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Medical News & Perspectives
March 25, 2020

Boosting the Ranks of American Indian and Alaska Native Physicians

JAMA. Published online March 25, 2020. doi:10.1001/jama.2020.2349

Jasmine Curry feels lucky to be a first-year medical student. The daughter of a single mother in Arizona, she spent summers and winter breaks in Kaibeto, a small Navajo Nation town. Now, she’s looking forward to a primary care career to help combat preventable illnesses in Native American communities.

“It’s everything my family and I have ever prayed for,” Curry said in an article describing her nontraditional path to medical education. She is 1 of 5 first-year students at the Oregon Health & Science University (OHSU) Medical School who were in last year’s inaugural class of the innovative Wy’east program, which gives a second chance to Native American and Alaska Native students who didn’t get into medical school on their first try.

Jessica Souphanavong (center) during a blanket ceremony celebrating her successful completion of the Wy’east program, an alternative to the traditional medical school admissions process.

Michael Schmitt/Oregon Health & Science University

The Wy’east pathway was developed to identify students “on the cusp of [acceptance] to medical school,” explained Erik Brodt, MD, director of the Northwest Native American Center of Excellence at OHSU. After successfully completing Wy’east’s rigorous 10-month medical school preparation program, participants, who must be citizens of a federally recognized tribe, receive provisional acceptance in OHSU’s medical school.

Expansion is in the works through a partnership with Washington State University College of Medicine and the University of California Davis (UC-Davis) School of Medicine. This school year, the program has 10 seats. Next year, up to 4 more students will be eligible for provisional acceptance to Washington State University’s Elson S. Floyd College of Medicine. Two years later, 4 more seats will be available for conditional enrollment at UC-Davis, bringing the program’s total class size to 18 students.

“We're seeding this program and these ideas at other medical schools because that's what's going to make a difference for this region,” said Brodt, who is Anishinaabe (Ojibwe).

Wy’east is part of a movement led by American Indian and Alaska Native physicians across the country to grow their ranks from the ground up by working in partnership with some of the more than 500 tribes in the United States. A 2018 report coauthored by the Association of American Medical Colleges (AAMC) and the Association of American Indian Physicians (AAIP) found that American Indians and Alaska Natives make up about 1.7% of the US population but only 0.56% of physicians.

In fact, the proportion of medical students who identify solely as American Indian and Alaska Native decreased from 0.39% to 0.20% between the 2006-2007 and 2017-2018 school years, while the proportion who identify with 1 of these groups in combination with another race grew only slightly, from 0.66% to 0.76%. More recent data suggest the problem persists. Only 241 of the 22 686 students accepted to medical schools during the 2019-2020 school year identified as American Indian or Alaska Native alone or in combination with another race, according to AAMC data.

“Despite there being more medical schools, despite there being more medical students, our overall percentage is actually going down in the US medical student body,” Brodt said.

Representation Matters

Greater representation of indigenous physicians in medicine is essential to helping eliminate serious health disparities and improve access to care in American Indian and Alaska Native people, according to the AAMC-AAIP report. It describes the historical trauma that American Indian and Alaska Native families endured following the colonization of the Americas, which led to loss of land and subjugation of indigenous people. The report also discusses how policies such as forced boarding school attendance disrupted families and contributed to both health disparities and underrepresentation of indigenous people in medicine.

“This is a national crisis that we need to attend to,” said Norma Poll-Hunter, PhD, senior director of the AAMC’s Human Capital Initiatives and coauthor of the report.

American Indian and Alaska Native physicians are more likely to work in indigenous communities and with other underserved populations, Poll-Hunter noted. Native physicians can also help influence their colleagues to improve care by bringing new perspectives and innovations in care, she said.

“Increasing the representation of Native Americans in medicine will improve health equity, not just for Native Americans, but for all Americans,” said Alec Calac (Pauma Band of Luiseño Indians), a medical student at the University of California San Diego and founder of the school’s chapter of the Association of Native American Medical Students.

More representation is also essential to making patients feel comfortable and providing role models for aspiring American Indian and Alaska Native physicians. Mary Owen, MD, president-elect of the AAIP and director of the Center of American Indian and Minority Health (CAIMH) at the University of Minnesota, Duluth, said she has felt the discomfort patients may face without access to Native clinicians.

In the tribal health system serving her Tlingit community in Alaska, Owen said she “had no Native nurses, no Native doctors taking care of me, and I had the feeling of being a foreigner in my own health care system. I was frustrated by that.”

That frustration inspired her to become a physician and to apply to the University of Minnesota Medical School, Duluth (UM MSD) campus, which has been committed to educating Native physicians since its founding in 1972. Her decision was cemented when she met CAIMH’s then-director Gerald Hill, MD, current chairman of the Klamath Tribes Health Advisory Committee.

