Tuesday, June 16, 2009

An Open Letter to President Obama

Dr. John Brady runs a successful micropractice in Newport News, VA, and was Virginia's 2008 Family Physician of the Year. He has written a letter to his state legislators and President Obama regarding the healthcare crisis that is so well written that I am reposting it here, with Dr. Brady's kind permission:


Dear President Obama,

I feel obligated to express my opinions on health care reform. I am a solo family physician working in Newport News, Virginia and am part of a nationwide collaborative of physicians dedicated to providing great care to their patients (

I am experienced working on the front lines of health care for the past 15 years, and I have dedicated my last six years to trying to understand how to provide superior care to my patients. I am independent, I have no axes to grind, and I represent no interests except those of my patients.

There is no question we need reform. The health care system is disintegrating daily and taking a lot of wonderful patients and doctors with it. Patients are literally dying from both not having access to good primary care and from the poor quality care they receive once they get through the door. Doctors are imprisoned by mounds of administrative minutia which strip away their freedom to practice medicine individualized to the patient’s wants and needs (patient-centered collaborative care) and serve as a wedge between them and their patient.

Study after study has shown that the stronger the relationship between a doctor and his patient, the greater the quality and the lower the costs, but our system is set up not to enhance but to destroy this cornerstone of medicine. Unless the reform ideas being proposed address this fundamental flaw in our system, they are doomed to increase healthcare costs while remaining unable to enhance quality. Indeed, it is the failure of the doctor-patient relationship over the past twenty years which has been the true reason behind the cost escalation and the quality chasm.

Doctors are paid for quantity. The faster we push our patients through, the more money we make. The problem is that the faster we push our patients through, the less we know each one and the less we know each one, the more we rely on testing and specialty referrals to augment our clinical judgment.

Over the past 20 years, reimbursement has not kept up with overhead costs and so doctors have had to see more and more patients a day. The number of tests being done has exploded with the resultant explosion of costs. Insurance companies, seeing this trend, have tried to put roadblocks up to halt testing and referrals, but all this does is increase the administrative costs of the office forcing the doctors to see even more patients per day.

Harried doctors become burned out and begin to lack empathy leading to worsening quality and increased liability. Medical students see the trend of increasing workload, flat salary, and miserable physicians and have begun to avoid choosing primary care as a life choice. All this is occurring at the exact time the population is aging, which puts the country on the precipice of a complete meltdown of the medical system.

Clearly, the toxic reimbursement system needs to be fundamentally changed such that policies are adopted which enhance the relationship between doctors and patients. A simple solution would be to offer doctors the ability to opt out of the current nightmare payment scheme into a new system where the physician gets a dollar a day for every patient who chooses him/her as their primary care doctor. That reimbursement is then adjusted up or down quarterly based on the patient’s experience of care. Questions surrounding access, efficiency (waiting time), continuity, information exchange, and coordination can all be easily attained through a simple survey like How’s Your Health (

By doing this, doctors will be encouraged to provide the best service to their patient, and the resulting happier, healthier patients will be much less likely to go to the ER or have to get admitted to the hospital. Doctors, vying for high satisfaction grades, will quickly adopt quality initiatives like secure e-mail, online appointments, etc. Primary Care salaries will become much closer to that of the specialists, but more importantly as the relationship with their patients strengthen, overall medical costs will decrease, physicians will have higher job satisfaction, and medical students will flock to primary care. Truly this becomes a win-win situation for everyone.

I know this solution does not involve covering the uninsured or forcing the implementation of new tools or cool (expensive) technology, but that is why it will work. Covering the masses is a laudable goal, but doing this prior to fixing primary care is the equivalent of giving everyone a car and not building any roads.

Turning to computers and electronic medical systems to try and make a medical office a “medical home” is similar to thinking that adding the internet or a flat screen TV to a house will make it a home. It is the relationships, not the furniture, which makes a house a home. Similarly, to encourage the development of medical homes, we have to start by encouraging the development of strong relationships and only then worry about where the furniture (computers, integrated systems, etc) should go.

I appreciate you taking the time to read this letter, and I hope it resonates with you. I fear the potential harm to my patients and my country if we decide to do what might be politically easy instead of what is right. I remain willing to discuss any part of this in more depth if you desire and I can forward many good studies supporting everything I have stated.

Providing high quality, cost effective care is possible in today’s environment—I do it every day. But, in order to encourage quality care to become mainstream, we have to change the way doctors are paid. If that cannot be accomplished, nothing else will matter.


John E. Brady, MD, FAAFP
The Village Doctor
2008 VAFP Virginia Family Physician of the Year