The Caregivers Podcast

Why do Indigenous communities distrust the healthcare system, and how do we fix it?

In this episode of The Caregivers Podcast, Dr. Mark sits down with Dr. Jamaica Cass - the first Indigenous woman in Canada to earn both an MD and a PhD. Dr. Cass shares her mission to decolonize medicine, from reshaping medical school curricula to building localized health education programs.

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What is The Caregivers Podcast?

The cost & courage of caring - stories that spark resilience.

Welcome to this week's episode of

the Caregivers Podcast.

I'm your host, Dr.

Mark Ropeleski,

and you can call me Dr.

Mark.

My guest today is Dr.

Jamaica Cass, the first Indigenous

woman

in Canada to earn both an MD and a

PhD.

She's a family physician helping

reshape how future

doctors are trained.

Dr.

Jamaica Cass, welcome to the

Caregivers Podcast.

We're so happy you're

here with us today.

Thanks so much for the invitation

to chat.

So tell me, why don't

Indigenous communities trust the

healthcare system anymore?

That is a big question with a lot

of nuance, and it actually goes

back much farther than you and I

have been practicing.

And so if we

think back to the systems and

structures that Indigenous peoples

have been placed in since

first contact.

So we have the Royal Proclamation,

which of course then turned into

the Indian Act,

we have things like the reserve

system and the residential school

system, forced and coerced

sterilization, Indian TB hospitals

where folks were cohorted with

tuberculosis and had vaccinations

tested on them without their

knowledge.

These are still very much in the

recent memory of Indigenous

peoples in Canada.

And so this is a population of

people who every time they have

encountered these

colonial institutions, that is the

healthcare system, they have been

harmed.

They have been harmed and

they still live in a system that

often like doesn't acknowledge

that these things have happened.

And so when that is your entire

lived experience, I'm sure you can

imagine how much terror and

distrust

there might be in the healthcare

system in general.

And then on the news and in the

media,

you're seeing stories about

Indigenous peoples being left to

die in emergency department

waiting

rooms or not taken seriously once

they're admitted to hospital and

then die because of that.

And so I think

it's really accurate to say that

anti-Indigenous racism kills

people in Canada still.

And so with that

context, of course, people are

distrustful of the healthcare

system.

When you describe healthcare as

colonized, what does that actually

look like in a hospital or a

clinic

setting in everyday life?

So Western healthcare, as you

know, those of us with MDs

typically practice it, is very

much

set up in a way that models the

systems and structures of European

colonization as they're present in

Canada

today.

And so we don't actually practice

healthcare.

We actually practice sick care,

right?

Illness care, right.

And so, yeah.

And so we don't actually consider

health, wellness, and well-being

when we treat patients.

We look for a problem and then we

try to fix it or we try to manage

it, right?

And so you're

automatically tackling the patient

with a deficit-based lens.

And so all of these concepts

are very colonial.

However, and there's significant

diversity amongst the Indigenous

cultures of Turtle

Island, but I'm generalizing a

little bit when I say that health

and wellness is broad, right?

There are

different elements to health and

wellness and there are different

elements to healing.

That might look like

a traditional medicine, but that

also might look like a ceremony or

being on the land and connecting

with

the spirit.

That might be, you know, time with

community.

That might be healing through

food.

Like food is very

much medicine.

And culture is medicine.

And that means different things

for in different Indigenous

communities.

That might be art.

That might be dance.

For me, it's beadwork.

And these are really challenging

concepts for Western healthcare

providers to understand and

process.

And I think that can be really,

really

challenging when you are trying to

work with healthcare providers who

maybe want to integrate some of

these

concepts into working respectfully

into working respectfully in a

care plan, but aren't really sure

how.

I mean, many Canadians don't trust

healthcare right now for many

reasons also.

Where is Indigenous mistrust

similar, but where is it clearly

different?

That's a great question.

I think we all, Indigenous people

and non-Indigenous people alike,

see this

strain on the healthcare system.

So we see, you know, rural

emergency departments closing.

We see

surgeries being canceled.

We see people, you know, the

people that are the foundation of

the healthcare

system.

And I don't mean the doctors and

nurses.

I mean the people that keep the

hospitals open,

healthcare.

And that's pretty scary when you

are the patient waiting for care

or trying to access care

and you can't, or you're on the

gurney in the hallway, right?

And that doesn't necessarily have

to do with

whether or not you're Indigenous.

So I think there is alignment

there absolutely in that worry and

that

concern about, you know, what kind

of care you'll get.

Where I think it's different is I

think people

that aren't Indigenous or don't

identify with a racialized

minority community aren't afraid

to walk

into the emergency department and

have somebody accuse them of

stealing or being drunk instead of

being sick.

And that's where I think kind of

the difference starts.

some patients sort of experience

physicians and doctors and

training as agents of the colonial

system

we've talked about.

But that can occur even when a

doctor is trying their best and

meaning well.

How does that gap between intent

and impact show up in care and in

the patient experience?

Yeah.

That's a, that's a challenging

one.

