While born in Hawai‘i and living in Honolulu for most of my life, I did not have many opportunities to visit the neighbor islands. I was blessed with the opportunity to visit the Big Island during my first summer of medical school (MD5). Away from all the hustle and bustle of the city, I stayed in a quaint little boathouse (on land) at Captain Cook. I primed myself for a summer of shadowing physicians on the Big Island along with experiencing the joys and challenges of working in smaller communities. To gain a broader view of the different aspects of healthcare, I shadowed physicians at the Kona Community Hospital, at a private practice in Kona, and at the West Hawai‘i Community Health Center.
Stop 1: Community Hospital
My first stop was at the Kona Community Hospital where I followed radiologists, radiation oncologists, and oncologists. This small community hospital had a wide variety of specialists, nurses, and staff who keep things running smoothly and efficiently. The physicians I spoke with all enjoyed working at the hospital due to its set working hours, job security, and more centralized administration/billing services — all benefits of working in a larger institution. Interestingly, among the physicians that I had the chance to work with, many of the specialists belonged to separate physician groups contracted by the hospital. Depending on the hospital, more hospitalists may be employed or services sought through contracts with private physician groups. Working at this hospital also meant regular access and collaboration with other specialists as needed. For example, when one of the radiation oncologists had questions, pathology and radiology resources were just down the hall enabling us to simply walk over and talk face-to-face with them.
I quickly discovered that one drawback in working on a neighbor island is the smaller number of physicians. Specialists are fewer or entirely unavailable as doctors retire or move with no one to replace them. I was surprised, for instance, to see one of my Professors substituting for the hospital's regular pathologist who was on vacation for the week. I also shadowed an oncologist who was there as a locum tenens (a Latin phrase meaning “to hold the place of, to substitute for.) as the previous specialist had moved. Originally from the mainland, he said locum tenens gave him a good chance to experience working at a hospital with only a short-term commitment to see how he liked it before hopefully being offered a position. This strategy also assisted the hospital in its struggle to recruit adequate numbers of physicians to work there. With the physician shortage, some patients must fly to Honolulu for consults or to continue their care. In some cases, insurance companies opt to fly patients over if the treatments are less expensive. Even with access to telemedicine, I don't think anything can fully replace direct contact between patient and physician.
Given the smaller number of physicians working at the hospital, they are pressed to expand their knowledge and skills sets to meet the populations health needs. When faced with any problem, they are the ones that need to respond if possible since the only other alternative is to fly patients to Honolulu. Although this makes their workload broader and more intensive, many enjoy the experience of seeing more diverse medical problems and intervening which they normally wouldn't have the chance to do. Such a tradeoff for these physicians makes working in more rural areas on neighbor islands an ideal place for broad training and experience.
Stop 2: Private Practice
My next stop was shadowing a pediatrician working in a private practice just outside the Kona Community hospital. Compared to the hospital, the private practice was faster-paced with fully packed schedules. On some days, he was also on call and would go back and forth between his practice and the hospital. When I asked what he liked most about working in private practice, he declared that he enjoys being his own boss and free to do as he pleased. Because there are no set schedules in private practice, he could spend as much time as he believed was required to provide quality care for each patient, including seeing a patient after hours if needed. There was also no administration to tell him what to do. He also noted the downside of private practice which essentially involves keeping your own business cost effective. With several support staff and a nurse, maintaining a large enough volume of patients to keep afloat in terms of finances can lead to very full schedules. There is also the impending risk of lawsuits that can devastate a small private practice. In larger hospitals, the hospitals themselves have malpractice insurance to cover their physicians — shielding physicians from sole responsibility. Moreover, it has been increasingly difficult for private practice physicians to stay afloat under the newly implemented Affordable Care Act (ACA).
Often, the reimbursement for Medicaid patients is so low under the ACA that some physicians “cherry-pick” patients—which means they avoid seeing patients with Medicaid or Quest. I was proud to hear that the person I was shadowing tried not to turn away patients. Being one of the few pediatricians in the area, it was important for him to support the community as best as he could, despite incurring financial losses. In fact, up to 80% of his patients were on Medicaid, which approaches the same rate as many federally funded clinics. Unfortunately, this is harder on private practice physicians since they do not get the additional federal funding per patient that health centers do. Like other physicians that I spoke with in a private group at the hospital, many doctors of the previous generation had the dream of working for themselves. With all the new changes in healthcare, our generation seems to be pushed towards being doctors that will be working in larger groups or hospitals, such as a Kaiser Permanente, while the independent private practices start to fade. What people don't commonly understand is that for many patients, the decline of private practices combined with low Medicaid reimbursement rates often makes access to medical care more difficult, especially in emergency situations where patients are located far from any hospital. If no specialist is available nearby, nearly an hour is added to the time required to get patients to the airport when a flight to Honolulu is required. Many Medicaid patients also have difficulty securing transportation to a hospital on their own.
Shadowing a pediatrician was a very unique experience beyond my exposure to what community-minded private practice can look like. At the very core, I had the chance to experience the “art” of medicine, a practice that cannot be learned from books or in lectures during the academic year. In the field, I learned effective and efficient interactions that can make or break an appointment. With children, it was more about maintaining the interaction— how to encourage them to cooperate, to smile, or even just to get them to stop crying—in order to expedite a more effective exam. These interactions tell us the most about our patients and fostering strong relationships that are key to becoming great physicians.
Stop 3: Community Health Center
My final stop was at the West Hawai‘i Community Health Center, a federally funded, community based clinic in downtown Kona. Since it is federally funded, the health center does not turn away any prospective patients. In addition to physicians, there were many nurses and support staff with more specific roles in helping the clinic function, such as scheduling, rooming patients, entering medications, and checking-in patients. The center had a lab area for performing basic tests, a mini pharmacy room, and many exam rooms. Small surgical procedures could be done at the health center, which enabled fewer hospital transfers. The clinic was much different from the hospital and the private practice in that many physician assistants (PAs) provided support. Here, I had the chance to shadow one of the family medicine physicians as well as one of the PAs.
I found that much of the work of the PA was similar to that of the physicians. Talking with the physicians and PAs, I also found that there were many benefits to working in a community health center. One of them is the issue of liability. Unlike private practices and hospitals, the federal government takes over in the case of any lawsuits. This provides superior protection for workers at the health center. There are also loan repayment programs, which make it very attractive to work there. However, the turnover rate of physicians is much higher than at hospitals and they have difficulty retaining physicians. Overall, in my estimation, the health center had a good approach to community health services. For instance, in addition to medical care, there are in-house behavioral specialists and psychologists available to address behavioral health issues. I believe this is an important quality because many patients also have behavioral health related problems. Having these services in-house allows for the easy, “warm handoff” of patients, rather than losing them to referral or follow-up.
In conclusion, my trip to the Big Island was a great learning experience. There are many different flavors of healthcare that can be provided, such as a hospital providing comprehensive healthcare, a private practice providing outpatient visits, and a community health center supporting the community at large. Each of the three places showed the vital role they play in our current care health of our communities. The ongoing physician shortage in Hawai‘i continues to grow and there is an ever-important need for new physicians to practice in more remote locations, such as the neighbor islands. Even with all the challenges physicians face on the neighbor islands, the opportunities and experiences can be gratifying and endless.
Conflict of Interest
The author identifies no conflicts of interest.