Healthy Futures Report - LIME Network

HEALTHY FUTURESDefining best practice in the recruitment and retention ofIndigenous medical students

The Australian Indigenous Doctors’ AssociationYaga Bagaul Dungun

HEALTHY FUTURESDefining best practice in the recruitment and retention ofIndigenous medical studentsMs Deanne MinnieconProject CoordinatorDr Kelvin KongMedical OfficerAUSTRALIAN INDIGENOUS DOCTORS’ ASSOCIATION

Healthy FuturesAIDA Working GroupDr Alex Brown, Ms Jane Magnus, Dr Helen Milroy, Dr Mark Wenitong, Dr Ngiare Brown, MrRomlie Mokak, Dr Tamara Mackean© Australian Indigenous Doctors’ AssociationFirst published in September 2005 by the Australian Indigenous Doctors’ Association.This work is copyright. It may be reproduced in whole or in part for study or training purposes,or by Aboriginal and Torres Strait Islander community organisations subject to anacknowledgement of the source and not for commercial use or sale. Reproduction for otherpurposes of by other organisations requires the written permission of the copyright holder(s).ISBN 0–9758231–0–8Additional copies of this publication can be obtained from:The Australian Indigenous Doctors’ AssociationPO Box 3497 Manuka, ACT, 2603Tel: 61 + 2 62735013 Fax: 61+ 2 62735014 Email: aida@aida.org.auOriginal artwork: Mr Duncan SmithPhotography: Deanne Minniecon and Casey Eldridge. Thanks to Julie Tongs and staff atWinnunga Nimmityjah Aboriginal Health Services, ACT.Copy editing: ThemedaDesign: ThemedaPrinting: Elect Printingii

FOREWORDAssociate Professor Helen MilroyFirst I would like to acknowledge my people,the Palyku people, in particular mygrandmother and mother who taught meabout health and healing through my life.As current President of the AustralianIndigenous Doctors’ Association, I have greatpleasure in introducing this important work.As an Indigenous medical graduate myself, Ihave enjoyed seeing our Indigenous medicalstudents complete their studies and take uptheir place as colleagues in our health caresystems.Through researching this report, we have hadthe privilege of hearing many remarkablestories of Indigenous courage, strength andresolve. However, these stories have alsohighlighted that the strength of individuals,on their own, is not enough.Our children must have every opportunity toachieve their dreams, fulfil their potential andcontribute to the health and life outcomes forIndigenous people as well as the nation.This can be achieved through comprehensivepathways into medicine, culturally safe andaffirming student experiences, and recognitionof the unique and beneficial contributions tobe made as Indigenous medical practitioners.It will however, require a real and sustainedcommitment with observable actions at alllevels by governments, universities, medicalschools, and primary and secondary educationsystems.The Australian Indigenous Doctors’Association, as the sole body for Indigenousmedical graduates and students in the country,promotes the pursuit of leadership,partnership and scholarship in Indigenoushealth. We commit to all three dimensions,both within our Indigenous world and withour non-Indigenous peers and partners in therealisation of the Best Practice Framework.I look forward to the day when the numbersof Indigenous medical students and graduateshave equitable representation across the healthand education sectors. The implementation ofthis framework can go some way in achievingthis goal.On behalf of the Australian IndigenousDoctors’ Association, I would like to sincerelythank Deanne Minnecon, Project Officer,Jane Magnus, AIDA Secretariat, and DrKelvin Kong for their commitment andexcellent work in producing this report.Dr Kelvin KongI acknowledge and thank my family, mybeautiful wife, and the Worimi communityfor their support and belief in this project. Aspecial thanks to Deanne Minniecon who hasbeen instrumental in the project developmentand progression. I also wish to thank JaneMagnus who has dedicated a lot of her timeensuring the viability of the project. Withoutthe assistance of these people this projectwould not have been successful.This document has been the desire andpassion of many students and graduates for along time. We hope that key stakeholders (e.g.Department of Education, Science andTraining [DEST], Office for Aboriginal andTorres Strait Islander Health [OATSIH],Australian medical schools; and secondary,primary and other education systems), thehealth workforce and wider community willrise to these challenges and fulfil theirobligation not only to Indigenous Australia,but to Australian society as a whole.iii

Healthy Healthy Futures FuturesI have always had an interest in health,probably as a result of being surrounded by illhealth during my upbringing in the Worimicommunity. As I grew older it became moreobvious that it was our community beingaffected and not that of our non-Indigenouscounterparts. I was unsure how one wouldever know the answers nor the avenues toattempt to address the striking healthinequalities.I can recall the very day that cemented myinterest in pursuing a medical career. I was inyear 8 and participated in a careers day atuniversity. Two of the then Indigenousstudents were talking about studying medicineand how, as an Indigenous person it was arealistic option. Prior to this, studying beyondyear 10 was something I had never considered.These two students, now very successfuldoctors, Dr Louis Peachey and Dr SandyEades, gave me the inspiration to follow intheir footsteps. As I have progressed to bewhere I am now, I have never forgotten myinspiration in the beginning, nor thecontinued support I have attained from AIDAand its membership. I am fortunate to besurrounded by a group of Indigenous overachievers.Working on this report was a way toextend my inspiration, to give back, to assistand to encourage others as I have been.iv

CONTENTSForeword ............................................................................................................................ iiiAbbreviations .................................................................................................................. viiiAcknowledgments ...........................................................................................................ixExecutive summary .......................................................................................................... xi1. INTRODUCTION ............................................................................................................. 11.1 The Australian Indigenous Doctors’ Association ............................................. 11.2 The Best Practice Project .................................................................................... 22. METHODOLOGY ............................................................................................................ 32.1 Methods ............................................................................................................... 32.1.1 Literature review ........................................................................................ 32.1.2 Surveys ........................................................................................................ 32.1.3 Unstructured interviews ............................................................................ 42.1.4 National workshop .................................................................................... 42.2 Study limitations ................................................................................................... 53. LITERATURE REVIEW ....................................................................................................... 63.1 Indigenous education ........................................................................................ 63.1.1 The early years ........................................................................................... 63.1.2 Barriers to education ................................................................................ 63.1.3 Higher education ...................................................................................... 63.2 Indigenous health workforce ............................................................................. 83.2.1 National Strategic Framework for Aboriginal and TorresStrait Islander Health .......................................................................................... 83.2.2 Aboriginal and Torres Strait Islander Health WorkforceNational Strategic Framework.......................................................................... 83.4 Recruitment and retention of Indigenous medical students in Australia .... 93.4.1 Barriers for Indigenous medical students ............................................... 93.4.2 Recruitment and retention studies ....................................................... 10v

Healthy Futures3.5 Recruitment and retention of Indigenous medical studentsin comparative countries ....................................................................................... 123.5.1 New Zealand ........................................................................................... 123.5.2 United States of America ....................................................................... 143.5.3 Canada.................................................................................................... 163.6 Australian Indigenous doctor and medical student numbers .................... 174. FINDINGS ...................................................................................................................... 184.1 Indigenous doctors and why they pursue medicine .................................... 184.1.1 Indigenous medical student and doctor numbers ............................ 184.1.2 Reasons for pursuing and staying in medicine ................................... 194.2 Existing Indigenous recruitment and retention strategies in Australia ........ 194.3 Themes in relation to best practice ................................................................ 214.3.1 Personal contact and community engagement ............................... 224.3.2 School and university visits ..................................................................... 234.3.3. Indigenous health support units ........................................................... 244.3.4 Indigenous medical school staff ........................................................... 264.3.5 Mentoring ................................................................................................. 274.3.6 Indigenous content in medical curriculum ......................................... 284.3.7 Cultural safety ......................................................................................... 294.4 Other themes in relation to recruitment and retention ................................ 304.4.1 Promotion ................................................................................................. 304.5 Admissions .......................................................................................................... 324.5.1 Alternative entry schemes ..................................................................... 324.5.2 Quotas for Indigenous medical students ............................................. 334.5.3 GAMSAT and UMAT ................................................................................. 334.5.4 Identification............................................................................................ 354.6 Support ............................................................................................................... 354.6.1 Finances ................................................................................................... 354.6.2 Scholarships ............................................................................................. 364.6.3 Tutorial assistance ................................................................................... 374.6.4 Collegiate support .................................................................................. 384.6.5 Career progression and development ................................................ 394.6 LIME Connection statement of outcomes and intent .................................. 40vi

CONTENTS5. DISCUSSION ................................................................................................................. 415.1 Approaches in Australia and other comparative countries ....................... 415.1.1 Targets and affirmative action .............................................................. 415.2 Gaps and barriers in the current strategies and ways forward ................... 425.2.1 Promoting medical degrees to Indigenous people ........................... 435.2.2 Enabling pathways for Indigenous people into medicine ................ 455.2.3 Appropriately supporting Indigenous people in medicine ............... 465.3 Recruitment and retention of Indigenous medical students iseverybody’s business .............................................................................................. 475.4 Summary............................................................................................................. 506. FRAMEWORK ............................................................................................................... 516.1 Headline targets ................................................................................................ 516.2 Principles ............................................................................................................. 53ATTACHMENT A................................................................................................................ 55References ...................................................................................................................... 63Endnotes .......................................................................................................................... 68vii

Healthy FuturesABBREVIATIONSABSAEPAIDAAIHWAMAAMCAMSAMWACCDAMSCPMCCPMECDESTGAMSATHECINMEDISUITASKRAAustralian Bureau of StatisticsNational Aboriginal and TorresStrait Islander Education PolicyAustralian Indigenous DoctorsAssociationAustralian Institute of Healthand WelfareAustralian Medical AssociationAustralian Medical CouncilAboriginal Medical ServicesAustralian Medical WorkforceAdvisory CommitteeCommittee of Deans ofAustralian Medical SchoolsCommittee of Presidents ofMedical CollegesConfederation of PostgraduateMedical Education CommitteeDepartment of Education,Science and TrainingGraduate Australian MedicalSchool Admissions TestHigher Education ContributionSchemeIndians into MedicineIndigenous (student) supportunitIndigenous Tutorial AssistanceSchemeKey Result AreaLIME Leaders in Indigenous MedicalEducationMAPAS Maori and Pacific IslandAdmissions SchemeNAHS National Aboriginal HealthStrategyNAIDOC National Aboriginal and IslanderDay Observance CommitteeNSFATSIH National Strategic Frameworkfor Aboriginal and Torres StraitIslander HealthNOMS Northern Ontario MedicalSchoolOATSIH Office for Aboriginal and TorresStrait Islander HealthUBC University of British ColumbiaUMAT Undergraduate Medicine andHealth Sciences Admission Testviii

ACKNOWLEDGMENTSThe Australian Indigenous DoctorsAssociation wish to thank the manyAboriginal and Torres Strait Islander medicalstudents and graduates who participated inthis study, as well as the Medical Faculties andschools, and Indigenous support units andstaff for allowing us to visit and for sharinginformation with us so willingly and openly.We would also like to pay our respects to andacknowledge the Aboriginal and Torres StraitIslander community as well as the generalmedical community for their support andguidance throughout the life of the project.We want to give a special thanks to theCommittee of Deans of Australian MedicalSchools for their assistance and supportduring the project and for the opportunity towork collaboratively for the duration of thisproject. AIDA hopes to continue thisinvaluable working relationship in the future.Thank you also to Mr Duncan Smith forallowing us to use his artwork throughout thedocument.Finally, we wish to acknowledge and thank theAustralian Government Department of Healthand Ageing, Office for Aboriginal and TorresStrait Islander Health for providing fundingfor this critical project.Without the support from these groups, thisproject would not have been possible.* In this document, we use the term ‘Indigenous’ to refer to the Aboriginal and Torres StraitIslander People of Australia. The terms ‘Aboriginal and Torres Strait Islander Peoples’,‘Indigenous’, ‘First Australian’ and ‘Indigenous Australian are used interchangeably.ix

Healthy Futuresx

Healthy Futures●●mentoring;curriculum; and● cultural safety.The Best Practice Project findings support theevidence that there is a severe shortage ofIndigenous doctors in Australia and showthere has been no growth in Indigenousmedical student numbers since 2003.It is clear that Australian medical schools arenot recruiting enough Indigenous studentsinto medicine and retaining them. Accordingto the literature, prior educational and otherdisadvantages severely impact on Indigenousstudents’ opportunities to successfully applyfor medicine. However, the findings indicatethat some medical schools are significantlymore successful at recruiting and retainingIndigenous medical students, even given thesedisadvantages. Successful recruitment andretention approaches can also be found inother comparative countries such as NewZealand, the USA and Canada. 9It is apparent that many national, state andinstitutional policies and strategies said toassist Indigenous people have failed. This isevident in the fact that the gap in mortalityrates between Indigenous and non-IndigenousAustralians remains at 20 years while in othercomparative countries it has significantlyfallen. 10 As noted in the CDAMS IndigenousHealth Curriculum Framework ‘there is aconvincing case that the health and wellbeingof Indigenous people in Canada, the USA andNew Zealand is strengthened by having theirsovereignty recognised and having controlover their own health care service delivery.’ 11Australian governments and medical schoolsneed to seriously consider what theseobservations mean for the success ofIndigenous medical student recruitment andretention strategies. The Best Practice Projecttherefore provides Australian governments andmedical schools with a framework, includingtargets, principles and actions, that will assistin this process.Headline targetsBy 2010:· Australian medical schools will have established specific pathways into medicine forIndigenous Australians· CDAMS Indigenous Health Curriculum Framework will be fully implemented byAustralian medical schools· There will be 350 extra Indigenous students enrolled in medicine 12xiiPrinciple 1All Australian medical schools and principalstakeholders have a social responsibility toarticulate and implement their commitmentto improving Indigenous health andeducation; and mustPrinciple 2Make the recruitment and retention ofIndigenous medical students a priority for allstaff and students and show leadership to thewider university communityPrinciple 3Ensure cultural safety and value and engageIndigenous people in medical school businessPrinciple 4Adopt strategies, initiate and coordinatepartnerships that open pathways to medicinefrom early childhood through to vocationaltraining and specialty practicePrinciple 5Ensure all strategies for Indigenous medicalstudent recruitment and retention arecomprehensive, long term, sustainable, wellresourced, integrative and evaluated

1. INTRODUCTIONIt is well known that Indigenous people arethe most disadvantaged group in Australia.Overall, they have poorer physical and mentalhealth; are less likely to complete primary,secondary and tertiary education; and do nothave the same employment opportunities asnon-Indigenous Australians. They are alsodealing with the compounding impact ofmultigenerational grief, loss and traumarelated to colonisation, the stolen generation,racism and discrimination, and culturaldislocation on a daily basis. 13Indigenous Australians are also dying at amuch younger age than either non-IndigenousAustralians or Indigenous people in other firstworld countries. The life expectancy gapbetween Indigenous and non-IndigenousAustralians remains at twenty years. Incomparison, the life expectancy gap inCanada, New Zealand and the USA has fallento between five and seven years. 24For both state and national Australiangovernments, the question remains: why doIndigenous Australians continue to live insuch extreme comparative disadvantage withwidening disparities, despite governmentpolicies and strategies aimed at eliminatingsuch disadvantage? More importantly, whatcan we all, Indigenous and non-Indigenous,do about it?In relation to medicine, the positive effects ofIndigenous doctors for Indigenous people’sphysical, emotional and cultural wellbeinghave long been recognised by government andother Indigenous and non-Indigenousstakeholders. 15 Clearly, more Indigenousdoctors are needed. According to theAustralian Medical Association (AMA), 928Indigenous doctors need to be trainedimmediately to reach workforce levelsproportionate to that of non-Indigenousdoctors to population ratios. 16Current government and university policiesrelevant to Indigenous medical studentsinclude allocated places for Indigenousstudents, alternative entry options andIndigenous (student) support units (ISU). Yet,most Australian medical schools still struggleto recruit and retain Indigenous students, andallocated Indigenous medical student placesmay be filled by other students.To better understand this, the AustralianIndigenous Doctors’ Association (AIDA) weresupported by the Australian GovernmentDepartment of Health and Ageing throughthe Office of Aboriginal and Torres StraitIslander Health (OATSIH) to research andreport on best practice in the recruitment andretention of Indigenous medical students.This project has become known as the HealthyFutures Best Practice Project.1.1 The Australian IndigenousDoctors’ AssociationThe Australian Indigenous Doctors’Association (AIDA) is the leadingorganisation for Indigenous medicalworkforce issues and through this projectconfirms its commitment to leadership andinnovation in this area.AIDA provides collegiate and professionaldevelopment support to Indigenous medicalgraduates and undergraduates. It strives todevelop and maintain strong workingpartnerships with Australian medical schools,medical colleges, and key health andeducation organisations.AIDA recognises the outcomes of this projectas critical work in Indigenous medicaleducation and to that end will work withpartners in ensuring the implementation ofthe framework.1

Healthy Futures1.2 The Best Practice ProjectThe aim of the Best Practice Project is to assistAustralian medical schools, governments andother stakeholders in their efforts to supportmore Indigenous Australians in commencingand completing medical degrees.Project objectives●●●●●●Report on current numbers of Aboriginaland Torres Strait Islander doctors andmedical students and identify factors thatencouraged them to pursue a career inmedicine.Identify, collate and report on existingrecruitment, retention and graduationstrategies at Medical Faculties throughoutAustralia and include an audit ofIndigenous support units within thefaculties and their existing initiatives.Where possible, this work will takeaccount of any other recent studiesundertaken in this area and will notduplicate results.Liaise and collaborate with Committee ofDeans of Australian Medical Schools(CDAMS) to produce information andrecommendations that complement thework of the CDAMS Indigenous HealthCurriculum Project.Develop guidelines for mentorship ofIndigenous students. This shall includeresearch on how other countries havesucceeded in recruiting and supportingIndigenous students to graduation andcompare experiences in New Zealand,Canada, the USA and other Pacificcountries.Organise a workshop to present anddiscuss the draft report of the project tokey stakeholders.Identify resources required to ensuremedical schools adopt recruitment/retention/graduation strategies andmentorship programs.Intended outcomes●●●●●●Development of recommendations onbest practice models for recruitment,retention and graduation of Indigenousstudents in medicine.Development of best practice models forsupport units within medical schools.Development of best practice models forcultural safety for Indigenous medicalstudents.Identification of appropriate models formentorship.Resourcing of models of best practice forrecruitment, retention and graduation;mentorship; cultural safety; and otherissues as identified.Identification of key stakeholders to workcollaboratively in implementing projectrecommendations.2

