Breaking trail in the Northwest Territories: a qualitative study of Indigenous Peoples' experiences on the pathway to becoming a physician.

Currently, there is a lack of Indigenous physicians in the Northwest Territories (NWT), Canada. The goal of this qualitative study was to explore the underlying factors that influence the journey to becoming a medical doctor and returning home to practice for Indigenous students from the NWT. Eight qualitative, semi-structured interviews were conducted by phone or in-person. Participants represented Dene, Inuvialuit and Métis from the NWT and were at varying points in their journey into careers in medicine, from undergraduate university students through to practicing physicians. The main themes identified included access to high-school courses, the role of guidance counsellors, access to mentors and role models, a need to prioritise clinical experience in the NWT, influences of family and friends, diversity and inclusion, and finances. Interpretations: Significant barriers, some insurmountable, remain at every stage of the journey into medicine for aspiring Indigenous medical doctors from the NWT. These findings can inform policy development for pathway program that assist aspiring Indigenous physicians at each stage.

Introduction

Rural and remote regions of Canada experience a unique context in the delivery of healthcare services due to remote geographies, Indigenous values, health inequities and climate change [1]. Providing responsive services in this unique context in these regions requires system-wide approaches across sectors of government. One system factor that has been consistently raised is the need to address human resource challenges, specifically those related to increasing cultural competencies of the system through Indigenous participation and improving the consistency of Indigenous physician services.

The Royal Commission on Aboriginal Peoples report of 1996 [2] and the Truth & Reconciliation Commission’s (TRC) Calls to Action of 2015 have both recommended the training and hiring of more Indigenous healthcare workers in Canada (as a note for readers, the term “Aboriginal Peoples” is the old term for what is now referred to as “Indigenous Peoples”). The TRC’s Call to Action #23 specifically recommends that all levels of government strive to increase the number of Indigenous healthcare professionals working in Indigenous communities [3].

In 2016, 0.8% of the 93,985 specialists and general practitioners in Canada identified as Indigenous, with Indigenous Peoples representing 4.9% of the population [4]. In 2016, it was estimated that 2.6% of first-year medical students were Indigenous [5]. When this research project began in 2016, there were no Indigenous physicians working within the territory, where slightly over half of the 44,520 people are Indigenous. In comparable terms, that is 0% Indigenous physicians, where 50% of the population is Indigenous. Historically we know that in the past two decades there have been six individuals from the NWT who have completed medical school and residency. Of these, there have been three who returned to practice at the NWT, then left. As of 2019, there was one Indigenous physician from the NWT practicing in the territory.

The context for Indigenous physicians in the NWT is also influenced by the rural and remote context. In Canada, the proportion of rural and remote regions, including much of the NWT, experience a maldistribution and a relative shortage of physicians compared to urban areas: the 2016 Canadian census showed that 16.8% of Canadians live in rural areas [6], whereas only 8.2% of physicians work in these areas [7]. The shortage of Indigenous physicians in the NWT exists against a backdrop of a 34% shortage of general practitioner physicians in the territory, as of the most recently published data [8]. Smaller, primarily Indigenous communities in the NWT experience these shortages disproportionately compared to the capital city of Yellowknife. These smaller communities rely almost entirely on short-term solutions to maintain physician-provided services, including locum hiring that brings up doctors from Southern Canada. Others have described the reasons that southern doctors have practiced in the NWT [9], including a desire for adventure, the challenge of remote medicine, the desire to work with an underserved population, and competitive compensation.

The training of Indigenous physician workforce experiences has been described within the literature on Indigenous recruitment strategies. Internationally and in other Canadian provinces, physician recruitment and retention in remote and/or Indigenous communities has been studied [10,11]. One review that used a Kaupapa Māori Research (KMR) methodological approach found that elements influencing the development of an Indigenous workforce is part of a larger pathway of system supports [12], which includes high school outreach, medical school admissions support and cultural supports while in medical training. These supports target future physicians from a young age through to when they become a licenced physician and are looking for a job. These programs focus on admitting medical students from underserved regions and teaching them medicine in these regions, all with the goal of having them return to practice there. The now-defunct National Aboriginal Health Organization conducted a review of best practices to recruit mature Aboriginal students into medicine and recommended that best practices include preparatory programs, recruitment initiatives, financial support, Indigenous supports in medical school, and responsive curriculum [13]. Currently, most of these supports do not exist for in the NWT. Further, there are not any medical schools in Canada that strategically engage with Indigenous students from the NWT.

