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University of Washington

Meeting the Needs of Regional Minority Groups: The University of Washington’s Programs to Increase the American Indian and Alaskan Native Physician Workforce

Acosta, David MD; Olsen, Polly

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doi: 10.1097/01.ACM.0000238047.48977.05
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Abstract

Minority populations in the United States are growing rapidly. Some racial and ethnic minority populations will steadily outpace the white population in growth (Figure 1).1 African Americans, Hispanics, Asian/Pacific Islanders, and American Indians/Alaskan Natives (AI/ANs) composed 26.4% of the U.S. population in 1995. By 2010, these groups will compose 32.0% of the population, and by 2050, 47.2%.2

Figure 1
Figure 1:
Population projections for the United States by race and ethnicity, 2000–2050.Source: U.S. Department of Health and Human Services, Health Resources and Service Administration. Council on Graduate Medical Education, 17th Report: Minorities in Medicine: An Ethnic and Cultural Challenge for Physician Training—An Update, 2005.

The Pacific Northwest has experienced a dramatic increase in population diversity. In the state of Washington, the total population grew from 4,866,692 in 1990 to 5,894,121 in 2000 (Table 1), while the Hispanic, AI/AN, and African American populations doubled.2,3 Similar demographic changes are occurring in Wyoming, Alaska, Montana, and Idaho.4–7

Table 1
Table 1:
Demographics of the States of Washington, Wyoming, Alaska, Montana, and Idaho, 1990 and 2000

In the next century, physicians will provide care for a very different population than they do today, with potentially very different patterns of disease and health care needs. Recent reports describe the need to enlist greater numbers of minority physicians into the workforce and to train all physicians to become culturally competent to care for all populations.1,8–10 Minority physicians are more likely than white physicians to practice in underserved areas and to care for minority, poor, underinsured, uninsured persons, and those on Medicaid.2,8,9 Minority patients are more likely to be satisfied with their care when their physician is of the same racial or ethnic background,8,9 but the diversity of the physician workforce is not keeping pace with demand.

Despite the clear need, minorities in medicine are underrepresented at all levels.2 In 1997, African Americans, Hispanics, and AI/ANs represented 24% of the U.S. population, while only 12% of all students in U.S. allopathic medical schools were underrepresented minorities. In 2002–2003, 7.4% of U.S. medical students were African American; 2.9% were Mexican and Mainland Puerto Rican, 3.5% were from other Hispanic groups, and 0.9% were American Indians. Whites made up 64% of U.S. medical students in 2002–2003, and Asians and Pacific Islanders constituted another 20.5%.1

Pipeline programs play an integral part in keeping minority students involved in their pursuit of health careers. These programs enhance underrepresented minority (URM) youth’s ability to overcome educational barriers and succeed academically.1 When URMs stay in the academic pipeline, proportions of URM college graduates who apply to medical school are similar to or even higher than proportions of white college graduates applying to medical school.11 Increased efforts are needed to ensure that URM children succeed in elementary and high school so they will enroll in and graduate from college. Overcoming these early hurdles will result in increased applications and admissions of URMs to medical school.

Nevertheless, significant social, demographic, cultural, academic, and financial barriers remain8,11,13–20 (see List 1). Medical schools must be cognizant of and sensitive to those barriers while understanding how to overcome them in strategic planning. In this article, we describe pipeline and minority recruitment programs at the University of Washington School of Medicine (UWSOM), focusing on activities to recruit AI/ANs.

List 1 Barriers to Underrepresented Minorities in the Education Pipeline Leading to Medical School 8,11,13–20

Programs Focusing on American Indians and Alaskan Natives

The Native American Center of Excellence

UWSOM is the only medical school serving a five-state region; this region comprises Washington, Wyoming, Alaska, Montana, and Idaho (called the WWAMI region). Known for its research programs, UWSOM has also established the WWAMI program, a successful regional community-based medical education program that emphasizes primary care to meet regional needs.21

Twenty-four percent of the U.S. AI/AN population lives in the WWAMI region. There are 41 federally recognized American Indian tribes within this region; Alaska alone has over 200 village corporations located in isolated bush villages.22–24 Given the uniqueness of the WWAMI program, the mission and commitment of the medical school, and the demographics of the region, UWSOM is well positioned to meet the needs of the region’s communities and enhance physician workforce diversity.

