NHSC NHSC is a system to keep poor people poor even if they become doctors. Welcome to indentured servitude.

[suckafish]

When I went through undergraduate and medical school as a single mom it caused me a lot of money. I was repeatedly reassured that the payoff would be worth it and that there would be longer payment programs in my future. When I actually got into residency on the NHSC student to service program my loans were reduced significantly by the $30,000 per year forgiveness for 4 years which started in my final year of medical school.
I knew where I wanted to practice and that it was a qualifying area for the program and so I thought it would not be a problem to do 3 years of full-time work and pay off my loan obligation.
I trained as a full scope family practice provider and I work in the clinic, OB, as a hospitalist, and I work for the hospice program in my county and work an inpatient palliative service. This seems like a lot but it all falls within full scope family practice in a rural community. There were a few important things I wish I had known before I became involved in the National health service core.
1. They only count the work I do in the clinic and none of the other work I do in my community qualifies for the hours that they require. AND they required documentation endlessly.
2. Full-time for my clinic means every waking hour of your life. After a few months I had to drop down to part-time (0.65) in order to sleep at night. Once you discontinue full-time service you will always be considered part-time by the NHSC. You are not allowed to go back. Now the obligation is double the number of years. For me that means 6 years.
3. I know many of my colleagues who have had their service requirement extended for many more years than I can imagine.
4. Clinics that qualify for the loan forgiveness program do not pay their doctors a living wage. They leverage their ability to hire NHSC providers and use it to their advantage. In my case the CEO of the clinic that I work for was a kind and compassionate man who felt strongly about serving his community and shortly after I started working there he died. Now the company is run by a heartless CEO who has no investment in my community and pays providers barely enough to live on. Not only do I love working in the hospital but I also have to work in the hospital to afford my house and my very high loan payments every month.
5. Once you are in the National health service core you do not qualify for other loan forgiveness or repayment programs. California has excellent programs and if I had known that I would be out of debt now and not an indentured servant with still 100s of thousands of dollars to pay off and no forgiveness programs available until I complete my 6 years of indentured servitude. At that point, I will not qualify for most of the programs as I will be too far out of residency.
6. The penalty for quitting the program early, even now, after of paid off half of my years (3 years) is still far more than they forgave on my loans. They forgave $120,000 and after 3 years my penalty if I stopped working for this clinic is $200,000 plus the maximum amount of interest allowed by law. They offer no other options and when you ask they let you know that this is a mandate by Congress and there is no flexibility.
7. You cannot communicate with the National health service corps. It is a government agency and a bureaucracy with no real people who will ever talk to you on the phone. There are no exceptions on any of the rules and there is no consideration for people serving their communities and working themselves to death.
8. I am in debt because I come from a poor family. I am in debt because they went to college after having a divorce and becoming a single mom. I was older when I started college and older than my peers when I started medical school. I started practice after residency at age 37. I may never be out of debt. I will always be scrambling to make ends meet and my son will have to take out loans for college too.
9. Point 8 is the point of this post. This program allows clinics to make doctors into slave labor. It prevents some doctors from ever actually getting out of debt. It serves it's purpose of bringing more doctors into primary care but it does it by scamming the doctors. DON"T DO IT!
10. I will quit primary care the day I am out of this horrible program. I have the date blazed in my mind and I can't wait for it to come. If I work 1/2 as many hours in the hospital as I work now in clinic I will make twice as much money and actually be able to start paying off some actual debt. Until then I will preach to anyone who will hear me. DO NOT MAKE THE MISTAKE I DID. I will quit primary care to pursue the things I love and the things that are profitable. And, to be truthful, I will quit because I hate this program so very much I do not want them to make me into some success story. This program is a horrible institution and I can only pray that it falls apart with the evil administration in the white house right now. Someone please free me from this terrible situation.
11. Also, just in case you think residency is painful. I work more hours now then I did in residency. I never thought this would be so very hard.

