- Special Projects
We have known about a doctor shortage in Hawaii for a while. The latest evidence comes from a University of Hawaii report indicating that the problem is only expected to get worse.
This is especially true in my field of primary care, where we have 300-plus fewer doctors than we need to take care of our ever growing, and aging, population. That’s not even counting other doctors who plan on retiring soon.
How bad is the situation? There aren’t enough slots in UH’s John A. Burns School of Medicine to fill the gap anytime soon, even if every single student went into primary care. So we could passively wait for the situation to devolve into a deep crisis, or we could look for solutions that are right in front of us.
If you’ve gone to your local pharmacy recently, perhaps you’ve noticed — or visited — the walk-in clinics that have popped up in recent years. Staffed by nurse practitioners and open at convenient hours, they can handle many simple medical issues and prescribe medication when needed. In other words, they can tend to people who then, in most cases, have no reason for a prized doctor’s appointment.
For those who have more complex and urgent health issues, there are other alternatives, especially at urgent care clinics. Many of these are run by emergency-room certified doctors, including some with specialties like orthopedics.
With more and more walk-in clinics popping up at a time when openings for new patients in private offices seem to be virtually non-existent, a combination of the two could undoubtedly help respond to the doctor shortage.
As it stands now, anyone who goes to a walk-in clinic is asked about his or her primary-care provider. In fact, most are told to follow up with a visit to the doctor within a few days, to confirm they have gotten better.
I’m too busy, seeing a lot of people the day they call, for illnesses that I can’t really do much about.
Considering our shortage of primary care doctors, what if urgent care facilities became primary care providers?
Now, many of my colleagues might balk. I have heard their past protests. Some say that practicing medicine is a lot more complicated than just fixing sore throats. Others argue that four years of medical school and two decades of practice can’t be learned overnight. Those things are true, but that doesn’t mean that we shouldn’t take these steps.
Let’s not forget, we have a true emergency here — with more and more people needing primary care doctors and not enough to go around.
What will happen when all the primary care providers are full and no one is accepting new patients? Where will people go?
Community health centers across the state have been acting as primary care providers for years. Staffed by a variety of practitioners — including nurses, doctors, physician assistants, and more — they have filled a niche for the neediest patients who sometimes cannot find or afford care elsewhere. Not only have the health centers filled this role for many patients, they’ve done it very well.
But the demand can’t be met by those centers alone.
Some primary care doctors already have a nurse practitioner working in their offices, providing basic care on an as-needed basis, helping to expand the convenience of the office’s availability. But there’s still not enough to go around.
What about walk-in clinics or urgent care offices providing the basic services that many people need, including blood pressure testing, diabetes screening, cholesterol monitoring and treatment for the occasional cold or flu?
Let’s face it, nothing can beat the convenience of a 24-hour clinic open at a pharmacy where medications can be filled at any hour.
That level of accessibility doesn’t happen in my own office, unless you count the emergency room next door. But convenience does not make something an emergency, and for all those who come in after hours because their doctor isn’t available, others with true emergencies have to wait. It’s always better to save the ER beds for people who really need them.
Which brings me back to my work routine. Let me share something with you: I probably don’t need to see about one-third of all of my patients that I see each day. They are mostly sick-visits, bronchitis, sinus infections and things that will eventually get better on their own.
This is a problem because I get requests all the time to take on new patients and, unfortunately, I don’t have the room in my practice to do so. I’m too busy, seeing a lot of people the day they call, for illnesses that I can’t really do much about.
Why? People need sick notes, or just some reassurance that their health isn’t going to get worse. I like to be there when patients need me.
But as a consequence, I have to limit access to other people in order to give more access to fewer patients.
There are people who need to see a primary care provider routinely.
Remember, the most common cause of death in the United States and locally here in Hawaii is heart disease followed up closely by cancer, and these conditions require regular medical evaluation and treatment, especially with a continuity of care. And yet, with the ever-increasing shortage of primary care providers available, such serious illnesses will be missed, and people will die as a result.
It’s not possible to hire the 300 or more primary care doctors we need in Hawaii overnight, and the UH report noted that one-third of our active providers have already reached retirement age.
So what if urgent care and walk-in clinics became a type of basic care provider? The hours are great for patients, the locations convenient and, if someone needed more complex care, they could be referred to a primary care provider who spent all their time handling serious cases.
My current census of 2,000 patients could be increased to 2,500, or more. Multiply that increase by the numbers of primary care providers available now in the state and the access issue could be solved. There would be more than enough doctors to go around in Hawaii.
Now, of course, some people will say it doesn’t pay to see more complex patients and that it is easier to see more people with simple problems than to see fewer patients with serious illnesses.
Insurance companies would have to compensate those who agree to see more complicated cases and, logistically, there are a lot of roadblocks that would need to be resolved.
But what’s the alternative? It’s not possible to hire the 300 or more primary care doctors we need in Hawaii overnight, and the UH report noted that one-third of our active providers have already reached retirement age.
The lack of access to doctors across the state is a crisis already, and it will get worse. That will result in a human toll and in added costs for the people of Hawaii at a time when the price of paradise is high enough.