This study aims to further contextualise the literature on medical school access for Indigenous persons, and aspects related to physician recruitment specific to the NWT. The objectives are two-fold: firstly, to identify the factors that affect NWT Indigenous students on their journey pursuing medical training and secondly, to identify the factors that influence their decisions of where they choose to practice.

The implications of this research may be of further interest to other circumpolar Indigenous populations that have faced similar issues, including for such populations as the Sami and Alaska Natives, who have previously had allocated seats at medical school for them [14,15]. While we recognise that there are ongoing initiatives in the circumpolar world regarding Indigenous physician training and recruitment, such as in Greenland, Russia, Scandinavia and Alaska, it is difficult to discern the extent of current initiatives given the paucity of up-to-date literature on the topic. Further, it is not the intent of this study to conduct a full comparison of what initiatives currently exist across circumpolar jurisdictions.

Methodology

Thematic analysis was the method used for this research project. This method was chosen for its flexibility in categorising themes in wide-ranging interviews.

The initial development of the interview questions and the eventual categorisation of data were guided by a recruitment pathway framework that was developed from an Indigenous recruitment review of 70 articles by Curtis et al. [12]. The framework identified themes along the pathway from education and training to workforce experiences. As such, recruitment refers to the lengthy process of first becoming interested in medicine, through medical training, and finally into a job as a healthcare provider. We conducted semi-structured interviews by phone or in-person until data saturation was achieved. The questionnaire was developed based on five broad contexts of recruitment activities along the pathway described in the review by Curtis et al. [12]. Specifically, question style was designed to explore and describe the positive and negative factors faced by Indigenous Peoples from the NWT across these five broad recruitment categories of early exposure, transitioning, tertiary retention/completion, professional workforce development and across the pipeline [12]. A pilot interview was conducted with an Indigenous medical student who is not from the NWT. Feedback on this interview was provided by a qualitative interview expert, Dr. David Snadden, and suggestions were incorporated into the questionnaire and future interviews. Our target population from the NWT included Indigenous students at various stages of their journey in medical training, including premedical studies, medical students and residents, and Indigenous physicians already in practice. Ethics approval was from the Aurora College Research Ethics Committee under protocol number 20,160,605.

The positionality of the researcher (TD) was acknowledged as a potential source of bias and pre-conceived ideas. Specifically, his own context as a Métis person from the NWT and, at the time this study was conducted, a first-year medical student with his own experiences related to his journey into medicine. However, rather than a hindrance to this research, his experience with the study’s topic and his cultural competence as an Indigenous researcher enhanced his suitability as an interviewer for this qualitative method.

The interviews were conducted from 20 Aprilth to 26 Mayth, 2017. Eight participants were identified and recruited via snowball method via email. Further demographics of interviewees are included in the results section. Questions were provided to participants prior to the interview. Written or verbal consent was obtained from all interviewees. The interviews were audio-recorded and were done over video call, telephone or in-person at the Institute for Circumpolar Health Research in Yellowknife, NT. The interviews ranged in length from 38 to 94 minutes. No repeat interviews were conducted. No field notes were taken. Transcripts were returned to participants to comment on the interpretation of data and to confirm quotes that were identified by participant number. Requested changes were made.

Interviews were transcribed and then coded using Dedoose software (TD). The initial coding framework was guided by the five contexts that reflect the factors involved in a journey into a healthcare career for Indigenous Peoples [12]. SC reviewed the coding of the first transcript done by TD and provided suggestions regarding appropriateness of codes and suggestions for additional codes. Additional codes were added during the coding process that reflected themes not covered in the literature. SC and KS assisted TD in identifying themes from the data. Participants were not provided with a description of the coding tree at the time of interviews. Original quotes from the participants are used in the results section of the paper to improve the rigour of the study. Quotations are identified by participant letter. The coding approach enabled us to determine when data saturation was achieved within the study sample.

