Podcast

Being Indigenous in med school

June 29, 2022 CMA

Medical school is tough enough. For Indigenous students, it can also be fraught with racism, and the pressure to share their cultural ‘expertise’ with teachers and classmates.

“A lot of the time, the stereotypes they’ve grown up with, their internal bias, the racism they don’t realize is there, comes to the surface, and it can be very traumatic as an Indigenous student to hear that, to sit through that, to sometimes have the questions directed at you.” - Jayelle Friesen-Enns

On this episode of Sound Mind, Dr. Caroline Gérin-Lajoie speaks to Josha Rafael from McMaster University and Jayelle Friesen-Enns from the University of Manitoba, about the blessings and burdens of being an Indigenous role model, and where they find support.

This episode is available in English only.

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The opinions stated in Sound Mind are made in a personal capacity and do not reflect those of the Canadian Medical Association and its subsidiaries.

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Equity and diversity in medicine Stress Peer support

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Being Indigenous in med school

Dr. Caroline Gérin-Lajoie: Welcome to Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gérin-Lajoie. I'm recording this podcast from my home in Ottawa, Ontario, the traditional unseeded territory of the Algonquin Anishinaabe people. I also wanted to highlight that June is National Indigenous History Month. In 2019, Canada's 17 medical schools unanimously endorsed a joint action plan on Indigenous health in response to the truth and reconciliation commission's calls to action. They committed to increasing the number of Indigenous faculty, tackling racism in medical education, and developing an Indigenous health curriculum among others. And they agreed to work towards admitting a specific minimum number of Indigenous students each year.

While the recommendations are a necessary step in changing the culture of medicine, their implementation places a huge amount of pressure on Indigenous medical students. Josha Rafael is a second year medical student at McMaster University in Hamilton, Ontario. She is a mentor in the university's Indigenous students' health sciences office, and student director on the Indigenous Physicians Association of Canada or IPAC. Jayelle Friesen-Enns is a third year medical student at the university of Manitoba. And is co-founder of the Indigenous Medical Students Association of Canada. Thank you both for joining us today.

Josha Rafael: Thank you so much for having us.

Dr. Caroline Gérin-Lajoie: Jayelle the joint action plan on Indigenous health is still fairly new. Are you seeing progress at your school?

Jayelle Friesen-Enns: I think I've definitely seen some progress. My perspective is only over the last approximately three years. So there's only so much progress you could see during that time. But even during that time, I've seen more and more Indigenous students being welcomed into the school, being admitted to the medical program. There is an increasing number of acknowledgements of Indigenous culture and history through our medical learning, which has been really good. A lot of the changes have been led by students and often Indigenous students, which is wonderful to see, although it's not necessarily a burden that they should have to bear, but I've definitely been seeing some positive changes throughout my short time in medical school.

Dr. Caroline Gérin-Lajoie: Many faculties are now offering courses that examine the legacy of colonialism, the Indian act, the residential school system, and how these continue to impact Indigenous health and wellness. Jayelle, what's it like to sit through a course like that as one of the few Indigenous students in your class?

Jayelle Friesen-Enns: It can be extremely difficult as an Indigenous student to sit in this room that is supposed to be a safe space for settlers non-Indigenous students, to ask all the questions, ask about things they don't understand. And a lot of the time their stereotypes that they've grown up with, their internal bias, the racism they don't realize is there comes to the surface and it could be very traumatic as an Indigenous student to hear that, to sit through that, to sometimes have the questions directed completely at you. And a lot of the time it becomes our burden to teach these non-Indigenous students about what it's like and to share our traumas, or to be tough when they've set a microaggression out of complete ignorance and you know they want to learn and you want to help them learn, but it can still be very difficult to sit through that. And it's a really hard balance between knowing that you want them to have this opportunity to learn, but also recognizing that a safe space for them isn't necessarily a safe space for Indigenous students at the same time.

Dr. Caroline Gérin-Lajoie: And Josha, have you had a similar experience in those courses?

