The popular conception of the Hawaiian islands as a paradise is a foil to a stark reality—Native Hawaiian and other Pacific Islander individuals experience among the worst health outcomes across all racial and ethnic groups. The relative unawareness to the plight of this population’s health metrics may be in part due to the historical, although imprecise, practice in health outcomes research of grouping Native Hawaiian and other Pacific Islander individuals with Asian American individuals, who themselves represent a heterogeneous group that generally shares little culturally with Native Hawaiian and other Pacific Islander individuals. Moreover, many studies may exclude Native Hawaiian and other Pacific Islander individuals completely. When Native Hawaiian and other Pacific Islander individuals are analyzed separately, it is apparent that—compared with Asian American individuals—they experience poorer social determinants of health, including lower rates of health insurance and lower educational achievement as well as elevated rates of life-limiting chronic conditions, such as diabetes, obesity, and substance abuse.1
Addressing these health disparities requires a multifaceted approach, including building and sustaining a culturally competent physician workforce to provide the best care. Although Native Hawaiian and other Pacific Islander individuals represent approximately 20% of the population of Hawaiʻi, only 5% of the state’s physicians identify as Native Hawaiian and other Pacific Islander. Elsewhere in JAMA Network Open, Taparra et al2 use Association of American Medical Colleges data to examine the shortage of Native Hawaiian and other Pacific Islander–identifying allopathic medical students, residents, and faculty physicians and demonstrate a widening representation gap over the last 2 decades. The study uses a method that also appears in several other workforce diversity studies; they compute a representation quotient (RQ) comparing the number of Native Hawaiian and other Pacific Islander individuals in the physician workforce pipeline with the total number of Native Hawaiian and other Pacific Islander individuals according to the US Census. The authors show the number of allopathic medical students who belong to this racial group has not achieved parity with the general population since 2010. Between 2015 and 2020, there were only approximately half as many students and residents as would be proportional to the general population (ie, an RQ of approximately 0.5). Representation of Native Hawaiian and other Pacific Islander individuals among academic faculty was near this level or even lower between 2000 and 2018, with some medical specialties recording no Native Hawaiian and other Pacific Islander academic faculty at all.
The study by Taparra et al2 is consistent with other studies demonstrating a trend of persistent (or worsening) underrepresentation among individuals with backgrounds considered underrepresented in medicine (URM), based on the American Association of Medical Colleges’ definition, across nearly all specialties over multiple decades.3 This is in sharp contrast to the fact that the United States has become a more racially diverse country during this time. To address the underrepresentation of Native Hawaiian and other Pacific Islander individuals in medicine, we must consider all barriers on their journey to becoming potential physicians and physician-mentors. More research must still be done, but there are lessons we can learn based on studies of other URM physicians’ experiences. One particularly salient phrase is: “if you want to be it, it helps to see it.”4 Exposure to URM role models can help combat stereotype threat, inspire students to pursue medicine, and even make a particular medical specialty appear more welcoming. However, at the level of academic faculty, URM physicians may be significantly less satisfied with their careers and more often consider leaving academic medicine altogether due to burnout, which can lead to a paucity of faculty mentors for the next generation of URM physicians, which begets further underrepresentation in the future.5 For those students, including Native Hawaiian and other Pacific Islander students, who are the first in their families (and even in their communities) to attend medical school, the lack of peers and faculty role models from similar backgrounds can be discouraging and even lead to imposter syndrome. Training far away from home, which is especially relevant for those Native Hawaiian and other Pacific Islander individuals originating in Hawaiʻi but training elsewhere in the United States, can invoke feelings of isolation and being seen as other. Black and Hispanic residents may be as much as 30% more likely than White residents to withdraw or be dismissed from residency,6 but the rate for Native Hawaiian and other Pacific Islander residents is unknown. Such statistics may be the result of the unique challenges in the clinical environment that some URM residents (and academic faculty) face, including but not limited to microaggressions, bias, and a minority tax if they are tasked (either directly or indirectly) as race and ethnicity ambassadors at their institution.
There are local efforts in Hawaiʻi to mitigate the low level of Native Hawaiian and other Pacific Islander individuals in the physician workforce. For instance, the ‘Imi Ho‘ōla pipeline program has helped approximately 170 college graduates between 1973 and 2019—many of whom identify as Native Hawaiian and other Pacific Islander—matriculate to the state’s only medical school.7 Unfortunately, the decades-long trend of underrepresentation described by Taparra et al2 has persisted despite such efforts, meaning that much more work (and perhaps much more financial investment) is warranted at all educational levels, including high school and college, to help more Native Hawaiian and other Pacific Islander individuals cultivate a desire to pursue medicine and provide them with opportunities that will make their applications to medical school competitive. Increased racial and ethnic diversity in the physician workforce better meets the needs of a diverse US population and is associated with increased health care access for the medically underserved, including Native Hawaiian and other Pacific Islander individuals. Racial concordance between Native Hawaiian and other Pacific Islander patients and their physicians—although not yet studied—could reasonably be inferred to increase patient satisfaction, based on studies of Black and Hispanic patients. The study by Taparra et al2 should urge a rallying cry to reinforce and sponsor efforts to help more Native Hawaiian and other Pacific Islander individuals enter the physician pipeline. To perform that hard work will require the support of many, including the current Native Hawaiian and other Pacific Islander physician workforce as well as nonprofit organizations and local and national governments. Finally, an important part of that support must be from those who do not identify as Native Hawaiian and other Pacific Islander but are allied to the cause of helping ensure the physician workforce reflects the community, including members of this racial group. Only then will we be able to reverse this disappointing trend.
Published: September 20, 2021. doi:10.1001/jamanetworkopen.2021.25399
Correction: This article was corrected on October 19, 2021, to fix the spelling of Kekoa Taparra’s name.
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Mori WS. JAMA Network Open.
Corresponding Author: Westley S. Mori, MD, Department of Dermatology, University of Minnesota Medical School, 516 Delaware St SE, Phillips-Wangensteen Bldg, Ste 4-240, Minneapolis, MN 55455 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
Mori WS. On the Lack of Native Hawaiian and Pacific Islander Individuals in the Physician Workforce. JAMA Netw Open. 2021;4(9):e2125399. doi:10.1001/jamanetworkopen.2021.25399
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