Results

Participants included one undergraduate university student, three medical students, three practicing physicians and one medical school applicant who has been unable to get into medical school thus far. Approximately half of the participants are from the capital city of Yellowknife, and half are from medium-sized communities in the NWT ranging in population from 1,000 to 5,000 people. Perspectives from the three broad Indigenous groups of the NWT, namely Dene, Inuvialuit and Métis, were all represented among the sample.

In the context of the population of Indigenous Peoples from the NWT who have ever been admitted to medical school, six out of eleven were interviewed during the study period. Eight of these eleven had completed medical school by the time of writing. Six of these eight were trained in the last two decades. Of these eight physicians originating from the NWT, one was deceased (and therefore not identified as a potential interviewee), two were contacted but were unavailable for interview, and two others could not be contacted for interview. The three who were interviewed are all practicing in a rural or remote location outside the NWT. Two are general practitioners and one is a specialist. These three participants completed their medical training within the last ten years and they are all under the age of forty-five. The locations where these physicians were trained is omitted to preserve confidentiality. Since the NWT has a relatively small population, and the principal investigator has kinship ties across the territory, it is believed that the study sampling snowball technique was effective in capturing an accurate representation of Indigenous population in the NWT, and identification of people who have attended medical school. TD had previously met five of the eight study participants prior to recruiting them for this study.

The data analysis identified seven themes that emerged during interviews and during the coding process. These included access to high school courses, messages from high school guidance counsellors, access to mentors and role models, a need for government to prioritise clinical experiences in the NWT for Indigenous medical trainees, influences of family and friends, diversity, and inclusion and finances. Below we expand on these themes with the data that informs the context for the NWT (see Boxes 1–7). We also purposely include narratives that capture the personal impacts of these experiences. The decision to include personal narratives was made to target audiences of this work, including the medical community at large, healthcare administrators, medical school leaders, high schools, and youth interested in pursuing medicine.

Discussion

The interview method for open-ended questions was effective for this small population context. The process allowed participants to voice either negative or positive aspects of their journey into medicine. The interviews revealed more negative themes, like barriers, than positive themes, like resilient personality traits. Some of the main themes uncovered by this project were the microaggressions and the assumptions of inferiority experienced by the participants, such as participant G being referred to as “some native” by a classmate. Ideas that Indigenous medical students were inferior were also voiced by the participants’ high school classmates, guidance counsellors and medical school classmates. The access to desirable clinical rotations in the NWT was seen to most as a barrier to returning to practice there. Financial barriers included costs of travelling large geographic distances and a lack of post-secondary funding for medical students. The lack of support from family and friends was a barrier for some and, conversely, the presence of support was a strong facilitator for others. Related to this, given the long-term and intensive commitment of medical training, some family and community members, although generally supportive of the individual, did not understand the path their youth were taking when they left home to pursue medical training. Although all three physicians interviewed voiced a desire to practice in the NWT, administrative challenges with the return-for-service program and hiring processes dissuaded them, and even prevented them, from returning to practice in the territory.

There was one study participant who was notably different from the others in that they had moved to the NWT after high school and did not face some of the early challenges that other participants who grew up there had experienced. We do not provide further characteristics or unique aspects about this participant here because this would compromise their confidentiality.

The literature reflects our findings of how diversity, inclusion, equity and racism remain as challenges within the student body of Canadian medical schools where Indigenous students are still underrepresented [16-19]. The assumption that Indigenous medical students were inferior because they were admitted through an alternative admission process and the belief that this process is unfair to non-Indigenous students has been previously documented by Currie et al. (2012) and DeCoteau et al. [19,7, 20]. The feeling of abandonment experienced by family and friends of participants in this study is corroborated in the literature on nursing: Indigenous nurses in Saskatchewan had a similar experience of being viewed as “too good” for their community or as outsiders for leaving the community to pursue post-secondary studies [21]. This experience emphasises the geographic challenges of post-secondary education. The findings of this study align with a similar study on Indigenous students in Manitoba from 1992 and with a study from the US by Hollow et al. [2006, 22,23,24–26]. At the time, the University of Manitoba had a program called the “Special Premedical Studies Program” that assisted students on their pathway into medicine. Students and physicians who were a part of this program cited inadequate career advising, lack of role models in their desired field, inadequate schooling prior to university, and financial barriers as important factors in their education.

