Monday, March 13, 2006


Disappearing Doctors: Hawaii looks for quick but questionable fixes

Hawaii is suffering an acute shortage of doctors, particularly in rural areas. On the Mainland it's possible to drive to a nearby city for quality medical treatment, but if you live on Molokai or the Big Island, that's not going to work.

In a well-written op-ed piece Crisis point: Don't get hurt on Big Island in the Honolulu Advertiser, Dr. Barry Blum warned:
It's probably wise for anyone who has any ongoing serious medical condition to avoid moving to the Big Island. We cannot guarantee that there will be doctors here to take care of them if they need hospitalization.
Dr. Blum is an orthopedic surgeon, but the problem crosses professional boundries.

The federal government reduces Medicare payments and for no particular reason, Hawaii's monopolistic insurance companies follow suit. With diminishing reimbursements and fewer patients in rural areas, doctors simply can't cover expenses. This is pretty much across the board, with some professions in shorter supply than others. Hospitals can't find doctors willing to be on call night after night as more of them leave the state. This can and should be fixed before the state becomes a health disaster zone.

A bill is moving through the Hawaii legislature that proposes a quick but risky fix to a shortage of psychiatrists in rural areas of the state. The bill, HB2589, calls for giving psychologists practicing at health centers prescriptive authority under a restricted formulary.

Far from solving the problem, this will condemn those who depend on these services to second-class and possibly dangerous treatment, and will limit them to a choice of drugs that may not include the ones that work best for them.

First of all, a resticted formulary is always a problem. The oldest, cheapest drugs will be the ones provided, not the newest and most effective. Many organizations have policies against restrictive formularies. See, for example, the policy posted on Kokua Council's website (pdf).

A psychiatrist is first of all a doctor and keeps up with the medical literature through journals and continuing education. Most stay connected with UH's school of medicine and attend periodic grand rounds. Medicines have differences--one may be better than another for a given condition, or one may have troublesome side effects that become known over time. Older people often take multiple drugs and interactions are not only possible but fairly common.

A psychologist, without contact with the medical community, is simply playing in a sandbox filled with medicine bottles.

From testimony at the hearings, it's clear that psychiatrists are not objecting to other professions having prescriptive authority. Advanced practice registered nurses are granted prescriptive authority by the Department of Commerce and Consumer Affairs. This was supported by the Hawaii Psychiatric Medical Association at the time the law was proposed. The bill before the legislature today does not propose similar training and is more like a free pass to prescribe, which is not in the public interest.

Advocates for the psychologists point to the Department of Defense program in which psychologists prescribe. The Hawaii bill does not provide anything approaching the level of training that the limited DOD group was given, and does not provide for the supervision by psychiatrists that the DOD requires.

Testimony gave several examples of the danger in this quick fix. A patient arriving at the emergency room has psychotic symptoms, but the psychiatrist, who is a trained medical doctor first, orders a scan and discovers that the patient has suffered a stroke. The patient is treated appropriately for the stroke.

Imagine that you were that patient and were seen only by a psychologist without medical training, and whose toolkit has only a single hammer, the ability to prescribe certain medicines.

Imagine that an elderly person required treatment, but could only see a psychologist (health centers would quickly get rid of any psychiatrists they still had around). There would be nothing to prevent a potentially deadly mix of meds from damaging rather than improving the older person's health. Geriatric psychiatry is a specialty by itself requiring additional medical training which the cheaper psychologist won't have.

It wouldn't do on the Big Island to have physical therapists doing the work of orthopedic surgeons, and it won't do to require underserved and poorer populations to be treated by psychologists instead of medical doctors.

We need to find real solutions to the problem of Hawaii's disappearing doctors, not quick and dangerous fixes.


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