Central Line

Episode Number: 119

Episode Title: Challenges Abound for Indigenous Peoples of North America

Recorded: January 2024

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. KIYA LOCKE:

Welcome to Central Line. I'm your host for today's episode, Dr. Keya Locke, and I'm really excited to be hosting my first episode. And I'm equally excited to welcome Dr. Elizabeth Drum to the show. Dr. Drum is the guest editor of the February Monitor, which educates readers on the challenges facing indigenous people of North America and the anesthesiologists who work with this patient population. I'm looking forward to learning more about this important topic, so please help me to welcome to the show Dr. Drum. Dr. drum, how are you?

DR. ELIZABETH DRUM:

Hi. I'm great. Thanks so much for inviting me.

DR. LOCKE:

Awesome. And so let's start first by learning a little bit about you. Can you tell us a little bit about your background and how this topic has touched your life and your career?

DR. DRUM:

Sure. I'm a pediatric anesthesiologist, and I've been in practice for more than 30 years, and I have been privileged to work in several different institutions in my career and interact with a lot of different people. And one of the things I love about anesthesia is that I'm always learning something, even today, from one of my patients, for example.

But the way I really found myself into part of my career, which I had no anticipation of, was I was working at an institution that closed its children's hospital. And as part of the time after that, where I was trying to figure out how I wanted to spend my time in life and professionally, uh, a friend, a surgical friend asked me to accompany him on a trip to Ethiopia, where he was going to treat a subset of patients or evaluate a subset of patients. And that really sort of opened my eyes to a whole world that I didn't really know existed. Through that really became involved in global health and outreach and educational training around the world. And as part of that, made me much more aware of disparities and limited access to health care in a way that I had not really recognized before. I worked in a very low-income hospital setting in the poorest part of Philadelphia, but really had little understanding about the rest of the world and what challenges many other people around the world faced. And so that was really what opened my eyes. And this issue itself is sort of another, I don't know, episode in that chapter of me really starting to understand another people, another population, another part of care needs that people have around the world that I just was not aware of until recently.

DR. LOCKE:

And thank you for that. And so I think as you mentioned, yeah, we often talk about, you know, poorer socioeconomic classes within the US. But when we think about global health, uh, many of us think about low and middle income countries and the challenges patients and practitioners grapple with in those settings. So can you center that discussion here for us and sort of elaborate on how the US fits into that broader conversation? Uh, and additionally, why it's important to zoom in on this population.

DR. DRUM:

Yes, that's a very good question. And you're right, I think many times when people think of health disparities or health inequity or even people who have poor access to care, many of us, and I would put myself in this category, who are reasonably well off, have had, um, excellent education and opportunities in our life, don't always recognize the disparities in health inequities that are right in our own neighborhoods and are right around us. And I think one of the things that I've learned throughout my work in global health is that there are inequities everywhere, in every country and in many communities that we're unaware of. Some of those were probably becoming more aware of in terms of poorer parts of our population or members of our own communities that don't have very good access to care. But when you look at things in a global sense, for example, access to care--we don't really have time to get into The Lancet Commission on Global Health--but for example, one of the things they talked about in there is certain procedures which ideally you should have access to within two hours of where you live, one of which is a access to a C-section. And I'm pretty sure there's communities in the United States where a pregnant person does not have access to C-section within two hours, or treatment for certain things that to us in a big academic medical center or in a big city hospital seem routine and commonplace, like care for stroke or a car accident. There are many rural communities in the United States, and rural hospitals or small hospitals that just don't have access to that. So this is part of the whole same health inequity, uh, problem that we face around the world.

DR. LOCKE:

I believe you had also mentioned at one point that, um, over 50% of enrolled members of federally recognized tribes live off of reservations or in urban settings. So is that sort of the population that you're talking about as well, in addition to like just really poor areas of the country?

DR. DRUM:

Yeah. So for example, in Philadelphia, where I live, I actually don't really know what the population of, um, American Indian or Alaska Natives are in Philadelphia. But I'm pretty sure it's pretty small compared to some other parts of the US. So Arizona, New Mexico, Oklahoma. And so people like me tend to think, well, that population isn't really where I live. They're all in other parts of the United States on a federally recognized reservation or something. But that's, as you point out, not really true. And so when you start to learn about some of the cultural disadvantages and the educational limitations that those populations have, it becomes even more magnified when we don't even know that they exist. And that was one of the eye-opening things to me in preparing for and trying to learn about this issue to present it in the ASA monitor.

DR. LOCKE:

Excellent. And so my next question, I'm looking to talk about working with indigenous peoples and what kind of challenges do patients and anesthesiologists working in tribal nations face, for example?

