A career fighting infectious disease

Physician and Connecticut state epidemiologist James Hadler sees the public as his patient.

James L. Hadler, M.D., FW ’80, M.P.H. ’82, said that his relatives, many of whom are physicians, sometimes tease him for not working at the bedside. “They ask me, ‘When are you going to be a real doctor?’ ” But, he said laughingly, “The public is my patient.”

Hadler, who retired in June after almost 25 years as Connecticut’s state epidemiologist and chief of the state health department’s Section of Infectious Diseases, has steered the state through a plethora of public health crises, from AIDS to Lyme disease to anthrax. Although he started his career as a physician while working on the Navajo reservation for the Indian Health Service and the Centers for Disease Control (CDC), Hadler found he liked looking at health from the perspective of populations. The experience, he said, “sold me on a career in public health.”

He came to the state health department in 1984, just as the AIDS epidemic was picking up speed. For the first four or five years, “HIV became my life.” High-profile debates kept him in the public eye. For example, Connecticut had one of the first cases of a school-aged child with AIDS, and under national media attention, Hadler developed safety guidelines to allow the child to return to school.

The mid-1990s saw a dramatic shift in emphasis after the Institute of Medicine published a paper stating that the country was unprepared to combat emerging infectious diseases. In 1995, the Emerging Infections Program, affiliated with the CDC, was established in partnership with the state health department and the Yale School of Public Health. It was soon busy with outbreaks of Eastern equine encephalitis and West Nile virus and the re-emergence of the then rare tick-borne diseases babesiosis and ehrlichiosis.

After September 11, 2001, bioterrorism preparedness became a priority. Hadler was on the front lines during that year’s anthrax attacks (he still attends an annual symposium in honor of victim Ottilie Lundgren, a Connecticut resident and one of five people who died from exposure to anthrax), and later faced a crisis of conscience when he was instructed to prepare mass smallpox vaccinations prior to the invasion of Iraq, which he strongly opposed. Reasoning that to do so might embolden the Bush administration’s threat to invade, he considered resigning. In the end, he decided that to quit or go on strike would not stop the war, and chose to stay, “although uneasily.”

While in office, Hadler also oversaw an increase in childhood vaccinations against preventable diseases, the elimination of race-based disparities in childhood vaccination rates and the reduction of the rates of tuberculosis and several sexually transmitted diseases.

Hadler said that what has motivated him, in large part, is the combination of Connecticut’s small size and its great population diversity. Its problems come in manageable “little packets.” “New Haven has its down-and-out side, Hartford does, but … they’re all small compared to New York or Chicago,” he said. “To me, [Connecticut] is a perfect laboratory to try to take on the challenges of diversity and health disparities.”

adler grew up in Bethesda, Md., where his father worked as a naval architect and international consultant. The family hosted exchange students and had friends from other countries, and Hadler says those experiences—and his stint in Pakistan as an exchange student—gave him and his three siblings a global perspective.

He attended McGill University in Montreal, then went to Columbia University’s College of Physicians and Surgeons. After an internship at Roosevelt Hospital in Manhattan, Hadler joined the Indian Health Service in a position supported by the CDC as a tuberculosis control officer. He completed his residency at Waterbury Hospital in Connecticut, did an infectious diseases fellowship at Yale-New Haven Hospital and then earned an M.P.H. Finally, he and his wife and two children spent a year in China as part of a School of Medicine exchange with Hunan Medical College. He began as Connecticut’s state epidemiologist the following year.

The job, he said, has allowed him to combine diverse interests and to work with people from all walks of life. “Public health is dynamic,” he said. “I love that aspect of the job.”

Hadler lives in New Haven with his wife, Alice, who speaks several languages and whose experiences with adult education on the Navajo reservation with her husband grew into a teaching career; she is now an associate dean at Wesleyan. They have three grown children.