Josha Rafael: Yeah, I think I echo everything that Jayelle said. And I think the thing is you're so often called upon to be a teacher to your non-Indigenous classmates. For myself, I think I'm of two minds because these are my future colleagues that are going to be obviously working with Indigenous patients in their lives and I want them to feel equipped and have this knowledge, but at the same time, it's so difficult to have to teach and tell stories that hit so close to home. It's so vulnerable to be sharing these kinds of things about Indigenous people broadly while also knowing that you're sharing stories about your family and your lived experiences.

So there was a period of time in McMaster's curriculum where there was quite a few sessions, actually, maybe four or five sessions on Indigenous health to varying capacities. And I would leave those sessions feeling so, so drained. Even if I wasn't called upon to be the solo teacher, which I often was, still just having to re-experience this history, think about it in the context of my own family, have it hit so close to home and walking away from that yeah, it was quite difficult.

Dr. Caroline Gérin-Lajoie: Jayelle, are there other ways that being Indigenous in medical school can be even more challenging than for non-Indigenous med students?

Jayelle Friesen-Enns: Yeah, I definitely do think that it can be more challenging. So there are a couple of ways and just the first two that come to mind are one, that you often come from a more disadvantaged position and you don't necessarily feel like you belong. There's a lot of stereotypes about how it's easier for Indigenous students to get into medical school in the first place and that we're not as smart, we're accomplished and that we're just there so the school can tick off a mark on their list. We did it, we got more Indigenous students. And so it's really difficult to not internalize that as you're going through this extremely difficult program. And they talk a lot about imposter syndrome in general, and I think Indigenous students often suffer even more from that because we have that added burden and that added stereotype of not being as smart or as accomplished as our peers.

And then I think on top of that, if you do come across a struggle during medical school, because unfortunately, life still goes on, hard things happen, you might fail a test or someone in your family might pass away, you go through some sort of hardship that makes school more difficult. And it's very difficult to not spiral when those things happen, because it feels like when you're failing, that's exactly what everyone thought you would do and maybe you don't belong here after all. And so it can be very difficult to pull yourself out of that and to remind yourself that you do belong in medical school and that you earned your spot there just the way everyone else did.

And on the flip side of that, you are a representative to your entire Indigenous community, you are a beacon of hope in this medical system that has so much mistrust in it. And it's so wonderful, but also it's a lot of pressure to feel like you're representing an entire community throughout your entire schooling and very difficult schooling might I add. And so it's just a lot of pressure and it can be very difficult.

Dr. Caroline Gérin-Lajoie: And what about for you, Josha? What's been your experience like?

Josha Rafael: Yeah, no, I agree with what Jayelle said. And I think to add to that, to be the flip side of that being the representation of not only your entire community, but for non-Indigenous peoples, you are like the capital Indigenous person in the room oftentimes. And so the weight of feeling like you represent all of Indigenous peoples can be a lot as well. Particularly in these spaces where there's really not that many of us. So you very well could be the only Indigenous person in that 200 person lecture hall feeling like being the face of what Indigenous people are in Canada, it can be a lot of pressure as well. And then, yeah, I think that imposter syndrome that Jayelle was talking about is really real.

And coming into medical school, I definitely felt that, and it took quite a few months I think for me to replace this voice in my head that was saying, you don't belong here. Why are you here? You're not good enough. All of these kind of nagging back of your head voices to replace that with a stronger voice that was like, actually, no, you definitely belong here. You worked hard to get here. You deserve to be here. That was an internal process for me.

Dr. Caroline Gérin-Lajoie: And you both have talked about feeling exhausted at times, you've talked about the emotions or the feelings of not fitting in or having some of that imposter syndrome. But I am curious about the cognitive impact because on a previous podcast on racism, one of the things I learned from our guest was that the constant scanning that they were doing in the room, just trying to figure out how they fit in or not, or feeling like they had to outperform everyone else because they really had to prove themselves to others. Have you guys noticed whether there's also a cognitive load because of these issues?

