Michael Fischer, MD, is the medical director at the Alaska Family Wellness Center in Anchorage. In his capacity as medical director, Fischer sees patients, supervises the clinical staff, and coordinates patient education. On the Alaska Family Wellness Center web site is the statement: "Our goal is to help our patients maximize their personal and life resources to move towards greater health and vitality." In this interview, Fischer expounds on how he strives to meet that goal while running a small business, talks about how electronic health records have changed the practice, and shares his thoughts about what policy makers should know to better meet the needs of practitioners. In the interest of full disclosure, Dr. Fischer is my own primary care physician. Part of the this interview was conducted in person and part by email exchange in mid-October. It was edited for length and clarity.Links to selected topics listBuilding bridges between conventional and alternative medicine AHPR: Please tell the Alaska Health Policy Review readers a little bit of your background. For instance: When did you begin practicing in Alaska? Did you practice anywhere prior to coming to Alaska? What path did your career take? Where are you now in terms of your career? What career changes do you anticipate in the next five to ten years?Fischer: I moved to Alaska in 1991 after completing my family practice residency at the University of Utah. I began work in Kotzebue working for the Maniilaq Association where I stayed for a year and moved to Fairbanks for a few years and finally settled in Anchorage in 1995. My undergraduate degree was in psychology and I worked in the mental health professions for about 10 year prior to starting medical school, which was the perfect background for primary care that I do now.
I have always had an interest in looking deeper for the cause behind the manifestation and found myself often in the role of "bridge builder," in this case between conventional and alternative medicine. This approach is now known as Integrative Medicine, trying to provide the best of all possible options for promoting health and wellness for my patients, not just managing symptoms.
Conventional primary care is a demanding task, maintaining knowledge in alternative/natural medicine is a demanding undertaking, combining the two into a coherent whole can be rigorously demanding. I plan to deepen that integration process in my practice and life over the next 5 to 10 years.
"I decided on medicine as a career as I recognize I have the drive to be a "helper" and really enjoy science and its practical application."
AHPR: Why did you want to become a physician? Would you make the same choice today? Is there any advice you would give to someone today who is just beginning a medical career?Fischer: When I was in the mental health positions I found myself confronted by situations that were extremely distressing and sometimes didn't seem to have solutions. As is often the case in mental health I experienced "burn out" and looked around to find a more satisfying life path. I decided on medicine as a career as I recognize I have the drive to be a "helper" and really enjoy science and its practical application. In primary care I knew I would be able to combine several areas of interest and focus into one career.
It is said in medical school that there are two types of medical students, precynical and cynical. I have found that is somewhat true in medicine in general, although I don't think it has to be that way. I think if a person has and can maintain that striving towards idealism it makes for a kinder, more effective clinician. How one practices - setting, schedule, hours, support all play a role in avoiding cynicism and physical burnout.
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Medical system oriented toward paying for procedures rather than intellectual processing AHPR: Health insurance concerns. Electronic health records. HIPPA. A presidential election that will result in either a continuation of the Affordable Care Act or its possible undoing. The cost of medical care. And more. It is a confusing time for patients and I suspect it is for health care providers as well. What worries you? What keeps you up at night? Fischer: It is obvious that health care costs are out of control and there is a mixed motivation among physicians to change it. There are many well-known contributors to this including the steady advance of technology and pharmaceutical progress that are drivers. Ones that are only occasionally discussed include the power of medical liability concerns. That pushes providers into doing more and more to avoid any possibility of missing a diagnosis and to document, document, document one's evaluation while doing it as quickly as possible. Thus, physicians order tests knowing the likelihood of a finding is small but covering their exposures.
It is also important to acknowledge that physicians feel the forces of the market and like others in our capitalist society are motivated to find ways to make more money, usually by finding ways to expand services provided, do a more sophisticated and more effective intervention, and so on. Dealing with medical problems is a high demand, high stress profession and physicians rightly feel they deserve compensation accordingly.
Our system has been oriented towards paying for procedures rather than intellectual processing so surgical specialists are well paid and primary care providers struggle to handle the large bulk of health problems but at much, much lower pay scale. I am worried that divergence will continue and worsen. Especially since many primary care providers have adopted the 12 minute appointment model and the pressure to see more and more patients will grow as doctors are more and more employees rather than their own bosses. This supports the symptom based treatment model and underlying causes are shunted to the side as they take too long to look at. That trend is likely to continue and worsen.
