Enhancing American Indians’/Alaska Natives’ Knowledge, Confidence, and Community During the Medical School Application Process: Findings From the Northwest Native American Center of Excellence

Purpose To describe a Medical School Applicant Workshop (MSAW); present lessons learned about its impact on American Indian/Alaska Native (AIAN) participants’ knowledge, confidence, and sense of community; and report on participants’ medical school application progress 1 year after workshop completion. Method The Northwest Native American Center of Excellence at Oregon Health & Science University developed and implemented an annual 1-day AIAN MSAW in 2018. The main objectives of the workshop are for participants to gain insights into the medical school application process; learn strategies to competitively apply; receive feedback on their personal statement and mock interviews; and discuss the medical school application process with AIAN faculty, admissions deans, and peer-mentors. Recruitment of AIAN participants occurred via email; social media; text messaging; medical association contacts; and AIAN and science, technology, engineering, and mathematics organizations. Two surveys were administered: one immediately after and another 1-year after the workshop. Results Forty AIAN MSAW participants were accepted in 2018–2020. Findings indicate statistically significant increases in participants’ self-reported knowledge of the medical school application process and in their self-reported confidence. Participants reported meeting other AIAN students was highly beneficial and feeling connected to a community of AIAN health professionals after attending the workshop. Among the 25 participants who completed the 1-year follow-up survey, 12 (48.0%) indicated applying to medical school; all 12 of these participants were invited to interview, and 11 were offered acceptance to at least one medical school. Conclusions Completing the MSAW increased participants’ knowledge, confidence, and sense of community. If other programs and institutions were to consider using the MSAW model to reduce barriers and provide supports specifically designed for AIANs before and during the medical school application process, medical schools may stand to further increase AIAN representation in the physician workforce and ultimately to decrease health inequities among AIANs.


Method
The Northwest Native American Center of Excellence at Oregon Health & Science University developed and implemented an annual 1-day AIAN MSAW in 2018. The main objectives of the workshop are for participants to gain insights into the medical school application process; learn strategies to competitively apply; receive feedback on their personal statement and mock interviews; and discuss the medical school application process with AIAN faculty, admissions deans, and peer-mentors. Recruitment of AIAN participants occurred via email; social media; text messaging; medical association contacts; and AIAN and science, technology, engineering, and mathematics organizations. Two surveys were administered: one immediately after and another 1-year after the workshop.

Results
Forty AIAN MSAW participants were accepted in 2018-2020. Findings indicate statistically significant increases in participants' self-reported knowledge of the medical school application process and in their self-reported confidence. Participants reported meeting other AIAN students was highly beneficial and feeling connected to a community of AIAN health professionals after attending the workshop. Among the 25 participants who completed the 1-year follow-up survey, 12 (48.0%) indicated applying to medical school; all 12 of these participants were invited to interview, and 11 were offered acceptance to at least one medical school.

Conclusions
Completing the MSAW increased participants' knowledge, confidence, and sense of community. If other programs and institutions were to consider using the MSAW model to reduce barriers and provide supports specifically designed for AIANs before and during the medical school application process, medical schools may stand to further increase AIAN representation in the physician workforce and ultimately to decrease health inequities among AIANs.
Serious physician vacancies persist within the Indian Health Service and reservation-serving clinics, due in part to the disproportionate underrepresentation of American Indians/Alaska Natives (AIANs) among medical school matriculants compared with other racial/ ethnic groups in the United States. 1,2 As of 2018, 90% of U.S. medical schools had 3 or fewer AIAN students. 3 In 2017, the total number of medical school applicants who identified solely as AIAN numbered 106, and of those, only 45 (or < 1% of all accepted applicants) successfully matriculated. 4 AIAN physician shortages impact health inequities and the burden of preventable disease mortality for AIANs. [5][6][7][8] Morbidity weighs heavily on AIAN communities; AIANs are at higher risk for health problems, experience higher death rates, and have a lower life expectancy compared to the general population. 9 Because AIAN health care professionals are more likely to work with AIAN communities, 4,7,8 increasing the number of AIANs in the health care workforce is a critical mechanism to mitigate these health inequities. Research with students from underrepresented minority (URM) groups, including AIANs, provides some insight into their medical school admissions trajectory. Barriers to successful matriculation into medical school include a lack of guidance and mentorship during the application process, attaining acceptable Medical College Admission Test (MCAT) scores, and a lack of information about the application process. Thus, exposure to experts, role models, and peers with similar backgrounds who could support URM students through the application process is critical, as is access to academic supports, such as MCAT preparation programs. [10][11][12][13] Among AIANs, spirituality and culture can also play important roles in matriculation and retention; however, there are few initiatives specifically designed to equip AIAN students for the medical school application and admissions process and even fewer that incorporate spirituality and culture. [12][13][14][15][16][17] To address these issues, the Northwest Native American Center of Excellence (NNACoE) at Oregon Health & Science University (OHSU) developed and implemented an annual AIAN Medical School Applicant Workshop (MSAW) in 2018. The MSAW uses a culturally tailored approach designed to empower and equip AIANs with the skills needed to competitively apply, interview, and ultimately matriculate into medical school. This article describes the MSAW; presents lessons learned about its impact on participants' knowledge, confidence, and sense of community; and reports on participants' medical school application progress 1 year after workshop completion.

