Reconciliation and Diversity for Educators: The Medicine Wheel, Bloom’s Taxonomy, and CanMEDS Competencies

All parts of the wheel are important and depend on each other in the cycle of life; what affects one affects all, and the world cannot continue with missing parts. For this reason, the medicine wheel teaches that harmony, balance, and respect for all parts are needed to sustain life. —Elder Lillian Pitawanakwat, Ojibwe/Potawatomi1 In this special issue, Advances aims to bring attention to diversity, equity, and inclusion as part of the fabric of the modern world. As we planned the content, we noted news items about Indigenous Canadians and native Americans, including Pope Francis’ apology for the abuse of Indigenous children in Canadian Catholic residential schools.2 Through the Canadian Truth and Reconciliation Commission Calls to Action, Canada is now trying to correct the mistreatment of Indigenous peoples and commit to reconciliation.3 Inspired by these efforts and the mission of this special issue, your editors-in-chief have teamed up with educators from Queen’s University (Drs Amber Hastings-Truelove and Peggy DeJong) to write about reconciliation and diversity for skin and wound care educators. As educators, we often use Bloom and colleagues’ 1956 taxonomy (modified in 2001) to write objectives for teaching and learning programs. Skin and wound care programs have incorporated its trinity of knowledge, skills, and abilities as the basis for curriculum design. However, it is time to admit that this approach omits key aspects of what it means to be a “good” practitioner as the values of society and the profession move toward patient-centered, whole-person care. As part of this effort, there are many Western European-trained skin and wound care practitioners who can learn from Indigenous knowledge. There are many distinct versions of the medicine wheel across Indigenous nations, although not all Indigenous nations use a Medicine Wheel.1 There are some similarities across all versions in that they represent the alignment and interaction of the physical, emotional, mental, and spiritual aspects of each individual, as well as the need for balance. Based on a review of work from Indigenous scholars, and inspired by a presentation given by an Indigenous student (Charlene Leon), Marcella LaFever4 adapted the medicine wheel (Figure 1) for use as a teaching and learning framework that extends Bloom’s taxonomy, including the fourth “spiritual” quadrant that is currently lacking from learning outcomes. In LaFever’s adaptation, each of the four quadrants has five progressive descriptors leading to the combined attribute, “balance,” in the center.Figure 1: ADAPTED MEDICINE WHEELThis adapted medicine wheel and Bloom’s taxonomy have very similar steps for knowledge acquisition and processing. The descriptors in the intellectual quadrant, from the outer spoke to inner balance hub, mirror the first five of six levels of Bloom’s taxonomy (1956/2001 Bloom’s verbs in parenthesis): learn material (knowledge/remember), comprehend (comprehension/understand), apply (application/apply), analyze (analysis/analyze), and synthesize (synthesis/evaluate). The second quadrant of this adapted medicine wheel emphasizes the physical skills and attributes that move the learner through the perceiving, following, performing, adopting, and creating stages. The sixth classification of verbs in Bloom’s 1956 taxonomy was evaluation; in the 2001 revision, it mirrors the end of the physical skills medicine wheel quadrant by including creativity. We need to go beyond Bloom’s taxonomy for the third and fourth quadrants of the wheel and instead look to the seven competencies of CanMEDS,5 a framework for improving patient care designed by the Royal College of Physicians and Surgeons of Canada. The CanMEDS framework encompasses knowledge (Medical Expert, Scholar), working on a team (Communicator, Collaborator, Leader), and societal responsibility (Professional, Health Advocate). The Royal College defines a professional as “…committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.”5 The third quadrant of LaFever’s medicine wheel represents the emotional aspect of personal growth that can lead to a practitioner who can receive, respond, value, conceptualize, and internalize information to deliver quality healthcare for patients. One example of this is the University of Western Ontario Charter of Professional Responsibilities, which includes honesty to patients, patient confidentiality, and appropriate relations with patients, mirroring CanMEDS and the medicine wheel.6 As previously mentioned, the fourth quadrant features spiritual growth. This characteristic is different from religious commitment and features five spoke attributes (honoring, valued, connectedness, empowered, self-actualizing) that lead to a central “balance” hub. “Honoring” is learning that transcends narrow self-interest and is based on listening and observing patients/students. “Valued” highlights the use of the human spirit to build relationships. “Connectedness” is the ability to create a classroom or community culture that provides participants with a sense of belonging. “Empowered” refers to the ability to control one’s own life while also supporting others. “Self-actualizing” is to have an identity and contribute to the group of carers. Medicine wheels have several dimensions that are not included in Bloom’s taxonomy but that complement the CanMEDS roles for successful professional activities. To capture these values, we need to decolonize interprofessional education and expand the representation of the “spiritual domain” in our education programming. There is a need in Canada, the US, and beyond to improve care for persons with diabetes and foot ulcers (Figure 2).7,8 There is a disproportionately high incidence of foot ulcers and lower-limb amputations among Native Americans, Indigenous Canadians, and residents of isolated and remote areas of North America (Figure 3). Collaborative teaching and care models in the US and Canada are imperative to address this disparity.9,10 This can be achieved through in-person or blended education models, building trust, and resolving uncomfortable and difficult interpersonal relationships. We need to build transcultural awareness and collaboration to facilitate reconciliation. The medicine wheel could provide the transcultural foundation needed to bring diverse societies together.Figure 2: RATES OF MAJOR AMPUTATIONS RELATED TO DIABETES OR PERIPHERAL ARTERY DISEASE AMONG ONTARIO RESIDENTS 40 YEARS OR OLDER, 2007–2017Northern Ontario has three times the rate of diabetic foot amputation than the greater Toronto area.Reprinted from de Mestral C, Hussain MA, Austin PC, et al. Regional healthcare services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study. CMAJ Open 2020;8(4):E659-66.Figure 3: ADJUSTED SURVIVAL CURVE AFTER MAJOR LOWER-EXTREMITY AMPUTATION FOR FIRST NATIONS PEOPLE AND OTHERS IN ONTARIOLong-term survival after major lower extremity amputation is low for all people but even lower for First Nations people.Reprinted from Shah BR, Frymire E, Jacklin K, et al. Peripheral arterial disease in Ontario First Nations people with diabetes: a longitudinal population-based cohort study. CMAJ Open 2019;7(4):E700-5.

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