Podcast: Med Life with Dr. Horton — On good medicine and healing with Dr. Lisa Richardson
Transcript
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Jillian Horton: I'm Dr. Jillian Horton, host of Med Life with Dr. Horton on CMAJ Podcasts. I'm a general internist and associate Chair of the Department of Internal Medicine and the director of the Alan Klass Health Humanities program at the Max Rady College of Medicine in Winnipeg, Manitoba. I also host Insights, Arts, Medicine Life at the National Art Center in Ottawa. My guest today is Dr. Lisa Richardson. Dr. Richardson is an Anishinaabe internist and is a strategic adviser of Indigenous health in the Faculty of Medicine at the University of Toronto. And I've reached her in Toronto, today. Dr. Richardson, welcome. And thank you so much for joining.
Lisa Richardson: Hi, Jillian. Thanks for having me.
Jillian Horton: So my first question for you, you have been widely recognized as a deeply influential individual at the University of Toronto, in terms of the role that you've played bringing Indigenous health to the forefront of medical education. Can you tell me the story of how you became a leader in this area?
Lisa Richardson: So thank you for that acknowledgement. I never think of myself as being widely influential, but we never know what impact we're having. I came into medical school a little bit later in my life, I actually had started in an undergraduate degree in biology. And I realized that it felt very limiting for me to be just studying science. And in hindsight, I realized that that's because in from Indigenous perspectives on science, we don't necessarily separate out art and science, it's not a clear boundary in the way we would see it in a Western sort of bioscience framework. And so in my second year, I actually picked up another major in English literature, again, a story based area, and also resonating, I think, with Indigenous ways of knowing because of how we use stories to convey information, and started becoming very interested in how we can think about stories as important for our well being, and went deep into a world of critical theory and Indigenous theory and critical feminist theory, and then realized that I wanted to actually have an impact on the ground. And so medicine seemed like a way to do that. And to bring these interests together. My background is a privileged one, my mom is Anishinaabe and my dad is European. And so I grew up with an understanding of two different worlds. And I think, felt that medicine was a place where I could bring together these worlds and take the privilege with which I had grown up and make changes in the communities. And I knew that the experiences of First Nations, Inuit and Metis peoples in our health system were not good ones. And so in a way, I had a passion for education. So once I finally got through my medicine training, which was really hard, very, very difficult, and I think we'll talk about that later. But I had both my kids during my training, many moments felt dehumanizing, I would say. But finally when I emerged from my training, realized that the place I could have the biggest impact was through education. And so making sure that every single one of our medical students would graduate with some understanding and knowledge about Indigenous health, and also that we would recruit and support more Indigenous learners into our faculty.
Jillian Horton: So we talk a lot on this podcast about burnout, and both personal and systemic solutions to the crisis that we're finding ourselves in as a profession right now. And in a few minutes, I want to talk about what Indigenous models of health and wellness can teach us. But first, I'd like to ask you about your own experience with physician health or with burnout, both as a trainee, which you just alluded to, and perhaps also as a faculty member, and maybe even to ask you to reflect on the ways in which being an Indigenous woman and leader has intersected with that experience.
