23rd February 2018, Volume 131 Number 1470

Shannon Springer, Suzanne Pitama, Kate Leslie, Shaun Ewen

The Australian Medical Council (AMC) is an independent national standards body for medical education and training, which acts as an external accreditation entity for the purposes of the Health Practitioner Regulation National Law in Australia. The AMC also works with the Medical Council of New Zealand (MCNZ) to accredit programmes of study leading to general or specialist (vocational) registration in Australia and New Zealand.1 The AMC is responsible for ensuring that standards of medical education promote and protect the health of the community, including Aboriginal and Torres Strait Islander peoples of Australia and, through the MCNZ, Māori of New Zealand.2

In 2006 the AMC revised the Standards for Assessment and Accreditation of Primary Medical Programs to include standards about effective partnerships with Indigenous communities, organisations and individuals; curriculum coverage of Indigenous health and culturally competent communication and care; and recruitment of Indigenous students and staff. Australian and New Zealand medical schools have made substantial progress in meeting these standards.3 Currently in Australia approximately 1.6% (1.56%) of medical students and 0.3% of doctors identify as being Aboriginal and/or Torres Strait Islander.4 In New Zealand 14% of medical students and 3.2% of medical practitioners identify as Māori.5

Encouragement to embark on the same project for the Standards for Assessment and Accreditation of Specialist Medical Programs and Professional Development Programs came from multiple sources. After signing a collaboration agreement with Medical Deans Australia and New Zealand (MDANZ), the Australian Indigenous Doctors Association (AIDA) sought a similar agreement with the Committee of Presidents of Medical Colleges (CPMC). This was concluded in 2013 and included a priority output to “negotiate with the Australian Medical Council for the inclusion of specific standards to address Aboriginal and Torres Strait Islander health”. At the same time the AMC’s Indigenous Planning and Advisory Group began charting the AMC’s strategic options in Indigenous development. A key element of this strategy was to embed Indigenous health and medical education at all points throughout the training pipeline. Finally, during preparation for revising the standards, the Specialist Education Accreditation Committee (SEAC) of the AMC received feedback from colleges, jurisdictions, Indigenous organisations and other stakeholders that inclusion of new standards specific to the health and medical education of Indigenous people would be welcome.

The revision of the AMC accreditation standards to address Indigenous health affects specialist medical colleges, their Fellows and trainees, Indigenous health advocacy organisations and ultimately, Indigenous communities.

Across the 10 Standards, there were 34 substantive changes (including additions) that specialist medical colleges are now required to meet. Among the additions, five specifically address the health of Aboriginal and Torres Strait Islander peoples in Australia, and Māori in New Zealand. These standards are summarised below in Table 1.6 Training providers will be expected to demonstrate how they meet, or plan meet, the new standards.

Table 1: Five standards addressing Aboriginal and Torres Strait Islander and Māori health.6

Standards

Standard 1: The context of education and training

1.6.4 The education provider has effective partnerships with relevant local communities, organisations and individuals in the Indigenous health sector to support specialist training and education.

Standard 2: The outcomes of specialist training and education

2.1.2 The education provider’s purpose addresses Aboriginal and Torres Strait Islander peoples of Australia and/or Māori of New Zealand and their health.

Standard 3: The specialist medical training and education framework

3.2.9 The curriculum develops a substantive understanding of Aboriginal and Torres Strait Islander health, history and cultures in Australia and Māori health, history and cultures in New Zealand as relevant to the specialty(s).

3.2.10 The curriculum develops an understanding of the relationship between culture and health. Specialists are expected to be aware of their own cultural values and beliefs, and to be able to interact with people in a manner appropriate to that person’s culture.

Standard 7: Trainees

7.1.3 The education provider supports increased recruitment and selection of Aboriginal and Torres Strait Islander and/or Māori trainees.