So I think we all come into

healthcare wanting to help people,

right?

Like that's inherently, I think,

you know, the folks that sign up

to be frontline healthcare

workers really do start out at

least with the best of intentions.

And, and I really, really try so

hard

in all of the different kind of

hats that I wear to give people

that benefit of the doubt there.

But I think there's a big

difference between kind of wanting

to do your best and then doing the

work

to engage in the critical allyship

required to really walk a path

equally with an Indigenous person.

And so you can say, you know, I'm,

I'm not a racist or you can be

anti-racist, right?

And the difference

between those two things is

action.

People that are anti-racist, when

they see racism, they stand up to

it.

They use strong language and they,

and they disrupt it when they see

it.

And, and that's a kind of the

first example I can think of where

there's kind of that difference

between intent and action.

So, breaking, breaking up the

process and letting the dust

settle and then actually listening

the patient in front of you.

And I mean, when I think about it,

sometimes it's, it's actually,

there's a much bigger system issue

too, because it's not just the

physician who's the first to greet

or meet the patient as they engage

with the system.

And there are numerous potential

layers

where things can be challenged.

And what I love about some of the

work you're doing is that,

it will incorporate new learning

and new curricula, not only for

physicians, but for nurses and for

occupational therapists and

physiotherapists as we build out

the project up north, the

Weeneebayko

Queen's allyship to build a new

healthcare center, but also a

healthcare curriculum, which we'll

get into

a little bit later.

Can you tell me or take me to a

moment where, in your experience,

where Indigenous

mistrust actually changed a

patient's decision about the

course of their care?

What does that look like for our

listeners?

Certainly, I have had patients

have experiences where they

delayed, like attending emergency

departments for fear and distrust

and, and for fear that they'll be

treated how, you know, a family

member or how they have been

treated in the past.

I have had patients share with me

stories of,

well, I went to this emergency

department and they sent me away.

They said it was a stomach ache.

They

said I had a stomach bug.

And then they've gone to a

different emergency department and

they've had

some testing done or imaging and

an acute problem was found.

And I think the two cases that I'm

immediately thinking of, I think

both ended up with like emergent

surgery.

And initially they were kind

of told, they were told they were

fine and turned away.

And I ask myself when I hear

stories like that,

because they're common.

Did that happen because of

staffing shortages and, and

physician burnout and,

and all of these things, or was

that racism?

It's very difficult to tease out

at times, isn't it?

It is.

Yeah.

And I, and I'm mindful of the lens

with which I hear these things

because it's

certainly I'm getting it third

hand.

Uh, but I, but I wonder, and I,

and I worry, I worry for my

patients.

I mean, there's no doubt that, you

know, modern, modern medicine does

save lives, but why should

anyone believe that decolonizing

medicine won't just slow down care

and actually compromise results?

I think that's a really important

question.

And I guess, um, maybe what I

would share is just a little

bit of information.

And so indigenous folks are about

5% of the population in Canada,

but we are

over users of the healthcare

system because the social

determinants of health and the

inequities that exist

for indigenous populations, again,

as a result of colonization are so

significant that, um, life

expectancies are less and there's

significantly higher rates of

chronic disease in indigenous

populations.

And so a significant, like

disproportion of healthcare

dollars is spent on indigenous

peoples, not just in Ontario, but

nationally.

And so think about, like, imagine

what would happen if

all of a sudden our frontline

healthcare workers could practice

anti-racist culturally safe care

initially.

All of those patients that are

presenting late with these

expensive chronic diseases would

present earlier.

And if you took the extra time up

front to offer that culturally

safe care,

think of the time and money that

would be saved, like nationally.

It's surely in the, in the

hundreds

of millions to billions.

I mean, there was a time when I

think the indigenous culture had

built into itself those preventive

elements

of healthcare.

I mean, some of those chronic

diseases have evolved in rather

recent generations,

but there was a time where they

didn't exist.

And, um, it does give hope for a

return to greater

awareness that maybe we can

reverse that process and, and

start changing that.

I'd like to get into that a little

bit later when we hear about some

of your initiatives, but, um,

and that's not uncommon.

I mean, we read a lot about, um,

not just lifespan, but healthspan.

It's a very big

buzzword these days, but it's,

it's highly relevant.

And, uh, I've certainly, from my

experiences,

um, there's a lot of opportunity

to, uh, to build healthspan out.

And, um, I think we're hopefully

seeing it in some of the younger

generations of, uh, of indigenous

peoples that I, I've had some

encounters where it has, um, been

more engaging and there's, there's

an element of hope and

certainly reinforced in those

contexts that I recall by my

helping make my patient actually

feel that I

was invested in their care and

their future and in the moment.

And, uh, we all know how to do

that.

And, uh, adding a little bit more

love and kindness to the equation

and everything that we do can just

translate into so much momentum

forward.

And I think that should probably

have to transcend this whole

process.

Shouldn't medicine just sort of

focus on competence?

I mean, think about it, you know,

why do we bring history into it?

