Medical School Diversity

Q&A: How to support and retain Native American medical students

Timothy M. Smith , Contributing News Writer

Growing up as a member of the Pauma Band of Luiseño Indians, in Southern California, Alec Calac’s perspective on Native American health was truly unique: His father, Daniel J. Calac, MD, is the only physician in the tribe. In fact, his dad was the first tribal member from the Pauma reservation ever to receive a medical degree, in 1999, from Harvard Medical School.

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Daniel has gone on to become the chief medical officer for the Indian Health Council Inc., a consortium of nine tribes in northern San Diego County. He also had former appointments on the U.S. Department of Health and Human Services Health Research Advisory Council, American Academy of Pediatrics Committee on Native American Child Health, and the National Institute on Alcohol Abuse and Alcoholism Advisory Council. He has been the principal investigator for the California Native American Research Center for Health, a National Institutes of Health-funded project, since 2003. Dr. Calac is a shining example of the potential of Native Americans in the medical profession.

Alec Calac
Alec Calac chairs the AMA-MSS Committee on American Indian Affairs and took part in the 2022 AMA Interim Meeting in Honolulu.

Still, more than 20 years on, he remains the tribe’s only medical doctor—a striking statement about health equity and the near invisibility of Native American physicians in the U.S.

“I will be the second,” said Alec, a fifth-year MD-PhD student at the University of California, San Diego School of Medicine and Herbert Wertheim School of Public Health and Human Longevity Science.

The younger Calac also chairs one of the AMA Medical Student Section’s standing committees, the Committee on American Indian Affairs, serves as a part of the AMA Ambassador Program and is president of the Association of Native American Medical Students. Besides having a passion for caring for people, he has a strong commitment to research, especially on the topic of tribal public health, but also on the topics of medical education and workforce development, vaccine hesitancy and misinformation spread, and health technology and social media use.

More than anything, Calac wants to help grow the workforce of Indigenous physicians, starting with changing how they enter medical school and then addressing the factors that affect whether they stay long enough to graduate.

He recently co-wrote a letter, published in JAMA Internal Medicine, in response to a study of the association of sociodemographic characteristics with U.S. medical student attrition. Researchers found that American Indian, Alaska Native, Native Hawaiian, and Pacific Islander (AIAN/NHPI) students were more than four times as likely to drop out than white medical students. And more than 10% of Indigenous medical students don’t graduate—the highest of any group the researchers examined.

In his letter, “Attrition of Indigenous Medical Students Requires Swift Institutional Response,” Calac and his co-author outlined steps they believe institutions should take to support AIAN/NHPI medical students and residents, building on recommendations made in a corresponding commentary.

“The ‘bar’ does not have to be lowered to address Indigenous trainee attrition,” he wrote with his co-author, Kekoa Taparra, MD, PhD, a Native Hawaiian radiation oncology resident at Stanford Medicine. “Instead, institutions must acknowledge the importance of Indigenous representation in medicine and create learning and social environments that foster Indigenous belonging.”

Calac spoke with the AMA about how and why he has committed himself to advocating for other aspiring Indigenous doctors. Central to his work are the beliefs that U.S. medical schools don’t yet understand Native American students and that the principles driving a push for health equity require medical educators to learn more about this culturally diverse group.

AMA: What inspired you to pursue a career in medicine?

Calac: My father was my primary influence—seeing the impact that he's had in my community. In a very small tribal community, each person has a purpose, a role. He found his in healing and health care, and I think having that kind of close inspiration, a physician-parent, certainly drew me to medicine. But it wasn't until college and my time after college when I got into science and research, and then eventually health policy–that I could really see the impact that advocacy can have on people's health.

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AMA: How has your experience in medical school been so far?

Calac: It's been a long road. As a fifth-year MD-PhD student, going from medical to public health education and seeing the combination of the two, it's been a very rewarding experience. I can really see the impact of translating evidence into policy and then policy into practice.

It has also been enlightening to learn not just about health systems but also how individuals navigate the health care system through a public health lens. Plus, it’s been really inspiring to be part of a community of students who care just as much about advancing health equity as I do.

AMA: Were there any barriers you had to overcome to enter medical school?

Calac: I think the expectation of Native American students interested in medicine is that they will fail, that they will never be enough. Luckily, my parents and mentors saw my potential to succeed rather than my potential to fail. That really had a positive impact and pushed me through.

AMA: Not many Native Americans are attending medical school, and a relatively high percentage of those who do attend do not complete it. What can medical schools do to improve these numbers?

