The people of Hawaii continue to suffer from a severe and escalating physician shortage, especially on the neighbor islands. While a concerted effort to train, attract and retain more medical doctors has helped to mitigate this trend, care is increasingly being delivered by physician’s assistants and nurse practitioners. This is a necessary and viable solution to ensure access to care for Hawaii residents and visitors, but only if these providers are properly trained and adequately supervised.
The ability to function in a primary care setting is particularly challenging because it requires knowledge and clinical judgment over a tremendously broad swath of health concerns ranging from what constitutes a true emergency to routine preventive screening. This is in contrast to working with an endocrinologist, for example, focusing primarily on insulin management for diabetics. The ability to function successfully in a primary care setting requires fluidity and efficiency, together with the ability to prioritize and understand the big picture. Providers must know when and be able to access physician support and know when a referral to a specialist is needed or not. All of these factors affect patient satisfaction, clinical outcomes, liability and economic viability for the clinic.
In an effort to expand staffing to meet requests from new patients to join our practice during the past 16 years, Manakai o Malama has worked to refine team-based care that combines physicians with highly trained and experienced physician’s assistants and nurse practitioners. In fact, today we continue to recruit actively. Many applicants, however, seem to lack the necessary skills to carry a patient panel in the primary care setting, even those whose programs trained them specifically for this purpose.
The concern is that the nationwide physician shortage has spurned such a rapid and large-scale expansion of educational programs that the spirit behind the birth of these professions is at risk of becoming lost. Physician assistant programs were started when many Vietnam veterans with training as military corpsmen returned from war with distinguished service and substantial clinical exposure in the field. Sixteen- to 24-month programs were established to add academic training to hands-on medical experience. In contrast, today we see some applicants with minimal health care experience prior to their training program. Is the country moving too quickly to fill the gap? Twenty years ago there were fewer than a dozen accredited physician assistant programs in the U.S. Today there are 218.
The quality of nurse practitioners or advanced-practice registered nurses is also variable. The profession was originally formed by offering master’s degree programs to highly seasoned registered nurses. Doctoral programs are now also offered. Today some providers progress straight to the master’s program without substantial work experience as RNs. Here again Manakai has had an excellent experience employing nurse practitioners who had been able to combine solid didactic training with strong experience. Others who have applied seemed less prepared.
With support from state Sen. Josh Green (D, Naa-
lehu-Kailua-Kona), a partnership is being explored between UH Hilo and the University of Washington to train physician’s assistants for the first time in Hawaii.
“Initial conversations suggest that a partnership between UW and Hawaii could be a very good fit,” Green said. “Training PAs in Hawaii will help address our provider shortage, complementing several other initiatives that have been launched.
“I anticipate that we could start this program in just a few short years and would see almost immediate results, especially in rural parts of the state. The Big Island is an optimal setting to develop this program.”
The UW MEDEX PA Program is part of the Department of Family Medicine at UW and has been the No. 1-rated family medicine program in the U.S. for 22 years in a row and No. 1 for rural medicine for 27 years. A strong academic partner such as UW with a local training program could go a long way toward filling the widening care gap not only to achieve an adequate number of providers, but to also ensure that graduates are well prepared to integrate into busy primary care outpatient clinics.
Ira “Kawika” Zunin, M.D., M.P.H., M.B.A., is a practicing physician. He is medical director of Manakai O Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.
