Facing hard truths: Medical education's reckoning with settler colonialism in an era of reconciliation

Abstract

Introduction

Medical schools are responsible for embedding Indigenous health education across the training continuum. Central to this work is recognising settler colonialism as an ongoing structure that privileges non‐Indigenous peoples while producing and sustaining inequities for Indigenous communities. This paper explores key learning moments as non‐Indigenous medical learners and faculty reflect on their experiences within systems that promote reconciliation yet remain largely rooted in colonial logic.

Methods

Data collection and analysis were informed by the principles of narrative inquiry. Five non‐Indigenous medical students, a health research graduate student and 10 medical educators (MD and PhD) consented to participate in a narrative interview about how they positioned themselves and supported others engagement in ongoing reconciliatory efforts within their institution. Data were gathered over 2020–2022.

Results

Participants acknowledged their privileged position and aimed to leverage it to address educational or health disparities affecting Indigenous peoples. Yet intervening when they witnessed unfairness proved challenging. Although many attempted to adopt a proactive stance and advocate for systemic change, the prevailing tendency in such situations was to avoid disrupting the status quo due to perceived gaps in their knowledge or apprehension about professional backlash.

Conclusion

Non‐Indigenous medical learners and faculty struggle to navigate a system calling for transformation yet rife with historical and institutional barriers. This struggle often arises from the discomfort stemming from their privilege and a sense of limited influence within the medical hierarchy.

Short abstract

This paper explores the tensions that non‐Indigenous learners and medical educators wrestle with in their attempts to enact reconciliation meaningfully.

1. INTRODUCTION

Medical schools have an obligation to incorporate learning opportunities pertaining to Indigenous health across the medical education continuum. Integral to this work is medical educators and learners understanding and actively confronting the role settler colonialism plays in Indigenous peoples' health care experiences, both past and present. Settler colonialism as it relates specifically to Indigenous peoples is a distinct form of colonialism ‘motivated by access and control over territory, accomplished through the process of constructing white supremacy in relation to Indigenous inferiority’. ^{1 (p. 2)} Wolfe ² writes that settler colonialism ‘destroys to replace’^{(p. 388)} distinguishing it as an ongoing, and deeply structural project that continues today across all professions, including education and health care. ³ , ⁴ Its influence manifests in different ways, some clearly visible and well‐documented such as the underrepresentation of Indigenous learners and faculty in medical training and the frequent reported incidences of anti‐Indigenous racism and discrimination in formal education and health care settings. ⁵ , ⁶ , ⁷ Other expressions are more subtle, such as the discomfort—or at times outright denial—that arises when the conversation turns to how settlers, whether intentionally or not, uphold widely referenced ‘colonial scripts’ ^{1 (p. 8)} that produce and sustain inequities for Indigenous peoples. Readers have likely encountered evidence of these colonial scripts in their home and work contexts. They surface when Indigenous peoples are portrayed as deficient in their intelligence or ability, characterised as troubled or somehow deserving of hostility, or framed as recipients of unwarranted special treatment. ¹

Understanding how the embedded and often insidious practices of settler colonialism continue to infiltrate medical education is critical if equity and justice for Indigenous peoples is the goal. Yet even with formal institutional commitments made by medical schools to improve health and social outcomes for Indigenous peoples, challenges persist. ⁸ , ⁹ , ¹⁰ Previous research indicates that Indigenous health education offerings are frequently undervalued and seldom lead to the lasting attitudinal changes desired. ¹¹ , ¹² , ¹³ In some cases, these efforts may even discourage medical learners and educators from pursuing further learning, despite overwhelming evidence suggesting they should. ⁵ , ⁸

