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Running Head: INDIGENOUS MEDICAL EDUCATION

Indigenous Knowledges in Undergraduate Medical Education

Erin Menzies
University of British Columbia

ETEC521 Section 66A


Dr. Michael Marker
August 9, 2015

Prologue
I acknowledge that as an outsider (non-Indigenous Canadian) I cannot speak for Indigenous
groups. As a student and faculty member at the University of British Columbia, I acknowledge

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that my learning is facilitated through the Point Grey Campus, which is located on the traditional
and ancestral territory of the xmkyym (Musqueam) people.

Throughout this document, and for the purposes of consistency, the terms Indigenous and/or
Aboriginal are used interchangeably to refer to a diverse group of Canadians including, but not
limited to: members of the First Nations, Mtis, and Inuit groups. I acknowledge the limitations
of using a single term and/or terms to refer to multiple groups, each with distinct culture.

Introduction
Canadian undergraduate medical students (UGMD) learn in very regimented programs.
North American UGMD programs are subject to international accreditation standards (The
Association of Faculties of Medicine of Canada, 2015) which mandate comparability across
continental programs, with what can be interpreted as little room for pedagogical flexibility.
While these programs are often limited by these rigid standards, it is also true that Canadian

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medical schools have been incrementally changing to accommodate the demands of Canadians,
including developing distributed rural campuses,1 with the intent to both attract local students
and to encourage graduates to practice in these underserved locations. Similarly, all 17
accredited Canadian UGMD programs have demonstrated interest in attracting, admitting and
retaining Aboriginal students (Indigenous Physicians Association of Canada and the Association
of Faculties of Medicine of Canada, 2008b) through bursary models, scholarships, admissions
programs that specifically seek to admit a certain number of Aboriginal students, or by offering
programs with the intent to enhance Aboriginal and Indigenous health. These programs have
been developed in response to demographic analyses (Dhalla et al. 2002; Young et al 2012)
which indicate that Canadian medical students are both more economically advantaged than the
average citizen, and reflect a different ethnic makeup (fewer black and Indigenous students and
more Asian and South Asian students) than the average Canadian community.
However, it is unclear how these programs utilize Aboriginal pedagogies and worldviews
(see Appendix 1), Aboriginal teachings, Aboriginal lecturers, Aboriginal community rotations,
and other exposures to Aboriginal experiences in the classroom and in the community.
This paper explores the current state of curriculum integration of traditional
Aboriginal/indigenous healing methods and related pedagogies including use of the medicine
wheel/four directions (see Figure 1; The National Library of Medicine, 2013) into Canadian
undergraduate medical education programs. This is approached by mapping available curriculum
data to the standards of the CanMEDS Framework (2015), outlining core competencies for
graduating physicians alongside the existing First Nations, Inuit, Mtis Health Core
1 The University of British Columbia is an exemplar of this model, with distributed undergraduate medical
programs located in Victoria, Prince George, and Kelowna and clerkship sites in smaller communities provincewide.

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Competencies [FNIMHCC] (Indigenous Physicians Association of Canada and the Association
of Faculties of Medicine of Canada, 2008a).
Figure 1: The Medicine Wheel/Four Directions
Particular emphasis has been placed on why or
how medical schools traditional methods of
being, thinking and healing to encourage
Aboriginal enrolment in medical sciences or to
increase cultural fluency of graduates.

Methodology
A two-pronged approach was necessary to gather enough accurate information to make
any conclusions about the state of use of Aboriginal/Indigenous pedagogies in Canadian MDUG
educational programs: literature review and consultation of primary sources, in this case the
websites of the 17 Canadian medical schools and any shared curriculum data. First, a literature
review was completed to examine the state of research on use of Aboriginal/Indigenous
pedagogies in Canadian medical education. This search was run using the UBC Library
catalogue, and using databases including ERIC, PubMed/MEDLINE, CINAHL, and Google
Scholar. Google Scholar was selected for search due to its ability to recall grey literature
resources, (Woodward Library, 2015) which, ...include[s] reports and government information
that are not published commercially and that are inaccessible via bibliographic databases.

