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National Aboriginal andTorres Strait IslanderMedical Specialist Frameworkfor Action and ReportPrepared for the Committee of Presidents of Medical Collegesby Shaun EwenOnemda VicHealth Koori Health UnitCentre for Health and SocietyMelbourne School of Population HealthThe University of Melbourne

ContentsExecutive Summary 1Introduction 5Method 5Section 1: Pathways, Recruitment, Retention and Supportinto Medical Specialties (including General Practice) 7Recruitment 7Pathways 9Support and Retention 10Mentoring 11Section 2: Curriculum 13Evaluation 13Training in Indigenous contexts 14Quality Review 15Section 3: Action for Change 17Advocacy 17Celebrate Progress 18Summary 19Appendix 1 21National Curriculum InitiativesAppendix 2 25Pathways into Specialties, Australian Indigenous Doctors’AssociationAppendix 3 39Indigenous Health Position Paper, The Royal AustralasianCollege of SurgeonsAppendix 4 51Ethical Guideline 11: Principles and Guidelines for Aboriginal andTorres Strait Islander Mental Health, The Royal Australian &New Zealand College of PsychiatristsAppendix 5 59Aboriginal Health Curriculum Statement, The Royal AustralianCollege of General PractitionersAppendix 6 71Heads of Agreement, National Aboriginal Community ControlledHealth Organisation and The Royal Australasian College of Physicians

1Executive SummaryThe framework was commissioned by the Committee of Presidents of MedicalColleges (CPMC) in Australia to guide its commitment to close the gap in healthstatus between Indigenous and other Australians by specifically supporting thetraining of Indigenous medical specialists. This report does indeed take a‘recruitment to specialisation’ approach, recommending initiatives to recruit andsupport Indigenous medical students in their pathway from junior doctors toFellows.Three streams of action have been identified: recruitment and retention—andsuccessful completion—of Indigenous medical graduates in their chosen specialisttraining; reform of the curricula to incorporate Indigenous health perspectives,experiences and opportunities into core training; and the pragmatics of ensuringchange and implementation of strategies in these areas.The central legitimacy of this report rests on the contributions of 15 Indigenousmedical specialists, or specialists‐in‐training, from around Australia who generouslyshared their insights in interviews. Also, a literature review was undertaken lookingat the scope of published information related to mentoring in medicine as well ascultural competency and safety in specialist medical training. Key approaches weredrawn from the Medical Deans of Australia and New Zealand (MDANZ) andAustralian Indigenous Doctors Association (AIDA) collaboration agreement, whichaims to increase the number of Indigenous medical students, as well as ensure thatIndigenous perspectives are integrated into basic medical education.Australia has a poor record in the recruitment and retention of Indigenous people inmedicine. In contrast to other settler colonial nations such as New Zealand, theUnited States and Canada, who all graduated their first Indigenous doctors in thelate 1880s, Australia’s first Indigenous medical doctor graduated in 1983, andcurrent numbers represent only approximately 0.2 per cent of the medicalworkforce in Australia (but Indigenous Australians represent 2.3 per cent of the totalpopulation). The reality of these relatively small numbers of Indigenous medicalgraduates provide an opportunity for Colleges to address needs on an individualbasis in the short term, whilst putting in place a systemic approach for the future. Itis anticipated that Indigenous medical graduates will increase from current numbers(an estimated 137 doctors in training) by 10 and 20 per year for the three years from2010, with nearly double that in the following years (possibly up to 40).In framing the recommendations of this report, consideration has been given to thespecific factors that impact on Indigenous doctors’ decision to specialise. Whilementors play a significant role, an awareness of the poor state of Aboriginal healthwithin their own families and communities and the ability to improve this withspecialty skills also has an influence. The scope of impact in general practice wasanother emergent theme.The report discusses pathways into specialties, support, retention and mentoring,curriculum reform and pathways for change and concludes that existing expertise,goodwill and good intent alone do not ensure the successful execution of the

2necessary strategies that will ensure CPMC’s contribution to the close the gapcampaign. While some of the recommendations made in this report have beenmade previously in different contexts, they continue to be an important part of aMedical Specialist Framework for Action.Recommendations• Given the variability of national census data (as can be seen in table 1), Collegesshould collect the Indigenous status data of its members.• The Medical Student Outcome Database(http://www.medicaldeans.org.au/MSOD_Webpages/msod.html) should beused to track medical graduates’ pathways, and identify and better understandany enablers or barriers to success for Indigenous graduates.• A funded project officer should be appointed to develop and maintain anIndigenous‐relevant online access point for applications into training programs;and to support and facilitate applicants’ progress in their applications.• An online portal specific to Indigenous medical students, junior doctors andtrainees should be developed with a focus on support and identifying pathwaysinto specialist training.• The CPMC should develop and fund scholarships to support Indigenous trainees.This would help overcome financial barriers. The Puggy Hunter MemorialScholarship is an example of such a named scholarship for Indigenous healthscience undergraduates.• Colleges should provide the opportunity for their entire staff to undertake crossculturaltraining in Indigenous issues.• Utilising Continuing Medical Education, Colleges to encourage Fellows to attendcultural competence training related to Indigenous health.• CPMC to implement the recommendations of the AIDA Pathways intoSpecialties paper in all its member Colleges. Currently, initiatives are in place atRACP and RACS.• CPMC to implement an Indigenous Employment Strategy within its ownorganisation, at all levels.• To re‐affirm a partnership approach to Indigenous health. This recommendationneeds to be realised at the national, state and territory, and local levels.Specifically, relationships with NACCHO and their state affiliates, and othercommunity‐based organisations, could offer a broad range of trainingopportunities in Aboriginal health.• To develop a training module to support AMC accreditation teams to adequatelyassess College standards of cultural competence.• To systematically evaluate existing initiatives in Indigenous health and culturalcompetence curricula.• To develop a learning module or modules in Indigenous health, based upon theprinciples of vertical integration, using existing examples from General Practice

3and Psychiatry and consistent with recommendations from the Med Ed 2009conference. The CDAMS National Indigenous Health Curriculum should bedrawn upon here.• To develop a cyclical quality review tool, drawing upon the Critical ReflectionTool (http://www.limenetwork.net.au/content/critical‐reflection‐tool‐crt)developed by the LIME project, and seeking permission to modify it to ensurerelevance for Specialists Colleges.• CPMC to continue its collaboration with AIDA to develop the Indigenous healthworkforce, from recruitment to specialisation. Advances made through theAIDA–MDANZ agreement provide a framework upon which thisrecommendation may be operationalised.• Centralised, coordinated approach to providing trainee placements intoIndigenous health training posts. Particularly at more advanced levels, thisprovides valuable medical services to Indigenous people whilst exposing traineesto Indigenous contexts.• CPMC to support MSOAP in its efforts to provide services to Indigenous peoplebased on community identified needs and priorities, regardless of theirgeographic circumstances. This recommendation can best be met through astrong partnership with NACCHO and its membership.• Periodic (perhaps twice yearly) e‐newsletter from the CPMC Indigenous healthsubcommittee.• Implement an Indigenous Knowledge Initiative for CPMC leadership.

5IntroductionI think we have a real good opportunity here… This can revolutionise Australianspecialist training for both Indigenous and non‐Indigenous doctors. Dr KelvinKongThis framework was commissioned by the Committee of Presidents of MedicalColleges (CPMC) in Australia to develop a plan of action to guide its commitmenttoward closing the gap in health status between Indigenous and other Australians.This report is divided into three main sections, reflecting the three streams of actionneeded to address reform in Indigenous health in CPMC member Colleges.The first stream is recruitment and retention—and successful completion—ofIndigenous medical graduates in their chosen specialist training. This needs tohappen in parallel with the second stream, which is reform of the College trainingcurricula to incorporate Indigenous health perspectives, experiences andopportunities into core training. In the third section or stream, attention is given tothe pragmatics of securing systemic change based on the recommendationssupporting recruitment, retention, successful completion and curriculum reform.MethodMuch of this report has drawn on the insight, experience and expertise of 15Indigenous medical specialists. Their voice was sought to inform the developmentof this framework and is central to its legitimacy. Despite their incredibly busyworkloads and multiple demands from their profession, their families, and theircommunities, all those who were able to participate were extremely generous intheir time, many commenting how important this initiative was to them.In addition, a literature review was undertaken looking at the broad scope ofpublished information related to mentoring in medicine, and cultural competencyand safety in specialist medical training. Key approaches were drawn from theMedical Deans of Australia and New Zealand (MDANZ) and Australian IndigenousDoctors Association (AIDA) collaboration agreement, which aims to increase thenumber of Indigenous medical students, as well as ensure that Indigenousperspectives are integrated into basic medical education.The Indigenous specialists, or specialists‐in‐training, who were interviewed camefrom across the country. The interviews were recorded, transcribed and coded, andemergent themes—which became significantly repetitive—are reported here. TheUniversity of Melbourne Population Health Human Ethics Advisory Group,application identity number 1033061, approved the research that informs thisframework.Finally, this report takes a ‘recruitment to specialisation’ approach, which involvesthe recruitment and support of Indigenous medical students along their journeythrough to junior doctors, and a pathway for successful completion to Fellowship.

7Section 1: Pathways, Recruitment, Retentionand Support into Medical Specialties(including General Practice)RecruitmentAustralia has a poor record in the recruitment and retention of Indigenous people inmedicine. In contrast to other settler colonial nations such as New Zealand, the UnitedStates and Canada who all graduated their first Indigenous doctors well over onehundred years ago, 1 Australia’s first cohort of Indigenous medical graduates was ledby Professor Helen Milroy who graduated from the University of Western Australia in1983 (Anderson 2008:3).AIDA estimates that, as of September 2009, there were 140 Indigenous medicalgraduates in Australia, with another 137 in training.Source: < http://www.aida.org.au/pdf/Numbersofdoctors.pdf>Data from the 2006 census suggest that Australian Indigenous people made up 0.2 percent of the medical workforce (60 of 29,920 General Practitioners and 40 of 25,155other medical specialists), but they represent 2.3 per cent of the total population inAustralia. (AIHW 2008; ABS 2008).1 Dr Oronhyatekha, a Mohawk man, received his medical degree from the University of Toronto in1866. In 1889, Dr Susan La Flesche Picotte was the first Native American woman to graduate fromthe Women’s Medical College of Pennsylvania. In 1904, Te Rangi Hiroa (Sir Peter Buck) was the firstMāori to receive his medical qualification from Otago University.

8Table 1 – Medical practitioners by type of practitioner by Indigenous status 1996,2001, 2006 Census1996 2001 2006number per cent number per cent number per centGeneral Medical PractitionersIndigenous 41 0.1 54 0.2 82 0.2non‐Indigenous 28,914 99.5 31,839 99.5 35,169 99.3Specialist Medical PractitionersIndigenous 20 0.1 34 0.2 24 0.1non‐Indigenous 14,859 99.4 15,767 99.3 19,261 99.4Source: AIHW 2009, p. 13AIDA’s own data from their Fellows Position Paper (2009, see appendix) suggests avery different picture, claiming only 14 Fellows currently exist (although it appearsthat Fellows of the Royal Australian College of Physicians have been overlooked in thiscounting, adding another three known physicians).Source: Internal AIDA paperThe more specific and clear the data is on the make‐up of the Australian healthworkforce, the more targeted initiatives such as support and recruitment, andresource allocation can be. Achievements in recruitment and retention can also beaccurately reported and celebrated.In developing a plan of action for recruitment into specialist Colleges, considerationneeds to be given to the ‘pipeline’ effect and realities of relatively small numbers ofIndigenous medical graduates. The immediate increase in the number of Indigenousmedical graduates is between 10 and 20 a year for the three years from 2010, withnearly double that in the following years (possibly up to 40). This provides anopportunity for Colleges to address needs on an individual basis in the short term,whilst putting in place a systemic approach for the future.An area of discussion with the Indigenous medical specialists was about which factorshad influenced their choice of specialty. The typical response was that their interest topursue a specialty was spurred by community needs; an awareness that the poor stateof Aboriginal health within their own families and communities could be improved bytheir specialty skills. For example, for one Indigenous physician, the reason for

9specialising in sexual health was the increasing rate of HIV in the Indigenouspopulation, which surpasses that of the non‐indigenous population. The breadth ofimpact on Aboriginal Health in a community context for general practice was anotheremergent theme. These themes are not to obscure the issue of individual agency forgraduates, but to highlight the tension for specialists between community needs andpersonal choice.The strength of this influence in choice of career differs from the situation in whichmentors have a significant influence in the career direction of their mentees,particularly in Surgery (see McCord et al. 2009). The role of mentors will be discussedlater, but one finding from the interviews with Indigenous specialists or specialists‐intrainingwas that community is a much more significant motivator in the pursuit of aspecialisation than the influence of a mentor.Lifestyle factors were also raised, and the compatibility of family and communitycommitments were described as more suited to the professional demands of aGeneral Practitioner.PathwaysAustralian General Practice Training (AGPT) has links for prospective applicants,including information specific to both junior doctors and medical students. AnIndigenous portal, developed and supported by the AIDA and CPMC collaboration,could provide a supported pathway wherein Indigenous junior doctors or medicalstudents interested in pursuing a particular specialisation can register their interest.Implementation of such a resource requires a funded project officer who can ensureappropriate links and contacts are facilitated, and a tailored ‘development andmentoring’ plan is established. (Again, note that, for the foreseeable future, numbersof potential candidates are very low, allowing time for a system such as this to betrialed, evaluated, and changes made to accommodate the growing number ofpotential applicants.)This portal could also provide an avenue for online support, in terms of developing alearning community of scholars. The Royal Australasian College of Physicians (RACP)Trainee’s Café website (http://traineescafe.racp.edu.au) is an example of an existingonline community of scholars, targeting a particular group of training fellows. Thisprovides a model for further consideration for Indigenous trainees, perhaps across thespectrum of college activity.Another example is the Te Hononga Mātauranga Māori Doctoral Resource Portal(http://akoaotearoa.ac.nz/communities/te‐hononga‐m%C4%81taurangam%C4%81ori‐doctoral‐resource‐portal)that statesthis Doctoral Resource Portal provides support and information for MāoriDoctoral students. The Portal contains a suit of audiovisual information onMāori research, ethics, administration, writing, and the effective use of supporttechnology.It’s managed by the staff of Te Mata o Te Tau, The Academy for MāoriResearch and Scholarship, at Massey University in Wellington.

