A brief experience for medical students in a remote Aboriginal community

The health of the Australian population has improved since the 1980s. However, the gap in mortality between Aboriginal and Torres Strait Islander peoples and the rest of the population has not changed and is currently estimated to be 11–20 years.¹ There is a projected life expectancy gap of 9.5–10.6 years for those born in 2010–12.²

A shortage of primary healthcare professionals in Aboriginal primary care is one of the obstacles in accessing healthcare.^3,4 Achieving health equity is challenging, not only because of workforce deficits, finances and remoteness, but also because of service provider attitudes and practice, ineffective communication, poor cultural understanding and racism.⁵ The negative stereotype of Aboriginal and Torres Strait Islander peoples encourages ‘victim blaming’ and ‘further marginalisation’.⁶ This translates to their healthcare experiences, which results in disenfranchisement, neglect and paternalism.⁷ Such attitudes are also commonly displayed in the education environment.

The Australian Medical Council’s (AMC’s) accreditation requires all Australian medical schools to provide cultural awareness training specifically for Aboriginal and Torres Strait Islander peoples’ health as part of their core curriculum, while meeting the Committee of Deans of Australian Medical Schools’ (CDAMs’) Indigenous Health Curriculum Framework.^8,9

It has been postulated that ‘for a medical school to produce physicians who are sensitive to and competent working with diverse communities requires a balance between attention to difference, attention to self, and attention to power relations’.¹⁰ Opportunities to practise resilience, and for problem solving, taking initiative, cross-cultural communication, boundary setting, and recognition of one’s own capabilities can usually be gained only ‘in the field’ through individual ‘exposure’, rather than ‘passive acquisition of knowledge’.^10–14 Equipping medical students with critically reflective skills is essential for developing the future workforce and advocates required to address priorities and inequities in Aboriginal and Torres Strait Islander peoples’ health.¹⁵

Exposing students to a variety of Aboriginal health settings also allows consideration for future career opportunities and establishes a means for recruiting and retaining doctors in Aboriginal and Torres Strait Islander communities.^7,16,17

The aim of this project was to research the utility of exposing medical students to life in a remote Aboriginal community over a short, 2-day visit.

Methods

Medical students from ‘Insight’ at the University of Adelaide and the ‘Health in Human Rights Group’ at Flinders University (student-run global health groups) asked JB if they could attend monthly medical trips to remote Aboriginal communities. Purposeful sampling using a snowballing technique was used to select participants for this study from the two groups.¹⁸ The trips were not advertised and were known through ‘word of mouth’ from previous students in the global health groups. All students joined as volunteers, signed up as student members of Avant (a medical defence organisation), acknowledged that they travelled at their own risk and read an information sheet about the trip. They were involved in cultural awareness training as part of their university studies. Some received financial assistance from the Rural Doctors Workforce Agency, Insight, Health in Human Rights Group, the Adelaide University Rural Health Alliance or the Medical Specialist Outreach Assistance Fund. These organisations only required feedback on the number of students involved in the project.

About 250 Aboriginal people live in the remote location, which is approximately 200 km from the nearest rural town. JB has been working there for the past 8 years and has a good relationship with the Aboriginal people and the staff. She discussed the opportunity for students to gain insight into life in a remote community with community leaders, the Health Board and the other stakeholders, and all were enthusiastic about the project. The staff at the community health service, school, playgroup, in administration and local shops defined the list of activities for the visits (Box 1). The Board of the health service was kept informed of the process and supported the trips. The Aboriginal health workers provided cultural orientation.

Students were chaperoned by a health professional or trusted community member at all times. They slept in the same accommodation as the fly-in fly-out health professionals.

Students completed two questionnaires prior to their travel. The first questionnaire collected demographic parameters on participants. The second explored previous experiences in Aboriginal communities, medical course preparation for the trip and future interest in Aboriginal health. Answers were graded on a 4-point Likert scale ranging from 0 = not at all, through to 4 = a great deal. In addition to the two questionnaires, each student wrote short narratives of at least 250 words under the headings ‘cultural’, ‘personal’ and ‘medical’, to capture trip expectations before and outcomes after the trip.

Staff and community members involved with students were also asked to complete a questionnaire on the beneficial, and possible detrimental, aspects of the trip for the students, health service and community.