DR. DRUM:

Well, I think there's some things that would immediately come to mind when you think about populations that have limited access to health care, things like poor primary care or understanding of the role of primary care or preventive measures in terms of preventing, you know, long time health issues. As I mentioned earlier, there are many communities that don't have access to things that we consider standard of care. But beyond that, if you don't even know that those things exist, you can't even advocate for yourself or your family member to get them. Um, and then I think there's a whole other world that we don't often think about -- things like cultural expectations, when it's appropriate to seek medical care or treatment, what kind of things are available. The dollars that are allocated for care of Native Americans is not necessarily equal to the dollars of care that are available to others. So in addition to not having access to care, not knowing that care should exist, and not understanding what's available to you, sometimes there's just not enough money available to pay for things that many of the rest of members of the US population do have better access to. In addition to that, I think challenges that patients face, and we've talked about this in other populations is, it is difficult to find health care providers that share some of your perspectives, not only culturally, but understand your background and what kinds of things make it difficult for you to be able to follow up or seek medical care or follow recommended treatments. So many things that affect other, uh, disadvantaged populations, I think, are magnified in this population.

DR. LOCKE:

I think that's very well put. Um, can you talk to us about sort of what is being done to address some of these issues, for example, expanding services and workforce? Um, and then additionally, how do you feel that anesthesiologists and others are working to make things better in some way?

DR. DRUM:

Well, I think there's a lot of things at play. Number one, just the fact that we're having this conversation is amazing to me. The fact that one subset of patients in the US have definitely received substandard or less equitable care, um, shouldn't be a surprise to us as health care providers because we see that in our daily lives. But here we are in 2024 and we're just now as a community, I think, talking about the fact that we have Americans who don't have access to health care in a way that most people hadn't thought of. So we're talking about it. We have awareness. I think just the fact that I have now, leading up to and preparing for this special issue, met and spoken to and gotten to know two Native Americans who are in health care, one finished training and now starting as a faculty member and one who's a pre-med student. And just the fact that I've gotten to meet them and hear their story in person and read their writing is is a true joy and treasure to me. To get to meet people I would have no reason to meet otherwise and to learn something about them and their culture. And it reminds me of people I probably met previously in my life, but wasn't smart enough to really pursue getting to know them. So there's things like that.

There's definitely been an awareness of the challenges that some of the reservations faced during public health crises like Covid. And I think there are definitely people who are now aware of and interested in trying to figure out how to support those communities. For example, there's several programs to encourage Native American students to study science, engineering, Stem programs. There's some mentorship and pipeline programs, many of which I heard about from these two physician and physician trainees that I told you about. But then when I did some research, found a lot of other programs out there. And it's one of those things, you know, once you start looking around, you see things everywhere. So I've been just noticing in the news and places that I read on social media, like reading about programs for education and promoting awareness and education. So I do think that we're starting. But we're way behind, and we have a lot of work to do to to catch up to what is needed for representation in the, in this community.

DR. LOCKE:

Yeah, I would definitely, definitely agree. And when we talk about representation and equity, I always feel it's important to look within our own houses. And so thinking about representation within our workforce. Can you talk to us a little bit about that? And what percentage of anesthesiologists in this country are American Indian or Alaskan Native?

DR. DRUM:

Well, the best data I've read, most of which comes from the American Association of Medical Colleges, the AAMC, and in in their yearly review of demographics for 2022 and 2023, they discuss that only 1% of all enrolled medical students self-identified as American Indian or Alaska Native, and that of the almost a million so 940,000 active US physicians, only 0.4% self-identified as American Indian or Alaska Native. And that's all physicians, not just anesthesiologists. That data doesn't include other healthcare professionals, such as nurses and other allied health professionals. And there was an estimate that doing nothing, it would take more than 100 years for the representation of American Indian Alaska Native in the medical population to catch up with the percentage of the population which you know clearly is not in anyone's mind that that would be an equitable thing to wait 100 years. But during that time, also the population of American Indian Alaska Native would probably increase too. So clearly doing nothing is not really a good idea.

DR. LOCKE:

Right. That being said, looking at those numbers, are there reasons for us to be optimistic here? And are the workforce diversity efforts in this population working?