10Whilst not yet formally evaluated, feedback about the portal has been ‘universallypositive, the “hits” continue to climb, and interest has been maintained’ (pers comm.,Director, Te Mata o te Tau The Academy for Maori Research and Scholarship 2010). Aportal such as this could be a joint collaboration between AIDA and CPMC, as it coversthe aspirations and work of both organisations.Recommendation: Given the variability of national census data (as can be seen intable 1), Colleges should collect the Indigenous status data of its members.Recommendation: The Medical Student Outcome Database(http://www.medicaldeans.org.au/MSOD_Webpages/msod.html) should be used totrack medical graduates’ pathways, and identify and better understand any enablersor barriers to success for Indigenous graduates.Recommendation: A project officer should be appointed to develop and maintainan Indigenous‐relevant online access point for applications into training programs;and to support and facilitate applicants’ progress in their applications.Recommendation: An online portal specific to Indigenous medical students, juniordoctors and trainees should be developed with a focus on support and identifyingpathways into specialist training.Support and RetentionIndigenous medical specialists reported a variety of positive and negative experiencesduring their training, but a common theme was the range of competing demands ontheir time. Whilst this may be a familiar situation to many trainees, there are particulardemands made of Indigenous medical specialists in training. They reported significantfamily and community demands, often highlighted and exacerbated by being the first,or only, Indigenous doctor in their communities. This was not often understood noradequately acknowledged within the culture of the specialist medical Colleges.When you work as an Aboriginal doctor you’ve got your specialty then… oftenyou’ve been drawn into Indigenous issues at various levels… you still need tomaintain yourself and that can be very important… I spend all my breaks going toconferences and workshops related to Indigenous issues, you know. Nobody elsewas doing that. Dr David BrockmanThe ‘hidden curriculum’ of the medical profession is another important aspect thatneeds consideration. An acknowledgement that the aspirations of Colleges aroundtraining in Indigenous health and recruitment of Indigenous trainess, may not beconsistent with the messages of the hidden curricula, in terms of policies, resourceallocation, staffing profiles of colleges and institutional slang. This hidden curriculummay prove to be another specific challenge for Indigenous trainees and fellows.Most of what the initiates will internalise in terms of the values, attitudes,beliefs, and related behaviors deemed important within medicine takes placenot within the formal curriculum, but via a more latent one, a “hiddencurriculum,” with the latter being more concerned with replicating the cultureof medicine than with the teaching of knowledge and techniques. In fact, whatis “taught” in this hidden curriculum often can be antithetical to the goals and

11content of those courses that are formally offered (Hafferty & Franks1994:865).Recognition and reform of the hidden curriculum is required to achieve thenecessary fundamental changes to the culture of undergraduate medicaleducation (Lempp & Seale 2004:772).The values attitudes, beliefs and related behaviours of Indigenous specialists, andmedical colleges, may not always be mutually reinforcing. To support Indigenoustrainees, at times, the Colleges may need to do more than acknowledge challenges ofIndigenous trainees, and act to support the trainees. One example of the ‘hiddencurriculum’ is the employment profile of the organisation. There is a need to ensurethat and at all levels of professional and administrative responsibility, Indigenousperspectives are not overlooked. One way to do this is to ensure that Indigenouspeople are not invisible within the organisation.Reporting of financial hardship as both a barrier to entering specialists training and tocompletion was also widely noted. Waiver of examination fees was seen as way thatcolleges could and have provided support in the pastThe cost can be incredibly expensive… those courses aren’t cheap, they arethousands of dollars… and the exams themselves can be expensive, andparticularly if you fail, there's the extra pressure. It’s hard enough you havepressure on to pass, but then knowing that it's costing you $5,000 or whatevereach time you sit it… the costs can be considerable. Dr Tamara MackeanMentoringFrom time immemorial mentoring has been the angular stone sustaining thebuilding of medical and surgical education (Toledo‐Pereyra 2007).Whilst mentoring didn’t feature strongly as either a specific enabler or barrier toprogression for Indigenous medical trainees, the literature revealed that ’mentoredresidents are nearly twice as likely to describe themselves as having excellent careerpreparation’ (Lis et al. 2009) and that ‘mentoring in the medical faculty with higherreported levels of career satisfaction and career preparedness’ (Ramanan et al. 2006;Sambunjak, Jensen et al. 2008). It may also be that the absence of specific mentoringprograms may create a situation whereby trainees ‘don’t know what they don’t know’,and the development of a mentoring program in this context may reap the benefitsand rewards highlighted in other contexts.A key question to consider with regard to providing mentoring for Indigenousspecialist trainees is: what is the role of the mentor and what is the particular gain forthe trainee? Is it a cultural mentor, someone who has seen the traps and dangers froman Indigenous perspective, and able to provide support and guidance when needed? Isit a clinical mentor, which should be the key responsibility of the relevant Colleges? Ifcultural mentoring is not seen as lacking, then the role already played in this area byAIDA and its members should not be underestimated. AIDA’s core business is supportand informal mentoring. Targeted clinical mentoring from within the college systemcould strengthen AIDA’s informal and collegial cultural mentoring. Messages fromIndigenous specialists interviewed varied regarding their experiences of mentoring,

12but many reported that formal mentoring was ad hoc and mostly left up to theindividual to organise.The most notable comments about mentoring related not to Indigenous culturalsupport, but rather to support within the professional culture of medicine, and thepathway of the trainee.My mentors have been really good… being able to help me through some of thosebarrier times and those difficult times and being quite supportive and also helpingme do all the paperwork, ‘cause there’s an extraordinary amount of paperworkand bureaucracy… Indigenous specialist commenting on their mentoringexperienceJust learn the rules of the game and you know to keep you focused on what youneed to do because I think sometimes you can be distracted so I think having theparticularly training mentors… is really important and then you know you needthem for survival and being able to cope with being in the health sector at timesor being in medicine, being in training. Dr Tamara MackeanMentoring programs that have specifically focused on cultural or ethnic differencesand support have generally been successful in meeting their articulated aims(Coleman et al, 2005). Mentoring with Indigenous trainees should take a strengthsbasedapproach, not a deficit approach… Aboriginality [should be seen] as a strength rather as a weakness. IndigenousspecialistSome mentoring initiatives already exist, such as the RACP mentoring project withAIDA (see Fellows paper), and the RACS ‘cutting clubs’ mentoring project. Mentoringprograms need to have their objectives clearly identified so that their achievementscan be documented against their aspirations.Recommendation: CPMC to develop and fund scholarships to support Indigenoustrainees. This would help overcome financial barriers. The Puggy Hunter MemorialScholarship is an example of such a scholarship for Indigenous health scienceundergraduates.Recommendation: That Colleges provide the opportunity for their entire staff toundertake cross‐cultural training in Indigenous issues.Recommendation: Utilising Continuing Medical Education, Collegesencourage Fellows to attend cultural competence training related to Indigenoushealth.Recommendation: CPMC to implement the recommendations of the AIDA Pathwaysinto Specialties paper in all its member Colleges. Currently, initiatives are in place atRACP and RACS.Recommendation: CPMC to implement an Indigenous Employment Strategy withinits own organisation, at all levels.

13Section 2: CurriculumThere are two primary reasons for inclusion of Indigenous health, informed byIndigenous perspectives in training programs. The first is to ensure that all Fellows inAustralia are adequately trained to be able to work positively with Indigenous peopleand communities. The second is to ensure that the training curriculum doesn’talienate Indigenous trainees, and that Indigenous people are not further marginalisedin Australian society through invisibility in the curriculum. Central to curriculumdevelopment and delivery are Indigenous community priorities and Indigenousleadership.Most faculty appear open to cultural training, but desire a clear understandingof exactly what that would entail and how it can be taught (Chun 2009).EvaluationExisting curricula and training opportunities vary across Colleges, but consistent is thelack of longitudinal evaluation of curricula. There are many varieties of culturaltraining within medicine worldwide. Reasons for inclusion and expected outcomesvary and need to be considered at the outset so that realistic and relevant approachescan be implemented.Despite progress in the field of cross‐cultural medical education, severalchallenges exist. Foremost among these is the need to develop strategies toevaluate the impact of these curricular interventions (Betancourt 2003).There are a variety of initiatives already in place across specialist Colleges (see page 12for an exemplar from RACGP), but similar to many examples locally andinternationally, longitudinal evaluation of such modules is rare. A development in theAustralian basic medical education context is the National Indigenous HealthCurriculum Framework (see Appendix 1 for outline of key subject areas). Whilst mostrecent medical graduates should have had some teaching in Indigenous health, thedepth of learning and sophistication of approaches will vary. Many current specialiststrainees may have had very little Indigenous health teaching, and internationalmedical graduates may have had none. Others may have significant knowledge,exposure and understanding of Indigenous health. The challenge is to develop acurriculum that is flexible and which builds upon current levels of trainee knowledgeyet is introductory enough to ensure that every trainee is exposed to the basics(without being repetitive). Further, in specialist training, the learning opportunitiesneed to be relevant to the particular strand of interest of the trainees, and clinicallyoriented.A confluence of Indigenous health‐specific training, and cultural competency andsafety is common. Yet it should not be the sole responsibility of the ‘close the gap’initiative to address deficiencies in cultural competence and safety training in collegecurricula. Whilst there is some overlap with Indigenous health training, they are notthe same thing. Nevertheless, Indigenous health training may provide an opportunityfor evaluation of cultural competence and safety initiatives across college curricula.

14In February 2010, the RACGP launched the National Faculty of Aboriginal and TorresStrait Islander Health whose aims include encouraging Indigenous medical studentsand registrars to choose the specialty of general practice.The RACGP has been working closely with the National Aboriginal CommunityControlled Health Organisation (NACCHO) to develop training programs andcontinuous education modules in Indigenous health.RACGP encourages the recruitment of Indigenous registrars to the RACGP andencourages all GPs to extend their knowledge of Indigenous culture.RACGP provides a variety of services including supporting initiatives such as theRACGP fellowship exam, curriculum development and the RACGP Aboriginal HealthUnit.RACGP offers Aboriginal and Torres Strait Islander Health Service is one of the manyservices offered by the College’ extensive library collection, which after recentenhancement allows continued access to GPs and registrars working in Aboriginal andTorres Strait Islander Health Communities and other current staff members ofAboriginal Community Controlled Health Services.Training in Indigenous contextsA very clear message from interviews with existing Indigenous specialists was thatlearning opportunities in Indigenous health need to be clinically focused within theirdiscipline. Central to this is the fostering of local relationships with community andAboriginal Community Controlled Health services. This is already evident in theRACGP Aboriginal Health Curriculum Statement, which has a key principle:Partnership with Aboriginal people. Aboriginal educators from NACCHOaffiliated organisations are to be involved in all aspects of planning,development and implementation of the training.Models of engagement with Aboriginal Community Controlled Health Organisations(ACCHOs) are an area that has received limited attention when ensuring sustainablesites for training posts. Whilst models of engagement with mainstream teachinghospitals have a longer history, community controlled health services first appeared inthe early 1970s and close working relationships with specialist trainees have beenmore recent. The current capacity of ACCHOs to be training sites for more students,from more health disciplines, at more levels, creates an unsustainable burden on theAboriginal health services. Models of engagement, which include fundingagreements, need to be developed so that patients of the Aboriginal health serviceshave increased access to expert care, not decreased access due to too many traineesnot being adequately supported. These models need to be based upon a reciprocalrelationship between the training needs of specialists and health needs and prioritiesof the community. Skills of trainees, both basic and advanced, are a valuable resourceto meet health demands, and Indigenous contexts can provide a wonderful

15environment for trainees to learn and practice their skills with suitable support andguidance, provided there are the mechanisms in place to make this sustainable.I think there needs to be a coordinated approach to this. I think the last thing youwant is the colleges knocking individually on doors of services. So some sort ofbrokerage process that operates at a regional level that works across the collegesystem and …works out the Indigenous Health program and sets up someagreements, some agreed principles, and processes. A kind of an integrated,coordinated approach and that requires some resource. Probably the collegesshould all put in for it to support it, you need a coordinated approach to it forimplementation. Professor Ian AndersonACCHOs will not be the ideal training environment for all specialist trainees at allstages of their training. Integrated curricula in Indigenous health should support thedevelopment of knowledge for trainees working in other health contexts where theywill be working with Aboriginal people, covering the spectrum of the suburbancommunity health centres, to the high tech tertiary hospitals, from inner cities, torural and suburban communities across the country.Quality ReviewIn basic medical education, the implementation of the CDAMS curriculum frameworkin medical schools was supported by the development of a quality review process,called a Critical Reflection Tool.The CRT provides an opportunity for medical schools to critically analyse factorssuch as their structural relationship with existing Indigenous health units, andthe aspirations of the medical school as articulated through mission statements,through to the detail of the curriculum itself (including teaching and learning,assessment, implementation and review and evaluation) and Indigenous studentrecruitment and retention initiatives and strategies (Anderson et al. 2009:580).A similar approach could be developed at College level, supported by CPMC, so thatprogress can be measured, successes celebrated, and strategies for achievementshared across Colleges.Ultimately, the role of accreditation is central in terms of implementing new initiativesin medical training and ensuring that graduate attributes, at all levels, are what isrequired to meet Australian health workforce requirements.The AMC has an expectation that medical specialists will demonstrate culturalcompetence in their practice of medicine (AMC Standards for SpecialistTraining).The AMC is not as specific in its accreditation requirements for specialist education asit is for basic medical education in regards to Indigenous health. As the accreditingbody for college trainees and curricula, the CPMC may wish to work with the AMC tostrengthen these accreditation requirements. Progress in implementation ofIndigenous health curricula in undergraduate course may provide an existingframework, including accreditation criteria, which could be reasonably applied tospecialist training.

