Research article
Open Access

Reforming Indigenous health in medical education: Medical school accreditation as a targeted policy initiative

Shaun Ewen[1], Odette Mazel[1], Jenny Barrett[1], Karin Oldfield[2], Theanne Walters[2]

Institution: 1. The University of Melbourne, 2. Australian Medical Council
Corresponding Author: Ms Odette Mazel ([email protected])
Categories: Medical Education (General), Curriculum Evaluation/Quality Assurance/Accreditation
Published Date: 23/09/2016

Abstract

Aim

The accreditation of medical schools is a key leadership role for the Australian Medical Council (AMC) and its counterparts in other jurisdictions. The aim of our research was to identify how the inclusion of Indigenous health in the accreditation standards has influenced the reporting of activity related to Indigenous health in medical schools.

Method

A bi-national review was conducted of the AMC reporting of Indigenous health education initiatives against the accreditation standards from January 2007 to December 2014. Also reviewed was the AMC monitoring of medical schools that occurs via schools’ Comprehensive Reports and Progress Reports.

Results

The study showed that the inclusion of Indigenous-specific standards leads to specific reporting on aspects related to Indigenous peoples in accreditation assessments and monitoring of medical school programs. Where areas in the accreditation standards did not include Indigenous-specific requirements, AMC reporting was unlikely to mention Indigenous matters. 

Conclusions

The continuing commitment by the AMC – and comparable bodies in other jurisdictions – to assessing medical education programs against specific Indigenous health standards, represents significant leadership in educating a medical workforce committed to ongoing improvement of Indigenous peoples’ health. 

Keywords: Indigenous health; Accreditation; Medical Education; Reform

Introduction

Targeted policies that address issues of health service delivery have recently been highlighted as an important element for improving health outcomes for Indigenous peoples (Anderson et al., 2016). For over a decade, the Australian Medical Council (AMC) has addressed this principle through systematic embedding of Indigenous health into the accreditation standards for all medical schools in Australia and New Zealand (Australian Medical Council, 2007).

Reflecting the global situation, Aboriginal and Torres Strait Islander and Māori peoples bear a greater burden of disease and have lower life-expectancy than their non-Indigenous counterparts (Anderson et al., 2016; Australian Bureau of Statistics and Australian Institute of Health and Welfare, 2012; New Zealand Ministry of Health, 2008). This situation results from a range of social, historical and economic factors, and can also be attributed to the inappropriate and/or poor quality care provided to Indigenous patients and a lack of accessible healthcare services (Anderson, 2008). The medical schools responsible for the early education of our doctors, therefore, have a critical role in developing a workforce that is cognisant of, and responsive to the needs of Indigenous people (Hays, 2002; Jones et al., 2010; Mazel & Anderson, 2011; Sullivan & Mittman, 2010).

Historically, Indigenous health has been inconsistently taught and poorly embedded in medical curricula (Garvey & Brown, 1999; Phillips, 2004; Medical Deans Australia and New Zealand, Australian Indigenous Doctors’ Association, 2012). Since the development of the Committee of Deans of Australian Medical Schools’ (CDAMS) Indigenous Health Curriculum Framework (Phillips, 2004a), a number of initiatives have worked to improve both the teaching and learning of Indigenous health in medical education and the recruitment and graduation of Aboriginal, Torres Strait Islander and Māori students (Haynes et al., 2013; Ewen et al., 2012; Mazel & Ewen, 2015). The AMC has embedded content stemming from the Indigenous Health Curriculum Framework in the medical school Standards for Accreditation in order to systematically influence the quality of Indigenous health education, and quantity of Indigenous medical graduates (Australian Medical Council, 2007; Mackean et al., 2007).

Globally, the AMC standards remain the only set of medical school accreditation standards that specifically address Indigenous peoples in colonial settings; others broadly address culturally diverse, minoritized or under-served populations (Liaison Committee on Medical Education, 2015; Committee on Accreditation of Canadian Medical Schools, 2015). The standards used from 2007 recognised that:

Australia has special responsibilities to Aboriginal and Torres Strait Islander people, and New Zealand to Māori, and these responsibilities should be reflected throughout the medical education process ... Doctors must be aware of the impact of their own culture and cultural values on the delivery of services, historically and at present, and have knowledge of, respect for and sensitivity towards the cultural needs of Indigenous people. (Australian Medical Council, 2007)

Aims

The aim of our research project was to identify how the inclusion of Indigenous health in the accreditation standards has influenced the reporting of activity related to Indigenous health in medical schools. We were interested to better understand the role of accreditation as one of the key targeted policy initiatives required to improve Indigenous health. 

