National Health Service Corps Demands Additional Flexibility for Participants due to Center Closures in Pandemic-era

The National Health Service Corps is a federal program with a mandate to improve access to healthcare in underserved areas. The program provides incentives to physicians—and other medical workers including dentists, nurse practitioners, and physician assistants—to work in designated Health Professional Shortage Areas (HPSA) in exchange for scholarship or loan repayment funds.

There are three programs specific to physicians: 

1. Federal Scholarship Program: Full-time students who are U.S. citizens and complete a primary care residency are eligible to receive a scholarship for tuition and school-related expenses as well as a (taxable) stipend. For each year of scholarship, students are expected to serve a year working as a physician at an HPSA; there is a minimum of two-years full time service (or four years part-time) with a maximum of four years of scholarship. 

2. Federal Loan Repayment Program: If employed by NHSC-approved sites, primary care physicians can apply to receive loan repayment, including loans for tuition and living expenses for both their medical school and undergraduate education. Within this program, there are three tracks: general, substance-abuse workforce, and rural community. 

3. State Loan Repayment Programs: A state-tailored version of the program, with modifications on program eligibility and service requirements based on specific state-wide needs. 

The programs are competitive, with about ten percent of applicants receiving federal scholarships and entry into the loan repayment programs. However, medical students should carefully consider the contractual agreements when committing to the program. The Student Doctor Network describes the pros and cons of the program. The pros, of course, come in the form of loan repayment and scholarship, which for medical school, can provide a significant sum. The cons, however, are in the restrictive nature of the program. For physicians, scholarship recipients are locked into primary care and fellowships within primary care, which can be limited. Participants also need to be open to relocation throughout the United States, as the NHSC has the final approval on placement. This can be particularly onerous for medical providers with family responsibilities or ties to a specific geographic location. Finally, there are significant financial consequences for breaking the contract.  

The pandemic magnified the restrictive nature of the program and need for participant adaptability. Last week, the Wall Street Journal ran an article profiling several program participants who experienced center closures and resulting job loss. Upon losing their positions, they had 90 days to find a new job; in the cases profiled, the participants needed to relocate in order to find a qualifying placement and when they were unable to do so, they described significant consequences. They had to repay the money they’d received. And those who violated their contracts were charged heavy monetary fines. In one case, a dental hygienist owed a fee that was more than five times the original loan repayment. In all of the cases, the participants described obstacles that made it difficult, if not impossible, to find a qualifying role to continue their service, as well as the financial devastation that would come from repaying the loans with the penalty. 

So, is it worth it? The Student Doctor Network says, “It depends. Once you’re a physician there will be many opportunities to pay off your debt. You can choose a better paid position or find one that offers loan repayment. How committed are you to public service? To primary care? How expensive is your medical school? Like many programs with financial incentives, it is important to believe in the mission before you sign the dotted line.”

Medical Community Lauds Addition of Public Health Priorities to Methodology of U.S. News’ Medical Rankings

In response to criticism from the medical community, the U.S. News & World Report updated the methodology behind their 2022 Best Medical Schools in Primary Care ranking. A recent JAMA Viewpoint article entitled, “Increasing Transparency for Medical School Primary Care Rankings—Moving From a Beauty Contest to a Talent Show“ by Robert L. Phillips Jr, MD, MSPH, Andrew W. Bazemore, MD, MPH, and John M. Westfall, MD, MPH described the updates: “The rankings were modified in 2021 such that 30% of the score is now based on graduates practicing primary care after their residency training, rather than those entering primary care training. Initial residency comprises 10% of the score, which still overestimates primary care, but this measure has been reduced from its previous weighting of 30%. The remaining score (60%) is still largely based on reputation, which is assessed by (1) surveys of medical school deans, internal medicine chairs, or admissions directors (15%); (2) survey of primary care residency directors (15%); (3) student selectivity (median Medical College Admission Test score, 9.75%; median undergraduate grade point average, 4.5%; acceptance rate, 0.75%); and (4) faculty to student ratio (15%).” The authors call the updates to the methodology “a step in the right direction,” although they continue to express that the reputation portion of the score is subjective and self-perpetuating. 

More important than the methodology update, the authors say, is U.S. News's addition of four new data-based rankings. The newly added rankings include: 1) graduates practicing primary care; 2) most diverse medical schools; 3) graduates practicing in medically underserved areas; and 4) graduates practicing patient care in rural areas. These rankings were created with the Robert Graham Center, a division of the American Academy of Family Physicians, and were defined to measure medical schools’ performance on key health care issues. The graduate-based rankings use data collected five-to-seven years after a physician’s training, making them more reflective of student outcomes and better able to showcase the public health contributions of schools that are hidden within the broader rankings. For example, the authors point to the disparity seen in the Harvard Medical School rankings; the medical school, ranked 8th for Best Primary Care, ranks 141st for graduates practicing in primary care fields. Conversely, the Pacific Northwest University of Health Sciences, which is unranked in the primary care ranking, ranks second for graduates practicing in primary care fields, second for graduates working in medically underserved communities, and seventeenth for graduates working in rural areas.  

One of the article’s authors, Dr. Phillips, speaking with the AMA, notes that students should understand the large role that reputation plays in the mainstream rankings and should proceed with caution when using the rankings to inform their medical school options. “Students should be careful in using medical school rankings to inform their choices as many rankings are opinion-driven.” Rather, he recommended that students consider the more objective, data-driven rankings based on where and what graduates end up practicing. “We also hope that the new ranking heralds continued improvement of the information that help students make career decisions. 

On a wider-scale, the authors call out the importance of the four new rankings in providing transparency into how schools contribute to key social outcomes, for policy decisions by both states and medical schools themselves. “These outcome measures should help medical schools to assess fidelity to their missions and alter admissions, curriculum, and training settings if different outcomes are desired.”