Six ways to get a grip on teaching medical trainees on the convergence of Indigenous knowledges and biomedicine, within a culturally-safe Indigenous health curriculum

Abstract

As Indigenous knowledges and biomedicine come together in healthcare today, to improve health outcomes and strengthen cultural identity among Indigenous Peoples, it is vital for physicians to learn about this convergence during their training. This narrative review article aims to provide practical advice for educators when implementing teaching regarding this topic, using examples from the research literature, and pedagogical and practice-based methods used at the University of Toronto (UofT). The methodology on obtaining the research literature included a search of a computer database called Medline. Moreover, the medical school curriculum information specific to UofT, was obtained through the formal curriculum map and UofT’s Office of Indigenous Medical Education. The following six recommendations provide a way to successfully implement the teachings on Indigenous knowledges and biomedicine, within a culturally-safe Indigenous health curriculum.

Introduction

Indigenous healing practices have been an important part of Indigenous knowledges and ways of knowing that have existed for thousands of years. Colonization, forced assimilation, and racism have all contributed to these practices being split off from Indigenous healthcare.¹ Consequently, this has further impacted health disparities seen among some Indigenous communities today.¹ An important aspect of restoring these knowledges is the promotion and reclamation of Indigenous healing, which includes making space for Indigenous practices and knowledges alongside biomedicine.² Ways of making space take different forms in various programs -from including Elders in treatment care planning, to taking community-based approaches that enable communities to set and lead their own health priorities.³ Ultimately, these programs which integrate Indigenous knowledges with biomedicine improve health outcomes and strengthen cultural identity among Indigenous Peoples.²

Therefore, instead of learning about these knowledge systems separately, healthcare providers will benefit from learning about the convergence of Indigenous knowledges together with biomedicine during their training.² In fact, there is a willingness and motivation to learn about Indigenous healing practices among healthcare professionals.⁴

However, there are misguided practices to navigate in order to make these teachings successful, and to avoid furthering the racism or inequities that we seek to redress. In addition to the knowledge we seek to disseminate, we also need to consider the pedagogical approach, and ensure critical reflection on the history of harmful ideas and practices that can occur in teaching about the health of Indigenous populations. Some of these practices include: presenting only health disparities and risks, while omitting discussion of Indigenous community knowledge and strengths; creating curricula without Indigenous Peoples guiding, leading, and being educators in this process;⁵ or taking a “one size fits all” approach that fails to see the heterogeneity of Indigenous Peoples.⁶ Instead of striving to teach everything there is to know about complex and often privileged knowledge systems, it is far better to model cultural humility.⁷ Moreover, we and others believe both Indigenous and non-Indigenous knowledge systems must be equally valued for the teachings to be meaningful.⁸

With these considerations as a foundation, here are six recommendations to help introduce medical trainees to Indigenous knowledges, medicine and healing practices.

1. Use multiple teaching methods to introduce Indigenous knowledges

According to various Indigenous leaders and patients, a way to develop respect and equal valuing of both Indigenous and non-Indigenous knowledge systems is by providing education and awareness to health professionals through training.⁹ This education should be provided using multiple teaching methods. This means not only providing lectures or modules, but also using experiential methods to better understand Indigenous worldviews, cultural practices, and traditional ways of knowing.¹⁰

In fact, a Māori study which looked at Indigenous teachings in the medical curriculum, found that students enjoyed multiple teaching methods since it helped them engage with the content more and encouraged high levels of interaction between each other.¹¹ These multiple methods included lecture style teaching, small group discussions, participating in simulated patient interviews, and workshops.¹¹ Furthermore, an example of how to use multiple teaching methods can be seen with what is done at the University of Toronto medical school. While there are lectures, modules, and case-based learning sessions related to Indigenous health, every student participates in a KAIROS Blanket Exercise as a way to experientially learn about Indigenous histories and explore the nation-to-nation relationship between Indigenous and non-Indigenous Peoples in Canada.¹²

2. Encourage self-reflection and cultural humility among learners

Cultural humility is a process of self-reflection to understand systemic and personal conditioned biases.⁷ It is a way for learners to acknowledge oneself as a perpetual learner when it comes to understanding another’s experiences.

