NHSC and FM/EM Residency

[BronzD]

Hey all,
I'm a Pre-Med student looking at possible ways to finance medical school. I have a service background and the concept of the NHSC really appeals to me, as does primary care-type medicine. I know that just recently a dual residency in Family Medicine/Emergency Medicine (5yrs) has been approved. At this point, I think I'm most interested in this residency. This question may be difficult to answer, but do you think its possible the NHSC will incorporate this residency into it's "accepted" residencies? It seems that EM/FM would be very useful in an underserved area. Or maybe I shouldn't hold my breath.

On that note, if I do wait, do your chances for getting an NHSC scholarship go down if you're a 2nd year med student applying?

Thanks for any advice.
-Ryan

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[montessori2md]

1) Even if the combined residency is not approved soon, it could be approved before you enter residency.
2) Even if the combined residency is approved soon, it could be "dis" approved later.

A lot of us think straight-up EM should be an approved specialty, as there is no reason, really, not to put an EM boarded doc in a CHC someplace. The basic problem, I think, is that you finish your EM training and then go practice primary care (lots of chronic disease management) and you could get pretty rusty at things like airway management. But if you could moonlight at a local ED that could be ok. On the other hand, if you really want to be in an ED, then NHSC probably isn't for you, because their reason for existence is to increase primary care medicine, specifically non-acute primary care. But, once again, they let Ob/gyn in, never mind that most obs aren't going to just do paps and prenatal visits in a CHC for life and be happy w/ that, and there are very few NHSC positions that allow for lots of L&D and procedure time for them, but they're an acceptable specialty. Whatever. I see their argument that because they don't have EM specific positions, it doesn't make sense to have EM in the list of accepted specialties. Because of that, it strikes me as somewhat unlikely that they will include the combined either -they don't for, example, allow time for FM to do a sports medicine fellowship, so why would they allow time for you to do an EM combined?


As far as applying second year, I would think that would increase your odds of acceptance, with the exception of those applying in 2010, which has the extra funding from the stimulus. Why? They pay M2s less $$$ (you get 1 yr of debt). You're also one year into training, which in theory makes you less likely to regret accepting the scholarship given your newfound love of urology.

 

[BronzD]

Interesting things to think about. Thank you for the information!

 

[J ROD]

I was told EM was a no go....they dont need them based on what they do so I would not expect that combo to work....

Plus, when you get a double, you almost all times have to pick one or the other...but I guess you could moonlight somewhere in an ER.

 

[Rusino]

1) Even if the combined residency is not approved soon, it could be approved before you enter residency.
2) Even if the combined residency is approved soon, it could be "dis" approved later.

A lot of us think straight-up EM should be an approved specialty, as there is no reason, really, not to put an EM boarded doc in a CHC someplace. The basic problem, I think, is that you finish your EM training and then go practice primary care (lots of chronic disease management) and you could get pretty rusty at things like airway management. But if you could moonlight at a local ED that could be ok. On the other hand, if you really want to be in an ED, then NHSC probably isn't for you, because their reason for existence is to increase primary care medicine, specifically non-acute primary care. But, once again, they let Ob/gyn in, never mind that most obs aren't going to just do paps and prenatal visits in a CHC for life and be happy w/ that, and there are very few NHSC positions that allow for lots of L&D and procedure time for them, but they're an acceptable specialty. Whatever. I see their argument that because they don't have EM specific positions, it doesn't make sense to have EM in the list of accepted specialties. Because of that, it strikes me as somewhat unlikely that they will include the combined either -they don't for, example, allow time for FM to do a sports medicine fellowship, so why would they allow time for you to do an EM combined?


As far as applying second year, I would think that would increase your odds of acceptance, with the exception of those applying in 2010, which has the extra funding from the stimulus. Why? They pay M2s less $$$ (you get 1 yr of debt). You're also one year into training, which in theory makes you less likely to regret accepting the scholarship given your newfound love of urology.

I was kind of hoping I would be able to practice full spectrum FM after residency in a high HPSA score area. Your comment makes me think that is less likely. Will I not be doing deliveries of any kind? Can I moonlight in an ED or in inpatient contexts outside of my primary service site in a highly underserved area? I feel like that should be feasible.

 

[smq123]

I was kind of hoping I would be able to practice full spectrum FM after residency in a high HPSA score area. Your comment makes me think that is less likely. Will I not be doing deliveries of any kind? Can I moonlight in an ED or in inpatient contexts outside of my primary service site in a highly underserved area? I feel like that should be feasible.

