A Native Narrative: Caring for American Indian/Alaskan Native Patients

November is American Indian and Alaska Native Heritage Month. We invited Dr. Dan Calac, Chief Medical Officer of the Indian Health Council located in North County, San Diego, on the show to discuss health care of American Indian/Alaska Native peoples in the United States and the importance of medical education within this community.

Learning Objectives:
1. Describe the structure of the National Indian Health Service and the services it provides.
2. Give examples of the unique healthcare needs and disparities experienced by American Indian/Alaska Native populations.
3. Cite systemic barriers to the recruitment and retention of American Indian/Alaskan Native individuals  into medical and scientific careers and best practices to expand the workforce caring for these communities.

Season 2, Episode 2 Credits:
Co-hosts/Producers: Dr. Brittane Parker, Alec Calac
Executive Producer: Dr. Tammy Lin 
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Tiffany Leung
Senior Producer: Dr. DJ Gaines
Editor: Joanna Jain
Production Assistants: Sanika Walimbe, Sarahy Martinez
Website/Art design: Ann Truong
Music: Chris Dingman

Connect with us on Instagram at @thedayshift.pod and via email at thedayshifthealthcare@gmail.com

Transcript

[0:00] Brittane: Welcome to the DEI shift, a podcast focusing on shifting the way we think and talk about diversity, equity and inclusion in the medical field. I'm Dr. Brittane Parker

Alec Calac: I'm Alec Calac a medical student at the University of California, San Diego.

Brittane: And we will be your hosts for today's episode. Today we are excited to bring you this episode featuring our guest, Dr. Dan Calac. As you might have noticed our guest host's last name is also Calac, so they are father and son. In this episode, will be discussing medicine and some of the ongoing challenges faced by Native Americans which is a fitting time given that November is Native American Heritage Month.

[0:53] Alec: That is so right Dr. Parker, it is really my hope to focus on these challenges everyday of the year much like Dr. Calac in his work. It is a pleasure to introduce my father to our audience. Dr. Daniel Calac has served as Chief Medical Officer of the Indian Health Council located in North County, San Diego since 2003. He was raised on the Pauma Indian reservation and graduated from San Diego State University. He attended Harvard Medical School and completed his internship and residency at the University of Southern California Los Angeles County combined Internal Medicine Pediatrics Residency program. He is board certified in Internal Medicine and Pediatrics and also practices hospice and palliative care medicine as a member of the Pauma band of Luiseno Indians and is actively involved in his community. He also serves as the principal investigator for the California Native American Research Center for Health Program, which is a NIH-funded project providing a platform for community-based research and the American Indian Communities. In his spare time, he also enjoys hiking, backpacking and spending time with his four children and wife, Jacqueline, of 29 years.

Brittane: Dr. Calac, welcome to the show!

Dr. Dan Calac: Thank you very much, it's an honor.

Brittane: Well, we have a very engaging discussion today. Dr. Calac, first of all, we have been referring to our guests by their first name on the podcast, is that okay with you?

Dan: That's perfectly fine, yes.

Alec: Dan (father), we look forward to discussing this important topic with you. Before we get started is there anything else that I missed in your introduction that you would like our audience to know?

Dan: That was really spot-on and I think just the one other comment that I make is that we tripped up on the father versus Dan and recently I'm having the honor to work with my mother and having the same issue. Having to call her mom or Esther was always a conundrum.

Alec: Let's transition to our next segment called, A Step in Your Shoes.

[3:08] Alec: In this segment, we ask our guests to share something about their background that they would like our listeners to learn about. This could be anything from a type of food, or drink, a song, genre of music, or a poem-- the goal is not only to get to know our guest on the show but also build cultural competency and humility. With that said, father, what would you like to share with us today?

