NACCHO Aboriginal Heath :The good GP is always unlearning

DR Tim Senior

“In Aboriginal and Torres Strait Islander health, we are unlearning that we need to know about Indigenous cultures so we can change them to be more like us and discovering that we should learn about our own institutional cultures and try changing them instead, which, it turns out, is good for the health of all our patients

Nowhere is this more evident than in my field of Aboriginal and Torres Strait Islander health. My work in an Aboriginal Community Controlled Health Service has gradually taught me that our health institutions are profoundly cultural institutions. Our profession has a deeply ingrained culture of its own, every bit as influential as the much older Aboriginal and Torres Strait Islander cultures we are taught about in cultural awareness training. While learning about these other cultures is important, it’s most effective when we recognise and unlearn features of our own..

Dr Tim Senior  a GP working in Aboriginal and Torres Strait Islander Health at GP Tharawal Aboriginal Corporation writing in the Medical Republic

The nature of using evidence to improve our decision-making means we discover what we’ve become accustomed to doing is no longer deemed to be best practice, and we need to change it.

At times, the constant shifting of evidence can make it feel as if we’re building our practice on foundations of jelly. I remember the feeling of disorientation after graduating, when it turned out beta-blockers had switched from being contra-indicated in heart failure, to being indicated. There’s a reason that some alternative medicines find attractiveness in a claim of thousands of years of non-changing wisdom. You just don’t have to worry about new evidence or changing practices.

But I’ve never met a general practitioner who doesn’t want to do better tomorrow than they did today, and we accept, sometimes excitedly, changes that improve the care of our patients. Medical publications have a role in guiding us through discussions about these changes, where the highways are, and when we’re being led down cul-de-sacs. In the absence of infinite wisdom, if they’re doing this right, they’ll sometimes get this wrong.

The most challenging changes to our practice, though, aren’t small changes to the medications indicated in some conditions. Our major challenges often come from patients telling us, sometimes angrily, sometimes hesitantly, their experiences of using our services. It’s tempting to be dismissive. Most people don’t understand the complexities of decision-making in general practice. Why should we listen to outsiders?

Nowhere is this more evident than in my field of Aboriginal and Torres Strait Islander health. My work in an Aboriginal Community Controlled Health Service has gradually taught me that our health institutions are profoundly cultural institutions. Our profession has a deeply ingrained culture of its own, every bit as influential as the much older Aboriginal and Torres Strait Islander cultures we are taught about in cultural awareness training. While learning about these other cultures is important, it’s most effective when we recognise and unlearn features of our own.

Unlearning is a process – at its most profound, an uncomfortable one – of realising that what we have been accustomed to doing is no longer appropriate. It’s not just adding on new knowledge to existing frameworks, but rebuilding the framework itself.

The whole process of medical student education is one of introducing people into the doctor culture – the approaches we take to any given problem, the questions we ask, the behaviours we exhibit. We sometimes call this the hidden curriculum, but I’ve also heard it called brainwashing. It’s almost never explicit, and so it is deeply influential. Much of it is appropriate; “Above all do no harm”, the use of best available evidence to guide our management plans, learning a precise and accurate language for professional communication, and patient-centred care. Sometimes, however, this can hold us back from being as effective as we might be.

For example, we can do harm with the way we are taught to order tests – it’s a brave student who’d suggest not doing any investigations for a particular set of symptoms. Our use of evidence can privilege the best-on-average over what might be right for this particular patient in front of me – and eliciting that requires a particular set of skills to be unlearnt. Our language often includes terms like “compliance,” which is unhelpful, and really just a way of saying “The patient hasn’t done what we discussed, and I can’t be bothered to find out why”. And we love to think ourselves patient-centred, but rarely get around to asking patients what they think.

These are things we have to unlearn. We are already in the process of it, for example, with the suggestion that too much medicine can be harmful and the Choosing Wisely campaign, or in our realisation that we need to tackle the social and environmental causes of ill health that lie well outside our consulting rooms.

