Guam is seeing growth in its health care and medical capabilities. Several new clinics have opened, with several more to open in the coming years. Guam has come a long way in terms of health care infrastructure, technology and public health trends in general, but there are still some medical needs that must be addressed.
One area that has historically been an issue for Guam has been its lack of hospitals and hospital beds. Guam Memorial Hospital has been the only civilian hospital on island for decades. However, there have been improvements at GMH in terms of certifications and resources. In December, GMH opened its newly expanded hospital emergency room and intensive care unit. The renovated ER-ICU went from eight to 14 beds and increased in size from 120 square feet to 200 square feet.
In addition, GMH welcomed a donation of medical equipment from Naval Hospital Guam in May as the Naval Hospital completed its move to its replacement facility. An estimated value of $2 million worth of medical equipment was given to the hospital including X-ray, CT scan and fluoroscopy equipment, to name a few.
The donation highlights a relationship between Guam’s civilian and military hospitals. Although Naval Hospital Guam’s main mission is to support its readiness mission, it does supplement Guam’s bed capacity by providing emergency services for both Guam and military residents.
During a press conference held at GMH on May 8 announcing the donations given, Naval Hospital Commanding Officer Capt. Jeffrey Plummer said, “On this island, one of the things we recognize and is very unique to Naval Hospital on Guam alone is that in somewhat of an isolated community, we have a responsibility beyond that training and readiness, and that’s in emergency response and in training for contingencies that would occur on the island.”
By helping the civilian hospital, the Naval Hospital benefits as well from some services that it does not have but that are available at GMH, such as neurology.
“The service here at Naval Hospital Guam is the highest ER room in the entire Navy — a lot of the people don’t know that. Because of the emergency capability that we share with GMH, Naval Hospital covers the Southern part of the island; GMH covers the Northern part of the island,” Plummer said.
Supplementing health care on island are private clinics and physicians, many of whom have seen the landscape of health care infrastructure on island change.
“I have seen Guam’s health care boom over the years with new technology, such as CT scanners, MRI, CT angiograms and new services brought to Guam, such as cardiac catheterization and coronary artery bypass surgery to neurosurgery and the [Joint Commission on Accreditation of Healthcare Organizations] accreditation of Guam’s only civilian hospital,” says Dr. John Ray Taitano, an internal medicine specialist at The Doctors Clinic in Tamuning.
Dr. Saied Safabaksh of Pacific Medical Group has been practicing on Guam for 18 years. Some things have not changed in that time, he says. For many years, Guam only had one cardiologist and oncologist, for example.
“In most of the specialty cares, we either didn’t have or we only had one. And nothing changed,” he says. “There are some areas that have improved over the past 18 years. … When I came here, we had only one nephrologist — a kidney specialist — and today we have actually six nephrologists on island practicing. We had only one dialysis unit; now we have four dialysis units. It doesn’t mean we have a lot more disease on the island; it means that we are treating them better.”
In addition, Safabaksh says technology has improved over the past two decades, especially in radiology.
Dr. Annette David, founding partner of Health Partners LLC, says Guam has demonstrated success in the public health arena. Once public health policies are implemented on island, she says, data collected by various health organizations show results that are immediately felt. An example is in the decreased incidences of binge drinking once the legal drinking age was changed to 21 years in 2009. Another positive she notes is that Guam has a good network of physicians and primary health care providers.
In addition to recent advances, Guam does have high standards for doctors seeking to practice on island. The standards for physicians to practice on island are higher than most states. New physicians coming to Guam must have U.S. residency training beyond the first year after medical school, and new physicians must be board-eligible or board-certified before they can be licensed on Guam. This ensures physicians have training beyond general practice.
While Guam has seen many successes, there are still some resources the island does not have. In terms of specialties, Guam lacks rheumatologists.
“We have seen very interesting and some very aggressive cases here of rheumatoid arthritis, psoriatic arthritis, autoimmune disease — systemic lupus, for instance,” David says. Other specialists Guam lacks are gastroenterologists, pulmonologists, dermatologists and allergologists. In addition, there are procedures that cannot be done on Guam, such as cardiocatheterization. A team must fly in to perform this procedure.
“Yet heart disease doesn’t wait for people to fly in; it happens every day,” David says. “In fact, that is the number one killer on island. The number one cause of death is cardiovascular disease.”
