HL20: Sam Foote, MD—The Courage to Speak Up

Sam Foote, MD, found himself at the center of a national scandal in 2014 after he blew the whistle on scheduling delays and other irregularities at the Phoenix VA Health Care System, where he'd worked for more than 20 years. The internist's tip sparked months of investigations, which he says, uncovered a pattern of "cheating [at VA facilities] all over the country."

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. They are making a difference in healthcare. This is the story of Sam Foote, MD.

This profile was published in the December, 2014 issue of HealthLeaders magazine.

"I was just trying to get some issues fixed. Then it went viral. I just did not realize the extent of the cheating all over the country."

It would be an understatement to say that 2014 was an interesting year for Sam Foote, MD.

The unassuming 61-year-old internist and career physician with the Department of Veterans Affairs found himself at the center of a Category 5 national scandal this spring after he blew the whistle on scheduling delays and other irregularities at the Phoenix VA Health Care System, where he'd worked for more than 20 years.

"I was shocked," Foote recalls. "I was just trying to get some issues fixed. Then it went viral. I just did not realize the extent of the cheating all over the country."

Foote's tip proved to be the tip of the iceberg. Months of investigations and congressional hearings determined the irregularities in Phoenix were part of a systemic pattern at VA facilities across the country: Administrators, motivated by bonuses for meeting two-week waiting time targets, sought to paper over the actual delays experienced by veterans seeking medical care.

"I knew them saying they had the wait times down to two weeks was impossible from the experience I was seeing with the patients," Foote says. "It wasn't medically possible. We didn't have enough providers to get the numbers they were advertising."

In fact, Congressional investigators suggested that scores of veterans may have died while waiting for access to VA care.

"People were coming in saying 'I've been waiting 6, 9, 12, 14, 16 months for care,' " Foote says. "I had a heart patient waiting 14 months for an appointment who went to the ER with chest pains and had an EKG that said he'd had a prior heart attack. He was supposed to be given an appointment in three days. This was in January of 2013. His appointment was October of 2013."

For several weeks last spring the story dominated an insatiable news media. Ultimately, the revelations that began with Foote's whistleblowing forced VA Secretary Eric Shinseki to resign. President Obama and new VA Secretary Robert A. McDonald, the former CEO at Procter & Gamble, have vowed to fix the troubled system, but Foote says that won't be easy.

"In the short run they have no other choice but to go to the private sector, which is very expensive," he says. "There is a fundamental mismatch in the U.S. right now between primary care providers available for baby boomers. The VA has to compete with the private sector for a scarce resource, which is why I am not sure it is necessarily solvable."

Foote says the problems at the VA weren't created overnight but were the result of inaccurate demand projections over the decades. While those projections correctly anticipated the declining numbers of World War II veterans, they could not account for the War on Terror, the Great Recession, the open enrollment of the late 1900s and early 2000s, or the effects of the Affordable Care Act and the individual insurance mandate, all of which created thousands of new patients for the VA.

"Everything combined to put a huge demand on the VA, which was not in a place to handle it," Foote says.

For clinicians at the Phoenix VA, the cracks started showing at the bedside level about four years ago when their caseloads increased dramatically to meet unrealistic waiting time goals. As the caseloads grew, so did the exodus of clinicians, knowing their skills were in high demand elsewhere. The problem was thereby exacerbated for those who remained.

"In February 2011 we were seven providers down and 7,000 patients uncovered, and they didn't do anything about it," Foote says. "By December 2012 we were about 13,000 patients with over a one-year backlog in the computer, and some more that they never put in. Rather than try to address the issues, they tried to hide everything."

Foote's complaints went unheeded by his immediate supervisors, some of whom he alleges were involved in the cover-up. Foote filed a complaint with the VA Inspector General in April 2013, and he says the retaliation from supervisors at the hospital began that summer.  

"There is a huge culture of secrecy," Foote says. "It's like a fraternity or a secret order. You don't criticize it outside, and if you do you will be severely punished."

He expounds, "They were harassing me on leave issues along with everybody else. They were ramping our panel sizes up when people were pretty much working as hard as they could. For full-time primary care, the average caseload is 1,200 patients. They were jacking it up to 1,380. Nurse practitioners were supposed to be at 900, and they moved it to 990 and then 1,045. One of my nurse practitioners who collapsed under the strain mentally was pushed up to 1,300. They were working longer, and the VA wouldn't pay overtime or comp time. People were pushed to the max, and it drove away an incredible number of good providers."

Foote says he tries to stay clear of the inevitable partisan finger-pointing over the scandal. In his view, there is plenty of blame to go around.

"It's not a Democrat or a Republican issue. It's a national issue. The VA management is the problem," he says. "If you want to blame Bush for the war in Iraq, you can blame the Republicans. You can blame Obama for Obamacare. But these are not things that in and of themselves caused the problems. The main problem was they downsized. They got rid of facilities and people, and then they ended up with twice as many people as they were projecting to have when they downsized with a war on and the economy tanked. It was horrible planning on the VA's part, but they didn't know that at the time."

Retired now, Foote says he spends his free time trying to help veterans gain access to the healthcare they were promised by their country when they put on their uniforms. Even with all the personal upheaval and stress the scandal has caused him, Foote says he has no regrets about blowing the whistle.

"At the end of the day, I have to sleep at night," he says. "And if I'd let it go, I wasn't going to sleep."