New Project A Commitment To Native Americans' Health -- Bringing Indians Into Medicine

The middle-aged man's blood pressure is up and Kathy Gaglione plops down in the cluttered doctor's office to ask if it shouldn't be brought down right away.

What's abnormal should get to normal, she has learned in her first year of medical school.

Yes, that's true most of the time, says her mentor, Dr. Juan F. Juarez. But quickly dropping this patient's blood pressure with medications could kill him. A lifestyle change - stopping smoking and adjusting his diet - could do it more gradually and safely.

"You have to make sure the cure isn't worse than the disease. . . . You have to think of the total human being," Juarez explains, flashing another of his friendly smiles and playfully donning his 10-gallon hat.

Gaglione listens intently and quietly delights in the umpteenth real-life, clinical experience she has had this summer. "He's such a good teacher," she says when Juarez leaves the room.

Gaglione, of the Blackfeet Tribe of Montana, and Juarez, a family-practice physician and a Zuni Indian, are an important team. They are part of a major new effort by the University of Washington School of Medicine and the Indian Health Service to recruit and retain Native Americans and Native Alaskans as physicians.

Financed by a $1 million, five-year federal grant, the project also targets research at medical problems - such as diabetes and cervical cancer - that disproportionately affect these groups.

Native Americans are woefully underrepresented in conventional Western medicine: If Native Americans were physicians in proportion to their numbers, there would be more than 4,600 of them in the U.S. Instead, only 868 of the country's 587,000 doctors are Indians, and only about 300 treat Indians full-time.

"It is one of the contributing factors to Indian health problems," says Dr. Walter Hollow, a coordinator of the new UW program and director of the school's Center of Excellence for Native Americans.

Caucasian doctors, who mostly staff Indian clinics and hospitals, usually stay for only two years, to fulfill requirements for federal education loans. By the time trust is established, the doctor leaves, and many patients simply stop seeking care.

In communities served by Indian doctors, Native Americans' health is almost always better, Hollow says.

Gaglione is one of 14 Native American UW medical students aiming to help change things. Juarez is one of a network of Native American physicians in Washington, Alaska, Montana and Idaho opening their clinics to such students.

Real-life practice for students

In his Bonney Lake offices, Juarez is an eclectic blend of doctor, teacher, philosopher and friend.

"Life goes on like a stream," he says, obliquely explaining clinical training. "It flows. You can channel it or let it run. But flow it must."

It is training, he says, that takes students out of the artificial atmosphere of the classroom and into a natural flow of all kinds of patients who come to a family clinic.

On a recent, typical afternoon, Kathy Gaglione has a rich variety of learning experiences.

She interviews a woman who is having cramps and abnormal vaginal bleeding. She detects nerve problems in a woman's back. She follows Juarez's directions in writing a prescription for a boy with an ear infection.

"It's so nice to see clinical things we studied in the classroom applied to real people," she says.

Juarez, 49, is a contrast in this era of hurry-up medicine. He takes his time. He is one moment questioning, then analytical, then mischievous and full of fun. His patients obviously have a great fondness for him.

He speaks broken Tagalog to a Filipino-American patient who speaks perfect English and tells her the "animals" (meaning Lions, as in the Lions Club eye program) will help pay for her eye surgery. A doctor in a telephone consultation asks him where he practices; he responds, "on the Planet Earth."

Repeatedly he decries the fragmentation of medicine, with its oversupply of high-priced specialists and their sometimes narrow focus on solving medical problems.

"A man who has a hammer as his only tool is convinced the cosmos is a nail," Juarez says. More physicians in primary care, where so much healing is done, are especially needed for underserved populations such as Native Americans, he says.

In harmony with tradition

When Gaglione began her summer of training, one of the first things Juarez did was conduct a traditional Native American ceremony.

The ceremony, an "enchantment," was to get her training off to a good start, to improve her memory. It was conducted with chants and prayers and Juarez' 400-year-old Zuni ceremonial drum.

Such traditional ceremonies are an informal part of the UW program. Encouraged by physicians such as Juarez, the students attend a variety of ceremonies as a way to keep them in touch with their roots.

The ceremonies help them understand the needs of some Native American patients who want traditional Indian treatment in addition to conventional Western medicine. They help sensitize the students for when they may serve as liaisons with the healers.

"I've been away from it for a long time. . . . I really enjoy getting back to my cultural ties and keeping that," says Gaglione.

Native American healing relies on the spiritual side of their patients and the healing power of the mind.

"To Indians, medicine and religion are the same," says Hollow, the recruiting coordinator and a Group Health Cooperative physician.