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(Canadian Agency for Drugs and Technology in Health, 2015) It was important to identify
relevant grey literature on this topic as a 2006 work by the National Collaborating Centres on
Aboriginal Health found great divergence between issues covered in peer reviewed literature.
Aboriginal organizations focus less on disease-specific issues (e.x. diabetes) and place more
emphasis on research and policy to improve broader health outcomes. Second, a small-scale
environmental scan was conducted of Canadian UGMD programs, with attempts made to
determine if the FNIMHCC (2008a) were identified alongside the CanMEDS framework (2015)
identified Core Competencies in available curriculum data. Table 1 makes it quite clear that the
overlap between the competencies from the FNIMH and CanMEDS is complete (indicated
competencies are highlighted in green), with each CanMEDS role having a corresponding
FNIMH role (see Appendix 2 for more information). At this time Canadas two exclusivelyFrancophone UGMD programs were excluded due to language and translation limitations. Thus
15 medical schools were assessed for their acknowledgement of the importance of FNIMHCC
Core Competencies.

Table 1: FNIMH and CanMEDS Core Competency Roles Overlap


Role

Medical Communicator Collaborator


Expert

Leader
/Mana
ger2

Health
Advocate

Scholar

Professional

FNIMH
CanMEDS

2 The 2015 version of the CanMEDS framework has updated this category to read leader whereas previous
versions used the term Manager which is reflected in the older FNIMH document. They have been read as
analogous for this purpose.

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Literature Review
Dr. Mary Battiste (2002) suggests that we must accept two conceits before proceeding with a
literature review on Aboriginal/Indigenous topics:
1. The literature review is a critical analysis tool of the Eurocentric
knowledge system, a system which does not reflect the practices of Indigenous
knowledge transfer. Many Indigenous traditions are oral, or passed down from
generation to generation, and thus not housed in the library, thus discounting the
importance of a literature review to the Indigenous worldview. (p. 2)
2. Conducting a literature review on Indigenous knowledge implies
that Eurocentric research can reveal an understanding of Indigenous knowledge.
The issue wish such an approach is that the Indigenous knowledge system does
not map to the Eurocentric model, and thus there are limitations as to the
relevancy of traditional scholarship to such topics. (p. 2)
In spite of Battistes caveats, there does exist a small selection of recent and relevant literature on
the use of Aboriginal pedagogies in Canadian educational context, and it is worth examining
both what this literature brings to light, and similarly, to identify areas that would benefit from
further research. To counteract this methodological weakness, efforts were made to seek
literature which utilized oral interviews with Aboriginal/Indigenous health professions learners.
There is a paucity of literature on the use of Aboriginal/Indigenous pedagogies in
Canadian medical schools. In fact, the lack is so significant that a search of Google Scholar for
the broad terms "aboriginal pedagogy*" and medic* and Canada recalled only 102 results,
many of which discussed broader issues of cultural competency, but which did not address the
issue of integrating aboriginal pedagogies into health professions training. Some Australian and

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New Zealand-centric works emphasizing health professions training of the Maori and Torres
Strait Islanders (those countries major indigenous groups) have been published, but still do not
explore use of traditional pedagogies in formal training.
As a result, this review focuses on published literature which used survey methods to
assess the pedagogical and curricula references of Aboriginal/Indigenous Canadian health
professions students, but does not assess their experiences of learning in such an integrated
curriculum. Three major themes emerge in the literature gathered from the experiences of
Aboriginal/Indigenous health professions (e.x. nursing, social work) students:
1. Mandate culturally fluent teaching on the impact of residential schools.
Residential schools were identified as being the cause of major distress for Canadian
Indigenous communities and that systemic cultural genocide, underfunded educational
systems, and lack of consistent medical care and education have resulted in the
overrepresentation of Aboriginal/Indigenous persons in the healthcare system (Petrack,
2008, p. 39).
2. Mandate culturally fluent teachings on Aboriginal/Indigenous realities including
candid discussions on the impacts of racism, poverty, lower educational
provision/funding and overall life experiences of both on-reserve and urban
Aboriginal/Indigenous Canadians. (Claypool & Preston, 2011; Curtis et al, 2012; Petrack,
2008, p. 43).
3. Mandate formal acknowledgement of disparities between Aboriginal Contexts and
Westernized learning & assessment and discuss the need for community and
collaboration (Claypool & Preston, 2011; Petrack, 2008, p. 51).

