American Indians and Alaska Natives (AI/ANs)* have significant and persistent health status disparities compared with the U.S. general population.1 Addressing these disparities requires access to high quality health care, but a shortage of health professionals caring for AI/ANs2 and lack of cultural competence among providers pose significant barriers.3 Training more AI/AN physicians, who are better prepared to deliver culturally sensitive care4 and are more likely to choose primary care and locate in underserved communities where their special competencies are needed,1,3 is critical to addressing these problems.
AI/ANs have yet to achieve parity in medical school enrollment, and the numbers have been stagnating.3 During 2001–02, 520 AI/ANs were attending medical school, representing just 0.8% of medical students,5 half the proportion of AI/ANs in the total population (1.6%).† Our research aims to understand the supports and obstacles that AI/AN students experienced on their paths to medical school for the purpose of generating effective strategies to increase their representation in the physician workforce.
Method
Study sample
We invited all AI/AN medical students enrolled at the University of Washington School of Medicine in Seattle, Washington, (UWSOM) in 2002 and who were active in its Native American Center of Excellence (NACOE). We chose these students because we were interested in understanding the barriers and supports for those who identified with AI/AN culture. This resulted in a sample of 11 out of 17 AI/ANs enrolled at UWSOM at that time. This study’s methods were reviewed and approved by the University of Washington Human Subjects Division.
Semi-structured interviews
An Alaska Native, trained by a researcher with experience conducting qualitative research, conducted semistructured, one-on-one, confidential interviews with the participants (each of whom received $75). An interview guide was used that included 18 open-ended questions about sociodemographics, connections with Native communities, struggles and supports along the path to medical school, beliefs about healing and spirituality, and experiences with the medical school application process. The interviews were audiotaped and then transcribed for analysis. The exclusion of one unusable tape resulted in 10 valid interviews for analysis by the research team.
Qualitative data analysis
All four investigators, two of whom are Native Americans working with the NACOE, separately performed a content analysis of a subset of the interviews, concentrating on struggles and supports on the path to medical school. We resolved differences in thematic coding to reach group consensus and create a final coding scheme. Three coinvestigators then coded all transcripts independently. All four coinvestigators reviewed and resolved discrepancies in the final coding. Each student had an opportunity to review themes identified; none suggested changes to our interpretation. Our findings thus represent the investigators’ and respondents’ consensus on the key themes describing the respondents’ experiences.
Results
Although not a criterion for study inclusion, all respondents were women, ranging in age from 24 to 42 years. Five were from Indian reservations in the lower 48 states, three were Alaska Natives, and two considered themselves urban Indians raised off reservation. Six were single, four were married, and four were parents.
Educational experiences
Eight students reported enjoying school or having an aptitude for math or science as important supports. Three noted that a poor-quality education, especially in science, was a barrier to their pursuit of a medical career.
Academic and professional preparation programs spanning all educational levels—including programs in math or science enrichment, research, or medical school preparation—were key supports for nine interviewees. College enrichment programs, such as the Minority Medical Education Program (MMEP), provided practical support for pursuing a medical career: help with the Medical College Admissions Test and medical school application process, academic counseling, increasing awareness of career opportunities, and meeting fellow AI/ANs pursuing a medical career.
Six students mentioned the importance of the NACOE and the Office of Multicultural Affairs at the UWSOM, including MMEP staff. The fact that the UWSOM placed AI/AN health issues in its curriculum and provided strong regional primary care opportunities motivated them in choosing a medical career and attending the UWSOM in particular:
None of the other schools that I applied to had anything to offer Indian students, I mean nothing. Not a single class, not a single student group, nothing. So knowing that there was a curriculum here totally gave me purpose and totally made me know that there was a school that I wanted to go to.—Maryanne‡
While the majority of students were supported by educational programs, four noted that poor performance on standardized tests or lack of support prior to tests were barriers to their medical school application.