[Just yesterday, I learned] about a major cutback coming from Blue Cross for Alaska providers, including primary care doctors. I have an obvious bias as a primary care doc, but it seems that people who have racked up the high expenses are the sub-specialists. And so, the cost of providing a medical practice like this-- a little practice like this-- is expensive. So our overhead ultimately is much higher than the fellow who generates a higher income. It's a little bit like a middle class person paying high taxes and Gov. Romney paying 11 percent. You know? He can afford to pay a little more, middle class people can't.
So it's just a little bit galling to me, especially because I think primary care docs are the most cost-effective in terms of how they provide care. And I think what will happen is that doctors will leave preferred provider statuses and then patients will be caught in the middle of all this. And then there will be more and more patient unhappiness with insurance. And ultimately I believe we'll probably see a dual-tier system rather like Britain, so there will be some people who have insurance and other people, other doctors, will see patients for cash only and that's a likely evolution of what will be coming in our country here. And without all the overhead and hassles of insurance, the cost of medical practices would probably drop significantly.
There is so much hoop jumping that has to be done, not just in terms of governmental regulation, but also in terms of insurance regulation. It's just a daily event that we deal with insurance companies refusing this, or making this difficult, or pre-authorizing this. And all of those things take time. Someone has to deal with that, and it takes that much more time and effort.
AHPR: We talked a little bit about what worries you at night. What keeps you up at night out of excitement?Fischer: Well, I think that hand-in-hand with some of those changes, there likely is a change in the parameter in time, in terms of how medical care is done. Because of it's cost-effectiveness, there will be a shift towards primary care and hand-in-hand with that, a shift towards prevention. I personally believe that Integrative and so-called functional medicine are the most cost effective approaches of all, and that at least if our society maintains an open mindset we will eventually demonstrate how much more cost effective that is, and that model will be adopted. I think it's going to be a long time coming, but I think it's the reality. I think the way medicine is practiced now is a fossil. And eventually it's going to fall over the side and turn into fossilized bones.
AHPR: Do you feel prepared for changes in the way that health care is and may be delivered?Fischer: Like a lot of people, I am not sure if I really know all of what's happening [in health care]. I probably know as much as anybody and so I don't know that I'm really prepared, honestly.
Back to selected topics listPsychosocial issues are a major contributor to health problems but messy for doctors AHPR: What do you think patients want from their health care providers? Fischer: I think patients want someone who, first of all, is competent in terms of being able to help and sort through questions, but also someone who is compassionate. I think relationship is a cornerstone of medical care and another factor commonly ignored in many medical settings. [They want] a person who is able to help and find answers and also help them deal with the emotional aspects of what's going on. We know that psychosocial issues are a major contributor to health problems and they're kind of messy for a lot of doctors. You can't measure it, you can't put in a little five-minute package, doctors do tend to just give people prescriptions, "Here's some Valium, here's some Xanax" but those are not really solutions.
AHPR: What do you think interferes with that ideal of patient care?Fischer: I think that the model of practice in primary care, oriented towards 10-12-15- minute appointments absolutely undercuts that. For example, I've chosen not to do that. We see patients on a 30- or 60- minute visit, and even that seems like a short time sometimes. But it at least provides some opportunity to get started to work on some of those things. I do have concerns that the shift in medical care may make [appointment times] worse, so it's sort of a neck-and-neck race to see what's going to happen here.
"I think a lot of doctors are very frustrated, are very unhappy ... the more people who are able to kind of maintain their idealism and the goal of really providing true quality care, the better."
AHPR: What do you see that supports that ideal?Fischer: Well, I guess I would say in itself, idealism -- which is say, the notion that doctors who are doing medicine because they are really interested in patients or really care about what happens to them -- is part of what moves that forward. I think a lot of doctors are very frustrated, are very unhappy -- many people don't like doing medicine but they don't know what else to do -- and it shows in terms of how they give care. So, the more people who are able to kind of maintain their idealism and the goal of really providing true quality care, the better.
I think that there is part of that revolt that will be coming -- that may end up in that dual-tier system -- is likely connected to that. As doctors will say, "No, I don't want to do deal with this. No, I don't want to answer more questions for insurance companies. No, I don't want to do this. I'll simply spend more time with patients, charge less, and have a better relationship." And I think that may unfold in terms of helping relationships.
