Part 1 why has the U.S. experienced such difficulty? - medical staffing in underserved areas persists

Physician Executive, Nov-Dec, 1998 by Thomas P. Weil

2. National Health Service Corps

Since it was established by Congress in 1970, the scholarship and loan repayment program sponsored by the National Health Service Corps (NHSC) has focused on supplying physicians to medically underserved areas. Aside from these young physicians providing hands-on ambulatory care services in federally supported community health centers, the NHSC program has been designed to encourage the long-term retention of these doctors in areas to where they are initially assigned.

To evaluate the effectiveness of this program, the December 1991 American Medical Association Master File was used to determine the practice location and specialty of the 2,903 NHSC scholarship recipients who graduated from U.S. medical schools from 1975 through 1983 and who were assigned to non-metropolitan counties. (This study included 2.2 percent of all the U.S. medical school graduates during this eight-year period). (15) In 1991, 20 percent of the physicians assigned by NHSC to rural areas were still practicing in the county of their initial assignment; and, an additional 20 percent were located in some other non-metropolitan community.

In another study, a questionnaire was mailed in 1991 to all primary care physicians placed in rural communities from 1987 through 1990 while meeting their obligations to the NHSC program. (16) Minorities among the rural NHSC physicians (122 or 31 percent of the respondents) were less likely to have been raised in rural areas; and, while they attended medical school were less interested in rural practice. The relative urban preference among the minority physicians explains, in large part, why this group was more dissatisfied than the non-minorities with their work and personal lives while practicing in rural community health centers. Similar low retention rates were reported for minority (15 percent) and non-minority (21 percent) NHSC physicians.

The NHSC program (2,300 scholarships in 1979 plummeting to a fewer than 200 in 1991) has played an important role in: allowing young physicians to finance their medical school and related obligations; providing a reasonable modicum of medical care to some underserved communities; and encouraging additional physicians to continue practicing in rural environments. This federally sponsored program now underway for over a quarter century has demonstrated that NHSC officials as a preferred option should use, whenever possible, loan repayment and select from those medical school students who have previous ties to rural areas. These candidates offer a reasonable likelihood (35 percent might be a reasonable estimate) that they will establish their practices in such communities. The success of state funded medical school scholarships, such as those provided in North Carolina and Virginia, directly linked to later practicing in under-served areas provides further support for this recommendation.

This NHSC strategy, however, has to be weighed against the practical reality that in the future there could be fewer doctors in Americas rural areas. In this managed care-market driven environment, primary care physicians completing their residency training are being aggressively recruited by various single and multi-specialty group practices. These young physicians can select a middle-income city or suburban location with an attractive lifestyle; where congenial colleagues share coverage for continuing education and for nights, weekends, and vacations; and, where superior earnings can be envisioned without any significant personal investment.