The Indigenous Faculty Forum: A Longitudinal Professional Development Program to Promote the Advancement of Indigenous Faculty in Academic Medicine

Abstract

American Indian, Alaska Native (AIAN) and Native Hawaiian and other Pacific Islander (NHPI) faculty, are substantially under-represented (<1%) at US medical schools. The Oregon Health & Science University's Northwest Native American Center of Excellence and The University of Hawai‘i Native Hawaiian Center of Excellence have created an Indigenous Faculty Forum (IFF), a one-day structured course with flanking social activities, specifically designed to meet the unique needs of AIAN and NHPI academic faculty. It provided: (1) Indigenous space, (2) skill building, (3) networking, and (4) ongoing mentorship, each of which were included to specifically mitigate isolation and tokenism that negatively affects promotion and advancement. Two Forums have been conducted, first in Portland, OR in 2017 and the second in Hilo, Hawai‘i in 2018. Nine of eighteen AIAN faculty in the three-state region (CA, OR, WA) attended IFF Session #1, representing 50% of known AIAN faculty in this region. Thirty-four Indigenous faculty from around the world attended IFF Session #2, with twenty-nine completing program evaluations. Respondents were predominantly female (81.6%), under age 44 (52.7%), and either instructors or assistant professors (52.6%). In terms of career choice, both sessions included primary care physicians as the most represented group (55.6% at Session #1 and 62.1% at Session #2). Increasing Indigenous faculty representation in US medical schools, while simultaneously fostering their career advancement and meaning in work, is vitally important. We have begun the work needed to address this problem and look forward to conducting more efforts, including longitudinal evaluation designs to study effectiveness.

Introduction

The percentage of under-represented faculty has increased nationally across all medical schools since 2000; however, the promotion of minority faculty in academic medicine continues to lag behind that of non-Hispanic whites.¹ This issue is especially problematic for American Indian, Alaska Native (AIAN) and Native Hawaiian and other Pacific Islander (NHPI) Indigenous faculty, as they are severely under-represented at US medical schools. A recent analysis of trends in US faculty rank shows that Indigenous faculty are either not experiencing increases or are decreasing in representation, with Indigenous faculty comprising the lowest percentage (<1%) of full professors among all racial groups.² Despite efforts to increase minority faculty recruitment and development at US medical schools over the past two decades, Indigenous faculty appear not to benefit from these efforts as evidenced by their persistent overall under-representation and lack of advancement as medical school faculty.^2,4

In the early 1990's comprehensive minority physician faculty development programs began to emerge in the United States as a result of discordance between minority and non-minority faculty in recruitment, retention, and promotion.³ A 2013 study found these programs exist at 29% of US medical schools. However, other research indicates that the sole presence of a minority faculty development program is insufficient to increase underrepresented minority faculty representation, recruitment, or promotion.⁴ Yet subgroup analyses of these findings did reveal that programs in place for at least five years were associated with greater increases in underrepresented minority faculty. In a systematic review published in 2014, Rodriguez et al. identified four key elements linked to minority faculty program effectiveness, including: (1) networking activities, (2) specific skill development, (3) support of senior faculty, and 4) training on institutional culture.⁵

Despite these compelling findings, some faculty development initiatives may inadvertently contribute to perpetuating the failure to recruit and promote Indigenous faculty, as they may be deficient in addressing the unique needs of this group. We found only one published study exploring AIAN health care providers and their perceptions of academic medicine, which revealed that recognizing challenges in balancing AIAN and academic cultures, heightening career awareness, collaborating with the Indian Health Service (IHS) on faculty recruitment strategies, and identifying concordant role models/mentors were all important features for Indigenous faculty members.⁶ Novel, culturally-specific, professional development initiatives are needed to support AIAN and NHPI advancement in academic careers, which has the potential of further enriching the entire academic climate at US medical schools.

The Oregon Health & Science University's (OHSU) Northwest Native American Center of Excellence (NNACoE) and the University of Hawaii's Native Hawaiian Center of Excellence (NHCOE) are collaborating to deliver an annual Indigenous Faculty Forum (IFF) designed to increase the number of Indigenous faculty and foster their retention and advancement. In this paper, we describe the design and implementation of the IFF as a model for developing Indigenous faculty at US medical schools.

