Corps health care

Strapped with $109,000 in student loan debt when he finished his psychology doctorate in 2006, Darryl Salvador, PsyD, enlisted in the National Health Service Corps, the federally funded service and loan-repayment program for health professionals. Salvador, a native of Honolulu, spent the last four years as the behavioral health director and staff psychologist at the Molokai Community Health Center, a federally qualified health center and integrated-care clinic on the rural Hawaiian island of Molokai. Next month, he ends his service commitment with the NHSC debt-free.

gradPSYCH asked Salvador to talk about his experience with the National Health Service Corps, which expanded its offerings this year by adding a part-time service option and increased its funding for a two-year service commitment from $50,000 to $60,000.

What's a typical week for you?

I work four 10-hour days at the center. I fly in from Oahu on Tuesday mornings — it's a 25-minute flight on a single-propeller plane — and I stay on the island until Friday night. The center is a primary-care environment, so I work with a physician, a dentist and a nurse practitioner. I have regular patients, but I'm also available for consults with my colleagues when they need to call me into a session they're having. The caseload is pretty varied in primary care. A phrase people often use is "from cradle to grave," because you see whoever walks in. My youngest patient right now is a 5-year-old and my oldest is an 80-year-old.

What sort of problems do you treat?

A little bit of everything. I treat people for anxiety, attention-deficit hyperactivity disorder, depression, post-traumatic stress disorder, sexual assault trauma, domestic violence and substance abuse. Addiction to crystal methamphetamine is a big problem on our island and there is a lot of intergenerational substance abuse in these rural areas. There are high rates of hypertension, diabetes, chronic pain, obesity and other issues that have a behavioral component. I'm switching gears all day, and by the end of the day I'm usually pretty tired.

Are there challenges to working — and living — in a rural area?

At lunch or in the evening, I will go to the grocery store and people will say, "Hey, Dr. Salvador! I'll see you tomorrow for my appointment." I often tell people I treat that, to protect their confidentiality, I won't necessarily initiate greeting them outside the clinic. But if they say hello, I will, of course, say hello back. At the same time, another challenge on Molokai is that stigma about mental health problems is, unfortunately, still alive and well here. Some people think psychologists only see people who are hearing voices, and often I have to educate folks that seeing a psychologist can help with all aspects of behavior and emotions and that all these things are tied into their overall health care.

Gossip is also alive and well, and one worry many patients have is that people will know about their problems when they come to see me. We try to protect confidentiality by having all patients checked in as a medical patient, with their vitals taken at the beginning of their appointment, even patients who are only there to see me that day.

Can you explain how the loan-repayment program worked?

When you sign up with the NHSC, you make a two-year service commitment and you get $50,000 tax-free (now $60,000) to put to your qualifying student loan, which is separate from your salary and benefits. The third year, I reapplied for an "amendment" and I got $35,000 tax-free. I had $28,000 left on my loan, so I applied for a fourth year amendment, which is also $35,000, but they will only give you what you have remaining on your loan. I am loan-free now and, as of the end of April, I will be done with my service commitment.

How did you find your position on Molokai?

I heard a colleague speak about the NHSC at APA's convention, and I thought, "Wow, a way to pay off my loans doing what I went to school for and working with a population that needs the help." About that same time, I had gotten into a postdoctoral fellowship at Tripler Army Medical Center, which allowed me to work and train on Molokai one day a week. I did some research on the NHSC and found that Molokai is a designated health professional shortage area and therefore eligible for the NHSC, and the folks there were ready to build a behavioral health program, which is a mandated component for federally qualified health center funding. I started negotiating with the executive director about the possibilities of working there. There was a lot of legwork, negotiation, timing and paperwork involved, but everything eventually came together.

What advice do you have for others who may want to join?

Think about where you want to live, and look on the NHSC Web page, which lists specific sites with vacancies. Try to get integrated-care experience as a graduate student, perhaps in a medically underserved urban or rural area. Expose yourself to underserved populations and talk to other people who are doing this type of work. And if you do join the corps, I find it's important to consult often with colleagues and friends. Pardon the pun, but you can sort of be on an island when you are the only psychologist around.

What will you do next?

I'm trying to keep an open mind. My wife and I want to start a family and being on a different island for work most of the week — my wife works and lives on Oahu — isn't conducive to that. I may decide to explore part-time or telehealth opportunities to remain involved with the Molokai Community Health Center. Or I may look for rural care opportunities on Oahu. Some colleagues and I started a postdoc and internship training program on Oahu that provides training opportunities in rural and medically underserved clinics and federally qualified health centers. That experience may give me an opportunity to develop a new training site somewhere else. I do have a passion for serving the underserved, and I want to continue working in an integrated-care model.

What's it like to fly to work?

It's beautiful. The plane is a turbo-propeller, eight- or 30-seat plane that doesn't fly very high, and on a sunny day, you can really see the scenery of the islands. On a windy day, it can be better than a roller coaster ride at Disneyland.