“Hi, my name is Lora, I’m a first-year medical student, and I live in San Francisco.” This simple sentence, my brief introduction at the start of a meeting, reverberated in my mind. Hearing myself speak these words for the first time was jarring, the identities of “medical student” and “San Francisco resident” still feeling totally foreign to me.

My first several months of school have elicited a wide range of emotions. I feel privileged to have the opportunity to study medicine. I sometimes feel overwhelmed with the amount of information I am expected to learn. I also feel the enormity of the responsibility I am shouldering as a future physician.

I also feel an acute sense of displacement having moved across the country for the first time. I was born in Duluth, raised in the Northland, and attended college in rural Minnesota. This community instilled within me the values that guide my work and provided me with the spaces I needed to learn and grow.

And yet, like many young people, I have found an incredible sense of fulfillment and adventure in my cross-country move. San Francisco offers diverse cultural opportunities, the ability to study at an incredible institution, and, admittedly, much better weather than Duluth. For now, San Francisco is where I am living. But, when medical school ends, I will be faced with the question: Where should I call home?

It was my upbringing in the Northland that cemented my desire to pursue a medical career, particularly seeing how my family was impacted by provider shortages in our rural community. Just in October,

Essentia announced

it was ending urgent care at its Hermantown clinic, citing staffing challenges.

A 2022 Minnesota Department of Health survey found that there is a growing shortage of primary-care physicians in rural parts of the state. While metropolitan areas have an average of 20.3 pediatricians per 100,000 people, isolated rural communities have just 0.5. Physicians who practice in rural Minnesota are also on average 10 years older than their urban counterparts, and one in three rural physicians plans to retire within five years. This already urgent problem of rural-physician shortages will only compound in the coming years.

It is imperative we find new ways to recruit and retain doctors in rural Minnesota. We can call upon our elected officials to support legislation such as the bipartisan Rural America Health Corps Act, which aims to incentivize more health professionals to work long term in rural communities.

Returning to the question of where I should call home, on the one hand, the idea of coming back to the Northland to practice as a physician seems to be the culmination of all I have worked toward. It would be as much an expression of gratitude to the place that raised me as it would be a gift to reimmerse myself in this grounded, kind, and hard-working community. And yet, moving away from an urban environment means forgoing many of the compelling cultural, academic, and social opportunities that come with living in a city like San Francisco.

I’m not sure where my career will take me. I do know that no matter where I choose to live and work, I will continue to be an advocate for the health and well-being of our community, and I am certain that my fellow Northlanders will choose to do the same.

Lora Randa is a Duluth native studying to be a doctor at the University of California, San Francisco School of Medicine.

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Growing up on a ranch and having your own Shetland pony may seem like an idyllic childhood, but for Shannon Zullo, MD, the reality included a lot of hard work and being surrounded by poverty.

An aspiring dermatologist and Mohs surgeon, Dr. Zullo holds the titles of chair, alternate delegate and Resident and Fellow Section representative for the AMA Minority Affairs Section.

Dr. Zullo, who appeared in an episode of the “AMA Prioritizing Equity” video series examining the impact of COVID-19 on Native Americans, is one of the few reservation-born physicians in the U.S. She grew up on a ranch in the Navajo Nation, the largest reservation in the U.S., covering some 25,000 square miles with a population of around 165,000.

As a young girl, it was her job to provide water for the cattle, horses, sheep, goats, ducks, chicken and geese on the ranch. This required her to learn how to drive a stick shift at 12 so she could use the family’s old Ford pickup truck to get water at a windmill-powered pump and haul it out to the livestock.

In addition to watering the animals, Dr. Zullo tended to those needing first aid and medical attention.

“I’ve always wanted to be a doctor since I was a little kid, 5 to 6 years old,” Dr. Zullo said. “I’m told that I used to run around with a medical kit to aid any animals who were injured on our ranch.”

That desire to be a physician came to fruition many years later, as Dr. Zullo was accepted into the University of Arizona’s Pre-Medical Admissions Pathway (P-MAP) program for Arizona students from rural areas who belonged to historically marginalized populations. As a result, she earned a master’s degree in cellular and molecular medicine. She then went on to earn her medical degree from the University of Arizona College of Medicine.

Dr. Zullo is in her final year of dermatology residency at the University of California, San Francisco, and is applying for fellowship in Micrographic Surgery and Dermatologic Oncology.

Dr. Zullo spoke with the AMA about how growing up on the reservation affected her career choice, why COVID-19 hit the Navajo Nation so hard, the need for more Native American physicians and how organized medicine can help.

AMA: How did your life experiences influence your decision to go into medicine in general and into dermatology specifically?

Dr. Zullo: I was born and raised on the reservation in northeast Arizona in a small town called Chinle—which was one of the hardest hit places with COVID-19.

Throughout my childhood and adult life, there have been medical emergencies and inequities that have affected my family directly. During those periods, I can remember feeling a strong sense of helplessness and wanting to learn medicine so that I could support my family and community.

We had an Indian Health Service hospital in town, and that was my only exposure to medicine. I sometimes wonder if my desire to pursue medicine was in part from the desolation and the poverty on the reservation. I saw the doctors who came from other places as being smart, successful, and trustworthy. I respected those traits and wanted to embody those characteristics.

