Veteran’s Affairs Secretary David Shulkin’s tenure got off to a promising start, at least by Trump administration standards: a former hospital administrator and renowned academic, the Obama-era appointee was the only Cabinet nominee unanimously confirmed by the Senate. Yet in recent weeks, a scandal so severe has roiled Shulkin’s department that it’s drawn the attention of Donald Trump, who has reportedly come to view the V.A. head as a “major problem.” Engaged in an all-out cold war with senior staffers, Shulkin managed to avoid the axe following accusations that he misused taxpayer funds to bring his wife on a European vacation. A series of ill-conceived media contacts, however, may have damaged his relationship with the White House beyond repair, potentially leading to yet another high-profile ouster.

Shulkin has butted heads with Trump appointees at the V.A. from the outset, but the conflict came to a head after an inspector general’s report found “serious derelictions” in the way Shulkin’s office had handled a trip to Europe, among them allegedly doctoring e-mails to allow the V.A. head to justify bringing his wife along. The report brought Shulkin’s foes into the open, where they have demanded his firing; last month, The Washington Post reported that, in mid-February, one of Shulkin’s senior aides directly lobbied Republican staffers in Congress to demand the resignation of Shulkin and his deputy secretary, Thomas Bowman, an effort that they rebuffed. Shulkin then told Politico that he had the green light from the White House to crack down on “subversion,” adding that those who had defied him “won’t be working in my operation . . . those who crossed the line in the past are going to have to be accountable for those decisions,” he added.

Amid the atmosphere of suspicion, Shulkin has canceled morning meetings with senior Trump-appointed staffers, choosing instead to convene with aides whom he “trusts not to miscast his remarks,” the Post reported on Friday. An armed guard reportedly stands outside his office, in part due to the upheaval and in part as a response to threats Shulkin received after the I.G. report was made public.

But perhaps Shulkin’s most egregious move in the White House’s eyes has been his attempts to color himself in the media as acting with the administration’s blessing. Per Axios’s Jonathan Swan, back in February, Shulkin met with Chief of Staff John Kelly, who agreed to lend him a hand with staffing woes—not to authorize a so-called purge. Shulkin pulled a similar move last week, meeting with Kelly and subsequently calling up The New York Times to declare victory. “People need to get on board . . . or need to leave,” he told the paper. Both incidents “infuriated” White House staffers, and Kelly in particular, who apparently communicated to Shulkin at their most recent tête-à-tête that he’s “sick and tired of Shulkin freelancing and talking directly to the press. He wants Shulkin to just shut up and stop causing drama.”

At this point in Trump’s first term, it’s difficult to point to an agency that hasn’t fallen into dramatic, halting dysfunction. Rex Tillerson presides over a shrinking State Department, Ben Carson is wheedling his way through running Housing and Urban Development, and the heads of Health and Human Services, Interior, and the Environmental Protection Agency are all under scrutiny for their abuse of private air travel. But the V.A. battle hits close to home for Trump, who repeatedly promised to reform the agency by holding its employees accountable and revamping its approach to healthcare. Not only is Shulkin mired in a battle with his own staff, but he’s “extremely paranoid” at the prospect of another I.G. report expected to describe his “use of his security detail to run personal errands,” and an additional report last week found that on his watch, the V.A. medical center in Washington has “suffered a series of systemic and programmatic failures to consistently deliver timely and quality patient care.” (Shulkin said he did “not recall” the issue coming up when he was undersecretary of health.) “What gets lost with the palace intrigue is that reforms will stall,” Philip Carter, a senior fellow at the Center for a New American Security, told the Post. “It’s the president’s agenda that suffers with this kind of dysfunction.”