Kamehameha Schools graduate Kekoa Taparra would love to return home to complete his doctor training in Hawaii when he graduates from medical school. But he can’t.

A training program in radiation oncology — his chosen specialty — simply doesn’t exist in Hawaii.

“I have this mission to come back home and join the forefront against cancer, but I definitely have to stay on the mainland a bit longer,” he said over the phone from Rochester, Minnesota, where he attends the Mayo Clinic Alix School of Medicine.

Taparra, 28, entered his fourth year of medical school this fall and his graduate medical training will likely take at least another five years.

He’s not alone. Many local medical students must complete their graduate training, or residency, elsewhere. Residency positions in Hawaii are limited in number and competitive, and certain specialties such as emergency medicine and radiation oncology aren’t offered.

And the limited training opportunities are exacerbating the doctor shortage in Hawaii.

At last count, Hawaii has about 3,500 working doctors. But the state estimates it needs nearly 800 more physicians.

Almost half of the doctors needed in the islands are primary care physicians — those who practice internal medicine, family medicine, geriatrics or pediatrics — according to Hawaii/Pacific Basin Area Health Education Center Director Kelley Withy, who tracks Hawaii’s medical professional needs.

“If we look at the supply and demand lines, we’re diverging, so yes, we need more medical school training and residency training,” Withy said.

She estimates that Hawaii needs to double or triple both the number of medical students and the number of resident graduate doctors to sustain the system.

Home Grown

The University of Hawaii John A. Burns School of Medicine, the state’s only medical school, has grown its student body from 64 students to 77 over the past decade.

“It’s growing in size, and that’s a big accomplishment,”  said Leimomi Kanagusuku, who graduated from JABSOM in 2018. “But there is the issue of being able to house all the residents that we need here in hospitals. And if people do go away for medical school and residency, how do we get them to come back or stay in Hawaii?”

This year, Kanagusuku is among 232 resident doctors floating from hospital to hospital throughout JABSOM’s residency programs on Oahu. About a third of the doctors currently in residence in Hawaii hospitals attended JABSOM.  Selection of residents is extremely competitive. It’s also out of the school’s control, since medical school graduates across the world are placed into U.S. teaching hospitals by a national nonprofit organization called the National Resident Matching Program.  

“Most states have seen a significant increase in GME (graduate medical education) residencies,” said Jerris Hedges, dean of the University of Hawaii John A. Burns School of Medicine.

Not so in Hawaii, Hedges noted. The number of residency positions has actually declined slightly in Hawaii during the last decade — in 2009, there were 241 residents.

Currently the University of Hawaii’s medical school is able to oversee just 19 nationally accredited programs which are run by a separate nonprofit called Hawaii Residency Programs Inc. Training spots are available in specialties like internal medicine, family medicine, obstetrics and gynecology, surgery and psychiatry, among others.

“These are fairly bread and butter programs, ones we definitely need in Hawaii, but if one were inclined to do additional specialization, you’d need to leave Hawaii,” said Hedges, an emergency physician who has long advocated for the creation of an emergency medicine residency.

Fewer Spots, More Competition

For some medical specialties, larger institutions elsewhere in the U.S. offer the opportunity to work with a bigger volume of patients, which is often a requirement for training.

But Hawaii needs more training opportunities in family medicine, gastroenterology, emergency medicine and medical oncology, according to the Hawaii Medical Education Council.

A decline in funding from hospitals and from the federal and state governments is the main issue, says Hedges. It’s expensive to run training programs, and in some cases, there simply aren’t enough patients to validate a residency.

Hospitals would have to cover the cost of new training positions, and while the institutions receive federal funding to support them, it’s not nearly as much as what hospitals on the mainland receive.

Over the past several years, some teaching hospital partnerships have ended, including programs at Wahiawa General Hospital and St. Francis Healthcare System of Hawaii.

In the last two years, a combined training program in pediatrics and psychiatry closed, as well as a “transitional year” track. Meanwhile, a planned rural expansion for the family medicine program did not get off the ground because of a lack of funding, according to the most recent HMEC report. A potential gastroenterology fellowship could have brought someone in to help patients with liver disease, something that has a high prevalence among Pacific populations, but plans for it are on hold.

In an ideal scenario outlined by the HMEC report, the family medicine residency program would have 36 residents, instead of the current 18 positions, and there would be more rural training tracks on neighbor islands.

Practice Where You Teach 

The lack of doctors is felt most sharply on the neighbor islands, where far fewer physicians per capita practice — and where there are very few training opportunities.