If medicine can just focus on high

quality competence,

we kept history aside and focused

on the competence, wouldn't we be

able to deliver uniform

care across the board?

I guess it depends what your

definition of competence is.

That's a broad

term.

Competent in what?

Right.

Are we, are we just talking about

that, um, um, biomedical model?

Mm-hmm.

Can you name all of the bones?

Right.

Tell me about the Krebs cycle?

Or are we talking

about maybe some of the softer

skills?

Like I'm competent with, um,

shared decision-making and

agenda setting and, uh, you know,

understanding the patient's social

context so that I can, um,

offer a plan that not only, uh,

you know, moves us both toward a

shared goal of wellness,

but is, but is, uh, you know,

patients able to follow.

You know, we all were trained in

the biopsychosocial model, but

what I'm hearing

from you is that what we really

need to engage is the adaptive

biopsychosocial model

and informed by history and unique

elements that are pertained to one

culture and one community

versus others.

And, um, it takes effort and it

takes that kind of knowledge,

which, uh, hopefully

the next generation of trainees

here locally.

And then when, uh, your, uh, your

success is spread

globally, uh, among other efforts

to, to sort of shine light on how

the right way of doing things

is, that'll all change.

You know, again, we, we often hear

we want the best and the brightest

in medicine, but that doesn't

sound like it's enough, is it?

For a very long time that, you

know, that's how merit was

measured, right?

The highest test scores

and the, and the best grades.

And I don't know how, how much

that serves us as a society.

And I think

of myself as a patient, how much

that serves us, because I've now

been teaching for some time

clinically at the like

undergraduate MD and postgraduate,

um, family medicine, uh, residency

level.

And I can tell you that I have

seen learners who have phenomenal

grades and amazing test scores.

And,

and because they came through life

with the power and privilege that

I did not, they never had to

struggle.

And when they kind of come out

into medicine and, and are now

having to balance,

like studying, you know, taking

care of themselves, like, you

know, doing all of the kind of

daily

things that as adults we take for

granted, but they've maybe never,

never had to do all of those

things themselves before.

And they get to that part of their

lives where they're needing,

needing to

balance all of these things and

then, uh, deal with the rigors of,

of postgraduate medical training.

They, they, they really struggle.

They struggle.

And, and that makes me think about

how important grit

and resilience are in medicine,

particularly, um, in the, the

current climate of medicine and

how hard

it is to practice medicine with an

aging population.

People are getting sicker.

There's less funding and

funding for funding and money for

things.

And, and so we really all need,

need that, that ability to,

to be resilient.

And I think when our, our, um, up

and coming, um, folks in medicine

lack that,

I worry about their longevity.

You know, it's interesting because

we touched on this with Dr.

Sanfilippo, who, uh, was on the

podcast

several episodes back, but there's

also the resilience that comes in

the face of clinical

ambiguity, but perhaps even

cultural ambiguity, where it's not

just a melting pot of, uh, you

know,

fixed, fixed cultures.

And even you say yourself within,

within the indigenous population,

there's so

much variation and, and fine

tuning of our approach.

Uh, just like dialects vary,

cultures and traditions

within the indigenous population

may vary so much as well.

And it takes a certain skillset.

And, you know, black and white

thinking in terms of it's either

this way or that way and no

subtleties

in between really doesn't get you

far when you're trying to not only

deal with clinical ambiguity, but

the ambiguity that comes and how

we have to modify our approach to

be culturally sensitive and

culturally

safe.

What do you think about that?

And I also think there's a

humongous amount of humility and

understanding that we don't know

everything.

And I think fundamentally when we

agree to be physicians, we have

committed to

life of learning and, and again,

humility, have to have humility

with that.

And, and, um, you know,

they say the, it's very dangerous

to be the person who doesn't know

what they don't know.

Right.

Oh, absolutely.

And, and so I think that's really

important.

You know, I'm, there are, there

are some kind of, I think,

fundamental structural shifts that

are coming because there has never

been a provincial or

national quality standard for

cultural safety or indigenous

health in this country, despite

the

significant disparities in

outcomes between indigenous

patients and non-indigenous

patients.

And both of those

are being created right now.

And so really for the first time,

indigenous patients in Canada,

but also in Ontario will have

something they can hold in their

hand to say, this is the quality

of care

I can expect and I deserve.

And, and to be really honest at

the act actually is like a legal

obligation,

right.

Like Canada enacted the United

Nations Declaration on the Rights

of Indigenous Peoples Act

in 2021.

So it's actually now like

legislated that indigenous peoples

have the, um, have the right to

the

highest attainable level of

health.

And, and we're starting to see

that trickle down a little bit.

And so

when these quality standards are

launched, institutions, providers,

and patients and families will

have a clear

cut understanding of the

expectation that they treat

patients with dignity, respect,

and provide culturally safe

care.

I look forward to seeing, seeing

that, uh, bear success.

Tell me what you've championed in

recent years

through your involvement at

Toronto Metropolitan University,

but also more recently at Queens

to forward

this agenda.

So we have the right people in the

right places to be able to honor

these expectations of safe

cultural care for our indigenous

peoples.