Dan: The palette of experiences here, living on the Indian reservation in this rural community is wide and varied. I think just taking a couple comments about some early childhood experiences and transitioning into professional experience now, having lived in the area for the past 52 years there's been a variety of changes that have occurred within the valley. Just for geographical location and reference, we are located about 40 miles Northeast of San Diego. San Diego has grown tremendously over the past 50 years. The current population of San Diego county is about 3 million people and most of those people live along the coastal regions. And the area that I live in that is surrounded by approximately 18 Indian reservations, the area is very geographically diverse and actually home to the Hale Telescope which is on the highest peak in Southern California, Palomar Mountain. In this area nestled amongst the mountainous regions are the Indian reservations. As a child growing up in this area, I often site actually in my personal statement for Medical School said sagebrush and dirt were my best friends because that's all we did during the day, was play amongst the sage brush, built a lot of dirt/mud pies, and it was one of those ages the people often site that parents said "leave in the morning then come back when it gets dark". That was a very wonderful time to grow up in. In transitioning to the professional period and over the past 50 years, we've seen tremendous changes over the past 5 decades. The onset of much more traffic, much more people, and of course the major economic development of casinos and gambling entertainment venues in the area. It has put a very different face on the area where I initially lived. There is still a lot of sage brush and dirt but it's definitely taken on a different perspective. So I think with that, its been a very interesting time to practice not only from the medical field but the public health perspective in terms of dealing not only with the initial issues of poverty and disease and resilience within the community, but also dealing with the economic strains, the disparities between the communities, for those who are gaming and non-gaming, and just the different capacities for communities to really adapt to these new changes over the past 5 decades.

[6:46] Brittane: Yeah, thank you so much for sharing. One thing I wanted to start off with was for our audience to get to know a little bit more about you and about your background and family heritage. So maybe you could give us a few sentences on that?

Dan: Yes, so I often cite my enrollment number as a cultural and family heritage take-on point. So my enrollment number is number 12, and for people in the Navajo community or from much larger tribes in Oklahoma where the enrollment number is in the thousands, maybe tens of thousands. They always get a big kick out of how I'm number 12. In our reservation in our community, there are about 280 enrolled members, and you can see kind of where the number 12 comes into play. The areas from which I'm from, there are 9 reservations in the area. They are culturally and linguistically diverse in many ways, much more so over the past couple hundred years since the missionary period. Many of those cultural and religious practices were lost unfortunately because of the incorporation of many of the tribes within the spanish areas and they lost a lot of their cultural and religious practices. What we have now is a strong resurgence in the language that has persisted in the community and a preservation of the ceremonies that we do have, most of those surrounding bird songs, which are tribal/cultural songs that retell events since the Spanish colonization and also some of the strong cultural elements that persist in the area.

[9:04] Brittane: Thank you. During this episode we're going to be using a few different terms such as Native American, American Indian/Alaskan Native and I was wondering if both you, Alec and Dan, can tell us what those terms are and when to use them?

Alec: Sure. I think from my perspective and I think my father will certainly have a different interpretation, is that legally, American Indian and Alaska Native is defined as those maintaining tribal affiliation or community involvement from regions across the Americas in North, South, and Central America. However, in the United States the indigenous people in this area are legally known as American Indians/Alaskan Natives. However, the difference is that they can also be enrolled members in federally recognized tribes which are how they are recognized within the borders of the United States. So American Indian/Alaskan Native is the term that's frequently used by agencies like the Indian Health Service but there is a distinction that could be made for those who are affiliated with federally recognized tribes and that's not even to consider that there are even state recognized tribes as well.

Dan: Yes, I think that has well encapsulated the point. And to reference back my initial comment about my mother. My mother on that side of the family were south of the border (the Mexican/U.S. border). They're from a people known as the Huichol, even though they are 200-400 miles down below the U.S border, they're also examples of tribes crossing the border/tribal lands on both sides. A good example is the Tohono O'odham people in Arizona, but also the Kumeyaay nation also traverses and has land on both sides of the border, and the people from that tribe are on both sides of the U.S. national border. So, there's also a variety of other individual and cultural tribes that are not federally recognized, so that is an important distinction in how they access services because many of those people are impoverished or they were dislocated from their tribal lands the past several hundred years. They don't even have access to Indian Health Services for their care. So it's wide and varied in terms of whether you're federally recognized, whether you're on this side or the other side of the border and how you're designated and how you're referenced.

