Approaches to incorporating indigenous health into the Canadian medical school curriculum

In Canada, there are significant health status disparities that exist between Indigenous and non-Indigenous populations. Cultural competency among physicians is a probable way to address this large gap. The purpose of this article is to discuss the current challenges that exist in designing and delivering an Indigenous health curriculum in Canadian undergraduate medical school programs. This article will highlight the importance of cultural competency for improving the health outcomes of Indigenous populations. Additionally, it will explore potential approaches for better integration of Indigenous health into medical curricula. introduction The Indigenous peoples of Canada represent a subset of the population with worse health outcomes than their non-Indigenous counterpart,1,2 demonstrating the prevalence of health disparities that exist among them.3 In response to the growing awareness of the differences in health status between Indigenous and non-Indigenous people, more undergraduate medical school programs are incorporating curricula surrounding Indigenous health and history. We present current challenges that exist in developing and delivering Indigenous health curricula in Canadian medical schools. Additionally, we will explore potential approaches to better train undergraduate medical students in Indigenous cultural competency. First, we discuss the current mandates in place that emphasize the importance of cultural competency in Canadian medical school curricula. undergraduate medical schools In 2000, the Liaison Committee on Medical Education (LCME) set standards to ensure that all accredited Canadian medical schools would include mandatory cultural diversity education in the undergraduate curriculum.4,5 These standards aim to enhance the understanding of how health and illness are perceived across diverse cultural and belief systems.4,5 These standards also emphasize the need for medical students to be aware of their own biases, as well as the importance of providing culturally competent care.4,5 canadian family medicine residency programs Under the Canadian Family Medicine guidelines (College of Family Physician of Canada [CFPC]), Family Medicine residents and physicians are required to address the health needs of Indigenous populations.6 In 2012, the CFPC released new guidelines, the Triple C Competency-based Curriculum, which makes it mandatory for Family Medicine residents to incorporate Indigenous health issues in the curricula.6 The Triple C curriculum encourages the implementation of a curriculum that incorporates comprehensive care and education, ensures continuity of education and patient care, and emphasizes family medicine centered care. This curriculum encourages social accountability of medical schools to address “priority health concerns” among Indigenous populations through approaches like cultural competency education.6 current challenges Despite the guidelines that are currently in place, only 67% of Canadian medical schools provide some education on multicultural issues.5 Therefore, the incorporation of cultural diversity education and training in undergraduate medical curriculum remains insufficient.5 Additionally, there is lack of uniformity with regard to the concepts, structure, and formats taught in cultural diversity education, indicating an inadequate and standardized approach.5 Furthermore, cultural diversity education is more commonly provided as an elective during pre-clinical years, and rarely in clinical courses.5 Lastly, there are huge variations on the length of time allocated to cultural diversity education and training across different medical schools.5 While some medical schools provide comprehensive learning opportunities through field placements, community visits, and clinical rotations, others dedicate only few hours to teaching culturally competent care.5 Overall, there is lack of clarity and consensus on the definition of cultural diversity and what it encompasses, in terms of the pedagogical methods, content, format and structure needed for medical school curriculum.5 This lack of clarity, even among the licensing and governing bodies, creates confusion on what should be taught in medical schools.5 Additionally, there are challenges among students themselves, whose perception of the importance of cultural competence education is low.5 Lastly, the lack of evaluation strategies to assess medical students’ cultural competence, or more broadly, to assess the effectiveness of existing cultural competence educational models, is highly problematic.5 potential approaches for better integration of indigenous health in medical curricula Due to the existence of governing policies that continue to disempower Indigenous people, colonization is a critical determinant of health for Indigenous populations.7 As the mounting health concerns of Indigenous communities are largely perpetuated by historical attitude and structures that are ever-present today, chang-


introduction
The Indigenous peoples of Canada represent a subset of the population with worse health outcomes than their non-Indigenous counterpart, 1,2 demonstrating the prevalence of health disparities that exist among them. 3In response to the growing awareness of the differences in health status between Indigenous and non-Indigenous people, more undergraduate medical school programs are incorporating curricula surrounding Indigenous health and history.We present current challenges that exist in developing and delivering Indigenous health curricula in Canadian medical schools.Additionally, we will explore potential approaches to better train undergraduate medical students in Indigenous cultural competency.
First, we discuss the current mandates in place that emphasize the importance of cultural competency in Canadian medical school curricula.

undergraduate medical schools
In 2000, the Liaison Committee on Medical Education (LCME) set standards to ensure that all accredited Canadian medical schools would include mandatory cultural diversity education in the undergraduate curriculum. 4,5These standards aim to enhance the understanding of how health and illness are perceived across diverse cultural and belief systems. 4,5These standards also emphasize the need for medical students to be aware of their own biases, as well as the importance of providing culturally competent care. 4,5nadian family medicine residency programs Under the Canadian Family Medicine guidelines (College of Family Physician of Canada [CFPC]), Family Medicine residents and physicians are required to address the health needs of Indigenous populations. 6In 2012, the CFPC released new guidelines, the Triple C Competency-based Curriculum, which makes it mandatory for Family Medicine residents to incorporate Indigenous health issues in the curricula. 6The Triple C curriculum encourages the implementation of a curriculum that incorporates comprehensive care and education, ensures continuity of education and patient care, and emphasizes family medicine centered care.This curriculum encourages social accountability of medical schools to address "priority health concerns" among Indigenous populations through approaches like cultural competency education. 6

