Reforming Medical Curricula to Support Indigenous Students and Reduce Healthcare Disparities

Abstract

Introduction

Indigenous populations continue to experience health inequities that are exacerbated by systemic barriers in medical education. These challenges both limit the success of Indigenous students and leave the broader physician workforce underprepared to provide culturally safe care.

Methods

This narrative literature review explores the educational experiences of Indigenous medical students and examines evidence-informed strategies to enhance cultural competency and inclusion within medical curricula. Studies were identified through database searches using Ovid MEDLINE and relevant MeSH terms, followed by citation chaining. A total of 13 studies were included in the final narrative review.

Results

Key themes from the selected literature include structural marginalization in curricula, lack of Indigenous representation, and the emotional burden faced by Indigenous learners. Promising interventions include Indigenous-led simulations, cultural immersion programs, and experiential learning in community settings. However, implementation challenges—such as time constraints, faculty training gaps, and financial barriers—persist.

Discussion

A longitudinal, integrated model of cultural humility, embedded throughout medical education, is recommended. Such an approach supports both Indigenous and non-Indigenous learners in delivering more equitable healthcare.

Conclusion

Medical education reform must incorporate Indigenous knowledge systems, address institutional racism, and center Indigenous voices to achieve cultural safety and reduce health disparities.

Introduction

Medical education plays a central role in shaping healthcare professionals, but for Indigenous students, it can be a space of exclusion, invisibility, and systemic barriers. Indigenous students frequently narrate experiences of otherness in medical school, encounters marked by prejudice, racism, and stigmatization. While these experiences do not typically make up most indigenous students’ daily lives, the overarching structure of medical education continues to reinforce their marginalization. The curriculum continues to fail to reflect their histories, cultures, and healthcare needs. Indigenous students often find that medical school curricula do not adequately address Indigenous health disparities, traditional healing practices, or the effects of colonization on healthcare access. As such, Indigenous people are often positioned as “outsiders” within academic institutions that should serve all. ¹

The medical school environment is shaped by systemic disparities. This is evident as the content of most medical schools remain dominated by European medical perspectives. The educational material given to students for the purpose of learning is almost entirely made of European studies. In turn, Indigenous views about well-being, which are based on holistic care and community-centered improvement, are ignored in our courses. This exclusion creates a sense of isolation for Indigenous students and forces them through an education system that does not fully acknowledge their cultural identities or needs. This can create a sense of loneliness for many students and can even create resentment toward the curriculum that should include healthcare for all. These structural barriers extend beyond education and affect healthcare itself. A study in Canada found that 28.5% of the Indigenous population in Canada had experienced discrimination from healthcare providers due to implicit bias. ² Other marginalized groups also face similar issues. Racial disparities in pain management further highlight systemic inequities. A study of 9900 postpartum women found that compared with non-Hispanic white women, Hispanic and non-Hispanic Black women had significantly higher odds of reporting severe pain but received significantly fewer inpatient morphine for pain management. Additionally, both groups were significantly less likely to receive an opioid prescription at discharge. ³ These disparities showcase how structural inequities and implicit bias within healthcare systems contribute to ongoing health inequities among marginalized populations. Such discrimination creates significant obstacles to accessing care, discouraging people from seeking medical attention and contributing to detrimental health outcomes.

Silencing and invisibilization emerge as both a coping mechanism and a symptom of broader institutional failures. Indigenous students often remain silent about their struggles, whether to avoid further marginalization or because their concerns are systematically ignored. In many such cases, these lingering effects of silence can extend even into the workplace, which reinforces cycles of exclusion and burnout. An example of this includes a national survey of Māori (Indigenous people of New Zealand) medical students and physicians, which revealed high levels of exposure to racism and other forms of mistreatment, with nearly all respondents directly experiencing or witnessing racism. Nearly half of Māori medical students (48%) and over 60% of Māori physicians considered leaving medicine, with many citing racism, bullying, and harassment as key reasons. This mirrors trends in the UK and the US, where workplace discrimination correlates with physicians contemplating quitting their careers. Additionally, Māori medical students and physicians frequently witnessed Māori patients and their whānau (extended family) counterparts receiving substandard treatment compared to New Zealand European patients, highlighting the broader implications of systemic bias on patient care. ⁴

