 We're going to talk about community matters today with Esther Smith. Esther Smith is a family practitioner in Kealakapua, and we want to find out how that works, you know, because maybe one day we'll all be family practitioners, so she's going to tell us how we can become family practitioners, you know. Thank you for showing up Esther, appreciate it. We are very gratified to be able to talk to you because you're a kind of hero. You are a hero for Hawaii and for the big island. So Esther, how did you get to be a family practitioner? I mean, was there somebody who suggested, Esther, don't go into cardiology. Forget about radiology. You don't need to do brain surgery. How much is becoming a family practitioner? When was that moment? Oh, just a family physician is always a sore point for family physicians. I wanted to do some of everything. I wanted to be able to deliver babies and take care of children and take care of old people and do hospice. I wanted to do everything. And then, sounding corny, I genuinely wanted to help people. So it was always going to be, it was either going to be family medicine or obstetrics. And one of my obstetric preceptors actually did sort of talk me out of going into obstetrics because I had small children at the time. Well, I mean, maybe he told you about the cost of insurance. Oh, it wasn't so much that, although at the time, residency was limited to 80 hours a week on average. And that wouldn't be the same in obstetrics or in family medicine. I think that perhaps the obstetrics attending didn't quite understand how difficult a family medicine residency actually is. How difficult is it? Well, they're back to that 80 hours a week on average. I don't know if they've redone those rules since. But that was a huge reform that happened shortly before I became a resident. And you do rotations in just about everything. At the time, I was especially interested in women's health. So I did some eight months of obstetrical training at a high-risk facility. I did, I think, three months of surgery. Six months, I think, of inpatient rounding. I don't remember all the rest, but it's quite intensive. This is in Arizona. Spokane, Washington, actually. So, you know what strikes me is, and I have great respect for family medicine. Some of my best friends are family medicine doctors. But it strikes me that if you're studying family medicine, you have to know a very broad spectrum of things. You know, you're faced with any number of possibilities, and you have to do some pretty clever diagnostics to narrow that down. Am I right? Yes, the saying is knee deep and a mile wide. Yeah. Which I don't think is actually there now either, especially practicing somewhere where there are so few specialists. The depth of knowledge required to take care of patients with severe chronic issues can be enormous. Yeah. So, why Kiala Kokua? Kiala Kokua is a very, kind of, you know, it's a, shall I say, remote place. And, you know, what kind of practice can you have in Kiala Kokua? Well, let's start with serendipity is how I ended up in Kiala Kokua. It's a bit of a long story. But Kiala Kokua is actually where Kona Community Hospital is located, and so there used to be many doctors who were located either in Kiala Kokua or just slightly up. So, I actually took over a space between an OBGYN who is currently, I believe, 74 years old, and an internal medicine doctor who was 76 when he retired this year. So, there had been private practices in this building forever. Well, at least since before I was born anyway. And so, it was a place that people were used to having a primary care provider. And actually, through happenstance, a member of the community actually recruited me to replace her primary care provider who had retired. So, what's the general profile of your patients? I mean, I know it's going to be deep and wide, but to the extent you can define your patients, what are they like? I have mostly older patients, you know, over 60 to, I think I have a 100 year old one now. So, I'm practicing a lot of geriatrics, although older people in Hawaii do not equate to older people on the mainland and that people who choose to live here tend to be really active. And so, I find myself asking the Medicare questions that they require me to ask. And I'm basically sitting across from a 74 year old athlete who did like beat me at everything and having to ask them about how many falls they've had in the last year. So, I have the healthiest octogenarians I have ever seen in my practice where I forget how old people are. I have young working people, you know, of all stripes. And then not so many children because children are actually one of the better served communities on the island. And so, I'm doing what's needed. Well, let me guess and assume for a moment that your patients are not wealthy. Let me assume for a moment that you know, they can't spend that much on medicine. And so that sort of changes, and let me assume also there's a connection between people who don't have a lot of money and people who have a lot of heart attacks, diabetes, and strokes, you know, those kind of circulatory problems. Am I right? Yes. My retirees who moved here in retirement and bought big, beautiful homes are not the ones who were having the strokes and the heart attacks. They aren't the ones who were on five different, 10 different medications to manage their multiple medical problems. I chose to take every kind of Medicaid when I started against the advice of more practical people. And so I have a huge mix. I think that if I had to guess, I'm something like half Medicare, maybe a quarter Medicaid, quarter private pay, some tri-care thrown in, but I'm not positive. You know, you were a sterling number of the panel in our health care point counterpoint a couple months ago, and I had the impression watching it that you're, Esther, you're kind of different. You're not like regular doctors. You're different. Tell me, tell me as you agree, and if you do, tell me how you're different. Oh, I have a couple of things that make my situation