Geography Challenges Hawaii AFP's Ability to Grow Family Medicine

Collaboration With Medical School, Residency Aids Chapter's Efforts

February 28, 2011 07:10 pm Sheri Porter Honolulu –

The legendary surfer's paradise known as the Banzai Pipeline is located on the north shore of the Hawaiian island of Oahu. However, a very different kind of pipeline is the topic of the day -- every day -- at the Hawaii AFP.

Hawaii desperately needs to expand its primary care pipeline so that the state can provide medical care to its residents, says family physician Allen Hixon, M.D., an ardent supporter of the Hawaii AFP's efforts to address the state's physician shortage.

A past president of the Hawaii chapter, Hixon currently is an associate professor and vice chair of the department of family medicine and community health at the University of Hawaii at Manoa John A. Burns School of Medicine in Honolulu.

"We're an island state, and so we have populations that live on seven islands," he told AAFP News Now. "Those island populations range from 400 to 850,000 people. The primary care shortage on the neighbor islands is quite extreme."

According to Hixon, who also serves on the AAFP Commission on Education, the health care challenges in Hawaii, particularly in rural parts of the various islands, are very different from the rural health challenges in the rest of the United States. "Distances to care may be great (on the mainland) but you can get in a car and drive to get the services you need. That just doesn't exist here," said Hixon. "Geography is really a very defining issue for our health system."

Family Physician Likes Pace of Primary Care in Hawaii

Jason Florimonte, M.D., a family physician transplant from Ohio, practices in a four-physician multispecialty practice in Kailua on the Hawaiian island of Oahu.

"Hawaii is very accepting of family medicine. It's a good place for family physicians," Florimonte said in an interview with AAFP News Now. "The family unit is very important in the Asian Pacific Island culture. Everything is about the family, not about the individual. I see it every day right in front of me."

Contrary to what some might think, Florimonte said the health needs of his patients in Hawaii are not "tropical" in nature but, rather, represent the "bread and butter" of family medicine. By and large, what he sees in his practice are patients with the same diseases and conditions treated by his family physician colleagues on the mainland.

A typical morning for Florimonte begins at the hospital, where he checks on patients who have been admitted. Then he heads to his practice, where patients stream through the door at a steady pace. It's January, and despite the 70-degree temperature outside, patient complaints of coughs, sore throats, ear pain and congestion are no less common than they were back in Ohio.

Florimonte sees his share of patients with heart disease, metabolic syndrome, COPD and asthma. The Polynesian population, he said, is especially vulnerable to diabetes and its complications.

According to Florimonte, the biggest challenge he faces in running a small practice on Oahu is monetary; namely, the high cost of living -- including the rising cost of rent, fixed expenses, staff salaries and benefits -- and what he calls "a relative lack of adequate reimbursement" for family physicians.

But even though the downside to practicing family medicine in Hawaii is making ends meet, the upside -- a family-centered culture, a relaxed pace and a great outdoor environment -- make the tradeoff more than worthwhile, Florimonte said.

Jason Florimonte, M.D., uses percussion to evaluate patient Jeanette Warf during a typical day in his four-physician multispecialty practice on Oahu in Hawaii.

Hawaii Chapter Sees Resurgence in 2010

By all accounts, the Hawaii AFP struggled for nearly a decade to regain the momentum it lost with the retirement of an active chapter executive in 2000 -- not good news for a state with pressing health care needs.

FP Jill Omori, M.D., is director of predoctoral education at the medical school's department of family medicine. She said the Hawaii chapter officers -- all busy family physicians -- worked hard to keep the chapter going during those lean years. "It took a toll on all of us," said Omori, who has 12 years of service on the Hawaii AFP Board of Directors under her belt.

According to Hawaii AFP immediate Past President Andrew Nichols, M.D., the chapter began to turn around in January 2010 with the hiring of a new executive secretary, Ernel Roque, who took on the responsibilities of the previous chapter executive. "She's come in here with a lot of new energy and has been able to get the ball rolling in many areas," he said.

For example, Nichols said, the chapter's newsletter -- which had gone dormant during the down years -- was resurrected. That seemingly simple act reopened a major conduit of information for chapter members.

The Hawaii chapter is unique among AAFP constituent chapters, said Nichols, who also is a professor of family medicine and community health at the medical school, program director of the school's sports medicine fellowship and head team physician for the University of Hawaii at Manoa athletics department. "In our case, we have one medical school and we have one civilian family medicine residency program," he noted. (A military-affiliated program, also on Oahu, is run by Tripler Army Medical Center.)

"It's really the only show in town," said Nichols. "Many of our chapter activities are designed to help the medical school and to help promote primary care among the medical students." In fact, several of the chapter's board members also serve on the medical school faculty, and that makes it easy to integrate some of the Hawaii AFP's activities right into the school, he said.

FMIG Brings Physicians, Students Together

A significant chapter focus is raising medical students' interest in family medicine. The long-term goal is to grow family medicine on the islands. Therefore, the Hawaii AFP allocates financial and physician resources to the medical school's family medicine interest group, or FMIG.

"There's a nice relationship between the FMIG group and the Hawaii AFP," said Omori, who runs the school's FMIG and is charged with planning and coordinating activities of a group she described as "very, very active."

According to her colleagues, Omori is a genius at setting up the perfect mixture of serious and fun projects to draw medical students in. "We have workshops and do a lot of community service, so many students who hadn't thought about family medicine when they came into medical school join to see what we're doing," she said.

The real challenge comes in getting chapter members engaged in projects that put them face-to-face with the medical students. "There is so much we physicians can do and a lot of influence we can have in the medical school," said Omori.

Facts About the Hawaii AFP

Chapter executive secretary: Ernel Roque
Number of chapter members: 393
Date chapter was chartered (as a territory before statehood): Sept. 14, 1950
Location of chapter headquarters: Mililani, Hawaii
2011 annual meeting date/location: Feb. 25-27/Hilton Waikiki Prince Kuhio Hotel,

Residency Program Cranks Out FPs

According to Lee Buenconsejo-Lum, M.D., the family medicine residency program director at the University of Hawaii, her program pulls its weight when it comes to training family physicians for Hawaii.

The residency program trains a total of 18 residents each academic year. About 80 percent of the program's graduates stay in Hawaii, and, of those, 60 percent practice in rural areas -- half of which are federally designated shortage areas.

Only once in the past 15 years has the residency program not filled during the National Resident Matching Program, known as the Match. Still, graduating six new family physicians each year isn't enough to fill the medical need in Hawaii.

Buenconsejo-Lum, who also is an associate professor of family medicine at the medical school, said her program, in conjunction with Hixon and the Hawaii AFP, is taking a lead role in workforce development in the state, and that includes growing physician populations on the "Big Island," Hawaii, and on the other neighboring islands.

She pointed out that the shortage of physicians on the neighboring islands overloads the health care system on Oahu.

"I really believe that if we had a well-trained cadre of primary care physicians (throughout the islands), many patients wouldn't have to be transported to Oahu, as is currently being done," said Buenconsejo-Lum.

Of the residency program graduates who elect to stay in the state, said Buenconsejo-Lum, "less than 20 percent are in a small group private practice." Most of the graduates work in community health centers or for Kaiser Permanente. That's because Hawaii's notoriously high cost of living takes a toll on physicians trying to run small practices, she said.

"Property values are overinflated, and land is at a premium," said Buenconsejo-Lum. "This is a resource-limited setting with workforce challenges."

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