This research utilised interpretative phenomenological analysis to explore how students gave meaning to their experience.¹⁹ Inductive thematic analysis was conducted using ‘prevalence’ (frequency) and ‘keyness’ (meaningfulness) to search for patterns, and subsequently organise and understand students’ experiences.²⁰ The themes emerged were discussed and refined by the researchers individually and as a team.

Ethics approval was obtained from the University of Adelaide (H-019‑2009), Flinders University (4425) and the Aboriginal Health Council of South Australia Ethics Committee. Permission was granted by the Aboriginal Community Controlled Board of the Health Service. All participants provided written informed consent.

Results

Twenty-three students participated in the study between January 2009 and January 2012. Three completed the questionnaires but did not attach their demographic information. Two completed the ‘expectation’ questions but did not complete a reflection of the trip. All questionnaires were included in the thematic analysis.

Of those who completed the demographic question, there were equal numbers of males and females; three were under the age of 20; 13 were aged 21–25 and four were older than 25; six were from the University of Adelaide and 14 from Flinders University; eight were first-year students, six were second-year, five were third-year, one was fourth-year and one fifth-year; 14 grew up in an urban environment and six in a rural area; 12 were born in Australia and eight overseas. There was mixed previous experience in Aboriginal and Torres Strait Islander health, a perceived lack of preparation for this experience by the medical course and a strong interest in further work or experiences in Aboriginal communities (Table 1).

Students participated in a range of activities including assisting with supervising children at the swimming pool, assisting with major medical emergencies, undertaking research on scabies, pharmacy audits, helping to pack up a ‘sorry camp’ after a funeral, seeing a wombat skinned, doing the ‘ear run’ at the school (looking in the ears of all the children, especially to find chronic suppurative otitis media), delivering food to old people and setting up a football carnival.

Similar themes emerged on analysis of the narratives under the headings of personal, medical and cultural experiences. The research team decided to use the same thematic headings for the expectations and outcomes analyses (Box 2). This allowed for before and after comparison and interpretation of the themes in the context of the literature review and university-based learning. The themes were surprisingly similar across the range of year level, university, gender and country of birth.

For those who had previous experience in remote communities, the medical expectations matched more closely with the outcomes. However, the cultural and personal experiences were still profound and students mentioned how different each community was. The differences between urban and remote communities were emphasised by those who had previously been in an urban Aboriginal health service.

Cultural

‘No amount of reading, lectures or tutorials could have prepared me for this experience.’

Cultural themes are summarised in Table 2. Students were surprised at the children’s ability to organise and look after themselves, the importance of school in growth and development, the strong family and community focus, and people’s passion about their Aboriginal heritage.

Others described feeling confronted by the obvious poverty, lack of shoes, different gender roles, large numbers of unaccompanied children, packs of camp dogs, overcrowded housing and low levels of personal hygiene.

Many recognised the respect the community had for their Elders and their role in guiding community decision making, but could also see that they were few in numbers.

Students wanted to participate in community life, rather than as tourists, but were anxious about breaking cultural protocols. Individual goals included finding out how community members feel about being in an isolated community, how they feel about doctors and how the family helps to raise children.

For most of the participants, the trip was a cultural eye-opener, and they acknowledged that no amount of reading or lectures could have prepared them for it. They witnessed the resilience and self-determination in the strong family and community focus, in contrast to the individualistic focus in the city, but also commented that ‘despite many similarities within the community, my impression was that there are diverse attitudes and goals (eg towards family, spirituality, duty, health, education, etc)’.

Students hoped to gain a better understanding of the interplay between day-to-day activities, lifestyle choices and consequent health problems. They also wanted to learn about traditional practices, social problems, cultural barriers to healthcare and the competing priorities of family and community rituals.

Many felt confronted by the difficulties that people had in looking after themselves and their families, and in accessing adequate healthcare.

Medical

‘You go on a ward round, chat to your friends, do a tutorial and have coffee and nothing changes. You go to [this community] and you can see what you can really do.’

Medical themes are summarised in Table 3. All students knew they were likely to see an increased burden of illness, more complex illnesses, more illnesses associated with lifestyle issues and social determinants of health, and health problems than they would in urban areas. One said, ‘I hope to see some “real” medicine – the type of medicine that has application the world over to save sight, hearing and the devastation of losing a child or a parent.’