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[deleted480308]

Couple quick points/questions.

1. You say the clinic required every waking hour of you but you also said you have like 4 side jobs. Which is it? Or can you help explain that?
2. Almost all of us have loans, poverty isn’t required to need to take loans.
3. How much were they paying you for a full time clinic job you were hired for? How mucb for the part time you now have? “Slave wages” is a pretty big claim.

I know my questions are a little pointed but the post seems a littlehyperbolic, last I checked you were still allowed to change locations and can leave this employer

 

[suckafish]

Couple quick points/questions.

1. You say the clinic required every waking hour of you but you also said you have like 4 side jobs. Which is it? Or can you help explain that?
2. Almost all of us have loans, poverty isn’t required to need to take loans.
3. How much were they paying you for a full time clinic job you were hired for? How mucb for the part time you now have? “Slave wages” is a pretty big claim.

I know my questions are a little pointed but the post seems a littlehyperbolic, last I checked you were still allowed to change locations and can leave this employer

This is a good question and yes the post is hyperbolic. Clearly written by a tired and frustrated doctor. I assume people realize how much work goes into a primary care clinic but perhaps I assume incorrectly. "every waking hour" because you do not get time to get your work done during the day when you are seeing a patient every 15-20 minutes. There is a lot of work left to do when the patients are gone. In this clinic you work until you can't anymore. You fill meds and answer patient questions and close charts and call specialists and abstract reports from imaging and specialists. If you are working 5 days per week then you do all the other tasks for the remaining hours. For me to cut back to .65 means I ONLY work full time (for them). Support staff is underpaid and under-trained and the doctors end up doing more work then they would elsewhere. The hourly pay sounds high until you realize all the unpaid hours makes the pay much less. This is slave wages, the dollar amount is irrelevant but is on the lowest tier for any family practice job which, I know is more than the garbage man makes, but is not worth the trouble considering there are so many well paying jobs I am not working and could. I stay because this is my community. I am not a transplant, I am home. I would not leave, I would rather stay here and try to fix the system in the place I am.

When I started the job they told me I would be allowed to be a hospitalist but then allowed no time for it. So, I was able to do only one weekend a month and that is not enough to keep up hospitalist skills. I do OB through my primary clinic, so that is not another job, it is part of the .65 but, as you know, babies do not care about my schedule, so I might spend days waiting on an induction. Luckily the hospital and clinic are near each other but when patients are cancelled I often have to add more clinic days to see them.

Poverty is not required to take loans. But poverty makes them more burdensome, a bigger hole to crawl out of.
Here is the part that should stop anyone from taking a contract with NHSC: the amount they "forgive" is less than the difference in pay between most FQHC sites and a non-FQHC. That means ONE year annual pay would pay back more than the debt they forgave with still the same amount left to live on. WHY would anyone do this? Why did I do it? I love this community and planned to work here regardless. What frustrates me is that the clinic feels that they own me and can dictate where I work and they do own me, that is the slave part. I would happily work for the clinic as part of my full scope but they want more hours, they want all doctors to churn out patient encounters like a machine and do not take into account that some cases require more time. NHSC does not value continuity of care. I see a patient in hospital and the acute rehab/SNF and again back in my clinic. I do house calls in remote areas and to my dying patients and I work for the hospice (which is even less pay, but much more fulfilling and laid back than clinic). These organizations do not want that. They want clinic encounters more, faster, but also they want quality. That is not how you get quality.

It is not my clinic that is broken, it is our healthcare system. I am a good doctor but I will become more callous until I cannot be a good doctor anymore.

 

[deleted480308]

Submit a site transfer request and get out of that location. Get the terms of the new place in writing before you show up.

 

[suckafish]

Submit a site transfer request and get out of that location. Get the terms of the new place in writing before you show up.

That was fast. Did you read any of the response? There are no other sites up here. I live in a small city center in a very remote region. I am not going anywhere. I have family and community. I own a house here. I am not a travelling physician changing my life for NHSC. I am here to stay. Good luck with your locums job, not what I am looking for.

