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Addressing Critical Concerns of Healthcare Systems Serving American Indians/Alaska Natives

Private/Indian Partnerships


Ralph Forquera, M.P.H. (Juaneño Band of Mission), Executive Director, Seattle Indian Health Board, Seattle, WA.

Samuel W. Cullison, M.D., Director, Providence Family Practice Residency Program, Providence Seattle Medical Center, Seattle, WA.

The Seattle Indian Health Board (SIHB), an urban Indian program in Seattle, Washington, and the Providence Family Practice Residency Program, part of the University of Washington Medical School, have collaborated to develop a satellite residency program to train physicians for careers with American Indians/Alaska Natives (AI/AN) clienteles.

The two organizations have a relationship going back several decades. Personal relationships have increased the level of trust over time. The two agencies also share similar missions.

Ralph Forquera explained SIHB's motivations for undertaking this collaborative venture:

  • The need exists for more Indian physicians (approximately 800 Indian physicians practice nationwide). Even for Indian physicians, becoming reacclimated may be necessary after being away from Indian communities for the 11 years of necessary schooling.
  • SIHB seeks different ways of financing service delivery.
  • SIHB was looking for a way to distinguish itself from other healthcare providers in its efforts to develop political support and obtain funding.
  • Providence had experience in running satellite residency programs in other culturally diverse areas.

Sam Cullison explained Providence's motivations for becoming involved:

  • As the University of Washington is the only medical school for five States, it takes seriously the goal of serving different populations.
  • Providence's goal is to provide care to the medically and socially underserved by training family physicians to provide culturally appropriate care. Other satellite sites serve primarily Latino, African American, and immigrant populations.
  • Mr. Forquera had experience incorporating a residency program into clinic operations (from positions held before joining SIHB).

The goals of the satellite residency program include:

  • Training physicians for careers working with AI/AN populations: If physicians are trained in a special setting, they are more likely to practice successfully in that setting in the Long-term.
  • Exposing trainees to cultural sensitivity and appropriateness and health issues particular to AI/AN populations.
  • Recruiting AI/AN medical students: Data show that the highest retention rate for physicians working with minority populations is among those having a personal membership in a minority population.

Operating since 1994, the satellite residency program is the only AI/AN residency program in the United States. Applicants are required to either be AI/AN or to have extensive experience in AI/AN communities. Six residents can participate at SIHB; two each in their first, second, and third years of residency. Residents complete several rotations at SIHB. They spend 2 half-days on-site during their first year, 3 half-days during their second year, and 4 or 5 half-days during their third year.

Contractual relationships between SIHB and Providence include:

  • Providence pays the residents' salaries, benefits, and 20 percent of the administration salary of the site director (a physician on the university's faculty). (This equals approximately $250,000 annually.) It also provides all nonclinic training.
  • SIHB provides the clinic site, patient population, site director, and clinic preceptors. It also provides customizing of the curricula to incorporate issues in AI/AN healthcare, including curriculum on traditional healing.
  • SIHB retains income from patient fees.
  • Providence retains income from Medicare graduate medical education (GME) funds (used to offset salary costs).
  • Both complete the initial recruitment and intern match process. Providence's residency director is responsible for the final selection.

Thus far, six residents have graduated from the program since 1997. Four work in AI/AN healthcare facilities. Two work in community health centers with large numbers of AI/AN patients. Four are AI/AN.

Challenges faced in making this project work include:

  • Bridging the requirements/rules of a working clinic and an educational program.
  • Funding, including how to compensate for reductions in graduate medical education funds.
  • Advocacy to maintain the program.
  • The small pool of Indian medical students (158 out of 67,651 in graduate medical education) makes recruitment difficult. Dr. Cullison stressed the need for "pipeline programs" that expose school-age children to the idea of becoming medical professionals.

Cullison's advice for making a partnership work included:

  • Understand the nature of the agencies involved.
  • Start with a shared goal.
  • Develop personal relationships, rather than basing a partnership on a business relationship.
  • Determine a project that will be to the mutual benefit of the parties involved (e.g., SIHB now has three Indian physicians, and Providence has added dimensions to the residency program).
  • Where possible, create the structure up front.
  • Expect problems.
  • Be willing to compromise; decide in advance how much compromise is possible.


Cooper-Patrick L, Gallo JJ, Gonzalez JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999 Aug 11;282(6):583-9.

Saha S, Komaromy M, Koepsell TD, et al. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med 1999 May 10;159(9):997-1004.

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