unique. One, I had my children when I was quite young, and so my daughters are grown, which gives me a certain amount of time. And then that also means my children are out of the house and I'm still relatively young, and so I have that energy to be able to do the things that I do. I think that I am more altruistic than sensible if I'm being perfectly honest. That was visible. I have. You're very altruistic. No, my friends and family have urged me to choose a career path that is kinder to myself. It's rough. The doctors here, I have two good friends who are physicians who have been in the hospital with serious conditions that are entirely stress-related in the last month or so, and one of them was texting me from the emergency room with a blood clot in his lung, being like, I am so sorry. I can't see your patient. You're referring to me. I'm in the emergency room with a blood clot in my lung, which I got for standing in surgery when I was told I shouldn't. And like, there have been so many people who have passed rather early from doing what I do. All week, I've been coming up with cases to discuss with you because there's so many just examples of like why things are challenging now. I'd love to tell you one of those. Well, I'd like you to do that, but I have to ask you a question first. So, you know, you presented that healthcare program and you do on your website as somebody who is altruistic and who is compassionate. And I suggest to you that that's not necessarily stressful. Compassion is good for you, is it? Yes, but that's also during that panel, there was a discussion of doctors wanting better work-life balance. And I brought it then and bring up now. It's not the helping people part that brings us down, that makes us feel burnt out. It's the fact that there's twice as many hours in front of a computer than in front of a patient. You know, I will very willingly sacrifice time. This week, I had a patient I had to give a diagnosis of cancer to. She didn't want to tell her husband. So her husband came in that afternoon. I went and saw him, even though that is like completely uncompensated time. And I do it again because it's actually caring for someone. That's actually helping. You went to their home? No, she said her husband after she was gone. I'm right on the highway, so anyone who's commuting back south past from Kona goes right past my office. But that feels the well. Like when people are helped and when they tell you or just when you know you've done something, that's not what gets you down. It's the why am I filling out this prior authorization for the fourth time with almost the exact same information. Information that the insurance company already has in their databases because they know what they paid for and has failed. Why am I doing that on my weekend? That's what causes burnout. Well, it sounds like frustration in the sense that you want to help. It will be gratification if you can help. But these people who don't, these insurance people would have you who don't really understand your nexus with your patients are standing in the way. And that's unadulterated frustration. It's the death by a thousand cuts. Each one of these things is not a huge issue. And so the insurance companies, the government doesn't think of any of it as being a big deal because it's just like one little thing. But it's all of the little things that result in more of my time being spent in part of a computer rather than in front of a patient. I'm sorry to hear it. I was sorry to hear it when you described it. The preauthorization and all the red tape and all that because it is forcing doctors like you to work for big hospitals or to give it up after you go through all the commitment involved in medical school. One thing that I have a hard time getting through to people is that doctors are smart and that at some point they will make choices that are better for themselves. And so you can go back in or you can go into hospital work. You can open a med spa where you do nothing but fillers and Botox all day. You can do online care only. I looked at a job where I could be working very little from home taking care of people overnight in Georgia. That's another thing telemedicine has given us more options. Are you doing that? I'm not. I picked up a hospital job where I'm very much needed because again I have a problem. Okay. Let's go back to your practice and I do want to ask you about the cases you've been thinking about. But it strikes me that one of the big restraints if you will for a patient is time with the primary. And I mean if the patient makes a list of 10 problems that he wants answers for he may in general not get through the 10 problems because there's no time but come back later. And so my my impression is that you as distinguished from others you give them the time. I do and then I pay for it in paperwork that I have to do at home. I actually took a day off to do nothing but catch up on back documentation which I did for some 16 hours I think. So these things happen and by the way if you tell your provider 10 different problems and they let you try to get through all that things will get dropped or confused because you can't like about the time you hit problem number six. The six problems not getting taken care of as well as the first. So it is in your own best interest to come in with about three things at a time. I don't know how many times where I've like forgotten to send in the cream for the you know rash because it was like the fifth or sixth thing brought up. We're finding some really valuable advice here. Like they think it's just for us that we're like no no we can't do all these problems once it's actually like it is not beneficial to you after a certain point. How do you treat yourself? Of course. When's the last time I saw a primary care doctor for myself? Oh no no no it was when I signed up here so three years ago. Okay all right so you're not without some external needs that's that's okay. So what about these cases you have in your mind to discuss today? I have a couple that do a pretty good