Where does this tendency to disengage from these necessary, albeit challenging conversations originate? Some scholars propose that it stems from a persistent sense of unease when settlers' positionality as beneficiaries of past and present injustices are brought to the forefront during discussions of equity and racial justice. ¹⁰ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ For those who benefit from their racial position, awakening to the devastating impacts of settler colonialism can be cognitively and emotionally distressing. Previous research shows many medical learners incur feelings of guilt, defensiveness and ambivalence when issues of racism and discrimination towards Indigenous peoples in the health care system are introduced into health professional training. ¹⁶ , ¹⁷ , ¹⁸ Dion ¹⁹ describes the reluctance of non‐Indigenous peoples to delve into the complexities of their relationship with Indigenous peoples as adopting the wilful stance of a ‘perfect stranger’. Rather than recognising their complicity in the oppression of Indigenous peoples, individuals position themselves as a ‘respectful admirer’, a ‘moral helper’ or a ‘protector of law and order’, shifting the responsibility of improving education and health outcomes for Indigenous peoples onto a small number of Indigenous advocates as their problems to solve. ⁶ , ¹⁹ , ²⁰ , ²¹

Academic structures also remain firmly entrenched in a culture of whiteness. ²² Tuck and Yang ¹⁶ alongside many Indigenous and critical scholars draw attention to the increasing trend among non‐Indigenous individuals and institutions to espouse decolonising discourse without non‐Indigenous peoples ‘giving up land or power or privilege, without having to change much at all’.^(p.10) Consequently, the omnipresence of whiteness in medicine and medical education and its seemingly imperceptible nature allows racism to ‘hide in plain sight without ever noticing that it is the structure upholding privileged perspectives within society’. ^{22 (p. 903)} Indeed, numerous years of academic analysis and commissioned reports on Indigenous/settler relations would conclude that there has yet to be a compelling need for non‐Indigenous peoples to intentionally undertake what settler scholar Paulette Regan ¹⁵ refers to as a process of unsettling the settler within much less focus attention on a relational understanding of accountability to Indigenous peoples.

Discussions around alliance building and transformative learning have long highlighted the necessity and value of self‐evaluation as a critical step in gaining understanding of ourselves, our behaviour and the world around us. ³ , ²³ , ²⁴ , ²⁵ Yet, we know too that many people working in medical education struggle with how to reflexively assess their own positions of privilege, let alone begin to dismantle the settler‐colonial structures and mindsets that exist within the spaces where they learn and work. ²⁶ We too are implicated in this tension. Regardless, this does not mean refraining from doing this work within ourselves and our institutions. To step back from this responsibility would be antithetical to the teachings that Indigenous peoples have time and time again asserted: the importance of relationality, and more specifically, that the building of meaningful and mutually respectful Indigenous–settler alliances is not work that one person can do on behalf of another. It is work we each must take up. This article builds on a previous publication, which explored the pathways taken by non‐Indigenous medical educators and leaders in Canada to advance reconciliation in medical education. ²⁷ Here we include learners' experiences alongside those of faculty, focusing more on the internal work participants were undergoing in their attempts to understand and contribute to reconciliation, including how they personally grapple with their complicity in upholding systems of inequity that continue to disadvantage Indigenous peoples.

The Truth and Reconciliation Commission (TRC) of Canada recognises reconciliation as an ongoing process of relationship and transformation that requires non‐Indigenous peoples to take responsibility for acknowledging colonial harms, atoning for them and committing to systemic change. ²⁸ Often, reconciliation in the post‐secondary context is framed through a lens of Indigenous inclusion, that is, how best to incorporate more Indigenous content, perspectives or representation into pre‐existing, largely colonial structures. Although such initiatives can have impact, this approach can inadvertently position Indigenous peoples as primarily responsible for advancing change ²⁹ and risk obscuring the central reality that reconciliation is relational, and it is the responsibility of non‐Indigenous peoples—including non‐Indigenous medical educators and learners—to actively engage in challenging and ideally, transforming, existing structures. This paper captures the complexities, missteps and often uncomfortable process that non‐Indigenous peoples working in medical education must be willing to navigate to meaningfully contribute to this transformative work.