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These themes are not new in literature addressing the need for Aboriginal research. In
1991, Kirkness & Barnhardt addressed all of these themes and more in their milestone article
First Nations and Higher Education: The four R's-Respect, Relevance, Reciprocity, and
Responsibility. The four Rs of health research can be expanded as:
(a) respect is demonstrated toward Aboriginal Peoples' cultures and
communities by valuing their diverse knowledge of health matters and
toward health science knowledge that contributes to Aboriginal
community health and wellness;
(b) relevance to culture and community is critical for the success of
Aboriginal health training and research;
(c) reciprocity is accomplished through a two-way process of learning and
research exchange in which both the community and university benefit
from effective training and research relationships; and
(d) responsibility is empowerment and is fostered through active and
rigorous engagement and participation.
(Archibald, Jovel, McCormick, Vedan, & Thira, 2006, p. 146-148.)
While Canadian medical schools have indicated Aboriginal students as a priority group
for both recruitment and retention (Indigenous Physicians Association of Canada and the
Association of Faculties of Medicine of Canada, 2008b) none are publishing curriculum or
assessment research on this topic.The simple fact that Canadian health research lacks literature
exploring the integration of the FNIMHCC or similar culturally-specific competencies into
Canadian undergraduate medical programmes indicates that deficiencies exist in the planning
and implementation of curricula.

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Environmental Scan
In the context of the use of aboriginal pedagogies in Canadian medical schools, it was
most useful to conduct this environmental scan with a view to assess the current state of
integration of such pedagogies in the published curricula of these schools. This assessment was
conducted by visiting the public websites of all English-language Canadian medical school
websites and searching for first nation*3 and core competenc* in the hopes of recalling any
statement about the use of FNIMHCC in the local curriculum. The FNIMHCC is mapped to the
CanMEDS Framework (Frank, Snell, & Sherbino, eds., 2015), adding Aboriginal-specific
competencies under each relevant role. Both models identify graduates core competencies into
the following roles: scholar, health advocate, manager, collaborator, communicator, and
professional.
The data collected as a result of this exercise is provided, in full, as part of Appendix 2. To date,
only three medical schools, Memorial University, the Northern Ontario School of Medicine and
the University of British Columbia, have incorporated these core competencies formally into
their curriculum goals, arguably using these outcomes as a mandate to incorporate some
elements of Aboriginal pedagogy into their curriculums.
Conclusion
June 2015 saw the long-awaited release of Canadas Truth and Reconciliation
Commissions [TRC] Summary Report (2015a) , which formally announced the governments
role in the cultural genocide of our nations First Peoples. The Summary Report shared many
important truths and detailed recommendations for formal acknowledgement of damage done
and both formal and informal next steps that will assist in moving towards true reconciliation. In
3 The * symbol is used as a wildcard in search syntax, meaning that the resulting search will recall words containing
the root with any suffix.

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the TRC Call To Action (2015b) document the term education is highlighted 28 times, and
indicated as being critical for the preservation of legacy and for the process of reconciliation.
Knowing that education is a foundational tenet of this process provides the impetus for pursuit of
information regarding the state of education, by, for and about Aboriginal learnings.
Information gathered from the literature review and the environmental scan, provided a
picture of the state of use of Aboriginal pedagogies in Canadian undergraduate medical
education. It is not a good picture. While the vast majority of medical schools make reference to
the importance of First Nations, Inuit and/or Mtis students to their cohorts, most make little
reference to these groups beyond affirmative-action style admissions procedures which increase
opportunities for Aboriginal students to study medicine. The literature illustrates that this type
affirmative action does not meet the needs of Aboriginal/Indigenous students, who struggle to
integrate culturally, socially and politically into the Westernized/colonizer classroom. As
medical curriculums renew (UBC and Memorial University of Newfoundland are in the midst of
this multi-year process at the moment), efforts can and should be made to integrate the
FNIMHCC into the existing CanMEDS Framework (Frank, Snell, & Sherbino, eds., 2015), and
to develop practical and respectful ways of teaching that integrate Aboriginal pedagogies and
worldviews, including use of narrative storytelling, teaching about social and political issues
(e.x. poverty, reservation life, Residential Schools, etc), and models such as the Medicine Wheel.