“I'd never met a Native physician,” she said. “Meeting a Native physician who was so insightful about what was true, and his empowerment of me at that moment, solidified everything. It was clear as day all of a sudden that this is where I needed to be.”

To help more American Indian and Alaska Native youth envision becoming a clinician, Brodt helped found the nonprofit organization We Are Healers

“We came upon the idea [to share first-person] narratives of American Indian and Alaska Natives who have been successful in the health workforce to try and inspire American Indians to see who they could become one day,” Brodt said. By partnering with tribes and a youth-led organization called We R Native, they built the capacity to share these videos of indigenous clinicians’ stories with thousands of indigenous youth through social media platforms, he said. (Video).

Video. Inspiring More American Indian and Alaska Native Students to Become Physicians

We Are Healers aims to inspire Native youth to envision themselves as medical professionals through narrative videos. In this video, Dr Erik Brodt, who helped found the nonprofit organization, reflects on his vision and uncommon path to medicine. (Video used with permission.)

Successful Models

With their long, successful track records of graduating American Indian and Alaska Natives, medical schools like UM MSD and the University of North Dakota share many strengths: Native leadership, close ties with tribes in their region, and an ongoing financial commitment.

“There was a conscious effort from the get-go to really reach out to and begin to build relationships with community members,” said Anna Wirta Kosobuski, EdD, an assistant professor at UM MSD. That has led to ongoing close partnerships between the school and the 11 tribes in Minnesota. For example, Owen serves as physician for the Leech Lake Band of Ojibwe, which gives students an opportunity to shadow her in the clinic.

The University of North Dakota’s Indians Into Medicine Program has a tribal advisory board with representatives from 25 tribes in 5 states—Montana, Wyoming, North Dakota, South Dakota, and Nebraska—that meets quarterly, said the program’s director, Donald Warne, MD, MPH, associate dean of diversity, equity, and inclusion at the university. The school accepts students from across the country, Warne noted, but he said the advisory board has been instrumental in helping them find promising students, many who eventually return to provide care in their communities.

Owen also emphasized the importance of having Native faculty on the admissions committee to help identify promising students who are committed to serving their communities. Native faculty can help American Indian and Alaska Native students navigate the unfamiliar territory of medical school interviews or application materials, Poll-Hunter said.

“Many of us don't know the little nuances [of applying for medical school] because we didn't grow up in this milieu,” Owen said. For example, she didn’t know to send a headshot with her application and when asked for one she sent a candid shot of herself fishing with her family.

Poll-Hunter also emphasized the importance of using a holistic admissions approach for all underrepresented students. The AAMC has a tool kit and workshops that help schools implement holistic admission processes that consider students as a “whole person” and include students’ experiences, attributes, and background in addition to academic performance and test scores.

Once students get in, it is also important to provide them with financial, academic, and social support. Owen noted many American Indian and Alaska Native students come from lower socioeconomic backgrounds and may struggle to cover certain costs. In addition to dealing with the rigors of medical school, they may have family members who are struggling as a result of historical traumas, she said. Owen credited her own success in medical school to having Native American leaders and mentors at UMMSD. “That knowledge of who we are and what our battles have been—that was critical,” she said. “I couldn't have done it without that mindset, that awareness of who we are.”

Warne also emphasized the importance of building a community through regular social activities, providing dedicated study spaces, and creating cohorts of underrepresented students who can support one another. Hill noted in a recent commentary that 90% of medical schools have 3 or fewer American Indian or Alaska Native students.

“It can be really isolating to go to the medical school where you're the only American Indian and Alaska Native,” explained Allison Empey, MD, deputy director of OHSU’s Northwest Native American Center of Excellence and a member of the Confederated Tribes of Grand Ronde.

Both the University of North Dakota and UM MSD send their American Indian and Alaska Native students to the annual AAIP meetings so that they can connect with the larger Native physician community. Owen and her colleagues also work to build a community, including local tribes, around students.

“We start out right off with having a drum ceremony as part of the white coat [ceremony],” she said. “We also have a big community dinner for them, to welcome them.”

Many American Indian and Alaska Native students struggle academically in medical school, which may put them at a disadvantage when applying to residency programs, noted Socia Love-Thurman, MD, who directs the Seattle Indian Health Board’s residency program, a satellite of the Swedish Family Medicine Residency at Cherry Hill.

“We see it as a strength if people have had to take tests multiple times and they succeeded and passed the test,” said Love-Thurman, a Cherokee Nation citizen who also identifies as Delaware and Yuchi. “It shows that they have strength and resiliency and that's a factor that we look for.”