current challenges
Despite the guidelines that are currently in place, only 67% of Canadian medical schools provide some education on multicultural issues. 5Therefore, the incorporation of cultural diversity education and training in undergraduate medical curriculum remains insufficient. 5Additionally, there is lack of uniformity with regard to the concepts, structure, and formats taught in cultural diversity education, indicating an inadequate and standardized approach. 5Furthermore, cultural diversity education is more commonly provided as an elective during pre-clinical years, and rarely in clinical courses. 5Lastly, there are huge variations on the length of time allocated to cultural diversity education and training across different medical schools. 5While some medical schools provide comprehensive learning opportunities through field placements, community visits, and clinical rotations, others dedicate only few hours to teaching culturally competent care. 5verall, there is lack of clarity and consensus on the definition of cultural diversity and what it encompasses, in terms of the pedagogical methods, content, format and structure needed for medical school curriculum. 5This lack of clarity, even among the licensing and governing bodies, creates confusion on what should be taught in medical schools. 5Additionally, there are challenges among students themselves, whose perception of the importance of cultural competence education is low. 5Lastly, the lack of evaluation strategies to assess medical students' cultural competence, or more broadly, to assess the effectiveness of existing cultural competence educational models, is highly problematic. 5

potential approaches for better integration of indigenous health in medical curricula
Due to the existence of governing policies that continue to disempower Indigenous people, colonization is a critical determinant of health for Indigenous populations. 7As the mounting health concerns of Indigenous communities are largely perpetuated by historical attitude and structures that are ever-present today, chang-feature article es need to be made to address the ways that these inequities are continually recreated within the healthcare system.Ensuring that this knowledge is instilled among undergraduate medical students is one approach to foster the growth in numbers of doctors with Indigenous cultural competency.
In response to the inadequate coverage of Indigenous health in the medical school curriculum, advocates for Indigenous communities have advised medical schools on how to expand teaching time and resources dedicated to Indigenous health.To ensure that students acquire Indigenous cultural competency, medical school curricula need to allocate adequate teaching resources and time to Indigenous health.An understanding and acknowledgement of the residual effects of colonialism can help ensure that medical professionals can more effectively address the health inequities that disproportionately affect Indigenous communities. 8Medical students need to recognize the historical structures rooted in colonialism that continue to produce health disparities for Indigenous peoples, such as the Indian Act, the reservation system, and discriminatory practices in employment, education, and housing.In addition, medical students need to understand how their personal privileges can affect clinical practice, and how ignorance to the social contexts of Indigenous patients and families can lead to inappropriate recommendations for care. 8There are three key questions that need to be taken into consideration when incorporating post-colonial perspectives into Canadian healthcare training programs: (i) what content relating to post-colonialism and health should be taught; (ii) how this content should be taught, including teaching strategies and who should teach the content, and; (iii) why this content is being taught. 8Collaboration with Indigenous partners to answer these three questions is key in developing teaching strategies and training programs. 8arious medical schools have taken novel approaches to enhance the knowledge, cultural competency, and commitment of medical students to Indigenous health.In particular, the incorporation of experiential learning has been shown to be effective for the Indigenous health curriculum. 9During years 1 and 2, the Northern Ontario School of Medicine (NOSM) incorporates clinical learning experiences with case-based modules that focus on Indigenous health topics. 10Additionally, medical students at NOSM engage in an Indigenous cultural immersion experience, where they continue their medical education through sessions in Indigenous communities, while also focusing on cultural activities and community learning. 10Currently, the success of this program can only be gauged in relation to the thoroughness of Indigenous health topics discussed in the curriculum and through the sustained commitment of Indigenous community partners. 10Similar cultural immersion programs implemented in New Zealand demonstrate significant shifts in students' self-perceptions of their commitment and preparedness to improve Indigenous health. 9dditionally, arts-based teaching programs are often incorporated into medical school curricula through various mediums, such as literature, drama, visual arts, and music. 11In one arts-based teaching program, medical students who attended workshops that explored healthcare issues worked to develop their professional skills in communication, self-presentation, and observation. 11Overall, students found that this arts-based teaching program was a valuable contribution to their education, with group work facilitating opportunities to learn new skills and engage with people of different backgrounds. 11When incorporating Indigenous health into the medical curriculum, arts-based teaching programs may be potential avenues to explore in order to increase student engagement.
However, it is also important to acknowledge the challenges with developing and delivering an Indigenous health curriculum in medical schools.Traditionally, medical schools are constrained by discipline and lecture-based courses and it can be challenging to find the appropriate space in the curriculum to accommodate these changes. 10Another significant challenge is being aware of the stereotypes and misconceptions that are associated with Indigenous people, and ensuring that these views are not reinforced by the curriculum. 10Lastly, there are challenges in evaluating the impact of such programs and ongoing efforts to track specific educational outcomes need to be further pursued. 10

conclusion
The divide in health status between Indigenous and non-Indigenous populations is well-documented in the current literature. 1,2ultural competency is frequently suggested as a probable way to address this large gap. 6Experiential learning allows students to be fully immersed in Indigenous health care.This immersion allows them to better understand and witness first-hand the hardships and barriers that are currently present within the healthcare system. 10upplementary to this, arts-based learning is very engaging and creates a safe space for the students to learn and examine multiple perspectives on the problems that Indigenous populations encounter in healthcare. 11espite how promising these teaching strategies may be, there are challenges to curriculum implementation, including reinforcement of stereotypes and incorporation into predominantly didactic curriculum structures. 10In spite of these challenges, it is important to improve the Indigenous health curriculum in medical schools to foster the growth of doctors who advocate for Indigenous populations.Most importantly, educational content relating to post-colonial health should be better integrated into the medical school curriculum to ensure the provision of equitable healthcare services by culturally competent care providers.