DR. DRUM:

Well, that's a good question, because I actually did have some moments in here when I was reading and doing some research about these articles, that I was pretty depressed about it. But talking to the two physicians, the anesthesiologist and the pre-med student who wrote articles for me, in talking to them in person and also reading the things that they wrote, I was struck by how optimistic and energetic they were. And so I am choosing to try to channel their energy and help support them and figure out how we can support them. And in talking to them, they both identify that mentorship and having programs for people who want to pursue medicine or other health care professions, or even Stem education for the younger population, are really key to successes. They both identified programs that really helped support them, that they've been involved in now, both as a mentee and starting to be a mentor. And it reminded me of many of the other similar programs within the ASA. But for example, at the most recent annual meeting in 2023, there was a big mentorship workshop that one of these physicians that I that wrote an article for me participated in, and that really energized and motivated him to continue those efforts. So things that the ASA does, like the Doctors Back to School program, some of the efforts of the committee and professional diversity, some of the other focus on mentorship for young professionals. Some of the subspecialty societies have specific mentorship programs for young people interested in this field. I think those are all the way of the future that we really have to make medicine something that people want to do, and not just people who have physicians in their family and in their sphere of friends. We have to make sure that people can see that, that they too can become physicians and join the workforce.

DR. LOCKE:

Thank you so much. I have several more questions for you, but we need to take a short patient safety break, so please stay with me.

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DR. JONATHON COHEN:

Hi, this is Doctor Jonathan Cohen with the ASA patient Safety Editorial Board. Amy Edmondson's best selling book, The Fearless Organization, revealed something surprising about psychological safety in health care settings. Better teams report more errors. Higher functioning teams don't actually make more errors, but they have a climate of openness that allows them to be reported more easily different from a safe space free of differing opinions. A culture of psychological safety encourages members to ask questions, speak up when things seem amiss, and admit mistakes. As leaders on the perioperative care team, anesthesiologists can help foster this climate by doing things like admitting their own fallibility, asking for team members opinions, and responding productively when they voice a concern, ask a question or admit an error. People will make errors when team members feel comfortable speaking up. We can prevent those errors from harming our patients.

VOICE OVER:

For more patient safety content, visit asahq/patientsafety.

DR. LOCKE:

All right, we're back. Um, and I'd like to learn a little bit about the Indian Health Service or IHS. Can you talk about the history of IHS and how it compares to Medicare and Medicaid?

DR. DRUM:

Yes. Again, this is another area which I feel like I've just begun to scratch the surface and understand the history of this and what's going on now. And it's an example of of how I went all through medical school training and practice for decades and really knew nothing about this, and never even dawned on me that I should know something about it. So, um, shame on me for not knowing that. But but now I'm trying to make an effort to learn more. So the Indian Health Service, or IHS, was established in 1955 to fulfill the United States responsibility to provide health care to indigenous people who are enrolled in one of the federally recognized tribes. And so it's part of the long standing agreements that were made between the tribes and the US government. However, like many other parts of the US health care system, there's funding challenges, there's workforce challenges, and it's dependent on how the money is allocated. And for example, in 2021, the federal expenditure per capita for IHS was half of other federally funded programs. So per user, the IHS received $4,140, compared to 15,000, some for Medicare and almost 9000 for Medicaid. So the same person, had they been enrolled in Medicare or Medicaid, would have received a lot more dollars allocated to them than through the IHS. So even just look, understanding how we allocate money and resources to provide care for this population should make it obvious that we haven't completely supported the necessary care.

DR. LOCKE:

Okay. Thank you so much. So what role is self-governance playing when it comes to the topic of healthcare among indigenous communities? Is there a shift towards more self-governance and what can we learn from the innovative reforms? Tribal nations have developed.

DR. DRUM:

I think one of the things that historically has been difficult for American Indian and Alaska Native and other indigenous peoples is that this situation in which they were dependent on someone else to allocate money or resources to them, led to inequities in access to care. And some of this involved not just health care, but many other things like land use and other cultural and maltreatment of people that is at the stem of it. And so I think there's been a long standing distrust of whether the US government is really providing the necessary support and care for indigenous populations. So over the last few decades, there have definitely been some examples of certain tribal nations really becoming more involved and implementing some self-governance models that have really sort of transformed their ability to provide for their own population. Some good examples have taken place in Washington state, in which case several tribes have been able to assume management of the federal dollars and have been able to open clinics that really meet the needs of their populations, including regular health care, but also things like treatment for addiction and other things that are at higher levels of incidence within the population. And I think it clearly shows that with appropriate support, the indigenous communities, like many others, have really strong advocates and leaders within their own communities. But those people have never been allowed to assume responsibility. So there's definitely some inspiring stories of how communities have banded together and have become more self-sufficient and been able to manage their own community's health from their perspective, as opposed to someone like me coming in and telling them how they should do it.

DR. LOCKE:

Yeah, that's very interesting. Um, that you mentioned about, you know, this sort of history of mistrust and this sort of self-governance model being born out of that. I'm just curious, do you feel that this particular subset of the population has done sort of a good job of really leaning into that self-governance model in order to improve the situation?

