Most individuals can identify numerous compelling reasons to relocate to Hawai’i and pursue a career in the health care sector. It’s a stunning jewel of a location, filled with hospitable individuals and the Aloha Spirit. Why accumulate funds for a rare Hawaiian getaway when you could be basking in sunny shores, warm seas, and tropical forests throughout the year? The issue arises as Hawai’i’s health care system has predominantly transformed into a revolving door for those who did not fully understand the drawbacks of residing in paradise.

My spouse and I transitioned to Hawai’i Island (commonly referred to as the Big Island) from Denver in December 2021. The move required extensive preparation and a significant financial investment, so it surprises me to witness the number of health care professionals who relocate to Hawai’i only to return within a year. What makes it so challenging to retain health care workers?

The living expenses are exorbitant. The current median housing price on O’ahu surpasses $1 million. A standard one-bedroom apartment rents for over $2,000 monthly. Grocery costs are at least 20 percent higher than the national average, given that 90 percent of Hawai’i’s food is imported. Gas prices run roughly $1.50 higher per gallon than in other parts of the U.S., and electricity costs are over three times higher per kilowatt-hour.

Your earnings might be lower. Physician compensation is relatively modest in Hawai’i, especially when considered against the cost of living. The state is predominantly influenced by a select few local health care organizations along with a handful of private practices. The extremely high costs of operating here pose significant challenges for independent and small-group practices. A 4 percent general excise tax on all medical services doesn’t assist, either. Moreover, opportunities may be scarce on O’ahu, where approximately three-quarters of the state’s health care workforce resides and operates.

Health care services can be more difficult to obtain. In most regions of the U.S., when a patient at a small critical access hospital requires a higher level of care, they can be transported by ambulance to the nearest major city and stabilized in the emergency department. Outside of O’ahu, all the Hawaiian islands previously referred to as the “outer islands” (the friendlier term “neighbor islands” has gained popularity recently) must airlift their most critically ill patients. Hospitals on O’ahu often operate at or near full capacity, and they receive transfers only when available beds exist. Tropical storms can restrict transfer opportunities. Although water ambulances exist, transferring between islands this way would take hours over turbulent seas.

The hospital I work at in Kona is half a century old. It lacks a cath lab, interventional radiologist, neurosurgeon, and vascular or cardiothoracic surgery services. There is one larger hospital on the Big Island that possesses some of these facilities, but it often operates at full capacity. Even services that are available may not have reliable staffing. For instance, I am the sole infectious disease physician serving Kailua-Kona and surrounding areas, so if I become ill or take a vacation, there’s no alternative. Specialists are generally not abundant on neighbor islands, and most individuals travel to O’ahu for specialized care.

It’s quite remote. Geographically, Hawai’i stands as the most isolated populated region in the world. The islands are more than 2,000 miles away from the U.S. mainland, and even the shortest flights take nearly six hours. During Daylight Saving Time (which Hawai’i does not follow), a six-hour time difference exists between Hawai’i and the East Coast. For those with friends and family on the mainland—especially those with aging relatives facing health issues—being so far away can be quite challenging.

Don’t anticipate all the usual conveniences. Power outages are relatively frequent, particularly on neighbor islands. Water primarily comes from underground aquifers, and, at least in my area, water restrictions are often enacted due to insufficient rainfall and/or malfunctioning pump systems on the wells.

Numerous national retail and restaurant chains do not operate in Hawai’i due to its elevated costs and lower profit margins, which might limit your access to favorite shopping and dining options. Online shopping faces some limitations due to regulations on transporting hazardous materials over the Pacific. When you do buy online, do not expect quick shipping—two-week delivery times are more typical.

Hawai’i has no major league professional sports teams, so if attending such sporting events is a crucial part of your leisure activities, Hawai’i might not suit you. High-profile music artists may occasionally visit Honolulu, but we typically do not experience many large national performances coming to the state. When they do occur, these events are almost exclusively on O’ahu, requiring residents of neighbor islands to fly to attend.

Public transportation is underdeveloped, and the majority of people depend on private vehicles. Roads are