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Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential

Tamara Mackean, Romlie Mokak, Allan Carmichael, Gregory L Phillips, David Prideaux and Theanne R Walters
Med J Aust 2007; 186 (10): 544-546.
Published online: 21 May 2007

The Australian medical education system is at a critical juncture in relation to what and how it delivers for Aboriginal and Torres Strait Islander health. The recent work of three key organisations concerned with medical education provides a toolkit for implementation of sustainable reform within medical schools.

The Australian Medical Council’s Assessment and accreditation of medical schools: standards and procedures (2006)1 for the first time centrally locates Australia’s Indigenous peoples within its assessment and accreditation framework. The Medical Deans Australia and New Zealand’s CDAMS Indigenous health curriculum framework (2004)2 provides a set of guidelines for success in developing and delivering Indigenous health content in core medical education. The Australian Indigenous Doctors’ Association’s report Healthy futures: defining best practice in the recruitment and retention of Indigenous medical students (2005)3 establishes clear targets, principles and actions to ultimately achieve a greater number of Indigenous people in the medical workforce.

These major advances in relation to Indigenous health have been undertaken over the past 3 years.

Each organisation commits to continuing on a journey of collaboration and has its sights clearly set on the destination — a medical workforce trained in Indigenous health, and more Aboriginal and Torres Strait Islander doctors, leading to better health for Australia’s Indigenous peoples.

CDAMS Indigenous health curriculum framework (2004)

The Medical Deans Indigenous Health Project commenced in 2003 as the result of a partnership between Medical Deans Australia and New Zealand (formerly Committee of Deans of Australian Medical Schools [CDAMS]), the Australian Government Department of Health and Ageing, and the University of Melbourne’s Onemda VicHealth Koori Health Unit.

In its first phase, the project aimed to:

  • audit medical schools nationally for their existing Indigenous health content;

  • develop a nationally agreed curriculum framework that outlined desirable key learning outcomes; and

  • have the curriculum framework endorsed by all deans and the Australian Medical Council (AMC).

Phase two of the project is concerned with:

  • developing the capacity of medical schools to deliver the curriculum framework;

  • establishing a national network of medical educators and Indigenous health professionals;

  • working with postgraduate medical councils and medical colleges to more seamlessly integrate Indigenous health curriculum throughout the learning continuum; and

  • developing a quality review process to ensure ongoing evaluation, growth and improvement.

The CDAMS Indigenous health curriculum framework is a nationally agreed set of guidelines for success in designing and delivering an Indigenous health curriculum in medical education. It contains a rationale and guiding principles, key learning objectives and subject areas, and the pedagogical approaches that are more likely to increase the effectiveness of curriculum delivery and learning. Its major recommendation is that Indigenous health should be embedded into all areas of the curriculum, rather than being taught as discrete or elective content.2

This is the only time the deans of medicine have agreed to a national set of curriculum guidelines. The deans accepted the guidelines because they involved a key area of need, they were written flexibly enough to allow individual schools to tailor them to their own circumstances, and, critically, because they respected schools’ individual autonomy in curriculum matters.

Phase two of the project is primarily concerned with capacity-building within medical schools to ensure the curriculum framework is embedded into the life of the medical school, rather than relying on individual champions or discrete and elective Indigenous health courses only.

The primary mechanism to support this has been the development of the LIME Network. LIME stands for Leaders in Indigenous Medical Education, and is an attempt to link medical educators and Indigenous health professionals across Australia and New Zealand. The network aims to support:

  • quality teaching and learning through a website and communications infrastructure that allows easier access to appropriate teaching and learning resources;

  • professional development through collegial sharing, learning and feedback; and

  • the professionalisation of Indigenous health as a discipline within its own right through the planned development of an e-journal.

Additionally, the project is currently developing a quality review process. This is not intended to duplicate the formal AMC accreditation processes, but to support medical schools in reviewing their progress between accreditation visits. For the quality review process, two components are proposed: an internal critical reflection tool which will ask schools to consider the key management, structural and coordination issues in designing and delivering an Indigenous health curriculum and Indigenous student recruitment and support initiatives; and an external preformatted template for schools to publicly report their progress in a collaborative and collegiate manner.

The LIME Connection, first held in Fremantle in 2005, is the biennial face-to-face meeting of the LIME Network. At these meetings, the capacity building, professional development, quality review and professionalisation functions of the Network are actualised. The LIME Connection II will be held in Sydney in September 2007, hosted by the University of New South Wales.

Assessment and accreditation of medical schools: standards and procedures (2006)

The AMC endorsed the CDAMS Indigenous health curriculum framework in 2004, with the full support of the deans of the Australian medical schools, and agreed to review its standards for accreditation of medical schools in the light of this decision.

The AMC has reviewed its accreditation standards through a consultative process, building on the strong support for the framework from the deans of medical schools, and in collaboration with the Australian Indigenous Doctors’ Association. Because AMC accreditation standards are used to assess New Zealand medical schools as well as Australian ones, the Medical Council of New Zealand also contributed to the review.

