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The Honolulu Advertiser
Posted on: Sunday, March 28, 2010

Hawaii’s shortage of doctors may double or triple over next decade

BY Greg Wiles
Advertiser Staff Writer

An interim report on Hawai'i's physician shortage says the state is at least 500 doctors below national averages given its population and that the severity of the deficit may double or triple in the next decade if nothing is done.

The 2010 Hawai'i Health Workforce Assessment study done by John A. Burns School of Medicine researchers said the state has roughly 20 percent fewer doctors than it should when compared to physician-to-population ratios nationally.

"If you're on a Neighbor Island right now it's severe, particularly the Big Island," said Dr. Kelley Withy, a researcher and practicing family physician.

"If you're on O'ahu and you need a cardiologist or a primary care doctor you've got to wait a long time."

The report paints a picture of a severe physician shortage for parts of the state, with the situation worsening as time progresses because of a number of factors, including doctors retiring and baby boomers requiring more medical care as they enter their senior years.

The study is also significant because it puts numbers to a doctor shortage that's been talked about for years but hasn't been quantified. The report's initial results were released to the Legislature recently as part of a discussion on the shortage and what needs to be done.

Previously it was thought that as many as 8,000 physicians might be practicing here, but through the study it was determined that half of the licenses were held by people with Mainland addresses. Further research determined that about 2,900 doctors were practicing here, with some of those working less than part time.

The report is of little surprise to many people, especially in Hawai'i County which has the lowest doctor-to-population ratio in the state. In Kona, the problem is readily apparent to Dr. Stephen Denzer, a Kona Community Hospital physician.

"This month, we have at least half of the days that are not covered by an orthopedic surgeon," Denzer said.

"A community this size absolutely should have sufficient orthopedic surgery coverage but we do not."

That's a problem, he said, because on average someone falls and fractures their hip about every day and a half in the community. If a surgeon isn't available, extra time is chewed up finding a hospital — usually on O'ahu — where the surgery can be done and arranging an air ambulance.

Denzer said that's not ideal — the quicker the surgery takes place, the fewer the complications. It's also not good for patients who are away from home during their recovery and rehabilitation time.

"In the end it costs everyone more," Denzer said.

Withy, who is working on the report with Dr. David Sakamoto, said the study is being refined with more data on Hawai'i health usage and the number of doctors.


The initial findings presented to the Legislature talk about a shortage of 754 physicians. At that time, the authors had identified the full-time equivalent 2,626 doctors in the state when 3,380 are needed based how medical services are used nationally.

Withy said more work is being done to get more data on physicians here as well as medical usage locally. Because it is possible more physicians will be located by the study, she feels more comfortable saying the state's doctor shortfall is more than 500.

But the data snapshot from earlier this year suggests shortfalls exist statewide, with only the severity of the deficiency varying. On O'ahu, for example, there are 17 percent fewer physicians than what are thought to be needed.

The shortfall is 38 percent for Hawai'i County and 33 percent for Maui County. On Kaua'i the number is 30 percent.

The numbers also cut across specialties, with a big gap between the number of primary care physicians needed and those that are in the state. There are shortfalls in more than two dozen specialties with big gaps in cardiology and most surgical types.

To be sure, there are some specialty areas in which physician supply outstrips estimated demand, such as in pediatrics.

"It is pretty interesting in terms of its results," said Dr. Roy Magnusson, medical school associate dean.

"Primary care is one of the biggest needs. But there are shortages in other categories."

There are a number of reasons why the shortage has developed. In a study published in the Hawaii Medical Journal about the Big Island's shortage the list started off with a big one —physicians in Hawai'i aren't paid well given what they say are low insurance reimbursements from Medicare, Medicaid and private insurers.

At the same time, they face high costs. In areas where there aren't many other professionals, they also face excessive on-call burdens and less sub-specialty back up.

The article also referred to lack of new facilities, difficulties in transferring patients to hospitals with necessary services and specialties and frustration with the medical malpractice environment here.

Physicians also cite a lack of employment opportunities for spouses, parental care support and educational options for children, the report said.


Sharon Vitousek, a Big Island physician and one of the authors of that article, said the situation is such that keeping existing physicians from moving away is sometimes difficult. She said the Big Island has 14 percent of the state's population, but only 5 percent of its licensed physicians.

That results in patients sometimes waiting weeks to get appointments or traveling elsewhere in the state or the Mainland to get treatment.

"There's a delay of care," Vitousek said. "New residents have problems getting a primary care doctor."

And it's expected to get worse in coming years. The study by Withy and Sakamoto notes the average age of Hawai'i physicians is 52.5 years, while the average age nationally is 48.

The result is that 43 percent of doctors here currently will be 65 years old or older by the year 2020. That may result in 1,100 retirements during the next decade.

The study projects the current physician shortage could grow to 1,500 in 2020. The notion that Hawai'i can simply recruit doctors from the Mainland to fill that need are belied by forecasts of doctor shortages in the U.S. in coming years and that some places in the state already have a tough time attracting people to set up practice here.

Some ideas for addressing the situation may come from the Big Island where Vitousek said physicians, hospitals, business leaders and others have joined in the Hawaii Island Healthcare Alliance to discuss improving access to services.

The group is exploring both short-term and long-term ideas to improve recruitment and retention of physicians, including getting people to do their residencies at Hilo Medical Center.

"There's probably not a quick fix," said Vitousek, who is vice chair of the alliance. "It's going to be a multipronged approach."


The shortage is also being studied at the Legislature, where Sen. David Ige, chairman of the Senate Health Committee, said getting the study data along with more granular detail in the future is a big step forward.

"The data allows us to set priorities" Ige said. That includes talking to the medical school about expansion, looking into residency programs for rural areas and exploring ways to lure back former Hawai'i residents who went away to medical school.

At the medical school there also have been discussions on how to address the shortage. Magnusson said the school has expanded its 62 student annual class size to 64 and is looking for ways to possibly increase the size to 75.

"That's going to be hard for us to do in budget-cut times, but we think it's pretty important to do," he said.

However, the medical school can't be expected to address the situation alone. One estimate is that the state will need to graduate or recruit 150 physicians a year to maintain current staffing ratios and that to close the gap with national norms by 2020 would take 234 new physicians per year.

"It's scary when you look out," said Rep. Ryan Yamane, head of the House Health Committee.

"As a state we need to find ways of supporting our physicians and increasing our capacity to support local doctors."

Withy also has explored potential solutions in focus groups with hospital administrators, doctors, students and business leaders. The results of the work will be published in an upcoming medical journal article.

Overall, it was apparent that it will take more than the medical school's work to pull the state out of the crisis.

"The solution is that everyone is going to have to work together and we're going to have to use a number of ideas," she said.

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