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LISTENING to what the Indigenous community needs, rather than doctors telling them, is a key factor in improving the health of Indigenous Australians, according to experts in the field.
The main factors impeding improvements in health are stereotyping of patients and a lack of awareness about the “culture of medicine”.
In a “For debate” article in the latest MJA on the concept of cultural competence, the authors wrote that educational interventions to improve cultural competence were linked to improvements in health outcomes. They said the final — and best — judge of whether a health professional had achieved cultural competence was “the patient as the recipient of services”. (1)
Dr Paul Johanson, a GP at the Majellan Medical Centre in Scarborough, Queensland, agreed, telling MJA InSight that the practice of listening to what the Indigenous community told him they needed, rather than him telling them what he could do, had been a key to Majellan becoming a “local hub for Aboriginal health” in the past 3 years.
“The key thing is building those conversations and contacts away from the medical context”, Dr Johanson said.
“There isn’t one silver bullet that will solve all the problems of improving the health of Indigenous people. It’s about building trust, building confidence so that they know that when they come to us they will receive good service and respect.”
Dr Johanson said stereotyping could be an issue in medical practice.
“Some doctors assume that the Indigenous patient in front of them comes with a whole raft of problems that they don’t in fact have. Or they can be completely blind to cultural differences.
“It’s not enough to send someone to a seminar on cultural competence and hope that will result in better health care for Indigenous people”, Dr Johanson said.
“Trust is a big part of it, understanding and getting a sense of people’s social and family context. Non-Indigenous people have little contact with Indigenous people on a family or community level.
“There’s a strong mindset in Australians that most Indigenous people live in the bush [when] in fact, most live in an urban context.”
But things are improving, Dr Johanson said.
“There is a different atmosphere now. The communities feel a lot more empowered and feel more able to ask for what they want from the health care system.
“The question is how we are able to respond to those community needs.”
Dr Tammy Kimpton, president of the Australian Indigenous Doctors’ Association, said that to be culturally competent, doctors first needed to be aware of their own culture and the “culture of medicine”.
She agreed with the authors of the MJA article who wrote that the culture of medicine included “the presence of institutional racism, power imbalances and the role of professional socialisation”.
“We must allow the Indigenous patient to be themselves, to express themselves”, she told MJA InSight. “Assuming that all Indigenous people are the same ignores the fact that there are significant variations in cultures across the country.”
Dr Kimpton said the best thing that could be done for Indigenous health was to have Aboriginal and Torres Strait Islander health leadership “that is involved in negotiating a national health plan with measurable targets and clear tracks for where we want to be in the next 20 years”.
In an editorial in the same issue of the MJA, Dr Kimpton called on non-Indigenous health care professionals to take note of the upcoming National Aboriginal and Torres Strait Islander Health Plan, due for release later this year, and ask themselves a question. (2)
“Ask yourself what your role is in delivering quality and culturally appropriate health care to Aboriginal and Torres Strait Islander people, and … consider how this role could be strengthened”, she wrote.
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I agree that more placements in rural aboriginal communities may lessen their fears or mistrust of medical professionals…but this would take time and any noticeable differences could take decades. I see no harm in having an education plan that might bring the aboriginal and medical communities closer together.
My father was an MD in the 1950’s and 1960’s in Canada when we faced similar challenges with our aboriginal communities…and over time and with education the issue of mistrust of non indigenous medical professionals has improved greatly.
I could not disagree more with the premise that the patient knows best.
I have a significant percentage of Aboriginal patients in a rural setting and the local nation was one of the first to get their native title rights acknowledged.
The presenting local Aboriginal lacks awareness of the germ cause of both acute and chronic infectious disease, has no idea of the difference between viral, bacterial and fungal/parasitic origins of infection/infestation and so ask for or demand inappropriate prescribing from us frequently.
As with all cultures, wealth and status is bound up with choice, supply and consumption of foods and traditional ideas completely fail to supply indigenous people with sufficient tools to assess the food value and the appropriate quantities and frequencies of consumption of what is available at fast food outlets, supermarkets and local farmers markets.