Josha Rafael: Yeah. I think that's unfortunately, one thing that you can do when you internalize these stereotypes about not being good enough for only getting in to be the minority check mark, et cetera, et cetera. When you internalize that, I think you can feel that you not only have to be good enough, but you have to be amazing. You have to be better just in order to feel adequate. You have to be the best. Yeah. I have definitely felt that. I don't think that's sustainable, at least for me to constantly have to be going at 125%. Yeah. Jayelle, what do you think?

Jayelle Friesen-Enns: Yeah, I 100% agree. There are just so many times when I step into a room and I look around and I'm just like, oh, there's no one else who looks like me here and I don't know when the last time an Indigenous person has been welcomed into this space or had a chance to speak here or been represented in this way. And yeah, it feels like you need to be at 125% all of the time, because if you mess up then that reflects back on everyone. And it goes back to that being a representative for your entire community thing again, where it's just a lot of pressure, but also it's a really important opportunity, and I'm often scared of messing that up for my people.

Dr. Caroline Gérin-Lajoie: You are both positive role models for your communities and you have a huge opportunity to help Indigenous people access better healthcare. Is that a blessing or is that a burden? Maybe we'll start with you Jayelle.

Jayelle Friesen-Enns: I think that it's both, honestly. I think that I feel very privileged to be able to make changes that seem like they're going to be lasting and to be a representative. I think the burden portion of it comes in when I realize that if I'm not the one doing these things, no one else will be. And not knowing when some changes will be made, not necessarily knowing other people in the community nearby who can take on projects or take on those burdens because medical school is exhausting. It's a lot of work and it's hard to try to make these changes on top of your studies and your life.

And so then I feel like while I'm so blessed and so happy with all the connections I've made and the groups I'm a part of and the advocacy that I've done, I feel burnt out a lot of the time and I get really worried that I'll get to a place where I can't do it anymore and I don't know if there's someone else who can or will take on these projects and take on these changes. And so, yeah, that's just a little scary to me sometimes.

Dr. Caroline Gérin-Lajoie: Josha, is it a blessing or a burden?

Josha Rafael: I also agree. I think it's both. I feel like I do have hope nowadays that Indigenous health is becoming an area that more people are gaining interest in. There are more Indigenous medical students that are going through medical school and Indigenous and non-Indigenous medical students taking interest in these issues. So I do have hope that there will be more and more people to shoulder the work that needs to be done. I think what's sad is sometimes I look up to my older Indigenous colleagues, doctors, and all those that occupy very important high Indigenous health positions in this country. And a lot of them are just so burned out because they are shouldering all of that work that needs to be done. So I have hope that there will be more and more generations of medical students that will take part in the work that needs to be done.

Dr. Caroline Gérin-Lajoie: Let me continue with you a little bit, Josha. You started your clerkship in a hospital setting this year, and what's been your experience as an Indigenous student in that environment?

Josha Rafael: Yeah, a bit of a mixed bag I would say, a bit of a mixed bag. There's a big push at the medical school level to start talking about topics like Indigenous health marginalization, social determinants of health, all those things are big topics that we're just beginning to uncover. And at least there's externally on the surface an effort being made to promote these things. I will say in a clinical environment, I have not experienced the translation of that just yet. And I think that oftentimes because I'm the only Indigenous person in the room when I hear racist, derogatory prejudice things said in front of me, by nurses, by doctors, by other healthcare workers, it can be very distressing. I kind of have two stories and they both have different endings.

I was in clinic with a doctor one day and it was at the end of the day and we were doing teaching and we were talking about diabetes and he was doing a big overview of diabetes and diabetes management and he said something to the effect of, oh yeah, and there're certain populations that have much higher diabetes burden than others and he started listing a bunch and Indigenous groups were one of the groups that he listed. And he went on to talk about the very, very highly genetic component of the disease of diabetes. And I said to him, at least for Indigenous people's, sure genetics might be one thing, but I think colonialism is a much, much bigger factor here when we see the high diabetes prevalence and you can't really talk about diabetes in Indigenous populations without that context. And he said, well, what does it matter? What does it matter if it's genetics or colonialism? The treatment is the same.