2. METHODOLOGYThe Best Practice Project draws on both quantitative and qualitative methodology:●●assessment of quantitative data was used as a basis for assessing gaps in current recruitmentand retention strategies and as a platform for setting targets; whilethe qualitative data provides a way of deriving meaning and the ‘lived experience’ ofIndigenous medical students in order to better understand the context within which thetargets and principles will ideally be achieved.2.1 MethodsThe methods used to gather and discussfindings relevant to the recruitment andretention of Indigenous medical students andthe project objectives and outcomes included:●●●●a review of the literature;development and dissemination ofsurveys to Australian medical schoolsthrough Indigenous medical studentsupport workers, Indigenous medicalgraduates, and Indigenous medicalstudents;unstructured interviews; andconvening of a national workshop.2.1.1 Literature reviewNational and international literature relevantto the recruitment and retention ofIndigenous medical students was reviewed.The literature review was conducted betweenJuly 2004 to January 2005. Material wassourced from MEDLINE and PROQUESTdatabases, a library search, governmentdocuments, internet searches and unpublishedreports. Search terms included: ‘recruitment’‘retention’, ‘support’, ‘Indigenous’,‘Aboriginal’, ‘Torres Strait Islander’, ‘Black’,‘medical student’, ‘Indigenous education’ and‘Indigenous health’.2.1.2 SurveysSurveys were developed by AIDA withreference to information identified during theliterature review. Questions targetedIndigenous medical students, graduates andmedical schools (see Attachment A forsurveys). They were distributed to 15accredited Australian medical schools, two ofwhich are privately funded. Thirty surveyswere distributed to Indigenous medicalstudents, and another 30 were distributed toIndigenous medical graduates. The AIDAmembership database was used to identifypotential student and graduate participants forthe surveys. Where possible, this was crossreferencedwith student and graduatedatabases from the Indigenous support unitsof medical schools across Australia. Fourteenof the 15 medical schools, 15 of the 30medical students and 17 of the 30 medicalgraduates completed and returned the surveys,representing 93%, 50% and 57%participation rates respectively.3

Healthy Futures2.1.3 Unstructured interviewsUnstructured interviews were conducted withthirteen of the fifteen Deans of Australianmedical schools. Major aims were to:●●introduce the project and surveys;encourage support and leadership inrelation to issues specific to recruitmentand retention of Indigenous students inmedical schools; and● discuss and invite involvement of theDeans at a national workshop.Discussions with some Deans also extended toissues relating to the recruitment andretention of Indigenous medical students andin particular promotional and supportingactivities, resources, Indigenous support units,and Indigenous staff.Unstructured interviews were also conductedwith Indigenous and non-Indigenousuniversity staff, and Indigenous medicalstudents and graduates. The main reason forthese interviews was to engage keystakeholders and current or previous studentsin exploring the key drivers and determinantsof successful pathways throughout medicalschool in a comfortable and non-threateningmanner. The interviews recorded informationbased on participant-driven narratives anddialogues outlining their own or witnessedexperience of medical training and the contextin which it was conducted. Major themesincluded discussion of challenges andsuccesses, support needs, gaps and barriers,views on medical schools, views onrecruitment and retention, and livedexperiences of being an Indigenous medicalstudent.All interviews were conducted by the seniorauthor of the project. All qualitative interviewdata was recorded by hand, expanded andtranscribed, and then analysed in order toidentify major themes.2.1.4 National workshopA national workshop—the Leaders In MedicalEducation (LIME) Connection—was held inPerth on 8–10 June 2005 and was co-hostedby CDAMS and AIDA. The aim of theworkshop was for CDAMS to present theIndigenous Health Curriculum Frameworkand AIDA to present the initial findings of theBest Practice Project in order to encouragediscussion and feedback from workshopparticipants. Key stakeholders in Indigenousmedical education and Indigenous medicalstudent recruitment and retention in Australiaand New Zealand also made presentations.Participants were encouraged to discuss andfeed back on Indigenous medical curriculaand recruitment and retention issues in‘dynamic sessions’ that were recorded and thenpresented back to the workshop as a whole.Through this process, initial outcomes wereidentified and agreed by all workshopparticipants. Attendees at the LIMEConnection included:●●●●●●●●Deans of seven medical schools;medical and university recruitment,retention and development staff;Indigenous doctors, students and otherhealth professionals;representatives from the University ofOtago, New Zealand;representatives from two MedicalColleges;postgraduate Medical Councilrepresentative;Australian state and national governmentrepresentatives from OATSIH andDEST; andlocal community-controlled Aboriginalmedical services representatives.4

METHODOLOGYThe initial outcomes of the LIMEConnection focused on implementation,resourcing, partnerships and capacity issues inrelation to Indigenous medical education andthe recruitment and retention of Indigenousmedical students. Final outcomes and intentsof the LIME Connection are included in theFindings section of this book (see p. 40).2.2 Study limitationsStudy limitations are related to difficultiesidentifying the target group, students who didnot complete their degree course andparticipation rates.Data on the number of Indigenous medicalstudents and graduates may be misrepresentedsince it was difficult to estimate the total studypopulation from which to draw participants:●●●●Indigenous people may choose not toidentify as Indigenous for a number ofreasons;students and graduates are a mobilepopulation;cross-referencing to the AIDA databaseonly identified AIDA members ratherthan the entire target group; andnot all state and territory medicalregistration authorities maintainAboriginal or Torres Strait Islanderidentifiers.Reasons why some of the target group chosenot to participate in this project include busyschedules and hesitancy to divulge experienceof difficulties in relation to social, financialand academic issues.Students who had withdrawn or did notcomplete their medical degree were notincluded. Unfortunately, few resources wereavailable for identifying this difficult-to-findtarget group. In essence, non-inclusion of thisgroup may well bias the reports findingstoward the experience of those who were ableto negotiate and complete their medicalstudies. Inclusion of the factors thatcontributed to non-completion is clearly animportant target for further exploration of thecontext of the recruitment, retention andgraduation of Indigenous medical students.5

Healthy Futures3. LITERATURE REVIEW3.1 Indigenous educationIndigenous students continue to be the mosteducationally disadvantaged student group inAustralia. 17 The 2003 Overcoming IndigenousDisadvantage Key Indicators Report, 18 indicatesthat:●●●●●national school participation rates forIndigenous five year olds in 2002 wasonly 10.1%;Indigenous primary school students havesignificantly lower literacy and numeracyachievement than non-Indigenousstudents;Indigenous secondary students are lesslikely to complete compulsory schoolingthan non-Indigenous students;poor health impacts on schoolattendance; andthere is a strong correlation between lowincome families and lower scores inlearning outcomes.3.1.1 The early yearsThe impact of educational disadvantage onstudents during the early years of schooling ismanifested in learning difficulties, constantexperience of failure, alienation from teachersand peers, dropping out of school anddifficulty attaining higher education andgaining employment. 19Ensuring that Indigenous children beginformal learning as early as possible, are lessabsent from school, and are safe, healthyand supported by their family andcommunity will go a long way to improvingeducational outcomes. 20Steering Committee of the OvercomingIndigenous Disadvantage Report3.1.2 Barriers to educationThe Queensland School Curriculum Council,2002 21 identified a number of barriersaffecting Indigenous student participation andengagement in education (see Table 1),including:●●●●●●isolation, alienation and marginalisation;language and cultural barriers;health and wellbeing;socioeconomic circumstances and accessto resources and public services;racism and prejudice; andemployment opportunities.3.1.3 Higher educationOnly 12.5% of the Indigenous populationaged 15 years and over have attained postsecondaryqualifications, compared to 33.5%of the non-Indigenous population. 22Indigenous people are also much more likelyto attend a technical or further educationalcollege, including TAFE colleges than auniversity. The types of courses they undertakeare also more likely to be enabling and nonawardcourses, rather than postgraduatecourses. Indigenous students also have aharder time completing their studies andattaining qualifications than non-Indigenousstudents. 236

LITERATURE REVIEWTable 1. Barriers affecting Indigenous student participation and engagement ineducation.Isolation, alienation and marginalisation●Influence of distance, socio-cultural and geographic isolation on Indigenous studentsparticipation in schoolLanguage and cultural barriers●●●●●●The interest and relevance of curriculum and test materials for Indigenous studentsUnderstanding of Indigenous cultures (including staff and students)Cultural identity and linguistic backgrounds of Indigenous students, their families andcommunitiesIncorporation and recognition of ways of knowing and learning styles of IndigenousstudentsAccessibility of information and ideas, to Indigenous people for whom standard AustralianEnglish is not their first languageCommunity decision-making processes.Health and wellbeing●●Influence of violence on students participation in schoolInfluence of health factors (particularly hearing impairment) on students’ participation inschoolSocioeconomic circumstances and access to resources and public services●●Appropriateness of resources for Indigenous studentsEquity of access to and availability of resourcesRacism and prejudice●●●●Inclusiveness and cultural appropriateness of assessment frameworks for IndigenousstudentsHow learning is valuedRacism and prejudice in schools towards Indigenous studentsInvolvement of community members, parents and carersEmployment opportunities●Influence of employment opportunities on Indigenous students’ participation in school7

Healthy Futures3.2 Indigenous health workforceThe Standing Committee on Aboriginal andTorres Strait Islander Health developed theAboriginal and Torres Strait Islander HealthWorkforce National Strategic Framework inMay 2002 to… transform and consolidate the workforcein Aboriginal and Torres Strait Islanderhealth to achieve a competent healthworkforce with appropriate clinical,management, community development andcultural skills to address the health needs ofAboriginal and Torres Strait Islander peoplessupported by appropriate training, supply,recruitment and retention strategies. 24Following this, the National Aboriginal andTorres Strait Islander Health Council preparedthe National Strategic Framework forAboriginal and Torres Strait Islander Health(NSFATSIH) in July 2003 as a framework foraction by governments.3.2.1 National Strategic Framework forAboriginal and Torres Strait IslanderHealthThe goal of the NSFATSIH is:To ensure that Aboriginal and Torres StraitIslander peoples enjoy a healthy life equal tothat of the general population that isenriched by a strong living culture, dignityand justice. 25The framework identifies nine key result areas(KRA). KRA 3 (a competent healthworkforce) recognises that… a competent health workforce is integralto ensuring that the health system has thecapacity to address the health needs ofAboriginal and Torres Strait Islanderpeople. 26The objective of KRA 3 is:A competent health workforce withappropriate clinical, management,community development and cultural skillsto address the health needs of Aboriginaland Torres Strait Islander people supportedby appropriate training, supply, recruitmentand retention strategies. 27KRA action areas are based on theimplementation of the Aboriginal and TorresStrait Islander Health Workforce NationalStrategic Framework.3.2.2 Aboriginal and Torres StraitIslander Health Workforce NationalStrategic FrameworkThe Aboriginal and Torres Strait IslanderHealth Workforce National StrategicFramework is based on the nine principlesconsistent with the 1989 National AboriginalHealth Strategy (NAHS):●●●●●●●cultural respect;a holistic approach;health sector responsibility;community control of primary healthcare services;working together;localised decision making;promoting good health;● building the capacity of health servicesand communities.The framework identifies five objectives.Objectives 1 and 4 directly relate toAboriginal and Torres Strait Islander medicalworkforce issues:Objective 1: to increase the numbers ofAboriginal and Torres Strait Islander peopleworking across all the health professions;andObjective 4: to improve the effectiveness oftraining, recruitment and retentionmeasures targeting both non-IndigenousAustralian and Indigenous Australianhealth staff working within Aboriginalprimary health care. 288

LITERATURE REVIEW3.4 Recruitment and retention ofIndigenous medical students inAustraliaVery little literature has been published on therecruitment and retention of Indigenousmedical students in Australia. Informationthat is available, is mainly found in articlesand reports concerned with wider Indigenousand often mainstream medical, health,education and workforce issues or in-housepublications of individual universities.Gail Garvey from the University of Newcastlehas produced a number of papers onIndigenous medical student recruitment,retention and curriculum issues in Australia.Her work includes:●●●Garvey G, Brown N. Project of NationalSignificance Final Report: AboriginalHealth A Priority for Australian MedicalSchools. 1999a. 29Garvey G, Rolfe E, Pearson S. Agents forsocial change: the University of Newcastle’sRole in Graduating Australian AboriginalDoctors. 2000. 30Garvey G, Atkinson D. What can medicalschools contribute to improving Aboriginalhealth. 1999b. 31Garvey (1999a) notes in the Project ofNational Significance Final Report: AboriginalHealth A Priority for Australian Medical Schoolsthat...universities exist in partnership with avariety of organisations including schoolsand local communities that can worktowards reconciliation. The responsibility isfar reaching and is much more than simplygraduating competent and caring doctors.While medical schools cannot singlehandedlycompensate Australia’s racisthistory or for the inequitable representationin society of Australia’s ‘minority’ doctors,they can choose to act as agents for socialchange through a variety of academicmeans, including admissions policies andcurricula reform. 323.4.1 Barriers for Indigenous medicalstudentsIn a 2002 Rural Practice article on Indigenouspeople becoming doctors and the obstaclesfacing them, Garvey is quoted as saying that… Aboriginal and Torres Strait Islanderpeople face many obstacles in obtainingsimilar educational outcomes as their non-Aboriginal counterparts … this isparticularly so for health programs,including medicine. 33In this article, Garvey also states that factorsthat may be obstacles to the recruitment andretention of Indigenous medical studentsinclude:●●●●●●●●●●unfamiliarity with the roles andresponsibilities of health professionals,partly as a result of the limited number ofIndigenous health professionals withincommunities;levels of academic achievement that areconsistently lower compared with thegeneral student population;insufficient information regarding entryin to medicine including universitycourses and alternative entry programs;acceptance by medical schoolcommunities for those who have beenaccepted under alternative entryprograms;impacts on family responsibilities ofmature age student usually;impacts on family and communityobligations and responsibilities fromleaving family and community to study;isolation within university and fromfamily and community;learning to adapt to academic andstructured language patterns of medicine;lack of recognition of Indigenous peopleand cultures within curricula;dealing with discrimination andstereotyping;9

Healthy Futures●●financial support; andpressure to go back and practice only inIndigenous communities or organisationsboth from their own community and thewider community.3.4.2 Recruitment and retention studiesVarious studies and publications have beenundertaken by universities, individuals andgovernment agencies on the recruitment andretention of Indigenous medical students.Newcastle UniversityA report on the characteristics of studentsentering Australian medical schools by theAustralian Medical Workforce AdvisoryCommittee (AMWAC) in 1997 34 brieflyconsidered the recruitment and retentionactivities currently being undertaken by anumber of Australian medical schools. Thecommittee identified Newcastle University ashaving the most comprehensive and effectiveapproach through its course promotionactivities, culturally appropriate admissionprocedures and Supportive learningenvironment (see Table 2).Indigenous students in QueenslandA 2000 Queensland study on the role oftertiary education in strengthening Indigenoushealth by Williams and Cadet-James 36 foundthat a number of factors influenceparticipation and retention outcomes forIndigenous students including that:●●●potential students are concerned thattheir level of education is insufficient toallow them to undertake or sustaintertiary study;family and community support may beforthcoming only if they are able toperceive benefits of the study for thestudents and the community and theeducation process; andthe support by fellow students bothduring and after completion of study.Table 2. Approach by Newcastle University to recruitment and retention of Indigenousstudents.Course promotion activities●●●●Promotion of courses by academic staff, Indigenous students and graduates at schoolsand to Indigenous communities and Indigenous community health organisationsAdvertising of courses nationally through relevant media, including Koori mail and radioprogramsProvision of career development days with Indigenous students and graduatesparticipatingDocumentation about admission procedures and the Indigenous Liaison Office in facultypromotion material and the University Admission Centre guideCulturally appropriate admission procedures●●●Processes that are consultative to ensure that students receive family and communitysupport as well as support from the local Indigenous communitiesBroadly defined eligibility criteria that takes into account prior disadvantageRigorous application of final selection criteria, conducted over three days and based on:oooa briefing session followed by the Undergraduate Medicine and Health SciencesAdmission Test (UMAT);a community-based interview; anda structured interview and assessment10Supportive learning environment● A learning environment that provides teaching and research about Indigenous healthissues. 35

LITERATURE REVIEWThe report recommended that:●●●●tertiary institutions consider developingcourses that can be structured to enablethe incremental development of students’skills.whenever possible, educational activitiesshould take place within the community;tertiary institutions adapt admissioncriteria and educational strategies toreflect educational opportunities, bothformal and informal, Indigenous andnon-Indigenous, available in students’communities; andteaching institutions foster thedevelopment and maintenance of thestudent community and facilitate itscontinuing function as a past students’support network. 37Recommendations from this study were basedon the conclusion that recruitment andretention must involve a range of activitiesaddressing the holistic needs of the student.No shame jobNo Shame Job, by Adams (1999) is an easy-toreadbooklet aimed at encouraging Indigenouspeople to pursue a career in health. 38 Itcontains stories and messages from studentsenrolled in health degrees.The objective for putting this booklettogether is to encourage other youngIndigenous people to choose a career inhealth to show that there are many ways toreach you goals and that there is plenty ofinformation, places to study and people togive you advice and direction. 39Kiarna Adams is an Indigenous medicalstudent at the Centre for Aboriginal Medicaland Dental Health at the University ofWestern Australia, a 2001 member of theNational Youth Roundtable and the AIDABoard 2004/05 Student Representative. NoShame Job demystifies the process of applyingto university and other tertiary institutions,addresses common questions and concernsraised by potential applicants and addressesissues such as:●●●●●career choices in health;ways to reach your goals;educational and study concerns;institutional expectations; andhousing and financial assistance.Aboriginal and Torres Strait IslanderEducation PolicyThe Australian Government Aboriginal andTorres Strait Islander Education Policy (AEP)plays a role in efforts to increase therecruitment and retention of Indigenousmedical students. 40 The higher educationinstitutions’ Indigenous Education Statementsstate that improving access for Indigenousstudents is imperative, and that… issues such as disadvantagedbackgrounds, remoteness, financialconstraints and alienation form theeducation sector need to be overcome toensure adequate access for Indigenousstudents. 41Institutions have devised varying programsand initiatives to improve access in theirrespective institution. Some examples ofprograms include:●●●●alternative entry programs;outreach programs;scholarships; andalternative delivery modes.11

