too often the message changes and shifts and that confuses the organization, so remaining focused on those priorities. And then of course, finding the right team. And often leaders take too long to get rid of people on the team that aren't contributing or committed to accomplishing the task or capable of accomplishing the task. And leaders then have to, once they get the right team, empower that team and support the team to be able to go out and to get this done. Now, the VA, many people may not realize, is a very large organization. It's$ 210 billion a year in budget. The second largest federal agency. It has 425, 000 employees all across the United States and in fact the world. So you need a team to do this. No one individual could possibly get that type of consistency of messaging and the consistency of an operational plan. I think those are the key objectives. I think once a leader sets a plan in place that's clear with messaging, provides the tools, the resources, and the people to get it done, then you have to be able to be accountable for the results and make course adjustments. And that's why I felt it was so important to publish publicly our results in wait times. I did the same thing with opioid use, another problem in the VA. We published all of our medical centers and the percent of opioids that they were prescribing for their patients. We did the same thing with our disciplinary actions. We published how we were holding our own employees being accountable. And so I think that that's an important part of addressing a crisis as well, being transparent.
Dr. Pat Basu: Well, those are terrific. And so much of what you said, again, just applies to American healthcare in general. In many ways, what you did is a microcosm or maybe a tip of the spear of some of the things going on in American healthcare. And your attributes that you spoke about in leadership, I think, during crisis are so germane today as the nation and the world struggles during this, in many ways, unprecedented time with respect to the global pandemic and all the second order effects affecting healthcare, affecting the economy, and so many things. So I think some tremendous attributes there. Another aspect that we're certainly dealing with I know is we're just coming out of an election, recent election here. And it's a time when the country has a lot of strife and divisiveness and partisan politics, but you hold a couple of very, I think, incredible distinctions. You were confirmed by the US Senate, first of all, 100 to 0, which is remarkable, in general. You don't see that normally, and you certainly see that less and less than in these times. And then you served both President Obama and President Trump. Take us back to the transition. You were serving the VA, you'd done some of these things that you've talked about, and then you got a call from President Trump to serve. Take us through that.
Dr. David Shulkin: For me, I was there in public service. I didn't come to run for office. I didn't want to get elected to office. And so keeping the politics out of what I was doing was very important. And traditionally, veterans' issues, military issues, frankly, I think healthcare should be the same, should not be a political issue. And in fact, it traditionally had not been. People who worked with me, like many of the senators that I work with the entire time I was in Washington and I worked closely with, said to me when I left, " Thank you. We enjoyed working with you. I have to say I couldn't tell you today if you were a Democrat or Republican." And I said, " Senator, perfect. That's exactly the way it should be because that has nothing to do when people serve our country, our veterans, they're both Democrats and Republicans. They're all Americans." And that's the way that I always wanted to run the VA. In terms of how I got to be the secretary, yes, I was appointed under President Obama. I was a presidential appointee. Like every political appointee, when the new election happened and the inauguration was going to occur on January 20th of 2017, I had turned in my resignation as every political presidential appointee does. My boxes were packed. I was leaving Washington to go back to the private sector. And in mid January, I got a call that the president elect wanted to see me in Trump Towers in New York. And I thought, " Boy, what a great opportunity to essentially have an exit interview, where I could share with the president what we had accomplished, the tremendous progress that we had, and give my recommendation for what a new administration should hopefully continue and what opportunities they had, in my opinion, to even make greater strides for our veterans." I left and I felt good. I had a good exit interview. A couple of days later, I happened to be watching TV when the president elect was doing a press conference. And he announced that I was his new secretary.
Dr. Pat Basu: Well, I love your attitude, I love your sense of accountability, your devotion to a higher purpose. And so as we just look back at your story, this all- American guy wants to grow up to be a firefighter, his grandfather served in World War I, higher sense of purpose and devotion and dedication to this great nation, which I know you and I share. And so you have these experiences. You make a tremendous difference on serving the veterans of our nation. At the same time, I know as President Obama once said to me and some others, " No matter how much you've done, there's always more to do." And so obviously there was some things that were left unfinished that we'll get to in a moment here. But you came out and you wrote this book that I think has an incredible title, It Really Shouldn't Be This Hard to Serve Your Country. I know many of us feel that way. Tell us a bit about what you were trying to achieve with that book and what the spirit of that book is.