Standard 8: Implementing the programme—delivery of education and accreditation of training sites

 

8.2.2 The education provider’s criteria for accreditation of training sites link to the outcomes of the specialist medical programme and:

  • ensure trainees receive the supervision and opportunities to develop the appropriate knowledge and skills to deliver high-quality and safe patient care, in a culturally safe manner
  • support training and education opportunities in diverse settings aligned to the curriculum requirements, including rural and regional locations, and settings which provide experience of the provisions of healthcare to Aboriginal and Torres Strait Islander peoples in Australia and/or Māori in New Zealand. 

The aim in writing this paper is to raise the profile of the new standards, and to share some perspectives from experts in the field, spanning Indigenous health medical education and assessment of medical education programmes.

Seven areas for consideration to meet the AMC’s Indigenous specific standards

Improving Indigenous health outcomes in Australia and New Zealand requires the medical profession to take philosophical, practical and strategic actions towards Indigenous peoples and their health needs. In the context of specialist medical colleges, a transformative change (and successful accreditation against the standards) will only be achieved by a developing and consolidating a comprehensive organisation-wide approach with reconciliation at its core. In the Australian context, ‘reconciliation’ has many different meanings and actions. However, it remains the foundation for respectful relationships and genuine organisational intent towards addressing Indigenous disadvantage. An approach that does not recognise this fundamental principle and makes specific ‘quick fixes’ to meet accreditation standards is unlikely to neither satisfy the AMC nor bring about real change for Indigenous peoples. The seven recommended areas for consideration listed below will assist colleges with their own transformative strategies through leadership and governance, partnership, health workforce development, advocacy strategy, curriculum and assessment, collaboration and celebration. These recommendations are discussed in detail below. Figure 1 diagrammatically brings together the seven recommended areas of action. The diagram highlights the central role that we expect leadership and governance to play in realising the aspiration behind the inclusion of the new standards. It represents how the seven principles work together within an organisation to grow transformative change. Each principle complements each other. Principles 1 and 2 are the foundation stones to developing principles 3 to 5. Principles 6 and 7 reinforce the process by sharing and embedding the collective vision and experiences by bringing people and communities together. The diagram was developed by author SS, and modified through discussion by the team.

Figure 1: Seven recommended areas for action. 

c 

1. Leadership and governance

Leadership

Transformative change of an organisation requires ‘leadership from the top’, as well as supporting strategies to support change throughout the organisation.6 College leadership needs to be demonstrably supportive of Indigenous health as a college priority. Growing positive attitudes and values across the membership and organisation will assist in achieving the AMC standards and mitigate resistance and barriers that stifle progress and undermine future actions. The drive of a few, without clear institutional support and direction towards Indigenous health, can never be a pattern for a transformative change, let alone meeting the AMC standards.

Indigenous representation

Governance structures that include Indigenous peoples in leadership positions with decision-making capacities will be intrinsic to success.Where it is not possible to have Indigenous representation on committees, the college should consult with key Indigenous organisations and support and value Indigenous leadership in decision making.

Operationalising Indigenous health initiatives

An action plan should be developed for each of the operational areas of the college, including those that are relevant to AMC accreditation. Input from internal and external stakeholders into developing this plan is critical. The action plan will provide the overarching framework that will guide a set of goals and subsequent actions over the life of the plan. The “Indigenous health (or reconciliation) action plan” (however recognised or named) needs to align intimately with the college’s core business. It should be fashioned in a way that is both symbolic and practical, and should identify a clear commitment to improving Indigenous health with targets, actions and reporting processes. The plan should address, at a minimum, the key principles outlined in this paper. The administration of the Indigenous health activities outlined in this plan should be similar to other operational areas of the college. Some colleges have developed Indigenous health committees that include members with Indigenous health expertise to oversee the initiatives set out in their strategies.7 These initiatives should be funded and resourced in the standard college budget to demonstrate their equal importance to other college functions. Resourcing and funding in this way can help protect Indigenous health initiatives in a scarce funding climate.