Collectively, these studies highlight the urgent need for structural change. Addressing the marginalization of Indigenous students requires a shift in medical curricula, one that actively incorporates Indigenous knowledge systems, challenges implicit bias, and fosters an environment that seeks to be heterogeneous. By integrating Indigenous health perspectives into medical education, institutions can work toward producing healthcare professionals who are not only culturally competent but also equipped to reduce healthcare disparities. This paper will explore several reform strategies aimed at addressing these issues, including the incorporation of experiential learning, curriculum changes to include Indigenous health knowledge, and efforts to increase cultural competency among students. Failure to address these systemic issues risks perpetuating cycles of exclusion, harming both Indigenous medical students and the communities they aim to serve.

Literature Review/Thematic Analysis

This paper presents a narrative literature review aimed at exploring the experiences of Indigenous medical students and evaluating educational strategies designed to foster cultural competency in medical education. While this review is not systematic in nature, elements of transparency and methodological rigor were incorporated, drawing on the principles of the PRISMA 2020 guidelines to enhance clarity and reproducibility. A comprehensive search was conducted using the Ovid MEDLINE research platform. The search strategy combined Medical Subject Headings (MeSH) and relevant keywords across five main concept areas: (1) Indigenous populations, (2) medical students, (3) medical education and curriculum, (4) sociological factors, and (5) cultural competency. MeSH terms included “Indigenous Peoples,” “American Indian or Alaska Native,” “Māori People,” and “Education, Medical,” among others. Keywords included terms such as “native*,” “medical student*,” “cultural competence*,” “inclusive*,” and “curricula*.”

Studies were included if they were peer-reviewed, published in English, and directly addressed Indigenous medical students’ educational experiences, the barriers they face, or educational strategies aimed at improving cultural competency and inclusion in medical training. Studies that focused exclusively on non-medical fields such as nursing or dentistry, or that did not include Indigenous-specific data, were excluded. The initial search yielded 202 articles, of which 41 were screened in full-text. Based on relevance to the research aims and quality of discussion, 10 core studies were selected for inclusion. An additional three studies were identified through citation chaining and hand-searching, leading to a final set of 13 included studies.

Although no formal quality appraisal tools such as CASP or JBI were applied, included studies were evaluated for relevance, clarity, population focus, and methodological transparency. Because this was a narrative review, data were not synthesized statistically but instead organized thematically to identify patterns in Indigenous students’ experiences and educational innovations. This approach allows for a more holistic and context-sensitive interpretation of findings across diverse educational settings.

A total of 202 articles were identified through database searching, of which 13 met the inclusion criteria. The selection process is summarized in Figure 1.

Figure 1.

PRISMA-style Flow Diagram Outlining the Study Selection Process for this Narrative Review.

Results

Structural obstacles and inequalities still create an unjust hardship for Indigenous medical learners. This circumstance mirrors the more extensive health differences observed among American Indian plus Alaska Native (AI/AN) groups. The Indian Health Service, responsible for supplying healthcare to approximately 2.56 million AI/AN people belonging to 573 federally acknowledged tribes, reported that Indigenous communities have about a 5.5-year lower life expectancy than the overall US population. ⁵ They further exhibit excessively elevated rates of chronic ailments. These groups also have disproportionately elevated rates of heart disease, diabetes, as well as liver disease.

