Need: Hawai'i is experiencing a huge shortage of family medicine physicians.
Intervention: The Hawai'i Island Family Medicine Residency (HIFMR) program uses an interprofessional team-based approach so residents learn how to care for many types of patients in different healthcare settings.
Results: Since 2017, HIFMR has graduated a class of 3 to 6 Board-certified family medicine physicians annually. Most graduates have remained in the state to practice medicine; those who have left have entered fellowship programs and plan to return to Hawai'i Island to practice.
is the largest community on the rural island of Hawaii
(also called the Big Island). While the state is
attractive to tourists and locals alike, the Big Island
struggles to recruit and retain family medicine
physicians. Geographically and culturally distinct,
Hawai'i experiences high rates of complex health issues.
With limited health infrastructure and workforce
pipeline, communities remain underserved.
The shortage of physicians hurts the diverse and complex
populations who receive care at Hilo Medical Center
(HMC), a safety net hospital that serves the entire East
side of the island and hosts the second busiest emergency
room in the state.
Hawai'i Island Family
Medicine Residency (HIFMR) began in 2013 with a
complement of four residents. Fully accredited by the
Accreditation Council for Graduate Medical Education
(ACGME), HIFMR's team-based model provides a supportive
educational environment with a robust community medicine
experience with the hope that residents will stay and
practice in rural Hawaii after graduation. Residents work
with other providers such as Advanced Practice Registered
Nurses (APRNs), behavioral psychologists, community
health workers, and clinical pharmacists to care for
their patients' needs. Behavioral health is integrated
into the primary care setting, allowing for scheduled as
well as warm handoff visits.
With a "grow local" approach to creating a healthcare
workforce, HIFMR encourages applicants with ties to
Hawaii. In the spirit of a multidisciplinary learning
environment, the Hilo Medical Center-based program also
hosts learners from:
University of Hawai'i (UH) at Hilo's Daniel K. Inouye
College of Pharmacy
UH at Hilo's School of Nursing
UH Mānoa's Nancy Atmospera-Walch School of Nursing
Other residencies, on a short-term rotation basis
HIFMR runs on a modified block schedule format, with at
least 2 half-day outpatient family medicine clinics each
week. HIFMR residents learn and work in varied hospital
settings – from geriatrics to surgery to
emergency medicine – with all ages of patients, including
those with acute illnesses and chronic diseases. In
addition to the usual scope of family medicine, residents
learn from faculty members who also have special
expertise in HIV medicine and addiction medicine.
HIFMR residents work in other communities on the island,
including Kailua-Kona, Pāhala, and Pāhoa. The clinical
pharmacists in the clinic, along with their Doctor of
Pharmacy (PharmD) learners, provide consultation to
patients, manage the diabetes groups, and provide
education on pharmacology. The psychology post-doc
learners commit to the clinic for 1 to 2 years so
continuity is developed among the residents, mid-level
graduate students, and patients.
HIFMR residents also learn about ocean safety and rural
EMS and participate in disaster-preparedness training for
tsunamis, hurricanes, and volcanic emergencies and
eruptions. The residents cared for patients during the
2015-2016 Big Island epidemic outbreak of dengue fever,
potentially foreshadowing how the Zika or Chikungunya
viruses might have spread. In the last two years, the
family medicine residents have been caring for COVID-19
patients in ambulatory as well as inpatient settings.
The Big Island is also home to other vectors rarely
encountered on the mainland, including rat lung worm
disease and leptospirosis, allowing the residents to gain
expertise in tropical diseases.
Residents learn about cultural competency and humility in
working with different populations in the community, such
as Native Hawaiian, Japanese, Chinese, Micronesian,
Filipino, Mexican, and Russian patients as well as
tourists from around the world.
Here is an 11-minute video giving a tour of the residency
Of the five graduating classes to date, all residents
passed their Board exams on the first attempt, and over
85% have remained in the state to practice medicine.
Graduates are employed in a variety of settings:
inpatient hospitals, outpatient Hilo Medical Center
clinics, community health centers, private clinics, and
HIFMR is the first and only Hawaii residency program not
on the urban island of Oahu and is the second civilian
family medicine residency program in the state. In 2021,
over 800 medical students – many with ties to the state –
applied to the Hawai'i Island Family Medicine Residency
In 2020, the HIFMR's primary ambulatory site, now named
East Hawaii Health Clinic-Primary Care, was designated as
a rural health clinic, paving the way for more financial
stability of residency and allowing the community to be
The residency program took nearly 20 years of coordinated
financial, political, and educational effort to gain
momentum and backing from the hospital and community and
received initial accreditation in October 2013 from
ACGME. State funding remained uncertain several months
before the first class began but was provided, and HIFMR
is now a line item in the State of Hawaii budget.
Developing a program in a "residency naïve" community
requires educating the medical community about the
requirements, responsibilities, and regulations
associated with family medicine residency programs today.
As the only Hawaii program sponsored by a state hospital
system, HIFMR has found the Hilo Medical Center
Foundation's financial support to be essential in
providing funding for program components not allowed by
The clinic was established prior to the residency
program, anticipating that the ACGME would grant
approval. Faculty were hired and alliances with the
health professional education partners were developed and
codified to establish an interprofessional worksite,
allowing for residents to have a patient base from the
Having advocates who can speak personally about their
loved ones unable to be treated by a primary care
practice helped to persuade the state legislators that
the need is real. Community support from individuals, the
Rotary Clubs, and the Hilo Medical Center Foundation has
buoyed HIFMR's efforts and are continuing to help link
residents to employment opportunities on the island and
across the state.
The residency has worked hard to become indispensable to
the overarching sponsoring institution, in implementing
monthly Grand Rounds presentations, formalizing
precepting agreements and roles, ensuring resident
involvement on hospital-level committees, and becoming
major players in running various inpatient services.
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.