The state is scrambling to identify enough medical professionals to care for a potential surge of coronavirus patients in Hawaii. However, some doctors are concerned that the outbreak will further worsen the state's long-standing physician shortage.
Dr. Alistair Bairos, a general surgeon, has been practicing medicine on the Big Island for the past 35 years. Since the coronavirus outbreak, he's been seeing only about a third of the patients he usually does.
“Some doctors have cut back completely on face-to-face encounters,” he said. “The problem is then that the doctors still have practice expenses from which they’re going to get no or very reduced income.”
He said he does not think his practice can continue much longer with the small number of patients he's seeing.
Because of the stay-at-home order imposed by Gov. David Ige and the suspension of elective surgeries and other procedures, many private practices are going to struggle, said Dr. Scott Grosskreutz, a member of the Hawaii Physician Shortage Crisis Task Force. It’s a group of physicians on Hawaii Island working to address the lack of doctors in the state.
“If private practices are basically fiscally failing in the next three to six months, you don’t want these physicians to basically say, 'I’m bankrupt, I need a job' and leave because other states are recruiting,” Grosskreutz said.
“Other states are going out of their way to make it attractive for physicians to practice in their state. Requirements for state licensure have been stopped."
Doctor shortage exacerbated by coronavirus
Hawaii currently has a statewide doctor shortage of 24% with 2,974 physicians working full time. That percentage rises to 44% in locations such as Hawaii Island.
Dr. Elizabeth Ann Ignacio, treasurer with the Hawaii Medical Association, which represents doctors, explained that hospitals are trying to open opportunities for private practice physicians. She has been coordinating with the Hawaii Department of Health and the Healthcare Association of Hawaii, the hospital group, to bring together a medical workforce to deal with the current crisis.
“A lot of the hospitals are offering temporary disaster privileges,” Ignacio said, allowing doctors to practice in hospitals where they normally don't. “They’re asking their community providers to sign up for those. So there are opportunities for them to continue having income and work while their practices are kind of quiescent.”
Hawaii's aging, vulnerable doctor workforce
Another challenge for Hawaii is the age of many of its physicians: the state the second oldest population of doctors in the nation after New Mexico. Twenty percent of Hawaii’s doctors are over the age of 65.
The U.S. Centers for Disease Control and Prevention reports those over 65 have a higher risk of mortality if they become infected by the coronavirus. The mortality rate for people between 65 and 84 is between 3% and 11%. For those between 20 and 54 years old, the mortality rate is less than 1 percent.
Dr. John Lauris Wade, also a member of the Hawaii Physician Shortage Crisis Task Force, used the mortality rates and a population infection estimate of 30% from the University of Nebraska, and applied it to Hawaii's doctor population.
He calculates that out of the 594 doctors over 65 years old, 178 could fall ill and 6 could die.
Wade considers these numbers an underestimate because he used the lowest percentage of 3% to calculate the possible fatal cases.
Young doctors not attracted to Hawaii
Wade noted that one of the reasons Hawaii’s doctor population skews older is a deficit of younger doctors coming to the state.
He said the cause is probably a mix of factors. Unlike other states, Hawaii does not offer debt relief for young doctors with large student loans. The state’s high cost of living and its general excise tax that is often passed onto physicians who serve Medicare and Medicaid patients are other reasons.
Both Wade and Grosskreutz said these factors make it difficult for Hawaii to compete with other states.
Wade believes the coronavirus outbreak could also cause more doctors to retire. In 2019, 91 doctors retired and 152 left the state.
“Our concern is that by adding an extrinsic stress of widespread coronavirus within the state of Hawaii, that process that is already in place will simply accelerate,” he said.
There are doctors like Bairos, the Big Island general surgeon, who do not want to retire — even through two of the physicians with whom he shares an office will do so at the end of the week.
“We do it because it’s a calling,” he said. “You don’t want to give up, especially in a time of major need.”
Bairos is over the age of 65 and lives with his wife. While he does not plan to care for coronavirus patients directly, he still worries.
“You wonder what you’re bringing back home. It’s one thing if I go to the hospital one day or to the office to see a patient who I ultimately know turns out to be COVID positive. Your fears are absolutely realized,” he said.
“But you have to know at the same time you can be exposed every day to somebody who is currently asymptomatic, but they are actually infecting you. So every day, when you go home — do I start sleeping in a separate bedroom? Do I wash things separately?”
Waiving licensing requirements unlikely to help
Wade and Grosskreutz said the state should not expect to get an influx of health care workers from out-of-state coming to care for Hawaii patients, even though Gov. David Ige’s Supplementary Proclamation waives the state licensing requirements for many health care workers.
“We’re going into this with an army of physicians. It’s too small,” Wade said. “But sometimes you go into battle not with the army that you want, but the army that you have. And that’s what we’re doing.”
Lt. Gov. Josh Green, an emergency room physician, estimated Hawaii has about 5,000 non-practicing physicians.
“We would have a lot of capacity for individuals,” he said. “Of course, we only bring people off the bench when we have great need,” nothing that about two-thirds of the 5,000 are over the age of 65.
Given the advance age of the group, Marjorie Tayao, the Medical Reserve Corps coordinator at the Department of Health said, officials would only place older medical workers in less risky positions.
“Those that have the knowledge and have the experience can still help without being at risk. They don’t need to be in-person . . . whether it be a lot of trainings over the phone or using the internet,” she said. “There’s so many innovative ways we could utilize them.”
The Medical Reserve Corps is seeking workers with professional health backgrounds to sign up as volunteers. There’s no pay, but it’s a way to heed a call for service.