Introduction by Croakey: The Federal Government and universities across Australia have been urged to invest in measures to improve the retention of Indigenous medical students, and thus the number of Indigenous medical graduates.
While Australia currently has around 500 enrolled Indigenous medical students, many do not receive appropriate support to enable them to complete their courses and graduate, according to Indigenous scholars at the University of Wollongong’s Graduate School of Medicine.
“The ongoing situation resembles that of a leaky pipe that has grown to allow increasingly more water in, but that has not yet attended to repairing the defects throughout the length of the pipeline, resulting in a relative trickle at the end of the line,” write Ashlee Williams-Barnes, Associate Professor Paul Saunders and Sophie Pitt.
In the article below, they put forward three areas where greater investment and focus could help to boost numbers of Indigenous doctors, including:
- Scholarships and bursaries that are easily accessible and substantial enough to deter the need for supplementary income via paid employment.
- Increasing the number of First Nations academic and professional staff within medical schools, to provide cultural support, mentorship, and contribute to creating and maintaining culturally safe learning environments.
- Enhancing and expanding faculty cultural capability, including by embedding Indigenous ways of knowing, being, and doing within and across medical school operations.
Ashlee Williams-Barnes, Paul Saunders and Sophie Pitt write:
Medical education in Australia is experiencing the greatest transformation since the latter half of the 20th century, when the Karmel Report catalysed diversification and local accreditation oversight. The need for such change in the contemporary setting stems, largely, from ongoing inequitable healthcare access and unequal health outcomes between population groups.
One group that negatively experiences such inequitable access and outcomes are First Nations Peoples, a collective of diverse Peoples and Communities whose ancestral, cultural, and spiritual ties have been engrained in this land for time immemorial.
Eurocentric ideological structures and systems of medical education, imposed during colonisation, continue to dominate in the Australian context, and indeed throughout many colonised nations. While there are benefits to Western medicine and medical education, the exclusion of Indigenous health and wellbeing knowledges and practices in this space is to the detriment of our society, and contributes to the hindrance of culturally safe healthcare experiences for First Nations Peoples.
In addition to this epistemological (knowledge) exclusion, a relative lack of First Nations medical students and practitioners further compounds culturally unsafe healthcare environments, ensuring cultural access to healthcare remains inequitable.
To address these foundational gaps in realising health and healthcare equity, Commonwealth Government departments and agencies have engaged in transformative work that has impacted national legislation, medical education and training accreditation, and health professional registration.
However, while there has been much welcomed government attention given to First Nations health and healthcare reform at a policy and statutory level, crucial gaps remain to achieving tangible outcomes in this space.
Building the First Nations medical workforce is seen as a vital focus in The National Aboriginal and Torres Strait Islander Health Plan 2021–2031, with the recent abolition of caps on Commonwealth Supported Places for First Nations medical students.
Commitment and capacity?
While this is applauded by First Nations health and medical advocates, it poses an important question: Do we currently have the commitment and capacity within our medical schools to effectively support these increasing numbers of First Nations students through to graduation?
It is known that First Nations medical students are more likely to have negative experiences during medical school when compared to their non-Indigenous peers, with higher attrition and non-completion rates.
Such negative experiences and withdrawals have been attributed to racism, financial hardship, lack of institutional support, inequitable assessment and progression modalities, cultural segregation via pervasive structures such as the ‘hidden curriculum’, competing cultural, family and Community responsibilities, and a relative lack of accessible social and cultural support networks due to factors such as geographical distance from family and Community.
In 2016, the then Australian Indigenous Doctors’ Association student director, Kersandra Begley, and president of the Australian Medical Students’ Association, Elise Buisson, presented a snowclone (an adaptation of a well-known quote to fit a new context while preserving recognition to the original quote) using Professor Tom Calma’s 2005 assertion as the then Aboriginal and Torres Strait Islander Social Justice Commissioner: “It is not credible to suggest that delivering effective support to 310 Indigenous medical students nationwide is a task beyond the purview of universities, government and the medical profession itself, led by the Indigenous community.”
Now, 10 years later, while the figure has risen to near 500 enrolled Indigenous medical students nationwide, we find ourselves in a similar position of inadequate support and disproportionate completion rates, even after a robust call to action via the Healthy Futures report in 2005.
The impact of this is widespread, and for the departing First Nations student, is felt well after withdrawal from medical school, with the very limited formal evidence suggesting it has negative effects on confidence, self-efficacy, and social and emotional wellbeing.
The ongoing situation resembles that of a leaky pipe that has grown to allow increasingly more water in, but that has not yet attended to repairing the defects throughout the length of the pipeline, resulting in a relative trickle at the end of the line.
Associate Professor Emma Walke and colleagues articulate this in the context of inequitable assessment as ‘Opening the door, closing the path’, whereby a central focus on First Nations medical student recruitment has come at a cost of neglect of retention and support.
Plugging the leaks
If we are serious about increasing and building the capacity of the First Nations medical workforce, as a key contributor to enhancing cultural safety within healthcare systems and services, then we ought to focus our collective attention equally on recruitment and retention (and graduation).
So, what is needed to address the First Nations medical workforce ‘leaky pipeline’?