16Recommendation: To re‐affirm a partnership approach to Indigenous health. Thisrecommendation needs to be realised at the national, state and territory, and locallevels. Specifically, relationships with NACCHO and their state affiliates, and othercommunity‐based organisations, could offer a broad range of training opportunities inAboriginal health.Recommendation: To develop a training module to support AMC accreditationteams to adequately assess College standards of cultural competence.Recommendation: To systematically evaluate existing initiatives in Indigenoushealth and cultural competence curricula.Recommendation: To develop a learning module or modules in Indigenous health,based upon the principles of vertical integration, using existing examples fromGeneral Practice and Psychiatry and consistent with recommendations from the MedEd 2009 conference. The CDAMS National Indigenous Health Curriculum should bedrawn upon here.Recommendation: To develop a cyclical quality review tool, drawing upon theCritical Reflection Tool (http://www.limenetwork.net.au/content/critical‐reflectiontool‐crt)developed by the LIME project, and seeking permission to modify it to ensurerelevance for Specialists Colleges

17Section 3: Action for ChangeHow can the medical profession further contribute to Australia becoming ahealed nation? As a collective, we can promote understanding of themultiple determinants of Indigenous Health—the physical, psychological,social, cultural and spiritual aspects of wellbeing; ensure this understandinginforms clinical interactions as well as policy and resource allocation;advocate for and practise culturally appropriate health service provisionacross the care spectrum; encourage sectors such as housing, education andjustice to with the health sector to create reform; and advance anappreciation of the healing strength of reconnecting with family, culture andCountry (Mackean 2009:522).The final section of this report pulls together issues of recruitment, retention,support and curriculum, and makes recommendations as to how the CPMC canmeaningfully, and immediately, capitalise on the significant expertise of itsmembers, their goodwill and good intent, to contribute to improving the health andwellbeing of Australia’s Aboriginal and Torres Strait Islanders. This section alsodraws upon and acknowledges the significant work already being done in this area.For example, the various college position statements on Indigenous health whichare included in the appendix.AdvocacyDevelopment of the advocacy role of the CPMC, in relation to Indigenous health,emerged as a theme from the interviews, alongside support for the work currentlybeing undertaken.… I’d like the college to be more engaged in, at a local level, of what otherpeople want, and then to try and bring better balance and partnerships. Usingtheir influence at the higher levels of policy. Dr David BrockmanClearly advocacy and policy component of a large college like the College ofPhysicians has a role and they've certainly attempted to do that around 'closethe gap' and … I think that's been helpful. Stronger policy advocating from TheCPMC is vital to close the gap. Dr Tamara MackeanMedical specialists have huge influence on governments and on policy and it'sthe kind of things that really all the specialist colleges should be jumping upand down about all the time ‐ it's just unacceptable standards, unacceptablestatistics. At the same time they should allow some of the Indigenous doctorsand specialists to take a lead on these things because you can becounterproductive if you don't do things strategically around advocacy. It'sreally important that advocacy is part of a structured plan and that it fits inwith where we need to go. So the advocacy stuff is important but probably notjust the colleges themselves probably something that's worked out withindigenous groups such as AIDA and others who can influence policy and giveyou good advice on how best to influence policy in the right way. Dr MarkWenitong

18The Medical Specialist Outreach Assistance Program (MSOAP) aims to improve theaccess of rural and remote communities to medical specialist outreach services.However, health status—and access to health services—for many urban (and outermetropolitan) Indigenous people is on a par with their rural counterparts, and asimilar scheme should be made available in urban areas. At the time of writing itwas understood that changes were being made to MSOAP’s operational guidelinesin relation to Indigenous communities.Indigenous Knowledge InitiativeEvery second year, in conjunction with their biennial conference, the Medical Deanshave committed to participating in a comprehensive Indigenous KnowledgeInitiative. This initiative, developed in conjunction with AIDA, provides the Deanswith first‐hand experience of Indigenous culture and aspects of Indigenous health tobetter understand the nature and complexity of issues impacting on Indigenoushealth. Informal reports from some Deans are that this is a highly valuedexperience. Such an initiative could be implemented for Presidents of medicalColleges.Celebrate ProgressMuch valuable work has been already undertaken, with much more still to be done.It is important to celebrate the progress and achievements to date, by focusing onsolutions to problems, highlighting models of relationships with Aboriginal HealthServices, sharing good news stories, and supporting and advocating successfulapproaches to improved services to Aboriginal communities. Community inputshould be actively sought and supported where appropriate, and successful modelsfor cross‐College partnerships should be highlighted. Such an approach alreadyexists within GPET and is evidenced by the Ngaaminya Newsletters(http://www.gpet.com.au/IndigenousHealthTraining/NgaaminyaNewsletters/).Recommendation: CPMC to continue its collaboration with AIDA to develop theIndigenous health workforce, from recruitment to specialisation. Advances madethrough the AIDA–MDANZ agreement provide a framework upon which thisrecommendation may be operationalised.Recommendation: Centralised, coordinated approach to providing traineeplacements into Indigenous health training posts. Particularly at more advancedlevels, this provides valuable medical services to Indigenous people whilst exposingtrainees to Indigenous contexts.Recommendation: CPMC to support MSOAP in its efforts to provide services toIndigenous people based on community identified needs and priorities, regardlessof their geographic circumstances. This recommendation can best be met through astrong partnership with NACCHO and its membership.Recommendation: Periodic (perhaps twice yearly) e‐newsletter from the CPMCIndigenous health subcommittee.Recommendation: Implement an Indigenous Knowledge Initiative for CPMCleadership.

SummaryThe commissioning of this report by the CPMC is implicit recognition of the need foraction, and goodwill to pursue change. However, expertise, goodwill and goodintent alone do not ensure the successful execution of a plan of action. Some of therecommendations made in this report have been made before in different contexts.To ensure that the CPMC successfully executes these recommendations, and do allit can to recruit, support and graduate Indigenous specialists, whilst improving theknowledge and skills of the specialist medical workforce in Indigenous health, linesof responsibility need to be clearly articulated, benchmarks need to be set andreported on.The establishment of the CPMC Indigenous health subcommittee provides a centralpoint for expert advice to be sought regarding realisation of some of theserecommendations, but the responsibility lies not just with this subcommittee, butalso with the CPMC membership, at both institutional College level, and individualmember level.Success should be measured objectively and initiatives rigorously evaluated on aplanned regular basis (e.g. annually).19

21Appendix 1National Curriculum Initiatives

National Curriculum InitiativesSuggested Subject Areas from CDAMS National Indigenous Health CurriculumFramework:1. History2. Culture, Self and Diversity3. Indigenous Societies, Cultures and Medicines4. Population Health5. Models of Health Service Delivery6. Clinical Presentations of Disease7. Communication Skills8. Working with Indigenous Peoples – Ethics, Protocols and ResearchIndigenous public health competencies for Master of Public Health programs:1. Analyse key comparative health indicators for Aboriginal and Torres StraitIslander people2. Analyse key comparative indicators regarding social determinants of health forAboriginal and Torres Strait Islander people3. Describe Aboriginal and Torres Strait Islander Health in historical context andanalyse the impact of colonial processes on health outcomes4. Critically evaluate Indigenous public health policy or programs5. Apply the principles of economic evaluation to Aboriginal and Torres StraitIslander programs, with a particular focus on the allocation of resources relativeto need; andDemonstrate a reflexive public health practice for Aboriginal and Torres Strait Islanderhealth context.

25Appendix 2Pathways into SpecialtiesAustralian Indigenous Doctors’ Association(original document)

September 2009Paper for internal use onlyPathways into SpecialtiesA strategic approach to increasing the number of Aboriginal andTorres Strait Islander FellowsContextThe poor status of Aboriginal and Torres Strait Islander health and the 17-year lifeexpectancy gap is well documented. The burden of disease experienced byIndigenous Australians is estimated to be two and a half times greater than theburden of disease in the wider Australian population.Aboriginal and Torres Strait Islander people experience higher death rates than non-Indigenous Australians across all age groups, from all major causes of death. i This –in a nation which in general, has one of the healthiest populations of any developedcountry and which has access to a world-class health system – is unacceptable.Since the 2008 national Apology to the Aboriginal and Torres Strait Islander peoplesof Australia, the Australian Government has demonstrated commitment toovercoming the disadvantages faced by Aboriginal and Torres Strait Islander people.In signing the Close the Gap Statement of Intent (2008), the Australian Governmentcommits to developing a comprehensive, long-term plan of action to achieveequality of health status and life expectancy between Aboriginal and Torres StraitIslander peoples and non- Indigenous Australians by 2030. This commitmentincludes the training of an adequate number of health professionals to deliver healthcare services.The Council of Australian Governments (COAG) National Healthcare Agreement (29November 2008) provides for a significant funding reform package that will enablethis to occur through:o $500 million in additional Commonwealth funding for undergraduate clinicaltrainingo An increase of 605 postgraduate training placeso 212 additional ongoing GP training places and 73 specialist training places.The (former) National Aboriginal and Torres Strait Islander Health Council (NATSIHC)auspiced the development of the Blueprint for Action: Pathways into the healthworkforce for Aboriginal and Torres Strait Islander people - a framework forAustralian, State and Territory government to retain and build the capacity of theexisting Aboriginal and Torres Strait Islander health workforce by addressing ongoingsupport and career development needs. iiIn response to this key document, Ministers Gillard, Roxon and Macklin agreed toform an interdepartmental committee (IDC) to consider the recommendations of theBlueprint for Action report. The 21 recommendations raise significant implications1

September 2009Paper for internal use onlyfor cross-portfolio initiatives and are congruent with the Council of AustralianGovernment’s (COAG) workforce strategies under the Closing the Gap agenda.The current environment provides the political will, intent and opportunities todevelop and imbed a range of strategies that will have long-lasting positive benefitstowards improving the health and well-being of Aboriginal and Torres Strait Islanderpeople.There are significant roles for key agencies such as the Australian IndigenousDoctors’ Association (AIDA) to play in advocating for improved Aboriginal and TorresStrait Islander health workforce development.Profile of Indigenous FellowshipThere are currently 140 Aboriginal and Torres Strait Islander medical graduatesthroughout Australia and some 137 Aboriginal and Torres Strait Islander medicalstudents. Within the cohort of Aboriginal and Torres Strait Islander medicalgraduates, there are many examples of success.Exemplar: Aboriginal and Torres Strait Islander FellowsAustralian & New Zealand College of Psychiatrists – 1 FellowCardiac Society of Australia and New Zealand – 1 FellowRoyal Australian College of General Practitioners – 10 FellowsRoyal Australasian College of Surgeons – 1 FellowRoyal Australian and New Zealand College of Obstetricians and Gynaecologists – 1 FellowNote: There is limited data available regarding the number of Aboriginal and Torres StraitIslander Fellows. The information provided is indicative of AIDA’s knowledge across thenetwork.These exemplars have a flow-on effect for other medical graduates in that Fellowsare paving the way, supporting and championing for Registrars and others. This inturn provides an increased critical mass of the Aboriginal and Torres Strait Islandermedical specialist workforce across Medical Colleges.The current 137 Aboriginal and Torres Strait Islander medical students providesfertile ground with which to grow the Aboriginal and Torres Strait Islander medicalworkforce. Given the increasing numbers of Aboriginal and Torres Strait Islandermedical students and graduates, it is feasible that a range of strategies be developedin partnership with Medical Colleges and the Committee of Presidents of MedicalColleges (CPMC) to clarify pathways into specialty training, and support the currentand future Registrars in training.There is a greater role that AIDA can play in ensuring a smoother pathway formedical graduates into Fellowship and thereby increasing the number of Aboriginaland Torres Strait Islander graduates into Fellowship.2

September 2009Paper for internal use onlyPathways into SpecialtiesAIDA’s Aboriginal and Torres Strait Islander medical graduates have identified fourstages in the ideal pathway into Fellowship. These comprise:• Medical School graduation• Post Graduate Year 1 (Intern) & Post Graduate Year 2 (Junior MedicalOfficers)• Registrar Training• FellowshipDiagram 1: Continuum of Education and TrainingMedical School PGY 1 & 2 (RMO) Registrar FellowshipHowever along the continuum of education and training, many Aboriginal and TorresStrait Islander people face barriers, including lack of knowledge of the optionsavailable, lack of access and contact with key people, and isolation from colleagues.The AIDA graduate membership has identified a range of support strategies whichwould smooth the pathway for medical graduates into Fellowship. These include:• The promotion of prerequisites for entry into Medical Colleges. For example:the Royal Australasian College of Surgeons (RACS) requires research andpublication of articles.• Information, support and assistance about the pathway into Medical Colleges.For example, exams to prepare for, introductions to influential people andnetworking, choosing your referees.• Professional mentoring and cultural support along the continuum. Forexample, Dr Kelvin Kong’s “Cutting Clubs” with surgical registrars.• Development of an induction or “survival” kit as an Aboriginal and TorresStrait Islander Doctor. This needs to include information regarding dealingwith stress, dealing with death in a culturally appropriate manner, healingyourself, and what to do if you fail an exam?• Medical Colleges implementing an accredited Indigenous health curriculum.• Facilitating flexible training opportunities that develop a suite of skills withinthe portfolio, including Indigenous health3