Growing up in a community with lower health literacy, stigmas can develop, especially for patients with skin conditions. I remember a gentleman who had neurofibromatosis in our community, and he was just riddled with neurofibromas. People ostracized him and treated him as if he was contagious for a genetic condition.

In medical school, we did a survey study on acne and acne scarring in members of federally recognized tribes who lived on a reservation. We found higher rates of scarring than in other populations.

On the reservation, we didn’t have access to many specialty options, including dermatology. The Indian Health Service is underfunded and focuses its resources mostly on primary health needs. Out of roughly 12,000 practicing dermatologists, only 31 self-identify as Native American. So, there’s a profound need for Native American dermatologists who understand the patient population and know how best to help them.

Related Coverage

Why we should think of the physician workforce as an ecosystem

AMA: What health care needs are going unmet on reservations? What’s lacking that would be considered basic service?

Dr. Zullo: A lot of the Navajo Nation reservation is very rural, and one of the biggest impacts on health is that roughly 30% of our community doesn’t have running water. Some folks spend days just figuring out where they’re going to haul water from next.

With COVID, we saw that impact because people couldn’t regularly wash their hands.

Chinle is a small tourist town, so we had running water and electricity, but my grandparents—who we went to see almost every weekend to work on their ranch—didn’t have running water. We had to haul water to them in large barrels.

Much of the reservation is also a “food desert.” Nutritious food is hard to come by, and when available, it was incredibly expensive. Growing up, I ate a lot of canned fruits and vegetables because that was what we could afford.

And though I had running water, it came out of the tap yellow. We never drank it. There was a real fear about contamination in the water due to poor infrastructure like old pipes. So, I grew up drinking predominantly soda. To this day, I’m still mostly a seltzer drinker.

Unfortunately, many of these basic health issues still exist. And it’s a big reason why Native Americans have the lowest life expectancy of any racial group in the United States.

AMA: There have been 86,000 cases of COVID-19 reported in Navajo Nation and more than 2,200 deaths. Why was the impact so severe?

Dr. Zullo: I think it goes back to the basic unmet needs: access to water, to healthy food, and to more housing. Many of our homes are multigenerational.

As a young child, I lived with my grandma. There were times when it was my grandma, my great grandma, my aunt, my uncle and his family plus my family—all in a three-bedroom home with only one bathroom.

And that was considered good. Many Navajo families have it worse.

When you can’t wash your hands, take a shower, and don’t have indoor plumbing—you are at a severe disadvantage against a respiratory pandemic. We have roughly 165,000 Navajo people living on the reservation, and 2,200 died. That’s like one in every 75 people. A profound loss of life, especially of our elders and the potential cultural knowledge we have lost.

AMA: Why would having more Native American physicians help?

Dr. Zullo: Native Americans are the most underrepresented group in medicine. There’s about 850,000 physicians in the U.S. and there are only 2,600 who self-recognize as Native American. That means only about 0.3% are physicians. Nearly 3% of the U.S. population, per our last census, self-identified as American Indian or Alaska Native – so that’s a huge disparity.

Every time you meet a Native American physician, there should really be 10 of us.

Unless you grow up in that kind of environment, it’s harder to understand how to best treat or care for the people. These are communities built on trust.

Related Coverage

Q&A: How to support and retain Native American medical students

There was a research study looking at Native American medical student matriculation and found that a high percentage of AI/AN graduates were likely to practice in underserved areas, including reservations—and at a higher rate than their peers.

The important thing is that we need to get the people who come from these places to go into medicine because they’re the ones who are most likely to go back and serve. We need to do more to reduce the largest representation gap in the physician workforce.

AMA: Tell us about your work in organized medicine.

Dr. Zullo: I love being a part of the AMA, because we have the opportunity to work with physicians and medical students from all over the country to tackle our biggest problems—like reservation healthcare.

Also, within the AMA, there are many avenues to make difference—whether it be meaningful policy, programming, communications, or new initiatives.

My leadership philosophy has been motivated by my upbringing. If the corral fence breaks, I can’t complain about it for three months and hope someone else fixes it. It must get done. So, you roll up your sleeves, you think creatively about how to fix it, and you work with others to make it happen. During our governing council meetings, I try to make time for a brainstorm session to find actionable objectives. The ideas have been amazing and we’re working on exciting things.

I am lucky to have an incredible governing council, with leaders from every facet of representation, and many of them having served as national leaders themselves. For my term, our primary focus has been to restrengthen the MAS in a positive way, through solutions, data-driven policy and creating new opportunities for our membership.

I think the sky’s the limit as far as what you can accomplish in organized medicine. To other Native Americans out there – please know that you can truly make a difference. The AMA has been very supportive.

But it’s a labor of love. You must have a reason for why you want to do this. For me, it’s because I’ve seen too much suffering in my community to not do something about it. And if I don’t step up, who’s going to do it? There are only a few of us who can even be in the room.

People ask: “When is our work done?”

For me, my work will be done when my people have running water, access to nutritious food and good health care. When Native Americans are on parity with other racial groups in medicine. I believe in that future, and I’ll keep working at it until we get there.

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