Overseas-trained doctors in Indigenous rural health services: negotiating professional relationships across cultural domains
Dr Angela Durey, Combined Universities Centre for Rural Health, University of Western Australia, PO Box 109, Geraldton, WA 6531. Fax: 08 9964 2096; e-mail: firstname.lastname@example.org
Objective: To examine how OTDs and staff in rural and remote Indigenous health contexts communicate and negotiate identity and relationships, and consider how this may influence OTDs’ transition, integration and retention.
Method: Ten case studies were conducted in rural and remote settings across Australia, each of an OTD providing primary care in a substantially Indigenous practice population, his/her partner, co-workers and Indigenous board members associated with the health service. Cases were purposefully sampled to ensure diversity in gender, location and country of origin.
Results: Identity as ‘fluid’ emerged as a key theme in effective communication and building good relationships between OTDs and Indigenous staff. OTDs enter a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice shaped by the Australian Indigenous context. These are negotiated through differences in language, role expectation, practice, status and identification with locus with uncertain outcomes. Limited professional and cultural support often impeded this process.
Conclusion: The reconstruction of OTDs’ identities and mediating beyond predictable barriers to cultural engagement contributes significantly not only to OTDs’ integration and, to a lesser extent, their retention, but also to maximising effective communication across cultural domains.
Implications: Retention of OTDs working in Indigenous health contexts rests on a combination of OTDs’ capacity to adapt culturally and professionally to this complex environment, and of effective strategies to support them.
The experiences of overseas-trained doctors (OTDs) withinAboriginal and Torres Strait Islander (Indigenous) health services, and the experiences of these services with OTDs is largely undocumented. Ganguly1 draws attention to this neglected professional interface, and argues in the context of cultural awareness training, that the complexity of ‘non English-speaking Indigenous relations’ in Australian health service provision is not adequately captured by ‘binary (Indigenous/non-indigenous) models’. While differential experiences of professional and social integration by country of origin have begun to be identified,2,3 these have not been articulated within an Indigenous health context.
The problems of recruitment, retention and high turnover of medical practitioners in Indigenous primary care are well-recognised.4–6 In just under a decade from the mid-90s to 2004, overseas-trained general practitioners (GPs) servicing rural and regional areas increased by 80% in comparison to 8.8% for Australian-trained GPs.7 Substantial numbers of OTDs have been granted Medicare provider numbers with geographic restrictions on practice.8–11 This evidence, combined with rural and remote workforce data showing the proportions of GPs providing Aboriginal health services, as well as services by remoteness index12 allow us to extrapolate that the role played by OTDs as general practitioners (GPs) in Indigenous health, in rural and remote areas, is significant. There are however, no publicly available national data on the percentage of OTDs working in state, private or community-controlled Indigenous health services.
Recurring challenges for rural and remote OTDs and their employers have been highlighted in reviews and surveys:13,14 fulfilment of immigration and medical registration requirements, affordability of relocation costs, and inconsistencies in the provision of orientation to local practice environments. Overlaid with these, OTDs have expressed difficulties adjusting to remoteness, the extent of morbidity and mortality, difficulties in relationships with colleagues, and, what has been described as ‘the culture of service provision’.15
Emerging from this is the notion of different cultural domains, and in particular, diverse perceptions of what constitutes the professional ‘space’. Health practitioners within Indigenous health settings have noted the expanded repertoire of skills and attributes required for all doctors – whether Australian or overseas trained – to practise effectively.16 These include: the need for advocacy skills,17 accountability to community and equality within a health care team18 as well as recognising differing cultural ‘knowledges’, such as Aboriginal knowledge about illness and wellbeing.19,20 Further, the ambiguities of where doctors might be placed in relation to their own experiences of racism, cultural differences from the Australian mainstream as well as their own social and political backgrounds, add another layer of complexity within the cultural and policy landscape of Indigenous medical practice.
The historical context leading to the establishment of Aboriginal Medical Services (AMS) across Australia is well-documented.18,21–23 There are now more than a hundred Commonwealth funded AMSs around Australia. Distinguishing features of this practice environment are Aboriginal self-determination and community control and a primary health care model of service delivery, operating within an Indigenous concept and perception of health as determining all aspects of life.24 GPs work in a multidisciplinary team where the doctor is not necessarily a dominant player. This is different from private general practice where the GP often owns the service and controls how it is structured and operated.
