Fulfilling First Nations health, cultural safety and equity accreditation standards in primary medical education: reflections from a First Nations desktop review team

Abstract

Realising health equality for First Nations Peoples and Communities in Australia and New Zealand (Aotearoa) demands a shift in the way primary medical education providers conceptualise and enact equity, through their functions and programs. Following the release of the Standards for assessment and accreditation of primary medical programs¹ (2023) by the Australian Medical Council, a desktop review team, comprising First Nations medical education stakeholders from across Australia and Aotearoa, was formed by the Australian Medical Council. The team was tasked with evaluating preliminary self-assessments of primary medical education providers, regarding if and how they are currently positioned to meet the new standards pertaining to First Nations health, cultural safety and equity. In this perspective article, we offer our reflections on the desktop review process. Through sharing our reflections as First Nations Peoples, we aim to inform primary medical education providers and stakeholders of the challenges and benefits in a shared sovereignty approach, to realise meaningful progress in this space, and others.

Most of the authors of this article, but not all, are members of the Australian Medical Council (AMC) Desktop Review Team (DRT) for primary medical programs (9 out of 12 members), as well as members of the AMC Indigenous Policy and Programs (IPP) team (AS, MJ, BG). We are a collective of Aboriginal and Torres Strait Islander Peoples from across Australia (the only Māori DRT member did not opt for authorship on this article), working daily in the medical education context: PS is a Biripi man, NM is a Wadawurrung/Wurundjeri woman, MM (Mackay) is a Wiradjuri woman, IL is a Larrakia/Karajarri man, MH-B is a Wiradjuri woman, MC is a Wonnarua/Kaapay Kuuyun/Yirrganydji/Meriam Mir/Kala woman, EM is a Gundungurra woman, MM (Muscat) is a Bidjara woman, KM is a Central Arrernte/Mara/Bunuba/Kija/Jaru woman, AS is a Wiradjuri man, MJ is a Pitjantjatjara woman and BG is a Dharug woman.

We represent often invisible, yet strong threads, entwined to hold many community relationships, medical schools and societies together. We are united in our efforts to realise a liberatory agenda, one that seeks to progress the medical education space for First Nations Peoples and Communities. Fundamentally, our objective is to amplify First Nations’ conceptualisations, knowledges and voices within medical education, working to attain equality for our peoples through centring equity. We represent great diversity in our cultures, perspectives and experiences; however, are united in our determination to be acknowledged and appreciated within the medical education academy.

We invite you to consider the potentials of social justice and epistemic pluralism within the medical education and health care environments, underpinned by cultural humility. We invite you to conceptualise a space where diverse knowledges, beliefs and realities are equally valid and valued, a space where ideological domination presents with it, limitations in realising equity, and thus equality. We invite you to demonstrate civil courage, to swim against the tide of Eurocentric superiority, to cast a critical lens over the realm of medical education, and to recognise the value in First Nations Peoples self-determining their medical care journey, supported by a culturally safe medical workforce.

Within this article, the term “First Nations Peoples” is used to refer to Aboriginal and Torres Strait Islander and Māori Peoples. The term “Indigenous” is also used when referenced by specific groups. A short glossary of key terms has been included (Box).

In 2023, after three years of comprehensive consultation, collaboration and development, the AMC released transformational accreditation standards for primary medical education providers in Australia and Aotearoa.¹ The new standards represent a significant contextual shift regarding what domains are valued in the contemporary medical profession. Notions of cultural safety, equity, self-determination, collaboration and the inclusion of First Nations knowledges and perspectives are palpable within the new standards. However, despite such focus, transforming medical schools to genuinely embed these concepts within their programs first requires a fundamental shift in institutional ideology.^{2, 3} Medical education institutions that privilege Eurocentric, biomedical-informed practices are challenged to refocus and reconceptualise their role as socially responsible establishments that exercise their authority to promote epistemic pluralism, cultural safety and critical consciousness.^{4, 5}

Perceived barriers to such transformation, often touted through narratives of capacity and resource limitations, institutional bureaucracy and ignorance, undermine the basic function of medical education. That is, as declared by the Medical Deans Australia and New Zealand, to “contribute to healthy communities through the development of high-quality, work-ready, adaptable, and patient-focused future doctors” (https://medicaldeans.org.au/). Such intent honours notions of professionalism, responsiveness and person-centredness, where the future medical workforce can provide care that is of high quality, regardless of a patient's background, lived experience or intersecting identities.