These disparities are tied to inadequate education, financial difficulties, in addition to unfair treatment within the health system. These ongoing gaps show a requirement for better support, increased funding for Indigenous health services, and a varied strategy to fix unfairness in education for medical students. Furthermore, Indigenous communities face significant difficulties due to a lack of representation from physicians from their own communities. A report by the Association of American Medical Colleges showed that in 2023–2024, “less than one percent of active medical residents identified as Indigenous.” ⁶ This difference is especially troubling given that doctors from these groups can often best understand and fix the health requirements within their communities. Considering that there are over 500 federally recognized tribes in the U.S. alone, the lack of Indigenous physicians leaves many communities vulnerable to a lack of culturally competent care. While efforts should focus on increasing Indigenous representation in medicine, reforms take time. In the meantime, it is important to implement novel strategies that encourage cultural competency among current medical students. By creating a deeper understanding of Indigenous communities and their healthcare challenges, these initiatives can help bridge existing gaps and improve health equity.

Many methods have been attempted to try and bridge these gaps. Some of the most recent include adding lectures by Indigenous faculty to improve competency among all medical students. These lectures included information about indigenous history, culture, and health. One study did this by adding seven didactic hours on Indigenous health to a first-year medical school curriculum. Results of this study indicated that the lectures on Indigenous health had lasting effects on students’ knowledge, with improvements observed up to at least 6 months postintervention. However, the impact on other areas such as cultural intelligence and ethnocultural empathy was less significant, particularly over time. Cultural empathy increased during the second year but did not have long-lasting effects, suggesting that while didactic teaching on Indigenous health can improve students’ knowledge, it is not capable of lasting changes in beliefs and attitudes, particularly about cultural humility and social justice. Programs that have incorporated experiential learning, such as community service or clinic-based projects, have shown stronger and more sustained effects on cultural competence and interpersonal skills. For example, programs at the University of Arkansas and the University of Hawaii included service learning and community engagement alongside lectures, resulting in improved readiness to work with Indigenous populations. ⁷

Another innovative approach was used by the Northern Ontario School of Medicine, which aimed to create more authentic learning scenarios for culturally safe care by involving Indigenous actors, known as “animators,” who brought their lived experiences to the development of simulated patient cases. The cases were cocreated with clinical faculty, and reflected diverse community members, such as a tribal police officer and a traditional knowledge keeper, and focused on conditions such as diabetes and frostbite. The goal was to help students understand cultural perspectives in health through patient interviews and feedback. The study highlighted that while these sessions were beneficial for cultural understanding and empathy, there were challenges in implementation, including the need for tutors trained in implicit bias and cultural safety. Future improvements include better preparation for students, more time for the sessions, and culturally appropriate evaluation of animator feedback. The project successfully promoted cultural safety awareness but emphasized the need for further refinement in teaching and feedback strategies. ⁸

Cultural immersion also emerged as an effective approach. A study conducted in 2020 and 2021 on first-year medical students as part of a new Indigenous Health curriculum highlights this potential. The immersion experience consisted of five stations: bush tucker (native foods), yarning circles on intergenerational trauma, weaving, bush medicines, and Indigenous culture/artefacts. Pre- and post-event surveys showed notable improvements in students’ knowledge of Indigenous cultural beliefs and history, as well as their confidence in working with Indigenous populations. In 2020, the percentage of students with “no knowledge” of cultural beliefs dropped from 26.67% to 8.25%, and history knowledge improved from 22.97% to 8.25%. A similar trend was observed in 2021. Confidence in working with Indigenous patients also increased, with the percentage of students feeling “not confident” dropping from 34.67% to 4.12% in 2020 and from 28.04% to 3.90% in 2021. Analysis of student reflections revealed that they reflected a deeper understanding of Indigenous culture and history, as well as being able to reframe their attitudes toward Indigenous patients. These findings highlight the effectiveness of cultural immersion in improving both knowledge and attitudes for culturally safe practice. ⁹