David also says the island does not have all the modalities for treatment of cancer. “Although that has improved quite a bit,” she says. Improvements in the cancer area are due to work done by community advocates, such as the American Cancer Society, the Comprehensive Cancer Coalition and the University of Guam Cancer Research Center, to name a few.
“We’ve seen an increase in the resources we now have for cancer, and we are fortunate to have that, but we still need more. So it’s an ongoing process,” David says.
Another need in Guam’s health care industry is simply infrastructure, David says, meaning hospitals. “There’s a certain ratio of hospital beds to a population that is sustainable and that’s desirable, and that is hovering at around three per 1,000 people. Guam […] is currently at 1.92 beds per 1,000 people,” David says. These figures point to a need to boost Guam’s hospital bed capacity.
In general, Guam needs more physicians, nurses, physical therapists, speech pathologists and other types of health care professionals, Taitano says. He brings to light the issue of burnout among Guam’s health care professionals, which is exaggerated by the few health care providers. The world ratio of physicians to population is about 14: 10,000, and in the United States, it is about 24:10,000. Guam’s population of about 180,000 to 200,000 should have about 480 physicians to service the population base, Taitano estimates. As reported in the 2012 Guam Statistical Yearbook from GMH and the Department of Health and Social Services, Guam had 160 physicians including licensed military physicians working part-time at GMH.
“We need more subspecialists, such as more endocrinologists, ENTs, gastroenterologists, pulmonologists, neurologists, urologists, so that physicians do not suffer burnout and have adequate coverage when a physician goes off-island for education or vacation,” Taitano says. In addition, he says the island needs to bring transplant medicine and a cardiac bypass team that would do at least five to 10 bypasses a week in order to maintain skill levels.
GMH is working to fulfill its strategic plan by bringing additional services to Guam. The island will have joint replacement procedure available at the hospital by mid-June, says Joseph P. Verga, CEO and administrator of GMH. A local orthopedic surgeon will conduct the procedures; GMH will provide support for the procedures, including equipment and staff; and the rehabilitation department will provide post-surgery care. This added service will keep residents on island for this specialized type of care.
According to Dr. Thomas Shieh, an OB-GYN who runs Dr. Shieh’s Clinic, Guam’s medical needs stem from the need for greater accessibility to providers and insurance coverage improvements.
“There are still too many limitations on patients from Guam’s health insurance policies. For example, from a mother’s perspective, if a baby has a genetic defect, some insurance companies refuse to cover them. They also refuse to cover some high-risk pregnancies, which is by no fault of the baby’s. Additionally, insurances still refuse to cover outpatient technologies that can prevent major hysterectomies. So patients are still having to go to the hospital, have the uterus removed and stay two to four days, when we have on Guam now outpatient ablations that can prevent that,” Shieh says.
When it comes to specialties needed on Guam, Shieh says the island needs a cardiothoracic surgeon permanently. “It’s hard for cardiac patients to go off island, and in order for us to ensure the safety of any future cardiac outpatient interventions with the latest technologies, we need an open heart surgeon to ensure safety. By that I mean an experienced team,” he says.
Dr. Robert Nerves, also a nephrologist, is the medical director at Pacific Medical Group. “Based on the patients I have been seeing for the past five years, most of the problems that are being encountered here are basically because of hypertension and diabetes,” Nerves says. Unfortunately, Pacific Islanders are genetically predisposed to these conditions. In fact, a study published in the May 29 issue of The Lancet conclude that the Federated States of Micronesia is in the top 10 countries with the highest rates of obesity in adults.
“The problem is compounded by the fact that Guam doesn’t have enough medical support to meet the problem because we’re not just dealing with regular hypertension and diabetes here; we’re looking at more severe forms of the disease for some reason or another — whether its lifestyle genetics or stuff like that — the disease burden on-island is so much greater than if we go to, say, the mainland and look at a small-town population,” he says.
Hypertension, diabetes and kidney disease are preventable if treated at an early stage. However, most patients go to the doctor when they are in the advanced stages, and there is not much that can be done other than palliative care.
“As far as kidneys are concerned, everything is available here, except for maybe the transplant program. Kidney disease is really a problem that is just an offshoot of a lack of preventive care and adequate primary care given the fact that the population is highly predisposed [through] genetics and other factors like lifestyle,” he says.