Additionally, the Australian Commission for Safety and Quality in Health Care, the Australian Health Practitioner Regulation Agency (Ahpra), Te Tāhū Hauora Health Quality and Safety Commission, and Te Kaunihera Rata O Aotearoa Medical Council of New Zealand all promote health care that is culturally safe, of high quality and free from racism and discrimination.^6-9 The progressive rhetoric evident throughout the directives of these peak authorities aligns intimately with, and is referenced in, the revised AMC standards, clarifying the responsibility of the modern medical professional to emphasise social, cultural and epistemic justice in health care.

The significance of self-determination for First Nations Peoples is discernibly centred throughout the structure and function of the AMC. This is evident across their business, which has allowed the organisation to establish a culturally safe and productive platform for First Nations Peoples and perspectives, to meaningfully contribute to equity and equality within medical education institutions and programs across Australia and Aotearoa. Such autonomy was extended to us, as the First Nations DRT, via the AMC IPP team, to enhance a culturally safe approach to reviewing the various medical school self-assessments against the revised standards, within the bounds of the AMC published procedures.

In sharing our experiences, including those of the AMC IPP team, it is hoped that other health and education institutions across Australia, Aotearoa, and indeed the world, enhance their understanding of a shared sovereignty approach with First Nations Peoples and Communities.

The CONSIDER reporting criteria checklist for health research involving Indigenous Peoples¹⁰ was completed for this article and can be found in Supporting Information, part 1.

Following the desktop review process (detailed in Supporting Information, part 2), we agreed that sharing our experiences may be of benefit to others, both from a DRT and an AMC IPP team perspective. A short anonymous survey was developed by the AMC IPP team (Supporting Information, part 3) that DRT members could complete (6 members completed the survey). The survey sought to gain an understanding of the experiences of DRT members during the desktop review process, and explicitly stated that responses would inform a reflective peer-reviewed publication, as implied consent. In addition to the survey, PS developed a list of reflective questions (Supporting Information, part 3) that DRT and AMC IPP team members could respond to, based on their experience during the process. The individuals that did respond are co-authors on this article. Both survey and reflective question responses underwent reflexive thematic analysis¹¹ by PS and were then verified by the co-authors.

As a group, we (DRT members) had a particularly positive experience working with the AMC during the desktop review and felt well supported, genuinely engaged, respected and valued, with a strong sense that our voices were able to lead conversations during the process. Many of us reported feeling culturally safe during the experience. Critical feedback included feeling overwhelmed and burdened by our involvement in the process, confusion surrounding the review for those new to AMC processes, assumptions and ignorance demonstrated by medical schools, limited communication to medical schools by the AMC, and a lack of review training provided by the AMC. Four intersecting themes were generated via reflexive analysis of our reflections: First Nations-led and self-determination; capacity and confidence building; collaboration and collectivism; and cultural safety.

The collaborative approach adopted by the AMC regarding the review of primary medical education provider self-assessments against the revised accreditation standards demonstrates the significance, effectiveness and efficiency of shared sovereignty with First Nations Peoples. The reflections represent a focused, insightful and unified voice that echoes First Nations Community's calls for equity, equality, self-determination and a centring of First Nations perspectives within health and medical contexts.¹² Despite this, a lack of Māori representation in the authorship is a glaring limitation of this article, with only one Māori person involved in the DRT. The merit in a First Nations sovereign approach, where leadership and decision-making lie exclusively with First Nations Peoples, cannot be overstated, and is reflective of a broader First Nations collective self-determination agenda.¹³