September 2009Paper for internal use onlyRationaleAIDA is dedicated to the pursuit of leadership, partnership and scholarship inAboriginal and Torres Strait Islander health, education and workforce. AIDA is alarge membership based organisation, which plays a critical role in advocating for anincrease in the numbers of Aboriginal and Torres Strait Islander graduates andmedical students.AIDA operates at a range of levels to influence for an increased Aboriginal andTorres Strait Islander health workforce including; communities and schools,universities, government and Parliament.AIDA members are unique to the medical workforce in that they not only are able topractice a high level of clinical medicine, but they also bring an understanding andknowledge of the Aboriginal and Torres Strait Islander concept of holistic health:“Not just the physical well-being of the individual but the social, emotional, andcultural well-being of the whole community. This is a whole-of-life view and italso includes the cyclical concept of life-death-life.” iiiIn this respect, the benefits of an increased Aboriginal and Torres Strait Islanderworkforce are two-fold:1. Indigenous medical practitioners offer a unique combination of clinical andcultural competence and expertise in improving the health and wellbeing ofAboriginal and Torres Strait Islander people and communities.2. The medical fraternity and wider community are enriched by embracing thecultural diversity of Aboriginal and Torres Strait Islander professionals.Through the development of culturally safe environments for Indigenousmedical graduates, more Aboriginal and Torres Strait Islander people are ableto reach their potential.4

September 2009Paper for internal use onlyAimsThis paper forms part of AIDA’s policy framework and engagement with keystakeholders and aims to: Increase the number of Aboriginal and Torres Strait Islander graduatesrecruited, supported and retained by specialist Medical Colleges. Ensure smoother pathway into and through specialty training for Aboriginaland Torres Strait Islander medical graduates.Targets1. All government policy and programs regarding workforce developmentcommit to resourcing the capacity of Aboriginal and Torres Strait Islandermedical graduates into Fellowship.2. CPMC and Medical Colleges provide advocacy and leadership in relation toimproving Aboriginal and Torres Strait Islander health.3. CPMC establish an integrated plan that encourages, supports and resourcescross-College initiatives on Aboriginal and Torres Strait Islander projects andprograms.4. All Medical Colleges develop and implement a recruitment and retention planto support Aboriginal and Torres Strait Islander medical graduates intoFellowship.5. All Medical Colleges identify, record and collate Aboriginal and Torres StraitIslander status of Fellows and Registrars.6. All Medical Colleges provide culturally competent and safe support toAboriginal and Torres Strait Islander medical graduates, Registrars andFellows.5

September 2009Paper for internal use onlyRoles and ResponsibilitiesAIDA is not able to achieve the aims of increasing the numbers of Aboriginal andTorres Strait Islander Fellows and ensuring a smoother pathway alone.Key roles and responsibilities for the pathway into specialist medical education,training and Fellowship are held with key organisations including Government, CPMC,and Colleges.Diagram 2: Roles and ResponsibilitiesPathways into Specialties – increase numbers, smoother pathwayPartnershipCPMCAIDACollegesAccountabilityGovernment – funding, policy frameworks Government - the Australian and State Governments play dual roles isestablishing the policy frameworks for medical education and enabling theresourcing of training positions and posts. AIDA is committed to advocating, supporting and growing the number ofAboriginal and Torres Strait Islander medical graduates into Fellowship. The CPMC ensures that medical specialties have a broad base ofintercollegiate knowledge to provide the highest quality of medical care to theAustralian public. Medical Colleges are responsible for the training, assessment, andrepresentation of specialist medical doctors throughout Australia and in somecases New Zealand.6

September 2009Paper for internal use onlyAustralian Indigenous Doctors’ Association (AIDA)AIDA is dedicated to the pursuit of leadership, partnership and scholarship inAboriginal and Torres Strait Islander health, education and workforce. AIDA providesadvocacy, information and collegiate support across the membership network ofAboriginal and Torres Strait Islander doctors and medical students.PrioritiesAIDA is committed to growing the numbers of Aboriginal and Torres Strait Islandermedical graduates into Fellowship and identifies the following priorities for the next3-5 years: Data on Aboriginal and Torres Strait Islander medical graduates- AIDA will establish the infrastructure to collate and maintain data andinformation regarding the numbers of Aboriginal and Torres Strait Islandermedical graduates.- AIDA will synthesise, analyse and promote the trends, patterns, andidentifiable gaps in data.- AIDA will advocate the needs and career aspirations of our members toCPMC, Medical Colleges, governments and other key organisations. Build knowledge and expertise amongst the AIDA network regarding postgraduateoptions- AIDA will promote, support and facilitate access of our medical graduatesalong the pathway to Fellowship.- AIDA will facilitate knowledge and development of AIDA members in researchand writing for publication.- AIDA will establish an AIDA Fellows network to draw on and provide adviceon increasing the numbers of Aboriginal and Torres Strait Islander Fellows. Support and Mentor Aboriginal and Torres Strait Islander medical graduates- AIDA will implement a mentoring program that provides collegiate supportand connects members with professional mentors.- AIDA will develop a range of support tools. For example: a survival kit withcareer guidance and an “Old fullas” network.- AIDA will facilitate skills development and capacity building. For example:how to operate a small business and life planning. Maintain a high level of partnership- AIDA will establish a framework that outlines key partners for engagementand priorities for review.- AIDA will monitor and evaluate progress against the framework in increasingthe numbers of Aboriginal and Torres Strait Islander medical graduates intoFellowship.Exemplar: AIDA Graduate and Student WorkshopsEach year at the AIDA Symposium, targeted workshops are held for AIDA graduates andAIDA medical students on a range of issues which members have identified as priority. TheAIDA Graduate and Student Workshops provide an opportunity for the dissemination ofinformation, training and collegial support in a culturally-safe, supportive family environment.7

September 2009Paper for internal use onlyGovernmentThere are several key roles that the Australian government and State governmentplay in the area of medical workforce development.The Australian government establishes national policy frameworks for workforcedevelopment and accreditation of medical education. The Australian governmentalso provides funding to State governments and Medical Colleges to implement theseframeworks and regulates the number of medical school places and GP training placeavailable.State Governments determine the distribution of government funding for publichospital and community health services, including medical services and specialist or‘vocational’ training. State Governments also set medical registration standards andconditions and employ a significant number of practitioners for hospitals and thecommunity health sector.PrioritiesGovernment at both the Australian Government level and State government levelneed to commit to improving the representation of Aboriginal and Torres StraitIslander people into and through the continuum from medical schools to Fellowship.In achieving this aim, the following actions need to be a priority over the next 3-5years: Data on Aboriginal and Torres Strait Islander medical graduates- State Governments will establish the infrastructure to collate and maintaindata and information regarding the numbers of Aboriginal and Torres StraitIslander medical graduates in Post Graduate Internships. Prioritise Aboriginal and Torres Strait Islander medical graduates- Governments will prioritise Aboriginal and Torres Strait Islander medicalgraduates for internships within hospital and community health setting. Required training in Aboriginal and Torres Strait Islander health- Governments will require Colleges to demonstrate curriculum in Aboriginaland Torres Strait Islander health. Advocacy on Aboriginal and Torres Strait Islander medical workforce development- Governments will work with AIDA and other Indigenous health leadershiporganisations in the spirit of partnership to improve the Aboriginal and TorresStrait Islander workforce.8

Committee of Presidents of Medical Colleges (CPMC)September 2009Paper for internal use onlyThe Committee of Presidents of Medical Colleges (CPMC) is the unifying organisationof and support structure for the 12 specialist Medical Colleges of Australia. TheCPMC seeks to ensure the ready availability of high quality medical care in all medicaldisciplines, delivered in accordance with accepted ethical principles.PrioritiesCPMC aims to support Medical Colleges in the provision of an adequate, wellqualified,experienced and capable medical workforce to serve the best needs of thecommunity. In achieving this aim for Aboriginal and Torres Strait Islander people,the following actions need to be a priority over the next 3-5 years: Working effectively with AIDA in the spirit of partnership. Establishment of the CPMC National Aboriginal and Torres Strait Islander MedicalSpecialist Framework- CPMC will increase the number of Aboriginal and Torres Strait Islandermedical specialists by actively promoting options to general practitioners anddoctors during their early postgraduate years.- CPMC will integrate Aboriginal and Torres Strait Islander health issues intoexisting specialist medical training programs across all disciplines and MedicalColleges, to build a greater understanding amongst mainstream healthservices of the issues in the provision of specialist health care to Aboriginaland Torres Strait islander people.- CPMC will identify and develop a professional development support programfor Aboriginal and Torres Strait Islander medical specialists. Leadership on Cultural Safety Training across all Colleges- CPMC will ensure that all Colleges are properly trained and competent toprovide the highest standards of culturally appropriate, safe and respectfulcare to Aboriginal and Torres Strait Islander patients and their families.Health care delivery to Aboriginal and Torres Strait Islander communitiesmust be provided in an acceptable manner that observes social and culturalsensitivities. Advocacy on Closing the Gap in Aboriginal and Torres Strait Islander healthdisadvantage- CPMC will develop position statements and guidelines, in partnership withAIDA, that advocate for improved Aboriginal and Torres Strait Islander healthcare.Exemplar: Australian Indigenous Health Subcommittee (AIHS)In 2008, CPMC established an AIHS to provide develop and facilitate activities to:• increase the number of Indigenous doctors and medical specialists• develop mentoring and other programs to support Indigenous medical students anddoctors in training• enhancing training in Indigenous health for doctors and• establishing collaborative cross-college projects designed to address the gap inIndigenous life expectancy.The AIHS is co-chaired by Peter O’Mara, AIDA President and Geoffrey Metz, President of theRoyal Australasian College of Physicians (RACP).9

September 2009Paper for internal use onlyMedical CollegesMedical Colleges are responsible for the training, assessment and representation ofspecialist medical doctors throughout Australia and in some cases New Zealand.Medical Colleges have a duty to better the health of all Australians and NewZealanders through development of health and social policy and advocating for itsimplementation.PrioritiesAll Medical Colleges need to improve the representation of Indigenous Fellows andRegistrars in order to close the gap in workforce underrepresentation. In achievingthis aim, the following actions need to be a priority over the next 3-5 years: Development relationships, in the spirit of partnership with Indigenous healthleadership and organisations Development and Implementation of Indigenous health curriculum- Medical Colleges will develop and implement cultural safety, cross-culturaltraining for all Registrars- Medical Colleges will integrate Aboriginal and Torres Strait Islander healthcontent into existing specialist medical training programs- Medical Colleges will facilitate flexibility in secondments to Indigenous trainingposts and sites Support and Development of Indigenous Fellows- Medical Colleges will develop and implement a recruitment and retention planfor Aboriginal and Torres Strait Islander medical graduates into Fellowship.This will include quotes and targets for Indigenous people.- Medical Colleges will identify and collate information regarding the numbersof Aboriginal and Torres Strait Islander Registrars and Fellows. Mentor and Support Aboriginal and Torres Strait Islander Registrars- Medical Colleges will recognise the breadth and depth of community workundertaken by Registrars in support of and improvement to Aboriginal andTorres Strait Islander health.- Medical Colleges will facilitate a space for mentors to be mentors- Medical Colleges will provide financial support to Aboriginal and Torres StraitIslander Registrars through such initiatives as scholarships, fees (subsidy orwaiver), etc. Advocacy on Closing the Gap in Aboriginal and Torres Strait Islander healthdisadvantage- Medical Colleges will develop positions statements and guidelines ensuringthe provision of high quality, culturally appropriate, safe and respectful careto Aboriginal and Torres Strait islander patients and their families.Exemplar: Medical Colleges in Aboriginal and Torres Strait Islander healthAs key partners in the Close the Gap Campaign – that includes Australia’s leading health,human rights and Aboriginal organisations – the Royal Australian College of GeneralPractitioners (RACGP) and the Royal Australasian College of Physicians (RACP) are leading theway in growing the number of Aboriginal and Torres Strait Islander Registrars in training andFellows.10

