Tackling implicit bias towards Indigenous peoples in Canadian health care through Canadian medical education Translated title: S’attaquer aux biais implicates implicites envers les peuples autochtones dans les soins de santé au Canada grâce à l’éducation médicale canadienne

Abstract

Background The healthcare needs of marginalized communities remain unmet in the modern healthcare system. According to a 2016 study, 16.2% of those with an Aboriginal status, compared to 11.2% of those without, had unmet healthcare needs stemming from a lack of health services; long wait times, services being unavailable, and the associated costs. 1 Furthermore, 28.5% of the Indigenous population has experienced discrimination from healthcare providers due to their implicit bias. 2 , 3 This discrimination by healthcare providers creates barriers for Indigenous Peoples, dissuading them from seeking future healthcare and contributes to determinantal health outcomes. 2 Overall, there is a need for systemic change in the attitudes of Canadian healthcare providers. To address this, Canadian medical institutions have modified the undergraduate curriculum, providing opportunities for understanding Indigenous culture and needs. 4 More specifically, students engage in pre-clerkship and clerkship training focused on Indigenous health. Pre-clerkship training: 1st and 2nd year Early experience with marginalized communities is impactful in engaging medical students with specific populations. Canadian medical institutions, such as Northern Ontario School of Medicine (NOSM), offer pre-clerkship placements with Indigenous communities that allow 1st-year medical students to experience rural settings and gain insights into local healthcare barriers. 5 By shadowing local nurse practitioners who incorporate traditional medicine in their patient consultations, medical graduates can further understand the importance of providing culturally-sensitive healthcare. 5 These experiences resulted in greater empathy and understanding of Indigenous populations, and has had a lasting effect on students’ future practice and knowledge. 5 For example, among the eight NOSM medical graduates who completed Indigenous placements within First Nation communities, five serve many Indigenous patients in their family physician practice today. 5 The efficacy of pre-clerkship experience with populations with healthcare disparities is seen at other North American medical institutions as well. After completing an elective course on healthcare disparities, first-year medical students at the Albert Einstein College of Medicine improved their knowledge, attitude, and confidence in addressing such issues in the low socio-economic status community of Bronx, New York. 6 Along with NOSM’s pre-clerkship opportunities, 5 similar pre-clerkship courses should be implemented at all Canadian medical schools, promoting empathy and other soft skills required to develop culturally competent physicians. Additionally, settler colonialism is an important determinant of health that is sometimes not transparently discussed in the context of Indigenous communities. 7 This topic could encourage future physicians to critically reflect and advocate for a more equitable practice on an institutional level. 7 Overall, these discussions during pre-clerkship courses can provide opportunities for acknowledging and building trust between the Indigenous communities and future physicians. From an academic perspective, the NOSM Community Engagement Through Research (CETR) program allows medical students to work with Indigenous education sites to explore health services-related research questions. 8 Their research has been appreciated by the Indigenous communities and pre-clerkship students alike, while providing valuable experience in community needs, understanding the importance of Indigenous research relationships, and practicing integrative and collaborative research practices. 8 Combining research with clinical experience allows medical students to further foster social accountability towards Indigenous communities. Along with didactic training, role-playing simulations can be implemented. In a study with Ontario family medicine residents, 14 decision-making scenarios were used to help participants better comprehend the difficulties Indigenous Peoples face in healthcare. 9 These scenarios often focused on a lack of access to culturally competent healthcare. Overall, participants showed an increase in empathy, knowledge of Indigenous culture and motivation to engage in a culturally competent manner. 9 Moreover, at the Truth and Reconciliation Report (TRC) reading group at the University of Toronto Office of Indigenous Medical Education, 10 involving Indigenous elders or community members provided greater insight into Indigenous-based lectures, educating others from a primary source. 11 Overall, these simulations promote ‘real-world’ interactions in a controlled environment, providing opportunities for making mistakes, uncovering personal biases, and finding growth. 6 Clerkship training: 3rd and 4th year Many Canadian medical institutions offer students opportunities in rural healthcare environments during their clerkship years. Rural clerkship electives allow students to choose their rural site, and experience the day-to-day challenges Indigenous Peoples may face. To be a culturally competent physician, real patient interactions within the marginalized communities are pertinent to broaden one’s perspectives. Although theoretical knowledge of a culture is essential, the underlying empathy and social justice beliefs of students do not significantly improve with informative lectures alone. 12 Beyond cultural competence we must understand Indigenous Peoples through the lens of cultural humility. Adopting cultural humility involves self-reflection of our own cultural biases. 13 Students must recognize that ‘cultural competence’ is only a step towards better healthcare, and it cannot be treated as a ‘check-mark’ on a list of topics to understand Indigenous populations. 14 Indigenous Peoples must be treated as a set of different communities, each having their respective cultures and beliefs, rather than just one large community. 14 These placements can help change how Indigenous Communities often tend to be portrayed as the “other” and instead, instill a more inclusive problem-solving mindset. Moreover, medical students should foster open communication, which seems instinctual, yet is often overlooked. 16 We must learn from Indigenous Peoples what better healthcare means for them. 16 Ultimately, these clerkship placements help medical students bridge the gap in Indigenous healthcare by promoting critical self-reflection, 10 recognizing individual biases, understanding day-to-day racism, and acknowledging existing health inequities. 17 Students may also explore rural communities beyond those required in their mandatory electives. For example, at the McGill University Faculty of Medicine, one 4th year medical student accompanied an ophthalmologist for a one-week placement in Puvirnituq, Nunavik, Quebec, and assisted in providing ophthalmic care for the Inuit Peoples. 18 Such opportunities provide an experience in clinical settings, along with understanding the commitment, resilience, and adaptability required to provide specialized care for remote Indigenous populations. Conclusion To promote change in healthcare, medical students should be culturally educated. Through pre-clerkship and clerkship opportunities, Canadian medical schools are preparing future physicians to provide adequate care to marginalized communities, such as the Indigenous Peoples. In the future, longitudinal studies should investigate whether pre-clerkship lectures and simulations, along with clerkship immersion opportunities, can have long-lasting effects on a physician’s ability to provide culturally competent care.