The educational experiences, advice, and encouragement provided by key individuals were important to nine interviewees. These persons included faculty at educational preparation programs, teachers, counselors, Indian Health Service (IHS) physicians, researchers, and AI/AN role models. Both high school and college counselors and advisors helped them decide and prepare for their career path. Six students cited the importance of exposure to or mentoring from AI/AN health professionals. The mere knowledge of another Native’s success in medicine mattered:
The other role model I have, is my cousin, he’s a doctor. And I didn’t know him growing up real well … but just having that, knowing that he is a doctor in the village and still maintained ties at home.—Rhoda
Seven students mentioned AI/AN community members, other than immediate family members or health professionals, who played a significant role in the pursuit of their goals. Others found guidance through national AI/AN organizations, such as the American Indian Science and Engineering Society. Despite the support of mentors, role models, and advisors, half the students identified a lack of AI/AN role models as a barrier on the path to medical school:
Many Indian kids get scholarships to go play sports at big colleges and they go away and within a year they’re back at home. And people are like, ‘well, so and so couldn’t handle it.’ It’s not that they can’t handle it, but it’s not having anybody to show you the way, you know?—Darlene
Competing career options and priorities
Five students reported difficulty or uncertainty in choosing medicine over other career options. Some had already established other satisfying careers. This decision process created significant angst for Kelly:
I struggled for years … I knew I couldn’t go into medicine until I figured out my place in it, and it was through that work that I met some really fabulous doctors and realized that there was a place for me and that I could make it fit.
Health care experiences
All respondents reported personal, family, or professional health care experiences, both positive and negative, that supported their career choice in medicine. Working in health care or experiencing a personal or family illness helped several decide on a medical career. These experiences included exposure to the IHS/Tribal/Urban Indian Programs medical system, caring for sick relatives, witnessing poor health care, and realizing there was a need for AI/AN physicians to provide culturally appropriate care. Edith explained:
When … my mother died of a curable illness, it just made me even more want to be a doctor because then I realized how the people on the reservation aren’t really comfortable with going to see the physicians because they’re not Indian … I think she waited too long to go to the doctor … So that’s kind of what sealed it for me.
Finances
All but one student mentioned financial supports or barriers. Supports included the Indian Health Care Improvement Act’s 437 IHS scholarship program and other funding sources. Having an orthodontist explain the mechanics of both debt and earning potential helped dispel Rhoda’s doubts about a medical career:
I told him it’s going to cost too much. And he said no, he sat me down and … tallied everything up … and he said, you know, it’s okay, don’t ever let money be a problem.
Seven students mentioned financial hardship; four noted the significant expense of the medical school application and interview process alone. As Lynnette explained:
I had no idea just to apply it was so expensive. I knew a girl who took out a thousand dollars in loans to apply … I mean she needed that huge, huge loan … and I didn’t have anybody … to borrow [from], I just had my one coworker willing to give me some money.
Cultural connections
Students differed in their degree of connectedness to their Native communities and cultural traditions. Some led AI/AN cultural activities and organizations, and those from Indian reservations stayed closely connected with home during medical school, while urban Indians and Alaska Natives generally visited home less frequently. A motivation to serve AI/AN people and supportive connections to AI/AN communities helped sustain students’ medical career aspirations:
We need to get the kids going at an early age into—just to explore health careers in general—yes, you know, we have a Native doc; you can be a doctor … I just think that’s important for people to go back home after they’re educated to show the kids this is what you can do. There’s too many not leaving, because they think, like I thought, when I finished, I’m going to leave and not come back.—Edna
For seven students, strong connections to their tribe or village and the long distance to the medical school campus were impediments. Most lamented the lack of AI/AN community in higher education and in the health professions. The pull of community and culture had the potential to disrupt some students’ pursuit of medical education:
That’s the problem … you lose that constant being around your culture and I think that’s what makes it really difficult to go off to college.—Rhoda
Eight students cited the stress of being caught between Native and non-Native cultures. They expressed concern about “fitting in” to Western medicine while feeling that the profession would distance them from their traditional Native culture and change their roles within their home communities, as Darlene described:
It’s hard to leave because it’s a different world. That was a big obstacle. I didn’t only go through culture shock moving off the reservation into a big city. I went through culture shock … from who I was there into this whole professional role, being a young new doctor, it’s been a challenge to accept it … It’s been a challenge in my community to accept it too.