Lisa Richardson: That's a great question. Thank you for asking it and creating the space for this conversation. So my experience as a resident when I was a medical student, I was very involved in our in what became the Indigenous Physicians Association of Canada. I had an amazing group of fellow medical students from across the country with whom I currently still work today people like Dr. Marcia Anderson, who's in Winnipeg and Dr. Cheryl Barnabe, so I had a nice community. It was really when I got into residency that it became a very stressful time for me as a person and as a mixed blood Indigenous woman. I decided not to delay childbearing because I was in a long stable relationship and had my first child who was my daughter as an intern, and really felt that that experience was extremely taxing physically, but also emotionally and, spiritually and mentally. And I think there is an expectation about what is, quote, a good resident. And when you're a woman who's a mother, who's trying to be an advocate for your community, you're not necessarily fitting into an expectation of how our residents would quote, typically behave. And so I think I always had an experience of being an outsider in the residency training program, and that is difficult. I didn't have enough mentorship, I realized, in hindsight, I had a few people who were very kind, but I didn't have anyone who really understood what my experience was like. And I think that's a lesson learned. And something that I try to practice now is acknowledging how important it is to have people who can mentor you. And then when I became a staff physician, there's this whole stress around, what does it mean to be an academic physician, and what is, you know, appropriate scholarly work. And again, my passion being Indigenous health and Indigenous health advocacy, and education was not typical work. And it wouldn't typically have qualified as scholarship and scholarly work. So having to advocate to have that work recognized. And, you know, we can talk about impact of like a New England Journal publications, but what about the impact of mentoring even one Indigenous student and teaching and thinking in different ways. That has been for me, always, the challenge is having recognition for work that's not necessarily classically considered academic medical work, but having it recognized and being able to follow my passion and do that. And I mean, I've been very fortunate now as a staff person, and I've been a staff for 10 years to have that kind of mentorship and people who've really created the space for me to do that. But that's been critical. The layer around being an Indigenous woman physician leader, is a massive one. When I recently took a new position, a colleague on Twitter said to me, thank you for all of the emotional labour that you do. And I think when you're working in a system that's built on, that's a colonial system, that's a Western model. And you think in a different way, and you relate to people differently, or perhaps have different values, or values that haven't necessarily been recognized that have been excluded. It's a lot of work, because you're constantly trying to explain and also constantly trying to advocate and make space.
Jillian Horton: And you know, it's interesting, just what I find myself thinking about is how that emotional labour and the work that we have to do to bring new ideas, new ways of thinking, system change is often work that is not rewarded in traditional academic structures.
Lisa Richardson: Yeah, absolutely. And so I think a part of that system change that I've been working on is how do we actually recognize this? How do we redefine what we consider to be academic excellence in our academic health sciences faculties? And how do we recognize the importance of this work that our communities recognize is important, but you know, that haven't necessarily been allowed, as and recognized in these spaces. So it's so critical, and it applies not just to the work that Indigenous scholars do, but for example, the work that you do in the humanities and many, you know, other critical scholars across medicine and across the Health Sciences fields.
Jillian Horton: So here in Winnipeg, where I work, at any given time when I'm attending on a clinical teaching unit, I would say that at least 50% of my patients are Indigenous. And I am often struck by how little I learned in medical school and residency about Indigenous models of health and healing, and how much I still have to learn. So I wonder if you could talk for a few minutes about some of the concepts that you would see as universally important in terms of understanding Indigenous health and healing.
Lisa Richardson: So there are so many concepts, but I'm going to try and summarize with what I think are some key points. And I think one of the pieces that I want to highlight is that we now are very conscious of recognizing, as you and I spoke about earlier, in preparation for this, that, indeed, there isn't a single, you know, universal or monolithic Indigenous perspective. That we have many different nations, and even within, you know, for Anishinaabe peoples for example, practices will vary based on your your community and, location. But I think that there are some shared concepts that are important. But before talking about some of the shared ideas around Indigenous models of wellness and well being, it's important to think about the experiences of your patients in these colonial institutions, meaning educational institutions, the justice system and the healthcare system. And how those experiences can be so traumatizing, because of the racism that people encounter, and the mistreatment, and because of retraumatization. So going, you know, bringing up either personal trauma that you've experienced, or history, what we call historical trauma, which is the trauma of that the whole community has experienced due to residential school. So an awareness of that is key, and then we talk about anti-racist practice as being key as well, because we know that there's so much racism still within our healthcare system that affects the outcomes. And then cultural safety, which is not actually about