Providing Anti-Oppressive Health Care

Introduction to Anti-Oppressive Practice (AOP) in Medicine

For candidates preparing for the MCCQE1, understanding Anti-Oppressive Practice (AOP) is critical. It falls under the Population Health, Ethical, Legal, and Organizational Aspects of Medicine (PHELO) category. The Medical Council of Canada (MCC) expects physicians not only to treat disease but to recognize how power imbalances, systemic racism, and social structures impact patient health outcomes.

AOP is deeply rooted in the CanMEDS framework, particularly within the Health Advocate, Communicator, and Professional roles. It requires a shift from merely recognizing diversity to actively challenging the systems that create health inequities.

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MCCQE1 High-Yield Concept: In the Canadian context, AOP is inextricably linked to Indigenous Health and the Truth and Reconciliation Commission (TRC) Calls to Action. You must understand the difference between Cultural Competence and Cultural Safety.

Core Concepts of Anti-Oppressive Care

To succeed in the PHELO section of the MCCQE1, you must be able to distinguish between several related but distinct concepts.

Cultural Competence

Cultural Competence: Historically, this referred to acquiring knowledge about other cultures (e.g., “In culture X, they believe Y”).

Critique: It can lead to stereotyping and assumes a finite endpoint of “competence.” It often centers the physician’s knowledge rather than the patient’s experience.

The “Coin Model” of Privilege and Oppression

Understanding privilege is essential for the MCCQE1. Privilege and oppression are two sides of the same coin.

The Coin Model

Top of the Coin (Privilege): Unearned advantages enjoyed by a group (e.g., White, male, cis-gendered, able-bodied, settler).
Bottom of the Coin (Oppression): Unearned disadvantages faced by a group (e.g., Indigenous, racialized, LGBTQ2S+, living with disability).

Clinical Relevance: Physicians often reside on the “top of the coin.” AOP requires using that position to dismantle the structures maintaining the coin.

Intersectionality in Clinical Practice

Coined by Kimberlé Crenshaw, Intersectionality is a framework for understanding how various social and political identities (race, class, gender, sexuality) combine to create unique modes of discrimination and privilege.

For the MCCQE1, do not treat demographic factors in isolation.

Example: A Black woman’s experience with the healthcare system is distinct from a White woman’s or a Black man’s experience. She may face both racism and sexism simultaneously (misogynoir).

Structural Competency

This involves recognizing the “upstream” factors affecting health.

Term	Definition	Clinical Example
Structural Violence	Social structures (economic, political, legal) that stop individuals, groups, and societies from reaching their full potential.	Poverty, discriminatory immigration laws, lack of clean water on reserves.
Implicit Bias	Unconscious associations that lead to negative evaluations of a person on the basis of irrelevant characteristics.	Assuming a First Nations patient presenting with ataxia is intoxicated rather than having a cerebellar stroke.
Microaggressions	Brief, everyday exchanges that send denigrating messages to certain individuals.	”Your English is so good,” or misgendering a trans patient.

Indigenous Health and Anti-Oppression

This is arguably the most critical component of AOP for the MCCQE1. You must be familiar with the historical and current context of Indigenous peoples in Canada (First Nations, Inuit, and Métis).

Key Historical Traumas

Residential Schools: Forced assimilation, abuse, intergenerational trauma.
The “Sixties Scoop”: Mass removal of Indigenous children from their families into the child welfare system.
Indian Hospitals: Segregated, substandard care.

The Truth and Reconciliation Commission (TRC)

The TRC released 94 Calls to Action. Calls 18–24 are specific to health.

Call to Action 23: “We call upon all levels of government to… provide cultural competency training for all healthcare professionals.”

Jordan’s Principle and Joyce’s Principle

Jordan’s Principle: Ensures First Nations children can access all public services when they need them. The government of first contact pays for the service and resolves jurisdictional disputes later.
Joyce’s Principle: Aims to guarantee to all Indigenous people the right of equitable access, without any discrimination, to all social and health services (named after Joyce Echaquan).

Implementing Anti-Oppressive Care: A Step-by-Step Guide

Use this framework when approaching CDM (Clinical Decision Making) cases or OSCE stations involving vulnerable populations.

Step 1: Self-Reflection (Positionality)

Before entering the room, acknowledge your own biases and social location. Ask yourself: “What assumptions are you making based on the chart review?”

Step 2: Establish Safety and Trust

Use inclusive language.

Ask for pronouns: “I use he/him pronouns. How would you like me to refer to you?”
Acknowledge past negative healthcare experiences: “I know the healthcare system hasn’t always been safe for people in your community. I want to ensure you feel heard today.”

Do not just check boxes. Explore the Social Determinants of Health (SDOH).

Housing: “Do you have a safe place to sleep?”
Food Security: “Do you ever worry about running out of food?”
Income: “Can you afford the medications I am prescribing?”

Step 4: Trauma-Informed Physical Exam

Ask permission for every step.
Explain why you are touching.
Allow the patient to stop the exam at any time.
Keep the patient clothed as much as possible.

