Physician burnout and attrition rates have hit unprecedented levels over the past three years. In 2017 the Canadian Medical Association (CMA) conducted the National Physician Health Survey (NPHS), which revealed that 30% of physicians were highly burned out. A follow-up survey conducted in 2021 found that rates of burnout had increased to 53%. For medical students going through rigorous education and training, coming of age during COVID-19 and health care shortages may leave many questioning their decision to go into the field altogether.
For Indigenous medical learners, the experiences of burnout and overwhelm take on a different tenor as students face distinct challenges of representation and cultural sensitivity in the classroom, in clinical settings and beyond. Hear from three Indigenous medical students as they share their perspectives on health and well-being during times of unprecedented upheaval and change.
The road to getting into medical school
The achievement of getting admitted to medical school is an intense rite of passage for aspiring physicians. Between Medical College Admission Test (MCAT) scores and multiple mini-interviews (MMIs), the intensity of applying to medical school is rarely comparable to the application process for other fields. But for Indigenous learners, there are layers of complexity even before gaining admission that their peers and educators may not be aware of.
“In high school, I didn’t think that being a doctor was even an option,” says Santanna Hernandez, a second-year medical student at the University of Calgary and the president of the Canadian Federation of Medical Students.
In a previous CMA article, Hernandez shared that, rather than being encouraged by her guidance counsellor to pursue post-secondary education, the only “wisdom” the counsellor imparted was to avoid getting pregnant before graduation.
“I can't remember a high school counsellor, or anyone, really, saying words of encouragement that I could become a doctor. So, I looked at taking some midwife courses or doula courses instead,” she explains. It wasn’t until her child’s pediatrician took note of her aptitude and encouraged her to apply to medical school that Hernandez realized she brought something exceptional to the table as a mature student, a mother and an Indigenous woman.
For second-year McMaster University medical student Josha Rafael, the path to medicine was also definitely not linear. Rafael began by enrolling in every Indigenous health course her university offered, traversing health sciences, anthropology and humanities. As she spent time in the university’s Indigenous Students Health Sciences Office, the director had a heart to heart with her and encouraged her to apply to medical school. Rafael credits that as the push that thrust her into an area she might not have otherwise considered. Today, she serves as the student representative for the Indigenous Physicians Association of Canada (IPAC).
She quickly learned that the medical school application process was different for Indigenous students.
In addition to meeting the university’s academic requirements, Rafael had to submit an autobiographical essay about who she is and what Indigeneity means to her and gather letters of recommendation from her community.
Jayelle Friesen-Enns, a third-year University of Manitoba student and co-chair west of the Indigenous Medical Students’ Association of Canada, describes a similar admissions experience. The requirements included writing a personal essay and participating in an extra panel interview, both of which are time consuming and emotionally taxing for applicants who already have a high burden of stress.
“While the admissions committee genuinely wants to get to know you and talk about the struggles you've been through, it’s never an easy thing to talk about, and it brings up a lot of trauma,” explains Friesen-Enns.
“It’s quite a different experience for Indigenous students. It is tough because you go through so much more work in the application process, yet there's this perception that Indigenous students may have an easier time getting into medical school. Or that we aren't as smart. These are some of the microaggressions Indigenous students have had to deal with throughout the years. But, no, the reality is that I actually had to meet all of the academic requirements expected of every student and then some.”
The pathway to survive and thrive in medical school
After navigating their way into medical school, these three Indigenous learners quickly realized the disproportionate burden that would rest on their shoulders in representing their communities. The costs and implications of often relocating to distant destinations, sometimes with families in tow and without community support systems, can present additional stresses that educators and peers may not realize.
Additionally, going through the medical school experience during the pandemic has been a source of extreme isolation.
“The first five months of my medical school experience were completely remote. All virtual learning,” says Rafael. “So, I wasn’t learning like I usually would. The people I would have typically been connected to were not there, and the everyday flow of life was totally interrupted. Everything felt very new and topsy-turvy.”
Living with other Indigenous medical students as roommates helped Rafael maintain a sense of belonging. “I think that's what honestly saved my sanity through online school,” she acknowledges. “Now, in clerkship, with everything in person, it feels different.”
Friesen-Enns feels lucky to have experienced some part of medical school pre-pandemic. “I got through about three-quarters of the first year in person,” they explain. “And at my university, we have a very nice Indigenous lounge for medical students, which helped me make connections before the school moved us to online learning.”
The pandemic’s isolation magnified some of the insecurities and other negative feelings many Indigenous students report experiencing in medical school. “I think most Indigenous students experience a dichotomy of, like, ‘I worked very hard to get here, but I don't always feel like I belong.’ And also feeling like other people think that I don’t belong here, too,” explains Friesen-Enns.
“For the first couple months of medical school, I struggled with the outside voices saying things like ‘You had it easier, you just got in because you're Indigenous,’” Rafael says. “It took me quite a while to work through that imposter syndrome and replace it with a stronger, more confident voice. Because this is exactly where I am meant to be — and I worked pretty damn hard to get here.”