Methods

Program Design, Implementation & Evaluation Tools

OHSU Northwest Native American Center of Excellence (NNACoE) was launched in 2017 to increase the number of AIAN physicians and better train tomorrow's healthcare leaders in tribal health.⁷ NNACoE is a partnership between OHSU, Portland State University (PSU), and the 43 federally recognized tribes of the Pacific Northwest through the Northwest Portland Area Indian Health Board (NPAIHB).⁸ NNACoE supports programs in several key areas including: (1) Tribal Engagement, (2) Outreach and Recruitment, (3) Education, and (4) Comprehensive Evaluation, which are spread across the three partner institutions in the form of six teams. NNACoE is guided by a Pathways Advisory Council comprised of Indigenous experts and leaders in AIAN medical education. The Indigenous Faculty Forum (IFF) is a key component of the education team and is NNACoE's primary effort to specifically recruit, retain, and advance AIAN and NHPI faculty.

IFF is a one-day structured CME course with flanking social activities specifically designed to meet the unique needs of junior Indigenous faculty by providing: (1) Indigenous space, (2) skill building, (3) networking, and (4) ongoing mentorship. Based on tokenism theory, “tokens” or those who represent less than 15% of a group's total, are very likely to experience a variety of difficulties in the workplace, such as feelings of unwanted heightened visibility, isolation, and limited opportunities for advancement.⁹ Each of these themes were addressed in the IFF specifically to mitigate isolation and tokenism. The first IFF occurred in Portland, Oregon in November, 2017 and the second IFF occurred in partnership with the University of Hawai‘i Native Hawaiian Center of Excellence (NHCOE) and was held concurrently with the Pacific Region Indigenous Doctors Congress (PRIDoC) in Hilo, Hawai‘i in July of 2018.

Recruitment for IFF was multifaceted due to the scarcity of Indigenous faculty and relied on personal connections, professional organizations, offices of diversity and inclusion, and social media. Faculty who identify as being American Indian and Alaska Native were included in the first forum. The initial recruitment effort identified eighteen AIAN faculty at medical schools in Washington, Oregon, and California. The most effective means of recruitment was through “word-of-mouth” and personal connections of potential participants.

Content and organizational structure of Session #1 is outlined in Appendix A. Briefly, after a traditional AIAN opening, introductory remarks were made by OHSU's Vice Provost for Diversity and Inclusion. These remarks were followed by three content-specific interactive presentations. The first presentation focused on strategic career development planning; the second addressed maintaining cultural identity within the larger institutional culture; and the third addressed building bridges with tribal clinics and communities. A focus group was held in the afternoon session and was designed to better understand the professional development needs of AIAN faculty, as well as the enablers and barriers to their career success. The focus group was followed by a program evaluation that included five questions assessing the extent to which the program enhanced participants’ knowledge about topics covered during the forum and two open-ended questions about the most influential aspects of the forum and areas for improvement. The evaluation also included the 22-item Diversity Engagement Survey, which measures perceptions of institutional culture as it relates to diversity and inclusion.¹⁰ Lastly, a social gathering was held in the evening. A follow-up survey is mailed one year after each IFF to assess progress and any changes in institutional culture. This component of the project is still underway and will be described in a future manuscript. All activities were reviewed and approved by OHSU Institutional Review Board (IRB #17588).

After the success of Session #1, and after identifying persistent under-representation of AIAN faculty and the statistically significant decline in NHPI faculty, OHSU NNACoE and UH NHCOE joined efforts to offer IFF Session #2 as a pre-conference workshop of the 2018 Pacific Region Indigenous Doctors Congress (PRIDoC). Started in 2002, PRIDoC provides space for Indigenous physicians and students, researchers and health professionals from across the Pacific to gather around shared issues of well-being, to network, to discuss issues of mutual interest, and to share scientific advances and best practices as well as ancient wisdom and traditional knowledge to further the health and well-being of Indigenous communities.¹¹

PRIDoC hosts a biannual meeting that rotates throughout the Pacific region. PRIDoC 2018 was hosted by ‘Ahahui o nā Kauka (Association of Native Hawaiian Physicians). Other members of PRIDoC include Te ORA (Maori Medical Practitioner's Association), AIDA (Australian Indigenous Doctors Association), IPAC (Indigenous Physicians Association of Canada), and MAIPT (Medical Association of Indigenous Peoples of Taiwan). Members of the AAIP (Association of American Indian Physicians) also attend PRIDoC, however AAIP is not an official member of PRIDoC at this time. Medical education has been a common thread throughout the conferences. PRIDoC 2018 provided a perfect opportunity for the second IFF given that it would highlight collaboration between the two Indigenous COEs in the United States.