Our paper arises from a national research project addressing social and cultural issues effecting OTDs'professional and social integration into Indigenous health services. It also draws on a literature review of OTDs in Indigenous health services25 and the knowledge gaps identified as a result of this review.26 The paper presents our research findings and asks: 1) what factors influence successful communication across different cultural spaces; 2) how are professional relationships negotiated across these cultural spaces between OTDs, their workplace colleagues and the community, as represented by Board Members of the local Indigenous health service; 3) how may OTDs’ effective negotiation of cultural domains influence their transition, integration and retention in these services?
We gained ethics approval from universities, government health departments and Indigenous health committees in the relevant jurisdictions. Project support was also obtained from peak Indigenous health bodies and local Aboriginal Medical Services. We used a case study approach to gather information and defined a case as an OTD providing public, private or primary care services where a substantial proportion of the practice population were Indigenous people. OTDs included sub-continental Indians, Europeans, Afrikaners, South Pacific Islanders, Africans and Chinese. Cases were purposefully sampled to ensure diversity in gender, geographical location and ethnic background (Table 1).
Table 1. Case study classification.
|Type of service||H||CH||ACCHS||Private||Private||ACCHS||ACCHS||ACCHS||ACCHS||ACCHS|
|Ethnicity of OTDs||Ind||Pac||Afr||Eur||Afk||Ind||Eur||Afr||Ch||Afr|
|Total no. informants for each case||7||4||10||3||2||5||3||1||6||9|
Ten case studies were conducted in rural and remote Queensland, the Northern Territory and Western Australia involving 49 participants. For the purpose of clarity, data from the 10 OTD case studies and their OTD colleagues have been combined. Case studies also included Indigenous and non-Indigenous co-workers and Board Members of the local Indigenous health service who comprised the category ‘community’(see Table 2 for identification of quotes). Multiple perspectives allowed for deeper understanding of how relationships were perceived and negotiated in the workplace.
Table 2. Identification of quotes.
| ||Non medical co-worker||m/f|| ||9/Coworker/f/Indig|
| ||Australian Medical Colleague||m/f|| ||3/Colleague/m/Aus|
| ||Community member||m/f|| ||10/Community/f/Indig|
Researchers sought permission from CEOs in the Aboriginal health service (AHS) to contact OTDs and co-workers. Potential participants were then identified and approached by researchers in person, via telephone or by e-mail. The researcher arranged a mutually convenient time and place to conduct interviews. Information sheets were distributed and the researcher verbally summarised the purpose of the study and the structure of the interview. Semi-structured interviews were conducted subject to participants’ signed consent and lasted approximately one hour. All interviews were tape recorded and transcribed and imported into NVIVO, a qualitative analysis software package.
NVIVO was used by one researcher for a primary analysis of interviews from which common themes emerging from the data were identified. Findings were then compared, discussed, refined and summarised into further themes and sub-themes with members of the research team. Two researchers independently rated quotes reflecting specific themes as positive or negative in content (Table 3). Researchers interpreted the themes by noting similarities and differences in responses within and between work contexts, individuals, groups such as OTDs or Indigenous co-workers and identified the overarching themes threading through responses. This deeper analysis, coupled with a critical review of previous research, generated ideas that responded to research questions and informed the theoretical framework of the study.27,28 These ideas were explored and developed further by individual researchers and then collectively in several feedback meetings.
Table 3. Major themes identified 2006 OTD study.
|Importance of navigating cultural domains||25||4||11||10|
|OTD perspectives of their overall experience||19||Pos 3 Neutral 6 Neg 10|| || |
|Access to professional orientation and support||16||Pos2 Neg13||Neg1|| |
|Recognised need for cultural training and support||23||3||11||9|
|Cultural/professional expectations||8||Pos 3 Neg 2||Pos 1 Neutral 1||Pos 1|
|OTD specific cultural challenges||9||9|| || |
|Institutional relationships||22||Pos 4 Neutral 7 Neg 11|| || |
|OTD relationships with local medical community||12||Pos 1 Neutral 1 Neg 5||Pos 2 Neutral 1 Neg 2|| |
|Building relationships between OTDs and staff||22||Pos 4 Neg 1||Pos 15 Neutral 1 Neg 1|| |
|Relationships between OTDs and local community||13||Pos 5 Neutral 3||Pos 2 Neutral 1||Pos 2 Neutral 1|
This study focused specifically on case studies of OTDs working as GPs in rural and remote Indigenous health settings. It did not research the experiences of OTDs in urban contexts.