Study limitations

There are likely many more potential interview participants who have not yet been to medical school but who are interested in pursuing medicine. For this study, only two from this population were interviewed. One population that was not interviewed were Indigenous high school students who are interested in medicine. Additional studies on these groups are needed to describe their path to postsecondary studies. There are further limitations related to the potential participants who were unavailable for interview. They have unique characteristics that would potentially provide a different perspective. We do not define these unique characteristics here because this would identify them and would also identify those within this limited population that did participate in the study.

Conclusions

There are few academic papers that describe the journey into medicine for Indigenous students [23] and only one that reflects the experience of Indigenous students in Canada [22]. Furthermore, until now, there were no papers that explored this topic pertaining to the unique context of the NWT, a jurisdiction distinct from other Canadian provinces and territories. The NWT is a jurisdiction without a university, with vast geographic distances and with significant cultural diversity across the three distinct Indigenous groups, namely the Dene, Inuvialuit and the Métis. While the small population of study may be seen as a methodological weakness, it also highlights the severity of the challenges of pursuing medicine for Indigenous residents in the NWT. In addition, where the NWT persistently has no Indigenous physicians on staff, we felt an in-depth qualitative study could uncover experiences that are grounded in NWT cultures and could highlight policy levers specific to health and education systems in the NWT. Elements identified could provide a baseline and inform medical schools, health departments and education sectors in the development of pathway program strategies for the NWT. We hope this research will highlight the inequities and provide direction for action with an outcome of increased participation of Indigenous residents from the NWT in medicine. Specific recommendations that could be applied include (see Box 8):

This study provided rich data that is specific to the NWT policy environment. Policy and programming impacts include education (high school courses, guidance counsellors), financial aid, medical services (electives, mentorship) and medical schools at universities (mentorship, career guidance, application process). Each of these sectors operates independently and would benefit from a collaborative process that develops a strategy for Indigenous physician development and a pathway model specific to the NWT. Cross-cutting this initiative, there should also be an evaluation process built in, which could allow for quantitative and qualitative data of the pathway experience to inform modification of policies as the strategy is implemented. In addition, data on the number of Indigenous physicians in the territory should be captured and monitored for improvements. Further, we hope that other Indigenous Peoples’ groups in similar contexts in the circumpolar world may find these elements helpful in addressing their own healthcare human resources challenges.

Box 1. Access to high school coursesMany students in the NWT are unable to take university-entry courses at their community’s high school and some high school graduates are unaware that the courses they took are not university-entry level. University-entry 30-1 courses are only offered in the larger towns in the NWT and students from small communities must travel to these towns to take them or enroll in distance E-learning. Participant E explained the following:A lot of students are graduating grade 12, and they don’t have the requirements to start on an undergraduate degree and have to take multiple years of upgrading. I think where the support needs to be is in those final three years of high school to help students be successful. Because to go and take two years of upgrading away from home when you could have done those two years when you were living at home in high school is a recipe for a difficult situation financially, socially, and emotionally.Although there are significant educational challenges, participant E explained the unique and enriching extracurricular opportunities available to students from the North:I went to Antarctica and the Arctic with Students On Ice, and I went to national debate conferences in Winnipeg in my high school years. Those opportunities wouldn’t have existed to me if I wasn’t living in the North. I attribute some of that success to the fact that I lived in the North and had access to those opportunities.