Back to selected topics listProvider/patient relationships are more significant than grocery/consumer relationships AHPR: You are both a physician and a small business owner. How do those two roles conflict? How do they support each other? How do you manage both roles? Fischer: Well, it's definitely a difficult dance in some ways, partly because physicians generally don't have much training or background in business so I think lots of doctors tend to make lots of business mistakes. And fortunately they tend to go and pick up the pieces or have someone who can help with that process. I've made lots of business mistakes. Fortunately we've lived to tell the story.
The climate of medical practice is so complex in terms of regulations, it's just a given that you have to have people to handle that stuff now. So that's difficult. The other difficult part is just the business of money itself, and you know, this is a capitalist society. That's kind of the basis of how things happen here. And I think there's kind of confusing messages that our society gives medicine about that kind of stuff, because everybody else gets to be sort of a capitalist and doctors can be, but then again this also is a relationship that has more significance than buying groceries at the grocery store.
I think all those make this very awkward and complicated. Certainly that conflict has come up when patients don't pay their bill and [we want] to continue to provide care to people. But I have bills to pay too. My staff needs to be paid. I've had patients accuse me of being greedy for money [as my] only motivation. And so, that's painful because I feel like I really make an effort to not be avaricious, you could say.
AHPR: How do you personally manage both roles?Fischer: Fortunately, I have an outstanding business manager now, and she really plays that role. I'm closely connected in that process from day-to-day, my wife, Marsha, and I basically co-manage the business with her, and that involves, pretty much weekly business meetings and daily discussions as issues arise. Fortunately she's a real take-charge person who is extremely organized, which I'm not. So that's a major forte' on her part, is that she can really keep us focused on tasks.
It's amazing to think how this little practice has so many details to handle. So that's really how it works is to have a superior business manager. With regard to electronic health records and all of that: That process has been expensive for us to do that, but I think ultimately it has made things considerably more organized, and chart notes are much better and more accurate information, so, electronics, ultimately for all of its pain, has probably been pretty helpful to us.
Back to selected topics listElectronic health records afford benefits and challenges to providers and patients AHPR: You mentioned electronic health records. I am a patient here in this office. As a patient I increasingly see changes in your office in the use of technology. How has the use of technology changed in your office? Would you give a 15-second history of where you started and where you are now? Fischer: We started with classic paper records and had gigantic walls of records, and trying to keep that all organized was just a huge headache. All of these files were busy moving around the office all the time and sometimes they would disappear. Get stuck under somebody's desk or something like that and then oh, man, then you had a problem.
Our systems are now double, triple backed up, and so our records will not disappear if there's an earthquake, if a bomb falls -- you know, we can get the records and back in place again. So that's a major plus, because we obviously want to keep the information available. I think getting information in this electronic age is much more easy, so now lab information is downloaded directly into our system, and the world of FAX has made a big difference in terms of notes directly from docs, and communication by email with other docs or patients has really sped that up, too. So all of those things, ultimately, have helped the transmission of information. So, that's a plus.
I think the downside is that I'm spending time [makes typing noises], sitting and typing on a computer, instead of talking to people. Because you know, really getting back to the notion of relationship, you can sort of talk through a computer but really you want to talk to and with that person. I think that that's a significant interfering problem.
AHPR: What do you think about patients having easy access to their medical records? Fischer: Ultimately that will be the case for all patients -- just based on mandates that are coming from the federal government. Knowledge is power and obviously power can be used or misused. So assuming benign motivations, I think ultimately that's a good thing. And the other thing is that it keeps doctors on track about what they're saying, what they're doing, how they're communicating.
I think probably doctors are pretty attentive to what they put in notes anyways, just because it's the medical/legal era, and so [they are] being attentive about what they write. But you'd hope that patients would find the information, first of all accurate, and secondly, acceptable to them in terms of what is being put on paper about them.
" ... electronically, we are a lot more efficient so that now, three people can handle what used to be five, sometimes six people."
AHPR: You have made staff changes in order to keep up with technology demands. What kind of staff do you need now that you never had need for in the past?Fischer: Well, [in terms of staffing], ultimately we probably have less staff. At one point, we just had a large crew of people in the front room in terms of trying to keep up with stuff, and I think it reflects the fact that we're a lot more organized now. And electronically, we are a lot more efficient so that now, three people can handle what used to be five, sometimes six people. All billing is done electronically, and that has also saved gigantic headaches. We have a company outside that does that for us. They can connect directly to get that information and transmit it on to those who need to know.
