Photo by Kara Hoegh

Dr. Zach Vosburg and his wife, Alexis, returned home to rural Iowa so their sons could grow up with extended family close by. Vosburg's willingness to broaden his practice to a neighboring county identified as a veterinary shortage area netted him a grant from the U.S. Department of Agriculture worth $75,000 in school loan payments over three years.

Morning is devoted to dogs and cats, surgeries and practice-management duties. After lunch, it’s time to bundle up for a drive through a frozen landscape to ranches to check on pregnant or calving cows or sick calves. Late afternoon, it’s back to the clinic for more small animal appointments. That might constitute a typical winter day, if there were such a thing, for Dr. Zach Vosburg.

Vosburg’s clinic isn’t the only veterinary practice in his part of rural Iowa, some 100 miles north of Des Moines. But a neighboring county was designated a few years ago by the state and federal governments as having a shortage of veterinarians. That distinction and Vosburg’s willingness to extend his practice geographically won him an award of $75,000 to be applied over three years toward his veterinary school debt of about $100,000.

Debt payments by the Veterinary Medical Loan Repayment Program (VMLRP) are an incentive offered through the U.S. Department of Agriculture (USDA) since 2010 to try to attract and keep young veterinarians in communities deemed in need. But it wasn’t the promise of $75,000 that drew Vosburg to Hampton, population 4,500.

Vosburg grew up in Hampton. He returned to his hometown so his children could live near their grandparents. The family moved there in 2008, three years before Vosburg secured the loan repayment assistance. The money did not bring him to Hampton, but the veterinarian said it almost certainly roots him there.

“The difference in the student loan (balance) has allowed us to actually be able to purchase the clinic that I’m at,” Vosburg said. “My wife and I have owned it for a little bit over a year now. … My long-term game plan was to not just be an associate veterinarian, but to buy the practice. By them granting me this (assistance), it guarantees that I’ll be able to stay.”

Four years into the USDA loan repayment program, anecdotes suggest it is working well in at least some shortage areas. A definitive assessment is elusive, however, owing in part to a federal confidentiality policy that conceals the identities of award recipients even from officials in the states where the veterinarians pledge to serve.

“It makes it harder to evaluate because you don’t know who (is there),” said Dr. Bruce King, Utah State Veterinarian. “But we do the best we can.”

Authorized by the National Veterinary Medical Services Act of 2003, the VMLPR aims to fill perceived geographic shortages of veterinarians in food animal medicine, public health, epidemiology and food safety. Shortage areas tend to be in rural America, where farm animals far outnumber people, and where people and animals alike may be situated over long distances, requiring considerable travel time to reach.

As an incentive, the program offers up to $75,000 in loan repayments to successful applicants who commit to serving three years in a shortage area. The prospect of debt assistance can be a strong attractant, as nine out of 10 new veterinarians owe an average of $162,113 upon graduation, according to the American Veterinary Medical Association.

To date, the government has committed $20.9 million to 219 veterinarians. (The program also covers federal income taxes assessed on the awards.)

The VIN News Service interviewed three recipients whose identities it learned through word-of-mouth. All credited the loan-repayment assistance with helping to bolster their futures financially, and all expressed an intent to stay put.

Helping veterinarians settle for the long term in a previously underserved area is what Dr. Gary Sherman, manager of the VMLRP, calls “the brass ring” of the loan repayment program. How many will stay is an open question.

The experience of the National Health Service Corps, established in 1970, which offers loan repayment to physicians and other medical professionals willing to practice in underserved communities, may be a guide. A survey in 2012 found that 55 percent of participants had remained in their respective service areas for at least 10 years following completion of service. Said Sherman: “I hope we can at least match, if not do better than that.”

Chicken or egg?

On the veterinary side, the promise of loan repayment is not necessarily what brings veterinarians to a shortage area, as Vosburg's story demonstrates. Practitioners already situated in or near shortage areas when they receive awards outnumber 2-to-1 practitioners who move there after securing the financial assistance, according to Sherman.

Dr. John Thomson, a retired veterinary school dean and former large animal practitioner whose political advocacy helped create the loan repayment program, said it makes sense that many top applications are submitted by veterinarians already in the target areas.