Box 2. Messages from high school guidance counsellorsConversations with guidance counsellors about students’ interest in pursuing careers in medicine was a common theme in this study. These occurred in the context of one-on-one meetings discussing career options with students. In an environment where few students are interested in or proceed on to medical school, there may exist among guidance counsellors a lack of knowledge about medical school or some felt there may be an inherent bias that most students are unlikely to be successful in pursuing medical training. Although most of these experiences were negative, the insights shared by participants showed resilience in overcoming the often-negative messaging from counsellors. Participant G explained:I had a guidance counselor who essentially laughed at me when I said I wanted to be a physician when I was in Grade 9. I wasn’t the best student and I really had to teach myself to be a better studier and stuff like that at university. So I mean, it starts, to me at least, it could’ve started at that point where if there was the support of a guidance counselor who could say, ”There’s medical schools in Edmonton and Calgary and University of British Columbia, and this is prerequisites, this is what you’ll need to take when you’re at university.” That never happened. I was laughed at because nobody took me seriously. I was a B student that became valedictorian, and then all of a sudden it was like, ”Wow, okay, maybe we should’ve taken this guy seriously.”Participant E shared a similar story. She said her conversations with counsellors made her feel confused and second-guess her career plans. She explained how she turned these discouraging conversations into a source of motivation:I found myself agreeing that maybe those comments were true. People would attribute my high school grades to the fact that, ”the only reason why your grades are good is because you’re smart compared to the small population of students that are here. Your grades probably aren’t all that good. If you were to go to school down South and actually compete, you’d find that you’re below average. You just happen to be good in the North.” There was a lot of ”You’re good for here, but you’re actually not good enough.”It was demotivating. It took a while for me to actually turn that constructive criticism around and use it as a motivating factor. When you’re a teenager and you’re just trying find your way amongst your peers and now questioning your decisions for carrying on in future studies. It’s a pretty difficult time.Participant A had a different experience and was encouraged by her counsellor:I know my guidance counselor was really helpful and encouraging to like, ”Yeah, you can do this. You can be a doctor,” and everything. I know that helped me a lot, especially applying to university, he helped me apply for everything, too.

Box 3. Access to mentors and role modelsMentorship and role modeling emerged as an important topic. Participant E explained how she never saw physicians as role models in her community:To be honest, there was absolutely no one. Professionals in the community seemed to be unattainable, physicians were rotating quickly in and out of the community. In a sense physicians never integrated with the communities, so you never saw that local physician as a person. They were never something that you could say, ”Oh, I could see myself being that person,” because they weren’t a person, they were a doctor.She later explained how this impacted her medical school interview when she was questioned about how she knew she wanted to be a physician when she didn’t have any physician role models.Participant C shared a different perspective about how the physicians and Chief Medical Officer with the Government of the Northwest Territories (GNWT) were influential in her decision to pursue medicine: “there’s so many really amazing doctors here that are reaching out to students”.Several participants in this study said youth mentorship needs to start at a young age prior to high school. Participant G elaborated that:To me, I think if we’re trying to improve recruitment, we should be engaging students who are at that point of making decisions, and who are open to, I guess, sort of new ideas that aren’t, ”Hey, let’s go work at Diavik”, or you know, like, ”I’m gonna drop out in Grade 10 and go make 80 grand up at the diamond mine.”He further explained how the medical schools that partnered with the NWT for clinical training didn’t conduct enough outreach at the time:I think, you know, obviously there’s these partnerships with various universities, but at no point in the past had I ever seen an ambassador from those schools come down and say, ”This is a realistic program, there’s these spots available, this is what you would be doing, this is what you would need to do to get here.” I had to figure all this stuff out myself, and kind of work towards what I thought would get me into medical school.Participant C echoed the need to highlight and leverage the successes of the cohort of Indigenous physicians who have come out of the NWT:If someone showed an interest in science or medicine at a young age, it’d be great to be able to reach out to this organization and have almost like a Big Brother and Sister program. Because realistically, one of the biggest barriers is just self-doubt for indigenous youth. What better way than having indigenous doctors willing to reach out to them and easily accessible to them to help them jump over that one barrier.

