Indigenous educators: We must unburden Indigenous patients and learners
In this article:
- Why cultural safety is more than just “good patient care”
- How Dr. Jillian Roberge and Dr. Ryan Giroux hope to influence change in postgraduate curriculum and accreditation standards as Royal College Indigenous educators
- Why all physicians need knowledge of Indigenous health, even if they rarely interact with Indigenous patients
- How the lack of foundational knowledge and safe learning environments can burden Indigenous individuals
“I’ve seen firsthand what racism looks like in the health care system, both in terms of patient interactions and co-worker interactions, and so I feel a responsibility to do something about it.”
Jillian Roberge, MD, FRCPC, an emergency physician of Métis heritage, recalls getting involved in Indigenous health education and cultural safety work while doing her specialty training.
“The need was there and, at the time, very few of the post-grad programs had any teaching on it. As a resident myself, I wanted to create a more welcoming environment for the residents and medical students that were coming behind me, and for the patients that we were seeing.”
Dr. Roberge and Ryan Giroux, MD, FRCPC — a pediatrician who is also Métis — are new Indigenous educators with the Royal College of Physicians and Surgeons of Canada. Together, they are collaborating with committees, stakeholders and working groups to integrate Indigenous health knowledge and concepts into curriculum development and accreditation standards.
“I’m of mixed background. We often describe it as walking in two worlds. I was able to get to a place where I can impact health care and feel it’s my responsibility to do that,” says Dr. Giroux.
“Either I can focus all my clinical work on trying to fix something right down at the end, or I can contribute from an advocacy or medical education perspective so that the physicians that come after me have a foundational knowledge that will help make our health care safer for Indigenous patients in Canada.”
Dr. Jillian Roberge and Dr. Ryan Giroux (Photo: Royal College of Physicians and Surgeons of Canada)
Cultural safety is more than just “good patient care”
Cultural safety has become the dominant term used to define culturally appropriate care for Indigenous patients. While the term has roots in the nursing field and reflects benefits for all patients, it takes on special meaning in the context of Indigenous health.
“There is a long history of harms that have been done to Indigenous Peoples within the field of medicine. There is mistrust that has been borne out of that. So, part of our work is to equip physicians to be safe people for Indigenous patients,” says Dr. Roberge.
She adds, “To say that something is culturally safe care is actually defined by the patient. It is particularly critical for Indigenous Peoples because we know that this has morbidity and mortality outcomes for them. A patient-centered, cultural safety approach to care is where we consider the whole patient and the context and, most critically — and this is what sets cultural safety apart from other perspectives like cultural awareness — is the understanding of the role of power differentials.”
Dr. Giroux further emphasizes the importance of the patient.
“If you look at things like cultural competency, it centres the provider as the person who needs to learn and it de-centres the patient experience, whereas cultural safety really centres the patient in that context.”
Working Indigenous health into curriculum and accreditation
Dr. Roberge has been engaged to lead curriculum development. She is helping map out a process that postgraduate programs can adopt to integrate an introductory level of Indigenous health knowledge for all learners and then within specific programs.
“The aim is for that to be built upon longitudinally within a Competence by Design perspective throughout the training process,” she adds, explaining that she is closely liaising with the specialty committees to determine what this will look like and assure it meets their needs.
“The hope is to develop something that’s going to help programs to look at themselves in terms of what does reconciliation look like within their program? And then how they can help to educate their learners and to engage with their local communities. We want to try as much as possible to lighten the burden on the local Indigenous health educators that are doing this work on the ground at all of these institutions.”
In contrast, Dr. Giroux’s role is the accreditation piece. Right now, he is working with Royal College staff to determine a set of recommendations that accreditation committees can use to integrate Indigenous health concepts within the new iteration of the institutional and program standards.
“We know that if concepts or indicators are in accreditation, then it gives programs and institutions direction on what they need to focus on. We are also looking at the bigger process of accreditation and how we can make that more supportive of Indigenous residents and faculty, to continue pushing forward change.”
All physicians need knowledge of Indigenous health concepts
According to Dr. Roberge and Dr. Giroux, Indigenous health principles are important for all physicians, even if they feel they do not regularly care for Indigenous patients.
Dr. Roberge explains, “Indigenous folks look all different ways and so I can guarantee that physicians are encountering Indigenous patients. They may not always be aware that they are, and so that’s part of the learning.”
Likewise, many are working alongside Indigenous colleagues and may not be aware of it.
“I’d also add that some specialties may not directly interface with patients but they are still dealing, in many cases, with part of the person; it’s important to understand tissue, blood, placenta as still an extension of that person that you need to be aware of,” says Dr. Giroux. He gives the example of an Indigenous patient who may want the placenta back after a placental pathology. While the request may be rare, understanding such requests is important.
Dr. Jillian Roberge and Dr. Ryan Giroux (Photo: Royal College of Physicians and Surgeons of Canada)
Creating safe spaces for Indigenous patients and learners
With more foundational knowledge of Indigenous health, the burden placed on Indigenous individuals to challenge assumptions and help educate others is lessened.
“Throughout medical school and residency, I was the person that people would ask questions of. I was happy to do it but sometimes it really gets to you — like people assuming I don’t pay tax or people asking ‘how Indigenous are you? You look really white,’” recalls Dr. Giroux. “Sometimes having to explain the same thing over and over can be really draining.”
Dr. Roberge remembers a pivotal experience that still haunts her. She was part of a team caring for a visibly Indigenous patient. At a multidisciplinary meeting, racist comments were made about the patient. No one spoke up — including her because she didn’t feel safe to do so.
“Driving home that night, I was so angry with myself. I recited all the things I wished I had said in the moment. For that future Indigenous care provider or patient that’s in that position, I would wish for a situation where someone would have spoken up because I know in my heart that there were other people at that table who were not comfortable with what was being said.
“With education and with that administrative support and those pathways, my hope is that more people will feel empowered to speak and that future Indigenous learners and team members would have the tools and the support of their non-Indigenous colleagues so that they didn’t feel personally responsible to be the only one to speak.”
