Recently, the 2015 PAEA Matriculating Student Survey found that at the start of their PA programs, over half of students thought they were likely or very likely to work in a medically underserved community upon graduation.
If you are a blog follower, you will know that I questioned whether the reasoning for this was the high student loan burden that most students take on at the beginning of their programs.
Far less than half of all graduating PA students take positions in an underserved community. So what is at the root of the discrepancy?
I recently had the pleasure of exploring this question and learning more about the largest student loan repayment program with Wilton Kennedy, the PA member of the National Advisory Council on the National Health Service Corps, a former NHSC Scholar with experience in migrant health, a doctor of health science, and Director of Clinical Education at Jefferson College in Roanoke, Virginia.
What is the National Health Service Corps?
The National Health Service Corps (NHSC), part of the US Department of Health and Human Services, was established in 1972 to provide primary health services to underserved communities through loan repayment or scholarships for health professionals in exchange for service.
Currently, over 9,600 members, including PAs, provide access to care to more than 10 million people at 5,000 health care sites.
What does NHSC provide for physician assistants?
In exchange for 2 years of service, PAs are granted $50,000 in student loan repayment.
For PA students, the NHSC Scholarship Program also requires a 2-year commitment following graduation, however the students’ tuition, books, and other school costs are paid by the scholarship and the program also provides a living stipend.
How is the loan repayment granted?
Applicants commit to work at an approved NHSC site in a high-need, underserved area. After accepting a position, applicants apply to the NHSC program for loan forgiveness. NHSC sites are ranked by a Health Professional Shortage Area (HPSA) score, the higher the score, the greater the need and the more likely an applicant is to be accepted into the program.
Payment is free of federal income tax and payment is made at the beginning of service. Service may be extended for an additional year after the first 2 years are completed for additional loan repayment assistance.
Insights from the Inside
The National Health Service Corps is the largest program available for student loan forgiveness and provides one of the few opportunities for a PA school scholarship, yet a small minority of PAs take advantage of this opportunity.
I asked Dr. Kennedy about his background working with underserved populations and why he thought there was a large gap in the incoming PA students who seemed interested in working in an underserved community and those who ultimately participate the NHSC after graduation.
How did you get started with NCHS?
I had a background as a health educator outreach worker at a migrant health center in western North Carolina. I applied to the National Health Service Corps as a scholar, and fortunately I got it. I had a 3-year commitment at an NHSC site and I went back to the site where I had worked as an outreach worker and worked as a PA there for 7 years.
Is it typical to stay on after the commitment is completed?
There is some very interesting data that has just come out of NHSC, and I cannot recall all of it, but the majority of NSCH loan repayers and scholars stay at underserved clinics. They don’t always stay at their original site, but they tend to transfer to other underserved sites with high HPSA scores.
Do you know how the NSHC loan repayment funds are prioritized beyond the standard 2-year commitment and if current members would get preference for funding for staying beyond the initial two years?
It would primarily have to do with the [HPSA] scoring of the site, and the available funding for that particular year. The funding for the NHSC can vary year to year based on what is passed by Congress.
Of the students that I had go to work at a NHSC loan repayment sites, most of them have stayed within the system and they have been able to continue to get loan repayment money even after 2 year commitment. I’ve had a few students who decided it wasn’t for them and they left after 1-2 years, but most have stayed beyond their 2 year commitment.
What do you see or hear from your students that you think keeps them in the program?
For some students, it’s a calling. I have other students that just need to get out of debt because they financed all of PA school. It is a great program and is a great way to gain a lot of great skills.
You are taking care of people that have a lot of medical problems and they access issues, so you learn a lot about the health care system, a lot of primary care, and a lot of procedures. A lot of patients couldn’t or wouldn’t go to an emergency room, so you gain a lot of experience with a good base of skills that you probably would not get in your standard primary care practice that can transfer to any specialty.
Could you speak to what types of backgrounds you see for the students awarded a scholarship?
The scholarships are divided up amongst the different professions supported by NHSC, and that is mandated by Congress. So, MD students may get X dollars, dentists, PAs, nursing, mental health all have a set dollar amount that is given as a percentage of the overall budget. The scholar process is very competitive.
They look at the applicant, their demographics, their background and it is much harder to get those scholarships than it is to get loan repayment. The scholarships are more expensive because the NHSC will pay for a more expensive school if that is where the student is going.
For the loan repayers, the money is a lot easier to get because there are more opportunities from slots not being filled by scholars, so there are a lot of sites that have high scores to attracts PAs and doctors into those positions. For me, it makes a lot of sense to go that route as a student because you will have more options in terms of where you can go than a scholar would.
So a scholar still chooses but from a smaller pool of sites?
The scholars have to go to a set number of sites within a list that is provided to the scholar. The loan repayment site list is a lot bigger, so as a student, there are a lot more option of where you can go if you do loan repayment.
From the NHSC materials, it seemed like the way the loan repayment program works is that you commit to a site first and then apply for loan repayment. Is there any danger of not being funded after committing?
The sites should know in advance whether they will have money based on their score. The salaries can actually be pretty competitive. I think there is a big misconception that you are going to take a huge hit in salary if you take loan repayment, and that has not been my experience with my graduates. They have had competitive salaries plus they got loan repayment.
What do you think is the source of the discrepancy between new PA students who seem interested in underserved work and the small number of new grad actually going into underserved roles?
Are students saying that because they think that is what think that is what we want to hear? Do they say that because they get into school and they realize that they are $100,000 in debt and that persuades them to consider it for the loan repayment aspect? Or do they genuinely mean it when they start school, but life changes during PA school and maybe a significant other is now involved and loan repayment for a life in a rural setting does not seem worth it any more?
It’s a very interesting question. Being PA faculty for 16 years, I can tell you that during the interview, students know what to say. It’s a lot of “primary care” and “service to the community” and that kind of stuff because they feel like they are being scored on that because the PA mission is primary care. The reality is people change during PA school and a higher salary may look better.
I interview a lot of prospective PA students, and I am in charge of the clinical rotations for the program and so I sit down with all of the students and ask “so what are your top interests?” and primary care is not one of them, and I’m like “hey man, a year ago…”
(Did you pay attention to that? Schools are wise to everyone claiming to want to work in an underserved areas. Be honest in your interview, you may stand out if you are one of the few not "reading from the script".)
Do you find that the students that come into the PA program with experience in community service are the ones more likely to be interested in underserved rotations and eventually careers?
Clearly there are some students that come in with that frame of mind and that calling. Other students have completely blown me away because I thought they would be the last person that would ever consider being in a rural underserved site, and they end up there. I have been shocked more than once over students that have ended up in a rural site where I never saw it coming.
A big thanks to Dr. Wilton Kennedy for taking the time to share his perspective on this program. I, for one, was among the misinformed that assumed that all loan repayment positions meant accepting a lower salary in exchange for repayment.
The cost of PA school continues to rise and the vast majority of students finance their PA education. In the coming weeks, we will look at more strategies to pay for PA school that will not leave you with crippling debt, and if you already took on the crippling debt, we will discuss damage control measures to help you get out.
Physician Assistant Education Association, By the Numbers: Matriculating Students 2015, Washington, D.C.: PAEA, 2016. doi: 10.17538/MSS2015.003
National Health Service Corps. US Department of Health & Human Services. http://www.nhsc.hrsa.gov/