Table 1.

The E4E Care Framework for re-centring the relationship

KEY CONCEPTS OF RE-CENTRING THE RELATIONSHIP	RECOMMENDATIONS
*Colonization^ and inequity within health care** Unequal treatment The health system, as a social and cultural construction of Canadian society, is perceived (and experienced) by patients as an institution that supports and facilitates ongoing colonization and control over Indigenous people through racist, oppressive, and exclusionary practices Power and authority Indigenous patients’ heightened awareness of and reaction to the power and authority mismatch within the doctor-patient relationship arises from historical injustices that undermined individual autonomy and from negative experiences of authority from residential schooling	Addressing colonization and inequity within health care: Identify and critically reflect on your own stereotypes, assumptions, and biases Negotiate an agreeable power balance Identify and explore moments of discord, paying particular attention to patient resistance, hesitation, and withdrawal Refrain from an authoritarian approach that relies on language rooted in oppression and racism
Culture informs relationships^† Reciprocity Creating an authentic relationship involves sharing key social contexts in order to build rapport and trust Process and pace Providing appropriate care requires attention to issues of process and pace to allow for exploration of and reflection on the patient’s experiences Connectedness Patient experience of diabetes and diabetes care is embedded in relationships, family dynamics, and community supports and structures	Reflecting on how culture informs relationships: Critically reflect on your own concepts of health and diabetes care and potential assumptions about Indigenous perspectives Reflect on professional distance and objectivity, and in the spirit of reciprocity, consider sharing aspects about yourself to build trust Adjust your pace when exploring the patient’s world Connect and work to foster positive relationships at the individual, family, and community levels

KEY CONCEPTS OF RE-CENTRING THE RELATIONSHIP

RECOMMENDATIONS

Colonization^* and inequity within health care
Unequal treatment

The health system, as a social and cultural construction of Canadian society, is perceived (and experienced) by patients as an institution that supports and facilitates ongoing colonization and control over Indigenous people through racist, oppressive, and exclusionary practices

Power and authority

Indigenous patients’ heightened awareness of and reaction to the power and authority mismatch within the doctor-patient relationship arises from historical injustices that undermined individual autonomy and from negative experiences of authority from residential schooling

Addressing colonization and inequity within health care:

Identify and critically reflect on your own stereotypes, assumptions, and biases
Negotiate an agreeable power balance
Identify and explore moments of discord, paying particular attention to patient resistance, hesitation, and withdrawal
Refrain from an authoritarian approach that relies on language rooted in oppression and racism

Culture informs relationships^†
Reciprocity

Creating an authentic relationship involves sharing key social contexts in order to build rapport and trust

Process and pace

Providing appropriate care requires attention to issues of process and pace to allow for exploration of and reflection on the patient’s experiences

Connectedness

Patient experience of diabetes and diabetes care is embedded in relationships, family dynamics, and community supports and structures

Reflecting on how culture informs relationships:

Critically reflect on your own concepts of health and diabetes care and potential assumptions about Indigenous perspectives
Reflect on professional distance and objectivity, and in the spirit of reciprocity, consider sharing aspects about yourself to build trust
Adjust your pace when exploring the patient’s world
Connect and work to foster positive relationships at the individual, family, and community levels

E4E—Educating for Equity.
↵* Colonization is a traumatic historical episode and an ongoing process resulting in uneven power relations between Indigenous people and Canadian society. It is the mechanism by which inequality shapes diabetes and health care outcomes for Indigenous people. Participants attributed racism and societal exclusion of Indigenous people to ongoing processes of colonization. Approaches that establish physician authority, expertise, status, and professional distance can negatively affect clinical relationships in the context of these historical relationships, social exclusion, and trauma.
↵† Cultural perspectives inform how patients experience diabetes and engage with health care, as well as how physicians approach care. Patient resistance might reflect incongruence and the need for physician reflection.