1.1. Locating ourselves in the research

Readers will already have noticed our decision to write in the first person. Our use of ‘we’ is intentional, meant to signal our own efforts to turn the gaze inward and, in doing so, reflect the very practice we are encouraging others working in medical education to take up. Our authorship team is made up of non‐Indigenous educators, learners and researchers. Our training and professional experiences have unfolded within institutions deeply rooted in settler culture, and the words you read here are part of an ongoing process of reckoning with what that means. OE is a Nigerian immigrant to Canada and a third‐year medical student. He brings the lived experience of a Black man navigating medicine and academia. His research focuses on medical education and health equity, with particular interest in how structural barriers shape access to care, representation and learning within health care systems. LB is an Afro‐Caribbean woman with an interest in public health research. LD is a White settler woman with extensive research experience across multiple areas of studies, including environmental studies, education and health. She has more than 15 years of experience working with Indigenous communities, organisations and governments. KL is a White settler American woman and immigrant to Canada. She is a PhD researcher who primarily uses a gender lens to explore the impact of discrimination on the well‐being and professional development of physicians and medical learners. She comes to this research struggling with the discomfort of confronting her White settler privilege and is in the process of learning how to engage in social justice without upholding ‘colonial scripts’. SB is a White settler woman who has worked in education for over 15 years. She began her career as an elementary school teacher in a remote First Nations northern community in Canada and now works as a PhD researcher at a large research‐intensive university. Her experiences working in Indigenous education have propelled her to pursue research and self‐study on how settler colonialism contributes to the radically differentexperiences Indigenous peoples face in education and health care.

We are acutely aware of how research without Indigenous peoples involvement has historically been defined and undertaken. ³⁰ We came to this work precisely because we did not want to perpetuate harm—particularly by contributing to the workload and emotional burden many Indigenous faculty and learners already carry in academic spaces. ⁶ , ³¹ This decision was made after seeking counsel from trusted Indigenous colleagues working in higher education and health carewho generously acted as a sounding board at different times throughout this inquiry. Still, we recognise our choice to focus this inquiry solely on non‐Indigenous peoples may create a degree of imbalance in the story we are about to tell. Where appropriate, and we hope, without appearing disingenuous, we have included evidence of our relational engagement with Indigenous peoples throughout our inquiry, while also remaining mindful of our responsibilities and limitations as non‐Indigenous researchers.

1.2. Language choice

When it comes to relationships between Indigenous and non‐Indigenous peoples, terminology is continually evolving. Language is powerful—names can be a source of great pride, but they can also dehumanise and be misused—and therefore must be approached with sensitivity, respect and situational awareness. In this paper, we often use the term Indigenous peoples because we felt it to be well recognised by a diverse international readership. In Canada, the term Indigenous refers specifically to individuals who identify as First Nations, Métis and Inuit. We use non‐Indigenous to describe individuals who do not identify as First Nations, Inuit, or Métis. This term was often used by many of our participants when narrating their experiences; however, we recognise its broadness and how this may be seen as a limitation to some. When relevant, we also use the term settler. Within our study context, this term is often used to reference individuals of European ancestry whose families settled in what is now Canada; however, it can also be used in relation to those who benefit from the colonial structures embedded in our contemporary society. Throughout the writing process, we regularly consulted Gregory Younging's Elements of Indigenous Style: A Guide for Writing by and about Indigenous Peoples ³² and Chelsea Vowel's Indigenous Writes: A Guide to First Nations, Métis & Inuit Issues in Canada ³³ as key resources to extend our knowledge in this area.

2. METHODOLOGY

Emphasising storytelling, narrative inquiry is rooted in ‘an interest in life experiences by those who live them’. ³⁴ Phillion ³⁵ describes three essential qualities of a narrative inquiry: thinking narratively—seeing experiences as fluid rather than as fixed; being in the midst of lives—seeing research as living in the daily experiences of participants; and making meaning of experience in relationship—developing understanding in relationship with participants. The value of narrative inquiry resides in its invitational nature; enabling both the participant and the researcher to ‘mutually engage in an exploration of values and beliefs’ in a range of contexts, making it well‐suited to explore our phenomenon of interest. ³⁶ Studying experiences narratively offered our research team the opportunity to ‘come alongside’ our participants as they reflected on their relationship to colonisation at a time where commitments to reconciliation were becoming normalised across education institutions. ³⁷ Specifically, we were curious about what would happen if we gave participants deliberate space to think more deeply about their roles and learning in the context of Indigenous/settler relations, particularly at a point in time where, in the Canadian context, reconciliation‐related rhetoric was omnipresent.