understanding, you know, oh, well, you know, what's an Anishinaabe base smudging practice? What specifically does that mean? It's not about developing a whole list of expected behaviors of you know, a person who's from a particular group. It's about recognizing that there is a major power differential in the relationship between a physician and patient, and we need to work to mitigate that. And that power differential is heightened when you're an Indigenous person who's had, you know, historical or ongoing experiences of mistreatment. So how do you bring that awareness into your practice. And then lastly, the trauma informed lens, which I've alluded to. So recognizing the widespread impacts of trauma and what's called trauma-informed and violence-informed care. So those are sort of some of the theoretical frameworks that I like to talk about. But I also then say we need to build on our strengths based approach of all of the incredible strengths within our cultures, and how those will help not just the healing of Indigenous people, but the well being for all people. Those are things like, we would say, well, that's good medicine, you might hear that kind of a phrase or expression, and good medicine from, I'm going to speak from an Anishinaabe worldview, or in perspective, because that's my location is everything we take in is medicine. And that's not just what we physically ingest. So good medicine is more than a medication that you take for heart failure. Good medicine is food, and having an access to healthy food. Good medicine is relationships. So having strong relationships with family and community. Good medicine is about being able to participate in your culture, and have access to those, to ceremonial practices. Good medicine is about sleep. So it's so much broader than the way in which we conceptualize what is medicine, I think in medicine, and in you know, you and I are both internists. So we're, very good at prescribing. We are not cutting, we're prescribing. So what does, so how can we conceptualize of good medicine as being a much broader idea? And then I think another really, really important concept is that health, the way in which health and wellbeing is often conceptualized is of just attending to physical health, or just attending to mental health. And again, this is a theme that we'll run across Indigenous cultures across the world. We speak about the medicine wheel teachings and understanding, which really is about understanding health as being multi-dimensional, it's about the physical health, it's about mental health, but it's about emotional health and about spiritual health as well. And if we don't understand that, you may have experienced something extremely difficult that's giving you sadness, that's giving you grief that's really causing what, you know, one of my elders would call a soul wound, it's going to be hard to feel whole and to feel well. So that's a second really key concept is there's multiple dimensions of health and wellbeing. And then lastly, I think, a strong learning for all peoples from Indigenous concepts of wellbeing is land-based learning and land-based activities. So getting out, you know, apparently, in Japan, they do something called forest bathing and, they recognize the healing power of the forest. And I think we, as Indigenous peoples understand the healing power of being on the land. And even if you can't, even if you're in an urban center, and attention, like being in a physical space, where you can appreciate and see the trees and think about, you know, I saw a peregrine falcon in an alleyway near us, in Toronto. So just having that awareness and if you can immerse yourself in a land based activity, that's ideal. So those are a few ideas.
Jillian Horton: You mentioned something meaningful that an elder had said to you and I want to talk for a bit about incorporating elders into medical education. Tell me what that's looked like within your program efforts and how it's different than simple mentorship.
Lisa Richardson: So elders, or traditional knowledge keepers can provide mentorship. Often actually, their mentorship would not be through telling one what to do in my experience, it may be through asking questions that would allow me to find a path to determine where I want to go. But elders also are carriers of huge amounts of knowledge, and of what we might call Indigenous science and Indigenous medicine and Indigenous ways of being and knowing. And so they bring that incredible wisdom that comes from all of their teachings and learnings and cultural knowledge, to an interaction. So when I was talking about, thinking about, you know, attending to your physical and mental health, elders allow us really force us and can guide us around thinking about our emotional and spiritual well being as well. And when I say spiritual, I want to differentiate it from what's commonly conceived of as a spiritual practice, in a Euro-Western tradition, which is religion, it's important to recognize how Indigenous conceptions of spirituality are different from organized religion, there are many people who do have religious practices as well. But it's this idea from my teachings, the idea that there may be spirit in everything in spirit and everything that we do, and in particular, recognizing the spirit of the land. So I think those sorts of ways of seeing the world you don't typically get in, when you walk into a counselor's office, in your Faculty of Health Sciences, or when you you know, seek mentorship or guidance from a person who's senior to you on the academic track. So I think that's been why elders are important. And we work with elders, around teaching our medical students to bring that broad perspective. One of the others with whom we work, we did a panel a few weeks ago, and he talked about how the forest, he said the forest is my pharmacy. So even laying that kind of learning and different perspective to the students is important. But then also those one on one meetings, for in particular are Indigenous learners. But the incredible importance of having them involved for other non-Indigenous learners too who really enjoy sitting and learning and being with elders.