The Native American Center for Excellence (NACOE) was established in 1992 under the direction and leadership of Walt Hollow, MD, the first American Indian (Assiniboine/Sioux) to graduate from UWSOM. Funded by the U.S. Department of Health and Human Services, Human Resources and Services Administration (HRSA), NACOE strives to attract AI/AN students into medicine; integrate Native healing traditions into allopathic education; provide an Indian Health Pathway certification program; provide professional development for Native physicians; and encourage research on Native health issues.

Recruitment

Increasing numbers of pipeline programs have been developed in the United States to enhance applicant pools.1 UWSOM and NACOE have developed a number of pipeline programs. Several are described below; some have had a significant impact for AI/AN students.

UDOC.

Through UDOC (this is not an acronym), high school juniors and seniors explore health careers at UWSOM while being introduced to college life. Funded by the HRSA Health Careers Opportunities Program (HCOP), UDOC encourages applications from students from disadvantaged backgrounds with an interest in the health care field. The program is held concurrently on the UWSOM campus, and in WWAMI university (not medical school) sites—University of Alaska-Anchorage; Washington State University-Pullman/University of Idaho-Moscow; Montana State University-Bozeman; and the University of Wyoming. UDOC serves almost 80 students per year in all five sites. NACOE recruiters, assisted by WWAMI Area Health Education Centers (AHECs), target high schools with high percentages of AI/AN students. Washington has five tribal high schools; another 14 high schools have student bodies with large numbers (25% or more) of AI/AN students. Since UDOC’s start in 1994, 99 AI/AN students have completed the program.

Summer Medical/Dental Education Program.

The Summer Medical/Dental Education Program (SMDEP), a national six-week summer enrichment program for college undergraduates from disadvantaged backgrounds, offers an intensive, personalized preparation for medical and dental school. Funded by the Robert Wood Johnson Foundation (RWJ), SMDEP offers academic courses in basic sciences, math, writing and oral presentation skills, and health topics. Learning skills and career development skills are emphasized. Each student receives an individualized education plan to identify areas that require additional focus, with the goal of making each student a competitive applicant. Eighty positions are available annually. NACOE recruiters, assisted by WWAMI AHECs, target local and regional tribal colleges; 9 of the 32 federally recognized U.S. tribal colleges and universities are located in the WWAMI region.13,22,24,25 Since 1989, 358 AI/AN students have completed this UWSOM program. Current data from the RWJ reveal that from 1989 through 2004, 54% of all SMDEP participants nationwide apply to medical school and 61% are accepted.26

Retention

The pipeline does not end with recruitment. AI/AN students require continuous support via mentorship, academic tutelage, counseling, career advising, financial assistance, and ongoing community service.

The Prematriculation Program.

This six-week program facilitates the transition of matriculated students into medical school, particularly those from educationally disadvantaged backgrounds. The program’s goal is to prepare all students for the pace, rigor and challenges of medical school, and to develop skills to succeed. Funded in part by both HRSA-COE and HRSA-HCOP,18–20 students participate each summer. Students take a full-quarter histology course condensed into five weeks. The favorable teacher-to-student ratio builds confidence and a better understanding of how to work closely with faculty and teaching assistants. At the end of the program, participants are given a challenge exam; those who pass receive course credit and can reduce their course load in the regular first quarter. Courses in study skills, test-taking, and stress and time management are also offered. The NACOE has made a special effort to ensure participation by AI/AN students. Since its inception in 1986, 42 AI/ANs have participated and all have passed the histology course.

Support resources.

Support services for AI/AN students help ensure that they receive optimal opportunities to succeed. UWSOM’s pass/fail/honors grading system fosters collaboration rather than competition. The newly developed College system and the provision of a mentor for each student provide direct supervision at the bedside for the best learning environment.27 Each student receives individual attention to foster clinical-skills development and learns about appropriate provision of quality and culturally responsive care. This mentorship across the students’ entire education ensures access to faculty and support during stressful periods.

Students at UWSOM have the option of either “expanding” the first year into two years, or expanding the second year into two years. Students who take this option usually have unexpected or extenuating circumstances, such as marginal academic performance, medical conditions, personal stress, family stressors etc. This expansion strategy can optimize student retention. Approximately 15% of each class expands each year, and the rate is slightly higher for URM students. In the 2004–05 class of URM students, 17% had an expanded schedule. For American Indian students, the expansion rate has been as high as 41% over a 10-year period. Currently, only 2 of 13 AI/AN students have expanded their schedules for academic reasons. Much of this improvement can be attributed to collaboration between students, NACOE staff, and College faculty, who have worked to proactively achieve academic success.

Mentorship.

