Posted on: Tuesday, May 10, 2005

ISLAND VOICES

By Barry Blum, M.D.

I moved from California to the Big Island of Hawai'i in 1986 at the age of 45. With no other orthopedic surgeon on the staff of Kona Hospital, I accepted the responsibility of being on call to the emergency room every night and day. Whenever I was on the island of Hawai'i, day or night, I agreed to stop whatever I was doing — sleeping, eating, playing, praying — and come to the hospital when called.

I worked three times more and earned two times more than I did in California. After 1 1/2 years, another orthopedic surgeon joined our hospital staff and I received the gift of half of my life.

After being on call every other day and night for 13 more years, the other orthopedist and I reduced our call schedule to every third day and night. It was difficult to tell our emergency room that we were just too worn out to keep up the pace and to explain that we had other parts of our lives to attend to (like family).

In fact, we both continued to come in even on days that we were not on call whenever it was possible.

Meanwhile, every year Medicare and all the other insurance companies reduced our level of reimbursement for our ER work as well as for our other work. Government-mandated rules and regulations for documentation and billing required ever more complex billing demands and expenses. The population of our island grew. Retirees were lured here by new residential development.

Meanwhile, we watched many of our colleagues abandoning their hospital practices either to confine their work to their offices where they could escape the increasingly onerous responsibilities of being on call or of moving to the Mainland where they could earn more money.

Hawai'i's Big Island has long held the sad distinction of having the highest levels in the state of drug and alcohol abuse, child and family and spouse abuse, as well as the highest level of automobile accidents. Since social measures were not reducing these risky behaviors, medical care after the fact was increasingly in demand. Yet those of us continuing to practice at Kona Community Hospital were noting the decreasing availability of internal medicine specialists and general surgeons to provide needed care to our friends, our patients and even to ourselves.

In desperation, too long after we as a medical staff outlined these problems to our administration, our hospital began to recruit specialists from the Mainland to fill the gaps here and to pay them to be on call. Extraordinarily reluctant at first to pay anyone already on the medical staff to be on call, the administration finally relented and began to pay general surgeons to be on call but only when those local surgeons were no longer willing to sacrifice not only their sleep but also their very livelihoods.

None of the orthopedic surgeons on the Big Island ever asked for money from the hospital to be on call. However, we all started to reduce our availability to be on call as we all grew more and more weary, as we all grew older, as we noted the absence of the arrival of any new, younger orthopedic surgeons moving here. We did not compare notes on this at first. It just happened.

I finally stopped being on call when my wife noted the toll that chronic sleep deprivation was taking on me and her. My orthopedic colleague at Kona Community Hospital also stopped as his family responsibilities grew and his practice could no longer support his call requirements to the emergency room. Nevertheless, to this day both of us continue to respond to calls from the emergency room whenever we can.

Now, there is no orthopedic surgeon on call at any time on the Big Island. None of us is willing to agree to sign up on a list that puts us at risk of being fined by the federal government or of losing hospital privileges just because we commit in advance to being available. All of us do come in to our emergency rooms when we are able, but we cannot guarantee in advance that we will do so on any specific day.

Nobody thinks this is a good thing. If we cannot come in, patients do suffer. They may have to be transported to another Big Island hospital, they may need to be air-evacuated to O'ahu, they may be admitted to our own hospital overnight by another non-orthopedic doctor and have their definitive treatment a day or two or three later.

All this raises the cost and lowers the quality of medical care. So far, no one has died or lost a limb because of this. But it could still happen; it could even happen to one of us.

What went wrong? For one thing, no new orthopedic surgeon has moved here in nearly a generation. He or she can't afford to. With typical medical school and college loans to repay, the astronomic cost of buying a home and the impossibly low rate of reimbursements coupled with the high cost of medical liability insurance and buying all the equipment needed to set up an orthopedic practice, why would any young orthopedic surgeon choose to move to Kona?

What's next? It's probably wise for anyone who has any ongoing serious medical condition to avoid moving to the Big Island. We cannot guarantee that there will be doctors here to take care of them if they need hospitalization. Certainly senior citizens should exercise extreme caution before moving here.

Vacationers must also reconsider their plans particularly if they want to drive anywhere. The roads are too unsafe and the emergency care or specialist care they may need cannot be assured. Since Queen's Medical Center is the only Level I Trauma Center in the state of Hawai'i, and since there are only two orthopedic surgeons taking trauma calls there and no more are in sight, it may even be impossible to transfer critically injured people from here to there.

The masters of Medicare have told us that there is no problem because American doctors are still willing to accept Medicare-level payments even with reductions in payment every year. They believe that medical care is the same as ordinary business-for-profit. They have told us that if doctors, trained by sleep-deprivation techniques and dedicated by selection and training to care for human beings in distress regardless of their ability to pay, don't quit Medicare, then Medicare's fees must be OK.

And other insurance companies have taken the same perspective, even though Medicare was created to care for our nation's seniors and disabled, a population we are all supposed to honor and assist. These other companies, like HMSA, are now paying physicians even less than Medicare.

Finally and inevitably, the system is failing. The peripheral areas of our state, the Neighbor Islands, are failing first. Gradually our collapse will overload the center, Honolulu. All of us who are still practicing medicine are still clinging to the hope that when our time comes, the system will not yet have totally fallen apart. This may be a false hope. How long will it be until the medical care system in Hawai'i fails completely?

Barry Blum, M.D., is one of two orthopedic surgeons on active staff at Kona Community Hospital.