I guess.

Yeah, absolutely.

So I spent two years as the

indigenous health lead at Toronto

Metropolitan University's new

school of medicine, which opened

this past September, uh, in

Brampton, Ontario.

And that was a really unique

opportunity.

I worked on the

senior leadership team for two

years to help them, um, um,

reconciliation and decolonization

into, um,

all aspects of the medical school.

And so I got to work with, uh, the

local indigenous community to

build, uh, culturally safe and

barrier-free admissions processes.

And they had a very high

number of applications.

I think they actually have, um,

the, now the two years of

admissions processes that

they've run, uh, we had a

phenomenal amount of community

engagement, like indigenous

community

engagement that went into

curriculum building.

I developed a four year mandatory

indigenous communities

and health course so that every

year TMU will graduate 94

physicians who have taken four

years of courses to

learn about the context of

colonization and its impacts on,

uh, health of indigenous peoples

and how to provide

culturally safe care.

If they don't pass it, they don't

graduate.

It is mandatory.

Um, we, we worked

really hard to make sure that when

we were going through all of the

HR processes to bring on leaders

as the

school grew, that we were making

sure we were asking hard questions

about people's understanding and

their

actions around incorporating, um,

like principles around

decolonization and reconciliation

and, and what

their relationship was and where

they were in their journey of

reconciliation.

Uh, and I think

that, I don't think those, those

are things that have kind of ever

been done before, um, kind of from

this

start.

And I've now had an opportunity to

go back and guest lecture a few

times there, both at the post-grad

level and at the undergrad level

and what a phenomenal group of

learners they have there.

And they're just

like, he just hearing the, the

optimism and the, um, like the

vision they have, um, for how they

want to

practice medicine is just, it's

really inspiring.

And it was a, it was a great

opportunity.

When medical schools start

changing how doctors are trained

in order to relate better to

indigenous

patients, where do you sense, or

where do you see the pushback that

people may have?

And why does that

still, or why could it occur?

So it's a little bit, so it's a

little bit different depending on

the

context.

And so I'll say I was very

fortunate at TMU because we had a

blank slate.

And so we were

building a curriculum and prior to

my coming on board.

And actually the reason why I

agreed to come on

board is because the university

had committed to it already.

Uh, however, when we look at, um,

institutions who are, uh, updating

a modifying curriculum, they, they

sort of have something

set already.

And so there, there's always the

question of where will it fit?

Where will we put it?

Uh, and I think there are lots of

different areas and specialties

that are kind of, I don't want to

use

the word fighting, but that are

interested in kind of adding more

content.

And so I think that's a big

challenge is just time.

Where does it go?

I think the cost, right?

It's not cheap.

Um, I think it's

particularly important.

We discussed the, the nuances of

the diversity of indigenous

populations.

I think

when you're developing indigenous

curricula, um, within a medical

school, the, the geography is

essential, right?

Whose territory are you on?

Whose land is this?

And what do those relationships

look

like?

If you want to have, um, like

culturally safe curricula, you

need to build relationships with

the local indigenous community,

which takes time, which takes like

money.

And then, and then developing

that curricula takes money.

So of course it's expensive and

all universities are under

financial

pressures and strain right now.

So, so that's challenging.

Um, there, I, I know that we've

all

heard these sort of anti-DEI

rhetoric that is starting to shift

North from the U.S.

And when I,

I kind of hear about that, I, I

will remind people that indigenous

peoples have inherent treaty,

constitutional, um, and legal

rights that are different from

other groups.

And so we, we,

you can't really lump in, um,

reconciliation work with DEI.

And in fact, when you do, it's

really,

it's another form of erasure.

And so I think it's really

important that, um, the indigenous

context

needs to be considered separately

from other groups you might

consider marginalized or, or

equity

deserving.

You said a couple, a couple of

minutes ago, like, where will we

put this effort?

Where will we put

this project?

Where will it land?

But right now through your work at

Queens University and the

Weeneebayko area, uh, health

authority, we are actually

building a landing pad, not just

for physicians,

but for allied healthcare

providers as well.

So tell me about that and the

journey where, where,

where that's heading.

I mean, I think it's so exciting

and I'm, uh, always glad to go up,

uh, to Moose Factory to see

patients and engage with some of

my patients where you've

traditionally seen

here.

But, uh, it's, it's been a

wonderful opportunity going up

there and also feeling the pulse

of excitement

of what's to come and actually

getting a tour of the new area

that's being built.

And, um, so this is right off

the press.

You're right involved there.

Tell me about where we're headed

and, and the progress that's being

made.

Yeah, absolutely.

I think a common theme in rural

and remote indigenous communities

is the challenge that comes

with delivering care, uh, so far

from, from urban centers.

And there's a lot of challenges.

There is, um,

finding providers period.

So getting all of the staff there

and, and maintaining a staffing

complement.

There's, there's staff that know

and understand the nuance of the

region and the unique challenges

that

come with living in those regions.

