Demographics, Clinical Practice Patterns, and Concerns of Physiatrists in the State of Hawai‘i: 2011

Abstract

Background

Although the State of Hawai‘i overall may have an adequate number of physiatrists, there are physiatrist shortages on the neighbor islands. This study describes the demographics, practice type, and most important concerns of current practicing physiatrists within the state of Hawai‘i.

Methods

A phone survey was conducted of 44 actively practicing Hawai‘i physiatrists. Eligible participants were members of either the American Academy of Physical Medicine and Rehabilitation (AAPMR) or the Hawai‘i Society of Physical Medicine and Rehabilitation.

Results

Thirty-six of 44 local physiatrists responded to the survey. Thirty-two of the thirty-six (89%) respondents were currently practicing on O‘ahu, nine (25% of respondents) completed medical school at University of Hawai‘i, 19 (58% of respondents) were not planning on recruiting in their practice for at least five years and the physiatrists' most common concerns included poor reimbursement, practice management problems, and high workload.

Discussion

Further recruitment efforts should be tailored to attracting physiatrists to our neighbor islands. Increasing reimbursement, addressing hospital administration issues, developing a musculoskeletal fellowship program, and increasing incentives to practice on neighbor islands are proposed changes that would directly address the concerns of Hawai‘i's physiatrists.

Background

PM&R (physical medicine and rehabilitation) physicians, or physiatrists, are medical doctors board certified in the medical specialty of physical medicine and rehabilitation. There are currently 77 Accreditation Council for Graduate Medicine (ACGME)-accredited PM&R residency programs and over 8,000 board certified physiatrists.^1,2 Physiatrists are focused on diagnosing and treating musculoskeletal and neurological disabilities resulting from disease or injury. They treat a variety of conditions, from brain and spinal cord injuries, osteoarthritis, and back pain, to stroke and burn injuries. With the goal of restoring or preserving maximum function lost through injury or illness, physiatrists work in a wide variety of settings.

The medical specialty of PM&R has exhibited unequal growth throughout the country, with some parts of the country having many physiatrists per capita and others having significantly fewer. For example, in 2009 the District of Columbia had one physiatrist per 16,207 people, the highest number of physiatrists per capita. In contrast, Wyoming had only one physiatrist per 90,712 people.³ In 2009, Hawai‘i was ranked fifteenth with one physiatrist per 30,120 people.³

This lopsided trend of varying number of physiatrists per capita within the country is evident even within the different islands of Hawai‘i. As of December 2010, there was a supply of 1.3 physiatrists (and a shortage of 3.7 physiatrists) working on the island of Hawai‘i, a supply of 1.0 physiatrist (and a shortage of 1.0 physiatrist) working on the island of Kaua‘i, and a supply of 3.3 physiatrists (and a shortage of 0.7 physiatrists) working on the island of Maui. However, on the most populated island of O‘ahu, home to the state capitol of Honolulu, there was a supply of 32 physiatrists, while the demand was only 25 physiatrists.⁴ Thus, although the islands of Hawai‘i, Kaua‘i and Maui have physiatrist shortages, O‘ahu has seven physiatrists more than current demand, bringing the overall total supply of physiatrists in the state of Hawai‘i higher than what is theoretically needed. The purpose of this study is to describe the demographics of physiatrists in the state of Hawai‘i, characterize their clinical practice patterns and identify their most important concerns.

Methods

This study was approved by the University of Hawai‘i Institutional Review Board and oral informed consent was obtained. Eligible phone survey participants included all 44 non-retired Hawai‘i physiatrists in 2011. Eligible participants were members of either the AAPMR or the Hawai‘i Society of PM&R, and each had working telephone numbers. Hawai‘i Society of PM&R meets quarterly and is a voluntary tax-exempt networking organization comprised of physiatrists licensed to practice medicine in the State of Hawai‘i. Survey questions were modifi ed from Chen's 2006 study regarding the state of PM&R in Iowa.⁵ Questions explored include physiatrist demographics, their practice setting and hours, patient demographics, clinical focus and whether participants felt there was a current shortage of physiatrists in the United States and in Hawai‘i. If the physician did not know the patient demographics, they were asked to estimate. The participants were also asked to rank their top five out of twelve concerns: on-call responsibilities, hospital administrative issues, practice management, continuing medical education (CME), high workload, low workload, recruiting new physiatrists, retention of current physiatrists, costs of malpractice insurance, reimbursement, recertification, and other. These concerns were given five points if ranked number one, four points if ranked number two, three points if ranked number three, two points if ranked number four and one point if ranked number five. If no particular ranking was specified by the respondent, three points were given for each concern.

