Two-Eyed Seeing (Aistotsastip) and the Medicine Wheel for the Plastic Surgeon

Across what has now become known as Canada, the challenges Indigenous people face within the healthcare system may not be fully known to non-Indigenous people. ¹ Medical education is progressing to recognize the importance of awareness of Indigenous health. The CanMEDS Physician Competency Framework revisions for 2025 include Indigenous health as a major emerging concept deserving of improved representation. ² Our editorial seeks to inform the readership of the Journal of Plastic Surgery of Indigenous ways of being by sharing 2 traditional teachings, the Medicine Wheel and Two-Eyed Seeing.

Understanding traditional Indigenous conceptualizations of health may help plastic surgeons provide culturally competent healthcare to Indigenous patients, especially as we recognize the second National Day for Truth and Reconciliation (September 30, 2023). This Day is an important reminder to all Canadians of the injustices suffered by survivors and non survivors of residential schooling, and the intergenerational trauma that ensued. It is important as plastic surgeons that we pause and acknowledge the experiences of our Indigenous patients as a means to continually provide patient-centered care.

Indigenous people are twice as likely than the general population to die prematurely from avoidable causes, such as assault, suicide, and accidental injuries.^3–5 Plastic surgeons frequently care for Indigenous patients presenting to hospitals for plastic surgery care, which may include trauma, cancer, and self-harm. Compared to the non-Indigenous population, Indigenous people experience higher rates of complications which may be related to the nature of injuries, decreased access to care, and complexity of care.^1,7

In Canada, there is a persistent narrative that Indigenous persons’ lower standard of living and poor health is self-inflicted. ¹ Many Canadians are working to unlearn negative perceptions of Indigenous persons through improved awareness of the legacy of assimilation, cultural genocide, residential schools, and overrepresentation in the child welfare system. ⁷ Each encounter plastic surgeons have with Indigenous patients provides an opportunity to reflect upon their perceptions of Indigenous people and how it may impact patient care.

One potential way to open culturally appropriate dialogue is by using the Medicine Wheel, adapted from Métis Cree Elder teachings. This is a theoretical framework embraced by many Indigenous communities that represents how the domains of health fit and operate within their unique cultural contexts. Indigenous groups across Canada may have slightly different interpretations of the Medicine Wheel or may not include it in their cultural way of life.

The Medicine Wheel is a circular symbol divided into 4 equal quadrants; each quadrant is a dimension of learning and human development, represented by the mental, emotional, spiritual, and physical aspects of oneself (Figure 1). The physical aspect of health is equally represented alongside emotional, mental, and spiritual health, intertwined and inseparable. Optimal health is attained in the center of the Wheel, where there is a balance between the 4 aspects of oneself. The Medicine Wheel is circular rather than linear or hierarchal, emphasizing interconnectedness, equality, and sustainability. The CanMEDS Diagram has notes of the Medicine Wheel, as a Venn diagram with overlapping circles representing physician roles, reinforcing to educators that undergraduate, postgraduate, and continuing education programs in Canada aim to produce a physician with good balance in all roles, such as advocate, communicator, collaborator, and leader, in order to provide the optimal individualized holistic care to each patient. Recognizing the connection between physician and Indigenous values may build a mutual understanding to improve physician-patient relationships and health outcomes.

Figure 1.

A typical rendition of the medicine wheel as described above. The wheel may differ in colors and quadrants based on different Indigenous groups. The figure was created using BioRender.com.

Two-Eyed Seeing is a term used to describe an approach to intercultural collaboration, originating from the Mi’kmaw term Etuaptmumk. ⁸ In Blackfoot, a similar term is “aistotsastip” which means to look at both sides. The Indigenous concept of Two-Eyed Seeing encourages the merging of Western and Indigenous ways of knowing. This can be applied as from one eye, plastic surgeons may view patient care through the lens of plastic surgery principles; and through their second eye, they behold and support Indigenous principles of balance, relationship, and sustainability. We propose that in understanding the importance of the Medicine Wheel to Indigenous health, plastic surgeons can adopt Two-Eyed Seeing as a reconciliatory step toward improving healthcare for Indigenous patients. We write this editorial on the traditional territories of the people of Treaty 7, including the Blackfoot Confederacy, Tsuu’Tina, Stoney Nakoda, and Métis Nation Region 3.