And, and especially in rural and

remote indigenous communities,

being able to provide culturally

safe care and continuity of care,

which is so crucial.

And so

there was a lot of groundwork that

I cannot take credit for because I

was not involved, but the

MasterCard Foundation, uh, worked

with our former Dean, um, Jane

Philpott, who's now working with,

um,

the ministry, uh, at Ministry of

Health in Ontario, of course, and

then Lynn Innes as the CEO of the

Health

Health Authority to really imagine

what could be possible with,

instead of pulling learners out of

the region to, to learn health

professions in these, um, kind of

bigger urban programs, what might

it look

like to deliver education

differently, grounded in

indigenous ways of being, knowing,

and doing, uh, and,

and delivered in community.

And so, um, what, um, folks who

don't live in those communities

or, or have a

good understanding might not

realize is, is one of the many

reasons why there are not more,

uh, indigenous, uh,

health care providers, for

example, is there is even a huge

barrier with attending

post-secondary

education in rural and remote

communities because high school

teachers that can teach high

school

prerequisite courses to get into

universities just aren't there.

And so if teenagers want to go to

university, they actually have to

leave community to go south, uh,

to, to a town or city with a, with

a high

school to, to do high school.

And so they have to leave their

families, leave their communities,

um, at

least for high school.

And then of course, to attend

education.

And then when they get there,

often

they're not successful and they

don't fail due to academic

reasons.

Typically it's sort of all of the

other things.

It's the culture shock.

It's the lack of support, the lack

of connection to community and

culture and family.

And, and then, you know, uh, also

dealing with the, you know,

financial pressures

and all of these things that, that

other folks maybe just might not

think about.

And so with all

of those things in mind, um, I am

now the director of the Queens

Weeneebayko health education program

and have the like distinct honor

and privilege to work with, uh,

the communities on the Western

coast of

James and Hudson Bay to support

bringing post-secondary education

to, to the region.

And so we are working,

working to do that so that we can

recruit, train, and then retain

indigenous peoples from the

community

to care for the community.

And that'll have so many forward

positive impacts.

And then imagine yet the next

generation after that

and so forth that the power of

that, uh, I don't know if I'll

still be around to, uh, to see the

final, uh, fruit porn of that, uh,

seed, but, uh, it's wonderful to

hear.

We have a tradition, uh,

Jamaica of having, uh, the

production team, get a couple of

questions in too, just to add a

different

spin on, on the podcast.

Are you cool with that?

Yeah, sure.

Did you guys have any questions

today?

I'm just trying to think of some

pushback that you might get in

like the TikTok comment section.

Um, you know, there's people love

to be, uh, keyboard warriors.

Um, I get one of the main ones

that sort of pops into the top of

my head is like, there's the

healthcare system is under so much

strain

right now.

And there's like 6, 6 million

people without primary care

doctors.

And is, I guess,

is this the time to focus down on,

on one particular group of people,

um, when the entire

system feels like it's ready to

implode?

Um, and so I guess, you know, one

of the criticisms or pushback

might be, we need to get overall

Canadian healthcare in a better

place before we can, you know,

start to,

to, to sort of focus down on one

group or another.

What would you sort of say to that

sort of pushback?

That's a common one.

And I hear it too.

And, and that's kind of one of

those times where I would,

again, like just purely like

outside of my bias as an

indigenous person and a primary

care provider,

just go to the data, right?

Like I'm a, I'm a researcher.

And so if I tell you that, for

example,

in, in one community, the

government is spending $10 million

a year just to shuttle people back

and

forth because the care can't be

provided in the region, that

doesn't count housing them and the

actual care provision, et cetera,

that's just one part of their

transportation, then I'm sure you

can

quickly appreciate how those

hundreds of millions of dollars

and resources build up because of

the

inequity in being able to provide

and receive care.

And so again, the, the commitment

to doing this,

yes, I could tell you that it's

like, it's a, it's a legal

obligation.

It's a treaty obligation,

et cetera.

That's, that's one piece.

And certainly it is, but it also

is just good business.

It's,

it just makes good economic sense

to put the money in on the front

end to develop, um, healthcare

workers who can deliver care in

region to bring like really truly

to improve those health

disparities

and bring the health of the

population, the quality of life up

so that we're not spending all of

this

money later with these late

presentations and these expensive

illnesses, dialysis, et cetera.

Right.

Makes sense.

Um, maybe one last question.

Do you find the support, um, for

these initiatives

divided along any particular

political lines or is it more

complex than that?

I haven't yet, which I actually

think is really interesting and

kind of speaks to Canada's ability

to stand on its own, uh, according

to its values and morals, because

like an example of the initiatives

that I'm working on this, um, this

education campus as a tribe

partner initiative, I have

institutional alignment up to the

head of the university being so

supportive.

I have met with

representatives in, um, MCURS,

which is the ministry of colleges,

universities, um, research, um,

excellence

in security.

I have met with folks, um, at the

ministry of health, um,

provincially and, and the

community is so supportive.

So never have I actually seen so

much like cross-sector alignment

for one like initiative.