The Medicine Wheel Society (MWS), a feature of the NACOE, brings together medical students with the AI/AN people, traditions, and customs, and provides the spirit that enables AI/AN medical students to maintain their sense of community. A social network, MWS is open to both Native and non-Native students and offers premedical and medical students, alumni, faculty, and other health professionals opportunities to interact socially and in community service projects.

To help maintain AI/AN culture while in school, MWS hosts social events throughout the year where members and guests can share traditional customs and beliefs among peers. In addition to traditional ceremonies, the organization hosts outreach programs locally and nationally. Members attend local and regional powwows to pass along information to the American Indian population about health profession opportunities. NACOE offers encouragement and financial support to send medical students to major conferences and workshops as part of continuing education. An annual traditional feast for the Elders is held each year.

MWS holds mini-health fairs around Washington; these provide health care screenings for local tribal communities, expose students to AI/AN patient populations and give students an opportunity to inspire young AI/ANs to pursue health careers.

Curriculum

The Indian Health Pathway (IHP), a model curriculum (described below), was established in 1992 by UWSOM as part of the NACOE to provide medical students with information and experiences to make them better practitioners in urban and rural AI/AN communities, since professionals working with AI/AN populations must understand and respect the cultural traditions of their unique heritage.2 Encouraging research on Indian health issues and integrating a curriculum on Indian health issues are additional IHP goals.

The pathway provides a unique educational experience for medical students beginning in the first two years of basic-science training, with specialized lectures and small-group discussions on AI/AN health issues and traditional medicine. Students participate in a problem-based learning course with case simulations representative of common AI/AN health problems. AI/AN and other faculty, the majority with vast experience working with Native populations, teach these components.

UWSOM’s Department of Family Medicine preceptorships for students in their first two years provide immersion experiences in local and regional community health clinics that serve rural and urban AI/AN populations. The Rural/Underserved Opportunities Program, a six-week preceptorship with a rural or urban underserved population, offered between the first and second years of training, allows students to work directly with practicing AI/AN physicians and participate in community-assessment research projects. Preceptorships and elective clerkships in the third and fourth years exist at 25 designated Indian Health Service (IHS) and tribal health-clinic sites in the WWAMI region (Figure 2).

Figure 2
Figure 2:
Clerkship/preceptorship sites of the Native American Center of Excellence Indian Health Pathway in the five-state WWAMI region. The Rural/Underserved Opportunities Program, a six-week preceptorship with a rural or urban underserved population, offered between the first and second years of training, allows students to work directly with practicing American Indian and Alaskan Native physicians and participate in community-assessment research projects. Preceptorships and elective clerkships in the third and fourth years exist at 25 designated Indian Health Service and tribal health clinic sites.Source: University of Washington School of Medicine, Native American Center of Excellence, 2006.

Each year near graduation, NACOE honors medical students who have completed the Indian Health Pathway curriculum with a special ceremony held at “Daybreak Star,” an urban base for American Indians. This “Blanket Ceremony” honors IHP students for their passion and commitment to serve the AI/AN community.

Research

Each UWSOM student conducts an individual research project, known as the Independent Investigative Inquiry, as a graduation requirement. NACOE requires all IHP students to select a topic in AI/AN health to qualify for their Certification of Completion.

NACOE has sponsored 39 research projects related to American Indians’ health. A research advisor counsels and supports IHP participants, and maintains a portfolio of AI/AN health care-related research topics. Each student works closely with an AI/AN faculty sponsor who mentors the student in the development of a research proposal.

Research is a new and unfamiliar landscape for many AI/AN students. NACOE partners with the Native American Research Centers for Health (NARCH), under the umbrella of the Northwest Portland Area Indian Health Board, to assist students in research. NARCH is a research-based center that aims to increase research on American Indian health issues. The organization runs research training programs for AI/AN students and also conducts research on American Indians’ health problems. The research agenda is set by the tribal health organization, with the UWSOM and Oregon Health Science University (OHSU) providing researchers and faculty support to accomplish its goals.

NARCH trains up to five first-year AI/AN medical students between their first and second years of medical school. These students spend six weeks at the NARCH program at OHSU, and receive stipends for living and travel expenses. During their stay, NARCH assists students in developing their Independent Investigative Inquiry research project, and provides guidance on grant writing, research methodology, IRB approval if needed, and statistical analysis. NACOE and NARCH have collaborated on development of the Research Resource Guide that is provided to each participant. This guide helps identify AI/AN research investigators within the WWAMI region, provides data on AI/AN populations, and describes individual research projects conducted by other investigators. It includes community and population assessment tools, assistance with questionnaire and survey development, assistance with study design, and how to conduct culturally sensitive research whose participants are members of various racial and ethnic groups.

