Reforming Indigenous health in medical education: Medical school accreditation as a targeted policy initiative

Aim The accreditation of medical schools is a key leadership role for the Australian Medical Council (AMC) and its counterparts in other jurisdictions. The aim of our research was to identify how the inclusion of Indigenous health in the accreditation standards has influenced the reporting of activity related to Indigenous health in medical schools. Method A bi-national review was conducted of the AMC reporting of Indigenous health education initiatives against the accreditation standards from January 2007 to December 2014. Also reviewed was the AMC monitoring of medical schools that occurs via schools’ Comprehensive Reports and Progress Reports. Results The study showed that the inclusion of Indigenous-specific standards leads to specific reporting on aspects related to Indigenous peoples in accreditation assessments and monitoring of medical school programs. Where areas in the accreditation standards did not include Indigenous-specific requirements, AMC reporting was unlikely to mention Indigenous matters. Conclusions The continuing commitment by the AMC – and comparable bodies in other jurisdictions – to assessing medical education programs against specific Indigenous health standards, represents significant leadership in educating a Ewen S, Mazel O, Barrett J, Oldfield K, Walters T MedEdPublish https://doi.org/10.15694/mep.2016.000083 Page | 2 medical workforce committed to ongoing improvement of Indigenous peoples’ health.


Introduction
Targeted policies that address issues of health service delivery have recently been highlighted as an important element for improving health outcomes for Indigenous peoples . For over a decade, the Australian Medical Council (AMC) has addressed this principle through systematic embedding of Indigenous health into the accreditation standards for all medical schools in Australia and New Zealand (Australian Medical Council, 2007).
Reflecting the global situation, Aboriginal and Torres Strait Islander and Māori peoples bear a greater burden of disease and have lower life-expectancy than their non-Indigenous counterparts ; Australian Bureau of Statistics and Australian Institute of Health and Welfare, 2012;New Zealand Ministry of Health, 2008). This situation results from a range of social, historical and economic factors, and can also be attributed to the inappropriate and/or poor quality care provided to Indigenous patients and a lack of accessible healthcare services (Anderson, 2008). The medical schools responsible for the early education of our doctors, therefore, have a critical role in developing a workforce that is cognisant of, and responsive to the needs of Indigenous people (Hays, 2002;Jones et al., 2010;Mazel & Anderson, 2011;Sullivan & Mittman, 2010).
Historically, Indigenous health has been inconsistently taught and poorly embedded in medical curricula (Garvey & Brown, 1999;Phillips, 2004;Medical Deans Australia and New Zealand, Australian Indigenous Doctors' Association, 2012). Since the development of the Committee of Deans of Australian Medical Schools' (CDAMS) Indigenous Health Curriculum Framework (Phillips, 2004a), a number of initiatives have worked to improve both the teaching and learning of Indigenous health in medical education and the recruitment and graduation of Aboriginal, Torres Strait Islander and Māori students (Haynes et al., 2013;Ewen et al., 2012;Mazel & Ewen, 2015). The AMC has embedded content stemming from the Indigenous Health Curriculum Framework in the medical school Standards for Accreditation in order to systematically influence the quality of Indigenous health education, and quantity of Indigenous medical graduates (Australian Medical Council, 2007;Mackean et al., 2007).
Globally, the AMC standards remain the only set of medical school accreditation standards that specifically address Indigenous peoples in colonial settings; others broadly address culturally diverse, minoritized or under-served populations (Liaison Committee on Medical Education, 2015; Committee on Accreditation of Canadian Medical Schools, 2015). The standards used from 2007 recognised that: Australia has special responsibilities to Aboriginal and Torres Strait Islander people, and New Zealand to Māori, and these responsibilities should be reflected throughout the medical education process ... Doctors must be aware of the impact of their own culture and cultural values on the delivery of services, historically and at present, and have knowledge of, respect for and sensitivity towards the cultural needs of Indigenous people. (Australian Medical Council, 2007)

Aims
The aim of our research project was to identify how the inclusion of Indigenous health in the accreditation standards Ewen S, Mazel O, Barrett J, Oldfield K, Walters T MedEdPublish https://doi.org/10.15694/mep.2016.000083 Page | 3 has influenced the reporting of activity related to Indigenous health in medical schools. We were interested to better understand the role of accreditation as one of the key targeted policy initiatives required to improve Indigenous health.