“When I started on Guam, we were only taking 200 or 250, and five years down the road we were already taking care of 500 more or double that,” Nerves says. The increase in number includes both new patients and patients who are living longer due to the availability of facilities.
While Guam struggles with this lack of resources, several facilities and physicians are rising up to the challenge to provide more resources. The community is eagerly awaiting the new Guam Regional Medical City as it undergoes construction. As of May, the new hospital was about 75% complete, says Gloria J. Long, chief operating officer of Guam Regional Medical City.
GRMC will include a cardiac center and a cancer center of excellence. The cardiac center will include a cardiocatheterization lab, a cardiothoracic surgeon and a cardiovascular specialist. In the future, the facility hopes to offer cardio bypass surgery, but the facility does have most of the equipment for it.
The hospital will have 130 beds with the capacity to expand to 250. Some specialists the hospital will be bringing to Guam are ear, nose and throat physicians; an additional endocrinologist; a neonatologist; a gastroenterologist; a dermatologist; a neurosurgeon; an orthopedic surgeon for joint replacements; a breast imaging specialist; and a rheumatologist. Although Guam has a hematologist and oncologists, GRMC will bring in pediatric hematology and oncology care for the treatment of children.
Another goal of the hospital is to provide equipment for other doctors with specialties who do not have the necessary equipment to support those skills.
“We will never alleviate the need for people to go off island, and the reason why is there is always going to be somebody that has some special case. Each individual is an individual and their health care will have to be tailored to each of their specific needs,” Long says. Instead, the hospital hopes to at least provide most of the initial and follow-up care.
“I think [GRMC is] just part of the changes that you’ll see come about in the health care system on Guam,” Long says.
In June 2013, Guam welcomed International Health Providers LLC, which does business as IHP Medical Group. The American Medical Center has plans to open a second clinic in Mangilao. And Hagåtña Med is another new development as of January, offering primary and urgent care. The clinic is adding to Guam’s medical capabilities by offering urgent care services and utilizing modern technology. Hagåtña Med opened to serve the populations living in the central and Southern villages of the island.
“Urgent care service is really an emerging concept still,” says Melissa Taitano, president and co-owner of the clinic. “People are very accustomed to traditional medical offices, where you have to call, and it takes three weeks to set up [an appointment] or see a provider. We wanted to be able to provide and answer the call [for] accessible care.”
Dr. Davina Lujan, medical director and co-owner of Hagåtña Med, says problems in receiving episodic care also motivated the opening of the urgent care clinic. “[…] at that point you really have limited access because if you call your clinic, often times you’re told they’re full. They say they’ll try to squeeze you in, and you may find yourself in a waiting room for several hours. And that was the experience of my patients. And that’s what motivated us to open an urgent care. Because I was a primary care physician, I enjoy the management and prevention part of it, but at the same time, my patients didn’t have access to me when they had problems,” she says.
Just as important as the urgent care services, primary care services offered at the clinic are essential for residents’ health care. “Primary care is so critical, because it is the entry into the health care system. […] I’m not certain we don’t have enough primary care physicians; it’s perhaps that we don’t have enough access to primary care physicians,” Lujan says.
The clinic is small, with a staff of eight, including a physician, a physician’s assistant, a registered nurse, a licensed practicing nurse, X-ray technicians and three MEs. There are four exam rooms, but the clinic is fully equipped to address urgent care needs with a digital X-ray machine and an EKG machine.
“Because we’re dedicated to complete access, we never know what’s going to happen that day, sort of like an emergency room, but less acute,” Lujan says. Urgent care in the clinic includes initiating treatment, stabilizing the patient and transferring the patient to the GMH emergency room, if needed.
In addition to easy access to health care, Hagåtña Med utilizes technology to facilitate health care. Each room has a tablet and a laptop for the providers to interact with patients and pull up graphs. Technology is used to run the clinic’s practice management, including clinic operations and electronic medical records and electronic billing. The clinic partners with a local company, Data Management Resources, to set up network and security protocols. Through the company, Hagåtña Med has set up an emergency plan and recovery plan, which includes triple redundancy and outside storage.
When it comes to integrating medical care and technology, many positive outcomes could result. Taitano says Guam could benefit from the implementation of electronic health records in order to minimize errors, recognize potential drug interactions, increase accessibility to medical records and consolidate medical reports.
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