2.1. Our study context

This study was conducted in Canada during a period where discussions concerning relations between Indigenous and non‐Indigenous peoples were prominent in communities, classrooms and workplaces. The TRC's final report, released in 2015, tasked all sectors of Canadian society—from education to medicine—to review their organisational policies and practices with the eventual goal of eliminating the ongoing and intergenerational impacts of colonisation that persist throughout the country. Seven of the 94 TRC Calls to Action relate directly to Indigenous health, including a specific call for medical schools to improve education and training about Indigenous peoples' health needs in Canada. ²⁸ To date, none of the seven calls concerning Indigenous health have been fully realised. ³⁸

2.2. Data collection

This study was approved by Dalhousie University's Social Sciences and Humanities Research Ethics Board. We concentrated our recruitment efforts on engaging non‐Indigenous medical educators and learners with an academic or professional affiliation with a Canadian medical school. Aiming to capture a wide range of perspectives and experiences, we adopted a broad recruitment strategy. We invited non‐Indigenous faculty and learners from all Canadian medical schools (n = 17) who self‐identified as having an interest in Indigenous health or a direct connection to the reconciliatory initiatives underway within their medical school. We also reached out to relevant interest groups, requesting them to disseminate information about our study through their respective networks and listservs. Data collection spanned the 2020/2021 and 2021/2022 academic years and was overseen by two research assistants (LB and LD).

In total, five non‐Indigenous medical students, a health research graduate student, and ten medical educators (MD and PhD) consented to participate in a narrative interview over MS Teams. Participants represented diverse career stages, leadership roles and geographic locations. Participants used different terms to position themselves in relation to our study focus, including White, non‐Indigenous and settler. For additional demographic information about our participants, please refer to Table 1. Participants were asked to share how they positioned themselves and supported others engagement in ongoing solidarity efforts with Indigenous peoples. We were keen to learn what reconciliation meant to them personally and their perceived role in advancing the TRC's Calls to Action. Additionally, participants were invited to describe the challenges they encountered personally and professionally in undertaking reconciliatory work within medical education and to reflect on the most perplexing aspects of these experiences (see Appendix S1 for the full interview guide).

TABLE 1.

Participant characteristics.

Total number of study participants	16
Gender (M:F)	6:10
Geographic location of Canadian medical school	3 The Atlantic provinces (NL, PEI, NS, NB) 9 Central Canada (QC, ON) 3 The Prairie provinces (MB, SK, AB) 1 West coast (BC)
Number of physician participants	2 Generalist physicians 7 Specialist physicians
Number of PhD scientist participants	1
Number of medical learner participants	5
Number of graduate participants	1

Interview questions were intentionally crafted to elicit deeper accounts of each participant's experience while considering the shifting cultural and institutional forces that might influence how participants position themselves within this inquiry. Anticipating that participants may experience some emotional distress related to the topic under study, we assured participants prior to beginning the research interview of the steps being taken to limit possible impacts on their academic or professional standing because of their study participation. All interviews were audio recorded, transcribed verbatim and de‐identified prior to beginning data analysis.

Listening to our participants share their stories moved us to reflect on who we were becoming and how we were changing both individually and as a team. Although most of the research team had prior experience researching sensitive topics, there were still moments during this study when we felt we had reached the limits of our understanding, unsure of how or whether to proceed. These feelings were intensified by the fact that, at the time of interviewing, Indigenous/settler relations in Canada were under strong scrutiny, making it difficult at times for statements of reconciliation to be seen as anything more than empty rhetoric. Almost daily, there was a news story addressing issues such as self‐determination, inadequate funding for infrastructure and services and the collective trauma of past institutional policies. These stories were heavy, carrying the weight of past abuse and inducing at times feelings of guilt, shame and defensiveness. It would have been easy to retreat or to disregard these feelings and proceed with the study. However, as an ethical dimension of this work, we dedicated time throughout our study to voice our questions and concerns with one another, to speak with Indigenous colleagues within our professional network, to critically examine our research process and to discuss the contentious nature of this work within the current historical context we found ourselves in. The specific activities varied depending on the stage of our research. Sometimes it involved phone calls or virtual meetings with one another or Indigenous colleagues to reframe our perceived problems within the broader context of why we originally embarked on this project. A few team members were also fortunate to work closely with an Indigenous scholar who introduced us to the theory and practice of decolonising critical reflection (DCR). ³⁹ Through this work, we began learning how to critically appraise, question and when necessary, reframe the tacit worldview assumptions we carry—both within ourselves and embedded in the educational content and professional spaces we routinely inhabit. At other times, the work was more introspective and personal, including learning how to show compassion and understanding towards ourselves when the emotional aspects of navigating the inherent uncertainty of doing this type of research became difficult to bear.

