DENNIS ODA / DODA@STARBULLETIN.COM Dr. Hao Chih Ho, director of trauma services at Queen's Medical Center. Queen's doctors are increasingly burdened because of a shortage of many specialists elsewhere in Hawaii, especially the neighbor islands.

Demand without supply

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It is one of the most fundamental principles of economics: When there is a need for services, and money to pay for them, a supply generally follows. But that isn't the case for some medical specialties in Hawaii -- especially on the neighbor islands, where a relatively small population and a high cost of maintaining a practice have conspired to drive specialists away. In this three-part series, Nina Wu examines the problem, the causes and the unsettling prognosis.

While vacationing on the Big Island, Seattle resident Douglas Suhm suddenly fell ill, waking up the next morning with a sharp pain in his knee.

His wife drove him one hour to see a doctor at the North Hawaii Community Hospital in Waimea, who determined early in the afternoon that he had an infection and would need to undergo surgery right away.

Suhm waited for hours, uncertain of where he would be treated, as the doctor made desperate phone calls to every surgeon that he knew in Hawaii.

No one was available on the Big Island, and the Queen's Medical Center, which fields most trauma cases from neighbor isles, had no beds available.

Finally, at midnight, Suhm found out he was to be transported by Medevac to Castle Medical Center to be operated on the next morning by Dr. Linda Rasmussen of the Windward Orthopedic Group.

"We never expected this to happen," said Suhm, 79. "We figured this is not a Third World country, and certainly there would be some kind of help available to us. Probably the worst part was the apprehension of what was going to happen."

Suhm was able to connect with Rasmussen because his daughter had gone to school with her. Rasmussen was not on call, but she made herself available for the operation.

But not every patient has been so lucky.

There have been elderly patients with broken hips, who have waited in pain for days on Maui and the Big Island, before an orthopedic surgeon was available to see them. Those delays in treatment can result in more complications such as blood clots or pneumonia.

On the weekends, anyone who gets into a car or motorcycle accident is out of luck -- if there are no surgeons on call, they will most likely be flown to Honolulu.

In one case, a visiting physician who was injured on the Big Island is now brain damaged because he did not get to Honolulu fast enough.

Like the rest of the nation, the Aloha state faces a doctor shortage. But in Hawaii, it is magnified by transportation barriers, the cost of running a private practice here, compounded by lower reimbursements and an ongoing exodus over the last 10 to 12 years.

While Hawaii's existing surgeons are retiring or moving to the mainland, the doctors of tomorrow coming out of the University of Hawaii's medical school and residency programs are also leaving to pursue opportunities outside of the isles, leaving the Aloha state short-handed.

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DENNIS ODA / DODA@STARBULLETIN.COM Dr. Linda Rasmussen, orthopedic surgeon, with patient Irene Judd, who was getting a check-up. Rasmussen said she gives all her patients a hug. Irene said Rasmussen was her best doctor -- if she moved, she would move too. Rasmussen says she's here to stay, but is very vocal about the things that need to change in order to keep more doctors from leaving Hawaii.

The ongoing exodus of doctors from Hawaii is overburdening the state's lead trauma center on Oahu, and leaving neighbor islands in the lurch.

The situation was critical a decade ago -- today, it's worse.

Hawaii's hospitals are short of many physicians, ranging from orthopedic surgeons to anesthesiologists, gynecologists and general family practice physicians. But when a major trauma occurs, such as in a major car accident, the impact of the shortage can be felt most in the emergency room.

The Big Island only has a handful of orthopedic surgeons -- and many of them have cut back their hours significantly. Even more alarming, of all the neighbor isles, only Maui has a neurosurgeon.

Hao Chih Ho, director of trauma services at the Queen's Medical Center and a trauma surgeon, said it has admitted an average of about 1,600 cases for the last five years.

Neighbor island trauma cases increased about 17 percent, from 209 to 245 between 2005 and 2006. More cases are coming in from the Big Island, where there is a growing population and shortage of surgeons.

The lack of on-call doctors willing to work on the weekends there means anyone who gets into a vehicular accident will likely be flown by air ambulance to Oahu for emergency treatment.

The same goes for Maui, Molokai and Lanai.

On Kauai, a new center at Kauai Veterans Memorial Hospital in Waimea helps alleviate some needs, but still needs more on-call services for emergency cases.

Many times, if a patient has a broken arm from an ATV accident in Hilo, for instance, he or she is informed it might be more viable to buy an airplane ticket to Honolulu and to check into emergency at Queen's, rather than to wait to be sent by air ambulance.

"We are running pretty much at capacity most of the time," said Ho. "The growth rate has been highest on the Big Island."

Queen's has seven trauma surgeons, with four that take most on-call cases. Two surgeons left over the last two years, and only one has been hired so far.

When the regular staff is not available, Queen's has had to outsource its emergency trauma cases to private practice physicians.

Queen's loses about $2.7 million a year on the trauma services it provides to the community.

Most serious trauma cases do involve broken bones, according to Ho, with the numbers of cases growing from accidental falls-particularly when mango and lychee season comes around in Hawaii.

But the number of orthopedic surgeons in the state is diminishing.

Linda Rasmussen, president of the Hawaii Medical Association, said the number of orthopedic surgeons has gone from 68 in full-time private practice in 1995 to only 48 now.

On the windward side of Oahu, where she practices, there were seven orthopedic surgeons a year ago -- today only four remain.

DENNIS ODA / DODA@STARBULLETIN.COM Dr. Hao Chih Ho, right, director of trauma services at Queen's Medical Center, and Sally Jones, trauma coordinator, stood in the loading dock where the ambulances unload trauma patients going to the Queen's emergency room.

Reasons for leaving

In recent years, surgeons here have left to take jobs at Kaiser Permanente in California, as well as to set up private practice in Texas, which recently passed tort reform legislation. Others have taken an early retirement.

Rasmussen said that the neighbor isles pose a considerable challenge for physicians because of the lack of support for special or complicated cases.

"When you are on call on the Big Island, you don't have the support of a specialist who can take the more complex cases," she said. "These can include complex fractures of large bones in kids, hand injury cases, major spine or pelvic trauma."

If Queen's is full, she said, a doctor might be stuck taking caring of something he or she may not have the expertise to care for.

The same could be said for the infrastructure, such as an available anesthesiologist, an operating room and support staff.

Ho said that the smaller populations on the neighbor isles do not attract specialists such as neurosurgeons because there wouldn't be enough cases to set up a private practice. But the problem is when a case does occur -- and there's no one available to take care of it.

"Ideally, people on neighbor islands would have access to the same kind of care that's over here," said Ho, "but it's hard for sub-specialties to be based in a smaller community where there aren't enough non-emergency cases."

The more trauma specialists who do leave, said Rasmussen, the more difficult it becomes for those who remain in Hawaii because they have a smaller referral network for complex problems.

Under current laws, an on-call physician that has a patient with an open fracture is responsible for transferring him or her to another physician.

"Emergency room physicians, referring physicians and nurses are spending an increasing amount of time just trying to get a patient transfer to an appropriate facility," she said.

Rasmussen said some physicians with private practices are only making about $50,000 after expenses, while others are making no profit at all, and use savings to keep their practice alive.

True, she could work for a health maintenance organization like Kaiser, with a regular salary and no overhead, but Rasmussen said she prefers the personal patient-to-doctor relationship and believes patients should be able to seek a specialist directly.

So what keeps Rasmussen here? Family.

"I love the people," said Rasmussen. "Hawaii's great, the people are just so warm. I just pretend I'm in a Third World country doing my job, and that makes it easier. My patients are like a huge family."