In Aboriginal and Torres Strait Islander health, we are unlearning that we need to know about Indigenous cultures so we can change them to be more like us and discovering that we should learn about our own institutional cultures and try changing them instead, which, it turns out, is good for the health of all our patients.

So, I wish The Medical Republic well, and hope it is around long enough to report on which of our current practices we must unlearn. I’d love to see it help that along by challenging us, being subversive, and sometimes, as a measure of its success, just plain wrong.

Dr Tim Senior is a GP working in Aboriginal and Torres Strait Islander Health at GP Tharawal Aboriginal Corporation

For more on unlearning see Rushmer R, Davies HTO. Unlearning in health care. Quality and Safety in Health Care. 2004 Dec;13(suppl 2):ii10-ii15. Available from 

NACCHO Aboriginal Health Social media: Twitter yarn- Community engagement in an Indigenous health context


The tradition of yarning in sharing Indigenous knowledge is also being used in research and clinical contexts – but the notion of Twitter-based yarning is something new.


Our thanks to Melissa Sweet, Siv Parker and Dr Tim Senior


Siv Parker, an award-winning Aboriginal writer with longstanding experience in the health sector, has been at the forefront of developing tweet-yarns, as was in evidence last week while she was guest tweeting for @WePublicHealth.


“There’s no better way to explain complex health matters than a yarn,” she said.

Below are some of Siv’s tips about effective community engagement and how to run a community meeting, followed by a Twitter yarn which shows how an engaging story can unfold within the limitations of 140 characters.

Siv, who is also a keen blogger, says she treats social media very seriously, after many years of  jobs (including working on the NT Intervention) where she was unable to have a public voice (and you will be able to read more about this when her first book is published later this year).


HOW YOU CAN CONNECT THE NACCHO (6,000+ Twitter followers)

Connect to CROAKEY @croakeyblog

Community engagement

‘Community engagement’ in an Indigenous health context….. will be the difference between achieving ‘outcomes’, or not.

  • For some CE is a sausage on a barbie & muffled announcements thru a megaphone. For others it’s a minuted monthly committee mtg.
  • I was asked is there a handbook for every cmty re CE, cultural protocols etc. Tools exist, but it comes down to who are U & why are U here?
  • Can you explain who are you? Why are you there? What do you want? If you can’t how will anyone trust you? Would you trust you, with health?
  • If you are going to a cmty: do your homework. Going to the trouble of flying/driving to a cmty? Research the place you are going to.
  • Listening to grievances takes skill. Tip: Don’t promise to ‘look into an issue’ if there’s no intention of following it up. Common mistake.
  • CE requires groundwork. Research your org’s dealings with the cmty & the cmty in general; and maintain an up-2-date cmty contacts directory.
  • My CE: When I mean ‘no’ I say ‘no’. If I mean ‘yes’ I say ‘yes.’ When I can’t change what happened the last time I say so from the get go.
  • It’s worth searching for submissions from cmtys/orgs to the various Intervention inquiries for suggestions on effective CE from cmty people.
  • Operators don’t really want to hear the ‘negativity’ from the cmty that goes with CE. But think their own lack of trust is legitimate. Hmm?
  • If you work in health & seek effective CE, I suggest you erase the expression ‘gatekeeper’ from your vocabulary/approach. ‘Gatekeepr’ is a gross distortion. It’s largely an insult and wholly inaccurate. It’s used to ‘explain’ failure to get CE.
  • CE is not about outsiders deciding who you want and who you don’t want to talk to. Setting up a meeting of people that you like is not CE.
  • Need to have ‘your’ mind on CE the whole time. If ‘you’ revert back to ‘controlling’ check ‘yourself’.
  • The essential role that advocacy groups, eg @NACCHOAustralia @congressmob play is they already know the cmtys. They’re invaluable resources.
  • #design Layouts for cmty clinics? Consider outdoor seating. If you have shelter for people outside, you are more likely to get them inside.
  • Indg people have not engineered their own disadvantage. When people claim to not have time for CE, they follow a long tradition.
  • Takes up our time needing to repeat ‘Indg people/cmtys are diverse’. That means CE is req’d & not just with a few.
  • When you are Indg there is an expectation that you must represent all Indg people, at all times. I don’t. It’s an unreasonable expectation.
  • Some people tell me of their disappointment in not being able to find an Indg person to talk to ‘when they need one’. That sums it up.
  • On advocacy, there’s a diff btwn CE & knowing the cmty perspective & offering solutions or reporting on a cmty as if it’s a foreign country.
  • Simply put, if you want the ‘Indg cmty perspective” you need to speak to more than 1 person, unless that 1 is engaging the rest of the cmty.