The research crosses a complex of theoretical issues, but highlights the rich interplay between identity and relationships in health services for Indigenous communities. Rowse's29 concept of the ‘cultural domain’ in the administration of Australian Indigenous communities has been explored through the experience of Indigenous health managers in health services in Indigenous communities, identifying two distinct cultural spaces within – and between – which Indigenous managers move, negotiating the demands of their own culture and society against the implicit ‘Western’ cultural construction of the health service.18,30
In health services for Indigenous communities, the interface between the domains is complex, with cultural accommodation required from Indigenous and non-Indigenous stakeholders. Non-Indigenous health professionals moving into these spaces need to undertake a similar social task to that of Indigenous health managers. While often confident in their professional culture in Australia, they need to respond to the demands of culturally safe practice, reshaping their communication strategies, and whole habitus in the Aboriginal cultural environment.1,31 The transition is not easy: for health professionals working in Aboriginal communities, political commitment to Indigenous self-determination finds itself in tension with a desire to effect change, resulting in an uncomfortable ambivalence around their roles.32 For some, interactions within this complex world are experienced as unpredictable, and well-intentioned initiatives result in confusion and discouragement.33
The high dependence of Indigenous health services on OTDs adds a further dimension to this complexity. The OTD identity is itself constructed through the process of recruitment and migration: for many OTDs this is their first cross-cultural engagement. Their transition into Indigenous health services – often without adequate orientation or preparation- places them at the intersection of three cultural domains, adding their own culture to those already described.26,34 Diversity within these three cultural domains is multi-layered, and becomes explicit through language, role expectation and practice, status and identification with locus – especially the divide between rural and urban, country of origin, both in the broader sense and in the specific sense of place that shapes Indigenous identity. The OTDs’ own (and perceived) motivation for migration, their professional experience and competence, their intended professional trajectories, and their ability to align themselves professionally, determine to a large extent their own self perception, and the identities applied to them by others.
Yet identity is fluid, responsive, multilayered, flexible and invites redefinition both by individuals and those with whom they engage.35,36 For some OTDs – as for other non-Indigenous Australians working in Indigenous communities – this presents as an exceptional space within which to rework their identity: ‘Reflexive self-awareness provides the individual with the opportunity to construct self-identity without the shackles of tradition and culture’.37
The fluid and responsive nature of identity emerged as a key theme in professional relationships and communication. All OTDs interviewed negotiated their identity across three cultural domains: the Australian medical system, an Indigenous setting and their own cultural background. Language, role expectation and practice and identification with locus, whether country of origin, model of practice in an Australian Indigenous setting or rural or remote location all reflected the complex diversity inherent in these cultural domains.
OTDs step into a social space where their own cultural and professional beliefs and practices intersect with the expectations of culturally safe practice in an Australian Indigenous context through language, role expectation, practice and status. This space reveals not only tension in the interplay between identity and relationality, but also identity as multilayered and flexible, inviting change both by individuals and those with whom they engage. Such redefinition, influenced by external context and self-reflexive awareness, informed how professional and cultural integration was negotiated. The analysis of the findings has been structured to highlight these external influences, and the reflexive response of OTDs and co-workers and illustrate the similarities and differences in responses (Table 3).
External pressures: orientation to the workplace
Soon after arriving in Australia, many OTDs from culturally, linguistically and socially diverse backgrounds began work in rural and remote Indigenous health settings within a primary health care model of practice. Orientation to the local workplace varied across contexts though generally failed to adequately prepare OTDs for medical practice in these settings (Table 3). While one larger centre offered comprehensive orientation, most offered little or none:
“One day, you know, I was told this computer literacy for about fifteen minutes and then from the next day I was supposed to see the patients.” (10/OTD /m/Ind)
With often minimal support, OTDs attempted to meet expectations of professional and cultural proficiency in a context where their status as doctors was not assumed. They negotiated demands for clinical and technical competence alongside frustrating bureaucratic expectations to ‘fill in the same forms every year … to get your provider number and nothing has changed … but you have to do exactly the same thing’(5/OTD /m/Eur).
