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Despite the recognition of Aboriginal and Torres Strait Islander health in medical curricula by the Australian Medical Council (AMC), there remains a significant gap in the effective application and practice of this knowledge to transform health systems.
Creating a curriculum that meets the needs of Aboriginal and Torres Strait Islander communities involves many considerations. In 2006, the Australian Medical Council (AMC) set specific standards for primary medical education, setting in motion the developmental journey to address Aboriginal and Torres Strait Islander health challenges through medical education. Early approaches were often piecemeal, focusing on teaching “about” the ill health of Aboriginal and Torres Strait Islander peoples through a Western lens. This deficit-focused approach reinforced stereotypes and left many of our Aboriginal and Torres Strait Islander students and academic staff confronting racism.
The Aboriginal and Torres Strait Islander Health Curriculum Framework was developed in 2014 and introduced a much-needed shift in the learning narrative. Informed by our Aboriginal and Torres Strait Islander scholars, it reoriented emphasis away from “the Aboriginal problem” towards using Indigenous pedagogies in learning how to address racism and transform health systems. Additionally in 2015, the AMC completed the developmental learning pipeline by introducing specific standards for specialist training colleges. These standards were characterised by developing a “sophisticated” understanding of our communities and their needs.
Many doctors enter Aboriginal and Torres Strait Islander health without prior exposure to its scope, challenges, and personal and professional rewards. Applying the principles outlined in this article to specialist medical training and health service delivery, in my view, will help to drive systemic change and assist in preventing a piecemeal approach in building a workforce capable of addressing Aboriginal and Torres Strait Islander health needs.
Curriculum approaches
When designing a curriculum for specialist trainees to meet both community needs and professional standards, two principles become apparent. First, the teaching approach must build on primary medical education and junior doctor training programs. When doctors decide to specialise, the Aboriginal and Torres Strait Islander curriculum must evolve alongside them. This means integrating their specialisation within the context of Aboriginal and Torres Strait Islander community needs. Developing or rehashing a basic “deficit-based Aboriginal Health 101” module or workshop can undo good work and reinforce racist attitudes and beliefs, which ultimately become damaging for communities and Aboriginal and Torres Strait Islander health professionals working in health care. Although not all health professionals have the necessary knowledge, attitudes or skills to build upon or strengthen culturally safe practices, it is a pitfall to design a curriculum that specifically caters to a lagging professional standard. Developing a substandard curriculum base sends a harmful message to our communities and reinforces a system that marginalises our people. Colleges should be able to direct trainees and consultants to develop their knowledge and skill gaps through micro-credentialing or intensive programs. Most government-funded hospitals and health services have their own cultural safety programs; however, their relevance and effectiveness should be scrutinised. Setting community needs and expectations as the bar is the message here.
A specialist curriculum needs to draw on the strengths of Aboriginal and Torres Strait Islander communities and create opportunities to identify and dismantle institutional racism. A curriculum should foster learning opportunities designed to:
- develop doctors’ skills to recognise and practise a strength-based approach, valuing culture as a protective factor and determinant of health;
- use Aboriginal ways of knowing, being, and doing in co-designing programs and research that works “with” communities rather than “on” communities;
- create learning and teaching opportunities through college and health service partnerships that disrupt systems supporting health inequity and institutional racism.
Additionally, from early medical training through to ongoing professional development, self-reflection and critical analysis of one’s own practices and biases are essential for developing an anti-racist skillset. All health professionals should be supported to recognise and address any prejudices or systemic barriers that may affect their work with Aboriginal and Torres Strait Islander patients. This reflective practice is essential for fostering a genuinely culturally safe health care environment. However, reflection needs to be monitored or moderated; otherwise, it risks becoming a case where people don’t know what they don’t know, and if left unchecked, it can reinforce existing biases. Structured guidance and feedback are critical to ensure that reflective practices lead to meaningful and positive changes in attitudes and behaviours.
Professional development
Professional development should be an ongoing process that evolves with the changing needs and knowledge of the field and community in which we are embedded. It’s not enough for doctors to receive a one-time training in cultural safety or “Indigenous health”. Instead, there must be continuous opportunities for learning and growth that are integrated into their everyday practice and specialisation.