I think that the skills of staff may have changed, in terms of the need to be highly fluent technologically. And a lot of conversations that used to be on pieces of paper and sort of passed back and forth, or in the hallway, are now done either by email or electronic communications via the medical record, so ultimately that's better, it just requires a lot of people doing [typing noises] this kind of stuff again. And that's sort of the mixed blessing of electronic records.
AHPR: You've mentioned some of your thoughts about how technology benefits and interferes with the relationship between health care providers and patients. Is there anything you want to add?Fischer: I guess the one comment I can make about how it interferes -- and I think this is especially an issue in hospitals for diagnostic procedures -- is that they're designed by engineers not by interior designers. They tend to be kind of cold, and sterile and unpleasant environments for people. And I think that has very significant emotional impact upon people. And negative health impacts, both in terms of stirring feelings that first of all aren't beneficial for people, but secondly also putting people off to avoid health issues in general. I think that there is a lack of awareness of how important that is. Hospitals don't have to look like boutiques necessarily, but I think that just really paying attention to gigantic noisy machines rumbling around warrants a lot more attention.
Back to selected topics list"Focus on quality" is the first and foremost principle AHPR: In my mind the issue that takes the forefront for patients is access to quality, affordable health care. You've talked a little bit about that. Do you think about quality, affordable care when you are making office policies? Fischer: I try to make that the first and foremost principle, which is to say a "focus on quality." I think that hand-in-hand with quality is the question of time spent and so, you know, that's a decision we made and probably has economic consequences to us in terms of not seeing as many patients. That's okay; we can live with that.
In terms of access to care, you know, we see Medicaid patients and we don't presently accept new Medicare, but we do continue to see patients if they become Medicare. That's kind of a compromise, just on the realities of what we can or can't afford to do as an office. There are a lot of people in need on Medicaid who get care here they couldn't get anywhere else, even though there are other offices in town that do care kind of like ours, they don't accept Medicaid. Those people come see us. So I think that improves accessibility of care for many people. I guess those are the big decisions we've made.
AHPR: Aside from electronic health records, are there any other changes or procedures that you are implementing in your office as a consequence of the Affordable Care Act or other mandates?
Fischer: At this point in time the MU [meaningful use], which basically has to do with the whole process of kind of meeting those standards kind of put together by CMS [Centers for Medicare and Medicaid Services] that are kind of developing over the next couple years and so that process is unfolding in terms of our electronic medical records, and I think that will continue to happen in terms of that process developing.
With regards to the Affordable Care Act, again it's a little overwhelming, in terms of knowing what all of these things mean. It's a giant document, and you hear a vast range of opinions about what's going to happen and not happen. It remains to be seen what happens in November in terms of which way Washington will shift and what effect that's going to have. I think it's going to be pivotal. It will be hugely impactful in terms of where things move from here. I recently read in my professional journals about that stuff and it seems like there is a lot of feeling that things are up in the air, and so I guess I'm waiting for guidance in some of those things.
AHPR: How do you keep up with changing health care findings?Fischer: Well, it involves pretty much continuously monitoring literature. And primary care -- the goods, the bads of that -- is that it's very interesting, and a good primary care doc knows lots about a lot of things, but there is simply no way to know everything. So, always, the orthopedist is going to know more orthopedic medicine, the psychiatrist knows more mental health, the gynecologist is going to know more female care, [and so on], so that can be frustrating. It just means there is also a vast knowledge base to embrace. On top of that, of course, I also do Integrative Medicine, and that's another vast knowledge base. I have interest in Chinese medicine. And so it just really requires some determination to stay with and continue to expand that knowledge base.
AHPR: How are you preparing for or responding to changes in how health care is delivered? For instance, there is the patient-centered medical home model, or the concierge or retainer model.Fischer: Well, those are topics of common discussion in many medical journals. Some are specifically oriented around some of those economic questions. There's probably a magazine you've heard of, it's called
Medical Economics. They have oriented towards a variety of specialties. There's one for primary care that I read, and I am sure there are others out there for the specialists as well.
They are really doing a good job educating and identifying those issues. And so, concierge model is probably, sort of a present status version of that parallel track we talked about earlier. I have a feeling that will change over time, as economics kind of modify that. But that's a common topic of discussion, again reflecting the sense of frustration many docs have.