Non-First Nations governed institutions, such as medical schools, health care services, and accreditation institutions have an ethical responsibility to ensure meaningful, ongoing collaboration with First Nations Peoples that centre self-determination and cultural safety.¹⁴ This responsibility extends to ongoing critical self-reflection and reflexive practice when working with First Nations People, ensuring accountability.¹⁵

To advance First Nations equity within medical schools and programs, collectively critiquing Eurocentric discourses and practices that dominate medical education, and health care more broadly, is encouraged.² Primary medical education providers and stakeholders must be critically conscious of the limitations in these power-laden epistemes and consider how epistemic pluralism expands knowledge potential for all.⁴ Valuing and validating diverse health perspectives enables genuine inclusivity in health care for First Nations Peoples, promoting equity in health care access and equality in health care outcomes.¹⁶

It is important for primary medical education providers and accreditors to recognise that we, as First Nations Peoples, are stewards of our Communities, positioned with privilege within the academy to fulfil a goal of improved health care and outcomes for our People. It is through us that the voices of First Nations Peoples and Communities are centred, propagated and amplified within the medical education space. This mandate requires meaningful establishment and support of culturally safe spaces by primary medical education providers, where self-determination, collaboration and capacity building can realise this objective. Moreover, our diverse knowledges and experiences offer great potential to transform medical education, re-centring humanitarianism in medicine.

The benefits in open, shared learning between First Nations and non-First Nations Peoples cannot be overstated. This extends well beyond the medical education space, or even the broader education and health space, into such spheres as business, politics and environmental management.¹⁷ A shared sovereignty framework and approach to working can enable a plethora of perspectives and methods to collide, interact and transform, to produce novel understandings that offer mutual benefit potential (as was evident during the desktop review).

Despite an identified need to address fundamental priority areas, such as cultural safety, medical schools can realise tangible progress in meeting and exceeding the new standards through a genuine commitment to shared sovereignty, centring principles of “First Nations-led” and “self-determination”. The AMC approach to the desktop review is an imperfect model that other institutions, including medical schools, could learn from and adopt within their local context. Ultimately, a shared sovereignty approach values First Nations perspectives and knowledges, which can enhance cultural safety, equity, agency, self-determination and student cultural capability development, and thus school advancement to meet and exceed First Nations health, cultural safety and equity standards.

Open access publishing facilitated by University of Wollongong, as part of the Wiley – University of Wollongong agreement via the Council of Australian University Librarians.

Paul Saunders is a member of the Australian Medical Council (AMC) Medical School Accreditation Committee (MedSAC) and the AMC Aboriginal, Torres Strait Islander and Māori Committee, both of which provide a sitting fee. Maria Mackay is a member of the AMC Prevocational Standards Accreditation Committee (PREVAC) and the AMC Aboriginal, Torres Strait Islander and Māori Committee, both of which provide a sitting fee. Melissa Johnson, Adam Shipp and Belinda Gibb are employed by the AMC. Paul Saunders is a Guest Editor for the 2025 NAIDOC Week MJA Special Issue and was not involved in any editorial decision making about this article.

Not commissioned; externally peer reviewed.

Saunders P: Conceptualization, data curation, formal analysis, methodology, project administration, writing – original draft, writing – editing and review. Mercer N: Data curation, methodology, writing – editing and review. Mackay M: Data curation, methodology, writing – editing and review. Lee I: Data curation, methodology, writing – editing and review. Hudson M: Data curation, methodology, writing – editing and review. Cavanagh M: Data curation, methodology, writing – editing and review. Milliss E: Data curation, methodology, writing – editing and review. Muscat M: Data curation, methodology, writing – editing and review. Martin K: Data curation, methodology, writing – editing and review. Shipp A: Data curation, methodology, writing – editing and review. Johnson M: Data curation, methodology, writing – editing and review. Gibb B: Data curation, methodology, writing – editing and review.