DR. DRUM:

Well, I'm clearly not an expert, but reading the article that Dr. Tom Locke wrote for me, for the Monitor really gave me an insight into that world, which I knew nothing about. And I still don't know very much about it, but helping me to understand how communities and specific tribes can learn with appropriate support from people like him or other public health officials, to really learn how to advocate for themselves, and to be able to speak up about what they need, and then help them to learn how to navigate within the system that they're in to get better benefits for themselves. So I'm inspired and motivated and encouraged, mostly because other people who have worked in those systems do feel like it's been transformative.

DR. LOCKE:

That's very encouraging. And so what do you think listeners like myself can do to learn more and to do more when it comes to this subset of patients?

DR. DRUM:

Well, I think part of it starts just what we're doing today, like just opening your eyes and your ears to something you know nothing about. That I personally think is one of the joys of our profession, that we get to interact with patients and their families at really very personal moments in their lives, whether it's a joyful thing or a not so joyful thing or it's a really devastating part, but we are there to and are witnesses to that part of their life that normally you wouldn't. And so one of the responsibilities I think that gives to us is to really try to learn from other people and from other people's perspectives. So just listening to this podcast or going back and reading these articles in the Monitor and just learning a little for yourself, I think is a good way to start.

And then once you realize that there are Native Americans out there that you probably don't know anything about, like you can learn more, you can read books, you can go online, you can look for articles. If you have the privilege of meeting a few people like I did, uh, get to know them, ask them their story, and they will certainly tell you if you ask them. But many times, they aren't going to answer if you don't know and asks them, or they may never have had the opportunity to be able to tell their story, which is how this all started for me in the first place. I'm hearing someone talk about their journey to becoming an anesthesiologist as a Native American. I had no idea. Even if I thought I did, I really didn't. And so once you learn a little bit, there's so much more out there. And and there's endless social media things, online resources, museums, books, articles. Smithsonian has a lovely museum and a magazine that comes out. They have art museums. There's celebrations once a month, certain times during the year, different communities that you can definitely learn about if you keep your eyes open.

DR. LOCKE:

Thank you for that. Before we let you go, I'd like to hear about your experience editing this issue of the Monitor. You mentioned some young people wrote a couple articles for the Monitor as well with you, um, what do you feel like you learned? And and importantly, what do you hope that readers will take away from the issue?

DR. DRUM:

Well, that's a great question. I learned, um, that there are many stories and voices out there that we need to listen for because if we don't listen for them or actively seek for them, we won't hear them. So that's the first thing.

There's also a wealth of resources out there. Some of that I just mentioned a few minutes ago that once you start digging, you'll find a many of them. And it makes me realize that there's probably many other areas within medicine that are like this that I don't even know they're there. And so it makes me realize I need to look out for them.

I think the other thing that was a little sobering to me, to realize that I've just scratched the surface even in this particular issue. I really didn't at all look into how many nurses or how many surgeons, or how many healthcare administrators are there that are American Indian or Alaska Native. And then there's many other indigenous peoples and populations even in this part of the world that I really didn't have time to properly dedicate information to. For example, not only Hawaii and Alaska, but Canada and Mexico and other parts of Central and South America that also clearly have some of these same factors at play, which I did not have time to do justice. So there's definitely more questions that are out there than I got answers to.

DR. LOCKE:

Right. And I think that what you said initially was very powerful and that there are a lot of voices out there. And I feel like, as an organization, as we always, you know, push for increased membership and engagement, it's really, really important to push to hear from those people that you don't normally hear from. Because they are out there. As you mentioned, there were a few that you got to meet. So it's really vital that we give those sort of underrepresented groups of folks an opportunity to be heard, as you so eloquently put it. I think this has been a great conversation. I learned a lot from you today, and I really hope that our listeners did, too. Thank you so much for stopping by.

DR. DRUM:

Thank you, and thanks for having me.

DR. LOCKE:

And to our listeners, thank you for joining us for Central Line. You can learn more about the topics Dr, Drum touched on today at asamonitor.org. And please join us again for the next episode of Central Line.

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VOICE OVER:

Cultural competence is a key component to ensuring equitable health care. Explore Asa's Enhancing Patient Communications Program toolkit to learn how anesthesiologists can better provide culturally competent care, and for tips on how you can communicate more effectively with patients in the limited time you have with them. To ensure better patient care. ASA members download your toolkit at asahq.org/madeforthismoment.

Subscribe to Central Line today wherever you get your podcasts or visit asahq.org/podcasts for more.