Tips for a successful community meeting (reproduced direct from tweets)

1. Notify the cmty you are coming. Western Sydney, Logan, or Borroloola – notify all the Indg orgs.

On 1. Don’t assume someone will do all the running around for you. It’s your meeting. And say why & who will be attending the mtg.

On 1. You may only go there one time in your life, but why be the dud one? Notify ahead as a courtesy & you may well get a better reception.

2. If you are not comfortable with a mic, for the love of frogs, don’t use one. But don’t call a big mtg either & expect people to lip read.

3. Visual aids. Use them where ever possible. And if you have a report in your hand, bring copies. Don’t refer to ‘mystery book’. It’s rude.

4. Introduce yourself & repeat why you are there. Do you want a decision ‘today’? Are you just providing info? Do you want to plan an event?

On 4. Introduce yourself – to people inside & outside – who you are, where you are from & what you do AND let them know how to contact you.

On 4. If it’s a health related matter, brief e/one who works in health before you arrive. Tap into all of the existing cmty health networks.

On 4. Closing the gap is about all areas of disadvantage. Eg health is related to housing, educn, employment, dogs, drains, ditches etcetc

5. How big is the mtg? Wrong: ‘We don’t need everybody to come.’ Right: ‘The mtg’s to talk about xyz. Who from the cmty should be there?’

6. Now we get to a big issue: catering. Do not cater 8 sandwiches for a mtg of 240 people & ask me to distribute them. You’re on your own.

On 6 in gen’l, catering depends on where you are, how far people travelled, was it suggested, your budget? Or will tea/coffee suffice?

7. Venue. Ask the cmty where they hold mtgs. Myth: Indg people want to be outside at every opportunity. Do not decide the air temp yourself.

8. You’ve been waiting to know about ‘sitting fees’. ? Be straight up; some do, some don’t, deal with it & be prepared to repeat yourself.

When I hear reports that no mtgs have been held (ever) because of a dispute over sitting fees…I say ‘you’re doing it wrong’.

9. Do your research before you arrive. If you are asked Qs you may have to to ‘take them on notice’. But if you say you will respond, do it.

10. Minutes are essential. Get attendees contact details, Don’t assume they have no net access. Don’t assume they have access to a printer.

11. If you say ‘the cmty leaders must be at the mtg’ & you are an ASO4 ask yourself: Are you a ‘leader’? Why are you using that language?

12. Be prepared for cmty phone calls after you leave AND to return for a 2nd mtg. Don’t expect an answer from 1 mtg. Be careful with pics.


NACCHO political alert: Health policy debate Q and A tonight:Have you submitted a question from your mob yet?


Health policy is up for debate tonite at 9.30 am (Monday April 22 ) on ABC TV’s Q and A program, featuring Federal Health Minister Tanya Plibersek and the Opposition’s health spokesman Peter Dutton

You can lodge your questions here



Or follow some the commentary on CROAKEY

Some of the comments from our ACCHO’s include

Selwyn Button, CEO, Queensland Aboriginal and Islander Health Council
Self-determination and self-responsibility – in recent weeks much has been spoken about the notion of practical reconciliation from the opposition, whilst there is still some talk of self-determination being critically important to improve outcomes for Indigenous Australians.

