Elliott, Barbara A. PhD; Dorscher, Joy MD; Wirta, Anna MLS; Hill, Doris Leal PhD
They know me first as a Native woman who happens to be a doctor… . I love medicine, and medical education is my specialty, and that's what I do. It is not who I am. Who I am goes to my soul. And that is the Native American. Whether I was a doctor or a teacher, a race car driver, whatever I could have become, doing things [is] not the same as who I am. - —Comments by an interviewee, August 25, 2006
Success is experienced differently by each person and is defined by the culture that forms us. As is evident in the quotation above from one of the women interviewed for this study, this Native American woman's place in the world is clearly defined by her cultural identity. Today, only 30 Native American women are trained as medical doctors and working as faculty in American medical schools.1 Clearly, few Native American women have found paths to success in medical school settings; they are severely underrepresented among the faculty. Why is this? What can we do to ensure their increased success and expand the diversity of our faculties?
Academic medicine is increasingly sensitive to the need for diversity among our faculty and students.2 Increasing diversity of our faculty is important as a strategy in eliminating racial and ethnic disparities in health care and in improving the quality of the care that is delivered.2–5
Overall, minorities are underrepresented in medicine,6 and the effect of being both female and a racial or ethnic minority reduces the numbers even further. In fact, the Sullivan Report7 noted that in 2004, African Americans, Hispanics, and American Indians/Alaska Natives combined made up just 6% of all U.S. physicians. Within academic medicine specifically, Hispanics, African Americans, and American Indians/Alaska Natives made up just 3.5%, 2.1%, and 0.2% of tenured faculty, respectively.7
Few people choose to move into positions where opportunities for success are limited. Among the challenges and issues that minority faculty face in academic medicine are limited opportunities for professional advancement, underrepresentation in leadership or administrative positions, lack of mentoring and role models, discrimination, ethnic or racial bias, undeserved scrutiny, pressure, and an environment of cultural homogeneity.2,3,8,9 In fact, many minority faculty leave academic medicine because of systematic segregation, discrimination, tradition, culture, and elitism.3,9
Add to this academic medicine setting the additional element of being a Native American woman, with its own distinct sense of health, wellness, illness, spirituality, and worldview. Native Americans have a holistic worldview that is lived and experienced in a circular manner.10 As revealed in the interviewee's comment above, the nature of being a Native American woman and physician working in academic medicine is guided by this unique sense of the world.
Here, we report how Native American women who are medical faculty describe personal and professional success. If our faculties are to become more diverse and include more Native American women, we must understand how to create pathways that meet both their academic and personal definitions of success. The findings reported here emerged from interviews in a qualitative study designed to investigate the experiences of the group of Native American women who have became physicians and medical school faculty. In the interviews, the participants described the cultural and social foundations that define success in their lives. Native American culture and its expectations are primary to these women's identity. For these American Indian women to pursue success in academic medicine, they acknowledged that they first needed to be able to participate in life as Native American women. For them, success can be achieved only when they meet the expectations of success as established in their primary culture.
The term “Native American” references people who have “descended from or who have ancestral connections to any of the original (indigenous) peoples of North America.”11
The institutional review board of the University of Minnesota (UMN), Minneapolis, Minnesota, approved this qualitative research study. Three authors of this study are Native American women: One is a physician faculty member (J.D.), one is affiliated with the UMN medical school (A.W.), and one is Hispanic/Native American (D.L.H.) and was working at the UMN medical school at the time the interviews were conducted. The fourth researcher is a female Caucasian faculty member in the same setting (B.A.E.).
We selected qualitative methodology for this project, knowing the limitations it brings to any insights gained through the research study. However, because our research question has not been previously studied, the qualitative approach is specifically indicated to generate enough information and insight for future hypothesis testing. In addition, because our research sample for the current study consisted of Native American women faculty who are accustomed to oral traditions, it was culturally appropriate to use conversation and open-ended questions in pursuing the desired information.
For the study, six subjects were identified by snowball methodology12 as qualified to participate on the basis of the following criteria: They were Native American women who were both physicians and faculty at U.S. medical schools. One declined to participate because she was involved in a similar research project. The other five who were invited to participate in this project consented and were interviewed face-to-face between August 2006 and April 2007. Their ages ranged between 42 and 60 years of age; they practiced and taught both primary and subspecialty care in four states, and they represented five different tribes. After the fifth interview, the desired information was becoming redundant, and we determined that qualitative saturation had been achieved. No additional women were invited to participate in the study.