Methods
A bi-national review was conducted of the AMC reporting of Indigenous health education initiatives against the accreditation standards from January 2007 to December 2014. Also reviewed was the AMC monitoring of medical schools that occurs via schools' Comprehensive Reports and Progress Reports. This monitoring mechanism was established after the Health Practitioner Regulation National Law Act (2009) required the AMC to systematically set conditions for medical schools when accreditation standards aren't met. The obligation to act on conditions within a set timeframe in order to maintain accreditation status represents an important step in increasing medical schools' accountability against specific accreditation standards.
The results of our review provide important insights into both the reporting against accreditation standards relating to Indigenous health and the consequent monitoring. These Indigenous-specific standards are located in the areas of Educational Expertise (1.4), Interaction with the health sector (1.6), Staff resources (1.8), Mission (2.1), Curriculum structure, composition and duration (3.2 or 3.5), Student intake (7.1), Admission policy and selection (7.2), and Clinical teaching resources (8.3). As an example, standard 3.5 and 7.2.3 of 2012 state:

The medical education provider has specific admission, recruitment and retention policies for Aboriginal and Torres Strait Islander peoples and/or Maori.
A complete table showing the location of Indigenous health in the standards and accompanying notes is available electronically: see Appendix 1.  Table 1 shows that there were 282 Indigenous-specific comments from 39 accreditation reports across 19 schools. Table 1 demonstrates that the inclusion of Indigenous-specific standards influences the reporting of Indigenous health activity in medical schools (see comments in standards 1,2,3,7 and 8). It is clear in Table 1 that there is little reporting on matters related to Indigenous health where there is no Indigenous-specific standard (standards 4, 5, and 6). Table 1 also points to an increase over time in the frequency of reporting on Indigenous health across six of eight standards, reflecting the effects of changes required under the Health Practitioner Regulation National Law Act (2009) explained above. We reviewed the AMC's 64 monitoring reports and found 45 comments related to Indigenous health between July 2010 and December 2014. Once again, most of these comments were located in standards 1, 3, 7 and 8 with few comments against standards 4, 5 and 6.

Discussion and Conclusion
We undertook this study of the AMC reporting of Indigenous health activity in medical schools with an interest in the role of accreditation as a targeted policy initiative to improve the learning and teaching of Indigenous health in medical education. In reviewing accreditation reports on 19 medical schools in Australia and New Zealand over a period of eight years, our study found that where the accreditation body includes specific standards related to Indigenous health, there is an increased number of references to specific actions taken regarding Indigenous health in the medical program. Conversely, in standards where there are no specific requirements to report on Indigenous health, there were very few references to Indigenous health. In the AMC accreditation standards there is reference to Indigenous health in matters of governance, curriculum content and student intake, but little reference to Indigenous Ewen S, Mazel O, Barrett J, Oldfield K, Walters T MedEdPublish https://doi.org/10.15694/mep.2016.000083 health in standards related to teaching and learning, student assessment and program evaluation. That pattern is also evident in the Comprehensive and Progress reports that are provided between official accreditation assessments. This pattern highlights the benefit of the inclusion of Indigenous-specific standards, and the need for further development of standards relating to those elements of medical school programs that relate to daily pedagogical practices in medical schools and health services -teaching, learning and student assessment.
The study shows that the inclusion of specific accreditation standards relating to Indigenous health in medical school programs is a significant milestone and can be seen as a driver of reform. Indigenous health is now embedded in the conversations about the performance of medical schools. This good news reflects the effort of both the AMC and the schools over a relatively brief period to address health equity in Australia and New Zealand. By acknowledging the unique position of Aboriginal and Torres Strait Islanders in Australia and Māori in New Zealand, these specific requirements show commitment to Indigenous health as distinct from the broad notions of 'underrepresented', 'culturally diverse' or 'minority' groups. It also demonstrates the development and maturation of the domain of Indigenous health in medical education. It particularly reflects the development of an Indigenous-led academic workforce that successfully negotiates curriculum and policy change in mostly conservative academic environments.
The AMC accreditation standards act as high level and targeted policy that supports the implementation of globally relevant and place-based activity to develop the next generation of the health and medical workforces. Indigenousspecific accreditation reform provides an exemplar to international accreditation bodies. Further reform may be achieved through increasing the number of Indigenous health experts on accreditation teams, systematic training on Indigenous health particularly for non-Indigenous team members and inserting Indigenous-specific standards for learning, teaching and assessment.

Take Home Messages
Where an accreditation body includes specific standards related to Indigenous health, there is an increased number of references to specific actions taken regarding Indigenous health in medical programs. There is a need for further development of standards in Australia and New Zealand relating to those elements of medical school programs that relate to daily pedagogical practices in medical schools and health servicesteaching, learning and student assessment.