2.3. Data analysis

According to Kiesinger, ⁴⁰ ‘the stories that we tell about our lives often become the frameworks of meaning out of which we act, think, interpret, and relate’. Recognising then, that our participants' experiences were profoundly influential on how they negotiated their roles as educators or aspiring physicians, we felt it necessary to approach our analysis holistically. This approach involved careful consideration of both the individual and the broader social, historical, and cultural milieus in which participants' stories were situated.

To achieve this, we relied on Connelly and Clandinin's ⁴¹ three analytical tools for narrative inquiry: broadening, burrowing, and storying and restorying. The first tool, broadening, involved adopting an aerial perspective on the stories participants shared with us. This allowed us to detail in general terms how our participants had engaged with or learned about Indigenous/settler relations in the context of medical education. At this stage, we focused on describing the events and influences—whether people, places or texts—that solidified participants' understanding of and engagement in this relational work. Next, we shifted to burrowing, which required delving deeper into the particularities of each participant's narrative. This included examining the feelings, understandings and negotiations involved in advancing work that can simultaneously be both tough and fulfilling. During this stage, we used writing as a form of inquiry combined with thematic narrative analysis to generate portraits of how each participant navigated the complexities of reconciliatory work. ⁴¹ , ⁴² These portraits were developed collaboratively among team members and emphasised the experiences that appeared to have the most insightful impact on the participant's evolving perception of their role in reconciliation. In coding the data, we concentrated on how participants had come to understand reconciliation, recognising that this social justice movement, like many others, is underpinned by a complex assemblage of discourses and colonial policies that continue to marginalise Indigenous peoples and their worldviews. In writing each portrait, we remained close to the data, attuned to the broader themes constituting participants narratives, their choice of words (e.g. ‘it's fundamentally about surrender’), as well as identifying key moments in our conversations with participants. This work occurred iteratively rather than in a linear fashion to leave space for further reflection and interpretation. It was during the portrait development stage that we simultaneously engaged with the DCR method as it prompted us to think more critically about some of the negotiations and enactments that our participants underwent while attending to real structural and systemic constraints.

The final step in our analysis was storying and restorying. In this stage, we synthesised our insights from the previous two stages to create the data representation presented in the next section. Throughout all three stages, we held recurrent team meetings and engaged in different meaning‐making exercises. In the following sections, we present our findings from this inquiry. We invite readers to pay close attention to what is happening within yourself—what reactions are you experiencing as you read?

3. RESULTS

In many instances, participants' motivation to learn more about Indigenous/settler relations and campaign for social and educational change appeared linked to an acknowledgement that their privilege as a non‐Indigenous person could be leveraged to challenge and, in some cases, redress the institutional inequities that persist in Indigenous health. Despite this awareness, some participants admitted to struggling to understand their own relationship(s) to settler colonialism and the individual role they should assume in advancing reconciliation with Indigenous peoples. It seemed that participants were feeling somewhat constrained at the ‘nothing about us without us’ stage, believing that much of this work needed to be driven by and involve Indigenous peoples. Others grappled with concerns about causing unintended but potentially harmful consequences. Participant quotes are labelled ‘F’ for faculty participants and ‘L’ for learner participants.

