Exploring medical students’ experiences with indigenous patient care: a phenomenological study

ABSTRACT

Background

Indigenous Peoples in Canada bear a disproportionate burden of disease and experience poorer health outcomes as compared to non-Indigenous populations within Canada; these conditions are said to be mediated and exacerbated by pervasive and uninterrupted anti-Indigenous racism. Third and fourth-year medical students at a Canadian medical school were asked to reflect on their experiences working with Indigenous patients in clinical settings, and how their preclinical Indigenous health curriculum impacted these experiences.

Method

Phenomenology was used, guided by Goffman’s theory of social stigma. Eleven undergraduate medical students were recruited using purposeful sampling. Semi-structured phone interviews were conducted to gain an in-depth understanding of the participants’ experiences. Interviews were recorded and transcribed verbatim. Data were analyzed using the four main processes for phenomenological analysis.

Results

Four main themes emerged from students’ descriptions of clinical experiences involving Indigenous patients: 1) students describe how their Indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context; 2) racism was evident in students’ clinical interactions with Indigenous patients, but students do not always perceive these biases nor the impact of this on patient care; 3) identifying the impact of racism on care is complicated by situational clinical encounters; and 4) practicality of preclinical Indigenous health education is desired by students to prepare them for working with Indigenous patients in the clinical setting.

Conclusions

In their clinical experiences, students witness racism against Indigenous peoples yet are unprepared to stand up against it. Findings highlight the importance of enhancing undergraduate medical training to allow students to better understand the unique experiences and perspectives of Indigenous patients. The results support the need for ongoing Indigenous health education, to foster culturally sensitive experiences while learning about Indigenous patients.

KEYWORDS:

• Phenomenology
• indigenous health
• training
• undergraduate medical education
• curriculum
• systemic racism

Introduction

Indigenous peoples bear a disproportionate burden of disease and have poorer health outcomes as compared to non-Indigenous populations within Canada [1]. Indigenous peoples face challenges during medical visits that include bias, microaggressions, provider turnover, and a lack of understanding of Indigenous health beliefs [2–4]. These outcomes are specific to First Nations, Inuit and Métis (FN/I/M) peoples as the sole targets of colonialism; they arise, in part, from the legacy of colonialism and racist colonial policy regimes that continue to mediate the inequitable provision of basic programs and services available to all other people [5]. These include access to care, transportation, food security, racism and access to clean drinking water, among other things [1]. Racism is defined as prejudice or discrimination against a person or a group of people based on dominant groups’ own racial superiority which may take many forms. Racism is the basis for social stratification determined by the ‘dominant culture’ [4]. The depth and pervasive nature of these health outcome disparities are also mediated and exacerbated by pervasive and uninterrupted racism within the health system that is enacted by health professionals against Indigenous peoples in Canada [6,7]. Allan et al. in their executive summary ‘First Peoples, Second Class Treatment’ contend that, ‘at the level of health care service and delivery, there has been a variety of developments aimed at increasing access to health care for Indigenous peoples and mitigating the impact of racism they experience in attempting to manage their health and well-being in the Canadian health care system.’ [7] (p. 31) Further, ‘since 2000, there has been a steady emergence of policy statements and guidelines for the medical professional and medical training organizations in Canada intended to identify and develop the competencies needed by health professionals to optimize the care they provide to Indigenous individuals and communities.’ [6] (p. 36) Although medical education alone cannot address this systemic inequality and racism, education can support and equip doctors to work with First Nation peoples and communities to overcome such challenges [5]. Existing literature has shown that incorporating Indigenous Health teaching into a medical curriculum had a positive impact on changing undergraduate students’ attitudes toward Indigenous health, improved knowledge and decreased student-reported pre-existing biases towards Indigenous Peoples [4,8]. A study conducted by Lewis et al. in 2017, reported that the most important topics that needed to be included in an Indigenous Health curriculum for Undergraduate Medical Education (UME) were cultural humility, Indigenous culture, social/political/economic determinants of health, and successful tribal health interventions [9].

Our medical school introduced an integrated longitudinal undergraduate Indigenous Health curriculum in 2017, designed to build student capacity in understanding the historical manifestations of the current health crisis among Indigenous peoples and to develop their skills and ability to work safely and respectfully with Indigenous peoples in health care settings. This curriculum mainly takes the form of a lecture or small-group based learning in the preclinical (first and second) years, with ongoing reflective activities in the clinical (third and fourth) years. In this study, we aim to explore student clinical experiences with Indigenous patients, as well as to explore the role of the Indigenous Health curriculum on students’ perspectives. The following research questions were explored: (1) How do medical students perceive their clinical interactions with Indigenous patients? (2) What impact did the preclinical Indigenous curriculum have on these clinical experiences?