Despite their prior learning, none of the students reported feeling prepared for their experience. The social determinants of health and public health were far removed from most students’ personal experience. Many aimed to gain insights into the obstacles to health and wellbeing, and the different strengths and challenges to health.

Students reflected on their experience as a valuable glimpse into the social, cultural, economic and geographical issues that affect people’s health status (eg showering, nose blowing, brushing teeth, education, housing, the swimming pool and nutrition). One said, ‘My eyes were opened to the complexity of the interaction between medical conditions and the community’s remoteness, the Aboriginal culture, the limited resources (staff, medical supplies and technology), politics and socioeconomic difficulties.’

Another said, ‘Medical and healthcare efforts can only go as far as the infrastructure supporting it. No matter how great the health service is, if the government doesn’t spend money on increasing living standards, the community will still face the same health issues.’

Students experienced the challenges faced by staff in an environment designed to concentrate on acute medicine. There is often little time for health promotion, chronic disease or preventive health.

Students anticipated gaining new skills in communication after this experience. Afterwards, they felt they had a better grasp of how imperative it is to take a patient’s cultural practices into consideration when planning healthcare management.

Most students expressed surprise at how politics plays a major role in healthcare. Doctors must be active advocates for the community in order to be effective. Students participated in staff meetings, research, coordination of evacuations, discussions during lunch time, and clinical consultations and screening. They appreciated the importance of research and its benefits, and the business side of the clinic.

The burden of bureaucracy was evident to many and they saw the frustrations of the staff in dealing with issues such as organising transport for appointments and finding out what medications were changed while a patient was in hospital.

The students also witnessed the enjoyment and commitment of the staff, and described how ‘the Aboriginal health workers were fantastically dedicated people trying to improve the lives of their fellow Aboriginal people’ and the importance of Aboriginal health workers in liaising between clinic staff and community.

Students were encouraged by being with ‘doctors who are enthusiastic about Aboriginal health and yet have so many other outside interests. I was so impressed that they still wanted to further their study’. They also saw how it is ‘important for health professionals to look after their own physical and psychological wellbeing, to establish appropriate boundaries and to recognise and heed warning signs’.

Personal

‘Before I went on this trip I was a princess. I’m not a princess anymore.’

Personal themes are summarised in Table 4. Before the trip, all of the students were well aware that they would be ‘stretched beyond my usual boundaries, out of my comfort zone, and challenged intellectually and personally’.

On reflection, after the trip, various emotions were expressed, from shocked, confronted and angry at the situation people were living in, to ‘surprise at how much I enjoyed the experience and dismayed at how quickly the time disappeared’. None of the students had any doubts about their safety or concerns that they would be expected to do anything beyond their capabilities. One said he was ‘utterly exhausted’ and another found the ‘odours confronting’. For most, the main difficulties revolved around ‘how different everything was to my preconceptions and images’.

Students wrote about wanting to ‘grow as a person’, and ‘to learn about another culture’ and ‘more about myself’. Many told stories of the unexpected acceptance and openness from the community. For some, the contrast with their own standard of living gave them a strong appreciation of their own privilege. Some gained insights such as ‘how to work towards being a more effective person, to take more initiative, to be more resourceful, to be a better problem-solver and to be good at what I do’.

For many, the trip challenged their views of bureaucracy, politicians and the media on remote Aboriginal communities. The students were particularly concerned about the health and future prospects of children in the community, stating that they ‘could see great potential in the young people who, clearly, had dealt with significant adversity in their lives’.

Most reported that the trip ‘inspired me to do work in Aboriginal communities in the future’. Conversely, several found the experience too confronting:

‘Though I felt compassion and was distraught about the standard of living, 
I wasn’t sure I had it in me to work tirelessly with few thanks from the people who I was working for.’

Health service and community opinions

Community members and staff were enthusiastic about having the students as part of the team. The staff were very grateful for the assistance they received from the students. Community members enjoyed their role as teachers and emphasised the importance of the next generation of doctors having a well informed understanding of life and health issues in remote communities.

Discussion

The degree to which each university involves students in an Aboriginal and Torres Strait Islander environment varies widely. Involvement ranges from a formal presentation in an urban clinic to immersion in a remote environment for several months with off-site supervision. However, many students are never given the opportunity to have close contact with Aboriginal and Torres Strait Islander peoples or remote communities. Their learning is based mostly in the classroom.