The results of applied Western medicine are wonderful and not perfect. The longevity of both men and women are at record high levels, the quality of life in old age is immensely improved and the infant death rate at an almost theoretical minimus (apart from the indigenous community). European civilisation has been a boon to all peoples of the world who have emulated its agricultural, technical, scientific and communications revolutions. Again, immensely valuable and not perfect as all human endevours will always be.
We also have a significant anti-immunisation, anti-pharmaceutical and pro-alternative medicine population. Their health is observably inferior to the ordinary patient. This is no surprise to me having worked in the countries where their ideas originate and fail to achieve anything like the benefits in the first world.
I agree that the best judge of competence of the health professional is the patient.
Perhaps all medical students and doctors in training should do placements in rural, remote communities and urban Aboriginal medical services.
Where do the patients want to be in the next 20 years ? Patients are worried whether they will be alive next year, so the 20 year plan strikes me as lacking cultural awareness , while displaying a political stereotype.
We Aussie doctors are not to blame for what the English ruling class have done here since they colonised this country, any more than we are to blame for the oppression of our ancestors who came here to escape persecution.
Thanks MJA it is always good to have these issues on the agenda.
We know in the last decade that medicare billings for Indigenous Australians were only about 40% compared to non-Indigenous Australians, despite double the disease and death rates, so the reality is many are not coming to us as GP’s and we have to ask ourselves why. I am willing to try harder or make change. Are others?
I disagree that the answer is in science. We already know the science. We know metformin in diabetes saves lives, and ACE inhibitors in nephropathy halt disease. One answer lies in making our clinics a place where people actually feel comfortable coming – and my experience, like Dr Johanson’s, is you do a far better job getting people in the door and talking about their health when you have their trust and welcome them rather than judge them.
History and governmental policies through the years play a big part in why some people might mistrust or avoid healthcare, but having a look at ourselves, and our way of doing things, instead of just pointing the finger at ‘non-compliant patients’ and ‘parental neglect’ has been a massive help to me in gaining people’s trust in my own practice. Having a bit of two-way conversation with people as to how we could help them be more comfortable accessing healthcare seems a bloody sensible thing to do.
Thanks MJA.
Dr Warren Jennings
Talk about teaching doctors to suck eggs. For heavens sake, the intelligent highly trained doctors of Australia are not the enemy! Stop publishing (without balance) pseudo-scientific articles that are only polemiscist treatises that always implicitly and explicitly denigrate western medicine. We have been assaulted with this psycho/socio-babble for decades by the ‘social scientists’ (yes an oxymoron) pretending to provide some deep and profound insight into the human condition on earth that only these left wing delphic oracles understand. To state openly that medicine in this country is institutionally racist is just plain nonsense so stop validating the commonly held description of the MJA as the ‘Blue Comic’. There are over 200 diverse cultures repesented in 21st century Australian society and those numbers are expanding rapidly through immigration, both controlled and uncontrolled. Each and every one of those cultures could easily be substituted for the Aboriginal community in similar future articles by these authors if they wished and would be just as valid in their eyes. I guess on the positive side it would provide them with further taxpayer funded work, an expanded personal CV and this journal with articles to fill its pages well into the future. Demanding that doctors must solve the social, economic and health inequities experienced by the aboriginal community and to imply that they are racist because we don’t follow some prescribed pathway known only to them is wrong, insulting and is akin to the constant demand on teachers to solve the problems of childhood neglect.
Cultural awareness is all very nice but we need to figure out the science first. I would suggest most non infectious indigenous health problems ( heart disease, diabetes etc) is really just carbohydrate poisoning. Y
You are really opening a “pandora’s box” when you make the statement…’patient’s will be the judge of cultural competence’ as if sickness and disese is a respector of cultural boundaries!
But, the ‘boundaries of cuture’ will certainly limit what and how effective treatments can be to patients who are under the bondage of “pagan culture”
We are all….’TRI-partite’ in our being…ie; we are spirit, soul and physical body…forget one part in the healing process and you place a limitation on what, how and when healing will be achieved !
What ‘culture’ will do for a medical practitioner is give insight into the regional “strongmen” ie; Pharoahs, Herods and Goliaths that must be know about before one blunders into that particular geography and expect to have a “free-passage”…….remember Ephesians 6:12-13
OR …..ignore it at your own peril and that of your patients !!