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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Aboriginal and Torres Strait Islander health

Definition

In the Aboriginal and Torres Strait Islander health setting there are a number of key terms used. These terms are contested and need to be considered in local contexts. The following definitions are offered as a way to understand these concepts in the context of this Aboriginal and Torres Strait Islander Health Curriculum Statement.

Aboriginal and Torres Strait Islander health setting

This phrase is used throughout this document to refer to any professional interactions with Aboriginal and/or Torres Strait Islander people, or to discussion about Aboriginal and Torres Strait Islander health issues in any professional setting.

Aboriginal community controlled health service

Today there are community controlled health services for Aboriginal and Torres Strait Islander people. The National Aboriginal Community Controlled Health Organisation (NACCHO) describes an aboriginal community controlled health service (ACCHS) as: ‘a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it (through a locally elected Board of Management).’1

Aboriginal and Torres Strait Islander health

The National Aboriginal Health Strategy Working Party defined health as: ‘Not just the physical well-being of the individual but the social, emotional, and cultural well-being of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life.”2 This is the definition used in this curriculum statement.

Consistent with the holistic approach to Aboriginal and Torres Strait Islander health, as well as with the World Health Organization (WHO) model of primary health care,3 delivery of healthcare to Aboriginal and/or Torres Strait Islander patients is more than just a clinical service. The learning objectives in this curriculum statement reflect this approach of broader healthcare delivery by being closely linked across the domains of general practice, and by referencing the individual patient.

Community control

The 1989 National Aboriginal Health Strategy describes community control as: ‘the community having control of issues that directly affect their community… Aboriginal people must determine and control the pace, shape and manner of change and decision-making at local, regional, state and national levels.’2

Cultural advisor

This term is used in this document to refer to those who provide advice to assist healthcare professionals working in the Aboriginal and Torres Strait Islander health setting. Most commonly and appropriately these people will be Aboriginal and/or Torres Strait Islander.

Culture

This term has a wide range of meanings but for the purposes of this document the following is used: ‘Culture, for us, then, is more than “a people’s way of life”. Culture tells us what is pretty and what is ugly, what is right and what is wrong. Culture influences our preferred way of thinking, behaving and making decisions. Most importantly, culture is living, breathing, changing – it is never static.’4

Cultural safety

This term describes: ‘an outcome of health practice and education that enables safe service to be defined by those who receive the service.’4

Empowerment

This term describes the state of being empowered.5 Empowerment cannot be ‘given’. Individuals and groups can only empower themselves when they make informed choices, determine their own fates and acquire resources to support their decisions. Empowerment, then, is part and parcel of self determination.4

Partnership

A term used in this document that refers to a mutually respectful relationship with equity that seeks to achieve agreed outcomes having regard to legal, ethical, cultural and policy considerations.

Self determination

This term is used to refer to: ‘a process where Indigenous communities take control of their future and decide how they will address the issues facing them.’6

Social determinants of health

These are defined by the WHO as: ‘The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon… Together, the structural determinants and conditions of daily life constitute the social determinants of health.’7

In the Aboriginal and Torres Strait Islander health setting this includes the processes of colonisation, dispossession, racism, marginalisation, oppression, stigmatisation, paternalism and prejudice.8

World view

This term is used in this document to describe the perception and experience of existence as shaped by the culture, history, spirituality, belief systems, and political and social interactions of the individual.

Rationale

The health of Australia’s first peoples is this country’s most pressing and important health priority. Aboriginal and/or Torres Strait Islander people are among the most disadvantaged indigenous peoples in the developed world.7,9,10

The available evidence suggests that Aboriginal and Torres Strait Islander people continue to suffer a greater burden of ill health than the rest of the population. Overall, Aboriginal and Torres Strait Islander people experience lower levels of access to health services than the general population, are more likely than non- Indigenous Australian people to be hospitalised for most diseases and conditions, and are more likely to experience disability and reduced quality of life due to ill health, and to die at younger ages than other Australians. Aboriginal and Torres Strait Islander people also suffer a higher burden of emotional distress and possible mental illness than is experienced by the wider community.11

Aboriginal and Torres Strait Islander health inequity occurs across all health indicators and many areas of health continue to worsen. Whilst there have been recent gains, the gap is widening as the health of other Australians improves faster.12

General practitioners have a key service delivery role in addressing this inequity in partnership with Aboriginal and Torres Strait Islander communities, either within an ACCHS or other GP settings.

