Fall 2021 (Volume 31, Number 3)
The Welcoming Practice
Creating an Environment that Promotes Cultural
Safety for Indigenous Patients
By Cheryl Barnabe, MD, FRCPC, MSc
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It is a privilege of our specialty to have
longitudinal engagement with the patients
in our practice, and I suspect we
are all adept at communication skills that
nurture and maintain these relationships.
The Canadian Rheumatology Association
Indigenous Health Initiative sessions are
devoted to discussing and practicing communication
approaches specifically for our
interactions with Indigenous community
members. These approaches are needed
to rebuild trust in Western health systems
and healthcare providers, as Indigenous patients have historically
experienced punishment for pursuing traditional
health practices, suffered from harm in residential schools
and Indian hospitals, and continue to face racism in health
systems. Here are some suggestions we share during the
sessions on how to establish a culturally safe clinical environment
for Indigenous patient care. (If you have other
ideas, please email me, and we will include these in our
teaching materials.)
Personal and Staff Preparation: The sources of the
inequities that Indigenous peoples face in society and their
consequences are complex and take time to understand;
engage in your personal learning and provide opportunities
for your staff to do so as well. Be cognizant that misinformation
and misrepresentation of facts is a strategy that
has been used by colonial governments and societies to
retain privilege, so choose learning resources wisely. Start
using nonjudgmental questions in clinical interactions so
that they become your default approach. As an example,
rather than asking "Are you taking your medications regularly?"
you could instead ask "Are there circumstances that
have interfered with you taking your medications regularly?"
Become knowledgeable about resources available to
Indigenous community members that could support their
rheumatic disease management, such as local allied health
supports, or how to connect them to traditional healing
practices if requested. Identify colleagues in other specialties
with expertise in the care of Indigenous patients that
you can preferentially refer to when indicated.
Appointment Scheduling and Notification: Have
your staff gather multiple ways of contacting patients
about appointments and also notify the primary care provider
— due to resource limitations Indigenous patients
may not have access to the communication methods that
we take for granted. Appointment times and days may need
to align with the patient’s transportation
arrangements rather than the rheumatologist’s
preferred scheduling. It is important
to book an appropriate appointment
length to allow for conversation and relationship
building which leads to trust. You
may offer telephone or virtual appointments
to patients rather than relying only
on in-person assessments; also consider
providing a walk-in option for times when
urgent concerns arise. Missed appointment
fees should be waived, and patients should
not be discharged from a practice for a missed appointment;
these approaches will only discourage a patient from
returning to your practice. Instead, take the extra step to
connect with the primary care provider, who may be able
to provide the reason for a missed appointment, and who
could be the liaison for care until a new appointment is
secured.
The Clinic Environment: Ensure comfort and space
for the patient and any accompanying family members
or friends. It is a cultural norm for family and friends to
support those who are ill, and they will facilitate the visit
by supplementing symptom review and helping make
treatment decisions. Some participants from the CRA Indigenous
Health Initiative have shared they have put up art
work purchased from local Indigenous artists as a demonstration
of their support for the community.
Your Approach: Be aware of authoritative body language
and actions. It is best to not wear your white coat,
and to ensure you are seated when speaking with the patient
(and positioning your chair a little lower than the patient’s
seat). Accept if they decline to have a learner in the
room. Be prepared to first visit with the patient and learn
more about them, and to offer to share a little about yourself
before proceeding to the reason for the visit. While we
all have time pressures in our practices, these few minutes
are critical to building trust for longitudinal care. At the
time of the physical exam, explain first what you will be
doing and why, and seek permission before proceeding.
Follow through on promises made to connect the patient
to resources.
If Something Does Not Go Well: Cultural humility
goes beyond the simple understanding or knowledge of a
culture or its norms; it includes elements of personal reflection on our interactions with Indigenous patients, and
longitudinal growth through learning from them. Be attentive
to the patient’s body language and, if you perceive
tension or discomfort, then stop and inquire. Respectfully
ask if you have done something to offend the person.
Listen intently, apologize if needed and commit to learning
from the interaction. This can be where personal discomfort
arises in the learning process, but is an important step
forward to providing better quality rheumatology care to
Indigenous patients.
Cheryl Barnabe, MD, FRCPC, MSc
Professor, University of Calgary,
Calgary, Alberta
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