Calac: When considering medical school attrition for American Indian and Alaska Native students, I think there are a number of factors, including whether they feel like they belong, whether they are prepared for their studies and whether they have mentors. No matter if they are leaving on their own or being asked to leave, that does a disservice to Native communities, which already face tremendous health challenges.

As it stands now, one in 10 American Indian, Alaska Native, Native Hawaiian and other Pacific Islander students are asked to leave medical school. In addition, according to the Association of American Medical Colleges, the four-year graduation rate for American Indian and Alaska Native medical students is 70%.

So, if you have one in 10 leaving and then three in 10 not finishing in four years, that also adds a tremendous cost that students must bear. Though beforehand, just being accepted into medical school is a challenge. The number of Native people going into medicine is about the same as it was four decades ago. It might even be smaller.

AMA: Are there things medical schools can do to boost that enrollment or encourage Native Americans to finish their education?

Calac: I always like the phrase “Just as budgets reflect [institutional] values, so do curricula, and so do public spaces.” It's important to think about the spaces that Native students walk through and how to make them feel welcome away from home—to give them the proper support, not just personally and professionally, but also culturally.

Fortunately, the AMA recently adopted policy that recognizes the importance of cultural identity in fostering the success of American Indian, Alaska Native and Native Hawaiian trainees.

AMA: There must be a lot of variety in the experiences of Native Americans seeking admission to U.S. medical schools. What are some of the struggles that typify those experiences?

Calac: Often, because Native students are among the very few at their institutions that identify as American Indian or Alaska Native, they take on additional burdens. So instead of being the trainee, they are the educator, and they are expected to be the expert in all things about American Indian and Alaska Native communities.

The reality is that there are 574 federally recognized tribes in the United States. So, if you are from one community, you are only familiar with that one community, not hundreds of others. As a group, American Indian and Alaska Native medical school applicants have a matriculation rate that is comparable to other racial and ethnic groups. But when you disaggregate that data and look at it by Tribal affiliation, you see that acceptance rates by tribe vary tremendously.

So, when we think about this very culturally heterogeneous group, we must think about the needs of individual students. They are all from very different communities.

AMA: You have been very active as a member of the Medical Student Section and in the AMA House of Delegates. What are some policies regarding Native American health that you have worked on?

Calac: One was on cultural leave for American Indian trainees, which recognizes the importance of cultural identity, as well as having medical schools, residency and fellowship programs accommodate cultural observances. Being an active member of one's community is crucial, given that culture is such an important part of a Native student's identity.

Another policy just decided by the AMA Board of Trustees looks at medical school admissions and the importance of affirmative action-like policies for Native students based not just on their racial identification as American Indian or Alaska Native, but also on their political status as members of tribal  communities.

The AMA is recognizing that when you are a member of or affiliated with a specific tribe, tribes have a special interest in the training of Native students, because they are more likely to go back and serve their own communities, which helps foster tribal self-governance and self-determination. The Indian Health Service’s federal-facility physician vacancy rate today ranges from 25% to 50% depending on the location. I really think training our own will be how we close those gaps.

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AMA: What specialty are you interested in pursuing?

Calac: I think MD-PhD students change their minds every year, if not every month. But I really want to find a specialty in which medicine, public health and policy readily intersect.

AMA: What do you picture as your career path? Where do you want to practice? Do you want to practice on a reservation in a Native American health center, in a private practice or as an academic physician?

Calac: My father is in primary care and does a lot of national policy work for the American Academy of Pediatrics and the National Institutes of Health. I see myself more in an academic medical center, focused on medical education, workforce development and community outreach.

I really want to form strong tribal-academic partnerships that align institutional and communities priorities and have a strong hand in policy. Whether in the Department of Health and Human Services or the Indian Health Service itself, there aren't that many people in the nation who are familiar with tribal health policy. I think I have a valuable perspective that could be useful.

AMA: Where would you like to see medicine in 25 years in terms of health equity?

Calac: My vision for health equity is to live in a world where the Native American life expectancy is not the same as the American public’s life expectancy in 1944. In some areas, it’s still under 65.

The formation of our Committee on American Indian Affairs is something I pushed for. It has been a channel for positive policy outcomes through the AMA Medical Student Section, having the nation's medical students be the expert body on the subject to the AMA House of Delegates.

Of the 21 members, 19 are American Indian or Alaska Native. It's now in its second year, and it has provided a creative space for students who don't necessarily have advocacy opportunities at their institutions. It gives them a chance to embrace narrative-based advocacy, which, at least in my mind, considers both their subject matter expertise and their lived experiences to improve the delivery of health care to Native American communities.