Other methods of addressing exposure to indigenous populations were tackled by a study done that focused on an Indigenous-led student placement model, which involved 938 students from 32 disciplines and 13 universities in Australia between 2017 and 2019. Placements varied from 1 to 3 days for community events to over 2 months for clinical services. Students received a 2-h orientation history of the IUIH and its Member ACCHSs, cultural training underpinned by the IUIH's “Making Connections” framework, and participated in the “Propa Ways” cultural skills program to reflect on personal values and develop cultural competency. The results were highly positive: 94% of students were satisfied with the quality of their placements, and 69% expressed an intention to work in Aboriginal and Torres Strait Islander health settings in the future, a significant increase from 40% in previous studies. Almost all students (96%) reported that they would recommend placements in urban Indigenous health contexts, and 87% agreed or strongly agreed they would apply for a suitable position at their placement site if advertised. Students reported notable improvements in cultural awareness, with 88% stating they had a good understanding of Aboriginal and Torres Strait Islander cultures post-placement, compared to 80% before. Additionally, 79% of students felt confident in their clinical skills in urban Indigenous contexts, up from 70% in a previous study. The interprofessional collaboration during placements, involving students from health and non-health disciplines, contributed to students’ understanding of their roles within the broader health system. Previous research suggests that positive placement experiences in rural and remote Indigenous health environments influence graduates’ intentions to work in these settings, potentially contributing to workforce supply over time. ¹⁰ This study highlighted that regionally coordinated placements in urban Indigenous settings improve students’ cultural responsiveness, professional competence, and confidence, while significantly increasing their likelihood of pursuing careers in Indigenous health.

Discussion

The studies presented in this paper offer different and valuable strategies to deal with the systemic barriers experienced by Indigenous medical students, as well as ways to improve cultural literacy and empathy among medical students. These actions show the immediate requirement to tackle health inequalities that largely affect Indigenous people and highlight how vital educational change is in medical schools. The value of these studies exists not just in their variety, from lectures to experimental learning to immersion in culture and even into placements led by Indigenous people, but also in their capability to demonstrate measurable improvements in student knowledge and views about Indigenous health. However, the actual reality of implementing these actions into existing courses is still difficult to answer, especially given the many demands that medical students encounter.

Medical education is already highly demanding, and the addition of new content must be carefully balanced to avoid overwhelming students. Students must balance learning the intricacies of science as well as being able to apply those principles to sharpen their clinical skills. For many such students, adding cultural training might seem like a further demand to a schedule that is already jam-packed. The strain of navigating medical school, while also preparing for high-stakes exams, conducting research, and building professional networks, can make it difficult for students to fully engage with initiatives that require time, energy, and reflection. From a medical student's point of view, the issue is not just how complex the subject is, but also the emotions linked to talking about subjects that are difficult, such as racism, past trauma, and unfair treatment in healthcare for Indigenous groups. While many such students want to improve their skills in cultural competency, they may have trouble finding the strength to take part in these areas without feeling weighed down by their academic responsibilities.

The concept of “cultural humility” also merits attention here. Cultural competency programs are useful; however, they can wrongly create the thought that learners will instantly gain expert knowledge of Indigenous health after some brief lectures. This may cause feelings of inadequacy at the task, especially for learners who feel like they are unable to grasp the depth of Indigenous cultures and experiences in that brief duration. It could also wrongly place the cultural competence requirement as an “extra” component instead of a key piece of medical education. This lowers its ability to create lasting change and diminishes overall effectiveness. It is crucial, then, that cultural competency must be integrated into the curriculum in a way that does not add to the already intense academic pressure faced by medical students but instead is woven into the fabric of the curriculum in a sustainable and meaningful manner.

Implications for Practice or Policy

When looking at possible solutions, it might prove helpful to think about a gradual, integrated method for teaching cultural understanding. Instead of adding isolated lectures or short immersion experiences, medical schools could choose to include the topic in all parts of the curriculum, starting from the early preclinical years all the way to clinical rotations. This approach would allow students to have continuous engagement with Indigenous health issues that could also be used to increase their grasp of the field of medicine. For instance, Indigenous health could be incorporated into discussions of social determinants of health, ethics, and healthcare delivery, ultimately assisting students to see how these topics have relevance in the context of patient care. Additionally, including cultural competency training in clinical settings could offer students the chance to experience integral opportunities for experiential learning while also ensuring that these lessons are grounded in real-world situations.