3.1. Navigating duality

Both medical learners and faculty contended with the duality of seeking to challenge colonial structures woven into medical education while simultaneously benefiting from and participating in them. This internal tension spurred participants to adopt two distinct, yet seemingly contradictory, strategies. One strategy involved participants ‘leveraging’ (L1) their privilege to address harmful behaviour and advocate for curricular and systemic changes in medical education and health care. Participants described their engagement in reconciliation largely in an activist capacity, with some specifically referencing the CanMEDS Health Advocate role and ‘the day‐to‐day activities of advocacy’ (F6) that could be undertaken within their sphere of influence to respect Indigenous rights and address inequitable health outcomes. Many participants, emphasised for example, the importance of consistently delivering ‘culturally competent and safe care’ (F8), greater integration of traditional health and wellness practices in the treatment of Indigenous patients and supporting Indigenous colleagues and learners within both the pre‐clinical and clinical learning environments. What stood out in the examples participants provided was the frequency with which participants referenced providing help or assistance to Indigenous peoples.

The alternative strategy, driven partly by a perceived knowledge deficit around Indigenous issues—‘it's still pretty daunting what I don't know’ (F2), or past experiences suggesting that raising concerns about Indigenous issues may trigger defensiveness from those being addressed, caused participants to opt for a bystander role. Learners struggled with this most during their clinical rotations, unsure how to call out bad behaviour, particularly if their preceptor or another health professional was the offender:

I don't recall the school ever telling us what to do if you see racism when you're on a clinical rotation…You know, if your preceptor says something racist about a patient that you've seen, it's incredibly uncomfortable [to confront them] because they're the ones that at the end of the shift are going to be doing an evaluation on your performance. L3

Learners offered two main reasons for their diminished sense of agency in the clinical environment. First, they proposed that medical education's inherent hierarchy placed them in ‘a really awkward position’ (L2) where their dependence on favourable evaluations from their preceptors took precedence over their decision to confront anti‐Indigenous practices or behaviours. Second, some learners observed a tendency to view themselves as naïve and ignorant in clinical settings, thereby reinforcing asymmetrical power dynamics and consequently, their complacency as beneficiaries of the structural advantages they experience. As Participant L1 noted, ‘… your very existence [in the clinic] is like, oh, “I'm here to learn, and I'm kind of an idiot, and so, just tell me the things I need to know.”’

Faculty had a different view, noting that there was a greater drive for systematic change from medical learners. But that optimism, as illustrated by F5 below, seemed tempered by their own perceived lack of agency within deeply entrenched colonial structures:

Our students are so passionate about moving things forward… they really just want change now. And I totally get that. But then I have reality on the other side and experience of life that says, yeah, these are all really great, great goals but we're not going to get there tomorrow.

Although participants acknowledged their considerable privilege and recognised their involvement in reconciliatory efforts ‘as the right thing to do’ (F5), they also perceived themselves as having limited power to change the institutional and educational practices necessary for meaningfully advancing reconciliation.

3.2. Struggling with guilt and discomfort

Upon initial consideration, both strategies—leveraging privilege and assuming a bystander role—seemed like valid approaches for participants seeking to advance reconciliatory work. In fact, it was not uncommon for participants to switch between approaches depending on the situation they found themselves in. However, participants shared with us certain experiences that prompted them to question and doubt the effectiveness and feasibility of these approaches. For instance, Participant F9, an early career physician, shared an experience in which a senior colleague made discriminatory comments during a professional encounter in the presence of a medical learner. They conveyed to us the discomfort they felt throughout the entire discussion, noting their attempt to change the topic, which, admittedly, did not succeed. Constrained by professional norms, they found themselves ‘toiling over’ the conversation for days following the incident:

I didn't know what to say. And this person is like a colleague that I work closely with … I think I said something like ‘that makes me uncomfortable’ … And then I ended up like toiling over that conversation … I called the resident a couple of days later just to say, ‘you know what, I just want you to know I was uncomfortable in that moment, and I don't agree with those sentiments.’ But I didn't have the bravery in that moment to say, ‘you're wrong’ or ‘that's ridiculous.’