Jillian Horton: So if we come back to the question of physician health and personal wellness, how does everything that we've just talked about inform the way that you practically care for yourself?
Lisa Richardson: Probably the most helpful tool or practice for me around thinking about my own well being, is going back to those four different dimensions of health. So and, paying attention to my physical well being I've realized, you know, I was saying that sleep is good medicine, and realizing, I think we've got a lot of literature emerging around the healing power of sleep, and the importance of sleep, but being tuned in to what my physical needs are around sleep and physical activity. Being attentive to what the mental stressors are of the job, what it's like when we care for someone who has died, what it's like when we feel that we've made a mistake. And those are things that affect us deeply, I think as physicians, but that we don't often have the space to think about and talk about. And so when I'm deliberately thinking about mental well being, I think about that and if I've had a difficult experience in my clinical practice, I need to take time and space to think about it. And it may not be in the moment because there may be, you know, 15 other patients who I have to see on the ward that day. But it would be, okay, I need to come back to that. And I need to process it and take the time to work through that and understand how it's affected me and my mental well being. And the emotional dimension of health, for me is partly linked in to what we've been talking about. But it's also teaching that I've had around the relationships, and how we don't exist in isolation. And so what are those emotionally nurturing relationships in my life, both with colleagues, where I could, you know, debrief one of these incidents that maybe I've talked about, or in life outside of medicine, and paying attention to those relationships and nurturing those is really important. And when I was reflecting recently on what it's like to be a leader in a system, which really is hierarchical and transactional, as opposed to being someone who's very relational, and values relationships. And that thinking about relationships, at work, as well as outside, I think really can help one's well being. And lastly, the spiritual realm is about what do I need to stay to really honor my role as someone who's responsible for healing others? And how I need to always be thinking about healing myself, and my spirit in order to do that well.
Jillian Horton: I love that. If we move away now, from thinking about ourselves as individuals, what do you think our goal should be when it comes to how we teach traditional concepts of Indigenous healing to all of our medical learners? How close or how far are we from that goal right now? And how are we going to get where we need to go?
Lisa Richardson: Well, we still have a ways to go, I would say, one of the key points is to recruit more Indigenous faculty. And those faculty don't need to be solely physicians, but others who are, you know, passionate about education and our Indigenous peoples who are well connected to their culture and communities, and can support our Indigenous learners. So I think that piece number one is we need to recruit more people and, mentor Indigenous leaders to be leading and guiding this work in our faculties. Secondly, there's actually a fair bit of debate around how much of these conceptualizations around indigenous well being is appropriate to be taught in the medical system. And that's not about not recognizing the legitimacy of Indigenous science. And I specifically call it Indigenous science based on learning from my my friend, Dr. Carrie Bourassa, who's the head of the Indigenous Peoples Health Institute at CIHR. She said least we have to call it Indigenous science to really ground the legitimacy and understand and recognize the weight of this knowledge that's existed for thousands of years. But the problem is that there's always a risk when you bring Indigenous concepts into these institutions, that they be appropriated, and that the intellectual property not be respected. And maybe, you know, misused. A lot of our healers and elders, some have told me to be cautious about what we're able to bring in. I'm also very conscious that I can't teach this contact. We need traditional knowledge keepers to be able to share this. I'm trained as, you know, a Western, in a Western model of medicine, I've practiced ceremonial and cultural knowledge, but I'm not an expert in this area. So recognizing who the experts are, and making sure we create space for elders, and that they are recognized as experts. Like I say, you know, just it's like having the chair of Internal Medicine from Harvard comes into our class, when we have, you know, some of our language speakers and elders with us, we really need to see that legitimacy of this amazing knowledge that they have. And then I think what people struggle with is you can talk about the concepts like I've mentioned. So we can talk about the concepts of cultural safety and anti-racist practice and trauma- and violence-informed care, but what does it really mean? Like when you're at the bedside, with Indigenous patients? So I think that's where we're still working on how to translate these ideas into teaching in the clinical realm and what does that really look like? And of course you in Manitoba, you're well ahead of many of our institutions in this area, because you have an amazing cohort of faculty who are doing this work and thinking about it, and also evaluating it like how do we know that this teaching is making a difference in the lives of Indigenous patients and the experiences of Indigenous patients? So I would say, like, those are some of the system level things that we need to address in terms of health sciences, education for Indigenous health.
