Capacity building of the Australian Aboriginal and Torres Strait Islander health researcher workforce: a narrative review.

BACKGROUND: This paper provides a narrative review that scopes and integrates the literature on the development and strengthening of the Australian Aboriginal and Torres Strait Islander health researcher workforce. The health researcher workforce is a critical, and oft overlooked, element in the health workforce, where the focus is usually on the clinical occupations and capabilities. Support and development of the Australian Aboriginal and Torres Strait Islander health researcher workforce is necessary to realise more effective health policies, a more robust wider health workforce, and evidence-led clinical care. This holds true internationally. It is critical to identify what approaches have resulted in increased numbers of Aboriginal and Torres Strait Islander people in health research, stronger local community partnerships with universities and industry, and research excellence and have contributed to evidence-led health workforce development strategies. METHODS: The search was for peer-reviewed journal articles between 2000 and early 2018 on capacity building of the Aboriginal and Torres Strait Islander health researcher workforce. Databases searched were CINAHL (EBSCO), PubMed, PsychINFO, LIt.search, and Google Scholar, combined with manual searches of select journals and citations in the grey literature. A coding scheme was developed to scan research coverage of various dimensions of health research capacity building. RESULTS: Twenty-four articles were identified. Eight focused on strengthening research capabilities of community members. A recurrent finding was the high research productivity of Aboriginal and Torres Strait Islander health researchers and strong interest in furthering research that makes a substantive contribution to community well-being. Action-based principles were derived from synthesis of the findings. Generally, research capacity building led to numerous gains in workforce development and improving health systems. CONCLUSIONS: There is a shortage of literature on health researcher workforce capacity building. National-level research on capacity building strategies is needed to support the continued success and sustainability of the Australian Aboriginal and Torres Strait Islander health researcher workforce. This research needs to build on the strengths of Aboriginal and Torres Strait Islander researchers. It also needs to identify clear and robust pathways to careers and stable employment in the health workforce, and health researcher workforce more specifically. This need is evident in all settler colonial nations (e.g. Canada, United States of America, New Zealand), and principles can be applied more broadly to other minoritised populations.

Understanding practitioner professionalism in Aboriginal and Torres Strait Islander health: lessons from student and registrar placements at an urban Aboriginal and Torres Strait Islander primary healthcare service.

Aboriginal and Torres Strait Islander peoples continue to be pathologised in medical curriculum, leaving graduates feeling unequipped to effectively work cross-culturally. These factors create barriers to culturally safe health care for Aboriginal and Torres Strait Islander peoples. In this pilot pre-post study, the learning experiences of seven medical students and four medical registrars undertaking clinical placements at an urban Aboriginal and Torres Strait Islander primary healthcare service in 2014 were followed. Through analysis and comparison of pre- and post-placement responses to a paper-based case study of a fictitious Aboriginal patient, four learning principles for medical professionalism were identified: student exposure to nuanced, complex and positive representations of Aboriginal peoples; positive practitioner role modelling; interpersonal skills that build trust and minimise patient-practitioner relational power imbalances; and knowledge, understanding and skills for providing patient-centred, holistic care. Though not exhaustive, these principles can increase the capacity of practitioners to foster culturally safe and optimal health care for Aboriginal peoples. Furthermore, competence and effectiveness in Aboriginal health care is an essential component of medical professionalism.

Cultural competence in medical education: aligning the formal, informal and hidden curricula.

The concept of cultural competence has become reified by inclusion as an accreditation standard in the US and Canada, in New Zealand it is demanded through an Act of Parliament, and it pervades discussion in Australian medical education discourse. However, there is evidence that medical graduates feel poorly prepared to deliver cross-cultural care (Weissman et al. in J Am Med Assoc 294(9):1058-1067, 2005) and many commentators have questioned the effectiveness of cultural competence curricula. In this paper we apply Hafferty's taxonomy of curricula, the formal, informal and hidden curriculum (Hafferty in Acad Med 73(4):403-407, 1998), to cultural competence. Using an example across each of these curricular domains, we highlight the need for curricular congruence to support cultural competence development among learners. We argue that much of the focus on cultural competence has been in the realm of formal curricula, with existing informal and hidden curricula which may be at odds with the formal curriculum. The focus of the formal, informal and hidden curriculum, we contend, should be to address disparities in health care outcomes. In conclusion, we suggest that without congruence between formal, informal and hidden curricula, approaches to addressing disparity in health care outcomes in medical education may continue to represent reform without change.