“It’s much easier for them to match the need if they’ve got a (job) offer or they have a practice that they’re buying, that type of thing,” said Thomson, who for two years managed the panel that selects the winning applicants. “It would be hard for them to tell the board they’re going to do something if they’ve never looked into what everything is going to cost.”

In fact, Thomson said, “I’ve told many, many students, you don’t go to the area (just) to get the loan.” As he and others note, being successful in a shortage area requires more than financial assistance. You have to like the place. If you’re married, your spouse should like it, too, and be able to find work if desired. Having family support can make a big difference, as can familiarity with the environment, culture and lifestyle.

At least two loan repayment recipients are veterinarians who have joined their families’ practices, according to interviews with state veterinarians.

Asked why a practitioner would need a government incentive to work in a family business, Sherman replied, “This gets into a more challenging part of the selection process. We cannot always determine all the factors at play in a given application.”

The selection panel does try to determine “Would this person really have gone back there anyway?” and “Would they be a good match for the described shortage?” Sherman said. “The case must be made by the applicant that either they would not have been able to serve the designated area without the help, or that they will be able to mitigate the shortage situation much more effectively and sustainably…."

He acknowledged that some might criticize the program for awarding people who are already in place. But the goal, he said, is not only to bring doctors to underserved areas but to provide financial stability to those in place, and help them expand their reach, such as by traveling farther to practice in a previously unserved community. “No one receives an award ... for staying in the same practice and doing the same work as before receiving an award,” Sherman said.

Matchmaking 'magic'
 
Awards are offered each fall for service that begins the following year. In each round so far, a few applicants have declined the offers. Sherman said the reasons typically have to do with changes in plans, such as having secured employment elsewhere.

Among those who have entered the VMLRP, three or four have left before completing their service, Sherman said. The USDA excuses those with a compelling cause, such as a death in the family, serious illness or being called to military service. A participant who leaves for an unexcused reason is considered in breach of contract and must repay the government plus 7 percent interest. Sherman said all who have left to date were excused.

For every veterinarian who has left the program early, many more apparently have settled in comfortably, even when the odds seem against them. Sherman offered the example of a veterinarian who applied to serve in a remote part of a northern Plains state. In discussing her application, the selection panel worried that if the veterinarian and her spouse wished to start a family, the lack of access to schools and other services within reasonable driving distance might prevent them from setting down roots.

But the applicant was judged to be an “excellent match” to the needs of the state and won an award. She later called Sherman, jubilant. “She was on Cloud Nine,” he said. “They’re working it out, business is great and steadily growing."

The concept that some personalities are uniquely suited to meet the challenges of particular underserved communities is at the heart of the loan repayment program, Sherman said.

“I hesitate to say this because it sounds like it’s minimizing what we do, but it’s eBay,” he said. “One man’s trash is another man’s treasure. … If you can match one person’s skills, professional motivation and expertise to a location in need of that enthusiasm and ability, that’s where the magic is.”

For that reason, Sherman rejects as simplistic an ongoing debate in the profession about whether shortage situations are a product of too few veterinarians or local economics that can’t or won’t support a veterinary practice.

“It isn’t just one or the other,” he said. “There’s a huge difference between the person who seeks a 9-to-5 job and the person who seeks the challenge of serving a shortage area and is highly motivated and delighted to have a chance to pursue food animal medicine.”

He added: “This is a high-risk proposition for many of the awardees. … Some of them make it and set down roots. Some of them may pack their bags and go as soon as their 3-year contract period ends.”

Even if only temporarily, every veterinarian in the program provides a benefit to the country and to the states in which they serve, Sherman maintained. “In the worst-case scenario, three years of an additional set of veterinary eyes and ears were present in an area deemed a priority shortage …” he said.

Assessing shortages not easy

From the perspective of states, the quality of the service overall is hard to ascertain.

Because of the VMLRP privacy policy, “It’s sometimes difficult for the states to get feedback as far as what happens after a veterinarian is placed, or whether it improves the situation,” said Dr. Holly Hughes-Garza, a staff veterinarian at the Texas Animal Health Commission who manages shortage-area nominations in her state.

No uniform method for identifying veterinary shortage areas exists; each state has its own approach. In Texas, Hughes-Garza said, the state puts out a general call for nominations each year. It typically receives more nominations than it’s allowed to submit.
 
