Indigenous Health

No single support strategy explains Newcastle University’s strength, over two decades, in attracting Aboriginal and Torres Strait Islander students to its medical program and supporting them through to graduation. It is a combination of strategies and, most importantly, people.

There are currently 76 Aboriginal and Torres Strait Islander students enrolled in Newcastle University’s Joint Medical Program with University of New England [1], which means that almost one in five of Australia’s Indigenous medical students are studying in this program – a leading position amongst Australia’s 22 medical schools.

“The first 100 Aboriginal and Torres Strait Islander medical students graduated from Newcastle over a period of about 20 years [2] but I think we’ll reach the second hundred within the next five years,” says Professor Peter O’Mara, Director of Newcastle University’s Thurru Indigenous Health Unit, School of Medicine and Public Health. “We have a really strong network and all of our current undergraduates have absolutely got what it takes to get through. The things that might stop them are things we can’t predict or prevent; we can only support them through it.”

Medicine is a demanding course for any student but can be especially challenging for Aboriginal and Torres Strait Islander students from communities which still endure the long-term negative impacts of colonisation and dispossession. Newcastle nurtures the strength and resilience developed by its Indigenous students despite these negative impacts.

For Peter O’Mara, the idea to study medicine only came to him when listening to a talk by a young Newcastle medical graduate, Sandra Eades, who later became Australia’s first Aboriginal Dean of Medicine. Becoming a doctor wasn’t something that was ever in Peter’s sights – or a probable outcome for a former Newcastle mines worker – until he heard Sandra speak. Decades later, Peter, like Sandra, has inspired many Aboriginal and Torres Strait Islander people to study medicine.

Building Critical Mass

Sustained recruitment is the first objective for any medical school seeking to graduate more Indigenous doctors. It builds a critical mass [3] of Indigenous students, who form an expanding network of peer support for each other and become role models for new students once they have launched their medical careers. Attracting a sustained critical mass of Indigenous students has been a fundamental part of Newcastle’s success over time.

Newcastle and New England’s Joint Medical Program approaches recruitment with a high Indigenous admissions target that is set well above parity [4] with Australia’s Indigenous population. It reserves up to 10 per cent of domestic medical student places (up to 17 places) each year for Aboriginal and Torres Strait Islander students, which is a strategic response to the very low proportion of Aboriginal and Torres Strait Island doctors in the national medical workforce. [5] Annual commencement numbers do not always reach 10 per cent and conversely, the target can be exceeded in a particular year, depending on the applicants.

Newcastle and New England each run a bridging program for Aboriginal and Torres Strait Islander people wanting to attend their university. This resonates with research showing the importance of culturally appropriate pre-entry programs for both recruitment and retention of Indigenous students. [6]

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Each year the University of Newcastle’s Joint Medical Program reserves up to 10 per cent of domestic medical student places for Aboriginal and Torres Strait Islander students.
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Targeted recruitment to the medical program is managed by the Thurru Indigenous Health Unit, whose staff travel around the state to engage with Aboriginal communities.

“The success of our program has been built on reputation and grown through word-of-mouth,” says Thurru doctor and academic John Towney. “We go out and talk to people face to face, and they see us and find out who we are. We are all from areas within or around the footprint of the medical program, so we’re travelling and meeting people on an equal level, we’re not waiting for people to come to us to look at the university. You can’t really sit on campus and engage with people who live 500 miles away.”

One strand of this decentralised approach is taking a one-week Indigenous admissions program to multiple locations across regional NSW for applicants wanting to ‘test run’ what it would be like to study medicine.  Another is relationship-building with a wide range of Aboriginal-run health and community organisations where Thurru places medical students studying the Aboriginal Health curriculum. This builds positive word-of-mouth about the medical program amongst the staff and clients of these Indigenous-run organisations.

Tough Admissions Process

Accompanying the Joint Medical Program’s high 10 per cent Indigenous recruitment target is an intensive, one-week program for admission through the Aboriginal and Torres Strait Islander entry pathway. Peter O’Mara believes this Miroma Bunbilla Program has been a critical success factor for Newcastle.

“When I started working here at the university I felt that we were setting people up for failure. There was an academic mark requirement and we had an interview process, and I felt that some people were being brought on board to the medical program when it wasn’t the right time in their lives or they didn’t have enough science behind them, these sorts of things,” he says.

“Whether it’s uncle, aunty, cousin or sister, whoever becomes a medical student, there’s quite an air of excitement in the community that one of our own is going to be a doctor. But if they get broken and go back feeling a failure, that is generalised to the rest of the community – ‘Oh that Western medicine, it’s not for us. We can’t do that university stuff’. What we’ve done to stop that cycle occurring is develop a program where there are a lot more hoops to jump through – it’s really hard to get in but if you do, the chances of getting through are really high.”

