Overcoming Disparities in Surgical Care among Native Americans

HIGHLIGHTS

  • Describes the inequities in oncologic surgical care for Native Americans
  • Identifies how the recruitment of Native Americans into healthcare improves disparities and enhances trust in the US medical system
  • Summarizes the Wy’east Post-Baccalaureate Pathway program, which is designed to increase matriculation rates among Native Americans into medical school

Native Americans and Alaskan Natives are the original inhabitants of the Americas; however, European colonization, as well as legislative and military action by emerging American nations, resulted in the decimation, displacement, and marginalization of hundreds of unique tribes over the course of centuries. Consequently, Native Americans now are a marginalized group, not just in society, but in healthcare as well. As with all specialized services, healthcare or otherwise, oncologic care is an area of significant disparities for Native American patients. This article highlights this problem and provides details on how Oregon Health & Science University (OHSU), Portland, has sought to address these inequities.

Disparities in Oncologic Care for Native Americans

According to the First Nations Development Institute, 68% of Native Americans live on or near reservations or tribal lands, which are largely rural.1,2 The Indian Health Service (IHS), a branch of the US Department of Health and Human Services, operates healthcare facilities near these regions. These institutions often suffer from inadequate staffing and funding. According to the National Congress of American Indians, the IHS was allocated $2,849 per capita for patient expenditures in 2013 versus $7,717 per patient for healthcare spending at the national level, and the IHS budget covers only 59% of the calculated cost per patient.3 Because of location and underfunding, IHS-operated centers are understaffed by 25% on average.4 Furthermore, because of the relatively low cancer volume at these institutions, there is a lack of providers who are able to deliver cutting-edge treatments—such as those offered at the National Cancer Institute-designated Comprehensive Cancer Centers—to these populations.

When looking at population-level data, the lack of access to oncologic care translates to several disturbing findings. Native American patients are more likely to present with higher-stage disease at diagnosis for the four most common cancers (lung, breast, prostate, colon) and are significantly less likely to receive curative-intent resections for these malignancies than White individuals after accounting for relevant clinicopathologic differences.5,6 In addition, Native Americans with breast and colon cancer are far less likely than their White counterparts to receive adjuvant therapy. Moreover, the adequacy of postoperative surveillance in Native American patients with resected prostate and breast cancer is suboptimal compared with White patients.5

Trust: A Missing Ingredient for Change

It is clear from the available data that health systemwide efforts to improve access to care are important; however, trust is an important factor in ensuring that Native American patients will use available care at rates similar to other racial and ethnic groups. Unfortunately, in many tribes, historical trauma from colonization, genocide, displacement, and mistreatment by medical providers remains a shared memory.

A study by Guadagnolo and colleagues showed that Native American race was predictive of higher mistrust and lower satisfaction scores for cancer care.7 Native American patients more often and more strongly agreed that “in the past, clinics and hospitals have done harmful things to patients without their knowledge.” Furthermore, more Native American patients “worry that doctors and nurses will do experimental studies…without telling or asking,” and reported delaying “medical care in the past” out of fear of being treated disrespectfully.7 Trust must be rebuilt in order to broadly address outcome disparities in cancer and surgical care, as must the infrastructure that would allow Native Americans to access high-quality cancer care.

Inclusion: An Important Part of the Solution

A critical step in improving trust in the US medical system and reducing disparities in cancer and surgical care is the recruitment of Native American individuals in medicine. More representation in the medical specialties would improve advocacy for the structural changes necessary to improve the healthcare of Native American patients.

A critical step in improving trust in the US medical system and improving disparities in cancer and surgical care is the recruitment of Native American individuals in medicine.

Unfortunately, Native Americans compose only a small portion of active physicians in the US. Based on the most recent data, only 2,570 (0.3%) physicians in clinical practice identify as Native American out of a total of 918,547 in the US.8 Similar underrepresentation is noted among academic surgeons; a 2020 study identified 23 Native Americans (17 male and six female) among 14,340 academic surgery faculty (0.16%).9 Furthermore, recent trends in Native American matriculation rates to medical schools show a decrease from 0.39% in 2007 to 0.2% in 2018.10 Although there has been recognition of the need to improve diversity in medicine, these numbers are troubling and underscore the lack of focused attention on recruiting and retaining Native American physicians.

