March 25, 2020 Bridget M. Kuehn, MSJ JAMA. 2020;323(14):1330-1332.
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.”
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
No comments:
Post a Comment