Box 4. A need for government to prioritize clinical experiences in the NWT for Indigenous medical traineesSeveral participants described barriers to clinical training in the NWT because they were attending medical schools that didn’t have partnerships with the NWT. Participant F shared that:I had to find and make that opportunity for myself. There wasn’t really any elective opportunities in the NWT offered, unless I inquired about it. But, when it came down to the credentials, they said, ”basically we like to take from our pool of people going to the University of Calgary, University of Alberta.” Other places were not high on their list. I did ask if they would make exceptions for people who are from the north, and moreover, people who are Aboriginal from the north. They said, ”yeah that’d be great”. But, it seemed to me when it came down to the crunch it wasn’t as easy to get that spot in Yellowknife as I was led to believe. Hence, I just called around and tried to find a preceptor… So, I had to do some of the leg work myself, which is not really all that big of a deal if you keep bugging or know the right people.Participant E explained her concerns about not being able to get clinical electives in the NWT:Electives have the ability to influence where you do residency and therefore influences whether or not I come back to the North at the end of the day. I’m nervous that my motivation to return to the North will be gone by the time I complete residency because at that point I won’t feel that the North is home. Every year that I spend further away, I lose a bit more of that connection, that sense of belonging, that sense of home. It makes it harder to want to return because it’s not a part of you. I will love the North forever and I always said that I wanted to return to the North, but I just might not end up in the Northwest Territories for that reason.Participant G proposed his ideas to facilitate clinical learning opportunities for Indigenous medical learners:I think if the government of the Northwest Territories was serious in recruiting Indigenous physicians, they would essentially be opening doors and creating opportunities for us to go back. Like, electives in first year and second year, rotations in third and fourth year … encouraging residency positions in places that do send people up for residency, or like residency rotations and stuff like that, in our one and two years. I mean there’s, to me it seems easy. Actually call us and let us know that there’s these opportunities, because the only emails I ever got from the government of the Northwest Territories revolved around money, and whether or not I intended to be using the Medical Student Bursary the next year. At no point were they like, ”Hey, you’re going into your second year. Would you consider doing an elective with such and such physician? We could open this up for you.” Whenever I essentially emailed, I was told that all the spots are full, and that included emailing nine months in advance.He suggested that flexibility in creating elective opportunities could address these barriers:”Hey, this physician is interested in opening up an extra two-week elective for you despite the fact that all elective spots are full. We’ll make an exception because we understand who you are and where you’re from, and that you’re quite interested in coming back, even though you’re at the U of A as opposed to other schools, that we readily take our students from.”

Box 5. Influences of family and friendsThe intent to return to practice in the NWT was common in this study. Several participants explained how being down South for education for a long period can influence life plans. Participant H shared the following:It’s interesting to try to get people out of the North to train them, but also have them wanting to go back to the north. Sometimes the duration of your training is so long, like mine was five years to get in, four years of medicine, five years of training. That’s 14 years. Right? So after 14 years of kind of being a southerner, you get used to a certain thing, and you make relationships, and sometimes that’s a barrier to going back. Like I know my husband and I spent a lot of time discussing … he’s from Calgary. The idea of moving to Yellowknife was big for him.Others had different experiences and were not encouraged by some community members back home. Participant G explained the following:I wouldn’t exactly say that … outside of my employer, and I guess my direct family, that I really had a lot of support in the community, because at the time, a lot of my friends were out drinking and partying and stuff like that every weekend. I was seen as the lame guy that just didn’t really want to go out and wanted to read his books and was better than everybody else because he went to university and stuff like that. So there was a bit of a blow-back from me, socially, in choosing what I did.So yeah, I guess … I didn’t have a ton of support from my friends, which was kind of a shame. But then, I guess when I tried it the second time, it was a little bit easier because I think people understood that I was taking things seriously, and then … they kind of treated it, I guess, a bit more seriously as well. So yeah, trying to win over my friends was a bit of a battle that I didn’t expect to have, and I can’t say that my friendships have been the same, having graduated and stuff like that, because now there’s a bit of intimidation and stuff like that when I go back home. It’s really hard for them to see me as I was, as opposed to now.Participant C explained how communities can experience a sense of abandonment when a young person leaves:If you leave, people are just, “you left, you abandoned your community, you think you’re so much better than us now, blah, blah”. I got that a lot from family members coming back. Abandoning and just taking off and thinking that, yeah, that I was somehow superior because I was down South in school.She described how this could be fixed by spending time in the community and arranging a community ceremony to acknowledge and better understand the reasons for leaving:Go in the summer times or any time in a break to go back and see family and be seen. There probably could be even like community celebration that someone’s leaving as opposed to saying this person’s going to study medicine and come back and help the community. And then it would be viewed as something positive as opposed to someone leaving.Participant C also told a story about how the medical school she went to didn’t let her go home to the NWT after the death of a family member. Having only two days off for family commitments ended up jeopardizing her medical studies:So I flew out for the funeral, flew back down. I went in to talk to them, “Okay, you’ve had all this stuff happen to you and all these emotions. We need you to put that in a box, put it in the back of your brain and just ignore it. Put it in a box, put it in the back and just get through this”. So I tried to, I tried really hard. I passed, but I wasn’t doing as well as I could. I wasn’t nearly absorbing as much as I should and I just hit that wall where I just fell apart.