It's actually pretty complicated. It seems like it should be easy, but it's not.

To clarify - how high the HPSA score is doesn't necessarily indicate what you will be able to do. Many urban CHCs have extremely high HPSA scores, because HPSA scores are calculated based off of a lot of things, not just how many doctors are in the area. Those patients may live near large urban hospitals that would not be willing to extend Labor and Delivery privileges to a family medicine physician.

To break down your concerns:
- You might be able to do deliveries, especially if you're FM-OB, and especially if you're in a more rural area. That is certainly feasible, although it would be extremely clinic dependent. You would have to be sure to get a lot of OB experience and to keep excellent track of your procedure logs during residency.

- Some rural CHCs may have their doctors admit patients into the hospitals and do rounds. This is certainly not universal, and certainly unpopular with many physicians, but you could conceivably find a clinic and a hospital that would allow you to do this.

Keep in mind that the decision to allow you to see patients both inpatient and outpatient depends on both the clinic AND the hospital. The hospital may not be willing to do the extensive, long, and frankly tedious paperwork required to allow you to have inpatient admitting/treatment privileges.

- Moonlighting is a dicey topic, especially for FQHCs and their providers.

Some CHCs forbid outside moonlighting in their contract. If you continue to push for it, they may decide that you are not worth the effort and will not hire you. If you mess up while moonlighting elsewhere, then you might not be employable and that is a huge loss for them. So they may be really unhappy with you working elsewhere on your off hours.

Even if they were to allow moonlighting, you would be responsible for finding (and paying for) your own malpractice. FQHCs get their malpractice insurance through the Department of Justice and it is, unsurprisingly, extremely good malpractice insurance. However, the malpractice insurance only covers you when you are working for the FQHC - so, if you're moonlighting at an ER or at another hospital, your malpractice insurance doesn't cover you. Most ERs and hospitals do not want to provide malpractice insurance for moonlighters/per diems, so you would have to pay for it on your own. And most people would not find the expense worth it.

The misconception on SDN is frequently that CHCs and FQHCs have looser regulations than big hospitals so "maybe they can accommodate the way that I envision myself practicing." This is absolutely, 100%, unequivocally false. FQHCs have SO MANY federal regulations that they have to meet in order to get federal funding, and they have to be extremely strict with them so as not to lose that funding.

 

[smq123]

I was kind of hoping I would be able to practice full spectrum FM after residency in a high HPSA score area. Your comment makes me think that is less likely. Will I not be doing deliveries of any kind? Can I moonlight in an ED or in inpatient contexts outside of my primary service site in a highly underserved area? I feel like that should be feasible.

Another option would be to seek out FQHCs that have an urgent care built into their clinic - they may not have the resources for a full ER (and hence why the NHSC does not give the award to ER physicians), but some FQHCs have their own urgent care adjacent to their main clinics. That could be an option for you if you want some of the acuity of an ER without giving up the scholarship entirely. This might require A LOT of geographic flexibility but it's something to consider.

 

[Rusino]

It's actually pretty complicated. It seems like it should be easy, but it's not.

To clarify - how high the HPSA score is doesn't necessarily indicate what you will be able to do. Many urban CHCs have extremely high HPSA scores, because HPSA scores are calculated based off of a lot of things, not just how many doctors are in the area. Those patients may live near large urban hospitals that would not be willing to extend Labor and Delivery privileges to a family medicine physician.

To break down your concerns:
- You might be able to do deliveries, especially if you're FM-OB, and especially if you're in a more rural area. That is certainly feasible, although it would be extremely clinic dependent. You would have to be sure to get a lot of OB experience and to keep excellent track of your procedure logs during residency.

- Some rural CHCs may have their doctors admit patients into the hospitals and do rounds. This is certainly not universal, and certainly unpopular with many physicians, but you could conceivably find a clinic and a hospital that would allow you to do this.

Keep in mind that the decision to allow you to see patients both inpatient and outpatient depends on both the clinic AND the hospital. The hospital may not be willing to do the extensive, long, and frankly tedious paperwork required to allow you to have inpatient admitting/treatment privileges.

- Moonlighting is a dicey topic, especially for FQHCs and their providers.

Some CHCs forbid outside moonlighting in their contract. If you continue to push for it, they may decide that you are not worth the effort and will not hire you. If you mess up while moonlighting elsewhere, then you might not be employable and that is a huge loss for them. So they may be really unhappy with you working elsewhere on your off hours.