Healthy Futures3.5 Recruitment and retention ofIndigenous medical students incomparative countriesA considerable amount of literature isavailable on the recruitment and retention ofIndigenous medical students in comparativecountries and only a summary of thesefindings are presented. The studies andpublications from New Zealand, the USA andCanada considered in this report include:●●●New Zealand: Maori Participation inTertiary Education, by Jefferies, 1999 42 ;Training Needs Analysis for Maori MedicalStudents by Robbins and Tamatea,2001 43 , Maori and Pacific AdmissionsScheme, Te Kupenga Hauora Maori andPacific Health Website, 2005 44 ; andliterature from the University ofAuckland, website including the Vision2020 Strategy.United States: Preparing the Workforce forthe Twenty First Century (Project 3000 by2000) by Ready, 1994 45 ; Indians intoMedicine (INMED) program fromUniversity of North Dakota, 2004 46 , and;literature from the American MedicalAssociation 47 and Indian Health Service 48 .Canada: Aboriginal Health Care CareersProgram, University of Alberta, 2005 49 ;Northern medical school prioritisesaboriginal health, by Crump, 2004 50 ; 5%of Enrolment spots should be filled byNatives, by Haley, 2001 51 , and; literaturefrom the University of British Columbia(UBC) 52 , and the Northern OntarioMedical School (NOMS) 53 .students made up 7.5% and 2.9% of overallmedical enrolments in 2004. Maori andPacific Island numbers have increasedsignificantly in recent years and it is estimatedthat the number of Maori and Pacific Islandmedical practitioners will increase by 18%and 35% respectively in by 2005. 55Maori Participation in Tertiary EducationA study on Maori participation in tertiaryeducation by Jefferies, 1999, 56 identifiedshort- and long-term solutions to the lack ofMaori doctors in New Zealand. Short-termstrategies include●●affirmative action programs;bridging and enabling; and● students loans.Long-term strategies include:● improving overall education outcomes;● changes to career delivery advice;● improving the home environment; and● influencing teachers’ expectations andattitudes.A study by Robbins and Tamatea, 2001, ontraining needs analysis for Maori medicalstudents showed that mentoring, peersupport, personal development, placementwithin Maori health providers, Maori healtheducation and collegiate support were themost important factors for the successfulcompletion of medicine by Maori medicalstudents.3.5.1 New ZealandNew Zealand studies highlight low retentionand success rates by Maori in tertiaryeducation and aim to identify solutions toovercome potential barriers. According to theliterature, Maori doctors made up 2.7% of themedical workforce in New Zealand in 2003and Pacific Island doctors made up 1.1% in2001. 54 Maori and Pacific Island medical12

LITERATURE REVIEWUniversity of Auckland Vision 20/20Vision 20/20 is a University of Aucklandstrategy which includes a goal that by the year2020, 10% of the Auckland Medical Schoolwill be Maori. This program has been inoperation since 1999 and aims to encourageMaori and Pacific Islander school leavers toenter in to the medical school and healthrelatedsciences. Graduates from this programreceive a Certificate in Health Sciences. Oncompletion of this course students are able toapply for medical school or other healthrelatedcourses. 57 To date almost all graduateshave been accepted in to medical and healthcourses at the University of Auckland. In2002, nine of the twenty-seven graduates hadbeen admitted to medicine. 58Maori and Pacific Island AdmissionsSchemeIn order to increase the number of Maori andPacific medical students a separate entrypathway is available within the University ofAuckland through the Maori and PacificIsland Admissions Scheme (MAPAS). Thisprogram was established in 1972 as anaffirmative action program and seeks toprovide a supportive environment wherestudents, their families and staff accept acommitment to academic achievement andcultural integrity. 59 Potential applicants arerequired to demonstrate a high level ofacademic achievement and an activeinvolvement within their communities.The program offers a number of opportunitiesto successful applicants, including:●●●●●additional tutorial assistance;mentoring support;cultural opportunities on campusincluding Pacific language development,involvement in Maori and Pacific healthissues, and links with cultural activitieson campus;the Maori and Pacific fresher camp;support in gaining a University ofAuckland Access Award;●support to access the student learningservice; and● support through shared experiences andopportunities for family members tomeet staff.Successful applicants to this program areexpected to:●●●●●●attend class and complete assignmentwork;seek help early;attend tutorials as required;learn to speak Maori or a language of thePacific;support and mentor other Maori andPacific students;act as role models as future health leadersand representatives for their community;● contribute to the development of theFaculty.The success of the program is identified by thedemand for more places. Early in the programonly three places were allocated each yearhowever evidence suggests this has increasedto nine in 1972, 12 in 1990 and 25 by 2003.Treaty of WaitangiBehind most strategies to increase Maoriparticipation in tertiary education is theTreaty of Waitangi. The University ofAuckland in their Missions, Goals and Strategies(2001) acknowledge and support theresponsibilities and obligations of the Treatyof Waitangi when setting strategic goals. 60They currently have in place a number ofstrategies to increase participation ineducation for both Maori and PacificIslanders. These strategies include:●●recognising that all members of theuniversity community are encompassedby the treaty with mutual rights andobligations;supporting and resourcing the Runanga;13

Healthy Futures●●●●●●●●●●●recognising that significant levels ofdisadvantage accrue to Maori within theeducation sector;increasing numbers and improvingsuccess rates of Maori students at bothundergraduate and postgraduate levels;addressing issues related to access,participation, performance andoutcomes;increasing the numbers and improvingthe qualifications of Maori academic andgeneral staff within specific recruitment,development and retention plans;acknowledging that Maori staff havecommunity obligations that call on theirtime and expertise and recognise theappropriate performance of these throughthe rewards systems of the university;identifying and supporting leading edgeMaori academic initiatives;developing quality academic structuresand innovative programs that supportMaori language, knowledge and culture,and initiating the wananga;increasing the levels of Maori staffparticipation in research and publicationincluding support for innovative researchsuch as Kaupapa Maori approaches;ensuring Maori participation in keyaspects of the management structures andinstitutional life of the university;identifying and supporting individualsfrom departments and faculties who willliaise with the Maori academiccommunity; anddeveloping national and internationalrelationships as appropriate witheducational and cultural institutions andindigenous academic groups. 613.5.2 United States of AmericaThe Centre of American Indian and MinorityHealth website states that of America’s morethan 800 000 practising physicians, only1175 were American Indian in 2005. 62However, overall racial and ethnic minoritygroup (including African American, Hispanicand American Indian) medical schoolmatriculation rates increased 36.3% between1990 and 1994 to 12.4 percent of the totalnumber of medical school matriculations,coinciding with Project 3000 by 2000 andother initiatives. 63Project 3000 by 2000Project 3000 by 2000 was a national ethnicmedical student campaign developed by theAmerican Medical Colleges. It aimed to raisethe number of ethnic students enteringmedical school to 3000 in the nation’s 126medical schools by the year 2000. 64 Theprogram targeted potential students fromminority ethnic groups in high schools,introduced science programs into poorlyequipped schools, and provided mentoringand counselling for university studentsconsidering medicine. However, the projectemphasised that although short-termenrichment programs could contributesignificantly to increased enrolments inmedical schools, … strong academic highschool curriculum and access to a good collegewas more important, since far too fewminority students had access to either. 65Since the commencement of the project, alarge number of medical schools have becomeinvolved in a variety of educationalpartnerships with local school systems,minority community-based organisations andundergraduate colleges. Although the finalproject was unsuccessful in reaching its 3000ethnic medical students by 2000, it wassuccessful in maintaining educationalpartnerships between academic medicalcentres, colleges, secondary schools, andcommunity groups. These partnerships werefound to be key in long-term strategies toincrease the applicant pool of minoritystudents ready to pursue a career in medicine.14

LITERATURE REVIEWDoctors Back to School ProjectThe American Medical Association DoctorsBack to School Project 66 sent ethnic minoritydoctors and students back into theircommunities to attract young minority peopleto medicine by acting as role models andraising awareness. Presentations wereconducted in conjunction with othercommunity activities and different age groupswere targeted including:●●●●kindergarten through to third grade;fourth through to sixth grade;seventh through to ninth grade; andtenth through to twelfth grade.Indians into MedicineThe Indians into Medicine 67 (INMED) is… an academic support program aidingAmerican Indian Students in their quest toserve the health care needs of our nativecommunities.The program offers comprehensive educationand support to American Indian students tohelp them prepare for health careers. Supportservices include academic and personalcounselling for students, assistance withfinancial aid application, and summerenrichment sessions from junior high throughto professional school levels. Over 100American Indian health students participate inthis program each year and another 100attend the INMED annual summerenrichment sessions at junior high, highschool and medical preparatory levels. Most ofthe participants excel in maths and science.The INMED program maintains closerelationships with the University of NorthDakota School of Medicine & HealthSciences, area tribes and several nationaleducation organisations. The American IndianBoard of Directors ensures the programrepresents the Indian populations. Thenumber of Indian students who participate inINMED increases each year and the scopeof the program’s activities are expanding.INMED is making an impact. As of 2005,the program had graduated 163 Indianmedical doctors. 68 A total of 317 Indianhealth professionals have also graduatedthrough the program.Indian Health ServiceOther initiatives developed in the USA havebeen implemented through the Indian HealthService to increase the number of AmericanIndian health professionals in the workforce.The Indian Health Service by law must giveabsolute preference to American Indian/Alaskan Natives when recruiting staff, wherethe applicant has met all qualificationrequirements. The Indian Health Service alsoprovides a number of scholarship programs toAmerican Indian/Alaskan Natives includingthe following.●●●The Health Professions PreparatoryScholarship Program provides financialassistance to students enrolled in coursesthat will prepare them for acceptance intohealth professions schools. Courses maybe either compensatory (to improvescience, mathematics, or other basic skillsand knowledge) or pre-professional (toqualify for admission into a healthprofessions program).The Health Professions Pre-graduateScholarship Program provides financialsupport to students enrolled in coursesleading to a bachelor degree in specificpre-professional areas (pre-medicine andpre-dentistry).The Health Professions ScholarshipProgram provides financial assistance tostudents enrolled in health professionsand allied health professions programs.The recipient incurs obligations andpayback requirements on acceptance ofthis scholarships funding. Priority isgiven to graduate students, and juniorand senior level students, unlessotherwise specified. 6915

Healthy Futures3.5.3 CanadaThe literature suggests there are approximately200 Canadian Aboriginal physicians, whoaccount for 0.3% of the 60 000 physicians inCanada overall. The evidence also suggeststhat most of these physicians are recentgraduates and that this may in part be due to anumber of university initiatives aimed atincreasing Canadian Aboriginal enrolments inmedicine. 70University of AlbertaThe Office of the Aboriginal Health CareCareers Program was instituted by theUniversity of Alberta Faculty of Medicine andDentistry in 1998. 71 The program assistsAboriginal students to gain admission andgraduate from the Faculty of Medicine andDentistry and other Professional HealthSciences Faculties. As of 2001, the Faculty hadgraduated 23 Aboriginal physicians, and morerecent figures suggest that graduations haverisen to 33. 72 The mandate of the program isto:●●recruit Aboriginal students into theFaculty of Medicine and Dentistry andthe other Professional Health SciencesFaculties in order to correct the underrepresentationof Aboriginal physiciansand other health professionals;provide academic, administrative andsocial support and referral to applicantsand students in the program; and● familiarise and sensitise faculty and non-Aboriginal students to Aboriginal healthissues including traditional medicine.The faculty has a national recruitment policyand has recruited Aboriginal students fromacross Canada. The Coordinator of theprogram and Aboriginal medical students andgraduates… present[s] information on the program atnational and regional career fairs,workshops, schools, universities andconferences. 73Recruitment posters featuring Aboriginalstudents are produced annually anddistributed to Aboriginal schools,organisations and interested individuals acrossCanada. 74Northern Ontario Medical SchoolsThe Northern Ontario Medical School(NOMS) 75 targets potential Aboriginalmedical students and exposes non-Aboriginalstudents to Aboriginal issues and communitiesas part of the academic and clinicalcurriculum from their first year of medicine. 76They have also used community forums toidentify five major recruitment and retentionthemes. These include:●●●●●the need for pathways to encourage andnurture Aboriginal peoples into andthrough medical school;the need for knowledge and respect ofAboriginal history, culture and traditions;knowledge and exposure to the resourcesand expertise already available inAboriginal communities;opportunities for collaboration andpartnership between Aboriginalcommunities; andan understanding of the challenges andspecific health priorities of Aboriginalcommunities.The school has already begun to implementthe recommendations, starting from theschool bylaws call for … a minimum of fiveAboriginal representatives on the 35 memberboard of directors. 77 To ensure success ofAboriginal students admitted to NOMS, themedical school is assessing current supportsystems. In addition, non-Aboriginal studentsare exposed to Aboriginal issues andcommunities as part of the academic andclinical curriculum for all first-year students. 7816

LITERATURE REVIEWUniversity of British ColumbiaThe University of British Columbia (UBC) 79allocated 5% of its 128 medical seats forAboriginal students in 2004 and havedeveloped a number of recruitment strategiesand initiatives. Hayley, (2003), reports on astudy conducted by a group of first-year andsecond-year medical students at UBC. 80 Thisstudy found a lack of consistency throughoutthe country in how medical schools developedpolicies and initiatives to recruit and supportAboriginal people. On completion of thestudy the group committed themselves toproviding support to other Aboriginal medicalstudents. The group also developed arecruitment program that encouragedAboriginal high school students to considerhealth care as a career, including:●●●●Aboriginal medical students visiting highschools and talking to Aboriginalstudents;developing posters highlighting the needfor Aboriginal physicians;facilitating a network for high schoolstudents to obtain information aboutapplying to study medicine;linking Aboriginal students withAboriginal medical students andphysicians, thereby providing supportprior to entering medical school; and● a proactive associate Deans of admissionspolicy committeeUBC will also implement a program thatprovides support to Aboriginal students andaddresses the concerns of both theAboriginal community and the medicalschool. The same academic standards applyto Aboriginal people as to other students.However they are only required to achieve50% of the standard criteria for admission.The other half relates to community service,involvement in health care, the approach tothe practice of medicine, letters of referenceand so on.A number of Canadian universities have alsoembedded Aboriginal perspectives into theircurricula. Funding has been made availablefor Aboriginal students, and the need forgreater collaboration with Aboriginalcommunities in the region of medicalschools has also been acknowledged. 813.6 Australian Indigenous doctorand medical student numbersAccording to the AIHW, 2003, there were 90Indigenous Australian doctors compared to48 119 registered doctors in Australia overallin 2001. 82 This indicates that Indigenousdoctors account for 0.18% of the medicalprofession, despite 2.4% of the Australianpopulation being Indigenous. 83DEST data indicates that 102 Indigenousstudents were enrolled in medicine in 2003.CDAMS data 84 indicates that 9233 domesticand international students are currentlyenrolled in medicine in Australia overall.These figures indicate that Indigenous medicalstudents still only make up 1.1% of themedical student population.The AMA commissioned Access Economics 85to undertake a study on the Indigenous healthworkforce in 2004. The Australian MedicalAssociation (AMA) 2004 Discussion PaperHealing Hands – Healing Hands: Aboriginaland Torres Strait Islander WorkforceRequirements,... the AMA believes that to improve thehealth of Aboriginal peoples and TorresStrait Islanders it is critical to increase theproportional representation of this groupemployed within the general healthworkforce. To increase the proportion ofAboriginal peoples and Torres StraitIslanders working as health professionals tonon-Indigenous levels 928 doctors ... need tobe trained.According to the AMA, to fill the gap in 10entry years, fifty Indigenous students wouldneed to enrol in medical schools acrossAustralia each year for the next four years andthen one hundred would need to enrol eachyear after that. This would mean that eachmedical school in Australia would need toenrol three Indigenous students each year forthe first four years and seven each year afterthat. 8617

Healthy Futures4. FINDINGS4.1 Indigenous doctors and whythey pursue medicine4.1.1 Indigenous medical student anddoctor numbersAccording to the findings of the Best PracticeProject, 102 Indigenous medical students wereenrolled in medicine in 2004/2005. Incomparison to DEST figures for 2003 thisindicates that overall Indigenous medicalstudent enrolment numbers did not increasebetween 2003 and 2004.Indigenous medical student enrolmentnumbers have remained at 1.1% of overallmedical student enrolments since 2003 (seeTable 3).The Best Practice Project findings found thatthere were 76 Indigenous doctors in 2004/2005 compared to 90 in 2003 identified bythe AIHW statistics. 88 However, only 28.5%of medical schools surveyed kept an updatedrecord of the number of Indigenous studentswho had graduated in previous years.Table 3. Comparison of Best Practice Project findings on Indigenous medical studentenrolments with data on overall medical student enrolments collected by CDAMS(2004). 87University Indigenous medical Medical students Proportion ofstudents overall Indigenous to(BPP 2004/05)* (CDAMS, 2004) non-Indigenousstudents (%)Bond University 0 n/a** n/aFlinders University 2 387 0.5Griffith University 1 n/a n/aJames Cook University 16 388 4.1Monash University 1 993 0.1Notre Dame University 0 n/a n/aThe University of Adelaide 12 809 1.5The University of NSW 10 1274 0.8The University of Newcastle 24 455 5.3The University of Queensland 6 1029 0.6The University of Sydney 7 935 0.7The University of Tasmania 2 479 0.4University of Melbourne 2 1533 0.1University of Western Australia 19 869 2.1Australian National University# 0 82 0.0Total 102 9233 1.1* Data based on voluntary identification. Numbers may have altered since the course of theproject.** CDAMS does not carry data on privately funded medical schools.# The Australian National University did not participate in the Best Practice Project survey.18

FINDINGS4.1.2 Reasons for pursuing and stayingin medicineIndigenous medical graduates chose to pursuea career in medicine for a range of reasons:●60% of medical graduates stated that itwas their desire to work in Indigenoushealth and with their community;● 86% attributed family members and rolemodels with providing encouragementand support to pursue a career inmedicine.Other factors influencing Indigenous medicalgraduate enrolments in medicine includedmarketing (e.g. seeing posters and articlesfeaturing Indigenous medical students anddoctors), university orientation camps and,collegiate support from Indigenous studentsalready enrolled.I wanted to help my people to dosomething personally to address theappalling state of Aboriginal health.Seeing a poster advertising Indigenouspeople studying medicine.Indigenous medical graduatesAll Indigenous students surveyed in thisproject stated they were determined to stay atmedical school and complete their studiesdespite experiencing many personal,academic, financial and other challenges.I am determined to finish and become adoctor and can’t wait to change the[poor situation of] our health.I have a burning desire to make adifference … I have come this far, I’m notgoing to give up now.I have strong personal commitment to mypeople, they are counting on me. I knowmy success in this will give them thegreatest satisfaction.Indigenous medical students4.2 Existing Indigenousrecruitment and retentionstrategies in AustraliaThe Best Practice Project found thatAustralian medical schools currently employ arange of recruitment and retention strategiesfor Indigenous students (see Figures 1 & 2, seenext page).19

