Before I had even begun medical school, I already knew that I would enter primary care when I finished. I had successfully applied for and received a scholarship from the National Health Service Corps Scholars program. By the time I graduated, I knew that after my three years of residency training, I would practice in an underserved area for at least four years, one year of service to America for each year Americans, through their taxes, had paid for me to go to medical school.
By committing to primary care early, and getting paid for that commitment with a monthly salary and medical school fees, and being threatened with paying back $200,000+ worth of loans in that amount, times 3, with interest, I had an even stronger commitment to primary care as I finished medical school. I didn’t want to be a million dollars in debt before I even began my working life. And so rather than running away to join the circus, or write a book, or become a surgeon, I entered family medicine. Now I get to be part of the solution to our country’s health care crisis.
An important part of health reform is to strengthen primary care, and get more people to see their doctors to stay healthy. But more primary care to keep people healthy requires more primary care doctors. And right now we’re experiencing a national shortage. It’s a tough sell convincing medical students to enter primary care.
The students I work with on the family medicine clerkship look at the doctors and see us working hard to cover lots of complex issues in fifteen minute visits, while living at the bottom of the medical totem pole.
As one student wrote in a reflective writing piece for the clerkship: If it weren't for the system of reimbursements that we are mired in, it seems obvious that the smartest people in this profession should be on the front lines. Is that it, then? Have we found our clarion call for reforming our broken health care system: better reimbursements for primary care so that doctors can spend more time with patients and so that the smartest minds will provide intelligent triage and preventative care?
Well, improved reimbursements for primary care are one goal of health reform, with 10% higher payments to primary care (still far short of narrowing the 2:1 pay differential between specialists and primary care physicians). That may nudge some students to choose a lifepath into primary care.
But at the same time America needs more primary care doctors, it also needs to distribute those docs around the country to work where they are most needed.
The National Health Service Corps was established in 1972 as a way for the government to direct the most needed physicians to the neediest Health Professional Shortage Areas (HPSA). Physician NHSC Scholars go through school and graduate knowing they will become a primary care physician—a family physician, an internist, a pediatrician, a psychiatrist or an ob/gyn. Then there are loan repayors, who first find themselves a job in a clinic with a sufficiently high HPSA score to qualify, then apply for additional support from NHSC to pay off their loans.
With the ACA, the NHSC loan repayment program just got a lot bigger and a lot more generous. Instead of paying off $40,000 worth of loans in the first two years, it’s jumped to $60,000, with up to $170,000 in repayments for a five-year service commitment, with the possibility for complete repayment of loans with six or more years of service. They’ve also sweetened the deal—and made sure that the most passionate physicians are able to teach the next generation—by arranging for eight or twenty hours out of a 40 hour work week that may be dedicated to teaching. There is also a half-as-much-time for twice-as-long option. These applied to the loan repayors, and coming up soon (perhaps as soon as this week) will start to be applied to Scholars also.
I love the combination of clinic work and teaching. I applaud the NHSC for creating what I think of as the "clinic plus" positions, allowing dedicated physicians to serve the underserved while grooming the next generation of primary care physicians to look after the nation’s health.