Putting Indigenous patients before our discomfort

ARE you sitting comfortably? Well, perhaps you shouldn’t be. When it comes to Aboriginal and Torres Strait Islander health, we’ve known the statistics showing the gap in health outcomes for a while now.

While there have been some improvements, they have not so far been at the rate required to meet the Closing the Gap targets.

As doctors, when we see a problem, we see a need for education. Education, of course, is helpful, but perhaps not all education, and it may well be that we get trapped in hidden curricula that obstruct us from making real progress.

In our thinking and teaching about Aboriginal health, we fall back on what makes us comfortable in medical education, and this leads us to think about Aboriginal health in ways which are incomplete and unhelpful.

Aboriginal health as a set of medical conditions

Medical education of course involves teaching about different diseases. Symptoms are related to differential diagnoses. History, examination and investigations are geared towards identifying the correct diagnosis to get the correct treatments.

This can lead us to think of Aboriginal health as a collection of diseases. We always include type 2 diabetes, renal disease, cardiovascular disease, otitis media, perhaps drug and alcohol abuse and mental health.

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But what about systemic lupus erythematosis, which has a high prevalence? What about breast cancer, which has lower incidence but higher mortality? Are we not closing the gap because these diseases aren’t taught adequately? Shouldn’t we be able to manage our Aboriginal patients no matter what their presenting complaint or their diagnoses?

It’s rare that an Aboriginal patient will say that it was the clinical knowledge about their diabetes that was at fault. Placing Aboriginal health in the realm of a set of diseases is firmly within our own education comfort zones.

Aboriginal health as risk factor

When learning about diseases with no clear cause, we learn about the things that predispose people to those conditions – risk factors.

You know them all: smoking, sedentary lifestyle, junk food, cholesterol.

The problem with adding Aboriginal to this list is it makes us assume it’s another pathology to be cured. Rather than Aboriginal health being a collection of diseases, being Aboriginal is the disease.

In fact, the opposite is the case. People who are connected to their culture are healthier – being Aboriginal is the cure!

Aboriginal health as seeing lots of Aboriginal patients

We often assume that by working in the Northern Territory or other parts of rural and remote Australia with a high proportion of Aboriginal patients, we’re doing Aboriginal health.

In fact, we’re just seeing Aboriginal patients! Of course, we need to see them to make some sort of difference, but if all we’re doing is treating everyone the same, then we’re not meeting the need.

Cultural education is crucial, but too often we imply that “they” – those Aboriginal people, different to us – have a culture but we don’t, and if we get to know it better then we can teach them to be more like us.

We need to start from a position of recognising our own cultures, including our professional cultures and the cultures of our health services. Often they can be highly off-putting for many of our patients.

Then we need to recognise the parts we can change. For some of us that will be in the way we consult. Others may have control over the appearance of waiting rooms or billing policies. Some are able to choose to employ Aboriginal staff and to create management that allows Aboriginal decision making over our practice.

This recognition of our own cultures and attempts to do things differently isn’t easy and can make us uncomfortable. But let’s pause for a moment and think of our Aboriginal patients. How much more uncomfortable have they been, and for how much longer?

Dr Tim Senior works as a GP in Aboriginal and Torres Strait Islander health. These are his personal views. He says: “I refer to Aboriginal health, as that is where most of my experience lies. It is likely that these thoughts also apply to our thinking about Torres Strait Islander health as well.”

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