Methods

Study design

This project used phenomenology [10,11] to gain an in-depth understanding of undergraduate medical students’ clinical experiences working with Indigenous patients. A phenomenological methodology seeks to describe the common meaning of several individuals’ lived experiences of the phenomenon in question [10,11]. Phenomenology as a research methodology in medical education has been undertaken to study trainees’ lived experiences and many aspects of students’ everyday lives in UME [12]. Within the phenomenological approach, our study was guided by Goffman’s theory of social stigma, which defines stigma as a social identity that is perceived to negatively deviate from societal norms and values [13]. In the context of our study, this sensitizing concept focuses on understanding why stigma against Indigenous patients is manifested in the first place among undergraduate learners. Is it due to implicit biases that their preceptors may unknowingly be transferring to these learners and promote stigmatizing attitudes? Are there influences in the clinical environment that perpetuate biases against Indigenous patients? Goffman’s theory of social stigma guided our study to ensure that we captured these experiences in an in-depth and accurate manner.

Positionality statement

We (MR, NA, KF) acknowledge that as non-Indigenous researchers, we have not done research involving distinctions-based Indigenous peoples in the past. Hence, to ensure that our research was conducted safely and respectfully, we have sought out guidance from our Indigenous colleagues TK and PL for this work. TK was involved with the design and delivery of the Indigenous curriculum and provided valuable insight through her experiences as an Indigenous person and Indigenous educator about the complex relationships between Indigenous Peoples, racism, and the health care system throughout the study. PL reviewed the draft of the manuscript and provided recommendations on further directions for this area of research from his experience as an Indigenous person, Elder, and advisor.

Study participants and recruitment

Purposeful sampling was used to recruit medical students for individual interviews over 12 months in 2020. Participant recruitment occurred via email invitation distributed by educational administration to all current third- and fourth-year medical students at our medical school. Eleven students agreed to participate, this number of participants was a sufficient sample to reach theoretical sufficiency [12]. Eight participants were female, and three participants were male. Eight participants were in their third year of medical school, and three were in their fourth. An information sheet outlining details of the study (purpose, background, expectations for participation, risks, benefits, etc.) was provided, and if potential participants agreed to participate, they were asked to sign an online consent form. All participants provided written consent. To mitigate any hierarchy in the research process, the recruitment was conducted by an intermediary (administration).

Data collection

Data were collected through semi-structured interviews using an interview guide. This approach enabled the use of probing questions to elicit further details and information, leading to richer descriptions and allowing for more natural interaction with the participants throughout the interview. The interview guide was developed by creating relevant questions that focus on some of the concepts related to bias and stigma using Goffman’s theory. Once we developed the guide, TK provided feedback on the interview guide as an Indigenous expert on this study. It is significant to note that the interview guide questions evolved as data collection proceeded, thus, more questions were added to fill in any gaps that emerged during the data analysis. We also ensured that the interviews were conducted conversationally during which we often asked spontaneous prompts to make sure that the interview flow was not disrupted. See Appendix 1. for the full interview guide.

Eleven interviews were conducted by NA, a pediatric trainee to ensure no involvement of research team members who may have a perceived power differential. Interviews lasted between 45 and 60 minutes and took place at a location of the participant’s choice due to COVID-19 with social distancing guidelines in effect; most interviews were conducted via phone. Interviews were recorded on an audio-only recording device for ease of transcription. To achieve a deep understanding of the phenomenon under study, follow-up interviews were requested of all participants; seven participants agreed. These were conducted to explore additional questions and for further calcification of data/themes [14]. Our analysis demonstrated theoretical sufficiency [12] when we observed sufficient depth in our data and our universal themes across interviews. Theoretical sufficiency is the point at which we were confident we had been rigorous enough in our data collection, and analysis to gain in-depth, exclusive, and nuanced understandings [12].

Data analysis

Interviews were audio recorded to facilitate data analysis and data were initially transcribed via Otter.ai voice-to-text and then edited manually to ensure that the content was transcribed accurately and verbatim. Data were analyzed using the four main processes of phenomenological analysis described by Moustakas [10] in 1994:

Stage 1 (Epoche): In stage one of this approach, the researcher works to bracket, or suspend their own beliefs, biases, and preconceptions to evaluate any idea that came from the data. This was done by ensuring that we had conversations that enabled us to understand participants’ stories and ensuring that it was not based on what we were looking for or assuming about the data. Stage 2 (Phenomenological Reduction): This stage consists of attaining the core meanings of the participants’ experiences by compiling exemplary experiences and grouping them into initial codes. This was done by reading and re-reading interview transcripts to identify relevant statements about participants’ experiences to generate themes. Coding was done by NA, MR and KF. During this phase, we also discussed if there were any gaps in the data that needed further exploration in the subsequent interviews with the participants. Based on these discussions our interview questions evolved as the study progressed. Stage 3 (Imaginative Variation): This stage required the research team members to examine all possible meanings or interpretations of participants’ experiences, and to develop explanations that represented participants’ experiences. Stage 4 (Synthesis of Meanings): The final stage in this analysis approach entailed developing the underlying meaning of participants’ experience by combining textual descriptions (what was experienced) and structural descriptions (how it was experienced). This leads to the essence of the experience and helped us convey the participants’ stories in their true form and authentic manner.

