Representation of American Indian and Alaska Native Individuals in Academic Medical Training

Abstract

Importance: Identifying gaps in inclusivity of Indigenous individuals is key to diversifying academic medical programs, increasing American Indian and Alaska Native representation, and improving disparate morbidity and mortality outcomes in American Indian and Alaska Native populations.

Objective: To examine representation of American Indian and Alaska Native individuals at different stages in the 2018-2019 academic medical training continuum and trends (2011-2020) of American Indian and Alaska Native representation in residency specialties.

Design, setting, and participants: A cross-sectional, population-based analysis was conducted using self-reported race and ethnicity data on trainees from the Association of American Medical Colleges (2018), the Accreditation Council for Graduate Medical Education (2011-2018), and the US Census (2018). Data were analyzed between February 18, 2020, and March 4, 2021.

Exposures: Enrolled trainees at specific stages of medical training.

Main outcomes and measures: The primary outcome was the odds of representation of American Indian and Alaska Native individuals at successive academic medical stages in 2018-2019 compared with White individuals. Secondary outcomes comprised specialty-specific proportions of American Indian and Alaska Native residents from 2011 to 2020 and medical specialty-specific proportions of American Indian and Alaska Native physicians in 2018. Fisher exact tests were performed to calculate the odds of American Indian and Alaska Native representation at successive stages of medical training. Simple linear regressions were performed to assess trends across residency specialties.

Results: The study data contained a total of 238 974 607 White and American Indian and Alaska Native US citizens, 24 795 US medical school applicants, 11 242 US medical school acceptees, 10 822 US medical school matriculants, 10 917 US medical school graduates, 59 635 residents, 518 874 active physicians, and 113 168 US medical school faculty. American Indian and Alaska Native individuals had a 63% lower odds of applying to medical school (odds ratio [OR], 0.37; 95% CI, 0.31-0.45) and 48% lower odds of holding a full-time faculty position (OR, 0.52; 95% CI, 0.44-0.62) compared with their White counterparts, yet had 54% higher odds of working in a residency specialty deemed as a priority by the Indian Health Service (OR, 1.54; 95% CI, 1.09-2.16). Of the 33 physician specialties analyzed, family medicine (0.55%) and pain medicine (0.46%) had more than an average proportion (0.41%) of American Indian and Alaska Native physicians compared with their representation across all specialties.

Conclusions and relevance: This cross-sectional study noted 2 distinct stages in medical training with significantly lower representation of American Indian and Alaska Native compared with White individuals. An actionable framework to guide academic medical institutions on their Indigenous diversification and inclusivity efforts is proposed.

Figure 1.. Odds of American Indian and Alaska Native Alone Trainee Representation at Successive Medical Stages Compared With White Counterparts in 2018-2019

Odds were calculated by the Fisher exact test from the 2 continuum categories listed at each measurement point for American Indian and Alaska Native individuals compared with White individuals. Odds ratios are displayed on a log scale. Error bars indicate 95% CI. Data were obtained from the American Association of Medical Colleges, US Census Bureau, and Accreditation Council for Graduate Medical Education. ^aP < .001.

Figure 2.. Proportion of All American Indian and Alaska Native Alone or in Combination Residents in the Indian Health Service Priority Residencies in 2019-2020

The 2018-2019 Indian Health Service Commitment Handbook designates the 8 residencies as in need for American Indian and Alaska Native communities. Dual residency programs were omitted. The horizontal dashed line represents the proportion of American Indian and Alaska Native physicians in all specialties combined. Data were obtained from the American Association of Medical Colleges.

Figure 3.. Trends in the Proportions of American Indian and Alaska Native Alone Resident Representation From 2011 to 2020 in Indian Health Service Priority Residencies

The 2018-2019 Indian Health Service Commitment Handbook designates the 8 specialties as in need for American Indian and Alaska Native communities. Surgical (surgery and obstetrics and gynecology), medical (family medicine, internal medicine, pediatrics, and psychiatry), and hospital based (anesthesiology and emergency medicine) are categorized according to the Accreditation Council for Graduate Medical Education. ^aP < .05. ^bP < .001. ^cP < .01.

Figure 4.. Proportion of Active Physicians in the US Who Identify as American Indian and Alaska Native Alone in 2018 by Specialty

Specialties are in descending order from highest to lowest relative representation among all physicians of all races and ethnicities. Data were obtained from the American Association of Medical Colleges.