The NHCOE is part of the Department of Native Hawaiian Health at the University of Hawai‘i, John A. Burns School of Medicine and ‘Ahahui o nā Kauka is a partner of the NHCOE. In existence since 1999, it focuses on improving Native Hawaiian health through education, research and community initiatives that enable Native Hawaiians to successfully pursue careers in medicine and other health professions. Specific focus areas include: (1) student recruitment and training, (2) faculty and student research, (3) faculty development, (4) cultural competency training, (5) providing informational resources and (6) developing community and university partnerships.

IFF Session #2 included Indigenous faculty from the Pacific Rim representing medical schools in Australia, Canada, New Zealand, Taiwan, and the United States (continental and Hawai‘i). Together NNACoE and NHCOE co-designed the forum to focus on the key areas of mentorship, networking, and skill building in an Indigenous space supportive of Indigenous expression and being. Content and organization structure of Session #2 is outlined in Appendix B. To create a safe place in the forum, an ‘ohana (family) style design was used where participants entered the building without shoes, illustrating respect and immersion into a Hawaiian place of learning. The University of Hawai‘i at Hilo Hale ‘Olelo (School of Hawaiian language) provided the setting for the workshop. A traditional Hawaiian opening featured a welcoming oli (chant) that acknowledged the ancestors, the place, and the group that was gathered for the forum. The Directors of NNACoE and NHCOE gave opening remarks, which were followed by keynote speaker Dr. Michael Painter from the Robert Wood Johnson Foundation. Thereafter came an opportunity for all present to greet and network with each other, followed by breakout sessions led by Indigenous senior faculty. The session topics centered on meaningful mentoring, strategic career planning, and bridging academic medicine with clinical work. Time was allocated for participants to discuss lessons learned from the breakout sessions with the wider group, followed by a panel on racism, unconscious bias, and microaggression in academia. The day concluded with a presentation on navigating academia and clinical practice while living Indigenous values and maintaining a focus on Indigenous health. Program evaluation similar to that for Session #1 was administered, with the five knowledge enhancement questions tailored to align with Session #2 content.

Data Analysis

Descriptive statistics were used to characterize demographic and clinical practice/career information. Because small cell sizes could result in identifying participants, cell sizes less than 6 were regrouped into larger categories with descriptors for each of the groups. SPSS version 24 was used to conduct analyses.

Results

NNACoE staff identified 18 AIAN faculty in the three-state region (CA, OR, WA), and 9 attended the IFF Session #1, representing 50% of all known AIAN faculty in this region. There were 34 attendees at the 2nd IFF, 29.4% were from Hawai‘i, 23.5% were from the Continental US (all Native American except for 1 Pacific Islander), and the remaining participants were from Canada, New Zealand, Australia or Taiwan. Twenty-nine of the 34 attendees completed program evaluations (85.3%) revealing that participants were predominantly female, under age 44, and either instructors or assistant professors (Table 1).

Table 1.

Demographic Information for Attendees of the Indigenous Faculty Forum Session #1 and #2

	Attendees Combined n = 38		Session #1 n = 9		Session #2 n = 29
	n	%	n	%	n	%
Gender
Female	31	81.6	8	88.9	23	79.3
25 – 34	5	13.2	-	-	5	17.2
Age
25 – 34	5	13.2	-	-	5	17.2
35 – 44	15	39.5	6	66.7	9	31.0
45 – 54	8	21.1	2	22.2	6	20.7
Older than 54	8	21.1	1	11.1	7	24.1
Missing	2	5.3	-	-	2	6.9
Faculty Rank
Junior Faculty	20	52.6	4	44.4	16	55.2
Associate Professor	7	18.4	3	33.3	4	13.8
Professor	3	7.9	-	-	3	10.3
Other*	8	21.1	2	22.2	6	20.7
	Mean (Range)	Standard Deviation	Mean (Range)	Standard Deviation	Mean (Range)	Standard Deviation
Years as Faculty Member	8.55 (0.25–26)	7.12	8.8 (1–26)	6.8	7.8 (0.25–22)	8.9