September 2009Paper for internal use onlyExemplar: The Royal Australasian College of Physicians (RACP)The RACP has established an Aboriginal and Torres Strait Islander Health Expert AdvisoryGroup that provides expert advice across the College on Aboriginal and Torres Strait Islanderissues. Activities thus far have included:• Close the Gap Summit (with AIDA)• Cultural Competency (with AIDA)• Mentoring Project (with AIDA)• Increased Pathways for Physicians in AMSs via the Outer Metropolitan SpecialistTrainees Program (OMSTP) & Expanded Settings for Specialist Training Program(ESSTP)• Aboriginal and Torres Strait islander Trainee Scholarship fund• Strategic Plan 2008-2012 commits to improving the health of Aboriginal and TorresStrait Islander communities• Reconciliation Action Plan• Heads of Agreement with NACCHO to build capacity of ACCHSs and their access tophysicians• Advocacy through an RACP Indigenous representative on the National IndigenousDrug and Alcohol Committee (NIDAC)• Advocacy through an RACP Indigenous representative on the Committee ofPresidents of Medical Colleges’ (CPMC) Australian Indigenous Health Sub-Committee(AIHS)RecommendationsThe following recommendations are strongly advocated by AIDA in order to increasethe number of Aboriginal and Torres Strait Islander graduates into Fellowship:1. The CPMC and Medical Colleges commit and advocate to improving theinequalities in health outcomes for Aboriginal and Torres Strait Islander peoples.2. The CPMC and Medical Colleges partner with AIDA to identify and supportexisting, new and potential Indigenous medical students, graduates and Fellowsto increase the number of Indigenous medical specialists by 2013.3. The CPMC and Medical Colleges develop College wide plans regarding theimplementation of a range of systemic support for Indigenous Fellows andRegistrars by 2010.4. AIDA commits to the partnership with other stakeholders and seeks to reviewprogress to improve the pathways into specialties for Aboriginal and Torres StraitIslander people.5. Governments will prioritise Aboriginal and Torres Strait Islander medicalgraduates for internships in hospital and community health.11

September 2009Paper for internal use onlyAccountabilityAboriginal health change can only be realised when all key stakeholders commit toand take responsibility for improving the abysmal status of Aboriginal and TorresStrait Islander health.In advocating leadership, partnership and scholarship in Aboriginal and Torres StraitIslander health, education, and workforce development, AIDA will continue tomonitor progress in smoothing the pathway and increasing the numbers of Aboriginaland Torres Strait Islander medical graduates into Fellowship. The barometer ofprogress in this area will become a standing item at the annual AIDA Symposium.In the spirit of partnership and collaboration, it is opportune for facilitate multipleengagement points and bi-lateral relationships with such bodies as CPMC andMedical Colleges. The CPMC AIHS is well placed to monitor improvement ofpathways into specialties (annually).Final NoteAs a number of Medical Colleges include New Zealand medical specialists, it isnecessary that any developments to increase the participation for Aboriginal andTorres Strait Islander people should also consider improvements for the participationof our Maori brothers and sisters.iAustralian Bureau of Statistics (ABS) 2008.iiCommonwealth of Australian 2008. A Blueprint for Action: Pathways into the healthworkforce for Aboriginal and Torres Strait Islander people. Canberra: CommonwealthCopyright Administrators.iiiNational Aboriginal Health Strategy Working Party 1989, x)12

39Appendix 3Indigenous Health Position PaperThe Royal Australasian College of Surgeons(original document)

INDIGENOUS HEALTH POSITION PAPER1. PURPOSE AND SCOPEThe Royal Australasian College of Surgeons Position Statement on the health of the Indigenous peopleof Australia and New Zealand explains the College’s commitment to address health outcomes forAboriginal, Torres Strait Islander and Maori people in Australia and New Zealand.This Position Statement explains the framework in which the College proposes that productive andculturally appropriate approaches to improve Indigenous health should be developed. As a professionalmedical body, the College is uniquely placed to champion the rights of the first people of our countries.2 BACKGROUNDThe College has a long and proud history of advocacy resulting in significant improvements in publichealth and safety. The College also has vast experience in the training of the surgical workforce forspecific health issues.The College recognises that the health of our Indigenous populations is a public health problem ofserious proportions. The College further recognises that Indigenous populations are over-represented inevery way in the poor determinants of health.The College is committed to addressing the health discrepancies of the Aboriginal, Torres Strait Islanderand Maori populations of Australia and New Zealand.2.1 The current state of Indigenous healthAmong the people living in Australia and New Zealand, Aboriginal, Torres Strait Islander and Maoripeople experience higher rates of cardiovascular, respiratory and diabetic diseases as well as higherrates of trauma related injuries. The most unacceptable result of such poor health is diminished lifeexpectancy 1,2Chronic disease burden is often the end result of illness and impacts on daily living. The Renal Unit atAlice Springs is one of the busiest in Australia, largely due to high prevalence of renal disease in theIndigenous population of the area. The likelihood of hospitalisation for a number of other conditionsclearly shows that the health of Indigenous persons is different to that of the non-Indigenous population.• Diabetes – 4.1 times more likely• Injury and poisoning - 2.3 times• Respiratory disease – 3.3 times• Mental illness – 1.8 times• Circulatory disease – 1.8 times• Skin disease – 2.8 times• Infectious and parasitic disease – 3.0 timesSimilarly, Indigenous persons in New Zealand are more likely to be hospitalised for 2 :• Diabetes – 2.6 times• Complication from diabetes – 7.5 times• Injury and poisoning – 1.4 timesThese figures under-represent the extent of the inequities because many Indigenous persons do notidentify or are not recorded as Indigenous and more frequently fail to seek treatment 3 . The above figuresexclude the burden of disease of conditions where hospitalisation is not warranted, such as the highprevalence of ear disease.2.2 Historical factorsFactors that confound these issues include the fact that Indigenous Australians were only made citizensof Australia in the past 35 years 3 . In New Zealand, while the Treaty of Waitangi enshrined the rights ofRoyal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 1 of 9

INDIGENOUS HEALTH POSITION PAPERIndigenous New Zealanders in 1840 4 , there have nevertheless been cultural and social barriers toadvancements in Māori health.The College acknowledges that historical inequalities in social and economic status currentlyexperienced by these groups contribute significantly to poorer health outcomes, particularly to decreasedlife expectancy 2,4,5 .2.3 Cultural issuesThe College appreciates the diversity in the Aboriginal, Torres Strait Islander and Maori cultures,languages, spiritual beliefs and recommends that Indigenous healthcare policies, projects and researchfrom all institutions and organisations are developed in collaboration with the Indigenous people toensure they are culturally relevant and delivered in an understandable and useful way. There are severalreasons for this.Firstly, there will be localised issues affecting healthcare where the local communities have knowledgethat may be medical or social in nature (related to the physical environment, locality, or circumstances).Furthermore, the College lacks the mores of these cultures to develop effective initiatives that would beattractive and meaningful to the Indigenous populations.The differences between Indigenous populations necessitate taking account of local culture, spiritualityand beliefs when developing Indigenous healthcare policies. Despite these differences, there is anunderstanding that strong kinship ties, connection to land, and the important role of and belief intraditional healers, are common to Indigenous cultures and must be respected, and indeed should be avalued inclusion in the solutions to Indigenous health problems.2.4 Indigenous population statistics in Australia and New ZealandThe Australian Bureau of Statistics (ABS) reported in the population Census of 2006 that around 456,000(2.3%) of the 19,855,287 population of Australia identified themselves as an Aboriginal or Torres StraitIslander. A report from Statistics New Zealand’s 2006 Census Count 6 indicated that the Maori populationmade up around 565,000 (14.7%) of the total New Zealand population..Although Aboriginal, Torres Strait Islander and Maori people are a minority in the Australian and NewZealand populations, the College believes that higher proportions of health resources need to beinvested in achieving goals for Indigenous health to reverse the unacceptable consequences of historicalinadequacies.2.5 Indigenous medical practitioners in Australia and New ZealandThe College submits that Indigenous people would be more likely to present for medical treatment andcomply with treatment guidelines if increased numbers of Indigenous people were represented in themedical workforce at all levels of the provision of care 7 .It is important to note that in Australia there are approximately 125 Aboriginal and Torres Strait Islanderdoctors within a medical workforce of approximately 50,000 doctors. This represents a mere 0.25% ofthat workforce despite an Indigenous population of 2.5% overall. Indigenous New Zealanders aresimilarly under-represented among medical practitioners 8 . The Medical Council of New Zealand’s(MCNZ) 2007 Annual Report confirms that Māori doctors made up 2.6% of the 9518 doctors thatcontributed to the MCNZ 2005 workforce survey 9 .Furthermore the College acknowledges that Australia and New Zealand have a severe shortage ofIndigenous surgeons, and that there is currently no evidence of change to this disproportionate underrepresentationof Indigenous healthcare workers in the field of surgery. This may be a result of prior lackof access to research and publication opportunities, and a general lack of broadly based educational andcareer opportunities, which has had a profound impact on the choice of surgery as a career. The Collegerepresents over 6000 surgeons in Australia and New Zealand. While the College is considering providingRoyal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 2 of 9

INDIGENOUS HEALTH POSITION PAPERFellows and Trainees the opportunity to record their ethnicity, it is aware that to date there is only oneAboriginal surgeon and approximately five Maori surgeons.In recent years, the College has provided new surgical trainees with the opportunity to identify theirethnicity. In 2007 and 2008 three of the new trainees (3.3% of the intake into NZ posts in those twoyears) identified their ethnicity as Māori or Māori plus one other ethnic group. This is a positive indicationthat Māori doctors are considering surgery as a training option but further improvement is required.3. OBJECTIVES FOR INDIGENOUS HEALTHThe College feels that significant and urgent improvements need to be, and can be, made to IndigenousHealth and Health Care. The College will be proactive in addressing these.3.1 ObjectivesThere should be no health discrepancies between the Indigenous and non-Indigenous populations ofAustralia and New Zealand:• The rate of infant mortality should not differ,• There should be no significant discrepancy in life expectancy,• The overall rates of disease and sickness should not differ significantly,• The rates of injury should not differ significantly,• There should be equity of access to medical and allied health services, including primary care,and surgical and other hospital care, and after hospital care,• There should be improvements in the social determinants of health to enable equity in healthoutcomes.The College recognises the serious nature of Indigenous health shortfalls, and therefore recommendsembracing a model of capacity building to ensure sustainable and tangible improvements. The capacitybuilding should have the strong support and participation of the local Indigenous population. Areas ofimportance include the following:• Professional training, including Indigenous workforce participation in all areas of healthworkforce,• Public education,• Cross-cultural communication and support tailored to meet specific local differences,• Research which may target cultural differences and needs; and for other research to consider ifthere are or may be cultural issues involved,• Advocacy for disease and injury prevention, with particular reference to Indigenous communities,• Advocacy for improved health services for Indigenous people whether they reside in urban,regional or remote communities,• Recognition and support for other healthcare organisations focussing on Indigenous healthissues in all settings.4. COLLEGE STRATEGIES FOR INDIGENOUS HEALTHThere are several strategies that the College agrees are important to pursue and which will be articulatedin a College Indigenous Health Strategic Plan.The College focuses on both prevention and treatment of surgical conditions and recognises thatimprovement of Indigenous health in Australia and New Zealand will require collaborative, crossdisciplinaryefforts.The College will pursue activities that address the delivery of health services to Indigenous patients andtheir families, particularly pertaining to surgical care.Royal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 3 of 9

INDIGENOUS HEALTH POSITION PAPER4.1 Contribution to the Indigenous Health WorkforceThe College aims to improve the representation of Indigenous Fellows and Trainees, to close the gap insurgical workforce under-representation. To achieve this the College acknowledges it needs to enrol andtrain increasing numbers of Indigenous doctors in its Surgical Education and Training program. Howeverto do this there first needs to be an increase in the number of Indigenous doctors trained by Australianand New Zealand Universities. Whilst the College has no ability to influence University selection, activerecruiting amongst current indigenous doctors is a priority.The College will consider within its Indigenous Health Plan how it could achieve the ambition of at least50 Indigenous surgeons in Australasia in 10 years4.2 Training in Cultural CompetenceTo ensure better health outcomes for Australia and New Zealand’s Indigenous populations the Collegewill ensure that all surgeons are properly trained and competent to provide the highest standards ofculturally appropriate surgical care to Indigenous patients and their families. Health care delivery toIndigenous communities must be provided in an acceptable manner that observes social and culturalsensitivities.Therefore there is a need to develop and deliver educational programs and materials, such as trainingmodules and support for surgeons that focus on Indigenous health issues and cultural awareness.In 2006 the College worked collaboratively with the Royal Australian and New Zealand College ofObstetricians and Gynaecologists (RANZCOG), on an Australian Government funded project to developtraining modules in Indigenous cultural safety, for Indigenous and non-Indigenous Fellows, Trainees andInternational Medical Graduates in Australia.On the strength of this experience, the College will aim to:• Recognise training in Indigenous health care• Recognise training time spent with Indigenous populations, including community healthcentres• Directly collaborate with governments on developing and implementing training programsin effective delivery of healthcare to Indigenous patients and their families.• Seek government support in both countries and all states to fund such programsThe College commits to providing resources for training in cultural competence for all its Trainees andFellows. The training curriculum of the College will be enhanced to include modules in:• Communication with Indigenous communities, families and patients• Structuring the patient journey through primary health care and onto hospital to beculturally friendly and less intimidating to Indigenous patients and their families.These enhancements will occur in the curriculum for all specialties in Surgical Education and Training,under the competencies of:• Professionalism• Communication• Health Advocacy• Management and Leadership.The College is committed to providing funds to train the surgical workforce in Indigenous health issuesand encourages and challenges governments to support these activities with financial contribution.4.3 Building PartnershipsThe College acknowledges that there have been numerous fora looking into the health and welfare ofIndigenous communities of Australia and New Zealand, and that the recommendations emanating fromsuch fora need to be recognised.Royal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 4 of 9