job of demonstrating how broken things are here. So 90 year old woman um has been on steady on her feet fell down and literally broke her neck. So her family not wanting to bother anyone manages to take her down eight stairs get her to the hospital where she's seen and that's when they diagnosed that she has a C2 fracture. Wow yeah it should and if it sounds scary because it should um they see it on the CT scan the docs want to just stabilize her and send her to Oahu um understandably but the neurosurgeon who's on call in Oahu says no no you're good you can do an MRI there there's an argument because the MRI is actually down and can't be used until the next day. So this woman is in a hard collar which are very uncomfortable for most of another day right um and then finally gets her MRI and it is deemed that this kind of neck fracture is stable enough that she can go home um yeah um this woman who is unsteady on her feet before they put her in a collar they um so the collar is left on even though that's not actually the standard you actually get a soft collar if you're going to be doing things this way um she actually has not established with a primary care provider since her doctor retired um thankfully um she her doctor retired was actually one of the ones I took over for so I assumed care and started trying to work on all of these issues um her family gets her up the seven stairs back into her house but she's been uncomfortable and has not wanted to walk around which is really bad for people if you are on bed rest you can lose five percent of your strength a day if you're over the age of 75 so um she's there and while I wanted to arrange home care for her but to arrange home care she really needs to be seen in person by the person who writes the home care orders for the because of Medicare rules so I managed to see her by phone long enough to like make sure her medications are ordered and I had to go to her house a couple of days ago to actually see her and then finally we could order all of the the home health needs that home home health care that you can she may be able to get physical therapy at home I'm not sure we're going to try we might be able to get some skilled nursing at home I'm not sure we're going to try um because we have had shortages in both of those things recently so I'm not positive she'll get those we actually have not very much for durable medical equipment suppliers here so even getting the hospital bed and such is a complicated process um in my office I have myself my receptionist office manager and my medical assistant and a nurse practitioner I do not have a social worker to arrange all of these things to follow up on all of these things and so we're doing that you know and I am not getting down on my hospital colleagues at all I know how restricted their resources are also but in a robust health care system like I knew in a bigger in mainland places before COVID I can't speak to what things are like after COVID because it's rough everywhere but she would have been admitted for probably three days because that's a requirement to go to skilled nursing that is forced by Medicare which actually does some weird things to care and she would have had the physical therapy she would have had all the things she needed and she was a patient who was very willing to go right so I'm like she doesn't have pneumonia I'm happy to say and like I think I think it's going to be okay but you know a week of bed rest that didn't need to be a week of bed rest is a problem you know um especially if she has a neck if she has a broken neck it's really important she doesn't fall well yeah anything could really exacerbate that too very serious you know like and the stories just go on like I've been thinking about it since I knew what was coming here it's like the time it took me nine months to be able to get a bone tumor treated in a patient where I knew it was there everyone else knew it was there but like between the coordination of the different specialists and the travel and everything else it took nine months thankfully that one turned out all right also um but it didn't have to turn out all right um you know it's just you know I have and it comes to simple things too like I have a young man who's got um you know he's got a nasal polyp that's just like wreaking havoc on his life this is a small thing but it is not going well and it has been as long as the six month wait to see the ear nose throat doctor on this island and there's only one of them yes um we have you know at least we have one of those we don't have a rheumatologist you know so speaking of how things go in the practice like if I'm taking care of somebody who has a complicated autoimmune disease and they're not willing to travel to obahu or they can't or whenever then it becomes my job and then thanks to the glories of the internet I can look up anything as long as I recognize what the problem is assess the patient correctly I can look anything up but if I have to spend 20 minutes looking up xyz condition because I only see it once every few years to make sure that I'm doing all of the modern things that is 20 minutes in which I am not seeing somebody else so when they talk about the shortages in primary care I actually think they under count not over count because they're not dealing with the fact that people like me are filling in for rheumatology we're filling in like we're doing more of the work up for cancer diagnoses than you do when you're on the mainland so you are if you are an internal medicine doctor in Honolulu you don't do well woman exams you refer those out if you are family physician especially a female one in you know kona or kyao kakua you're doing well woman exams and that's time that you can't do other things I'm glad to do those things but it's just the recognition of how much we're all carrying so what's the dynamic on this sester they're getting better from your point of view your observation or if they're getting worse and if it's getting worse where is it all going in terms of the delivery of reasonable