As 1 of the Urban Indian Health centers that serve the 70% of American Indian and Alaska Native people who live in urban areas, the residency program emphasizes preparing its trainees to provide culturally sensitive care to the many Pacific Northwest and Native Alaskan tribes that predominate the area. Love-Thurman noted that half of the program’s graduates to date have gone on to serve in Indian Health Service, tribal, or Urban Indian Health centers, and 75% have served underserved populations.

Many of the programs have also turned their sights on reaching American Indian and Alaska Native students starting as early as elementary school with programs stretching through middle school, high school, premed, and into bridge programs like Wy’east. Wirta Kosobuski has partnered with a public elementary school in Nett Lake, Minnesota, where the student body is composed predominantly of members of the Bois Forte Band of Ojibwe. In the last 3 years, students’ performance on the Minnesota Comprehensive Assessment exams has improved.

“It's absolutely essential to make that front-end investment because by the time kids are in high school, even by the time kids are in middle school, it's often too late,” Wirta Kosobuski said. Starting earlier lets students learn to love learning and “build internal motivation for wanting to persist or to progress in education,” she said. “These kids are scientists and physicians of the future.”

Ultimately, Brodt said the recipe for success in training American Indian and Alaska Native physicians is pretty basic.

“You've got to start with the tribal community because that's where most of the strength lies,” he said. “Then you have to recruit American Indian and Alaska Native faculty. Then you have to build a program from within that will be able to endure. That is what has resulted in students coming to OHSU.”

Already that formula is helping propel more students like Curry into medicine.

“Our families are so proud of us,” Curry said of herself and her fellow Wy’east alums who are now in medical school. “We’re going to be the first doctors in our family. We know how it is on the reservation. We can help our community overcome those challenges. Coming from the same background, we will be culturally competent doctors for Native patients.”

Box Section Ref ID

Dearth of Indigenous Faculty Hampers Progress

US medical schools are missing an essential component to help them recruit and train medical students who are American Indian, Alaska Native, Native Hawaiian, or Pacific Islander: Indigenous faculty—the most underrepresented group among professors at US medical schools.

Only 10 full professors in US medical schools were American Indian or Alaska Native in 2016, based on a recent analysis of AAMC data. In fact, only 194 American Indian or Alaska Native faculty of any rank numbered among the 481 753 faculty members at 141 US allopathic medical schools that year. It was a slight uptick from 173 in 2014.

The ranks of Native Hawaiian and Pacific Islander faculty actually fell from 392 in 2014 to 184 in 2016. Most indigenous faculty members are assistant or associate level professors, noted lead author Erik Brodt, MD, director of the Northwest Native American Center of Excellence and associate professor of family medicine at the Oregon Health & Science University School of Medicine.

“We are not advancing in the promotion and tenure process,” Brodt said. “If you don't have American Indian and Alaska Native people at the table who make decisions, usually like the associate or the full professor rank, you're not going to be able to make the system change to be inclusive of American Indians and Alaska Natives.”

To help more indigenous faculty move up through the ranks, Brodt and his colleagues created the Indigenous Faculty Forum to discuss promotion and advancement, build collaboration, and hopefully publish together. To do this, they’ve partnered with AAMC, the Native Hawaiian Center of Excellence, and the Pacific Rim Indigenous Doctors Congress. To date, Brodt said, their 3 meetings have been a very helpful outlet for indigenous physicians who often feel isolated at their home institutions.

“Many people take the opportunity to have that kind of freedom of expression, freedom of space, the freedom to be yourself, for granted,” he said. “Many of the participants in the forum are the only indigenous academic faculty at their medical school.”

To help grow the ranks of indigenous scholars, the University of North Dakota in January created the first Indigenous Health PhD program in the United State or Canada.

“We have programs that focus on medical anthropology or global health, but really don't have programs addressing the unique circumstances of indigenous populations that lead to health disparities, particularly things like colonization and historical trauma,” explained Donald Warne, MD, MPH, professor of family medicine and director of the Indians Into Medicine (INMED) and Master of Public Health Programs at the University of North Dakota. “We need interventional research identifying and testing culturally relevant ways to improve health outcomes at the population level.”

The Indigenous Health PhD program, which is scheduled to begin this summer, will complement the INMED medical training program. Scholars will be able to complete most of the course work remotely online or through interactive video and will only come to campus twice a year for 1 week. So far, the response has been overwhelming, with more than 300 potential PhD students expressing interest in the first class’s 12 openings.

“[The response] really reflects that there's a need in this area that historically academic health programs have just not addressed,” Warne said.

— Bridget M. Kuehn, MSJ