Alec: It's really a matter of someone's personal preference. There are those who like using the term American Indian and there are those who prefer Native American. There's also another group where it's kind of situational where you decide to use this term or that term. When I'm introducing myself for a speech, you know, I will not use American Indian or Native American and I don't even like to use Luiseno. I like to use Payomkawichum, the words that our people used to describe ourselves as opposed to the words that the Spanish or the words that the United States gave us.

[12:54] Alec: Something that I really look up to about my father is that he's the first physician from our tribe and I will be the second when I graduate from medical school. Looking for role models is something that's really difficult to find for Native American medical students, so I was wondering, what do you tell the Native medical student who sees themselves as the only one or the one of the few in their training? What advice to give them?

Dan: I actually had one individual I would talk to regularly. God bless him, I would call him out of the blue. His name is actually Dr. David Lucero. I remember him, distinctly remembering him, responding to my question about Indian Health Services and my scholarship: "Should I do the Indian Health Scholarship or not?" He was always there providing directed guidance and more as any good mentor does, being the sounding wall and the sounding board for ideas. Reaffirming what you really wanted to do. He was a sign post and a guiding individual who not only allowed me to develop professionally, but also traverse that unguided territory because as Alec had mentioned, at that time I was told I was the 6th California Native American to be a physician from the tribes within California. So having little to no guidance on what to do next, whether it was courses in college, or career opportunities, or research opportunities, it really came off a variety of mentors as well as the ones I've looked with, like David, to make those next steps to follow along the professional guidelines.

[15:06] Alec: Thank you so much, Dad. I think many of our listeners are unaware that tribal members have a legal right to healthcare. I was wondering if you could talk about that and how that kind of plays out in the Indian Health Service and also how the Indian Health Service looks different in the state of California?

Dan: So across the United States, it's a very mixed bag. When I say mixed bag, Indian Health Service has really come a long way, and it continues to really develop and progress even over the past years that I've been practicing. Just as an example within California, California is really broken up into 110 (it increases all the time) tribal entities. Those tribes, who are fairly recognized, have the capacity to band together much like the tribes that I serve. So there is a non-consortia tribal group that uses the funds from Indian Health service to form a non-profit to provide care for those individuals. These are all federal monies that come down from the Indian Health service or are congressionally appropriated. This is actually a model that has been replicated throughout California. Through a public health lot, 630 A, these tribes are allowed to compact and provide these healthcare services within California. Now outside of California and more traditionally within the Public Health Service/Indian Health Service, the Indian Health Service has been a medical care delivery service that has been centrally located in different regions in the United States. These regions are sometimes hundreds of miles away from where people are, and people have to travel anywhere from 1 to 6 hours to get care at times. As a matter of fact, in South Carolina, there are people that travel from as far as Georgia, Kentucky because that's the area they prefer and where the Indian Health Services are and where they can receive care. The clinic where they can receive care is about 20,000 sq ft, it's not a huge facility. There are facilities that are large, that are hospital based, but those areas are being still utilized, but they are being developed and modified to either provide better care, or more sensitive, appropriate care for the areas that they serve in across the United States.

Brittane: And I think most people who are in our audience and just across the country don't really understand the challenges of getting care and some of the issues that the American Indian and Alaskan Natives have, so I thank you for just highlighting those.

Dan: Yes, thank you. Beginning really in 1970, when care became much more technologically advanced. And we kind of look at 1970 as the onset of the CT scan then shortly after the MRI. And then much more so laboratory and specialized testing and really the development of the sub-specialists. Those areas have not been really kept up with within the Indian Health Service. The Indian Health Service still provides a lot of primary care. The advent and the use of technology has really broadened the gap and how it's funded and how this population is able to access those services. So, it's much like a capitated insurance agency, that provides care. There needs to be pre-approvals. There needs to be resource utilization that is addressed at each of these individual setters. Many times because of the historical issues that the people have dealt with, the level of health literacy and how we access those services and what are appropriate is sometimes challenging for the population and the providers to deal with.

