What Doctors Didn’t Know About Indigenous Health

Indigenous health curriculum pioneered at University of Minnesota

A medical school that requires students to learn how best to treat indigenous patients? Unheard of in the United States. Until now.

In 2014 the University of Minnesota Duluth (UMD) Medical School implemented a seven-hour mandatory curriculum on indigenous health for first-year, first-semester medical students. The course begins with a super-condensed 50-minute history of tribes in the United States and then goes on to cover topics such as the impact of historical trauma and adverse childhood events on physical health, the history of Western medicine in Native communities and discrimination against American Indians through a series of presentations by Native medical practitioners, professors and community members.

One of the presenters for the series, Dr. Brian McInnes, Wasauksing First Nation, told ICMN, “My lecture was called ‘Culture, Spirituality, and Resilience: Traditional Practices and Contemporary Practitioners,’ which related my experience working with both medical professionals and traditional healers in indigenous community contexts. We talked about indigenous constructs of well-being, spirituality, health, and healing.”

So far, about 180 medical students have taken the indigenous health curriculum, according to its developer, Melissa Lewis, Cherokee Nation. “It is so important to provide [students] with this kind of information before you start talking about health disparities. Just giving them epidemiology stats and talking about mental health, physical health, diabetes, alcoholism, and suicide can lead to bias, and you’re not providing them with any tools to work more effectively with these patients,” she told ICMN.

Lewis describes the steps she took to develop the curriculum in an article in the journal Academic Medicine, “The Development of an Indigenous Health Curriculum for Medical Students,” co-authored with Amy Prunuske.

Courtesy Justin Kelley/University of Missouri / Melissa Lewis, Cherokee Nation, developed a curriculum on indigenous health to help students at the University of Minnesota Duluth Medical School better understand their patients and the contributions that American Indians make to science and medicine.

Two other schools in the United States—the University of Hawaii John A. Burns School of Medicine and the University of Washington School of Medicine—include indigenous health content in their medical education programs as electives, and others, including the North Dakota State University, the University of Wisconsin at Madison and Evergreen University, provide opportunities for students to be exposed to the practice of medicine in Native communities, said Lewis, but the UMD Medical School is the first to require that all medical students learn about the Native populations with whom they will likely work.

“The UMD medical students are picked from a rural area and they are going to go back to a rural area. In Minnesota the largest minority group they will treat will be American Indians,” said Lewis, who was an assistant professor in the Department of Biobehavioral Health and Population Sciences at the UMD Medical School when she developed the curriculum. She is now an assistant professor in the Department of Family & Community Medicine at the University of Missouri School of Medicine.

The goal of the curriculum is twofold: “We wanted everyone to have better skills to work with the indigenous people who are going to come into their clinics. And we wanted to educate people in the medical field that indigenous people are also researchers and scientists and have important cultural components to add to science and medicine and the art of human interaction,” said Lewis.

Another lecturer in the program is Jill Doerfler, a first degree descendent from the White Earth Nation and head of the American Indian Studies department at the university. She said, “We want to help students avoid pitfalls such as making stereotypical comments and to teach them how to ask informative and appropriate questions. If they have a basic understanding of the tribes they’re working with, that could result in improved health outcomes for American Indians.”

Courtesy University of Minnesota Duluth / Jill Doerfler, head of the American Indian Studies program at the University of Minnesota Duluth, is one of the lecturers for the curriculum on indigenous health for medical students at the university. She is a first degree descendent of the White Earth Nation.

The program is also intended to bring an indigenous influence into medical education, said Lewis, who describes in the article how at the beginning of the process of developing this curriculum she invited students, faculty and community members to a retreat and used that event to demonstrate the integration of indigenous values into a Western medical setting.

“The retreat was meant to demonstrate what an indigenous-led meeting could look like. A traditional healer started the meeting with a pipe ceremony. We held the meeting in a zero-carbon footprint building because that reflected the values of the community. We had the meeting catered by a local Ojibwe wild rice and maple syrup processor, Bruce Savage from Spirit Lake Native Farm, and Dan Cornelius, from the Intertribal Agricultural Council. They served traditional foods and provided the face of local indigenous business. It was an open format meeting. I got there and I sat down after I asked the question, ‘What is it that you would like your physicians to know? What would you like these medical students to learn?’ I wanted to set an example and a tone for how we could combine indigenous culture and medical school culture,” she told ICMN.

Lewis believes the principles underlying this curriculum can—and should—be used by other medical schools, but she cautions against “applying this [exact] curriculum in other institutions. I think you really have to have experts in that particular culture be the teachers. You can’t make it pan-Indian or pan-cultural. You have to prepare students based on the population they’re learning from [and treating]. Hopefully then when they move on to the next population they’ll use that same enquiry strategy, that same set of critical tools,” to learn about their new patients’ cultures, she explained.

“There is a pedagogical principle that says cultural competency needs to be separate from multicultural competency, that they are inherently different. I think if you’re going to do this you should do it right and just using a broad overview of different cultures is not sufficient,” she added.

Nathan Ratner, a non-Native second year medical student from Minneapolis, says the curriculum will make him a better physician. “I’m interested in primary care—how do you take care of people? What I learned is that it’s not enough to just take a personal history and ask what medical conditions have you had? What surgeries have you had? What diseases have you had? To really take care of somebody you have to talk about what happened with their ancestors. Given that so much of what we treat in medicine are chronic diseases which require a really strong relationship between the physician and the patient, it’s critical to understand where your patient’s coming from and the experiences they’ve had and the experiences that their ancestors have had,” he said.

Lewis explained that this kind of medical training is common in Canada, Australia and New Zealand for doctors who will be working with indigenous patients. In the U.S., the UMD indigenous health curriculum is unique, but Lewis will continue spreading the word about how it works and why it’s important. Another article is due out this summer based on student surveys, and she is developing a strategy for examining what impact the curriculum has in the real world, which, she notes, is what really matters—do patients have better health outcomes when their doctors better understand who they are?