The American health care system continues to struggle with physician workforce shortages. These shortages manifest in several ways. First, with a growing and aging population, we simply need more physicians. Second, there is longstanding maldistribution of our physician resources to larger cities and metropolitan areas that leaves many rural communities without adequate care. Third, we continue to see significant underrepresentation of many minority groups in the physician workforce despite our determined focus on diversity, equity and inclusion.
Indian reservations and other rural areas with large populations of Native Americans have long suffered from physician shortages and lack of access to health care. One of the contributors to that unmet need is the dramatic underrepresentation of Native Americans in the physician workforce. Nationally, only 0.3% of students entering medical school are Native American, representing a ten-fold underrepresentation of the nearly 3% of Native Americans in the U.S. population.
The state of Oklahoma, with many reservations and a large Native American population, ranks 46th in the nation for active primary care physicians per capita. Oklahoma needs an additional 732 doctors to reach the national average of 92.5 practicing primary physicians per 100,000 residents. Demographics show Oklahoma’s rural physician needs will continue to grow. Fifty-seven percent of physicians currently practicing in rural Oklahoma are older than 55; 27% are 66 or older.
‘Innovation is critical’
Physician recruitment efforts in rural and tribal areas, including federal loan repayment programs, have helped lessen the disparities but have not solved the problem. Innovation is critical to effecting meaningful change in both the physician workforce and the health inequities impacting rural and tribal citizens in Oklahoma and across America.
When we think about strategies to address, distribute and represent shortages in rural and Native American communities, one solution is to take the training to them: Allow rural and Native American students from the communities that are in greatest need to train to be physicians in those communities. In doing so, we remove many of the socioeconomic and cultural challenges placed on rural and Native American students when they must attend medical school in a traditional urban educational environment.
The Oklahoma State University Center for Health Sciences College of Osteopathic Medicine (OSU-COM) in Tulsa opened in 1972 with the mission to train primary care physicians to serve rural and underserved communities in Oklahoma. Since that time, OSU-COM has graduated over 3,000 physicians, with two-thirds pursuing primary care. More than half of these physicians are in active practice in Oklahoma; 1 in 4 serve communities of less than 10,000 citizens. OSU-COM has been recognized nationally for its commitment to rural and underserved populations and was ranked in the top 10 in rural care and in Health Professional Shortage Areas for 2022 by U.S. News & World Report.
Building on its rural medicine success, OSU recently opened a first-of-its-kind four-year medical school campus on a tribal reservation in Tahlequah, Oklahoma, the capital of the Cherokee Nation. Students in Tahlequah are immersed not only in medical education, but also in a rural environment infused with Native American culture. In doing so, OSU and the Native American tribes in Oklahoma are re-examining where and how we educate the physicians we desperately need.
OSU-COM Tahlequah represents the shared mission of the OSU Center for Health Sciences and the Cherokee Nation to improve health care for citizens living in rural communities and on reservations. The shared goal of this partnership is to develop young physicians who aspire to serve Native American citizens and rural Oklahoma. Nationally, only 0.3% of medical school students are Native American. At OSU-COM Tahlequah, the percentages are 22% and 25%, respectively, in our first two matriculated classes.
OSU-COM Tahlequah’s location on tribal land incorporates Native American culture into all aspects of the academic learning environment. The medical school building is an architectural work of art on the Cherokee Nation Health W.W. Hastings campus. The facility integrates traditional Cherokee cultural elements found throughout the adjacent Cherokee Nation Outpatient Health Center. For example, the front of the building prominently features seven orange mullions representing the seven Cherokee clans. Flower beds that adorn the front walk include plants traditionally used by Cherokee healers.
The interior of the building houses an extensive Cherokee art collection with more than 170 pieces of Cherokee art on display, curated by the Cherokee Nation in collaboration with OSU. The artworks by Cherokee artists are in many different mediums, and they incorporate themes of family, health, culture, and community. Students are reminded of Cherokee culture and traditional healing practices as they go about their studies.
One-of-a-kind learning opportunities
The close integration of the campus with Cherokee Nation Health Services provides many early clinical opportunities to students – from participating in COVID-19 vaccination clinics to interacting with the public health team responsible for deploying influenza vaccinations across the 14-county reservation. During their clinical rotations, students will complete rotations at the Cherokee Nation Healthcare Center and other tribally operated health care facilities, Indian Health Service facilities, community hospitals and academic medical centers throughout Oklahoma. The Tahlequah campus has also expanded residency programs affiliated with tribal health care centers and in rural community hospitals.
Our medical school offers a Tribal Medical Track that prepares students to address the overall health of Native American communities. These unique learning opportunities support motivated students to fully develop the attitudes, knowledge, and skills to be successful in a challenging practice environment. They not only learn important medical knowledge, but are immersed in the rich and diverse cultures of Native American tribes.
The opening of the school on the Cherokee Nation campus has also benefited OSU Center for Health Sciences in Tulsa and created new educational opportunities for students from both campuses. For example, our medical students can now choose an elective in Cherokee language (and next academic year Choctaw and Chickasaw language classes will be offered). The Cherokee language elective provides students with more than just an introduction to language. Students also learn about culture, history and the intersection of language, health, and community.
OSU-CHS’s innovative approach of partnering with Cherokee Nation and taking medical education to rural and tribal communities has received national recognition in the press. We were awarded the AOA’s inaugural DEI Unification Award and the 2021 INSIGHT into Diversity Health Professions Higher Education Excelling in Diversity (HEED) Award. These awards recognized our efforts to increase the diversity of the physician workforce and create inclusive and welcoming learning environments.
The beginning of a long journey
True to our mission at OSU Center for Health Sciences, we seek out unique opportunities to develop primary care physicians to care for Oklahoma’s rural, tribal and underserved communities. OSU has a long history of reaching out to communities across Oklahoma and presenting pathway programs like Operation Orange, which inspire youth to pursue their dreams of becoming osteopathic physicians.
Based on OSU’s experience educating physicians for rural Oklahoma, we believe that recruiting students from rural and tribal communities and affording them the chance to complete the continuum of medical education in a rural/tribal community is one of the most effective strategies to address the challenges of underrepresentation and distribution of the physician workforce. In Tahlequah, the numbers show that our efforts are paying off. Native American students made up 22% of the inaugural class of 54 students, and 25% of the second class of 53 students. While these numbers are small, it demonstrates the beginning of a long journey to bring about equity of representation for Native Americans in the physician workforce.