Trustworthiness

To demonstrate rigour and trustworthiness, the techniques described by Sundler et al. were followed, including reflexivity, credibility, and transferability [15]. The process of reflexivity entails maintaining a reflexive attitude and questioning one’s pre-understanding of the phenomenon in question. This must be maintained throughout the study process. It is imperative that the researcher questions their understanding of themes and reflects on what the data is truly showing, not just the researcher’s understanding of the data. This was achieved by having regular group meetings related to the data analysis throughout the study. We constructively questioned each other’s decisions about the coding and themes to ensure that we were focusing on the richness and depth of the data as well as our participants’ experiences as opposed to what was interesting to us as individuals.

Credibility refers to the clarity and consistency with which findings are presented [15]. To achieve credibility, information was provided on how transcendental analysis was performed, as well as descriptions of how meanings were devised and how themes were identified. Trustworthiness was further ensured through the processes of peer debriefing and member checking by bringing the analysis back to participants to ensure their experiences were accurately represented. Transferability relates to the usefulness or relevance of the study findings [15]. By applying the sound methodology, the transferability of this work was increased.

Ethical approval

Approval from the local health ethics research board (REB) [Pro00092511] was received.

Results

Students described many examples of racism towards Indigenous patients; however, the students’ reflections on these situations demonstrated at times discordance between perceptions of racism and the described encounters. From our analysis, four major themes emerged: 1) students describe how their Indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context; 2) racism was evident in students’ clinical interactions with Indigenous patients, but students do not always perceive these biases nor the impact of this on patient care; 3) identifying the impact of racism on care is complicated by situational clinical encounters; and 4) practicality of preclinical Indigenous health education is desired by students to prepare them for working with Indigenous patients in the clinical setting.

Theme 1: students describe how their indigenous patients encounter the health care system and their own lack of cultural sensitivity in this context

Students described that knowing that a patient identified as Indigenous was important and provided examples of how this could both hinder or help with the provision of care. In some situations, it impacted students’ ability to develop therapeutic relationships (relationships that are based on trust, care, and respect with patients) and connect with patients, yet in others it allowed them to identify unique care needs. This theme excludes specific examples of racism that occur from knowing a patient is Indigenous and the important negative impacts on their care.

Students acknowledged that being of a different background from an Indigenous patient made it at times difficult to interact. This seemed to reflect assumptions about how an Indigenous patient may perceive non-Indigenous health care providers which is indicative of the fact that these learners’ perceptions stem from a broader issue of medical student’s lack of knowledge about Indigenous people as evident in the following quotation:

I feel like I struggle with finding a connection. Like, I’m a blond haired, blue eyed white girl from rural Alberta. And I feel like … when I walk into the room, I go in with this notion already [thinking] that they’re not going to listen to me, they’re going to see that we have nothing in common, and it’s going to be a struggle to build the therapeutic relationship. If I’m thinking about even just patients that I’ve come across that are just clearly from a different ethnic background, I feel like I don’t get quite as hung up on it as I do with my Indigenous patients. (Interview 2)

Contrarily, students were also able to identify positive sequelae of knowing that a patient is Indigenous, primarily by filling a perceived need for more culturally competent care. A student described offering cultural services and resources to a patient that they felt might benefit them:

I think now there’s a greater recognition towards the need of, for example, creating space for Indigenous healing. … I’ve never seen the staff refer a patient to the[Indigenous Healing Centre]… But I do know these resources exist … and I’ve definitely talked about them [with patients]. (Interview 7)

Several students also described that they were the ones who made the effort to arrange for the traditional healing ceremonies that were of value to their patients, which allowed them to provide unique aspects to their care. As this participant described:

This man that I was taking care of actually asked to have a smudge ceremony in the hospital … And since I did know about it, I was like, “Oh yeah, that sounds reasonable.” And I actually ended up organizing that with one of the hospital chaplains. (Interview 1)

Knowing a patient was Indigenous, however, could result in a student assuming a patient’s needs in an attempt to provide culturally competent care. This could harm the therapeutic relationship where students failed to recognize that not every Indigenous patient’s needs are the same. As described by this participant,

I would easily assume that other people, like any Indigenous patient, were connected to their culture and that they might want that to be incorporated into their care. And there are tons of people who just are like “Yeah, I’m Indigenous, but … I don’t need to be using sage and tobacco or whatever, that’s rude that you would assume that”. (Interview 10)

Some of our participants described times when Indigenous patients would share their own stories of experiencing racism and discrimination. This allowed participants to reflect on the histories of Indigenous patients with the health care system, and an understanding of how that negatively impacts their care and therapeutic relationships in the present. For example, one student said:

I remember one woman that we met up with, and we were just chatting with her, and she said these women would almost rather die than go into the [hospital] … They will wait until they’re virtually dragged in by their friends and on death’s door before going into the emergency. And she said it was specifically because of the discrimination that they’ve faced in the past. (Interview 2)

Through this theme it became evident that having knowledge of the histories of Indigenous patients with the health care system, and hearing their stories allowed participants to reflect on how Indigenous patients have experienced systemic racism.

