"It's extremely difficult," said Ben Mead, the chief recruiter, even though there is "not a big turnover."

The most recent effort did not take a year, only six months, and Mead feels he's found an ideal candidate. However, there's a hitch.

She's a Pakistani national, studying in Florida on a "J" exchange student visa. Ordinarily, a student in the country on a J has to leave the United States and cannot seek to return as an immigrant for three years.

However, for medically underserved areas – which include all the Neighbor Islands and rural Oahu – waivers are available to allow the exchange student to begin working in the United States. Mead hopes to have his recruit legal and onboard by September.

The scarcity of pathologists is just a small subset of the difficulty to recruiting all sorts of medical professionals in the state.

"It's especially difficult on the Neighbor Islands," Mead told The Maui News.

Clinical Labs has about 900 employees statewide, which is almost as many as a medium-size general hospital. Maui Memorial Medical Center has a staff of about 1,100.

Most of Clinical Labs' staffers are technically certified, but only a few are physicians.

Clinical Labs employs 20 pathologists, which Mead estimates are about half the pathologists in the state. It has two on Maui, Drs. Barry Shitamoto and Anthony Manoukian.

Both were recruited because they already had island ties. Shitamoto was born and raised here; Manoukian did a residency at the University of Hawaii.

PERSONAL TIES A FACTOR IN RECRUITING

Personal ties are almost always a factor in recruiting a pathologist, Mead said. His recruit from Pakistan studied at the John A. Burns School of Medicine and is familiar with Hawaii. Shitamoto says more than half of Clinical Labs' pathologists "had some connection with Hawaii" before accepting jobs with the company.

Patients seldom come into contact with pathologists.

On Maui, Manoukian achieves some public notoriety because he performs autopsies in homicides and other police cases. Shitamoto's work is almost entirely behind the scenes. He is a specialist in examining tissue samples for evidence of cancer.

He examines 30 to 40 cases a day and finds "one, two or six cancers a day."

It's quiet but satisfying work, he says.

The new recruit is finishing a special course in cytopathology. This is a rapidly growing subspecialty in which clinicians, instead of slicing out tissue, aspirate a small sample of cells for the pathologist to examine. It is less invasive.

For some reason, Mead said, Maui Memorial does an unusually large proportion of cytopathology samples, so his recruit "is perfect."

FEW PATHOLOGISTS WANT TO WORK IN ISLES

It may be surprising that so few pathologists want to work in the islands.

Mead says there are about 20,000 pathologists in America. By population, Hawaii's share would be around 70 – nearly twice what it actually has.

Though both Manoukian and Shitamoto say they find pathology a satisfying career, Mead said it can be wearing. For example, Clinical Labs has one pathologist in Hilo, Dean Won.

"He's on call 24/7," Manoukian said.

Manoukian himself is on call for occasional police or accident cases, and in fact is a consultant in forensic pathology nationally. He spent time in New Orleans following Hurricane Katrina, and was featured in Robert Mann's book "Forensic Detective" for his help with an odd death in Kona.

"We try to staff two pathologists at every location," said Manoukian, but in the Neighbor Islands that isn't always practical.

Clinical Labs also considered recruiting older physicians who might be ready to work less than full time, he said, but "that doesn't work that well."

"We thought about it," he said.

Openings come up infrequently, and they often produce plenty of inquiries. However, part of Mead's job is to sift out the ones looking for a free visit to Hawaii. Clinical Labs looks for "believability about wanting to live in Hawaii."

Perhaps surprisingly, Mead says he has not found the low reputation of Hawaii's public schools to hinder recruiting.

What does hurt is the relative pay scale. A starting salary of $100,000 doesn't stretch as far here as in other places.

Mead points out that by the time a physician is ready to go to work full time as a pathologist, he or she has spent four years in medical school, four years in a residency, and perhaps a year in a forensic or other subspecialty training program. (Some also have Ph.D.s as well as M.D.s., which adds another two or three years.)

"They're getting close to 40 and are just starting out."

One comparative study found that a salary of $100,000 in Oklahoma would support a lifestyle that would require $175,000 in Hawaii.

The fresh but nearly middle-aged M.D.s are also probably carrying large student loan balances. Hawaii housing prices can leave them with sticker shock.

Mead said Clinical Labs does not offer housing assistance, other than "putting them in contact with a Realtor."

For some medical specialties, lack of facilities can be a deterrent. Or, there just isn't enough of the most challenging work to keep a specialist sharp.

But Manoukian said he "has never heard of skills to be an issue." Hawaii provides challenges to pathology as great as in other places, he said.

Shitamoto says pathologists have to have a different personal rewards system from doctors who deal with live patients.

"Your reward comes from helping your peers. They come and talk to you. It's nice to help the other doctors."

"The clinicians are our clients," says Manoukian.

Mead says he hopes the story behind the recruiting of Maui's new pathologist will help medical consumers understand some of the challenges facing Hawaii's medical care system. Not just Clinical Labs and not just physicians.

The pay may seem high, but the long hours can deter people from entering the medical field. In his experience as a recruiter, he's found that "most people are more than happy to forgo the overtime."

There's one other consideration in recruiting a new pathologist. The spouse.

During an interview, Mead said one wife asked about a clothing outlet store: "Where's your Eddie Bauer?"

He said he knew he wasn't going to recruit that husband.