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.
Dr. Aaron Kauhane is one of just two doctors who work at Lanai Community Hospital, the only hospital on the island. The work is so demanding that physicians often last just three years before moving on. Photo by Linny Morris Cunningham.
“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.
Care in these communities will only improve with more Hawaiian physicians entering the workplace. In 1975, the John A. Burns School of Medicine graduated its first four-year class. At that time, there were only 11 Hawaiian doctors on record. Since then, 178 Native Hawaiian physicians have graduated from UH’s medical school. About 130 Native Hawaiian physicians now practice in Hawaii, representing nearly all specialties.
Each community requires a singular combination of educated skill and intuitive cultural awareness. Doctors who have chosen this path say they are constantly learning. But judging from the outstanding Native Hawaiian professionals profiled on these pages, they also have much to teach.
MOMI KAANOI, M.D.
WAIMEA, KAUAI
Dr. Momi Kaanoi’s patients tell her she looks like their daughter and sounds like their mother. But it still took time for the Native Hawaiian graduate of the John A. Burns School of Medicine to gain the trust of fellow Hawaiians who hadn’t seen a physician in years.
“Practicing on a Neighbor Island is so different,” says the 34-year-old Kaanoi, who attended Sacred Hearts Academy through 12th grade. “Science is the easiest part.” Rather, it’s the art of medicine that challenges her constantly, “the kind of stuff that’s not taught in med school. Really spending time developing relationships … that’s what’s important to them. I try to give them the respect, power and authority to make decisions themselves. But if they feel that you’re too busy, or you don’t have time, they won’t come back.”
For those who simply won’t visit the clinic, Kaanoi makes old-fashioned house calls. She integrates traditional remedies by working unofficially with a Hawaiian healer, supplementing treatments but never substituting therapy for life-threatening illnesses. Rewards for her services range from saving lives to a deep appreciation from the community she has altered forever.
It wasn’t an easy path. During her residency and fellowship through the Department of Family Practice, she prepared for her job on Kauai with rotations in Hana, Molokai, Hilo and the Marshall Islands. “I knew I was going to work on a Neighbor Island because the need is greater there,” she says.
Late in 2001, Hoola Lahui Hawaii, the healthcare system —that provides services to those in need on Kauai, hired her to help open a clinic in Waimea. She was the sole provider. For two years she saw patients full-time and also served as the clinic’s administrator, conducted research, gave speeches around the state about colo-rectal cancer, traveled to meet healthcare demands on the other side of the island, and began a new satellite clinic in Anahola. “I did it because it needed to get done,” she says. Yet she admits with a laugh, “I look back and think, how in the world did I do it?’”
Two new doctors now help Kaanoi in the Waimea and Kapaa clinics (the latter opened in April), but she still juggles her roles as provider and administrator at all hours, dealing with four interruptions that require immediate attention during a 45-minute interview. It’s no wonder. As director of both clinics, she monitors all medical, dental and behavioral health, which includes social work, substance abuse counseling and case management. She also serves as medical director of Hoola Lahui Hawaii.
“I have the energy and the passion for it; otherwise I wouldn’t be doing it,” she says. “It’s very rewarding.” Patients express their gratitude by bringing poi and chicken luau to the clinic. And Kaanoi says her immersion has led to a deeper understanding of her native language, culture and history.
Now finishing her third year of service in return for the Native Hawaiian Health Scholarship, she is not sure what the future holds. She is interested in pursuing her Master’s in Public Health in her ongoing efforts to create a model to improve care for Hawaiians across the state.
Kaanoi is articulate and modest, with a sense of humor vigorous enough to carry her through the most difficult times. But for years, she admits that she didn’t feel smart enough to become a physician. An adviser in college confirmed these insecurities, urging Kaanoi to avoid medicine. “I never imagined I would be a doc. There’s just something about feeling like you’re not good enough,” she observes, linking it to the humility inherent in the culture. “Now, I love to go out into the community; I love to tell kids, If I can do it, you can do it!’”
Spending time that each patient requires and deserves while keeping clinics financially sustainable is the ultimate artistic endeavor. There’s little doubt that Kaanoi is up to the task. “It feels like it’s been a calling,” she says. “Everything that’s happened…is meant to be.”
BILL THOMAS, M.D.
MOLOKAI
Dr. Bill Thomas could easily think of the local supermarket on Molokai as his second office. Even in the produce section, the requests keep coming: “Did you get my lab test back?” or “I need more of that medicine, the small white one.”
He’s invited to many luau, which become opportunities for an impromptu clinic or a casual inquiry about a friend’s diabetes—sensitive confidentiality issues he must evade in a lighthearted manner. “In small towns, the culture of the community is different, and you sort of have to work within that,” says Thomas, a former restaurant manager who began his formal education at age 30 at Kapiolani Community College. He then progressed to the University of Hawaii, and graduated from medical school at the University of Massachusetts.