Theme 2: racism was evident in students’ clinical interactions with indigenous patients, but students do not always perceive these biases nor the impact of this on patient care

Events of racism were observed and described by students, as exemplified in this theme. Students describe a myriad of personal reactions to these situations, including feeling uncomfortable or ‘thrown off’, but also were reflective of their own inherent biases. Some situations were identified as racism, with ensuing negative consequences, yet in other situations, participants did not connect the observed biases as impacting the care of the patient. Conflicting emotions resulted in a complex picture of how students respond to observed racism towards Indigenous patients in the clinical setting. One student described the following:

… Preceptors even just looking at a patient’s last name… “Oh, it’s an Indigenous last name. I know that they’re gonna be an alcoholic.” [or] “this patient comes from a reserve, so they probably won’t even show up for their appointment”. (Interview 1)

Such examples demonstrated overt negative consequences on patient care. Participants describe feeling that an Indigenous patient was treated differently by staff because of their race; assumptions about patient motives were described which impacted a patient receiving care. A participant provided the following example:

The threshold of pain seems to be much higher to get the opioid if you’re Indigenous versus if you’re white. Because it’s viewed as you know “Are you here for drugs or, you know, some other reason?” There seemed to be the assumption that there was an alternative motive as to why they were here. (Interview 6)

Contrarily, even when overt racism was described, participants could not always name this as racism and at times there was almost a justification that it did not impact patient care. As evident in the following quote:

I don’t think it affected their care. I can’t speak for when she went to the adult side of emerg, but on our side, no, I don’t think it affected their care. … I think they were otherwise treated like anybody would have been in that situation. (Interview 4)

However, racism clearly resulted in an emotional response of discomfort with the situation. That same student described their thoughts on hearing discriminatory comments from the nurse:

I got thrown off because I hadn’t really seen a situation like that before … My initial reaction was to be on my guard … because I hadn’t dealt with a situation like that before … . So, I was kind of bracing myself. (Interview 4)

Contrary to situations when in-the-moment medical care was perceived to not be impacted, students identified that subtle differences in how the medical team interacts with Indigenous patients and their illnesses had easily foreseeable longer-term consequences for those patients. Several examples reflected this discrepancy in terms of immediate versus future impact. One example from a participant is as follows:

I can think of one very clear example of the amount of support that one patient got was very different. So, they were in for Parkinson’s disease … But the clearly Indigenous patient did not get the same conversations, not as much explanation as to why we’re choosing this medication over another, and where we go from here, and our entire management plan. So, I found that communication between the team and the Indigenous patient was lacking. And I think in the long term, it’s going to affect this patient’s care. From his day-to-day care, it may not have impacted that much. But I think long term, it’s going to kind of bite us in the butt so to speak. Like, maybe not, but long term, this is going to come up again. (Reinterview 3)

When students reported being uneasy with comments about Indigenous patients that they were going to see, they reflected on their own biases and how they navigated this discomfort.

I think I try my best to keep an open mind and remind myself that this is an isolated case of a person who is dealing with certain things. And part of it is due to the fact that they were in this environment, or they grew up on a reserve or whatnot. But at the same time, there are people who aren’t in those situations that also end up in the state … I just tried to keep myself in check, I suppose, and limit the bias that I have when I’m speaking to the patient. (Interview 5)

Keeping an open mind is also, sort of, keeping an open ear … I recognize that I have an inherent bias and that there’s bias being introduced. And so, by acknowledging it, I’m hoping to reverse it or address it, at least. I think that’s, in the moment, that’s the only thing you really can do. (Reinterview 1)

Even though students reflected on these introduced biases and their personal reactions, some acknowledged difficulty in reducing their own biases; as noted above, these introduced biases result in differences in care during clinical encounters. As described by these students:

I tried to go in with an open mind as possible, but I can admit that sometimes knowing something before going in, kind of swayed me towards one differential versus another. For instance, I think a lot of the calls I took with alcohol intoxication, a number of times, it was mentioned that this person is Indigenous … then you start getting these scripts being developed in your mind, where your bias leans towards “Maybe this person has been drinking too much. This person’s probably alcoholic. This person’s probably a chronic substance abuser” sort of thing. And I don’t particularly like that, but it definitely has swayed the kind of impression that you get, I think in terms of the learning. (Interview 5)

