Equitable representation of American Indians and Alaska Natives in the physician workforce will take over 100 years without systemic change

While there has been significant recovery of the American Indian and Alaska Native (AI/AN) population and revitalization of Indigenous knowledge systems, AI/AN physicians remain underrepresented in the United States (U.S.) physician workforce. Despite greater enrollment of underrepresented medical students between 1997 and 2017, the per capita enrollment of Black and African American, Latino, and AI/AN medical students decreased relative to the general population, and AI/AN medical students were the only racial group that did not experience an absolute increase in medical school enrollment.¹ According to 2022–2023 data from the Association of American Medical Colleges (AAMC), only 1% of total enrolled medical students self-identified as AI/AN, compared to 2.9% of the 2021 U.S. population.^2,3

The underrepresentation of AI/AN individuals is even worse among practicing physicians. According to the 2021 AAMC State Physician Workforce Report, only 4104 (0.4%) active physicians in the U.S. self-identified as AI/AN.⁴ If AI/AN representation in the physician workforce matched their proportion in the U.S. population, there would be nearly 30,000 AI/AN physicians today. In the absence of transformative efforts to address this health equity crisis, population parity will never be a reality.

Solutions must begin by increasing enrollment of AI/AN medical students. During the 2021–2022 academic year, only 227 AI/AN students entered U.S. medical schools.⁵ If this annual number of matriculating AI/AN medical students remains constant, it will take 102 years to overcome the deficit of AI/AN physicians relative to the 2021 AI/AN population (Fig. 1).^3,5 However, if the number of AI/AN students entering medical school doubles, triples, or quadruples from 2021 onward, it would take 51, 34, and 25 years respectively to achieve a representative number of AI/AN physicians. To achieve a representative proportion of AI/AN physicians within five years, 4632 AI/AN medical students would need to enroll annually—20 times higher than the number of matriculants in 2021. It is important to note that these estimates are likely conservative, as they do not account for future AI/AN population growth. A 2022 study found similarly striking deficits of Black and Latino physicians relative to the 2015 U.S. Census.⁶

Fig. 1.

Years to correct AI/AN physician deficit in scenarios where the annual matriculation remains the same, double, triples, orquadruples.

Since AI/AN physicians practice medicine with a worldview informed by their cultural values and often serve areas with critical physician shortages, the underrepresentation of AI/AN physicians exacerbates AI/AN health and social inequities.⁷ These inequities are downstream consequences of centuries of settler-colonial genocide and disruption of Indigenous knowledge systems.⁸ To close the gap in AI/AN physician underrepresentation in far less than a century, systemic policy solutions must be embraced. We advocate for the following multi-level interventions:

• Policy:

  • 1)
    Increase federal funding for Tribal Colleges and Universities (TCUs).
  • 2)
    Introduce explicit federal guidance from the U.S. Department of Education to clarify that affiliation with or descent from a federally-recognized AI/AN Tribe or Village is a protected class distinct from race based on Morton v. Mancari,⁹ particularly in the wake of the recent Supreme Court decision to dismantle race-conscious affirmative action in higher education in Students for Fair Admissions v. Harvard College.¹⁰
  • 3)
    Enact state and federal legislation to address systemic barriers to educational attainment for AI/AN youth, such as broadband connectivity, food insecurity, and housing instability.⁸
• Institutional:

  • 1)
    Implement policies to guarantee designated seats for academically qualified AI/AN students at U.S. medical schools.
  • 2)
    Create and sustainably support AI/AN pathway to medicine programs.
  • 3)
    Invest endowment funding to make in-state higher education and professional school tuition free for AI/AN students.
  • 4)
    Develop and teach Indigenous-led and strengths-based core curricula on AI/AN health in U.S. medical schools.
  • 5)
    Invest in the recruitment and retention of AI/AN university and medical school faculty, who can help foster positive psychological climate, support, and a sense of belonging for their AI/AN students and colleagues.
  • 6)
    Deemphasize the Medical College Admissions Test (MCAT) as part of holistic review of AI/AN applicant’s upbringing and adversity.
• Public, private, and nonprofit sectors:

  • 1)
    Invest in transformative, multi-sector partnerships to establish new tribally and Indigenous-run health professions schools, expanding upon lessons learned from the first tribally affiliated medical school at the Cherokee Nation.¹¹

Our proposed recommendations seek to not only ensure proportional AI/AN representation in medicine, but also to foster a positive learning environment for AI/AN medical students throughout their health professional training. Educational institutions and policymakers alike must ensure AI/AN students are not just represented, but that their lived experiences and knowledge are also seen as a valued contribution to the medical field.

Contributors

Victor A. Lopez-Carmen: Lead author, data interpretation, literature review, revisions.

Nicole Redvers: Writing authorship, literature review, data interpretation, mentorship of junior authors, revisions.

Alec J. Calac: Writing authorship, data interpretation, literature review, revisions.

Adaira Landry: Writing authorship, mentorship of junior authors, data interpretation, literature review, revisions.

LaShyra T. Nolen: Writing authorship, data interpretation, literature review, revisions.

Rohan Khazanchi: Senior author, mentorship of junior authors, writing, literature review, data interpretation, revisions.

Declaration of interests

No interests to declare.