“Each time I saw the doctor, he would say: ‘You have to pay attention or you are going to die from this.’ It made me sad … I was sad.”
(Roy and Facteau, 2005)
Reflective exercise 1
Communicating with Indigenous patients
The general principles of communication between physician and patient are no different with Indigenous patients; the patient-centred model applies. However, many non-Indigenous physicians feel unsuccessful and/or uncomfortable when interviewing Indigenous patients. In spite of good intentions, things do not seem to go well. In many cases, this is not due to a language barrier since Indigenous people often speak English. If they do not, then working with an interpreter is necessary, as discussed in the “Medical communication skills module.” The challenges in communicating with Indigenous patients relate primarily to two issues:
- The history of the relationship between Indigenous peoples and the government, including health services
- Cultural differences between Indigenous and western worldviews
How these two issues impact upon the physician-patient relationship is explored in the following article, which you might want to read before doing “Reflective exercise 1”:
After watching the first scene between Clyde and Dr. Nyrit, answer the following questions. There is nothing to submit for this exercise.
- What is Dr. Nyrit’s worldview of diabetes?
- What is Clyde’s worldview of diabetes?
- Do you think Dr. Nyrit understands Clyde’s worldview of diabetes? Why or why not?
- Do you think Clyde understands Dr. Nyrit’s worldview of diabetes? Why or why not?
- What can Dr. Nyrit do to find common ground?
Commentary on reflective exercise 1
One way of thinking about a physician-patient conversation is to divide it into three parts or functions (M. Lipkin, 1996):
- Information gathering
- Building rapport
- Counselling or management
Interviewers often make the mistake of jumping to the third function before thoroughly exploring the first two. In such cases, the advice or counselling is much less likely to be followed. The patient’s story has not been heard and a therapeutic relationship has not yet been established. The mistake is compounded when the patient returns and is labeled “non-compliant” by the physician, who feels they gave clear and reasonable instructions.
- How much information does Dr. Nyrit obtain from Clyde?
- She is obviously eager to help him. Does she build rapport?
- How does she handle the characteristic presentation of an Aboriginal patient, as described in the literature?
Clear transmission by the expert does not mean that the message has been understood, accepted or can be acted upon by the patient. The analogy to the teacher-learner dialogue is apt. All of us have listened to what the teacher feels is a clear lecture, but which is not understood by the less expert student. In both cases, the person receiving the message is blamed for the poor outcome.
We will visit this issue again in “Reflective exercise 2” when we discuss behaviour modification in more detail.
Before continuing with the case, listen to the Indigenous elder describing her view of the physician-patient relationship.
Knowledge check 1
The meaning of health and the burden of illness
Health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. (Declaration of Alma-Ata, WHO, 1978.)
Check only one answer unless instructed otherwise.
According to data from the last National Household Survey published in 2011, 1,400,685 people had an Indigenous identity, representing 4.3% of the total Canadian population. Indigenous people accounted for 3.8 per cent of the population enumerated in the 2006 Census, 3.3 per cent in the 2001 Census and 2.8 per cent in the 1996 Census.
For additional information, visit the Statistics Canada website.
Census data from reserves is often incomplete because of the lack of participation; however, an estimate can be made based on location information. Respondents are not required to answer questions on their ethnic origin, therefore it is possible that Indigenous people living off-reserve are not accounted for, even if they did respond.
The Indigenous population is much younger than the rest of Canada. The birth rate is higher, and at the other end of life, they die younger. While children are seen as the hope for the future, and an important part of Indigenous self-determination, education is a major challenge on many reserves. Keeping children in school, or having to send older children away for high school, are frequent problems.
In 2011, children under the age of 14 represented 28 per cent of the total Indigenous population and 7 per cent of all children in Canada. Indigenous people between 15 and 24 years old represented 18.2 per cent of the total Indigenous population and 5.9 per cent of all youth in Canada. In the non-Indigenous population, youth represent 12.9 per cent of Canada’s total population.
For more information, visit the Statistics Canada website.
The residential schools have been described as the lowest point in the history of relations between First Nations people and the government. Although they began to be phased out earlier, the last school was closed only in 1996, and the settlement for survivors was even more recently completed in 2007. The “Sixties Scoop” is a related episode of government action in which Aboriginal children were removed from their homes and placed in foster care, or even adopted, against the wishes of their parents.
Indigenous children represent 40 per cent of the children in child welfare out-of-home care in Canada, according to a 2003 study.
Blackstock, C. (2003). First Nations child and family services: Restoring peace and harmony in First Nations communities. In K. Kufedlt and B. McKenzie (Eds.), Child Welfare: Connecting Research Policy and Practice. 331-342. Waterloo, Ontario: Wilfred Laurier University Press.
While all of these choices are higher in Indigenous youth than the general population, suicide leads the list, especially in males.
[Translation] “Injuries and poisoning were the main causes of death for people between the ages of 1 and 44. Accidental injury was the main cause of death of children under the age of 10. Suicide and self-mutilation were the main causes of death for young adults and adults up to the age of 44. For people 45 years old and up, problems with the circulatory system were the leading cause of death. These statistics are similar to those of the general Canadian population.”
University of Ottawa website, La société, l’individu et la médecine. Updated September 12, 2014.
The prevalence of type 2 diabetes varies considerably among Canadian Indigneous people, depending on geography, length of contact with Europeans and other factors. Most overall estimates are of two to three times the non-Indigenous rate.
The Indian Act decreed that if a First Nations woman married a white man, or moved off the reserve, she lost her status — essentially became a “non-person.” At the same time, non-First Nations women who married First Nations men were granted status. In both cases, this legislation often resulted in the separation of families and great difficulties for those who no longer had status. This statute was changed only in 1985, with bill C-31: An Act to Amend the Indian Act. It restored status to a variety of First Nation people, mostly women.
Increased fat is felt to be the major dietary factor in the “epidemic” of diabetes in Indigenous peoples. It is a major contributor to the metabolic syndrome.