Do indigenous health curricula in health science education reduce disparities in health care outcomes?

OBJECTIVE: To undertake a systematic literature review to determine the scope, rationales, and evaluation foci of indigenous health curricula included in university-based professional training of health care service providers. STUDY DESIGN: Systematic review. DATA SOURCES: We searched the Australasian Medical Index, ATSIhealth (Aboriginal and Torres Strait Islander Health Bibliography), CINAHL PLUS, MEDLINE, SCOPUS version 4, and Web of Science databases using relevant keywords. Our initial search identified 1247 articles and our refined search identified 57 articles. Thirty-six articles published between 1999 and 2011 that referred to indigenous health-related curricula within university health science courses were selected for review. DATA SYNTHESIS: While almost all the articles were explicit that improving indigenous health was an aim of their curriculum, none evaluated the impact of curricula on patient outcomes. CONCLUSION: There appears to be a widespread assumption in the literature that improving practitioner skills, knowledge and attitudes will lead to improvements in indigenous health outcomes. The literature showed evidence of efforts towards evaluating learner (student) outcomes, but no evidence of evaluation of patient outcomes. We need to begin to design methods that focus on evaluating the impacts of indigenous health curricula on patient outcomes, while continuing to investigate the impact of curricula on learner outcomes.

"Unwell while Aboriginal": iatrogenesis in Australian medical education and clinical case management.

INTRODUCTION: Attention to Aboriginal health has become mandatory in Australian medical education. In parallel, clinical management has increasingly used Aboriginality as an identifier in both decision making and reporting of morbidity and mortality. This focus is applauded in light of the gross inequalities in health outcomes between indigenous people and other Australians. METHODS: A purposive survey of relevant Australian and international literature was conducted to map the current state of play and identify concerns with efforts to teach cultural competence with Aboriginal people in medical schools and to provide "culturally appropriate" clinical care. The authors critically analyzed this literature in light of their experiences in teaching Aboriginal studies over six decades in many universities to generate examples of iatrogenic effects and possible responses. RESULTS AND DISCUSSION: Understanding how to most effectively embed Aboriginal content and perspectives in curriculum and how to best teach and assess these remains contested. This review canvasses these debates, arguing that well-intentioned efforts in medical education and clinical management can have iatrogenic impacts. Given the long history of racialization of Aboriginal people in Australian medicine and the relatively low levels of routine contact with Aboriginal people among students and clinicians, the review urges caution in compounding these iatrogenic effects and proposes strategies to combat or reduce them. CONCLUSION: Long overdue efforts to recognize gaps and inadequacies in medical education about Aboriginal people and their health and to provide equitable health services and improved health outcomes are needed and welcome. Such efforts need to be critically examined and rigorously evaluated to avoid the reproduction of pathologizing stereotypes and reductionist explanations for persistent poor outcomes for Aboriginal people.

Unequal treatment: the possibilities of and need for indigenous parrhesiastes in Australian medical education.

This paper investigates the relationship between the unacceptably poor levels of Indigenous health in Australia, the very low levels of representation (As at 2009, approximately 140 Indigenous medical graduates Australia wide) of Indigenous people within the medical field, and the potential for parrhesia (translated as "fearless speech") to challenge the medical hegemony, and as a tool of self-care for Indigenous medical students. This paper outlines the elements that make up parrhesia, the current state of Australian Indigenous (ill) health and Indigenous participation in the Australian health workforce, with some international comparison. Using Huckaby's (Educ Phil Theor 40: 770-788, 2008) conceptualization of specific parrhesiastic scholars, the paper introduces the idea of an Indigenous parrhesiastes. The paper then discusses, and endeavors to briefly address three questions that Foucault articulated in his series of lectures on parrhesia in 1983: "How can we recognize someone as a parrhesiastes? What is the importance of having a parrhesiastes in the city? What is the training of a good parrhesiastes?" (Foucault, http://foucault.info/documents/parrhesia/, 1985). In conclusion, this paper shows that Indigenous parrhesiastes could make a strong and positive contribution to medicine and medical education.