2. Partnerships

There are many Indigenous organisations that lead in Indigenous health advancement that can assist colleges in developing Indigenous health strategies and methodologies that are more likely to translate into meaningful outcomes. Nurturing, respectful and mutually sustainable Indigenous health partnerships can amplify the reach to Indigenous medical students, doctors and the wider Indigenous communities. Table 2 includes six Indigenous organisations that work in the areas of Indigenous medical education, recruitment and support of Indigenous medical students and doctors, Indigenous research development and Indigenous health advocacy with Australasia.

Table 2: Indigenous organisations.

Organisation

Purpose

Leaders in Indigenous Medical Education (LIME)

LIME aims to ensure the quality and effectiveness of teaching and learning of Indigenous health in medical education, as well as best practice in the recruitment and graduation of Indigenous medical students.

The LIME Network Programme seeks to establish a continuing bi-national presence that encourages and supports collaboration within and between medical schools in Australia and New Zealand to support the development, delivery and evaluation of quality Indigenous health content in medical education.

Australian Indigenous Doctors’ Association (AIDA)

AIDA’s ultimate goal is to reach population parity of Indigenous doctors, and to inform and support a culturally safe healthcare system.

Te Ohu Rata o Aotearoa (Te ORA)—Māori Medical Practitioners Association

Te ORA is a professional body representing Māori medical students and doctors working as clinicians, researchers and teachers.

Te ORA’s vision is to provide Māori medical leadership to the health sector to affect Māori health development.

Lowitja Institute

The Lowitja Institute facilitates research and knowledge exchange that improves the health and wellbeing of Aboriginal and Torres Strait Islander peoples.

National Aboriginal Community Controlled Health Organisation (NACCHO)

NACCHO is the national peak body for Aboriginal health. It is entrusted to represent the needs and interests of Aboriginal health on behalf of its members in the national arena.

Reconciliation Australia

Reconciliation Australia was established in 2001 and is the lead body on reconciliation in the nation. It is an independent not-for-profit organisation which promotes and facilitates reconciliation by building relationships, respect and trust between the wider Australian community and Aboriginal and Torres Strait Islander peoples.

Mauri Ora Associates

Mauri Ora Associates are an Indigenous lead health education research centre that provide e-learning courses in Māori health and cultural competency for a range of health professionals. 

3. Health workforce development

Colleges need to actively support the development of a health workforce that is culturally safe and responsive to addressing Indigenous healthcare access. Each college needs to implement strategies to actively recruit and retain Indigenous doctors into their respective specialities. Colleges should also aim to recruit non-Indigenous doctors who intend to make Indigenous health a professional practice priority. Developing strategies in the following areas can assist in growing the workforce of Indigenous doctors and non-Indigenous doctors working in Indigenous health. These strategies include:

  • Demonstrating a commitment to improving Indigenous health
  • Ensuring a safe learning and practice environment to support Indigenous and non-Indigenous doctors that prioritises their professional development within Indigenous health
  • Ensuring supportive pathways to Fellowship for Indigenous doctors ie, developing Indigenous candidate’s awareness of college selection criteria and providing appropriate support and direction to promote their eligibility
  • Providing support through initiatives such as scholarships, assistance with fees and training courses, and mentorship
  • Creating Indigenous training posts or opportunities to work with Indigenous organisations or communities in a safe, supervised and structured way ie, clinical specialist rotations within Aboriginal Community Controlled Health Organisations (ACCHO’s)
  • Supporting Indigenous research partnerships and opportunities for Indigenous health research.

