June 24, 2024

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How tribal medical education programs could solve the rural health care crisis with Natasha Bray, DO | AMA Update Video

11 min read

AMA Update covers a range of health care topics affecting the lives of physicians, residents, medical students and patients. From private practice and health system leaders to scientists and public health officials, hear from the experts in medicine on COVID-19, medical education, advocacy issues, burnout, vaccines and more.

A look at Oklahoma State University College of Osteopathic Medicine’s unique partnership with The Cherokee Nation. Natasha Bray, DO, dean of OSUCOM at the Cherokee Nation, joins to share how this innovative partnership came to life and the impact it’s expected to have in the local community. Dr. Bray details the unique clinical training students receive and why it’s important for physicians to truly understand the communities they serve. AMA Chief Experience Officer Todd Unger hosts.


  • Natasha Bray, DO, dean, Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation

Unger: Hello and welcome to the AMA Update video and podcast. Today we’re talking about one medical school’s innovative approach to improving health care in Native American and rural communities. I’m joined by Dr. Natasha Bray, the dean of Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation. I’m Todd Unger, AMA’s chief experience officer in Chicago. Dr. Bray, welcome.

Dr. Bray: Thank you so much for having me.

Unger: OSU’s College of Osteopathic Medicine at the Cherokee Nation is the first and only tribally-affiliated medical school in the country. Why don’t we just start by having you tell us a little bit about the partnership with the Cherokee Nation and what that looks like?

Dr. Bray: Oklahoma State University is so thankful to have the opportunity to partner with the Cherokee Nation. We really have a shared mission of addressing Oklahoma’s primary care health workforce needs. And aligning in this partnership really allows us to come together to talk about how we train physicians to serve both our rural and our tribal populations.

Unger: It’s a unique relationship. And I’d love to hear you talk more about what motivated OSU and the Cherokee Nation to come together like this and how the partnership itself came to life.

Dr. Bray: So starting in around 2003-2004, Cherokee Nation approached OSU with a with a challenge that they were having, and that was getting and maintaining a physician workforce to meet the needs of their population. They recognized that they had a lot of physician turnover. They were getting physicians primarily through programs like the Indian Health Service Scholarship Program, where they had repayment options.

But what would happen is, physicians would come. They would fulfill their service obligations. And then they wouldn’t necessarily stay in the community. And the question was, how can we address this? How can we really think about long-term solutions?

So starting around 2005, OSU started placing third and fourth-year students within the Cherokee Nation’s health system for clinical rotations. A family medicine program was started in partnership in 2008. And those programs built on one another, really leading to, is it possible to put a four-year medical school campus in a rural community? Tahlequah, Oklahoma, is about 15 to 16,000 people, and in the capital of the Cherokee Nation, so that we really are taking students through their entire educational continuum, from those preclinical courses into their clinical rotations and then into residency training within the community.

And would that change our long-term outcome? Would we be training physicians to serve the population, keeping them in the community, and really creating some stability and workforce and addressing a lot of the major health care disparities and health inequity that are faced by these populations?

Unger: Are you finding that the change in the approach is delivering what you set out to, which is to keep those folks there in the community?

Dr. Bray: Yeah, so I can’t tell you what’s going to happen with graduating medical school students because we’ll graduate the first class in May of 2024. But if we look what has happened prior to that with the start of the residency program, there’s both a family medicine as well as an internal medicine family—or internal medicine program here in the community. And what we’ve seen is that those residents who come through those training programs are staying in this community or in communities that look like this, meaning that they really do go into rural practice. They’re going to communities that are medically underserved. And they’re establishing practice there and staying there throughout their careers.

Unger: Wow, it’s great to hear that. And I’m eager to learn more about the training part. So tell us a little bit more about the training that the students receive that specifically prepares them to serve tribal and rural communities. And if you can, share an example or two that illustrates how that might be different from training they might get elsewhere.

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Dr. Bray: Yeah. So first of all is our location. We are located in the capital of the Cherokee Nation in Tahlequah, Oklahoma. We are on tribal reservation land. We sit next door to WW Hastings Hospital, which is Cherokee Nation’s hospital. And across the parking lot from their 450,000 square foot outpatient, multidisciplinary, medical home-based clinic. So the environment itself, from the time students step onto campus, they’re embedded in Cherokee culture.

And we think that that’s really important because, if we want them to serve a community, we need them to understand, what are the needs of the community? What are the challenges in that community? And that comes a lot easier when you live in the community than when we begin to try to talk to you about how social determinants of health impact access to care.

So they’re able to see that. They’re able to have that lived experience. Our students have the opportunity very early in their educational experience, during second semester of first year, to begin to have early clinical exposure through courses like service learning and community engagement. They have early clinical experience between the first and second year. And those all happen within the Cherokee Nation Health Care Center.

For the most part, they’re with the family medicine residency program and the family medicine clinic. They do have the opportunity, some of them spend time in pediatrics as well. But we really try to get them out where they’re engaging with patients. And what we’ve seen is they get excited. When they come back for their second year and they’re back in the classroom in their basic science, they begin to talk with each other. What were the challenges that their patients were experiencing? What did they learn that they didn’t expect?

