Focus
Our bureaucratic wall of shame

By James Dannenberg
Retired state judge and freelance-writer

In spite of our blessings — and we have many — there is much in Hawai'i's nature that is inbred and dysfunctional.

There is a shortage of paramedics in Hawai'i to take on duties such as helping victims at an accident scene. But licensing requirements make it nearly impossible for out-of-state applicants to fill vacancies. Advertiser library photo • Sept. 14, 1999

Here's an example: recent news accounts have made clear that Honolulu is experiencing a critical shortage of paramedics, and indications are that the problem will worsen before it improves. No one applauds this potential public health crisis, and earnest public officials are doubtless scrambling to find solutions. But the darker side of our institutions may well snatch defeat from the jaws of victory, as it has in many other circumstances.

The story of a young man I know, whom I'll call Alex, illustrates this quite well.

Alex grew up in Hawai'i, attended both public and private schools, and left, at the urging of his parents, to further his education on the Mainland. He always intended to return, for since he was a kid he dreamed of being a paramedic in Honolulu.

He attended school, completed his training and was licensed as a paramedic in Madison, Wis., working there in that capacity for a couple of years, often supervising ambulance crews. In the meantime he got married and when Alex heard that there was a shortage of paramedics in Honolulu. he and his wife decided to move back home.

Before he moved Alex took and passed the rigorous examinations necessary to obtain his National Paramedic Registry certification.

He also spoke with city and state agencies to find out about licensing and employment requirements but was given very little specific information, except that he would have to re-establish Hawai'i and Honolulu residency before applying for his state license and then city employment.

Given the well-publicized shortage of paramedics in Honolulu, one might suppose that, upon moving to Hawai'i, Alex's application was greeted with open arms and that another of Hawai'i's sons came back home to live happily ever after.

Unfortunately, it didn't work out that way.

Bureaucracy isn't necessarily a dirty word. As a relatively recent political invention, it was meant to supplant the privilege and arbitrariness inherent in more autocratic governmental institutions with impersonal, impartial and predictable application of laws and rules by independent civil servants.

In its best forms, bureaucracy can be a bulwark against the baser deficiencies of governments.

Sometimes, however, that doesn't happen.

After moving to Honolulu, Alex contacted the state Board of Medical Examiners to begin the application process. After several weeks of attempts, he was able to talk with one of the board's employees, who indicated that it was very unusual for the board to issue a license to someone trained in another state. As it turns out, most of Hawai'i's licensed paramedics were trained at Kapi'olani Community College, and the board's licensing standards are patterned after Kapi'olani's curriculum.

Nevertheless, Alex was told to fill out an application and submit it to the board.

After a couple of months Alex was informed that the board had denied him a paramedic license.

The reasons:

• Alex's training included 900 hours of "ride-along" training time, while the Kapi'olani program and the licensing board require 1,300 hours.

• A questionnaire returned by Alex's Wisconsin trainers indicated that his training program had not covered approximately six (out of more than a hundred) listed "skills" even though Alex's program and work experience had trained him in other skills beyond those listed.

When he asked whether his nearly two years of actual service as a licensed paramedic in Wisconsin might somehow be treated as the functional equivalent of the 400 training ride-along hours, he was told unequivocally, "Work experience means nothing to us." Only training hours could be counted.

As to the specific skills he was supposedly lacking, he asked how he might make them up for licensing purposes and was directed to the administration of the Kapi'olani program.

Finally, as he was willing to work temporarily as an entry-level emergency medical technician, or EMT, a position requiring considerably less training and skill, if by doing so it were possible to make up his paramedic licensing "efficiencies," he asked if his qualifications were at least enough to merit a Hawai'i EMT license.

Technically, Alex didn't qualify for this entry-level license, since he was no longer listed as a National Registry EMT, having long since graduated to National Registry paramedic status, but after another month or two of deliberation the board decided to license him as an EMT, apparently the first time it had ever done so under such circumstances.

This process took approximately four months. In the meantime, Alex took a temporary job at Queen's as an EKG technician and set about to find out what he might do to get his license. He spoke with the city about available positions but was told that until he was licensed there was nothing they could tell him.

Impossible mission

He also contacted the administration of the Kapi'olani program to see how — if at all — he might be able to make up his licensing requirements. He quickly found out that it would be next to impossible for Kapi'olani to tailor its resources to fit his specific needs. Yes, it was technically possible for Alex to contact individual instructors and contract with them for training in the few skills he was deemed to lack.

Yet after several weeks of trying to arrange for individual instruction it became clear to Alex that institutional resistance was far too great. At one point one of the administrators told him that it would take him longer to "make up" particular skills than to complete the entire program from scratch and that he should consider just enrolling as a new student in their paramedic program, which takes two years to complete.

That would probably be the only way he would be allowed to make up the missing ride-along hours in any event.