The Northwest Native American Center of Excellence (NNACoE) at OHSU is an example of a successful program designed to increase Native American matriculation rates to medical schools. The NNACoE offers the Wy’east Post-Baccalaureate Pathway for Native American applicants who have unsuccessfully applied to medical school, have Medical College Admission Test scores that fall short of minimum requirements, or lack other clinical experience. Upon successful completion of the intensive 10-month program, students are granted conditional acceptance to one of three participating medical schools.

The Wy’east program is unique and specifically focused on Native American students. Led by Native American faculty, Wy’east places a priority on cultural activities and knowledge and fosters a learning environment focused on the unique needs of Native American students. This cultural focus culminates in a blanket honoring ceremony upon successful completion of the program, which is a significant cultural milestone.

(Left to right) Wy’east Post Baccalaureate Pathway students, following a blanket ceremony on June 14, 2019 at PSUÕs Native American Student Community Center: Jacob Smith, Audrey Juliussen, Kayla Murphy, Kyna Lewis, Jessica Souphanavong and her daughter, Matilda, Jasmine Curry, Ashley Wirth, Baroness ÒBÓ Castra Nemici, Candice Jimenez, and Aaron Thomas. The Wy’east program provides conditional acceptance into the OHSU medical school, for students who complete the pathway. (OHSU/Michael Schmitt)

The Wy’east program serves as a model for successful strategic recruitment intended to increase the number of Native American physicians in the US. Based on the success of the Wy’east program for medical students, OHSU is considering expansion into other healthcare schools at the university. These efforts are reproducible at other institutions and are key to improving Native American trust in the US medical system as well as improving disparities in cancer and surgical care for Native American patients.


References

  1. US Census Bureau. American Indian and Alaska Native Heritage Month: November 2012. Available at: https://www.census.gov/newsroom/releases/archives/facts_for_features_special_editions/cb12-ff22.html. Accessed February 10, 2022.
  2. Guadagnolo BA, Petereit DG, Coleman CN. Cancer care access and outcomes for American Indian populations in the United States: Challenges and models for progress. Semin Radiat Oncol. 2017;27(2):143-149.
  3. National Congress of American Indians. Fiscal Year 2017 Indian Country Budget Recommendations: Upholding the Promises, Respecting Tribal Governance: For the Good of the People. Available at: https://www.ncai.org/resources/ncai-publications/indian-country-budget-request/fy2017. Accessed February 10, 2022.
  4. US Government Accountability Office. Indian Health Service: Agency faces ongoing challenges filling provider vacancies. Available at: https://www.gao.gov/products/gao-18-580. Accessed February 10, 2022.
  5. Javid SH, Varghese TK, Morris AM, et al. Guideline-concordant cancer care and survival among American Indian/Alaskan Native patients. Cancer. 2014;120(14):2183-2190.
  6. Jemal A, Clegg LX, Ward E, et al. Annual report to the nation on the status of cancer, 1975–2001, with a special feature regarding survival. Cancer. 2004;101(1):3-27.
  7. Guadagnolo BA, Cina K, Helbig P, et al. Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment. J Health Care Poor Underserved. 2009;20(1):210-226.
  8. Association of American Medical Colleges. Diversity in medicine: Facts and figures. 2019. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/figure-18-percentage-all-active-physicians-race/ethnicity-2018. Accessed December 30, 2021.
  9. Valenzuela F, Romero Arenas MA. Underrepresented in surgery: (Lack of) diversity in academic surgery faculty. J Surg Res. 2020;254(10):170-174.
  10. AAMC Applicant Matriculant Data File and AAMC Student Records System. July 2007 to June 2018. Available at: https://www.aamc.org/media/8826/download?attachment. Accessed February 16, 2022.

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