AMC accreditation standards cover the overall goals and objectives of medical education and the medical curriculum, and the institutional processes, settings and resources required to achieve these objectives. The review of AMC standards considered Indigenous health as a curriculum topic, as well as the processes, settings and resources that will lead to successful education in this area. For example, admission, recruitment and support of Australian Aboriginal and Torres Strait Islander or New Zealand Māori students and staff are addressed in the new standards.

The new standards, being used for AMC accreditations from January 2007, recognise:

Australia has special responsibilities to Aboriginal and Torres Strait Islander people, and New Zealand to Māori, and these responsibilities should be reflected throughout the medical education process.

Doctors work in a context in which the Indigenous peoples of Australia and New Zealand bear the burden of gross social, cultural and health inequity. Doctors must be aware of the impact of their own culture and cultural values on the delivery of services, historically and at present, and have knowledge of, respect for and sensitivity towards the cultural needs of Indigenous people.1

As occurs for all other AMC standards, medical schools preparing for AMC accreditation will describe their programs and processes and provide evidence of strengths, and plans to address weaknesses. The AMC recognises that these are new standards, and medical schools will be at different stages in their response to them. As is AMC process, the AMC will seek feedback from stakeholder organisations on the new standards, and will review them formally in 3–5 years.

Healthy futures: defining best practice in the recruitment and retention of Indigenous medical students (2005)

The Australian Indigenous Doctors’ Association’s Healthy futures report and framework aims to assist Australian medical schools, governments and other stakeholders in their efforts to support more Indigenous Australians in commencing and completing medical degrees.

The framework, which provides a foundation for individual institutional responses that are locally relevant, flexible and action oriented, has been recognised and supported by a number of leading forums, including the National Aboriginal and Torres Strait Islander Health Council, Medical Deans Australia and New Zealand, the Australian Medical Association, and the Royal Australasian College of Physicians.

In relation to medicine, the positive effects of Indigenous doctors for Indigenous people’s physical, emotional and cultural wellbeing have long been recognised. The report found that 102 Indigenous students were enrolled in medicine in 2004–05, accounting for 1.1% of the medical student population.3 Clearly, more Indigenous doctors are needed now.

The framework articulates three headline targets by 2010:

  • Australian medical schools will have established specific pathways into medicine for Indigenous Australians;

  • the CDAMS Indigenous health curriculum framework will be fully implemented by Australian medical schools; and

  • there will be 350 extra Indigenous students enrolled in medicine.3

Five principles underpin the framework:

  • All Australian medical schools and principal stakeholders have a social responsibility to articulate and implement their commitment to improving Indigenous health and education; and must

  • make the recruitment and retention of Indigenous medical students a priority for all staff and students and show leadership to the wider university community

  • ensure cultural safety and value and engage Indigenous people in medical school business

  • adopt strategies, initiate and coordinate partnerships that open pathways from early childhood through to specialty practice

  • ensure all strategies for Indigenous medical student recruitment and retention are comprehensive, long term, sustainable, well resourced, integrative and evaluated.3

Medical schools with the greatest number of Indigenous medical students have implemented a comprehensive approach. Best practice elements in the recruitment and retention of Indigenous medical students include personal contact and community engagement, university and school visits, Indigenous health support units, Indigenous staff, mentoring, curriculum, and cultural safety.

Strategies of success

Implementing Indigenous health in the medical curriculum, along with improving the recruitment and retention of Indigenous people in medicine, is primarily a task in organisational reform. At one level, it would be easy to develop a set of guidelines for success and think that was all that was required for curriculum, recruitment and retention reform.

Instead, the collective work above indicates that relationship-building (within and external to the medical school), capacity-building, staff development and training in cultural safety, the identification and commitment of realistic resources, and the ability of a medical school to reach out and form partnerships with local Indigenous communities, organisations and individuals are also critical in implementing quality teaching, learning, recruitment and retention initiatives.

This work is ongoing and must be planned and implemented strategically to ensure quality outcomes rather than token gestures. It will be best supported by collaborative review processes. The tools for planning and implementation are now available for schools, universities, governments and partners.

In this year, the 40th anniversary of the 1967 referendum (which removed from the Australian Constitution two references that discriminated against Indigenous peoples), the Australian Indigenous Doctors’ Association, Medical Deans Australia and New Zealand, and the AMC affirm our commitment to work together to achieve the shared goal of a better trained medical workforce in Indigenous health and more Aboriginal and Torres Strait Islander doctors. This represents a small but significant contribution toward eliminating the life expectancy gap between Indigenous and non-Indigenous Australians.

  • Tamara Mackean1
  • Romlie Mokak1
  • Allan Carmichael2
  • Gregory L Phillips3
  • David Prideaux4
  • Theanne R Walters5

  • 1 Australian Indigenous Doctors’ Association, Canberra, ACT.
  • 2 Faculty of Health Science, University of Tasmania, Hobart, TAS.
  • 3 Medical Deans Australia and New Zealand, Melbourne, VIC.
  • 4 Working Group, Review of Medical School Standards and Process, Adelaide, SA.
  • 5 Australian Medical Council, Canberra, ACT.

Correspondence: romlie@aida.org.au

Competing interests:

None identified.

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