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References
Archibald, J. A., Jovel, E., McCormick, R., Vedan, R., & Thira, D. (2006). Creating
transformative Aboriginal health research: The BC ACADRE at three years. Canadian
Journal of Native Education, 29(1), 4.

Battiste, M. (2002). Indigenous knowledge and pedagogy in First Nations education: A literature
review with recommendations. Ottawa: Apamuwek Institute.

Canadian Agency for Drugs and Technology in Health. (2009). Grey Matters: a practical search
tool for evidence-based medicine. Retrieved from:
https://www.cadth.ca/resources/finding-evidence/grey-matters-practical-search-toolevidence-based-medicine

Claypool, T., & Preston, J. (2011). Redefining Learning and Assessment Practices Impacting
Aboriginal Students: Considering Aboriginal Priorities via Aboriginal and Western
Worldviews. in education, 17. Retrieved from
http://ineducation.ca/ineducation/article/view/74/561

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Curtis, E., Wikaire, E., Stokes, K., & Reid, P. (2012). Addressing indigenous health workforce
inequities: A literature review exploring best practice for recruitment into tertiary health
programmes. Int J Equity Health, 11, 13.

Dhalla, I. A., Kwong, J. C., Streiner, D. L., Baddour, R. E., Waddell, A. E., & Johnson, I. L.
(2002). Characteristics of first-year students in canadian medical schools. Canadian
Medical Association Journal, 166(8), 1029-1035.

Faculty of Medicine Curriculum Committee - University of British Columbia. Exit


Competencies. (2013). Retrieved July 31, 2015 from
http://cr.med.ubc.ca/files/2014/11/UBC-MDUP-Exit-Competencies.pdf

Faculty of Medicine & Dentistry - University of Alberta. (n.d.). Retrieved July 31, 2015, from
http://www.med.ualberta.ca/

Frank, J., Snell, L., & Sherbino, J., eds. (2015). The Draft CanMEDS 2015 Physician
Competency Framework. Retrieved from
http://www.royalcollege.ca/portal/page/portal/rc/common/documents/canmeds/framewor
k/canmeds2015_framework_series_III_e.pdf

Indigenous Physicians Association of Canada and the Association of Faculties of Medicine of


Canada. (2008a). First Nations, Inuit, Mtis Health Core Competencies: A curriculum

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framework for undergraduate medical education. Retrieved from
https://www.afmc.ca/pdf/CoreCompetenciesEng.pdf

Indigenous Physicians Association of Canada and the Association of Faculties of


Medicine of Canada. (2008b). Summary of Admissions and Support Programs for
Indigenous Students at Canadian Faculties of Medicine. Retrieved from
https://www.afmc.ca/pdf/IPACAFMC_Summary_of_Admissions_&_Support_Programs_Eng.pdf

Kirkness, V. J. & Barnhardt, R. (1991). First Nations and higher education: The four R's
respect, relevance, reciprocity, responsibility. Journal of American Indian Education,
30(3), 1-15.

Memorial University of Newfoundland. (n.d.). Aboriginal Health Initiative [brochure]. Retrieved


from https://www.med.mun.ca/getdoc/9d1d0b5e-cd0c-4a07-b5e3310f001425f9/Aboriginal-Health-Initiative-brochure.aspx

National Collaborating Centre for Aboriginal Health. (2006). Landscapes of Indigenous Health:
An environmental scan by the National Collaborating Centre for Aboriginal Health.
Retrieved from: http://www.nccah-ccnsa.ca/docs/setting%20the%20context/nccahLandscapesofIndigenousHealth-march2008.pdf

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National Library of Medicine. (2013). Medicine Ways: Traditional healers and healing. Retrieved
from: http://www.nlm.nih.gov/nativevoices/exhibition/healing-ways/medicineways/medicine-wheel.html