“The way to get them home is to grow them and train them where you want them to practice — that’s the tested formula,” said Lee Ellen Buenconsejo-Lum, a family medicine physician and the director of graduate medical education at JABSOM. “But to do that you need faculty and clinical education space.”

During their third and fourth year of medical school, JABSOM students may participate in clinical rotations at some community health centers or hospitals located on neighbor islands. But when they graduate and look to apply for a residency position, nearly all training opportunities are concentrated on Oahu.

The state’s sole neighbor island residency program, the Hawaii Island Family Medicine Residency Program in Hilo, is part of the Hilo Medical Center run by the Hawaii Health Systems Corp. The program welcomed its first class of resident doctors in 2014 has graduated 10 doctors to date. It’s supported by a recurring state appropriation and philanthropic support.

Walker says the training is particularly intensive, as many patients have not had access to primary care or preventive medicine for years.

“It forces us to be at the top of our practice because I don’t have the luxury of handing off my patient to a specialist,” said Walker.

Walker said Hilo’s model could be adopted on other islands, but only if there’s enough financial backing and the support of the community.

Some community health centers are also exploring ways to provide doctor training in primary care.

The Waianae Coast Comprehensive Health Center hosts 10 new medical students a year through its partnership with A.T. Still University School of Osteopathic Medicine in Arizona, but many leave.

“Most of the graduates of our A.T. Still training program have to go elsewhere for their residencies,” said Richard Bettini, president and CEO of the Waianae Coast Comprehensive Health Center. “Even though they’ve established working relationships, if they have to go to the continent, they develop new bonds and they stay.”

Now, Bettini and Bradley are exploring the possibility of starting a residency program so their medical students can stay for the required training. Waianae Coast Comprehensive Health Center already offers residency positions in dental care.

“It’s turning the paradigm on its head, saying, if you want to train primary care physicians for the community, the best place to train them is in the community with providers who are working in that environment,” said Steve Bradley, the chief medical officer at Waianae Coast Comprehensive Health Center.

Creating Incentives

Meanwhile, officials also say Hawaii has a harder time retaining physicians because of lower salaries and reimbursement rates for care compared to other parts of the U.S. And when students graduate saddled with debt, more are picking higher-paying specialities.

“You can earn a lot more as a specialist, so the tough work of a primary care physician is undervalued in the U.S., and that drives physicians to go elsewhere and practice in different environments,” said Bradley, a former professor at JABSOM.

Nash Witten, co-chief resident of the UH Family Medicine Residency Program, says many of his peer resident doctors live at home with family if they can. When they finish their residency, they face difficult financial choices if they stick with family medicine, considering Hawaii’s high cost of living and other factors, such as the steep price of malpractice insurance.

“They’ll go out and start working and expect those normal basic things … like a car … and they realize they can’t do it,” he said. “You get an email from Alabama offering $350,000 as an emergency department doctor, when a federally qualified health center might be offering $120,000 for the same job. For my colleagues that don’t have family ties here, Alabama looks really good.”

This year, in an effort to keep doctors it trains home, JABSOM offered scholarships that require students to practice in Hawaii after graduation.

Kanagusuku said she wouldn’t have been able to go to medical school without financial scholarship funding that she received from a Native Hawaiian scholarship program. Two years of her tuition were covered, and once she completes her residency in family medicine she’ll be required to serve at a Native Hawaiian Health System clinic or a health center in Hawaii.

There are other incentives being offered to doctors willing to practice in underserved areas. The state offers a loan repayment program that has assisted 56 doctors with repaying their loans if they work in primary care or mental health, according to Withy.

“We’ve kept 50% of them, which is actually good compared to the 25% retention rate for national loan repayment,” Withy said.

But Buenconsejo-Lum says it’s far more difficult to convince doctors to stay when they’re not from Hawaii.

“Unless that person is from Hawaii, they’re going to do their three years and then they’re gone,” she said. “If they’re not from Hilo, or a small town, and their kids get to middle school age, they may move to Oahu. To get doctors to neighbor islands, you have to make sure there’s a job for the spouse and education (for their children).”

Hoping To Come Home

Taparra, who completed a doctorate degree in cellular and molecular medicine before deciding to pursue becoming a doctor, thinks there are enough patients to justify at least some doctor training in oncology in Hawaii.

In the years since he began studying cancer biology on the East Coast, Taparra said 10 of his loved ones received a cancer diagnosis and five of them have passed away. That adds urgency to his desire to return.

“Looking at cancer rates in Hawaii, Native Hawaiians have the highest mortality rates for both men and women compared to any other ethnicity in Hawaii,” he said.

“Looking at why our people are disproportionately dying from cancer is a big question. I’m just learning as much as I can, really just trying to do my best so hopefully one day I can come home.”