Recruitment, eligibility, application, and selection process
Recruitment was conducted via email; social media; text messaging; medical association contacts; and AIAN and science, technology, engineering, and mathematics organizations with regional and national reach. Potential participants completed an online application that included gender (female, male, two spirit, prefer to describe, prefer not to answer), tribal affiliation, additional race/ethnicity (African American, Asian/Pacific Islander, Latino, White, other race/ethnicity), and a personal statement draft. Individuals nationwide who self-identified as AIAN and planned on applying to medical school within 2 years of workshop completion were eligible. There were no other eligibility requirements (e.g., age, state of residence). No maximum number of participants was set for the workshop. Applications were screened by the NNACoE team for eligibility and were then reviewed by faculty, deans, and program directors at OHSU School of Medicine. Acceptance to 1 of the 3 MSAWs hosted to date has been offered to all applicants who met eligibility requirements and submitted a complete application and personal statement. The 2018 and 2019 cohorts received financial support for travel, lodging, and meal expenses, while the 2020 cohort received a stipend for costs associated with meal expenses, Internet access, and phone usage due to the shift to a virtual platform in response to the COVID-19 pandemic.

Workshop description
The overall goals of the MSAW are to prepare participants to submit a successful medical school application and to allow them to practice skills that will be tested during their interview day. The main objectives of the workshop are for participants to gain insights into the medical school application process; learn strategies to competitively apply; receive feedback on their personal statements and mock interviews; and discuss the medical school application process with AIAN faculty, admission deans, and peer-mentors. The complete list of learning objectives is available in Supplemental Digital Appendix 1 (at http://links.lww.com/ACADMED/B329).
The 1-day workshop delivers structured sessions on the application processes (including the interview portion) and practical tips for writing a personal statement and requesting letters of recommendations. The MSAW also provides one-on-one mentorship, with breakout sessions on personal statements and interviews. There are panels with AIAN health care professionals; a panel of current AIAN medical students; and informal networking opportunities with AIAN physicians, medical students, and other MSAW participants. AIAN culture is interwoven throughout the workshop, including a traditional opening and AIAN presenters who provide insights on the nuances of being an AIAN in medicine. Additionally, participants take part in 2 mock interview sessions: a traditional interview and multiple mini-interviews. 14 After the interviews, participants receive feedback on their performance and specific suggestions for improvement. In 2018 and 2019, NNACoE offered a preworkshop social dinner event; this event was not offered in 2020 due to the COVID-19 pandemic.

