INTERVIEW: MMS President Irina deFischer, MD

Steve Osborn

Irina deFischer, MD, a family physician at Kaiser Permanente, becomes president of the Marin Medical Society in July. Born in San Francisco in 1955, she grew up in Marin County and attended Stanford University, where she received both a BS in biology and an AB in French, the language her parents spoke at home. She made use of her bilingualism by attending medical school in Switzerland, at the University of Lausanne.

After receiving her MD in 1981, Dr. deFischer returned to the United States to complete her internship and residency in family medicine at UCLA and the Antelope Valley Hospital in Lancaster. “I had been interested in family medicine every since I was in college,” she recalls. “I was really attracted to the breadth of the specialty and the opportunity to have continuity of care with patients across their lifespan.”

In 1985, Dr. deFischer moved back to Marin County, joining the Ross Valley Medical Clinic. One year later, she also became medical director in the residential treatment facility for adolescents at Sunny Hills, an agency for foster children. After the Ross Valley clinic closed in 1989, she was in private practice for a couple of years and then became medical director of the Villa Marin Retirement Center, a post she held until 1997. Thereafter, she worked as a pool physician for Kaiser Permanente, as medical director of the Pine Ridge Care Center, and as an associate physician at Tamalpais Family Practice. She became a full-time physician at Kaiser Petaluma in 2003, shortly after Kaiser San Rafael opened its family medicine section.

Dr. deFischer is married to Dr. Scott Sinnott, a critical care internist whom she has known since high school. They have two children: Jeanne-Marie, who is graduating from medical school in June, and Marc, who is working in real estate in Los Angeles. In addition to her work at Kaiser, Dr. deFischer regularly volunteers for the Rotacare Free Clinic and is also active at the St. Nicholas Orthodox Church in San Anselmo.

This interview was conducted at Dr. deFischer’s home in Greenbrae on April 19.

Q: In your view, what are the most pressing medical needs in Marin County?

A: One of the big issues is trying to provide care for the uninsured. We do have the community clinic safety net, but it is often difficult for patients to access because they can’t get appointments or they have to travel too far or they cannot afford the copays. That would be one issue. Another one is lifestyle--things like drinking. Marin residents are relatively healthy, but we drink more than other people in the state. It might be tied to the breast cancer epidemic. There is also the problem of underage drinking and drug use. Delinquency among young people affects their health and the health of the community.

Q: Do you see these problems in your own practice, among your patients?

A: I deal with the problems of the uninsured when I volunteer at the Rotacare Free Clinic. At Kaiser I do not see that many uninsured people, but I definitely see people who have illnesses that are the result of poor lifestyle choices.

Q: Can you talk a little bit more about the Rotacare Free Clinic?

A: We opened the clinic in 1997, and I was involved with recruiting volunteers to staff the clinic. It started out at the Ritter Center, which is a center in San Rafael for homeless people. We treated a much smaller number of clients back then. Several years ago we moved to Kaiser in downtown San Rafael, so now we have more space, and a lot more volunteers, and a variety of clinics that are offered. We have podiatry, dermatology, neurology, psychiatry and different specialty clinics that are held in conjunction with the Rotacare Clinic. We work with Marin Community Clinics for referring patients who need ongoing care, and we work with Operation Access for people who need surgery. Their volunteers offer free outpatient surgeries for the uninsured.

Q: How frequently do you volunteer at the Rotacare clinic?

A: I work there about once every one or two months in the evening.

Q: The idea is that anybody can show up, if they have no insurance? They can just present at the clinic and be taken care of?

A: Right. It’s just like a drop-in clinic for urgent care needs, whatever can be provided on an outpatient basis.

Q: How much has the clientele expanded since the clinic was founded?

A: Quite a lot. I don’t know the actual numbers, but we have thousands of visits a year. We’re open on Monday and Thursday evenings, and we usually have three physicians and a nurse practitioner working on any given evening. We also have volunteer pharmacists, nurses, interpreters and Rotarians who come help out. We provide free medications, and we have radiology and laboratory services available for the clients that are donated by local hospitals.

Q: As a geriatrician, what are the main challenges you see for older people?

A: One of the first issues that comes up for older people is their general loss of independence and not being able to drive. We do not have a very good public transportation system, and it is difficult for people to get around when they don’t drive. Also, getting help at home is expensive. The poorest people can qualify for in-home supportive services, but that is somewhat limited. A lot of the elderly population needs some sort of in-home care and cannot afford it. They do not really qualify for a skilled nursing facility or getting custodial care that would be covered by Medicaid. They’re in an in-between stage where they need assisted living.

Q: Do you think we are well-equipped to handle the increasing number of older patients?

A: We are going to need a lot more doctors, especially primary care doctors. We are definitely not training enough doctors in California or in the states to meet our needs.

Q: In addition to geriatrics, you also have a specialty in eating disorders. How did that come about?

A: I became interested in eating disorders shortly after I joined Kaiser and had a couple of patients with eating disorders. I started attending case conferences where we would discuss the patients, and after a while I was asked to be the point person for monitoring adult patients from a medical standpoint when they were being treated for eating disorders. I have been doing that for five or six years now.