Jillian Horton: And, you know, one thing you just made me think about, as you were talking is, we're talking a lot about medical education settings, where an individual who is insightful and motivated to learn more about anti-racism practices, and really wants to create a healing and welcoming space for Indigenous patients, you know, there are ways that they can go and begin to get more insight and education into how to change their own practices and create that space. But one question I have for you is just for a physician listening, who is practicing outside of an educational institution, who really would like to become more skilled in this regard and learn more about best practices? Where would you advise that person to begin?
Lisa Richardson: So I think, starting with yourself, always, as a practitioner, and doing that inward looking to think about, you know, who you are. And when we become physicians, we put on our white coat. And the expectation is that we erase our whole history and our cultural background. And that's certainly, I think, what's in part contributing to our burnout is we suddenly have to behave like automatons. We also have to be compassionate too right. So starting with yourself, and really doing what I would call that reflexive work. It's reflexivity. So understanding your journey to where you are, and also understanding the biases that you may have picked up along the way, just based on living in this society, actually, where there are a lot of stereotypes and bias and racist habits that we learn. So thinking about your own situated perspective. And then also simultaneously reading and talking to people and resources for reading, we've created an Indigenous health primer for the Royal College that people are really liking. It's about a 50 page read I think, and you can find it on their website. And it goes through a lot of key concepts related to Indigenous health, including some things like jurisdictional boundaries around provincial versus federal. Including some of these concepts like the anti-racist practice and what that means. And also some other important knowledge, like non-insured health benefits. What does that mean, who's covered by that? So that's an important resource. The San'yas cultural safety module is amazing. It's an online learning module that's been evaluated and shows how much the physicians learn when they do that. It's about an eight to nine hour commitment, but you can do it, you do it over several months. And that's amazing. And then whatever your local resources are, like, if you're in a community where there's a friendship center, are they offering any sort of cultural activities and learning opportunities. And then I think when you're actually at the bedside, in practice, I always tell people to go back to some basic concepts, humility. And this applies with all of our patients. We don't understand what it's like to be, you know, what this person whom we're treating has experienced, what they're living with, what their symptoms feel like. So having humility in our interactions, and really listening to what our patients are telling us. And then secondly, building relationships. So if you are, you know, entering into an interaction with a patient with what we would call an open heart and an open mind, so that you're open and you've thought about your biases that you may bring, and you're working to mitigate those and you have that open heart so you're present with humility, and you're present to listen deeply to what your patients are telling you, then you can build a relationship and when you have a strong foundational relationship, then it doesn't matter if you know, you can say to a patient, how would you like me to refer to you or, you know, what nation are you from? And you're not, even if you make a mistake in how you ask the question, when you're there and present, in that way the patient feels that you are committed to the relationship, that doctor-patient relationship, then you can make those sorts of mistakes, right? Because people often worried Oh, I don't know what to say, I don't know what language to use. And, so I do like to counsel people that it's really about being present and authentic and having humility and focusing on the relationship building.
Jillian Horton: You talked earlier about storytelling as one of the potentially universal principles of sharing knowledge and Indigenous health, again, recognizing that that's a generalization and there are an infinite number of practices and beliefs that we're referring to there. But I wondered, you and I are both proponents of narrative medicine. We both have backgrounds in English before medicine and strong believers in the role of the humanities. Are there particular books or narratives that you have found really useful in your own teaching when it comes to bringing this work, and bringing the experience of Indigenous patients alive to those who are really looking to develop more cultural competency?