Results

Thirty-six phone surveys were completed, yielding an 82% response rate. The results are summarized in Table 1. Thirty-two physiatrists were currently practicing on the island of O‘ahu, three were on Maui and one was practicing on Kaua‘i. Fourteen worked in multispecialty groups, 11 were solo practitioners, six were from single specialty groups, three were from hospital practices, and one was from administration. The average length of time lived in Hawai‘i was 19 ± 14 years (range 1–48), and the overall time as a practicing physiatrist was 15 ± 11 years (range 0.08–36). The average age of the responding physiatrists was 48 ± 11 years of age (range 31–69). Physiatrists reported working on an average of 48 ± 12 hours per week. Their practices were on average 18 percent inpatient and 82 percent outpatient. Seventy-five percent of respondents spent 90% to 100% of their time only on outpatient care, while 11% of respondents spent 90%–100% of their time only on inpatient care. Twenty-five respondents treated primarily musculoskeletal conditions, followed by neurological/spinal cord injuries (five respondents), pain disorders (two respondents), rheumatological/arthritic disorders (two respondents), and general medical conditions (one respondent).

Table 1.

Summary of Hawai‘i Physiatrists Survey, 2011

Survey Respondents/Total	36/44 (82%)
Demographics
Multispecialty Group	14
Solo	11
Single Specialty Group	6
Hospital	3
Administration	1
Island of primary practice
O‘ahu	32
Maui	3
Kaua‘i	1
Average Age (years)	48 ± 11	Range 31–69
Male	26/36
Time in Hawai‘i (years)	19 ± 14	Range 1–48
Time as a physiatrist (years)	15 ± 11	Range 0.08–36
Medical School Training	Hawaii	9
	West Coast	4
	Midwest	11
	South	1
	South West	1
	South East	1
	East Coast	6
	International	3
PM&R Residency	West Coast	16
	East Coast	12
	Midwest	6
	Southern	2
Average hours worked per week	48 ± 12	Range 15–70
Average hours performing administrative work per week	8 ± 7	Range 0–20
Average time spent on inpatient care	18%
No. Inpatients/week	4
Average time spent on outpatient care	82%
No. New consults/week	17
Next available new patient appt	14.7 ± 14.2 days	Range 0–60
No. of return patients/week	47
No. Electrodiagnostic medicine/week	5
No. Spinal injections/week	4
No. Peripheral injections/week	10
No. Osteopathic manipulations/week	2
Percentage of physiatrists spending 90–100% of their time on outpatient care	75%
Percentage of physiatrists spending 90–100% of their time on inpatient care	11%
No. of students/residents/fellows taught/year	2
What is the primary category of conditions that you treat?	Musculoskeletal	25
	Neurological/spinal cord injury	5
	Pain disorders	2
	Rheumatological/arthritic	2
	General medical conditions	1
Currently Recruiting?	Yes	1
	No, but plan on recruiting within next 5 years	13
	No, not planning on recruiting for at least 5 years	19
Patient Referral Sources
Other MD	73%
Self	14%
Non-MD provider	11%
PT or OT	2%
Payer Mix
Commercial insurance	36%
Medicare	33%
Other/Work Comp/No-fault/Tricare	18%
Medicaid/Quest	11%
Self-pay	2%
Top Concerns of Physiatrists
1. Poor Reimbursement	114 points
2. Practice Management Problems	106 points
3. High Workload	51 points
4. Hospital Administrative Issues	44 points
5. Recertification Requirements	32 points
6. Continuing Medical Education	27 points
7. On-call Responsibilities	23 points
8. Other Concerns	23 points
9. Increasing Malpractice Premiums	21 points
10. Low Workload	11 points
11. Recruiting New Physiatrists	8 points
12. Retention of Current Physiatrists	8 points
Shortage of PM&R in US?	Yes 21	No 8
Shortage of PM&R in Hawai‘i?	Yes 17	No 16

The physiatrists interviewed performed an average of 17 new outpatient consultations, four inpatient consultations, 47 outpatient follow-up visits, five EMGS, four spinal injections, ten peripheral injections, and two manipulation procedures per week. They also spent an average of eight hours performing administrative work and supervised or taught two medical students, residents, or fellows per year. The average time before seeing a scheduled new patient was 14.7 ± 14.2 days (range 0.0–60.0).