Even if they were to allow moonlighting, you would be responsible for finding (and paying for) your own malpractice. FQHCs get their malpractice insurance through the Department of Justice and it is, unsurprisingly, extremely good malpractice insurance. However, the malpractice insurance only covers you when you are working for the FQHC - so, if you're moonlighting at an ER or at another hospital, your malpractice insurance doesn't cover you. Most ERs and hospitals do not want to provide malpractice insurance for moonlighters/per diems, so you would have to pay for it on your own. And most people would not find the expense worth it.

The misconception on SDN is frequently that CHCs and FQHCs have looser regulations than big hospitals so "maybe they can accommodate the way that I envision myself practicing." This is absolutely, 100%, unequivocally false. FQHCs have SO MANY federal regulations that they have to meet in order to get federal funding, and they have to be extremely strict with them so as not to lose that funding.

Great response, thank you.

A bit disappointing though, frankly. One of the things that attracted me to being a physician in the first place was the potential to do multiple things at the same time. I certainly hope I am not relegated to outpatient 9-5 FM clinic for the duration of my service. I guess I can handle that, for the mere 2 years of my contract. But if that is the case, I will certainly not be staying at the site after I finish working and will be looking for other options. Now, if I can find a way to do full spectrum rural FM, that is a different story. I want all the variety. Hell, I was at least hoping to diversify my income streams by moonlighting with a telehealth company or helping manage a SNF/longterm care facility.

Edit: Definitely important to understand what the future holds and to have realistic expectations to avoid disappointment and annoyance down the line, so I do appreciate the information. At the same time, there is a sad lack of info on physician careers (even more so with rural ones) out there.

 

[smq123]

Great response, thank you.

A bit disappointing though, frankly. One of the things that attracted me to being a physician in the first place was the potential to do multiple things at the same time. I certainly hope I am not relegated to outpatient 9-5 FM clinic for the duration of my service. I guess I can handle that, for the mere 2 years of my contract. But if that is the case, I will certainly not be staying at the site after I finish working and will be looking for other options. Now, if I can find a way to do full spectrum rural FM, that is a different story. I want all the variety. Hell, I was at least hoping to diversify my income streams by moonlighting with a telehealth company or helping manage a SNF/longterm care facility.

Edit: Definitely important to understand what the future holds and to have realistic expectations to avoid disappointment and annoyance down the line, so I do appreciate the information. At the same time, there is a sad lack of info on physician careers (even more so with rural ones) out there.

I understand the disappointment. Like I said, it is certainly possible that you will be able to find an FQHC site that will allow you to have a wide scope of practice, but it would probably require A LOT of geographic flexibility. As in, basically, you don't really care what part of the country you end up in.

If it reassures you, when I was applying for jobs at the end of residency, many many FQHCs (mainly in the western part of the country) were heavily recruiting FM-OB. They really wanted family med physicians who wanted to include OB as part of their practice, so if you're ok with that, then you should have no issue finding an FQHC that fits your needs. Adding on ER and inpatient is going to be tricky, though.

You will also likely have to push them on whether or not this "full spectrum" is even an option. Many family med physicians, especially at that stage in their lives (i.e. after residency) are not necessarily looking to work those kinds of hours. So very few FQHCs are going to make this kind of practice set up mandatory or even widely advertise it - their goal is to attract providers to their centers (hence why they are even bothering to participate in the NHSC). Telling providers that the expectation is that they will do OB AND Emergency AND inpatient AND nursing home is a surefire recipe to make sure that they stay understaffed forever.

Finally, if a site is that remote and that understaffed that they need a family physician to cover OB and the ER and the inpatient service and a nursing home, then it is highly unlikely that they have the staff/organizational bandwidth to participate in the NHSC. If you find such a site, and they do not participate in the NHSC, you may have to push and prod them to fill out the paperwork to be registered as a site. That is another potential option.

 

[Rusino]

I understand the disappointment. Like I said, it is certainly possible that you will be able to find an FQHC site that will allow you to have a wide scope of practice, but it would probably require A LOT of geographic flexibility. As in, basically, you don't really care what part of the country you end up in.

If it reassures you, when I was applying for jobs at the end of residency, many many FQHCs (mainly in the western part of the country) were heavily recruiting FM-OB. They really wanted family med physicians who wanted to include OB as part of their practice, so if you're ok with that, then you should have no issue finding an FQHC that fits your needs. Adding on ER and inpatient is going to be tricky, though.

