Updated: Two medical students share what it's like to navigate medicine as Native medical students.

Or, in English, “As a member of the medical profession: I solemnly pledge to dedicate my life to the service of humanity.”

Native people have always been healers in their communities. Healers through food, traditional medicine, ceremonies and stories. The ways of healing for Indigenous people in North America are older than the revised and 2,500-year-old Hippocratic Oath, or Physician’s Pledge, most physicians now recite and abide by.

The first two lines of the Physician’s Pledge were said in Diné Bizaad, the Navajo language, by Jaron Kee and Nicole Lee. It was the first time ever this was included at the University of New Mexico Health Sciences Center graduation this spring. The oath has been recited in English and Spanish in previous years.

Kee and Lee were part of the five Native students who graduated and on their way to becoming physicians. Four of the students are Navajo and the fifth student is Crow Creek Sioux.

It may also be the first time that a medical school recited the pledge, also known as the Declaration of Geneva, in an Indigenous language in the country.

Reading the pledge in Navajo during the ceremony was presented to the university’s Health Sciences Center Chancellor Paul Roth and he decided to add it, according to spokesman Mark Rudi.

This unique opportunity shows other medical schools why the University of New Mexico ranks fifth in the nation to graduate the most American Indian and Alaska Native students: a total of 87 graduates between 1980 and 2017.

The medical school was one of the four medical schools profiled in a recent report titled “Reshaping the Journey: American Indians and Alaska Natives in Medicine.” It was co-authored by the Association of American Medical Colleges and the Association of American Indian Physicians.

These top four institutions exemplify to other schools what it looks like to be inclusive of American Indian and Alaska Native students in medical schools.

They hire Native faculty, created physical space for Native students, make Native communities part of their school mission, acknowledge the land and history of Native people, collaboration with local tribal communities and more.

UNM has the Center for Native American Health, which gives support to Native students wanting to pursue a career in any health-related field.

Casey Smith, Diné, found that the center played a crucial role in helping him apply to medical school at the University of Minnesota at Duluth campus.

He was paired up with provider in the area that he could shadow as well as a current medical student as part of a new mentorship program provided by the center. The medical student and provider were both Native.

He and the medical student met on a monthly basis throughout his senior year of college to talk about her experiences and she assisted him the medical school application process.

“Being paired up with the medical student I feel like it was a very invaluable experience,” he said.

He didn’t know what the path to medical school looked like. Let alone what that path was for Native students. He didn’t see any Native people as providers or medical students until the program.

“And aside from the advice and the kind of sharing her experiences, again, kind of going back to the importance of seeing someone who knew what it meant to be a Native person was again, tremendously helpful and very encouraging and was very helpful on my part,” he said. “And so I feel like she played a very, she probably doesn't feel like she did, but I feel like she played a big role and kind of being supportive and providing kind of that inspiration to me.”

She gave him pointers on writing his personal statement and edited it, which Smith dusted off last month and tweeted a couple lines from it.

“Re-read my personal statement to medical school this morning and feel re-grounded because of this quote, ‘Uncle, you go back to school, become a doctor, and come back to care for me and our people. We need Navajo doctors.’ -- Diné Elder.”

This interaction with the elder was part of Smith’s two gap years after receiving his bachelor’s degree in psychology. He worked for a nonprofit organization in Gallup, New Mexico, his hometown, that focused on community outreach and “patient empowerment.” He tagged along with community health representatives on home visits. They traveled to patients’ homes on the Navajo Nation to provide healthcare needs, such as giving health education, obtaining vitals, and more.

The Diné elder said something that the numbers show: There aren’t enough Native physicians within IHS and in the country.

There were 766 physicians, civil service physicians, and Commissioned Corps medical officers within the Indian Health Service as of May 1, and this doesn’t include contractors or physicians within the tribal systems, according to IHS spokesperson Jennifer Buschick.

Commissioned Corps medical officers also have the option to report their ethnicity and race, so the figures could be off.

