American Indian and Alaska Native Medical School Applicants: Physician Workforce to Address Health Disparities or Social Reproduction in the Profession of Medicine?

The paucity of American Indian and Alaska Native (AI/AN) physicians is an ongoing challenge in medicine’s efforts to provide health care for all Americans. A physician workforce reflecting the nation’s diversity is vital. Racial, cultural, and linguistic concordance between care providers and patients leads to better health outcomes. Moreover, greater inclusivity in the physician workforce atones for the profession’s role in the historical discrimination and atrocities inflicted upon America’s marginalized groups. Physicians who are representative of American Indian and Alaska Native communities are integral to better care. They are also essential to the federal obligations owed Tribal Nations. Tribes were promised health care in the still-valid treaties created when Indigenous peoples were forced to relinquish their ancestral homelands to White colonizers and settlers. Despite decades of educational pipeline programs, the proportion of AI/AN applicants continually hovers around one percent of medical school applicants. By contrast, the percentage of AI/AN people in the U.S. population has grown to over two percent. Compounding the problem of few AI/AN applicants is a lack of knowledge about them. The group is severely understudied. In this investigation, secondary data analysis was conducted to describe the sociodemographic and educational attributes of the 2002-2012 AI/AN medical school applicant pool. To explore the heterogeneity within this pool, the group’s data were disaggregated by AI/AN identity subgroups for part of the analysis. The purpose of the study was to learn more about the AI/AN group, including in comparison with other applicant groups, to find ways to increase the number of AI/AN students in medical schools. The AI/AN applicant group shared more characteristics with the other historically underserved/marginalized groups than with the White applicant group. Historically underserved/marginalized groups more often reported socioeconomic and educational disadvantage, lower educational attainment and non-professional occupations for their parents, and lower mean GPAs and mean MCAT scores compared to the White applicant group. AI/AN applicants who indicated only American Indian or Alaska Native for race/ethnicity were more often designated as rural applicants, applicants that grew up in medically underserved areas, and attenders of community colleges and tribal colleges compared to AI/AN applicants who specified additional race/ethnicity groups. There was no statistically significant difference in admission outcome between the AI/AN identity subgroups. Regression models indicated MCAT scores and undergraduate GPA were the strongest predictors of acceptance to medical school for AI/AN applicants. Moreover, female AI/AN applicants and disadvantaged AI/AN applicants were accepted more frequently than AI/AN male applicants and non-disadvantaged AI/AN applicants. Study findings highlight the effects of White hegemony, which continues to impact the daily lives of Indigenous people. Critical theories, especially tribal critical theory, re-frame the dearth of AI/AN physicians from a pipeline problem to a case of social reproduction. The enduring dampening of the AI/AN medical school applicant pool stems from larger socioeconomic structural forces that constrict educational and economic opportunity for Indigenous people, particularly those in tribal and non-tribal rural communities. Within this framework, the unique legal, sociopolitical status of Native Nations is instrumental in expanding AI/AN medical student enrollments. One strategy would be to give preference to citizens of Tribal Nations, like the current preferences for in-state residents (AAMC, 2018). Another approach would be to establish Indigenous-focused medical schools on tribal lands through inter-governmental agreements and business partnerships between the sovereign Tribal Nations, the federal government, academic partners, and health systems. Besides increasing the number of AI/AN medical students, such a collaboration would improve Indigenous health care systems and advance research that enhances the health and well-being of Indigenous people