Q: How common are eating disorders among your patients?

A: Patients who have really severe anorexia are relatively rare, the tip of the iceberg. There are many undiagnosed eating disorders among our patients,including bulimia or binge eating disorders, which can aggravate other medical conditions.

Q: In Marin County, many physicians are consolidating into large groups. What effect do you think this consolidation is having on medical care in Marin County?

A: Having these networks is good both for physicians and for patients because it increases the availability of care at different times for patients and offers physicians more predictable scheduling and opportunities to have time off. A lot of these groups use electronic medical records that are shared between the different members of the network, which is good for continuity of care. If a patient calls on the weekend and gets a different doctor who is not familiar with them, the doctor can access their records. The doctor would not have been able to do that in the past; they would just know whatever the patient told them about their problems.

Q: Do you think it’s a good thing that the physicians are consolidating into networks?

A: I think it is good. I think that we are able to provide quality care at a more affordable price.

Q: With the doctors in different groups, what is your sense of the impact on the collegiality among physicians in Marin County? Do you interact with physicians in the other medical groups?

A: I do. One of the things I like about the Marin Medical Society is that it allows me to interact with doctors in other practice modes. I have maintained my contacts and relationships with them over the years by being in the medical society.

When I was in private practice, I felt that I had good relationships with my colleagues. It is a little bit of a different dynamic. Often the primary care doctors will join together in call groups so they cover each other’s patients and so forth. And then there is the different dynamic in dealing between primary care and specialty when you are in private practice or someplace like Kaiser, which is an integrated group. In private practice there is a fee for service model, so you don’t get paid unless you see a patient. The specialists are usually kind of wooing the primary care doctors and wanting them to send patients. In a group like Kaiser, everybody is salaried, and the specialist is more likely to just give the primary care doctor advice on how to manage a patient over the phone instead of seeing the patient in person. The specialist is more likely to want to share their knowledge and skills with the primary care doctor to offload some of the work.

Q: Many health problems in American society can be traced to our culture, to fast food, and to poor urban design where people have no opportunity to walk. How involved do you think doctors should be in addressing these problems?

A: I think we need to be very much involved in that, and that is something that medical societies have traditionally done over the years. We have been involved in things like seatbelt and antismoking legislation, and a host of public health measures, such as trying to get sodas out of the schools.

One of the things I’m proud of in this area happened when I became medical director at Sunny Hills Children’s Garden. At that time, the kids were allowed to smoke. As rewards for good behavior, they would get cigarettes. I just really put my foot down and said I don’t think we should be allowing these kids to smoke here. So we got them all to quit smoking.

Q: What do you think doctors should be doing to address the obesity epidemic, outside of what they see in the office?

A: Increasing the availability of healthy foods for the population by supporting farmers markets, delivery of produce baskets at the workplace, and working with schools on having healthier lunch programs for the kids. Trying to work with city planners to have more pedestrian friendly areas and developments that include work and residential areas that are close together so people can walk back and forth. We also need healthy ways for kids to walk or bicycle to school.

Q: How well do you think the medical society is serving the physicians in Marin County?

A: The main thing we do is to advocate for physicians and patients at the local, state and national levels. We provide a venue and forum for physicians to get together and network; to socialize and get to know each other; and also to take their issues forward in the form of CMA policy and legislation.

Q: Do you have any specific projects in mind for when you are president?

A: I mostly want to be there to serve the members and carry out the wishes of the members. I would like to reach out to medical students and residents in surrounding communities to introduce them to our members and encourage them to think about coming to practice in Marin someday. Having medical students and residents involved increases the vitality of the organization.

Q: Where would the students and residents come from?

A: From UCSF and Touro medical schools, and the Santa Rosa Family Medicine Residency for starters.

Q: Do any Marin hospitals offer rotations for these students?

A: Some of them do. We have recently started a program at Kaiser where UCSF students are rotating through the medicine clinics in San Rafael and Petaluma. We have also had individual students from different schools who have done rotations privately in different offices. If they are exposed to the physician community here, I think that would help them build relationships with the physicians and encourage them to join to practice here later on.

Q: Are there any other things that you think the medical society should be doing in the larger medical community?

A: The medical society is a forum to exchange ideas, a resource for various practice needs, and a medium for sending representatives to CMA and AMA. The society has been a constant for me in my 27 years of practice. I have changed practice a number of times, but I have continued my involvement with MMS, and the staff has been really helpful to me over the years. I have enjoyed being able to keep in touch with all my colleagues in the different modes of practice, and I feel like we have more in common than we actually have differences. The medical society staff does a great job of keeping us all organized and on track.

Q: Do you have any closing thoughts?

A: Yes. I am trying to listen more closely to what my patients are saying and to acknowledge the relationship and that something important has happened between us in the visit. I appreciate the trust my patients place in me. I really appreciate getting to get to know so many different people and to be involved in their lives. It is a privilege and an honor.

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Mr. Osborn edits Marin Medicine.

Email: irina.defischer@kp.org