I think it does still affect care. Because whether it’s inside the room or not, there are multiple things that play into a patient’s care. And part of it is perception of the team. So even if it wasn’t very obvious in front of the patient, if it’s still obvious outside of the patient’s room, I think it still has an impact. And especially if a more senior person says something that’s kind of off putting, or might be racist to some extent, it changes the way the team also views that patient. And so with the trickle down effect, somebody is going to eventually bring that into the room, whether they know it or not. (Reinterview 3)

Further, no students described situations where they spoke out about racism, reflecting their discomfort yet inability to disrupt the racism they were witnessing.

Theme 3: identifying the impact of racism on care is complicated by situational clinical encounters

In cases where racism toward Indigenous patients was observed, students noted co-occurring concerns of substance misuse, homelessness, or a history of frequent visits to the emergency department for the same complaint. This made it difficult for students to name racism directly as a contributing factor in patient experiences. One student gave the following example:

We did have a couple of patients who were Indigenous and homeless, and it was hard to say whether that maybe they got slightly different care because they were frequent flyers in the hospital and the preceptors were just tired of seeing that situation over and over again. But it’s hard to tell whether that was coming from the fact that they were Indigenous, or other parts of their social circumstances. (Interview 1)

Another said:

I found that a lot of alcoholic patients in general, whether Indigenous or not, got treated differently because they were frequent fliers. So, I personally can’t tell if it was because they were a frequent flyer, because of the alcohol addiction or if it was because of their Indigenous background. (Interview 8)

Health professionals’ interactions with Indigenous patients differed in comparison to other patients they served. The interactions were often rough and harsh in manner and exhibited a less empathetic nature at times. When asked the participants what the reason might be, they reported health providers interacting a certain way with an Indigenous patient was more complex when not expressed explicitly.

I always find it hard to tease out whether it’s the care provider who goes in with a bit of a bias and prejudice, or if it’s the situation, the person’s attitude, the person’s state, that dictates, like, how the care provider reacts to the situation. But if I were to be honest, I do think sometimes the staff are a little more abrasive or a little less empathetic with these patients, and I don’t know if it’s because they’re jaded after years of dealing with these kinds of cases, or if there’s an underlying bias or prejudice against Indigenous patients. (Interview 5)

These findings, reflective of the complexity of interactions between health care providers and Indigenous patients, may be attributed to many situational or personal factors; our participants found it hard to point out if differences in care received were due to their biases given the implicit nature of these circumstances.

Our data also indicated that although the care delivery may not be perceived to differ for Indigenous compared to non-Indigenous patients, there is however, a difference in how healthcare providers interact when it comes to Indigenous patients in the clinical settings. As evident in the following participant statement:

I didn’t feel like there’s a difference between the ones that were Indigenous or not. But it was mentioned more. It was mentioned, if a patient was Indigenous or not, which I just always found was a little bit odd. Because you wouldn’t mention if the patient was Caucasian. (Interview 5)

Theme 4: practicality of preclinical indigenous health education is desired by students to prepare them for working with indigenous patients in the clinical setting

Students felt that having a practical and more hands-on approach such as having a guest lecturer come in and talk about their experiences as an Indigenous patient in a clinical setting was more valuable than someone without a personal connection to the subject matter. We acknowledge that while it is not the responsibility of Indigenous community members to deliver the curriculum, having them provide personal experiences and contribute to this learning was noted to be highly impactful by several students:

I think it’s very different when you’re learning about it on paper as opposed to seeing the actual person. (Interview 7)

I think the most important learning in pre-clerkship wasn’t just classroom-based teaching but having people from different First Nations communities actually come talk to us. Because I think that having those lived experiences really changes the way that they talk about these things versus just having somebody try to teach us whatever material. (Interview 1)

In general, students appreciated learning about Indigenous Peoples’ relationships with Canada and the Canadian health care system. Through this curriculum, students felt that they were able to bring a better understanding of Indigenous culture to the clinical setting and provide better culturally competent and safe care through that lens. Gaining a better understanding of where these patients were coming from was reported to be significant in enhancing their knowledge for providing appropriate care. This is evident in the following students’ statements:

I thought the Indigenous curriculum we had, and pre-clerkship was really good for laying the foundations of present issues that are facing Indigenous populations. Did a lot of history work, which was great, a really great point to be able to understand where Indigenous populations are coming from. (Interview 9)

I think it brought to light a lot of what we’re dealing with, especially with intergenerational trauma. And for somebody, if you don’t understand it, it’s very confusing when you see it on the wards. So, I think it did a really good job of preparing us for kind of those social impacts that some of our Indigenous patients may have, but also at the same time, don’t assume everybody has the same traumas. (Interview 6)