 

[suckafish]

Submit a site transfer request and get out of that location. Get the terms of the new place in writing before you show up.

So interesting that you thought I was looking for advice.

 

[deleted480308]

That was fast. Did you read any of the response? There are no other sites up here. I live in a small city center in a very remote region. I am not going anywhere. I have family and community. I own a house here. I am not a travelling physician changing my life for NHSC. I am here to stay. Good luck with your locums job, not what I am looking for.

I don’t need a locums job, I’m content with my situation.

I hope you find happiness somehow

 

[smq123]

This is a good question and yes the post is hyperbolic. Clearly written by a tired and frustrated doctor.

When I read your post, I felt conflicted about whether or not I should respond.

Because on one hand, yes, it was clearly meant as a vent - I can tell that you're tired, and exhausted, and overwhelmed, and I am sorry.

But on the other hand, I know (from personal experience) that many people read this forum to gain insight into whether or not they should take the scholarship or participate in the Loan Repayment Program. There are precious few places on the internet to hear opinions from people who have actually participated in these programs, so I feel like there is a responsibility to make sure that both sides of the story are heard.

It sounds like you are working very hard, and your experience has not been positive - for that, I am sorry.

That being said:

- It is absolutely not a secret that the NHSC only counts clinic hours. That is very clearly outlined in their application.

Full-Time Clinical Practice. Full-time clinical practice is defined, for the purposes of the NHSC, as a minimum of 40 hours per week, for a minimum of 45 weeks each service year. The 40 hours per week may be compressed into no less than 4 days per week, with no more than 12 hours of work to be performed in any 24-hour period. Of the 40 hours per week, a minimum of 32 hours must be spent providing patient care. ” section. Scholars do not receive service credit for hours worked over the required 40 hours per week and excess hours cannot be applied to any other work week. Also, time spent “on call” will not be counted towards the service commitment, except to the extent the provider is providing patient care during that period.

- The NHSC is not requiring you to work as a hospitalist, do OB, or do hospice care. That's what you have chosen to do, because that is important to you. That's fine, but I want anyone reading this to acknowledge that the NHSC did not make that decision for you - you did, because those were important aspects of clinical care that you did not want to give up. And that's ok, but I don't want that to deter anyone from taking the scholarship or doing the LRP.

- I am not clear what you mean by "endless" documentation. I only ever had to report how many weeks off I had taken twice a year and, honestly, after I did a poor job the first few times, HR just ended up doing it for me.

- It is a shame that your CEO changed, and the new CEO's vision for the company differs from yours. However, that is a possibility in any job - your shift manager changes and the new one is a tight-a**. Your supervisor has a baby and the substitute is clueless and disorganized. Etc.

As @sb247 pointed out, however....you can leave. The NHSC does not require you to stay in the same practice site for your entire service obligation. Your house, your child's school, and your ties to the community are what are keeping you there, but NOT the NHSC.

- When you say that you have had colleagues who have had their service obligation extended "for more years than you can imagine" - why? What happened? I have never heard of that happening. Once your time is up, the NHSC sends you an email asking if you want to extend it, but no one forces them to.

- I would also like to point out for people reading this that the OP works in California. Salaries in California are, generally, lower than other parts of the country. The cost of living is also much higher. Even rural California is not "cheap," at least not compared to rural Mississippi or Idaho - the tax burden alone is much higher. I am honestly surprised that you can afford a house on a single salary (even if you're a physician) and I am surprised that you were able to find a suitable NHSC site in California - California is a notoriously hard market to break into.

I will be the first to tell people that the NHSC is not a perfect program. I have made that abundantly clear in my other posts. However, I do not want someone to read your post (which you admit is hyperbolic) and not get the other side of the story.