^*For Sessions #1 and #2 “Other“ includes non-faculty attendees

Participants were asked how long in years they had been a faculty member. For participants in Session #1, seven responded (two were not faculty) with a mean number of years as a faculty member of 8.8 (range = 1 year to 26 years). Among participants of Session #2, the mean number of years as a faculty member was 7.8 (range 0.25 year to 22 years) (Table 1). In terms of career choice, both sessions included primary care physicians as the highest represented group with 55.6% at Session #1 and 62.1% at Session #2 (Table 2). Sub-specialty physician participants were represented by 22.2% in Session #1 and 10.3% in Session #2 and non-physician faculty represented by 22.2% in Session #1 and 17.2% in Session #2. Because small cell sizes could result in identifying participants, Indigenous affiliations were categorized as follows: (1) American Indian/Alaska Native; (2) Canadian First Nations; (3) Native Hawaiian; (4) Other Indigenous Affiliation; and (5) No Indigenous Affiliation. Across both sessions, 31 Indigenous Affiliations were represented, with 100% of participants reporting an American Indian/Alaska Native affiliation for Session #1. For Session #2, 24% of participants identified as American Indian/Alaska Native, 17% as Canadian First Nations, 10% as Native Hawaiian, and 45% as having an “Other” Indigenous Affiliation.

Table 2.

Primary Specialty Groups According to Program Session

	Session #1 n = 9		Session #2 n = 29
	n	%	n	%
Primary Career Group
Physicians	6		22
Primary Care	5	55.6	18	62.1
Sub-Specialty	2	22.2	3	10.3
Other	-	-	1	3
Non-Physicians
Faculty from Other Disciplines	2	22.2	5	17.2

Discussion

This paper fills an important gap in existing literature in its description of a novel faculty development program designed to meet the unique needs of Indigenous faculty in academic medicine toward fostering their retention and professional advancement. Regrettably, in 2016 there were fewer than 20 Indigenous faculty at the full professor rank at all US medical schools, and to our knowledge, there has yet to be an Indigenous Dean. For the Indigenous junior faculty currently in academia, an abysmal gap in cultural mentorship exists which, if present, could foster greater success in academic career pathways.² The role of mentorship is widely recognized as influencing complex academic faculty career pathways; however, minority faculty have minimal access to ethnically and racially concordant senior faculty mentors. This limitation has been reported as a barrier to advancement among minority physician residents pursuing academic careers.¹²

Importantly, under-represented minority US medical school graduates pursuing non-clinical career tracks report intention to work with underserved populations that is twice the rate of other minorities and non-Hispanic Whites.¹³ Failure to foster the academic career pathways of Indigenous faculty may further contribute to the disparities seen in the inclusion of minorities in to research and education initiatives. Indigenous representation is so miniscule in academia that these important voices are vacant from both the academic culture and the literature that describes minority faculty development programs and their related outcomes.

The IFF includes features that created a space safe for Indigenous faculty to freely exist without repressing their full “self,” where it is safe to express one's culture and identity without repression. The forum also succeeded in building an informal network among Indigenous faculty, with just a few degrees of separation, among AIAN, NHPI and other Indigenous faculty around the world, creating a foundation upon which to develop their skills and advance their careers.

Session #1 represented a pilot program and we were able to attract 50% of known Indigenous medical school faculty from California, Oregon, and Washington. An important success of the IFF Session #2 was that it was held concurrently with PRIDoC, which resulted in convening a large number and concentration of Indigenous medical school faculty at a single conference. This is important, given that Indigenous faculty (all Indigenous groups combined) represent far less than 1% (0.29%) of all US medical school faculty, with the percentage of AIAN faculty trending flat between 2014 to 2015 at 0.11%, and decreasing from 0.25% to 0.18% for NHPI faculty.² These findings suggest that Indigenous faculty may not be receiving or benefitting from existing faculty development programs.^4,12

This work is in its early stages. NNACoE is currently planning to continue the IFF through the duration of our current 5-year funding period. After three iterations that include completion of the corresponding follow-up survey, we will know more about the impact of the forum on the advancement of participants in terms of promotion as well as changes in the culture at their institutions regarding diversity and engagement. We are actively planning for IFF Session #3 to be hosted in Portland, OR and have begun early discussions to co-host IFF Session #4 concurrently with PRIDoC in 2020. We will continue to explore funding opportunities and make programmatic improvements based upon our evaluations, which may involve increasing both the intensity and frequency of forum activities and more formalization of the mentoring process.

Limitations of this work include that the IFF experience is less frequent and less intensive than is likely needed to be optimally effective. However, the time commitment for participants is minimal, which makes it feasible for busy clinical and nonclinical faculty to attend. Future research should examine which elements are most effective, which will require a more in-depth evaluation than is currently being conducted. For example, it will be important to determine if participation in the IFF contributes to faculty success in terms of recruitment, retention, and academic advancement, which would require a randomized controlled or cross-over study design. Another limitation is that we are currently unable to report robust outcomes as the oneyear follow-up data are not yet available. We do plan to report those data when they are available.