[20:03] Alec: Does the Indian Health Service receive enough money for the charge that it has in caring for over 3 million Native Americans across the country?

Dan: The short answer is no, unfortunately the Indian Health Service is dramatically underfunded to provide the level of care that this population really needs. At baseline, this is not acknowledging the historical trauma, the behavioral health issues, the geographic/remote nature of the reservations, the food deserts, the variety of issues that these people, my people, our people have to contend with. This actually goes across many underrepresented individuals as well. In providing the medical care in perpetuity for these people, we are only funded about half of what we really should have in terms of what we need to provide and the level of care we would need to provide for these individuals. That's really been more apparent to me within my travels with the Committee on Native American Child Health (CONACH). It's been a wonderful opportunity to travel across the United States for the past few years with CONACH, which is an Indian Health Service and American Academy of Pediatrics combined group, to help communities provide a level of pediatric care that is commensurate with mainstream. Again, it is not our role to critique or grade, but more to support and nurture these communities in order to provide pediatric care. As mentioned, there are a variety of issues dealing with the food desert, nutritional aspects, safety, crime, human trafficking, substance abuse issues, maternal-fetal care. There's a variety of things that these communities deal with but the Committee on Native American Child Health has allowed this group of individuals, which are primarily pediatricians, or certain individuals from Indian Health Service or representatives from the American College of Obstetrics and Gynecology that go out and help support programs that are providing care for pediatric programs. But in doing so, you can really see the level of not only commitment amongst individuals and professionals who would work with the Indian Health Service and within these communities that provide care, but see the major problems that still persist to this day.

[23:00] Brittane: Yeah I think it's really important you brought up that organization. I also want to highlight the Association of American Indian Physicians and one thing I learned from Alec is that in 1969, there were only 30 American Indian physicians in the country, which was surprising for me. In my reading one thing that I found is that the Association of American Indian Physicians was founded in 1971 and it is an educational scientific and charitable non-profit corporation. At the time of its founding, the organization's primary goal was to remain and improve the health of American Indians and Alaskan Natives. Their mission as described was to really pursue excellence in Native American Health Care by promoting education and medical disciplines honoring traditional healing practices and restoring the balance of mind, body, and spirit. In 2018, the Association of American Medical Colleges put together a report on American Indians and Alaskan Natives medicine in conjunction with the Association of American Indian Physicians. This publication really distilled down into one document what is known and being done to increase the number of American Indian and Alaskan Native medical students and physicians, and summarized the best practices of many successful programs from around the country. We know that there are not enough Native American and Alaskan Native medical students and physicians in this country. This report, which we will put on our website, really highlights what is being done and what should continue to be done to increase these numbers.

Alec: Dr. Calac, I know that you are affiliated with the Indian Health Council Student Development Program that works with San Diego State, UC San Diego, and Cal State San Marcos to help support the next generation of Native American professionals and biomedical researchers. From my standpoint at UC San Diego, we are the region's only academic medical center. So I was wondering if you could talk about the importance of tribal academic partnerships and increasing the capacity of tribes that train their own students?

Dan: Yes, Alec. I would love to talk about that. As we spoke about 50 years hence, I can recall walking the Escondido Swamp Meet with my father, like any other 8 year old kid I saw this microscope sitting on this tarp on the asphalt. So of course I had to have it. So I think beginning with the interest in science then progressing towards taking a strong interest in science in high school moving forwards really started early. Being a pediatrician I have to admit/confess I've been whispering in my 5+ year old patients' ears "You want to be a doctor right?" So I've been slowly brainwashing these children over the past 17 years I've been working at this medical practice. However, that brings up a point, that's very important, very true is that you really have to start early when working with any population.

[26:37] Alec: The unfortunate reality is that 43% of medical schools have no enrolled Native American medical students which really exacerbates the workforce crises that we're seeing across the Indian Health Service. We've seen tribes really want to be a part of the solution and just this year the Oklahoma State University Center for Health Sciences and Cherokee Nation partnered to open the nation's first tribe Affiliated College of Medicine. So the question I have for you, Dad, is why are these partnerships important in increasing the capacity of tribes that train their own people?