You will also likely have to push them on whether or not this "full spectrum" is even an option. Many family med physicians, especially at that stage in their lives (i.e. after residency) are not necessarily looking to work those kinds of hours. So very few FQHCs are going to make this kind of practice set up mandatory or even widely advertise it - their goal is to attract providers to their centers (hence why they are even bothering to participate in the NHSC). Telling providers that the expectation is that they will do OB AND Emergency AND inpatient AND nursing home is a surefire recipe to make sure that they stay understaffed forever.

Finally, if a site is that remote and that understaffed that they need a family physician to cover OB and the ER and the inpatient service and a nursing home, then it is highly unlikely that they have the staff/organizational bandwidth to participate in the NHSC. If you find such a site, and they do not participate in the NHSC, you may have to push and prod them to fill out the paperwork to be registered as a site. That is another potential option.

Great tips as always!

I know you may not have this info, but I still want to ask: from your job search/recruiter outreach/connections, are you aware of availability of FM-OB positions in the rural Southeastern states? In particular NC, though I do not want to dox myself too much by revealing my location... Transparent information about physician job availability and conditions continues to be less accessible to me as a medical student than I would like.

I am ultimately geographically flexible for the 2 years of service I will be doing, but I hope to return to the SE after service and it would help to stay in the same place I do my service (better continuity of care for patients too, as I am aware that rapid turnover of NHSC docs is not great for patient care in the long run, especially for having a reliable PCP).

I will keep in mind the option of connecting with rural sites and getting them to file for NHSC status as I network in residency.

Perhaps I will moderate my expectations to mostly FM-OB, possibly limited inpatient care if lucky. ED may be a bit of a stretch, though still something to consider for moonlighting down the road (after service, and yes, I remember the liability insurance concerns).

 

[smq123]

I know you may not have this info, but I still want to ask: from your job search/recruiter outreach/connections, are you aware of availability of FM-OB positions in the rural Southeastern states? In particular NC, though I do not want to dox myself too much by revealing my location... Transparent information about physician job availability and conditions continues to be less accessible to me as a medical student than I would like.

There are a couple of reasons for this:
- Recruiters/Human Resources are interested in hiring NOW. TODAY. Not 6 months from now, not 2 years from now, and definitely not 6-7 years from now.

- There is no one single clearinghouse for job information. There are too many jobs for this to be possible. Furthermore, posting all of that information, and staying up to date on it, is usually at the very bottom of the to-do list for most people who work in Human Resources, especially at an FQHC. And, no offense, but the last thing they want is to post that information and get an email from a medical student (or, worse, a premedical student) asking about a job that they are not eligible to apply for for 5+ years.

- Many jobs, even in the FQHC/NHSC world, are passed along through word of mouth, not through job ads or even the HPSA website.

- The job description that you read about today could change drastically in 2-3 years, for a variety of reasons. That FQHC could close. The hospital that they do their deliveries at could close their OB unit. The CEO or Chief Medical Officer could resign and the new CEO/CMO restructures the entire organization and that job disappears. FQHCs are constantly in motion and jobs/job conditions that you read about now could be totally obsolete in less time than it takes to finish medical school. And forget salaries - those change so quickly, that deserves its own post.

That being said:
- FQHCs are always hiring. ALWAYS. I've yet to see an FQHC that wasn't hiring/actively recruiting/preparing to actively recruit at any given time. So if you find an FQHC/NHSC site that has FM-OB, they will continue to hire for that position unless something catastrophic happens (like the nearby hospital closes down).

I don't know specifically about FM-OB at FQHCs in the Southeast, and there is no way to have any idea about the availability of positions that will be open to you in 6 or 7 years. That being said, if you have a very strong OB experience in residency (or, even better, do an OB fellowship and can get c-section privileges), you will be valuable commodity for many rural NHSC sites. You would also be a valuable commodity for many residency programs as well, if you wanted to do academics after your service obligation.

 

[Rusino]

There are a couple of reasons for this:
- Recruiters/Human Resources are interested in hiring NOW. TODAY. Not 6 months from now, not 2 years from now, and definitely not 6-7 years from now.

- There is no one single clearinghouse for job information. There are too many jobs for this to be possible. Furthermore, posting all of that information, and staying up to date on it, is usually at the very bottom of the to-do list for most people who work in Human Resources, especially at an FQHC. And, no offense, but the last thing they want is to post that information and get an email from a medical student (or, worse, a premedical student) asking about a job that they are not eligible to apply for for 5+ years.