Participant F9's experience brings to view a major drawback some participants felt in their attempts to leverage their privilege: it relies solely on personal choice and circumstance, albeit in the moment it does not always feel that way. Similarly, learners expressed regret over their complicity in situations where they witnessed discriminatory behaviour but shied away from speaking up: ‘there are times where I wish I said something, and I didn't. And then I feel a lot of guilt for being a bystander or silently encouraging without actually saying anything’ (L6). Consequently, when participants perceived a lack of agency, or found themselves in situations with competing interests, such as preserving collegial ties or desiring a favourable evaluation from their preceptor, the prevailing tendency was to avoid disrupting the status quo. As Participant L5 noted, ‘… as a med student, and as a female med student, you're kind of conditioned to not want to make waves.’ In fact, some participants intentionally steered clear of taking on leadership roles in reconciliatory initiatives for fear of being labelled a ‘white saviour’ (L2) or their efforts being misconstrued as self‐aggrandisement. Participant F9 admitted that they ‘struggle a little bit with the kind of self‐serving nature of these things…Like I get credit for doing these things, and then it kind of further enhances my own privilege.’ Although praise was not typically participants' goal, they admitted that it also ‘satisfied something’ (F9) within themselves, personally and professionally.

Participants recognised that their ability to contribute to some reconciliatory efforts while opting out of others was a privilege many of their Indigenous peers and colleagues did not have: ‘Indigenous students [want] more support because they're being asked to do more to speak on behalf of Indigenous peoples’ (L6). Additionally, Participant L4 mentioned this regarding the treatment of Indigenous faculty within the academy:

The institution doesn't treat Indigenous faculty, fairly. They are often overburdened and have to do all of the institutional work to advocate for Indigenous learners to be in these spaces. But they also have to produce research papers and have a productive research lab, and they also have to teach. And then we don't do anything for Indigenous faculty members' health and well‐being and the potential of burden.

Participants' often spoke about how it was crucial to foster environments that not only encourage active participation on the part of non‐Indigenous peoples but also address the structural barriers that inhibit realising the goals of reconciliation. Participants seemed to be constantly navigating a delicate balance between direct action and passivity, feeling constrained by systemic structures, professional norms and their personal struggle with guilt and discomfort.

4. DISCUSSION

Little to date has been discussed regarding non‐Indigenous peoples' individual embarkment on deepening their understanding of settler identity and the privileges it confers in medical education. In fact, previous research largely demonstrates the contrary; disengagement when conversations turn towards indigenising medical education. ¹² Our research contributes additional understanding about how the medical education context may encourage disengagement, even among those who are seemingly invested in engaging in this work. ⁴³ , ⁴⁴

Participants expressed feeling conflicted about how they themselves might evoke the structural changes needed to improve Indigenous peoples' experiences throughout training and in health care. They recognised the positions of privilege they held and aspired to mobilise their privilege to speak out against the problematic practices that reinforce systems of inequality. Yet, despite this self‐awareness, participants rarely acknowledged how their decision to sidestep leadership roles in reconciliation‐oriented activities might inadvertently increase the workload placed on their Indigenous counterparts. Notably, even in sharing their reflections with us, some participants occasionally fell into deficit‐based framing, making prescriptive suggestions about what Indigenous peoples ‘need’ or should do—unwittingly reinforcing subtle paternalistic assumptions and overlooking the primacy of Indigenous self‐determination.

We also identified from participants' narratives how outwardly denouncing colonial worldviews and traditions can feel risky at times; the sensitivity of these topics combined with the hierarchical nature of medical education and apprehension about potential repercussions left participants struggling to consistently call out troubling behaviour and unfair processes. Participants' stories illuminate a dilemma that many people are grappling with as they contemplate the extent of their involvement in reconciliation‐driven change and equity work in general. On the one hand, there is a sincere desire to seize the present historic moment and bring forth tangible structural change. However, this desire coexists with a persistent and oftentimes valid fear that confronting behaviours inherently at odds with the goals of reconciliation may result in personal and professional repercussions, ultimately discouraging individuals from enacting the very changes they recognise as necessary. ⁴⁵ This reflects a massive structural problem that demands urgent attention.