4. Curriculum and assessment

Australian and New Zealand medical graduates are expected to have developed emerging professional skills related to Indigenous health upon graduation.8,9 Specialist medical colleges must capitalise on this knowledge and skill, and further develop Indigenous health-competent medical specialists. Colleges need to draw on their membership, and on Aboriginal and Torres Strait Islander and Māori health experts to develop their Indigenous health curriculum framework. The curriculum standards in this framework need to produce a specialist with a “substantial understanding” of Indigenous health in their area of expertise. Indigenous health post-graduate learning that has been pitched at an undergraduate level has been met with resistance and pushback from trainees. Such an approach has not lent itself to ongoing professional development of clinician’s Indigenous health capabilities and has contributed to a lack of confidence to advocate on behalf of Indigenous patients. Indigenous health curriculum within the college should be mapped to a “national Indigenous curriculum standard.” This generic blueprint can be implemented to each training site by engaging and including local Indigenous organisations and communities where doctors are embedded. Where possible the Indigenous health curriculum should be integrated horizontally and vertically throughout the training programme and should be mapped to assessment.9–13 Colleges will need to ensure learning in Indigenous health to the required standard is occurring in all its jurisdictions and training sites. Developing a monitoring, evaluation and reporting process will be an essential requirement as part of the oversight.

5. Advocacy strategy

Colleges are in a position to advocate for improvements in Indigenous health outcomes by contributing to the evidence around Indigenous health and promoting government/s and community action on Indigenous community concerns. Developing Indigenous representation on research committees and collaborating with Indigenous research organisations, such as the Lowitja Institute, can orientate culturally acceptable research opportunities that can deliver meaningful health outcomes. Publishing this information in a peer-reviewed journal will see greater transference of Indigenous health best practices and evidence into the medical profession.

6. Collaboration

Indigenous health is a universal platform where colleges can work together to develop their shared values, experiences, resources and expertise. There are many areas where colleges will find similarities, for example recruitment and retention, curriculum development and assessment and research opportunities. The various Indigenous health committees from each of the colleges should share their strategies, challenges and successes in each of the domains outlined in this paper as they negotiate and advance forward. This process will be a new/emerging process for some colleges. Other colleges however, have made and continue to make considerable inroads in the development of Indigenous health curriculum, Indigenous doctor recruitment/retention strategies, Indigenous heath professional development opportunities and social contracts with Indigenous communities.

7. Celebration

Having an organisational wide approach to improving Indigenous health provides everyone with an opportunity to celebrate the milestones and achievements. Celebrating each milestone strengthens the vision and the purpose of this important collective transformative process. The act of “showcasing” positive stories helps to challenge the deficiency-focused learning models that we deliver “about” Indigenous peoples. This, in turn, creates a hidden curriculum where by people may engage in meaningful conversations about continuing to apply Indigenous health initiatives in the college and the wider medical profession.

Conclusion

Having a set of standards focusing specifically on Indigenous people’s health, the AMC is signalling the importance of accountable Australian and New Zealand medical professionals in Indigenous health. Most Australian and New Zealand medical schools have undergone considerable institutional development to include Indigenous medical students, curriculum, leadership development and staff over the last 10 years. This transformative change, while not yet complete, has reorientated primary medical programmes and their awareness about and action with regard to Indigenous health. With the AMC Indigenous health standards now firmly in place, it will not be a question of if colleges develop the required changes to meet the standards, but rather a question of when, and how. The aspiration is that by applying the areas for consideration outlined in this paper, that the medical profession will not only meet these standards and improve Indigenous health outcomes, but also come to value Indigenous peoples’ knowledge on health and wellbeing and the contribution they can make to the wider medical profession, and add to the overall excellence of the college activities.

Summary

The Australian Medical Council (AMC) sets the standard that specialty medical professionals should achieve to ensure that the community has safe doctors that meet the needs of the public. Due to the health differences between Indigenous and non-Indigenous peoples, the AMC has changed the standards to ensure medical colleges respond to this inequity. This paper helps colleges deliver on these standards in a practical way.

Abstract

Since 2006 the Australian Medical Council (AMC) accreditation standards have required medical schools to comprehensively address issues related to the health of Aboriginal and Torres Strait Islander peoples in Australia, and Māori in New Zealand. This has spanned areas of staff expertise, staff and student recruitment, curriculum and institutional leadership. These Indigenous specific standards have, until now, been absent for specialist medical college accreditation. The AMC revised its accreditation standards for specialist medical colleges in 2015, and for the first time included Indigenous specific standards. This commentary presents a guideline to support Australasian medical colleges’ responsiveness to these Indigenous specific standards.