- Many jobs, even in the FQHC/NHSC world, are passed along through word of mouth, not through job ads or even the HPSA website.

- The job description that you read about today could change drastically in 2-3 years, for a variety of reasons. That FQHC could close. The hospital that they do their deliveries at could close their OB unit. The CEO or Chief Medical Officer could resign and the new CEO/CMO restructures the entire organization and that job disappears. FQHCs are constantly in motion and jobs/job conditions that you read about now could be totally obsolete in less time than it takes to finish medical school. And forget salaries - those change so quickly, that deserves its own post.

That being said:
- FQHCs are always hiring. ALWAYS. I've yet to see an FQHC that wasn't hiring/actively recruiting/preparing to actively recruit at any given time. So if you find an FQHC/NHSC site that has FM-OB, they will continue to hire for that position unless something catastrophic happens (like the nearby hospital closes down).

I don't know specifically about FM-OB at FQHCs in the Southeast, and there is no way to have any idea about the availability of positions that will be open to you in 6 or 7 years. That being said, if you have a very strong OB experience in residency (or, even better, do an OB fellowship and can get c-section privileges), you will be valuable commodity for many rural NHSC sites. You would also be a valuable commodity for many residency programs as well, if you wanted to do academics after your service obligation.

I see your points about the difficulties with job postings. I will be starting service in about 4 years, not 5-7, but I think your point still stands. To be clear, I less want exact job listings. More a wide range of possibilities so that I know what to expect. I realized I want to be a rural FM doctor and have very little idea what that looks like if you get down to brass tacks. I'll just work on connecting with current docs and learning from them what I can.

Anyways. I did some brief research and it was not totally clear to me if you have to do an FM-OB 4 year program to do Cesareans, or if a 3 year FM program is enough if your residency includes adequate OB exposure. Seems like a really cool option. My likely future residency site is one of the ones that offers an FM-OB fellowship after the 3 year FM program, but I hear it is highly competitive because people from around the nation apply.

 

[smq123]

Anyways. I did some brief research and it was not totally clear to me if you have to do an FM-OB 4 year program to do Cesareans, or if a 3 year FM program is enough if your residency includes adequate OB exposure. Seems like a really cool option. My likely future residency site is one of the ones that offers an FM-OB fellowship after the 3 year FM program, but I hear it is highly competitive because people from around the nation apply.

It's not totally clear to you because there isn't a clear cut answer.

Some hospitals may look at your residency experience, especially if it was particularly strong (>50 c-sections, for instance) and feel that that's good enough. Other hospitals, particularly bigger ones, may say that that's not enough and will not grant you privileges. And other hospitals may say that they feel that it's ok for you to be first assist, but not primary surgeon. It varies and there's no way to tell - it's very much a case by case basis.

If you are ok with it, I would encourage you to do a fellowship that gives you strong c-section experience (>100 at least). This does not come anywhere close to approaching what an OB resident would have, obviously, but it would make it more likely that you will consistently be granted hospital c-section privileges. Relying solely on residency experience may, one day, not be enough and then you'll be SOL.

 

[Rusino]

It's not totally clear to you because there isn't a clear cut answer.

Some hospitals may look at your residency experience, especially if it was particularly strong (>50 c-sections, for instance) and feel that that's good enough. Other hospitals, particularly bigger ones, may say that that's not enough and will not grant you privileges. And other hospitals may say that they feel that it's ok for you to be first assist, but not primary surgeon. It varies and there's no way to tell - it's very much a case by case basis.

If you are ok with it, I would encourage you to do a fellowship that gives you strong c-section experience (>100 at least). This does not come anywhere close to approaching what an OB resident would have, obviously, but it would make it more likely that you will consistently be granted hospital c-section privileges. Relying solely on residency experience may, one day, not be enough and then you'll be SOL.

I would love to do such a fellowship if I can land one!

Thank you for all of your time and answers, as always. I think I have a better sense of some things and I realize that other questions may not be answerable right now.

 

[smq123]

I would love to do such a fellowship if I can land one!

Thank you for all of your time and answers, as always. I think I have a better sense of some things and I realize that other questions may not be answerable right now.

My pleasure! I wish that the NHSC offered more insight and information on the service repayment part, beyond just “do’s and dont’s.”

Feel free to ask the questions anyway, if you like. I’ll do my best to answer.