According to the Association of American Medical Colleges (AAMC), members of groups that have been identified as underrepresented minorities (URMs) in medicine comprise only 8.9% of the physician workforce.1 Although the total number of active URM physicians has increased over the past several years, the percentage of active physicians from these groups declined from 2010 to 2013.1 Thus, it is imperative that the educational pipeline for URM students continue to employ innovative, collaborative strategies for producing the number of URM physicians needed to address changing demographics and health care disparities in the United States.2–5 Such strategies are especially needed for the American Indian/Alaska Native (AI/AN) population, which has the lowest representation in medicine, limiting the opportunity for tribal communities to fully meet their health care needs.
In 2013, the number of active AI/AN physicians practicing in Arizona, Colorado, New Mexico, and Utah was 229, out of a total of 25,718 active physicians in the region, which is known as the Four Corners. The average percentage of active AI/AN physicians in these four states was 0.9%. Although this percentage exceeded the overall national average of active AI/AN physicians (0.4%), it was far below the percentage of the population in the Four Corners region that was AI/AN (3.3%).1
A variety of pipeline initiatives aim to improve the recruitment of AI/AN students to medical school.6 The Indians into Medicine Program, funded by the Indian Health Service, was started in the early 1970s and provides extensive educational resources and support services through five-year grants to public and nonprofit educational institutions. The Native American Center of Excellence and the Health Careers Opportunities Program, both supported by the U.S. Department of Health and Human Services, have had an impact on AI/AN student recruitment. However, pipeline programs that rely on federal funding and the support of foundations have struggled with sustainability.7 Though some gains were noted after the implementation of these programs, more focus on regional capacity building, especially in the Four Corners states, is needed.
More comprehensive and consistent methods for tracking data regarding AI/AN students’ pursuit of health professions careers are also needed to inform and improve pipeline initiatives. Because of their small numbers and inconsistency in how applicants identify their tribal affiliation during the admissions process, the literature often excludes AI/AN demographics data.
To reduce health care disparities, enrich the educational environment, and meet the need for a culturally and linguistically competent and diverse workforce, in 2011, the medical schools at the Universities of Arizona (Phoenix and Tucson), Colorado, New Mexico, and Utah collaborated with the Association of American Indian Physicians (AAIP) to create the Four Corners Medical Education Alliance. As part of this initiative, these schools set out to collectively pursue the complex mission of increasing AI/AN student diversity at each institution. Founded in 1971, the AAIP supports AI/AN communities and students by offering educational programs, services, and activities that motivate AI/AN students to remain in the academic pipeline and pursue health professions and/or biomedical research careers. The AAIP also hosts forums on the integration of modern medicine with traditional and cultural practices for the purpose of enhancing health care delivery to tribal communities.
The Four Corners Medical Education Alliance represents an unprecedented collaboration between medical schools to support AI/AN students applying to medical school and to grow the overall AI/AN applicant pool, rather than vigorously competing for the small number of AI/AN applicants. The Alliance’s activities are supported by an interstate team of organizers, including staff from the AAIP and the admissions and diversity offices from each school, along with staff from the local Area Health Education Centers, AAMC, Indian Health Service, University of New Mexico Center for Native American Health, Arizona Indians into Medicine, Inter-Tribal Council of Arizona, and various health professions programs.
Yearly from 2011 to 2016, the Four Corners Medical Education Alliance convened a two-day preadmissions workshop (PAW), hosted in turn by each of the five participating medical schools, to prepare participants for the process of applying to medical school and to serve as a pipeline and recruitment program to expand the AI/AN physician workforce. The PAWs were open to all AI/AN undergraduate, graduate, and postgraduate students interested in a health professions career. Interested students submitted an application to the AAIP, and all five institutions reviewed, discussed, and selected the participants. This effort allowed the five medical schools to establish a sustainable and long-term commitment to collaborate on diversity-related issues that impact them and their partnering organizations.
The PAW objectives were to (1) provide information and activities that foster awareness of the medical school admissions process; (2) deliver individualized coaching and guidance throughout the medical school admissions process, particularly during the preapplication phase, so students are able to present a competitive application; (3) create awareness about the educational opportunities at the participating medical schools in the Four Corners states; and (4) promote self-efficacy and cultural identity. The workshop attempted to identify and contextualize the short- and intermediate-term steps to increase the AI/AN applicant pool to ultimately facilitate AI/AN representation in the physician workforce long-term.
The costs associated with the PAW were divided equally among the five institutions, with each medical school identifying funding sources to cover its portion of the expenses, including student travel, lodging, meals, handouts, and other materials. The average annual cost of the workshop was approximately $25,000, in addition to the personnel time required for planning and implementation. Joint planning was conducted via twice-a-month conference calls to define responsibilities, logistics, and evaluation. The AAIP served as the lead administrative partner responsible for application processing, student travel arrangements, hotel and catering contracts, and AAIP physician speakers. The host institution was responsible for the venue, session presenters, medical student panels, tours, and on-site activities. The alliance as a whole was responsible for recruiting and selecting students, agenda development, workbook creation, evaluation, and event logistics.
A typical PAW agenda is shown in Chart 1. The workshops generally included admissions simulation activities, writing workshops, Medical College Admission Test (MCAT) presentations, time management skill development, mock interviews (traditional and multiple mini interviews), financing-a-medical-education workshops, individual consultations, and cultural activities. These components provided participants with networking opportunities. The PAW also promoted a problem-based learning curriculum designed especially for AI/AN students and provided mentorship and access to an education ecosystem that aimed to foster students’ success in the physician workforce.