General practitioners are also important advocates in improving the health of Aboriginal and Torres Strait Islander people. Australian governments have not only failed to deal with the ongoing consequences of colonisation but in some cases, they have actively promoted racism for political ends. Key health policies such as the National Aboriginal Health Strategy2 remain largely unimplemented.8

It is time that Australia dealt with its history of suppression and oppression of Aboriginal and Torres Strait Islander people in accordance with international best practice in the field of human rights.8,13 It is time that the rights of Aboriginal and Torres Strait Islander people, including their inalienable rights to self determination and community control are not only recognised but given full expression. Empowerment is central to this critical process in the maturation of modern Australia. To overcome Aboriginal and Torres Strait Islander disadvantage requires political will and leadership. It requires the recognition of the profound, diverse and dynamic cultures of Aboriginal and Torres Strait Islander peoples. It requires the generous provision of appropriate and sustainable resources and the commitment of those in leadership roles in our community.

To most effectively assume these roles of health service provision and advocacy, GPs require relevant knowledge, skills and attitudes. The National Aboriginal Health Strategy (1989)2 recommends that: ‘Tertiary institutions for undergraduate and postgraduate medical, nursing, and paramedical courses be approached to include the compulsory study of Aboriginal culture and history and health issues as part of formal course work,’ also recommending that: ‘Aboriginal people should be involved in the development and teaching of these units.’

This is the guiding principle by which this document was developed. This curriculum statement sets out a framework of essential attitudes, skills and knowledge required by GPs in order for them to work respectfully and appropriately in Aboriginal and Torres Strait Islander health settings and to advocate for equity in health and related outcomes with Aboriginal and Torres Strait Islander people.

The Five domains of general practice - Aboriginal and Torres Strait Islander Health

Communications skills and the doctor-patient relationship

Culturally safe communication skills are fundamental to the GP’s effective engagement in the Aboriginal and Torres Strait Islander health setting.

There is a diversity of cultural beliefs and practices, world views and behaviours among Aboriginal and Torres Strait Islander peoples. General practitioners should respect and be sensitive to this. Aboriginal and Torres Strait Islander peoples’ views of health and wellbeing differ to, and are more holistic than, those encapsulated by the biomedical model. They include diverse aspects such as social and emotional wellbeing, community relationships and connection to land. General practitioners who incorporate this into their practice will be better able to understand their Aboriginal and/or Torres Strait Islander patients’ needs and motivations. Trust plays a very important role in the development of a therapeutic relationship in the Aboriginal and Torres Strait Islander health setting. A GP may find that they are unable to achieve their desired outcomes until a certain level of trust has been established. General practitioners working in the Aboriginal and Torres Strait Islander health setting must ensure at all times that they avoid a paternalistic approach when delivering healthcare.

A partnership approach is more empowering and is more likely to lead to successful outcomes.

Applied professional knowledge and skills

‘Applied professional knowledge and skills’, contains further learning objectives relevant to ‘Communication skills and the doctor-patient relationship’. Aboriginal and/or Torres Strait Islander people are more likely to have a complex interaction of significant health issues including risk factors and medical conditions as well as underlying social and emotional issues. General practitioners require comprehensive and up-to-date knowledge and skills across the spectrum of these health issues.

Management strategies should incorporate an understanding of the views of health and wellbeing, and the social determinants of health and their influence on health behaviours of Aboriginal and/or Torres Strait Islander people and communities. They should be consistent with the comprehensive patient centred approach outlined in the RACGP Common learning objectives14 curriculum document.

A key component of assessment and management in the Aboriginal and Torres Strait Islander health setting is recognising and incorporating the knowledge and skills of Aboriginal and/or Torres Strait Islander health workers, liaison officers and cultural advisers. The capacity to work in a multidisciplinary team partnership approach is a GP key skill for better health outcomes. There are related learning objectives in domains 4 and 5.

Population health and the context of general practice

Colonisation and government policy decisions have had and continue to have a profound effect on the wellbeing of past, current and future generations of Aboriginal and Torres Strait Islander people. General practitioners need to understand that the healthcare they deliver is affected by these policies and the social determinants they have influenced.

General practitioners working in an Aboriginal and Torres Strait Islander health setting require a sound knowledge of the epidemiology of Aboriginal and Torres Strait Islander health and relevant preventive and other population health strategies.