Dan: In addressing the healthcare needs for the community, it's been shown in many different interviews and surveys that people go where they are from and like to practice their profession from the communities they were brought up in. That is paramount in addressing the shortage of Native American communities across the United States and probably you and I [Alec] are really great examples of that, in that being from the area, we have a connection to the area in Southern California. It's a fantastic opportunity to one, make an impactful change and also recognize that the relatively few and far between the Native Indians that are professionals that need to serve a large area. Simply stated, there might not be enough people to actually go around, and the need to actually have those academic partnerships to develop them and to encourage tribes to nurture those same relationships is key not only to educate and inform the universities but also to break down any stereotypes that the tribe and the community at large has with outside agencies. There's a longstanding distrust of larger agencies, governmental agencies, within the Native American and Alaskan Native community so by having those conversations early and showing there's definitely a reciprocal type of relationship that can exist, not one that the universities and/or large agencies can use as an advantage over the communities but definitely there can be collaboration and a give and take that benefits both.

[29:43] Brittane: So one thing I want to ask you, Dan, because of all of your experience with American Indian Alaskan Native populations, is what are some things that you want non-American Indian and Alaskan Native physicians to know when they're taking care of this population?

Dan: So thankfully, the agency that I work for has been very supportive and providing a medical educational opportunity for nurse practitioners, for nurses, for physicians assistants and for medical students and partnering with UCSD. And I think that the one of the most single theme that emanates from people rotating here is that they actually say something to the effect of "I had no idea this was out here" or, "oh, my gosh, the experience was just fantastic". And I also get that same experience from professionals that provide the specialty care here is like, "wow, you are seeing stuff that we would normally never see out in the mainstream medical areas". And so the Indian Health Service and, you know, many of these rural areas really provide a wonderful, not only opportunity, but a wonderful option to give back to a population that is in dire need of continued ongoing primary as well as specialty care. Specifically, I like to use Steve Hole. Steve Hole was the pediatric consultant for Indian Health Service and he commented that you really don't have to go outside the United States to have a global type of experience. You could actually just go to Indian Health Service and have a global health experience. And it's very true to this day is that for individuals who are non-American Indian, who want to have a life changing experience and to really get into really fulfill their initial inkling to quote-unquote, change the world as physicians, is to actually practice within Indian Health Service.

Alec: And when thinking about these experiences, I certainly learned from a few Indian health service physicians that it was just one clinical rotation that made a difference in choosing a 40 year career in the Indian Health Service. I know that you just started taking on medical students from UC San Diego at the Indian Health Council through their tribal ambulatory health care experience. So I was wondering if you could reflect on, you know, really, you know, you've touched on this what you're hoping these students learn about the very communities where you grew up in.

Dan: So as is the practice with many people within the culture, American Indian/Alaskan Natives, they always start with the story and tell a quick story about my experience. So my 'aha moment' was when I was at the North End Community Center and I realized that I can both do internal medicine and pediatrics. It's really satisfying my need to really have the academic rigor as well as providing care for children. And so when I found out that I could do Med/Peds as my residency program, I feel it was the same 'aha moment' that the students have when they rotate through here from the medical students from UCSD and the ambulatory traditional and ambulatory health care clerkship, but also the other physician assistants and interns that come out that have that same 'aha moment' and really having that fire back in their eyes about why they went into medical school and/or their professional programs to put themselves through that rigor in order pursue an environment like this. And truth be told, the medical staff now is probably 90 percent comprised of former students that had the 'aha moment' and I want it to come back and work here.

Brittane: Ok, thank you for that story. It's great to hear the work that you're doing and that people want to sign on and stay and work there, so we should send more medical students to you. With that said, we definitely need to have more medical students and physicians who are of American Indian and Alaska Native origin. But we have to be clear about our intention for recruiting and retaining these healthcare professionals. Now, Alec, you had shared with me a very interesting tweet about this, and I was wondering if you wouldn't mind sharing it with our audience.