Most of the literature on medical students’ placements in Aboriginal health services involves urban or rural health services, or longer periods in remote areas. While there are many similarities between urban and remote Aboriginal health services, there are some significant differences.

As examined in this study, exposing medical students to a remote Aboriginal community deepens their understanding of the cultural and social determinants of health through ‘authentic, community-based early learning experience’.^21–23 This allows them to develop relationships with Aboriginal people and offer a more ‘balanced and open-minded view of Aboriginal cultures’,²⁴ and an appreciation that ‘culture and health requires an approach that acknowledges the fluidity, diversity, strength and vitality of Aboriginal cultures’.^6,25

For many students, most of their teaching on Aboriginal health takes a ‘deficit’ approach rather than positive interactions, as seen from those who participated in this study.^14,17 The cultural ‘otherness’ that might be generated in lectures is balanced with personal encounters that can lead to a sense of social responsibility.²²

Evidence-based medicine for remote Aboriginal communities can be learned in the classroom. However, experience is the only way to learn how diseases interact with each other, the impact of bureaucracy, the social determinants of health, the importance of advocacy, and cultural safety in practice.^14,21 As illustrated by these students’ comments, ‘getting students out of urban hospitals and into places where Aboriginal people live is crucial to creating shifts in awareness and knowledge in relation to Aboriginal health’.²¹

Self-reflection has become an important tool in most medical schools, as it is acknowledged as an essential aspect of being a culturally safe doctor. Encouraging students to challenge their ‘own attitudes, assumptions and thinking’ in the context of a remote community is a much more effective way to learn.²⁵ The personal relationships students built during this short visit were deeply meaningful. Students found that learning from the patients themselves and reflecting on these interactions were far more valuable strategies than being given a recipe for how to ‘deal’ with Aboriginal people.

These face-to-face cultural experiences are obviously of immense value and are likely to remain embedded in the students’ future relationships with Aboriginal people, and their future career choices.

Limitations

The students who participated in this study were self-selected and, therefore, not ‘typical’ of all students. Many had previous experience in Aboriginal and Torres Strait Islander communities. Even so, the trip had a profound effect on them, which suggests that students with less experience or interest would at least be similarly affected.

JB has a longstanding relationship with this remote community and was able to vouch for the students as part of her team. As such, the students were accepted more easily by the staff and community members, and were trusted to be involved in a variety of activities. It may not be possible to replicate this elsewhere.

JB holds academic positions at both the University of Adelaide and Flinders University, and was able to liaise with student groups to develop this program. This also may not be replicated in all universities.

Students were part of the fly-in fly-out team. Not all remote communities have a similar team or ground staff who will have the resources to assist with such a program. Remote communities cannot accommodate every medical student in Australia to take part in such a trip.

Conclusion

Even though a 2-day trip to a remote Aboriginal community is short, it was sufficient to allow students to reflect on the medical, cultural and personal aspects of cross-cultural competence. This cannot be learned in lectures or tutorials. Such an experience is likely to assist students in making a more informed decision about working in Aboriginal health in the future, in gaining valuable cultural and personal skills, and in being patient-centred practitioners. The effects of this trip were formative for most students.

We recommend that medical students should be encouraged to spend time in remote Aboriginal communities, and that Australian medical schools consider facilitating similar placements.

Authors

Jill Benson AM, MBBS, DCH, FACPsychMed, MPH, Director, Health in Human Diversity Unit, Discipline of General Practice, University of Adelaide; Medical Director, Kakarrara Wilurrara Health Alliance, Adelaide, SA. jill.benson@adelaide.edu.au

Courtney Ryder, BSc, BEng (Biomed) (Hons), Indigenous Health Lecturer, Poche Centre for Indigenous Health & Well-Being, Flinders Health Care and Workforce Innovation, School of Medicine, Faculty of Medicine, Nursing and Health Sciences, Flinders University, Bedford Park, SA

Madeleine Gill MBBS, Resident Medical Officer, Royal Adelaide Hospital, Clinical Associate Lecturer, University of Adelaide, Adelaide, SA

Anna Balabanski MBBS, Resident Medical Officer, Royal Adelaide Hospital, Clinical Associate Lecturer, University of Adelaide, Adelaide, SA

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.