Dr. David Shulkin: The strange thing about when you serve in government, before I came home that evening, I was the head of an agency of 425, 000 people responsible for caring for 20 million American veterans. And following a short tweet later, I was no longer in that role and had no ability to share what I was trying to accomplish, where I felt I was making progress, where I felt that there was a barrier. I had no way to give my advice to a new person that would eventually have to get confirmed by the US Senate to lead the agency. And so you take all of this knowledge and all this experience and passion for helping improve veterans' lives and there's nowhere to go with it. You're just simply irrelevant after that point in time. So I really felt an obligation to put down on paper what my plan was, what was working, what my advice is, and recommendations to keep this system healthy and what needs to happen in the future. And I believe, like most executives, that when you're trying to change an organization as big as the VA and as bureaucratic as a big government organization, it's going to take years to happen and that we better have some consistency in that plan and a consistency in leadership. So this was very much written for future leaders of the VA. I feel that it was really my best advice to people as to how we could continue to make the progress that I think we were seeing in the VA. But the title of the book, It Shouldn't Be This Hard to Serve Your Country, really has two meanings. One is it's also written for veterans to honor them and their families like we will on Veterans Day, but to talk about why this was so important, why it's important that we have a government agency that does this, why we just don't send all of our veterans out to the private sector and let the private sector, which takes care of the rest of us in a pretty good way, why they really need this and why this is a responsibility that we have as citizens to support the Department of Veteran Affairs. So it's about veterans. But it's also about my personal story and what I went through, my family went through to be able to serve the country. And certainly, I don't want anybody feeling sorry for me. When I see the men and women who have truly sacrificed, including people who've given their lives serving our country, my sacrifice is nothing compared to theirs. But this was a very personal and difficult environment to serve in. My family and I went through a lot. I tell that story about the subversiveness, the division, the political gamesmanship that you have to go through to run an agency like this. And frankly, it shouldn't be that way. We need the very best and brightest like you, Pat, to raise their hand and to go to Washington and being willing to serve, to make our country work. And if it's just filled with this type of partisan politics, a lot of people are going to say, " You know what? I'd like to go, but I'm not going to put myself and my family through that." And I had a lot of people advise me, " Don't do it. You're going to ruin your reputation. You're going to end up getting involved in stuff that, frankly, why not just stay as a hospital CEO where you're doing fine and making a lot of money." And I said, " No, look, that's not what matters to me. What matters to me is making a difference." So I hope that this book encourages people to go into public service, but do it with their eyes wide open. I hope that this book helps veterans get better care. And I hope that the average American reads it, understands why it's so important that we have a strong functioning VA if we want this country to continue to have a military that's going to be something we're proud of.
Dr. Pat Basu: Speaking of this, we had Greg Simon, who I believe you know on the show previously. He shared some of his thoughts from leading that Cancer Moonshot previously. Obviously, there's a lot on the minds of Americans, there's a lot of the minds of all of us here during this period. Certainly, our cancer patients want to know what they might expect. What are some thoughts you have about what a future administration might do with respect to cancer care?
Dr. David Shulkin: Well, I'm so glad you had Greg on the show, Pat. He's an example of what the country needs. You take counted people from the private sector who have a real passion for seeing improvements and changes, and you bring them in the government and you watch what changes can happen. And I had the privilege of working on the Cancer Moonshot in 2016 as part of the Obama administration, my role at the VA, of course. And Greg was a high energy guy. Of course, he's a cancer survivor himself. And he really wanted to implement both President Obama and Vice President Biden's vision to find a cure for cancer, but to make cancer care better for all Americans. I remember one meeting I came into, the Cancer Moonshot, in the vice president's office, and Greg comes running in, and he was wearing a tuxedo suit top and blue jeans for his pants. I said, " Greg, that's an interesting combination that you're wearing." He looked at himself and this was clearly the first time that he realized that he wasn't wearing matching clothes. And he said, " I got home so late last night that I went right to sleep. And in the morning, I just grabbed my clothes and I ran back to the office." I thought, " You know what? That makes a lot of sense to me, a guy who's trying to cure cancer and running as if he was running towards the end of the finish line in a sprint." Who's got time to worry about if their clothes match? He's got something more important to take care of. And that just gives you an idea of how hard these guys were working. But for me being part of the Cancer Moonshot really showed how, if the leadership, and in this case, it was Vice President Biden was saying, " Look, we are going to do something big here. We're going to focus on something. And I don't want to have any of these institutional silos." In other words, the Department of Defense, the Department of Veteran Affairs, NIH, the FDA, the National Cancer Institute, everybody had cancer initiatives. But we didn't ever talk about them. We didn't share data, we didn't share best practices. We were doing them in our independent silos. And the Moonshot was about breaking down those silos and working towards a common good. I saw more happen in a short period of time and more progress we made even within the Department of Veteran Affairs by breaking those walls down across government that it truly impressed me that significant goals can be accomplished if we just put our minds to it and put the politics aside.
Dr. Pat Basu: Couldn't agree with you more. I know that I am and so many of our listeners are looking forward to that happening, generally speaking. And in particular with respect to cancer care, with respect to veteran care, that we can really take some leap forwards in the years ahead. We've touched on this theme throughout the show here. And as we begin to conclude some of the similarities, some of the intersections between veterans care and cancer care, sadly, many veterans suffer from this highly prevalent and horrible disease known as cancer. But as you look forward, what are some of the top priorities that you see that we need to address with both respect to cancer care, veterans care, maybe the intersection of both, what would you say are some of the top areas of focus?