The year before Newcastle piloted the Miroma Bunbilla Program, 50 per cent of its Aboriginal and Torres Strait Islander medical student intake failed the first semester. In the year the pilot was introduced, only one student failed one subject at the end of first semester. “Things just changed dramatically,” Peter says.
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The Miroma Bunbilla program is structured to give participants an insight into what studying medicine will be like, with tutorials and problem-based learning, and participants required to hit learning targets and complete all activities to qualify. It also has a cultural component, giving applicants the chance to connect with Indigenous patients.

In some cases a program participant will choose not to continue with their application for medicine. The Thurru team see this as a part of a successful recruitment strategy and support these applicants in developing an alternative study pathway.

Progressing through to Graduation

After recruitment, the next critical objective for medical schools is supporting Indigenous students to progress through to graduation. Commencement of Aboriginal and Torres Strait Islander students in Australian medical programs has grown in recent years to reflect population parity, but graduation levels have yet to catch up. [7] Targeted and strategic support is required to empower Aboriginal and Torres Strait Islander students to negotiate the additional challenges many face in studying medicine.

Within the culturally safe space of the Thurru Indigenous Health Unit is a hardworking  Indigenous team of eight full and part-time academic staff and one administrative staff. They spend a week with Aboriginal and Torres Strait Islander applicants for the Miroma Bunbilla program, then continue to provide academic and pastoral support to successful applicants from enrolment through to graduation. A good proportion of these staff are Newcastle medical graduates themselves, from areas across the footprint of the Joint Medical Program. Together they form the crucial ‘people’ component of the Newcastle success formula. The value of having a relatively large number of Indigenous academic staff, and the positive impact of these staff on Indigenous students, cannot be overestimated.

“Our students feel safe, with our support, to be pushed outside their comfort zone,” says Darren Nolan, lecturer and communications lead with Thurru. “I think that’s part of the reason we have higher retention and graduation rates. We will back students and support them when otherwise they might think, ‘this is just too hard for me’ or ‘I can’t do it’. We say, ‘we know you can do it; we’ll support you’.”

The motivation of Thurru staff to work long hours, travel around the state and push hard to get the students through to graduation comes from a determination to achieve better health outcomes for Aboriginal and Torres Strait Islander communities.

“The students are part of our community and we view them as an extension of our community,” says Karen Nicholls, a doctor and academic with Thurru. “Their getting through the course reflects on us and there’s a lot more at stake because if we don’t have the Indigenous doctors out there, we are not going to have the impact on the health system that we need to close the gap. Every single student that gets through has the potential to make such a huge difference.”
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“When you treat an Indigenous patient and they have never come across an Indigenous doctor before, it is the most humbling and inspiring thing to experience – for both the patient and the doctor. There is nothing like it.”
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Like most of the Thurru team, Karen could be making a more money elsewhere but chooses to work on expanding the Aboriginal and Torres Strait Islander health workforce: “When you treat an Indigenous patient and they have never come across an Indigenous doctor before, it is the most humbling and inspiring thing to experience – for both the patient and the doctor. There is nothing like it.”

Multiple Support Measures

Putting in place one or two isolated support measures – like a scholarship or Indigenous entry pathway – is not enough to nurture and retain all Indigenous students recruited to a medical program. The medical schools which graduate the highest number of Aboriginal and Torres Strait Islander students, like Newcastle, implement a spectrum of best practice measures [8] including: culturally appropriate recruitment and selection processes, orientation and pre-entry programs, a supportive and enabling school culture, Indigenous academics, mentoring and tutoring programs, flexible delivery of content, accessible Indigenous Student Support Centre; social and financial support, and ‘leaving the university door open’ for students who leave before graduation to return.

Peter O’Mara believes that leadership at university level has been another critical enabler at Newcastle: “I have seen a number of universities around the country that have good people there with lot of knowledge, but the leadership don’t listen to them and don’t act on their advice, and as a result they don’t get the outcomes. Our uni listens to what we have to say – whether it’s the Dean of Medicine or the Health Faculty; right up to Vice Chancellor level.”

Teaching Aboriginal Health

Thurru also runs the Joint Medical Program’s Aboriginal Health component, a six-week pathway open to all medical students in 4^th and 5^th year who elect to have an extra skillset in Aboriginal Health. Now in its third year, the Aboriginal Health pathway has more medical students wanting to take the course than it has places available, says Kirsty Jennings, the doctor and academic who manages the pathway.

