Article Figures & Tables
Tables
- Table 1: Participant quotations about students from southern Ontario training in northern Ontario
"I just remember one in particular because we were sharing some of the stuff about residential schools and roles of the elders, stuff like that. He was Canadian, and had no idea, had never heard of this 60s scoop or anything like that. So that was really shocking to me." (Interview 10) "Almost always there was very little knowledge in the group. And that's one of the reasons we had the content that we did. Because we realized that you don't get this in your health care training program." (Interview 10) "The only time they've seen a reserve is Six Nations. So they see these very high end, organized, beautiful places and that's their experience of what a First Nations reserve is like. ... So they don't understand what reserves in the rest of Canada are like. They don't have a good appreciation of residential schools or the Third World living conditions that exist right within our community." (Interview 13) "I've had a couple individuals from Toronto come down ... I think they were frustrated. ... Without taking into account their patients can't afford to go to Kenora, or they can't afford time off work or the day that it takes with the medical van. That sort of judgment came across and it wasn't appreciated by the population." (Interview 15) - Table 2: Participant quotations about students from the Northern Ontario School of Medicine and comparison with students from southern Ontario
"You know, since NOSM University has been around, they are way more prepared than the other universities. I think they have a community component to their curriculum." (Interview 1) "I do know just through a friend that did the Northern Ontario School of Medicine that they receive a lot of education on the First Nation culture. And she did feel prepared for those conversations." (Interview 4) "Are the northern students that much more aware? I would say they are, but they still have a lot to learn ... in their first 3 months they are out already on their first northern placement. It's not necessarily a clinical one, it's an immersion in the culture and they are sent to different First Nations communities for 4 weeks. So their awareness and knowledge really develops very early in the program. As far as living conditions, social economic conditions, health challenges." (Interview 10) "There's 5 NOSM students right now, some of them are from the North. ... I think they have a better appreciation and understanding of the demographic in the region than someone coming from Toronto who have never maybe been on a reserve. ... I think a lot of the students we have right now from NOSM have a pretty good appreciation of the social deprivation that exists in some of these far north communities. ... So I think there is a difference, I think for some of our students that we had from the Toronto area, aren't familiar with the North." (Interview 11) Note: NOSM = Northern Ontario School of Medicine.
"Yes, there are clinics in the community. Some of them have everything and some of them have nothing. So we have to bring our own stuff like pap lights and blood pressure cuffs." (Interview 1) "No, we don't have ECGs, there's no testing done here. We're more of a health centre than a medical centre. The only professionals that are here are the nurses and the nurse practitioner." (Interview 5) "I'm waiting for an answer to see when we're going to get our new health care facility. This one is very small. We're overcrowded. We don't have a lot of places to put storage. We don't have anywhere to put medical files." (Interview 5) "Some communities have nursing stations that have home care services or have medical drivers that can get people to town. But ... if a student doesn't realize that someone might not be able to get to town because it's over an hour away and it's $100 ... that's going to have an impact on [the patient's] health." (Interview 11) "It's 110 km north of Kenora, so it takes just over an hour to drive. Sometimes the road's out, which always makes it exciting. ... It's a regular road but several areas along the road they have washouts because of water, and culverts are not maintained. ... And often they have to close it for repairs, so you can travel through it. They only open it up to let people through for 1 hour a day, so it really limits the travel to the community. (Interview 15) Note: ECG = electrocardiogram.
"Probably the access to the hospital is easier now than it was 40 years ago because of roads and because of the helicopter. The helicopter brings a lot of people from the reserves." (Interview 3) "A lot of the family doctors have adopted a First Nations community. So they are receiving care at that level too." (Interview 4) "The outreach of physicians going to the communities has had a world of change." (Interview 16) "There are a lot of negative impacts that happened from the residential school, and that goes into each generation." (Interview 7) "The history of colonization and residential schools, how that has affected our population here ... people don't understand, they don't make the connection that your ER patient today, how it affected their family and their mothers, their grandparents or themselves." (Interview 8) "Generations of disruption, that nobody knows how to raise kids, survive as a family, survive without intoxicants which help you forget about all the other stuff that you don't want to remember." (Interview 13) "So, we are trying to deal with the residential school and those impacts. We try to have sharing circles and I think we need to work on that awareness. The healing has to happen from their own hearts." (Interview 14) "I expected to see the legacy of the residential schools and that would all be starting to fade and we'd be seeing a light, but it's no different now than it was 20 years ago. In fact, in some cases it's worse." (Interview 16) ER = emergency room.