Family and friends
It was not always possible to neatly distinguish “family” from “Native community,” but we attempted to preserve an analytical distinction because at times they represented different spheres of influence. All students reported that close friends or family members were important supports on their path to medical school. In spite of the overwhelming support that students’ families provided them, family issues presented barriers to nine students. Loneliness away from family was similar to the yearning for Native community. Half the students described needing family support and yet being far from it as an impediment to higher education:
There were so many times that I was just so lonely, so lonesome for home, that I didn’t think I could do this … This is hard and you have to have that support from home to do this.—Darlene
Family matters posed other challenges. Crises, such as a loved one’s death or illness, a lack of family support for education or career aspirations, and difficulty balancing the demands of higher education with raising children were all obstacles on the path to medicine.
Spirituality
Native medicine traditions are intertwined with spiritual beliefs and practices, affecting both AI/AN patients and AI/AN caregivers.6 When asked about the influence of spirituality on their lives and medical career, all cited important spiritual beliefs, events, or messages. Several visited tribal spiritual leaders who encouraged them to pursue a career in medicine and helped address concerns over potential conflicts between modern Western medicine and Traditional Indian Medicine (TIM):
I was afraid that I would be doing something wrong in our religion, in our way of life, in terms of dealing with the cadavers or in terms of reaching into somebody’s body like a surgery … So I went to a man on my reservation who is considered to be my godfather, and he has some of the spiritual power to communicate … And in a ceremony he brought up the questions, what I was wondering, and they told me not to worry about it.—Lynette
Spiritual experiences and beliefs helped some students trust their chosen path, even when facing obstacles:
I’ve learned to really trust myself which I think is a manifestation of the Great Spirit … A lot of it has come from my idea about healing and wellness, about being in balance and being in harmony … I’ve had to just do a lot of leaps of faith that things would work out, which is also kind of core in my spiritual beliefs … with all the struggles I’ve had … I’ve just had to go back to it’s happening for a reason, I don’t understand it, but I have to trust, it’s part of my path to keep on going. And so I have.—Anita
Discrimination
Five students described direct and indirect discrimination or racism that they encountered. Some of these experiences were specifically related to their educational pursuits:
When I got to college … it was point blank a racist community … My advisor didn’t really have any support to offer me and the first quarter of school I wanted to take 15 credits all in premed, and he said well, being Native American you should only take 12 first.—Darlene
Whatever the nature of the prejudice, these incidents represented a challenge that students felt they had to overcome to succeed in their goals.
Discussion
The struggles and supports that AI/AN students experienced on their paths to medical school ranged from the personal, to Native community connections, to formal programmatic and educational resources and challenges.
Educational experiences from elementary school through college were the most frequently mentioned supports to the respondents. Poor educational experiences, however, worked against some students, a finding consistent with research documenting academic disadvantage among underrepresented minorities7–10 and the importance of early math and science preparation.11
Negative health care experiences either motivated respondents to become physicians themselves so that they could provide culturally appropriate care or created an image problem to overcome. Interactions with health care systems are instrumental in shaping awareness of what it means to be a physician, but poor or culturally inappropriate care could turn young Native people off to the medical profession.
Nearly all of the students faced financial challenges, including the significant fees and travel expenses of the application process, for which few scholarship funds were available. Financial barriers for AI/ANs can be especially formidable in the medical career training process,7–10 but our finding suggests that the application process itself may be beyond the financial means of some AI/AN students.
Connections to AI/AN communities had a powerful influence on the study subjects, providing both support and conflicts. AI/AN students tend to be more strongly connected to their communities of origin than other students,12 but the stress of living in two very different cultures was palpable for almost all respondents. Traditional AI/AN cultures that value the survival and success of the tribal group over the success of the individual13 contrast with a white culture that values individual success. These divergent cultural orientations set up a conflict that AI/AN students must resolve at each stage of the journey to becoming a doctor. Spiritual beliefs were another dimension of this culture clash, compelling some students to verify with tribal healers or spiritual leaders that pursuing modern Western medicine would not conflict with TIM. The spiritual dilemma that AI/ANs may face, its implications, and its resolution have not been adequately examined in the context of medical education.
