Indigenous Health in Postgraduate Medical Education: Pathways for Enhancing Anti-racism Literacy and Praxis for Advanced Trainees

Racism is detrimental to health; it widens gaps in health inequities by marginalizing specific populations and sustaining structures that perpetuate harm. This results in social fragmentation that hampers the capacity of affected communities to achieve well-being. Racial hierarchies tend to characterize aspirations for equity as unachievable, using the complexity of the need to shift institutions, attitudes, and whole cultures to undermine expectations that equity be a core component and not simply an added benefit of a just society. This doctoral thesis aims to mitigate the impact of racism on health disparities experienced by Indigenous peoples in Canada by addressing unequal treatment in health systems through the advanced training of healthcare professionals, specifically medical residents across specialties. It is aligned with the Truth and Reconciliation Commission of Canada’s (TRC) Call to Action #24, which emphasizes the expansion of “skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism” for all health professionals in Canada. Decolonial and anti-racist education are promising pathways explored here for advancing healthcare equity, as they place historical, political, and social experiences at the centre of the learning process and objectives. These pedagogies promote the active involvement of learners, an approach that would seem to suit advanced medical trainees whose programs usually involve practice-based experiential learning mentored by established physicians. Such training also offers the possibility for adult learning approaches known to favour behaviour change, such as critical self-reflection over time. However, medical residency and fellowship training often involve limited exposure to the lived realities of Indigenous patients and, in turn, limited direct feedback or guidance from these. This complicates possibilities for integrating historical, political, and social components of Indigenous-focused anti-racism. This thesis presents a largely qualitative body of work that approaches these dilemmas in three parts. It begins by eliciting guidance from semi-structured interviews conducted in one Canadian province with Indigenous individuals who have accumulated experiences in health systems and health professional training (n=12). It then draws on a document analysis of formal Indigenous training in post-graduate medical education (PGME) across Canada. Finally, it returns to perspectives on health professional learning among advanced medical trainees through semi-structured interviews with non-Indigenous residency preceptors (n=19) and residents (n=14) across specialties. These sources offer insight into Indigenous guidance for PGME training in Indigenous health and anti-racism in Canada, current approaches across medical schools, and needs and possibilities for growing Indigenous-focused anti-racism learning from mentors and mentees within PGME programs. This work emphasizes that addressing anti-Indigenous racism in healthcare is essential for achieving Indigenous health equity. Integrating insights from 45 interviews and the scanning of 1179 curricular documents related to PGME with a close review of 46 containing any form of Indigenous content, this work offers a preliminary index of specialty-specific Indigenous health and anti-racism content as a potential starting point for more refined curricular development. An important implication of this work is greater clarity around how training may incorporate unique dilemmas faced in distinct medical fields and the cultural, social, and geopolitical diversity of Indigenous peoples in Canada.

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