Hadler plans to work as a public health consultant to the state and to New York City. He will also write scientific papers, deliver talks and continue to teach at the School of Public Health.

—Jenny Blair

A primary care physician finds peace of mind in concierge medicine

On a typical day two years ago, Steven Fugaro, M.D. ’81, saw a patient in his solo primary care practice every 10 to 15 minutes. Onerous paperwork and economic difficulties made it hard for the San Francisco-based physician to provide the quality of care he felt his 3,000 patients deserved. “I was becoming increasingly dissatisfied with what I was doing,” he said, “although I was probably too busy to be reflective of it at that point.”

Then MD², a concierge medicine group, based in Bellevue, Wash., approached him. Would he like to join them as a concierge physician and gain the time and resources to provide extraordinary care for a small number of patients? His decision to do so changed his life and made him part of a controversial trend in primary care.

Fugaro had opened a private practice after an internal medicine residency at the University of California, San Francisco, and eight years in academic medicine. Although he loved primary care, physicians in that field are under tremendous pressure to see patients in great numbers—time is tight, reimbursement rates are stagnant and preventive care must take a back seat to immediate problems. Few medical students choose the field, and many weary primary care physicians are retiring early or taking jobs in industry or administration. These doctors are in short supply.

Enter concierge medicine. In this model, introduced in 1996 by MD² founder Howard Maron, M.D., patients pay a yearly fee ranging from $15,000 for an individual to $25,000 for a family of four. In return, physicians make themselves readily available, offering prompt appointments, house calls and other extras.

Critics of the practice, also known as “boutique medicine” or “retainer-based medicine,” call it unethical. The retainer is beyond the means of many people and because concierge physicians care for fewer patients than other primary care doctors, the practice increases colleagues’ burdens and may endanger access to care. But many concierge doctors say that they would have quit practicing altogether if not for this option. Fugaro agonized for months over his decision. “I was worried about what my colleagues would think. I was worried about … leaving patients. I wondered if I would be intellectually stimulated,” he said. “On the plus side [was] being able … to have basically unlimited time with [patients], to be able to care for them in a very holistic way and to have balance back in my life.” For Fugaro that meant more time for such pursuits as mountain biking and spending time with his wife of 22 years and their son, who studies theater at Northwestern University.

In 2007, Fugaro arranged for the patients in his primary care practice to be cared for by a successor, Allan Treadwell, M.D., relinquishing the practice free of charge. Then Fugaro joined MD².

He cares for just 50 families now, and on a typical day sees or speaks to six to 10 of his patients. The office does many of its own tests, with results available on the spot. He makes regular house calls. Many of his patients have complex medical conditions and he is better able to anticipate problems before they arise. “I was juggling so many things before,” Fugaro said, “it was clearly possible for something to fall through the cracks, and that’s far less likely now.” He also accompanies patients to specialty appointments and the ER, and enjoys learning from subspecialty colleagues at such times, “as opposed to just communicating through a consult letter.” For about 5 percent of his patients, the retainer fee is waived.

Fugaro is partnered with another physician; neither leaves town unless the other can stay. Though always “on call,” Fugaro said he has more time now for nonclinical professional pursuits. In 2007, he was elected president of the San Francisco Medical Society, where he pushes for such public health measures as restrictions on secondhand smoke, and partners with the California Medical Association to battle Medicaid cuts. He also has volunteered at a clinic in Mexico.

Fugaro says his colleagues’ reactions have been mostly positive. Indeed, several are opening retainer-based practices of their own, including Treadwell, the physician who took over his old practice. Fugaro acknowledged that access to primary care is a tremendous problem in American medicine. “We need to create a better model for primary care doctors to continue doing what they’re doing and be emotionally rewarded for it, as well as deriving reasonable economic compensation. And right now our system is broken in that regard.”

—Jenny Blair


			Originally published in Yale Medicine, Autumn 2008. Copyright © 2008 Yale University School of Medicine. All rights reserved.