“Rather than looking at a deficit discourse or data-based teaching, we’re trying to engage students with lived experience so that they develop empathy and understanding,” she says. “And it’s not just the medically-based Aboriginal Community Controlled Health Organisations (ACCHOs) that we engage with, we travel to rehab services, out of home care, cultural centres; I’ve had students delivering meals on wheels to COVID-positive patients.”
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“We see the Aboriginal Health training we do in medical school and later on in the medical colleges really as a quality control mechanism. It helps graduate better doctors all round.”
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“The community overall have been really positive in contributing to teaching medical students about how to work with our Aboriginal communities – giving them good feedback and experience. I also make sure the students understand the importance of giving something back,” she says.

Success Builds Success

Peter believes that the training provided through the Aboriginal Health pathway equips all graduates to become better doctors: “When students are trained to practice Aboriginal Health well, they become a better practitioner for everyone because Aboriginal Health is about trauma-informed care, whatever the patient group may be…We see the Aboriginal Health training we do in medical school and later on in the medical colleges really as a quality control mechanism. It helps graduate better doctors all round.”

If Peter’s predictions are correct, Newcastle’s Joint Medical Program will be graduating its 200^th Aboriginal and Torres Strait Islander doctor in 2027 – a great result in a country with such low numbers of Indigenous doctors in its national workforce. The simple but extremely powerful message that Peter and the other members of the Thurru team continue to spread as they travel to Aboriginal communities across NSW is, “If we can do it, maybe you can too”.

[1] 2022

[2] 105 Indigenous medical students had graduated from Newcastle Uni by 2022

[3] “A critical mass of eight students has been identified as the minimum number of enrolees at any one time likely to result in successful completion of studies.”  Meiklejohn B, Wollin JA, Cadet-James YL. Successful completion of the Bachelor of Nursing by Indigenous people. Australian Indigenous Health Bulletin. 2003;3(2).

[4] About 3.3 percent of Australians are Aboriginal and Torres Strait Islanders [Australian Bureau of Statistics].

[5] In 2020, 0.47 per cent of employed Australian medical practitioners identified as Aboriginal and Torres Strait Islander [Australian Government Department of Health], equivalent to 494 doctors.

[6] Beyond Enrolments, Emma V. Taylor, Alex Lalovic & Sandra C. Thompson. International Journal for Equity in Health, 2019. https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-019-1038-7

[7] In 2021, 3.2% of commencing domestic students, and 2.1% of domestic graduates, were Aboriginal and Torres Strait Islander people (2020_MDANZ-Student-Statistics-Report-1.pdf, medicaldeans.org.au).

[8] Emma V. Taylor, Alex Lalovic, Sandra C. Thompson, Beyond Enrolments, International Journal for Equity in Health, 2019.

Western Sydney University’s School of Medicine is a leader in graduating students – both Indigenous and non-Indigenous – with the skills and cultural proficiency to improve health outcomes for Aboriginal and Torres Strait Islander patients.

Western Sydney University (WSU) opened the doors of its medical program in 2007, preferencing applicants from Western Sydney to address a scarcity of doctors in the region. A second major driver was to grow the number of Indigenous doctors, given Western Sydney has the highest Aboriginal and Torres Strait Islander population in Australia.

“The whole course is underpinned by this model of social accountability, so the doctors trained here have a kind of ingrained understanding that they’re accountable to their community and society, and that being Western Sydney, it’s a relatively socially disadvantaged society,” says Paul Saunders, a doctor and Senior Academic with WSU School of Medicine. “We want to select students embedded in the community who will go back and be a doctor for that community.”

As a young Biripi man living and working on Dharawal land in Western Sydney, Paul was part of the very first cohort of WSU medical students in 2007. Now on staff, he has witnessed the level of support for Indigenous students rise from relatively little when he was studying, to the current wrap-around program which is empowering a growing number of Aboriginal medical students to graduate from Medicine.

Embedding Indigenous Health

The medical curriculum Paul teaches has Indigenous Health embedded across each year of the five-year degree.

“We develop the students’ knowledge of Indigenous cultures, then try to influence attitudinal change, which is the foundation for skills development – like how to communicate with an Indigenous person, understanding the resources available for you in the clinical setting, and being able to apply these skills in practice. That process takes five years. It’s not something you can do in the first year; it’s a transformational approach running across the whole course,” he says.
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“You’re never going to be culturally proficient until you’re actually embedded within that community, seeing Aboriginal patients coming in the door and communicating and treating them.”
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“Cultural immersion is a big factor. You’re never going to be culturally proficient until you’re actually embedded within that community, seeing Aboriginal patients coming in the door and communicating and treating them.”

WSU is in an enviably strong position to offer its medical students cultural immersion, due to the strong relationships it has built with Aboriginal Medical Services (AMSs) around NSW.