And it actually, I was expecting

that I truly was.

And I just haven't

seen it.

And I think, I think, you know,

everyone just understands how, how

much of a, how much

benefit to the community there is

just on all levels.

Like, you know, again, like from a

reconciliation

standpoint, from an economic

standpoint, from a, like a health,

um, health of the community

standpoint, like culturally, like

all of that, like it's, it's, it

just, it's, it's hard to find a

negative.

And I think, I think that the

folks that I've seen like our, our

understanding of that.

And it's, it, I think it's, it's

so great.

Well, we've enjoyed this tradition

of, uh, having our

production team participate in

thought-provoking questions.

We're back from the break and

onwards

with our guest, Dr.

Jamaica Cass.

Jamaica, when we say decolonize

medicine, are we changing the

science

or are we changing the system

around it?

I, I certainly see that more as

changing the systems and

structures.

And so I think part of

decolonizing is, is inherent in

that team-based approach.

I know that, you know, I'm, I'm a

primary

care provider and that is sort of

the way things are shifting, but I

myself work for an

interprofessional

primary care team and the, the

ability to work with like an

interprofessional team collegially

and on

the same level is absolutely a

decolonized approach.

I am not the most important person

in the room

because I'm a physician.

Absolutely not.

And again, like that, that

grounding in humility, like I know

when I need support from my allied

health colleagues, et cetera.

I think, I think that's so

crucial.

That doesn't

change the science.

That doesn't change the medicine

and the, that, that sort of

Western MD lens that I,

that I, that I see through,

although I do that, um, with, with

a culturally safe lens, but, uh,

certainly

I see us doing our best to, to

change that system and that

structure so that we can, um, do

the best for

the patient, um, with the

resources that we have.

So when it's just you and the

patient alone in the room

and you're delivering a

life-changing diagnosis, how does

heritage and cultural identity

manner in that

moment?

It starts so much, um, so much

earlier than that moment is the

first thing I will say.

I'm really, uh, I'm really, uh,

fortunate in that the clinic that

I work for is an alternately

funded

model and I have time with my

patients.

And so I've spent years

establishing rapport with my

patients

and building that relationship.

Like when you talk to indigenous

peoples and you talk about, um,

how to

respectfully engage with

indigenous peoples, you're

constantly going to hear how

important relationships

are.

And, and that is just all the more

crucial in medicine when people

are coming in against this

system and structure that they

distrust and they, and they need

your advice, right?

And they, they need

support.

And so I have spent years

establishing like trusting

relationships with my patients,

like to

the best of my ability.

And I don't always get it right,

of course, but, but I've, it's,

you know,

it's something that I, I really

work on and I really, I really pay

attention to.

And it's really

important to me and in my practice

as a physician in modeling for my

learners and in teaching to my

learners, I really support them in

that.

So that when there comes a time,

when there is delivering a

life-changing diagnosis, they know

that I'm there for them.

And of course, frequently when

things like

this come about, I'm not

necessarily going to be the

provider that's providing the

primary service for

whatever it is, but they know that

I'm always there.

They know that I'm getting the

results.

They know

that I'll support them through the

side effects and, and that I'm,

I'm reachable and, and that I'm

there

for them to connect them to other

services they might need and, and

the community is there for them.

And I

think kind of that's where the

cultural grounding comes in.

A lot of that sounds holistically

like just good medicine.

But I heard you mention that at

sometimes you

don't get it right.

And maybe that might be more

reflective of a deeper layer of

distrust that even, for

example, uh, an indigenous

physician like yourself may not be

able to establish.

So are there different

layers of mistrust?

Are there, despite your

qualifications at numerous levels,

that trust is

still very difficult to

reestablish among very traumatized

indigenous people?

Absolutely.

Like there's a, there's a spectrum

and there's variants, right?

Like, you know,

just just like any other

population of people, there's not

going to be everybody acting or

doing

the same thing.

And I would say, sure.

Yeah, absolutely.

I have patients that'll kind of

come

in and say, yep.

Okay, doc.

Sure.

And then they walk out of my

office and don't fill the

prescription

and don't go and see the

specialist and don't go to the

test and all of those things.

And for a lot

of reasons, distrust may be one of

those reasons.

So yeah, certainly.

You alluded to before that you

were trained in research and you

go to the data, but to understand

mistrust more and elements of how

culture affects health outcomes,

as part of decolonizing medicine,

opening up new avenues to

scientific data gathering and

scientific interpreting.

And

is it, do we need to turn to other

scientific methods in a more

decolonized healthcare system to

really get the data that reflects

what's going on in community?

I think more and more we are

moving towards like indigenous

assessment methods and data

collection

methods to understand that the

nuances of, of indigenous

communities, certainly.

And so you might be

looking at, you know, whereas as

opposed to looking at data and

numbers, lab values, blood

pressures,

et cetera, you might be going into

community and doing some

community-based precipitory

research

where the community actually

drives the questions and tells you

what is important.

And then you take that

and you work with them to

establish evaluation methods that

make sense for that community.

