What integrating traditional Indigenous care into medical practice really means
Much needs to be unlearned when it comes to providing culturally safe care to Indigenous populations, a recent Doctors of BCwebinar highlighted, but progress is possible if conventional and Indigenous care is integrated.
Foremost among the misapprehensions of conventionally trained physicians is the notion that patients will automatically and immediately trust a doctor simply based on their status.
“I've learned this humbly over the years. You have to earn the respect of people, it's not granted to you based on your degrees,” said Dr. David Tu, a family physician who presented along with Elder Bruce Robinson, both from Kílala Lelum Health and Wellness Cooperative in Vancouver’s Downtown Eastside.
The webinar, “Integrating Indigenous Cultural Safety into Care: Practical Advice for Physicians,” was hosted by the Joint Collaborative Committees of Doctors BC and moderated by Dr. Terri Aldred, Medical Director for Primary Care for First Nations Health Authority.
Participants heard how to put Indigenous cultural safety and humility into practice, what a typical office visit looks like, how to partner with local Elders and traditional healers, and how to navigate creating meaningful relationships with local Indigenous communities.
10-minute encounters
“We learned through our medical training that we can walk into a room with a stranger we just met, barely introduce ourselves and say, ‘What are you here for today?’ and expect to have intimate details of their personal life shared,” said Dr. Tu.“One unlearning is that physicians need to accept that you cannot expect to have that trust with the majority of Indigenous patients. We have to unlearn that pattern we constructed of our 10-minute encounters and accept that we are going to have to earn people’s trust. And we have to be willing to share some of ourselves if we’re going to expect people to share in return.”
Dr. Tu and Elder Bruce were joined by Dr. Michael Dumont, an Anishinaabe from Shawanaga First Nationand medical director for Lu’ma Medical Centre, also in the Downtown Eastside.
Kílala Lelum(Butterfly House) and Lu’ma (New Beginnings) emerged from a 2014 pilot program that researched and explored the impacts of providing access to Indigenous Elders as part of routine primary care within Vancouver’s Downtown Eastside. The pilot demonstrated that Indigenous healing and Western medicine, when partnered, can improve health outcomes.
One-on-one mentorship
The primary care model for both centres is a combination of patient medical home and leadership from local Indigenous Elders and knowledge keepers. The clinics are Indigenous-focused and Elder-led, and family physicians are provided with one-on-one mentorship by Elders, resulting in a partnership or “two-eyed seeing” of care.
“There was a feeling there weren’t safe spaces in Vancouver for the Indigenous community,” said Dr. Dumont. “Our goal very much has been to bring together Indigenous physicians, allied health practitioners, elders and traditional healers to build a safe space for Indigenous community members living in the city to access care.”
Dr. Dumont presented Lu’ma’s eight strategies in serving the largely Indigenous patient population, which can be complex, he said, with a higher-than-average proportion of patients in government care or who have diabetes, addictions, mental health issues, PTSD, Sixties Scoop trauma, and autoimmune and rheumatological conditions.
The Lu’ma strategies, which are similar to those woven into Kílala Lelum,are:
- Cultural safety: geographic safety, family-friendly, access to sacred medicine, Indigenous hiring practices, warm spaces, sacred spaces, and spaces for smudging, singing and drums.
- Authentic engagement: 30-minute visits are standard, and the emphasis is on relationship-building.
“As part of the onboarding process with our new practitioners, we really speak to and encourage careful attention at the beginning of that relationship. You get one chance to make a first impression,” said Dr. Dumont. “For so many people, they've had traumatic experiences and experienced racism and discrimination—or they just haven't felt heard. So, we call it a welcome visit as opposed to an intake visit. We focus on physical, mental, emotional, and spiritual health using trauma-informed language.”
- Upstream solutions: Social navigators are employed by the clinics to act as advocates for patients and their families, with a focus on supporting family preservation and the health of children and youth.
- Opening doors of opportunity: The clinic connects patients to community programs, services and skills training.
- E-health data development: Robust data is collected with longitudinal measurement of wellness and illness indicators. “The better we understand Indigenous patient health and track longitudinal progress with our model, the better we can demonstrate the need for resources to build capacity to meet community needs.”
- Excellence in Western medicine onsite: Every effort is made to provide complete care onsite, including prenatal care with an Indigenous midwifery team, on-site bloodwork collection and specialists, with a pharmacy to open soon.
“We provide as many services as possible for our patients in-house so they're not having to go to other sites and centres. A lot of creating that safety within our space is also so the people will follow through. Getting blood work, for example, may seem fairly simple but if you've had a horrible experience at a lab, dealing with extra layers of things like racism and discrimination and many other things going on in your life it's really helpful when you have an RN onsite—somebody that you've seen before and trust— to collect your blood.”
- Culture as treatment / medicine: Traditional healers and helpers assist patients in re-connecting to cultural practices, activities and teachings (sweat lodge drumming, traditional medicine workshops, regalia-making workshops, traditional foods programs, etc.) “There is scientific literature to show that traditional healing practice practices are associated with lower anxiety and depression scores and a reduction in tertiary care utilization. These are medicines in every sense of the word.”
- Permanency: The focus on establishing long-term and secure healthcare relationships means a focus on staff retention. “It's really important when you’re building a therapeutic relationship with somebody, especially in a primary care space to be reliable and accessible. So, we need to look after our staff, make it a safe space to work and build their careers.”
Read: New outreach centre for youth aims to save lives in Vancouver's Downtown Eastside
Bringing in the spirit
Many Indigenous people in the city have been disconnected from traditional knowledge and cultural knowledge, said Elder Bruce.
“What the Elders bring is that the spiritual part of the person. You know, a lot of times that's neglected in the medical system,” he said. “We bring in the humanity. I don't just work with our members (patients), I also help the staff so that they can continue on doing all the good work they need to do.”
Elder Bruce recommends physicians ask patients what they want and what they need. “They know,” he said, and you will learn a lot if you really listen. In the end, he said, respect, going both ways, is the foundation of culturally safe care. “We all have to work together. If we don’t nothing will change. We can be that medicine for each other.”
Read: Racism partly to blame for unequal healthcare provided to Indigenous women: PHAC study