Healthy FuturesFigure 1. Recruitment strategies in Australian medical schools.AdvertisinginformationIndigenousheallthsupportunitIndigenousstaffPre-medical,enabling &bridgingprogramsOrientation/universityprogramsQuotasRecruitmentWHAT WORKS?Community/family linksAlternativeentryRecruitmentworkshopsMentorsSchool visitsRole modelsCareermarketsFigure 2. Retention strategies in Australian medical schools.ProfessionaldevelopmentIndigenousstaffIndigenoushealthsupport unitCollegiatesupportTutoringPracticalequipmentgrantsRetentionWHAT WORKS?Academic,clinicalsupportCommunitypartnershipsRole modelsIndigenouscontent incurriculumCulturalsafetyScholarship& financialassistanceMentors20

FINDINGSMany recruitment strategies draw onthemes similar to those used in retentionand vice versa. However, not all medicalschools employ all of the above strategiesand some do not employ any (see Table 4).Of the 14 medical schools surveyed by theBest Practice Project:●●●●57% have recruitment workshops;86% offer an alternative mode of entry;36% offer enabling or bridging programs;and36% have specific Indigenous health ormedical support units.4.3 Themes in relation to bestpracticeMedical schools with the greatest number ofIndigenous medical students identified acomprehensive approach including thefollowing elements:●●●●●locally based strategies;building relationships with potentialstudents, families and communities;Indigenous medical or health supportunits; andIndigenous staff; anduniversity and school visits.Table 4. Recruitment and retention strategies in use at different medical schools acrossAustralia.Medical schools MS1 MS2 MS3 MS4 MS5 MS6 MS7 MS8 MS9 MS10 MS11 MS12 MS13 MS14Recruitment workshops – – – – – – Enabling/ bridging – – – – – – – – – Identification – – – – – – – Alternative entry – – Subquotas – – – – – – – – Indigenous health units – – – – – – – – – Indigenous staff – – – – – – Scholarships – – – – – – – – – 21

Healthy FuturesMentoring, curricula and cultural safetywere also identified by staff, medicalstudents and graduates as integral to bestpractice. However, they said that not all ofthese elements were being implementedeffectively. The findings indicate that thethemes in relation to best practice are:●●●●●●●personal contact and communityengagement;university and school visits;Indigenous health support units;Indigenous staff;mentoring;curricula; andcultural safety.4.3.1 Personal contact and communityengagementThe importance of maintaining personalcontact, building trust and developingsupportive relationships, partnerships andnetworks was identified by all Indigenousstudent support workers as the mostimportant strategy for attracting Indigenousstudents to medicine and retaining them.… face to face contact visits as they givepersonal stories, detailed information andprogram and institution specific details.… personal contact, communityengagement … word of mouth.Indigenous student support workers on themost successful strategiesBest practice Indigenous health supportunits currently involve Indigenouscommunities in a number of ways,including:●●●●●●consulting, developing and implementingrecruitment and retention strategies withlocal community representatives;involving Indigenous communitymembers in the medical studentinterviews, selection processes andsupport;encouraging Indigenous communitymembers to regularly teach Indigenoushealth and cultural issues;providing regular opportunities forstudents to visit Indigenous communitiesand health services to talk withcommunity members and listen tocommunity issues;arranging clinical placements inAboriginal Medical Services (AMS); andmedical (or health school) staff buildingrelationships with local Indigenouscommunity members and families andregularly providing information onmedicine, higher education and medicalcourses.The community [members are] involvedwith the admissions interviews, delivery ofAboriginal Health curriculum, [and are]guest speakers etc. All medical studentsare offered to do electives with Aboriginalmedical services and communities inurban, rural and remote locations.Community research partners have beendeveloped [and there is] comprehensivecommunity engagement [and]representation on community boards.Indigenous student support worker at amedical school with a high number ofIndigenous students22

FINDINGSHowever, Indigenous medical graduates alsowarned against tokenistic and unsupportedcommunity involvement. This included notadequately preparing Indigenous communitymembers for the challenges of teaching intertiary institutions and concerns that contactwith communities was not comprehensive andappropriate.… you can’t just throw [communitymembers] in the deep end.… on paper it looks like they do a lot ofcommunity activities, but attendingNAIDOC week once a year is not enough.Indigenous medical graduatesOther issues raised by Indigenous studentsupport workers included frustration over lackof time to ‘get to the community’ due to otherwork pressures and concerns that theimportance of community involvement wasnot adequately valued by the medical schoolas a whole.Personal contact, building trust anddeveloping supportive relationships,partnerships and networks is the mostimportant strategy for attracting Indigenouspeople in to medicine and retaining them.4.3.2 School and university visitsSixty-seven percent of Indigenous studentsupport workers emphasised the importanceof engaging with primary and secondaryschool students regularly and in a number ofdifferent ways, depending on their age. Theseincluded:●●●●Indigenous medical students and doctorsvisiting schools and communities to talkabout medicine;Indigenous medical students and doctorsacting as role models and mentors foryounger children;primary and secondary students visitingmedical schools and universities fororientation days, and summer and healthcamps;arranging different recruitment activitiesand strategies for different age groups;and● regularly attending Croc festivals, Vibe 3on 3s and other local career festivals.Each of our strategies target differentpotential students. The year 8, 10 and 12camps are probably the best for schoolage. Word of mouth for older students.Media ads … [for] career options.Indigenous medical student supportworkerPlanned visits to the medical schools, touringthe school’s facilities and meeting faculty staffwere identified as significantly contributing tothe recruitment of Indigenous people tomedicine and/or other health fields.School contact, building relationships withprospective students, Indigenous specificcareer events and word of mouth.The building of relationships with both theprospective student and with theirfamilies is of paramount importance.Indigenous student support worker23

Healthy FuturesA number of these activities are also held inconjunction with other faculties anddisciplines within the university, particularlyin health.… we don’t really mind which course theyend up in – as long as they’re happy withtheir choice and believe in themselves.Indigenous student support workerThe need to engage with Indigenous childrenfrom an early age was emphasised by manyparticipants. However, many Indigenousstudent support workers felt that moredefinite government strategies and policieswere needed in this area. For example, anumber of workers were concerned thatschool careers advisors were steeringIndigenous students away from university andtowards technical qualifications.… we don’t really mind which course theyend up in – as long as they’re happy with theirchoice and believe in themselves.4.3.3. Indigenous health support unitsWhile 86% of the 14 medical schoolssurveyed for this project had links withgeneral Indigenous Support Units, only 36%had Indigenous health support units and 14%had Indigenous medical support units,depending on if they were part of a faculty ofhealth or medicine.The medical schools with Indigenous healthor medical support units have the mostIndigenous medical students enrolled. Forexample, the medical school with the longestestablished Indigenous health support unit hasthe highest number of Indigenous students.Another newly established medical school thathas strong links to an Indigenous healthsupport unit, attracted a significant number ofIndigenous medical students in their first yearof operation.Fifty-seven percent of the students interviewedduring this study rated Indigenous health ormedical support units as their main criteriafor choosing to attend their particularuniversity, equal only to being close to home.The support needs they identified as receivingfrom Indigenous Health Support Unitsincluded:●●●●●●mentoring and clinical guidance;access to Indigenous health staff anddoctors (internal and external);transition and career/professionaldevelopment support;opportunities to sustain and maintainrelationships with other organisations/departments that support and nurturetheir personal development in medicine,such as AIDA;links to other social, emotional,academic, financial and cultural supportservices;access to computers, internet, printers,photocopiers, and health and medicallibrary resources;24

FINDINGS●●●●●tutorial rooms specifically for Indigenoushealth and medical students;tutorial and other assistance in preparingfor assessments and exams;information about specific health andmedical scholarships and grants;assistance to attend health conferencesand educational meetings;information on cadetships, and assistancewith holiday employment; and● collegiate and social activities such asbarbeques, sporting activities andcommunity/university events.The location of these units appeared to beintegral to their success. For some, thelocation was within the medical school, whilefor others it was within the wider Indigenoussupport unit. Importantly, these units neededto be perceived by students to be convenientand easy to access.Indigenous health support unit is physicallylocated within the medical school.[Indigenous medical support unit] and[general Indigenous support Unit] are colocated… this is pivotal to the success ofthe recruitment, retention and support ofstudents.Co-location of support units also providedfor greater access to and sharing of resources.Co-location also provided importantsupport to the Indigenous staff.However, a number of concerns aboutexpectations that Indigenous support unitswill ‘do everything’ were raised by staff andstudents. In particular, many Indigenoussupport workers felt there was a tendency formedical schools to delegate ‘everythingIndigenous’ to the support unit, including allrecruitment, retention, support andpromotion activities. Workers felt this placedtoo much demand on the unit (which mayoften only have one part-time staff member)and meant they had less time to spend withthe students. This was also reflected incomments from students and graduatesYes, they might have a great [Indigenous]support unit.. but no one is ever there.Indigenous medical studentFifty-seven percent of the students ratedIndigenous health or medical support units astheir main criteria for choosing to attend theirparticular university.Indigenous student support workers25

Healthy Futures4.3.4 Indigenous medical school staffTwenty-two Indigenous academic and generalstaff are employed across the 14 medicalschools in Australia, but most of these areworking part-time or on a casual basis.Indigenous staff, both academic and general,provide invaluable contributions to therecruitment and retention of Indigenousmedical students, including:●●●●●●●experienced academic, clinical andemotional support;mentoring and role modelling;cultural safety;shared personal, academic, and culturalexperiences;trust and confidence both with studentsand wider Indigenous community;sensitivity to racism, discrimination,impact of history;advocacy and links with other Indigenoussupports; and● understanding of family, community andcultural needs and issues.Medical schools with the greatest numbers ofIndigenous students employ significantlymore Indigenous staff. They also employIndigenous doctors to both teach and supportIndigenous students. For example, onemedical school employs two permanentIndigenous doctors and one non-Indigenousdoctor, two of whom are available on a fulltime basis. Another medical school has twofull-time Indigenous support workers andIndigenous doctors regularly taking up shorttermteaching and support positions.… being able to talk to an Indigenousperson about any issues that might arise.… knowing that if they’re there and thatthey’ll go out of their way to help me.Indigenous medical students on thebenefits of having Indigenous staffmembersHowever, the findings indicate that manyIndigenous staff employed across the medicaland/or health faculties, feel overworked andunder pressure to address the substantial issueof Indigenous medical student recruitmentand retention on their own or with very littleassistance.[we have] … a ridiculous workload thatincludes teaching across the entire school,research, publications, student support,clinical and community responsibilities.… it is impossible to implement[recruitment, retention and curriculum]strategies while there is only one singularfractional appointment in Indigenoushealth.Indigenous student support workerThe demands placed on Indigenous staff arecomplex and wide ranging. Their rolesinclude:●●●●●●●●●●●●●●●●student teaching;Indigenous student support;marketing, recruitment, and selection ofstudents and staff;academic, personal, economic and careercounselling;tutoring in study skills;curriculum development;internal and external advisory functions;funding and budget responsibilities;managing and coordinating staff andstudents;community engagement andresponsibilities;mentoring students;supporting non-Indigenous studentsstudying Indigenous health;research;professional development seminars;conference presentations, publicspeaking; andadvocacy.26

FINDINGSA number of concerns and pressures werereported by Indigenous staff within medicaland health faculties. These included:●●●●●●●●●●●●●●●●●usually short-term employment contracts;externally funded employment contracts;lack of job security;high staff turnover;lack of program stability and staffcontinuity;lack of access to experienced Indigenousstaff;confusion and inequities in positionclassification, salary levels;multiplicity of tasks, roles andresponsibilities;work overload;pressure to seek alternative fundingsources for student recruitment, retentionand staffing;career development including access topromotional structures;lack of opportunities for careerdevelopment and promotion;relationship to the institution, includingisolation, lack of communication, lack ofrecognition from peers and lack ofsupport;tokenism;inadequacy of physical resources oftenresulting in overcrowding, inadequateequipment and resources;lack of cultural safety for staff; anddealing with racism and discriminationwithin the university.4.3.5 MentoringWhen asked about the support they wouldlike during their degrees, 43% of surveyedIndigenous medical students identifiedmentoring. Mentoring is important both forproviding support to students during theirdegree and guiding graduates in theirprofessional development and negotiating thehealth workforce.This [mentoring] is most important, youneed to be able to talk to someone who isa doctor and has undergone what youhave gone through. This mentorship wouldalso be very useful for junior doctors to beable to talk to a senior doctor.The contact with people who are here orwho have studied here seems to be themost successful, and it provides theongoing support and guidance.Indigenous medical graduates andstudent support workerAlthough 50% of Indigenous medicalstudents had a mentor, most of these hadsought that person out for themselves.I have just sourced my own mentor.Found [mentor] myself – or rather he askedme if I would consider him to be mymentor.Indigenous medical students… it is impossible to implement [recruitment,retention and curriculum] strategies while thereis only one singular fractional appointment inIndigenous health.27

Healthy FuturesStudents and graduates tended to refer tomentoring and role modelling as meaning thesame thing.Role models that can act as mentors andcareers guidance in the medical world.… [mentoring] is always helpful to see thatother role models have gone before andachieved.Indigenous medical graduatesMentoring is most important, you need to beable to talk to someone who is a doctor andhas undergone what you have gone through.4.3.6 Indigenous content in medicalcurriculumAlmost all Indigenous medical studentssurveyed in this project (there was oneexception) were disappointed with the lack ofIndigenous content in the medical curriculumand the inappropriateness of that content.… there was only one case study in twoyears and it came at the worst time wheneveryone was preoccupied [with otherwork] … it was low priority.… pathetic – one lecture and discussionpanel given in fourth year.… it is limited and paternalistic in nature …a strongly biased western focus.In 2004, CDAMS Indigenous HealthCurriculum Project developed the nationallyagreed Indigenous Health CurriculumFramework for the inclusion of Indigenoushealth into core medical curricula. Thisdocument has been endorsed by all Deans andis included in the Australian Medical Council(AMC) accreditation guidelines. This willrequire all medical schools to report on theimplementation of the CDAMS Frameworkas part of their accreditation process. CDAMSis currently in the second phase of this projectwhich involves supporting medical schools inthe development and implementation ofIndigenous health content into their curricula,using the Indigenous Health CurriculumFramework as a guide. 89Some medical schools have already beenembedding Indigenous curricula in theirmedical courses where possible. These schoolscurrently have the most Indigenous medicalstudents enrolled.… pathetic – one lecture and discussion panelgiven in fourth year.In 2004, CDAMS Indigenous Health CurriculumProject developed the nationally agreedIndigenous Health Curriculum Framework forthe inclusion of Indigenous health into coremedical curriculaIndigenous medical students28

FINDINGS4.3.7 Cultural safetySixty-six percent of Indigenous medicalstudents surveyed for this project said theyexperienced racism and discrimination. Sixtyfourpercent felt that they were not supportedadequately by their medical school. Lack ofsupport was often equated with the absence ofan Indigenous health support unit and lack ofIndigenous staff. In medical schools wherethere are limited numbers of Indigenous staff,some students said they were being left toteach non-Indigenous staff and students aboutIndigenous cultural issues and handleconfronting attitudes towards Indigenouspeople.We [Indigenous students] were separatedinto groups and left to describe andeducate other students [about Indigenousissues] … this can be confronting at times.Indigenous medical studentIndigenous medical graduates also reportedexperiences of racism and discrimination in anumber of forms.Odd comments … that I had failed allexams but [was] only allowed to continuebecause I was ‘blackfella’.Following successful completion of [a verydifficult specialist exam] one colleaguecommented ‘you only got through cos’you’re black’.[I was] often made to feel inferior by otherstudents and/or faculty members, [saying]that [I] ‘must be dumb’ because [I] onlygot into the course because [I’m]Aboriginal.Individuals who entered medicine viaalternative entry said that they were exposedto discrimination by staff and peers whoimplied they were given ‘special treatment’and were not good enough to compete withthe rest of the applicants. Students also saidthey experienced racism and discriminationbecause of the way they did or apparently didnot ‘look’.Many think we have a lot of benefits andopportunities that others don’t get.Students are always sceptical ofIndigenous students and their entrancecriteria.Having a mixed cultural background andnot looking traditional provides for somenot thinking I am Indigenous, this is verystressful.Indigenous medical studentsIn comparison to cultural awareness, culturalsafety maintains that individuals are diverse. 90It is based around attitudinal change,respecting an individual’s cultural values andaddressing issues surrounding powerimbalance. Cultural safety aims to identifyattitudes that may exist, either consciously orunconsciously, towards cultural differences,allowing individuals to see the impact theseattitudes have on others and attempt tochange those attitudes.Sixty-six percent of Indigenous medicalstudents surveyed for this project said theyexperienced racism and discrimination.Indigenous medical graduates29

Healthy Futures4.4 Other themes in relation torecruitment and retention4.4.1 PromotionAdvertising and available informationAccess to clear, concise and culturallyappropriate information on medicine andmedical degrees, targeted at different age andsocial groups was identified as critical byIndigenous support workers and students.Two Indigenous graduates said that it wasadvertising featuring pictures and informationby Indigenous doctors that first encouragedthem to pursue a career in medicine.I saw a poster up at [a universityIndigenous support centre].[I] saw an advertisement in the papercalling for Indigenous people to enrol inmedicine.Indigenous doctorsHowever, Indigenous student support workersand medical students said that not enoughadvertising and information about how to getinto medicine is available. They identified theneed for both general and Indigenous-specificmedia involvement, advertising andinformation brochures in order to get theirmessages across.I think that very few Indigenous HSCstudents are aware that Indigenousmedical entry programs even exist, most ofthe time if they do, none actively seek outthe information and they miss out’.There needs to be info sharing around howto get into medicine and this informationneeds to be culturally appropriate.Wider advertising and encouragement [is]needed to increase [the] number ofapplicants.Only 21% of the medical schools advertisedtheir course through one or more of thefollowing forms of Indigenous media:●●●●●Koori Mail;Torres News;Indigenous Times;Yamatji News;Aboriginal and Islander Health WorkerJournal; or● Indigenous radio service.Other low cost advertising included:● university newspapers/letters;● Aboriginal Health Organisationnewsletters;●mailouts to schools and organisations.… [there needs to be more] utilising ofIndigenous communications and media.Indigenous student support workerThe university’s generic Indigenous SupportUnit usually develop Indigenous advertisingmaterial for both mainstream and Indigenousmedia. In some cases this is done incollaboration with mainstream marketingdepartments. However, anecdotal evidencesuggests it is uncommon to see Indigenouspeople featuring in mainstream universitypromotional material.I think that very few Indigenous HSC studentsare aware that Indigenous medical entryprograms even exist, most of the time if theydo, none actively seek out the information andthey miss out.Indigenous student support worker andmedical students30