And I said, well, the reason it matters is because it matters in how I relate to my patient. It matters in how I talk to my patient about their disease. And he got a little bit quiet and he laughed and made a joke about how he thinks of himself as somewhat "woke", and the conversation moved on, but it left me with such a sour taste in my mouth and this is just for anyone, we're not treating diseases, we're treating people in the context of their lives. And so to think that you can separate something that's such a vital etiology of this disease from the patient in front of you was disheartening to see in medicine. The other story I have was a little bit happier and that it was the end of an emergency medicine shift.

I was in the emergency department, it was actually the end of a night shift so I was exhausted. There was about maybe three or four doctors huddled in this back room, a couple of residents and a nurse. And the nurse came in to tell us about a patient that she had just seen. And she was describing this patient to the doctor on call and basically said, oh, I have this patient 25 years old, again, really poorly controlled diabetes. He's really not doing well. And he's so obviously Indigenous. And she said this and the room went quiet for a few moments. And I looked around, nobody was saying anything. I was just exhausted. It felt like I was watching this on a TV screen. It was like I wasn't even there and I checked out and I maybe went into fight or flight a little bit, because I could hear my heart in my ears after she'd said this.

But luckily a very senior doctor in the room had overheard this and after those few moments paused, he turned to her and he said actually being Indigenous is not a risk factor for diabetes, we don't even consider that in any part of this at all. And it's like the room let out a sigh of relief a little bit. And I just thought how incredible all of these doctors, these residents, these nurses, myself are witnessing this senior doctor say something so simple, yet so powerful. Everyone came away from that experience understanding how that experience should go in an ideal world. Like something is said that is really quite racist and derogatory and it's corrected so clearly and concisely in that moment and from a person in leadership. And so I really learned a lot that day as a medical student of how powerful it can be when our leaders are knowledgeable about these things and willing to say something.

Dr. Caroline Gérin-Lajoie: So great role modeling and perhaps a form of allyship.

Josha Rafael: Absolutely.

Dr. Caroline Gérin-Lajoie: And Jayelle, for you, what's it been like working with patients, specifically Indigenous patients?

Jayelle Friesen-Enns: Yeah, I think because I've had similar experiences to Josha that she's already talked about, I'll talk about something a little bit different. So a couple of scenarios come to mind. One big one is those patients who are always trying to explain themselves or talk to me about something and then pause and say, well, you're Indigenous, right? You understand, or you know this about my culture, but our culture. So it's really great that you're here and you can explain this to the doctor who's not understanding me right now. And it's really beautiful to see that they trust me and they know that I can understand them. And just that I don't know, having a face like them and showing how important it is to see someone who looks like you in the medical setting has been really wonderful, but it can also be really sad.

I had this one patient who was requesting help, we were in the ER and patching up a wound and he looks over at me and we had that talk about, oh yep, I'm Indigenous and you are too and whatnot. And then he says, okay, I want you to tell me, honestly, do you think this white man will help me? Do you think he will actually get me the help I've been asking for? And it was really hard to sit there in that moment and realize this person who'd been here how many times asking for help, trying to get help and was never able to trust that he would get that help and had to ask me and I'm just a medical student, if I thought something would happen. And unfortunately, I had to say I don't know. I think this doctor is being sincere. I think they're trying to do their best.

But also with this system, frankly, I don't know if you will actually still be able to get this help that you want so badly. And it was a beautiful moment, but it was a sad moment because I felt like we really connected at that time. He put his trust in me to ask the question that it seemed like he'd been wanting to ask for a while and a really difficult moment in his life and it was wonderful to be able to share that as an Indigenous person. But just really reflective of how a lot of Indigenous people feel in this healthcare system. And they feel a lot of the time they want help, but they don't believe that they're going to get it here. It can also be very difficult though because every once in a while you'll hear something that someone says on the medical team, whether it's racist or just a microaggression or just feels bad.