Professional development programs must be tailored to specific medical specialties, ensuring that the knowledge and skills relevant to working with Aboriginal and Torres Strait Islander communities are directly applicable to the doctors’ areas of expertise. For instance, a cardiologist could conduct an audit to identify barriers to accessing cardiovascular investigations and diagnostic tests for Aboriginal and Torres Strait Islander people. By then collaborating with the local Aboriginal and Torres Strait Islander community, they gain insights into culturally relevant solutions. This high-level learning outcome fosters the ability to translate these insights into meaningful changes within health systems, ensuring practices are more inclusive and respectful of Aboriginal and Torres Strait Islander cultural knowledge and practices. These learning opportunities require the support and collaboration of the institutions in which specialists are embedded. This demonstrates why co-designing curriculum with health services for their communities is necessary.
Moreover, there should be a strong emphasis on mentorship and peer support. Experienced professionals who have successfully integrated cultural safety into their practice can provide valuable guidance and support to their colleagues. This mentorship can help bridge the gap between theory and practice, offering practical advice and fostering a community of practitioners committed to health equity. As the saying goes, “culture eats strategy for breakfast,” highlighting that systemic good behaviour changes and attitudes are crucial and often part of the hidden curriculum. By embedding these cultural safety practices into everyday professional behaviour, we can ensure that positive changes are sustainable and deeply rooted within the health care system. Finally, professional development should be recognised and rewarded. Achieving excellence in Aboriginal and Torres Strait Islander health and cultural safety should be a key criterion for career progression and professional recognition. This not only incentivises doctors to engage in these programs but also signals the importance of this work within the medical profession.
By ensuring that professional development is continuous, practical, reflective, and supported, we can build a health care workforce that is not only skilled in their medical specialties but also deeply committed to reversing health inequities and providing culturally safe care to Aboriginal and Torres Strait Islander communities.
Conclusion
To achieve this higher level of learning, colleges and health services need to explore opportunities to co-design action-oriented learning approaches. However, it is recognised that current resources and capacity to do this work present an obvious challenge. I argue that there is a need for a First Nations Specialist Training facility, led by Aboriginal and Torres Strait Islander experts, to assist colleges in this work. This is where I see the interface between curriculum development and the development of a culturally safe and responsive workforce. Asking colleges to lift educational standards to this level without such support is impractical and unrealistic. Some of what I have mentioned will fall outside of their remit. Appropriate guidance and resourcing are needed to ensure training is relevant and appropriate to the needs of Aboriginal and Torres Strait Islander communities. Redesigning this approach would foster a culturally competent workforce committed to promoting health equity and self-determination within Aboriginal and Torres Strait Islander communities. Lastly, it will prevent the duplication of curriculum design and implementation efforts that significantly draw on a small number of Aboriginal and Torres Strait Islander doctors who are becoming burnt out and moreover, this will prevent community engagement fatigue.
Shannon Springer is a leader in the field of Aboriginal and Torres Strait Islander health and medical education. He currently works as a GP at the Charleville and Western Areas Aboriginal and Torres Strait Islander Health Service in remote Queensland. He is a Fellow of the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine, specialising in Aboriginal and Torres Strait Islander health. Shannon is also an adjunct professor at Griffith University, where he has designed and implemented the First Peoples Health Curriculum and assisted in the recruitment of Aboriginal and Torres Strait Islander medical students.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Just to ensure a reasonable level of competence in “western” medicine to a basic level usually takes 6 years, followed by specialist training of another four years, after a couple of years as a junior medical officer. I acknowledge Dr Springers special interest especially in view of his location, but cannot reconcile my or many of my colleagues capacity to absorb all the extra knowledge and accurately remember and apply it over our working lifetime, especially as it seems several extra years of full time study would be required to meet a very basic standard. Becoming fluent and fully culturally aware in up to 600 different Aboriginal and Torres Strait Islander languages, plus the many more languages and cultures from around the world who have migrated to Australia and whom we are equally legally obliged to treat with the same consideration would require a major reduction in the medical curriculum that would be expected to result in poorer treatment than we have achieved to date. Given the huge diversity in modern society even within ethnic groups (i.e. LGBTQIA+++) the only way to “correctly” manage all those scenarios for a specific individual would to be to “Google” the applicable cultural and linguistic options and recommendations, perhaps including AI, provided online by government approved institutions. They have a lot of work to do if they want to push their current agenda of complete integration in a standard manner, as in my opinion the staggering amount of information would take at least several lifetimes for an individual to peruse even without learning it to the standard they would accept and enforce.