Evaluation instrument development and implementation
The NNACoE evaluation team developed a post-program survey to assess learning outcomes and community based on MSAW objectives, which was administered immediately following the workshop. A follow-up survey, also developed by the NNACoE evaluation team, was administered 1 year after workshop completion to determine participants' progress in the medical school application process.
The postprogram survey that participants completed was a retrospective prepost assessment of knowledge and confidence associated with completing the application process, including writing personal statements, requesting letters of recommendation, and interviewing using a 5-point scale for knowledge (1 = very low to 5 = very high) and a 4-point scale for confidence (1 = not at all confident to 4 = very confident). Meeting other AIAN students interested in pursuing a career in medicine was assessed using 1 question, which asked participants to reflect on the benefit of these relationships using a 4-point scale (1 = not at all beneficial to 4 = very beneficial). Connection to a community of AIAN health professionals was assessed with one question, which asked the extent to which participants felt connected to them, using a 4-point scale (1 = not at all connected to 4 = very connected). Lastly, participants responded to open-ended questions about these relationships, their favorite aspects of the workshop, and what could be improved.
The 1-year follow-up survey asked participants if they had applied to medical school since the workshop and if yes, to which schools, which medical schools granted them interviews, and where participants were accepted and/or waitlisted.

Data analyses
We calculated descriptive statistics for demographic information (e.g., age, gender, other identified race/ethnicity); social connections to other AIAN students interested in pursuing a career in medicine and AIAN health professionals; and the number of medical schools to which participants applied, were granted interviews, and were accepted or waitlisted according to cohort (i.e., 2018, 2019, or 2020). For reporting purposes, additional race/ethnicity data were combined into one category. Kruskall-Wallis tests assessed whether statistically significant differences in demographics existed among the 3 cohorts, and paired sample t tests assessed participants' retrospective Research Report pre-post confidence and knowledge on topics covered in the workshop sessions. All tests were 2-tailed with alpha set at less than .05 for statistical significance. We reviewed open-ended questions to identify domains of interest (i.e., knowledge, confidence, and community) and selected exemplar quotes to represent our findings. C.E.V.G. and A.H. separately reviewed and then came to consensus on key emergent themes for each domain according to cohort. Not all comments fell into a single domain; in rare cases, comments were double coded for 2 of the 3 domains. Further discussion then occurred with C.T. and C.D. for final consensus.
This study was approved by the OHSU Institutional Review Board (study #17588).

Results
Thirteen, 11, and 16 AIAN MSAW participants were accepted in 2018, 2019, and 2020, respectively, for a total of 40 participants. One participant attended the 2018 and 2019 workshops and is included in each year's count. One participant from the 2018 and 2019 workshops declined to participate in the evaluations, for a total of 38 evaluation participants. Postworkshop survey response rates were 12 (92.3%) for 2018, 10 (90.9%) for 2019, and 16 (100%) for 2020. Participants represented 37 federally recognized tribes (6.4% of all federally recognized tribes), and 21 (55.2%) participants indicated they also identified with at least one additional race/ethnicity. Participants' mean age was 26.45 years (standard deviation [SD] = 4.53), and the majority identified as female (29, 76.3%; Table 1). There were no statistically significant differences in participant demographics among the 3 cohorts.
Increases in self-reported knowledge about medical school application processes were statistically significant for all MSAW sessions (P < .001 for all but one session; Table 2 Increases in self-reported confidence in each of the topics covered during the MSAW sessions were statistically significant (P < .001 for all but one topic; Table 3). For sessions offered to and evaluated in all 3 cohorts, before to after workshop increase in confidence was greatest for writing personal statements and requesting letters of recommendation  (48.0%) indicated they had applied to medical school (Table 4). For 2018 and 2019, participants who had not yet applied indicated they were finishing degrees or prerequisite requirements or had not yet taken the MCAT. For 2020, the reasons for not yet applying included needing to care for family during or being unable to complete prerequisite requirements due to the COVID-19 pandemic. In 2018 and 2019, participants applied to a mean of 5.67 and 4.20 schools, respectively, and in 2020, they applied to a mean of 1.80 schools. Interview and acceptance data were similar among the 3 cohorts and are reported in aggregate due to small cell counts. All of the participants who applied to medical school were invited to interview (n = 12), and 11 were offered acceptance to at least one medical school (range: 1-4).