Family and community can have a powerful influence on the health of Aboriginal and Torres Strait Islander people and the healthcare of Aboriginal and Torres Strait Islander people needs to be understood in the context of family and social relationships.

Effective primary healthcare in an Aboriginal and Torres Strait Islander health setting requires the provision of equitable access to holistic healthcare that addresses the social determinants of health and the right to self determination.

Professional and ethical role

Cultural advice is a key component of working in an Aboriginal and Torres Strait Islander health setting.

Each GP needs to be conscious of their worldview and its influence on their work within the Aboriginal and Torres Strait Islander health setting. This is an ongoing process across the learning life of the GP and includes openness to feedback from cultural advisors.

Self care strategies are important in order for GPs to overcome the personal impact of the level of disadvantage and inequity in the Aboriginal and Torres Strait Islander health setting.

General practitioners have a role to play in advocating for their patient group and for Aboriginal and Torres Strait Islander health equity.

In the Aboriginal and Torres Strait Islander health setting, academic roles including those of teacher and researcher have the potential to contribute to reducing health inequalities. These roles require an awareness of ethical considerations specific to this setting.

Organisational and legal dimensions

There are many models of health service delivery to Aboriginal and Torres Strait Islander people. The ACCHS model has a pivotal role in the delivery of primary healthcare to Aboriginal and Torres Strait Islander Australians and is an expression of self determination.

The learning objectives across the GP professional life

Medical Student

Communication skills and the patient-doctor relationship

  • Compare Aboriginal and Torres Strait Islander views of health and wellbeing with the prevailing models of healthcare
  • Define culturally safe communication with Aboriginal and Torres Strait Islander people
  • Demonstrate an understanding of the diversity of Aboriginal and Torres Strait Islander cultures and their relationship to identity in contemporary Australian society
  • Explain the importance of establishing trust when communicating with Aboriginal and/or Torres Strait Islander people
  • Discuss the differences between a paternalistic approach to health service delivery and an empowering approach and demonstrate how they might influence outcomes in the provision of healthcare to Aboriginal and/or Torres Strait Islander patients.

Applied professional knowledge and skills

  • Describe conditions and diseases that have specific implications for Aboriginal and/or Torres Strait Islander people
  • Discuss the interaction between Aboriginal and/or Torres Strait Islander views of health and wellbeing, social determinants of health, health behaviour and health outcomes
  • describe the roles of the Aboriginal and/or Torres Strait Islander health worker, liaison officer and other cultural advisors within the multidisciplinary team in the Aboriginal and Torres Strait Islander health setting.

Population health and the context of general practice

  • Examine the significance of cultural contact between Aboriginal and/or Torres Strait Islander people and non-Indigenous Australians and its impact on the social determinants of health
  • Present an overview of Aboriginal and Torres Strait Islander health epidemiology
  • Discuss how family structure, kinship and social relationships of Aboriginal and/or Torres Strait Islander people and communities impact on health decisions and behaviours
  • Discuss the concept of primary healthcare in relation to the Aboriginal and Torres Strait Islander health setting.

Professional and ethical role

  • Discuss how to access cultural advice and why this is important
  • Reflect on the GP’s own background, worldview and views on health and how this impacts on interactions with Aboriginal and/or Torres Strait Islander people and patients
  • Discuss the importance of continual self appraisal of intercultural skills
  • Describe the roles of the teacher and the researcher in reducing health inequality in the Aboriginal and Torres Strait Islander health setting
  • Explore the issues related to self care when working cross culturally in an Aboriginal and Torres Strait Islander health setting
  • Discuss the professional role of a doctor in promoting equity in healthcare outcomes and working against racism among peers, health colleagues, and others in the Australian community.

Organisational and legal dimensions

  • Compare the range of models of healthcare delivery within the Aboriginal and Torres Strait Islander health setting.

Prevocational

Communication skills and the doctor-patient relationship

  • Demonstrate knowledge of how an Aboriginal and/or Torres Strait Islander person’s views on health and wellbeing may impact on their experience of the health system
  • Identify strategies for culturally safe communication with Aboriginal and/or Torres Strait Islander people
  • Describe the ways in which Aboriginal and/or Torres Strait Islander patients’ worldviews may impact on health behaviours including presentations to and interactions with doctors and health services
  • Describe skills to establish trust with Aboriginal and/or Torres Strait Islander patients
  • Describe the skills required to work in partnership with Aboriginal and/or Torres Strait Islander patients.