 

[simpler2]

@suckafish I am sorry to hear about your specific experience. I would like to echo @smq123 concerns that it is important for those considering NHSC programs to understand that experiences with the program vary widely. In speaking with countless scholars and those in LRP over many years, my impression is that most of those who participate with NHSC programs are very satisfied with the results and suffer minimal burden for participation. I personally had a great experience as a NHSC scholar and then loan repayment recipient and as result paid zero dollars on my medical education.

Colleagues working in my same medical system are, and will continue, to pay off student loan debt for the next 15-20 years (eventually doubling or tripling the amount they pay due to interest).

I would warn anyone considering NHSC that the program is not designed to be flexible. If someone has very specific ideas about how they want their practice to look or where they want to practice, NHSC programs may not be a great fit.

 

[gyngyn]

NHSC was the best decision I made in medical school.

 

[Leonardsean]

I am a family med doc (boarded in osteopathic and allopathic family medicine) working at an FQHC, NHSC site, and I echo your sentiments.

I am working 3 jobs: Suboxone clinic (I started it with the CEO of a local rural health center, not my NHSC site) 1 night per week, I pick up 1 weekend per month at the local in-patient drug and alcohol detox/rehab unit, and work Full time at my FQHC. At the FQHC, I have barely enough time to see the patients in the allotted appointment times, reviewing lab results, attaining quality measures, dictating charts, responding to patient requests, refilling meds, filling out paperwork, all ends up getting done at home on the weekends. It results in an 80-90 hour work week, from just the demands of the FQHC site. Administration works against the providers, just trying to squeeze as much revenue out of us as possible, and always crying poor-mouth, but then spending (embezzeling?) grant money like drunken sailors. Support staff is drastically underpaid. As a consequence we are VERY understaffed. We lost 3 providers in the last 1-2 years, and the solution was, "You have to see their patients as well." I am the only provider in the agency willing to write for pain medications (appropriately: with monthly follow up, drug screens, pill counts, etc.) I provide mental health treatment (schizophrenia, bipolar d/o, depression, PTSD, ADHD, drug dependence, etc.) while other providers in our office are afraid to write for an antidepressant. Needless to say my no-show rates are lower than the other remaining providers, so I typically see 1.5X as many patients as the other providers.

During the past year, I had used 33 of my 35 allotted days off with 3 months remaining (studying for and taking boards as well as obtaining CME at a conference).

During COVID-19, while our midlevels and one new grad physician were hiding under their beds (they refused to come to work), myself and a number of other seasoned docs were still "seeing" patients, either by telemed or in person. We were the only health center/primary care office in the area that was seeing patients in the office at the height of COVID and taking on new patients (Because admin cared more about revenue than patient or staff safety).

I was burned out. I called the NHSC, tried to get my Suboxone clinic hours to count towards my 40 hour total so I could drop my hours at the FQHC back to 32. Nope. I called to complain/argue with a telephone rep at the NHSC: I stated, "You people just don't care about supporting front-line workers, during this pandemic!" The response I received was, "What do you mean, 'You people?'" As if I was a racist, denigrating her skin color...over the phone?! (She also addressed E-mails to me as "Mr. Leonard.")

This is the "public service" that the NHSC/BHW offers.

I am in the loan repayment program. I received $50,000 for 2 years of service (however my site made me sign a 3 year contract, and I wasn't eligible to apply to the NHSC program for 1 year after starting. If I fail to complete the terms, I may end up owing a minimum penalty of $25,000, plus so much for each additional day (or week?) not worked. There aren't any other local sites at the same level of underservedness to allow for a switch, I would have to relocate my family in order to switch sites.

So, yes, the NHSC program is definitely horrible. Indentured servitude is accurate. Customer Service is not a thing.

My recommendation is try and find other avenues for loan repayment/forgiveness. My state offers a similar program. Some hospitals may negotiate loan payments as part of your contract.

--Sean

 

[smq123]

I am a family med doc (boarded in osteopathic and allopathic family medicine) working at an FQHC, NHSC site, and I echo your sentiments.