FINDINGSSchool careers advisorsAnother issue raised during the project wasthe lack of or inappropriate advice provided toIndigenous students by career advisors withinhigh schools. Two Indigenous support workersfelt that there was a tendency among someschool career advisors to assume thatIndigenous school students were not capableof entering and/or achieving in tertiary studiesand medicine in particular. They said thatschool careers advisors often seemed to steerIndigenous students towards TAFEqualifications and careers instead. They feltthis was partly due to school careers advisorsnot being well enough informed or committedto advancing career opportunities forIndigenous people.Working with career counsellors doesn’tseem to have much of a positive impacteither, I think that the old ways of believingre: Indigenous students academiccapabilities is still around.… the information is mailed out to careersadvisor[s] and they may not receive it,read it or do anything about it …Indigenous student support workersSchool careers advisors often seem to steerIndigenous students towards TAFEqualifications and careers.Mature age entryTwenty-nine percent of Indigenous medicalstudents surveyed for this project highlightedthe need to focus more on mature age studentsand students from other disciplines whenrecruiting Indigenous medical students.… scour the biomed and health sciencedegree students … and show them howthey could do med after their degree.… recruit mature age students fromcurrent health workers and nurses.… there still seems to be a large proportionof mature age students that could betargeted better.Indigenous medical students commentingon recruitment issuesIndigenous support workers also identified theneed to reach out to mature age studentsmore, particularly for graduate entryprograms.… there needs to be information forpeople who are not at schools oruniversities but could apply.Indigenous student support workerSome university representatives at the LIMEConnection workshop felt there is not a bigenough pool of graduates to recruit tomedicine. Other representatives argued thereis a great untapped pool of potential matureage entrants and that students enrolled inother university degrees and people in theworkforce needed to be more effectivelytargeted.… there still seems to be a large proportion ofmature age students that could be targetedbetter.31

Healthy FuturesPre medical, enabling and bridgingprogramsOf the 14 medical schools interviewed onlytwo offered a pre-medical program toIndigenous students and five deliveredenabling or bridging courses thatcomplemented entry into medicine. ThreeIndigenous medical students said they choseto enrol at their particular university becauseof the pre-medical or bridging programoffered.It happened somewhat accidentally, I wasactually thinking of enrolling in [anotherdegree]. I went on a trip to a couple ofunis and [one university] offered a newentry scheme for Aboriginal studentswanting to do medicine.Indigenous medical graduatePre-medical programs are short term andoffered to Indigenous people either thinkingof applying to do medicine or about tocommence first year. Enabling and/orbridging courses are usually offered to provideIndigenous students with the necessary skillsto undertake a medical or other health degree.Both options provide Indigenous studentswho may not be ready to go straight intomedicine with the opportunity to improvetheir chances of being accepted in thefollowing year. These courses are developed to:●●●●provide educational pathways forstudents lacking traditional qualificationsfor entry into university;prepare for university study, students whorequire additional preparation throughfoundation skills and knowledgedevelopment, confidence building and/orawareness;assist prospective students with thetransition into higher education, andhence better position students forpersistence and success; andgenerally promote widening participationin higher education and breaking downof traditional barriers to study. 914.5 Admissions4.5.1 Alternative entry schemesAll universities offer an alternative mode ofentry to students who are from disadvantagedgroups or mature aged. While someuniversities have Indigenous-identifiedalternative entry schemes, government policyon increasing access and participation tohigher education includes … conductingalternative selection procedures andrecommending on admissions for a range ofdisadvantaged groups. 92 Indigenous peopletherefore fall under the ‘disadvantaged’ ormature age category and can apply touniversity under alternative entry, as can manynon-Indigenous people.Ninety-three percent of medical schoolsrequire applicants to sit the GraduateAustralian Medical School Admissions Test(GAMSAT) / UMAT before they apply foralternative entry. Applicants who are eligiblecan then apply to the medical schools underthe alternative entry scheme. In many casesthis means that students’ qualifications forentry into medicine are assessed according totheir GAMSAT/UMAT score, year 12 scoresand an interview. Factors taken intoconsideration in interviews include prioracademic performance, life and workexperience, contribution to community,references, and commitment to medical andhealth issues. Medical schools may alsorecommend that students spend a year or twoin a Bachelor of Science or other relevantbridging course before transferring tomedicine. For Indigenous applicants,Indigenous community representatives may beasked to participate in interviews as panelmembers, applicants may be able to bringalong a family member and community-basedinterviews may also be offered. However, ingeneral, alternative entry methods are notexclusive to Indigenous people.32

FINDINGS4.5.2 Quotas for Indigenous medicalstudentsOnly six medical schools have identifiedplaces available for Indigenous medicalstudents. The number of places available forIndigenous medical students range from onestudent to a maximum of eight. Howeversome medical schools will take moreIndigenous people if they apply. The medicalschools with the greatest number of identifiedplaces have the greatest number of Indigenousstudents enrolled.However, identified places for Indigenousstudents are only subquotas. This means thatthe places offered to Indigenous students arenot extra and must be accommodated withinthe medical schools’ overall student quota. Italso means that if not enough Indigenousstudents apply to medicine, these places canbe re-allocated to non-Indigenous applicants.Thirty-six percent of Indigenous students saidthat current quota arrangements lead toperceptions that Indigenous students whoapply via alternative entry are ‘taking away’places that could be going to non-Indigenousstudents who have applied through standardprocesses.4.5.3 GAMSAT and UMATNinety percent of medical graduates feltstrongly that the GAMSAT and UMAT testswere not an effective way of recruitingIndigenous students to medicine. Althoughthe tests are said to be developed and designedin a culturally fair and equitable way 95 manybelieved the tests were not appropriate,particularly for Indigenous Australians.GAMSAT is a real issue, whether it is aculturally appropriate tool, very westernparadigm.… other people can have a similarworldview to Indigenous peoples but onthe whole I think the admission processfavours white middle/upper classapplicants.Indigenous student support workersI never felt like I belonged, I always felt likean outsider. Medicine was full of extremelywealthy people that looked down on me[saying] …’you took my friend’s spot inmedicine’.Indigenous medical graduateThe Australian Medical Association 2004discussion paper, Healing Hands – Aboriginaland Torres Strait Islander WorkforceRequirements, has called for full scholarshipsfor all Indigenous medical students. 94I never felt like I belonged, I always felt like anoutsider. Medicine was full of extremelywealthy people that looked down on me[saying] …’you took my friend’s spot inmedicine’.33

Healthy FuturesThese participants felt that the tests wereculturally biased and did not take intoaccount cultural differences, historical events,language barriers and the health andeducation status of Indigenous Australians andother minority groups (see Table 5).Table 5. Example of a UMAT question andcomments on its appropriateness forIndigenous applicants. 96SECTION 1: LOGICAL REASONING ANDPROBLEM SOLVINGQUESTION:The life expectancy of Australian women isabout 82 years, double that of women in the1850s. While the average age of menopause(the end of fertility – generally about 50 yearsold) has remained steady over this time, thatof menarche (the onset of fertility) hasdropped markedly.From this information, it follows that:A) the likelihood of women conceivingduring their fertile years has decreased.B) women are, on average, having fewerchildren during their fertile years than theydid in the 1850s.C) for women who live to menopause, thenumber of years during which they canconceive children has increased.D) Australian women are living, on average,about the same number of years aftermenopause as they did in the 1850s.There is no specific program to supportapplicants, Indigenous or not, in preparing forand undertaking the UMAT/GAMSAT orinterview process. However, anecdotalevidence suggests that private tutoring in theGAMSAT/UMAT is available to mainstreamapplicants who can afford it. This can createfinancial barriers for Indigenous students whomostly cannot afford these costs and who alsooften live outside the test centre areas.Now, those that can afford it, can get allthe preparation they can buy [forGAMSAT/UMAT].… have a GAMSAT venue in a rural areaand offer financial travel assistance to getto the interviews.Indigenous medical studentsHowever one Indigenous support unit didoffer some assistance in preparing for theapplication process.ISU and Indigenous Health Unit haveoffered tutoring in the interview processand if students were identified early theycould contact and discuss/tutor for UMAT.Indigenous student support workerNow, those that can afford it, can get all thepreparation they can buy [for GAMSAT/UMAT].COMMENT:This UMAT question excludes Indigenouswomen as ‘Australian Women’. Lifeexpectancy for Australian Indigenous womenis approximately 20 years lower than for otherAustralians. Over the period 1998-2000, thenational perinatal mortality rate for babiesborn to Indigenous women was twice as highas that for babies born to non-Indigenouswomen. 9734

FINDINGS4.5.4 IdentificationAll Australian Medical Schools identifiedIndigenous students through the admissionsprocess. However, only half the medicalschools require applicants accessingIndigenous services to provide supportingevidence of their identity includingconnection to community.Medical schools that require proof ofidentification may do so through theirIndigenous support unit. These Indigenoussupport units often require candidates toprovide confirmation of their Indigenousidentity in order to access Indigenous specificprograms. In most cases this involvesindividuals completing a ‘Confirmation ofAboriginality’ form, which must be endorsedby an Aboriginal and/or Torres Strait Islandercommunity organisation. The form is usuallybased on the government ‘three-partdefinition’ which requires information ondescent, self-identification and communityrecognition. 98When collecting information on the numbersof Indigenous people in Australia,identification is only provided by individualson a voluntary basis. This is the same for thoseapplying for entry into tertiary institutions.There area isolated cases where non-Indigenous people have unintentionallymarked the ‘Indigenous box’ during thetertiary admissions application process. Inthese instances, the Indigenous Support Unitsusually identify these individuals and steerthem in the right direction. Anecdotalevidence suggests that some non-Indigenousindividuals have taken advantage of alternativeentry options for Indigenous Australians bydeliberately marking the ‘Indigenous’ box.Identification is a sensitive issue. Somemedical schools asked for guidance on ways toaddress identification issues during selectionprocesses.4.6 Support4.6.1 FinancesEighty-six percent of Indigenous medicalgraduates interviewed during this studyidentified financial hardship as one of thedifficulties they experienced during theirstudies. Three graduates surveyed mentionedthat they had deferred training during theircourse for financial reasons.Financial support is a big thing especiallywith six years out of the workforce. This is abig burden especially for older studentswith families where the financial impact isnot just on personal compromise butcompromises the family as well.Indigenous medical graduateGraduates interviewed in this study stated thatfinancial support during studies comprisedsome form of government assistance(Abstudy), scholarship, grant or employment.All graduates interviewed said that they hadbeen employed in part-time work at somepoints during their university life (Figure 3).Figure 3. Financial support received byIndigenous medical students during theirdegree.Number of people20151050AbstudyScholarshipEmployedAnecdotal evidence suggests that some non-Indigenous individuals have taken advantageof alternative entry options for IndigenousAustralians by deliberately marking the‘Indigenous’ box.35

Healthy FuturesGraduates indicated that they often supportedother extended family members or youngersiblings during their studies and were expected toassist relatives with medical or other healthproblems. They also said that they struggled withbasic resources such as computers, printers, emailaccess and travel costs.Eighty-six percent of Indigenous medicalgraduates interviewed during this studymentioned financial hardship as one of thedifficulties they experienced during theirstudies.4.6.2 ScholarshipsOf the 14 medical schools interviewed onlyfour offered direct access to medical-specificscholarships, bursaries or grants forIndigenous medical students. The amountsoffered through these schemes ranged from$1000 to $6000. Other scholarships areavailable through state and nationalgovernment and non-government schemessuch as the Puggy Hunter Scholarship, RotaryGrants and the AMA Indigenous medicalscholarship. The findings indicate that 59% ofIndigenous graduates had received scholarshipassistance during their medical degree.Indigenous medical students and graduatesfelt that more scholarships should be availablefor Indigenous medical students in the future.Scholarships can also be adversely affected ifa student fails a year of the course and isrequired to repeat the year. Variousscholarships are bonded and also remaintaxable and therefore affect student’s Abstudypayments. 99The AMA has called for fully funded trainingplaces and full scholarships to close the gapbetween Indigenous and non-Indigenousparticipation in the health workforce. 100Scholarships need to be designed in a waythat it does not affect Abstudy paymentsnor delete any social security benefits orincur penalties through academicdifficulties.Careful consideration to bondedscholarships is needed to prevent stiflingpostgraduate vocational training.Indigenous medical graduatesThe AMA has called for fully funded trainingplaces and full scholarships to close the gapbetween Indigenous and non-Indigenousparticipation in the health workforce.…[we need] more scholarships/governments support.[we need] … HECS free - fully paid andfunded medical degrees.Indigenous medical students36

FINDINGS4.6.3 Tutorial assistanceSeventy-six percent of Indigenous medicalstudents identified tutorial assistance as one oftheir main support needs. However, manystudents found the process of applying for theIndigenous Tutorial Assistance Scheme (ITAS)(formerly Aboriginal Tutorial AssistanceScheme) difficult and time consuming andtherefore a disincentive. While some studentsfelt the Indigenous support units wereresponsible for the difficulties of obtaining anITAS tutor, in many instances this is not thecase. Finding appropriate tutors and endlesspaperwork is a time consuming process andone which is tied to funding agreements.Finding tutors and completing paperworkis a huge process and one which is tiringand a particular disincentive toparticipating in the program.… having to beg for assistance is notproductive.… in first year, a [professor] said he wouldhelp arrange some tutoring, butbureaucratic paperwork always made itimpossible … I gave up asking.Indigenous medical studentsFurthermore, many students said that the wayITAS was structured and provided was notsuitable for medical students. In particular,they argued that ITAS did not recognise thatmany of their courses were the equivalent of anumber of courses combined and shouldtherefore attract more than the minimumnumber of tutorial hours per course.Indigenous medical students also said that,in some cases, the kind of tutorial supportthey were getting was not appropriate. Theyemphasised the need for medical specifictutorial support from medically trained tutors,Indigenous or not.… [tutoring] not suited to medical students… [and tutors] do not understand thespecial needs.… [tutoring has to be] led by a tutor who isup to date with the curriculum of thecourse.Indigenous medical studentsHowever, some medical schools haveimplemented strategies to provide intensivesupport to Indigenous medical students inthe first few years of their degree. To addressdifficulties with tutorial support, oneuniversity employs a medically trained tutorto work part time with the Indigenousmedical students.The program [ITAS] is designed for standarduniversity courses and takes no considerationfor medicine courses which have a differentstructure to mainstream courses.The ITAS unit was not at all supportive ofmedical students because our subjectswere an all in one subject. They did notunderstand the amount of time weneeded in tutorials and the diversity ofsubject material that needed to becovered.The program is designed for standarduniversity courses and takes noconsideration for medicine courses whichhave a different structure to mainstreamcourses.Indigenous medical students37

Healthy Futures4.6.4 Collegiate supportAll Indigenous medical students with oneexception said that they would like moreopportunities to work in groups with otherIndigenous students. Students said that groupactivities provided them with opportunities towork, study, socialise and talk about issueswith other Indigenous medical students in anon-judgemental way.… [the] communication is better … [we]can discuss ideas.… we provide a more comfortable nonjudgmentalenvironment to study and giveeach other support.… this is a great way to build relationshipswhich are enduring beyond theparameters of medical school and whichgive rise to the opportunity ofunderstanding … experiences andappreciating strengths …Indigenous medical studentsCollegiate support is often provided throughthe university Indigenous support units.However, many Indigenous medical studentsfelt the need for more specific support groupsthat focused on their needs as medicalstudents.The [Indigenous medical] students have byand large supported each other. We havedevised a strategy that enables us tounderstand what we really needed tostudy.Indigenous medical studentSome Medical Faculties and Indigenoussupport staff provide Indigenous medicalstudents with regular opportunities to gathertogether for both social activities and learningopportunities. At one university, Indigenousand non-Indigenous doctors hold regular extraclinical tutorials for Indigenous students onthe weekends.… [we have Indigenous student specific]weekend tutorials – including simple andcommon CXR, AXR, ECGs, practisingexamination skills and presentation skills toa Doctor.Indigenous medical studentCollegiate activities provided by AIDA werealso mentioned favourably by Indigenousstudents and graduates.… having an affiliation with AIDA, learningwhat I have and knowing that some dayI’ll make a difference.One student on their biggest reward inmedicine so farI want to be able to continue to developthe relationships I have with otherAustralian and International IndigenousDoctors which is something I have beenable to achieve through the fantasticsupport which has been provided throughAIDA.Being involved in the ongoing processes ofAIDA is something I have been veryrespectful of and look forward tocontinuing for many years!Indigenous medical students andgraduates38

FINDINGSAIDA provides Indigenous medicalundergraduates and graduates with regularcollegiate activities such as:●●●●the AIDA Annual General Meeting andHealth Symposium;regional AIDA dinners and activities;regional student dinners and activities;andopportunities to participate inrepresentative activities such as Crocfestivals and Vibe 3 on 3.… this is a great way to build relationshipswhich are enduring beyond the parametersof medical school and which give rise to theopportunity of understanding … experiencesand appreciating strengths …4.6.5 Career progression anddevelopmentIndigenous medical graduates said thatchallenges in pursuing vocational training andentry into specialist colleges hindered theirprofessional development.However, graduates also said that they feltpressured from both Indigenous and non-Indigenous people to work purely in the areaof Indigenous health and within theircommunities.… Indigenous students/doctors have anadded burden either real or imagined, thisburden to ‘work with your people’, insteadof being a pathologist (for examplefollowing your own dreams). This burdenseems to come from your fellow medicalstudents (for whom you are the firstIndigenous person they have ever met),from well-meaning community members,from some consultants etc.It is important as a workforce that we notonly have Indigenous doctors in AMSs butwe have Indigenous doctors as surgeons,intensive care specialist and cardiologistsas well.Indigenous medical students andgraduatesIt is important as a workforce that we not onlyhave Indigenous doctors in AMSs but we haveIndigenous doctors as surgeons, intensive carespecialists and cardiologists as well.… further training and specialisation isexpensive, prolongs entry into theworkforce and means longer time awayfrom family and community.[it was difficult] explaining to my extendedfamily that I want to pursue further trainingbefore I go home to practice.Indigenous medical graduates39