However, exposure to real life cases that were experienced by learners first hand was felt to be a much better learning experience for students than non-clinical learning. One student describes the impact of their clinical experiences on their understanding of the social determinants of health:

You just can’t teach the effects of drug abuse, or you can’t teach the effects of a lack of social support systems for a family, who’ve just been diagnosed with depression, or somebody who doesn’t have a stable income to be able to support themselves if they need to be in hospital. … We talk about this in in books, and we say, “Oh, you know, you have socioeconomic determinants of health, and health outcomes,” but really, it’s only until you see it in action, and you see the real, practical effects of it that actually hits you on a personal level, that you can actually learn from it and develop a deeper understanding of it. (Interview 10)

With the exposure to the Indigenous curriculum, students reported improvement in their knowledge about the importance diverse nature of the Indigenous communities and that they cannot generalize information they learned about one Indigenous community to all Indigenous communities:

They try to avoid giving us the idea that like, it’s a cookie cutter, one size fits all approach to Indigenous health and Indigenous health issues … It’s just as dangerous to generalize based on the information, the background that you’ve learned, as it is to not have an understanding of that background at all. (Interview 5)

In addition, students reported that the curriculum had a significant impact on their understanding of individualized care. They reported improvement in their understanding of the fact that personal experiences were very valuable, especially gaining an appreciation for the fact that not every Indigenous person is the same or has the same experiences:

Everybody is human at the end of the day, right? So, I think that, to me, it was very interesting, just given how they’re portrayed in the media or given how much attention is given to the fact that they are [Indigenous], it just makes them much more unique from an intellectual perspective. But then when you go and meet people like that, well, they’re just people. I mean, they’re no different than you and I. (Interview 10)

Discussion

This study revealed several key findings related to the experiences of undergraduate medical students focusing on their clinical encounters with Indigenous patient populations during their clerkship. These included findings related to anti-Indigenous racism, discrimination, and stigma associated with being Indigenous while receiving care. Our findings were guided by Goffman’s social stigma theory; the sensitizing concepts of stigma and racism are particularly evident in the participants’ responses. For instance, study participants reported evidence of whether intentional or unintentional stigma against the Indigenous population was prevalent which hurt the learners and care delivery.

Racism was clear in the encounters that our participants described involving Indigenous patients, although an interesting finding was that despite reported stigma to Indigenous patients, the impact on patient care was not always identified. There is a large body of literature that reports the negative impacts of racism and stigmatization on health care delivery to Indigenous patients [16,17], and reports of discriminatory behaviours and stigma from health professionals towards Indigenous patients are well documented in the existing studies [18,19]. In a study focusing on health professionals’ perspectives on barriers faced by Indigenous patients when accessing health care, healthcare providers reported stigma as the root that limited Indigenous peoples’ access to care [20]. This stigmatization also resulted in the lack of a warm environment, confusing when there are genuine healthcare provision-related problems. This hostile environment was also understood as an important cause of why Indigenous people avoid getting care [20].

While medical students in our study reported that racism did exist, a finding unique to our study was that they seemed willing to overlook or provide excuses to justify a perception that the care of patients was not impacted at the moment. In addition, although racism is not on a spectrum (something either is racist or not, it is not in-between) some students identified experiences as ‘sort of racist’, which implies a continuity of racism. These ambiguities could be attributed to several factors impacting medical students’ ability to see and name the effects of racism in clinical contexts. For one, medical students are at the beginning of their development of clinical acumen, and it can be challenging to identify differences in care when still learning what standard of care is. Secondly, as research pointed out, some of the effects of these differences in treatment will only be evident in patients’ future interactions with healthcare, or in their ability or willingness to return to care at all [9,21]. Thirdly, medical students only see a narrow scope of a patient’s interaction with the healthcare system, and therefore may not see how racism is manifested in various aspects of their care. Importantly, despite students not being able to label the interactions they saw as racist, we acknowledge that individual Indigenous patients were harmed in the experiences shared. This inability to directly identify this harm as racism contributes to the perpetuation of racism in healthcare and the inadequate care of Indigenous patients.

An important and unique finding of our study is that our participants’ descriptions of their encounters with Indigenous patients and racism did not include any student responding to witnessing racism. Undergraduate students may be aware of the mistreatment and racism that is exerted towards Indigenous patients but one explanation for lack of action may be from being a low-status member of the hierarchy in their medical training; this status may have resulted in students not reporting or labelling derogatory terms and other instances as racism. Existing literature suggests that hierarchy negatively impedes learners’ ability to report patient mistreatment, abuse and stigma as well as impacts their ability to speak up in the presence of their superiors [22]. Indigenous history in educational initiatives has been seen to be a valuable way of increasing students’ skills, knowledge, and experience to provide culturally responsive care to Indigenous patients [21]. Further exploration of why students do not take a stand for Indigenous patients who face racism during care delivery will be a valuable future contribution to this area of research. Based on our findings, we recommend that qualitative and quantitative studies be undertaken to evaluate the impacts of anti-Indigenous medical education to help ascertain what is most effective to reduce racism while providing care to Indigenous patient populations without burdening our Indigenous colleagues. Additionally, the exploration of traditional medicine as equal to Western medicine will be an important aspect to consider in future studies. Students require more educational opportunities to provide them with tools and empower them to stand up against racist situations, and we see this as an area for further development and exploration.