Methods

A bi-national review was conducted of the AMC reporting of Indigenous health education initiatives against the accreditation standards from January 2007 to December 2014. Also reviewed was the AMC monitoring of medical schools that occurs via schools’ Comprehensive Reports and Progress Reports. This monitoring mechanism was established after the Health Practitioner Regulation National Law Act (2009) required the AMC to systematically set conditions for medical schools when accreditation standards aren’t met. The obligation to act on conditions within a set timeframe in order to maintain accreditation status represents an important step in increasing medical schools’ accountability against specific accreditation standards.

The results of our review provide important insights into both the reporting against accreditation standards relating to Indigenous health and the consequent monitoring. 

Results

Across the period of analysis (2007-2014), the AMC standards were revised in 2010 and again in 2012 (Australian Medical Council, 2010; Australian Medical Council, 2012). In each of the 2007 and 2010 Standards for Accreditation, from a total of 34 standards, eight explicitly referred to ‘Indigenous’, ‘Aboriginal’, ‘Torres Strait’ or ‘Māori’. In addition, alongside the standards, there were 13 (2007) and 14 (2010) Indigenous-specific accompanying notes. In the 2012 Standards, of the total 41 standards, there were again eight that were Indigenous-specific.

These Indigenous-specific standards are located in the areas of Educational Expertise (1.4), Interaction with the health sector (1.6), Staff resources (1.8), Mission (2.1), Curriculum structure, composition and duration (3.2 or 3.5), Student intake (7.1), Admission policy and selection (7.2), and Clinical teaching resources (8.3). As an example, standard 3.5 and 7.2.3 of 2012 state:

3.5 The medical program provides curriculum coverage of Indigenous Health (studies of the history, culture and health of the Indigenous peoples of Australia or New Zealand).

7.2.3 The medical education provider has specific admission, recruitment and retention policies for Aboriginal and Torres Strait Islander peoples and/or Maori.

A complete table showing the location of Indigenous health in the standards and accompanying notes is available electronically: see Appendix 1.

Table 1: Location of the Indigenous health comments in the 39 accreditation reports reviewed in this study

Table 1 shows that there were 282 Indigenous-specific comments from 39 accreditation reports across 19 schools. Table 1 demonstrates that the inclusion of Indigenous-specific standards influences the reporting of Indigenous health activity in medical schools (see comments in standards 1,2,3,7 and 8). It is clear in Table 1 that there is little reporting on matters related to Indigenous health where there is no Indigenous-specific standard (standards 4, 5, and 6).

Table 1 also points to an increase over time in the frequency of reporting on Indigenous health across six of eight standards, reflecting the effects of changes required under the Health Practitioner Regulation National Law Act (2009) explained above. We reviewed the AMC’s 64 monitoring reports and found 45 comments related to Indigenous health between July 2010 and December 2014. Once again, most of these comments were located in standards 1, 3, 7 and 8 with few comments against standards 4, 5 and 6.

Discussion and Conclusion

We undertook this study of the AMC reporting of Indigenous health activity in medical schools with an interest in the role of accreditation as a targeted policy initiative to improve the learning and teaching of Indigenous health in medical education. In reviewing accreditation reports on 19 medical schools in Australia and New Zealand over a period of eight years, our study found that where the accreditation body includes specific standards related to Indigenous health, there is an increased number of references to specific actions taken regarding Indigenous health in the medical program. Conversely, in standards where there are no specific requirements to report on Indigenous health, there were very few references to Indigenous health. In the AMC accreditation standards there is reference to Indigenous health in matters of governance, curriculum content and student intake, but little reference to Indigenous health in standards related to teaching and learning, student assessment and program evaluation. That pattern is also evident in the Comprehensive and Progress reports that are provided between official accreditation assessments. This pattern highlights the benefit of the inclusion of Indigenous-specific standards, and the need for further development of standards relating to those elements of medical school programs that relate to daily pedagogical practices in medical schools and health services – teaching, learning and student assessment.

The study shows that the inclusion of specific accreditation standards relating to Indigenous health in medical school programs is a significant milestone and can be seen as a driver of reform. Indigenous health is now embedded in the conversations about the performance of medical schools. This good news reflects the effort of both the AMC and the schools over a relatively brief period to address health equity in Australia and New Zealand. By acknowledging the unique position of Aboriginal and Torres Strait Islanders in Australia and Māori in New Zealand, these specific requirements show commitment to Indigenous health as distinct from the broad notions of ‘underrepresented’, ‘culturally diverse’ or ‘minority’ groups. It also demonstrates the development and maturation of the domain of Indigenous health in medical education. It particularly reflects the development of an Indigenous-led academic workforce that successfully negotiates curriculum and policy change in mostly conservative academic environments.