“However, as of May 1, 2019, of the 92 Commissioned Corps medical officers on duty in the IHS, six show on available reports as being American Indian or Alaska Native,” said IHS spokesperson Marshall Cohen.

There’s also the factor to consider that the number of physicians fluctuate weekly.

Despite the fluctuation, approximately 10 percent of the physicians within IHS are American Indian or Alaskan Native, Cohen said. Again, this excludes contractors and physicians hired by tribal organizations or nations.

Approximately 10 percent of the 766 physicians in Indian Health Service identify as American Indian or Alaska Native as of May 1, 2019. (Data by Indian Health Service | Table by Jourdan Bennett-Begaye)

It’s also important to mention that 60 percent of the healthcare system in Indian Country is not Indian Health Service, but tribal health programs or not-for-profit organizations managed under tribal governance as well as urban Indian clinics and centers.

IHS could not provide the statistics of physicians contracted in the 60 percent of IHS. Those numbers are tracked locally by the organizations, clinics and centers.

But there are students like Smith, who is now a fourth year medical student, and others trying to get there.

There’s no doubt that seeing more Native providers in Native communities is beneficial to the healthcare of Native people.

“I feel like patients find a lot of comfort and it's very powerful to be able to go into a doctor's office and to see a Native provider and to be able to kind of have and know that shared experience,” Smith said.

His clinical experiences show that.

He spent a month at the Northern Navajo Medical Center in Shiprock, New Mexico, between his first and second year of medical school.

“It was just really cool to interact with them -- and in Navajo. I'm not fluent, but it was just really cool to be able to, you know, be able to treat them and say goodbye to them in Navajo or like just kind of ask some questions or phrases or use phrases or ask them questions that I had known in Navajo and being able to use that and the clinic,” he said. “I thought that was really special to me and it was very special to them.”

He noticed that patients were more comfortable with him, especially as a Navajo provider in a Navajo community. There’s already an understanding of kinship and clans to establish a relationship beyond the doctor-patient relationship.

“We were able to kind of exchange clans and I thought that was really cool because you were able to really identify a relationship between you and your doctor that was a son or a daughter or an uncle or grandpa,” he said. “I think that really sets a good foundation for the provider and the patient moving forward and really creating an environment that's comfortable and that patients will be able to feel empowered to share things that are very important in terms of their health care and how providers can be, is that very important information and kind of moving forward with their healthcare.”

On the other hand, Smith found that to be the best physician he could be, he had to expand his experiences and working with a population he wouldn’t normally work with. He finished his last clinical rotation with a veteran affairs hospital in Minneapolis. He worked with Native people before and in other underserved communities, but not with veterans.

He’s never been in a rotation where he was asked, “where are you from?” so often, especially growing up in a diverse state.

Once he told patients about the Land of Enchantment and being Native, the conversation went one of two ways: they either said, “Your community must be proud of you,” or they asked him what he thought about Native imagery in popular culture.

That’s where it got sticky, especially when Native mascots came up.

Patients told him, “Hey, you should be proud that, you know. People are using this imagery and you shouldn't be seeing it as kind of a negative.”

“And the first couple of times it happened, I didn't kind of know how to react because as a provider you have a good relationship with the patients. And so I kind of, I guess I'm still kind of learning like how do I find that balance between having a really good relationships and providing good healthcare, but also how do I create boundaries as a provider,” Smith said. “But also I guess trying to find time to kind of provide education and saying, you know, 'no, that's not what may have changed. That's not how we view. Um, I guess for this example like mascots and kind of how they're very kind of hurtful to Native communities.”

Another patient found out Smith was Native and the patient started talking about how he dated Native women in the past including “a Native princess.” The patient was “romanticizing them or sexualizing them.”

“I don't think I reacted good way in that...well not in a negative way, but I just don't think I stood up for kind of how he talked about the situation just because again, kind of going back to how do I respond and be respectful at the same time,” he said.