Chart 1Example of a Typical Preadmissions Workshop (PAW) Agenda, Four Corners Medical Education Alliance, 2011–2016
Incorporating cultural activities
Culturally sensitive recruitment efforts and support services within medical schools are essential to attaining a critical mass of URM physicians. PAW planners aspired to create an environment that incorporated participants’ cultural identities and commitment to serving their communities. One unique aspect of the PAW was the prevalent thread of cultural integration, which enhanced participants’ cultural identity and appreciation for the dual role of living as an AI/AN physician and a tribal community member. The PAW was structured to reinforce participants’ self-efficacy (the belief in one’s ability to succeed) and cultural identity, in alignment with Weiss’s Theory of Change paradigm.8
Each PAW opened and closed with a spiritual expression, such as a blessing or prayer, that was offered by a local tribal community member. Participants attended a networking dinner at a local AI/AN cultural center and toured the facility, listened to ancestral stories and viewed artifacts from local tribes, and/or visited a local tribal community. All cultural activities emphasized tribal knowledge, health belief systems, heritage, and native origins. Evening events were carefully planned to coincide with local cultural, social activities where tribal community members come together to celebrate and share their cultures. PAW participants were exposed to AI/AN singers, drummers, and dancers, and they learned about the tribal traditions that exemplified the pride and dignity of their cultures.
For example, the New Mexico PAW included attendance at the annual AAIP Cross Cultural Medicine Workshop in Santa Fe. PAW participants learned about the history and integration of traditional medicine in clinical settings and the restoration of the balance of the body, mind, and spirit; listened to stories from AI/AN physicians describing their paths to medicine; and experienced hands-on herbal medicine preparation.
In 2016, we developed a 14-item survey that evaluated the major sessions/activities included in that year’s PAW. We administered a paper version of the survey to participants on the last day of the workshop. The institutional review board at the University of New Mexico Health Sciences Center approved this research.
From 2011 to 2016, 130 AI/AN students participated in the PAWs. Of these, 113 were first-time attendees, 15 participated on two separate occasions, and 1 participated on three separate occasions. Of the 90 first-time participants from the 2011–2015 cohorts, 19 (21%) matriculated to a U.S. medical school in the past five years. Additionally, 9 (10%) matriculated to another health-related graduate degree program (e.g., veterinary sciences, public health, clinical sciences, global health), according to internal program evaluation data. However, it is not clear what role the workshops played in the increasing number of participants who applied and matriculated to a health-related graduate degree program.
Twenty-two of the 23 participants in the 2016 PAW cohort responded to the survey (96% response rate). They were asked, on a five-point Likert scale, whether their interest in pursuing a medical and/or health professions degree increased as a result of the workshop. Twenty (91%) participants reported that the workshop increased their interest in pursuing such a degree, either extremely (13; 59%) or moderately (7; 32%). Participants also were asked to rank the three most informative or beneficial sessions/activities and the three least informative or beneficial sessions/activities. Sixteen (73%) participants found the interview preparation session to be either the most or second most informative session, followed by the individual consultation session (14; 63%) and the writing preparation session (8; 37%). Participants indicated that the greatest application challenges they faced were the MCAT (6; 29%), followed by grade point average (4; 19%), interview (4; 19%), personal statement (3; 14%), finances (2; 9.5%), and other (2; 9.5%). Previous studies also have reported that AI/AN medical students experience academic barriers in their pursuit of a health professions career.9
This work has several limitations. First, the survey data reflect only one year of responses at a single PAW site. We do not know whether the session rankings are representative of previous participants’ preferences. In addition, the PAWs were held in a region that includes the largest AI/AN tribe in the United States (Navajo Nation); these findings may not be achievable at other medical schools that have limited geographical access to AI/AN tribes and thus may not be successful in increasing the general U.S. AI/AN applicant pool. Finally, the reported matriculation rate for PAW participants includes MD-granting schools only, so we could be undercounting the total number of matriculants by excluding participants who matriculated to DO-granting schools.
Since the implementation of the PAWs, the number of AI/AN applicants (who self-identified as American Indian or Alaska Native alone, not in combination with any other race/ethnicity) who applied to U.S. medical schools from the Four Corners Medical Education Alliance states has steadily increased (see Table 1). In 2016, there were a record 25 AI/AN applicants (25/127; 19.7% of all U.S. AI/AN applicants). We do not know what proportion of these applicants participated in a PAW; however, this increase suggests that collective activity has had a positive impact on expanding the AI/AN applicant pool from this region. During this same time period, however, AI/AN matriculation rates from this region have been inconsistent, and nationally they have remained unchanged, with a total of 54 matriculants in 2016 (see Table 1).
In a time of dwindling resources for medical student recruitment, multi-institutional partnerships, such as the Four Corners Medical Education Alliance, offer a promising opportunity to implement recruitment strategies for AI/AN students. More often, these programs are competitive ventures instead of cooperative ones, making our alliance unique. The increase in the number of applicants to the PAW has encouraged us to expand our current partnership to include more states to achieve broader geographical representation. In addition, future initiatives will include more robust measures of success. Through intensive evaluations of future PAWs, we hope to identify the specific elements that are the most likely to result in the successful matriculation of AI/AN students.
Additional studies are also needed to determine the potential for cultural integration frameworks and activities, as we have built into the PAWs, to increase the number of AI/AN medical school applicants and matriculants. The AAIP plans to conduct a national survey with past PAW participants to identify their final career choices and the impact that such pipeline initiatives have had on AI/AN communities. The AAIP also plans to conduct a longitudinal evaluation of all AI/AN medical education pipeline programs to assess their impact on physician workforce development.
The authors wish to thank the preadmissions workshop planning team for their efforts in helping to facilitate the workshop for the past six years and Cheryl Schmitt for her assistance with the survey design and data analysis. They also wish to acknowledge Linda Don and Margaret Knight for their vision in conceptualizing the initial Four Corners Medical Education Alliance.