Doctor–patient communications in the Aboriginal community: Towards the development of educational programs
Introduction
The health of the indigenous Aboriginal people of Canada (including First Nations, Inuit and Métis) is worse than that of the general population on virtually every measure of health and every health condition [1], [2]; a similar situation is found with other native populations in westernized regions such as the USA and Australasia. Reasons for health disparities are multifactoral and include historical loss of cultural and political institutions, colonialism, racism, and residential school experiences that have had multigenerational impacts. For example, the mental health of Aboriginal people in Canada has been linked to the history of colonialism and government interventions, including the residential school system, out-adoption and centralized bureaucratic control [3]. In a public opinion poll of First Nations people in 2002, 68% identified the residential school experience and 63% the loss of land and culture as contributing to poorer health [4]. The need to improve health care through culturally relevant, community-based initiatives has been recognized and a variety of strategies have been proposed, including the specific training of health professionals to deliver culturally appropriate care. Although most Canadian medical schools have initiatives to increase the number of Aboriginal doctors [5], currently only 0.3% of Canadian doctors are Aboriginal [6]. The majority of medical care for Aboriginal people will therefore continue to be delivered by non-Aboriginal physicians.
The quality of the doctor–patient relationship and communication affects health. Good communication has been demonstrated to lead to good health outcomes [7], including emotional health, symptom resolution, function, physiologic measures and pain control [8], and increases patient satisfaction, recall and understanding of information, and adherence to treatment [9], [10]. Poor communication can lead to adverse outcomes, including non-adherence to treatment and medical error [11], as well as patient complaints and claims for malpractice [12]. Communication behaviours found to be positively associated with health outcomes include empathy, reassurance and support, various patient-centred questioning techniques, encounter length, history taking, explanations, positive reinforcement, humour, psychosocial talk, time in health education and information sharing, friendliness, courtesy and summarization and clarification [13]. Physicians have poorer communication with minority patients that lead to health disparities [14]. Specific problems in miscommunication and misunderstandings between health care providers and Aboriginal people have been documented in Canada [15], the USA [16] and Australia [17]. Kaplan [18] has identified three primary areas where the different cultural backgrounds of North American Indians and the white medical profession cause communication difficulties: language use, worldview and different understandings of the history of Indian–white relations. Studies have demonstrated the limitations of the medical model [19] and the need to consider political and cultural factors that lie outside the immediate context of the medical encounter and beyond the control of either physician or patient [20].
Various guidelines for health professionals are available. For example, Ellerby et al. [21] identify seven essential qualities of ethical approaches to communication and caregiving involving Aboriginal people: respect the individual; practice conscious communication; use interpreters; involve the family; recognize alternative approaches to truth telling; practice non-interference; allow for Aboriginal medicine. Other guidelines deal with a particular type of communication such as counseling [22] or with the culture of specific First Nations communities [23].
How do non-native physicians navigate through these complexities to provide culturally sensitive care? Kelly and Brown [24] documented a process of acculturation that occurred for non-native physicians working in First Nations communities. The evolutionary communication process involved several variables including: awareness of the different styles of verbal and non-verbal communication strategies (e.g. speaking less and avoiding eye-contact), increased understanding of the connection between illness and community context, and over time, a greater respect for the culture within First Nations communities. As this progression occurred physicians became more aware of the need for specific behaviours required to communicate with patients. While their results provided important departure points for doctors seeking to better understand interactions with patients in a Canadian First Nations environment, the authors conceded that to understand communication dynamics better, the opinions of both participants in the interaction, namely physicians and patients, should be included. They also concluded that the process of successful physician acculturation and development of culturally appropriate communication strategies was difficult and took years to develop.
This study builds upon the work of Kelly and Brown by asking Aboriginal patients to provide perspectives on their interactions with physicians, with a focus on communication processes. The goal of this qualitative exploratory study was to understand the complexity of doctor–patient communication in Aboriginal communities in order to design educational interventions to assist medical students to develop culturally appropriate relationships with Aboriginal patients.
Section snippets
Methods
Data were collected through semi-structured interviews and focus groups with Aboriginal people. Focus groups were chosen to promote a less threatening setting for participants in community settings, consistent with the literature that suggests that focus groups are best used when a power differential exists between participants and decision makers, and when a gap exists between professionals and their target audiences [25].
Participants were recruited through key contacts at the University of
Results
The most frequently coded themes in the interviews and focus groups that related to positive and negative encounters between Aboriginal people and physicians were: history, trust and time. They were often coded simultaneously suggesting an interaction between them.
Discussion
Based on the data, we propose a model for the relationship between the major themes of history, trust and time that affect the doctor–patient relationship (Fig. 1a). Depending on the initial interactions with their physician, Aboriginal patients place different weights on these three factors when forming perceptions of their relationship with their physician.
For patients who relate feelings of fear and distrust of physicians we suggest that the relationship looks like that in Fig. 1b. For
Acknowledgements
The project was funded by a grant from the UBC Faculty of Medicine Special Populations Fund. We thank James Andrew and Roslyn Ing for information, advice and assistance with making community contacts. We thank Stephanie Calvert for assistance with recruitment and data collection, and Andrew Laing for assistance with data analysis and interpretation.
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