“It’s not as easy as just going out and saying, ‘Will you take on our students? There will be a fee in it for you’. It’s about building a relationship based on trust. A lot of Aboriginal communities have been approached about an arrangement or a deal and then been left in the lurch. That’s happened all too often. So now it’s about trust; about showing your face regularly and being cautious about promising too much,” Paul says.

The Dean of Medicine at WSU, Distinguished Professor Annemarie Hennessy, has worked hard over a decade to develop and maintain the school’s good relationships with AMSs. Working with her in the leadership team is Professor Aunty Kerrie Doyle, Associate Dean, Indigenous Health. Another key team member is Uncle Ian Kennedy, who has the complex job of managing the students on clinical placements in AMSs around the state and plays a major part in maintaining the good relationships which give WSU access to these organisations.
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“It took three years to build the partnership with Broken Hill, and schools looking to forge similar partnerships with Aboriginal-controlled organisations should count on a similar lead time”
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WSU most recently partnered with the AMS in Broken Hill, which includes Wilcannia and three small AMSs near the border of NSW and South Australia, where WSU students fly in and out for clinical placements. It took three years to build the partnership with Broken Hill and schools looking to forge similar partnerships with Aboriginal-controlled organisations should count on a similar lead time, Aunty Kerrie says. To help convey lessons learned, she is writing a handbook documenting the team’s collective experience in building positive relationships with Aboriginal communities and organisations.

Graduating more Indigenous Doctors

The recruitment target at WSU is ten Indigenous students per year, within a total cohort of 130 to 140 commencing students. It was once difficult to recruit the ten, but Indigenous applications have grown to 20 to 30 per year and the target is now generally achievable.

“We start giving parents information about the medical course when their kids are in Year 6, and we run a FutureDoctors@email for people to let the school know they are thinking of doing medicine so we can keep our eye on them and get in touch once a year. We send some of our students into high schools to say, ‘Think about becoming a doctor; this is what you have to do’. It’s a big team effort,” Aunty Kerrie says.

When Annemarie recruited Aunty Kerrie to the position of Associate Dean, the medical program had a fairly high rate of attrition of Indigenous students in the early years of the degree. The wrap-around Indigenous student support program now overseen by Aunty Kerrie aims to minimise the life pressures many Indigenous students are dealing with, to allow them to focus more on their medical studies.

On the second day of each year’s Orientation Week, all Year One students in Medicine are taken to the Tharawal Aboriginal Corporation for a cultural immersion day where they meet some of the local Elders, learn some Indigenous knowledge and history of the surrounding Campbelltown area, and watch an Aboriginal performance.

“Right at the start, what that does for the Indigenous students is they get this feeling that their culture is accepted and valued within medicine. It’s like giving them permission to continue to be proud of their culture while they’re in the course and makes them feel more at ease,” she says.

The holistic support provided to Indigenous students by the school includes:

• Onboarding well before the students arrive.
• A tutor assigned to each student
• An Indigenous support centre close to the medical school, providing access to a kitchen, food, computers, textbooks and anything else students need to study effectively
• A weekly food hamper, recognising the financial constraints of many students
• In addition to the Puggy Hunter scholarship (available to all Indigenous students in a health discipline), a $7,500 housing scholarship available for those struggling to pay for accommodation or coming to university from a distant location
• Contact with Centrelink to ensure students receive the highest (Masters) level of Abstudy
• Encouraging students to apply for a $3,000 Summer scholarship in research
• Discouraging students from taking an external job while studying medicine.

Aunty Kerrie and Paul work from offices located about 15 metres from the Indigenous support unit their students use and less than 50 metres from the School of Medicine. They are highly accessible and encourage students to knock on their doors at any time.

“I announce at the beginning of every year: ‘We’re not happy if you’re hungry and we’re not happy if you’re homeless, so call me. We can sort anything’,” Aunty Kerrie says. “I think having that safety net there is a big help for a lot of our students. Some of them have come to the course without even a laptop.”

Both Aunty Kerrie and Annemarie are skilled at reeling in funds from multiple sources to cover the cost of additional resources – be it a computer a place to stay or tutoring. This ‘can-do’ attitude on the part of the leadership team makes a difference in a university environment where funding is tight.
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“We really don’t lose any [students] now. We have had a couple fail due to an accident or illness but they’re not failing because they can’t do the work or because they’re not interested; they’re failing because of life events.”

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.Attrition rates have dropped substantially since the support program was implemented: “We really don’t lose any [students] now. We have had a couple fail due to an accident or illness but they’re not failing because they can’t do the work or because they’re not interested; they’re failing because of life events,” Aunty Kerrie says.

 
Career Pathways

The variety of Indigenous medical specialists who have graduated from the WSU medical program is a point of pride for this relatively young medical school. These specialists include a Neurologist, an ED specialist, two Dermatologists and, very soon, the first Indigenous female Surgeon.