Of the five interviews, three were completed by one author (A.W.), another by A.W. and D.H., and the fifth by D.H. Each interview was arranged at the convenience of the participant; three were completed at a national meeting, and the other two took place at locations selected by the participants. At the beginning of each interview, the interviewer(s) explained the purpose of the study, obtained written informed consent, and instructed each participant to complete a brief questionnaire on demographic and contact information. Each interview was recorded. Interviewers used an interview guide developed by the authors to focus on points of interest. The guide listed simple questions, which allowed the women to expand their answers as much as they wished using a culturally effective format. The questions used to guide the interviews are shown in List 1; nondirective probes were added when appropriate to extend the discussions. At the conclusion of each interview, participants were also asked to offer suggestions for women who choose this professional path in the future.
Table. List 1 Questi...Image Tools
Data collection and analysis were simultaneous and continuous. Following transcription, each interview was read by all of the investigators to obtain a “sense of the whole.” During this first phase, the investigators each identified codes, words, and/or phrases by which to organize the data. The investigators then met to develop a unified system of coding. Data were divided and organized within QSR NUD*IST6 (2002, Victoria, Australia) to allow for comparisons among interviews. Finally, the data were interpreted to generate tentative themes and working hypotheses.
We took several steps during the data analysis process to enhance the rigor of our analysis. Each of the four investigators coded the transcripts independently, then we convened to reconcile coding differences in face-to-face discussion to ensure we arrived at common conclusions.13 We also explored alternate explanations for the findings by returning to the transcripts. Every effort was made to ensure that the codes, patterns, and themes we developed were reflections of the participants' words and intended meanings. Competing explanations were discussed until the team reached consensus.14 The diversity of our research team was essential to this process.
Three themes about success in these women's lives emerged from the review of the interview transcripts: (1) the values of Native American belonging and connectedness, plus their expression in giving back to the community, are central to the interviewees' sense of success, (2) success becomes defined and perceived differently over time, and (3) mentoring relationships and interpersonal connections make professional success possible when these relationships also honor the personal (cultural) expectations.
Native American values central to success: Belonging and connectedness, expressed in giving back
The women we interviewed consistently referenced several values as important in allowing these women the ability to continue in a professional direction. The values help the women maintain their relationships with and within Native American communities.
First, all of the participants described the importance of having a defined sense of “belonging” and of being “connected” to their culture. As a Native American value, the sense of belonging as connectedness is recognized to be the spiritual relationship between a person and her world (e.g., family, community, nature, creator, land, ancestors, etc.).15 Three of the participants described how the connectedness is essential to their sense of how they relate to the world and their spiritual base. As one woman said,
All things are connected. You know, our traditional value that we're all related, that there needs to be harmony and balance and that means that there has to be a social life, a religious life, an emotional life as well as the physical life that we all need.
Echoing the importance of cultivating human and spiritual connections, another participant explained,
And so I think that that's the base of our happiness, because no matter what the turmoil or the challenges and the things that have gone on around me through the years, I've had that connectedness with God and with my friends and my loved ones. I've been grounded enough to deal whatever came.
Finally, a third participant highlighted the necessity for connectedness in professional as well as personal environments:
I think life's all about relationships, so whether it's me as an individual person or me as a physician connecting with my patient in a way that they really want to work to help themselves because I can motivate them. Me as a parent, me as a wife, as a daughter, whatever. So I think since relationship is a bottom line, then there's got to be connectedness and I think that beyond, there's also connectedness as far as I'm concerned with me and my creator, because without that connection, none of the others are going to work.
The second value described by all of the respondents is the responsibility Native American women have to develop their gifts and talents so they may better enrich their community by “giving back.” One woman attributed this value to
traditional teachings from my tribe … if you were given something then you need to give it back, and if you have a gift that you're really holding back, that doesn't serve your community very well. So you have a responsibility.
Highlighting another potential inspiration for this value, another participant noted, “I have achieved absolutely everything that I could have dreamed of and more. I haven't necessarily given back as much as I want to.” Perhaps this is one reason another interviewee observed that
I would say, [Native American women who are good people are] giving to the community, to professional work, professional life and in any other way they possibly could, if it's through giving financially to organizations, to help or volunteering the best they could given you know, where they are.
Indeed, although “giving back” may not be unique to female Native American physicians, it is important to note our respondents' focus on their own Native American communities when it comes to acting on this value:
Usually [a Native American woman who is a good person] would be someone who … gives back. Maybe more or less traditional, but still maintains community ties, doesn't forget where they came from kind of thing.