INDIGENOUS HEALTH POSITION PAPERThe College will continue to seek advice from groups listed and others from time to time.• Australian Indigenous Doctors Association (AIDA)• Close the Gap Indigenous Health Equality Summit, 2008 10,11• The Darwin Declaration from the Royal Australasian College of Physicians, 1997• Hauora – The National Māori Health Workforce Development Organisation• Māori Health web site 2• The Medical Council of New Zealand (MCNZ’s)• National Aboriginal and Torres Strait Islander Health Council (NATSIHC)• National Aboriginal Community Controlled Health Organisation• Te Ohu Rata o Aotearoa (Te ORA), the Māori Medical Practitioners Association of Aotearoa/New ZealandThe College will continue to promote and support:• Involvement in the Committee of Presidents of medical Colleges (CPMC) Sub committee onIndigenous Health• Inclusion of Indigenous people and Indigenous health topics at College conferences• College representation at Indigenous health fora• Engagement in Indigenous health policy development and advocacy.The College is committed to creating collaborative partnerships on Indigenous health projects withIndigenous health organisations, primary healthcare organisations, governments and other medicalcolleges.The College also recognises that governments are a vital source of leadership and funding in the creationof collaborative partnerships and projects in Indigenous health.4.4 Research Scholarships in Indigenous healthResearch in Indigenous health is a very delicate area that must not be mishandled. The potentialoutcomes of any research proposal must be evaluated to ensure community benefit. Risk mitigation mustbe carefully considered. Ethics Committees with appropriate membership, including Indigenousmembership, and cognisant of Indigenous health issues, should consider all research proposals in theIndigenous health area.The College will consider within its Indigenous Heath Plan:• Creation of a specific surgical research scholarship in the area of Indigenous health• Promotion of research that meets the needs and the will of Indigenous communities• Encouraging Indigenous applicants to fulfil these research roles• Ensuring appropriate feedback to community, with results being accessible.• Encouraging Indigenous determination of parameters and aims of research• Promotion of Indigenous expertise• Respect for Aboriginal, Torres Strait Islander and Māori peoples’ perspective and culturalsensitivities• Respect for specific cultural views with respect to publication of photos, art and intellectualproperty.4.5 Improving Indigenous health outcomes4.5.1 Advocacy on surgical issues in Indigenous healthThe College will advocate for:• Improved health services• Disease and injury preventionRoyal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 5 of 9

INDIGENOUS HEALTH POSITION PAPER• Improved availability of services• Improved access to services• Training in delivery of healthcare at all levels to Indigenous people• The highest standards of care.The College will seek to achieve these aims by:• Undertaking research to understand the surgical dimensions of Indigenous health• Engaging actively with the media• Providing submissions to Government Forming partnerships with Government, other Collegesand Indigenous health organisations• Lobbying all government agencies to focus on the poor determinants of Indigenous health• Lobbying for appropriate funding allocations to Indigenous health.4.5.2 PreventionThe College has a robust history of advocating for injury and disease prevention, with notable success inthe area of prevention of serious trauma related injuries.The College continues to focus on advocating the following initiatives as a means to help prevent surgicalconditions among Indigenous people:• Prevention of injury and trauma• Support for holistic care models that focus on the full range of health care, from prevention toprimary care to definitive surgical and other hospital care, and all the associated multi-sectoralancillary health care services• Promotion of healthy lifestyles• Support for community health education initiativesAs highlighted throughout this document, clinical collaboration among all healthcare workers and otherjurisdictional authorities is vital to bring about preventative health measures and positive healthoutcomes.4.5.3 TreatmentCultural education is critical for making surgical treatment more accessible and culturally appropriate toIndigenous people.To ensure effective treatment of Indigenous patients, the College therefore advocates for• All hospitals to provide cultural training and education for healthcare workers as culturallyappropriate services will contribute to improved rates of presentation for surgical services• Improved access to surgical services, including improved transport and increased surgicalresources in hospitals.4.5.4 College support of other Medical Colleges and Professional groupsThe College supports like-minded bodies in their efforts to advocate for improved health for thecommunities we serve, including improved Indigenous health. The College commends and endorses thefollowing position statements and guidelines. While recognising that the issues covered are critical to theimprovement of health outcomes among the Indigenous populations we serve, the College alsoacknowledges that this will only happen for Indigenous populations where these messages arerepresented in culturally relevant formats. the College endorses and supports the following PositionStatements and leadership from the following specialist colleges and health organisations:Royal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 6 of 9

INDIGENOUS HEALTH POSITION PAPER• A blueprint for action: Pathways into the health workforce for Aboriginal and Torres Strait Islanderpeople 12• Alcohol – the joint statement of the Royal Australasian College of Physicians and RANZCP 13• Children – National Aboriginal Community Controlled Health Organisation (NACCHO) positionstatement, endorsed also by the RACGP on the health of Indigenous children 14• Diabetes and other conditions that lead to kidney disease – The Royal Australian College ofGeneral Practitioners (RACGP) position statement on diabetes 15• Ear disease - the NACCHO position statement on ear disease 14• Healthy Futures Report (Australian Indigenous Doctors Association) 8• Heart disease – The joint position statement on chronic heart failure of the National HeartFoundation of Australia, and the Cardiac Society of Australia and New Zealand 16• Māori Health - The Royal New Zealand College of General Practitioner’s Position Statement onMāori health 17 ;• The Medical Council of New Zealand’s (MCNZ’s);- “Statement on cultural competence 18 ,- “Statement on best practices when providing care to Māori patients and their whānau” 19 ,- Resource booklet on “Best health outcomes for Māori : Practice implications 20 ”,• Mental illness - The Royal Australian and New Zealand College of Psychiatrists (RANZCP) policyand approaches to mental health in Indigenous populations 21 .• Overcoming Indigenous Disadvantage, Key Indicators 2005 Report 5• Physical activity – the RACGP position statement 22• Smoking tobacco - the RACGP position statement on smoking 235. TOWARDS SOLUTIONS – THE ROLE OF THE HEALTHCARE COMMUNITY5.1 Training and Education for healthcare providersThe College acknowledges that input from existing Indigenous healthcare providers and Indigenous alliedhealth educators, community leaders and traditional healers is necessary when developing thecurriculum for training in Indigenous health issues. The College supports a unified and integratednational approach in Australia and New Zealand to educate healthcare providers in the reasons for thehigh rate of disease and injury experienced among Indigenous populations. This training must beavailable to all healthcare workers.Additional development of targeted training of the health workforce is necessary to build up and increasethe numbers of Indigenous medical graduates, allied health workers, liaison officers, primary healthcarepractitioners and medical specialists:5.2 Community Education in Indigenous HealthcareCulturally appropriate educational material on health issues and diseases should be readily available.Patients, families and their communities must be supported on the health issues they encounter,including education on preventative strategies.Royal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 7 of 9

INDIGENOUS HEALTH POSITION PAPERFocussing on education for both professional and community groups provides opportunities to addressboth the prevention and treatment of disease and injury, and ensures the general public is betterinformed on Indigenous health issues.5.3 Healthcare InfrastructureTo ensure that the needs of the Indigenous community are being met the College advocates for thedevelopment and implementation of culturally appropriate, accessible and sustainable healthcareservices and measures. Emphasis should be on servicing of community needs in collaboration withthose communities.While the College recognises the right of every Australian and New Zealand resident to receive properlyresourced healthcare, it also recognises that the situation for Indigenous communities is significantlybelow the standard that should be accepted..The College supports a sustainable and co-ordinated healthcare response that adopts culturallyappropriate strategies to address physical, socio-economic and cultural barriers currently present in thedelivery of health care services.5.4 Socio-economic inhibitors of acceptable Indigenous health outcomesThe social determinants of health underlie the wellness or otherwise of the individual and his\hercommunity. These factors are compounded in Indigenous populations by the multigenerational grief,loss and trauma associated with low self esteem, colonisation, the stolen generation in Australia, manylayers of racism, discrimination, and cultural dislocation. The College recognises that ‘closing the gap’ isimperative if disparities in life expectancy are to be addressed.In New Zealand, the obligations and requirements that arise from the Treaty of Waitangi are active inmany aspects of present day New Zealand life, including the delivery of health, education, social, housingand justice services and a vast number of what might loosely be termed social development issues andinitiative. All of these are relevant to issues of indigenous health and that makes the current status of theTreaty very relevant to this Statement.6. REFERENCESRoyal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 8 of 9

INDIGENOUS HEALTH POSITION PAPER1Australian Institute of Health and Welfare http://www.aihw.gov.au/indigenous/health/mortality.cfm2 Maori Health, New Zealand Government http://www.maorihealth.govt.nz/moh.nsf/indexma/health-s tatus-indicators3 Australian Indigenous HealthInfoNet. http://www.healthinfonet.ecu.edu.au4Archives New Zealand (accessed September 2008). Treaty of Waitangi - Te Tiriti o Waitangi.http://www.archives.govt.nz/exhibitions/permanentexhibitions/treaty.php5 Productivity Commission, Australia. Overcoming Indigenous Disadvantage, Key Indicators 2005 Report.http://www.humanrights.gov.au/social_justice/conference/index.html6 Statistics New Zealand Tatauranga Aotearoa (2006). Latest statistics. http://www.stats.govt.nz/default.htm(Accessed 9 October 2008).7 Hayman N (2003). Improving Indigenous access to a mainstream general practice. National Rural Health Alliance7th National Rural Health Conference, Tasmania, Australia.8 Minnecon D & Kong K, Healthy Futures: Defining Best Practice in the Recruitment and Retention of IndigenousMedical Students, Australian Indigenous Doctors Association Canberra, 2005.9 Medical Council of New Zealand Annual Report 2007http://www.mcnz.org.nz/portals/0/publications/Annualreport2007.pdf10 Human Rights and Equal Opportunity Commission, Australia. Close the Gap Indigenous Health Equality Summit,2008. http://www.humanrights.gov.au/social_justice/health/statement_intent.html11 Council of Australian Governments (2008). Closing the Gap for Indigenous Australians.http://www.coag.gov.au/coag_meeting_outcomes/2008-10-02/index.cfm#gap (accessed 6 October 2008).12 National Aboriginal and Torres Strait Islander Health Council (2008). A blueprint for action: Pathways into thehealth workforce for Aboriginal and Torres Strait Islander people. http://www.aida.org.au/pdf/Pathways.pdf13 The Royal Australasian College of Physicians, and The Royal Australian and New Zealand College of Psychiatrists(2005). Alcohol Policy: Using evidence for better outcomes. (Accessed October 2008)http://www.racp.edu.au/download.cfm?DownloadFile=A95582CE-2A57-5487-D2BF018963D2E72014National Aboriginal Community Controlled Health Organisation (2005). National guide to a preventive healthassessment in Aboriginal and Torres Strait Islander peoples. (Accessed August 2008).http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/NationalguidetoapreventiveassessmentinAboriginalandTorresStraitIslanderpeoples/20050926National_guide.pdf15Royal Australian College of General Practitioners (2008). Diabetes management in general practice 2008/9:guidelines for Type 2 diabetes. (Accessed October 2008).http://www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/Diabetesmanagement/2008DiabetesManagementInGeneralPractice.pdf16National Heart Foundation of Australia, and Cardiac Society of Australia and New Zealand (2006). Guidelines forthe prevention, detection and management of chronic heart failure in Australia, 2006. (Accessed August 2008).http://www.heartfoundation.org.au/document/NHF/CHF_2006_Guidelines_NHFA-CSANZ_WEB_PDF-1.2MB.pdf17The Royal New Zealand College of General Practitioners Position Statement on Māori Health (Accessed March2009)18 The Medical Council of New Zealand (2006). Statement on cultural competence (Accessed August 2008)19 The Medical Council of New Zealand (2006). Statement on best practices when providing care to Māori patientsand their whanau. (Accessed August 2008)20 The Medical Council of New Zealand (2006). Best Health Outcome for Māori: Practice implications (AccessedAugust 2008)21 Royal Australian and New Zealand College of Psychiatrists (2002). Position Statement #50 – Aboriginal andTorres Strait Islander Mental Health Workers. (Accessed October 2008).http://www.ranzcp.org/images/stories/ranzcpattachments/Resources/College_Statements/Position_Statements/ps50.pdf22Royal Australian College of General Practitioners (2008). Physical activity. (Accessed August 2008).http://www.racgp.org.au/scriptcontent/policy/policydocs/Physical_activity.pdf23 Royal Australian College of General Practitioners (2006). Smoking.http://www.racgp.org.au/scriptcontent/policy/policydocs/Smoking_poli cy.pdf (Accessed August 2008).Royal Australasian College of SurgeonsManual:Division:Subject:Guidelines and Position PapersFellowship and StandardsINDIGENOUS HEALTH POSITION PAPERRef. No.:Approval Date:Review Date:FES_FEL_001June 2009June 2012Page 9 of 9

51Appendix 4Ethical Guideline 11: Principles and Guidelines for Aboriginal andTorres Strait Islander Mental HealthThe Royal Australian & New Zealand College of Psychiatrists(original document)