In conclusion, it is vitally important to increase Indigenous faculty representation in US medical schools while simultaneously fostering career advancement and meaning in work. General minority faculty development programs may not be the most effective for AIAN and NHPI faculty. We have begun the work needed to attend to this problem and look forward to conducting more efforts, including rigorous evaluation designs to study long term effectiveness.

Table 3.

Participants' Indigenous Affiliation According to Program Session Attended

	Session #1 n = 9		Session #2 n = 29
	n	%	n	%
Indigenous Affiliation
American Indian/Alaska Native	9	100	7	24
Canadian First Nations	-	-	5	17
Native Hawaiian	-	-	3	10
Other Indigenous Affiliation	-	-	13	45
No Indigenous Affiliation	-	-	1	3

Abbreviations

AAIP

Association of American Indian Physicians

AIAN

American Indian, Alaska Native

AIDA

Australian Indigenous Doctors Association

IFF

Indigenous Faculty Forum

IPAC

Indigenous Physicians Association of Canada

MAIPT

Medical Association of Indigenous Peoples of Taiwan

NHPI

Native Hawaiian and other Pacific Islander

NHCOE

Native Hawaiian Center of Excellence

NNACoE

Northwest Native American Center of Excellence

OHSU

Oregon Health & Science University

PRIDoC

Pacific Region Indigenous Doctors Congress

APPENDIX A. Indigenous Faculty Forum Session #1 Portland, Oregon 97201 November 16-17, 2017

Description:

A special learning forum designed to support the professional development and academic success of American Indian/Alaska Native (AI/AN) faculty with content tailored to their specific career needs.

Conference Goals:

1. Provide instruction in key professional competencies leading to academic success.

2. Address unique cultural considerations for AI/AN faculty.

3. Foster networking and enhanced ongoing career support for AI/AN faculty.

Agenda:

Thursday Nov 16
6:00p – 8:00p	Evening social gathering
Friday Nov 17
8:00 – 8:30	Traditional Opening (Polly Olsen, NNACOE Deputy Director of Tribal Engagement)
8:30 – 8:50	Welcome and Introductions (Dr. Brian Gibbs, PhD, MPA, Vice President, Equity & Inclusion, Oregon Health and Science University)
8:50 – 9:40	Content Session 1: Strategic career planning (Patrice Eiff, MD, Professor and Director of Faculty Development, Department of Family Medicine, Oregon Health & Science University)
9:40 – 10:30	Content Session 2: Maintaining one's own cultural identity within the larger institutional culture (Arne Vainio, MD, Family Practice Physician, Cloquet, MN)
10:30 – 10:50	Break
10:50 – 11:40	Content Session 3: Building bridges with tribal clinics & communities (Joe Finkbonner, RPh, MHA, Executive Director NPAIHB)
11:40 – 12:30	Lunch (PSU Food Carts)
12:30 – 2:00	Focus Group – Questions designed to better understand the professional development needs of AI/AN faculty and the enablers and barriers to their career success.
2:00 – 2:15	Complete Evaluation & Wrap-up
6:00	Evening social gathering

APPENDIX B. Indigenous Faculty Forum Session #2: Hilo, Hawai‘i July 12, 2018

Time	Session
7:00–8:00	Breakfast
8:00–8:10	Welcome - Erik Brodt (NNACOE) and Malia Lee (NHCOE)
8:10–8:40	Opening Welcome: Michael Painter, MD - Robert Wood Johnson Foundation
8:40–8:55	AIAN and NHPI faculty-current status - Erik Brodt
8:55–9:15	Meet your colleagues-small groups
9:15–10:15	Break-out Sessions Providing Meaningful Mentoring - Carlos Gonzales, MD Room 202 Strategic Career Planning - Naleen Andrade,MD Room 211 Bridging Academic Medicine and Clinical Work - Dee-Ann Carpenter, MD Rm 207
10:15–10:30	Coffee break
10:30–11:00	Reports from Breakout sessions
11:00–12:30	Panel: Racism, unconscious bias, microaggression in academia Drs. Elana Curtis, Dennis McDermott, Andrea Hermosura
12:30–1:30	Lunch
1:30–2:15	Navigating Politics, Clinical Practice and Academia - Maintaining Our Focus on Indigenous Health - Evan Adams, MD
2:15–2:30	Closing
Opening protocol: Wainaku Estate

Conflict of Interest

None of the authors identify a conflict of interest.