COVID-19 pandemic, Hawaii’s patients have faced escalating delays in medical care and are increasingly required to travel between islands for specialty or even general care.6


This is costly and


sometimes impossible for patients who cannot afford the travel or cannot get time off of work or arrange childcare during work hours.


The physician shortage Despite being billed as a “paradise,” the state has a critical shortage of practicing physicians. A 2021 analysis found that Hawaii County had the third highest shortage of primary healthcare professionals in the nation, and a 2022 report found that 75% of Hawaii’s rural hospitals were at risk of closure.3,4


“We’re making such great technological advances, but we’re also widening the gap.” —ELIZABETH IGNACIO, MD


community,” Dr. Ignacio said. “So many will leave after 2 years here.”


Many


states like Hawaii suffer from an ongoing physician shortage, and the level of subspecialty shortage in fields such as IR remains unclear and likely underreported.


According to Dr. Ignacio, the difficulties of practicing in Hawaii make it hard to retain physicians in the state.


“Very often, if prospective physician interviewees are asked why they want to practice in Hawaii, they will say that they traveled here on vacation and love the outdoors and hiking and surfing,” Dr. Ignacio said. “That’s an honest answer, but those passions won’t necessarily sustain you when you see how difficult it is to practice here.”


Like many rural areas, the cost of living and housing is a substantial barrier to recruitment. According to World Population Review rankings, the cost of living in Hawaii is almost twice the national average, making it the most expensive state in the United States to live in. Groceries cost almost 50% more than the national average due to shipping requirements, and the state has a well-documented housing crisis.5


For incoming physicians, these


barriers, coupled with lower salaries and reimbursement rates, make it both difficult and undesirable to establish a practice in Hawaii.


“It can be very disheartening and discouraging to practice here as a young physician, struggling with enormous student loans, barely able to afford your workspace and staff, and so far from family with no connection to the


Those cultural connections and willingness to gain cultural competency is crucial to practicing in an area like Hawaii—and that connection is what drives Dr. Ignacio’s commitment to the state’s residents. “It is the warmth and kindness of the small and rural communities that has easily drawn me in. I know that the spirit of Aloha is real. People want to get to know you, to look you in the eye and know how your day is going, even if you’re just standing in line at Walmart. It’s called talk-story, and that ability to genuinely connect is beautiful—it’s a unifier of the multiethnic culture of Hawaii.”


Is telehealth the answer to provider access? In July 2022, Community First Hawaii published Access to Care,6


a Centers


for Disease Control–funded review of the state health disparities developed in partnership with the county of Hawaii, the state department of health, the Hawaii Medical Association, and the largest insurance and health providers in the state. The review surveyed both patients and providers with the aim of closing these disparities and improving access to care. According to the findings, the state must address the provider shortage and adapt practices to reflect the values and identities of local populations.6


One often-cited solution is expanding access to telehealth services. But according to Dr. Ignacio, telehealth can


Glossary


Socioeconomic status (SES): The social standing or class of an individual or group. It is often measured as a combination of education, income, and occupation.


irq.sirweb.org | 31


be a blessing for some and a nightmare for others.


Telehealth became increasingly popular during COVID, as it allowed physicians to see more patients a day and negated many of the logistical barriers to care. However, the Access to Care survey found that many Hawaii residents are hesitant or unable to use telehealth. A sizeable number of residents don’t have reliable internet access or smart devices, or they are unable to afford the data bill required for such a phone.6


“We’re making such great technological advances, but we’re also widening the gap,” Dr. Ignacio said. “Studies show that even as we make technological advances, we’re also making it harder for people from socioeconomically challenged backgrounds and underrepresented communities to gain access.”


In addition to logistical issues, many patients said they felt the technology causes a lack of personal interaction and connection, and this was especially true for older patients. Patients also said they don’t trust physicians to diagnose them through a phone and may feel uncomfortable answering personal questions from someone who doesn’t understand the realities of where they live, Dr. Ignacio says.


“Many of our patients, especially those who are native Hawaiian, Pacific Islander or Filipino, don’t trust the telehealth platform,” Dr. Ignacio says. “The doctor may not understand their language, or they feel hesitant and/or embarrassed having to go to a health center to access


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