Applied professional knowledge and skills

  • Demonstrate skills in diagnosis and management of acute and chronic conditions that have specific implications for Aboriginal and/or Torres Strait Islander people
  • Demonstrate patient management strategies that incorporate an understanding of health behaviours and their influences of Aboriginal and/or Torres Strait Islander people
  • Discuss ways of working as part of a multidisciplinary team that include primary healthcare providers in the Aboriginal and Torres Strait Islander health setting.

Population health and the context of general practice

  • Discuss the history of government policies in the area of ‘Indigenous affairs’ and the outcomes of these policies
  • Describe population health approaches relevant to the epidemiology of Aboriginal and Torres Strait Islander health
  • Demonstrate how use of knowledge of the influences of family and social structures enhances the care provided to Aboriginal and/or Torres Strait Islander patients
  • Examine workplace aspects that could facilitate or obstruct health equity and self determination in relation to Aboriginal and Torres Strait Islander people.

Professional and ethical role

  • Demonstrate ability to work in partnership with Aboriginal and/or Torres Strait islander cultural advisors
  • Describe how the interaction of worldviews could influence the care provided by a GP in an Aboriginal and Torres Strait Islander health setting
  • Describe methods of continual self appraisal of intercultural skills
  • Discuss self care strategies to protect against and minimise the potential personal impacts associated with the level of disadvantage when working in an Aboriginal and Torres Strait Islander setting
  • Discuss strategies at the systemic, organisational, professional and individual levels to promote health equity and eliminate racism
  • Use appropriate guidelines to describe the key features of an ethical approach to research in the Aboriginal and Torres Strait Islander health setting.

Organisational and legal dimensions

  • Analyse the history and pivotal role of community controlled health services in the delivery of primary healthcare.

Vocational

Communication skills and the patient-doctor relationship

  • Integrate views of health and wellbeing of Aboriginal and Torres Strait Islander people and communities into a holistic approach to clinical practice
  • Demonstrate culturally safe communication with Aboriginal and Torres Strait Islander people
  • Demonstrate skills used to establish trust with patients
  • Demonstrate skills used to develop a partnership approach with patients. Applied professional knowledge and skills

Applied professional knowledge and skills

  • Demonstrate the skills required when working with complex health presentations
  • Demonstrate use of holistic management strategies and working in partnership with health workers, liaison officers and cultural advisors.

Population health and the context of general practice

  • Describe ways to deliver healthcare that can help overcome Aboriginal and/or Torres Strait Islander people’s health inequities (including the inequities that are a result of government policies)
  • Describe preventive and population health approaches in the local Aboriginal and/or Torres Strait Islander communities
  • Identify situations in which family and social relationships influence healthcare for Aboriginal and/or Torres Strait Islander patients and demonstrate strategies to optimise health outcomes in such situations
  • Describe principles and processes in the development of an Aboriginal and Torres Strait Islander primary healthcare program.

Professional and ethical role

  • Analyse the role of cultural advisors in the delivery of healthcare to Aboriginal and/or Torres Strait Islander patients
  • Describe strategies to ensure positive outcomes from the interaction of world views in an Aboriginal and Torres Strait Islander health setting
  • Demonstrate self appraisal methods to improve skills in interacting with people in an Aboriginal and Torres Strait Islander health setting
  • Demonstrate self care strategies to protect against and minimise the potential personal impacts associated with the level of disadvantage when working in an Aboriginal and Torres Strait Islander setting
  • Describe strategies you have used in promoting equity of health outcomes and working against racism
  • Discuss the roles of the GP as teacher, learner and researcher in the Aboriginal and Torres Strait Islander health setting.

Organisational and legal dimensions

  • Discuss the organisational, legal and ethical issues that are relevant to delivering primary healthcare in the Aboriginal and Torres Strait Islander health setting both within the Aboriginal community controlled health sector and more broadly.

CPD

Communications skills and the doctor-patient relationship

  • Demonstrate openness to learning about the diverse range of Aboriginal and/or Torres Strait Islander worldviews
  • Identify resources for review and improvement of consultation skills with Aboriginal and/or Torres Strait Islander patients.