I am working 3 jobs: Suboxone clinic (I started it with the CEO of a local rural health center, not my NHSC site) 1 night per week, I pick up 1 weekend per month at the local in-patient drug and alcohol detox/rehab unit, and work Full time at my FQHC. At the FQHC, I have barely enough time to see the patients in the allotted appointment times, reviewing lab results, attaining quality measures, dictating charts, responding to patient requests, refilling meds, filling out paperwork, all ends up getting done at home on the weekends. It results in an 80-90 hour work week, from just the demands of the FQHC site. Administration works against the providers, just trying to squeeze as much revenue out of us as possible, and always crying poor-mouth, but then spending (embezzeling?) grant money like drunken sailors. Support staff is drastically underpaid. As a consequence we are VERY understaffed. We lost 3 providers in the last 1-2 years, and the solution was, "You have to see their patients as well." I am the only provider in the agency willing to write for pain medications (appropriately: with monthly follow up, drug screens, pill counts, etc.) I provide mental health treatment (schizophrenia, bipolar d/o, depression, PTSD, ADHD, drug dependence, etc.) while other providers in our office are afraid to write for an antidepressant. Needless to say my no-show rates are lower than the other remaining providers, so I typically see 1.5X as many patients as the other providers.

During the past year, I had used 33 of my 35 allotted days off with 3 months remaining (studying for and taking boards as well as obtaining CME at a conference).

During COVID-19, while our midlevels and one new grad physician were hiding under their beds (they refused to come to work), myself and a number of other seasoned docs were still "seeing" patients, either by telemed or in person. We were the only health center/primary care office in the area that was seeing patients in the office at the height of COVID and taking on new patients (Because admin cared more about revenue than patient or staff safety).

I was burned out. I called the NHSC, tried to get my Suboxone clinic hours to count towards my 40 hour total so I could drop my hours at the FQHC back to 32. Nope. I called to complain/argue with a telephone rep at the NHSC: I stated, "You people just don't care about supporting front-line workers, during this pandemic!" The response I received was, "What do you mean, 'You people?'" As if I was a racist, denigrating her skin color...over the phone?! (She also addressed E-mails to me as "Mr. Leonard.")

This is the "public service" that the NHSC/BHW offers.

I am in the loan repayment program. I received $50,000 for 2 years of service (however my site made me sign a 3 year contract, and I wasn't eligible to apply to the NHSC program for 1 year after starting. If I fail to complete the terms, I may end up owing a minimum penalty of $25,000, plus so much for each additional day (or week?) not worked. There aren't any other local sites at the same level of underservedness to allow for a switch, I would have to relocate my family in order to switch sites.

So, yes, the NHSC program is definitely horrible. Indentured servitude is accurate. Customer Service is not a thing.

My recommendation is try and find other avenues for loan repayment/forgiveness. My state offers a similar program. Some hospitals may negotiate loan payments as part of your contract.

--Sean

Can you step away from the suboxone clinic and inpatient detox unit for a bit?

I understand why you tried to get your hours at the suboxone clinic to count towards your NHSC requirements but...it's very clearly laid out in the LRP/scholarship paperwork. If it's not your primary site, it doesn't count. If it's not an NHSC approved site, it doesn't count. I am confused why people keep trying to do things that the NHSC clearly states will not count, and then get upset when...<gasp>....the NHSC doesn't accept it.

 

[Leonardsean]

One of the NPs I worked with had applied for the NHSC repayment plan, she had $7500 +/- in unpaid student loans, Figured the NHSC was free money, and applied, received it, and 6 months later decided she had enough of the working conditions, poor management and other negative aspects of our FQHC (see my post above). She left owing 16 months on a 24 month NHSC contract, and moved to Florida. She contacted the NHSC and they are working with her to find her new employment, COVID-19 pandemic and all... Closest equivalent site is > 100 miles away

She may owe $120,000 (penalties = $7500 per month x 16 months, minimum of $31,000) for $7500 payment.