Northern Ontario School of Medicine. (2014). Working with Aboriginal Peoples: Health
Sciences CC Implementation Toolkit 2014. Retrieved from
http://www.nosm.ca/uploadedFiles/Education/NODIP/Aboriginal%20CC
%20Implementation%20Toolkit_Competencies_Feb2014.pdf

Petrack, H. (2008). Aboriginal Nursing Students Experiences in a Nursing Program. Retrieved


from
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The Association of Faculties of Medicine of Canada. (2015). Accredited Canadian Medical


Education Programs. Retrieved from: https://www.afmc.ca/accreditation/committeeaccreditation-canadian-medical-schools-cacms/accredited-canadian-medical

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The Truth and Reconciliation Commission of Canada, (2015)b. Truth and Reconciliation
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Objectives. (n.d.). Retrieved July 31, 2015, from
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Young, M. E., Razack, S., Hanson, M. D., Slade, S., Varpio, L., Dore, K. L., & McKnight, D.
(2012). Calling for a broader conceptualization of diversity: Surface and deep diversity in
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Appendix 1: Aboriginal & Western Worldviews

Aboriginal and Western Worldviews4


A worldview is a collection of perceptions, beliefs, and values held by an individual or group of
individuals pertaining to the structure of the universe and its philosophical and physical
association to life. In what follows, we present a description of Aboriginal and Western
worldviews.
Aboriginal Worldview
4 Excerpted from Claypool & Preston, 2011.

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Integral to Aboriginal worldviews, is a physical, intangible, and highly intricate relationship
between all things on earth, such that everything is one (Atleo, 2004, p. xi). Based on this
premise, each student needs to find his or her distinctive purpose in life by connecting with self,
family, community, and the natural world. For Aboriginal students, learning and assessment finds
its genesis in the self and then extends toward family, community, and the universe; once
learning and assessment is extended toward the influence of others and society, it then embodies
a cyclical action by returning to the self in the form of self-reflection and personal growth. In
such a manner, Aboriginal learning and assessment are a reciprocal circular concept of selffamily-community.
Employing the concepts permeated within Aboriginal worldviews means embracing the power
and potential of subjective personal knowledge. Aboriginal epistemology is grounded in
understanding oneself by unleashing the capacities of intuition, the inner spirit, and the unknown.
This unique exploration of self is a personal journey of constant development. Miller, Cassie, and
Drake (1990) believed self-introspection has the power to promote skill development and
strengthen spiritual attunement with and for the environment. In such ways, learning is an
introspective realization of how the self is an elaborate, balanced network of mind, body,
emotion, and spirit, all of which are connected to the natural environmental forces of life.
Another aspect of an Aboriginal worldview incorporates knowledge pertaining to the Medicine
Wheel (Elliott, Halonen, Akiwenzie-Damm, Methot, & George, 2004; Walker, 2001;
Whiskeyjack, 2000; Wilson, 1994). There are many Aboriginal teachings of the Medicine Wheel
and many cultural variations of its themes. For those Aboriginal people who use the Medicine
Wheel, its teachings describe four components of a balanced lifestyle (or states of being): the
intellectual, physical, emotional, and spiritual (Preston, 2011). In examining the states of being,
the Medicine Wheel addresses a persons location in relation to individual, family, community,
and nation contexts.
Westernized Worldview
As compared to an Aboriginal worldview, a Western worldview represents life within demarked,
finite boundaries, where time is a linear concept and space is a three-dimensional physical entity.
Years are broken down into months; months are subdivided into weeks; weeks are broken into