Through his job at Queen's he came in contact with many Honolulu paramedics, and he quickly learned that tradition was working against him. Apparently no more than a handful of "outside" paramedics had ever been licensed in Hawai'i.

Still, Alex wanted to stay in Hawai'i if possible, so in early January he made formal application to the city for an EMT position, hoping that once in the lower-level job he would somehow be able to work toward paramedic licensing. He was certainly more than qualified for an EMT position, which requires only a semester's training, and even after his experiences with the state licensing board and Kapi'olani he was optimistic that things would work out.

Considering Alex's qualifications and experience, he hoped that his application might be considered expeditiously.

It was not to be. Months passed before he was interviewed. Even though he scored as high as a nonveteran can on the qualification scale, he heard nothing for more months. It was not until May — almost five months from the date he applied — that he was called for a physical exam, and even at that stage he was not told that he would be hired if he passed.

In early June, almost a year after moving to Hawai'i and beginning the licensing process, Alex and his wife decided that there was no future for them here and made plans to move back to the Mainland.

A week later the city wrote to tell Alex that they would hire him as an EMT and that he should report to work on June 20, almost six months from the date of his application.

It was too little, too late. Alex left Hawai'i for greener pastures.

No problem on Mainland

In stark contrast to the difficulties he faced in Hawai'i was the ease with which he was able to establish his paramedic credentials in the states he and his wife are considering for a new home. In quick order, and through the mail, he was granted paramedic licenses in Minnesota, California and Illinois, simply on the basis of his qualifications and experience.

Lest one surmise that these states are medical backwaters with low standards, national surveys suggest that they are among the best in the nation for medical care. Minnesota, for example, has three hospitals, including the Mayo Clinic, listed among the top 50 in one recent national ranking. Hawai'i's hospitals, by contrast, made no appearances among the elite.

So on one level Alex will be fine. He will be able to get a paramedic job virtually anywhere in the United States.

Anywhere except Hawai'i, that is.

And we are all losers for that fact. Alex loses out on his dream to come back to Hawai'i to live and raise a family. And we lose out on the opportunity to hire an obviously qualified paramedic — and a local kid at that — to help fill what everyone agrees is an almost desperate shortage.

How can this happen?

Well, every time Alex came in contact with a Hawai'i bureaucracy he encountered either our pernicious form of protectionism, reflected in a rigid and unbending application of seemingly objective "rules" that for all practical purposes exclude "outsiders" or just simple indifference.

In an informal discussion with one of the licensing board members Alex was told that the board was simply interested in perpetuating "high standards" despite the obvious needs of local agencies.

Unfortunately, these "high standards" exist in a vacuum and can be discerned only in relation to the program at Kapi'olani CC. There is no way to meet the standards except to complete the local program or be lucky enough to attend one elsewhere that exactly mirrors Kapi'olani's. A paramedic licensed nationally and in every other state, with 20 years of experience in the toughest city in the United States, would not qualify in Hawai'i if his initial training program ride-along hours were fewer than Kapi'olani's.

The board's procedures are so rigid that they do not allow for functional equivalence through experience or proof of skill by testing.

They do guarantee, however, that every student who finishes the Kapi'olani paramedic program will be licensed and employable, as Kapi'olani does not graduate enough paramedics to fill all the vacant positions.

If there were some alternate way to gain a license, the city might well fill all the vacant paramedic positions, but it is also possible that enough Mainland-trained paramedics would come that some Kapi'olani graduates might have to compete for positions.

A shortage of paramedics might trigger a public health crisis. An abundance of paramedics might theoretically mean diminished employment opportunities for local graduates.

It seems that the board has made its choice.

Misguided protectionism

This certainly isn't the first time that misguided protectionism has reared its head in Hawai'i.

Some years ago our federal court ruled that the state dental licensing board had discriminated against Mainland dentists in its licensing process. The same fate befell Mainland-trained psychologists until a lawsuit was filed and the Legislature mandated changes.

Not long ago lawyers could not even take the Hawai'i bar examination without having resided in the state for the previous 12 months. It is no secret that Mainland teachers have to hurdle almost insurmountable barriers to teach in our public schools, in spite of incredible teacher shortages.

Other examples abound.

There has been no dearth of media stories about local residents moving to the Mainland to pursue more fulfilling and remunerative careers in less expensive settings. Experienced cops are recruited by cities in the rainy Northwest. Teachers leave for more money on the Mainland. Lawyers, doctors, nurses and other professionals seem to emigrate in ever-increasing numbers.

Our children attend Mainland universities and often stay. Las Vegas has become a Hawai'i colony.

We lament the loss of our sons and daughters and blame the economy for driving them away, but that is far too easy an explanation. Maybe we should blame ourselves, too.

Alex wanted to come home, and we needed him here. We drove him away anyhow.

But the next time you call 911 you may well wonder whether help will arrive in time.