Box 6. Diversity and inclusionParticipants have experienced discrimination at various points in their journey into medicine. Participant G explained his experience of discrimination shortly after beginning medical school:It seemed to me that a lot of, that the students already knew each other. So you entered day one as a stranger kind of thing, and nobody essentially had ever met somebody from the Northwest Territories. There was only about a handful of us Indigenous students. So I felt like I was kind of othered right away, and it took a while to kind of break into the various cliques and stuff like that. I mean, I can’t say that there wasn’t racism during years one and two, because I had heard … I was being referred to as, ”Some native in the first-year class.”Sorry, I guess I should back this up a bit. I had gotten into a discussion with someone who I felt was being insensitive towards First Nations at a social gathering. I called them on it in public and then I found out the next week from a friend that they had overheard someone mention that at this gathering ”some native” got into an altercation with another student. So it was a bit frustrating, because, I guess it’s just a reminder that no, there’s no spot that’s kind of free of racism, and that included medical school.Participant C explained how attending medical school in southern Canada was a hostile environment. Like others in this study, she explained how she felt stigmatized by being admitted through the university’s Indigenous admissions process, which provides academic and cultural supports to prospective and current medical students.I just find Indigenous students, Indigenous youth across the north, there’s so much of this feeling of inadequacy in every way. I think a lot of it is residual shame that the parents’ generations are feeling for residential school and colonization and then you have this trickle-down effect of people feeling where do I belong?I don’t speak my traditional language and everyone’s really in limbo and I don’t belong down south. Where do I fit in and what opportunities are available to me? And it’s a huge amount of imposter syndrome, I think, when people go down south and they’re transplanted in this new place and people are telling them you’re only here because you’re aboriginal, you only got in because you’re aboriginal and you’re obviously not as smart as us.I got that a lot and it still happens a lot and it’s really too bad. I think it’s a really big reason that students don’t leave the NWT to pursue basically their dreams.

Box 7. FinancesThe financial barriers of pursuing medicine was a common theme. Participant B highlighted the thousands of dollars it can cost for a single medical school application cycle:So I may apply again this fall. But it’s an incredible cost to even just apply. Like I think it was $700 for the one. Plus then the flights down to Thunder Bay. Plus all of the hotels and everything else. Thankfully I used my flight points. But if I were to actually pay for it, it’d be about $5,000.Another significant application cost is to leave the NWT to write the MCAT, which costs up to $1,800 to fly from Inuvik and $315 to register for the MCAT. Accommodation costs are additional to this. Participant G explained his MCAT experience:I was broke after that, and demoralized and all this stuff. I can see that as … a real barrier in somebody ever taking the attempt again seriously, because that’s a big chunk of change.Currently, there is no writing centre for the MCAT in the Northwest Territories. Previously it was offered at Aurora College until 2007.The discussion on financial barriers was broad. Another common topic was the return-for-service program administered by the Government of the NWT that was discontinued in 2014. It provided $10,000/year to medical students, and an additional $15,000/year for a 2-year family medicine residency.Participant E explained how the program got her interested in medicine while in high school:I remember in high school hearing about a scholarship available to help you pay for tuition in medical school from the government of the Northwest Territories. I thought, “When I get there, eight years or six years from now, I will have access to that”. Needless to say, I got into medicine and started making some calls only to find out the program’s no longer in existence. Because they didn’t have enough people returning to the North despite providing them funding, so they cut the program. This was very disheartening.Medical school is an immense financial endeavor and I was relying on the financial support from the GNWT to provide much needed support after meeting the challenge finally entering medical school.She explained how the lack of a return-for-service agreement is affecting her career choices:Alberta has a scholarship program with a return of service agreement. You can get your four years of tuition covered for five years return of service in a rural community. Every year I watch that application arrive in my inbox and find it harder to turn down.One of the return-for-service recipients, participant G, explained how he felt mistreated by the program administrators:I mean another frustration was … I remember going to a conference, and I went up to the GNWT desk to talk about various opportunities, and they did know who I was, but I was referred to as the “return-of-service guy”. I wasn’t referred to as [my name], I wasn’t somebody that they were like, “Hey, there’s opportunities here in this community”. It was like, “Hey, there’s the return for service guy”. I remember them saying that, and then, “Hopefully we’ll be able to get this one”, was what they had said.I had just kind of laughed it off at the time, but afterwards, I was really offended because they really didn’t take the time to take recruitment seriously.Another return-for-service recipient, participant H, had her agreement broken when the job she was negotiating wasn’t available after residency:It had been my plan to come back in residency, even up until my chief year, I had done electives in Yellowknife. And then, in November of my fifth year of residency, at the end of my four weeks, they just said, “We don’t have a job”.We had several letters back and forth, cause previously there was gonna be a job, there was gonna be a job.The Northwest Territories Student Financial Assistance program (SFA) was another common topic. SFA is a program run by the Department of Education, Culture and Employment that provides 12 semesters of post-secondary grants to Indigenous students to travel out of the territory to attend university. Participants highlighted how the funding was crucial to their bachelor-level education but that it runs out after 12 semesters and doesn’t support both a 4-year bachelor’s degree and a 4-year medical degree afterwards, typically a minimum of 18 semesters. A maximum of $60,000 of territorial student loans available after this funding is exhausted also doesn’t reflect the approximately $20,000/year tuition for 4 years at medical school.Another common financial topic was the line of credit of $275,000 to $300,000 that is available to Canadian medical students. Participants agreed how crucial this is in funding their medical studies after they have used up their SFA grants and now that there is no longer a return-for-service agreement.