Ethical Guideline 11Principles and Guidelines for Aboriginal andTorres Strait Islander Mental HealthJune 2009BackgroundAboriginal and Torres Strait Islander people of Australia suffer levels of mortality, morbidity andcompromised wellbeing far in excess of non-Indigenous Australians. This reflects issues of socialinjustice, particularly persistent social, economic disadvantage and the historical legacy of colonisationwith its destruction of Indigenous culture.Mental health professionals within Australia have been slow to respond to the social and clinical needsof Aboriginal and Torres Strait Islander people and the response to Indigenous needs has often beenfrom a biomedical perspective which has denied the social and historical context. Such a perspectivefails to take into account of the strengths and resilience of Indigenous cultures and populations.Openness to new models and the modification of old onesIt cannot be assumed that the ethical and clinical models derived from a western individualistic viewpointcan be automatically applied to Aboriginal and Torres Strait Islander individuals and communities. Norshould we assume we have a mandate to automatically apply such models. That is not to say that suchmodels are not useful; it is more that parts of such models, in some circumstances, may need to bediscarded or greatly modified.Health Professionals and Stereotypes of Indigenous PeopleHealth professionals and scientists have considerable influence in the creation of stereotypes and overtheir eventual abandonment. At times, health professionals have contributed to the development ofpejorative and disempowering stereotypes of Aboriginal and Torres Strait Islander people. On the otherhand, health professionals have considerable influence over the beliefs and practices of the widercommunity and can make great contributions to breaking down prejudice and unfair practices.Psychiatrists have an important part to play in the removal of prejudice from all mental health servicesand the encouragement of Indigenous community efforts to improve mental health and social andemotional well being.Participation and PartnershipHistorically, the control and delivery of health services in and for Aboriginal and Torres Strait Islandercommunities have not involved their participation and the profession of medicine and the discipline ofpsychiatry have been very slow, by comparison with other Anglo settler societies (Canada, the UnitedStates and New Zealand) in supporting Indigenous entry into the professional workforce.Political ImplicationsHealth professionals need to be aware that interventions within the arena of Indigenous healthnecessarily have political implications. Involvement in this area of professional practice often involveschallenging government policy and community attitudes which have the potential to impact negatively onAboriginal and Torres Strait Islander social, emotional, cultural and spiritual wellbeing.Ethical Guideline 11 – Principles and Guidelines for Aboriginal and Torres Strait Islander Mental Health Page 1 of 5

GuidelinesThe Royal Australian and New Zealand College of Psychiatrists has prepared the principles andguidelines below to help psychiatrists and psychiatric trainees work constructively and effectively withthe Aboriginal and Torres Strait Islander people and their communities and organisations.1. For a health professional to allow stereotyping and prejudice to influence thinking about orbehaviour towards individuals and communities is a serious breach of ethical and practicestandards.2. Participation, partnership, respect, negotiation and a willingness to learn are the pathspsychiatrists should follow if they are going to make a useful contribution to the mental health ofAboriginal and Torres Strait Islander people.3. The College recognises that optimal mental health care and access to appropriate mental healthservices is a right of all Australians.4. The College requires that mental health services and private psychiatrists should always respectthe dignity and human rights of those who seek or require help with mental health or social andemotional problems.5. The College recognises that there is a broader understanding of mental health within indigenouscommunities. This involves a holistic construction of social, emotional, cultural and spiritualwellbeing.6. The College is firmly committed to the principle that Aboriginal and Torres Strait Islander peopleare entitled to effective mental health care which is appropriate to their culture and needs.7. The College believes that negotiation, consultation, participation and partnership should be thebasis on which psychiatrists and psychiatric trainees assist with mental health services forAboriginal and Torres Strait Islander people and communities.8. The College recognises that the asymmetry of power is often amplified in interactions betweenmental health professionals and Indigenous Australians. Effective and empathic communicationbetween non-Indigenous professionals and Aboriginal and Torres Strait Islander clients mayrequire special effort and resources. Psychiatrists should be aware of and acknowledge their owncultural assumptions, respectful of the client and the client's culture and learn about those localfactors (historical, contextual and behavioural) which support effective and empathiccommunication.Ethical Guideline 11 – Principles and Guidelines for Aboriginal and Torres Strait Islander Mental HealthPage 2 of 5

With regard to their own knowledge and attitude, psychiatrists and psychiatric trainees should:• recognise the importance of land, spirituality and culture to the mental health of Aboriginaland Torres Strait Islander people• understand and respect cultural traditions as they affect verbal and non-verbalcommunication• understand that a culturally appropriate and safe environment is necessary for indigenouspeople to resolve mental health problems and do their best to help provide such anenvironment• recognise that working with Indigenous Australians may require special expertise andunderstanding• recognise that special expertise and understanding of indigenous mental health issues isavailable within Aboriginal and Torres Strait Islander communities, especially fromIndigenous health and mental health workers• recognise that traditional healing practices of Indigenous Australians may have much tooffer in the treatment of mental health and social and emotional problems• understand the mental health implications of the history of contact between IndigenousAustralian communities and Australia’s mainstream society• understand the tragic impact which attitudes and policies of the mainstream Australiancommunity have had on the mental health and social and emotional well being ofAboriginal and Torres Strait Islander people and take this into consideration when workingwith Indigenous Australians• recognise that social injustice, racism and mainstream hostility and ignorance are stillcausing serious suffering and mental ill health for Aboriginal and Torres Strait Islanderpeople• recognise that the serious general health problems which burden the lives of so manyAboriginal and Torres Strait Islander people have, as a significant part of their cause,social, emotional, substance abuse and psychiatric difficulties which are often untreatedor inappropriately treated• be aware of, respect and acknowledge the value systems and protocols which exist inAboriginal and Torres Strait Islander communitiesEthical Guideline 11 – Principles and Guidelines for Aboriginal and Torres Strait Islander Mental HealthPage 3 of 5

• resist the stereotyping of any client or patient because of ethnic, cultural or racialbackground and pay particular attention that this does not happen with Aboriginal andTorres Strait Islander peopleWith regard to how they behave and deal with Indigenous Australians, psychiatrists andpsychiatric trainees should:• promote the mental health and social and emotional wellbeing of Aboriginal and TorresStrait Islander people and their communities• work to increase their personal understanding of the culture and traditions of Aboriginaland Torres Strait Islander people• always treat Aboriginal and Torres Strait Islander people who are patients or clients withcourtesy and dignity and allow for difficulties and differences in dealing with health caresystems• make whatever contribution is possible to the improvement of courtesy, understandingand flexibility in mainstream mental health facilities• treat Aboriginal and Torres Strait Islander health and mental health workers as respectedcolleagues with special knowledge which can be essential for appropriate mental healthcare for Aboriginal and Torres Strait Islander people• make every effort to ensure that the language used during consultation does not presenta barrier to full understanding and sharing of information and, if necessary, make use ofIndigenous health professionals and interpreters to facilitate communication• seek out and utilise Aboriginal and Torres Strait Islander expertise including traditionaland contemporary practitioners• take into account cultural differences when considering the result of any standardevaluative processesWhen undertaking research projects involving Indigenous Australians, psychiatrists andpsychiatric trainees should:• refrain from doing studies which will harm the Aboriginal or Torres Strait Islander subjectsof the study or their communitiesEthical Guideline 11 – Principles and Guidelines for Aboriginal and Torres Strait Islander Mental HealthPage 4 of 5

• ensure that the Aboriginal or Torres Strait Islander community involved and individualsparticipating in any research study are involved in a proper process of informedconsultation and that the NHMRC Guidelines on Ethical Matters in Aboriginal and TorresStrait Islander Research be followed• follow the human research ethics policy of the RANZCP and consult with the involvedcommunity and with Aboriginal and Torres Strait Islander health organizations regardingthe ethical implications of any study• recognise that the knowledge gained from a research project has been provided by thesubjects of the study and that such knowledge should be developed in conjunction withthe Indigenous subjects of the study and shared with them• consult with the Aboriginal or Torres Strait Islander community or individuals studied tosee if some service can be offered in return for the privilege of having access to thecommunity for study purposesSuggested readingFurther information can be obtained the Australian Indigenous Mental Health website:http://indigenous.ranzcp.orgThe Australian Indigenous Mental Health website was set up by the members of the Aboriginal andTorres Strait Islander Mental Health Committee behalf of the Royal Australian and New Zealand Collegeof Psychiatrists. The purpose of the website is for people to gain both knowledge and understanding ofAboriginal and Torres Strait Islander mental health issues. The Committee’s aim is to work together withmental health professionals to improve the mental health and life outcomes for Aboriginal and TorresStrait Islander peoples and communities.ReferencesThese guidelines were prepared by the RANZCP Aboriginal and Torres Strait Islander Mental HealthCommittee in consultation with Indigenous mental health workers and communities.Adopted: April 1999 (GC1/99. R16)Amended: May 2009 (GC2009/2 – R 32)Currency: Review every 3 years (next review May 2012)Owned by: Aboriginal and Torres Strait Islander Mental Health CommitteeEthical Guideline 11 – Principles and Guidelines for Aboriginal and Torres Strait Islander Mental HealthPage 5 of 5

59Appendix 5Aboriginal Health Curriculum StatementThe Royal Australian College of General Practitioners(original document)

Aboriginal HealthCurriculum Statement4CONTENTS• Rationale• Learning Objectives• Curriculum Requirements• Special Considerations• Teaching and Learning Approaches• Resources• Assumed Prior ExperiencenRationaleThe Aboriginal Health curriculum statement was developed in recognition of the urgentneed to address the current state of Aboriginal health in Australia. The National AboriginalHealth Strategy states:‘Aboriginals have the worst health of any identifiable group in Australia. They carry aburden of poor health and mortality far in excess of that expected from the proportionthey comprise of the total Australian population.’ 1One of the recommendations in the Strategy was that:‘Tertiary institutions responsible for undergraduate and postgraduate medical, nursingand paramedical courses be approached to include the compulsory study of Aboriginalculture and history, and health issues as part of formal course work. 2Furthermore, it was recommended that Aboriginal people should be ‘involved in thedevelopment and teaching of these units’.Similar recommendations can be found in the recommendations of the Royal Commissioninto Aboriginal Deaths in Custody (1991) and the South Australian Aboriginal Health Policyand Strategic Framework (1995).Role of the GPGPs have a key role in implementing the National Aboriginal Health Strategy and improvinghealth services for Aboriginal people.Strategy for ImprovementKey strategies for improving Aboriginal health relate to:—• developing an understanding of Aboriginal culture, history, and an holistic view ofhealth and well-being, and• addressing factors related to the disproportionate percentage of Aboriginal peoplewith poor health and increased mortality.1National Aboriginal Health Strategy, Working Party Report, AGPS, Canberra. 1989.2Ibid.4—5

4Aboriginal HealthCurriculum StatementPurpose of this Curriculum StatementThe Final Position Paper of the Aboriginal and Torres Strait Islander Health CurriculumDesign Project of the RACGP Faculty of Rural Medicine 3 emphasises that:programs for doctors should aim at a comprehension of the Aboriginal experience ofhealth, which is based in the history of colonialism in Australia, and encompasses atotal cultural and spiritual view of health and well-being.This curriculum statement is designed to fulfill this aim.nLearning ObjectivesThe following learning objectives relate specifically to Aboriginal health. It is also importantto look at the common learning objectives in Part 3 of the Curriculum.The learning objectives describe the breadth and depth of the knowledge, skills andattitudes required, and relate directly to the content of the Curriculum, which is listedalphabetically in Part 5.The registrar will be able to:—Communication Skills and the Doctor-Patient Relationship• understand the importance of using culturally appropriate forms of communicationwhen interacting with Aboriginal people (e.g. observing protocols);• apply their knowledge of the effects of culture contact in Australia whencommunicating with Aboriginal people (e.g. social Darwinism, Terra Nullius);• establish trust when communicating with Aboriginal people;• understand Aboriginal family structure, kinship, social organisation and decisionmaking;• understand the effect of racism on self-concept and identity formation, and howthis affects communication with Aboriginal people (e.g. individual/institutional);Applied Professional Knowledge and Skills• apply their knowledge of Aboriginal definitions of health to clinical practice;• outline common presenting conditions and diseases among Aboriginal people (andtheir origins), linking them with the associated socio-economic, cultural andenvironmental factors (e.g. hypertension, cardiovascular disease);• discuss Aboriginal views of health and well being, and apply models and managementstrategies which reflect them in their clinical practice (e.g. primary health care/public health approach);• discuss the major cultural accommodations to be made when working with Aboriginalpeople (e.g. protocols, cultural healing practices);3Final Position Paper of the Aboriginal and Torres Strait Islander Health Curriculum Design Project. RACGP Facultyof Rural Medicine. 1994.4—6

Aboriginal HealthCurriculum Statement4• discuss ways of working (as part of a multi-disciplinary team) with Aboriginal healthworkers or liaison officers, outlining their importance in the delivery of primaryhealth care;• apply critical thinking and problem-solving strategies in caring for Aboriginal people;Population Health and the Context of General Practice• define the concept of culture and its relationship to Aboriginal identity;• outline the broad geographic, demographic and socio-economic context ofAboriginal communities in Australia;• outline how the Aboriginal definition of health fits into a primary health careframework of well being;• outline how equity and social justice principles could be applied to interactionsbetween Aboriginal communities and Australian society;• outline the health resources available in the Aboriginal community (e.g. elders,women);• outline the major factors and trends accounting for the epidemiology of Aboriginalhealth (e.g. common disease patterns, health policy);• outline the case for participation and/or community control in the delivery ofAboriginal health care (e.g. self-determination);• discuss the importance of recent cultural change and cultural healing in the definitionof Aboriginal health;Professional and Ethical Role• outline the importance of general practitioners being informed about culture contactbetween Aboriginal and non-Aboriginal Australians and its impact in Australian society(e.g. National Aboriginal Health Strategy review);• show sensitivity to Aboriginal speakers presenting an Aboriginal perspective onculture contact in Australia (e.g. stolen generation, dispossession);• discuss the importance of continuing education about intercultural communicationin Aboriginal health;• recognise their own limitations in the area of Aboriginal health and be prepared tostand back;• identify their own values, attitudes, priorities, beliefs, vulnerability and gender issueswhen working with Aboriginal people;• discuss the professional role of a general practitioner in promoting equity of accessto heath care and working against racism amongst peers, health colleagues, andothers in the Australian community;• be informed about definitions, epidemiology and approaches to Aboriginal health;• discuss the issues related to self-care when working cross culturally (e.g. cultureshock, personal adjustment, and stress);4—7