Conceptually both these discussions a sound in there logic and proposed approach, although still do not go to the heart of real self-determination of ensuring that not only are Indigenous people provided with access to required services, resources and involvement in decision-making about how this happens, but going a step further to give overall autonomy and responsibility for policy, planning, program development, delivery and outcomes to Indigenous people.

This can and should happen particularly in places where there is demonstrated capacity and willingness to take on this challenge and risk associated, although governments are risk averse in nature and generally shy away from this next step.

If Indigenous communities and organisations can demonstrate willingness, understanding, organisational maturity and capacity, perhaps we should take the risk together in order to support improved outcomes. This work is not ground breaking as it has already happened in Canada and NZ with significant results and could provide a template for greater autonomy in delivering services to Indigenous people by Indigenous organisations in or own country. Working alongside this notion is also the importance of Indigenous communities and organisations willing to accept the challenge and demonstrate capacity and leadership in this space for governments to want to take risks. This also would mean that not only are Indigenous communities and organisations willing to accept the challenge, we must also be willing to accept and embrace our failures if it doesn’t work.

Dr Tim Senior, a Croakey contributor and a GP working in an Aboriginal health service in Sydney, has a long list of questions, including:

  • What do you see as the future for Medicare Locals?
  • There is clear evidence that inequalities are a cause of ill health for everyone. How will your government tackle this?
  • Wherever we look, we see that those who need health care the most get the least. This is true in rural and remote Australia, and true in pockets of our cities. How will you address this?
  • How do you plan to increase the capacity of the workforce to manage increasing numbers of people with complex and chronic care needs?
  • How do you plan to incorporate training of health professionals in health services that are already stretched?
  • How do you see the use of e-health and telehealth initiatives in the future? What impact will your National Broadband Network policies have on this?
  • Given that the evidence shows improved health comes from primary care, rather than hospital care, what are your plans to fund high quality primary care?
  • How will you improve the integration of primary and secondary care? What are your plans for improving access to dental care?
  • Do you have any changes planned for the way Medicare funds health services?

Why Facebook should Unlike racism and the health sector needs to step up to the plate on racism

Our thanks to CROAKEY (Melissa Sweet) and Dr Tim Senior writes

As of this moment, more than 10,000 people have signed this petition calling on Facebook to take down the racist attack on Indigenous Australians that is in the news.

And more than 16,000 people have signed this one.

I wonder how many people from the health sector signed the petitions?

In the article below, Dr Tim Senior, a GP who works in Aboriginal health, argues that the health sector needs to step up to the plate in tackling racism. It is a public health issue well beyond the pages of Facebook.


Why Facebook should Unlike racism and the health sector needs to step up to the plate on racism

Dr Tim Senior writes:

Yesterday, news broke of a Facebook page called Aboriginal Memes, containing offensive stereotyping of Aboriginal people. Apparently, Facebook took the page down briefly, before reposting it with an addition to the title: “Controversial humour.”

I have had a look at the site, and I didn’t find any humour. I have written and performed comedy in a previous life, and my sense of humour hasn’t deserted me.

There was none there – just offensive racial vilification that made me feel sick. Humour doesn’t throw stones down from powerful to powerless – it throws rocks back up!

As of this morning, it looks like the original pages may have been taken down, but that the site appears to be back up, under a slightly different  name (which I’ve reported to Facebook).

Clearly, this is racist material. People who know better than I, say this breaks the law, not to mention Facebook’s own community standards.

However, there will be many who say, that while they disagree profoundly with what is said, they believe that this is an issue of free speech.

If, for just a moment, we allow that as an argument, it does not follow that free speech means that your ideas aren’t challenged. If you are really going to make the free speech argument about offensive material such as this, then you also have to allow free speech to those vigorously opposed.

