AAMC Reporter: March 2009

Viewpoint: "The Education and Importance of American Indian and Alaska Native Physicians"

Gerald Hill, M.D., president of the Association of American Indian Physicians

American Indians and Alaska Natives (AI/AN) continue to experience unacceptable health disparities. Recent statistics from the federal Indian Health Service (IHS) show age-specific death rates for AI/AN people to be 1.5 times that of the U.S. population. AI/AN death rates are more than twice as high for people ages 1 to 4 and ages 15 to 54. Tragically, AI/AN people die young: 28 percent of AI/AN deaths occur before age 45 versus only 9 percent for all races. Death due to diabetes is nearly four times that of the number for all races in the United States, three times higher from injury and poisonings, seven times higher for alcohol-related deaths, 91 percent higher from suicide, and 20 percent higher from heart disease.

The Association of American Indian Physicians (AAIP) believes that the recruitment, retention, and training of American Indians and Alaska Natives in medicine and other health careers is critical to eliminating these health disparities. For 37 years, this has been the primary mission of the AAIP.

The most obvious need that AI/AN physicians fill is the labor shortage in IHS, tribal, and urban Indian health programs. The physician vacancy rate in these programs is nearly 20 percent. Vacancies are particularly hard on reservation and rural clinics where only a few physicians are on staff. Without AI/AN health professionals, the vacancy rate would be even more severe. Since 1981, AI/AN health professionals in the IHS have increased by 272 percent and the proportion of AI/AN professional staff has increased by 138 percent.

Filling staff vacancies, however, is only one important challenge for AI/AN physicians. This has become clear to me in my time with the AAIP. In the 24 years since I became a member, I have seen AI/AN college students become medical students, medical students become physicians, and physicians become leaders in Indian health.

AI/AN physicians serve the IHS from the front lines to the top ranks of clinical medicine. We serve in reservation and urban Indian communities from coast to coast. AI/AN physicians help train future AI/AN physicians, and are leading researchers in AI/AN health. AI/AN physicians advocate for Indian health, serve on advisory committees for government and professional societies and on medical school admissions committees, advocate for Native American patients, and promote cultural competence.

Why is all of this important to the AAMC and U.S. medical schools? AI/AN physicians are underrepresented in medicine: There are only 56 AI/AN physicians per 100,000 population versus 171 per 100,000 for U.S. whites. The nation and the AAMC have recognized the importance of diversity in the physician workforce. We need more AI/AN physicians contributing to this diversity.

In a larger view, it is my opinion that the nation's medical schools are also responsible for creating a physician workforce that meets the needs of all our communities. The upcoming shortage of physicians projected by the AAMC and the lower proportion of medical school graduates entering primary care will likely exacerbate the shortage of physicians serving AI/AN communities. The ability of the IHS to compete for physicians is already limited. The IHS serves a largely rural population in often economically challenged communities. The pay rate for physicians in the IHS cannot compete with that of the nonfederal health care system. Thus, the projected U.S. physician shortage will put even more pressure on those who do serve AI/AN communities, likely leading to a reduction in physician retention.

To rectify the lack of native physicians, the AAMC and the nation's medical schools must ensure that natives are included in all diversity efforts. To do this effectively, the AAMC and medical schools must enlist the help of AI/AN people. During my time as director of the Native American Center of Excellence and the Center of American Indian and Minority Health at the University of Minnesota Medical School, we partnered with Indian tribes, tribal colleges, tribal schools, and the AAIP. We employed primarily AI/AN people in both the administrative and recruitment activities of the center.

Our success at increasing the number and improving the success of our AI/AN medical students surprised many, but proved the value of this collaboration. The University of Minnesota quickly became one of the highest producers of native physicians in the nation. In addition, we pioneered the first educational pathway in AI/AN health for native students in the country. We provided courses in Indian health and clinical experiences in Indian communities for our students. With the assistance of the AAIP, we provided the students with role models in AI/AN health and training in cross-cultural medicine. Graduates of our program now serve AI/AN communities in a number of states, and many have become leaders in AI/AN health.

It is my belief that increasing the number of AI/AN physicians to provide direct care, serve on medical school faculties, perform research in AI/AN health, and provide leadership in AI/AN health is critical to improving the health of Native people. The AAMC and medical schools can play an important role in this effort by assuring that native Americans are included in diversity programs and by developing partnerships with AI/AN communities and organizations. Working together, we can help meet the health care needs of one of the nation's most underserved populations.

Editor's Note: The opinions expressed by the authors do not necessarily reflect the opinions of the AAMC or its members.