NACOE has also established relationships and linkages with several American Indian agencies and tribes, both locally and in the WWAMI region, to help facilitate student access to relevant AI/AN populations.

NACOE requires students to provide final reports of their research project to the participating tribe(s) or clinic(s). This helps ensure that American Indian communities receive a benefit for participating in a research activity. AI/AN students have the opportunity to present their research findings at the annual Association of American Indian Physicians meeting. NACOE also encourages students to submit their research to the IHS Primary Care Providers, a monthly publication of the IHS Clinical Support Center that is distributed to approximately 8,000 IHS health care providers, urban Indian health programs, and tribal health programs.

AI/AN faculty at UWSOM also can receive NARCH training in research methodology. This enables the faculty to update their skills and learn new research techniques. This opportunity enables NACOE to retain present faculty sponsors by supporting and enhancing their skills, and helps recruit other AI/AN faculty to become future III sponsors. NACOE provides travel expenses and a stipend. Two physicians per year participate in this structured six-week research training program.

Faculty development

NACOE Faculty Development Fellowship.

Representation of minorities among medical school faculty nationwide is alarmingly low. In 2004, the total number of U.S. medical school faculty of allopathic medical schools was 114,087.28 Of these, 71.9% were white, 12.6% were Asian, and 7.2% were Hispanic, black, American Indian/Alaskan Native, and Native Hawaiian/Other Pacific Islander. There were only 117 American Indian faculty nationally, or 0.1% of the total number of U.S. medical school faculty.28

The NACOE Faculty Development Fellowship helps AI/AN physicians prepare for full-time teaching careers in an academic medical institution. Each fellow spends one year in the fellowship, functioning as a part-time medical school faculty member, receives a faculty appointment, and works on a mentored research project. Fellows participate in student and resident teaching, develop course content for the Indian Health Pathway, and attend formal workshops at the UWSOM (e.g., workshops for the Teaching Scholars Program; junior faculty development seminars) and abroad (Association of American Medical Colleges Annual Minority Faculty Career Seminar).

The fellowship program is a collaborative effort between NACOE and UWSOM’s Department of Medical Education and Biomedical Informatics (DMEBI). Each fellow spends half of his or her time learning new teaching methods, developing new teaching skills, and practicing these skills with medical student classes under the direct supervision of the faculty development director. Each fellow also serves as a research mentor for AI/AN medical students and their Independent Investigative Inquiry projects.

Each fellow spends the other half of his or her time on individual research of a specific AI/AN health issue. Faculty from the DMEBI and from NARCH collaborate and share mentorship responsibilities for fellows. NARCH facilitates research training and grant-writing skills.

Five American Indian faculty have completed the fellowship since its creation in 1993. Four of the five are now members of a medical school faculty.

Faculty development seminars.

These seminars, coordinated by NACOE, were initiated in 1998 to offer continuing medical education for AI/AN physicians in the WWAMI region on an annual basis. Many participants function as clinical preceptors for medical students and residents. The seminar series offers workshops in teaching methods, administrative skills, practice management skills, research training, and traditional healing.

Outcomes

A total of 477 AI/AN students have participated in UWSOM pipeline programs from 1989 to 2005. Ninety-seven have participated in the UDOC program and 380 in the Summer Medical/Dental Education Program. Of these, approximately 102 have matriculated into medical school somewhere in the United States. Thirty-four have entered medical school at UWSOM.

Of 68 medical students who have participated in the Indian Health Pathway since 1993, 50 were AI/ANs. Thirty-six of the 50 AI/AN participants have received certification, and 11 are still working on their coursework to attain certification. A total of 37 students have completed the entire program and received a certification of completion, and 27 more are still working on completing their certification requirements.

From 1993 to 2005, 50 AI/AN medical students graduated from UWSOM. Thirty-two completed their training in four years, and 14 completed their training in five years. An additional four students took five to eight years to graduate.

The choice of residency specialties by AI/AN students is encouraging. Thirty-two (approximately 65%) of the 49 AI/AN graduates have chosen primary care specialties. This is in concordance with data demonstrating that minority students have a two- to three-fold higher rate of choosing primary care than do majority students.28 Of the 32 students who chose primary care residencies, 27 chose family medicine, 4 chose primary care internal medicine, and 1 chose medicine/pediatrics. The other 15 (31%) AI/AN graduates chose a variety of other specialties: 3 chose preliminary internal medicine, 3 chose obstetrics–gynecology, 3 chose surgery, 1 chose physical and rehabilitative medicine, 2 chose orthopaedics, and 3 chose a transitional year. A total of 28 (approximately 56%) of the 50 graduates matched at UWSOM or at UWSOM-affiliated programs within WWAMI.