Author Information

Shannon Springer, Faculty of Science and Medicine, Bond University, Australia; 
Suzanne Pitama, Māori/Indigenous Health Institute, University of Otago, Christchurch; 
Kate Leslie, Specialist Education Accreditation Committee, Australia Medical Council, Australia;
Shaun Ewen, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia.

Acknowledgements

The authors wish to acknowledge the work undertaken by the Leaders in Indigenous Medical Education (LIME) network who has advocated and demonstrated ongoing leadership in this space of indigenous medical education.

Correspondence

Dr Shannon Springer, Faculty of Science and Medicine, Bond University, Australia.

Correspondence Email

sspringe@bond.edu.au

Competing Interests

Associate Professor Shannon Springer is a Leader’s in Indigenous Medical Education (LIME) Reference group member; and a board member of the Australian Indigenous Doctors’ Association (AIDA); and a board member for the National Faculty of Aboriginal and Torres Strait Islander Health Royal Australian College of General Practitioners (RACGP).

References

  1. AMC. (2013). Standards for assessment and accreditation of primary medical programs by the Australian Medical Council 2012. 
  2. CDAMS. (2004). CDAMS Indigenous Health Curriculum Framework. Melbourne: Committee of Deans of Australian Medical Schools
  3. MDANZ and AIDA. (2012). Medical Deans Australia and New Zealand (MDANZ) and Australian Indigenous Doctors’ Association (AIDA) 2012, A Review of the Implementation of the Indigenous Health Curriculum Framework and the Healthy Futures Report within Australian Medical Schools, MDANZ and AIDA, Parkes, ACT.
  4. MDANZ. (2015). Medical Deans Australia and New Zealand Workforce Data Report 2015 November 2015.
  5. MCNZ. (2014) Medical Council of New Zealand (2014) The New Zealand Medical Workforce in 2013 and 2014. http://www.mcnz.org.nz/assets/News-and-Publications/Workforce-Surveys/2013-2014.pdf
  6. AMC. (2015). Australian Medical Council (AMC) Standards for Assessment and Accreditation of Specialist Medical Programs and Professional Development Programs 2015. Australian Medical Council 2015. 
  7. Medical Council of New Zealand. Statement on Cultural Competence: Medical Council of New Zealand; 2006 [Available from: http://www.mcnz.org.nz/assets/News-and-Publications/Statements/Statement-on-cultural-competence.pdf
  8. Mazel O, Anderson I. Advancing Indigenous health through medical education. Focus on Health Professional Education: A Multi-Disciplinary Journal. 2011; 13(1):12.
  9. Jones R, Pitama S, Huria T, Poole P, McKimm J, Pinnock R, Reid P. (2010). Medical education to improve Māori health. New Zealand Medical Journal, 123(1316). Retrieved from http://www.nzma.org.nz/journal/archive.php 
  10. Copeman RC. Medical students, Aborigines and migrants: evaluation of a teaching programme. Med J Aust. 1989; 150(2):84–7.
  11. Zhou AW, Boshart S, Seelisch J, Eshaghian R, McLeod R, Nisker J, et al. Efficacy of a 3-Hour Aboriginal Health Teaching in the Medical Curriculum: Are We Changing Student Knowledge and Attitudes? Health Education Journal. 2011; 71(2):180–8.
  12. Pitama S. “As natural as learning pathology”: The design, implementation and impact of indigenous health curricula. [Unpublished doctoral thesis]. Christchurch: University of Otago; 2012.
  13. Shah CP, Reeves A. The Aboriginal Cultural Safety Initiative: An Innovative Health Sciences Curriculum in Ontario Colleges and Universities. International Journal of Indigenous Health. 2015; 10(2):117–31.