Dr. David Shulkin: My goal for all veterans in this country is that they should have access to the very best healthcare that this country can offer. And all along, I've been clear that the VA can't do this alone, that they have to be willing to develop a system, where if you put the veteran in the center. And that's all that matters, getting the veteran the best care. That means that they should have access to the private sector if the private sector is providing that care better. If there are clinical trials, if there are advances in cancer care that the VA doesn't yet have access to, the veteran should clearly get access to them in the private sector. But if there are centers of excellence and that best care can be provided in the VA healthcare system, the veteran deserves that as well. And so, for example, there are cancers that happen with certain toxic exposures that the VA knows a lot about because they are exposures that happen when our veterans were in those situations, like Asian Orange and currently with our burn pits, where there's cancers associated with these toxic exposures, and the VA has terrific ability and more experience in that than many places in the private sector. But they certainly don't have all the expertise in cancer. And so we should be creating a hybrid system that allows veterans to be able to seamlessly go between the private sector in the VA when they need that type of care that's possible. And I've been pretty public about that type of model. I published this model in The New England Journal of Medicine. I've talked about the need for VA to have to be subject to the competition that we see in the private sector, where good quality should be rewarded and bad quality should be punished. And I believe that that's the case for VA, which is why I published all the quality data when I was secretary so that people could see not how VAs compared to other VAs, but how VAs compared to local and regional and national hospitals in the private sector, because that's really the standard. So my vision is offering everything that the very best of this country can offer to our veterans. And that means working with places like CTCA and working with academic centers and working with regional community hospitals as well as strengthening the core programs that VA can do best.
Dr. Pat Basu: Well, that makes a ton of sense on so many levels. And I think some of those best principles, setting a high standard, not just a relative standard of how you compare against your internal system or your neighbor, but really what does the standard need to be? I think this notion of public- private partnership, the notion of putting the patient at the center is so applicable to veteran care as you and I have discussed it. So applicable to cancer care, where too often the patient is not put directly at the center. But the system really needs to put the patient in center and meet the patients where they are. It's one of many things that you and I talk about with respect to CTCA. And at the same time, really find that best hybrid between where the patient is located and where they need to get the best care. So we've talked before about a patient coming to CTCA for a complex surgery, or complex therapy, but getting their follow- up closer to home because that might just be down the street to them. And we are just better when we partner, we're better when we break the silos. I think that's true as a country. It's true as a health system. It's certainly true as a people. David, your comments today, I think, have that broad applicability to leadership, to country, to healthcare, to cancer care, certainly to veterans care. With that, I just, again, want to thank you. But anything that you want to leave the audience with, not just to veterans but to cancer fighters in the audience, any words of wisdom or advice that you might have?
Dr. David Shulkin: Well, I just want to share some optimism. 2020 has been a tough year in so many ways. I don't ever remember us dealing with so many crises at the same time. But I still maintain a strong belief that we can come together and we can solve the types of problems that the country has, where we have troubles when we're divided. And so what my hope is for not only the health part of our organizations and our healthcare system, but for the country as a whole, is that now that the election's over, we put aside our partisanship, we focus on some really tough problems. We see the problems for the reality that they are, but that we develop a national strategy and we stay consistent on message. And we put the resources in place to tackle this. This country has been through tough times before, and we'll have tough times ahead, but I'm confident that we can do this. And probably the most important part of leadership, I believe, is being principle- based and talking about what our principles are. Now, fortunately, we have a constitution that's filled with principals. But it's important that we make sure that we express what those principles are. And I know a principal that's important to you and why I respect your leadership so much, Pat, is that access to healthcare is really something that you believe in. And that's why you've taken CTCA and you've expanded the ability for more patients to be able to get access by entering insurance networks and providing that type of experience to as many peoples possibly you can have. And I think with our current pandemic still unfortunately with us, we have to make sure that all citizens have access to the type of care that they need, and that we as a country are doing everything we can to deal with this pandemic head- on. And so while it can appear at times bleak, I remain optimistic. I know that we can do this. I know that there is a path forward, and I look very much to participating in that. And for our veterans, again, on this Veterans Day, I just want to thank them for their service. Whenever there is a national emergency... And I remember traveling around the country with the president and the vice president after hurricanes, natural disasters, I get off Air Force One and I'd see people on the side of the road, setting up food stands and handing out hamburgers and handing out towels and things to help people. And almost inevitably, I'd go over and introduce myself. And they would tell me they're veterans, because veterans still volunteer in their communities more than most people. They still are looking for ways to give back. Again, on this Veterans Day, I know that they'll continue to be part of the solution and thank them again and their families. And thank you, Pat, for this opportunity today.
Dr. Pat Basu: Well, thank you. What a terrific way to end. I share your sentiment, to end where we began. Veterans, incredible sacrifices that have made them incredible people who are always willing to pitch in. I share your absolute heartfelt wish of a happy Veterans Day. Definitely share your sentiment that access is everything, what good is a great healthcare system or any system for that matter if people can access it. And then finally, I share your optimism. This is a country. We're people who have navigated through crisis before, who have risen through adversity, who have picked ourselves up from the bootstraps and gone on to great futures. I share your optimism for the year ahead. I can't thank you enough for taking the time, David. Thank you so much for your leadership, for sharing your thoughts with us today. Have a wonderful, wonderful day. Thanks again.
Dr. David Shulkin: Thank you.