Summer 2017 (Volume 27, Number 2)
By Philip A. Baer, MDCM, FRCPC, FACR
“History is written by the victors.”
– Walter Benjamin (1892-1940), often attributed to Winston Churchill.
What’s in the news:
The Truth and Reconciliation Commission. The federal inquiry into missing and murdered Indigenous women (MMIW). The Sixties Scoop. The Joseph Boyden controversy. The death of Inuk artist Annie Pootoogook in Ottawa in September 2016, a few months before the CRA 2017 Annual Scientific Meeting (ASM).
Recent articles in CMAJ:
- “The cultural erosion of Indigenous people in health care."1
- “Taking action on the social determinants of health in clinical practice."2
- ”Health care experiences of Indigenous people living with type 2 diabetes in Canada."3
With this backdrop, I took advantage of an opportunity offered by the CRA and enrolled in the fall of 2016 in an online eight-week course on Indigenous Cultural Safety Training sponsored by San’yas and the British Columbia Provincial Health Services Authority. The CRA sponsored eight members in this pilot project, providing a refund of the tuition fee, and eight hours of the difficult-to-obtain Royal College MOC Section 3 credits for successfully completing the course.
Royal College credits are particularly appropriate, as the Royal College has played a leading role in developing a framework for continuing medical education in this area,4 and a CanMEDS blueprint for respecting Indigenous health values and principles.5
We met online, introducing ourselves and our cultural backgrounds and healthcare roles. Most were front-line nurses and other allied health professionals. We were supported by a trained facilitator, Makonen Bondoc. The course progressed through eight weeks of modules, with an emphasis on videos and narrative testimonies of Indigenous people from across Canada, highlighting their interactions with the healthcare system. The history of Canada was reviewed through the lens of the experience of First Nations, including colonialism, racism and the effects of The Indian Act.
Many stories were familiar, including treaties being ignored, residential schools and their lasting impact, and efforts at cultural assimilation supported by various federal and provincial governments. The history of Indian hospitals was new to me. The testimony of survivors was powerful.
The training was very well executed. Each page had a suggested time required for completion, and the timer certainly worked. Staying on a page too long without any activity prompted an “Are you still there?” reminder. Quizzes were frequent, including pre- and post-tests. Keeping a private journal was required, and the moderator’s comments to individuals and to the group were valuable and discerning. There were many downloads available to enrich the key learnings of the core curriculum, as well as references to be used as reminders for the clinic. A post-course written reflection was also required to obtain full credit.
The LEARN model for consultations was promoted and has broad implications for any interaction with patients, whether of Indigenous background or not:
- Listen to your client
- Explain your own perspective
- Acknowledge differences and similarities
- Recommend a course of action
- Negotiate mutual agreement
The culmination of the course for the CRA-sponsored rheumatologists, and others interested in the topic, was participation in a special workshop at the CRA Annual Scientific Meeting (ASM) 2017, titled “Finding Common Ground: Communicating with your Indigenous Patients.”
This was led by Dr. Lynden Crowshoe, author of the CMAJ diabetes article listed above, a member of the Piikani First Nation, and a family physician and Associate Professor in the Department of Family Medicine, Cumming School of Medicine at the University of Calgary. The workshop featured two simulated patients and allowed several participants to interact with them, followed by insight from Dr. Crowshoe and the group on best practices in this setting. The workshop was videotaped as a resource for CRA members and medical school teaching. The atmosphere was welcoming and non-threatening, and provided an opportunity to put the course learnings into action in a safe setting.
I gained a great deal from participating in this novel exercise. Whether or not funding a later-in-career rheumatologist with a limited Indigenous practice was a wise investment could be argued, but I certainly appreciated the opportunity I was afforded. The value of being a CRA member was reinforced. I would highly recommend the course and the time investment required if it is offered again through the CRA. The lessons learned can be applied to all patients whose culture differs from our own, whether Indigenous or not.
For a taste of the course and the San’Yas program, you can listen to the podcast from Dr. Brian Goldman’s CBC Radio show White Coat, Black Art, entitled "I am a white settler: Why that matters in healthcare” originally broadcast in December 2016 (Reference 6 below).
Treating everyone exactly the same, regardless of culture, may not be the best model of care.
1. Matthews R. The cultural erosion of Indigenous people in health care. CMAJ. 2017 Jan 16; 189:E78-9. doi: 10.1503/cmaj.160167
2. Andermann A, CLEAR Collaboration.Taking action on the social determinants of health in clinical practice: a framework for health professionals. CMAJ. 2016 Dec 6; 188(17-18):E474-83.
3. Jacklin KM, Henderson RI, Green ME et al. Health care experiences of Indigenous people living with type 2 diabetes in Canada. CMAJ. 2017 Jan 23; 189(3):E106-12.
4. First Nations, Inuit, Métis Health Core Competencies. Available at: http://tools.hhr-rhs.ca/index.php?option=com_mtree&task=att_download&link_id=10852&cf_id=68&lang=en
5. Indigenous Health Values and Principles statement. Available at: http://www.royalcollege.ca/rcsite/documents/health-policy/indigenous-health-values-principles-report-e.pdf
6. “I am a white settler”: Why that matters in healthcare (CBC podcast). Available at: http://www.cbc.ca/radio/whitecoat/i-am-a-white-settler-why-that-matters-in-healthcare-1.3900354.
Philip A. Baer, MDCM, FRCPC, FACR