Box 8. Recommendations Access to high school courses. Students in many communities throughout the Northwest Territories do not have access to university-entry grade 12 classes and are required to move to larger towns in the territory to attend these classes. Recent e-learning in NWT communities, such as Ulukhaktok, has allowed students to finish university-entry courses that would not otherwise be available in those communities (24). Continuing to support the e-learning program could increase the pool of prospective university students and also the pool of prospective medical students. (2) Messages from high school guidance counsellors. High school guidance counsellors have a significant influence on Indigenous youths’ career and education plans. Medical schools should target high school counsellors with information on entry requirements and Indigenous student supports. With this information, the counsellors would have the knowledge and contacts with resources at medical schools who support Indigenous youth interested in medicine. Students could continue to access Indigenous access programs at medical schools through undergraduate years and get support through the steps towards the application process. (3) Access to mentors and role models. Finding physician mentors is difficult in communities that have high turnover of locum and short-term contract physicians. There is also a professional concern for establishing personal relationships within small communities. This could be addressed by developing a mentorship program where NWT Indigenous physicians and permanent physicians can be supported to mentor youth with activities such as shadowing clinical practice, workshops on medical practice, and outreach to schools. Hollow et al. previously showed that mentorship is important for aspiring Indigenous physicians in the USA (23). (4) Clinical learning experiences. To facilitate access to clinical opportunities in the NWT, preference could be given to Indigenous medical trainees from NWT when allocating elective positions in NWT communities. Specific clinical placements could be created to funnel these trainees into underserved communities. (5)External Supports or Family support - There is a need to improve understanding by students’ communities about the long duration of medical training. Some students feel alienated and some communities feel like their young people have abandoned them. Educating a community about the long journey that it takes to become a medical doctor, whether stemming from the students themselves or from a widespread community education initiative, could improve community relationships. Community education can be supported by medical schools, high school counsellors and Elders. Further, once in medical school a process that facilitates regular visits, which could take the form of travel funding or clinical rotations in the trainee’s home region, could help maintain these ties. (6)Access to financial supports for medical school applicants and medical students. This can be addressed by creating specific funding at the territorial government level that assists students in the application process, as well as re-establishing GNWT funding programs for medical students, such as return-for-service agreements. Extending the number of semesters of funding available through the GNWT Student Financial Services or creating a loan program with a return-for-service component specific for professional degrees was suggested. Further, medical school application costs could be reduced by offering video conference interviews for distant applicants, like what some schools in Australia offer (25). (7)Diversity and inclusion within medical school classes This is a systemic issue that could be addressed with cultural sensitivity and anti-racism training at various levels of education, including at medical schools as recommended by Call to Action #24 in the Truth & Reconciliation Commission’s report (3). An example of this training is the San’yas program that has been incorporated at the University of British Columbia medical school (26).