Priority 2: Grow and support the Indigenous physician workforce

There is currently a disproportionately low percentage of physician members who identify as Aboriginal and/or Torres Strait Islander or Māori. Encouraging the development of an increasingly diverse physician population is a strategic priority for the College. There is growing evidence that Indigenous doctors, whether in mainstream or Indigenous community controlled services, contribute to improved access to appropriate health care services, culturally safe patient experiences, and improved health outcomes for Indigenous people.

Although Indigenous doctors come from diverse backgrounds, they bring a shared understanding of cultural themes such as family, community, world views and concepts of indigenous health. They also possess lived experience of Indigenous social determinants of health, and often have a strong commitment to serving their communities no matter whether they work in a remote community or in a large urban teaching hospital. Indigenous doctors play strong advocacy roles in addressing racism, system changes, and the need for cultural competence training for other staff. That said, there is also a need to be mindful of the additional pressures and barriers faced by Indigenous medical practitioners, and the need to provide appropriate supports for Indigenous doctors. It is not the responsibility of Indigenous people to challenge and hold people to account for behaviours or policies that are racist, discriminatory or culturally unsafe; that is something that every one of us must do. Additionally, the RACP needs to be aware of challenges facing Indigenous trainees and Fellows and have in place effective processes and mechanisms that recognise these challenges and provide appropriate support.

The Australian Indigenous Doctors Association and Te ORA have called for their countries to achieve population parity with their Indigenous medical workforces. Population parity means that the ratio of non-Indigenous and Indigenous doctors is reflective of the percentage makeup of the general population. In practical terms, this means that approximately 3% of Australian doctors would be Aboriginal and Torres Strait Islander and 15.5% of New Zealand doctors would be Māori. The RACP New Zealand Committee formally adopted the output of the 2015 Hui that parity for trainee numbers should be the aim.

In relation to the RACP, it would be useful to consider what constitutes optimal representation within each specialty given the health profiles and needs of Indigenous populations. For example, child health, chronic conditions such as diabetes, renal disease, cardiovascular disease, and cancer, as well as care for older people, are priority areas for Indigenous health and could result in the most significant short and medium-term benefits from increased Indigenous physician numbers.

There is also an opportunity to draw on lessons learnt from the medical school experience, many of which have already achieved population parity in their intake of students, to inform our own strategies to growing the Indigenous physician workforce. The Framework should promote the recruitment and retention of Indigenous medical graduates by ensuring that the College is a competitive, culturally safe organisation which is recognised for prioritising and advocating for Indigenous health. There is an opportunity to improve the retention of trainees by reviewing current strategies, consulting with current and past Indigenous trainees and Fellows, and strengthening and developing new initiatives in response to this feedback. The RACP will also seek to work with health services to encourage them to recognise cultural considerations, including the provision of cultural competency and cultural safety training for their staff.

A key principle of the RACP’s newly developed Selection into Training Policy will involve seeking and embracing diversity; and a key element will be supporting the increased selection of Aboriginal and Torres Strait Islander and Māori physician trainees, working in partnership with training workplace organisations.

Such a change also needs to be thought of more broadly in terms of equitable approaches to selection. In other words, cultural, language, historical, and socio-economic backgrounds should not be factors which disadvantage or exclude anyone. Indigenous medical graduates bring prior knowledge and learning, and equitable approaches will be inclusive of such Indigenous knowledge systems, involving ‘two-way’ cultural collaborations to ensure culturally safe and fair outcomes. This includes knowledge and experience that is valued and reflective of all groups, particularly Indigenous medical graduates, and which does not reflect cultural bias or privilege one group over another.

Indigenous medical workforces, Australia and New Zealand (2014)

Strategies

Priority 3: Equip and educate the broader physician workforce to improve Indigenous health

The RACP has an important role to play in ensuring physicians are culturally aware, competent and safe, and are clinically competent in relation to Indigenous health matters. There is a need for specifically targeted professional development to equip all physicians with competencies to provide high quality, safe and accessible care for Indigenous patients in Australia and Aotearoa/New Zealand.

Although some good work has been done, there remains a need within the physician workforce for education, upskilling and engagement of many more physicians to focus on a strengths-based approach to improving Indigenous health through recognising the unique cultural and historical position of Aboriginal and Torres Strait islander peoples, and Maori, and the impacts of colonisation and historical trauma, as well as resilience and survival.

The RACP is in the process of renewing its education programs to suit the changing environment for physician practice. Throughout this period of renewal, the College is undertaking a suite of projects underpinned by a competency-based approach to training, split across three broad strategy domains, educational renewal strategy, new curricula, and better infrastructure and support strategies.

This educational renewal is an opportunity for the RACP to make strategic changes to drive towards equity for Indigenous peoples. These changes will include a commitment to incorporate Indigenous competencies, cultural priorities and knowledges where appropriate; as well as ensuring an inclusive and equitable approach to educational renewal, and curriculum content and development. Infrastructure and support strategies should be reflective of Indigenous perspectives in a changing physician practice environment.