Healthy FuturesLIME Connection statement of outcomes and intent4.6.1 Outcome 1Funding and resources will be key to developingand implementing quality curriculum and studentsupport outcomes.Intent – Develop a funding strategy that is alignedto the agreed resourcing responsibilities betweenmedical schools, DoHA, DEST and other partners.4.6.2 Outcome 2Leadership among Deans, medical educators,Indigenous community representatives, policymakers and medical colleges and councils is critical.Intent – Leadership will continue to be fosteredthrough the CDAMS Indigenous HealthCurriculum and AIDA Best Practice Projects, TheLIME Network and other initiatives.4.6.3 Outcome 3The inclusion of Indigenous health in the AMC’saccreditation process is a high priority.Intent – Work with CDAMS and the AMC toinclude Indigenous health in the accreditationguidelines, including appropriate protocols andprocesses, and ensuring the unique status ofIndigenous health maintains a protected focus inthe accreditation document and process.4.6.4 Outcome 4The AIDA Best Practice Report for the Recruitmentand Support of Aboriginal and Torres Strait IslanderMedical Students provides evidence that willfacilitate the further development of strategies. TheLIME Connection strongly supports the Report.Intent – CDAMS and medical schools will considerthe outcomes of the report in developing nationaland local implementation strategies. CDAMS andschools will collaborate with AIDA onimplementation.4.6.5 Outcome 5Staff capacity development on Indigenous healthwithin medical education (Indigenous and non-Indigenous) is a very high priority.Intent – Support medical schools to trial andimplement initiatives to train and work with theparticular needs of Indigenous and non-Indigenousstaff.4.6.6 Outcome 6Quality respectful partnerships with Indigenouscommunities are critical to quality medicaleducation.Intent – Medical schools will continue to developsuch partnerships and recognise the time andresources to do such, as well consider seeking acoordinated approach to funding studentplacements. The LIME Network will support thedevelopment of best practice for such partnerships.4.6.7 Outcome 7The sustainable resourcing and operation of TheLIME Network is of highest priority. This providesan opportunity to share resources and experience,and celebrate successes and outcomes.Intent – Work with partners to establish asecretariat, employ a project officer to develop thenetwork and consider database and otherinitiatives. Consider development of regular LIMEAwards and LIME Connections.4.6.8 Outcome 8Continuing to develop coordinated multi-facetedstrategies at school level for curriculum and studentrecruitment and retention reform andimplementation is of high priority.Intent – Medical schools resolve to continue todevelop such initiatives, and The LIME Networkand the two projects continue to support thisprocess.4.6.9 Outcome 9Vertical integration between undergraduate,postgraduate and vocational training forIndigenous health curriculum and studentrecruitment and support is of high priority.Intent – Develop a brief, speak with Confederationof Postgraduate Medical Education and Committeeof Presidents of Medical Colleges and convenesymposiums at their annual meetings.4.6.10 Outcome 10Ongoing collaboration between CDAMS andAIDA is critical to success.Intent – CDAMS and AIDA will strengthen andformalise their partnership through a statement ofintent for collaboration.40

5. DISCUSSIONThe Best Practice Project findings supportthe evidence that Australia has a severeshortage of Indigenous doctors and showthere has been no growth in Indigenousmedical student numbers since 2003. Thisis despite calls on government from seniormedical organisations such as the AMA tourgently train more Indigenous doctors. 101It is clear that Australian medical schools arenot recruiting and retaining enoughIndigenous students. Prior educational andother disadvantages severely impact onIndigenous students’ opportunities tosuccessfully apply for medicine.The findings also indicate that some medicalschools are significantly more successful atrecruiting and retaining Indigenous medicalstudents, even given these disadvantages.Successful recruitment and retentionapproaches can also be found in comparativecountries such as New Zealand, the USA andCanada.These observations suggest that improvementsare eminently possible in the recruitment andretention of Indigenous students in Australianmedical schools if effective approaches aretaken.5.1 Approaches in Australia andother comparative countriesOver 20 strategies are being used byAustralian medical schools to recruit andretain Indigenous medical students. A numberof observations can be made about thesestrategies:· They range from identified policies suchas alternative entry schemes to overallprinciples such as communityengagement.· They cannot easily be separated intoisolated recruitment and retentionapproaches.· Schools with the greatest number ofIndigenous medical students have themost comprehensive approach to thesestrategies.· Schools with the least numbers ofstudents undertake few strategies andthere is little consistency in the ones theychoose.· All current strategies contain gaps andbarriers..This suggests that while some approaches tothe recruitment and retention of Indigenousmedical students in Australia arecomprehensive and individual strategies haveelements of best practice, in general thepathways into and through medicine arelacking and unclear. The review of nationalliterature shows that very little has beenpublished on the recruitment and retention ofIndigenous medical students for Australianmedical schools to draw on.In comparison to Australia, countries such asNew Zealand, Canada and the USA havedeveloped clear policies and approaches torecruitment and retention of Indigenous41

Healthy Futuresmedical students and this has led tosignificant increases in Indigenous medicalschool enrolments. In particular, thesecountries have national and local targets,affirmative action strategies, projects,outcomes and evaluations.5.1.1 Targets and affirmative actionBy concentrating efforts and resources,Indigenous student enrolments in medicinehave increased in comparative countries andimportant lessons have been learned.●●●the USA Project 3000 by 2000 set a goalto recruit 3000 ethnic minority medicalstudents across the country by the year2000. Enrolments increased by 27% overthree years and while the target of 3000was not reached, … educationalpartnerships between academic medicalcenters, colleges, secondary schools andcommunity groups’ were maintained andthese were …found to be key to long termstrategies to increase the applicant pool ofminority students ready to pursue a careerin medicine. 102In New Zealand, the University ofAuckland Vision 20/20 and MAPASaffirmative action strategies and programshave steadily increased the number ofIndigenous students entering medicine.Places available to Indigenous medicalstudents had been extended to twenty fiveby 2003.In Canada, the University of AlbertaAboriginal Health Care Careers Programset a mandate to … recruit Aboriginalstudents into the Faculty of Medicine andDentistry … in order to correct the underrepresentationof Aboriginal physicians in1998 and by 2005, 33 Aboriginalphysicians had graduated. 103The targets identified by these comparativecountries have in most cases been determinedby calculating ratios of Indigenous doctors tothe Indigenous population compared to ratiosof non-Indigenous doctors to the non-Indigenous population. 104These observations suggest that Australianmedical schools and government need to:●set a national target for the recruitmentand retention of Indigenous medicalstudents; and● identify the strategies, pathways,principles and actions that will enablethem to get there.This approach is consistent with Objective 5of the 2002 Aboriginal and Torres StraitIslander Health Workforce National StrategicFramework to… include clear accountability forgovernment programs to quantify andachieve these objectives and support forAboriginal and Torres Strait Islanderorganisations and people to drive theprocess. 105This objective:Recognises that this framework shouldinclude accountability through quantifiableand achievable targets to the Objectives.The objective also recognises that thereshould be support for Aboriginal and TorresStrait Islander peoples to drive the process ofachieving the Framework’s objectives. 106The Australian Health Ministers’ AdvisoryCouncil also acknowledges… the task of developing a methodology fornationally consistent formulation ofindicative workforce ratio targets. 107The task of developing a methodology for anationally consistent formulation of indicativeworkforce ratio targets for Indigenous doctorsis one that still needs to be comprehensivelyaddressed. Nonetheless, using the AMAcalculations of Indigenous doctors inproportion to that of non-Indigenous doctorsto population ratios, 50 Indigenous studentswould need to enrol in medical schools acrossAustralia each year for the next four years andthen 100 would need to enrol each year afterthat to fill the current Indigenous medicalworkforce shortfall. On this calculation, anextra 350 Indigenous medical students wouldneed to be enrolled in medicine by the year2010. 10842

DISCUSSION5.2 Gaps and barriers in thecurrent strategies and waysforwardWhile some medical schools have beensuccessful in recruiting and retainingIndigenous medical students in comparison toothers, all Australian medical schools still needto recruit and retain more to reach levels equalto the non-Indigenous population. Thissuggests that a comprehensive approach usingthe current best practice strategies is not initself enough and the gaps and barriers inthese strategies also need to be addressed inorder to move forward.5.2.1 Promoting medical degrees toIndigenous peopleGreater efforts to promote medical degreesappropriately to Indigenous people areneeded. One of the best practices identified inthe findings is when… medical … staff build relationships withlocal Indigenous community members andfamilies and regularly provide informationon medicine, higher education and medicalcourses.Promotion needs to occur in different media,languages and cultural contexts, and accordingto a range of age groups. For example,promotion can range from advertising, writteninformation and media, to communityengagement and school and university visits,depending on the target audience. It shouldhighlight different pathways to medicine suchas bridging/enabling programs, other health/science degrees and quotas, and supportservices for students, such as Indigenoushealth support units.Community engagement and networksThe importance of community engagement ishighlighted in the observation by William andCadet-James, 2000, that… family and community support wasidentified as forthcoming only if they wereable to perceive the benefits of study for thestudents and the community and theeducation process. 109This suggests that promotional activities needto go beyond primary and high school visitsand include promotional activities for thewhole community that emphasise the benefitsof higher education and medicine inparticular. Some medical schools in Australiaand New Zealand have also provided …opportunities for family members to meet staff inorder to demystify medicine and theadmissions process. 110The findings also suggest that promotionalactivities that focus on networks andpartnerships are urgently needed. Inparticular, partnerships with school careeradvisors, school principals, the healthworkforce and other tertiary and vocationaleducation providers need to be developed.New Zealand recruitment strategies include…changes to career delivery advice … andinfluencing teachers’ expectations andattitudes. 111 Medical schools need to developlong-term and sustainable partnerships andnetworks with key individuals, educationalinstitutions, and Indigenous organisations andcommunities to provide leadership in therecruitment and retention of potentialIndigenous medical students. This is alsonoted in Outcome 6 of the LIME Connectionwhich notes… the need for quality respectfulpartnerships with Indigenous communitiesare critical to quality medical education. 11243

Healthy FuturesPromoting to different age groupsMedical schools with the most effectivepromotional activities specifically targetdifferent age groups:●●school visits by Indigenous medicalstudents, and attending Croc Festivalsand Vibe 3 on 3s are most effective foryounger students;university visits, summer camps andcareer festivals are more valuable forsecondary school students; and● orientation days, introductory coursesand pre-medical and bridging/enablingprograms are more useful for attractingmature age students.To capture potential Indigenous medicalstudents from a range of age groups,promotion activities need to be creative,flexible and opportunistic.Written and audiovisual informationIn comparison to other countries, such asCanada, 113 the amount of appropriate printedand audiovisual information on applying formedicine available for a range of different ageand cultural groups, particularly mature agestudents, in Australia was limited. Forexample, the UBC recruitment strategiesinclude … developing posters highlighting theneed for Aboriginal physicians. 114 OneAustralian university did showcase a newpromotional DVD for potential Indigenousmedical students at the LIME Connection.The LIME participants responded verypositively to the DVD and many indicated adesire to undertake a similar project at theirmedical schools. Another initiative suggestedby Indigenous support workers was theestablishment of an interactive recruitmentwebsite that provides information onmedicine and on applying for a medicaldegree, and is suitable for a range of agegroups.Overall, the lack of available written and visualpromotional information appeared to belinked to confusion over whose responsibilitysuch initiatives were and where coordinationand resources should come from. At oneuniversity, the generic Indigenous supportunit is expected to produce promotionalposters and information for the Indigenoushealth support unit, using their own budget.For this reason, the Indigenous support unit isreluctant to produce more than theminimum. A number of Indigenous supportworkers also indicated they would be expectedto individually pursue extra promotionalinitiatives and apply for funding outside themedical school. The need for medical schoolsto take responsibility for a comprehensiverange of promotional methods aimed atencouraging Indigenous people to pursue acareer in medicine and providing them withthe information to do this was apparent.Involving current students and doctorsThe most effective way of promotingmedicine to Indigenous people is to involvecurrent Indigenous medical students anddoctors in recruitment activities. For example,the University of British Columbia strategiesinclude … Aboriginal medical students visitinghigh schools and talking to Aboriginalstudents. 115However, mentoring and role modellingactivities are time consuming and put extrapressure on Indigenous students. They alsodepend on medical schools having courses andsupport programs that Indigenous studentswant to promote. If Indigenous medicalstudents are to be involved in recruitmentactivities, they need to be able to undertakethese voluntarily and be supported in this aspart of their medical degree and professional44

DISCUSSIONdevelopment. A positive example ofinvolving Indigenous medical students inpromotional and personal developmentactivities was provided at the LIMENetwork where one student made a proudand skilful presentation on their medicalschool’s recruitment and retentionstrategies. Demands on Indigenous medicalstudents and graduates to attend and makepresentations at every school, career festival,community event and meeting onIndigenous medical education issues can easilybecome excessive. If government and medicalschools want to involve Indigenous medicalstudents and graduates in recruitmentactivities in a genuine and sustainable way, anationally coordinated professionaldevelopment and leadership program based onIndigenous medical student recruitmentactivities may need to be developed. TheDoctors Back to School Project developed bythe American Medical Association MinorityAffairs Consortium is an example of thebenefits of this approach. 1165.2.2 Enabling pathways for Indigenouspeople into medicineDespite numerous strategies to recruit andretain Indigenous students, pathways intomedicine are not clearly defined forIndigenous people and many barriers areencountered. To successfully recruit and retainIndigenous people in medicine, multiple andflexible pathways need to be developed thattake into account peoples’ life stages,educational and socioeconomic backgroundand cultural context. For example, theUniversity of Newcastle was recognised byAMWAC in 1997 as having the best practicesin recruitment and retention of Indigenousmedical students due in part to its … broadlydefined eligibility criteria which takes intoaccount prior disadvantage. 117 Theseobservations are also noted in Outcome 8 ofthe LIME Connection which notes that… continuing to develop co-ordinatedmulti-faceted strategies at school level forcurriculum and student recruitment andretention reform and implementation is ofhigh priority. 118However, having encouraged potentialapplicants to consider a career in medicine,it is important not to discourage them fromthis pathway by allowing inappropriate orunnecessary barriers during the applicationprocess to stand in the way. The literature andfindings suggest that these barriers include:●●●lack of a ‘whole-of-school’ commitment;unclear admissions processes; andstudent socioeconomic issues.Lack of a ‘whole-of-school’ commitmentIndigenous people will not successfully pursue acareer in medicine if staff and students at themedical school and university do not value themand appreciate their life experiences. Evidencefrom comparative countries shows that efforts torecruit and retain Indigenous medical studentsmust be underpinned by a genuine commitmentto Indigenous issues from the whole of themedical school and government. As NOMS inCanada, note … [there is a] need for knowledgeand respect of Aboriginal history, culture andtradition. 119 At the University of Auckland, allstrategies to recruit and retain Indigenousmedical students are underpinned by the Treatyof Waitangi and recognise that … significant levelsof disadvantage accrue to Maori within the educationsector. 120 To consolidate commitment from thewhole of the medical school staff and students,the Deans of the medical schools need todemonstrate leadership. For example, the UBCrecruitment and retention strategies include … aproactive Associate Deans of admissions policycommittee. The need for leadership was also notedin the Outcome 2 of the LIME Connection,which stated that… leadership among Deans, medicaleducators, Indigenous communityrepresentatives, policy makers and medicalcolleges and councils is critical. 121These observations suggest that an awareness ofthe educational disadvantages facing manyIndigenous students will encourage medicalschools to develop multiple pathways for45

Healthy FuturesIndigenous students from an early age through tomature age entry. A whole-of-schoolcommitment to Indigenous issues will provideIndigenous students with the opportunities andcomprehensive support they need to successfullyapply to medicine and graduate. It will alsoprovide Indigenous staff with the support theyneed to make these opportunities culturally safeand available. To ensure a whole of schoolcommitment, leadership must be provided bythe Deans of Australian medical schools.Unclear admissions processesIndigenous people who have been encouragedto pursue a career in medicine can be easilydeterred by the process of applying formedicine. Admissions processes begin withalternative entry schemes and quotas, includetravel and test costs, the GAMSAT/UMAT,interviews, and premedical and bridging/enabling programs.Quotas and alternative entry schemes forIndigenous people need to be clearly explainedand promoted to the whole community. Theyalso need to send an unambiguous andpositive message to potential applicants. Thefindings show current quota arrangements areunreliable and imply that Indigenous peopleare taking away places that could go applicantswho have applied via mainstream entry. Thisis a deterrent to Indigenous people who donot want to be seen as receiving ‘specialtreatment’.The same problem applies for alternativeentry. Current alternative entry schemes implythat Indigenous people are being admittedunder special arrangements. However, thefindings show that while specific Indigenousalternative entry schemes are available,students from many different backgroundsenter medicine under alternative entry andthat this mode of entry is becoming morecommon, particularly as views about whatmakes a good doctor change. As noted on theSydney University website… there are a number of alternative entryschemes designed to allow competition foradmission by applicants who wouldotherwise be ineligible, or whose rank isjust below the cut-off. 122Quotas for Indigenous people need to be setat definite extra numbers that identify aminimum number of enrolments each yearthat cannot go to other students. These quotasneed to be protected and alternative entryschemes need to be promoted as a positiveway of attracting potentially good doctors tomedicine, including Indigenous doctors.IdentificationDifferent identification requirements can alsobe confusing for Indigenous applicants intomedicine. It is vital that all medical schoolsarticulate their policy on Indigenousidentification which is both appropriate andsensitive. By applying the Best PracticeFramework in the recruitment and retentionof Indigenous medical students, selectionprocesses and outcomes will improve. Thiswill result in a cohort of successful students,strong in identity.GAMSAT/UMAT and interviewsThe process of sitting the GAMSAT/UMATand attending interviews can be daunting andexpensive for Indigenous people. For manyIndigenous people, the process of travelling totest centres and sitting tests alone, unpreparedand unsupported can be enough to deter themcompletely. While direct tutoring in theGAMSAT/UMAT may not be appropriate,Indigenous applicants should be able to accessinformation and emotional, financial andpractical support through Indigenous healthsupport units prior to sitting the GAMSAT/UMAT and throughout the applicationprocess.However, the findings also suggest theGAMSAT/UMAT may not be inappropriatefor Indigenous applicants altogether. Todetermine if this is the case, it isrecommended that these tests urgently beindependently reviewed.46