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days, which are then further compartmentalized into hours, minutes, seconds, and portions of
seconds. Within these confinements, teaching and learning are delivered within pre-authorized
time units (Macbeth & Dempster, 2009). This linear value system is reflected through how
people interact (Indian and Northern Affairs Canada, 1999). For example, within human-focused
environments such as schools, the cultural norm is that subject-specific classes are scheduled,
objectives are created, and teacher and student deadlines ensure completion of tasks.
Westernized standards for student assessment are often presented through processes that are
subject-specific, time-bound, competitive, and based on written documentation depicting
quantifiable results (Preston, 2011). Popular terms related to such student assessment include
evidence-based, curriculum-based, daily data collection, goal-oriented, work samples,
benchmarks, anecdotal notes, checklists, portfolios, rubrics, grades, and criterion-referenced
measures (Gredler & Johnson, 2004; Oosterhof, 2009; Shea et al., 2005). These methods
primarily promote cognitive growth reflected through rational, linear, and accountable actions.
Western forms of student assessment are predominantly based on achieving written goals or
curricular outcomes, and the grades attained from participation in school-related activities and
assessment methods primarily focus on one dimension of learningthe cognitive. For the most
part, Western assessment techniques neglect to address the physical, emotional, and spiritual
domains of students.

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Appendix 2: Core Competencies & Canadian Medical Schools5


1. Medical Expert
The graduating student will demonstrate compassionate, culturally
safe, relationship centred care for First Nations, Inuit, Mtis patients, their
families or communities.
2. Communicator
The graduating student will demonstrate effective and culturally
safe communication with First Nations, Inuit, Mtis patients, their families and
peers.
3. Collaborator
The graduating student will demonstrate the skills of effective
collaboration with both Aboriginal and non-Aboriginal health care professionals,
traditional/medicine peoples/healers in the provision of effective health care for
First Nations, Inuit, Mtis patients/populations.
4. Manager
5 Excerpted from First Nations, Inuit, Mtis Health Core Competencies: A curriculum framework

for undergraduate medical education. (Indigenous Physicians Association of Canada and the
Association of Faculties of Medicine of Canada, 2008a)

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The graduating student will be able to describe approaches to
optimizing First Nations, Inuit, Mtis health through a just allocation of health
care resources, balancing effectiveness, efficiency and access, employing
evidence based and Indigenous best practices.
5. Health Advocate
The graduating student will be able to identify the determinants of
health of Aboriginal populations and use this knowledge to promote the health of
individual First Nations, Inuit, Mtis patients and their communities
6. Scholar
The graduating student will be able to contribute to the
development, dissemination, critical assessment of knowledge/practices and
dissemination related to the improvement of First Nations, Inuit, Mtis health in
Canada.
7. Professional
The graduating student will demonstrate a commitment to engage
in dialogue and relationship building with First Nations, Inuit, and Mtis peoples
to improve health through increased awareness and insights of First Nations,
Inuit, Mtis peoples, cultures, and health practices.
Table indicates clear correlation between curriculum goals and core competencies.
CC 1

CC2

CC3

CC4

CC5

CC6

CC7

U Alberta6

UBC7

U Calgary8
6 University of Alberta doesnt mention the FNIMHCC on their MDUE program page, instead the document is
housed in their medical students association site as a nice to know (Faculty of Medicine and Dentistry - University
of Alberta, n.d.)

7 UBC will launch a new curriculum which integrates these standards in fall 2015 starting with year one students.
(Faculty of Medicine Curriculum Committee - University of British Columbia, 2013)

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U
Saskatchewan9
U Manitoba10

NOSM11

Western12
Queens13
McMaster
McGill
U Ottawa
Memorial14
Dalhousie
U Toronto15

8 High profile reference to their Aboriginal recruitment/affirmative action programs but no mention of FNIMHCC
(University of Calgary, n.d.)

9 Has a committee to help integrate into curriculum but does not address core competencies (University of
Saskatchewan, n.d.)

10 UManitoba refers to the FNIMHCC but are not explicit re: specific responsibilities to FNIM people (University
of Manitoba, n.d.)

11 The NOSM are pursuing integration of FNIMHCC into curriculum actively (Northern Ontario School of
Medicine, 2014)

12 UWO does not mention FNIM interests anywhere on their website (University of Western Ontario, n.d.)
13 Queens University has updated their postgraduate medical education (residency) competencies to integrate
FNIMHCC, but UGME does not. (Queens University, n.d.)

14 Their revised curriculum will address FNIMHCC but their current curriculum does not. (Memorial University of
Newfoundland, n.d.)

15 A site search for first nation recalled only 4 results on medicine site with no reference to the competencies.
(University of Toronto, 2015).