Estimated payer mix included, on average, 36 percent from commercial insurance, 33 percent of patients from Medicare, 11 percent from Medicaid/Quest, two percent self-pay, and 18 percent from other payers, including Hawai‘i Workers' Compensation, No-fault, and Tricare.

Seventy-three percent of patients were referred to the responding physiatrist by other physicians, 14 percent by self-referral, two percent by physical or occupational therapists, and 11 percent from other sources, including worker's compensation carriers, no-fault insurance, attorneys, or non-physician providers.

Eighty-six percent of respondents were graduates of allopathic medical schools, while 14 percent were graduates of osteopathic medical schools. Nine respondents graduated from University of Hawai‘i John A. Burns School of Medicine (JABSOM), 11 graduated from medical schools in the Midwest, four were from West Coast medical schools, three were from Southern US medical schools, six were from East Coast medical schools, and three were International Medical Graduates. For PM&R residency, 16 attended schools on the West Coast, 12 attended schools on the East Coast, six attended schools in the Midwest, and two attended schools in the Southern United States.

When asked to rank their top five out of a list of twelve possible concerns, the greatest concerns included poor reimbursement (114 points), practice management problems (106 points), high workload (51 points), hospital administrative issues (44 points), recertification requirements (32 points), continuing medical education (27 points), on-call responsibilities (23 points), other concerns (23 points), high malpractice costs (21 points), low workload (11 points), difficulty recruiting (8 points), and retention of current physiatrists (8 points). Other concerns included “inconsistency in workload,” “being an employee rather than an employer,” “a healthcare system based on capitalism,” “a general ignorance of what physiatrists do,” “requiring prior authorization for procedures,” and “running a business.”

When asked if they were currently recruiting additional physiatrists, only one said yes, 13 stated they planned on recruiting within five years, and 19 did not plan on recruiting for at least five years. When asked whether PM&R was a specialty in shortage in the United States, 21 said yes, while eight said no. When asked whether PM&R was a specialty in shortage in Hawai‘i, 17 said yes, while 16 said no.

Discussion

Currently, the state of Hawai‘i is short 669 physicians.⁴ Certain islands are in need of physicians more than others. For example, O‘ahu is short 331 physicians, while the island of Hawai‘i is short 174 physicians.⁴ Medical specialties such as neurosurgery, cardiology, infectious disease, and general surgery, in particular, are in need. Neurosurgeons are needed on the islands of Hawai‘i, Kaua‘i, Maui, and O‘ahu. The field of PM&R is unique in that on the islands of Hawai‘i, Kaua‘i, and Maui there is a current shortage of 3.7, 1.0, and 0.7 working physiatrists, respectively. However, there are seven more physiatrists than the current demand on the island of O‘ahu.⁴

Seventy-two percent (26 of 36) of respondents in our study were under 55 years of age. On the other hand, 25% of respondents were older than 55 years of age. It is fortunate that only 25% of Hawai‘i's PM&R physicians are over the age of 55, since 41% of all Hawai‘i physicians are 55 or older.⁴ As physicians 55 or older reach retirement age within the next decade, Hawai‘i's PM&R physicians may be less affected, since they are, on average, younger.

Ninety-two percent of respondents were graduates of United States medical schools. Nine out of 36 (25%) respondents were JABSOM graduates. In Iowa, retention of Iowa-trained physiatrists has been higher and Chen 2006 reported seven out of 15 (47%) of responding Iowa physiatrists lived in Iowa during training.⁵ Previous data show that over one half of all JABSOM graduates practice in Hawai‘i and more than 85% of all JABSOM graduates who also complete a residency training program will end up practicing in Hawai‘i.⁶ Thus, perhaps increasing the training opportunities by expanding the medical school class, recruiting medical students from the neighbor islands, encouraging more rural health care training, increasing reimbursement rates, reducing costs and reducing workload, could all be potential, albeit idealistic, solutions to PM&R shortage problems on the islands of Hawai‘i, Kaua‘i and Maui.