OTDs worked in settings where cultural proficiency was highly prized by the Indigenous staff and community (Table 3). This was reflected in the pattern of responses, with the importance of navigating cultural domains dominating the interviews with health service board members and colleagues (20 quotes), but only cited in three cases by OTDs themselves. Most OTDs and Indigenous co-workers experienced expectations around cultural proficiency as an added tension. Limited orientation and training led not only to one OTD feeling ill-prepared to meet ‘the despair of the patient and sometimes the lack of compliance’(8/OTD /m/Afr) but also to Indigenous community members’ frustration at the effects of OTDs being untrained in cultural proficiency when communicating with Indigenous clients (Table 3):
“I know we get a lot of doctors come through here without any formal training in regards to Aboriginal culture and they come here and they don't last too long… because they just don't understand our way of life and the way we live the issues that we have and the health problems that we have.” (1/community/m/Indig)
Added to this, some OTDs were unprepared for their drop in status in a model of health care where respect for the doctor cannot be presumed despite the high dependence on OTDs’ services:
“Well it takes a longer time to be confident in the AMS for most doctors than it might be in another practice because in another practice the patients are educated upon the value of doctors. Here the doctor is just someone who is going to treat my sickness and then perhaps, if the doctor is not able to meet that need, then they say he is not a good doctor and a no good fella.” (10/OTD /f/nd)
While their diminished status caused indignation in some, others successfully negotiated their identity across this cultural space and valued working in an Indigenous setting and this had led to their decision to remain within this field:
“I enjoy Aboriginal general practice more than I enjoy other general practice… it feeds a bit of that thing of wanting to go back to where you come from. I enjoy it, the people are nice and they are open and they are friendly.” (6/OTD /m/Eur)
External pressures: training
OTDs come to Indigenous health settings with different professional expectations: only five of the 18 OTDs interviewed actively chose to work in Aboriginal settings. The majority migrated to Australia to improve their lives and those of their families and viewed this placement as a stepping stone to working in mainstream practice once they had met migration requirements. Despite OTDs’ differential clinical knowledge and experience, one OTD did receive good professional and cultural orientation and training from a larger centre. However, while this resulted in her prolonging her time working in the AMS it did not ultimately change her desired career trajectory, which was to work in general practice. Thirteen others identified a lack of adequate training and institutional support since arrival (Table 3). Little time and few resources in most centres were allocated to prepare OTDs for practice and ongoing retention leaving many feeling undervalued and unprepared to meet “the spectrum of illnesses [and] problems that confront you [which] are quite different from what you are used to” (9/OTD/m/Afr).
During the integration process support from the wider Australian medical community, while welcomed, was not always forthcoming (Table 3):
“They don't look after you well, they don't orientate you well and there is a lot to be said about doctors. We are not there to steal anything of them. I haven't come here for the money. I have money … and I haven't come here for that purpose. I have come here for a better life and I think after a few years they should mellow to us but they don't.” (1/OTD /m/Ind)
This experience was compounded by a perceived lack of support from medical institutions leading to inadequate guidance for most OTDs on the “depth and understanding that was expected … to go through the [qualifying] examination” (8/OTD/m/Afr) (Table 3). Without resources to meet expectations, frustration ensued, with little sense of being able to plan or negotiate their career trajectory:
“I wanted to do some training and I told [the manager]. He said no, it doesn't apply to you. … [It feels like] you are like an instrument to work, not to develop.” (9/OTD/m/Ind)
External pressures: the context of integration
Language added another layer of complexity to the integration process. English was a second language for many OTDs, co-workers and their clients, and concerns around communication were highlighted by health service staff and colleagues (Table 3). This led inevitably to linguistic misunderstandings that jeopardised negotiating successful relationships across cultural domains as OTDs and Indigenous staff and clients tried to understand each other:
“Something's wrong, maybe it's me maybe my personality but I don't think so because I am actually a very friendly person for people and I have that place to be sending me emails now so it means that I am not such a bad person so it must be something that I am doing wrong here or maybe it is because of the orientation was not put in place properly that is making me appear funny to them and that gives me some stress. I want to sit down in a place and be happy to do what I am supposed to be doing so I can give my patient the best of myself.” (10/OTD/m/Afr)
The interface between communication difficulties and cultural awareness is clear, however such problems were not insurmountable and successful negotiation of cultural spaces was possible despite linguistic challenges:
“[Dr X] attends every training and every workshop, and he has gone from being the doctor that nobody could understand to being the doctor nobody can really understand but they love going to him because he's a great doctor.” (3/Colleague/m/Aus)
OTDs with a flexible approach to working in an Indigenous setting were also able to enter a space where adopting a more fluid identity was more effective in negotiating the intersection between professional practice and Indigenous culture. Rather than relying solely on medical competence, one OTD demonstrated patience and goodwill towards Indigenous staff and clients which slowly built relationships and helped to develop trust:
“Because the people, if they think that what you are really trying to do is for the best of the community, then they will go out of their way to make your life easy; but if they think that you are one of those smart people who are not going to listen, they can also make your life difficult.” (2/OTD/m/Pac)
Others appreciated the integral role AHWs played in helping them successfully negotiate this cross-cultural terrain:
“… because they understand the people and their cultural point of view, then you can call the health worker in so they can try to mediate, and that's been good to use appropriately.” (3/OTD /m/Afr)
Building trust often required a more reflexive response to practice.