And sometimes I wonder if I'm overreacting or if I'm misinterpreting something or I'm just like, why did this person feel the need to specify that their patient was Indigenous when we were talking about this problem, right? A lot of the time they don't mention race for other patients, but they'll feel the need to do it for Indigenous patients. And it just feels uncomfortable. And when those moments happen, I feel the same thing and my heart starts pounding and I can feel it in my chest, in my head and I don't know if I should say something or do something. And I immediately wonder, is this patient getting the best care they can? Are they being seen by someone who is biased? And does this person even realize that they are being biased when they are repeatedly and constantly acknowledging race and ethnicity when they don't have to?

And it shouldn't affect the patient's care. And I find a lot of the time when I can, I will take Indigenous patients onto my patient list in order to I guess I feel like I'm the one who won't be biased. I won't treat them differently. And I won't let those stereotypes affect the way they are cared for, and it's really hard to take on that extra burden and feel like you can't trust those around you to give an Indigenous patient the best care they can. And sometimes it's not even about whether or not the other members of your team are good or not because often times they're wonderful. We have really great medical teams here, but it always feels, oh, maybe I, as an Indigenous person can give this Indigenous patient something that they need, that they can't get from someone who's not Indigenous. And it's a large burden to take on top of everything else as well to feel like you are the one who should be taking care of these Indigenous patients.

Dr. Caroline Gérin-Lajoie: So one of the messages that I'm hearing from both of you so far is that a lot of the reactions and the different emotions that you're going through is not just from your personal experience as an Indigenous medical student, but it's also being a witness to what patients may be experiencing as Indigenous patients within the medical system. And so these are two very different angles, but that really do have an impact on you, yeah, that's a lot. Both of you are directly involved in supporting Indigenous students. Can you talk a bit about how important it is to have that peer-to-peer support?

Josha Rafael: So, so, so incredibly important. I think it's been the backbone of my entire medical student experience. I somehow ended up in an apartment for the first year and a half of medical school of Indigenous medical students. And there's only five of us that I know of. And somehow I was living with two others, which was incredible, I had instant community. And of course, we were the Zoom medical class, so a lot of very restricted social time with a lot of our peers. So having that community and then that added extra layer of connection was just so foundational to my experience as a student going through what I've discovered is very difficult training overall. So yeah, that was huge for me, I think. And then also just huge in the sense of when racist things have happened and microaggressions have happened as they have many a time throughout my experience here, I had somebody that I literally lived with to turn to that I could open my door and walk down the hall and say, oh my God, do you know what happened to me today?

And there was not only sympathy, it was like a validating response from their personal experience as well, having knowing what that feels like. So that has been really huge for me. And I am very involved in the Indigenous process every year through McMaster. So for the last couple of years I've been part of the leading the workshop that helps all the Indigenous applicants prepare for the interview and prepare their applications. And so I get to meet all of the potential Indigenous incoming students through that process. And so when they do eventually get into medical school because they do, I already know them and there's that connection there and that continued community as well. So that's been really important part of my experience.

Dr. Caroline Gérin-Lajoie: What about for you Jayelle?

Jayelle Friesen-Enns: Yeah, it's been super important for me. I think that right when I started medical school and I was suddenly confronted with what it meant to be Indigenous and in medical school at the same time, it was incredibly important for me to have those Indigenous peers to turn to and talk to about all of the things that were happening. I'm lucky enough to have a large number of Indigenous medical students in my class. I think we have 14 or so, which is wonderful. And like I mentioned earlier, we have these Indigenous health courses that we would take. And a lot of the time, most of the time, something racist or microaggression would be said and something that we would always do afterwards is we would all go to the [inaudible 00:26:06] lounge, which is an Indigenous student support network we have at our school. And we would go there in an debrief and we'd talk about our frustrations and our feelings and the things that had come up.