Students also had to overcome discrimination and prejudice. Prejudice and stereotyping, whether experienced individually or witnessed in the culture at large, hamper minority achievement.10,14,15 Tokenism can add unnecessary pressure, and the well-documented phenomenon of stereotype threat can lead to anxiety that lowers minority performance, especially in advanced academic settings.10,15
This study sought to understand the experiences of students successful at gaining admission to medical school as a first step in exploring the supports and barriers of AI/AN aspirants to careers in medicine. Students in this study reported more supports than struggles, but these results might look different for applicants not accepted to medical school. We also targeted the study at those who demonstrated Native cultural identification because they are more likely to practice in underserved areas and provide culturally competent care to Native populations. We suspect that those with little connection to their AI/AN heritage might face different barriers, either in kind or degree, but cannot draw any conclusions based on this sample.
We were intrigued that all study subjects were women, which reflects the fact that only 2 of the 17 AI/AN students at UWSOM during the study were men. This gender imbalance, which is not consistent with national statistics, may be due to chance variation in a small population. Nearly equal numbers of AI/AN women and men apply and matriculate to U.S. medical schools nationally.16
Some factors affecting AI/ANs reported here, such as the importance of mentors, financial barriers, and family obligations, have also been identified as significant concerns for other underrepresented populations. But as a small minority among minorities, the AI/AN population is often not represented in research studies. The literature about minorities and the “pipeline” to medicine focuses primarily on African Americans, Hispanics, or the underrepresented as an undifferentiated group. For these reasons, there is a need for research specific to the AI/AN population, with its unique history, geography, culture, and health care systems, in addition to comparison studies with other minority groups and the majority population.
The lack of a comparison group, the retrospective nature of students’ accounts, and the small sample size are limitations of this study. Further research should seek to address these limitations and include Native men. Yet AI/AN medical students and physicians are rare, and this study offers a substantial contribution to the literature by examining these students’ formative experiences to understand their unique paths into physician careers.
The themes identified in our analysis suggest interventions that might improve the recruitment of AI/AN students to the medical profession. In collaboration with others who conduct programs to support AI/ANs pursuing health professions, we have described elsewhere17 several recruitment strategies based on our findings and a consistent body of related research. Briefly, these strategies, requiring the participation of both academic medical centers and preprofessional schools, Native as well as non-Native organizations and communities, include the following: (1) providing role models, advisors, and mentors; (2) involving AI/AN communities in research on Native health issues; (3) anticipating traditional Native spiritual practices to address concerns about belonging in modern Western medicine; (4) creating and implementing rigorous curricula that include indigenous perspectives; and (5) developing prodiversity institutional mission statements to inform admissions policies.
Factors from the deeply personal to the academic exerted powerful influences on our AI/AN study participants, acting as obstacles, supports, or both, on the path to medical school. Though further research is needed to improve our understanding of these dynamics, health workforce and educational policy development do not wait for more studies. Given the consistency of our findings with existing research on the underrepresented in medicine and AI/AN populations, and the urgent need for more AI/AN physicians, this research can help tribal, governmental, professional, and educational institutions develop a blueprint for supporting AI/ANs, starting in childhood, on the path to pursuing higher education and a profession in health service.
Acknowledgments
This study was supported through the WWAMI Center for Health Workforce Studies, which is funded by the National Center for Health Workforce Analysis, Bureau of Health Professions, Health Resources and Services Administration. The authors would like to thank Sonda Tetpon, who conducted the interviews of the medical students; Bradley Portin, PhD, who provided invaluable consultation on our qualitative study methods; Denise Lishner, who provided editorial assistance; and Apanakhi Buckley, whose earlier work with American Indian and Alaska Native students served as an inspiration for this work. The authors offer special thanks to the American Indian and Alaska Native medical students who shared their stories with us.
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*We will use the terms “AI/AN,” “Indian,” and “Native” interchangeably, except where we distinguish specifically between American Indians (from the lower 48 states) and Alaska Natives.
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†The Census 2000 total population figure includes only American Indians and Alaska Natives, but medical school enrollment figures from the Liaison Committee on Medical Education also include Native Hawaiians, so the disparity could be even larger.
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‡We refer to students with pseudonyms and have altered all identifying information in quotations to preserve confidentiality.
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