The Country Doctors
Meet three doctors who’ve given up city comforts to serve Native Hawaiians in some of the Islands’ most remote areas.
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Commuting between Oahu and Kalaupapa to treat Hansen’s Disease patients sometimes requires innovation beyond Dr. Kalani Brady’s medical expertise. The Honolulu physician flies to Molokai once a week. Yet inclement weather has prevented the plane from leaving the peninsula on three recent occasions. One of those evenings, he needed to return to Oahu for a meeting. So he borrowed a pair of tennis shoes from a patient with smaller feet, cut out the toes to avoid blisters, and hiked the grueling switchback trail in street clothes. At the end of the 1,700-foot climb, someone gave him a ride to the “topside” airport.
“These are challenges you don’t find at Queen’s,” laughs Brady, a Harvard-educated internist and Native Hawaiian raised in Kailua. Even while fulfilling his many cultural and educational duties on Oahu, he gets paged two to four times per day regarding patients in Kalaupapa.
Physicians who work in underserved areas must be everything to everyone—often at all times of the day and night. They act as doctors, case managers, administrators. Sometimes they juggle clinical visits and emergency room crises simultaneously. Daily obligations include keeping children healthy and monitoring geriatric patients in long-term care, and possibly delivering a baby on a moment’s notice. They can’t worry about whether someone has insurance, yet must keep their facilities financially viable. And often they must deal with a disproportionate number of health problems facing the predominantly Native Hawaiian communities, all while mastering cultural nuances that demand a unique approach to treatment and management.
Though support for physicians practicing in rural areas remains less than ideal, their services alone have improved care. They’ve also lobbied for change. And it seems to be helping.
In October 2003, the University of Hawaii Board of Regents approved the first department of Native Hawaiian Health at the John A. Burns School of Medicine to provide leadership in education, research and clinical care; The Queen’s Health Systems quickly stepped in with a $5 million grant over five years.
Brady, vice-chair of the new department, credits medical school leaders for recognizing the high incidence of disease and mortality rates among Native Hawaiians, who suffer more hypertension, heart disease, obesity, diabetes, kidney disease and certain types of cancers compared with national statistics.
One way to get physicians to stay in (or return to) Hawaii and practice in places like Kau or Hana is via the Native Hawaiian Health Scholarship program, which pays for healthcare training at any school in the country. Four years of financial support means doctors must live and work in an underserved area in Hawaii for the same number of years after training.
Another way to nurture potential healthcare professionals in rural communities is through the 30-year old Imi Hoola post baccalaureate program. The medical school accepts up to 10 disadvantaged premedical students annually, and educates them intensely for one year. Though many students are Native Hawaiian, the program is not race-based, says Brady. Anyone can apply. Successful completion results in automatic entrance into the highly competitive John A. Burns School of Medicine: Last year, a total of 1,373 students applied for 62 positions in the medical school.
Even when physicians are prepared to practice in rural communities, challenges await. “It’s a real labor of love,” says Tom Driskill, president and CEO of Hawaii Health Systems Corporation (HHSC), which operates 12 facilities on five islands.
Indeed, some doctors “take call” every other night, which can mean working 24 hours at a stretch. Frequently trained in family or internal medicine, they must become proficient in nearly every department, carefully determining when a patient must see a specialist on another island—often at great expense and inconvenience (doctors have been known to arrange and pay for travel, as well). Medicare, Medicaid or Quest supply most of the insurance. But in 2002 alone, HHSC recorded $12 million of uninsured patient visits. That number rose to $17 million in 2003. Reimbursements are minimal, pay is low, liability high.
“We have a pure safety net mandate,” says Driskill, former chief of staff at Tripler Army Hospital. HHSC hospitals take patients regardless of their ability to pay, and keep them as long as necessary. “They stay for months, and sometimes years.” Consequently, many rural hospitals have been forced to recategorize acute care beds to long-term care, a thorny, bureaucratic process. “You need some of both [beds] because often there’s no other option in the community.” Of HHSC’s 1275 beds, about 750 are designated for long-term care.
Financially, the population in rural communities does not support the operation. “We can’t justify having a hospital there, but there’s no other alternative if you’re going to have quality of life in that community,” notes Driskill.
Pioneering high-tech methods may help solve some of these issues. Dr. Marjorie Mau, chairman of the Department of Native Hawaiian Health and a diabetes specialist, currently offers weekly video telemedicine clinics to remote areas from her office in Kakaako. Thanks to federal legislation, Hawaii and Alaska are the only two states in the country allowed to bill for remote patient visits.
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