Most GP Supervisors and Medical Educators who took part in this study confidently identified generic communication and consultation learning needs in the simulated consultation and the need for a respectful approach. Most, but not all, referred to learning needs around cultural issues, however this generally lacked detail. This was in contrast to sophisticated detail on the teaching needed to promote communication and consultation skills. Strikingly, few documented a need to assist the patient through national programs and community supports for Aboriginal and Torres Strait Islander people as a teaching priority.
It is well known that structural barriers to equitable health care exist. Governmental, organisational and societal barriers to provision of accessible and culturally competent care can prevent health practitioners from providing effective care even if they strive to be culturally competent as individuals
. However, the converse is also true – health practitioners need to assist their patients to access available health initiatives which are designed to tackle health disparities in order for such programs to be effective. In the context of our study, teaching about doctor-patient communication appeared to overshadow consideration of cultural awareness, barriers to accessing health care and the availability of the Closing the Gap program. This may reflect a lack of explicit consideration of the impact of the patient’s cultural background on their access to health care.
Training which promotes cultural competence can be undervalued throughout medical training, influenced by a hidden curriculum in which biomedical knowledge is the key to success
. Teaching and supervising communication and consultation skills as well as medical competence are core and explicit roles of the GP Supervisor and Medical Educator. However, they are not necessarily trained to reflect on the cultural competence of their Registrars or practiced at debriefing consultations which demonstrate learning needs in managing Aboriginal patients. Some GP Supervisors may feel they are not in a position to provide advice on Aboriginal cultural issues if they themselves are not an Aboriginal person with accepted skills in cultural education or mentorship. However, cultural competence is a key aim of GP training, and Aboriginal and Torres Strait Islander educators are not usually available to provide opportunistic advice or supervision within GP training practices outside the IHTP network at the present time. Thus, many GP Supervisors will be directly faced with addressing this key training issue when Registrars are in need of guidance and during assessment of Registrar performance.
Many participants documented feedback which would promote patient-centred care for the patient, without further highlighting culture or the patient’s Aboriginality. Patient-centred care is a well-recognised principle of general practice, in which the patient perspective is respected and the GP and patient find common ground to achieve more effective healthcare and better health outcomes
. Culturally competent care is aligned to patient-centred care in terms of a respectful approach and a shared commitment to healthcare which is effective and acceptable to individuals in their context. However, it goes beyond this to explicit recognition of the power differential that exists between the dominant culture and other peoples and an active commitment to equity of care
[5, 6]. Patient-centred care and cultural competence are both important to improve cross-cultural communication, patient satisfaction and health outcomes
The professional uncertainty and disempowerment clinicians can feel when dealing with cultural diversity has been previously identified
. Family physicians may be reluctant to mention or consider culture within consultations for risk of stereotyping patients
. Cultural competence is a complex area which encompasses more than acknowledgement of ethnicity, and having some cultural awareness does not ensure health care providers have adequate understanding
. Training which aims to promote cultural awareness and cultural competence can instead risk promoting detrimental conceptualisations of those from non-dominant cultures as ‘different’ , thus further perpetuating bias
. However fear of stereotyping can lead to a failure to acknowledge the impact of a person’s sociocultural background on their health (including facing racism in life and in healthcare) and a lack of self-reflection as to the healthcare provider’s own cultural assumptions
[3, 4]. The approach where healthcare providers and services aim to provide the same care to all clients regardless of culture and ethnicity has been termed ‘cultural blindness’ and, although often well intentioned, favours the clients most assimilated into the dominant culture and can lead to healthcare providers overlooking opportunities to reduce health disparities
[4, 5]. This may have been an attitude influencing our research findings. The Supervisor focus on patient-centred care and on avoiding stereotyping rather than on a cultural competence approach to the consultation may explain why so little teaching was planned on cultural awareness and overcoming barriers to care, despite supportive systems being available.
Teaching is likely to be enhanced by specifically encouraging reflection on culture, both as it applies within the consultation and also in a societal context. The impact of culture on health and GP management when the patient is from a non-dominant culture, including the widening of power differentials within the doctor-patient relationship and barriers to care related to racism and unequal access to health services, deserves explicit consideration. Perceived preparedness to provide cross-cultural care was found in a US study of junior doctors to be related to the amount of training received and access to role models they considered good at providing cross-cultural care
. Supervisors with higher cultural competence have been found to deliver increased supervision in cultural competence to their supervisees
Despite the complexities of what is necessarily lifelong learning for cultural competence, advice on how to avoid communication misunderstandings and provide health services for Aboriginal patients can support GPs to work more effectively with Aboriginal people
[19, 29]. Experience working with Aboriginal patients is likely to increase the cultural competence of Registrars, but requires supervision that identifies cultural errors, encourages active consideration of the role of culture within consultations with Aboriginal people and guides the Registrar to learn more about Aboriginal health, including how to access supports to overcome health disparities. Though best supported by Aboriginal Cultural Educators and Mentors, cultural competence should be considered at every teaching and assessment opportunity in GP training, and falls within the domain of teaching provided by GP Supervisors when Registrars consult with Aboriginal patients in their training placements.
Our study has several limitations. The simulated consultation was specifically designed to illustrate cultural errors and omissions that could be made by non-Indigenous GPs when providing health care for Aboriginal patients, and was authorised as appropriate by the Aboriginal Cultural Mentors and organisations involved in its development. However, poor communication skills may have overwhelmed the lack of cultural competence demonstrated in the consultation.
Collected data on planned teaching comprised only that which GP Supervisors and Medical Educators documented they would intend to deliver when guiding the Registrar and may not have reflected the actual teaching they would give the Registrar, nor the level of detail which would eventuate. Exploration of communication issues and promotion of a patient-centred approach may have brought out other issues relating to culture or Aboriginal health for discussion. However, the coding categories we used in the content analysis were intentionally broad and required simply a mention of culture or Aboriginality to be seen as signifying the Supervisor would provide teaching around cultural competence and Aboriginal health, thus attempting to allow for these limitations. Furthermore, the cross cultural nature of the workshop and the purpose of the study were not hidden from participants. They were aware it was an activity to examine their skills and confidence in assessing Registrar consultations with Aboriginal patients, so the finding that a significant proportion of participants did not document a plan which referred to the patient’s Aboriginality or culture may suggest a lack of consideration of relevant cultural issues.
In seeking to investigate teaching priorities for Registrars consulting with Aboriginal patients, we chose to examine the explicit consideration of culture and Aboriginal health, an evident simplification of a complex area. Appropriate communication and medical management are also an integral part of an effective cross cultural medical encounter.