Back to selected topics listChanging health policies require attention and appropriate action AHPR: Have you seen a change in the health of the general population over the years? Well, fortunately I haven't been a doctor quite that long, so I don't necessarily have that perspective of sixty years. In terms of health problems we have coming in the door, I think they're pretty similar. How we deal with them, I think, is a lot better. So in that way it's improved, and you know, I don't do hospital medicine anymore, but I really don't very often have patients who need to be hospitalized. And I believe it's because our interventions are more effective.
AHPR: Ideally, how much should health professionals know about the health policy environment and how to change policy? Well, you know that's a good question. Being in the health professions, as we've said, involves an immense amount of time and energy just sort of keeping up with the flow of information. And so, that's probably for most doctors their first and foremost task: to maintain knowledge and apply it for patients.
Health policy questions obviously have a huge impact upon how we practice, and I think some doctors have interest in that more than others. A good friend of mine is the state association president for the state medical association -- Dr. Tanner -- and he has a big interest in this, and so he spends lots of time and energy on that.
To me, it's a topic that's important, but I'll have to say that I really don't have that much knowledge about it. And [it's] probably not number one on my list of priorities. Especially now I guess doctors really need to know about it. How much, or how much time, is sort of the question.
AHPR: As a physician in a private practice, how do you keep up with all the changes in governmental health care policies and regulations? Do national and state policies sometimes conflict?Fischer: I think that has come quite a bit in the past. Probably less of an issue now because systems are more organized. My professional association, which is the
American Academy of Family Physicians, does a really good job of providing information to members about that, and so that's made a very big difference. There is MGMA,
Medical Group Management Association, and you know they really are involved in kind of the day-to-day issues regarding management and those kinds of topics. They've been very useful for keeping information up-to-date for us.
My business manager is a super organized person, and has plenty of experience in this area so she really comes in the door with some kind of knowledge around that area and that as well has made a big difference.
AHPR: I think you have already answered this question but just in case. How can you be sure you are doing what you should be doing to keep up with the changes?Fischer: That's a good question. Well, I try not to live a life of paranoia, but I'm pretty aware that there are a lot of bodies out there that are punitive by nature, I guess you could say. I try to be aware of them. There are some big players that we think of: CMS, OSHA, DEA, state medical board, those kind of groups are the heavy hitters and we just keep our eyes open and listen. So, I guess that's kind of the best way I can answer that question -- the best way we can try to do that -- is to watch what we're doing and be responsive accordingly.
" ... it is also frustrating to have to justify one's actions at every turn and be refused coverage for a treatment well known to be effective and cost effective by a bureaucrat who knows nothing about the patient or the circumstances and only had a policy in front of him or her."
AHPR: What shapes your own office policies and procedures most? Government regulations? Health insurance regulations? Advances in technology? Fischer: The drive to provide the best possible patient care. Government regulations have evolved in the face of problems with performance and are often irritating and overwhelming for physicians to respond to. I think they have ultimately improved the quality of health care to some extent, have promoted bureaucracy and wasted time in other aspects. Insurance company rules and regs are also a real problem and I often find myself fighting with insurance companies regarding covering treatments that have been place often for many years with great success but fall off the "preferred" treatment list due to a committee motivated to save money.
While that is understandable it is also frustrating to have to justify one's actions at every turn and be refused coverage for a treatment well known to be effective and cost effective by a bureaucrat who knows nothing about the patient or the circumstances and only had a policy in front of him or her. EMRs are the reality for documentation and ultimately provide better documentation but don't really save time. Advances in diagnostic technology have dramatically aided evaluations but at a very high price.
Back to selected topics listPrimary care providers have generally done a better job of maintaining idealism AHPR: What do you think policy makers of all kinds should know to better meet the needs of practitioners such as yourself?Fischer: It probably goes back to my thoughts about primary care what [I heard in medical school about there being] two kinds of medical students: pre-cynical and cynical. Unfortunately, I think that is a little bit true about medicine in general, but I think that primary care has in general done a better job of maintaining idealism. My bias is obvious.
But I believe things that support the structure of primary care, whether it be family practice, internal medicine, pediatrics, even gynecology -- things that support that structure ultimately support the care of people. And so I think more and more the focus that builds towards primary care based on reasonable relationships where the doctors aren't just rushing in the door, throw a script, and rushing out the door, is going to promote long-term health. And ultimately be vastly more cost-effective and money saving than many of the pie in the sky ideas that I hear touted.
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