health care to people on the big island the expectation I think for most politicians and policy makers and insurance companies is that everyone is going to be served by large clinics you know and some of these large clinics aren't going to move to places like yala kakua the other thing I think they're trying to move us all towards a model where it's all like what has happened to pharmacy I think you're old enough to remember when you've had a pharmacist who knew who you were and might be able to like actually address some of your issues does that exist in in society anymore I and that's not to putting it on the pharmacist that's putting on the corporations who have chained these professionals who are pharmacists right um as far as how things are going in Hawaii um so the bill to limit or to remove taxes on Medicaid Medicare and TriCare which for my take home was 30 of my take home one year um didn't go anywhere it got stopped by one committee chair um after passing everything else the other one is but SB 397 went through it's currently stalled it that is the bill that increased Medicaid rates um which are up to Medicare rates um and we're waiting on CMS to tell us that's the big federal organization that manages such things how those reimbursements are going to go um I've actually personally keeping track of how our local insurance companies are intending to implement this law when it goes through because I'm a little worried that it's going to get diverted um so we're waiting to see that if that when that bill becomes enacted it will get a bit better I don't think it will be comfortable but I think people like me will be surviving at that point um and then you know Medicare is planning on reducing payments to people like myself like other primary care providers by 2% next year because because they say that there are fewer people in private practice and so since people are practicing in larger groups then costs are lower and so therefore they can pay us less so they're forcing you out well what's extra silly about it is I don't think those people in the larger practices I don't think the 9% inflation was compensated for by being a larger practice like it's comical to think that they think it costs 2% less to provide care it's all a pencil pusher MBA kind of experience you know and uh it's it's all about the accounting it's in the insurance companies it's all about the accounting and it's people who are not altruistic who are not compassionate who just look at the bottom line and that's more and more the case isn't it I'd like to end on at least a bit happier note like I do well by my patients and they are super thankful I like out of the corner of my eye I can see like a bag full of like local produce from somebody who just came in to be thankful wonderful wonderful and as long as they don't bring you live chickens yes I would that would that would not be helpful at this point um but my patients are so appreciative and they're such wonderful people and I love my community um you know they they're beautiful people here and when I do get to get outdoors it's it's beautiful here and that's what that's what actually keeps people healthy it's not our health care system it's the beauty and you know wonder that is these islands you know you know the big island is is really a beautiful place and it's it's too bad that we don't have the for one thing the cheap transportation I was telling you I I support the super ferry and maybe I'm the only one around but um and I and I think there's ways to improve the connection between the islands and that includes the medical connection between the islands you know um the other thing is I think I don't think that the government fully understands you know your situation your challenges the challenges of your patients and and there's so you know we've talked about this in john why hey and the panel in health care talked about this it just seems to me that if we rolled up our sleeves and we started looking for clear solutions we could make your practice life better we could make your life better we could make it clear that this is that as much as you enjoy this you can do it for a lifetime I would like to see you do it for a lifetime I think people have to fully appreciate the service you provide um through so much of the community but that's just that's not understood really in government I'm sorry yeah uh the the constant image of the greedy doctor who's out on the golf course um it remains despite the fact that people like me have haven't had a raise if you like look at inflation we haven't I think we're getting paid less than we got paid 20 years ago like it's it's crazy um they just keep watching it down and in meanwhile like those poor new graduates with 300 300 000 dollars in med school that when they get out now like how how were they going to choose family medicine how are you gonna pay that that amount of money without a loan that may actually be a problem for your whole life not dischargeable in bankruptcy and so forth that we're we're back so we're gonna get on to a whole different line of reform at that point but you know it's primary care is rough um and I I hope that it gets easier well what are the godrails for you ester I mean I I do fully and there are people who do fully appreciate your contribution to the community and it's visible just talking to you for a few minutes how much that means to you and that means to us but there must be godrails out there there's going to be a a line in the sand for you where if you cross that line you say I'm sorry I meant well but I've I've got to get out of this what's that line in the sand for you ester I think I think I just balanced off of that um just with the finance financial situation situation get dire enough per minute um if I worked every week like I worked this week forever um I couldn't do it I'd be the next one who's in the hospital um but I don't I don't know I have a really poorly developed sense of self-preservation um and so I don't know exactly what the godrails are I am I walked in this