Among the 35 UWSOM AI/AN graduates in practice as of 2005, 20 practice in the Indian Health Service, 1 practices in a self-determination contract tribal clinic, and 1 is in private practice. An additional 10 graduates practice in urban community health centers, and 3 are in academic medicine.

Challenges, and Lessons Learned

Challenges

Despite many successes with our programs, significant challenges remain. The decreasing applicant pool of AI/AN student applicants, especially male applicants, is worrisome. This means that many non-URM physicians will continue to provide a large portion of care for AI/AN communities. Ensuring equitable and culturally sensitive care will be challenging,11 and requires an assessment of how we at UWSOM and its affiliated programs will train future physicians. Cultural competence must be a mandatory part of medical education.

Continued federal funding for pipeline programs has again been threatened. Recent federal budget cuts will devastate programs such as ours, and will not only eviscerate progress that many members of NACOE and other pipeline programs have made, but will insure that these programs will no longer be able to operate. This will have a tremendous negative impact on the diversity of present and future physicians. All medical schools must work to overcome this major obstacle of reduced federal funding; identifying the best strategies will be a significant challenge.

Lessons learned

Tribal communities.

In our experience, academic institutions should consider several key elements when recruiting and working within tribal communities. Prior to initiating any proposal, it is important to first identify the most appropriate community representative to contact. Demonstrating respect for and following protocols of the governing tribal council are imperative. We also make the following recommendations:

  1. Provide a forum where tribal leaders can describe their tribal history, customs, traditions, and beliefs, and their community’s most significant issues.
  2. Avoid sharing data based on evidence from needs assessment until requested by tribal leaders.
  3. If there are individuals within the academic institution or local community who have gained the trust of leaders and others in tribal communities, ask those individuals to join the negotiation team, as this enhances trust.
  4. Participate in tribal meetings, gatherings, and other events. The additional visibility of the academic institution within the tribal community (outside of the proposal) that these activities will make possible is very important.
  5. Involve the tribal community from the beginning of the process. This gives the tribe a sense of ownership and encourages tribal leadership to participate and share in leading project roles.
  6. Follow-through by the academic institution with project evaluations, outcome data, and other information that the tribal community can utilize is essential. Lack of follow-through is often a major source of frustration and distrust for tribal communities.

Improving retention of AI/AN medical students.

Our experiences indicate that retention of AI/AN students can be enhanced by including several key elements. Implementing a proactive network of academic support services that includes tutoring, mentoring, study skills, and time management is critical. Tutorial assistance that emphasizes that “prevention is the best medicine” is also important. This means working directly with course directors and encouraging them to identify marginally performing students earlier in the process so that tutorial assistance can be provided before they fail. Providing financial assistance for students who have demonstrated difficulty with standardized tests to enroll in courses to prepare for the United States Medical Licensing Examination board exams has improved our students’ ability to pass Step I Boards on their first attempt. A structured mentoring system must also be in place, and utilization of local AI/AN physicians is preferred in order to match AI/AN students with role models who can provide social, emotional, and possibly academic support. Group tutoring sessions by other AI/AN medical students in their third and fourth years has improved students’ confidence and academic performance. These sessions emphasize the concept that peer-to-peer learning provides a safer environment for students who feel marginalized. We have also found that introducing all students to a one-on-one introductory meeting with a counselor during orientation, rather than waiting for crisis intervention, helps ease the taboo of seeking mental-health services and enhances utilization of these services. Identifying and providing access to local traditional healers for students has enhanced their ability to maintain connections to traditional practices and to construct a new “community” away from home.

Final Thoughts

Significant barriers are encountered by AI/AN students along the path to their dream of becoming a physician. Knowing what some of these barriers are, coupled with awareness of the tiny and fragile pool of applicants who survive the tumultuous journey and achieve their dream, are important for medical schools in order to resolve the issues at hand. More work is needed to effect the changes needed in the physician workforce. As our report shows, pipeline programs and retention programs play a vital role in keeping this possibility alive, and, as demonstrated by NACOE and the other programs described above, can result in successful outcomes. Minority faculty development and cultural competence education also play critical roles for the future.

The process is slow and tedious, but it is the right thing to do.

References

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