Teaching clinicians about ‘unconscious bias’ can lead to improved health outcomes for Indigenous patients, say experts.
In April last year, the blind Aboriginal singer Gurrumul Yunupingu languished at the Royal Darwin hospital’s emergency rooms waiting to be treated while he bled internally for eight hours. Yunupingu’s manager and his private nurse had taken him to the hospital and had gone home confident that he would have immediate surgery to stop the bleeding.
Mark Grose, Yunupingu’s manager, later told ABC radio he believed the hospital delayed the life-saving treatment because staff made an assumption that Gurrumul’s liver damage was a result of heavy alcohol use, and not the chronic hepatitis B infection he had since he was a child.
While the hospital strongly refuted the claims, the case put a spotlight on the very real problem of discrimination against Indigenous patients in the health care system.
In a study of 7,000 Indigenous people (published in the International Journal for Equity in Health in 2013), one third (32.4%) of Indigenous patients said they were discriminated against in a medical setting most or all of the time. The discrimination included being “treated rudely, as if they were inferior or with disrespect; [and being] ignored, insulted, harassed, stereotyped or discriminated against”, the study’s researchers wrote.
Deakin University’s Dr Yin Paradies, an expert in the effects of racism on health, told The Lamp that numerous studies show discrimination is having real effects on Indigenous health.
“More than a dozen Australian studies have found disparities in medical care experienced by Indigenous patients, compared to non-Indigenous patients, after adjusting for a range of medically appropriate factors such as age, sex, marital status, place of residence, etc.
“These studies suggest that Indigenous patients are about a third less likely to receive the medical care that non-Indigenous patients receive for the same conditions.”
A disparity in care between Indigenous and non-Indigenous patients
The disparity in care in some areas of health care is even higher, Dr Paradies notes. “For example, Indigenous patients were three times less likely to receive kidney transplants in one study.”
Tackling discrimination against Indigenous patients in the health care system effectively requires “working across various parts of the system”, said Dr Paradies.
“From changing implicit and explicit attitudes and beliefs of healthcare providers and other hospital staff, to ensuring processes are in place to support Indigenous patients during their hospital journeys.
“In practice, this involves a range of cultural competency and anti-racism training, improving the quality of data on Indigenous patients in the system and having feedback mechanisms for Indigenous patients and their broader communities to ensure the health care system is free from discrimination and culturally appropriate.”
Writing for The Conversation news site, Gregory Phillips, Associate Professor, Research Fellow in Aboriginal Health, Baker IDI Heart & Diabetes Institute, concurred.
“Teaching health professionals about Indigenous health will effectively require teaching about unconscious bias and racism; one’s own culture, values and motivations. It requires training in ‘unlearning’ preconceptions; regular reflections on one’s own practices; as well as education about Aboriginal and Torres Strait Islander cultures,” he wrote.
With time and patience, attitudes change
Dr Phillips singled out a program at the University of Western Australia for mention. Researchers assessing the program found “a key shift in understanding and engagement occurred when fourth-year students on medical rotation were required to complete a comprehensive case history and discussion, including reflective comments, in relation to an Aboriginal person they have seen during that rotation”.
Dr Phillips noted that educators have found “patiently moving Australian medical students who were initially hostile to Aboriginal health curricula through their discomfort to reach the ‘a-ha’ moment, is a key teaching strategy in producing better prepared doctors”.
But Dr Phillips added the proviso that cultural awareness training will only be truly effective when systemic factors are also addressed: “workplace culture, policies, power, funding and criteria on which decisions are made”.
What is needed is something he describes as the “deeper transformational work of institutional decolonisation”. This means asking questions such as “how can power be shared? On whose terms are decisions made? Who owns institutions and services? Whose criteria are used to judge effectiveness?”
The bottom line, according to Dr Phillips, “is that Aboriginal and Torres Strait Islander definitions and measurement tools of success are more likely to contribute to producing better outcomes than those where unconscious bias and racism is implicit”.