JAMA Medical News & Perspectives—A Partnership with the Cherokee Nation Advances Medical Education on Tribal Land
Last summer, 54 students donned white coats as the inaugural class of the Oklahoma State University (OSU) College of Osteopathic Medicine at the Cherokee Nation. Located at the foothills of the Ozark Mountains in the Cherokee Nation capital of Tahlequah, it’s the first US medical school on tribal land, writes Mary Chris Jaklevic, MSJ.
Through a partnership between OSU and the sovereign tribal government, the school is situated on the campus of the Cherokee Nation’s W. W. Hastings Hospital. Its goal is overcoming 2 threats to the health of many Oklahomans: a severe deficit of American Indian physicians and rural physician shortages.
US rural areas are projected to lose 23% of their physician workforce by 2030, exacerbating access problems that lead to poor health outcomes. Meanwhile, American Indian and Alaska Native individuals comprise less than 1% of medical school students.
Against this backdrop, William Pettit, DO, has taken the reins as the school’s first dean. He grew up in Whittemore, Iowa—population 500—and practiced medicine in southwestern Oklahoma before joining OSU’s faculty at the main campus in Tulsa, where he championed rural medical training.
During a recent interview with JAMA, Pettit said he views his job as a calling and described the school as the “ultimate pipeline” to increase the number of clinicians serving rural and tribal communities. The following is an edited version of that conversation, in which Pettit discusses students’ backgrounds, strategies to keep newly minted physicians in rural communities, and how the school plans to measure its success in improving access to care.
JAMA: How did this school come about?
Dr Pettit: This was a work in progress over a decade. We started our students rotating at Hastings Hospital back in about 2006, and that led to residency creation in Tahlequah for family medicine in 2009 and for internal medicine in 2013. In the middle of that, the Cherokee Nation really became interested in a shared mission of providing health care to rural underserved Oklahoma. For them, it was health care for their tribal nation members and not just for today, but for generations to come. They saw the benefit of having these young men and women on their campus, and we began negotiations to start a school. So it really all started from the mission of both the Cherokee Nation and OSU.
JAMA: Where did the funding come from?
Dr Pettit: It's a partnership, so the Cherokee Nation built our medical school building. The Cherokee Nation Businesses has funded the entire structure, approximately $43 million now. What goes on in the inside has been the responsibility of our university, so it comes from our state-allocated funds, from our clinical monies that we generate through patient care as well as from grants and donations.
JAMA: The building had its ribbon-cutting in January. It's 84 000 square feet with state-of-the art laboratory facilities, lecture halls, classrooms, and a gym. What are some other distinctive features of the school?
Dr Pettit: The biggest thing is to have tribal and rural young men and women, or urban if they have the interest, to be at that school and from day one start in a rural setting and in a tribal nation culture. But the unique thing in the building itself is that we partnered with Cherokee Nation art developers and artists, and every hall has original Cherokee Nation art and wall hangings. It just strikes you, the cultural heritage that we're a part of.
JAMA: Tell us about the first crop of students. What are their backgrounds?
Dr Pettit: We're already into the second semester, so we've gotten to know them. We're 50/50 men and women and we are unique in the United States in that we have 22% Native Americans. About 33% of our medical students are underrepresented minorities, and nearly half of the young men and women have a rural background in the state of Oklahoma. We have to take 75% Oklahomans by what the state regents of Oklahoma have allowed. If we can get 100% Oklahomans, we'll go there, but we generally have some out-of-state students.
We have a second class that we recruited—50 students—for next year and the demographics are very similar. They're bright, their [Medical College Admission Test scores], and grade point averages, and all that stuff are equal between our 2 campuses, essentially within decimal point differences. But for us, it isn't just about the score, it's about who you are.
JAMA: Do you have any particular goal, in terms of the percentage of students you'd like to get from rural areas or from local tribes?
Dr Pettit: If we could get to 100% rural and tribal students, that would be something. I don't think we particularly have that as a goal as much as we do to see that the young men and women that come to join us share in our mission and vision of health care. But we have to nurture that, so we develop programs to make sure they don't forget where they came from, so to speak. If you bring somebody into an urban setting and train them for 7 years, the odds are, they're going to stay in an urban center. Tahlequah by contrast is about 16 700 people.