morning to get yelled at because I hadn't responded to some uh results that was was from yesterday and you know I wanted to hang up the towel for a minute then but then I sat down with her and you know she was waiting on a cancer biopsy results and you just have to realize that we're all in this together and like of course she was upset she had to wait a day and so you know went from you know I'm going to reach quit now to this is what I'm called to do again and just back at it again I don't know the other alternative is you're not there and she'd be waiting a long time and to hear about it you know and she'd be less happy you know it's an interesting concept that um people think people in in the small communities like yours they think they can achieve the same level of health care with independent solo practitioners that they can if they were living across the street from queen's hospital uh no sorry it doesn't work that way you don't you don't have the kind of depth you know to provide the same level and speed of service as somebody in queen's hospital I I think that people fail to realize that my problems are Oahu's problems because if my patient can't get in to see rheumatology here they're going to go to Oahu for that care and where your rheumatologists there aren't an abundance of them when we need a specific kind of surgeon that we don't have here where are they going to go they're going to be there and so I know that there are places on Oahu where there's like a three month wait for a mammogram just like there is here so that's statewide then so I'd like to go back to something I asked you before I asked you whether you were unique I believe you you are unique but you may disagree with me you may not be unique you know any other estrus myths out there in the big island who are just like this estrus myth I you know I know plenty oh my goodness I can think of two obstetricians off the top of my head who are constantly working so hard they are in their 70s I know that they do a lot of unpaid work and I see them working just as hard as I am at 70 something years old you know like running to the hospital to deliver babies at 74 years old you know I know I've been asked actually like advice and how to help some other folks actually in Honolulu where a patient of a doctor there was like how how can I help my doc he is there he's working with his wife by the way this is a common way that people are in private practice the only reason they can do it is because they employ their spouse and somebody else who's also doing unpaid labor right but my she's like my primary care doctor he's there until nine o'clock at night every night with his wife trying to do the paperwork trying to get everything done so that they can they can stay open make they're out there hmm yeah you're right about the husband and wife teams especially may I say in family practice yeah well that's what you would then in my own little office building it was the internal medicine doc and the OPGYN too yeah so okay where we are almost out of time and I'm sorry we don't have more time but I want to ask you one more one more thing um you can you can be optimistic to a certain degree that it'll work itself out um but if you had the chance to address every level of government right now at least in the state of hawaii what would you tell them uh is the fix for the the shortage in the health care providers and um and the fix for people who may may not be getting enough health care um it's investing in primary care um it's been proven over and over again that it is cost effective more dollars spent in primary care means less dollars spent in the ICU it means less dollars spent in the cardiac cath suite it means more years of productive life for people um how do you invest in primary care well you could stop taxing taxing us for taking care of Medicaid Medicare and tri-care patients that's a thing that they could do tomorrow if they wanted to well next session if they wanted to um those are those are the biggies it's just you just have to pay us and then ideally you stop having us fill out paperwork that is meaningless yeah those two things it's a bunch of things it's like you work access less and stop you don't want to have 10 things on the list Esther you want to have only three things I can I can go on for a long time like did you know one of the hepatitis c drugs costs more by active ingredient weight than gold but somehow doctors wanting to get paid more is the problem right and that's going to increase you know with the sophistication of the pharmaceutical industry you know you know the uh I work with a bunch of people who are actually advocating for you know health care reform and they're always just like please don't tell them that they need to pay you more because everyone will get back to the greedy doctors thing and you guys get paid more than some other people 51st in the nation by wallet hub we're 51st in the nation for favorability of practice somebody has to just speak honestly about the problem ah jeez well my heart goes out to you and I and I feel that it's very important that you continue to practice it's also very important that the state supports you you know even even a bill on tax is more than just money what it says is that the government thus the people appreciate what you're doing they're giving you a nod they're saying we value your industry we value your service we value your compassion and the government really shouldn't do that whether it's by you know a better tax break or something else giving you the nod giving you the support giving you a statement of caring and that's what we need across the board thank you Esther Esther Smith Dr Esther Smith if you don't mind thank you very much for joining us I hope we can do this again soon thank you I have lots of other things to talk about thank you so much for watching think tech hawaii if you like what we do please click the like and subscribe button on youtube you can also follow us on facebook instagram and linkedin check out our website think tech hawaii.com mahalo