The WSU Indigenous Health team meet with the NSW Health and Education Institute (HETI) at least three times a year to support transition of Indigenous students from medical school. They discuss vocational training preferences with the students and provide information on what the different medical colleges are looking for and how to approach the interviews. They also encourage students to have least at least one publication as first author (e.g. in Journal of Public Health) by the time they graduate.

Paul believes that the most critical factor holding back the growth of Indigenous specialists is a lack of Indigenous leadership: “As with anything, you need to build Indigenous agency in whatever it is that you’re doing. If it’s the School of Medicine, you need to recruit Indigenous people – and not just level A, they need to be Indigenous leaders. We’ve got that with Aunty Kerrie. Annemarie recognised the need for that and we are now witnessing the impacts.”
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“We want to graduate doctors with the generic attribute of being able to offer unconditional positive regard for Indigenous people.”
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For Aunty Kerrie, the green shoots seeded by the program create the greatest joy: “I got a letter from this Aboriginal woman I know to thank me for teaching the students how to care for Aboriginal people. She was admitted to the Emergency Department at Wyong and said she’s never had a doctor before who really knew the questions to ask her. That was really heartening for us. We want to graduate doctors with the generic attribute of being able to offer unconditional positive regard for Indigenous people.”

The University of Otago is home to one of the most successful programs supporting Indigenous health workforce development in Australia and New Zealand. Over the past decade it has made a significant contribution to New Zealand reaching population parity [1] in the percentage of Māori doctors graduating from medical school.

Each year of the medical program at the University of Otago has its challenges but the first year of Health Sciences – a mandatory year for all aspiring medical students – has typically been the point of highest attrition for Māori students. So there was great interest in 2012 when the number of Māori students completing Health Sciences First Year and transitioning into medicine jumped dramatically – from an average of 18 students in previous years to 45 students.

There had been no change in the selection criteria for Māori entry to medicine that year. The catalyst for change was a support program developed by a small and passionate team at Otago’s newly created Māori Health Workforce Development Unit (MHWDU), with funding from the New Zealand Ministry of Health.

Since that time the Ministry has continued to fund MHWDU based on the continued success of its Indigenous support programs. The number of Māori medical graduates at Otago has risen steadily, reaching a high of 21.6 per cent Māori medical graduates in 2021 [2]  (61 of the total cohort of 287).

Targeted Support for Māori Students

Professor Joanne Baxter (Ngāi Tahu, Ngāti Mamoe, Waitaha, Ngāti Apa ki te Rā Tō), now Dean of the Dunedin School of Medicine, was one of only two people in the MHWDU team in its first couple of years. Zoe Bristowe (Ngapuhi, Ngāti Porou), Programme Manager with MHWDU, was the other.

“Before we had any targeted support for Health Sciences, Māori students were not doing well,” says Zoe. “We had the Māori Centre providing some academic support and offering a counselling service, but there was nothing targeted specifically to Health Sciences First Year, which had one of the highest attrition rates for Māori students at the university. The issue, of course, was what was happening in secondary school and not all students having the requisite sciences when they got here.”

The MHWDU team identified and recruited 14 Māori students for Tū Kahika, a new scholarship program to support students through a Foundation Year in 2010 – effectively a bridging program between secondary school and the highly competitive Health Sciences First Year common to all health professional programs at Otago. Rather than recruiting the ‘best’ Māori students from the ‘best’ schools – which would have done little to lift overall Indigenous numbers – the strategy was to identify potentially promising students from diverse backgrounds, including some who would not otherwise have been likely to go to university, and provide them with a scholarship, accommodation at an Otago residential college and wrap-around pastoral support during the Foundation Year.

Most of the 2010 Foundation Year scholarship students [3] were admitted to Health Sciences in 2011, where they met with other Māori students. MHWDU stretched its resources to embrace all Māori students in Health Sciences First Year – providing information, food, events and a lot of the team’s time. When the two Māori student groups coalesced, they lifted the collective performance of the Māori cohort in Health Sciences First Year to an unprecedented level, achieving a record 45 places in Otago’s 2012 medical program.

“In an environment that had some quite hostile cultural norms for Māori students we wereable to create a sheltered space around the students,” Zoe says. “We developed really good partnerships with the residential colleges and we would be invited up there for dinner, so we became just like an extended family, all with a similar goal. It was quite motivating for the Foundation students; for some of them it was the first time they had met another young Māori person who wanted to become a health professional. When they went into Health Sciences First Year, they pulled others into the fold.”