When the women described the impact of their professional studies on their lives, they acknowledged that their studies put them at risk of losing their ability to belong or to give back to their home communities. They explained that many who live in these communities continue to have memories of how the majority culture changed their lives by taking children from them and putting the children into boarding schools. With these memories, community members commonly question the level of commitment of anyone who leaves the community and spends many years in educational settings. The women described this potential isolation as a painful burden:
It's almost like the longer you are away from community to get your education, sometimes the harder it is to go back … but if people know you and understand your heart and who you really are … then it's easier.
Another woman we interviewed observed,
There's the mistrust that when you leave the community for such a long time and get trained and maybe get brainwashed and you no longer understand the traditions or are honoring those traditions, so it means an extra effort to show that you remain a cultural person and yet walk between two worlds.
The combined need to give back, to belong, and to be connected were also evident in all of the respondents' reports of how they had found ways to extend their professional work into Native American settings. Participants were not necessarily focused exclusively on their own tribal homes, but they were able to create opportunities to use the skills obtained in their professional education as a mechanism to give back to other Native American communities that share the participants' cultural values. As one woman noted, “We are not currently doing any work with my tribe, but just being involved with the [other] Native community is rewarding and enjoyable in my work.” Another participant described the rewards of being involved with a Native American community different from her own:
In terms of their activities, you know I work for a small tribe that are of River people which is like my people who are people of the River too. And they're working on their cultural issues, and I'm working with their health ward board and making a community garden, and you know, it's a very cool process. I feel like I'm a part of that community. They allowed me to take care of their Elders. Yeah, so it feels good.
Success defined and perceived differently over time
Participants described their experiences by telling stories of their own paths. Each of them relayed her story as a developmental process revealed over time. The value of connectedness as a spiritual understanding of each one's place in the world was also described as unfolding over time:
Well I think just the fact that those [mind, body, emotion and spirit] are all connected that you can't separate a human being into these individual pieces; they are each essential, and at different times and at different aspects of growth, one may be more predominant than another, but you know you can't lose sight of the fact that you need a holistic approach to the human condition.
The successful experiences in the participants' personal lives were described developmentally too. The need to become trained and do professional work came in addition to their “real lives” in which true success was being defined and measured. They also described how success is currently known and will be defined as they age further. One participant made a point to note her sense of personal success: “Well first I am very, very fortunate in my immediate family: my husband, children, siblings, and mom.” Another recalled the beginning of her path to success: “Trying to fill that empty hole, but nothing else fit—except medicine. So when I was pregnant with my fifth child, I went back and did my premed work as a postbaccalaureate effort.” Participants also contemplated how success would be defined farther down the path:
I'm thinking, if I could be like some of these grandmas when I'm their age, you know, if I can do a fraction of what they are doing, I would be… . So keeping connected with them is great. Look at them, in their 60s, 70s and 80s still learning. I want that.
When focusing on their professional lives and how they now recognize the success they are enjoying, the women assessed the snapshot of their current experience very positively. As one woman reflected, “[My students] are serving Indian communities or they are serving urban underserved people. It's a 70% rate… . I never even dreamed that this would be an outcome, but it's so cool.” A similar observation was echoed by another participant, who noted, “I think I'm doing well… . I mean you know, I'm living the dream. You know, now I teach the full spectrum. I mean, I never dreamed it.”
However, the challenges of trying to maintain their values while working in an academic setting were very real, especially when considering the personal consequences over time. A participant noted that “it's very complex … especially if you are earlier on starting your career. If you are not very careful, your career can get upside down, and if things don't kind of happen at the right place and time to build, very often it all comes back to haunt you.” The sense of maintaining one's values and identity in the challenging academic culture was evident:
It's like … I don't want to be sucked into some of the things that [they] are doing; our values are not the same, or I see my vision as a little bit different within a different continuum and … [it's] been really hard to stand up and say that.
Mentoring relationships and interpersonal connections make success possible
The women attributed their successes, both personal and professional, to the people who had helped them become successful. They also cogently described barriers to their successes and attributed these barriers to systems or institutions that interfered with their ability to maintain both their Native American values and the expectations of academe. They described experiences in which they were faced with choices between who they are and what they do. In one example, a respondent lamented that “academic areas don't provide enough flexibility for having children you know, and feeling like they have to choose between having a family and having a career, an academic career… . ” Another participant noted that such work–life balance concerns may be of more significance to Native American academic physicians:
There are ways to get through, but I think [academic expectations] certainly [are] more of a barrier for … Native women in particular, because of strong values they have for families and staying culturally true to that.