I was just wondering if the government finds it lucrative charging people for their broken contracts? I wonder what the incidence of broken contracts is and amounts of penalties obtained?

--Sean

 

[Leonardsean]

Can you step away from the suboxone clinic and inpatient detox unit for a bit?

I understand why you tried to get your hours at the suboxone clinic to count towards your NHSC requirements but...it's very clearly laid out in the LRP/scholarship paperwork. If it's not your primary site, it doesn't count. If it's not an NHSC approved site, it doesn't count. I am confused why people keep trying to do things that the NHSC clearly states will not count, and then get upset when...<gasp>....the NHSC doesn't accept it.

No. I am waivered for 100 patients and see probably 60 Suboxone plus an additional 10+ vivitrol patients monthly. I have no back up (just a PA who is waivered for 30 patients and slowly building her panel). I have worked every Monday afternoon/evening for the last 2.5 years (except one when I went to a conference...I had to schedule everyone on that particular Monday for the week before or the one after...)

My point in reaching out to NHSC...was that my Suboxone clinic site IS an NHSC site...it is just not at the same HPSA level. Needless to say the customer service was limited to suggesting I was a racist, and reading prewritten statements off a computer screen. Other providers in our office quit during covid-19, and were provided a period of time to apply for and obtain employment. Her service requirement was put on hold for over a year now in order for her to gain employment at an NHSC site. They were even willing to consider a nonNHSC site if they had a certain proportion of free or charity care...

Me, I received inflexibility and rudeness from "customer service" employees during a worldwide pandemic when I was working on the front lines...

--Sean

 

[stillers]

@suckafish I am sorry to hear about your specific experience. I would like to echo @smq123 concerns that it is important for those considering NHSC programs to understand that experiences with the program vary widely. In speaking with countless scholars and those in LRP over many years, my impression is that most of those who participate with NHSC programs are very satisfied with the results and suffer minimal burden for participation. I personally had a great experience as a NHSC scholar and then loan repayment recipient and as result paid zero dollars on my medical education.

Colleagues working in my same medical system are, and will continue, to pay off student loan debt for the next 15-20 years (eventually doubling or tripling the amount they pay due to interest).

I would warn anyone considering NHSC that the program is not designed to be flexible. If someone has very specific ideas about how they want their practice to look or where they want to practice, NHSC programs may not be a great fit.

Also had a great experience with NHSC and the Indian Health Service, where I served my time. Did a substantial amount of inpatient and ICU work while with the IHS, in addition to clinic time. Loved the community and outdoor activities. Paid off what debt I had from undergrad, and was financially solvent after leaving IHS w/ substantial savings.
It's not for everyone and all FQHCs are not created equal. Make sure you look around, having geographic flexibility is very important. Highly recommend IHS for anyone wanting to continue inpatient medicine.

 

[Muslim_Med_Student_2021]

Also had a great experience with NHSC and the Indian Health Service, where I served my time. Did a substantial amount of inpatient and ICU work while with the IHS, in addition to clinic time. Loved the community and outdoor activities. Paid off what debt I had from undergrad, and was financially solvent after leaving IHS w/ substantial savings.
It's not for everyone and all FQHCs are not created equal. Make sure you look around, having geographic flexibility is very important. Highly recommend IHS for anyone wanting to continue inpatient medicine.

Inpatient medicine?! This is what I’ve been searching for. I’ve been trying to find NHSC jobs on the workforce connector website which allows for inpatient work so that I could keep up with my skills after residency, but I have not been very successful. I havent found any that advertise jobs with an inpatient component.

How did you find your site? Did you search for one that allowed for inpatient medicine specifically? What proportion of your work was outpatient vs inpatient? Please let me know as I was kinda bummed that I may not be able to practice inpatient medicine after residency, but your post gave me hope