[35:20] Alec: Sure, Brittane, so the tweet was part of an ethics chat with the AMA Journal of Ethics and this indigenous professor said, think about why you want American Indian and Alaska Native students at your institution. Is it for equity, diversity and inclusion indicators or is it truly because you want to change the structure of health and medicine in these communities? So hearing that, Dad, what are you thinking? What's your message to send back to, you know, people who are wanting to do this work?

Dan: Wow, that is a great question and I say great, because it really touches on really both sides of the argument, because there is a frustration that exists on both sides of that comment. One, I'll say obviously the most obvious frustration is on the community side. More Native physicians, more individuals who understand culture, who are from the community, who can really delve into not only why a client is stressed and why they're not fulfilling their regularity with care and being adherent to the plan of care for themselves. Because they're dealing with a variety of issues. And I'm going to touch upon the other side of the fence in a second. But a short comment, an illustration of why they're stressed. And so when I have clients and I talk to them about behavioral health issues or why they're not adhering to the medical care and says, well, you know, let's look at why there could be some things getting in the way. So let me see, you're coming from an impoverished community. You have poor access to food. You're probably living twice under the poverty lines. You have issues regarding drug trafficking, human trafficking. You have no transportation. You have a variety of other issues that you have to contend with. And so in any other situation that would create stress in an individual and by the patient saying, I'm not stressed, there is a big disconnect and realizing what they're kind of contending with.

Dan: And that stress is real and they're feeling that they just don't probably acknowledge it because it's become a community norm and that is the perfect example of resiliency in terms of accommodating what they have to deal with and then incorporate it into their lives. And then it's almost becomes normal and then continuing on as best they can. Being American Indian or Alaska Native and appreciating the stress that the community members are dealing with is critical to understanding where to intervene and how to support these patients to address their needs. Now, on the other side of the fence or at the side of the argument on the University-side, the big frustration not only amongst people who want to affect change because of where they are doesn't allow a rapid enough or broad change to occur. And I would like to highlight one of my greatest mentors, Dr. David Potter. So Dr. David Potter was a brilliant neuroscientist, and actually he was one of the pioneers in neurobiology and dealing with the nerve impulse in the squid axon, which again formed a lot of the basic neurobiology and neurophysiology around why and nerve impulse propagates across a nerve. And so he was my one of my mentors.

Dan: In terms of being frustrated, he was at a major institution there on the East Coast and he accommodated my summer internship within his lab. And I could tell right away that he was frustrated and like, we have to do more, Dan. And to this day, some of my colleagues and I even performed small parodies on him because he would say, like, "Oh, Dan, Harvard is so lucky to have you here." And I'm like, "No, no, I'm lucky to be here at Harvard." And he says, "No, no, no, no, we are so lucky to have you here." And it's really examples of some of the activities yet - because it wasn't only at the medical school that he had these students come out within the Four Directions summer research program to do medical internships within labs, but also in the Dakotas. He had summer programs for high school students. And I think he was really the epitome of what existed from the frustrations on the academic side and really trying to change that. We need to have more numbers to deal with that frustration. Of course, from other sides of it, you, of course, would want more numbers, but I think there's a definitely a midpoint that both frustrations are actually addressed. And you can have equity across both sides of it.

Brittane: And this is a really important conversation, especially now in our current climate in the United States when there's a large focus on inequality and diversity and what you talked about, making sure that there's equity in many areas and many different fields and professions in medicine, that we are mindful to look around and to see who is included and who's not included, who's not there, because if we don't have awareness, then we can't change things for the better and be like your mentor, who is continuously saying, let's do better, like let's make changes. So I really appreciate your stories.

[42:08] Alec: Reflecting on these inequities, I think it's also so important to think about the structures that we operate in and medicine, and we always try to enact change in the positions that we're in. And change is slow and it can be frustrating. But when I'm at the period of time when I'm the most frustrated, I look down and remind myself that I am on Indian land. And UC San Diego is built on Cumi Island. Yet the School of Medicine and there are 52 years, has never trained a Cumia physician. So I think it's really important for our listeners to acknowledge the land that our academic medical institutions are built on and really ask yourselves, you know, is the community, you know, in this area represented in our halls?