Lisa Richardson: There are so many incredible Indigenous writers right now in Canada. It's like, wow, it's this incredible resurgence of storytelling that's now made it to, you know, the book market. And so, I mean, I love work by Kate, because you're from Winnipeg by Catherine Burnette. I love her poem From the North End. I love all of her writing. I think people tend to really find Thomas King engaging because he has such a great sense of humor. Any work by Jesse Thistle, especially his memoir. I found people are transformed by reading his work. One of my favorite books right now is Tanya Tagaq, Split Tooth. She's the Inuit singer and performer who is just a spectacular writer as well. It's interesting because I've shared that book with numerous non Indigenous peoples who actually found it too difficult to read, because the content they said was, quite traumatic. But I think it's the beauty of her storytelling and her poetic voice is just so spectacular. And as you persist through the book, it really is a spectacular read. So it's called Split Tooth. And that's my favorite right now.
Jillian Horton: I have to add in my, one of my favorites, I just love Darrel J. McLeod's work. He has such an interesting section in his book, where he talks about his experiences thinking of being a medical student, you know, hoping that he could go to medical school, and of course, he became a chief land negotiator. But I found myself thinking in that book, oh, my heart almost broke. He's made such incredible contributions elsewhere, but thinking of you know, this brilliant person to whom the door was closed to medicine at a particular time, I couldn't help but think what his contributions would have been if he'd had that opportunity. And he just offers such an interesting perspective on medicine as well, during the time that he was working as an orderly.
Lisa Richardson: That's a great suggestion. I'm in my office right now. And I'm looking at my bookshelf and, one that is standing out to me, for anyone who's interested in Indigenous narrative medicine is Lewis Mehl-Madrona, who's an American Indian scholar and physician who has a book called Narrative Medicine, more theoretical but helpful for people who are wanting to possibly engage in this work with their learners or others.
Jillian Horton: So I just want to ask you one more question. What is your favorite piece of advice for colleagues, for physicians for learners in terms of physician health?
Lisa Richardson: You know what I've learned? I've done many interviews with patients to try to understand what they hope for and what would make an ideal physician interaction. And one of the things that I keep coming back to is this idea of just being yourself, being human. And I think it goes back to the idea that I spoke about earlier around putting on the white coat and feeling that you erase your identity. And I think we need to teach our learners and as physicians, we need to remember that physicians are humans too, and not to hide that because that actually is where the strength of the ability to connect with our patients comes from. So being yourself, being human, being authentic.
Jillian Horton: You make me think about something that I frequently am interested in, in writing and teaching and everything else, which is that in creating this concept of professional boundaries, we've actually mistakenly taught people to erase the core of what is meant to sustain us in medicine and what is actually the most healing thing that we have to offer, which is just this deeply sacred physician patient relationship.
Lisa Richardson: I think it's so critical, and it's interesting how it has evolved because we have the Educating Future Physicians of Ontario report that led to, was a precursor to CanMeds you know, the different roles that we have as physicians, a scholar, communicator, advocate, etc. And, they in the Educating Future Physicians of Ontario report, there was a role of physician as person, and that actually got lost when it was translated. And I think we need to reclaim that role, and recognize the importance of that role. And that will go a long way towards sustaining us. I think it's especially important and you know, Eric Topol and Abraham Verghese are speaking about this a lot in their podcast around AI in medicine, but as AI and technology really starts to change our practices, I think we need to especially now hone in on the meaning of what doctor patient relationship is all about.
Jillian Horton: Well, Dr. Richardson, it has been an absolute pleasure speaking with you. Thank you so much for taking the time out of your day to talk with us.
Lisa Richardson: Thank you so much for being such a great interviewer, Jill.
Jillian Horton: Thank you. I've been speaking with Dr. Lisa Richardson, an Anishinaabe internist and strategic advisor of Indigenous health in the Faculty of Medicine at the University of Toronto. If you'd like to hear more podcasts in the series, Med Life with Dr. Horton, you can find them as part of CMAJ Podcasts on SoundCloud, Apple podcasts, or wherever you find your podcasts. And please don't forget to subscribe and leave us a rating. This podcast was made possible in part by the support of the Alan Klass Health Humanities program at the University of Manitoba. I'm Dr. Jillian Horton. Thank you for listening.