He spoke with three mentors about it. All of them were not Native but two of the three identified as people of color.

One mentor suggested to not acknowledge it because he is there to provide healthcare. The mentor also said those comments reflect the beliefs of the military population.

The older veterans are already apprehensive about having people of color as their providers. If the patient was older, they grew up in a time when “that wasn’t normal.” It’s difficult for the patients to handle.

“And he just kind of felt like the current political climate would kind of just further exacerbating those types of interactions,” Smith said.

Another provider, who was a person of color, assured Smith that those interactions are going to happen. But he suggested Smith could sit down real quickly with the patient and “describe why what they said was wrong” and why it “can be hurt be hurtful to certain communities.”

The mentor tried to find the balance between respect, professionalism, and personal experiences for Smith. It’s a balance for any Native physician, too.

Aside from the difficult conversations, Smith gained a better understanding of veterans.

He heard their stories which was “pretty special to be part of.” He got to work in a healthcare system that was a one-stop shop for patients without insurance companies. He also has a better understanding of the different challenges veterans face at a healthcare facility.

It’s no doubt that such an experience can be used in Native communities where Native people are the highest-serving ethnic group in the military.

As comfortable and uncomfortable both experiences were, Smith felt that he did grow as a person and all experiences definitely help him in the classroom.

Visiting patients’ homes for two years on the Navajo Nation allowed him to see the obstacles that doctors do not witness.

“I feel like what it really kind of showed me was that patients face different challenges and barriers that we don't often see when we're confined to the clinic walls,” he said.

Doctors typically see a patient for 15 to 20 minutes. That’s not enough time to hear their whole story.

Different barriers can keep patients from taking their medications. It could be a grandma taking care of grandkids, difficulties traveling long distances due to dirt roads, worry about finances or something else, he said.

Providers often blame patients for not doing what they should be doing to get better like not taking their medications. They may also say “they’re not living a healthier life and they have no motivation,” Smith said.

“And so when in fact, like there are other things in their lives that are probably not allowing them to do to do those things,” he said. “So I feel like it's really helped me to kind of dive a little bit deeper into patient visits and how can I identify those areas in their lives and help them to improve their health.”

Understanding the patients’ challenges is definitely something taught in medical schools and medical students learn from their rotations, too. Any medical student will learn this.

However, the challenges that Native medical students face on the path of becoming physicians were talked about very little or not at all. Often times students faced the battles while they’ve already in medical school.

Native medical students face multiple challenges right now that fall in the categories of lack of Native representation in medical schools, financial stress, mentorship, and support overall.

Smith and Shelbie Shelder, Little River Band of Odawa Indians, unexpectedly took on the task of tackling the lack of representation.

“Rezzies in Medicine”

The Native med duo sat in a coffee shop one afternoon last spring talking about medical school-focused Instagram accounts they each followed. “Oh! You should follow this person. You should follow that person.”

They liked the appeal of other medical students in the country sharing their class notes, study habits, inspiration, and experiences for four grueling years of nonstop information consumption and exam taking.

However, Smith and Shelder, a third-year medical student, saw all of these accounts but “there was really no kind of representation of Native students or providing that Native perspective within medicine.”

“They weren't people who look like me or who had the same experiences as me or who knew what it meant to be Native and trying to work in academia,” Smith said. “And so I think it was really important for current students and also people who are wanting to do medicine for them to see themselves in us because, I guess I want, I want to be the person that I didn't have when I was trying to get into medical school.”

So they decided to start their own Instagram account together named “Rezzies in Medicine.” (Perfect name, right?) The account took off. Their 32 posts gained them 1,352 followers.

One follower stated in a post, “This account makes me so happy! I’m scared to go into the vet med field because I know of absolutely no Natives in the college whatsoever that I want to go to. I’m terrified. But this account gives me hope and lets me know I’m not alone.”

The duo can’t recall the number of times younger students reached out to them asking for pre-medical school advice or thanking them for starting the account.