JAMA: How are you going to ensure that these students practice in rural areas once they graduate?
Dr Pettit: Well, there's the rub. There's no guarantee that that will happen. We have 7 communities that are non-Tulsa, non-Oklahoma City, where we have primary care residencies. Our experience has been that nearly 80% of graduates from those rural programs stay in rural Oklahoma. If you practice in a tribal nation setting or you practice in a community health center—if you do your training there—you understand it. You set up relationships, you develop community ties.
JAMA: Programs such as the US Public Health Service Commissioned Corps offer loan repayments to physicians who practice in underserved areas. How do loan repayments or other financial incentives fit in with the college's strategy?
Dr Pettit: We really have tried to address that. Certainly, the Indian Health Service offers programs for tuition and loan reimbursement. We have a state of Oklahoma program called the Physician Manpower Training Commission that we work with that will support up to 10 physicians a year, who can get up to $200 000 paid back for their student loans, with $50 000 repaid after each year that they practice in a rural community. We also are big in getting scholarships and endowments set up. We are probably right at a million dollars now that's been donated to help support students. So the federal programs are important, state programs are important, and we understand student debt and are doing what we can to help reduce that.
JAMA: How does the school's presence on tribal land influence the kind of training that students get?
Dr Pettit: The hospital that's beside us and the 469 000-square-foot clinic that's across the street from us, that's Cherokee Nation. What we do, we do in partnership. We reach out to the Cherokee Nation and make sure they're in agreement with what actions we take. Our first-year students are over at the Cherokee Nation outpatient health center, literally helping out by giving the [COVID-19] vaccine in coordination with their physicians and their nurses, supervised by our faculty. That’s the kind of thing that makes this so important, that we can help a sovereign nation with their health care. We actually are engaging our students in language courses in Cherokee, if they would like to do that.
JAMA: Can you talk about how other tribes are involved in the college?
Dr Pettit: We also have a residency program at the Choctaw Nation, which is in Talihina—population less than 1000. We also have one with the Chickasaw Nation in Ada, Oklahoma. Family medicine, both of those. So, while we have a medical school on the Cherokee Nation campus, we are very invested in other tribal nations across the state of Oklahoma. We partner with the Indian Health Service and with the other tribes to help encourage young men and women in their tribes to understand what it might mean to become a physician. No one may have ever said to them, “Have you ever thought of it?”
Not only did the Cherokee Nation sign a letter of support, but the Choctaw, Chickasaw, Creek, and Seminoles all signed on to say, “Let's create this. This is going to be good for American Indians.”
JAMA: Do these tribes have students represented in your inaugural class?
Dr Pettit: Absolutely. Probably the majority were Cherokee but we had a broad representation. We had a student from the Miami tribe, which is a small tribe in northeast Oklahoma.
JAMA: How will you measure the school’s success?
Dr Pettit: It’s how many men and women can we get to help take care of tribal and rural people. We actually have a grant from the Health Resources and Services Administration to focus on just that.
We have to see where our graduates do their residencies and then we have to see where our residency graduates go. So you're really looking at 6 years down the pike for that to happen. However, you can at 4 years, at graduation, see how many pick or try to get into a rural residency program or one of our tribal nation residency programs. We are going to look every year at who's involved in our tribal medical track and who's involved in our rural medical track, which are our 2 designated curriculums.
JAMA: What else would you like medical professionals to know about how to improve health care for rural and American Indian populations?
Dr Pettit: There’s been a lot of talk over the years about pipeline, meaning that you try to develop a way that medical students flow through the process from undergraduate to medical school and on. We all develop relationships, and if students do that in an area where we would like to see them practice or where we would like to see them participate, that's the way to do it. Our students don't start in an urban center and then have to go elsewhere. They start from day one where they meet the mission.
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Full link: https://jamanetwork.com/journals/jama/fullarticle/2778877