Hawai‘i physiatrists saw an average of 64.2 patients in an outpatient setting, while physiatrists in 1997 saw only 38.7 patients in an office or outpatient clinic.⁷ Additionally, Hawai‘i physiatrists saw the same number of new patients per week (16.8 in Hawai‘i 2011; 16.8 nationwide 1997), with four more days wait for a new patient to be seen (14.7 in Hawai‘i 2011; 11.0 nationwide 1997). Hawai‘i's population is expected to increase 28% between 2000 and 2030, and the number of Hawai‘i residents older than age 65 is projected to double during this same time period.⁸ Thus, Hawai‘i's demand for musculoskeletal and rehabilitation care will rise, especially on islands other than O‘ahu, where physiatrist shortages are already apparent.

Hawai‘i physiatrists spent a lower percentage of their time doing inpatient versus outpatient care as physiatrists did in Iowa in 2003 (18% and 82% Hawai‘i 2011; 33%, and 67%, Iowa 2003). Additionally, Hawai‘i physiatrists performed more electrodiagnostic medicine, spinal injections, and peripheral injections Iowa physiatrists did in 2003 (five, four, ten, respectively vs three, two, seven).

The number one concern among Hawai‘i physiatrists is poor reimbursement, a top concern shared among Iowa physiatrists in 2003.⁵ Practice management is another concern shared by physiatrists in Hawai‘i and Iowa. While physiatrists in Iowa reported “difficulty recruiting” as their number four concern, Hawai‘i physiatrists ranked “difficulty recruiting” tied with “retention of current physiatrists” at number 11 and 12 out of 12 concerns. And, although Iowa physiatrists work on average four hours more than Hawai‘i physiatrists (48 hours per week Hawai‘i vs 52 hours per week Iowa), “high workload” was concern number seven for Iowa physiatrists, while “high workload” was concern number three for Hawai‘i physiatrists.

Although the majority of Hawai‘i physiatrists believed there was a shortage of physiatrists within the United States (21 of 29 responded yes), they were more divided about whether there was a shortage in Hawai‘i (17 of 33 responded yes). The notion that fewer Hawai‘i physiatrists believe there is a shortage of physiatrists in Hawai‘i is consistent with the majority of PM&R practices not looking to recruit new physiatrists for at least five years (19 of 33 respondents). Furthermore, “difficulty recruiting new physiatrists” was not much of a concern among Hawai‘i physiatrists (tied for number 11 and 12 of 12 concerns). As an alternative to recruiting and hiring more physiatrists to work in remote areas, telemedicine could be a potential cost-effective solution to the physiatry shortages on the neighbor islands. By decreasing physician workload, telemedicine could decrease the physician demand in areas where physiatry demand is greater than its supply.

Because 32 of 36 of the responding physiatrists were currently practicing on the island of O‘ahu, there could possibly be sampling bias. That is, O‘ahu physiatrists' concerns, demographics, and practice types could be different and unique from those of their colleagues practicing on the other islands of Hawai‘i. The estimated 1.3 physiatrists working on the island of Hawai‘i, for example, were not represented in this data.⁴

Conclusions

In comparison with other medical specialties within the state of Hawai‘i and to the relative need for more physiatrists in other states, PM&R in 2011 Hawai‘i is not in a public health care crisis. However, with expected population growth and aging, as well as the anticipated retirement of 41% of Hawai‘i's practicing physicians, physician shortages, large or small, should not go unnoticed.⁴ Since Hawai‘i lacks a PM&R residency, further recruitment efforts should be focused on attracting both physiatrists completing residency programs on the mainland United States and physiatrists on O‘ahu to our neighbor islands. Reimbursement changes, addressing hospital administrative issues, hosting more PM&R conferences, developing a JABSOM musculoskeletal fellowship program, and increasing incentives to practice on neighbor islands are possible solutions that would directly address the concerns of Hawai‘i's physiatrists. Furthermore, another possible resolution would be creating a Telehealth system for O‘ahu's physiatrists to consult on neighbor island patients without anyone having to travel. This has been accomplished by Shriners Hospital to distant sites and could be expanded as need increases.

Conflict of Interest

None of the authors identify any conflict of interest.