4Aboriginal HealthCurriculum Statement• identify the particular difficulties associated with confidentiality when working inAboriginal communities;• outline the different learning styles of Aboriginal people, and use two-way learningapproaches;Organisational and Legal Dimensions• identify the organisational, ethical and legal issues which are relevant to undertakinggeneral practice in a Community-Controlled Aboriginal Health Service (or otherAboriginal Health Service).nCurriculum RequirementsThe learning objectives relating to Aboriginal health are a mandatory Curriculumrequirement. Check Part 7, Assessment and Feedback, for a description of the requirements.Also check the annual RACGP Training Program Handbook for any changes to theserequirements.nSpecial ConsiderationsWhen teaching/learning information in relation to Aboriginal health, the broad range ofpatients and approaches should be taken into account. In addition to presenting medicalconditions, relevant social, cultural, emotional, spiritual, and socio-economic factors shouldbe considered (e.g. cultural influences on the person’s willingness to form a trust-basedhealth partnership with a GP from a non-Aboriginal background).nTeaching and Learning ApproachesA variety of teaching and learning approaches are advised to ensure a depth and breadthof exposure to the issues. Emphasis is placed on the two–way learning approach andbuilding partnerships with Aboriginal people.Aboriginal people from a NACCHO affiliated Aboriginal organisation, such as a Community-Controlled Health Service or educational unit, are directly involved in all aspects of planningand delivery of the education release activities.Educational PrinciplesThere are three key principles that underlie the implementation of Aboriginal healthtraining:—1. Partnership with Aboriginal people. Aboriginal educators from NACCHO affiliatedorganisations are to be involved in all aspects of planning, development andimplementation of the training.4—8

Aboriginal HealthCurriculum Statement42. Training of educators. It is essential that all medical and Aboriginal educators involvedin implementing Aboriginal health training have undertaken their own cross-culturalawareness training beforehand.3. Local adaptation. As Aboriginal communities differ across Australia it is notappropriate to present a generalised account of Aboriginal society or health, thatdoes not account for differences in history, contemporary culture, practices andhealth issues. Therefore all training materials (i.e. Aboriginal Health Training Module),should be adapted by Aboriginal educators to suit the local needs.Aboriginal Health Training ModuleAn Aboriginal Health Training Module has been prepared to assist Aboriginal and medicaleducators in facilitating appropriate learning experiences.The module is divided into five segments that describe a process for meeting the curriculumobjectives. The first three segments are essential for all registrars. Segments four and fiveare self guided and are for those registrars who wish to extend their learning in this area.The emphasis is on participatory learning with opportunities for registrars to discuss withAboriginal people the ideas presented.It is intended that registrars will analyse, reflect upon, and adapt their own professionalpractice as a result of undertaking this training.The main teaching methods to be used are:—• presentation of main ideas and concepts in a workshop environment;• presentation of Aboriginal perspectives with specific examples;• small group discussion of ideas, concepts and perspectives;• values clarification exercises;• discussion of myths and stories and application of the ideas in clinical management;• essential readings, and• two-way learning strategies.The emphasis is placed on gaining a broad understanding of the issues and assessing theirimplications for clinical practice, rather than a detailed knowledge of the concepts and ideas.Self-guided learning packages (segments 4 and 5)The self-guided learning packages contain teaching and learning materials relating to thestated learning objectives. They take the form of:—• readings;• background notes;• discussion questions;• contact points for medical educators;• details of meetings or teleconferences;• self and peer assessment requirements;• feedback mechanisms.4—9

4Aboriginal HealthCurriculum StatementnResourcesGeneral resources are set out in Part 6 of the Curriculum. The following resources arespecifically recommended for the study of Aboriginal Health.Aboriginal Health Training ModuleThe Aboriginal Health Training Module is the key learning resource for this curriculumstatement. It contains guidelines for registrars and for Aboriginal and medical educatorson the design of workshops and the self-guided learning packages.The module is divided into five segments, consisting of a minimum of five to six contacthours each. Emphasis is placed on gaining a broad understanding of issues, rather thandetailed knowledge. Registrars are encouraged to examine their own attitudes, values,priorities and practices.StaffingThe key staff are Aboriginal educators from a NACCHO affiliated organisation, who areinvolved in all aspects of the planning, local adaption and implementation.Medical educators coordinate the arrangements for meetings and workshops and assistwith identifying Aboriginal educators and groups, and participate in the sessions.Training ResourcesThe following training resources are available from state offices:• Aboriginal Health Training Module (RACGP Training Program, 1998) which includesessential readings, the myths and stories booklet;• videotapes;• teleconference facilities;• availability of appropriate GP experience in Aboriginal organisations;• interactive workshops, and• see required text below.Required TextEckermann A, Dowd T, Martin M, Nixon L, Gray R, Chong E. Binan Goonj: Bridging Culturesin Aboriginal Health. 2 nd edition : University of New England Press. 1997.Recommended Texts and ReferencesAlcohol and Drug Foundation, Australia. Walk Tall. (video recording) Alcohol and DrugFoundation. Canberra. 1988.Anderson I. Koori Health in Koori Hands. Melbourne, Koori Health Unit, Health Departmentof Victoria. 1988.4—10

Aboriginal HealthCurriculum Statement4Anderson I. Aboriginal well-being. In Health Issues in Australia: Sociological Concepts andIssues. C Garbich (ed) Sydney: Prentice Hall. pp 57-58. 1995.Atherton G. Babakiueria. (video recording) Sydney: Australian Broadcasting Corporation.1986.Aboriginal and Torres Strait Islander Commission (ATSIC). As a matter of fact: Answeringthe myths and misconceptions about Indigenous Australians. ATSIC. Canberra. 1998.The stolen children and their stories. Bird C. (ed). Random House. 1998.Brock P. Outback Ghettos: Aborigines, Institutionalisation and Survival. Cambridge UniversityPress. 1993.Crowe C. Aboriginal health: Common illnesses. Australian Family Physician. RACGP.Melbourne, no 24, 1995.Dunlop S. All that Rama Rama Mob. (video recording) Alice Springs: Central AustralianAboriginal Congress. 1990.Eades D. Communication strategies in Aboriginal English. In Language in Australia. LorraineS. (ed) New York: Cambridge University Press. pp 84-93. 1991.Eckermann KA. et al. Binan Goonj facilitator’s materials, University of New England Press.Armidale. NSW. 1993.Gilbert K. Inside Black Australia. Harmondsworth, Penguin. 1988.Green A. Australian Aborigines and their Skin Conditions. (video recording), EducationalResources Production Unit, Royal Australian College of General Practitioners, SouthMelbourne. 1995.Hodgson J, Wahlqvist M. Koori Nutrition and Health. Melbourne, National Better HealthProgram. 1992.Hunter E. Aboriginal Health and History. Cambridge University Press. 1993.Johnstone M. Women’s Business: Report of the Aboriginal Women’s Task Force. Canberra.AGPS. CANBERRA1986.Keen I. Being Black: Aboriginal Cultures in ‘Settled’ Australia. Canberra. Aboriginal StudiesPress for Australian Institute of Aboriginal Studies. 1988.Kelly K. Demythtifying Aboriginal Alcohol Use. 12th National CRANA Conference. CRANA.Alice Springs. 1994.Lippmann L. Generations of Resistance: The Aboriginal Struggle for Justice. Melbourne.Longman Cheshire. 1992.Maris H, Borg S. Women of the Sun. Harmondsworth. Penguin. 1985.McLaren B. Aboriginal health: Reflections on 18 months in a remote Aboriginal Practice.Australian Family Physician, Melbourne. 24, 8: 1479-1480.4—11

4Aboriginal HealthCurriculum StatementNational Aboriginal Health Strategy Working Party. A National Aboriginal Health Strategy.Canberra, Report of the National Aboriginal Health Strategy Working Party. AGPS. Canberra1989.National Preventive and Community Medicine Committee. Guidelines for Preventive Activitiesin General Practice. 5th edition. RACGP, Melbourne. 1998.Ngarritjan-Kessaris T. Talking Properly with Aboriginal Parents. In Harris S, and Malin M.(eds) Aboriginal Kids in Urban Classrooms. Sydney: Social Science Press, p 117-122. 1994.Office of Aboriginal & Torres Strait Islander Health Services (OATSIHS) Future directions inAboriginal & Torres Strait Islander Emotional & Social Wellbeing (Mental Health) Action Plan.OATSIHS. AGPS. Canberra. 1996.Raphael B. The ways forward: Aboriginal and Torres Strait Islander Mental Health Issues.AGPS. Canberra 1997.Reid J, Trompf P. (eds) The Health of Aboriginal Australia. Sydney. Harcourt Brace Jovanovich.1991.Reynolds H. The Law of the Land. Harmondsworth. Penguin. 1987.RACGP, Faculty of Rural Medicine. Final Position Paper of the Aboriginal and Torres StraitIslander Health Curriculum Design Project. RACGP. Melbourne. 1994.Royal Commission into Aboriginal Deaths in Custody National Report: Overview andRecommendations by Commissioner Elliott Johnston QC. Canberra, AGPS. 1991.Saggers S, Gray D. Aboriginal Health and Society. North Sydney. Allen and Unwin. 1991.Swain T. A Place for Strangers: Towards a History of Australian Aboriginal Being. Cambridge.Cambridge University Press. 1993.Swan P. 200 Years of Unfinished Business. Sydney. Aboriginal Medical Service Redfern,Sydney. 1988.South Australian Aboriginal Health Policy and Strategic Framework, Aboriginal Health.Dreaming Beyond 2000: Our Future is in our History. Adelaide. Aboriginal Health Councilof SA and South Australian Health Commission. 1994.World Health Organisation. Community Involvement in Health Development: ChallengingHealth Services. Report of a World Health Organisation Study Group, 11-18 December1989. Geneva, World Health Organisation. 1991.4—12

Aboriginal HealthCurriculum Statement4New ResourcesNew resources are constantly being developed in this area. For information on thelatest materials contact the Virtual Resource Centre at resource.centre@racgp.org.auFinding and Obtaining Useful ResourcesFor help in finding and obtaining useful resources, see ‘How to Find and ObtainUseful Resources’ on page 6—11.nAssumed Prior ExperienceIt is recognised that the extent of teaching and learning in Aboriginal health at theundergraduate level varies. Hence, this curriculum statement is based on an assumptionthat registrars will probably have had little prior knowledge and experience in Aboriginalhealth.4—13

71Appendix 6Heads of AgreementNational Aboriginal Community Controlled Health OrganisationandThe Royal Australasian College of Physicians(original document)

Heads of Agreement (HOA)An equal partnership between the National Aboriginal Community Controlled HealthOrganisation (NACCHO) and the Royal Australasian College of Physicians (RACP)Aboriginal and Torres Strait Islander Expert Advisory Group.Statement of IntentIt is the intent of the RACP through its Divisions, Faculties, Chapters and a partnershipwith NACCHO to assist in efforts to build the capacity of Aboriginal CommunityControlled Health Services (ACCHSs) through increasing their access to servicesprovided by physicians. Our partnership will be characterised by cooperation,collaboration, goodwill and the constant pursuit of excellence.The RACP and NACCHO are committed to the reduction in infant mortality andincreased life expectancy for Aboriginal and Torres Strait Islander peoples of Australia asset out in the “Statement of Intent”, 20 March 2008.We share a common belief that improved health outcomes for Aboriginal peoples will beachieved when Aboriginal and Torres Strait Islander peoples and their communitycontrolledhealth services are empowered to act on their own behalf, and whenAboriginal peoples’ reduced access to mainstream and Indigenous-specific healthresources is improved.Our work together will seek to provide the best social, economic and health outcomes forIndigenous Australians.Our activities will be conducted with respect for each organisation’s system of work,culture and values and will support the delivery of services being carried out in aneffective, efficient and integrated manner.The primary objectives of the partnership will be:• to improve health, social and economic outcomes for Aboriginal and Torres StraitIslander peoples and as a priority, cultural safety; and,• to facilitate a unique training experience for physician and paediatrician trainees.These objectives imply having a good understanding and empathy with local Aboriginalcommunity culture as well as an understanding of the impact of social conditioning(ethnocentrism, prejudice, stereotyping) and the health care environment (social context,institutional policies, power inequalities) on the quality of health care.1

PrinciplesThe RACP and NACCHO will:• agree that they will present a united, professional and responsible front to thecommunities in which they work at all times, reflecting the principles of culturalsafety in their delivery of health; and,• participate in joint programs, projects or training where a united approach willbenefit the communities they serve.Work plan for 2008-2010 for RACP to work with NACCHO to:1. Support the delivery of specialist services in NACCHO affiliated ACCHSs,through supporting and encouraging local specialists to develop appropriate,accredited and sustainable training positions in ACCHs;2. Work with NACCHO to develop advice to ACCHSs on the full range of capacitybuilding strategies that will ensure that Aboriginal and Torres Strait Islanderpeoples have access to best practice primary and secondary health services.Duration and ReviewThis Heads of Agreement will come into effect on the date of the last signature and willremain in effect unless modified by the mutual written consent of the agencies.This Heads of Agreement will be subject to an Annual Review on or near the anniversaryof signing.ChairNick AdamsNational Aboriginal CommunityControlled Health Organisation (NACCHO)on behalf of the President of theMel MillerThe Royal Australasian Collegeof Physicians (RACP)2

Onemda VicHealth Koori Health UnitCentre for Health and SocietyMelbourne School of Population HealthLevel 4, 207 Bouverie StreetThe University of MelbourneVic 3010 AustraliaT: +61 3 8344 0813F: +61 3 8344 0824E: onemda-info@unimelb.edu.auW: www.onemda.unimelb.edu.au