Ultimately, greater Commonwealth Government and institutional (i.e., university) investment is needed to support the now 20-plus-year-old recommendations from the Healthy Futures report, which continue to demonstrate relevance.
We can be proud that many of the recommendations are progressing and have become ‘business as usual’ for most, if not all, universities and their respective medical schools. Initiatives such as alternative entry pathways and dedicated Indigenous Support Units are prevalent across institutions, largely established and maintained by First Nations Peoples.
However, ‘leaks’ remain in areas such as financial, academic and faculty support, mentorship, First Nations medical school staffing capacity, student and faculty cultural capability, culturally safe learning environments, and institutional and faculty community engagement.
While some of these longstanding ‘leaks’ are largely non-financial investments, many of them require sustained financial backing from government and universities, guided by meticulous planning with First Nations Peoples across Australia.
Some tangible outcomes can be realised relatively swiftly by investing in the following:
1. Scholarships and bursaries that are easily accessible and substantial enough to deter the need for supplementary income via paid employment. A recent literature review found that unpaid health and social care placements can have a negative impact on students’ academic performance, as they attempt to juggle employment, academic, family, and other social responsibilities. This is compounded by unique and potentially demanding cultural and community responsibilities for First Nations Peoples.
2. Increasing the number of First Nations academic and professional staff within medical schools, to provide cultural support, mentorship, and contribute to creating and maintaining culturally safe learning environments. A 2019 literature review identified First Nations health academic staff as ‘essential’ to student retention.
3. Enhancing and expanding faculty cultural capability via dedicated ongoing, experiential development opportunities, including establishing regular meaningful self-reflective practice, learning with and from First Nations Peoples and Communities, and embedding Indigenous ways of knowing, being, and doing within and across medical school operations. While this requires a fundamental shift in institutional culture, financial investment is required to ensure adequate staff capacity to deliver medicine programs while also engaging in such capability development (i.e., to increase FTE within faculties/schools).
With much more still to be done to realise a rich and flourishing First Nations medical workforce, the above points are but a few immediate and sustained impactful investment actions the Commonwealth Government and universities can implement to grasp tangible outcomes within and across the pipeline, along with established initiatives, such as removing the cap on Commonwealth Supported Places.
The need to nurture the entirety of the First Nations medical workforce pipeline, beyond a focus on recruitment, is critical to ensuring broader targets, such as parity workforce representation, culturally safe healthcare systems and services, and comparative health outcomes are achieved.
From a business perspective, the rationale for ensuring investment is diversified along the pipeline is a no brainer. The return on government investment to grow the First Nations medical workforce would encompass stubborn Closing the Gap targets that stretch far beyond direct health indicators to employment, education, and housing.
As Professor Tom Calma so profoundly declared: “It is not credible to suggest that one of the wealthiest nations in the world cannot solve a health crisis affecting less than three percent of its citizens.”
Author details
Ashlee Williams-Barnes is a proud Wandi Wandian, Wodi Wodi and Dharawal woman, born and raised on Dharawal Country. She is the Indigenous Student Recruitment and Outreach Coordinator at the University of Wollongong’s Graduate School of Medicine, and is a passionate Aboriginal health advocate, cancer survivor and consumer representative who draws on her lived experience to drive meaningful change across healthcare, medical education, research and Community.
Associate Professor Paul Saunders, MBBS, MPH, GradCert (Indigenous Research and Leadership), PhD, is a proud Biripi man, born and raised on Dharawal Country in Southwest Sydney. He is Academic Lead at the University of Wollongong’s Graduate School of Medicine, Deputy Director of Ngarruwan Ngadju and a former medical practitioner who works to ensure Aboriginal and Torres Strait Islander voices infiltrate Western medical systems, including medical education. Interests declared: Australian Medical Council Medical School Accreditation Committee (MedSAC); Australian Medical Council Aboriginal, Torres Strait Islander, and Māori Committee; Rural Health Multidisciplinary Training (RHMT) program 2.0 First Nations and Cultural Safety Working Group; Medical Deans Australia and New Zealand Indigenous Medical Education Leads Council; Royal Australasian College of Physicians Indigenous Health Curriculum Expert Advisory Group.
Sophie Pitt, BHSc (Mental Health), MPH, is a proud Torres Strait Islander (Meriam) woman living and working on Dharawal Country. A PhD candidate and Senior Lecturer in Indigenous Health at the University of Wollongong, her research focuses on strengthening the cultural capabilities of non-Indigenous educators in medicine. She also sits on governing committees for the Australian Medical Council, Royal Australasian College of Physicians, and is a Board Director of the Illawarra Aboriginal Medical Service. Interests declared: Australian Medical Council Assessment Committee; Australian Medical Council Aboriginal, Torres Strait Islander, and Māori Committee; Royal Australasian College of Physicians Indigenous Health Curriculum Expert Advisory Group.
Also read
The Medical Journal of Australia: Responding to the Revised First Nations Health and Cultural Safety Accreditation Standards in Australian Primary Medical Education: Institutional Principles and Qualities for Meaningful Progress.
See Croakey’s archive of articles on health and medical education
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