DISCUSSIONIndigenous students have usually beenidentified by the Indigenous health supportunits by the time they reach the interviewprocess. Current best practices suggest thatIndigenous students perform best when theyhave been adequately prepared for interviewsand are supported by the Indigenous healthsupport units. The findings also suggest thathaving Indigenous community memberspresent on the interview panel, having afamily member attend as a support person,and community-based interviews also makefor a more positive experience.Pre-medical, enabling and bridgingprogramsPre-medical, enabling and bridging programsneed to be promoted to Indigenous people asa positive way of entering into medicine.These courses help to prepare students for thedemands of a medical degree and providethem with the opportunity strengthen theirskills in particular areas. However, evidencefrom the literature shows that Indigenouspeople in general are more likely be enrolledin enabling, non-award courses rather than inhigher degrees. 123 Medical schools thereforeneed to judiciously use enabling courses. Theyalso need to provide Indigenous students withpathways that map their exit from enablingcourses and entry into and completion ofmedical degrees.5.2.3 Appropriately supportingIndigenous people in medicineSupport for Indigenous people in medicineneeds to be holistic and encompass studentssocial, emotional, cultural and practical needsas well as academic and learning ones. Theseneeds include:●●●●●cultural safety and curriculum;mentoring and collegiate support;financial and practical resources;tutoring and academic support; andprofessional development.Cultural safety and curriculumIndigenous students regularly experienceracism and discrimination, particularly inrelation to misperceptions from students andstaff that they are receiving special treatment.Anecdotal evidence also suggests thatIndigenous entry requirements can sometimesbe more rigorous than the non-Indigenousentry process. Regardless of entry points, allmedical students have to pass the sameassessments during their study. Medicalschools need to actively examine and addressthe admissions processes, myths andstereotypes that have allowed thesemisperceptions to flourish and encourageIndigenous students to express and celebratetheir culture, and family and culturalobligations in a safe and supportiveenvironment.The beliefs, attitudes, policies and practices oftertiary institutions can often act as barriers tohigher education for Indigenous students.Developing and maintaining a culturally safeenvironment is important in recruiting andretaining Indigenous Australians in medicine,and retaining Indigenous staff in theuniversities. To achieve this, it is essential forall staff and students within medical andhealth faculties to understand their owncultural identity, attitudes, values and actions;and how these impact on others around them.For example, the NOMS recruitment andretention strategies are to… target potential Aboriginal students and[expose] non-Aboriginal students toAboriginal issues and communities as partof the academic and clinical curriculumfrom first year. 124To ensure a culturally safe environment, it isessential that all medical schools provide staffand students with cultural safety training andthat the CDAMS Indigenous HealthCurriculum Framework is fully implemented.It is also essential that medical schoolsexamine the values, operations and cultureof their institution as a whole, including47

Healthy Futuresmanagement and decision-making processes.To ensure cultural safety is comprehensivelyadopted in medical schools, commitment isrequired at a number of levels. Management,organisational, budgetary and decisionmakingprocesses should incorporateIndigenous participants and perspectives. Thiswill not only assist in providing safeenvironments for Indigenous students but willalso contribute to the creation of a culturallycompetent medical professional workforce.Mentoring and collegiate supportIndigenous students highly value mentoringand collegiate support, and actively seek outopportunities to participate in these activities.This is supported by evidence fromcomparative countries (e.g. the University ofAuckland supports Indigenous students andgraduates mentoring other Maori and Pacificstudents). 125 The tendency to seek out amentor rather than be allocated one andconfusion about mentoring and rolemodelling provide important lessons for thedevelopment of mentoring programs forIndigenous medical students.The opportunities to speak honestly aboutissues in a non-judgmental collegiateenvironment also sheds important light on thekinds of support Indigenous students areseeking. As noted in a study on Indigenousstudents in Queensland … the support of fellowstudents was an important resource, both duringand after the completion of study. 126 Inparticular, these observations suggest thatIndigenous students need to feel safe and incontrol of the supports that are available tothem. This suggests that mentoringrelationships need to be culturally safe andbased on a two-way relationship and exchangebetween equals. 127 Indigenous students needto be supported in a way that respects theirunique skills, perspectives and life experiences.While AIDA is currently developing andimplementing a mentoring program based onthese principles, institutions should alsoconsider developing local mentoringprograms.Financial and practical resourcesEvidence from the literature and findingsclearly show that many Indigenous peoplecome from disadvantaged backgrounds andthat financial difficulties can impact onIndigenous medical students during theirdegree. As noted in the 2003 OvercomingIndigenous Disadvantage Report … there is astrong correlation between low income familiesand lower scores in learning outcomes. 128 ManyIndigenous medical students also have familyobligations, travelling and accommodationcosts that impact on their financial situation.Hence, Indigenous students are more likelythan other medical students to need financialsupport and other resources to ensure theyhave the same opportunities to complete theirmedical degrees. Medical schools andgovernment also need to be realistic abouthow much it costs to undertake a medicaldegree, given that students are usually requiredto live away from home and have little timefor extra employment.Adequate scholarships, bursaries and grantsthat do not negatively impact on students’government payments need be accessible. Thismay be partly achieved through equipmentgrants that assist Indigenous students topurchase academic texts, computers, medicalequipment and so on, without affecting theirAbstudy payments. Two medical schools thatcurrently demonstrate best practices in therecruitment and retention of Indigenousmedical students also provide access tosignificant medical-specific yearly scholarshipsfor all their students. One of thesescholarships is provided by the state healthdepartment to all Indigenous medicalstudents. The other is provided directly out ofmedical school funds. If medical schools andgovernment are genuine about recruiting andretaining Indigenous medical students, fullyfunded medical places and full scholarshipsshould be provided to all Indigenous medical48

DISCUSSIONstudents, as recommended by the AMA. 129● The University of Newcastle providesPartnerships also need to be developed with intensive support to Indigenous medicalphilanthropic, non-government organisations students in the first few years of theirand corporate bodies that may have access to degree as one of their retention strategies.other financial and practical supporting● The University of Western Australiaresources.medical staff provide weekend clinicalAcademic and transitional supportworkshops for Indigenous students in aculturally safe environment.Tutoring and academic support is necessaryfor most medical students, whetherCulturally safe support arrangements provideIndigenous or not. 130 However, the findings Indigenous students with valuableshow that most Indigenous students need to opportunities to perform at their optimal levelaccess this support through the ITAS rather in their medical degrees.than privately or through mainstream services.Professional developmentCurrent ITAS arrangements are complex andtime consuming and clearly deter Indigenous The findings indicate Indigenous medicalstudents who are seeking tutoring support students feel pressured to pursue careers inspecific to medicine. It is clear from the Indigenous health and are less likely tofindings that ITAS requirements need to be undertake further vocational training.urgently reviewed to provide more appropriate Indigenous medical students feelsupport for Indigenous medical students.… pressure to go back and practice only inMedical students in general often seek out Indigenous communities or organisationsextra academic and clinical support toboth from their own community and theimprove specific skills and finetune techniques wider community. 132for medical exams. However, Indigenous This pressure may be due to narrow views andmedical students who want to improve in misperceptions about the value of Indigenousparticular areas may feel more comfortable doctors, that imply their contribution lies inseeking support in collegiate groups. Some directly working in Indigenous communities.Indigenous health support units provide While this may encompass the aspirations of… tutorial rooms specifically for Indigenous some graduates, a wider and morehealth and medical students and tutorial sophisticated view of the value of Indigenousand other assistance with preparing for doctors needs to be encouraged, highlightingassessments and exams.their value as role models, mentors and leadersin their community as well as their highlySome Indigenous health support units offerskilled, holistic and unique contribution tointensive support to Indigenous students inmedicine in a range of areas. In this respect,the first few years of their degrees to deal withprofessional development opportunities fortransitional issues and prior educational andIndigenous medical students that includeother disadvantages. However, providing apresenting at schools, university orientationpositive first year experience is not unique toactivities and conferences may assist them toIndigenous students.make more confident and ambitious career● The University of Queensland has choices, while having the added effect ofdeveloped a strategy to provide extra encouraging other Indigenous people tosupport to all first year students, by pursue a career in medicine.understanding that … to engage first yearstudents, the university must be able to assistthem to deal with their social andeducational transition. 13149

Healthy Futures5.3 Recruitment and retention ofIndigenous medical students iseverybody’s businessThe significant task of recruiting andretaining Indigenous students in medicineshould not be delegated only to Indigenoushealth support units and Indigenous staff. Thefindings strongly indicate that Indigenousstaff are already overworked and expected to‘do it all’. Most Indigenous health supportunits do not have the resources to undertakeall promotional, supporting, cultural training,and teaching activities for Indigenous andnon-Indigenous students and staff withoutsupport from the wider Medical Faculty. Toensure a culturally safe environment forIndigenous medical students, all medicalschool staff and students need to valueIndigenous people and be involved in theirrecruitment and retention. Medical schoolsthat have genuinely embraced Indigenousmedical education and recruitment andretention of Indigenous medical students havebenefited from this process on many levelsincluding the:●●●wisdom, knowledge and richness thatIndigenous cultural perspectives,experiences and people bring to themedical course and environment;Indigenous holistic views of good healthas including the physical, social,emotional, cultural and spiritualwellbeing of the whole community;influencing concepts about what makes agood doctor and constitutes goodmedical practice; and● opportunity to make a practical andhumanitarian contribution to addressingthe Indigenous health and educationcrisis and the sense of pride, respect andempowerment that comes from this.Indigenous staff need to be employed, valuedand supported and Indigenous health supportunits need to be amply resourced to guidemedical schools in the implementation ofappropriate recruitment and retention ofIndigenous students, and to developcomprehensive Indigenous health curriculumframeworks. This includes providingprofessional development opportunities forIndigenous staff, such as those available toMaoris which include… increasing the levels of [Indigenous]staff participation in research andpublication including support forinnovative research … and ensuring[Indigenous] participation in key aspects ofthe management structures andinstitutional life of the University. 1335.4 SummaryIt is apparent that many national, state andinstitutional policies and strategies said toassist Indigenous people have failed. This isevident in the fact that the gap in mortalityrates between Indigenous and non-IndigenousAustralians remains at 20 years while in othercomparative countries it has significantlyfallen. As noted in the CDAMS IndigenousHealth Curriculum Framework… a convincing case has been made thatthe health and wellbeing of Indigenouspeoples in Canada, the US and NewZealand is strengthened by having theirsovereignty recognised and having controlover their own health care servicedelivery. 134Australian governments and medical schoolsneed to seriously consider what theseobservations and those discussed above meanfor the success of Indigenous medical studentrecruitment and retention strategies. The BestPractice Framework therefore providesAustralian governments and medical schoolswith a framework, including targets andprinciples and actions, that will assist in thisprocess.50

6. FRAMEWORKThe Healthy Futures Best Practice Framework has been developed for Australian medical schools,governments and principal stakeholders to improve recruitment and retention strategies forIndigenous medical students. The framework provides a foundation for individual institutionalresponses that are locally relevant, flexible and action oriented. The successful implementation ofthis framework will clearly require additional and adequate resourcing.The Best Practice Framework is made up of three headline targets for 2010 and fiveinterrelated principles.By 2010:●●Headline targetsAustralian medical schools will have established specific pathways intomedicine for Indigenous Australians.CDAMS Indigenous Health Curriculum Framework will be fully implementedby Australian medical schools.● There will be 350 extra Indigenous students enrolled in medicine. 135Principles●●●●●All Australian medical schools and principal stakeholders have a socialresponsibility to articulate and implement their commitment to improvingIndigenous health and education; and mustmake the recruitment and retention of Indigenous medical students a priorityfor all staff and students and show leadership to the wider universitycommunity;ensure cultural safety and value and engage Indigenous people in all theirwork;adopt strategies, initiate and coordinate partnerships that open pathwaysto medicine from early childhood through to vocational training andspecialty practice; andensure all strategies for Indigenous medical student recruitment andretention are comprehensive, long term, sustainable, well resourced,integrative and evaluated.51

Healthy FuturesPrinciple 1All Australian medical schools andprincipal stakeholders have a socialresponsibility to articulate andimplement their commitment toimproving Indigenous health andeducation; and mustAs a distinguished and respected professionknown for both its objectivity andcompassion, medicine is in a prominentposition to lead Australia in its efforts to acton the crisis in Indigenous health andeducation. Medical organisations, schools andcolleges across Australia know that Indigenousdoctors provide a highly skilled, professionaland unique contribution to the Australianmedical workforce.Actions●●●●●●Implement the Best Practice frameworkImplement the CDAMS IndigenousHealth Curriculum FrameworkProvide a variety of financial incentivesfor Indigenous medical studentsProvide and protect identified medicalplaces for Indigenous studentsProvide adequate resourcing forIndigenous health support unitsRecord and evaluate achievements inimproving medical education outcomesfor Indigenous studentsPrinciple 2Make the recruitment and retention ofIndigenous medical students a priorityfor all staff and students and showleadership to the wider universitycommunityThe Deans of medical schools and all theirstaff and students must demonstrate theircommitment to Indigenous health andeducation by actively participating inIndigenous student recruitment and retentionstrategies and showing leadership to the wideruniversity community. Indigenous staff andcommunity members must be empowered todetermine and lead these efforts and delegateresponsibilities as needed.Actions●●●●●●●Value and encourage the contributionthat Indigenous people bring to medicineDevelop and maintain meaningfulpartnerships with Indigenouscommunities and health services underthe guidance of Indigenous staffSupport Indigenous applicants inpreparing for and undertaking entryrequirements in to medicineDevelop and implement culturallyappropriate promotional material torecruit Indigenous studentsProvide administrative, academic andemotional support to Indigenous studentsProvide administrative, academic andemotional support to Indigenous staffand ensure they have time to pursue theirown professional developmentBe positive role models and mentors forIndigenous students and staff52

FRAMEWORKPrinciple 3Ensure cultural safety and value andengage Indigenous people in medicalschool businessMedical school staff and students have aresponsibility to examine and challenge theirattitudes, beliefs and practices towardsIndigenous Australians if they intend to workas health professionals. This will benefit allAustralians both delivering and receivinghealth and education services.Actions●●●●●●Establish cultural safety training for allstaff and studentsTake affirmative action against racismand discriminationEstablish an Indigenous advisorycommitteeEmploy adequate numbers of full timeIndigenous staff and ensure they are wellresourced and appropriately supportedand represented in the managementstructureEngage local Indigenous people inrecruitment, retention and teachingactivitiesIn partnership with Indigenouscommunities, provide practical andcultural learning opportunities andexperiencesPrinciple 4Adopt strategies, initiate and coordinatepartnerships that open pathways tomedicine from early childhood throughto specialty practiceFlexible entry and articulation pathways needto be developed and promoted. Recruitmentstrategies should target and provide support topotential Indigenous medical students atdifferent life stages including primary andsecondary school and mature age.Actions●●●●●●●Establish and maintain strong workingpartnerships with local/regional schools,technical colleges, the Indigenous healthworkforce and other university disciplinesto ensure that potential Indigenousmedical students are identified andencouragedUndertake regular recruitment activitiesat local schools, communities, healthservices and other educationalinstitutionsInvolve current medical students inIndigenous recruitment activitiesEncourage Indigenous medical studentsand graduates to act as role models andparticipate in mentoring programsProvide university orientationopportunities, summer camps, bridgingand premedical programs that aretargeted at a range of age groups andeducational levelsTailor admissions and alternative entryrequirements for Indigenous students andprovide support for applicants throughthis processProvide financial support for Indigenouspeople to cover costs associated withapplying for medicine53

Healthy FuturesPrinciple 5Ensure all strategies for Indigenousmedical student recruitment andretention are comprehensive, long term,sustainable, well resourced, integrativeand evaluatedThe recruitment and retention of Indigenousmedical students requires long-termcommitment and strategic partnerships fromAustralian governments, medical schools andthe wider community.Actions●●●●Consistent with the Aboriginal andTorres Strait Islander Health WorkforceNational Strategic Framework (2002) andtaking account of this framework,develop and implement a comprehensiveIndigenous recruitment and retentionpolicyEstablish Indigenous recruitment andretention plans and strategiesProvide financial and human resources toensure that recruitment and retentionplans and strategies remain open andflexibleConduct ongoing evaluation of theIndigenous recruitment and retentionplans and strategies54

ATTACHMENT ASurvey forms and questionsPO BOX 3497 MANUKA ACTPh: 02 6239 5013 Fax: 02 6239 5014The Australian Indigenous Doctors’ AssociationYaga Bugaul DungunSURVEY OF ABORIGINAL AND TORRES STRAIT ISLANDER MEDICAL STUDENTSThe Australian Indigenous Doctors Association (AIDA) is undertaking a project to identify bestpractice models in the recruitment, retention and graduation of Aboriginal and Torres StraitIslander students. This survey of Aboriginal and Torres Strait Islander medical students willhelp us to identify some of the advantages and disadvantages of current approaches.Your response will be treated with complete confidentiality. If any question is too difficultto answer or if there is any question you do not wish to answer, you may pass on to the nextquestion. The survey should only take approximately 5 to 10 minutes to complete (longer if youwrite comments).Please complete the form and return to AIDA, PO Box 3497, Manuka, ACT, 2603Fax 02 2395014. Please email aida@aida.org.au if want more information.1. At which university are you currently studying?2. What year of study are you in currently?3. What is the level of your course? Undergraduate Postgraduate4 What year did you first enrol in your present course?5. Please tick on or many options to indicate why you chose your current university. Indigenous Support Unit Bridging/Enabling Courses Financial Reasons Close to home Word of mouth Family has attended Friends told you about the course Easier to gain entry than other universities Advertised Other ………………………………………………………………………………….55

Healthy Futures6. Is there another University where you would prefer to study? Yes NoWhy? …………………………………………………………………………………………..7. What types of support do you need/want from an Indigenous Support Unit?8. Are you getting the support you need from the Indigenous Support Unit? Yes NoPlease comment:9. In your experience, does the Indigenous Support Unit have enough resources? Yes NoPlease comment:10. Are you receiving appropriate support from the University/Faculty? Yes NoPlease comment:11. Do you have a mentor? Yes NoPlease comment12. Are there any comments you would like to make on the recruitment of Aboriginal and Torres StraitIslander medical students?13. Would you prefer a central admission process for Indigenous Medical Students? Yes NoOR regional admissions? Yes NoPlease comment …………………………………………………………………………………………………..14. Is there any reason why you would stop studying to be a medical doctor?15. What reasons do you have to continue studying to be a medical doctor?16. Do you have any problems with the form of assessment of grades for medical students? Yes NoPlease comment17. Please comment on the process used by the medical school for identifying Aboriginal and/orTorres Strait Islander students.18. Do you feel that your confidence has improved since becoming a medical student? Yes NoPlease comment56

19. Would you prefer to do group work with other Indigenous students? Yes NoPlease comment20. Please comment on the Aboriginal and Torres Strait Islander content in the curriculum?21. What contributions do you feel the medical community and broader university communitybenefit from you?22. Have you personally experienced any discrimination or negativity from other students,residents, professors or physicians? Yes NoIf you answered yes to any of the above two questions, please describe briefly what happened.23. What have been the biggest rewards so far in pursuing your medical career?24. What have been the biggest challenges so far in pursuing your medical career?25. What are the main issues facing Aboriginal and Torres Strait Islander people in medicinetoday?26. What changes, if any, would you like to see for Aboriginal and Torres Strait Islander people inmedicine now and in the future?-OPTIONAL-Would you be available to be interviewed by AIDA for this project Yes NoWould you like more information about the Australian Indigenous Doctors Association? Yes NoNAME: …………………………………………………………………………………………………...ADDRESS: ………………………………………………………………………………………………EMAIL: ..…………………………………………………………………………………………………Thank you for participating in this survey. Your answers are very important and we lookforward to sharing the overall results with you57

Healthy FuturesThe Australian Indigenous Doctors’ AssociationYaga Bugaul DungunPO BOX 3497 MANUKA ACTPh: 02 6239 5013 Fax: 02 6239 5014The Australian Indigenous Doctors’ Association (AIDA) is undertaking a project to identify bestpractice in the recruitment of and support for Aboriginal and Torres Strait Islander medicalstudents. Your assistance during this project is appreciated and will assist with ensuring thatIndigenous medical students receive the support, information and care required to completetheir tertiary studies and ultimately increase the number of Indigenous doctors required to meetthe need health needs of Aboriginal and Torres Strait Islander Australians.Your response will be treated with complete confidentiality. If any question is too difficultto answer or if there is any question you do not wish to answer, you may pass on to the nextquestion. The survey should only take approximately 5 to 10 minutes to complete (longer if youwrite comments).Please complete the form and return to AIDA, PO Box 3497, Manuka, ACT, 2603Fax 02 2395014. Please email aida@aida.org.au if want more information.1. Why did you choose to become a doctor?2. Was there a particular person or incident that influenced your decision to become a doctor?3. Which university did you complete you studies?4. What year did you graduate?5. Did you identify as an Aboriginal and/or Torres Strait Islander medical student? Yes No6. Did you have an Indigenous Support Unit at the University you studied?YesNo7. What sort of support do you believe Aboriginal and Torres Strait Islander medical studentsneed:8. What types of difficulties did you face while studying:Academically:Socially:Family:9. Financially were you supported by ABSTUDY? Yes NoOr did you have a scholarship?YesNo58Was other help offered?