Reflexive practices: OTDs responding to the context
Tensions between OTDs and Indigenous co-workers and clients often occurred when different cultural knowledges and practice intersected with conflicting role expectations and ineffective communication. While there was no mistaking the belief that the Aboriginal Medical Services “would not have survived without the support of overseas trained doctors” (7/Co-worker/f/Indig), integration and retention were a problem. To work effectively in an Indigenous setting OTDs were required to negotiate the demands of their own cultural and professional training to meet expectations of culturally safe practice by reshaping not only their communication strategies, but their whole habitus (Table 3). Responses ranged from “not imposing your view of medical training and practice always” (3/OTD/m/Afr) to requests for more comprehensive cultural orientation and training, to adapting to their unfamiliar status as doctors working in an Indigenous setting, to considering ways to effectively build relationships across cultural spaces:
“Building relationships takes time you can't just go instantly into a community and expect every person to instantaneously accept you. People have to find out ‘is this person honest, what is his character like?’ Eventually if they are satisfied you will be accepted … and integrate easily into that community.” (9/OTD/m/Afr)
Cultural accommodation was also required from Indigenous stakeholders.
Reflexive practices: Indigenous co-workers responding to OTDs
Expectations across sites that OTDs “understand our culture here and work with it no matter what” (3/Coworker/f/Indig) were strong, reflected in the comments around navigating cultural domains (Table 3), with the assumption that the onus was on OTDs to breach cultural divides. However, this was tempered by Indigenous co-workers’ reflections on the need for reciprocity where “it's good to know their background, their cultural way” (9/Coworker/f/Indig) in order to effectively build relationships. This was evident in the 15 comments by health service staff volunteering their recognition of the contributions of ‘their’ OTDs. Trust developed when OTDs and Indigenous co-workers entered a space where barriers could be removed, and a deeper understanding of the OTDs’ own perceptions reached:
“He called us into his office to sit down at the whiteboard, the famous whiteboard and break down things for us. Then we truly appreciated where he was coming from and where he was going.” (2/Coworker/m/Indig)
Nonetheless, tension at the intersection between cultural domains was evident in Indigenous co-workers’ frustration when doctors misunderstood their culture and health problems and failed to adequately respond to the demands of culturally appropriate practice:
“It is no good having a doctor who comes from a country and expects to be a doctor and … do the clinical side of it. Working in AMS you actually have to do a lot more. You actually have to engage with the client and most importantly use the expertise of the staff when it comes to delivering health care to Aboriginal people.” (10/Community/f/Indig)
The recognition by OTDs that they needed assistance from Indigenous staff to access this domain, and Indigenous co-workers’ awareness that they could provide this cultural mediation produced very effective synergies in practice – recognised by both doctor and Indigenous co-workers.
OTDs’ identities are defined institutionally as ‘other’ during the recruitment and migration process. They are constrained by medical registration and geographic restrictions on practice and are often sent to ‘areas of need’ in rural and remote settings.25 The ‘fluid’ and responsive nature of identity emerges when OTDs from culturally, linguistically and socially diverse backgrounds trained in the Western medical model, now working in Australia in a rural or remote Indigenous health setting face the challenge of working in a primary health care model of practice. Here, they negotiate unfamiliar terrain in order to communicate effectively and become professionally integrated.