Several months after they started this account,the “Reshaping the Journey: American Indians and Alaska Natives in Medicine” report came out. It turns out that the number of American Indian and Alaskan Native students applying to medical schools decreased in the last 20 years.

This chart shows the number of “American Indian or Alaska Native (alone) applicants, matriculants, and graduates of U.S. MD-granting institutions, 1973-74 through 2001-02." (Courtesy of the Association of American Medical Colleges)

Of the 727,300 active physicians in the country in 2016, only 4,099 said they were American Indian or Alaska Native. So 0.56 percent of total active physicians are American Indian or Alaska Native, according to the American Community Survey.

This map shows “the distribution across the United States of active MD physicians who identify as American Indian or Alaska Native. Most physicians are concentrated in areas with high population of American Indian or Alaska Native people.” (Courtesy of the Association of American Medical Colleges)

In 2017, only 0.48 percent of full-time faculty at medical degree-granting institutions were American Indian or Alaska Native.

Of the approximately 727,300 active physicians in the United States in 2016, 0.56% reported as American Indians and Alaska Natives. So 4,099 out of 727,300 active physicians are American Indian and Alaska Native. (Courtesy of the Association of American Medical Colleges)

With those numbers, Smith and Shelder’s grand idea was needed so they could see more Natives in medicine, or as the other hashtag goes, #NativesInWhiteCoats.

The statistics are also reflected in the classroom even at Minnesota, which again is the number two medical school to train Native physicians.

There is a total of 30 Native students enrolled in the school of medicine, according to Dr. Mary Owen, Tlingit, and director of the Center of American Indian and Minority Health at the University of Minnesota Medical School.

It’s the new record as far as Owen knows who has been the director of the center since 2014. She also graduated from the university’s medical school in 2000.

Twelve students are part of the incoming class, six students in the second year class, three are in Shelder’s cohort, which includes her, and nine in Smith’s cohort, Owen emailed with excitement.

“I haven’t counted in a while,” she said.

The “Reshaping the Journey” report shows 177 American Indian or Alaskan Natives graduated from the medical school from 1980 to 2017. The University of Oklahoma College of Medicine is at the top with 313 graduates. The University of North Dakota School of Medicine and Health Sciences holds the third position with 132 graduates.

Despite that record-breaking number for the medical program, Shelder experiences the cultural differences and ignorance in classes.

“Sometimes it's hard like feeling, like people don't really understand where we come from,” Shelder said. The medical school does bring in students who want to serve in rural communities, but they may not have interacted with Native people.

In a class of 59, she said, people know you’re Native so “they’re going to call on you.”

They would ask generalizing questions about different Native topics or how the clan system works with the local tribes.

She often replied with, “Well, I’m only one person. I can’t speak about all Native people,” or “Well, I can’t answer that because I’m not from here.”

Other times, cultural differences make Shelder feel like she can’t be herself in class and feels like no one looks like her in class.

She still gets asked these questions after the medical program established a required American Indian Health course for all medical students.

Owen said it was a long time coming for that course.

It started out as teaching Native history, boarding schools, Indian Health Service, education, poverty, race, and specific health disparities.

The reaction is all over the spectrum for this class from what Dr. Owen sees.

“We have some students, like I said, who are born to be white who are those white allies and they suck it up and their great and they're going to be future advocates of lots of underserved people,” she said. “And then you have others who you get the glazed-eye look or they're playing on their computer and I can't tell you the numbers. I just know that I see both in the class and then probably most of the people are in between somewhere.”

The university has come a long way since 1973 when the university first launched the Native Americans into Medicine program.

The center was founded in 1987 and was advocated by the tribes in the state.

At one point, they owned an apartment that was safe space where Native students could study at. Grants from the Department of Health and Human Services paid for the apartment. The center doesn’t have those grants anymore so the apartment is gone.

Native students can go to the center itself to study, vent or relax. Owen doesn’t think the current one-room space is enough with 30 Native medical students trying to gather. She plans to remedy it.

