Equal Representation of Indigenous Docs Would Take a Century, Study Finds

At current rates, equitable representation of American Indians and Alaska Natives in the U.S. physician workforce will not be achieved for over 100 years, a recent paper in Lancet Regional Health – Americas found.

In this video interview, researchers Victor Lopez-Carmen, MPH, a medical student at Harvard Medical School in Boston and a member of the Hunkpati Dakota and Yaqui nations, and Rohan Khazanchi, MD, MPH, a resident in the Harvard Internal Medicine-Pediatrics Residency Program, discuss their findings and offer proposals for how to change that.

The following is a transcript of their remarks:

Lopez-Carmen: The lack of indigenous peoples in medicine is an issue all across the world, no matter where you go or where indigenous peoples are. We focused on the United States and on American Indians and Alaska Natives.

Our study found that to fill the deficit of American Indians and Alaska Natives will take 102 years if their matriculation rate into medical school remains stable going forward. I think this is important to understand in the context of equitable representation, because these numbers are not by accident. There are institutional policies and barriers that are keeping indigenous medical students from entering medical school.

Our study also proposed a number of solutions that will help to fill this gap, and we’re very optimistic about that opportunity.

Khazanchi: Yeah. I think in just thinking more about what really defines the scope of this issue, there are very few interventions in medical education that can reform health disparities in a meaningful way. One piece of evidence that we have that is unequivocally strong — has been proven in randomized experiments — is that when patients are taken care of [by] physicians that look like them, their health outcomes are better.

So I think the reason this matters — the reason this hundred-year deficit that we’re projecting if we do nothing and we keep matriculating indigenous medical students at the same rate as we have been — the reason this matters is that it’s health outcomes for indigenous communities we’re talking about. It’s communities that face some of the largest health disparities in the country and in the world.

Really reforming who is in our health workforce is one of the few interventions we can make that can transform that in a shorter period of time.

I think physicians have very loud and powerful voices in our communities, and we sit in so many spaces that would benefit from more folks asking the question, “Who’s not in the room right now?” That can be at the policy-decision-making table, that can be at the state or the local level, that can be in medical schools, in your clinic, in your hospital. Asking that question, “Who’s not in the room?” can motivate a more intentional look around and point out the opportunity to bring in other voices.

In this case, I think our clarion call would be really to invite in indigenous voices at every opportunity you have at every turn. Because we recognize that correcting this deficit is not going to be something that can only fall on the shoulders of the very few indigenous physicians that are already in our workforce. It really needs to be everybody.

I’m coming to the table in this study as somebody who’s a non-indigenous person of color, and I don’t think that my perspective or understanding of the issues is as in-depth as Victor’s or our other colleagues on this manuscript is. But at the same time, I’ve definitely recognized in my own work that having more indigenous colleagues at the table would help, it would make things better for the patients that I’m trying to serve. And so I view this as everybody’s mission, not just the mission of indigenous medical students and physicians. I think any individual practitioner can do the same.

Lopez-Carmen: Yeah, I totally agree.

I think if every medical school and the physicians that made up the faculty of these medical institutions just put a lot more focus into how can they partner with the tribes in their surrounding areas, I think this would make the progress move a lot faster.

I think, like Rohan said, a lot of people look at these numbers and look at the deficit and look at the health disparities and think, “Oh my God, what can I do? I’m just one physician.” Every academic institution on an indigenous territory working with the tribes around them, I think, is so much more effective because it builds that long-term relationship. It helps build the medical trust between the tribes and the medical institution.

It’s much easier for indigenous students to attend medical schools close to their traditional territories because it provides more access for the indigenous students to return home for ceremonies, to go home when there are cultural activities going on, which are so important. I think there’s a lot of potential there.

I also really think that [we should] invest in indigenous students, because we already have the responsibility to our communities baked into us. When you’re investing in indigenous students, you’re not only investing in them or their personal ambitions or their financial success or even the success of their family. Yeah, all those things are true, but you’re investing in an entire community.

Because you know that indigenous peoples, in our hearts, we’re in this for our community. We have that responsibility ingrained in us to our community, but to the future generations as well. I think that mindset is innovative in the sense that it brings something new to medicine.

Bringing an indigenous worldview, an indigenous mindset, to medicine, I think we’re going to see so many opportunities because of that mindset with regard to more indigenous recruitment into the field.

I think there’s a case to be made that there needs to be more understanding of the challenges that indigenous students face during medical school. I think in a lot of ways, coming into medicine still requires a certain level of assimilation in many respects.

The way that indigenous students think about professionalism, for instance. Professionalism can be seen very differently in the indigenous community versus in a medical institution. It might be professional in an indigenous community to remain silent when someone is teaching — to observe as much as you can and not speak over your elders or not speak up and just listen. I think in our communities, many indigenous students can relate to that. That’s how we learn.

You come into medicine, and there’s a different expectation. It’s almost as if there’s pressure to be more assertive, to speak up as much as you can. And a lot of indigenous students get castigated as uninterested because our learning style might not be seen as as-engaged, even though inside we’re very engaged and we might just learn a different way.

I think because there are so few indigenous students in medicine [or] a lot of indigenous physicians, people in leadership positions in medicine haven’t really had the exposure to the indigenous worldview, to indigenous students, our unique challenges. A lot of times, the first time they encounter one of these challenges with an indigenous student that might just be a cultural barrier or a cultural gap, there might be more inclination to enforce punitive measures because of that lack of understanding. And I think a lot of indigenous students, from what I’ve heard anecdotally, face that sort of situation.

So just more understanding of these challenges, I think, would go a long way in helping indigenous students get to that finish line.

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