Retention of Family Physicians in the National Health Service Corps (NHSC) in High-Need Areas

• Family Physicians
• Health Disparities
• Health Policy
• Health Workforce
• Medical Education
• Medically Underserved Area
• National Health Service Corps
• Physician Shortage Area
• Primary Health Care
• Rural Health

Shortages and maldistribution of primary care physicians persist.¹ High levels of debt and lower rates of compensation for practicing in high-need areas may exacerbate these shortages.^2–3 This reflects the dual challenges of financial barriers and recruitment difficulties, particularly in underserved settings. The National Health Service Corps (NHSC) scholarship and loan repayment programs defray the costs of medical school in exchange for a service commitment to practice in a high-need area (defined as working in a medically underserved area (MUA) practice, Health Professional Shortage Area (HPSA), or rural area). The NHSC is popular, with around 2,500 primary care physicians currently in the program.⁴ Retention rates range from 55% to 80% after ten years for all physician specialties.^4–6

There is limited research on NHSC primary care physician retention. One recent study found that family physicians in the NHSC were more likely than non-NHSC family physicians to practice in high-need areas 3 years after residency,⁷ but little is known about the long-term retention of family physicians in high-need areas. Our objective was to compare retention of family physicians in high-need areas (MUA practice, HPSAs, rural areas) at 3 and 6 years after completing residency, by NHSC participation.

We used linked data from the American Board of Family Medicine (ABFM) National Graduate Survey (NGS, 2016-2020; 3 years post-residency) and Practice Demographic Survey (PDS, 2019–2023; 6 years post-residency) to create a cohort of nearly 5,000 family physicians. Both the NGS and PDS collect practice organization and address. We defined MUA as practicing in a federally qualified health center (FQHC), rural health clinic, Indian Health Service, non-federal government clinic, or prison location. Practice addresses were geocoded to determine HPSA and rural status (defined as county-level Rural-Urban Continuum Codes >= 4). This study was approved by the American Academy of Family Physicians Institutional Review Board.

Only 235 (5%) of the 4,892 family physicians in the cohort were NHSC participants. Comparing 3 years and 6 years post-residency, the percentage of family physicians practicing in high-need areas declined (Figure 1). These declines were larger and statistically significant (p < .001) for NHSC participants in all types of high-need areas, including from 85.0% to 60.7% in an MUA practice, 76.0% to 66.2% in HPSAs, and from 29.8% to 21.3% in rural areas.

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Figure 1.

Practice location of early career family physicians by participation in the National Health Service Corps. Abbreviations: HPSA, Health Professional Shortage Area; MUA, medically underserved area practice; NHSC, National Health Service Corps.

While the majority of NHSC family physicians remain in high-need areas 6 years after residency, many are leaving. Given increasing primary care physician shortages, high demand for NHSC programs but limited funding,⁸ and large numbers of NHSC vacancies for primary care physicians,⁹ this research suggests that increasing funding for the NHSC program could increase the number of family physicians practicing in high-need areas and improve their long-term retention. Additionally, as more family physicians who chose to practice in high needs areas stay there 6 years after residency, identifying NHSC participants more likely to remain in high-needs settings longer term would improve the effectiveness of the program.

• Received for publication January 29, 2025.
• Revision received April 7, 2025.
• Accepted for publication May 12, 2025.