Mike is a family doctor who is also a health researcher. His studies are inspired by the day-to-day challenges he sees at the clinic level. His latest research reveals some surprising ways health practitioners can better serve Indigenous patients with diabetes.
“When I was in medical school in Vancouver, I was trying to figure out how I could have a career in medicine and also have some influence on health policy. I talked to a lot of people I respected and they all told me the same thing. I had to first have credibility as an experienced physician. I should do a family medicine residency and work in different settings. So I got really good exposure to rural medicine at Memorial University.”
After my residency, I got a job in Moose Factory.
“I was planning to go for a year but I ended up staying for eight.”
“It was a completely different part of Canada for me. And it was exciting because at the time, they were just embarking on this experiment in transferring governance of the whole health region from Health Canada to the Weeneebayko Area Health Authority.”
“The medicine was very challenging and interesting. Lots of complexity. It was a great place to live too. I went on my first snowmobile ride and I tried snowshoeing and cross country skiing for the first time.”
“Although I learned a lot when I was up in Moose Factory, I realized I didn’t have the research training that could help me make an impact in health policy. I chose a Masters program at Johns Hopkins in Baltimore. After that, I came here to Queen’s University where I practice family medicine, teach and do research. I spend about a third of my time seeing patients and delivering babies, which I love, and about two thirds of my time on research.”
“People often think of research as being boring. I get that all the time! But I love the combination of continuing to take care of patients and also being able to put a substantial amount of time into trying to figure out how to make things better in health care, and to understand why the system ticks and works the way it does… that is what makes my work fulfilling.”
“For example, there’s a big emphasis in international surveys on what proportion of patients can see their doctor on the same day they call, or the next day. But it’s not clear whether it makes a difference in the patient’s health if they’re seen that day or three days later. We’re doing a study that is based on provincial data to answer this question. So far, it seems that if patients aren’t able to book an appointment with their family doctors within a week, the risk that they’ll end up in the emergency department increases. But it doesn’t seem to make a difference to emergency visit rates if patients are seen by their family doctors within one day versus within three days.”
“I have been working for over four years now on a project funded by the Canadian Institutes of Health Research looking at how we can help family doctors be more effective in their face-to-face interactions with Indigenous patients with diabetes. We talked to patients, clinicians, Indigenous clinicians and educators, trying to figure out a framework to help clinicians engage with patients with chronic diseases. We then turned it into a training program for family doctors. We’ve run five sessions in Northern Ontario and we’re in the midst of doing an evaluation of whether it improves patient care.”
It’s important for clinicians to have a good understanding of the impacts of colonization and systemic racism on people’s capacity to respond to their health problems and do effective self care.
“Indigenous people may not have easy access to some of the exercise programs, activities or food that clinicians recommend. Certain foods may be associated in their minds with residential schools. A certain food could trigger a terrible memory.”
“We tell physicians that it’s important to get to know their patients and the community and to understand cultural norms. A patient might describe the foods that they eat with their family and friends, and health workers might say ‘Just cook for yourself, make sure you have a healthy meal.’ That can be acceptable in the health worker’s culture, but in the Indigenous person’s culture, it may be seen as selfish or rude to cook only for yourself, and to not eat the food that is eaten communally.”
“We’ve learned from our research that Indigenous people can be worried about what’s called the ‘stereotype threat.’ People are afraid they’re going to be discriminated against, and they start looking to see if that’s happening. So they’re using their mental capacity to look for bias. It may come across as if they’re not connecting, or they’re closed off and not interested in answering questions. There was a doctor who had been practicing in Indigenous communities for decades and it was amazing because even he was learning new things. Looking back, he could recognize this stereotype threat and that helped him better understand his patients. He said, ‘You know, I see that.’”
In our training, we explain that if a patient might be concerned about being stereotyped, it’s important to slow down and build trust over time.
“If a person doesn’t seem like they understand something, it may be because they’re paying attention to something else, because they’re assessing your perceptions of them.”
“You want to ask yourself ‘Are they comfortable in the interaction?’ And you may want to pose questions or conversations at another time when they are more comfortable.”
“You are not a First Nations person but you are doing research in Indigenous health.”
“I am conscious of that. I think it’s really important that I work with Indigenous scholars on my projects whenever possible. I think there’s a role for Indigenous and non-Indigenous researchers to work together. As I see it, I am there to help. The direction and leadership needs to come from the Indigenous members of our team, and even more so from the community that we are working with. We have to work together from the beginning. I can’t just go in with my own ideas.”
“With First Nations research, you have to respect the OCAP principles – Ownership Control Access Possession. They are at the core of working with First Nations. The principles outline that First Nations communities own their own information and data, and that it may belong to a community and not just an individual, which is different from the western view. First Nations communities should be able to hold on to their own data and have control over what happens to the data, so that someone doesn’t later use it for reasons that are different than what they said they were going to use it for.”
When collaborating with Indigenous researchers, the important thing is to stay in the room to have the difficult conversations.
“Our research agreements ensure that whatever the results are, there’s appropriate discussion and consultation about their interpretation. If we don’t agree, I would never put anything out that was my interpretation and not include the interpretation of others. You always try to seek consensus and if you can’t, it would be unethical to put out your view without the competing view next to it. In some cases, if you don’t provide the context or the interpretation of why the numbers reveal something – for example that a certain health issue is more prevalent – it can perpetuate stereotypes.”