Indigenous leaders have been encouraging the use of the concept of cultural humility, instead of ‘cultural competency’, because a person can never fully achieve cultural competency through training or a course.⁷ Instead, learning about another person’s culture is a life-long learning process. Healthcare providers should be encouraged to acknowledge the lifelong journey of learning and self-reflection, while being open to listening to what better care means for Indigenous Peoples. An example of encouraging the concept of cultural humility in a learning environment is what is done during the KAIROS Blanket exercise. This includes ensuring there is space for students to ask questions, to talk about difficult topics including racism, and have a moment during the teaching for self-reflection.¹² Ultimately, cultural humility is a vital part of creating a healthcare system which is culturally safe for all.⁷

3. Invite Elders and other Indigenous community members to guide, facilitate, and/or teach

Teachings involving the convergence of Indigenous knowledges and biomedicine, should involve Indigenous educators, as they are more knowledgeable about the cultures, histories, and worldviews of Indigenous Peoples. Even if it is not possible to have these educators directly teach, having an Elder or other Indigenous community member, oversee how and what is being taught is important to ensure the content is presented well without any negative bias.¹³

In fact, the Office of Indigenous Medical Education at the University of Toronto created a Truth and Reconciliation Report (TRC) Reading Group, where an Elder was involved in the planning, initiation, and facilitation process of three small group sessions. With only an idea in mind, of having a TRC Reading Group, the medical student who helped organize the event, met and communicated over email with the Elder multiple times to aid in planning and initiating the group. The Elder provided guidance in what the sessions would entail, including the idea that there should be smudging practices done to commence each session.¹⁴ Moreover, it is important when having an Elder partake in teachings, to ensure the honoraria provided to the Elder is respectful and appropriate for their knowledges provided.¹⁴ Indeed, Elders, Traditional Teachers, and Knowledge Keepers are now a vital presence at UofT, and the university encourages staff, students and faculty to engage and grow in connection with them.¹⁵

4. Consider the setting and learning environment

Although lecture halls can be used as a teaching environment, learning about Indigenous histories and knowledges can be more meaningful in other environments. For example, if the teachings involve traditional practices like smudging, it is important to find a room that supports this. Or maybe you want to find a room in a building which is significant for Indigenous Peoples, like a sweat lodge or Indigenous Gathering Place or even a university building meant to support Indigenous students. With consultation of Indigenous educators, finding a learning environment different from a lecture hall is possible, and can positively impact the teachings for the students.

In fact, the Māori study looking at the Indigenous health curriculum for medical students found learning at a marae (Indigenous meeting place) motivated the students to engage with the course content more deeply.¹¹ This learning environment also allowed students to experience specific traditional protocols, making their learning more meaningful.¹¹ Likewise, the TRC Reading Group done at the University of Toronto considered the learning environment when choosing where to conduct the sessions. In consultation with the Elder, two rooms were found which would allow for a smudging practice, which allowed for an enhanced learning environment.¹⁴ The two rooms used were the Labyrinth room in Women’s College Hospital which is meant as a quiet prayer/reflection room, and the lounge in First Nations House which is a place that provides culturally supportive student services to Indigenous students at the university.¹⁴

5. Cultivate the perspective of holism, and teach a relationship-based approach to making space for Indigenous knowledges and practices within biomedicine

While it is vital to think about how to best teach students from a learning environment and teaching methods perspective, it is also important to think about the content. After reviewing the literature on programs which converge Indigenous knowledges with biomedicine, here is what students should know about the key factors to successfully doing so:

• Build upon holistic models of wellness in the creation of programs that bring together Indigenous knowledges with biomedicine, while working with local Indigenous organizations, leaders and clients. Although there is great diversity amongst Indigenous nations and cultures, many share an approach to health that is wholistic. This includes spiritual, emotional, physical, and mental dimensions of life, including connections to the land and other non-human aspects of the world.^16,17,18

• Ensure that communities who are the intended recipients of health care participate in all stages of the development and implementation of integrated Indigenous and biomedical programs. Recruit, mentor and support program leaders and practitioners from within local Indigenous communities.^19,20

• Build and nurture strong partnerships, between Indigenous and non-Indigenous peoples, as the foundation for creating and maintaining integrated programs. This process of ‘two-way’ learning allows for sharing of knowledge, while maintaining integrity and respect of individual expertise from each cultural domain.⁸

• Build time and space when integrating Indigenous knowledge with biomedicine for individuals to focus on building trusting relationships.^19,21 While partnerships are important, the process of developing collaboration through relationship-building is equally vital. Relationship building is an essential process to many Indigenous communities and is deeply embedded in history and context.²²

6. Teach the concept of wise practices as a way to bring Indigenous knowledges and practices alongside biomedicine in a respectful and meaningful way

Wise practices are locally-appropriate principles, actions, tools, or decisions that contribute significantly to the development of equitable and sustainable social conditions.²³ An approach which values wise practices is especially important in healthcare when considering Indigenous knowledges and practices in the context of biomedicine.²³ Therefore, this is an important concept for medical trainees to understand before going into practice.

In contrast to the best practices approach, which creates a knowledge hierarchy and applies a proven method or process to many communities, wise practices acknowledges the heterogeneity of Indigenous peoples.²³ Failure to recognize this diversity and nation-specific knowledges and practices, can lead to pan-Indigenous approaches that over simplify and/or overgeneralize knowledge developed in one community to apply in other communities.²³ Indeed, each community has their own cultural background, knowledges, social practices, and unique experiences of colonization, and therefore generalizing practices into other contexts should not be the answer.²⁴ In fact, viewing Indigenous culture as a monoculture can reduce the effectiveness of Indigenous and mainstream health partnerships.⁶ Ultimately, healthcare professionals need to understand the core of this approach as a relational covenant of respect, and honor the autonomy and sovereignty of Indigenous peoples and communities.

Conclusion

Since medical schools across the country and world have different curricula, class sizes, and resources, teaching on the convergence of Indigenous practices with biomedicine will vary and have its own challenges. For example, a school may not have the funding to support an Elder to facilitate teachings, or a learning environment which would make Indigenous teachings meaningful. However, an approach based on the principles of cultural humility, holism, and the existence of a diversity of knowledges and practices, will create a culturally-safe Indigenous health curriculum in which wise practices can flourish. This flourishing though cannot simply be imparted on an individual learner basis. Instead, it will only thrive in institutional and social settings that also value Indigenous knowledges, and in health profession faculties that recruit and sustain students and teachers from diverse Indigenous backgrounds. Ultimately, these recommendations are based within the specific social location of UofT, and future research can include ways in which different social locations successfully involve Indigenous knowledges with biomedicine in their medical school curriculum.

Note from authors

As authors we recognize there are other examples of Indigenous Health frameworks in medical schools across Canada. However, we have chosen to focus on the UofT framework because of our specific social location of having developed and experienced the Indigenous health curriculum. Specifying social location is vital to the context of Indigenous Peoples, epistemology, and education. Therefore, we would like to specify our social location as a medical student, who experienced the curriculum, an Anishnawbe physician, and a non-Indigenous physician who has worked extensively in the field of Indigenous health.

Conflicts of Interest

None

Funding

From the Canadian Federation of Medical Students (CFMS) Indigenous Mental Wellness Summer Studentship. These funds were used to support the medical student for their research work commitment, and to aid with transport costs needed to complete the research