Health Equity

Why we should think of the physician workforce as an ecosystem

Timothy M. Smith , Contributing News Writer

AMA member LeeAnna I. Muzquiz, MD, doesn’t just remember when she wanted to become a physician; she also remembers when she assumed a career as a doctor was beyond her reach.

“I was thinking I would go to medical school because many of the people on my educational path had said it was a good fit for me. I was good in math and science, and I knew I liked to help people,” Dr. Muzquiz said. “But I didn’t understand what going to college was like. I didn't know what I didn't know.”

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A member of the Confederated Salish and Kootenai Tribes who grew up on the Flathead Indian Reservation in Northwest Montana, Dr. Muzquiz—pronounced “moo’ skee”—was on track to be the first member of her family to earn a four-year college degree.

LeeAnna I. Muzquiz, MD
LeeAnna I. Muzquiz, MD

“I had assumed freshman year of college would be like 13th grade. I made every mistake that you shouldn't make, and my grades suffered,” she said. “So I changed my major. I figured I would become a hospital lab technician—kind of a stepped-down version of going to medical school.”

Almost immediately after, her father passed away from a heart attack. He was just 44.

“I took some time off of college and came home and helped my mom, and this turned out to be that spark I needed to go back to school and refocus, because my dad had been very proud that I was going to college and planning to do something that he wasn't ever able to do,” Dr. Muzquiz said. “When I went back to school, the Native American studies community helped me identify people who had navigated those same waters, and I suddenly realized: I can do this.”

She was eventually accepted to the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Medical Education Program, at the University of Washington School of Medicine.

Fast forward to 2023 and Dr. Muzquiz, a family physician, has served her tribal community for more than 20 years. She also is associate dean for admissions at the University of Washington School of Medicine and the Association of American Indian Physicians’ representative on the AMA Minority Affairs Section Governing Council.

One of her professional goals is to reimagine how medical education administrators and other stakeholders conceive of physician workforce development. One way to do that: embrace a new metaphor.

AMA: Tells us more about what drew you to a career in medicine.

Dr. Muzquiz: I come from a family of helpers. I'm Salish and Kootenai, and we're very family-oriented and of service. That was instilled in me early on—serving, being there for others, helping people.

In my final year of lab tech study, I went to a conference where there were other Native health-profession students, and suddenly I was in a room with a bunch of students who were all on a similar journey. Many of them were either medical students or pre-med students who anticipated they would get into medical school. I told them I'd had some struggles with my grades and I thought those would disqualify me from medical school, and they said, “That doesn't matter—you’re doing well now. You really should pursue a career in medicine if that's what you want to do.”

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AMA: What are the recent trends in admissions for students from historically excluded racial and ethnic groups, generally, and American Indians and Alaska Natives specifically?

Dr. Muzquiz: When you look at American Indians and Alaska Natives, they run at the very bottom of any kind of graph. And the movement over time is almost immeasurable.

American Indians and Alaska Natives make up less than 1% of applicants, whereas our population is somewhere in the 2–3% range, depending on which census data you look at. Then when you look at the WWAMI region, the population that identifies as American Indian and Alaska Native is much higher—closer to 6–8% of the population—so we're looking to achieve parity with those numbers.

AMA: What do you think is keeping American Indian and Alaska Native students from aspiring to become doctors or applying to medical school?

Dr. Muzquiz: For one thing, I think it’s not typical for us to have many of the attributes that are ordinarily seen as valuable in medicine. By that, I mean things like promoting yourself, asking lots of questions, telling people what you're good at. It's just not the way that we behave in front of our elders—those things are often in conflict with traditional tribal cultural values.

But our younger generation, especially those going into health professions, are getting better at bridging those two worlds—as opposed to walking separately in two different worlds—and they’re not apologetic about it.

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AMA: You’ve said that today’s medical educators need to think about workforce development less as a pipeline and more as an ecosystem. Can you explain?

Dr. Muzquiz: If you think about it as a pipeline and you’re not situated right at the beginning of it, you’ll quickly conclude you can’t affect what’s already going through it. But if you think about it as an ecosystem, you’ll stop and look around and say, “Well, what can I do? What’s the contribution I'm making to this process?”

AMA: The ecosystem metaphor seems to put the onus on every physician to be more thoughtful about their role in workforce development. Is that correct?

Dr. Muzquiz: Yes. Even preschool students are part of the ecosystem. They’re patients, but they're also learners—they’re already on the continuum and they could become tomorrow’s pre-meds, medical students, residents, attendings and mentors.

I like to think about the water cycle. Water never really goes away; it just moves through the ecosystem. Human beings are similar—they move through the health care system, and when they stop to really think about the role they're playing in it, they can then help the next generation not just survive but also thrive and realize their potential.

At any given moment, you may struggle to do something meaningful, but years down the line, you may have the opportunity to do something that will have a huge impact on a learner. That's different from a pipeline where you show up one day and you take some limited action and then you hope for the best.