And it was just really wonderful to be able to support each other on that and to release those emotions after those events. And yeah, I feel like I've made really lasting friendships from that. Something else that has been super wonderful is this Indigenous medical students' association nationally. So I went to a conference this spring with the Canadian Federation of medical students, and I went there and I got to meet my co-founder in person for the first time and it was so cool. And then we got to meet an Indigenous medical student from this school and that school and then we were getting breakfast and hanging out and everyone was a part of [inaudible 00:27:01] and it was so cool just to have this community and to also hear that everyone's experiences are so similar across the country and to hear how excited people are and about how we want to change the medical system for the future and to help support each other and help other medical students.

It's just a really wonderful community to be a part of and it's been so important to have that always there for you in the background of what is a really difficult process of going through medical school.

Dr. Caroline Gérin-Lajoie: What advice would you give a young Indigenous person thinking about applying to med school, but who may be concerned about some of the issues that you've talked about today, Jayelle?

Jayelle Friesen-Enns: Yeah. So I actually have had this conversation before with a young Indigenous girl that I mentored who was interested in medicine. I actually think she might be applying this year, we will see. But anyways, we talked a lot about these issues and about how difficult it can be and the extra burden that is placed upon us as Indigenous people who are entering the medical field. And the advice that I would give would be to not let all of those external voices and stereotypes and assumptions get to you. And I know that's something that's very easy to think and believe, but harder to actually feel, but the really important thing is to know that you deserve to be there, you earned your way.

You not only worked just as hard as everyone else, but you have worked harder. You've been through a lot, and you being in the medical field is something that is not only wonderful just for you, but for our entire group of people. And to try to not take that as a burden, but as a wonderful opportunity. And to try to remember that we can create a space of belonging together and a community and that we belong in medicine. This is our land and this is a healthcare system that needs us. And so just to try to take all of those wonderful things and not let the bad things get to you, if you can avoid it at all.

Dr. Caroline Gérin-Lajoie: Josha, what would be your words of wisdom?

Josha Rafael: Yeah. So my first inclination is to say do it. If this is your passion and this is where you feel like your heart is, and this is where you feel like the work that you want to do in your life is then that's something that you need to listen to. And at the same time, though, of course, it's difficult to say that knowing some of the experiences I've had to go through, then thinking that another Indigenous student might have to go through the same as well is difficult to think about. I will say though, that as an Indigenous person, walking through society, you're going to encounter racism in every single field. Unfortunately, it's not just medicine's problem, it's a systemic thing, which is why we talk about systemic racism. So yeah, I think that if this is your passion, then do it. And I think I can speak at least for a McMaster when I say that our community of Indigenous students and Indigenous people at the university are strong enough to support each other if you need an extra hand and we're always there.

Dr. Caroline Gérin-Lajoie: So thank you both for sharing your experience, it really was a privilege and a pleasure. Josha Rafael is a second year medical student at McMaster University in Hamilton, Ontario and Jayelle Friesen-Enns is a third year medical student at the university of Manitoba.

Sound Mind is produced by PodCraft Productions. If you're looking for resources, tools, and research on the topics covered today, please visit the CMA physician wellness hub at cma.ca. We'd love to hear what you think of Sound Mind. Please consider giving us a rating or review through your favorite listening platform. And please share this program, it's really the best way to get the word out. I'm Dr. Dr. Caroline Gérin-Lajoie, thank you for listening.

Being Indigenous in med school

Topics

Physicians’ needs in coping with emotional stressors: The case for peer support

Breaking the stigma: A physician’s perspective on self-care and recovery

Facilitating peer support

“Buddy Up” for Peer Support

Know what to do when a peer is experiencing significant stress

Mindfulness in medicine

Are you in distress? Get help now.

Being Indigenous in med school

Topics

Related resources

Physicians’ needs in coping with emotional stressors: The case for peer support

Breaking the stigma: A physician’s perspective on self-care and recovery

Facilitating peer support

“Buddy Up” for Peer Support

Know what to do when a peer is experiencing significant stress

Mindfulness in medicine

Are you in distress? Get help now.

Being Indigenous in med school