Step 5: Advocacy and Management

Tailor the management plan to the patient’s reality.

If a patient cannot afford meds, find coverage (e.g., NIHB for status First Nations).
Refer to culturally specific support services (e.g., Friendship Centres).

Specific Populations and Considerations

LGBTQ2S+ Health

2S (Two-Spirit): An Indigenous-specific term reflecting gender/sexual diversity.
Standard of Care: Use gender-neutral language (e.g., “partner” instead of “husband/wife”).
Screening: Base screening on anatomy, not gender identity. (e.g., A trans man with a cervix still needs Pap testing).

Newcomers and Refugees

IFHP (Interim Federal Health Program): Provides limited, temporary coverage of health-care benefits for specific groups (refugees, asylum seekers).
Healthy Immigrant Effect: Immigrants are often healthier than the Canadian-born population upon arrival, but this health advantage declines over time due to SDOH and acculturation.

Key Points to Remember for MCCQE1

Exam Strategy Checklist

Never attribute a symptom solely to race/ethnicity without ruling out medical causes (avoids diagnostic overshadowing).
Always choose the option that empowers the patient or validates their experience in ethical scenarios.
Know the acronyms: TRC (Truth and Reconciliation Commission), NIHB (Non-Insured Health Benefits), IFHP (Interim Federal Health Program).
Trauma-Informed Care 4 R’s: Realize impact of trauma, Recognize signs, Respond by integrating knowledge, Resist re-traumatization.

Sample Question

Clinical Scenario

A 45-year-old First Nations woman presents to the Emergency Department with a 2-day history of diffuse abdominal pain and nausea. She has a history of type 2 diabetes and chronic back pain. Upon reviewing her electronic medical record, you notice a flagged note from a previous visit stating “drug-seeking behavior.” The patient appears guarded and answers questions in monosyllables. Her vitals are: BP 135/85 mmHg, HR 92 bpm, Temp 37.4°C.

Question

Which one of the following is the most appropriate initial action to provide culturally safe care and address the patient’s clinical needs?

A. Order a urine toxicology screen to rule out substance withdrawal.
B. Explain that you cannot prescribe opioids for abdominal pain but will offer acetaminophen.
C. Acknowledge the patient’s discomfort and explicitly ask about her concerns regarding her care today.
D. Immediately consult the on-call psychiatrist for pain management and addiction counseling.
E. Proceed directly to the physical examination to expedite the diagnosis.

Explanation

The correct answer is:

C. Acknowledge the patient’s discomfort and explicitly ask about her concerns regarding her care today.

Detailed Explanation

This question tests your ability to apply Anti-Oppressive Practice and Trauma-Informed Care in a clinical setting, specifically regarding Indigenous Health and combating Implicit Bias.

Choice C is correct. The patient is “guarded,” which may stem from a lack of trust or previous negative experiences (structural violence/racism), exacerbated by the stigmatizing note in her chart (“drug-seeking”). To establish Cultural Safety, the physician must first build rapport and trust. Validating her experience and giving her a voice (power-sharing) is the most effective way to obtain an accurate history and ensure she feels safe. This aligns with the CanMEDS Communicator and Health Advocate roles.
Choice A is incorrect. Ordering a tox screen based solely on a “drug-seeking” label without clinical evidence of intoxication or withdrawal is an example of bias and stereotyping. It violates patient autonomy and trust.
Choice B is incorrect. This is a defensive medicine approach (“pre-emptive denial”). It assumes the patient wants opioids and dismisses her presenting complaint (abdominal pain) before an assessment is complete. This is diagnostic overshadowing.
Choice D is incorrect. Consulting psychiatry immediately stigmatizes the patient and ignores the potential organic cause of the abdominal pain (e.g., DKA, cholecystitis, appendicitis).
Choice E is incorrect. Proceeding to a physical exam without establishing rapport with a guarded patient may be perceived as threatening or re-traumatizing, especially if the patient has a history of trauma.

Canadian Guidelines and Resources

CMA Code of Ethics and Professionalism: Highlights the duty to provide non-discriminatory care and address health inequities.
San’yas Indigenous Cultural Safety Training: A standard training program in many Canadian provinces (e.g., BC, Ontario) to enhance self-reflection and understanding of Indigenous history.
The First Nations Health Authority (FNHA): Provides guidelines on creating a climate of safety and humility.

References

Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives. Retrieved from mcc.ca
Truth and Reconciliation Commission of Canada. (2015). Truth and Reconciliation Commission of Canada: Calls to Action.
Royal College of Physicians and Surgeons of Canada. (2015). CanMEDS 2015 Physician Competency Framework.
Nixon, S. A. (2019). The coin model of privilege and critical allyship: implications for health. BMC Public Health, 19(1), 1637.
Canadian Medical Association. (2018). CMA Code of Ethics and Professionalism.
Turpel-Lafond, M. E. (2020). In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care.