And it might

be different for every single one.

I think another essential feature

of understanding and working with

indigenous community and the

research, um, in, in, in research

anywhere is, is, is making sure

that you

have, again, establishing those

trusting relationships and

understanding what data you're

collecting, why

you're collecting it, make sure

the community understands how

you're using it, where it's being

stored, who has access to it,

right?

We call those with First Nations

OCAP principles.

But then of course,

when you're dealing with Midsia

and Inuit communities, they have

their own like research ethics

that you

need to kind of be, that are, that

are nuanced and you need to be

aware of.

And I think that is where

you're going to get really rich

pieces of information that can,

um, that can inform not only care,

but,

but maybe what services or what

gaps, what services, et cetera,

are missing and needed.

And, and I think

more and more, we are seeing that

being accepted.

That is, that is, you know,

considered like,

still like now considered the kind

of more rigorous scientific

research, as opposed to maybe it

used

to be less accepted and for

example, harder to get funded.

But again, as we start to

understand,

um, indigenous populations as

costing a lot of healthcare

dollars, okay, what does it look

to work with communities to

support them in, you know,

understanding, understanding needs

so that,

so that these gaps can be closed?

I imagine so much understanding of

indigenous culture comes from

storytelling and narratives that

qualitative research will be an

important factor in gathering a

really good snapshot of when doing

needs assessments of a community.

Yeah, absolutely.

So, so storytelling is important

culturally for a lot of reasons

for indigenous folks.

So that was, you know, how oral

histories were traditionally

passed down, right?

So the learning

and education was, was kind of

done through storytelling.

And a lot of the teachings I

received,

of course, have been through

storytelling.

And so that is just a, such an

essential and a deeply rooted

method of communication that of

course it extends to research,

right?

And so what, in a colonial sense,

you might call a semi-structured

interview when it comes to, to an

indigenous population,

they might see it or receive it as

like that, that exchange of

information as being sort of a

storytelling methodology.

Yeah, absolutely.

So let's recap for our listeners

now.

If the science stays the same,

what actually has to change

to deliver modern medicine well in

indigenous communities?

Great question.

So I want to, I want to come back

to cultural safety for a second,

because that term gets thrown

around a lot.

And I think a lot of people don't

really

understand what it means.

And I want to just connect it with

something you said earlier,

which is like, that just sounds

like good care.

So cultural safety is an outcome.

It's not something

you do.

It's a patient defined outcome.

When you have a patient from a

population, such as an indigenous

person who feels that they've

received care that is free of

racism and discrimination,

nation and that they were treated

with dignity and respect as your

equal.

That's what cultural safety

is.

And so if you were to ask me, if

the science stays the same, then

what does it actually look like

to have a positive clinical

encounter with an indigenous

person?

That's what I would say.

And delivering care to an

indigenous Canadian could be

viewed as different from

delivering care to

someone from, let's say, Southeast

Asia or another immigrant

community.

Are there spots where people

get this confused?

I mean, I'm sure certainly there

are, but I also think there's a

lot of similarities.

And so that comes

to like taking your time, trying

to understand the patient in front

of you is like social and cultural

context, asking questions with

patience and, and, and humility

and, um, and openness and honesty

and

acknowledging your lack of

understanding and your willingness

to learn, um, you know, doing

things

like coming down to the patient

level and, and, you know, meeting

them at eye level and, um, that

establishment of rapport where

you're speaking to them in plain

language with an open and positive

demeanor.

And you allow enough time for the

clinical encounter for, for this

work to be done.

And when it

comes to the end of the encounter,

you engage in that shared

decision-making so that you, you

and your

patient both understand what the

plan is and they have the capacity

to, uh, to engage with the plan,

as opposed to the, here's what

you're going to do.

And then the patient just nods and

walks out and,

and you never see them again.

Absolutely.

And that, that, when, when things

are aligned and you have that

moment, uh, where a patient

feels culturally safe, uh, the,

the way the room warms up is

really quite, quite an experience.

And, um, I've experienced it

myself and I'm sure you have many

times, but it is a product of

taking

the time.

And unfortunately, much of the

healthcare system these days, time

is a dwindling currency.

And we see it from our neighbors

to the South and elsewhere where

managed care a lot's only a

certain amount of time for a

patient encounter.

And that certainly doesn't allow

for the most

culturally safe, uh, moments in

care, or if anything, they had to

be built up over several,

several visits because it's not

just a one quick one-off link that

forms.

You're absolutely right.

And so one of the hats I wear

outside of, of academia is

co-chairing

Ontario health's first quality

standards advisory council for

cultural safety and indigenous

health.

And one of the things I've really

advocated for at, at, in the

quality standard at the provincial

level is building in the

expectation that providers like

institutions give providers the

capacity to

have time to establish rapport, to

deliver culturally safe care,

because I think it's missing.

It's such

a gap and it's so harmful.

But just again, to the skeptics,

given how strained the healthcare

system

really is, should, should medicine

not aim to maybe just be

culturally agnostic and just try

and treat

everyone the same so at least a

bare minimum standard is achieved?