It is a well-known fact that Indigenous patients have always faced tremendous stigma and stereotypes [23]. Goffman’s work was instrumental in providing an initial conceptual framework for the analysis of stigmatizing conditions. From his work, we drew on his recognition that stigma is enacted within a social context and that perceptions of stigma can profoundly impact the quality of life and well-being of patients. Situations of stereotyping of Indigenous patients were described by student participants, similar to what has been described in the literature for example, in a study conducted on racism against Indigenous Peoples from the perspective of healthcare professionals, study participants reported systemic discrimination and racism against Indigenous patients that were ‘influenced by stereotypes, societal misconceptions, and poor cultural competence of health care workers.’ ^[24^](p. 40) A qualitative study using a Two-Eyed Seeing approach explored Indigenous participants’ experiences as patients; in a sharing circle, these participants reported being stereotyped as patients, which resulted in their feeling devalued, disrespected and abandoned [23]. In particular, Indigenous patients describe being labelled as ‘drug seeking’ which perpetuated mistrust in the health care system. Our student participants also describe similar situations where Indigenous patients were stereotyped. However, an interesting finding of our study was the assumptions students had about how Indigenous patients perceived them as healthcare providers. Furthermore, as evident from our findings in theme 1, participants reported challenges associated with building trust with Indigenous patients. This came with the assumption that the patient may have no trust in them simply because they were non-Indigenous as well as due to the overall mistrust that Indigenous people have in the Western medical system. Similarly, existing literature indicated that Indigenous patients fear hospitalization and often associate healthcare provision with trauma and discrimination [25]. These findings suggest that more needs to be done to foster the development of trusting relationships between students and Indigenous patients.

Medical students drew upon and valued the education they had received in their pre-clinical years as they described clinical encounters with Indigenous patients and reflected on their perception and understanding of these encounters. Existing research reveals that education is considered an opportunity to combat systemic racism within the healthcare system [26–29]. One study demonstrated that supplementary educational activities such as journal clubs can increase medical students’ self-perceived cultural competence [30]. The KAIROS Blanket Exercise has also been shown to alter medical students’ perspectives of racism towards Indigenous Peoples after participating [31]. However, there is a paucity of studies describing how such opportunities affect clinical practice from the learner’s perspective. In their paper entitled First Peoples, Second Class Treatment, Allan and Smylie write ‘despite the significant investment by health care professional organizations and schools in the training of healthcare professionals to enhance their communication with and care provided to Indigenous people, we were unable to identify any evaluations of these programs beyond immediate pre-post surveys of the participants concerning acquired knowledge and perceived impacts.’ ^[7^](p. 26) While Achonlonu et al. [32] describe an initiative aimed to help medical students identify microaggressions in the health care setting and to provide them with the tools to interrupt these microaggressions when they are witnessed, the impact of this in the clinical setting was not described. These findings indicate that there is a significant need to incorporate an awareness about racism in UME that is beyond providing equitable health care; and includes providing students with tools and strategies to interrupt witnessed episodes of racism. Institutions need to incorporate anti-racism into UME education in ways that are longitudinally reinforced and incorporate skills that will equip learners to interrupt racism in real clinical encounters. To ensure the effectiveness of such initiatives, medical schools need to incorporate standardized and rigorous training with consistent evaluation of these competencies for medical students [33,34].

The authenticity of pre-clinical educational experiences was valued by our study participants as they described having Indigenous guest lecturers such as patients and healers as improving their learning experiences by gaining firsthand accounts not only related to patients’ experiences with the medical system but also their traditional Indigenous healing practice. This is aligned with existing studies that indicated that combining traditional Indigenous healing practices with modern medicine was the most effective approach to enhancing the health and wellbeing of Indigenous patients [23]. A systematic review of Indigenous health curricula and health professions learners reported that most studies described face-to-face delivery and blended learning opportunities, including learning in an Indigenous setting [35]. Further, they describe the factors that contributed to positive learner reactions as being attitude, environment, educator skill, pedagogy and opportunities [3]. While our data cannot demonstrate the efficacy of our Indigenous Health curriculum, nor whether further education would enhance their care of Indigenous patients, our study participants describe that their exposure to this education, which involved interactions with Indigenous community members, was impactful. Students were able to grow from these early experiences and use them to engage with patient-centered learning more reflectively in the clinical years. Hence, we would recommend that the early introduction of authentic Indigenous health teaching be considered important to maximize the benefit of an educational intervention with longitudinal opportunities to explore application in the clinical setting to the Indigenous patients students serve.