10. Did you work or study before you became a Medical Student?YesNoPlease state ………………………………………………………………………………………………….11. Did you work whilst a medical student?12. Did you or have you deferred training? Yes NoIf YES why?ResearchPersonalFinancialOther13. What have been the biggest rewards so far in pursuing your medical career?14. What have been the biggest challenges so far in pursuing your medical career?15. What are the main issues facing Aboriginal and Torres Strait Islander people in medicine today?16. What changes, if any, would you like to see for Aboriginal and Torres Strait Islander people inmedicine now and in the future?…………………………………………………………………………………………………Thank you for participating in this survey. Your answers are very important and we look forward tosharing the overall results with you59

Healthy FuturesThe Australian Indigenous Doctors’ AssociationYaga Bugaul DungunPO BOX 3497 MANUKA ACTPh: 02 6239 5013 Fax: 02 6239 5014The Australian Indigenous Doctors’ Association (AIDA) is undertaking a project to identify bestpractice in the recruitment of and support for Aboriginal and Torres Strait Islander medicalstudents. Your assistance during this project is appreciated and will assist with ensuring thatIndigenous medical students receive the support, information and care required to completetheir tertiary studies and ultimately increase the number of Indigenous doctors required to meetthe need health needs of Aboriginal and Torres Strait Islander Australians.Your response will be treated with complete confidentiality. Could you please completethe survey to the best of your knowledge. If you are unsure of certain questions please stateso and any difficulties you may have finding the information.Please complete the form and return to AIDA, PO Box 3497, Manuka, ACT, 2603Fax 02 2395014. Please email aida@aida.org.au if want more information.INSTITUTION :SCHOOL:NAME:1. Does the University have a set number of places for Aboriginal and Torres Strait Islander medicalstudents?2. Does the University offer a bridging course for Aboriginal and Torres Strait Islander studentsmedical students?3. How many Aboriginal and Torres Strait Islander medical students do you intake in a total year?4 a. Does the School/University keep records of the number of Aboriginal and Torres StraitIslander student who do not graduate? Yes NoIf yes how many Aboriginal and Torres Strait Islander medical student have not graduated buthave enrolled in the Medicine Program?b. How many Aboriginal and/or Torres Strait Islander students are currently enrolled?c. How many in each year: 1 st …..….2 nd …….….3 rd ……..….4 th ……..….5 th ……....d. How many have graduated in total?e. What is the average time to graduate?60

5. a. What sort of support does the University/School have in place for Aboriginal and/or Torres StraitIslander medical students i.e. Tutoring, Indigenous Support Unit ((ISU), computer facilities etc.b. If the University has an ISU please briefly state what the unit comprises of i.e. staff, space etc.specific for Medicine.c. If the University does not have a specific support unit for Aboriginal and Torres Strait Islandermedical students is there a broader Indigenous support unit for staff to access knowledgeabout cultural awareness? Yes NoPlease comment: ……………………………………………………………………………6. Does the University/School produce any reports regarding Aboriginal and Torres Strait Islandermedical students? Yes No7. a. Does the University/School conduct recruitment workshops at:Primary SchoolHigh SchoolCommunitiesOther …………………………………………………………………………………b. Does the Medical School advertise through Indigenous specific media?YesWhere …………………………………………………………………………………….Noc. What recruitment strategies are most successful? Why?d. What recruitment strategies are less successful? Why?e. Does the School receive specific funding for recruitment/promotional activities? Yes NoIf you receive funding is the funding:ContinualOne-offAnnual submissionOtherf. Would the Universities/Schools admissions process be easier if there was a central admissionsfor Aboriginal and Torres Strait Islander medical students? Yes NoOr Regional admissions?YesNoPlease comment ……………………………………………………………………………..8. How does the University/School identify Aboriginal and Torres Strait Islander medical students?Does think this works? Yes NoIf no any suggestions …………………………………………………………………………61

Healthy Futures9. a. Please list the types of assessment used to assess medical students.b. Do you know if Aboriginal and Torres Strait Islander medical students have problems withcertain types of assessment? Yes NoIf yes please identify which assessments:c. does this differ from non-Indigenous students? Yes NoComment: ………………………………………………………………………………………10. Does the School have specific scholarships available for Aboriginal and Torres Strait Islandermedical students? Yes NoPlease detail the scholarship.11. Has the School developed or is the School developing partnerships/links with Aboriginal andTorres Strait Islander communities/organisations? In what capacity?12. How many Aboriginal and/or Torres Strait Islander staff does the School currently employ?(Academic and General)…………………………………………………………………………………………………Thank you for participating in this survey. Your answers are very important and we look forward tosharing the overall results with you62

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Healthy FuturesENDNOTES1 Steering committee for the Review ofGovernment Service Provision(SCRGSP). Overcoming IndigenousDisadvantage Key Indicators 2003.Canberra: Productivity Commission,2003.2 Standing Committee on Aboriginal andTorres Strait Islander Health. Aboriginaland Torres Strait Islander HealthWorkforce National StrategicFramework. Canberra: AHMAC, 2002.3 D Trewin, R Madden. The Health andWelfare of Australia’s Aboriginal andTorres Strait Islander People. Canberra:Australian Institute of Health andWelfare, Australian Bureau of Statistics,2003.4 Ibid.5 G Phillips. Committee of Deans ofAustralian Medical Schools IndigenousHealth Curriculum Framework.Melbourne: VicHealth Koori HealthResearch and Community DevelopmentUnit, 2004.6 Access Economics. Indigenous HealthWorkforce Needs, Australia: AMA, July2004.7 Australian Medical Association. HealingHands: Aboriginal and Torres StraitIslander Workforce Requirements.Discussion paper, Canberra: Aboriginaland Torres Strait Islander Health, 2004.8 Ibid.9 New Zealand Health Workforce.Framing Future Directions. Analysis ofsubmissions and draft recommendationsto the Minister of Health for HealthWorkforce Development, March 2003.T Ready. Health Science Partnerships:Preparing the Workforce for theTwentyFirst Century. Yale-New HavenTeachers Institute. New Haven. OnCommon Ground Fall 1994;3. Accessed01/09/04. .J Crump. Northern med schoolprioritizes aboriginal health. MedicalPost Toronto Mar 16, 2004;40(11):63.Accessed 02/08/04. < http://gateway.proquest.com.gateway.library.qut.edu.au/openurl?url_ver=Z39.88-2004&res_dat=xri:pqd&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&genre=article&rft_dat=xri:pqd:did=000000618720691&svc_dat=xri:pqil:fmt=text&req_dat=xri:pqil:pq_clntid=14394>.10 Fred Hollows Foundation website.Indigenous Health in Australia. TheHealth Emergency. Accessed 15/09/04..11 Op Cit, Phillips, 2004.12 Op Cit, Australian Medical Association,2004.13 Op Cit, SCRGSP, 2003.14 Op Cit, Fred Hollows Foundation,2002.15 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.16 Op Cit, Australian Medical Association,2004.17 Op Cit, SCRGSP, 2003.18 Op Cit, SCRGSP, 200319 Schools Council. The CompulsoryYears. Five to Fifteen: Reviewing the‘Compulsory’ Years of Schooling,Canberra: National Board ofEmployment, Education and Training,AGPS, 1993.68

20 Op Cit, SCRGSP, 2003.21 Op Cit. Schools Council, 1993.22 Op Cit, SCRGSP, 2003.23 Op Cit, SCRSGP, 2003.24 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.25 National Aboriginal and Torres StraitIslander Health Council. NationalStrategic Framework for Aboriginal andTorres Strait Islander Health,Framework for Action by Governments.Canberra: NATSIHC, July 2003.26 Ibid.27 Ibid.28 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.29 G Garvey, N Brown. Project of NationalSignificance Final Report: AboriginalHealth A Priority for Australian MedicalSchools, Newcastle: The Discipline ofAboriginal Health Studies Faculty ofHealth, University of Newcastle, 1999a.30 G Garvey, E Rolfe, S Pearson. Agentsfor Social Change: the University ofNewcastle’s Role in GraduatingAustralian Aboriginal Doctors.Newcastle: Faculty of Medicine andHealth Sciences, University ofNewcastle, 2000.31 G Garvey, D Atkinson. What CanMedical Schools Contribute toImproving Aboriginal Health? NewDOCTOR Summer 1998/9;70.Doctors Reform Society of Australia.Accessed 04/08/04. .32 Op Cit, Garvey, Rolfe, Pearson, 2000.33 Rural Practice. Indigenous Students inMedicine 2002;6(4):74–75.34 Australian Medical Workforce AdvisoryCommittee. Characteristics of studentsentering Australian Medical Schools1989 to 1997. AMWAC Report 1997.7AIHW cat. HWL 6 December 1997.Canberra: AIHW, 1997.35 Ibid.36 A Williams, Y Cadet-James. The Role ofTertiary Education in StrengtheningIndigenous Health. Cairns: Centre forIndigenous Health, Education &Research, July 2000.37 Ibid.38 K Adams. No Shame Job; A HealthCareer Information Guide forIndigenous Students. Canberra:Commonwealth of Australia, 1999.39 Ibid.40 Commonwealth Department ofEducation, Science and Training,National Report to Parliament onIndigenous Education and Training.Canberra: DEST, 2003.41 Ibid.42 R Jefferies. Maori Participation inTertiary Education: Barriers andStrategies to Overcome Them.Wellington: Te Puni Kökiri, theMinistry of Maori Development, 1999.43 Robbins F, Tamatea J. Training NeedsAnalysis for Maori Medical Students. TeUrunga o te Ra Dawn of the NewMillennium Hauiti Marae, Tolaga Bay 7to 9 April 2000. Accessed 04/08/04..44 Te Kupenga Hauora Maori and PacificHealth Website 2005. Maori and PacificAdmissions Scheme (MAPAS).Auckland: University of Auckland.Accessed 02/08/04..69

Healthy Futures45 Op Cit, Ready, 1994.46 University of North Dakota. Indiansinto Medicine. School of Medicine &Health Sciences. Accessed 02/08/04..47 American Medical Association. Accessed16/09/04. .48 Indian Health Service website. Jobs &Scholarships. Accessed 16/09/04..49 University of Alberta. Aboriginal HealthCare Careers Program. Accessed 02/08/04. .50 Op Cit, Crump, March 2004.51 L Haley. 5% of enrolment spots shouldbe filled by Natives: UBC dean. MedicalPost Toronto: Aug 21, 2001;37(28):2.Accessed 02/08/04. < http://proquest.umi.com.ezp01.library.qut.edu.au/pqdweb?did=358597911&sid=2&Fmt=3&clientId=14394&RQT=309&VName=PQD>.52 Ibid.53 Op Cit, Crump, March 2004.54 Health Workforce Advisory Committee,Fit for purpose and for practice: areview of themedical workforce in NewZealand. Consultation Document. NewZealand: HWAC, May 2005.55 Kiwi Careers website. Doctors. IndustryOverview. Accessed 02/08/04..56 Op Cit, Jefferies, 1999.57 Op Cit, New Zealand HealthWorkforce, 200358 University of Auckland. Vision 20/20.Accessed December 2004.. Universityof Auckland News 19 April, 2000.59 Op Cit, Te Kupenga Hauora Maori andPacific Health website, 2005.60 University of Auckland website.Accessed 04/08/04..61 Ibid.62 Centre of American Indian andMinority Health website. AccessedDecember 2004. .63 C Terrell, B Beaudreau. 3000 by 2000and Beyond: Next Steps for PromotionDiversity in the Health Professions. J. ofDental Education 2003;67(9).64 Op Cit, Ready, 2004.65 Op Cit, Ready, 2004.66 D Adams. Doctors hope to inspire byschool visits. American Medical NewsApr 15, 2002;45(15):11–12. Accessed04/08/04. .67 Op Cit, University of North Dakota,2004.68 Op Cit, University of North Dakota,2004.69 Indian Health Service website. Jobs &Scholarships. Accessed 02/08/04..70 M King. Commentry on trainingAboriginal health professionals inCanada. Accessed December 2004.. Edmonton: University of Alberta,2004.71 Op Cit, University of Alberta, 2005.70

72 Op Cit, King, 2004.73 Op Cit, University of Alberta, 200574 Op Cit, University of Alberta, 200575 Op Cit, Crump, 2004.76 Op Cit, Crump, 2004.77 Op Cit, Crump, 2004.78 Op Cit, Crump, 2004.79 Op Cit, Haley, 2001.80 Op Cit, Haley, 2001.81 Op Cit, Haley, 2001.82 Op Cit, Trewin, Madden, 2003.83 Op Cit, Trewin, Madden, 2003,84 Op Cit, CDAMS website,www.cdams.org.au85 Op Cit, Access Economics, 2004.86 Op Cit, Australian Medical Association,2004.87 Op Cit, CDAMS website.88 Op Cit, Trewin, Madden, 2003.89 Op Cit, Phillips, 2004.90 Irihapeti M Ramsden. Cultural Safetyand Nursing Education in Aotearoa andTe Waipounamu: A thesis submitted tothe Victoria University of Wellington infulfilment of the requirements for thedegree of Doctor of Philosophy inNursing. Accessed 29/04/05. . Wellington:Victoria University of Wellington,2002.91 JA Clarke, DD Bull, JR Clarke. USQ’sTertiary Preparation Program (TPP):More Than 15 Years of Evolution inDistance Preparatory/BridgingPrograms. The Factors InfluencingPreparatory Program Development atUSQ: 1985-2004. Toowoomba:University of Southern Queensland.92 E Bourke, R Farrow, K McConnochie,A Tucker. Career Development inAboriginal Higher Education. SouthAustralia: University of South Australia.Department of Employment, Educationand Training. Evaluations andInvestigations Program. Canberra:Australian Government PublishingService, 1991.93 Australian Medical Association. PublicReport Card. Aboriginal and TorresStrait Islander Health. Time For Action.Canberra: AMA, 2003.94 Op Cit, AMA, 2004.95 Australian Council for EducationalResearch. GAMSAT: InformationBooklet 2005. Camberwell, Victoria:ACER, 2004b.96 Australian Council for EducationalResearch website. Accessed December2004. .97 Australian Institute of Health andWelfare website. Accessed December2004. .98 J McCorquodale. The LegalClassification of Race in Australia.Aboriginal History 1986;10(1): 7–24.99 Department of Health and Ageing.Medical Rural bonded Scholarships.Accessed December 2004..100 Op Cit, Australian Medical Association,2004.101 Op Cit, Australian Medical Association,2004.102 Op Cit, Ready, 2004.103 Op Cit, King, 2004.104 Op Cit, King, 2004; Op Cit, Ready,2004; Op Cit, New Zealand HealthWorkforce, 2003.71

Healthy Futures105 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.106 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.107 Op Cit, Standing Committee onAboriginal and Torres Strait IslanderHealth, 2002.108 Op Cit, Australian Medical Association,2004.109 Op Cit, Williams, Cadet-James, 2000.110 Op Cit, Te Kupenga Hauora Maori andPacific Health website, 2005.111 Op Cit, Jefferies, 1999.112 Committee of Deans of MedicalSchools. LIME Outcomes. AccessedDecember 2004. .113 Op Cit, Haley, 2001.114 Op Cit, Haley, 2001.115 Op Cit, Haley, 2001.116 Op Cit, Adams, 2002.117 Op Cit, Australian Medical WorkforceAdvisory Committee, 1997.118 Op Cit, Committee of Deans ofMedical Schools, 2005.119 Op Cit, Crump, 2004.120 Op Cit, University of Auckland website.Accessed December 2004..121 Op Cit, Committee of Deans ofMedical Schools, 2005.122 Sydney University website. AccessedDecember 2004. .123 Op Cit, SCRGSP, 2003.124 Op Cit, Crump, 2004.125 Op Cit, Te Kupenga Hauora Maoriand Pacific Health website, 2005.126 Op Cit, Williams, Cadet-James, 2000.127 Mentoring Australia website. Officialwebsite of the National MentoringAssociation of Australia Inc. AccessedDecember 2004. .128 Op Cit, SCRGSP, 2003.129 Op Cit, Australian Medical Association,2004.130 Medical school websites (e.g. BondUniversity ).131 University of Queensland. Creating aPositive First Year Experience, Report ofa Working Party chaired by the DeputyVice-Chancellor, (Academic).Queensland: UQ December 2004.132 Op Cit, Rural Practice, 2002.133 Op Cit, University of Auckland website,.134 Op Cit, Phillips, 2004.135 Op Cit, Australian Medical Association,2004.72

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