Wednesday, August 19, 2009

"How Not to Hire a Physician"

Tuesday, August 04, 2009
How not to hire and retain a physician
Over the months I have been following closely the medical scene here on Saipan as reflected in the local press and would like to pass some experiences and observations on certain matters. First, what makes me qualified to do this? Well, I have lived in the “bowel of the beast” as former chairman of Emergency Medicine as well as serving as director of Medical Affairs at CHC and feel this puts me in the position to make some observational points on how not to hire and retain physician.
I resigned my position with CHC in April 2008 and not for reasons as regularly stated in the press: “Dr. X resigned for personal reasons” or “Dr. X resigned to be with family on the mainland or wherever Dr. X may hail from.” I resigned on issues that were strictly business, nothing personal; it was just business. What business you may ask? We will get to those matters later on in this discourse.
You must know this. One individual or single government office cannot be blamed for the overall state of affairs medicine is in here in the CNMI. It is strictly the “business of the system.” A collection of little broken parts that has led to a broken whole.
How so? The best approach would be to trace the process of getting physicians to travel to the CNMI to work. There are several avenues for this. A good many come to work in order to pay off student loans accrued while in medical school by serving to work in an undeserved area, which the CNMI magnanimously qualifies as such an area. Others come with a true sense of adventure and want to contribute. Others come for “the island life.” In addition, there are those who come for other reasons, which soon surface after some time passes. For the most part these sources account for bringing the majority of doctors here. How does one find out about work here in the CNMI? Most often it is by word of mouth from others who have been here in the past and pass on the word. As mentioned before, physicians looking to work in undeserved areas to offset school loan debt find out through Health and Human Service with the U.S. government. Also, rarely, one will find a random job placed in a professional journal about coming to the island paradise to work and play in the sun with a “not so truthful” description of the medical environment, which is usually written by the recruitment firm that places the advertisement in whatever journal or job board in question and collects a finders fee, often as high as $10,000 if a doctor signs on. For some time, many Canadian physicians came to Saipan as they were paid in U.S. dollars but, as the value of the Canadian dollar rose, it snipped that pipeline to some degree and few come as a result. By and large, the word of mouth pipeline and debit reduction account for the major sources of recruiting physicians here.
And of course you have the usual increase in inquiries from “short-time,” “cold-weather-bird” types who migrate from Canada or the U.S. mainland when the weather starts to cool down and the winter months are starting there.
So, okay, I want to come to the CNMI to work? Here I am. Now what? Ahhh, here lies the rub.
Prior to arriving you are often told your contract is in the “routing process”; the passing of the contract through several governmental offices for signatures. Normally this is told to you before arriving. When you do get here, often your contract is still routing through the various offices for signature. What does this mean in the real world? You likely start work with no signed contract, and that means no compensation is coming until it is signed by multiple governmental offices individually and passed on; which may take as long as two months! Why? Contracts are generated in one or two days elsewhere. Why is this allowed? CNMI law, I am told. Well then it is a law and process that is counterproductive and serves no function in a practical manner. Needs to be changed. You have to pay your doctors! Like anyone, you work you get paid. Not to even mention the issue of physician indemnity during this routing contract period.
One additional point should be noted. For the most part, no physician comes here for the money or to practice high- tech medicine with the latest and hottest tools in medicine. Why? Because these items do not exist here in the CNMI. Again, doctors do not come here for the money! So talking salary alone as a recruiting measure is somewhat ridiculous. The CNMI currently can never math what physicians make in the U.S., Canada or European market.