Navigating the nuanced complexity of cross-cultural communication is fraught with potential pitfalls when doctors arrive with little orientation or training, yet are expected to start work immediately while often nurturing plans to leave the service as quickly as possible. OTDs are faced with negotiating their clinical and technical competence with the high priority Indigenous staff, clients and community place on cultural proficiency. This transition is not easy. It requires a flexibility that invites redefinition of identity both by OTDs and those with whom they engage in order to increase the likelihood of successful integration and retention.
During the transition process from migration to integration, cultural spaces are created where OTDs can reconstruct their identities. By being open to new knowledges, developing more appropriate communication strategies and redefining their habitus, OTDs can accommodate different expectations of their roles and practice to ensure culturally proficient delivery of health care and long-term relationships with their clients:
“My mother just admires them because they have built up such a relationship … She feels more comfortable with [OTDs] and she won't go to anyone else so maybe there is a relationship there. … My mum won't leave here. We are trying to tell her to go back and live in our country but she says my doctors are here and she won't even go.” (6/Community/f/Indig)
Embracing new knowledge to deliver culturally appropriate health care paves the way to successfully negotiating professional relationships where effective communication is imperative and not restricted to language alone: professional competence, appreciation of difference, a caring attitude and community engagement also influence understanding and acceptance across cultural spaces.
Uncertainty as relationships are negotiated can cause tension as cultural accommodation is also required from Indigenous and non-Indigenous stakeholders. The role of the AHW is integral to the process of OTDs becoming more familiar with cultural beliefs and practices underpinning the social organisation of local Indigenous communities and to building relationships with co-workers and with their client base. This opportunity provides an exceptional space for OTDs to move across cultural domains to rework their identity as a team member rather than the dominant player.
While this process may facilitate integration, retention is not guaranteed. As migration and recruitment help construct OTDs’ identities, broader acceptance within Indigenous communities is based on an often unpredictable mix of personal and political factors. While this constitutes a challenge and an opportunity, the uncomfortable ambivalence surrounding their roles in Indigenous health is revealed when most OTDs:
“…come to this country for a better life and for a better lifestyle and a better income and that may be monetary, it may be safety, and it may be education for their children. It may be a lot of issues but they are certainly not coming here to come and work in our AMS's, not specifically.” (10/Coworker/f/Aus)
Conclusion and implications for health care practice
This study demonstrates the rich diversity of how identities can be reconstructed and relationships mediated beyond predictable barriers to cultural engagement. It highlights the institutional and cultural challenges OTDs face and suggests this may provide an exceptional space in which to support the career trajectories of OTDs toward Indigenous primary health care. Inadequate structural and cultural support to prepare OTDs for practice and integration implies that their services are undervalued. As long as Australian trained GPs remain reluctant to work in these settings, OTDs will provide an invaluable resource to meet Indigenous health care needs.8 Without effective orientation, training and resourcing at national, state and local levels to support OTDs working in Indigenous health contexts, retention is less likely.
Progress is slow despite several reports highlighting the need to improve orientation and training programs and assessment of OTD competence.38 Navigating cultural domains without such support is difficult. During the transition and integration process, the ‘never-ending story of proving myself over and over again’(7/OTD/f/Eur) fosters discouragement, frustration, feeling undervalued and pressured to meet institutional requirements. This can inhibit OTDs’ career trajectories in Indigenous and/or primary health settings being pursued. The implications of ongoing medical workforce difficulties in rural and remote Indigenous health services warrant serious policy reconsideration. What is missing, despite evidence and a number of excellent recommendations38,39 is action.
We would like to acknowledge all the participants in this research. The OTD research team also consisted of John Wakerman, Vanessa Lee, John Boffa, Susan Goodall, Anthony Zwi and Anna Whelan. We thank the National Aboriginal Community Controlled Health Organisation for funding this research and appreciate support offered by the Queensland and Islander Health Forum, the Aboriginal Health Council of Western Australia, the Aboriginal Medical Services Alliance of the Northern Territory and Geraldton Regional Aboriginal Medical Service.