Communication issues in particular seemed to underscore participants' concerns about barriers to professional success. One participant, for example, “was blown away when I took this other position because the issue of communication and hierarchy really stunned me.” Another revealed that “I have built a lot more trust and working relationship with the smaller group of faculty that I work with. But that's been tough; that's been a really tough thing.”
The mentors who were described as helpful—indeed essential—in the women's successes had formed relationships with them that included emotional support,role modeling, problem solving, help negotiating the system when needed, and even referrals for personal matters. Again, the women acknowledged that their mentoring needs developed and changed with their life circumstances over time. The importance of a beneficial mentoring relationship at the beginning of the women's careers was evident: “When I thought that I may not want to continue, that I may want to drop out of the program, he immediately helped to turn me around to get me refocused.” The importance of the unending support was also described by another woman: “She provided the support that I needed when I was very stressed out. And that is really the main thing.”
As the participants' careers developed, however, the role of their mentors shifted as well:
That influenced me too, to [know] that here's somebody who [shows you how] you could shift [directions]. You know, whatever is happening, life changes and he changed.
The women also described the role of current mentorship: “I have a couple of very good mentors and so I feel like I am moving along. It's just the process that takes time.”
It's hard to be the golden boy when you're neither a boy nor golden.
These words, spoken by one of the women interviewed for this project, truly represent the unique experiences as lived by Native American women who are medical faculty. These women live with multiple layers of minority status, and they define their success and identity as based in continuing their Native American values and relationships.
Previous work with women faculty from other minority groups is limited, but one study, at least, has also reported the importance of community involvement in these women's lives16; it may be a part of the cultural value system that these women have brought with them to academe as well. Interestingly, black women faculty explained their reason for community involvement as a means for them to gain support.16 As revealed by our data, the Native American women reported that their reasons for community involvement were much more than for support. They clearly identified a need to maintain their cultural connectedness and identity through community involvement. Also, when describing the challenges that come with work–family balance, the black women focused on their nuclear families and children.16 When talking about these same challenges, the Native American women identified their cultural family—the larger Native American community. These differences highlight the unique cultural issues inherent in cultural identity and offer important guidelines for mentors of women who are members of minority groups. Further study of how to mentor while addressing these unique needs is needed.
While operating within their own culture's understanding of success, Native American women live and work in two worlds.17 They have not and cannot assimilate into the majority world. Instead, they report finding ways to be present and participate while maintaining their primary culture's expectations. When the values to maintain connectedness and belonging are tested (e.g., with the need to return home because of a celebration or trauma), those expectations will always take precedence over academe's expectations. The cultural obligation to give back solidifies the community, overcomes the suspicions of the community, and maintains the sense of belonging and connectedness.
This insight about Native American women's sense of success is also evident in their description of the mentors these women have found helpful during their careers. To encourage Native American women's success in medical school faculties, we need mentors and systems that can allow the diversity of obligations, values, and responsibilities that Native American women experience. Not only is flexibility of scheduling on a day-to-day level important, “stopping the tenure clock” may also need to be considered for cultural reasons, such as honoring the significant time a Native American woman invests in events that occur in her extended family and community.
The findings of this study have implications for those who mentor a Native American woman faculty person. From the participants' stories we learned that there is a need to recognize and honor how this primary cultural identity is essential—and an advantage—in these women's professional development. Of course, mentoring also involves acknowledging and supporting the development of academic skills and opportunities, but in mentoring Native American women faculty, it is also important to find academic and clinical options that are consistent with these basic cultural values. This can allow these women to thrive personally while doing their professional work. Finally, as with all of us, our lives unfold over time. These women's stories demonstrate that mentors are also necessary to assist and support changing needs and concerns over time. In mentoring a Native American woman, careful attention to supporting her Native American identity and cultural connections is essential for her to be successful professionally.
When we live as part of the majority, our culture is an “invisible knapsack”18 that we carry along without realizing it. That knapsack holds the values and expectations that keep the individual who carries it in sync with the majority culture. For those of us who live as part of the minority, our culture is not invisible, although it does still serve as a knapsack of culturally specific values and expectations. By carefully asking and sensitively listening to the Native American women who participated in our study, we heard the gift they were offering us. They gave us insight into their cultural base and reality, and they described how personal and professional success are interwoven and interconnected through their knapsacks' values and expectations. Now we can apply this information to effect change within the system and within our relationships to help more of us become successful.
The authors wish to thank the women who agreed to be interviewed as part of this project. They also are grateful for Edie Schilling's technical assistance and wisdom.
This study was approved by the institutional review board of the University of Minnesota, Minneapolis, Minnesota.