OK, now your contract is signed. Now what? You soon find that at times there is often not an adequate blood supply available on the island of Saipan. You know how dangerous that is? Again, it is a system problem, a system with no reliable access to adequate medical supplies and needs. Why? While working in the emergency department at CHC as the director of Emergency Medicine, my colleagues and I often were faced with no “key” lab studies being available; a CT scanner that is essentially so old and of marginal diagnostic value. The CT scanner is an essential item in medicine today. I cannot emphasize how critical this item is. Again, more fallout from a broken system. No supplies is a common problem here. I mean basic items. The “not-on-island” supply list is long and impressive. For instance, the lack of proper suture material for wound repair and proper instruments to get the job done is standard in the Emergency Department. Sometimes it is like trying to pluck your eyebrows with a pair of pliers when closing a wound on a face or elsewhere. You have to think out of the box here as a physician. The medical environment here in the CNMI is definitely not for the faint of heart. The pioneer type, the adventurer, the physician with strong clinical skills, is the type of physician that is needed here. The physician who wants a practice challenge working in an undeserved area with limited resources is what is needed and not a cold-weather bird seeking the tropical escape or the wind surfer or Bali traveler. Efforts in recruitment should be channeled in this manner. Which means the need for “truthful recruitment” of physicians is what is required. Being upfront from the get go. Let them know how hot the fire is before putting their hand into it. Make sure the candidate doctor knows what the situation is here prior to coming so they are not met with surprises and disappointment when they arrive. You may be surprised by using this approach. the doctors that do take on the challenge may stay.
Limited resources, now what does that mean for medicine here in the CNMI? The “not-on-island” supply list has a big impact here on the quality of care and ability to render proper diagnosis in some cases. Example, cardiac enzymes. This is a test that helps the physician determine if injury to the heart muscle has occurred. Often this test was not consistently available at CHC in the past. Why? Cardiac enzymes are just one of many often lacking essential lab tests needed to practice “quality medicine.” Creatinine is one test of kidney function that is essential for managing patients on dialysis.often not available for months. Blood thinners are taken by many people here. PT or Prothrombin time is essential here. Coumadin or warfarin is a dangerous medicine, which needs to be monitored closely by using the PT or INR test. Often not available here for unacceptable periods or time. Why? These are the fundamental questions that need answers to start to fix the “broken wheels” of CNMI medical care. As I stated, the “not-on-island” supply list is long, impressive, and is a major obstacle to quality medical care.
What if you are critically ill or injured in the CNMI? There are certain medical scenarios that are a stamped death warrant here. Head injury being one of the major players, you sustain a head injury here in the CNMI of even moderate severity and your chances of not suffering long-term effects is a true gamble here. Severe head injuries are surely doomed. Significant heart injury is another one. There is no heart catheterization lab, which is the gold standard for acute heart attacks in most cases. Clot busters are given here, which is fine, but could be risky. The PT test that I mentioned earlier is critical here. Having no PT test means the risk of using clot busters is markedly increased. Get the picture? I think you can see the forest here as well as the trees that make it up.
I do hope that God speed a solution to the problems at hand. I, for one, will remain here in the CNMI to live with family and friends and I am always willing to lend a helping hand in health care here on Saipan in the Emergency Medicine department if treated fairly and with respect. The few physicians that remain here in this challenging medical environment should be applauded for doing so. They are currently being pushed to the limit yet the dam continues to spout new leaks. These endangered pioneers will soon run out of fingers to plug the holes in the medical care. They should be cherished resources.
The people of the CNMI deserve quality healthcare and that should be a primary budget consideration and funds should be allocated accordingly to fix the many broken wheels of medical care in the CNMI. Your health is your most important asset. In addition, the Human Resources Department at CHC should be applauded for their tireless efforts in assisting new as well as the seasoned physicians in adapting to the medical scene here on island. God bless.
Dr. Edward Cornett is a former chairman of Emergency Medicine and director of Medical Affairs at the Commonwealth Health Center.

-Although this article is a little long-winded, I think that Dr. Cornett brought up some interesting points about recruitment. I agree that the desire to work in Saipan is not all about the money for 99% of the doctors that come to the island. Truthfull recruitment may not be the solution however. Eliminating the "island life" doctors may cause a worse doctor shortage than we have now. In addition to the student loan forgiveness for working in an underserved area, CHC should try to recruit J-Visa medical school graduates that are allowed to stay in the U.S. instead of returning to their home country for 2 years. That avenue I believe would produce the greatest results.

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