At this point, readers might wonder about the broader impact of a few well‐meaning individuals who have engaged in this level of deeper evaluation. While it seemed for many participants that our study provided a much‐needed space to explore their experiences, an opportunity that seemed otherwise unavailable to them, how will such introspection meaningfully shift a profession that continues to cause harm towards Indigenous peoples? It is true that excessive self‐reflection alone will not dismantle the colonial histories of the institutions where we work and learn. However, let us not forget that individual actions and worldviews are situated within and understood through larger cultural, social, political and institutional histories. Therefore, we must begin at the individual level and create space for this level of interrogation if we aim to thwart and reorient how medical education is designed and delivered. We urge readers to familiarise themselves with the principles of practising critical allyship ³ , ⁴⁶ as well as the growing scholarship of Indigenous and critical scholars for continued guidance on how to evoke real and meaningful change in their spheres of influences—without requiring Indigenous peoples to expend further (and often undercompensated) labour.

We also hope our findings prompt medical schools to reassess the institutional frameworks that shape how medical learners and educators engage with topics related to Indigenous/settler relations. We advocate for the creation of psychologically supportive spaces where open dialogue and effective intervention against anti‐Indigenous practices are actively encouraged and mobilised. Creating such an environment requires several key elements to be implemented across the medical education continuum, including ensuring that medical learners and educators receive routine training on topics such as Indigenous specific anti‐racism, settler colonialism and cultural safety within their learning environments and workplaces; guaranteeing any breaches of safety are swiftly and effectively handled; and establishing clear, accessible channels for medical learners and educators to report concerns without fear of retribution. ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰

We would be remiss not to mention that the narratives shared here provide only a partial perspective on an enormously complex human rights issue that extends beyond Canada to other parts of the world. Numerous reports, both within Canada and globally (e.g. the United Nations Declaration on the Rights of Indigenous Peoples) detail the expertise of those with lived experience of the injustices and harms that continue to affect Indigenous peoples today as well as concrete steps to strengthen relations between Indigenous and non‐Indigenous peoples. ⁵¹ Given the sensitive nature of the topic under exploration, we are cognisant that participants may have felt compelled to present themselves in a more favourable light. This could have also led to an overstatement of their willingness to engage in reconciliatory actions and an understatement of their discomfort and hesitancy. We are also cognisant that our participants may have responded differently if interviews were conducted by an Indigenous researcher. As previously mentioned, the research interviews were conducted at a time when Indigenous/settler relations in Canada were prominently featured in the media, reflecting a period of increased public consciousness and willingness on the part of non‐Indigenous peoples to engage in discussions on reconciliation.

5. CONCLUSION

Non‐Indigenous medical educators and learners have a significant role to play in advancing reconciliation within the educational and clinical spaces they regularly occupy. However, our study findings reveal that they often struggle to navigate a system that demands transformation yet remains entrenched in settler colonial ways of being. This struggle frequently stems from the discomfort associated with their racial position and a perceived lack of influence within the medical hierarchy. By sharing the experiences of our participants, we aim to inspire others to lean into their discomfort as a catalyst for transformative action rather than a reason for inaction.

AUTHOR CONTRIBUTIONS

Obinna Esomchukwu: Writing—original draft; writing—review and editing; formal analysis; methodology. Lisa Bishop: Investigation; methodology; writing—review and editing; data curation; project administration; formal analysis. Libby Dean: Investigation; methodology; writing—review and editing; data curation; project administration; formal analysis. Kori A. LaDonna: Conceptualization; funding acquisition; methodology; formal analysis; writing—review and editing. Sarah Burm: Conceptualization; investigation; funding acquisition; methodology; formal analysis; writing—original draft; writing—review and editing; project administration; supervision.

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to report in this study.

ETHICS STATEMENT

This study was approved by Dalhousie University Research Ethics Board (REB #: 2020‐5279).

Supporting information

Appendix S1. Interview Guide.

Esomchukwu O, Bishop L, Dean L, LaDonna KA, Burm S. Facing hard truths: Medical education's reckoning with settler colonialism in an era of reconciliation. Med Educ. 2026;60(3):317‐325. doi: 10.1111/medu.70028

DATA AVAILABILITY STATEMENT

Research data are not shared.