Each tribe, he says, has its own beliefs and rituals, many of them very complex. But there are some basic concepts:

Everything on the Earth has life, including rocks, water, the soil. Each living being is responsible for maintaining Mother Earth. Illness occurs when someone is "out of balance," or not in harmony, with other beings.

Thus, a person may be ill when having negative thoughts or emotions about others. Or perhaps the person may not have honored or shown due respect to other beings. This is where ceremonies come into play - such as the Tulalip Tribes' annual celebration of the return of the salmon.

"The purpose in life is to maintain balance and keep in good health," says Hollow, a Sioux tribal member. "By doing that, you respect all things on Mother Earth."

Recruiting starts in grade school

Like most of the Indian medical students, Gaglione, 33, hopes to practice in primary care serving Native Americans. A former music teacher and Air Force Band clarinetist, she first must pay off her Air Force medical scholarship with four years' service as a doctor.

Gaglione decided to pursue her interest in medicine only after years of thinking about it and building her self-confidence. The UW-Indian Health Service recruiting program now goes out looking for youths with such a natural bent. They start as early as elementary school.

"That's the one time I wear a white coat," laughs Hollow. "We emphasize the need to do well in math and science."

Hollow goes on more than a dozen recruiting trips a year - from Seattle's Indian Heritage High School to schools on the Nez Perce Reservation in Idaho. Sometimes he just talks a little and visits. Other times, he gives hands-on, fun lessons like instructions on microscope use. He also enlists his medical students, residents and other doctors.

Recruiting "really has to begin early on. And we have to take steps along the way to keep students focused in the right direction and continue to reinforce that feeling," says Dr. John Coombs, associate dean of the UW medical school and chairman of the UW-Indian Health Service project steering committee.

The network of recruiters will follow prospects through undergraduate work, then medical school - befriending, encouraging, boosting. "I remember how lonely it was," says Hollow, the first Indian graduate of the UW medical school in 1973.

As part of his Center of Excellence for Native Americans, Hollow convenes monthly meetings of the Medicine Wheel Society at his house. The major purpose of the group, composed of Indian medical students, residents and some pre-med students, is to support Native American students through medical school.

Internships and residencies are arranged at facilities ranging from the Seattle Indian Health Board to Harborview Medical Center to rural clinics in Alaska. The training and special courses on Indian health problems are also open to non-Indians interested in serving Indian populations.

Student feels called to service

In the Harborview general-surgery recovery unit, Mike Painter, a Cherokee tribal member from Oklahoma, takes a breather from the hectic pace of a third-year medical student and talks about the clinical work he "absolutely loves."

Three years ago, Painter was making $85,000 a year as a San Francisco real-estate attorney not long out of Stanford Law School. He respected his colleagues and their work. But it just didn't fit for him.

"I felt so away from my roots and how I once pictured that I would be," he said. "I wanted to know real people and real people's problems."

Painter, 33, struggled with his dissatisfaction. What would his mother, a Native American activist, and his father, a Caucasian urban planner, think? What would his mentors and supporters think?

Yet there was no doubt about the crying need for Indian physicians, and Painter felt an obligation to help.

"I received a lot from my family and my mom's family and I feel the need to give something back," he says. "At the same time, it's something I really want to do for myself."

Painter and Hollow also speak of another dimension of the importance of recruiting more Native Americans to medical careers:

Many young Indians grow up in poverty. Pursuing a professional career may seem as likely as moving to another planet. Native American physicians as role models and mentors can help change that.

Painter speaks with emotion of his mother's influence and long-held belief.

"She feels very strongly that Native Americans are extremely capable of succeeding in any environment we face," he says. "We just have to learn to find it within ourselves and we can compete, given the right amount of support."

Finally believing: She's a doctor

Dr. Jessica Doney, a Turtle Mountain Chippewa tribal member who grew up in Montana, is a recent UW medical-school graduate who is now a family-practice resident at Group Health. Even though she was on an Indian Health Service undergraduate scholarship at Montana State University, she at first had trouble thinking of herself as a doctor: "Most I had ever known were middle-age white men."

But Doney, now 29, early on got the kind of encouragement and guidance the UW-IHS program fosters.

She joined the school's Minority Biomedical Research Program. She became a member of the American Indian Science and Engineering Society and got lots of support. She spent a summer at the National Institutes of Health in Bethesda, Md., studying how brain cells are affected by viruses.

In UW medical school, she got more reinforcement from physicians such as Hollow. She had a wonderful time returning for two months of clinical training on the Crow Indian Reservation in Montana.

"So many people I know are so proud to know an Indian physician," said Doney. "One little girl made me feel really good. She said, `When I grow up, I'm gonna be a doctor and my husband's gonna be a nurse.' "