By Kim Kowsky
Photography by Michal Czerwonka
Medical education in California was at a crossroads when Dr. Alan Fogelman became chair of the Department of Medicine nearly 20 years ago. His leadership has helped to transform the department and institute an era of renewed focus on primary care.
WITH HIS RECEDING HAIRLINE, warm, round face and thoughtful blue eyes, Alan Fogelman, M.D. ’66, bears some resemblance to his hero Winston Churchill, whose image peers from a pair of portraits that face Dr. Fogelman’s desk in an ornately decorated office replete with World War II memorabilia, sculpted frogs, antique clocks and custom, foot-tall chess pieces.
And indeed, Dr. Fogelman is a kindly man, as his features suggest. But he also is a determined man, with a measure of Churchill’s grit, who, when he became chair of the Department of Medicine in 1992, ushered through a remarkable transformation that had a profound effect on the way UCLA would approach the teaching and practice of primary-care medicine in the future.
The early ’90s was a tumultuous time to be taking over the department. California legislators, incited by the state’s shortage of primary-care doctors, were threatening to require University of California medical schools to train at least half of their graduates as general practitioners. This at a time when only two of the Department of Medicine’s 200 faculty members were themselves practicing primary-care medicine.
Rather than wait for a mandate from the state that would affect its curriculum, UCLA decided to meet the demand on its own. Dr. Fogelman spent the next several years working toward that goal – an enormous task with political and cultural hurdles for an academic institution that emphasized tertiary and quaternary care.
That he succeeded so well was a remarkable achievement, his admirers say, and in so doing, he not only reinvigorated primary care at UCLA, but also strengthened his department’s basic medical-research programs as well as its subspecialty training and practice.
“He is a medical visionary,” says Gerald S. Levey, M.D., dean emeritus of the David Geffen School of Medicine at UCLA and The Lincy Foundation Distinguished Service Chair. “He seems to have a special knack for knowing what to do and when to do it. When the history of this era is written, he will emerge as one of the most important chairpersons of a medical department, not only at UCLA, but across the nation.”
IT WASN'T A DIFFICULT STRETCH FOR DR. FOGELMAN to focus his efforts on rebranding UCLA as an essential training center for primary-care physicians. He completed his internship and residency in internal medicine at UCLA before undertaking a fellowship in cardiology.
“I really believe that the best care for an individual is care that is coordinated, and that if you have a good general internist or family physician who is well-trained and provides most of your care, you are better off,” Dr. Fogelman says.
To reach the goal of bolstering UCLA’s training of primary-care physicians, Dr. Fogelman needed to achieve two things: entice a new generation of medical students to become internists and create a community of general internists to train them.
“We found that one of the reasons our trainees didn’t go into general internal medicine was that they were trained in an environment of big clinics where many patients were underinsured,” Dr. Fogelman says. “That doesn’t make the patients any less important, but it makes it much more difficult to take care of them, because when they need something from a surgeon, for example, trying to get one to do something for them is much more difficult.”
One way to overcome the frustrations of “big clinic” medicine was to start training young physicians in smaller offices that included a healthy mix of managed-care patients with fee-for-service PPO, Medicare and Medicaid patients. For the managedcare patients, if a doctor requests a test and it meets UCLA’s guidelines, “it’s approved, because we’re paying ourselves,” Dr. Fogelman notes.
“We began to recruit faculty who worked in Westwood, and we also began to open practices in the community,” Dr. Fogelman says. “We would take over their leases and would pay them salaries and compensation that was probably better than they could do on their own. They had no risk, and they got to be members of the faculty.”
The plan presented some obstacles. These newly recruited physicians would be entering a university culture that requires its faculty not only to teach medical students, residents and fellows, but also to publish papers, compete for grants and serve on national committees.
It was a daunting set of expectations for busy primary-care physicians, says Tom Rosenthal, M.D., chief medical officer for UCLA Health System. “Dr. Fogelman first had to change the university’s promotion system itself. The success of getting the UCLA academic system to recognize the creative work of clinical physicians has been critical to the health system’s ability to carry out UCLA’s clinical mission over the past 15 years.”
Then, an online journal for the Department of Medicine, Proceedings of UCLA Health Care, gave primary-care physicians an outlet for their creativity, with short articles focused on case studies of common conditions that demonstrate a teaching point.
Such strategies worked. Over the next several years, the department recruited dozens of primary-care physicians in what spun off to become the Primary Care Network, with offices in Westwood and Santa Monica to support UCLA Health System’s newly acquired Santa Monica-UCLA Medical Center and Orthopaedic Hospital.
When that initial effort suffered a financial setback in 2003 and some of the community offices were closed, Dr. Fogelman responded by quietly rebuilding the department’s primary-care capacity – a project that coincided with construction of the new Ronald Reagan UCLA Medical Center. Because the new medical center would be smaller than the UCLA Medical Center it would replace, “The question was, who could move to Santa Monica?” Dr. Fogelman recalls. Tertiary and quaternary specialties were rooted in Westwood. “So it was decided a lot of internal medicine would move.”
Dr. Fogelman was able to build a new network of primary-care physicians by recruiting internists and secondary physicians such as cardiologists, gastroenterologists, infectious-disease specialists and pulmonary physicians to work together in small offices operating under the UCLA Department of Medicine shingle.
TODAY, THE DEPARTMENT OF MEDICINE employs about 100 primary-care internists on its faculty, many of who practice in one of the two-dozen offices that make up its Community Practice Network. Inspired by these physician-faculty members, about half of the department’s resident-graduates went into general internal medicine this past June.
It is not Dr. Fogelman’s Churchillian grit so much as the quality he shares with another notable strategist that has helped to move UCLA forward, suggests David T. Feinberg, M.D., M.B.A., president of UCLA Health System. “Alan Fogelman to me is more like Wayne Gretkzy then Winston Churchill,” Dr. Feinberg says. “Gretzkzy was known for skating to where the puck is going to be, not where it has been. Dr. Fogelman has that same sense about medicine. He knows before everyone else what changes are going to occur.”
Indeed, the network that he helped to establish also has proved to be good business for the Department of Medicine. Earnings from the community practices pay about half of the $400 million that the department will spend this year on expenses such as the salaries of its 550 faculty members and 1,500 staff employees, as well as supporting infrastructure for research and education. (Grants and contracts make up most of the rest; state sources only cover about 2.5 percent of the budget, Dr. Fogelman adds.)
And by helping to fund the department’s research and subspecialty training programs, Dr. Fogelman says, the network helped mitigate resistance to the changes it represented.
“Our faculty saw we were developing both primary care and the next generation of researchers,” Dr. Fogelman says. “So we weren’t abandoning the principles that the university is committed to in research and teaching. We were expanding that and also adding primary care at the same time.”
Kim Kowsky is a freelance writer in Los Angeles.