- Table 6: Participant quotations about provider-specific characteristics influencing care delivery
"I think if you're dealing with somebody who has some degree of empathy, and patience and a little bit of understanding, I mean, you don't need anything more than that." (Interview 3) "Being respectful and kind. I think that of many different cultures, so if you're being respectful to an individual and asking them, "How can I help you?", I think that can be perceived too as appropriate cultural care." (Interview 4) "When I have students with me I really remind them to have good listening skills. This sometimes means a lot of time and not talking. I do believe that you can then deliver quicker health care in the longer term because you can understand the patient and you're probably going to get better compliance." (Interview 10) "White health care people have not walked in the same types of shoes. We are so quick to talk and to give information and instructions and recommendations and with the First Nations population, you have to be a good listener and give time for someone to tell their story." (Interview 10) "Learn how to listen to the stories that the elders have to share. Sometimes the stories are pretty long but being able to really listen to them and take the little seeds that are pearls of wisdom, and if you learn how to do that you're going to benefit an awful lot. And you're going to find the time you're in that First Nation community a lot better, a lot easier." (Interview 17) "We do have part of our community that's at the far end and they are very untrusting. The grandfather got a flu shot and the next day he died. So they really thought that it was the flu shot that killed him. And I think to this day it's really hard to break that barrier." (Interview 5) "And I'm fine with people using native medicine; they need to be careful about interactions because there are some very powerful roots and herbs." (Interview 13) "I think from a mental health perspective, the sweats that they do and the sage smoking are very therapeutic. ... It is a negotiation with those patients to come to some sort of common ground to say, I'm okay with you using your traditional medicine but I think it's in your best health interest to also consider using Western medicine ... to optimize the treatment for that condition." (Interview 15) "It's understanding the very different attitude just towards parenting, towards social intervention, the concept of noninterference, which is totally at odds with our jobs. ... Western medicine is based on a concept of direct interference and the First Nations approach is noninterference, and it applies to parenting and it applies to health care and applies to justice." (Interview 16) - Table 8: Participant quotations about the necessity for and content of a predeparture curriculum
"It would be good for them to be prepared so that when they come they are aware of the stressors in the community. ... And what did it stem from." (Interview 4) "You could probably do an introductory type session; go over the pertinent social problems. Maybe some of the social dynamic issues about negotiating with patients and that you are not going to get everything on your optimal care list. And what's available, the cost of transportation, what's involved time-wise. Because in Toronto everything's there. And the expectation when they go elsewhere is that it should be there." (Interview 15) "I think it's a really good idea to go over that before you come because then when you have that first patient in your office who has multiple comorbidities, you have an understanding of where they're coming from. ... So certainly a historical perspective would make it a little easier." (Interview 16) "Knowing a little bit about the geography, some of the history of the community, of the First Nations people. Certainly ... an understanding of the Indian Act, the residential schools and the impact that it had over the generations." (Interview 17) "An appreciation for how to communicate, knowing that not looking people in the eye is not rude, if people don't look at you it's not that they're ignoring you." (Interview 13) "Some cultural interactions, like how to interact with the First Nations people ... they don't make eye contact, they often make a number of gestures. [Making] an effort to make or to learn a few words in their local language goes a long way to develop more rapport." (Interview 15) "I think if they attend a sweat lodge ceremony and learn the rationale behind it ... You will gain a better perception of what the cultures and beliefs are." (Interview 6) "I think every doctor that comes out should have some training in a First Nations community." (Interview 7) "We have had some storytelling from elders ... that is the most profound understanding that you can get." (Interview 8) "I think that maybe they can be given some resources or something in advance to help orient themselves. But I think it's really successfully done as an immersion approach. When you're here, you can learn, integrate and apply all at the same time, simultaneously." (Interview 10) "There's nothing that will overtake hands-on experiential learning. If everybody had a half day or a day of immersive learning ... it would add a lot to their teachings." (Interview 13) "I think spending time on a First Nations community is probably the best way to really understand and appreciate the health care challenges." (Interview 16) "Say, if you're going to work for someone like WNHAC, you know the people there are really awesome. They don't need to, but they'll bring you with them and they will introduce you, kind of ease you into it." (Interview 5) "When people come and go for short term, it's the best when they go with the physicians because the physicians are really community involved ... we are their gateway to the community for the students and residents." (Interview 13) Note: WNHAC = Waasegiizhig Nanaandawe'iyewigamig Health Access Centre.