What does it mean to provide culturally safe care for Indigenous patients?
Indigenous health will soon be a core component of postgraduate medical education (PGME).
To set the groundwork, the Indigenous Health PGME Implementation Steering Committee held its first meeting in March 2019. Their role is to provide strategic input, guidance and recommendations.
Lisa Richardson, MD, FRCPC, chair of the committee, believes that all specialists should be aware of the important role they have in improving the health status of Indigenous Peoples in Canada.
“When we [physicians] are caring for an Indigenous patient, we need to make sure that we are doing that in a culturally safe way. In doing so, we can support Indigenous Peoples in achieving the highest level of wellness possible — a level of wellness which is just as high as that of the average Canadian.”
Committee is being led by Indigenous leaders
At their inaugural meeting, members of the Indigenous Health PGME Implementation Steering Committee sought to answer the question: what does it mean to be a specialist physician who is able to meet the needs of Indigenous patients?
Their discussion took into consideration
- earlier work by the Indigenous Health Advisory Committee,
- content from the Truth and Reconciliation Commission of Canada and
- previous Indigenous health competencies.
The resulting list of behaviours and skills were then organized around the CanMEDS Roles.
“We have an incredible group of committee members,” said Dr. Richardson. “It’s really exciting to have all of these amazing leaders in Indigenous medical education gathered in one place.”
She added, “We very mindfully made sure that we have representation of First Nations, Inuit and Métis from across the country. And we had an Elder with us during the whole meeting, which was really important to keep us on track and focused.”
Universal competencies are the committee’s first — but not only — focus
The committee is first working on universal postgraduate competencies mapped to the CanMEDS Framework. Specialty-specific competencies (as applicable) may follow. Eventually, they want this learning to reach all physicians-in-practice. Already, medical students are being taught about the legacy of residential schools, the Sixties Scoop and the racism faced by Indigenous Peoples in the health care system. As they graduate with this knowledge, the approach at the postgraduate level will evolve.
“People who are currently in practice may go back to some of the earlier concepts that are now being taught to our medical students,” anticipates Dr. Richardson. “We also have an amazing primer that was developed by a collaborative group of Indigenous physician-writers, as well as a couple of staff at the Royal College. It outlines what we think are key content areas and approaches to thinking about Indigenous health. That primer will be available for everyone later this year. We’re hoping to eventually turn that document into an interactive learning module.”
The Indigenous Health PGME Implementation Steering Committee will meet again in the fall. In the meantime, sub-groups will continue to progress the committee’s objectives.
Examples of culturally safe care at the bedside
There are many ways to practice culturally safe care with your Indigenous patients. One of the most basic occurs during history-taking. Once you have built a relationship of trust and openness, Dr. Richardson suggests asking your patients what Nation they are from, how they refer to themselves and how they would feel comfortable with you referring to them.
Here are two other examples, from Dr. Richardson, of knowledge about Indigenous health that may guide your care:
Example 1: You’re a rheumatologist. You’ve just seen a First Nations patient who has rheumatoid arthritis. You need to start him on treatment. What knowledge should inform your next steps?
- You need to know whether or not this patient is a Status Indian under the Indian Act (i.e. is he registered or eligible to be registered with the government, and does he have a status card?)
- If he does have status, you need to know that he is covered by Non-Insured Health Benefits (NIHB), a special drug plan for eligible Inuit and First Nations people registered under the Indian Act.
- You need to work with a pharmacist to see what medications are covered by NIHB to treat rheumatoid arthritis. (And you may be surprised to learn that the current recommended first-line therapies may not be covered until your patient has failed other treatments — a clear example of structural inequity).
- You also need to know that the phrase “Status Indian” is terminology rooted in the Indian Act and should not be used except in this very specific context.
Example 2: You’re an obstetrician. You believe your patient should have a hospital birth but she expresses concern and insists on giving birth at home in her Indigenous community. What knowledge should inform your next steps?
- You need to understand where her concerns stem from. Think back to your knowledge of the historical experience of Indigenous women and childbirth in Canada (e.g. forced sterilization, the Sixties Scoop).
- Dialogue with your patient to contextualize why she may be concerned about the experience of childbirth in a hospital. Work to build a relationship of trust.