But what if the law were changed, so this wasn’t illegal, as Tony Abbott has suggested he might do. What if Facebook changed their community standards to allow for any sort of speech (except the depiction of breast feeding of course!)

Would there be any reason, then, to ask for the site to be removed? Is there any particular role of health professionals and health policy advocates? I believe there is.

It is already well established in tobacco control, seatbelt wearing and drink driving that the freedom to do something can be restricted by the excess risks this puts on people’s health.

Significantly, with all of these, the decision of one individual affects the health of others, through passive smoking (especially in children), and through traffic accidents to others.

The case is also being made convincingly in the availability of junk food (or “edible food like substances” as Michael Pollan correctly calls them). There is the start of a case being made for the health issues involved in man-made climate disruption, and in the health effects of inequality.

Which brings us to racism. There is a clear effect of the experience of racism on health. Some examples, quoted by Dr Angela Durey, who has researched the health effects of racism:

  • Those who experience racist verbal abuse are 50% more likely to report their health being fair or poor than those who haven’t experienced it.
  • Those who believed that most employers were racist were 40% more likely to report their health was fair or poor.
  • A US systematic review reported an inverse correlation of racial discrimination with physical and mental health
  • Experiences of Maori people in New Zealand with verbal or physical abuse or unfair treatment in health, employment or housing resulted in a wide range of worse physical and mental health – including higher smoking rates.

On an individual level, I know people who hate going to hospital because of their experiences, who won’t go to the police if they have trouble because of their experience of racism from police officers. Many people will have their own stories.

When we talk about Aboriginal health, we often talk as if the problem is “Being Aboriginal” but in reality, “Being Aboriginal” is a marker for having experienced racism, discrimination and colonisation.

Experiencing racism is a cause of so many of the health problems we keep describing, including lifestyle risks factors.

It seems clear that the experience of racism is a cause of ill health, and so working to eradicate racism is something we should do as a public health measure.

It’s also not enough to say that people can avoid experiencing racism by not visiting the website. This assumes that those contributing to the website and those visiting “just for a laugh” do not exist outside Facebook, that at work,or with friends, none of these attitudes come into play.

It assumes that an Aboriginal person can read that someone contributing to this website works for Consumer Affairs Victoria, Centrelink, an insurance company, a catering company, and believe that they will be treated fairly when they get there.

Those contributing to this group and reading it are reinforced in their beliefs that it is OK to talk like this, that it’s all just a bit of a laugh. But in the same way that drink driving harms other people, racism harms other people. It’s not OK, and that needs to be made clear.

What is the way forward? A first step has been taken – Facebook seems to have taken some action. But we need to remain vigilant, as others will pop up.

We should compare providing these pages to making someone work in a smoke filled room or lending the drunk driver your car keys.

Tweet your displeasure, post your disagreement to Facebook. We could all leave Facebook if the site if they persist in being slow to remove unhealthy racist material and quick to remove healthy breast feeding material.

We should follow with interest the investigations by ACMA and the Human Rights Commission.

We can challenge racism wherever you see it – All Together Now campaign well on this, and you can support them here.

And finally, as Durey says, we need to turn the lens on ourselves – “white privilege is an invisible package of unearned assets” that we seldom examine, or as John Scalzi imaginatively puts it “The lowest difficulty setting there is.

This is not about white guilt or self flagellation. This is recognising that we are stood at the top of a cliff, not at the end of a level playing field.

How are we constructing our health services? What is the experience of Aboriginal people using them?

The answers won’t usually be as dramatic as those Facebook pages, but they may be just as damaging.

To do this, however, we need to listen more closely to the Aboriginal voices out there. For they are telling us about their experiences if we care to listen.

Declaration: Tim Senior has represented the RACGP at the Close the Gap Steering Committee and works for the Tharawal Aboriginal Corporation.Though the organisations I work for would not disagree with these statements, they may not express it in these terms. These are personal opinions and not the official position of any organisations I work for.