An Indigenous Led Model

The Foundation Year scholarship program continues to take an average of 13 to 16 students per year but is relatively costly and time-intensive given its small numbers. The greatest success has been in Health Sciences First Year, where admission rates for Māori students have consistently increased across medicine and nearly all other Otago health professional programs.

“We’ve done well because we’ve been able to implement an Indigenous-led model underpinned by Indigenous values. It’s about that sense of family and connection, and also collective success, which in a year that has always been really competitive can seem foreign. We all support each other so we can all progress together, and that’s been powerful.”

MHDWU currently has eight staff and is applying its proven Indigenous support model to the more recently introduced equity pathway into health professional programs for students from schools in low socio-economic communities (the EQ Project).

The Clinical Years

Otago students complete the first three years of the medicine program together at the Dunedin campus, then separate for three years of clinical training at one of three Otago medical schools, based at Dunedin, Christchurch and Wellington.

About 20 Māori students start clinical training at Christchurch each year and about 50 Māori students are at the Christchurch medical school at any one time. These students come under the orbit of Dr Tania Huria (Ngai Tahu / Ngati Mutunga Wharekauri),  Associate Dean Māori and more recently also Associate Dean Student Affairs, Christchurch, a role encompassing all undergraduate medical students across the three clinical years.

Tania’s team first meet the new Māori students coming to Christchurch when they take all new medical students away to a Marae [4] at the start of their first clinical year. The team then has ongoing contact with the Māori students moving forward, providing clear touchpoints within the faculty so that students know who to approach for information or to discuss an issue.

Tania also links the Indigenous students into the Māori Health Innovation Health Institute (MIHI), which runs OSCE practice at crunch times during the year and provides opportunities for students to meet Indigenous doctors working in the community. A Tuakana-Teina (senior-junior) Māori student support network, devised by students, runs a buddy system and schedules dinners and anti-racism/resiliency workshops.

“We don’t get everybody. It’s not a perfect program by any means. But we get most of our students on board at the beginning of the year,” Tania says.

More than 140 hours of the three-year curriculum are devoted to Māori Health, with an emphasis on simulations featuring community members acting out real cases and Māori doctors and other health professionals helping to facilitate the sessions. This practical component is expensive but extremely effective.

Cultural loading [5] on Indigenous students has been a pervasive problem but is beginning to diminish at Christchuch, Tania says. “We’re very clear that we want our Māori students to be students, so if we hear of any incident where they have been asked to be Māori experts – in a tutorial for example – we tell them to ask whoever it is to come and talk to us. This can be really insidious for both staff and the students, although it’s not happening as much now because we’re developing a bit of a critical mass. We do a lot of post graduate training in Māori Health so a lot of clinicians at the hospital have been through our training, which is quite helpful, and a lot of the junior RMOs are our graduates.”

Taking a Stance against Racism

While cultural safety for Māori health students at Otago has improved over time, racism and discrimination remain problems just as they do in the health workforce and society, Tania says. She references a legal case challenging Otago’s Mirror on Society medical admissions policy, which was settled out of court in 2020, and a recent review of the university’s Physical Education Department following complaints of racism toward the Māori unit within that department. In the wake of these events, Otago’s Vice Chancellor has taken a very vocal stance against racism and strongly endorsed the Mirror on Society policy.

“It all comes down to leadership. If a university or a medical school has leadership that supports and invests in equity then it’s great, but if the leadership isn’t prepared to acknowledge racism or inequity, that is an issue. It has to be a priority. It’s not acceptable that Australian and New Zealand Indigenous people continue to have the worst health and wellbeing outcomes.”

Two of the three Deans leading Otago’s medical schools are Māori –  Professor Suzanne Pitama, Dean and Head of Campus, Christchurch, and Professor Baxter at Dunedin. This is a proud achievement for these medical education experts but also an inspiring milestone along the path to achieving more equitable health outcomes for Indigenous New Zealanders.

[1] Māori people comprised an estimated 17.1 per cent of the national population in 2021 https://www.stats.govt.nz/

[2] Medical Council of New Zealand, Workforce Survey, 2021 https://www.mcnz.org.nz/assets/Publications/Workforce-Survey/d9d2757aad/Workforce-Survey-Report-2021.pdf 

[3] All 14 students became eligible for admission to university, whereas half had not been eligible prior to the Foundation year.

[4] Māori meeting ground.

[5] Requests for Indigenous students to provide information about Indigenous cultures and related aspects of Indigenous health and wellbeing.

From its home in Far North Queensland, James Cook University is committed to improving the health of rural, remote, Indigenous and Tropical communities. Its focus on Indigenous health has been a drawcard for many of the Aboriginal and Torres Strait Islander students enrolling in its medical program.