The AMC accreditation standards act as high level and targeted policy that supports the implementation of globally relevant and place-based activity to develop the next generation of the health and medical workforces.  Indigenous-specific accreditation reform provides an exemplar to international accreditation bodies. Further reform may be achieved through increasing the number of Indigenous health experts on accreditation teams, systematic training on Indigenous health particularly for non-Indigenous team members and inserting Indigenous-specific standards for learning, teaching and assessment. 

Take Home Messages

  • Where an accreditation body includes specific standards related to Indigenous health, there is an increased number of references to specific actions taken regarding Indigenous health in medical programs.
  • There is a need for further development of standards in Australia and New Zealand relating to those elements of medical school programs that relate to daily pedagogical practices in medical schools and health services – teaching, learning and student assessment. 

Notes On Contributors

Professor Shaun Ewen (DEd) is the Foundation Director of the Melbourne Poche Centre for Indigenous Health at the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne.

Ms Odette Mazel (LLM) is a Research Fellow and Program Manager for the Leaders in Indigenous Medical Education (LIME) Network in the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne.

Dr Jenny Barrett (DEd) is a Research Fellow at the Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne.

Ms Karin Oldfield (MRemoteIndigHlth) is Executive Officer, Director Services Australian Medical Council Limited.

Ms Theanne Walters (BA) is the Deputy Chief Executive Officer at the Australian Medical Council Limited.

Acknowledgements

The authors would like to thank Melinda Donevski and Jessica Buckley for their input and assistance.

The Leaders in Indigenous Medical Education (LIME) Network is a program of Medical Deans Australia and New Zealand, and funded by the Australian Government Department of Health.

Bibliography/References

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Appendices

Additional File 1: Location of Indigenous-specific standards in the AMC Standards for Accreditation 2007, 2010, 2012 [red font italic denotes Indigenous-specific standards or section of the Standard] [* denotes Accompanying Note]

 

Declarations

There are some conflicts of interest:
Authors Theanne Walters and Karin Oldfield are employees of the Australian Medical Council.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

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Trevor Gibbs - (22/02/2019) Panel Member Icon
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A very well written and referenced paper about an important issue. Despite its association with Australia and New Zealand, the approach and perhaps the findings from the paper are easily transferable to other countries with similar issues. The message that I would take home from this paper, in addition to those outlined by the authors, is that we need to recognise that accreditation is a dynamic process that needs to be reviewed and re-aligned over time , in keeping with our increasing approach to diversity and recognition of our difference approach to society and healthcare. More work is necessary or demanded in accreditation to match this dynamic perspective. Like my co-reviewer I would have liked a little more description in the methods section.
Barbara Jennings - (23/09/2016) Panel Member Icon
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Just as learning is driven by an assessment and its blueprint, so the use of accreditation by governing bodies could drive educational policy and curriculum development.
Ewen et al. present a very interesting and well-written article describing their survey of medical school curriculum reports for references to Indigenous health education (IHE). They have bench-marked these against the accreditation standards of their governing body, the Australian Medical Council (AMC).
The rationale for this study is clearly laid out in the well-referenced introduction. The argument for improved IHE is compelling on the grounds of the health inequalities described; and the framework that led to IHE criteria being embedded in the accreditation standards was a significant intervention in the reform process. The authors include a quotation from the IHE AMC standards in 2007 that emphasises their scope; which is more extensive than a consideration of general social determinants of health, and specifically address indigenous peoples in colonial settings. This study examines the impact of the policy intervention on medical education.
The Methods section lacks detail. I would like to see a comprehensive account of search terms and a summary of the data extraction methods, including the author-roles, as well as a categorical description of the survey method used.
In the Results section, parts of the study protocol become clearer. The authors show that the IHE references have (1) increased over time (in the decade that followed the inclusion of IHE within the accreditation standards of the AMC) and (2) there are few references to IHE in categories for which there are no Indigenous-specific accreditation standards, such as assessment. The authors pick this up as an important area for ongoing development in their Discussion and Conclusion. One additional point of merit is the sharing of collated data in the appendix that could contribute to further analysis and meta-analysis.
I really enjoyed reading this thought-provoking paper, and recommend it to anyone with an interest in public health; health inequalities; or curriculum development and accreditation.