Confronting the crisis: Attracting Native students to medicine

After years of failing to produce a robust American Indian and Alaska Native workforce, medical schools need to up their game, argues the co-author of a new report on the issue.
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Cover art from the Reshaping the Journey report, created by Dyani White Hawk (Sičangu Lakota), a painter and mixed-media artist.

Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.

The U.S. health system — including our medical schools — is failing the original inhabitants of this land. American Indian and Alaska Native (AI-AN) people suffer some of the poorest health outcomes in the United States. Among the disturbing statistics is that we die much younger than others: 25% of AI-AN deaths occur before the age of 45, compared with 15% of African-American and 7% of white deaths. 

Monday, October 29, 2018

Leading the Way

In 2017, the six schools listed below enrolled nearly 40% of the medical students identifying as AI-AN alone, according to AAMC data. The new AAMC-AAIP report, Reshaping the Journey: American Indians and Alaska Natives in Medicine, profiles the efforts of several of these schools to recruit and support Native students and to integrate Native health into their education and training.

  • University of Arizona College of Medicine—Tucson
  • University of Minnesota Medical School 
  • University of New Mexico School of Medicine 
  • University of North Dakota School of Medicine and Health Sciences 
  • University of Oklahoma College of Medicine 
  • University of Washington School of Medicine 
     

This is devastating for AI-AN communities. Who provides childrearing, economic stability, community leadership, cultural continuity, and the advancement of our causes when so many are taken so young? It is the survivors who do this, just as they have from our first contact with the colonizers of our land. They work to heal the physical and emotional legacy of such traumas as the forced removal of children and the disturbing treatment of Native peoples by the medical establishment.

Medical schools and teaching hospitals must do more to promote the health and well-being of Native peoples. As my co-authors and I write in the recent joint AAMC/Association of American Indian Physicians (AAIP) report, Reshaping the Journey: American Indians and Alaska Natives in Medicine, they must work harder to admit and support future AI-AN doctors. 

There is no doubt that this country needs more AI-AN physicians. AI-AN physicians are more likely to practice in Native communities, where patient-physician connections could positively affect health outcomes. They are also more likely to practice family medicine and work in communities that suffer from physician shortages. And they assume vital leadership positions that promote Native health both locally and nationally.

Yet far too few medical schools recruit and train Native students. In 2017, the number of medical school applicants who identified as American Indian and Alaska Native alone, and not American Indian and Alaska Nativ plus another race/ethnicity, was just 100 — and a mere 42 matriculated. During the 20 years that I sat on the admissions committees of four different medical schools, I unfortunately too often saw racial bias contribute to the rejection of AI-AN candidates. In addition, representation on medical school faculties is dismal, with only 167 faculty reporting as American Indian and Alaska Native alone, a tiny 0.1% of the nationwide and total.

Currently, 90% of U.S. medical schools have three or fewer AI-AN students. Those schools can learn vital lessons from the six medical schools that have succeeded in enrolling 40% of all AI-AN students. The Reshaping the Journey report details steps several schools took to boost AI-AN applications and the likelihood of students’ success.

How did they do it? They made a conscious commitment to be part of the solution. They worked to understand and integrate social and cultural elements of AI-AN life into their institutions. And they recognized that engaging with AI-AN nations and communities is essential. 

Sometimes, these schools start as early as kindergarten to nurture the next generation of AI-AN physicians and scientists. They work with older youth to connect them with much-needed role models, for example, and help them navigate the complex process of applying to and paying for a medical education. For so many Native students, medical school can feel like an unobtainable dream.

There is much that schools can do during the admissions process. Some schools have initiated a process that focuses on evidence of a student’s unrealized potential, for example. And all successful schools have included an AI-AN individual on their admissions committees.

During the 20 years that I sat on the admissions committees of four different medical schools, I unfortunately too often saw racial bias contribute to the rejection of AI-AN candidates.

Once students are admitted, these schools support matriculants with appropriate advising and counseling as well as access to a supportive peer network and mentors. They also work to create a welcoming environment by including AI-AN images and rituals in the medical school environment. 

Such examples only begin to suggest what’s possible — and necessary — to create a diverse physician workforce that includes American Indians and Alaska Natives. 

What's more, this is not just a matter for a handful of schools in a few states. This is a matter for all of academic medicine. Every medical school should evaluate their pipeline programs, admissions processes, and institutional cultures. Nearly all medical schools are in states with Native tribes or nations, and they must reach out to AI-AN communities to collaborate on efforts to increase AI-AN enrollment. In addition, although the AAMC has worked with the AAIP to provide resources to support AI-AN initiatives, I also believe it is important to have a dedicated position at the AAMC that focuses on addressing the dearth of Native Americans in medicine and on AI-AN–specific strategies.

I urge every medical school dean, diversity officer, and admissions officer to carefully read and consider the report. As AAMC Chief Diversity and Inclusion Officer David Acosta, MD, writes, “There has never been a better time to bridge the cultural divide and remind ourselves of the social accountability we have, as academic medical institutions, to society.”

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Gerald Hill, MD, (Klamath) is chairman of the Klamath Tribes Health Advisory Committee and a member and past president of the Association of American Indian Physicians (AAIP).