Discussion
Developing a robust workforce of AIAN physicians is needed to address ongoing health inequities in AIAN populations. 10,18 There remains a dearth of AIAN providers in the United States. 1,2 Academic institutions, therefore, must do more to attract, prepare, and support AIAN students entering medicine. Our findings indicate that our 1-day, culturally tailored MSAW had positive effects on AIAN participants' self-reported knowledge and confidence about the application process. The MSAW also served to foster their sense of community and connections with other AIAN students interested in pursuing a career in medicine and AIAN health professionals. Based on these findings, we believe that the MSAW succeeded in supporting participants in their application process to medical school.
The high participant ratings may be attributed to the intentional culturally centered focus of the workshop and the implicit message that AIANs belong in medicine and are essential to the physician workforce, which may have allowed participants to envision their place within medical school and the medical field. Although previous studies have shown that in addition to the academic and financial aspects of getting into medical school, cultural aspects are also important for AIANs 19 ; more research is needed to better understand Table 2 Pre The medical school application process the impact of AIAN students' sense of belonging and spirituality on the medical school application process. The field of medicine has much to gain from AIAN physicians who offer diverse perspectives and can integrate traditional knowledge and patient care approaches into their practices. 20,21 Community is a critical part of AIAN culture, and research indicates the need for building a learning community during the medical school application process, especially for AIANs. 22,23 Therefore, developing community was an integral and highly valued part of the MSAW, which aimed to expand AIAN participants' exposure to peers applying to medical school, current AIAN medical students, and AIAN physicians. The journey of becoming a physician can be isolating for URMs who do not feel seen, heard, or valued. 24 Our findings on meeting other AIAN students and connecting with AIAN professionals are important as they may illustrate how providing a learning community could help increase AIAN medical school applicants. Additionally, the learning community ratings for the 2020 group, although high, were somewhat lower than those for 2018 and 2019, which may reflect the absence of some activities (e.g., group meals, welcome session) in the virtual platform. This difference will inform the structures of virtual MSAWs and the use of a hybrid approach for MSAWs in the future.
The path to medical school likely looks different for AIAN students compared to other applicants. Nontraditional students often take time off before medical school. 25 For AIAN students, taking time off is typically due to structural barriers rather than choice. 4 Some MSAW participants who had not yet applied to medical school at the 1-year follow-up timepoint still intended to do so but had not taken MCAT and/or were finishing degrees or prerequisite requirements, indicating that their not applying yet may have had more to do with them needing more time to prepare than with a lack of knowledge of or confidence in the process. We observed the potential impact of the COVID-19 pandemic on the 2020 participants' application process with a lower percentage of participants applying than in 2019 and applying to fewer medical schools than in the prior years' cohorts. Those who Table 3 Pre Overall medical school admissions process and interview experience had not yet applied indicated needing to care for family or being unable to complete prerequisite requirements due to the COVID-19 pandemic. AIAN communities have been disproportionally affected by the pandemic, and it is possible that these impacts reduced the number of students prepared to apply and the number of medical schools to which they applied. 3,26 Additionally, an element of this MSAW that may have contributed to its success was the make-up of the MSAW team itself. This is a unique aspect to the MSAW's approach. The team is racially/ ethnically and professionally diverse, with the majority of team members identifying as AIAN or URM and including faculty, directors, and deans who are all effective change agents within their institutions. Exposure to diverse teams, mentors, and leaders has been shown to impact AIAN student success. 11 Additionally, buy-in from institutional leadership is important for ensuring sustainability and, ultimately, systemic change. 27  In conclusion, findings from this study suggest that the AIAN MSAW may support acceptance of AIANs into U.S. MD-granting institutions by increasing participants' knowledge of the medical school admissions process, building participants' confidence through tailored guidance, and facilitating participants' connections with other participants and AIAN health professionals. If other programs and institutions were to consider using the MSAW model to reduce barriers and provide supports specifically designed for AIANs before and during the medical school application process, medical schools may stand to further increase AIAN representation in the physician workforce and ultimately to decrease health inequities among AIANs. Invited to interview at one or more schools 12 (100) Accepted at one or more schools 11 (91.7) Waitlisted at one or more schools 6 (50.0) Abbreviations: AIAN, American Indian/Alaska Native; MSAW, Medical School Applicant Workshop. a Due to possible participant identification, only combined data are presented in this table to suppress cell sizes of less than 5 for individual cohorts.