Nominations come from a variety of sources. “Some of them come from older veterinarians who are looking to retire, and maybe they don’t have somebody to take over their practice,” Hughes-Garza said. “We’ve also had nominations from producers and people in the communities who are looking to get a veterinarian in their area.”

Asked whether those who suggest nominations and later receive veterinarians report back that the shortage is resolved, she replied with a laugh, “No, but we don’t hear a lot about it if it goes smoothly, probably.”

She added: “We’ve had a couple of areas that received a vet but (the vet) didn’t end up staying very long. We get people asking if they can renominate (the area), which is certainly an option.”

State nominations are vetted by the USDA; some may be rejected by the agency. That happened to Montana last year when State Veterinarian Dr. Marty Zaluski renominated three regions where veterinarians had pledged to serve. Zaluski renominated the regions because they are large.

“If I identify a four-county area and it gets granted, they tell me someone has gone to the four-county area, but I don’t know where,” Zaluski said. “One veterinarian does not alleviate that shortage.”

Of 10 veterinarians who have committed to working in underserved parts in Montana, Zaluski said he knows the identity of none. He knows nothing of their practices nor how they’re faring. That lack of information, he said, makes it exceedingly difficult to update shortage assessments. “It’s ridiculous,” he said.

Sherman has heard this complaint from Zaluski and others, and he’s sympathetic. “You’ve hit on probably the weakest aspect of this program,” he admitted. “Our team has thought long and hard about how to deal with the requirement for financial privacy and awardee confidentiality, and the frustration that I know that the state animal health officials have about (it). I have not come up with good solutions to it.”

Program advocates name several reasons for confidentiality. The chief purpose is to protect awardees’ financial privacy. Further, regular or spontaneous checkups on participants or questions about the nature of their practice could be intrusive, Sherman said. Thomson said revealing their identities could expose them to resentment by others.

“I hear veterinarians say, ‘Well, I never got anything like that. I toughed it out,’ ” said Thomson. “There are all kinds of sensitive things.”

Zaluski sees it differently. “I wouldn’t be ashamed to say I received some assistance to go someplace no one else wanted to go,” he said.

In Washington, Acting State Veterinarian Dr. Paul Kohrs concurred that assessing which regions are short on veterinary services is tricky without more feedback. Kohrs worries about misidentifying a region as short, thereby placing a competitive hardship on existing practitioners. “It’s a tightrope we walk,” he said. “We need accurate information.”

State officials describe working in the dark in other aspects, as well. David Hecimovich, a Department of Agriculture manager who assists Kohrs in nominating shortage areas, said they don't know whether descriptions they write of the state’s needs are effective. They don’t know whether many veterinarians have applied to serve in Washington but not been selected for the program, or whether the shortage situations in the state somehow aren’t appealing or workable.

They know only that Washington has received just two veterinarians through the VMLRP in four years.

“If I knew the number of applicants," Hecimovich said, "I’d know if we’re successful at getting the word out." He said the state asked the VMLRP for the data but did not receive it.

Sherman initially told the VIN News Service that the USDA aims to share that information with states upon request. He reported a few weeks later that he’s since provided applicant figures from 2013 to every state.

A formal overall assessment of the VMLRP is on the way. Sherman said his agency is committed to enlisting outside evaluators to conduct a periodic comprehensive review, the first likely in 2016.

One criticism that particularly frustrates Thomson, the long-time champion of loan repayment incentives, is that the program is a Band-Aid that helps very few practitioners.

He said advocates never claimed that the VMLRP would by itself solve veterinary school debt and maldistribution of veterinary services. “Student debt’s a big deal,” Thomson said. “Rural practice is a big deal.”

Dr. Joe Hillhouse, a mixed-animal practitioner in Texas, knows the program both as a former member of the selection panel and as the employer of an award recipient.

Hillhouse acknowledged that it’s hard to discern overall whether the program is working as well as intended. But he knows it’s working very well for some individuals, and that’s worth something.

“It’s like the story of the man who saw starfish on the beach and started throwing them back in the water, one by one,” he said. “Someone came along and said, ‘Do you think it matters?’ He said, ‘Well, it mattered to that one.’ ”

1    2   NEXT