At a ceremony held one or two days before formal graduation, each Aboriginal and Torres Strait Islander student graduating from medicine at James Cook University (JCU) presses their painted hand onto a canvas that hangs in the foyer of the College of Medicine and Dentistry in Townsville. The painting is a visual reminder of the growing Indigenous medical workforce they are about to join, and a validation of their hard work to get to this point.

“One of our Aboriginal students told me she’d had some hard times during the course but walking down that College hallway and seeing that painting with the handprints of all the people who had come before helped her to get through those tough times,” says Karen Knight, Senior Lecturer with the College of Medicine and Dentistry.

The Handprint Ceremony is also an opportunity for the families of the new Aboriginal and Torres Strait Islander graduates to meet and connect with one another, with other Indigenous graduates and with the academic staff and deans of JCU’s health disciplines in a more intimate context than the formal graduation ceremony. JCU’s Division of Tropical Health and Medicine fosters this kind of personal engagement with families and communities as a means of supporting Indigenous students as well as a potential pathway to recruitment.

JCU’s Indigenous Family

In 2021, there were 25 Aboriginal and Torres Strait Islander students enrolled in JCU’s six-year undergraduate medical degree. The school attracts Aboriginal and Torres Strait Islander applicants from across Queensland, over the border into NSW, sometimes Victoria and in a couple of instances, South Australia and Western Australia.

In each of the last four years, five to seven Aboriginal and Torres Strait Islander students have commenced medicine at JCU, which is a comparatively strong and sustained result [1]. However, the most critical challenge for the College, as for all medical schools, is to nurture and empower these students to progress through what for many may be a difficult and challenging journey to graduation.

All Indigenous medical students at JCU receive a modest annual scholarship which, while it is a help, is smaller than many other scholarships on offer and not a key recruitment strategy for the College.

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JCU’s pastoral care and family-oriented culture is at the heart of the university’s offer to Aboriginal and Torres Strait Islander students.

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The central hub of what JCU refers to as its ‘Indigenous family’ is the Indigenous Education Research Centre (IERC), a newly built, well-appointed research centre and meeting place on the Townsville campus, which employs a large team of predominantly Indigenous staff who operate in both Townsville and Cairns, and have strong connections with Indigenous communities and families in the region.
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JCU also benefits from running the specialist GP Training Program for a large portion of Queensland, which connects the university to a wide range of Aboriginal-controlled health services across the state, providing a network of pathways channelling positive word of mouth about studying medicine at JCU into Indigenous communities.

Preparing Students for University

At the secondary school level, an important recruitment channel is the innovative program of Summer and Winter schools run by the IERC to encourage Aboriginal and Torres Strait Islander secondary school students to apply for university. Winter School is held in the middle of the year for students in years 10 to 12, while the Summer School at year’s end is for Year 12 students only.

“The students come in for a week; they do an induction on things you need to know about university then more specific programs on the courses they’re interested in,” says Donald Whaleboat, a Senior Academic with the College of Medicine and Dentistry. “For medicine, we give them some insight into anatomy and physiology, working with patients, understanding the health care system and that sort of thing. We also test them throughout the workshop, so that we have information which can strengthen their application if they decide they want to do medicine.”

“The whole experience of coming to uni goes a long way toward getting Indigenous students engaged in the system. We’re talking about people who may not have had a family member come to uni so they don’t understand the way the system works, and coming to Summer or Winter School really gives them that sense of connection at an earlier age and something to work towards. When they arrive at university for the admissions process, they know the people who have delivered the content for the Summer or Winter school. They see a familiar face and it makes them feel a bit more comfortable when they do their interviews,” Donald says.

JCU’s Summer and Winter schools started just two years before COVID-19 brought them to a close but are back again in 2022. The IERC is gathering data to develop an evidence base for how this initiative is laying some of the building blocks for the success of Indigenous students at university.

Pathways to Equity

Indigenous applicants to medicine at JCU are able to choose whether to apply through the Indigenous pathway, the mainstream pathway or both. Many choose to apply through both pathways and are interviewed by both selection panels.

“It’s part of the philosophy of the College on equity and working with disadvantaged groups,” Karen says. “They can choose to participate in both.”

Breaking down the inaccurate perception that Indigenous students take the place of other, more suitable candidates is vitally important for medical schools in Australia and New Zealand. This perception is an obstacle for all those working to close the gap in health outcomes for Indigenous peoples by growing the very small number of Indigenous medical practitioners in the national health workforces of both countries [2]. It is also one of the examples of racism most frequently cited by Indigenous medical students in Australia and New Zealand.
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“If other students don’t get it at the start, they get it as they go through the program; they understand why there is a targeted [Indigenous] pathway.”
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“Indigenous students go through the same exams and assessment process as all the other students, and a lot of Indigenous students are coming through with extra challenges. We have a lot of mature age students in the course who have done other studies and who have to work and support families. They have to do all that on top of studying medicine.”