Strengths and limitations

Our study is one of the first to investigate students’ clinical experiences of racism, moving beyond the classroom and into applied clinical experiences. By exploring students’ experiences through in-depth interviews, we were able to explore the nuances and subtle variations of racism in Indigenous health through the student lens. Interviews were conducted during the students’ clerkship rotations, and thus the experiences they described were relatively fresh in their memories. However, our study has several limitations. Our study captures perspectives from undergraduate learners during their clerkship rotations only. It will be valuable to explore the perspectives of different learner groups, such as residents, fellows, and other allied health trainees, on their clinical interactions with Indigenous patients in other diverse clinical settings and to examine if and how perspectives may be similarly or differentially experienced. While our data explored students’ reflections regarding experiences with Indigenous patients in terms of emotions, attitudes, and values, we did not explore in depth the cognitive aspects of students’ knowledge about Indigenous patients, thus limiting our ability to make conclusions about whether further knowledge and understanding, though desired, would lead to an improved ability to care for these patients. In addition, we collected our data from a small number of learners at a single institution; therefore, our data may not be representative of perceptions and experiences of learners in other academic centers given the complex nature of learners’ perceptions about and experiences with this diverse patient population, limiting the generalizability of our findings to other settings and participants. Despite this limitation, this does not delimit or undervalue the very real experiences of racism that Indigenous patients describe.

Conclusions

Racism in healthcare towards Indigenous Peoples of Canada is prevalent and described by medical students. The effects of this racism may take more subtle forms than directly impacting medical care now but are nonetheless present and important. Preclinical and clinical education frames how medical students experience these episodes of racism as part of the healthcare team. As reported by these students, the most valuable form that this education takes is through personal and practical experiences shared by people within the Indigenous community.

Disclosure statement

No potential conflict of interest was reported by the author(s.)

Additional information

Funding

Funding for this project was provided by a grant from the Women and Children’s Health Research Institute [WCHRI].

Appendix

1.

Interview Guide

• (1) How is the clerkship going?

  1. What is going well?

  2. What surprised you the most about the transition from the classroom to clinical work?

  3. What has been the most difficult so far?

• (2) Please describe if you had any clinical experiences with Indigenous patients.

  1. Were these positive or negative experiences? Why?

  2. If needed, pick the best and the worst and expand upon that.

• (3) Do you think knowing that a patient is Indigenous is important to patient care?

  1. Why or why not?

  2. Does the specialty you’re in matter (i.e., surgery vs medicine vs pediatrics vs psych)

  3. Is there a difference between what should ideally be the answer and what you’ve experienced?

• (4) Have you had any experiences in clerkship where you perceived an Indigenous patient was treated differently than if they had been non-Indigenous?

  1. Can you give me a specific example?

  2. What type of healthcare professionals do you see perpetuating this difference?

• (5) Do you think bias and stigma affect Indigenous people seeking healthcare? Tell me about that.

  1. Have you seen examples of this in your clinical time?

• (6) Have you witnessed other hospital staff or personnel make comments about Indigenous patients?

  1. Did this vary based on the specialty, location, or context within which you are working?

• (7) Have you had any emotional reactions (positive or negative) when working with Indigenous patients that you expected?

  1. Any that surprise you?

  2. Any distressing experiences?

  3. Can you share the experiences and what your reaction was?

  4. Do you have any thoughts or insights as to why you felt that way?

• (8) Do you feel you have any preconceived notions (positive or negative) about dealing with Indigenous patients in the health care setting?

  1. Do you recognize any personal biases? If so, would you be willing to share?

• (9) Do you feel as though your training in the first two years of medical school prepared you for working with Indigenous patients?

  1. What do you think worked well?

  2. What do you think could be improved upon?

  3. What surprised you about working with Indigenous patients?

• (10) Could you explain if your opinions about Indigenous patients have changed since starting your clinical rotations? In what ways?

  1. Do you feel you are more or less equipped to treat Indigenous patients now than when you started your clerkship?

  2. Did your curriculum in the first two years of medical school impact this in any way?

  3. Can you share the experiences and what your reaction was?

  4. Do you have any thoughts or insights as to why you felt that way?

• (11) Are there things you feel you don’t know about caring for Indigenous patients?

  1. Has this changed since you started clinical rotations?

• (12) Is there anything else you want to talk about?

  • If participants are Indigenous themselves, further questions may be explored.

• (13) Do you identify as Indigenous? If so, how has your identity as an Indigenous person affected how you’ve experienced caring for Indigenous patients?