Brittane: I think that's such a great point.

Dan: Yes. Thank you, Alec, for bringing that up. And so a couple of comments. One was that I was recently asked to speak to a group on climate change and it was in a remote area, in and amongst the mountains in the area that you just mentioned in terms of traditional American Indian land. And my comment on climate change in this beautiful, scenic, idyllic area was about the presence of American Indians at the table and determining policies regarding climate change. And so, you know, how many attorneys, how many environmentalists, how many physicians, how many community members are at these tables making decisions regarding resource allocation? And the take home is that there are few to none who are making those decisions. If you're not at the table making those decisions, if you can extend that metaphor out, how does it really pertain to the survivability of those populations who are at highest risk for climate change in terms of temperature, dust, fire, allergy, asthma exacerbations? You know, the list goes on and on. How is that any more different than a form of genocide for individuals? Because if you're not at the table making the decisions, you're at the behest of decisions being made for you. And that argument is really critical in considering who was at that table making those decisions. And so much like you had commented about the medical programs, if you're not having individuals who are making medical decisions and having not only individuals who are primary care, but also individuals who are chancellors, who are superintendents, who are presidents of companies making decisions in terms of resource allocation, you need to have individuals at that level as well, helping to make decisions, making informed decisions and guiding individuals who are as informed as they should to help and better educate the problems that exist and affecting the communities that then aren't there to have a voice.

Brittane: I think that is such an important point, and I just really appreciate having the duo, Dr. Dan Calac, and soon-to-be Dr. Alec Calac here and to talk about this crucial conversation. I really appreciate it.

[46:00] Alec: You know, and thank you so much for this discussion. You know, it's certainly very eye opening when you start to learn about the disparities that exist across Indian country. And, you know, I just want to leave my father with one last question, which is, you know, what are some practical points that you want our audience to take away and implement into their lives?

Dan: Practical points, so I think there's probably just one point that I want the audience to really kind of consider, whether it be professional, pre-professional, high school is the resource of time. So, the gift of time and in dealing with whatever you need to do, you know, in terms of your profession, your career, your loved ones is something that you will not get back. And so I think the utility and the allocation of time, whether it be for professional development, for outreach, for even spending time on your iPad, just Googling American Indian history, is time well spent. It can be American and it can be Irish history, it can be German history, but it's really educating yourselves about what is really out there and then using that time thereafter to make an effective change, because we only have just a few short hundred years here to make an effective change. And after living half of that, at this point in my life, I realized that I have half of it to really kind of make more of an effect of change moving forward. So I would say in dealing with what you have here, the most critical practical point that you have to take away is how you use your time.

Brittane: Thank you so much, Dan, for being with us today.

Dan: Thank you.

[48:12]: Brittane: We would like to ask our listeners to continue this discussion online. We'd like to hear your stories related to this topic, your questions and any specific barriers or challenges you have faced yourself. We will have additional resources, including a transcript and summary of our discussion, as well as a link to the entire 2018 AMC report on American Indians and Alaska Natives in Medicine on our website www.thedeishift.com. Feel free to contact us there and follow us on social media, on Twitter or Instagram @thedeishift. You can also email us at thedeishift@gmail.com. It was great having all of you with us today. Please tune in for future episodes.

[49:10] Outro

The DEI shift podcast and its guests provide general information and entertainment, but not medical advice, before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by the day shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by the DEI shift team are those of each individual and do not necessarily reflect the views or opinions of the DEI shift team and its guests, employers, sponsors or organizations we are affiliated with. Season 2 of the DEI shift podcast is proudly sponsored by the American Medical Association's Joan F. Giambalvo Fund for the Advancement of Women and the American College of Physicians, Southern California Region III Chapter. Our theme music is brought to you by Chris Dingman. Learn more at www.chrisdingman.com.