Linking Pastoral and Academic Support

The IERC is a welcoming space for Indigenous students to visit, during the day and in the evenings, to talk with Indigenous staff and meet other Indigenous students from disciplines across the university. The location of a centralised Indigenous support unit within a university – its proximity to the medical school – can have a big impact on how much busy medical students will visit and benefit from the services it provides. In earlier years there was a dedicated Indigenous support unit for the health programs at JCU but the trade-off for moving to the centralised IERC, located farther away from the College, was the volume of Indigenous staff and students working at and visiting the IERC, as well as the first-class study and recreation facilities located there.

Great care is taken to ensure that the Aboriginal Elders and other Indigenous staff at the IERC who provide pastoral care for Indigenous medical students work closely with the medical school staff who provide academic support at the College.

“Let’s say we have an Indigenous student who has some challenges, we’ll refer them to our medical academic support centre and they will make contact with the IERC to see if there is anything else we need to do, any gaps, in order to support a student,” Donald says. “The same happens if we don’t hear from a student. That student may be disengaged or remove themselves because they’re struggling a bit and they may not be as forward as others in asking for help – or know exactly what they need help with. We need to have our eye on the ball in regard to how they are travelling, so we look for the early warning signs and try to follow them up very quickly.”

Racism, Discrimination and Cultural Safety

An Indigenous student mentoring program linking senior students with those in the early years of medicine was recently introduced at the College. The senior students provide advice on how to navigate the later years of the medical degree to their younger peers and discuss career aspirations and potential career pathways, encouraging the juniors to think long-term about their medical career. This kind of peer support and mentoring can have a powerful positive impact on the confidence and resilience of Indigenous students if the school has a critical mass of Indigenous students to enable it.

The College supports and resources the mentoring program and encourages students to drive much of the discussion content for its events.

Dealing with racism and discrimination is a recurring discussion topic – like discussing whether something said in class can be considered racist or hearing from an Indigenous junior doctor who has come back to the school to talk about their experience of racism and discrimination in the workplace and how Indigenous students might prepare for that. This can be critical for students given the level of bullying, harassment and discrimination reportedly experienced by Indigenous junior doctors in the health workforce [3].

A commitment to diversity and zero tolerance for racism is woven through the culture and curriculum of the medical program and the College – in the professionalism stream within the medical curriculum, through the STAR Program (Stand Together Against Racism) and in first year orientation for all College students.
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“We introduce all our students to this thinking from first year and we have a couple of sessions on what to do if you are faced with racist behaviour or comments, so that if students see it, it’s not the first time they’ve thought about it and they have some skills in their toolbox,” Karen says. “We want all our students to back up our Indigenous students if ever they see racism occurring.”

Another aspect of cultural safety is ‘cultural loading’ – requests for Indigenous students to provide information about Indigenous cultures and related aspects of Indigenous health and wellbeing. Unless medical schools have sufficient expertise on staff to teach Indigenous Health, it is very likely that Indigenous students will experience various forms of cultural loading while studying medicine, adding an unwanted burden to their already busy lives.

Karen is very careful not to pressure any of her students to represent their culture as a whole in a class context: “If they want to share, that’s great, but we are careful not to put anyone on the spot.”

Both Karen and Donald acknowledge the difficulty of ensuring cultural safety for Indigenous students when racism is a society-wide problem: “We’re always thinking ‘Are we doing enough? How well are we integrating diversity? What more do we need to do to support our Indigenous students?’”

Medical schools need to be constantly asking themselves these questions – as JCU are – to welcome Aboriginal and Torres Strait Islander students to their program and support them through to graduation. Building a culturally safe environment remains a substantial challenge for medical schools in Australia and New Zealand, but is a core aspect to contributing to equitable health outcomes by graduating more Indigenous doctors.

[1] A total of 207 students commenced the JCU medical program in 2021.

[2] 0.47 per cent of employed medical practitioners identified as Aboriginal and Torres Strait Islanders in 2020. [Australian Government Department of Health], compared with 3.3 per cent of the national population [ABS]; 3.5 per cent of medical practitioners identified as Māori [2019 Medical Council of New Zealand], compared with 16.7 per cent national population [2020 NZ stats, NZ Government].

[3] Results of Ahpra’s 2021 Medical Training Survey show that 52% of Aboriginal and Torres Strait Islander trainees reported experiencing and/or witnessing bullying, harassment and/or discrimination (compared with 35% of trainees nationally), and of those experiencing bullying, harassment and or discrimination, 49% reported a moderate or major impact on their training (compared with 38% nationally).