A query about what he does in his free time elicits a long pause. “Sometimes I go for three weeks without a day off,” he admits. He wants to start fishing, but confesses he hasn’t “seen a fish—except at the store.”
The patients cherish his dedication. Soon after he arrived, word spread that a Native Hawaiian—who speaks and understands Hawaiian—had come to town. People who hadn’t visited a physician in years came for a check-up. Accustomed to a revolving door of doctors, they asked if he planned to stay. “I kind of thought it would be unfair to the community to come in, work for a short amount of time, and then leave,” he says. Though the 44-year-old is obligated to stay one more year to fulfill his Native Hawaiian Health Scholarship requirement, he says he bought a house and has no plans to leave.
Consequently, free time may continue to elude him. One of three internists, Thomas takes call about 10 days each month, duty that sometimes requires 24-hour shifts. He’s the hospital’s chief of staff, consultant to the diabetes care program, and the medical director of Na Puuwai, the Native Hawaiian Healthcare System for Molokai and Lanai. He also covers the emergency room two to three days per month, and directs long-term care.
Treating a multitude of chronic illnesses such as diabetes, heart disease, lung disease, asthma—and polishing his pediatric skills, as well—can spell exhaustion without a break for recovery. “Some nights you’re in the hospital most of the time,” he says, “and that can be kind of draining.”
Yet the community’s gratitude always revives him. “The people are so appreciative of everything I do,” he says. Everyone says hello; they constantly include him. “I don’t feel like an outsider.”
Thomas has felt the island calling ever since he listened to legendary Molokai physician Emmett Aluli speak about practicing there. In a matter of days, recalls Thomas, “I knew it was a perfect match, and I didn’t apply anywhere else.”
AARON KAUHANE, D.O.
LANAI
Dr. Aaron Kauhane can’t get sick. Charged with keeping Lanai’s 3,000 full-time residents healthy, Kauhane works at the two acute-care bed Lanai Community Hospital with partner Dr. Jon Gasper. Together they cover clinical care, emergency room visits, extended care, and dispense medicine as pharmacists.
When his partner goes on vacation, says Kauhane, “that means I have to cover the E.R. a week at a time by myself, 24 hours a day.” Forget about catching up on sleep the next day. Clinical duties beckon. “My partner and I are the only medical clinic on the island. That’s why the turnover is so high.” Doctors last an average of three to four years on Lanai before moving on to other positions.
Kauhane has completed two years of his commitment to the Native Hawaiian Health Scholarship that put him through osteopathic school, and is not sure what he will do when he finishes. Though his family lived with him on Lanai for the first year, his wife and two children have since moved back to Oahu for work and school and the support of extended family. Kauhane commutes between islands.
“It’s challenging,” the 35-year-old admits of the frequent travel, separation from family and constant demands at work. “But I’m really trying to balance everything out.”
Spiritual rewards facilitate that equilibrium. “Even if I didn’t have the scholarship, I think this would have been hands-down the job for me,” says the Punahou School and Whittier College graduate. “As a family medicine physician, it has everything that I trained for. We cover the full spectrum of life.”
A typical day begins at 8 a.m. with clinical visits. Between patients, he’ll walk down the hall to the pharmacy to process prescriptions. Whoever is on call must “drop what we’re doing” to deal with any emergency that arises a few hundred feet away. “We play physician, pharmacist, case manager, social worker … dealing with medical conditions from top to bottom.”
Emergencies are never simple. If a person has a stroke, for instance, Kauhane will call Hawaii Air Ambulance. The patient is put on a triage list. Maybe he’ll get med-evacuated, maybe not. It depends on the caseload for the Air Ambulance, which can’t cover every island at any given moment.
Furthermore, women are not supposed to deliver babies on Lanai, but Kauhane and his partner typically deliver three to six babies each year. “That’s probably our biggest challenge,” he says. While expectant mothers are supposed to go to Maui or Oahu two to four weeks before they’re due, financial limitations can derail plans. If family isn’t available to provide room and board elsewhere, women will stay on Lanai as long as they can, showing up in the E.R. when they go into labor. Sometimes the window of opportunity to med-evac them slips away. So mother and infant risk remaining in a hospital ill-equipped to handle obstetrics emergencies.
Kauhane is committed to lobbying for the means to have a third physician work on Lanai so they can avoid rescheduling appointments or making elderly patients wait for their medication if one doctor becomes ill or must travel. His top priority is to keep the quality of service high. “I want to be here as long as I can be,” he says. “I want to make sure we have a system in place to meet the needs of the community.”