The disparity in medical school experiences doesn’t just apply to in-classroom learning. As a mom to four young kids, Hernandez shares that she has to prioritize her family while other students can prioritize shadowing time and gathering recommendation letters. “Everybody works really hard, but working hard looks different for everybody. I don't know that I truly understood what that meant before medical school,” she explains. “And while I'm glad other students did not experience the barriers that I had in accessing health care, it just shows how much we need to make other pathways.”
Hernandez is in constant contact with medical learners across the country and cites family and socioeconomic needs as particularly prominent for Indigenous learners. “I haven't met many Indigenous learners who haven’t taken a leave of absence or had to repeat a year,” she explains. “It makes me question if our wellness is so poor — if that's why we as Indigenous students can't get through the same way as our peers.”
Equity, diversity, inclusion and belonging don’t come standard
The scarcity of Indigenous role models and mentors in the medical system is something that Hernandez, Rafael and Friesen-Enns hope to change. And although the established Indigenous physicians they look up to are extremely generous with their time and attention, the students are acutely aware that their role models are also overstretched in being the pillars of representation. It’s an expectation that trickles down to the students themselves.
Indigenous students are often looked to as providers of explanations and lived experiences in classes and practical settings. “It's a lot of pressure when you're the capital “I” — the only Indigenous person in the room,” explains Rafael. “Not only are you expected to be a source of infinite knowledge about Indigeneity, but you’re also carrying the weight of representing your community and supposedly all Indigenous people.”
Friesen-Enns has also felt the challenge of balancing the need to protect their health and well-being with the expectation to address questions or comments that are quite harmful, although they are not usually intended to be malicious. “It's not our job as medical students to teach the other medical students about racism and take the brunt of microaggressions. Privileged non-people of colour (POC), non-Indigenous people, have the chance to learn because we acknowledge that these are essential topics everyone needs to learn. But those sessions are usually traumatic for Indigenous students, and it's very frustrating to experience that repeatedly throughout medical school.”
Hernandez agrees that to achieve systemic change, the burden of educating medical students must shift away from minority students themselves, and the educational content needs to become standard across all medical schools. “The students who are signing up for this type of education aren't the ones who need it,” she says frankly. “It's the people who don't voluntarily sign up for these workshops who need to learn about things like social determinants of health and cultural sensitivity. Institutions and accrediting bodies need to make this a requirement in evaluations and accreditations.”
Rafael shares an example that left her speechless. After a long overnight shift in the emergency department, Rafael and several doctors were preparing to rotate out early the next morning. An emergency department nurse entered the staff lounge to discuss a new patient, describing the case — a 25-year-old with poorly controlled diabetes.
What should have been a routine clinical description included the unnecessary phrase, “They’re obviously Indigenous.” While the description of the poorly controlled diabetes through a derogatory racial characterization left Rafael speechless, a more senior doctor swiftly stepped in to clarify that being Indigenous was not a risk factor for diabetes.
“Except there were also six other doctors in the room, and nobody else said anything,” describes Rafael. For young doctors in that type of situation, it’s understandable that individuals like those profiled here feel an internal conflict about either trying to protect their health or constantly being the ones who speak up.
Protecting the health and well-being of Indigenous medical students
Shielding Indigenous medical learners from microaggressions and racism is an impossibility. But finding ways to protect their health and well-being is necessary wisdom shared by mentors and senior students. Otherwise, in the words of Hernandez, “it can be hard not to become resentful in some of these places that you have to work so hard to exist in.”
“I think I usually survive right on that edge of, like, not completely burnt out but tired and having a hard time,” laughs Friesen-Enns. “But to protect my energy, I have found that taking an evening off without judgment is very important. And I also do a lot of beading as a form of medicine.”
Creating space for activities beyond the world of medicine allows for decompression and fosters peace and joy. “Medicine is wonderful, but it’s not the only aspect of life that you need to be fulfilled in,” acknowledges Friesen-Enns.
Despite having hectic and demanding schedules, trying to ground themselves through culture and community can help Indigenous medical students to maintain their health and well-being.
“We have this concept of the medicine wheel where there’s the physical, emotional, mental and spiritual,” explains Rafael of the Indigenous medicine wheel. “To be well, you have to give attention to all four of the directions in the wheel.” For her, part of that presence came in taking Cree language lessons to stay connected to her community even while living far away.
And while Indigenous medical students will continue to face questions or comments in their education and training that will trigger deep emotions and trauma, there is a sense of community and support among students and the physicians who have come before them. Some may opt to be informal one-person equity, diversity and inclusion (EDI) departments, while others may enforce stricter boundaries around their Indigenous identities. The heavy responsibility of working through medical school as an Indigenous learner carries additional factors that the broader medical community has to learn from and better adapt to, particularly in the current health care staffing crisis.
Listen to Josha Rafael and Jayelle Friesen-Enns speak about the blessings and burdens of being an Indigenous role model, and where they find support.
If you are part of the Indigenous community and are experiencing pain or distress because of a residential school experience, the Indian Residential School Survivors Society offers a 24-hour crisis line supporting individuals and families. Please call 1-800-721-0066.
If you are a physician or medical learner who is struggling, contact your local physician health program.
Are you in distress? Get help now.