Applied professional knowledge and skills

  • Identify current evidence based, best practice guidelines for prevention, diagnosis and management of conditions with specific implications for Aboriginal and/or Torres Strait Islander people
  • Describe strategies for review and improvement of management strategies that reflect Aboriginal and/or Torres Strait Islander views on health and social determinants of health
  • Describe the systems within your work place for involvement of Aboriginal and/or Torres Strait Islander health workers, liaison officers and other cultural advisors in patient care. Population health and the context of general practice

Population health and the context of general practice

  • List local resources and services addressing the needs of Aboriginal and/or Torres Strait Islander people
  • Describe the GP’s responsibility in providing preventive and population health services to Aboriginal and/or Torres Strait Islander people
  • Demonstrate awareness of the main health policies that have been designed to address the ‘social determinants of health’
  • Demonstrate an awareness of changes that could be made in the GP’s local area to improve health equity and self determination in relation to Aboriginal and/or Torres Strait Islander people and communities.

Professional and ethical role

  • Describe pathways to access cultural advice appropriate to the GP’s current work environment
  • Describe methods to regularly review personal values and priorities when working in Aboriginal and Torres Strait Islander health
  • List professional supports available to GPs working in an Aboriginal and Torres Strait Islander health settings
  • Indicate how a clinician’s professional and personal practice promotes health equity, and work against racism
  • Identify opportunities for teaching, learning and research related to Aboriginal and Torres Strait Islander health in the practice setting and outline appropriate processes for engaging in these areas.

Organisational and legal dimensions

  • Describe how regular review of systems within the workplace by the GP promotes comprehensive primary healthcare in the Aboriginal and Torres Strait Islander health setting.

References

  1. National Aboriginal Community Controlled Health Organisation. Available at www.naccho.org.au/definitions/ams.html.
  2. National Health Strategy Working Party. A National Aboriginal Health Strategy. Canberra, 1989. Reprinted 1996. Available at www.health.gov.au/internet/main/publishing.nsf/Content/healthoatsih-pubs-NAHS1998.
  3. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-Ata, USSR, 6–12 September 1978. Available at www.who.int/hpr/NPH/docs/declaration_almaata.pdf.
  4. Eckermann A–K, Dowd T, Chong E, et al. Binan goonj: bridging cultures in Aboriginal health. 2nd edn. Sydney: Elsevier, 2006.
  5. Shorter Oxford English Dictionary. 5th edn. Oxford University Press, 2002.
  6. Australian Human Rights Commission. Social justice and human rights for Aboriginal and Torres Strait Islander peoples. Available at www.hreoc.gov.au/Social_Justice/info_sheet.html.
  7. World Health Organization. Closing the Gap in a generation. Health equity through action on the social determinants of health. Commission on Social Determinants of Health Final Report. WHO, 2008. Executive Summary. Available at www.who.int/social_determinants/thecommission/finalreport/en/index.html.
  8. Human Rights and Equal Opportunities Commission 2005, Aboriginal and Torres Strait Islanders Social Justice Commissioner. Social justice report. Available at www.hreoc.gov.au/social_Justice/sj_report/sjreport05/chap2.html.
  9. Australian Institute of Health and Welfare. Australia’s health 2008, The eleventh biennial report of the Australian Institute of Health and Welfare. Canberra: AIHW, 2008. Available at www.aihw.gov.au/publications/aus/ah08.
  10. Oxfam Australia. Close the Gap: solutions to the Indigenous health crisis facing Australia, April 2007. Available at www.ahmrc.org.au/Downloads/CTG.pdf.
  11. Australian Institute of Health and Welfare. Overview; Health; Indigenous Australians. Available at www.aihw.gov.au/indigenous/health/index.cfm.
  12. 12. Australian Health Ministers’ Advisory Council, 2008. Aboriginal and Torres Strait Islander Health Performance Framework Report 2008 Summary. Canberra: AHMAC, 2008. Available at www.health.gov.au/internet/main/publishing.nsf/Content/health-oatsih-pubs-framereportsum.
  13. United Nations Development Group Guidelines on Indigenous Peoples’ Issues, February 2008. Available at www2.ohchr.org/english/issues/indigenous/docs/guidelines.pdf.
  14. The Royal Australian College of General Practitioners. Common learning objectives. South Melbourne: The RACGP, 2007. Available at www.racgp.org.au/scriptcontent/curriculum/pdf/commonlearning.pdf.

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