Or do you find that without

cultural

sensitivity, the bare minimum

standard cannot be uniformly

achieved?

I think the health disparities in

indigenous populations with the

status quo speak for

themselves.

Yeah, you're right.

And so I think if you put the time

in on the front end, you'll reap

the rewards on the back end.

So when indigenous communities now

who you're working with ask for

trust, you know, what, what do

systems, what do hospitals, what

do medical schools now struggle

with the most to building that?

And

what parts of the past do they

struggle with giving up?

I think societally, we all want a

quick fix.

And I think the biggest thing I

can say that the

sort of a feature that's probably

present in all of those different

areas is that, right?

We need

something quick.

We need something cheap.

We need something we can do now.

And it will take time to

rebuild that trust takes time.

You know, it starts with

understanding the harms and the

histories, right?

That the first step in

reconciliation is that truth

telling.

And so it starts with learning

about the

histories and the, the prior

mistakes that have been made in

the past and the acknowledgement

of those

failures and those, and those, you

know, all of the, all of the harms

that have been caused in the past.

And then

relationship building with the,

with the indigenous peoples and,

you know, in the, in the context

whichever institution you're

talking about.

And like all of these things, they

take time, they take

money.

And I think, yeah, exactly.

And you got to keep, and you have

to keep showing up, right?

Like you

need to be in the room.

Exactly.

There needs to be, there need to

be like indicators for success.

There

need to be accountability

measures.

Like if you don't do what you say

you're going to do, what are the

repercussions?

Like all of those things need to

be in place for this to, for this

to work and be

sustainable.

And it's, it's, it's tough and

it's, it's nuanced and it's very

like context and geography

specific.

And so it's also really

challenging where there isn't a

one size fits all fix for, for a

problem.

And so it's complex.

I mean, this, this is, as far as

I'm concerned, under the umbrella

caregiving for people now,

caregiving for people of the

future, but caregivers can burn

out,

can appreciate with these efforts

and the obstacles and the

challenges that burnout and trying

initiate change can be a reality

for champions like yourself as

well.

How, how do teams of champions

trying to change the landscape

cope with the obstacles and are

people burning out trying to get

there?

I have seen people certainly that

have, I have seen, you know, there

are so many phenomenal

indigenous physicians who have

come before me and done

trailblazing work.

And many of them have stepped

back from that work because of the

burnout and because of just

constantly being asked to be the

indigenous person in a lot of

places and spaces.

But I find that when we as like

advocates and leaders

step up and drive change that

aligns with our values, then we

become supported by the systems

that used to

cause us harm.

And then like, for us, maybe the

healing isn't stepping back, it's

stepping upstream to drive

that change.

And knowing that we are making

better places and spaces for the

generations that come after

us.

And so I started out just being a

primary care doctor in my home

community.

And the, all of the

academic and, and, and clinical

and research kind of work I do now

in teaching kind of came out of

the fact

that I was constantly having

patients come to me and describe

these culturally unsafe and racist

experiences within, you know, the

local healthcare system.

And that just did not sit well

with me as to

them, the face of the healthcare

system.

And so I started teaching cultural

safety and anti-racist

practices to, you know, local

family medicine residents and

emergency medicine residents.

I started building

culturally safe admissions

processes to remove barriers for

indigenous learners coming up so

they are more indigenous doctors

and indigenous representation.

You know, I started doing, doing

some more kind of policy and

clinic-based work, like things

like cultural safety standards

and,

and looking at, you know, at the

College of Family Physicians

level, like what, what does it

look like to

bring cultural safety and

indigenous health into residency

training programs on kind of a

more,

like a more formal uniform level

across the country?

Like what might that do for care

provided to

indigenous patients in future

generations?

And so I, like that work gives me

energy and, and optimism,

and it allows me to then go back

into community and, and, um, have

the, um, have the, the energy and

the,

the, the drive to really provide

culturally safe care to patients

in my home community.

your home community and your far,

further away community up at

Musini, um, benefit from all of

those

efforts.

Do you find that that is taking

community to the next level in

terms of its ability to re-engage

with trusting?

I hope that slowly over time, it

will.

Um, I am buoyed by, you know,

every time a patient tells me,

you know, I didn't tell the last

doctor this, but dot, dot, dot,

and they've shared with me some

problem or concern that they've

had that they, you know, at times

in the past, haven't,

haven't felt safe, you know, but

with me, they feel safe.

And, and so I would say kind of

slowly,

there's certainly trust is, trust

is coming back.

Considering those efforts that you

just described and collective

efforts, is there one thing that

healthcare still does right now

that just actively destroys

indigenous trust?

It's kind of a, like a bucket or

blanket term, but I still think

there's just so, so, so much

anti-indigenous racism in the

healthcare system.

And that's, for me, that's the,

probably the

most important answer, I think.

Great question.

I think that there are, as you've

actually already pointed out, many

transferable skills there.

Wouldn't we all benefit from a

healthcare provider who's just a

little more

empathetic, who is just a little

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