Another potential option is to provide support to lessen the load on medical trainees. This might mean giving set hours within the curricula for cultural skills education, offering faculty mentorship programs for students interested in Indigenous health, and/or creating collaborations with Indigenous health experts and community leaders. These reforms could lessen the pressure on many students, allowing them to familiarize themselves with the material without the worry that their academic success might become compromised. Furthermore, giving students these resources helps alleviate the mental burden of learning about health disparities in Indigenous communities and could subsequently improve rates of burnout, along with promoting greater understanding of the material at hand.

It is important to note that the lack of involvement with Indigenous groups may not only be from educational obstacles but also to financial difficulties. Many medical students, especially those with scarce funds, may want to work with Indigenous groups but are unable to because of monetary concerns. For instance, work in rural or distant Indigenous areas may involve large travel costs, accommodations for housing, or other expenses that many students cannot pay for. Medical students often handle large money burdens such as tuition fees, living expenses, and loan repayments, which can make it difficult to prioritize working in settings that do not give financial support or aid as a priority. Addressing these financial barriers could be done by offering scholarships or stipends for placements in Indigenous communities. This could make these opportunities more accessible, allowing for more students to pursue careers in Indigenous health. By lowering the financial burden, medical schools can aid students with interests in Indigenous care and further help support the balance between financial and academic obligations, all while improving their cultural competency.

Lastly, it is crucial to identify that these reforms should not be seen as a temporary solution; rather, they should be looked at as a greater part of a long-term commitment to addressing health disparities and marginalization among medical students from these communities. As evidenced by the studies mentioned in this work, the increase in representation of Indigenous physicians and healthcare providers is an important piece of addressing culturally competent care and allows for further exposure to other students and doctors about the characteristics of Indigenous healthcare workers. Efforts should continue to recruit and retain Indigenous students in Medical schools to better serve their communities, but it is also important to reiterate that Indigenous students should not be the only ones expected to work in their communities. Creating these reforms in curricula should hopefully make non-indigenous students gravitate toward these communities and incorporate their culturally competent care to address these disparities. Furthermore, this same cultural competency training should not be limited to just students; it should also include faculty and other healthcare workers so that lessons learned in medical school can be carried into everyday practice. Addressing these issues will require time, but current models do not adequately support Indigenous populations. Instead of repeating ineffective patterns, we need to revamp the system. Continuing efforts in experimental learning should be done so that the best methods of teaching cultural competency can be identified and stratified for the use of medical education.

Limitations

This review has several limitations. First, as a narrative review, it does not apply the methodological rigor of a systematic review, including protocol registration or formal critical appraisal of study quality. Second, despite efforts to ensure comprehensive coverage, the search was limited to English-language studies and may not fully capture Indigenous experiences across all global contexts. Third, the absence of meta-analytic synthesis limits generalizability. Finally, due to constraints in the published literature, this review may underrepresent the experiences of Two-Spirit, LGBTQ+ Indigenous medical students or those in non-U.S. settings. Additionally, this review focused exclusively on medical education and did not include other health professions such as nursing, dentistry, or allied health, which may also benefit from similar curricular reforms and deserve future study. These limitations should be considered when interpreting the findings.

Conclusion

Systemic inequities in medical education continue to marginalize Indigenous students and undermine the delivery of equitable healthcare. Integrating Indigenous knowledge systems, improving cultural humility training, and reducing financial and structural barriers are essential to reform. This paper highlights feasible, evidence-based strategies that can guide educators and institutions in building more inclusive, responsive, and socially accountable medical education environments.