We put a lot of emphasis on the importance of elders in the community, traditional healing things that patients may not disclose to you if you’re not welcoming and you’re not open to hear those experiences. We also spend a lot of time talking about—we work very closely with the Cherokee Nation for their preclinical training. But as they go into their clinical training, we use what is a distributive training model, which means, rather than being in one academic health care center for their clinical core rotations in the third year, we send them out to the community.

And our students have some choices that they can make. They can choose to go into a rural training track, which means they’re going to do their core rotations in rural-based clinics or in critical access hospitals across the state of Oklahoma. They can choose to go into a tribal track, which means that those same core rotations are happening in tribal health care centers, primarily with the Cherokee Nation, Chickasaw Nation, Choctaw Nation, Muscogee Creek Nation, as well as some of the other tribes in Oklahoma or Indian Health Services.

We also have a relationship with the two urban Indian clinics that are here in Oklahoma. They can go into a traditional, which we pull them back into Tulsa for clinical rotations at OSU Medical Center. Or they can go into an urban underserved track, which puts them in FQHCS in the Oklahoma City or Tulsa community, but again, getting to those populations that may not have access to care or have limited access to care.

And what we’ve found is they share their experiences. And there’s something very powerful about the peer learning. If we have a student who is doing their tribal rotations and they’re with the Cherokee Nation, but they’ve got a classmate that’s with the Choctaw Nation, they begin to talk about what are the shared cultural attributes. What are they seeing? What are the experiences with those health care centers? And that really leads to powerful learning and powerful knowledge because they’re able to articulate that each patient is unique.

Each patient comes with their own background. And it really changes how we approach patients to ensure that we’re providing patient-centered care that’s respectful of culture, respectful of their language, respectful of their heritage, so that we really partner with our patients to ensure the best outcomes that we can for our patients.

Unger: Well, there are a lot of innovations and adaptations that sound very exciting. Do you think this kind of program and partnership that OSU has with the Cherokee Nation could work in other areas?

Dr. Bray: I think it’s critical that it works in other areas. We know we have wide areas of underserved populations in the United States. And we know that we have a maldistribution of our physician workforce. Yes, we have a physician shortage across the United States, especially in primary care and some critical services. But if we look at where those shortages are, they disproportionately affect our tribal, our inner city, our rural populations.

So we have to find ways to get the right physicians to those communities so that they can engage in care of those communities if we hope to really produce health equity, if we hope to change the health outcomes of our patients. So we really focus on, how do we recruit students who have grown up in those communities who are dedicated to serve those communities? How do we train them in those communities? Because we don’t want to send physicians who don’t have the knowledge, skills, competencies that it takes to be a physician into a community, because that has a potential to worsen health outcomes and health equity.

We want to make sure that they’re well-trained. So how do we train them in those communities and use the tele-education, the innovative educational tools that we have? And how do we keep them in those communities so that they’re supported into practice? Because it can get lonely in those environments. And we want to make sure that we provide resources to physicians to be successful in the practice, so that they’re able to serve their patients to the best of their ability.

Unger: Dr. Bray, when you look back at everything that it took to put something like this together, do you have any advice out there, maybe highlight one major challenge that you experienced along the way that you could advise folks on that might want to try the same thing?

Dr. Bray: Yeah, so my biggest advice is to listen. Medical educators tend to come with a lot of experience and a lot of expertise. But when it comes to serving the needs of our community, our primary job is to listen to what those needs are. We want to hear what the challenges are. We want to hear what their strengths are. And what are the real opportunities for partnership? How do we make sure that we are there in service to the community, rather than coming in as saviors, trying to save the community?

And they’re going to tell you what their needs are. So that’s probably the first thing for any of these types of partnership is really getting there, being present, and listening and actively listening and then using your expertise to support what they’re wanting to accomplish.

We opened the school in August of 2020, which means we were right in the middle of the COVID epidemic. And that presented a lot of challenges. It’s hard to open a building, bring a brand new class into an educational environment when we were dealing with all kinds of quarantine issues, and whether or not it’s safe to put students in the classroom.

I think, thought, that there were some really important lessons that came out of that. And that is—the biggest one being, when we had students coming in and out of quarantine, we were providing education to them, using things like video technology. So we really began to develop understanding about, what do we actually need students in the classroom to learn? What are the knowledge, skills, competencies that we need them face-to-face? What can we allow them to get in the way that they need it? Meaning we know we have students who have all kinds of different learning needs. They have all kinds of challenges outside the learning environment when it comes to caring for their families.

So how do we support them in getting the education in the way that allows them to be complete, authentic people and bring all of their identities into the medical education? Why that’s so important is, if we are talking about diversifying the people who are physicians, they’re going to come with a diverse sense of challenges. And the more we’re able to adapt our learning environments to support them in their success, rather than forcing them to adhere to our learning environment, the more we are able to produce success, the more we’re able to train physicians to be the people that we want to see, that we want caring for our family, our friends, our neighbors, and our communities.

And I think that that’s the most important lesson we can’t lose out of COVID, is that we can teach differently. And we can adapt to different situations to allow success for our learners.

Unger: Well, Dr. Bray, thank you so much for joining us. That’s such a great perspective, a great story, great effort. And it couldn’t matter more at this very moment.

If you enjoyed this discussion, you can support more programming like it by becoming an AMA member at ama-assn.org/join. That wraps up today’s episode. And we’ll be back soon with another AMA Update. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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