Strategies

Priority 4: Foster a culturally safe and competent College

Competence in Indigenous health matters is not the same as Indigenous cultural competence. In Aotearoa/New Zealand cultural competence is recognised as a key professional skill required to address health disparities for Māori, as enshrined in legislation through the Health Practitioner’s Competence Assurance Act 2003. Both the MHC and ATSIHC consider that clinical competence is not possible without cultural competence; and it provides the foundation for equity and collaboration. Both committees are guardians of cultural competence in the RACP. They articulate the values of cultural competence, and mediate their translation into RACP systems and processes.

Cultural competence is a central skillset and a key area for the College to work consistently to achieve the principles of the Te Tiriti o Waitangi (the Treaty of Waitangi). Cultural competence is also a core component of the RACP’s accreditation processes and assessed by the regulators, the Australian Medical Council (AMC) and the Medical Council of New Zealand (MCNZ).

Being culturally safe means that we recognise and ameliorate the impact that our own beliefs, assumptions, and behaviours have on others; and, for health care practitioners, recognising the serious adverse impacts on patients and whānau (family) of practicing in a culturally unsafe way. The impacts can be long‑term and widespread, reaching far beyond any one specific incident.

Within the RACP, cultural competence is implicit in all aspects of physician and paediatrician education, training, professional development, and practice. Cultural competence requires awareness of cultural diversity, understanding of issues faced by different populations, and the skills to function effectively and respectfully when working with people of different cultural backgrounds.

It is in these key areas that Indigenous cultural competence is differentiated from broader definitions of this concept. It is within the power of the College to lead the way in delivering culturally competent health care to Aboriginal and Torres Strait Islander peoples, Maori, and Pacific peoples.

The RACP has a key responsibility to provide access to role models, mentors, and teachers that can help equip doctors meet the needs of populations, and it is important that the RACP systematically record the ethnicity of its members through targeted resources and support. There are many examples whereby the cultures of health care and hospital systems have worked as a barrier to cultural competency. The RACP can change health and hospital culture for the better. The RACP can use its Curriculum Framework to set standards for culturally diverse praxis, in constructive critique of Western biomedical and biopsychosocial models. The RACP’s peak Indigenous health bodies, the MHC and ATSIHC, will be key facilitators for these changes.

Cultural safety is a correspondingly key attribute at the level of the organisation. Cultural safety is a concept that emerged in the late 1980s as a framework for the delivery of more effective health services for the Māori in New Zealand. Culturally safe practices include actions which recognise and respect the cultural identities of others, and safely meet their needs, expectations and rights. Conversely, culturally unsafe practices are those that “diminish, demean or disempower the cultural identity and well-being of an individual” (Nursing Council of New Zealand 2002, p. 9). There has been an increased uptake of cultural safety in medical schools in growing recognition of the value of the principles to medical practice that are contained in the framework, and their applicability to systems levels, i.e. culturally safe health services, and to the individual, whānau/family and community members Historically, health services have not been seen as safe places for indigenous people as a result of racism, cultural insensitivity, poor communication, disempowerment and historical practices, such as the removal of children.

An important principle of cultural safety is that it doesn’t ask people to focus on the cultural dimensions of any culture other than their own. Instead, cultural safety is primarily about examining the health professional’s own cultural identities and attitudes, and being open-minded and flexible in attitudes towards people from cultures other than their own.

Both cultural competence and cultural safety needs to be incorporated across all aspects of physician education, training, professional development, and practice. Training will require participants to examine their own implicit biases and to be mindful of power differentials, and have the opportunity to develop reflective practice, undertake ‘transformative’ unlearning, and contribute to a decolonisation of health services for Indigenous peoples. The RACP is in a position to develop and adopt its own Indigenous cultural competence/ cultural safety framework based on the incorporation of the principles from both concepts which most clearly reflect the of the RACP and its Indigenous health committees.

A framework for understanding Indigenous culture, health and cultural competence (originally developed by Dr Tamara Mackean, FAFPHM)

The diagram examines the generation of a culturally safe space for Indigenous Peoples, their families and their broader communities. It highlights the importance of acknowledging Indigenous world views and history, and ways the College can foster the generation of safe environments in healthcare settings throughout Australia and New Zealand.

Strategies

Priority 5: Meet the new regulatory standards and requirements of the Australian Medical Council (AMC) and Medical Council of New Zealand (MCNZ)

In recent years, regulators of medical colleges have increased their monitoring of Indigenous health activities. New Indigenous health standards for Specialist Medical Programs and Professional Development Programs came into effect in 2016 and these build on the standards in the earlier phases of medical education. The RACP must meet the AMC and MCNZ standards relating to Indigenous health in order to be accredited.

The RACP’s 2014 reaccreditation report from the AMC/MCNZ requires that the RACP report annually against progress in the following two areas:

• Condition 3: Develop and implement strategies to engage more broadly with organisations such as Aboriginal and Torres Strait Islander and Māori health groups, not for profit heath organisations, public health organisations, jurisdictional health bodies and other key health providers in the development of education policy and curricula.
• Recommendation FF(ii): Develop robust cultural competence outcomes and associated training resources for trainees and supervisors.

Strategies