These designated havens often become the places where students can build a community and a support system that are crucial to a student’s academic success and holistic well-being.

Navigating tough situations

Smith, Shelder and other medical students found support systems helpful in navigating tough situations in medical school.

Shelder found a community within the city of Duluth which is “kind of like a hub for a lot of the Ojibwe tribes.”

“And so like even being involved in the community there and meetings, I became really close with a lot of the community members and they kind of were like, I called them like my aunties,” she said with a laugh.

Every other weekend, she escapes the books by bonding with a Native women’s running group called Kwe Pack.

“And for me, like that was a huge, like a huge component, I think of how I was successful in my first few years was just having that support group of these women and their children and running with them on the weekends and going to ceremonies with them and going to cultural things and powwow and, and stuff like that,” she said.

Having their kids in her life also made an impact for her. They were her mentors and she was theirs. She got one of the daughters a stethoscope for a gift.

The Fond du Lac Reservation is a 37-minute drive away. Smith volunteered at their headstart and became a mentor for their high school students.

“I felt like being involved in any community really provided a supportive outlet for my first and second year of medical school. What I'm trying to talk about is I feel like they're very much needs to be a community aspect within a medical school,” he said. ”So I feel like there’s students who pretty much kind of check a box when coming into the school. I think that creates a very toxic environment for Native med students are really there who have and who really wanted to make community and feel like they’re going to a school that will gather and bring together these students.”

Just like Smith, Shelder had supporters who assisted her on the track to medical school.

Shelbie Shelder’s Story

Medical school wasn’t even on Shelder’s mind when she was nearing the end of her undergraduate years. She studied public health, nutrition and epidemiology at Michigan State University.

Shelder wanted to be a diabetes educator or do something along the lines of community-based research. Obtaining a masters in public health was in her line of sight before some of her public health mentors sat her down and told her she should consider medicine.

“And I think I just like self selected myself out of it because I felt like, ‘Oh, I can't go into that.’ Like, ‘I'm not good enough for that,’” she said. “Kind of being as a first-generation college student, I've really struggled with feeling like I'm adequate enough for that.”

It was imposter syndrome, she said, sometimes known as imposter phenomenon. A term coined by psychologists in the 1970s defined in Merriam-Webster as “a false and sometimes crippling belief that one’s successes are the product of luck or fraud rather than skill.”

Despite those feelings, she applied to medical school during her senior year of college.

Shelder gravitated toward Minnesota’s medical school because of its inclusivity of Native students and commitment to Native communities. The Duluth campus, where the medical school is located, sits near many Native communities that the center established relationships with so students can work in the tribal clinics for their clinical rotations.

“So there's opportunities to do your clinical, your preclinical work there, which was like another thing that was really important to me,” she said. “It was like making sure that that could be in tribal clinics while I was in med school.”

She hopes to go into family medicine because she will see a wider range of people, from babies to elders, and there’s more integration of public health. A popular test from the medical association, which many medical students take, recommended family medicine as a specialty to go into. Psychiatry is another option but she’ll see what happens later in school.

Two things are for sure: she wants to work with Native people during her medical career and she wants to work for Indian Health Service.

It made sense for her to apply for their scholarship if that’s what she wants to do. She owes them four years after she is completed with school.

“This is why I'm going to medical school. To me it was kind of like a no brainer,” she said.

Until then she'll be at coffee shops studying intensely every other weekend. She said in her undergraduate years, she would study really late and drink coffee really late.

Now, it’s all about taking care of herself and going to bed at 10 p.m.

After her big exam at the end of June, she’ll be back on Instagram with Smith updating “Rezzies in Medicine” and answering Native youth questions.

Jourdan Bennett-Begaye, Diné, is a reporter/producer for Indian Country Today in Washington, D.C. Follow her on Twitter: @jourdanbb. Email: jbennett-begaye@indiancountrytoday.com.